Title RECALLS 7 (NP3) - STUDENT COPY ✅

1 | Page RECALLS EXAMINATION 7 NURSING PRACTICE III CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS (PART A) MAY 2025 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 Situation: A woman who underwent hysterectomy 2 days ago is under your care. 1. Which nursing observations would MOST likely predispose the client to develop venous thrombosis in the lower extremity? A. Drinking coffee at least 3 to 5 cups in a day B. Refusing to get out of bed C. Taking soft diet only D. Requesting for analgesics frequently 2. The patient was prescribed to have antiembolism stockings. The nurse assess the patient knows its purpose when she states 1. It promotes venous return 2. It strengthens muscle tone 3. It prevents pooling of blood in the extremities A. 1 & 2 B. 1 & 3 C. 2 & 3 D. 1, 2 & 3 3. The nurse assesses the client for Homan’s sign. Which of the following is the CORRECT instruction of the nurse? A. Have the client push each foot hard against the mattress B. Tell the client to sit on bed and point to her toes C. Ask the client to contract her tight musclesma D. Instruct the client to extent her legs and flex each foot toward the head 4. Which client’s response suggest a positive Homan’s sign? A. Inability of the client to bend her knees B. Sudden numbness while extending the foot C. Tingling sensation throughout the affected leg D. Sharp, immediate calf pain in the legs 5. Based on the findings, the client has been diagnosed with thrombophlebitis. Which of the following nursing action must be AVOIDED? A. Elevating the client’s leg B. Massaging the affected leg C. Applying ice compress to the affected leg D. Ambulating at least twice each shift Situation: After a head injury, Mara, 36 years old, began to manifest signs and symptoms of Diabetes Insipidus. 6. The nurse in charge understands that Diabetes Insipidus (DI) is caused by an ADH deficiency resulting to which problem in metabolism. A. Protein B. Water C. Carbohydrates D. Fat 7. The nurse caring for Mara would expect to find which characteristic assessment findings? 1. Excessive thirst 2. Polyuria 3. Hyperglycemia 4. Glycosuria A. 1 and 3 B. 2 and 3 C. 1 and 2 D. 3 and 4 8. Which nursing action is critical in monitoring Mara’s condition? A. Measuring intake and output B. Assessing vital signs C. Monitoring sleeping pattern D. Analyzing blood glucose 9. The physician orders “weigh daily”. When instructing the nursing aide to weigh the client, what essential instruction is MOST important to obtain an accurate data? A. Weight the client on the same scale time of the day wearing the similar amount of clothing B. Ask the client to state her weight before the disorder manifested C. Instruct the client to weigh before breakfast daily D. Have the client remove her footwear 10. The client was prescribed with intranasal Lypressin (Diapid) 2 spray 4x a day and as needed. Which is the CORRECT way to administer the spray? A. Sitting in an upright position, insert the spray into the nostril then inhale while compressing the container B. Shaking the spray vigorously before inhaling in both nostrils C. Tilting the head to the side, and inhale the spray 2 times D. Inhaling with each spray 2 times Situation: Documentation is one of the topics for discussion among the nurse - orientees. 11. In the hospital, narrative documentation is used. From the guidelines below the nurse orientees were made to select which are the CORRECT guidelines related to narrative documentation. Select all that apply: 1. Use blue colored ink ball pen all the time 2. Date and time all entries 3. Completely document subjective and judgmental information gathered 4. Sign and affix appropriate title 5. Avoid evaluative statement 6. Do not leave blank spaces on documentation forms * NLE * NCLEX * CGFNS * HAAD * PROMETRICS * DHA * MIDWIFERY * LET * RAD TECH * CRIMINOLOGY * DENTISTRY * PHARMACY *

3 | Page Situation: Communication is one of the best tools in patient -nurse interaction towards safe delivery cure. 26. Mrs. Gomez told the nurse that she was concerned about her husband. Which of the following responses of the nurse would encourage Mrs. Gomez to open the discussion A. “Would you like to talk about the reason for your visit?” B. “Would it help to discuss your feelings? C. “What brought you to the hospital?” D. “Does it concern you on what happened to your husband?” 27. While listening to your patient about his near death experience during his last surgery, you crossed your arms on your chest. What message is the nurse conveying to the client? A. Trying to end the conversation with your client B. Conveying that you have ample time to listen to the client C. Pretending to listen to what the client is narrating D. Uninterested to hear what the client has to say 28. Another client told you that he was not looking forward to having this hemorrhoids removed. Which statement of the nurse would MOST likely stir up an expression of fear to the client? A. “are you implying that surgery is frightening?” B. “why don’t you just look forward to your surgery to relieve you of the present discomfort?” C. “don’t you think your surgeon is competent enough?” D. “have you ever bad surgery before?” 