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


B. Livor mortis C. Algor mortis D. Pallor mortis 49. The nurse is preparing to perform postmortem care for a deceased client. To maintain the body’s appearance and prevent discoloration, what is the most appropriate position for the nurse to place the body? A. Supine with head flat and arms at the side B. Prone with arms at the side C. Side-lying with knees bent D. Supine with the head slightly elevated and arms at the side 50. Which of the following is appropriate nursing intervention for a client who is grieving over the death of her child? A. Tell her not to cry and it will be better. B. Provide opportunity to the client to tell their story. C. Encourage her to accept or to replace the lost person. D. Discourage the client in expressing her emotions. Situation: Mr. Alcovendas, a 70-year-old male patient, presents to the emergency department with severe, persistent back pain radiating to the lower abdomen. He reports feeling a pulsating mass in his abdomen for the past few months but dismissed it. His blood pressure is 80/50 mmHg, and his heart rate is 120 bpm. Physical examination reveals a tender, pulsatile abdominal mass. A CT scan confirms a ruptured abdominal aortic aneurysm (AAA). 51. Which of the following is the most likely cause of this patient's low blood pressure and tachycardia? A. Severe dehydration B. Acute myocardial infarction C. Intra-abdominal hemorrhage D. Pulmonary embolism 52. Which of the following nursing interventions is priority in managing this patient's immediate condition? A. Administer intravenous fluids B. Obtain a 12-lead electrocardiogram (ECG) C. Prepare the patient for surgery D. Administer pain medication 53. Which of the following diagnostic tests confirm the diagnosis of a ruptured AAA? A. Abdominal ultrasound B. Chest X-ray C. Computed tomography (CT) scan D. Magnetic resonance imaging (MRI) 54. Which of the following preoperative nursing assessments is crucial for a patient with a ruptured AAA scheduled for emergency surgery? A. Assessing the patient's understanding of the procedure B. Monitoring the patient's fluid balance C. Assessing the patient's pain level D. Monitoring the patient's vital signs and oxygen saturation 55. What is the most important postoperative instruction to provide to a patient recovering from an AAA repair regarding activity and mobility? A. Avoid all physical activity for at least six weeks. B. Gradually increase activity as tolerated, avoiding strenuous activities. C. Maintain strict bed rest for at least three weeks. D. Resume normal activities immediately after discharge. Situation: Princess Carahey, a 28-year-old female patient, presents to the clinic complaining of episodic numbness, tingling, and blanching of her fingertips, particularly during cold weather. She denies any history of connective tissue disease or trauma. The symptoms resolve spontaneously after warming her hands. 56. Considering the patient's symptoms and history, which condition is most appropriate? A. Secondary Raynaud's phenomenon B. Acrocyanosis C. Primary Raynaud's phenomenon D. Peripheral artery disease 57. Which of the following is a key differentiating factor between Raynaud's phenomenon and acrocyanosis? A. Presence of hyperhidrosis B. Bilateral and symmetrical involvement C. Paroxysmal pallor of the digits D. Aggravation by cold temperatures 58. The nurse should advise the patient to avoid which of the following to minimize the frequency of her symptoms? A. Regular exercise B. Situations that may be stressful C. Nicotine use in any form D. Both b and c 59. The nurse is educating the patient on self-management strategies for her condition. Which of the following instructions is least important to emphasize? A. Avoid exposure to cold temperatures. B. Wear warm clothing, including gloves and hats, during cold weather. C. Immediately discontinue all nicotine use, including nicotine replacement therapy. D. Regularly perform range-of-motion exercises to improve circulation. 60. Which of the following patient statements indicates a need for further teaching regarding self-management of Raynaud's phenomenon? A. "I'll wear gloves when I handle frozen food." B. "I'll try to manage my stress levels." C. "I'll use a heating pad on my hands for long periods to keep them warm." D. "I'll avoid smoking and nicotine products." Situation: Mr. Balay, a 60-year-old male patient, is admitted to the hospital following a prolonged flight, complaining of right leg pain, swelling, and warmth. A physical examination reveals unilateral edema of the right lower extremity, with tenderness to palpation along the posterior calf. A Doppler ultrasound confirms a deep vein thrombosis (DVT) in the right popliteal vein. 61. Which of the following is the most significant risk factor for this patient's DVT? A. Age B. Gender C. Prolonged immobility during the flight D. Tenderness to palpation 62. Which of the following nursing actions is the highest priority during the initial care of a patient with suspected deep vein thrombosis (DVT)? A. Applying warm compresses to the affected leg. B. Encouraging active range-of-motion exercises. C. Elevating the affected leg. D. Massaging the affected leg to improve circulation. 63. The primary goal of medical management in this patient is to: A. Immediately dissolve the existing thrombus. B. Prevent further thrombus extension and embolization. C. Reduce leg pain and swelling. D. Improve blood flow to the affected leg. 64. Which of the following medications is commonly indicated for this patient’s condition? A. Aspirin B. Heparin C. Warfarin D. Clopidogrel 65. Which nursing intervention plays a vital role in preventing complications related to this patient’s deep vein thrombosis (DVT)? A. Applying warm compresses to the affected leg. B. Encouraging bed rest to minimize pain. C. Promoting early ambulation and leg exercises. D. Measuring leg circumference daily to monitor swelling. Situation: Mrs. Panis, a 45-year-old female patient, presents to the emergency department with sudden onset of shortness of breath, sharp chest pain worsened by deep breaths, and tachycardia. She reports a recent history of deep vein thrombosis in her left leg. Initial assessment reveals tachypnea, hypoxemia (SpO2 88% on room air), and a slightly elevated D-dimer. A multidetector computed tomography 4 | Page