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0% found this document useful (0 votes)
2K views7 pagesNP1 Np5
Uploaded by
AhrisJeannine EscuadroCopyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
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/ 7
TOPZRANK
+ NLE * NCLEX * CGFNS
REVIEW ACADEMY
AAD“ PROMETRICS * DHA “ MIDWIFERY * LET“ RAD TECH™ €RIMINOLOGY * DENTISTRY *
RECALLS 4 EXAM
NURSING PRACTICE 2
‘November 2022 Philippine Nurse Licensure Examination Review
DATE: SCORE:
INSTRUCTIONS. ole ne corectaroner brie blown questions Shaw ero tie croc saver Be canesponang questonn he xovon answer See
NAME:
STRICTLY NO ERASURES ALLOWED.
Situation: Patient Emily, 19 years old, is in het first
trimester of pregnancy. Because it isher first
pregnancy, she went for her prenatal check-up with
her mother. She asked a lot of questions which she
expects the nurse to answer het
1. The nurse asked for the personal data of the patient which,
to some, Patient Emily did not lke to answer. And so she
asked: “Why do you need to know if | am married?* what
should be a good response of the nurse? "I asted your marital
status because
‘A. Ifyou donot have a husband, then that can pose a!
big problem for you.”
BB. If you are married then your husband wil also suffer
from discomforts tke you.”
C. You need your husband to accompany you every
prenatal check-up.”
. Your husband is your best support system during your
pregnancy.”
2. The patient asked what isthe term for signs such as breast
changes, urinary frequency, fatique, morning sickness and
amenorthea?
‘A. Probable signs
Presumptive signs
Possible signs
D. Positive signs
3. The patient asked what causes newborn babies with total
absence of extremties. Thenurse answered that the cause for
|Ameta is intake of which ofthe following medications during
pregnancy
Kkatiemeties
B. Antibiotics
analgesics
Dianti-bacterals
4. The patient complained that every moffigyshe becomes
nauseated and oftentimes, she would vomit excessively. "What
could be the cause of this,” she asked? The nurse's answer is:
“Its due to increase level © 7
‘Aeart burn
B.ACG
C.heart rate
DiProgesterone
5. The nurse advised patient Patient Emily to report to er
physician which of the following MOST importent sion, fever
she wil suffer from it?
‘A.Cough
B.Vagiral bleeding
CHeadache
D. strong fetal movernent
Situation: As a newly-hired staff nurse of the hospital, Dani
learned that the hospitals have an in-service training for its
Staff. The in-service trainings conducted are based on hospital
and staff's needs. One of the identified needs was on
knowledge deficit of Mother and Baby Friendly Hospital
Initiative (MBFHI).
6. What is the FIRST step among the ten steps for successful
breastfeeding?
-A.Have a written breastfeeding policy that is
routinely communicated to al staff.
B.Inform all pregnant woren about the
benelits and management of breastfeeding,
Foster the establichment of breastfeeding
support groups.
D.Train at heeith care staf in sklls necessary
to implement the policy
7. When practicing reoming-in, how long should the taby stay
with the mother? hours.
AB
B24
C12,
D.10
8, What is the CORRECT time for which the mother should
intiate breastfeeding? It should be hours after bith.
Ae
9, Dani learned that newborn infants should ONLY be given,
hich ofthe following?
Art juice
B.Breastmilk
CC. water
D.D. cow's milk
10. Which is the LAST patt ofthe intiativey a5 recommended
by WHO and UNICEF, for the MBEHI external team to do
before its final desigration as MBFHI Hospital?
“AcAssess business facies i they follow the 10
steps for successful breastfeeding.
B. Develop a research on the benefits of
breastfeeding within the institution,
C. Disseminate the benefits of breastfeeding to
communities.
DéFolow up mothers if they are exclusively
breastfeeding.
Situation: Patient Natalie, 15 years old, GOP1, AOG 39
‘weeks, has been admitted at 6:30 in the morning for
lumbo-sacral pains and strong uterine contractions
‘every 10 minutes. Nurse Gracie was there to admit her.
‘She uses Focus, Data, Action’and Response (FDAR) as,
tthe form of charting:
LLcimaity type of charting or documentation, vhich of the
folowing should the nurse refer to and use to generate
and describe the status of patient Fe? Nursing
A.Assessment
B.Process
CC. actions
D.D. diagnosis
12, Which of the following are the purposes of documentation?