29. You are assessing a 60 year old client who lives alone by herself and with permanent colostomy. Which of the following statements of the client indicate that she has fully accepted her-present condition? A. “My children no longer visit me. I’m just waiting for my Creator to take me” B. “My life is slowly deteriorating each day” C. “I was a good O.R. nurse when I was younger. Now I’m just client” D. “I had a good life and I intend to enjoy it” 30. Mrs. Orchard, a post hysterectomy client with 7 children, made no comment about the recent death of her 13 year old daughter in a tragic car accident. She shifted topics quickly when asked about how her other children were adjusting to the loss of their sister. Which of the following interpretations of her actuation should receive your PRIORITY nursing intervention for Mrs. Orchard? A. Need of support system B. Changing life roles C. Avoiding a painful subject D. Resolved grief Situation: A G4 P5 client who is in labor pains is transferred from the delivery room to the Operating Room for emergency Cesarean section (CS). 31. As you reviewed the client’s chart, you found out that the reason for the emergency CS is “fetal distress”. Which of the following assessment findings would confirm the indication of emergency CS? A. Fetal heart rate of 180 beats per minute B. Multiple pregnancy C. Non-progressing labor D. A 6 to 6.7 lbs baby 32. The circulation nurse prepares the client to which of the following positions? A. Supine with wedge support under the right hip B. Supine with pillows for head support C. Lithotomy with padded stirrups D. Semi -Fowler’s position with one pillow under the knees 33. As soon as the baby is out, the scrub nurse must focus FIRST on which of the following nursing action? A. Slap the newborn to induce crying B. Wipe the mouth, nose and eyes with a sterile operating sponge (OS) C. Attach the name tag D. Suction the mouth and nose of the newborn 34. Prior to the closure of the endometrium, the scrub and circulating nurses should perform which of the MOST critical nursing intervention? A. Change drapes B. Have a large basin to contain the placenta C. Report sponge count status to the surgeon D. Prepare chronic cut gut suture for the endometrium 35. One week after surgery, the mother developed high fever and was found out that the cause of infection was a sponge left inside her body. The health care professional most liable for this case is: A. Anesthesiologist B. Surgeon C. Scrub Nurse D. Circulating Nurse Situation: the pyramid of success in cardiovascular disorder therapy points to client education is very essential. 36. Rose, a 65 year old retired teacher, post MI, lives alone and is in anti – coagulant therapy with warfarin sodium (Coumadin). The nurse would include in her instruction that warfarin sodium is usually given for 2 to 6 months after MI to: A. Enhancement cardiac muscle recovery B. Increase over-all percentage of recovery C. Facilitate oxygenation of myocardial tissue D. Decrease incidence of deep vein thrombosis and thromboembolism 37. Like any client on Coumadin, Rose should be advised to be monitored on prothrombin time and international normalized ratio (INR). If the INR is 1.5, Coumadin is: A. Maintained B. Increased C. Decreased D. Discontinued 38. The client should also be instructed regarding measures to prevent which of the following? A. Infection B. Excitement C. Bleeding D. Exposure to extreme temperature 39. The nurse would include in her dietary instruction to avoid which of the following? A. Yellow fruits and vegetables B. Nuts and seeds C. Green leafy vegetables D. Fish and poultry 40. Rose wants to be secured at home while on Coumadin. Which drug must be kept ready in the event of Coumadin overdose? A. Aqua mephyton B. Vitamin K C. Protamine sulfate D. Aqua gel Situation: A nurse admitted a 6 year old boy who is dyspneic, tachypneic with respiratory rate of 40 breaths/minute, afebrile, and with paroxysmal, irritative non – productive cough. The physician's diagnosis is asthma. 41. Which of the following correctly describes asthma? A. Often irreversible B. Inflammatory disorder of the airways
