Tiêu đề RECALLS 1 - NP3 - SC ✅

RECALLS 1 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: 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 form a blunt injury during a vehicular accident. 1. The admitting nurse understands that in pneumothorax, air accumulates abnormally in the: A. Pulmonary vascular system B. Pleural space C. Lung tissues D. Thoracic cavity 2. 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. 3. The nurse identifies with presence of chest tubes. Which of the following nursing interventions will be the nurse consider as APPROPRIATE? 1. Secure a loop of the drainage tubing to the sheet or groin of the client 2. Encourage DBE and coughing as needed 3. Maintain the collection apparatus below the chest 4. When turning client, ensure chest tube and drainage tubing are not occluded under the client. 5. Clamp the chest tube to practice pleural training A. 1, 2, 3, and 5 only B. 3, 4 only C. 2, 3, 4 only D. ALL OF THE ABOVE 4. The physician ordered, “report drainage that is cloudy and in excess of 70 ml per hour. The nurse knows that a cloudy drainage would indicate: A. Infection B. Presence of debris C. Impending hemorrhage D. Occluded tubing 5. When the nurse checked the water sealed drainage, she observed that the water level does not fluctuate simultaneously with the client’s breathing. The nurse interprets this observation as: A. An abnormal occurrence suggestion problem with the system’s patency B. Normal but may require water to be added to the suction control chamber C. Emergent requiring immediate reporting to the physician D. Expected with the client’s current condition Situation: A woman who underwent hysterectomy 2 days ago is under your care. 6. 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 7. 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 strengthen muscle tone 3. It prevents pooling of blood in the extremities A. 1 & 2 B. 1 & 3 C. 2 & 3 D. 1, 2 & 3 8. 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 9. 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 10. 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 begun to manifest signs and symptoms of Diabetes Insipidus. 11. 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 12. The nurse caring for Mara would expect to find which characteristic assessment findings? 1. Excessive thirst 2. Polyuria 1 | Page
3. Hyperglycemia 4. Glycosuria A. 1 and 3 B. 2 and 3 C. 1 and 2 D. 3 and 4 13. 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 14. 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 15. 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. Siting 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. 16. 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 A. 3, 4, 5, and 6 B. 1, 2, 4, and 6 C. 2, 3, 4, and 6 D. 2, 4, 5, and 6 17. Nurse Jell made an error in documenting an assessment finding on her client’s chart. She must CORRECT the error by: A. Over the wrong entry, write ERROR in red, then write the correct data B. Draw one line over the wrong entry, write the correct data, sign and put the date C. Erase neatly the wrong entry and write on the same place the correct data D. Delete the wrong entry and write the correct data 18. Another nurse -orientee administered an inaccurate dose of Ampicillin to her client. Following the assessment, reporting to the doctor and the head nurse, she accomplishes an incident report. The orientee understand that the report: A. Will form part of her 201 file B. Will result to her suspension from the hospital C. Will be reported to the Regulatory Board of Nursing D. Is a method of promoting quality care and risk management 19. The nurse-orientee was charting while waiting for the result of the cross-matching result of her client. When the fax machine activated, the nurse saw a result of the cross– matching of her client’s name but with another hospital – bed – number. The MOST appropriate action of the nurse would be to: A. Return the result of cross - matching and send another request B. Consider the result as that of her client C. Refer the matter to the head nurse D. Call the laboratory to confirm result of cross – matching 20. The nurse-orientee is to present a case in the meeting with the staff nurses. She Xeroxed the chart of her client to study at home. While she was dressing up to go home, a staff nurse saw the folder of Xeroxed copies of the patient’s record. The staff nurse would call the attention of the nurse-orientee that: A. This is a violation of hospital policy B. The owner of the record should be consulted C. Her action is against the client’s right to privacy D. A prior permission from the Medical Record Section should be obtained Situation: Nurses should demonstrate management skills while on duty to promote safe and quality health care delivery. 