Situation I -- Nurse a is assigned in the emergency unit meeting. Varied opportunities that developed her nursing skills.

1. A 17-year old is admitted following an automobile accident He is very anxious, dyspneic, and in severe pain. The left chest wall moves
in during inspiration and balloons out when he exhales. The nurse understands these symptoms are most suggestive of:

a. Hemothorax
b. Flail chest
c. Atelectasis
d. Pleural effusion

2. A young man is admitted with a flail chest following a car accident. He is intubated with an endotracheal tube and is placed on a
mechanical ventilator (control mode, positive pressure). Which physical finding alerts the nurse to an additional problem in respiratory
function?

a. Dullness to percussion in the third to 5th intercostals space, midclavicular line

b. Decreased paradoxical motion
c. Louder breath sounds on the right chest
d. pH of 7.36 In arterial blood gases

3. The nurse is caring for a client who has just had a chest tube attached to a water seal drainage system (Pleur-evac). To ensure that the
system functions effectively the nurse should:

a. Observe for intermittent bubbling in the water seal chamber

b. Flush the test tube with 30 to 60 ml of NSS 4 to 6 hours
c. Maintain the client in an extreme lateral position
d. Strip the chest tubes in the direction of the client

4. The nurse enter the room of a client who has a chest tube attached to a water seal drainage system and notices the chest tube is
dislodge from the chest. The most appropriate nursing intervention is to:

a. Notify the physician

b. Insert a new chest tube
c. Cover the insertion site with new petroleum gauze
d. Instruct the client to breath deeply until the help arrives

5. A 71-year old is admitted to the hospital with congestive heart failure. She has shortness of breath and a +3 - 4 peripheral edema. The
care plan to reduce the client's edema should include nursing strategies for:

a. Establishing limits on activity

b. Fostering a relaxed environment
c. Identifying goals for self care
d. Restricting IV fluids

Situation 2 - Oxygen is the most vital physiologic need for survival.

6. Mr. Sison, 65 years old has been smoking since he was 11 years old. He has long history of emphysema. Mr. Sison is admitted to the
hospital because of a respiratory infection, which has not improved with outpatient therapy. Which finding would the nurse expect to
observe during Mr. Sison's nursing assessment?

a. Electrocardiogram changes
b. Increased anterior-posterior chest diameter
c. Slow labored respiratory pattern
d. Weight-Height relationship indicating obesity

7. Mr. Sison is ordered oxygen via nasal prongs. The nurse administering the oxygen via the low-flow system recognizes that this method
of delivery:

a. Mixes room air with oxygen

b. Delivers a precise concentration of oxygen
c. Requires humidity during delivery
d. Is less traumatic to the respirator tract

8. Which statement by Mr. Sison indicates that client teaching regarding oxygen therapy has been effective?

a. "I was feeling fine so I removed my nasal prongs."

b. "I've increased my fluids to six glasses of water daily."
c. "Don’t forget to come back quickly when you get me out of the bed; I don't want to be without my oxygen for too long."
d. "My family was angry when I told them they could not smoke in my room."

9. Supplemental low-flow oxygen therapy is prescribed for a man with emphysema. Which is the most essential for the nurse to initiate?
a. Anticipate the need for humidification
b. Notify the physician that this order is contraindicated
c. Place client in high Fowler's position
d. Schedule nursing care to allow frequent observations of the client

Situation 3 - Mr. Silverio, 56 years old, has had significant problem with alcohol abuse for the past 15 years. His wife brings him to the
emergency department because he is increasingly confused and is coughing blood. His medical diagnosis is cirrhosis of the liver. He has ascites
and esophageal varices.

10. Assessment of Mr. Silverio would reveal all of the following, except:

a. Bulging flanks
b. Protruding umbilicus
c. Abdominal distension
d. Bluish discoloration of the umbilicus

11. Which laboratory value would the nurse expect to find in a client as a result of liver failure?

a. Decreased serum creatinine

b. Decreased sodium
c. Increased ammonia
d. Restricted sodium

12. The major dietary treatment for ascites calls for:

a. High protein
b. Increased potassium
c. Restricted fluids
d. Restricted sodium

13. A Sengstaken-BIakemore tube is inserted in an effort to stop the bleeding. Base on this information, the first action the nurse should
take is to:

a. Deflate the esophageal balloon

b. Encourage him to take the deep breath
c. Monitor his vital signs
d. Notify the physician

14. Because the detoxification of alcohol damages tissues a high-calorie diet, fortified with vitamins should be encouraged to protect Mr.
Silverio's:

a. Liver
b. Kidneys
c. Adrenals
d. Pancreas

Situation 4 - Rape is one of the most tragic things that could happen to anyone especially with young girls. Incidence such as these could develop
into a crisis situation involving not only the rape victims but also their families.

15. This type of crisis could be an example of which of the following?

a. Combination of developmental and situational

b. Situational
c. Emotional
d. Developmental

16. Noemi, a staff nurse in the emergency room, realizes that she has an important role to play as a patient advocate to rape victims. To
demonstrate this role, she takes note of one of the responsibilities?

a. Since this is a legal case, call the press about the incidence of rape
b. Perform thorough physical assessment and documenting objectively all the evidences of rape
c. Ask the patient to stay in one isolated room first to provide privacy while attending to other patients
d. Provide emotional support first and postponed physical assessment when patient is already calm

17. Which of the following is a form of active, focused, emotional environmental first aid for patients in crisis?

a. Attitude therapy
b. Psychotherapy
c. Crisis intervention
d. Re-motivation technique

18. Which of the following is true with regards to crisis?

a. Crisis is self-limiting
b. After crisis, the individual always return to a pre-crisis state or condition
c. Crisis always result in adaptive behavior
d. The person in crisis is not susceptible for any help

19. If help is not provided in a crisis situation, an individual may spontaneously resolve in negatively or positively by returning to pre-
crisis state, usually within which of the following duration?

a. 2-3 weeks
b. 3-4 weeks
c. 1-2 weeks
d. 4-6 weeks

Situation 6 - One Important fact that will guide the nurse in the practice of the profession is her knowledge of the nursing law.

