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1 Situation: The outcome statement includes a When implementing collaborative interventions it
time frame or date to clarify how long it would requires:2 years
realistically take for one to reach the level of DILI 6 MONTHS?
functioning. 6 months lang man ata if arm fracture?

A patient with arm fracture and underwent

surgery to fix it might accomplish a long period to
achieve his range of muscles and joints back.
Which of the following outcomes is applicable?

2 The nurse can delegates activities necessary True?opo

for achieving the client’s health goals.

3 Which of the following best describes the Assess, nursing diagnosis, goals, and
plan of nursing care? interventions?(4)

4 In the Evaluation Process, Nurse will do the To inform

following EXCEPT:

5 Implementation ends when nursing actions t

and client responses have been recorded in
the client’s chart.

6 Situation: Generally, several outcomes are Join nutrition class?????? (2)

written for each diagnosis, especially if there
is a broad scope to the problem. Patient
behavior is very important as this is what
shows in the future if the patient has some
improvement in the problem area.
Nutrition problem with more than body
requirement may be identified anytime with
a patient. Which of the following patient
behaviors can be applicable?

7 Situation: The outcome statement includes 4, to 30 mins?

a time frame or date to clarify how long it
would realistically take for one to reach the
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level of functioning. 5 Minutes?

Severe pain as verbalized by the patient must
be resolved ASAP. Which of the following
outcomes is appropriate?

8 SOAP NOTES allow interdisciplinary True

documentation.

9 The nurse knows the rationale in every Technical

nursing activity he performs. Which of the Intellectual?(2)
following implementation skills was utilized?

10 Priorities constantly change as the patient True?(1)

situation and condition change.

11 A female Patient complains of left lower Interdependent? (3)

quadrant pain. The Nurse refers the pain to
the doctor. The doctor assessed patient and INDEPENDENT interdependent ata kay gi refer sa
prescribes medication for pain in which the doctor (2)
nurse administer to her patient. Which type
of Nursing Intervention does the statements
relates to?

12 Which of the Interpersonal Intervention is Psychosocial? (2)

described when a nurse is having a
conversation with a mother who lost her Di ba parang supportive kasi may use of
baby and encouraging the mother to express communication skills
her feelings, identifying things that makes
her happy and help her identify significant
others that can help her during the process of
grieving?

13 When planning care, which of the Make sure??

following should the nurse use as a Make intervention
guideline?

14 Situation: At least one outcome is written correctly?

for each nursing diagnosis. Outcomes are
written to include specific components such
as patient behavior, criteria of performance,
conditions (if needed), and time frame.
The following are the levels at which the
patient will perform the behavior, EXCEPT:
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15 The nurse helps her patient to cope with

chronic pain. Which step of the nursing Implementation? (1)
process is associated with this nursing
intervention? uu dAKS LAGI KAAYO NI
HAHSHQWHADHAHDHAHDAHSDHASHDAHS

16 Situation: It is important that the nurses T

write correctly the patient outcomes. Critic No criteria, time frame, chuchu?
accordingly.
The patient’s hydration will improve.

17 Which of the following choices is the Plan of Care (2)

foundation of evaluation?

18 A problem that could result in medium

unhealthy consequences like emotional
impairment but not likely to threaten life
is considered as:

19 Nurse listens actively to her patient’s Interpersonal 2

needs and gives clear explanations before
rendering her nursing care. This shows
the nurse’s:

20 Which of the following type of pie

documentation which focuses on nursing
diagnosis for each shift?

21 Exactly 10am the patients Foley Patient’s response

catheter was removed, she needed to void
within 4-6 hours. The nurse on duty
encourage the patient to increase oral
fluid intake, after 4 hours the patient was
still not able to void. The nurse did some
hot and cold compress and let the patient
hear a gush of open running water. After
an hour of nursing intervention the
patient was able to urinate and verbalized
relief of discomfort before the due time.
Which of the following data is a
determinant that the care given is
effective?

22 Situation: Generally, several outcomes Joins a health?

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are written for each diagnosis, especially

if there is a broad scope to the problem.
Patient behavior is very important as this States basic food groups
is what shows in the future if the patient
has some improvement in the problem
area.
With regard to knowledge deficit
diagnosis, which of the following patient
behaviors is acceptable?

