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NUR 101 SCRIPT 2026 FULL CORRECT
ANSWER SET
◉During the nursing rounds Nurse Cathy is instructing the patient to avoid smoking to prevent the worsening of respiratory problems. The patient asked about the things that he can do when feelings of wanting to smoke arises. The nurse enumerates ways of dealing the situation. This is an example of a nurse's role as a/an: A. Advocate B. Clinician C. Change agent D. Caregiver. Answer: C. Change agent As a change agent, the nurse assists the client to MODIFY their BEHAVIOR. As an advocate the nurse intercedes or works on behalf of the client. As a clinician, the nurse would use technical expertise to administer nursing care. The role of a nurse as caregiver helps client promote, restore and maintain dignity, health and wellness by viewing a person holistically. ◉Nurse Cathy on the other hand, knows the case immediately even before a diagnosis is done. Based on Benner's theory she is a/an: A. Novice B. Expert
C. Competent D. Advanced beginner. Answer: B. Expert The ability to perceive something without further evidence is the development of intuition and is seen in Expert nurses. A novice nurse is governed by rules and usually inflexible. Competent nurses are planning nursing care consciously. Advanced beginners demonstrate acceptable performance. ◉Newborn screening is done to every newborn in the Philippines. This is an example of: A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Rehabilitation. Answer: B. Secondary prevention Promotion of early detection and early treatment of the disease is under secondary prevention. Example, breast self exam, TB screening, genetic counseling. ◉One of Nurse Cathy's co-workers is Annie who is flexible in any given situation. Annie is performing her duties well without supervision but still needs more experience and practice to develop a consciously planned nursing care. According to Patricia Benner's category in specialization in nursing, Annie is a/an: A. Novice
◉The nurse in charge measures a patient's temperature at 101 degrees F. What is the equivalent centigrade temperature? A. 36.3 degrees C B. 37.95 degrees C C. 40.03 degrees C D. 38.01 degrees C. Answer: B. 37. To convert °F to °C use this formula, ( °F - 32 ) (0.55). While when converting °C to °F use this formula, ( °C x 1.8) + 32. Note that 0.55 is 5/9 and 1.8 is 9/5. ◉During a change-of-shift report, it would be important for the nurse relinquishing responsibility for care of the patient to communicate. Which of the following facts to the nurse assuming responsibility for care of the patient? A. That the patient verbalized, "My headache is gone." B. That the patient's barium enema performed 3 days ago was negative C. Patient's NGT was removed 2 hours ago D. Patient's family came for a visit this morning.. Answer: C. Patient's NGT was removed 2 hours ago The change-of-shift report should indicate significant recent changes in the patient's condition that the nurse assuming responsibility for care of the patient will need to monitor. The other options are not critical enough to include in the report
◉A client is receiving 115 ml/hr of continuous IVF. The nurse notices that the venipuncture site is red and swollen. Which of the following interventions would the nurse perform first? A. Stop the infusion B. Call the attending physician C. Slow that infusion to 20 ml/hr D. Place a cold towel on the site. Answer: A. Stop the infusion The sign and symptoms indicate extravasation so the IVF should be stopped immediately and put warm not cold towel on the affected site. ◉Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68-year-old woman hospitalized due to Pneumonia? A. Oriented to date, time and place B. Clear breath sounds C. Capillary refill greater than 3 seconds and buccal cyanosis D. Hemoglobin of 13 g/dl. Answer: C. Capillary refill greater than 3 seconds and buccal cyanosis Capillary refill greater than 3 seconds and buccal cyanosis indicate decreased oxygen to the tissues which requires immediate
To be effective, the nursing care plan developed in the planning phase of the nursing process must reflect the individualized needs of the patient. ◉What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection? A. Use sterile gloves when obtaining urine B. Open the drainage bag and pour out the urine C. Disconnect the catheter from the tubing and get urine D. Aspirate urine from the tubing port using a sterile syringe. Answer: D. Aspirate urine from the tubing port using a sterile syringe The nurse should aspirate the urine from the port using a sterile syringe to obtain a urine specimen. Opening a closed drainage system increase the risk of urinary tract infection. ◉Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means: A. Pulse rate greater than 100 beats per minute B. Blood pressure of 140/ C. Respiratory rate greater than 20 breaths per minute
D. Frequent bowel sounds. Answer: C. Respiratory rate greater than 20 breaths per minute A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is considered hypertension. Pulse greater than 100 beats per minute is tachycardia. Frequent bowel sounds refer to hyper-active bowel sounds. ◉Formulating a nursing diagnosis is a joint function of: A. Patient and relatives B. Nurse and patient C. Doctor and family D. Nurse and doctor. Answer: B. Nurse and patient Although diagnosing is basically the nurse's responsibility, input from the patient is essential to formulate the correct nursing diagnosis. ◉The nurse listens to Mrs. Sullen's lungs and notes a hissing sound or musical sound. The nurse documents this as: A. Wheezes B. Rhonchi C. Gurgles D. Vesicular. Answer: A. Wheezes
The patient should be positioned with the head of the bed completely flattened to perform an abdominal examination. If the head of the bed is elevated, the abdominal muscles and organs can be bunched up, altering the findings. ◉Which of the following is inappropriate nursing action when administering NGT feeding? A. Place the feeding 20 inches above the point of insertion of NGT B. Introduce the feeding slowly C. Instill 60ml of water into the NGT after feeding D. Assist the patient in fowler's position. Answer: A. Place the feeding 20 inches above the point of insertion of NGT The height of the feeding is above 12 inches above the point of insertion, bot 20 inches. If the height of feeding is too high, this results to very rapid introduction of feeding. This may trigger nausea and vomiting ◉During application of medication into the ear, which of the following is inappropriate nursing action? A. In an adult, pull the pinna upward B. Instill the medication directly into the tympanic membrane C. Warm the medication at room or body temperature