20. The nurse practice Act of 1991 regulates the practice of nursing in the Philippines. Which of the following statements about this Act is
true?

a. This Act delineates the practice of nursing and midwifery

b. It was enacted in November 1991
c. The primary purpose is to protect the public
d. The Act defines the practice of nursing in the Philippines

21. When a nurse starts working In a hospital but without a written contract, which of the following is expected of her?

a. She's not bound to perform according to the standards of nursing practice

b. Provides nursing care within the acceptable standards of nursing practice
c. She's not obligated to provide professional service
d. The employer does not hold the nurse responsible for her action

22. A patient, G8P5, refused to be injected with the 3rd dose of Depoprovera. The
nurse insisted inspite of the patients refusal and forcibly injected the contraceptive. She can be sued for which of the following?

a. Misrepresentation
b. Assault and Battery
c. Malpractice
d. Negligence

23.A patient has been in the ICU for 2 weeks. The relatives have consented to a "Do not resuscitate order," When the patient develops a
cardiac arrest, the nurse will carry out which of the following actions?

a. Only medication will be given

b. All ordinary measure will be stopped
c. Basic and advance life support will not be given
d. Mechanical ventilation and NGT will be stopped

24. When a patient falls from bed, which of the following is your immediate action?

a. Report to the head nurse and calls someone to help

b. Determine any injury or harm
c. Refer to the resident on duty
d. Put back patient to bed

Situation 7 - Ms. May Mansur encountered vehicular accident on her way to the office and he remains conscious. Police officers brought her to
the hospital.

25. You have to observe for increase intracranial pressure. Which of the following is not a sign of increased intracranial pressure?

a. Headache
b. Vomiting
c. Vertigo
d. Changes on the level of consciousness

26. Which of the following drug may be given to reduce increase intracranial pressure?

a. Scopalamine
b. Lanoxin
c. Coumadin
d. Mannitol

27. Since she medicated to reduce increased intracranial pressure. What nursing measure must be done to prevent further complication?

a. Encourage her to observe bed rest

b. Check blood pressure every shift
c. Observe complete best rest
d. Measure intake and output

28. In what manner would you be able to assess accurately her motor strength?

a. Observe how he talks

b. Instruct her to squeeze her hands
c. Allowing him to stand alone
d. Pricking her skin with pin

29.Which of the following activities would cause her a risk in the increase of intracranial pressure?

a. Coughing
b. Reading
c. Turning
d. Sleeping

Situation 8 - Basic Psychiatric concepts a nurse should be aware of...

30. Mental experiences, operate on different levels of awareness. The level that best portrays one's attitudes, feelings, and desire is the:

a. Conscious
b. Unconscious
c. Preconscious
d. Foreconscious

31. The ability to tolerate frustration is an example of one of the functions of the:

a. Id
b. Ego
c. Superego
d. Unconscious

32. In the process of development the individual strives to maintain, protect, and enhance the integrity of the self. This normally
accomplished through the use of:

a. Affective reactions
b. Ritualistic behavior
c. Withdrawal patterns
d. Defense mechanisms

33. Sublimation is a defense mechanism that helps the individual:

a. Act out in a reverse something already one or thought

b. Return to an earlier, less mature stage of development
c. Exclude fro the conscious things that are psychologically disturbing
d. Channel an acceptable sexual desire into socially approved behavior

34. An example of displacement is:

a. Imaginative activity to escape reality

b. Ignoring unpleasant aspects of reality
c. Resisting any demands made by others
d. Pent-up emotion directed to other than the primary source

Situation 9 - Joan, age 34, is hospitalized because of alcoholism.

35. Joan denied that she has a problem with alcohol. The nurse understands that Joan uses denial for which of the following reasons:

a. To reduce her feelings of guilt

b. To iive up to others' expectation
c. To make her seem more independent
d. To make her look better in the eyes of others

36. Joan appears suspicious of others and blames them for her personal problems. The nurse understands the client is using this behavior
because which of the following difficulties?

a. In telling the truth

b. Meeting an ego ideal
c. With dependence and independence
d. In identifying who is creating the problem

37. When thinking about alcohol and drug abuse, the nurse is aware that:

a. Most polydrug abusers also abuse alcohol

b. Most alcoholics become polydrug abusers
c. Addictive individuals tend to use hostile abusive behavior
d. An unhappy childhood is a causative factor in many addictions

38. The most important factor in rehabilitation of a client addicted to alcohol is:

a. The availability of community resources

b. The accepting attitude of the client’s family
c. The client's emotional or motivational readiness
d. The qualitative level of the client's physical state

39. Joan asks if attendance of Alcoholics Anonymous is required. Which of the following would reflect the nurse's reply?

a. "You'll find you need their support."

b. "Do you have feelings about going to these meetings?"
c. "No its best to wait until you feet you really need them."
d. "Yes, because you will learn how to cope with your problem."

Situation 10 - Nurse Medie has been encountering schizophrenic and different psychotic disorders. .

40. A male client who has delusions of persecution and auditory hallucination is admitted for psychiatric evaluation after stabbing a
friend. Later a nurse on the unit greets the client by saying, "Good evening. How are you?" The client who has been referring to himself
as "man," answers, "The man is bad." This is example of:

a. Dissociation
b. Transference
c. Displacement
d. Reaction formation

41. A disturb client starts to repeat phrase that others have just said. This type of speech is known as:

a. Autism
b. Echolalia
c. Neologism
d. Echopraxia

42. Projection, rationalization, denial, and distortion by hallucinations and delusions are examples of a disturbance in:

a. Logic
b. Association
c. Reality testing
d. The thought process

43. The major reasons for treating severe emotional disorders with tranquilizers is to:

a. Reduce the neurotic syndrome

b. Prevent secondary complication
c. Prevent destructiveness by the client
d. Make the client more amenable to psychotherapy

44. The nurse recognizes that dementia of the Alzheimer's type is characterized by :

a. Aggressive acting out behavior

b. Periodic remissions and exacerbations
c. Hypoxia of selected areas of brain tissue
d. Areas of brain destruction called senile plaques
Situation 11 - Aisa, is a 4-year old with severe anemia. She is seen by the nurse in the clinic.

45. In addition to weakness and fatigue, which of the following problems should the nurse expect Aisa to exhibit?

a. Cold, clammy skin

b. Increased pulse rate
c. Elevated blood pressure
d. Cyanosis of the nail beds

46. Which of the following problems associated with anemia best explains why Aisa becomes dizzy during periods of physical activity?

a. An inflammation of the inner ear

b. Insufficient cerebral oxygenation
c. A sudden drop in blood pressure
d. Decreased level of serum glucose

47. Aisa is to receive a liquid iron preparation. Which of the following directions would be appropriate for the nurse to teach Aisa's
mother?

a. Administer this at least an hour before meals

b. Explain that loose stools are common with iron
c. Have Aisa take the diluted iron preparation through a straw
d. Avoid giving Aisa orange or other citric juices with the iron preparation

48. Aisa is to have blood transfusion. Which of the following problems is most likely associated with blood transfusion?

a. Serum hepatitis
b. Allergic response
c. Pulmonary edema
d. Hemolytic reaction

Situation 12 - Eric Pineda is admitted to hospital to have his urethra dilated by the physician. A urinary retention catheter is inserted following the
procedure.