23 In the measurement of goal All except include

attainment, the nurse would :
(SELECT ALL THAT APPLY)

24 Nursing interventions can be true

determined and selected prior to the
formulation of outcomes.

25 Situation: The outcome statement Immediately

includes a time frame or date to clarify
how long it would realistically take for
one to reach the level of functioning. 1 week
It may take long for a student nurse to
read a whole nursing book. Which of the
following outcomes is correct?

26 Which Major categories of Nursing Cognitive Interventions

Intervention wherein the nurse develops a
teaching plan?
The Nurse implements her nursing
interventions. A Collaborative interventions are
treatments that require:

27 The Nurse implements her nursing Nurse and client inter?

interventions. A Collaborative Health care team
interventions are treatments that require:
- Collaborative interventions Done
with other health team members (PT,
social worker, dietician, physician)

28 Situation: At least one outcome is

written for each nursing diagnosis.
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Outcomes are written to include specific

components such as patient behavior,
criteria of performance, conditions (if
needed), and time frame.
Which of the following components of
patient outcome can be thought of as
specific aids that will help the patient
perform a behavior at the level specified
in the criteria portion of the outcome
statement?

29 Which of the following best describes Assessment data?

the plan of nursing care?

30 Situation: Sometimes the nurse sets

outcomes with the patient that require the
use or presence of certain environmental
conditions. Conditions are circumstances,
if necessary, under which the behavior
will be performed.
Which among the conditions may be
appropriate for a problem on mobility?

31 Situation: At least one outcome is All can be used?

written for each nursing diagnosis.
Outcomes are written to include specific
components such as patient behavior,
criteria of performance, conditions (if
needed), and time frame.
The time frames stated in the outcomes
may be in:

32 Nursing Interventions Are based in true

clinical judgement

33 A care plan can be revised or modified T

depending on the need and condition of
the client.

34 One of the purposes of outcome True (4444)

identification is to promote patient
participation.
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35 The care plan calls for administration interpersonal

of a medication plus client education on
diet and exercise for high blood pressure.
The nurse finds the blood pressure
extremely elevated. The client is very
anxious with this finding. Which nursing
skill of implementing would be needed
most?

36 The nurse transfer of responsibility for delegation

the performance of the task to another
individual while retaining accountability
for the outcome. This refers to:

37 *Situation: *Sometimes the nurse sets Removal of catheter? (2)

outcomes with the patient that require the
use or presence of certain environmental
conditions. Conditions are circumstances,
if necessary, under which the behavior
will be performed.
For a problem on pain, which of the
conditions is applicable?

38 Situation: It is important that the

nurses write correctly the patient
outcomes. Critic accordingly.
The nurse will reduce the patient’s
anxiety.

39 The nurse teaches her patient with Implementation? (1)

cancer on how to cope with pain. Which
of the following steps of the nursing
process is associated with this nursing
intervention?

40 Situation: The outcome statement 6 hours

includes a time frame or date to clarify
how long it would realistically take for
one to reach the level of functioning.
An intermediate outcome is identified for
a patient after an abdominal surgery, such
as reestablishment of urinary elimination.
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With the student nurse’s knowledge on

anatomy and physiology, which of the
following specific outcomes can be
appropriate?

41 Priorities constantly change as the true

patient situation and condition change.

42 A 28 year- old female who is 1 day post Dependent

operation of Appendectomy. Upon
assessing, the patient complains of pain
with scale level of 8 out 10 with grimacing
face and clutching abdomen. The Nurse
refers the pain to the doctor and provide
the patient a pain reliever following the
Doctor’s prescribed medicine. Which type
of Nursing Intervention it belongs?

43 The patient was placed in the recovery SURVEILLANCE

room for closed monitoring. The nurse
check the vital signs and some abnormal
responses. Which of the following
interventions does the nurse would
perform?

44 Situation: Now that the nurse has patient?

collected data about the patient, analyzed
the data, and formulated some nursing
diagnoses, the outcome identification
phase of the nursing process begins.
The subject of patient outcome is which of
the following?

45 Situation: Now that the nurse has All? (2)

collected data about the patient, analyzed
the data, and formulated some nursing
diagnoses, the outcome identification
phase of the nursing process begins.
Which of the following best describes a
patient outcome?

46 *Situation: *Sometimes the nurse sets Without abdominal?

