Tiêu đề RECALLS 4 - NP3 - SC ✅

RECALLS 4 EXAMINATION NURSING PRACTICE III CARE OF THE CLIENT WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS (PART A) NOV 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 III” on the box provided Situation: Nurse Prima is assigned in the Emergency Department. She must be able to recognize early signs of clinical deterioration and initiate rapid response or cardiopulmonary resuscitation when needed. 1. A client who has been given Cardiopulmonary resuscitation is transported by ambulance to the hospital’s emergency department. During CPR, the nurse should deliver compressions at what rate? A. 60 to 80 per minute B. 80 to 100 per minute C. 100 to 120 per minute D. 120 to 140 per minute 2. When performing external chest compression on an adult during cardiopulmonary resuscitation, how deep should the rescuer depress the sternum? A. 0.5 inch (1 cm) B. 1 inch (2.5 cm) C. 1.5 inches (4 cm) D. 2 inches (5 cm) 3. The emergency medical service has transported a client with severe chest pain. Ask the client is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and unpalpable pulse. Which of the following task is appropriate to delegate to the nursing assistant? A. Assisting with the intubation. B. Placing the defibrillator pads C. Doing chest compressions D. Initiating bag valve mask ventilation 4. In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? A. Initiation of pulse oximetry B. Complete set of vital signs C. Client’s allergy history D. Brief neurologic assessment 5. The client will undergo right-sided cardiac catheterization. Which of the following should not be included in patient teaching? A. “You may have to fast for 6-8 hours before the procedure.” B. “You will experience warm or flushing sensation as the contrast medium is injected.” C. “You will be transferred the operating room and you will receive general anesthesia.” D. “You have to tell me if you have allergy to seafoods” Situation: Angina Pectoris and MI 6. A client newly diagnosed with angina pectoris has taken two sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client now reports headache. The nurse interprets that this is most likely represents which response? A. An early sign of medication tolerance B. An allergic reaction to the nitroglycerin C. An expected side effect of the medication D. A warning that the medication should not be used again 7. Clear you need nurse is caring for a client admitted with acute myocardial infarction. The nurse should monitor the client for which most common complication of MI? A. Heart failure B. Cardiogenic shock C. Cardiac dysrhythmias D. Recurrent myocardial infarction 8. Which of the following statements should the nurse correct when giving patient teaching about nitroglycerin sublingual tablets? A. Store the tablets in an amber-colored, airtight container. B. Do not refrigerate the medication. C. A burning sensation under the tongue indicates the medication is working. D. Report any burning or stinging sensation under the tongue to your healthcare provider 9. A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with an acute myocardial infarction. Which of the following actions would breach the client confidentiality? A. The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit B. The CCU nurse notifies the on-call physician about a change in the client’s condition C. The emergency department nurse calls up the latest electrocardiogram results to check the client’s progress. D. At the client’s request, the CCU nurse updates the client’s wife on his condition 10. Nurse Jamie explains that a Holter monitor will be used for Mr. Santos. Which statement by the client indicates a need for further teaching about the use of the Holter monitor? A. “I will keep a diary of my activities and symptoms while wearing the monitor.” B. “I can shower while wearing the Holter monitor as long as I’m careful.” C. “I should avoid using electric blankets or magnets during the test.”' D. “I should continue with my normal daily activities during the monitoring period.” Situation: BURNS 11. The client comes into the emergency department in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? A. Superficial partial thickness. B. Deep partial thickness. C. Full thickness. 1 | Page
D. First degree 12. A burn characterized by pale white appearance, charred or with fat exposed and painlessness is: A. Superficial partial thickness burn B. Deep partial thickness burn C. Full thickness burn D. Deep full thickness burn 13. A burn that is said to be “WEEPING” is classified as: A. First Degree B. Second Degree C. Third Degree D. Fourth Degree 14. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse in charge knows the purpose of this therapy is to: A. Prevent stress ulcer B. Block prostaglandin synthesis C. Facilitate protein synthesis. D. Enhance gas exchange 15. A client had burns of the right hand from boiling water. Which of the following nursing actions are inappropriate when caring for this client? A. immerse the right hand in cold water B. remove jewelries C. apply dressings on the fingers separately D. apply dressings with the fingers together. 