49. A routine urinalysis is ordered for Mr. Pineda. If the specimen cannot be sent immediately to the laboratory, the nurse should:

a. Take no special action

b. Refrigerate the specimen
c. Store on dry side of utility room
d. Discard and collect a new specimen later

50. The nurse understands that the structure that encircles the male urethra is the:

a. Epididymis
b. Prostate gland
c. Seminal vesicle
d. Bulbourethral gland

51. The nurse can best prevent the contamination from Mr. Pineda's retention catheter by:

a. Perineal cleansing
b. Encouraging fluids
c. Irrigating the catheter
d. Cleansing around the meatus periodically

52. When Mr. Pineda, who has urinary retention catheter in place, complaints of discomfort in the bladder and urethra the nurse should
first:

a. Notify the physician

b. Milk the tubing gently
c. Check the patency of the catheter
d. Irrigate the catheter with prescribed solutions

53. Mr. Pineda experiences difficulty in voiding after his indwelling urinary catheter is removed. This is probably related to:

a. Fluid imbalance
b. Mr. Pineda's recent sedentary lifestyle
c. An interruption in normal voiding habits
d. Nervous tension following the procedure
Situation 13 - Helen Alcantara is admitted to hospital with complaints of hematuria, frequency, urgency, and dysuria.

54. Mrs. Alcantara's signs and symptoms would most likely be associated with:

a. Pyelitis
b. Cystitis
c. Nephrosis
d. Pyelonephritis

55. Mrs. Alcantara has a higher risk of developing cystitis than does a male. This is
due to:

a. Altered urinary pH
b. Hormonal secretions
c. Position of the bladder
d. Proximity of the urethra and anus

56. The family of an elderly, aphasic client complain that the nurse failed to obtain a signed consent before insertion of indwelling
catheter to measure hourly output. This is an example of:

a. A catheter inserted for the client's benefit

b. A treatment that does not need a separate consent form
c. Treatment without consent of the client, which is an invasion of rights
d. Inability to obtain consent for treatment because the client was aphasic

57. When caring for a client with continuous bladder irrigation, the nurse should:

a. Monitor urinary specific gravity

b. Record urinary output every hour
c. Subtract irrigant from output to determine urine volume
d. Include irrigating solution in any 24 hour urine tests order

58. When urinary catheter is removed, the client is unable to empty the bladder. A drug is used to relieve urine retention is:

a. Carbachol injection
b. Neosporin GU irrigant
c. Bethanecol (Urecholine)
d. Pilocarpine hydrochloride (Pilocar)

Situation 14 - Arman Adriatico is admitted to hospital with extensive carcinoma of the descending portion of the colon with metastasis to the
lymph nodes.

59. The operative procedure that would probably be perform to Mr. Adriatico is a (an):

a. lleostomy
b. Colectomy
c. Colostomy
d. Cecostomy

60. The primary step toward long-range goals in Mr. Adriatico's rehabilitation involves his:

a. Mastery of techniques of ostomy care

b. Readiness to accept an altered body function
c. Awareness of available community resources
d. Knowledge of the necessary dietary modifications

61. When teaching Mr. Adriatico to care for a new stoma, the nurse should advice him that irrigations be done at the same time every
day. The time selected should:

a. Be appropriate hour before breakfast

b. Provide ample uninterrupted bathroom use at home
c. Approximate Mr. Adratico's usual daily time for elimination
d. Be about halfway between the two largest meals of the day

62. When performing the colostomy irrigation, the nurse inserts the catheter into the stoma:

a. 5cm
b.10cm
c.15cm
d.20cm

63.Mr. Adriatico should follow a diet that is:

a. Rich in protein
b. Low in fiber content
c. High in carbohydrate
d. As close to normal possible

Situation 15 - Richard Gabatan, a 32-year-old car salesman, suffered a spinal cord injury in a motor vehicle accident resulting to paraplegia.

64. A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back
complaining of pain in the back and an inability to move his legs. The nurse should first:

a. Leave Mr. Gabatan lying on his back with instructions to move and then go seek additional help
b. Gently raise Mr. Gabatan to a sitting position to see if the pain either
c. Roll Mr. Gabatan on his abdomen, place, a pad under his head, and cover
him with any material available
d. Gently lift Mr. Gavatan into a flat piece of lumber and using any available transportation, rush him to the nearest medical institution

65. Once admitted to hospital the physician indicates that Mr. Gubatan is a paraplegic. The family asks the nurse what that means. The
nurse explains that:

a. Upper extremities are paralyzed

b. Lower extremities are paralyzed
c. One side of the body is paralyzed
d. Both lower and upper extremities are paralyzed

66. The nurse recognizes that the major early problem for Mr. Gabatan will be:

a. Bladder control
b. Client education
c. Quadriceps setting
d. Use of aids for ambulation

67. The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures,
careful consideration must be given to:

a. Active exercise
b. Deep massage
c. Use of tilt board
d. Proper positioning

68. Rehabilitation plans for Mr. Gabatan;

a. Should be left up to Mr. Gabatan and his family

b. Should be considered and planned for early in his care
c. Are not necessary, because he will return to former activities
d. Are not necessary, because he will probably not able to work again

Situation 16- Karen Boltron, age 16, is withdrawn and non communicative. She spends
most of her time lying on her bed.

69. Which nursing intervention would be the most appropriate way to help Karen accept the realities of daily living?

a. Assist her to care for personal hygiene needs

b. Encourage her to keep up with school studies
c. Encourage her to join the other clients in group singing
d. Leave her alone when these appears to be a disinterest in the activities at hand

70. Which is the best plan of nursing intervention to encourage Karen to talk:

a. Try to get her discuss feelings

b. Focus oh non threatening subjects
c. Ask simple questions that require answers
d. Sit and look magazines with her

71. Which of the following is an important aspect of nursing intervention when caring for Karen?

a. Help keep her oriented to reality

b. Involve her in activities throughout the day
c. Encourage her to discuss why mixing with other people is avoided
d. Help her understand that it is harmful to withdraw from situations

72. One day Karen suddenly walks up to the nurse and shouts. "You think you're so damned perfect ad good. i think you stink," Which
response should the nurse make?

a. "You seem angry with me."

b. "Stink? I don't understand."
c. "Boy, you're in a bad mood."
d. "I can't be all that bad, can I?"