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outcomes with the patient that require the use

or presence of certain environmental
conditions. Conditions are circumstances, if
necessary, under which the behavior will be
performed.

For a problem on airway clearance, which of

the following conditions can be used?

47 What is the main purpose of the To describe the behavior?

expected outcome?

48 When implementing collaborative Physician and nurse -Health care team ata
interventions it requires:

49 The nurse performs catheterization. Maintenance?

Which of the following technical Psychomotor dito
interventions did she demonstrate?

50 Situation: It is important that the Correct

nurses write correctly the patient
outcomes. Critic accordingly.
The patient will talk about her labor in
sequence while reminiscing her
experience within 24 hours after delivery.

51 This is a system that can be used to Nursing outcome classification (2)

select outcome measure related to NURSING INTERVENTION?
nursing diagnosis.

52 A written care plan must be followed true

up by the nurse at all times.

53 Patient medical record is a confidential f

health related document that should not be
used for educational and research purposes.

54 Situation: At least one outcome is All can be used?

written for each nursing diagnosis.
Outcomes are written to include specific While on O2
components such as patient behavior,
criteria of performance, conditions (if
needed), and time frame.
The following are patient behaviors,
EXCEPT:
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55 A written plan of care is developed to planning

direct nursing care activities

56 Patient A is anxious of his upcoming Supportive (?)

surgery. The nurse showed a caring
behavior by staying with patient for a
while. Which nursing intervention
describes the statement?

57 In writing a nursing care plan. The All except outcome criteria

nurse must consider the following: Select
all that apply.

58 Multidisciplinary clinical plan of care t

promote better communication among all
members of the health team.

59 A plan of care that generated from computerized

assessment data entered a computer
about a specific patient

60 Which of the following would the nurse ALL

perform during the implementation
phase? Select all the applies

61 Which of the following is TRUE with Promote and direct? Dili apil and determine?
planning phase? Select all that apply.

62 Situation: Generally, several outcomes Will void? (1)

are written for each diagnosis, especially
if there is a broad scope to the problem.
Patient behavior is very important as this
is what shows in the future if the patient
has some improvement in the problem
area.
For an elimination problem, which of the
following behaviors of patients can be
correct?

63 After the Nurse initial rounds and Fever, is diaphoretic? (1)

assessment of her patients, which patient
would the nurse need to develop a care
plan first?
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64 Each intervention should be supported true

by a rationale that is based from the
nurse's experience.

65 The instructional plan of care used in true

practice is different from the required
clinical plan of care done by the students.
The nursing process is used, but the plan
is organized in a practical, concise format

66 In the process of evaluation, the nurse Review patient’s goals

would observe the patient’s behavior and
documents patient’s responses. Which of
the following activities does the nurse
performs?

67 Situation: Now that the nurse has criteria?

collected data about the patient, analyzed
the data, and formulated some nursing
diagnoses, the outcome identification
phase of the nursing process begins.
This is the level at which the patient will
perform the behavior.

68 Situation: The outcome statement

includes a time frame or date to clarify
how long it would realistically take for
one to reach the level of functioning.
A patient has high grade fever of 39
degrees centigrade, which of the following
outcomes can be applicable to this
patient?

69 Situation: Generally, several outcomes Attend physiotherapy?

are written for each diagnosis, especially Will ambulate man ata kasi maka walk na??
if there is a broad scope to the problem. (3)
Patient behavior is very important as this
is what shows in the future if the patient
has some improvement in the problem
Identify
area.
In regards to mobility problem, which of
the following patient behaviors may be
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appropriate?

70 The nurse oversees the overall care of supervisory

patient within her shift. Which of the
following interventions does she
demonstrate?

71 During evaluation process the nurse Implementation

determines the client’s health by using a Hindi planning? (1)
predetermined criteria identified in
the:AS

72 Which of the following types of Narrative?

progress notes that entries can be based
on the significant events, growth and FDAR? yes
learning of the patient?

73 In which phase of the nursing process planning

does the nurse delegates the planned
interventions for her client?

74 The student nurse has identified more readiness?

than three health problems. Which of the
following is considered as low priority?

75 Situation: At least one outcome is

written for each nursing diagnosis. Accurately and safely ata
Outcomes are written to include specific
components such as patient behavior,
criteria of performance, conditions (if
needed), and time frame.
Which of the following is considered a
condition as a component of a patient
outcome?

