RECALLS 6: NURSING PRACTICE 5

10. Honeylet should have been used according to Amanda ,

Situation: You are a nurse in the Psychiatric Unit. The use of
which kind of attitude?
therapeutic touch is an effective intervention in caring for your
A. motherly
patience.
B. friendly
C. passive
1. Which type of therapeutic touch is used when you assess skin D. matter of fact
turgor of the patient during physical assessment?
A. Friendship-warmth touch
Rationale: direct to the point; tell them what is the truth with
B. Love -intimacy touch
not being emotional
C. Social-polite touch
D. Functional-professional
Situation: David is a 72-year-old who is a smoker and a social
2. You gently guide a patient in going to her room. This is the
drinker. He consulted the OPD because of rectal bleeding. His
type of:
tentative diagnosis is colorectal cancer. He was advised by
A. Social-polite touch
the doctor for admission.
C. Friendship-warmth touch
B. Love-intimacy touch
D. Sexual-arousal touch 11. Which of the following would you likely expect as a specific
complaint of the client during your initial health history taking?
3. You put your arms around the shoulders of an elderly patient. a. Projectile vomiting
Which type of touch is this? b. Bouts of hematemesis
A. Love- intimacy touch c. Change in bowel habits
B. Functional- professional d. Passing out white watery stools
C. Social -polite touch
D. Friendship- warmth touch 12. Colonoscopy has been ordered. Which of the following is not
advisable for the client to do?
4. What type of touch is used when it involves tight hugs and a. Has to drink the electrolyte laxatives day before the procedure
kisses between relatives? b. Can take PRN medications when taking electrolyte solution
A. Love-intimacy touch c. Can have a liquid diet before the procedure.
B. Friendship -warmth touch d. Chilled electrolyte solution is allowed.
C. Social -polite touch
D. Functional -professional 13. When assessing a client who underwent a colostomy and the
stoma appears dusky-purple, it indicates ______.
5. Which of the following is NOT a type of therapeutic touch used a. Necrosis - AKA infarct; cell death; grayish in color
by the nurse in providing care to psychiatric patients? b. anemia
A. Social-polite touch c. viable stoma
B. Friendship -warmth d. Ischemia - inadequate oxygenation; buhay pa ang tissue
C. Sexual -arousal touch pero dying na :<
D. Love -intimacy touch
Rationale: dusky-purple color indicates impaired circulation;
Situation: Nurse Honeylet wants to improve in her care for Normal - pinkish, moist
patient Mar, who is an alcoholic. She asks help from her head
nurse Amanda. 14. The nurse should empty the ostomy pouch before it is 1/3
full. She should _____.
6. Honeylet goes to Mars' bedside to greet him. Amanda a. caution the client from straining after surgery.
corrects Honeylet of her greeting which is NOT appropriate to b. facilitate expulsion of flatus and gas
Mar c. prevent dislodging of the skin and ostomy drainage
A. "Hi, Mar! So you got drunk last night" d. hasten peristalsis and evacuation of feces
B. "Hi, Mar! I heard you enjoyed yourself last night"
C. "Hi, Mar! I heard you had a drinking spree last night" Rationale: if the pouch becomes too heavy there is a
D. "Hi, Mar! How was your drinking affair last night" possibility of dislodging

Rationale: Options BCD are non-judgmental 15. Which of the following should the nurse report
IMMEDIATELY to the physician after colostomy?
7. Mar turned his back away from Nurse Honeylet, saying "It's a. Presence of pink rose to brick red stoma.
none of your business, you ugly duckling." The appropriate b. No flatus in 24 to 36 hours.
response of Nurse Honeylet would be: c. Foul smelling odor on the ostomy bag.
A. "What you said hurt me, you alcoholic!" d. Skin slightly detached.
B. "You beast, you are as ugly as I am"
C. "You really are a drunkard" Rationale: Options ABC are normal; there should be no
D. "I don't think you mean what you have just said. Do You?" impaired skin integrity because it is indicative of skin damage
this might be d/t poor surgical technique
8. Amanda wished that Honeylet should have used a/ an:
A. non-verbal communication Additional Notes: Flatus returns after 5 days
B. therapeutic communication
C. empathic communication
D. casual communication Situation: The TQM nurse reported to their director that there
are a lot of medication errors committed by nurses and
9. Amanda suggested that Honeylet should use communication doctors in the hospital for the past 3 months. They made a
technique appropriate for the condition of Mar such as: decision to conduct a review of all the cases with these errors.
A. Concluding A clinical enhancement on drug administration was strongly
B. Analyzing recommended by going back to the basics. The following
C. questioning questions apply:
D. rephrasing