4 | Page C. Characterized by hypoventilation D. Dyspnea with respiratory rate of 40/minute 42. When the nurse examines the patient’s chest on auscultation, which of the following assessment findings would indicate that the obstruction progresses? A. Productive cough B. Audible wheeze C. Silent chest D. Prominent sweating 43. The nurse administered aminophylline as ordered. Which of the following assessments indicates effectiveness of the drug? A. Thinning of the tenacious purulent sputum B. Normal breath sounds C. Normal body temperature D. Decreasing bronchial secretions 44. The client was prescribed with a short term corticosteroid therapy, The nurse knows that the preferred route of administration is through metered-dose inhalation because it: A. Is well tolerated B. Minimizes mucous secretions C. Reduces cushingoid effects D. Enhances absorption of drug 45. Throat irritation is associated with nebulizer use. What nursing intervention is BEST to decrease irritation? A. Taking lozenges B. Drinking ice cold fruit juices C. Sipping or gargling water D. Chewing gum Situation: After a head injury, Jarrah, 36 years old begun to manifest signs and symptoms of Diabetes Insipidus 46. The nurse in charge understands that Diabetes Insipidus (DI) is caused by an ADH deficiency resulting to which problem in metabolism. A. Protein B. Water C. Carbohydrates D. Fat 47. The nurse caring for Jarrah would expect to find which characteristic assessment findings? 1. Excessive thirst 2. Polyuria 3. Hyperglycemia 4. Glycosuria A. 1 and 3 B. 2 and 3 C. 1 and 2 D. 3 and 4 48. Which nursing action is critical in monitoring Jarrah’s condition? A. Measuring intake and output B. Assessing vital signs C. Monitoring sleeping pattern D. Analyzing blood glucose 49. The physician orders “weigh daily”. When instructing the nursing aide to weigh the client, what essential instruction is MOST important to obtain an accurate data? A. Weight the client on the same scale time of the day wearing the similar amount of clothing B. Ask the client to state her weight before the disorder manifested C. Instruct the client to weigh before breakfast daily D. Have the client remove her footwear 50. The client was prescribed with intranasal Lypressin (Diapid) 2 spray 4x a day and as needed. Which is the CORRECT way to administer the spray? A. Sitting in an upright position, insert the spray into the nostril then inhale while compressing the container B. Shaking the spray vigorously before inhaling in both nostrils C. Tilting the head to the side, and inhale the spray 2 times D. Inhaling with each spray 2 times Situation: A woman who underwent hysterectomy 2 days ago is under your care. 51. Which nursing observations would MOST likely predispose the client to develop venous thrombosis in the lower extremity? A. Drinking coffee at least 3 to 5 cups in a day B. Refusing to get out of bed C. Taking soft diet only D. Requesting for analgesics frequently 52. The following are true regarding antiemboli stockings except: A. Too small stockings may cause skin breakdown. B. Apply stockings in the morning. C. The patient who has been ambulating should wait for 1 hour before applying the stockings. D. Antiemboli stockings can prevent edema of the legs and feet. 53. The nurse assesses the client for Homan’s sign. Which of the following is the CORRECT instruction of the nurse? A. Have the client push each foot hard against the mattress B. Tell the client to sit on bed and point to her toes C. Ask the client to contract her tight muscles D. Instruct the client to extend her legs and flex each foot toward the head 54. Which client’s response suggest a positive Homan’s sign? A. Inability of the client to bend her knees B. Sudden numbness while extending the foot C. Tingling sensation throughout the affected leg D. Sharp, immediate calf pain in the legs 55. Based on the findings, the client has been diagnosed with deep vein thrombophlebitis. Which of the following nursing actions must be AVOIDED? A. Elevating the client’s leg B. Massaging the affected leg C. Applying warm compress to the affected leg D. Crossing the legs when seated Situation: Chad, 35 years old was admitted in the surgical unit from the Emergency Department with a chest tube connected to a closed drainage system. Admitting diagnosis of physician is closed pneumothorax related to fractured ribs on the right side of the chest sustained from a blunt injury during a vehicular accident. 56. The admitting nurse understands that in pneumothorax, air accumulates abnormally in the: A. Pulmonary vascular system - air embolism B. Pleural space C. Lung tissues - Normal physiology; air breathed in goes to alveoli where gas exchange occur D. Thoracic cavity - this is just the GENERAL term about the space that surrounds the lungs, heart and other organs. 57. The patient is diagnosed with open pneumothorax. The nurse knows that this occurs when? A. The chest wall wound is large enough to allow air to pass freely in and out. B. There is a buildup of positive pressure occurring with each inspiration and the air is trapped. C. There is a rupture of air-filled bleb or blister on the surface of the lung. D. There is a presence of bronchopleural fistula.