NURSING PRACTICE I: FOUNDATION OF NURSING PRACTICE
SITUATION: 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 C. Nurse Researcher
B. Clinical nurse specialist D. Nurse anaesthesiologist
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. Benner’s “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
SITUATION: The nurse has been asked to administer an 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 track 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
1
,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 is applicable?
A. Pierce the skin quickly and smoothly at a 90 degree angle
B. Inject the medication steadily at around 10 minutes per millilitre
C. Pull back the plunger and aspirate for 1 minute to make sure that the needle did not hit a blood vessel
D. Pierce the 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
client’s 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 in using the Z track technique in an intramuscular injection is:
A. It decreases the leakage of discolouring and irritating medication 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: 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 Korotkoff’s 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 client’s hemoglobin level is low and if he needs blood transfusion
B. Check level of client’s tissue perfusion
C. Measure the efficacy of the client’s anti-hypertensive 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:
2
, A. inconsistent
B. low systolic and high diastolic
C. higher than what the reading should be
D. lower than what the reading should be
14. Through the client’s 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 client’s
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 on 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 bedsheet
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 assessed 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 client’s oral temperature?
A. 10 minutes B. 20 minutes C. 30 minutes D. 15 minutes
19. When auscultating the client’s 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 is the client’s 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: Oral care is an important part of hygienic practices and promoting client comfort.
3
, 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?
A. lemon glycerine C. Mineral oil
B. hydrogen peroxide 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 sidelying position with head of bed lowered
B. Keep the client dry by placing towel under the chin
C. Wash hands 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 client’s 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 ums
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 C. petroleum jelly
B. water D. mentholated ointment
Situation – 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
4
SITUATION: 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 C. Nurse Researcher
B. Clinical nurse specialist D. Nurse anaesthesiologist
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. Benner’s “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
SITUATION: The nurse has been asked to administer an 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 track 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
1
,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 is applicable?
A. Pierce the skin quickly and smoothly at a 90 degree angle
B. Inject the medication steadily at around 10 minutes per millilitre
C. Pull back the plunger and aspirate for 1 minute to make sure that the needle did not hit a blood vessel
D. Pierce the 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
client’s 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 in using the Z track technique in an intramuscular injection is:
A. It decreases the leakage of discolouring and irritating medication 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: 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 Korotkoff’s 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 client’s hemoglobin level is low and if he needs blood transfusion
B. Check level of client’s tissue perfusion
C. Measure the efficacy of the client’s anti-hypertensive 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:
2
, A. inconsistent
B. low systolic and high diastolic
C. higher than what the reading should be
D. lower than what the reading should be
14. Through the client’s 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 client’s
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 on 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 bedsheet
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 assessed 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 client’s oral temperature?
A. 10 minutes B. 20 minutes C. 30 minutes D. 15 minutes
19. When auscultating the client’s 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 is the client’s 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: Oral care is an important part of hygienic practices and promoting client comfort.
3
, 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?
A. lemon glycerine C. Mineral oil
B. hydrogen peroxide 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 sidelying position with head of bed lowered
B. Keep the client dry by placing towel under the chin
C. Wash hands 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 client’s 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 ums
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 C. petroleum jelly
B. water D. mentholated ointment
Situation – 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
4
