Title RECALLS 12 (NP1) - STUDENT COPY ✅

RECALLS EXAMINATION 12 NURSING PRACTICE I COMMUNITY HEALTH NURSING NOVEMBER 2024 Philippine Nurse Licensure Examination Review GENERAL INSTRUCTIONS: 1. This test questionnaire contains 100 test questions 2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalid your answer. 3. AVOID ERASURES. 4. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set. 5. Write the subject title “NURSING PRACTICE I” on the box provided 1. A client is admitted with vancomycin-resistant enterococci (VRE) in a leg wound. The wound is draining although dressings are covering the wound. To prevent the spread of the VRE, which is a nurse’s best plan of action? A. Assign the client to a private room B. Assign only one caregiver to the client C. Do not allow pregnant staff to enter the room D. Place the client in a negative-airflow room 2. A nurse is evaluating teaching for a client who has diabetes and is beginning insulin therapy using an insulin pen. Which behavior should best indicate to a nurse that teaching about the insulin therapy was effective? A. The nurse showing the client a video that explains how to use the insulin pen B. The client reading a handout that describes the different types of insulin and insulin pens C. The nurse demonstrating the correct procedure for preparing the insulin pen for administration D. The client preparing the insulin pen and self-injecting correctly on the first attempt 3. Which statement of the mother will indicate the contraindication of giving the DPT 2 vaccine? A. “I rushed my daughter to the ER the day after receiving DPT 1 due to seizure” B. “My son’s body temperature was fluctuating for 3 days; ranging from 36.5 to 37.7” C. “There’s an abscess formed after receiving DPT 1” D. “I think my son have been experiencing local tenderness for 3 days after his DPT 1 vaccine” 4. Due to shortage of staff in the hospital, a nurse is assigned to six clients, along with a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). One client is scheduled for surgery in a few minutes, another is having pain, one is complaining of a sudden onset of itching an redness after receiving a new medication, and another has family who wants to talk to the physician right away. Which action should the nurse take to best manage and delegate client care? A. Ask the LPN to give the client in pain an analgesic and the UAP to get the client ready for surgery B. Assess the client with itching and ask the UAP to get a cart for the client needing to go to surgery C. Ask the LPN to talk to the family and the UAP to notify the client with pain that an analgesic will be administered soon D. Assess the client with pain and ask the LPN to let the family know the doctor is coming 5. A nurse calls a physician regarding an improvement in the client’s condition who is on mechanical ventilator. The physician gives orders over the telephone for arterial blood gases (ABGs) to be drawn stat. Which is the most important safety consideration when obtaining the order? A. Writing the order down and reading it back to the physician B. Calling the respiratory therapist stat to draw the ABGs C. Giving the order stat to the health unit coordinator to place in the computer D. Writing down the order for ABGs immediately 6. As a knowledgeable nurse, you should be aware that one of the following illnesses cannot be prevented by vaccination, and as a result, no child can be given immunity. A. Mumps B. Polio C. German measles D. Asthma 7. During “Araw ng Sangkap Pinoy” which of the following is distributed among 5 years old & below? A. Carbohydrates B. Iodine C. Vitamin A D. Folate 8. Which of the following statement is in CONTRARY to the principles in planning a home visit? A. Home visit should have a purpose or objective. B. The plan should revolve around family health needs. C. A home visit should be conducted in the manner prescribed by the RHU. D. Planning of continuing care should involve a responsible family member. 9. The nurse is monitoring the status of a post-cesarean section client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? A. Altered level of consciousness and increasing restlessness B. A pulse of 86 beats per minute C. Blood pressure of 110/70 mm Hg D. Hypoactive bowel sounds in all four quadrants 10. A client is receiving patient-controlled analgesia (PCA). The client states, “I have pushed the button several times but there is still no pain relief!”. On examination of the PCA pump, it appears no analgesic has been delivered for 3 hours. Which is the safest action for the nurse to take? A. Replace the old pump with a new one. Place the old pump in soiled receiving. B. Check the programming on the pump to ensure it is programmed correctly. C. Replace the old pump with a new one. Sequester the old pump and label it “defective”. D. Report the pump malfunction to the supervisor 11. The charge nurse is assigned to make the patient assignment in every shift. The nurse manager should intervene if an experienced licensed practical nurse (LPN) is assigned to which action? A. Complete a foot soak for a 55-year-old client who has an infected heel ulcer B. Assist a 44-year-old client who is 6 hours postoperative following a vaginal hysterectomy to sit at the edge of the bed and then ambulate C. Discharge a 34-year-old client with pending discharge instructions and take home medications following a right mastectomy 4 days ago 1 | Page