To .
T.__ Ensure the development of organized
Comprehensive care plan
IL Have a cleer and accurate record of what was
done to the patient. TIL Have an evidence of the health care member's
accountability in giving care
IV. _ Detect patients who are clinically deteriorating
‘Al, I IV
8.1, 0, 1,V
Cc. 1 uy, ut
D.D. 1, HL, IV
13, Which ofthe following is the CORRECT definition of focus
charting?
‘A.It is an electronically form of documentation
of nursing care done to a patient by a
redistered nurse.
B.Iis @ note, witen or electronically
generated, to provide documentation related to
a specific focus.
C.ltie a nurse-centorod way of dé€umentation
that describes the patient status and nursing
care rendered.
D.ltis nurse-centered approach to
documentation.
14, In the given stuation, which is the FOCUS?
‘A Patient Netalie as the admitting nurse
B.Lumbo-sacral pains and strong uterine
contractions:
C.15 Yeats old, GOPI, AOG of 36 weeks
Admission at 6:30 in the morning
15, What is the term used to describe the patient's data or
assesment, the action done hasad on the assessment and
response based on the action made:
‘A Progress Note
B.Flow sheets
C.Standard of Care
Focus Format
Situation: This is the first postoperative day for patient
Shicla who delivered by caesarean section (CS). Nurse
Gemma a newly hired staff was assigned to her.
16. Patient Shiela asks the nurse why she has to get up and
walk the day after surgery. Which of the following is the
BEST response of the nurse? Waking hastens
‘A.Hastens lactation
B.Relieves pain
Heals wounds
D.Fast recovery from anesthesia
17. Which laboratory finding should the nurse assess on the
patient 24 hours after caesarian section delivery upon
doctor's request?
‘A Trace 1+ proteinuria
B. Hematocrit 35%6
.White blood cell count 20,000/eumf
D.Hemaglobin 7.0 g/¢l.
18. Patient Shiela complains of "afterpains”. What should be
the nurse IMMEDIATE action?
‘A.Advis2 her to stop breast-feeding for 2 day
B.Encourage her to drink more water
Assess vital signs and pain level
D.Administer an analgesic STAT
19, Patient Shiela is to be discharge 3 days after CS delivery
Which of the following observations of the nlirse would
cause the delay of her discharge and would warrant
notification to the physician?
‘A. Moderate amount of lochia rubra
8. Fundus is firm at umbilicus
C. Pulse rate of 61 beats/minute taken in 24%hours
D. Five voidings totaling 240 ecin 12 hours
20. On the third postpartum day, Patient Shiela reports that
she has voided five times that morning. What should the’
nurse INITIALLY do?
‘A. Insert a Foley catheter
B. Collect the next voiding and measure the urine
amount
C. Catheterize the client to check for residual urine
D. Call the physidan
Situation: Alexis is 23 years old. She and her boyfriend,
Patrick, are planning to get married in a couple of
months. Thereafter, they plan to have three babies. For
this reason they sought reproductive health counseling
for their benefit and the proper growth and
development of their future children. Nurse Susane
was there to help them.
BHMlexis asks vinat she must do in order to be healthy in case
‘she Becomes pregnant. Which among the answers of Nurse
‘Susane should NOT be folowed by Heather?
‘A. Get support from husband. and family.
B. May have'a massage from a lay midwife.
(GpsTo readily accept her preanancy.
D. Extlyiprenatal check-up
22. Patrick asks what possible contribution he could give for
the normal development of the baby. Nurse Susene agreed
that his BEST contribution would be the following EXCEPT
TA Stroke Heather's abdomen and talk to baby
‘A. Provide Heather nutrtious food and drinks
8 Join wife during prenatal check-up
C_ May smoke once in a while
23. For the normal developmental ofthe fetus, Nurse Susane
taught the couple that Heather should prevent Folic Acid
Deficiency anemia by good diet, correct way of cooking
vegetables and taking Folc Acd supplements. Which of the
following is NOT included among the outcomes of folic acid
deficiency to the baby?