16. Morphine is prescribed by the physician to manage the pain experienced by clients with severe burns. What is the best route of this medication? A. IV B. Oral C. IM D. Subcutaneous 17. A client is scheduled for hydrotherapy for a burn dressing change. Which action should the nurse take to ensure that the client is comfortable during the procedure? A. Ensure that the client is appropriately dressed. B. Administer an opioid analgesic 30 to 60 minutes before therapy . C. Schedule the therapy at a time when the client generally takes a nap. D. Assign an unlicensed assistive personnel (UAP) to stay with the client during the procedure 18. To facilitate fluid replacement in a burn patient, peripheral IV access is established. Which isotonic IV fluid is most appropriate to initiate fluid resuscitation? A. 5% NaCl B. Normal Saline C. Lactated Ringer's D. 0.33% Sodium Chloride 19. When a client accidentally splashes chemicals to his eyes at home, the initial priority care following the chemical burn is to: A. irrigate with normal saline for 1 to 15 minutes B. transport to a physician immediately C. irrigate with water for 15 minutes or longer D. cover the eyes with a sterile gauze 20. When a client will rush towards you and he has a burning clothes on, It is your priority to do which of the following first? You should tell the client to ______. A. log roll on the ground B. slap the flames with his hands C. Try to remove the burning clothes D. Splash the client with 1 bucket of cool water Situation: Nurse Gela is assigned to patients in the medical ward, several of whom are diagnosed with Diabetes Mellitus. The following questions apply. 21. River, newly diagnosed with Type 2 diabetes, asks about the primary treatment approach. What should Nurse Gela emphasize? A. “A pancreas transplant will cure my diabetes.” B. “I will take my oral antidiabetic agents only when my blood sugar is high.” C. “I will follow the weight loss plan provided by the dietitian.” D. “I will call the diabetes educator whenever I have questions about my insulin.” 22. A patient with diabetes has a morning glucose of 50. The patient is sweaty, cold, and clammy. Which of the following nursing interventions is the MOST important? A. Recheck the glucose level B. Give the patient 1⁄2 cup (4 oz) of fruit juice C. Call the doctor D. Keep the patient nothing by mouth 23. Nurse Gela is providing health teaching to River, a client with diabetes mellitus, about proper foot care to prevent trauma and the development of gangrene. Which of the following statements by the client indicates a need for further teaching? A. “I will inspect my feet daily for any cuts, blisters, or changes in color.” B. “I will wear well-fitting shoes and clean, dry socks every day.” C. “I can soak my feet in warm water for 30 minutes daily to keep them clean.” D. “I will massage my feet to help promote circulation.” 24. The nurse is monitoring a client diagnosed with type 1 diabetes mellitus. Today's blood work reveals a.glycosylated hemoglobin level of 10%. Nurse Claire creates a teaching plan based on the understanding that this result indicates which finding? A. A normal value that indicates that the client is managing blood glucose control well B. A value that does not offer information regarding the client's management of the disease C. A low value that indicates that the client is not managing blood glucose control very well D. A high value that indicates that the client is not managing blood glucose control very well 25. The nurse is instructing a client with diabetes mellitus regarding hypoglycemia. Which statement by the client indicates that need for further teaching is necessary? A. “Hypoglycemia can occur at anytime of the day or night” B. “I should drink 6 to 8 ounces of milk if hypoglycemia occurs” C. “If I feel sweaty or shaky, I might be experiencing hypoglycemia” D. “If hypoglycemia occurs, I need to take my regular insulin as prescribed” Situation: The following questions pertain to the proper administration of insulin, its types, and appropriate storage guidelines. 26. The nurse is teaching a client how to mix regular and NPH insulin in the same syringe. Which action should the nurse instruct the client to take? A. Draw up the NPH insulin into the syringe first B. Keep both bottles in the refrigerator at all times C. Mix regular insulin and NPH insulin in the same syringe D. Draw up regular insulin first, then NPH insulin in different syringes. 27. A client asks how long he can store a vial of insulin at room temperature before it goes bad. What is the best response? A. “If you use the vial within 1 month, it can be kept at room temperature.” B. “If you use the vial within 21 days, it may be kept at room temperature.” C. “If you use the vial within 2 weeks, it may be kept at room temperature.” D. “If you use the vial within 1 week, it may be kept at room temperature.” 28. Which of the following is a type of insulin that can be given intravenously? A. NPH B. Glargine C. Regular D. Lispro 29. A client diagnosed with diabetes mellitus receives 8 units of regular insulin subcutaneously at 7:30am. The nurse should be most alert to signs of hypoglycemia at what time during the day? A. 9:30 am to 11:30 am B. 11:30 am to 1:30 pm 2 | Page