73. On being discharged, a client with psychiatric problems should be encouraged to:

a. Go back to regular activities

b. Call the unit whenever upset
c. Continue in an after care situation
d. Find a group that has similar problem

Situation 17 - Danny Dasigao, age 63, has an obsessive-compulsive behavior disorder. He believes that the doorknobs are contaminated and
refuses to touch them except with the tissue.

74. Which intervention should the nurse make when dealing with Danny's fear of doorknobs?

a. Supply rim with paper tissue to help him function until his anxiety is reduced
b. Explain to him that this idea about doorknob is part of his illness and is not necessary
c. Encourage him to scrub the doorknobs with a strong antiseptic so he does not need to use tissues
d. Encourage him to touch doorknobs by removing all available paper tissue until he learns to deal with the situation

75. Which stimulus is possibly motivating Danny to use paper towels to open doors?

a. He is using the method to punish himself

b. He is listening to voices telling him that the doorknobs are unclean
c. He wants to unconsciously control unacceptable impulses or feelings
d. He has a need to punish others by carrying out an annoying procedure

76. Which action by the nurse would most likely decrease Danny's anxiety?

a. Explore with him the nature of his anxiety

b. Stimulate him to express his ritualistic actions regularly
c. Encourage him to participate in his therapeutic plan of care
d. Provide him with an environment that is both supportive and non-opinionated

77. Which intervention should be included in Danny's initial treatment plan?

a. Deny his time for the ritualistic behavior

b. Give a schedule for the ritualistic behavior
c. Determine the purpose of the ritualistic behavior
d. Suggest a symptom substitution technique to refocus the behavior

78. The most appropriate way to decrease a clients anxiety is by:

a. Avoiding unpleasant objects and events

b. Prolonged exposure to fearful situation
c. Acquiring skills with which to face stressful events
d. Introducing an element of pleasure into fearful situations

Situation 18 - Jennifer Yadao, age 16, is admitted with the diagnosis of anorexia nervosa. She has lost 10 kg in 5 weeks. She is very thin but
excessively concerned about being overweight. Her daily intake is 10 cups of coffee.

79. Which nursing intervention should the nurse initially perform for Jennifer?
a. Explain the value of good nutrition
b. Compliment her on her lovely figure
c. Try to establish a relationship of trust
d. Explore the reasons why she does not eat

80. Which stimulus is the most likely cause of Jennifer's disorder?

a. Allow self-esteem
b. Feelings of unworthiness
c. Anger directed at the parents
d. An unconscious fear of growing up

81 Jenifer is to be placed on behavior modification. Which is appropriate to include in the nursing care plan?

a. Remind frequently the client to eat all the food served on the tray
b. Increase phone calls allowed the client by or a per day for each pound gained
c. Include the family with the client in therapy sessions two times per week
d. Weigh the client each day at 6:00 A.M. in hospital gown and slippers after she voids

82. Another patient, Kara, 17 years old, is also diagnosed with anorexia nervosa. You have been assigned to sit with her while she eats
her dinner. Kara says to you, "My primary nurse trusts me. I don't see why you don't." Your best response is:

a. "I do trust you, but S was assigned to be with you."

b. "It sounds as if you are manipulating me."
c. "OK. When S return, you should have eaten everything."
d. "Who is your primary nurse."

83. Which observation of the client with anorexia indicates that the client is improving?

a. The client eats meals in the dining room

b. The client gains one pound per week
c. The client attends group therapy sessions
d. The client has a more realistic self-control

Situation 19 - Mr. Pascua is pacing about the unit and wringing his hands. He is breathing rapidly and complains of palpitations and nausea and
he has difficulty focusing on what the nurse is saying. •

84. Mr. Pascua is experiencing a high degree of anxiety. It is important to recognize if additional help is required because:

a. If the client is out of control, another person will help to decrease his anxiety level
b. Being alone with an anxious client is dangerous
c. It will take another person to direct the client into activities to relieve anxiety
d. Hospital protocol for handling anxious clients requires at least two people

85. He says he is having a heart attack but refuses to rest. The nurse would be Interpret his level of anxiety as:

a. Mild
b. Moderate
c. Severe
d. Panic

86.What should the nurse include in the care plan to Mr. Pascua when he is having
a panic attack?

a. Calm reassurance, deep breathing and modication as ordered

b. Teach Mr. Pascua problem solving in relation to his anxiety
c. Expiam the physiologic responses of anxiety
d. Explore alternate methods for dealing with the cause of his anxiety

Situation 20 - Joel is a toddler who has classical hemophilia.

87. Which of the following statements is true regarding Joel's disorder?

a. Hemophilia is an autosomal dominant disorder in which the woman carries

the trait
b. Hemophilia follows regular laws of Mendelian inherited disorders such as sickle ceil anemia
c. This disorder can be carried by either male or female but occurs in the sex opposite that of the carrier
d. Hemophilia is an X-linked disorder in which the mother is usually the carrier of the illness but is not affected by it

88. Joel has some internal bleeding. At which of the following sites is the most common for the child with hemophilia to bleed?

a. Joints
b. Intestines
c. Cerebrum
d. Ends of the log bones

89. Which of the following blood products is most likely to be given to Joel?

a. Albumin
b. Fresh frozen plasma
c. Factor VIII concentrate
d. Factor II, Vll, IX, X complex

90. Joel's parents ask if-their other children will be affected by the disorder. Which of the following statements should guide the nurse in
her response?

a. All the girls will be normal and the other son a carrier
b. All the girls will be carriers and one half the boys will be affected
c. Each son has a chance of being affected and each daughter a 50% chance of being a carrier
d. Each son has 50% chance of being affected or a carrier, and the girls will be all carriers.

91. A child is to receive a blood transfusion, if an allergic reaction to the blood occurs, the nurse's first intervention should be:

a. Call the physician

b. Slow the flow rate
c. Stop the blood immediately
d. Relieved the symptoms with an ordered antihistamines

Situation 19 - Mr. Villa who was admitted to the respiratory floor with COPD. The nurse finds him extremely restless, incoherent, and showing
signs of acute respiratory distress. He Is using accessory muscles for breathing and Is diaphoretic and cyanotic.