A. Cleft lip
B. Cleft palate
C. Neural tube defect
D. Fractures of all types
24. Alexs asks the nurse what possible diseases should she
avoid that would guarantee health for the baby? These are:
‘L. Rubella 2. Rheumaticfever 3. Anemia
“4: (Chronic hypertension
A 423
Bo 4,2,3,4
C124
D234
25. Nurse Susane adised the couple that the BEST way to
check the condition of the mother and the baby isto have
7A, Regular welt-selected exercise
B. Regular prenatal check-up
© Misic therapy
'D. Good food
Situation: A hospitalized adolescent Jordi suddenly has
‘a seizure while his family is visiting. Nurse Nisha notes
whole body rigidity followed by general jerking
‘movements. Jordi vomits Immediately after seizure.
26. Whi¢h ofthe following would be the PRIORITY nursing
diagnosis for Jordi?
‘A. Fhid volume deficit related to vomiting
Altered famly processes related to chronic hess
C_High Fisk for infection related to vomiting.
IDifRisk for aspration retated to loss of consciousness.
27. Which of the following would be the LEAST PRIORITY
fussing care for a chid wth selaure disorder?
K Observation and recording all seizures.
Ensuring safety and protection from injury.
C. Teaching the family ebout anticonvulsant drug
therapy: indication, dosage, route and effects.
1D, Assessing for signs"and symptoms of Increased
Trtracranial Pressure.
28. Jord. wil be taking phenytoin (Dilantin) regularly for
> shot with nex pen
54. Considering Kendra's condition, Nurse Linlin will anticipate
hat effect to the fetus? The condition wil be. ‘i
'. Small for gestational age
b. Macrosomic
Intrauterine growth reterdation (IUGR)
4. Meningomyelocele
55. On the first postpartum day, which of the following
requirements for insulin will be anticipated by the nurse to be
ordered by the physician?
2, Remain unchanged
b. Decrease sharply and suddenly
c. Increase rapidly
4. Decrease slowly and steady
Situation: Nurse Stella is newly assigned in the
Pediatric Ward in Grandline Medical Center. Since he
will be taking care of pediatric patients, there is a need
for Nurse Stella to be abreast with the legal aspects of
pediatric nursing care.
56. Which ofthe following regulates the practice of the nursing
profession?
a. Department of Health
b. Professional Regulation Commission
Civil Service Commission
d._ Professional Regulation Board of Nursing
57. One of the Stella's patients to undergo invasive procedure.
BeSedion the Patients Bill of Rights, sequence the persons
from whom Nurse tela could obtain consent?
1. Parents
2. Legal guardian
2 Next of kin
4 Physician
o>
2,
4,
12, 3
do 13,284
SalBased cn the Right to Privacy and Confidentiality under the
Patients Bill of Rights, the patient hae the right to demand the
following, but NOT pettainig to hiscareas
confident
‘Information. «. Records
b. Communication d. financial Status
59. The Right to Information coes not include
‘2. Any change in the plan of care before the
‘changes made
Extent to which payméhitmaybe expect from
Phineaith |
c Discount for the professional fee of the
attending dctor(s)
Result of the evaluation of the nature and
extent of his/her disease
60. A patient has the right to lave the hospital regardless of
his physical condition provided s/he is informed of which of the
folowing? Select al that epply.
‘Le Isiinformed of the medical consequences of
his! her decsion.
2. Releases those involved in his/her care from
any obligation relative to the consequences
Of his decision.
3. Hisfher decision will rot prejudice public
health and safety
4. Appropriate arrangement has been made to
settle the unpaid bil
a AL 82 e384
be B1,2,84 .1,2,3,84
b
e
ee
a3
a3
a
Situation: Mrs. Pamela, gravida 3 para 3003, is
admitted to the postpartal unit after an uncomplicated
labor and vaginal delivery. She opted to breastfeed her
baby. Nurse Jolly is around to take care of her.
61. The first. day/after delivery, Mrs, Pamela tells the nursethat
his wiféhas been talking constantly abcut her recent delivery
‘experience. He asks F this ic a sign of postpartal blues. What
should be the BEST response of the nurse?
“De you fee! uncomfortable about her talking
‘on her delivery experience?”
b. Yes, ItS clear sion of post-partum blues.
‘She may need a psychiatric evalution.”
“This isa normal reaction. It allows her to
accept the reality of the bith ef your baby.”
di No, you should divert her attention away
from her detvery.”