Rationale: Option D is the only therapeutic type of

communication

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16. Which of the following techniques in injection should the 20. The review of literature does not only include published
nurse use to minimize pain when administering imferon (Iron research studies but also theory. In this case which theory is
drugs). least related to the study?
1. Z-track technique A. Neuman’s system model
2. “Darting” needle quickly B. Lazarus’ theory of stress and coping
3. Withdraw needle quickly C. Nightingale’s environmental theory
4. Inject medication quickly D. Roy’s theory of adaptation
a. 2 and 3
b. 1, 2 and 4
Situation: Nurse Clara assists in the care of a male patient
c. 1 and 2
who has developed acute respiratory acidosis.
d. 1, 2, 3 and 4

21. Nurse Clara recalls the causes of respiratory acidosis. Which

Additional Notes: Z track technique → displacing the skin by
of the following are causes of respiratory acidosis?
moving it side ways to prevent staining and irritation brought
1. Chronic obstructive pulmonary disease (COPD)
about by tunneling from normal IM injection; mostly used in
2. Pneumonia
irritating substances
3. Pulmonary edemas
4. Atelectasis
5. Bronchitis
A. 1, 2, 3, 4, 5
B. 2, 3, 4, 5
C. 1, 3, 4, 5
D. 1, 2, 3, 4

22. Nurse Clara further recalls that respiratory acidosis nearly

always results from which of the following conditions?
A. Hyperventilation
B. Hypoventilation
C. Decrease amount of acid in body fluids
D. Low production of carbon dioxide

23. nurse Clara-reviews the results of the arterial blood gasses.

Which of the following would the nurse expect to read in the
17. In order to prevent error in insulin injection, which of the report?
following safety measures should you do? A. pH 7.25 PCO2 50mm Hg
a. Leave the drug in the client refrigerator and ask it when B. pH 7.40 PCO2 52mm Hg
needed. C. pH 7.35 PCO2 40mm Hg
b. Double check with your head nurse calculations and D. pH 7.50 PCO2 30mm Hg
consider high “alert” drugs.
c. Compute the drug, proceed to the patient, and administer 24. The patient is worried about his kidneys being affected
the drug. because of his condition. The nurse explains usually kidneys
d. Request the dietary department to keep the drug until A. can achieve optimal compensation in about 72 hours
needed. B. can achieve optimal compensation immediately
C. will compensate within 24 hours
18. When giving injections to obese client, which of the D. are unable to compensate
following needle size should you use?
a. 4-inch needle Rationale: Metabolic compensation slow
b. 2–3-inch needle Respiratory compensation fast [RR]
c. 4 ½ inch needle → DKA Kussmaul’s Breathing – rapid deep breathing
d. 1-1.5-inch needle respiration (DKA has metab acid, fast breathing
Respiratory Alkalosis, Balance of acid and alka)
Rationale: regular needle length: 1 inch
25. Based on assessment data gathered? Nurse Clara writes a
nursing diagnosis. Which of the following is the MOST
Situation: The ICU nurse assigned to a 60-year-old acutely ill
appropriate nursing diagnosis?
client with Parkinson’s disease who was hospitalized
A. Risk for injury
frequently. The initial confinement was due to electrolyte
B. Ineffective breathing pattern
imbalance. The following confinement was due to injury
C. Risk for respiratory infection
sustained from fall, he became to have incontinent of stools
D. Ineffective tissue perfusion
that further lead to development of skin irritation and
breakdown. Currently he was admitted due to respiratory
infection. Situation: Ms. E.D. 45—year-old is admitted to the medical
ward because of complaints of muscle weakness fatigue,
ptosis, and diplopia. The admitting diagnosis is myasthenia
19. Related literature included case situations similar to the case
gravis.
of the client. The nurse is interested in gaining further knowledge
that can help the client at risk for fecal incontinence. The nurse
should use which of the following methods to strengthen this 26. Based on the complaints of the patient, the nurse formulates
report? a nursing diagnosis, which of the following is MOST
A. Historical research method appropriate?
B. Qualitative research method A. Activity intolerance related to muscle weakness and
C. Experimental research method fatigue
D. Quantitative research method B. Imbalance nutrition: less than body requirements related to
muscle weakness and dysphagia
C. Ineffective airway clearance related to chest muscle
Rationale: measurements are needed to compute risk for
weakness and impaired cough and gag reflex.
fecal incontinence
D. Ineffective breathing patterns related to weakness of chest
muscle and fatigue

Rationale: dec acetylcholine receptors → muscle weakness

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35. You are aware that the primary purpose(s) of documentation

→ Descending Paralysis
are the following EXCEPT:
a. allow the nurse to express his or her opinion on patient
27. The nurse administers anticholinesterase medication, when care.
is the BEST time to give the medication? b. provide legal protection for the nurse in case of lawsuit.
A. 30 minutes before the meal. c. collect data to improve the quality of nursing care.
B. Before the patient sleeps at night d. communicate patient information to other members of the
C. Early in the morning health team.
D. When the patient has eaten a full meal.
Situation: The nurse admits a male patient with complaints of
Rationale: Anticholinesterase/ Cholinesterase Inhibitor: epigastric pain, fatigue, anorexia and weight Loss and pain in
Neostigmine/Pyridostigmine → to increase cholinergic the right upper quadrant. The probable diagnosis is primary
response; if too much might lead to cholinergic crisis liver cancer.

