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
C. 1:30 pm to 3:30 pm D. 3:30 pm to 5:30 pm 30. Nurse Kate provides teaching to the client about proper insulin administration. Which of the following client statements indicates a need for further teaching? A. “I can store my unused or unopened insulin in the refrigerator” B. “There’s no need for me to aspirate the needle before injecting the insulin” C. “I should aspirate the needle first before injecting the insulin to ensure proper placement to subcutaneous” D. “I can inject my insulin into my abdomen” Situation: Nurse Clara is assigned to care for clients with thyroid disorders in a medical-surgical unit. 31. Dos is diagnosed with hypothyroidism. Which signs/symptoms should Nurse Clara expect the client to exhibit, except? A. Weight gain B. dry, sparse hair C. slow speech D. diarrhea 32. As the nurse, you should anticipate to administer which of the following medications to Dos who is diagnosed to be suffering from hypothyroidism? A. Levothyroxine B. Lidocaine C. Propylthiouracil D. Methimazole 33. The client is diagnosed with hyperthyroidism. Which signs/symptoms should the nurse expect the client to exhibit? 1. bradycardia 2. moist hair 3. heat intolerance 4. constipation 5. hyperlipidemia 6. hypertension A. 1,3,5 B. 2,3,6 C. 1,2,5 D. 4,5,6 34. Which laboratory finding is most indicative of hyperthyroidism? A. Elevated TSH levels B. Low T3 and T4 levels C. Elevated T3 and T4 levels D. Normal T3 and T4 levels 35. Tapazole (Methimazole) is prescribed to a client with hyperthyroidism to inhibit the synthesis of thyroid hormones. Which of the following health teachings should the nurse include? A. “Report sore throat or fever immediately.” B. “You may stop the medication once symptoms improve.” C. “Administer the medication without meals for better absorption” D. “Weight loss indicates effectiveness of the medication” Situation: Shine is a graduating student nurse who aspires to top the boards. As a preparation, she decided to go over her notes on Fundamentals of Nursing and review the most salient concepts. 36. The nurse uses a stethoscope to auscultate a male patient’s chest. Which stamen about stethoscope with a bell and diaphragm is true? A. The bell detects high pitched sound best B. The diaphragm detects high pitched sounds best C. The bell detects thrills best D. The diaphragm detects low pitched sounds best 37. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis? A. 4,500/mm3 B. 7,000/mm3 C. 10,000/mm3 D. 25,000/mm3 38. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping and muscle weakness. These symptoms probably indicate that the patient is experiencing: A. Hypokalemia B. Hyperkalemia C. Anorexia D. Dysphagia 39. Which of the following statements about chest X-ray is false? A. No contradictions 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 40. The nurse wants to test the skin temperature of her client. Which part of the hand is best to be use by the nurse? A. Finger pads B. Ulnar part of the hand C. Dorsal part of the hand D. palm of the hand 41. The four main concepts to nursing that appear in each of the current conceptual models are: A. Person, nursing environment, medicine B. Person, health, nursing, support systems C. Person, health, psychology, nursing D. Person, environment, health, nursing 42. An emergency department nurse prepares to plan care for a child diagnosed with acetaminophen overdose. The nurse reviews the primary health care provider’ s prescriptions and prepares to administer which medication? A. Succimer B. Vitamin K C. Acetylcysteine D. Protamine sulfate 43. What action should the nurse take to assess the pharyngeal reflex on a child? A. Ask the client to swallow . B. Pull down on the lower eyelid. C. Shine a light toward the bridge of the nose. D. Stimulate the back of the throat with a tongue depressor. 44. A low dose of ondansetron is prescribed for a client receiving chemotherapy. The nurse anticipates that the primary health care provider will prescribe the medication by which route? A. Oral B. Intranasal C. Intravenous D. Subcutaneous 45. When performing an admission assessment on a newly admitted patient, the nurse percusses resonance. The nurse knows that resonance heard on percussion is most commonly heard over which organ? A. thigh B. liver C. intestine D. lung 46. A nurse is assigned to perform postmortem care. Upon touching the client's body, she notes that it feels cool to the touch. The physician declared the time of death 2 hours ago. Which postmortem change is the nurse observing? A. Rigor mortis B. Livor mortis C. Algor mortis D. Pallor mortis 47. During a forensic case, the nurse observes purplish discoloration on the dependent areas of a deceased client. What is the most likely stage of mortis present? A. Rigor mortis B. Livor mortis C. Algor mortis D. Pallor mortis 48. A client was pronounced dead at 6:00 AM. At 11:00 AM, the nurse notes that the body is stiff and hard to manipulate during postmortem care. Which stage of mortis is most likely being observed? A. Rigor mortis 3 | 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