92. The best initial action by the nurse is to:

a. Administered oxygen as ordered

b. Assess vital signs and neural vital signs
c. Administered medication which has been ordered for pain
d. Call respiratory therapy for a prescribed ABG (arterial -blood gas) analysis

93. An order is written for oxygen by nasal cannula at 2 liters per minute. Which assessment is most useful in assessing the adequacy of
the oxygen therapy?

a. Respiratory rate
b. Color of mucus membranes
c. Pulmonary function tests
d. Arterial blood gases

94. Mr. Villa needs frequent monitoring of arterial blood gases. Following the drawing of arterial blood gasses it is essential for the nurse
to do which of the following?

a. Encourage the client to cough an deep breath

b. Apply pressure to the puncture site for 5 minutes
c. Shake the vial of blood before transporting it to the lab
d. Keep the client on bed rest for 2 hours

95. The nurse is interpreting the results of a blood gas analysis performed on an adult client. The value include pH of 7.35, pC02 of 60,
HC03 of 35. and 02 of 60. Which interpretation is most accurate?

a. The client is in metabolic acidosis

b. The client is in compensated metabolic alkalosis
c. The client is in respiratory alkalosis
d. The client is in compensated respiratory acidosis

Situation 20 - The nurse is assigned in a counseling clinic about preventive measures for cancers.

96. Cancer is the second major cause of death in this country. What is the first step toward effective cancer control?

a. Increasing governmental control of potential carcinogens

b. Changing habits and customs that predispose the individual to cancer
c. Conducting more mass screening programs
d. Educating public and professional people about cancer

97. In order to educate clients, the nurse should understand that the most common site of cancer for a female is the:

a. Uterine cervix
b. Uterine body
c. Vagina
d. Fallopian tube

98.A client has just completed a course in radiation therapy and is experiencing radio-dermatitis. The most effective method of treating
the skin is to:

a. Wash the area with soap and warm water

b. Apply a cream or lotion to the area
c. Leave the skin alone until it is clear
d. Avoid applying creams or lotion to the area

99.A client with cancer that has metastazised to the liver is started on chemotherapy- His physician has specified divided doses of the
antimetabolite. The client asks why he could take the drug in divided doses. The appropriate response is:

a. " There really is no reason your doctor just wrote the orders that way."
b. "This schedule will reduce the side effect of the drug."
c. "Divided doses produce greater cytotoxic effects on the diseased cells."
d. "Because these drugs prevent cell division, they are more effective in divided doses,"

100. A client has possible malignancy of the colon, and surgery is scheduled. The rationale for administering Neomycin preoperatively is
to:

a. Prevent infection postoperatively

b. Eliminate the need for preoperative enemas
c. Decreased and retard the growth of normal bacteria in the intestines
d. Treat cancer of the colon

Situation 1 - Jimmy developed this goal for hospitalization. "To get a handle on my nervousness." The nurse is going to collaborate with him to
reach his goal. Jimmy was admitted to the hospital because he called his therapist that he planned to asphyxiate himself with exhaust from his
car but frightened instead. He realized he needed help.

1. The nurse recognized that Jimmy had conceptualized his problem and the next priority goal in the care plan is:

a. help the client find meaning in his experience

b. help the client to plan alternatives
c. help the client cope with present problem
d. help the client to communicate

2. The nurse is guided that Jimmy is aware of his concerns of the "here and now" when he crossed out which item from this "list of what to
know"

a. anxiety laden unconscious conflicts

b. subjective idea of the range of mild to severe anxiety
c. early signs of anxiety
d. physiological indices of anxiety

3. While Jimmy was discussing the signs and symptoms of anxiety with his nurse, he recognized that complete disruption of the ability to
perceive occurs in:

a. panic state of anxiety

b. severe anxiety
c. moderate anxiety
d. mild anxiety

4. Jimmy initiates independence and takes an active part in his self care with the following EXCEPT:

a. agreeing to contact the staff when he is anxious

b. becoming aware of the conscious feeling
c. assessing need for medication and medicating himself
d. writing out a list of behaviors that he identifies as anxious

5. The nurse notes effectiveness of Interventions in using subjective and objective data in the:
a. initial plans or order
b. database
c. problem list
d. progress notes

Situation 2 - A research study was under taken in order to identify and analyze a disabled boy's coping reaction pattern during stress.

6. This study which is a depth study of one boy is a:

a. case study
b. longitudinal study
c. cross-sectional study
d. evaluative study

7. The process recording was the principal tool for data collection. Which of the following is NOT a part of a process recording?

a. Non verbal narrative account

b. Audio and interpretation
c. Audio-visual recording
d. Verbal narrative account

8. Which of these does NOT happen in a descriptive study?

a. Exploration of relationship between two or more phenomena

b. Exploration of relationships between two or more phenomena
c. Manipulation of phenomenon in real life context
d. Manipulation of a variable

9. The investigator also provided the nursing care of the subject. The investigator is referred to as a/an.

a. Participant-observer
b. Observer researcher
c. Caregiver
d. Advocate

10. To ensure reliability of the study, the investigator analysis and interpretations were:

a. subjected to statistical treatment

b. correlated with a list coping behaviors
c. subjected to an inter-observe agreement
d scored and compared standard criteria

Situation 3 - During the morning endorsement, the' outgoing nurse informed the nursing staff that Regina, 5 years old, was given Flurazepam
(Dalmane) 15 mg at 10:00pm because she had trouble going to sleep. Before approaching Regina, the nurse read the observation of the night
nurse.

11. Which of the following approaches of the nurse validates the data gathered?

a. "I learned that you were up till ten last night, tell me what happened before you were finally able to sleep and how was your sleep?"
b. "Hmm...You look like you had a very sound sleep. That pill you were given last night is effective isn't it?"
c. "Regina, did you sleep we!!?"
d. "Regina, how are you?"

12. Regina is a high school teacher. Which of these information LE^ST communicate attention and care for her needs for information about
her medicine?

a. Guided by a medication teaching plan go over with her the purpose, indications and special instructions, about the medication and provide
her a checklist
b. Provide a drug literature
c. Have an informal conversation about the medication and its effects
d. Ask her what time she would like to watch the informative video about the medication

13. The nurse engages Regina in the process of mutual inquiry to provide an opportunity for Regina to

a. face emerging problems realistically

b. conceptualize her problem
c. cope with her present problem
d. perceive her participation in an experience

14. Which of these responses indicate that Regina needs further discussion regarding special instructions?

a. "I have to take this medicine judiciously."

b. "I know 1 will stop taking the medicine when there is an advice form the doctor for me to discontinue."
c. "I will inform you and the doctor any untoward reactions I have."
d. "I like taking this sleeping pill. It solves my problem of insomnia. I wish I can take it for life."