28. The nurse observes that the client had not been compliant 36. The nurse prepares the patient for the tests ordered by the
with her medication regimen of pyridostigmine (Mestinon). The physician. Which of the following procedures would confirm the
patient missed several doses. Which of the following diagnosis of liver cancer?
complications should the nurse watch for? A. Computed tomography (CT) scan
A. Gastrointestinal symptoms B. Abdominal ultrasound
B. Respiratory distress C. Abdominal flat place x-ray
C. Bradycardia D. Cholangiogram
D. Vertigo
37. The physician performs a liver biopsy on the patient. Which
29. The nurse prepares Ms. E.D. for diagnostic tests. Which of of the following complications should the nurse monitor
the following is NOT a diagnostic test for myasthenia gravis. IMMEDIATELY after the procedure?
a. Tensilon test - AKA Edrophonium; if improved - positive for A. Nausea and vomiting
MG; for diagnostic only and not therapeutic because it is B. Abdominal cramping
short acting C. Hemorrhage
b. Position Emission Tomography (PET) D. Potential infection
c. Serum assay for circulating Ach receptor antibodies
d. Electromyography (EMG)
Rationale: Goal in Liver biopsy - control bleeding, liver is a
highly vascularized organ
30. The nurse should always keep which of these drugs at the
bedside of a client with myasthenia gravis.
A. Atropine 38. The physician prescribes Adriamycin for the patient. Which
B. Tensilon of the following considerations has the HIGHEST priority when
C. Inderal preparing to administer the medication to a patient with liver
D. Neostigmine cancer?
A. Metabolism
B. Necessity
Rationale: Antidote for Cholinergic Crisis → Anticholinergic
C. Purpose
(Atropine)
D. Frequency

Situation: You are new registered nurse in the surgical unit. 39. Based on the information gathered, the nurse writes a
You admit a 30-year-old male with head injury sustained in a nursing diagnosis. Which. of the following is the PRIORITY
motorcycle accident. You understand that reporting nursing diagnosis for the patient?
information is a critical part of documentation. a. Acute pain related to abdominal pressure
b. Risk for infection related to complications of liver biopsy
c. Knowledge deficit related to self—care and cancer risk
31. You are aware that documentation should reflect objective prevention
data. Based on your assessment of the neurological function of d. Fear and anxiety related to actual or potential lifestyle
the patient's LOC, you chart the following observations. Which changes
of the following is an objective data?
A. Client appears confused. 40. The nurse understands the two basic types of liver cancer
B. Client looks lethargic. which are primary and secondary, which of the following
C. Vital signs are stable. statements is TRUE regarding primary liver cancer?
D. Patient has a score of 3-4-3 on the Glasgow Coma Scale. A. Women experience more primary liver cancer than men.
B. It is more common in developed countries.
32. You assess the pupils of the patient to and record your C. It is more common in the presence of chronic renal disease.
observations. Which of the following is LEAST important? D. prognosis is poor: there is < 20 percent survival rate.
A. Symmetry - equal
B. Size - mm
C. Color Situation: A 55—year old male. is admitted to the medical unit
D. Reaction to light - PERRLA with a diagnosis of Myocardial Infarction (MI). He complains
of difficulty breathing, excessive sweating, nausea and
33. Based on the information you gathered from the patient; you vomiting and chest pain.
write a nursing diagnosis. Which of the following is NOT a well-
written nursing diagnosis? 41. The nurse performs pain assessment Which of the following
A. Disturbed sensory perception related to cerebral injury. characteristics of pain is manifested in MI?
B. Fatigue related to cerebral injury. 1. The patient may experience crushing substernal pain.
C. Acute confusion related to altered cerebral blood flow. 2. Pain may radiate to the jaw to the back and left arm.
D. Lethargy related to non-specific cause. 3. Pain may occur without cause, primarily early in the
morning.
34 Based on the nursing diagnosis, you record an evaluation of 4. Pain is unrelieved by rest or nitroglycerin and is
the outcomes. Which outcome is NOT well written? The patient relieved only by opioids.
will . 5. Pain lasts 30 minutes or longer.
A. rest as needed A. 2, 3, 4
B. be conscious, oriented and will perform own self—care B. 3, 4, 5
C. have functional sensory status C. 1, 3, 5
D. feel lethargic - deterioration D. 1, 2, 3, 4, 5