21. Nurse Kell was waiting for her turn to use the Comfort room (CR) of the Nurses Station, when a nursing attendant Millie came out drying her face with sterile gauze dressing. Nurse Kell immediately called her attention to: A. Bring their own personal toiletries B. Use hospital supplies like dressings, judiciously C. Conserve water as there is not enough for everyone D. Limit the use of the nurse’s station comfort room for the staff on duty 22. A nurse is preparing to start an intravenous infusion of D5% Lactated Ringer’s solution with 40 mEq Kcl on a postoperative client with an infusion pump. When she attempted to plug the pump cord into the wall socket, the pump did not seem to work. Which of the following is MOST appropriate nursing action? A. Initiate the intravenous line without using the pump B. Use an extension cord from the corridor to plug the pump C. Contact the electrical maintenance for assistance D. Plug the pump cord in the available plug above the room sink 23. A nurse is going to change the soiled beddings of the client with ulcerative colitis. When personal protective equipment (PPE) should be worn by the nurse? A. Gown and gloves B. Gloves C. Goggles and gloves D. Gloves and mask 24. Nurse Kell has four clients. After the endorsement rounds, she plans to do assessment of her four clients. Which client would she attend FIRST? A. Client on oxygen inhalation who bad difficulty of breathing last night B. Client for chest x-ray C. A preoperative client for cardio pulmonary clearance D. The post vagotomy client who is for discharged 25. Nurse Kell observed that during meal hours, there are no orderlies present in the unit. Which nursing management strategy must be done? A. Plan a schedule of meal so that every staff will have a fix time to take lunch for 30 minutes. B. Any orderly who leaves the unit should ask permission from the head nurse C. When the orderly leaves for lunch, she/he should log in and out D. Allow a mid A.M. break of 15 minutes Situation: A 45-year-old female was admitted because of acute pancreatitis. Nurse Delly was assigned to take care of the client. 26. While nurse Delly was making her rounds before endorsement to the next shift, her client asks her which would be a comfortable position to assume. The nurse would recommend the following positions EXCEPT: A. Flexing the left leg B. Leaning forward C. Lying in supine position D. Sitting up 27. There has been an increasing rate of acute pancreatitis in the Philippines. She is aware that the most common cause of acute pancreatitis is? A. Alcohol Use 2 | Page

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 45. 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: 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. Physician’s diagnosis is asthma. 46. Which of the following correctly describes asthma? A. Often irreversible B. Inflammatory disorder of the airways C. Characterized by hypoventilation D. Dyspnea with respiratory rate of 40/minute 47. When the nurse examines the patient’s chest on auscultation, which of the following assessment findings would indicated that the obstruction progresses? A. Productive cough B. Audible wheeze C. Silent chest D. Prominent sweating 48. The nurse administered aminophylline as ordered. Which of the following assessment indicates effectiveness of the drug? A. Thinning of the tenacious purulent sputum B. Normal breath sounds C. Normal body temperature D. Decreasing bronchial secretions 49. 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 50. 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: 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 extent 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 action 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: Anemia in the Philippines is prevalent and needs an intervention. There are different types of anemia and the following questions are about it. 56. The nurse is admitting Cloyd, a 26-year-old male. In gathering his past medical history, he stated that he undergone a gastric bypass surgery for his obesity 3 years ago. The following assessment findings includes height 5’7’’, weight 81kg, P112, R26, BP110/70, pale mucous membranes and dyspnea on exertion. Upon assessment, the nurse suspects that the client is having what type of anemia? A. Folic Acid Deficiency B. Vitamin B12 Deficiency C. Sickle cell anemia D. Iron deficiency Anemia 57. The client with a diagnosis of IDA is prescribe FeSO4 orally. The patient should be educated about: A. Taking laxative for diarrhea B. Exercise being limited until tolerance to the supplement is achieved C. Red meats and organ meats are the only foods that should be consumed to increase the level of iron in the body D. The stools may appear dark green-black which may mask blood 58. The anemia of the patient diagnosed with CHF became so severe that requires the HCP to order two units of PRBCs to transfuse. The unit has 250 mL of RBC plus 45mL of additive. The nurse set the IV pump at what rate to infuse each unit of PRBC? A. 74ml/hr B. 62-63ml/hr C. 147ml/hr D. 125ml/hr 59. You are the charge nurse assigned in the ward. Patients with different types of anemia was admitted. As a charge nurse, you assigned which among the patient to the most experienced nurse? A. client with IDA taking supplements B. client with Vitamin B12 deficiency requiring intramuscular administration C. client with Renal problem with deficiency of erythropoietin D. client with aplastic anemia which developed pancytopenia. 60. The client diagnosed with anemia was discharged. Which among the health education given by the nurse is correct? A. Take the prescribed iron until it is consumed B. Checking the vital signs specially pulse and BP at botika weekly C. Performing exercises at least three times a week D. Have a regular blood workup for CBC at HCP’s office. Situation: Many times clients would ask to be admitted to their room of choice. The hospital is not always ready to give client their preferred room but consider other parameters that would nonetheless enhance safe environment while confined in the hospital. 61. The nursing aide is asked to prepare a room for a child with post-operative fever. The room should be equipped with the following EXCEPT: A. Game board B. Bedside rails C. Air conditioning unit D. Call system 4 | Page