D. Perform intermittent urinary catheterizations for residual urine for a 55-year-old client who had an abdominal hysterectomy 2 days ago 12. A hospitalized client, identified to be at risk for thromboembolic disease, has anti-embolism hose ordered. A nurse discusses the correct use of the stockings. Which direction should the nurse include in teaching this client? A. If ambulating 10 times daily for 5 minutes at a time, wearing the hose is unnecessary. B. The most appropriate time to apply the hose is before standing to get out of bed in the morning. C. If the hose becomes painful to the skin underneath, notify the nurse and request pain medication. D. Only cross the legs while wearing the antiembolism hose; otherwise keep the legs uncrossed. 13. A client receiving Vancomycin reports pain at an intravenous infusion site that has infiltrated. When a nurse applies a warm, moist compress to the site, the client asks how the treatment will help the condition. The nurse answers the client based on the understanding that the application of moist heat will: A. alter tissue sensitivity by producing numbness. B. decrease the metabolic needs of the involved tissues. C. stop the local release of histamine in the tissues. D. increase blood flow and improve capillary permeability 14. A nurse should inform a nursing assistant to avoid taking a rectal temperature for which client? A. The adult client who underwent ileostomy surgery because of a perforated bowel B. The adult client who has a frequent, productive cough and is receiving oxygen by nasal cannula C. The adult client who developed thrombocytopenia after receiving chemotherapy D. The adult client with hypothermia 15. A nurse takes a client’s blood pressure with an automatic blood pressure machine. The blood pressure is 86/56 mm Hg with a pulse rate of 64 beats per minute. Which action should the nurse do initially? A. Assess the client for dizziness and assess the skin on the extremities for warmth B. Obtain a manual blood pressure cuff and retake the client’s blood pressure C. Elevate the head of the client’s bed D. Read the client’s medical record and determine the client’s normal range of blood pressure 16. A nurse is caring for a client who has a sudden onset of severe allergic reactions. The client is now complaining of chest pain. The client has a history of several surgeries during childhood and spina bifida. The nurse suspects a latex allergy. Which order should the nurse carry out first? A. Transfer to the cardiac care unit B. Remove all allergens from the room C. Place in contact isolation D. Administer epinephrine subcutaneously 17. A delivery room nurse assesses that a laboring client receiving an oxytocin infusion has a contraction occurring 1 minute after the previous contraction and remains strong after 70 seconds. Which should be the nurse’s first appropriate action? A. Notify the physician B. Reassess the fetal heart tones C. Stop the oxytocin infusion immediately D. Prepare to administer terbutaline sulfate 18. In caring for a postpartum mother experiencing perineal pain and discomfort, which task is most appropriate for a nurse to delegate to a nursing assistant? A. Checking the perineum for degree of edema B. Preparing a sitz bath C. Evaluating relief after applying an ice pack D. Teaching the client how to apply an anesthetic agent after perineal care 19. A nurse is about to delegate the task of cup feeding a 24-hour-old term newborn to a nursing assistant. The nurse should evaluate the nursing assistant’s knowledge of this task by asking the assistant: A. how many times she/he has fed an infant previously. B. how long she/he has worked in the newborn nursery. C. how she/he would position the infant for the feeding. D. if she/he has children of her/his own. 20. . A client who was treated for constipation 1 month earlier comes to a primary care provider’s office for an appointment. A nurse interviews the client and obtains information from the client about bowel function and the effectiveness of the prescribed treatments. The nurse determines that the client is no longer constipated based on which statement? A. The client drinks 2,000 mL of fluids daily; including 4 ounces of prune juice. B. The client has had a soft, formed bowel movement without straining every other day for the past 2 weeks. C. The client self-administered one disposable enema the day of last month’s appointment. D. The client has minor discomfort from hemorrhoids during bowel movements. 21. A nurse receives a medication order for an adult client to administer ferrous sulfate 300 mg PO bid. After thinking critically about this order, the nurse should: A. administer the medication as ordered. B. contact the physician to clarify the route of the medication. C. contact the physician to question the twice daily administration of the medication. D. withhold the medication because the dosage is not within acceptable ranges. 22. A clinic nurse is administering HepB (hepatitis B vaccine) intramuscularly to a newborn prior to hospital discharge. Which site is best for the nurse to plan to administer the injection? A. Deltoid B. Ventrogluteal C. Dorsogluteal D. Vastus lateralis 23. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take? A. Increase the I.V. fluid infusion rate B. Irrigate the indwelling urinary catheter C. Notify the physician D. Continue to monitor and record hourly urine output 24. A nurse is caring for a client who does not go outdoors due to agoraphobia and also has an inadequate milk intake. For which vitamin deficiency should a nurse specifically assess when caring for the client? A. Vitamin B6 B. Vitamin A C. Vitamin D D. Vitamin C 25. The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? A. A client who is ambulatory demonstrating steady gait B. A postoperative client who has just received an opioid pain medication C. A client scheduled for physical therapy for the first crutch walking session D. A client with a white blood cell count of 14,000 and a temperature of 38.4°C 26. One of the participants in a hilot training class asked you to whom she should refer a patient in labor who develops a complication. You will answer, to the: A. Public Health Nurse B. Rural Health Midwife C. Municipal Health Officer D. Any of these health professionals 27. As an epidemiologist, the nurse is responsible for reporting cases of notifiable diseases. What law mandates reporting of cases of notifiable diseases? A. Act 3573 B. R.A. 3753 C. R.A. 1054 D. R.A. 1082 28. Which of the following is the BEST QUESTION for the nurse to ask to assess a family’s ability to cope? A. “Do you think your family copes effectively?” B. “What do you think of the current family problem?” C. “What strengths does your family have?” 2 | Page