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Rationale: toilet → Valsalva maneuver → vasovagal idea that you are a professional caring for a patient
stimulation → bradycardia predisposed to MI
Elements of Negligence/Malpractice:
1. Duty
42. The physician orders laboratory tests on the patient. Which
2. Breach of Duty - failure to provide standards of care
of the following findings would MOST concern the nurse?
3. Injury - harm
a. Creatine kinase (CK-MB): 150 U/L - normal: 5-25 u/L;
4. Causation
byproduct of muscle death, if CK MB is released in the blood
indicative of muscle injury
Gross incompetence - lack of skills (di ka marunong mag
b. Hematocrit (ECT): 42%
insert ng IV, compute ng flow rate)
c. Serum glucose: 100 mg /Dl
d. Erythrocyte Sedimentation rate (ESR): 10mm/h
Additional Notes:
Tort - Civil wrong
43 The physician further orders an arterial blood gas
Unintentional Tort:
measurement. the nurse obtains the specimen. What is the
1. Negligence
MOST appropriate action of the nurse immediately after
• Commission - may ginawa na hindi dapat
obtaining the specimen? The nurse should
• Omission - may hindi ginawa na dapat
A. obtain ice for the specimen.
2. Malpractice
B. apply a sterile dressing to the site.
C. apply direct pressure to the site • Professional Negligence
D. observe the site for hematoma formation • A type of Negligence

Beneficence
Rationale: specimen for ABG is to be taken in artery → → To do good
pressurized → at risk for bleeding; to control apply direct → To improve patient status
pressure
Nonmaleficence
44 The nurse reviews the arterial blood test results of the → To do no harm
patient. The laboratory report indicates a pH of 7.30. PCO2 of → Preventing harm
58mmHg, PO2 of 80 mmHg, and a HCO3 of 27mEg/L. Which → Promoting safety
acid base disturbance is the patient experiencing?
A. Metabolic acidosis 48. The facilitator cites a situation. Nurse x used medical
B. metabolic alkalosis equipment improperly which harmed the patient. The nurse may
C. respiratory acidosis be charged.
D. respiratory alkalosis A. Negligence
B. Assault
45 The nurse administers medications as prescribed by the C. Malpractice
physician. The nurse monitors the blood pressure closely after D. Battery
giving the medications. If the blood pressure Is less than 100
systolic or 25 mmHg lower than the previous reading, what is the 49. The facilitator gave an example of a nurse who gave the
INITIAL action of the nurse? wrong medication to a patient. The result was a severe allergic
a. Elevate the head of the bed and notify the physician. reaction. The nurse could be sued for
b. Lower the head of the bed and notify the physician. A. Battery
c. Take the BP three times, get the average and report to the B. Malpractice
physician, C. Negligence
d. Reassure the patient. Explain that his BF is normal in his D. Assault
condition.
50. The nurse could be sued for any of the following if s/he says
Rationale: flat on bed → walang kinakalaban na gravity → to a patient, If you don’t stop complaining, I will not allow you to
increases chances for increasing BP see your family when they visit.
A. Battery
B. Assault
Situation: You are a newly hired registered nurse in a tertiary C. Libel
hospital. You are required to attend an orientation activity on D. Negligence
legal implications of nurse actions.
Situation: Nurse Luisa is assigned in the coronary care unit
21. You are aware that you need a license to practice nursing of a tertiary hospital. She reviews the cardiovascular system
in the Philippines. Licensure is primarily required to protect before caring for patients with heart diseases.
which of the following?
a. The patients under her/his care, 51. Given a set of statements regarding the physiology of the
b. The school where the nurse obtained his / her nursing cardiovascular system. Which of the following statements is
education and training. TRUE?
c. The hospital where s/he is employed. A. When a person has heart muscle disease, the heart muscles
d. Nurses because they are vulnerable to Lawsuits. stretch as far as is necessary in order to maintain good
function.
47. The facilitator discusses negligence and malpractice. Which B. The heart rate increases when the parasympathetic system
of the following factors is unique to malpractice? is stimulated
1. There is a contractual relationship between the nurse C. The QRS interval on the Electrocardiogram represents
and the patient. the electrical impulses passing the ventricles. -
2. An inappropriate care is an act of commission. ventricular depolarization
3. The patient is harmed as a result of care. D. When there is a decrease in stroke volume, the heart rate
4. The Action of the nurse did not meet standards of care. decreases.
A. 3 only
B. 3 and 4
C. 1 only
D. 1 & 2

Rationale: Malpractice - professional negligence; Option 1 -

has presence of nurse-patient relationship; operating on the

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52 Nurse Luisa collects data from a patient with a primary