15. Regina commits to herself that she understood and will observe all the medicine precautions by;

a. affixing her signature to the teaching plan that she has understood the nurse
b. committing what she learned to her memory
c. verbally agreeing with the nurse
d. relying on her husband to remember the precautions

Situation 4 - The nurse-patient relationship is a modality through which the nurse meets the client's needs.

16. The nurse's most unique tool in working with the emotionally ill client is his/her:

a. theoretical knowledge
b. personality make up
c. emotional reactions
d. communication skills

17. The psychiatric nurse who is alert to both the physical and emotional needs of clients is working from the philosophical framework that
states:

a. All behavior is meaningful, communicating a message or a need

b. Human beings are systems of interdependent and interrelated parts
c. Each individual has the potential for growth and change in the direction of positive mental health
d. There is a basic similarity among all human beings

18. One way to increase objectivity in dealing with one’s fears and anxieties is through the process of:

a. observation
b. intervention
c. validation
d. collaboration

19. All of the following response are non therapeutic. Which is the MOST direct violation of the concept, congruence of behavior?

a. Responding in a punitive manner to the client

b. Rejecting the client as a unique human being
c. Tolerating all behavior in the client
d. Communicating ambivalent messages to the client
20. The rnentally ill person responds positively to the nurse who is warm and caring. This demonstration of the nurse’s role as:

a. counselor
b. mother surrogate
c. therapist
d. socializing agent

Situation 5 - The nurse engages the client in a. nurse-patient interaction.

21. The best time to inform the client about terminating the nurse-patient relationship is

a. when the client asks, how long one relationship would be

b. during the working phase
c. towards the end of the relationship
d. at the start of the relationship

22. The client says, "I want to tell you something but can you promise that you will keep this, a secret?" A therapeutic response of the nurse
is:

a. "Yes, our interaction is confidential provided the information you tell me is not detrimental to your safety."
b. "Of course yes, this is just between you and me. Promise!"
c. "Yes, it is my principle to uphold my client's rights."
d. "Yes, you have the right to invoke confidentiality of our interaction."

23. When the nurse respects the client's self-disclosure, this is a gauge for the nurse's:

a. trustworthiness
b. loyalty
c. integrity
d. professionalism

24. Rapport has been established in the nurse-client interaction time. I am committed to have this time available for us while you are at the
hospital and ends after your discharge."

a. "The best time to talk is during the nurse-client interaction time. I am committed to have this time available for us while you are at the
hospital and ends after your discharge."
b. "Yes, if you keep it confidential, this is part of privileged communication."
c. "I am committed for your care."
d. "I am sorry, though I would want to, it is against hospital policy."

25. The client has not been visited by relatives for months. He gives a, telephone number and requests the nurse to call. An appropriate
action of the nurse would be:

a. Inform the attending psychiatric about the request of the client

b. Assist the client to bring his concern to the attention of the social worker
c. "Here (gives her mobile phone). You may call this number now."
d. Ask the client what is the purpose of contacting his relatives

Situation 6 - Camila, 25 years old, was reported to be gradually withdrawing and isolating herself from friends and family members. She became
neglectful of her personal hygiene. She was observed to be talking irrelevantly and incoherently. She was diagnosed as schizophrenia

26. The past history of Camila would most probably reveal that her premorbid personality is:

a. schizoid
b. extrovert
c. ambivert
d. cycloid
27. Camila refuses to relate with others because she:

a. is irritable
b. feels superior of others
c. anticipates rejection
d. is depressed

28. Which of the following disturbances in interpersonal relationships MOST often predispose, to the development of schizophrenia?

a. Lack of participation in peer groups

b. Faulty family atmosphere and interaction
c. Extreme rebellion towards authority figures
d. Solo parenting

29. Camila's indifference toward the environment is a compensatory behavior to overcome:

a. Guilt feelings
b. Ambivalence
c. Narcissistic behavior
d. Insecurity feelings

30. Schizophrenia is a/an:

a. anxiety disorder
b. neurosis
c. psychosis
d. personality/disorder

Situation 7 - Salome, 80 year old widow, has been observed to be irritable, demanding and speaking louder than usual. She would prefer to be
alone and take her meals by herself, minimized receiving visitors al home and no longer bothers to answer telephone calls because of
deterioration of her hearing. 'She was brought by her daughter to, the Geriatic clinic for assessment and treatment.

31. The nurse counsels Salome's daughter that Salome's becoming very loud and tendency to become aggressive is a/an:

a. beginning indifference to the world around her

b. attempt to maintain authoritative role
c. overcompensation for hearing loss
d. behavior indicative of unresolved repressed conflict of the part

32. A nursing diagnosis for Salome is:

a. sensory deprivation
b. social isolation
c. cognitive impairment
d. ego despair

33. The nurse will assist Salome and her daughter to plan a goal which is:

a. adjust to the loss of sensory and .perceptual function

b. participate in conversation and other social situations
c. accept the steady loss of hearing that occurs with aging
d. increase her self-esteem to maintain her authoritative role

34. The daughter understood, the following ways to assist Salome meet her needs and avoiding which of the following:

a. Using short simple sentences

b. Speaking distinctly and slowly
c. Speaking at eye level and having the client's attention
d. Allowing her to take her meals alone

35. Salome was fitted a hearing aid. She understood the proper .use and wear of this device when she ways that the battery should be
functional, the device is turned on and adjusted to a:

a. therapeutic level
b. comfortable level
c. prescribed level
d. audible level

Situation 8 - For more than a month now, Cecilia is persistently feeling restless, worried and feeling as if something dreadful is going to happen.
She fears being alone in places and situations where she thinks that no one might come to rescue her just in case something happens to her.