76 *Situation: *Sometimes the nurse sets Laxative

outcomes with the patient that require the
use or presence of certain environmental
conditions. Conditions are circumstances,
if necessary, under which the behavior
will be performed.
Which of the conditions is necessary for a
problem on constipation?
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77 Nurse 1 observed that her patient High priority

shows difficulty of breathing in relation
with Ineffective airways. This is
considered to be a:

78 Situation: Generally, several outcomes Will drink

are written for each diagnosis, especially
if there is a broad scope to the problem.
Patient behavior is very important as this
is what shows in the future if the patient
has some improvement in the problem
area.
For a problem with dehydration, which of
the following patient behaviors may be
appropriate?

79 It serves as evaluation criteria. Plan of care

80 Which major category of Nursing surveillance (4) kay checking of VS man

Intervention is described when a nurse Hindi psychomotor?(1)
during her 12nn rounds took the patients
vital signs with a BP: 80/50 mmHg HR:
65 bpm PR:64 bpm RR: 14cpm T:36.0c,
immediately placed the patient in a
Trendelenburg position and rechecked
the vital signs after 15 minutes because
she noticed significant changes from the
normal baseline data.

81 What is the main purpose of the

expected outcome?

82 Situation: It is important that the nurses This is a nursing action instead of patient
write correctly the patient outcomes. Critic behavior?
accordingly.
**
Teach the patient AROM (active range of
motion) exercises.**

83 Situation: Now that the nurse has Pt behavior

collected data about the patient, analyzed
the data, and formulated some nursing
diagnoses, the outcome identification
phase of the nursing process begins.
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This is an observable activity the patient

will demonstrate at some time in the
future showing improvement in the
problem area.

84 To prevent bedsores, the nurse promotes Technical? (1)

proper positioning. This indicates:

85 It is a continuous process carried out Planning? Intervention?

during all phases of the nursing process? Assessment ata (2)

86 A male patient feels depressed due to Supportive

sudden loss of a family member. The
nurse plan of care is to help the patient
resolve his emotional problem. The
statement relates to:

87 The nurse assists during the daily routine Maintenance (?) TAMA PO
of basic hygiene of her patients to promote
wellness and prevent complications. Which of
the following type of interventions does the
nurse demonstrated?

88 Which of the following entries are Lahat except ivf? (1)

included in the Kardex?
(Select all that apply)

89 Situation: It is important that the korique?p

nurses write correctly the patient
outcomes. Critic accordingly.
The decubitus ulcer (bed sore) of the
patient will be healed totally using a
vacuum pack in a period of two weeks.

90 During busy shift, Nurse L is carrying Person, circumstance, task, communication,

out a doctor’s order of sending patient evaluation
down to the ultrasound department for a
STAT ultrasound of whole abdomen. She
needed to delegate the task to others.
What areIneffe the principles of
delegation that she needs to know?
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91 Nurse V always checks the survey

identification band of the patient before
doing nursing procedures. In which of the
following types of evaluation does this
statement relates to?

92 Which of following questions relates to

the specific component of criteria
outcome that may not be present in all
outcome statements?

93 Situation: Now that the nurse has criteria

collected data about the patient, analyzed
the data, and formulated some nursing
diagnoses, the outcome identification
phase of the nursing process begins.
Which of the following components of an
outcome statement is considered as the
circumstances, if necessary, under which
the behavior will be performed?

94 Nursing Diagnosis: Ineffective Airway Instruct in breathing, monitor

Clearance related to viscous secretions.
Select the following appropriate Nursing
Interventions applicable to the Nursing
Diagnosis?
SELECT ALL THAT APPLY.

95 *Situation: *Sometimes the nurse sets

outcomes with the patient that require the
use or presence of certain environmental
conditions. Conditions are circumstances,
if necessary, under which the behavior
will be performed.
The following are conditions for a
problem on pain, EXCEPT:

96 Which of the following is NOT Kardex? (2)

INCLUDED in the patient medical
record?

97 Nurse administers the medication technical

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through intravenous Injections. This is an

example of:

98 In writing a patient plan of care, it false

must not reflect the standard of care
established by the institution and
profession.

99 When planning care, which of the Make interventions?

following should the nurse use as a
guideline?

100 Which of the following types of care plan standardized

is written by group of nurses for a patient
population with specific medical diagnosis?