Rationale: bladder cancer → cystectomy → ileal conduit →
diagnosis of heart failure. The patient reports that he has
creation of stoma → incontinent → requires ostomy bag
experienced the following disorders. Which disorder does not
precipitate heart failure?
Perform cleansing enema first prior to the procedure
A. recent upper respiratory Infection - GABHS → rheumatic
heart disease → congestive heart failure
B. thyroid disorders - multi organ damage 59. The client undergoes a radical cystectomy and has an ileal
C. anemia conduit. Which of the following postoperative assessment
D. peptic ulcer disease findings should the nurse observe and report to the physician
immediately?
53. Nurse Luisa has a patient admitted for palpitations and mild A. Slight bleeding from the stoma when changing the appliance.
shortness of breath. An electrocardiogram (ECG) was taken. B. A urine output of more than 30mL per hour.
The results revealed a normal P wave, P—R interval, and QRS C. A red moist stoma.
complex with a regular rhythm and a rate of 108 beats per D. A dusky-colored stoma. - indicates ischemia
minute. Nurse Luisa recognizes this cardiac dysrhythmia as
A. Sinus dysrhythmia 60. Which of the following instructions should the nurse give the
B. Supraventricular tachycardia. client with an ileal conduit skin care at the stoma site?
C. Sinus tachycardia A. Clean the skin around the stoma with mild soap and
D. Ventricular tachycardia water and dry the area thoroughly.
B. Leave the stoma open to air while changing the appliance.
54. The electrical activity of the patient' s heart is being C. Cut the faceplate or wafer of the appliance no more than a
continuously monitored. Suddenly the patient has a short burst layer than stoma.
of ventricular tachycardia followed by ventricular fibrillation. D. Change the appliance before going to sleep.
Nurse Luisa should IMMEDIATELY
A. Run to the nurse's station quickly and call a code. Situation: Nurse Danj admitted a new patient to the Medicine
B. Administer atropine as ordered. Ward: Lianmuel, 30, complains of diarrhea for more than two
C. Prepare t ne patient for surgical placement of a pacemaker. weeks prior to consultation. The diagnosis made was Crohn’s
D. Call for help and initiate cardiopulmonary resuscitation. Disease (CD). A plan of care was made for Lianmuel.

Rationale: all VFib are pulseless → patient is in arrest

Additional Notes: By default there is no infection in IBD.
Shockable Rhythms
1. Pulseless VTach 61. Which of these assessments does Nurse Danj expect to see
2. VFib in the patient’s records?
I. Weight gain of 1kg/day - weight loss
II. Arthralgia
55. Nurse Luisa attends to a patient who has continuous ECG III. 10-20 liquid, bloody stools per day - this is seen in
monitoring. She observes that the monitor shows that the ulcerative colitis
rhythm has changed to ventricular tachycardia. Which of the IV. Tenesmus - straining on empty bowel
following interventions is the FIRST action by the nurse? V. Anorexia - part of inflammatory process
A. Quickly assess the level of consciousness, blood VI. Crampy, intermittent pain
pressure and pulse. a. i, ii, iii, iv, v, vi
B. Administer a precordial thump, b. iii, iv, v, vi
C. Administer intravenous lidocaine following emergency c. i, ii iii, iv v
protocol. d. ii, iv, v, vi
D. Quickly obtain a defibrillator and defibrillate the patient.
62. Nurse Danj should include which of the following
interventions for Lian?
Rationale: do not deliver shock because the patient has a a. Increase physical activity to promote intestinal activity
pulse! b. Instruct the patient to increase intake of raw fruits and
vegetables
56. The male client is admitted to the oncology unit. A c. Include high-fiber food choices following the acute phase of
cystostomy is performed, a tumor is visualized and biopsied. The the condition
nurse recognizes that the activity most often associated with d. Provide Sitz bath for the skin excoriation from bowel
bladder tumors is movements
A. Drinking three cans of carbonated beverages every day.
B. Smoking two packs of cigarettes a day. Rationale: damaged skin d/t increased bowel movements
C. Jogging 6 km a day.
D. working with heavy equipment every day.
63 What is Nurse Danj’s priority for Loan if the latter develops
57. The client receives a radiation implant for the treatment of fistula from his CD?
bladder cancer. Which of the following interventions is a. Fluid and electrolyte balance
appropriate? b. Pain management
A. Place client in isolation c. Self-esteem needs
B. Encourage fluid intake d. Skin protection
C. Monitor client for signs and symptoms of cystitis
D. Restrict fluid intake. Rationale: infection → peritonitis → septic shock

Rationale: place the patient in isolation because of presence 64. Which of the following signs and symptoms may suggest
of radiation implant presence of megacolon from antidiarrheal drug use?
a. Leukopenia
58. The physician plans to do a cystectomy and ileal conduit on b. Fever
the male client. The nurse prepares the client for the procedure. c. Bradypnea
Which of the following is an appropriate action of the nurse? d. Hypothermia
A. Perform cleansing enema and give laxatives as ordered.
B. Teach the client muscle—tightening exercises. Rationale: megacolon - abnormal dilation of the colon →
C. Demonstrate to the client the procedure for irrigating the inflammatory process → expect fever
stoma → Megacolon could happen in Hirschsprung Disease d/t
D. Limit fluid intake for 24 hours.