36. Cecilia is demonstrating:

a. acrophobia
b. claustrophobia
c. agoraphobia
d. xenophobia

37. Cecilia's problem is that she always sees and thinks negative hence she is always fearful Phobia is a symptom described as:

a. organic
b. psychosomatic
c. psychotic
d. neurotic

38. Cecilia has a lot of irrational thoughts: The goal of therapy is to modify her:

a. communication
b. cognition
c. observation
d. perception

39. Cognitive therapy is indicated for Cecilia when she is already able to handle anxiety reactions. Which of the following should the nurse
implement?

a. assist her in recognizing irrational beliefs, and thoughts

b. help find meaning in her behavior
c. provide positive reinforcement for acceptable behavior
d. administer anxiolytic drug

40. After discharge, which of these behaviors indicate a positive result of being able to overcome her phobia?

a. she read a book in the public library

b. she drives alone along the long expressway
c. she watches television with the family in the recreation room
d. she joint an art therapy group

Situation 9 - it is the first day of clinical experience of nursing students at the Psychiatry Ward- During the orientation, the nurse emphasizes
that the team members including nursing students are legally responsible to safeguard patient's records from loss or destruction or from
people not authorized to bead it.

41. It is unethical to tell one's friends and family member’s data bout patients because doing so is violation of patients’ rights to:
a. Informed consent
b. Confidentiality
c. Least restrictive environment
d. Civil liberty

42. The nurse must see to it that the written consent of mentally ill patients must be taken from:

a. Doctor
b. Social worker
c. Parents or legal guardian
d. Law enforcement authorities

43. In an extreme situation and when no other resident or intern is available, should a nurse receive, telephone orders, the order has to be
correctly written and signed by the physician within.

a. 24 hours
b. 36 hours
c. 48 hours
d. 12 hours

44. The following are SOAP (Subjective - Objective - Analysis - Plan) statements on a problem: Anxiety about diagnosis. What is the objective
data?

a. Relate patient's feelings to physician initiate and encourage her to verbalize her fears give emotional support by spending more time with
patient, continue to make necessary explanations regarding diagnostic test.
b. Has periods of crying, frequently verbalizes fear of what diagnostic tests will reveal
c. Anxiety due to the unknown
d. "I’m so worried about what else they'll find wrong with me"

45. Nursing care plans provide very meaningful data for the patient profile and initial plan because the focus is on the:

a. Summary of chronological notations made by individuals health team members

b. Identification of patient's responses to medical diagnosis and treatment
c. Patient's responses to health: and illness as a total person in interaction with the environment
d. Step procedures for the management of common problems

Situation 10 - Marie is 5 ½ years old and described by the mother as bedwetting at night.

46. Which of the following is the MOST common physiological cause of night bedwetting?

a. deep sleep factors

b. abnormal bladder development or structure problems
c. infections familial and genetic factors

47. All of the following, EXCEPT one comprise the concepts of behavior therapy program:

a. reward and punishment

b. extinction
c. learning
d. placebo as a form treatment

48. The help Marie who bed wets at night practice acceptable and appropriate behavior, it is important for the parents to be consistent with
the following approaches EXCEPT:

a discipline with a king attitude

b matter of fact in handling the behavior
c. sympathize for the child
d. be lowing yet firm

49. A therapeutic verbal approach that communicates strong disapproval is:

a. You are supposed to get up and go in the toilet when you feel you have to go and did not. The next time you bed wet, I’ll tell your friends and
hand your sheets out the window for them to see."
b. "You are supposed to get up and go in the toilet when you feel you have to go and you did not. I expect you to from now on without fail."
c. "If you bed wet, you will change your bed linen and wash the sheets."
d. "If you don't make an effort to control your bedwetting, I'd be upset and disappointed."

50. During your conference, the parent inquires how to motivate Marie to be dry in the morning. Your response which is an immediate
intervention would be:

a. Give a star each time she wakes up dry and every set of five stars, give a prize
b. Tokens make her materialistic at an early age. Give praise and hugs occasionally
c. What does you child want that you can give every time he/she wakes up dray in the morning
d. Promise him/her a long awaited vacation after school is over.

Situation 11 - The nurse is often met with t-he following situations when clients become angry and hostile.

51. To maintain a therapeutic eye contact and body posture while interacting with angry and aggressive individual, the nurse should:

a. keep an eye contact while staring at the client

b. keep his/her hands behind his/her back or in one's pocket
c. fold his/her arms across his/her chest
c. keep an "open" posture, e.g. Hands by sides but palms turned outwards

52. During the pre-interaction phase of the N-P relationship/the nurse recognizes this normal INITIAL reaction to an assaultive or potentially
assaultive person.

a. To remain and cope with the incident

b. Display empathy towards the patient
c. To call for help from the other members of the team
d. To stay and fight or run away

53. Which of the following is an accurate way of reporting and recording an incident?

a. "When asked about his relationship with his father, client became anxious."
b. "When asked about his relationship with his father, client clenched his jaw/teeth made a fist and turned away from the nurse."
c. "When asked about his relationship with his father, client was resistant to respond."
d. "When asked about his relationship with his father, his anger was suppressed."

54. To encourage thought. Which of the following approaches is NOT therapeutic?

a. "Why do you feel angry?"

b. "When do you usually feel angry?"
c. "How do you usually express anger?"
d. "What situations provoke you to be angry?"

55. A patient grabs a chair and about to throw it. The nurse best responds saying.

a. "Stop! Put that chair down."

b. "Don't be silly."
c. "Stop, the security will be here in a minute."
d. "Calm down."

Situation 12 - Nursing care for the elderly.

56. In planning care for a patient with Parkinson's disease, which of these nursing diagnoses should have priority?

a. potential for injury

b. altered nutritional state
c. ineffective coping
d. altered mood state

57. A healthy adaptation to aging is primarily related to an individual.

a. Number of accomplishments
b. Ability to avoid interpersonal conflict
c. Physical health throughout life
d. Personality development in his life span

58. The frequent use of the older client's name by the nurse is MOST effective in alleviating which of the following responses to old age?

a. Loneliness
b. Suspicion
c. Grief
d. Confusion

59. An elderly confused client gets out of bed at night to go to the bathroom and tries to go to another bed when she returns. The MOST
appropriate action the nurse would take is to:

a. Assign client to a single room

b. Leave a light on all night
c. Remind client to call the nurse when she wants to get up
d. put side rails on the bed

60. An elderly who has lots of regrets, unhappy and miserable1 is experiencing:

a. Crisis
b. Despair
c. Loss
d. Ambivalence

Situation 13 - Graciela 1 ½ year old is admitted the hospital from the emergency room with a fracture of the left femur due to a Tall down a
flight of stairs. Graciela is placed oh Bryant's traction.