D. “Can you describe how you successfully handled one family problem?” 29. A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is instructed to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: A. Visitors must wear a mask and a gown B. There are no special requirements for visitors of clients on contact C. Visitors should wash their hands before and after touching the client D. Visitors should wear gloves if they touch the client 30. A nurse is assigned on a client with salmonella infection. In performing the care for the client, the primary nursing intervention to limit transmission is which of these approaches? A. Wash hands thoroughly before and after client contact B. Wear gloves when in contact with body secretions C. Double glove when in contact with feces or vomitus D. Wear gloves when disposing of contaminated linens 31. A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care? A. Airborne precautions B. droplet precautions C. contact precautions D. compromised host precautions 32. The school nurse had Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? A. Scratching the head more than usual B. Flakes evident on a student’s shoulders C. Oval pattern occipital hair loss D. Whitish oval specks sticking to the hair 33. An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When the nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The nurse understands that which of the following is true in regards to giving immunizations to this child? A. Live vaccines are withheld in children with renal chronic illness B. The MMR vaccine should be given now, prior to the transplant C. An inactivated form of the vaccine can be given at any time D. The risk of vaccine side effects precludes giving the vaccine 34. The pediatric nurse is taking a health history from parents of a child admitted with possible Reye's Syndrome. Which recent illness would the nurse recognize as increasing the risk to develop Reye's Syndrome? A. Rubeola B. B.Meningitis C. Varicella D. Hepatitis 35. Dr. Garcia writes the following order for the client who has been recently admitted “Digoxin .125 mg P.O. once daily.” To prevent a dosage error, how should the nurse document this order onto the medication administration record? A. “Digoxin .1250 mg P.O. once daily” B. “Digoxin 0.1250 mg P.O. once daily” C. “Digoxin 0.125 mg P.O. once daily” D. “Digoxin .125 mg P.O. once daily” 36. Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement? A. A 34 year-old post operative appendectomy client of five hours who is complaining of pain. B. A 44 year-old myocardial infarction (MI) client who is complaining of nausea. C. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated. D. A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid. 37. A newly admitted female client who is taking Phenytoin (Dilantin) was diagnosed with agranulocytosis. The nurse formulates which priority nursing diagnosis? A. Constipation B. Diarrhea C. Risk for infection D. Deficient knowledge 38. When Nurse Trish is providing care to his patient, she must remember that her duty is bound not to do doing any action that will cause the patient harm. This is the meaning of the bioethical principle: A. Non-maleficence B. Beneficence C. Justice D. Solidarity 39. When the license of a nurse is revoked, it means that she: A. Is no longer allowed to practice the profession for the rest of her life B. Will never have her/his license re-issued since it has been revoked C. May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173 D. Will remain unable to practice professional nursing 40. Which element in the circular chain of infection can be eliminated by preserving skin integrity? A. Host B. Reservoir C. Mode of transmission D. Portal of entry 41. Which of the following patients is at greater risk for contacting an infection? A. A patient with leukopenia B. A patient receiving broad-spectrum antibiotics C. A postoperative patient who has undergone orthopedic surgery D. A newly diagnosed diabetic patient 42. A natural body defense that plays an active role in preventing infection is: A. Yawning B. Body hair C. Hiccupping D. Rapid eye movements 43. When removing a contaminated gown, the infection and control nurse should be careful that the first thing she touches is the: A. Waist tie and neck tie at the back of the gown B. Waist tie in front of the gown C. Cuffs of the gown D. Inside of the gown 44. Which of the following statements about chest X-ray is false? A. No contraindications exist for this test B. Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above the waist C. A signed consent is not required D. Eating, drinking, and medications are allowed before this test 45. A patient with no known allergies is to receive Benzylpenicillin G every 6 hours. When administering the medication, the nurse observes a fine rash on the patient’s skin. The most appropriate nursing action would be to: A. Withhold the moderation and notify the physician B. Administer the medication and notify the physician C. Administer the medication with an antihistamine D. Apply corn starch soaks to the rash 46. Prolonged deficiency of Vitamin B9 leads to: A. scurvy B. pellagra C. megaloblastic anemia D. pernicious anemia 47. Which biological used in Expanded Program on Immunization (EPI) is stored in the freezer? A. DPT B. Tetanus toxoid C. Measles vaccine D. Hepatitis B vaccine 48. Which immunization produces a permanent scar? A. DPT B. BCG 3 | Page