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aganglionic colon patient on semi-fowler’s to improve lung expansion

65 If Lian were a geriatric client, which of these is the first 72. Which of these is the best indicator that peristalsis has
indication of dehydration from fluid volume depletion? resumed after the surgery?
a. Tachycardia a. Active bowel sounds
b. Altered mentation - or confusion, agitation, or altered LOC b. Passage of flatus
c. Hypotension c. Drainage from NG suction
d. Fever d. Tympany upon percussion

73. A T-tube was inserted to maintain patency of the common

Situation: To carry out management functions in any health
bile duct. How should Nurse Jenna position the client for better
care setting, it is necessary for the nurse to integrate
drainage?
leadership skills that he/she developed.
a. Side-lying position
b. Prone position
66 The organizational chart of a nursing department illustrates c. Semi-Fowler’s
the structure and relationships of the nursing leaders and staff d. Low Fowler’s
of the organization. The following are the functions of an
organizational chart, except:
Additional Notes: t-tube is used for drainage of bile
a. To illustrate centrality of control in the organization and
chain of command
b. To indicate relationship of leaders to other management 74. Rico Yan was admitted due to severe and constant
staff abdominal pain. Nurse Jenna should conduct comprehensive
c. To identify managerial levels nursing interview:
d. To list all functions and duties of the staff - to be found in a. Right upon entrance to the emergency department
job description b. After the vital signs have been taken
c. After pain is controlled
67. Coercing a patient into taking medications by threatening d. During physical examination
punishment could legally be considered as:
a. Assault
Rationale: patient focuses on his pain; assessment would not
b. False imprisonment
be conducted properly if he is irritable
c. Malpractice
d. Battery - unconsented touching
75. Rico Yan was diagnosed to have acute pancreatitis from
68. The doctor assigned to the patient was also sued together excessive alcohol intake. Which of these is a characteristic of the
with the nurses. When it was his turn to take the stand during the abdominal pain in acute pancreatitis?
next hearing, he was told to bring with him a copy of the patient’s a. Sharp, intermittent pain
chart. The hearing officer will have to issue what legal order to b. Intense, boring pain - refers to parang binubutas
bring the patient’s chart? c. Relieved when in supine position
a. Writ of certiorari d. Worsens when a fetal position is assumed
b. Subpoena duces tecum - documents
c. Subpoena ad testificandum - testify Situation: Gastrointestinal problems are rampant in the ward
d. Writ of quo warranto Nurse Patricia is assigned in. The following questions apply.
69 Mr. Putanesca’s status has declined after being revived
yesterday after suffering from arrest. Dr. Risotto wrote a DNR 76. Jean is a patient admitted in the ward for her hemorrhoid
order. This order implies that: management. The following are recommended for caring for
a. The patient need not be given food and water. Jean, except:
b. The nurse need not give due care to Mr. Putanesca even a. Tepid Sitz baths - for comfort
gives a bed bath. b. Wiping to clean the anal area - could cause injury; should
c. The nurses and the attending physician need not do any be patting or dabbing motion only
heroic or extraordinary measures for the patient. c. High-fiber diet
d. The patient need not be given ordinary care so that his d. Use of moistened tissues in cleaning the anal area - to
dying process is hastened. reduce risk for injury

77 A patient with colorectal cancer who underwent surgery a

Rationale: following the patient’s wishes respect their week ago had a colostomy in place. What assessment finding of
autonomy the stoma is expected?
a. It is reddish pink and dry - should be moist
70 What ethical principle applies when the surgical team b. It is draining bright red blood profusely.
adheres to surgical asepsis during surgical procedure? c. It protrudes about 2 centimeters from the abdominal wall.
a. Justice d. It is dark red and flaccid. - indicative of ischemia
b. Nonmaleficence - prevention from infections
c. Maleficence 78. Which of these refers to the upper abdominal pain when
d. Beneficence eating?
a. GERD
b. Gastritis
Situation: Nurse Jenna is a nurse in Makati Doctors Hospital
c. Achalasia
caring for clients with problems in the biliary tree.
d. Dyspepsia - AKA Indigestion

71 A patient with complaints of indigestion and RUQ pain was

diagnosed with cholecystitis and underwent an emergency
laparoscopic cholecystectomy. Which of these should Nurse
Sisley not include in her post-operative care?
a. Instruct the client about splinting during coughing.
b. Encourage early ambulation.
c. Maintain the client flat on bed.
d. Assess the patient’s O2 saturation level frequently.