162. Later that day, Mrs. Pamela tell NUSe Jolly that she has
Utiated four times within the last hour but only in small
amounts. What should be the INITIAL ACTION of the nurse?
’@)_ Explain that this is normal during the first 24
hours ater delivery.
b. Palpate Mrs.Yetty’s fundus to assess uterine
consistency and locaton,
& Catheterize Mrs.Yetty immediately to expel
any retained urine.
4. Begin measuring and recording and
recording Mrs.Yetty's intake and output.
63. Which assessment finding is MOST indicative that Mrs.
Pamela is developing puerperal infection?
‘a. Increased pulse rate
b. Foul- smelling lochia
Elevated body temperature
4. Avhite blood call count of 25,000/meg
4 | Poge 64. Mrs. Pamela asks Nurse Jolly when her menstrual period
will return, The nurse answers that a breastfeeding patient
typically resumes menstruating in about .
2, Gto 12 weeks 6.4 to6
months
, 3t0.6 months 4.4106
weeks
65. Mrs. Pamela complains of pain due to breast engorgement.
What will the nurse do to encourage her ta continue
breastfeeding?
’@. Let her continue breastfeeding/ ii schedule
b. Put hot compress over the breast for 15
minutes before breastfeeding.
©. Put cold compress over the breas: for 15
minutes before breastfeeding.
Let her continue breastfeeding on demand.
‘Situation: Nurses Bonnie and Clyde are assigned in
high risk maternity ward. Here are some cases which
they handle for the morning shift.
66, Mrs. Minchin, 38 weeks generation is admitted at the High
Risk Ward. She was admitted due to labor pains with cervix of
6 cm. BP was 160/110mmHg, She is given MgS04 per IV. How
wil Nurse Bonnie determine that the MgSoa therapy nas been
effective?
a. Labor pains decreased.
Bb. There is conus of the ankle.
©. BP ismaintained.
d._ Seizures are prevented.
67. What would Nurse Clyde monitor to suspect MgSo toxicity
on Mes. Minchin?
2. Tingling in the toes
. Rapid pulse rate and hyperventilation.
©. Decreased deep tendon reflexes.
4. Hypertension
688, I" Mrs. Minchin Begns to exhibit signs of labor after
ediamptic seizure, what will Nurse Clyde anticipate to occur?
2. Severe infection.
b. Abrupto placenta
© Uterine atony.
d. Placenta accrete.
69, Nurse Bonne is assisting an obstetrician in the care of a
pregnant worran in labor with herpes simplex viral nfection.
The nurse would anticipate which management of the
condtion?
2. Administration of anti-viral drug,
. Vaginal douche.
©. Hot stz bath TID.
4. Preperation for Cesarian sétion.
70, One of the patients of Bonnie fas been exhibiting signs
and symptoms of Rheumatic Heart Disease (RHD). These are
the following, EXCEPT:
Fever <
Petechia
‘Abnormal pulse myth Heart
murmurs
Situation: Nurse Jackle is collecting data from a newly
admitted patient, Mrs. Fonda, who is pregnant with
twins. She has a healthy 3-year-old child who was
delivered at 38 weeks. She also revealed that she does
not have a history of abortion nor fetal demise. Her last
‘menstrual period began February 7, 2017 and ended
February 12, 2017.
71, Whats the GTPAL for Mrs. Fonda?
1,7
>>>
o
0
0
=0,
b.
©
4
72, Whats the expected change in the hematologic system
that occurs during the END of the first trimester of pregnancy
that Nurse Jackie should recognize?
a. An increase in hematocit
b. A decrease in WBCs
An increase in blood volume
4. A decrease in sedimentation rate
73, Mrs. Fonda asks about the functions of placenta. Which of
the following items should Nurse Jackie include inthe teaching
plan?
1. The placenta fiters the fetal urine.
2. Fetal and maternal blood mix in the placenta
to exchange nutrients.
3. "Theplecenta fies the alcohol from the
ether’ blood.
4. Substances are exchanged by the placenta
without mixing the maternal and fetal blood.
Se Fetal resprction, nutron and excretion are
‘carried out by the placenta,
a 12,3
b 45
«345
61,2
74, Mrs. Fonda asks *When will be my expected date of