C. Measles vaccination D. Hepatitis B vaccination 49. A 4-month old infant named Baby Rev was brought to the health center because of cough. Her respiratory rate is 42/minute. Using the Integrated Management of Child Illness (IMCI) guidelines of assessment, her breathing is considered A. Fast B. Slow C. Normal D. Insignificant 50. A mother brought her daughter, 4 years old, to the RHU because of cough and colds. Following the IMCI assessment guide, which of the following is a danger sign that indicates the need for urgent referral to a hospital? A. Inability to drink B. High grade fever C. Signs of severe dehydration D. Cough for more than 30 days 51. Where should you put a wet adult diaper? A. Green trashcan B. Black trashcan C. Orange trashcan D. Yellow trashcan 52. Nica was diagnosed with cancer of the cervix. You noticed that the radioactive internal implant protrudes to her vagina where supposedly, it should be in her cervix. What should be your initial action? A. Using a long forceps, Push it back towards the cervix then call the physician B. Wear gloves, remove it gently and place it on a lead container C. Using a long forceps, Remove it and place it on a lead container D. Call the physician, You are not allowed to touch, re insert or remove it 53. A nurse is teaching a client how to use the call bell system. Which level of Maslow’s Hierarchy of Needs does this nursing action address? A. Safety B. Self-esteem C. Physiologic D. Interpersonal 54. A nurse is teaching staff members about the legal terminology used in child abuse. What definition of battery should the nurse include in the teaching? A. Maligning a person’s character while threatening to do bodily harm B. A legal wrong committed by one person against property of another C. The application of force to another person without lawful justification D. Behaving in a way that a reasonable person with the same education would not 55. A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? A. Limits had to be set to control the child’s crying. B. The child had a right to remain in the room with the other children. C. The child had to be removed because the other children needed to be considered. D. Segregation of the child for more than half an hour was too long a period of time. 56. The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah’s Witnesses. What action should the nurse take? A. Institute the ordered blood transfusion because the client’s survival depends on volume replacement. B. Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. C. Phone the health care provider for an administrative order to give the transfusion under these circumstances. D. Give the spouse a treatment refusal form to sign and notify the health care provider that a court order can now be sought. 57. Which nursing behavior is an intentional tort? A. Miscounting gauze pads during a client’s surgery B. Causing a burn when applying a wet dressing to a client’s extremity C. Divulging private information about a client’s health status to the media D. Failing to monitor a client’s blood pressure before administering an antihypertensive 58. Which nursing action is protected from legal action? A. Providing health teaching regarding family planning B. Offering first aid at the scene of an automobile collision C. Reporting incidents of suspected child abuse to the appropriate authorities D. Administering resuscitative measures to an unconscious child pulled from a swimming pool 59. A weak, dyspneic, terminally ill client is visited frequently by the spouse and teenage children. What should the client’s plan of care include? A. Foster self-activity whenever possible. B. Plan care to be completed at one time followed by a long rest. C. Teach family members how to assist with the client’s basic care. D. Limit visiting to evening hours before the client goes to sleep. 60. A nurse is evaluating the appropriateness of a family member’s initial response to grief. What is the most important factor for the nurse to consider? A. Personality traits B. Educational level C. Cultural background D. Past experiences with death 61. How can a nurse best evaluate the effectiveness of communication with a client? A. Client feedback B. Medical assessments C. Health care team conferences D. Client’s physiologic responses 62. A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. What is the most therapeutic nursing intervention? A. Sitting quietly with the client B. Telling the client that crying is not helpful C. Suggesting that the client play a board game D. Recommending how the client can change this situation 63. A client has been told to stop smoking by the health care provider. The nurse discovers a pack of cigarettes in the client’s bathrobe. What is the nurse’s initial action? A. Notify the health care provider. B. Report this to the nurse manager. C. Tell the client that the cigarettes were found. D. Discard the cigarettes without commenting to the client. 64. “But you don’t understand” is a common statement associated with adolescents. What is the nurse’s best response when hearing this? A. “I don’t understand what you mean.” B. “I do understand; I was a teenager once too.” C. “It would be helpful to understand; let’s talk.” D. “It’s you who should try to understand others.” 65. When assessing a post-exploratory laparotomy client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action? A. Obtain the vital signs. B. Notify the health care provider. C. Reinsert the protruding organs using aseptic technique. D. Cover the wound with a sterile towel moistened with normal saline. 4 | Page