Rationale: improve lung expansion after surgery → put the

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79. A patient with duodenal ulcer experiences pain that is usually 84. Which of these is your priority in caring for a client who just
aggravated by which of the following? had a pacemaker installed?
Ingestion of food a. Encourage patient ambulation.
I. Caffeine b. Minimize patient’s activity.
II. Fried foods c. Increase frequency of passive ROM exercises.
III. Spicy food d. Instruct the client to perform pursed-lip breathing exercises.
IV. NSAID use
V. Corticosteroid use
Rationale: decrease cardiac workload → decrease patient
a. i, ii, iii, iv, v, vi
activity to give time for the patient to adjust from his new
b. ii, iii, iv, v
pacemaker
c. i, ii, iv, v, vi
d. ii, iii, iv, v, vi
85. Patient Elijah, who has an implanted pacemaker, is about to
enter the airport premise to be able to check in his flight to
Additional Notes:
Maldives. Knowing the dangers of the screening devices held by
→ Duodenal Ulcer - relieved by eating
the guards at the airport entrance, what is the best thing Elijah
→ Gastric Ulcer - relieved by vomiting
should do?
a. Request the security personnel to exempt him from security
80. Once peristalsis is established and confirmed after a patient checking because of his pacemaker.
underwent surgery for diverticulitis, which among these does b. Ask if the security can inspect him manually or through
Nurse Patricia expect to be given first? a hand search
a. Mashed potato c. Tell the security guard to keep his screening device.
b. Yogurt d. Proceed through since the handheld device will not
c. Plain gelatin interfere with the pacemaker.
d. Pudding
Situation: Hazel, 50 years old, a restaurant business owner,
Rationale: progression of foods to eat: clear liquid (non-fat) smokes and drinks in a lot of alcohol beverages especially
→ full liquid (with fat); this is d/t fat can slow down gastric when she is stressed at work. She is obese and has been
emptying therefore clear liquids are given first because they diagnosed to be a borderline diabetic. Recently, she is having
are easier to digest a yellowish discoloration of the skin. She consulted her private
physician and was advised to be hospitalized because of a
suspected fatty liver.
Situation: You are caring for patients with various
cardiovascular problems.
86. You are the Nurse-on-duty, when she was admitted. You
conducted the initial physical examination. The APPROPRIATE
81. In reading ECG tracings, which of these represents the time modality in examining an enlarged liver is to:
required for atrial depolarization, as well as the impulse delay in a. Palpate the liver below the level of the right rib of the
the AV node and the travel time to the Purkinje fibers? patient - this is where the anatomical position of the liver
a. PR segment b. Percuss the liver over the right rib cage of the patient
b. QRS complex c. Palpate the liver above the level of the right rib cage of the
c. PR interval patient
d. ST segment d. Auscultate the liver below the level of the right rib cage of
the patient
Rationale:
87. Ms. Hazel was ordered to undergo a liver biopsy. The nurses
Cardiac Conduction System:
responsibility includes the following except:
→ SA Node → AV Node → Bundle of his (Left and Right
a. Turn the patient on a supine position at the right edge of the
Bundle Branches) → Purkinje Fibers
bed.
b. Turn the patient to hold her breath while needle is being
82. A patient with first-degree AV block will usually manifest inserted to the intercostal space
which of the following in his ECG reading? c. Turn the patient on the left side after the procedure - to
a. Prolonged PR interval RIGHT, prevent bleeding
b. Widened QRS d. Secure informed consent
c. Irregular rhythm
d. Reverted P waves
Rationale: right side lying → puts pressure on part of the liver
where it is biopsied → prevents bleeding
Rationale:
AV Blocks Additional Notes:
→ 1st Degree: Prolonged PR Interval Right Lobectomy - has higher pressure on the left lung →
→ 2nd Degree: since it is more complete than the right this might cause
• Type 1: Progressive lengthening of PR Interval until tracheal deviation; patient should be placed on the affected
drop QRS side (right side lying) to counter the pressure

Pneumothorax - pressure is higher in the affected side, place

the patient side lying on the unaffected side
• Type 2: Constant PR Interval then drop QRS
CTT - place the patient side lying on the unaffected side