D. Press the tragus of the ear a few times to assist flow of medication into the ear canal. Answer: B. Instill the medication directly into the tympanic membrane During the application of medication it is inappropriate to instill the medication directly into the tympanic membrane. The right thing to do is instill the medication along the lateral wall of the auditory canal. ◉Kussmaul's breathing is: A. Shallow breaths interrupted by apnea B. Prolonged gasping inspiration followed by a very short, usually inefficient expiration C. Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea D. Increased rate and depth of respiration. Answer: D. Increased rate and depth of respiration Kussmaul breathing is also called as hyperventilation. Seen in metabolic acidosis and renal failure. Option A refers to Biot's breathing. Option B is apneustic breathing and option C is the Cheyne-stokes breathing. ◉The nurse is aware that Bell's palsy affects which cranial nerve? A. 2nd CN (Optic)
B. Regularity of meal times C. 3-day diet recall D. Eating style and habits. Answer: C. 3-day diet recall 3 - day diet recall is an example of dietary history. This is used to indicate the adequacy of food intake of the client. ◉Claire is admitted with a diagnosis of chronic shoulder pain. By definition, the nurse understands that the patient has had pain for more than: A. 3 months B. 6 months C. 9 months D. 1 year. Answer: B. 6 months Chronic pain is usually defined as pain lasting longer than 6 months. ◉It is the gradual decrease of the body's temperature after death: A. Livor mortis B. Rigor mortis C. Algor mortis D. none of the above. Answer: C. Algor mortis
Algor mortis is the decrease of the body's temperature after death. Livor mortis is the discoloration of the skin after death. Rigor mortis is the stiffening of the body that occurs about 2-4 hours after death. ◉Prolonged deficiency of Vitamin B9 leads to: A. Scurvy B. Pellagra C. Megaloblastic anemia D. Pernicious anemia. Answer: C. Megaloblastic Prolonged Vitamin B9 deficiency will lead to megaloblastic anemia while pernicious anemia results in deficiency in Vitamin B12. Prolonged deficiency of Vitamin C leads to scurvy and Pellagra results in deficiency in Vitamin B3. ◉Pia's serum sodium level is 150 mEq/L. Which of the following food items does the nurse instruct Pia to avoid? A. Broccoli B. Sardines C. Cabbage D. Tomatoes. Answer: D. Sardines
◉A skin lesion which is fluid-filled, less than 1 cm in size is called: A. Papule B. Vesicle C. Bulla D. Macule. Answer: B. Vesicle Vesicle is a circumscribed circulation containing serous fluid or blood and less than 1 cm (ex. Blister, chicken pox). ◉S1 is heard best at the: A. 5th left intercostal space along the midclavicular line B. 3rd intercostal space to the left of the midclavicular line C. Second right intercostal space at the sternal border D. Second left intercostal space at the sternal border. Answer: A. 5th left intercostal space along the midclavicular line The S1 heart sound is best heard at the apex of the heart, at the fifth intercostal space along the midclavicular line. (An infant's apex is located at the third or fourth intercostal space just to the left of the midclavicular line)
◉The correct site at which to verify a radial pulse measurement is the: A. Brachial artery B. Apex of the heart C. Temporal artery D. Inguinal site. Answer: B. Apex of the heart The best site for verifying a pulse rate is the apex of the heart, where the heartbeat is measured directly. ◉To promote correct anatomic alignment in a supine patient, the nurse should: A. Place the patient's feet in dorsiflexion B. Place a pillow under the patient's knees C. Hyperextend the patient's neck D. Adduct the patient's shoulder. Answer: A. Place the patient's feet in dorsiflexion Anatomic alignment prevents strain on body parts, maintains balance, and promotes physiologic functioning. To promote this position, the nurse should place the feet in dorsiflexion (at right angles to the legs). ◉Postural drainage to relieve respiratory congestion should take place:
B. Providing a safe environment C. Promoting a positive self-image D. Helping the patient accept the illness. Answer: B. Providing a safe environment A patient with hemiplegia (paralysis of one side of the body) has a high risk of injury because of his altered motor and sensory function, so safety is the nurse's main priority. ◉A sudden redness of the skin is known as: A. Flush B. Cyanosis C. Jaundice D. Pallor. Answer: A. Flush Flush is a sudden redness of the skin. Cyanosis is a slightly bluish, grayish skin discoloration caused by abnormal amounts or reduced hemoglobin in the blood. Jaundice is a yellow discoloration of the skin, mucous membranes and sclera caused by excessive amounts of bilirubin in the blood. Pallor is an unnatural paleness or absence of color in the skin indicating insufficient oxygen and excessive carbon dioxide in the blood.
◉A patient states that he has difficulty sleeping in the hospital because of noise. Which of the following would be an appropriate nursing action? A. Administer a sedative at bedtime, as ordered by the physician B. Ambulate the patient for 5 minutes before he retires C. Give the patient a glass of warm milk before bedtime D. Close the patient's door from 9pm to 7am. Answer: C. Give the patient a glass of warm milk before bedtime Warm milk will relax the patient because it contains tryptophan, a natural sedative. ◉If a patient sues a nurse for malpractice, the patient must be able to prove: A. Error, proximal cause, and lack of concern B. Error, injury and proximal cause C. Injury, error and assault D. Proximal cause, negligence and nurse error. Answer: B. Error, injury and proximal cause Three criteria must be met to establish malpractice: a nursing error, a patient injury, and a connection between the two.