Pneumonectomy - place the patient on the affected side

→ 3rd Degree: PR Interval not related to QRS complex

88. You are aware that Liver biopsy should NOT be performed
on patient Hazel if she has:
83. Which of these would characterize a third-degree AV block? A. prothrombin time of 12-15 seconds
a. Regular, rapid rhythm B. temperature of 37.2 degree Celsius
b. Irregular, rapid rhythm C. normal breathing pattern
c. Regular, normal to slow rhythm D. ascites
d. Irregular, normal to slow rhythm
Rationale: ascitic fluid might be aspirated rather than liver

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tissue Situation: Documentation is an important aspect of the

nursing process. Nurse Cora is assigned in the medical unit
and responsible for a group of patients. Reporting and
89. For the first 24 hours after liver biopsy the PRIORITY
Recording is a part of her job description. The following
untoward reactions that you should watch for:
questions apply.
a. change of mental status
b. stages of hemorrhages - liver is highly vascularized organ;
priority should be bleeding 96. Nurse Cora made an entry on the patient's care plan: "Goal
c. signs of increasing blood pressure not Met," patient refuses to undergo breast biopsy, patient
d. Cyanosis of the extremities claims it is painful. Which of the following should the nurse
undertake as an appropriate action guided by this recording?
90. In planning nursing care for a patient with fatty liver, the a. Reassess set objectives
nursing intervention should FOCUS on: b. Reassure the patient and accept decision - respecting
1. Limit alcohol intake patient’s autonomy
2. Weight reduction c. Notify the physician
3. Lifestyle changes d. Reassess patients behavior
4. Reduction of blood sugar
A. 1, 2, 3 and 4 97. The nurse is measuring the patient’s urine and is straining it
B. 2 only for the presence of stone. Which of the following should the
C. 1 and 2 Nurse record in the progress notes as an objective data? The
D. 1,2 and 3 patient
A. States "I did not see any stone in my urine"
B. Passed out 400 mL of clear urine
Rationale: Options 1234 are all risk factors for fatty liver
C. Claims "I passed few small stones in my urine"
D. Is complaining of flank pain during urination
Situation: Mr. Ros, a 50-year-old was admitted to the
hospital ward because of abdominal enlargement, and is Rationale: Options ACD are all reported by the patient;
scheduled for exploratory abdominal surgery the next day. An subjective
informed consent has to be accomplished.
98. Nurse Cora while reviewing the medication record has
91. Who among the members of the surgical team is responsible observed a handwritten order, which is unclear. What PRIORITY
to explain the informed consent? nursing action should the Nurse do?
A. Surgeon A. Call the attention of the doctor who prescribed the drug
B. Anesthesiologist B. Refer to the nurse supervisor for the incident report
C. Circulating nurse C. Call the pharmacist who dispensed the drug
D. Medical Director D. Read the drug reference to check the drug

92. It is important that Mr. Ros is advised by the Nurse to have 99. The team leader is assessing and recording the status of
nothing by mouth prior to surgery. If this is a major operation and their patients for the shift. Their documentation should reflect
the schedule of surgery is at seven in the morning, which of the which of the BEST cardinal principles?
following times for fasting should be observed by the patient? A. Quality and timeliness of nursing care
A. 7-8 hours fasting B. Interdisciplinary communication within the shift
B. 4-5 hours fasting C. Application of the Nursing process
C. 9-10 hours fasting D. Compliance with the documentation standards
D. 3-4 hours fasting
93. As a surgical nurse, which of the following interventions are
Rationale: RA 9173 states that the scope of nursing includes
included in your pre-operative teaching?
application of the nursing process
A. Deep breathing exercises
B. Hand and foot exercises
C. Valsalva Maneuver 100. When a patient is with hematemesis, which of the following
D. None of the Above should you read in the charting of nurse Lerma on a patient with
Gastrointestinal (GI) bleeding?
a. Small amounts of blood in gastric secretions detectable by
Rationale: patient has difficulty in breathing d/t abdominal
guaiac test - fecal occult test; stool
incision → splinting
b. Bloody vomitus appearing as fresh, bright red blood,
"coffee grounds" appearance
94. Patient asked the surgical nurse why he had an order of c. Bleeding coming from esophageal varices observed after
nothing per mouth. Your BEST response is to prevent: surgery - does not mention any vomiting
A. Shock d. Black, tarry stools cause by digestion of blood
B. Aspiration
C. nausea and vomiting
Rationale: hematemesis - presence of blood in the vomit; can
D. regurgitation
be found in Upper GI Bleeding but can also be passed as
Melena later on
95. Nurse Cleofe would like to assume a patient's advocate when
the patient for surgery. Which of the following is an example of
this nursing role?
a. Nurse ensures patient is appropriately prepared for
surgery
b. When the consent is signed by a legal person - should be
signed by the patient
c. She makes the patient understand the benefits and risks of
procedure - the surgeon must explain the procedure
d. A nurse makes documentation that the surgical procedure
is needed

RECALLS 6: NURSING PRACTICE 5