61. While on Bryant's traction, which of these observations of Graciela and her traction apparatus would indicate a decrease in the
effectiveness of her traction?

a. Graciela's buttocks are resting on the bed

b. The traction weights are hanging 10 inches above the floor
c. Graciela's legs are suspended at a 90 degree angle to her trunk
d. The traction ropes move freely through the pulley

62. The nurse notes that the fall might also cause a possible head injury. She will be observed for signs of increased intracranial pressure
which include:

a. Narrowing of the pulse pressure

b. Vomiting
c. Periorbital edema
d. A positive Kernig's sign

63. Graciela is assessed to have no head injury. The Bryant's traction is removed. A plaster of Paris his spica is applied. Which of these finding
as a concern of immediate attention that must be reported to the physician immediately?

a. Graciela is scratching the cast over her abdomen

b. The toes of Graciela's left foot blanch when the nurse applies pressure on them
c. Graciela's cast is still damp
d. The nurse is unable to insert a finger under the edge of Graciela's cast on her left foot

64. Part of discharge plan is for the nurse to give instructions about the care of Graciela's cast to the mother. Which of these statements
indicate that the mother understood an important aspect of case care?

a. I will use white shoe polish to keep the cast neat

b. I will place plastic sheeting around the perineal area of the cast
c. I will use cool water to wash the cast
d. I will reinforce cracked areas on the cast with adhesive tape

65. The nurse counsels Graciela's mother ways to safeguard safety white providing opportunities of Graciela to develop a sense of:

a. Trust
b. Initiative
c. Industry
d. Autonomy

Situation 14 - Jolina is an 18 year old beginning college student. Her mother observed that she is having problems relating with her friends. She
is undecided about her future. She has lost insight, lost interest in anything and complained and complained of constant tiredness.

66. Jolina is out on antidepressant drugs. These drugs act on the brain chemistry, therefore they would be useful in which type of
depression?

a. exogenous depression
b. neurotic depression
c. endogenous depression
d. psychotic depression

67. This is a tricyclic antidepressant drug:

a. Venlafaxine (Effexor)
c. Setraline (Zoloft)
b. Flouxetine (Prozac)
d. Imipramine (Tofranil)

68. After one week of antidepressant medication, Jolina still manifests depression. The nurse evaluates this as;

a. Unusual because action of antidepressant drug is immediate

b. Unexpected because therapeutic effectiveness takes within a few days
c. Expected because therapeutic effectiveness takes 2-4 weeks
d. Ineffective result because perhaps the drug's dosage is inadequate

69. Jolina continues to verbalize feeling sad and hopeless. She is not mixing well with other clients. One of the nurse's important
consideration for Jolina Initially is to:

a. Formulate a structured schedule so she is able to channel her energies externally

b. Let her alone until she feels like mingling with others
c. Encourage her to join socialization hour so she will start to relate with others
d. Encourage her to join group therapy with other patients

70. During the predischarge conference, the nurse suggests vocational guidance because it should help Jolina to:
a. Find a good job
b. Make some decision about her future
c. Realistically assess her assets and limitations
d Solve her own problems

Situation 15 - Group Approach" in Nursing.

71. Membership dropout generally occurs in group therapy after a member:

a. Accomplishes his goal in joining the group

b. Discovers that his feelings are shared by the group members
c. Experiences feelings of frustration in the group
d. Discusses personal concerns with group members

72. Which of the following questions illustrates the group role of encourager?

a. What were you saying?

b. Who wants to respond next?
c. Where do you go from here?
d. Why haven't we heard from you?

73. The goal of remotivation therapy is to facilitate:

a. Insight
b. Productivity
c. Socialization
d. Intimacy

74. The treatment of the family as a unit is based on the belief that the family:

a. is a social system and all the members are interrelated components of that system
b. as a unit of society needs the opportunity to change its own destiny
c. who has therapy together will tend to remain together
d. is "contaminated" by the presence of deviant member and all members need treatment

75. The working phase in therapy group is usually characterized by which of the following?

a. Caution
b. Cohesiveness
c. Confusion
d. Competition

Situation 16 - The mental health - psychiatric nurse functions in a variety of setting with different types of clients.

76. Poverty as reflected in prevalence of communicable diseases, malnutrition and social ills such as street children, homeless and
prostitution is a predisposing factor to mental illness. A community approach to cope with this problem is for the nurse to support:

a. aggressive family planning methods

b. provision of social welfare benefits for the poor
c. social action
d. free clinics and more hospitals

77. The MOST cost effective way to meet the mental health needs of the public is through programs with a priority goal of:

a. treatment
b. prevention
c. rehabilitation
d. research

78. Lorelle upon discharge was referred to a volunteer group where she has learned to read patterns, cut out fabric and use a sewing
machine to make simple outfits that will help her earn in the future. What type of activity therapy is this?

a. Recreational therapy
b. Art therapy
c. Vocational therapy
d. Educational therapy

79. In a residential treatment home for adolescent girl's the clients were becoming increasingly tense and upset because of shortening of
their recreation time. To die escalate possible anger and aggression among the clients it is BEST to play:

a. religious music
b. relaxation music
c. dance music
d. rock music

80. The parents of special children who are behaviorally disturbed need mental health education. Which of these topics would the school
nurse consider as priority for their parents’ class?

a. Drug education
b. Child abuse
c. Effective parenting
d. Sex education

Situation 17 - Nurse's in all practice areas are likely to come in contact with clients suffering from acute or chronic drug abuse.

81. The psychodynamic therapy of substance abuse is based upon the premise that drug abuse is:

a. a common problem brought about by socioeconomic deprivation

b. caused by multiplicity of factors
c. predisposed by an inability to develop appropriate psychological resources to manage developmental stresses
d. due to biochemical factors

82. Being in contact with reality and the environment is a function of the:

a. conscience
b. ego
c. id
d. super ego

83. Substance abuse is different from substance dependence is than, substance dependence:

a. includes characteristics of adverse consequences and repeated use

b. requires long term treatment in a hospital based program
c. produces less severe symptoms than that of abuse
d. includes characteristics of tolerance and withdrawal

84. During the detoxification stage, it is a priority for the nurse to:

a. teach skills to recognize and respond to health threatening situations

b. increase the client's awareness of unsatisfactory protective behaviors
c. implement behavior modification
d. promote homeostasis and minimize the client’s withdrawal symptoms

85. Commonly known as "shabu" is:

a. Cannabis Sativa
b. Lysergic add diethylamide
c. Methylenedioxy, methamphetamine
d. Methamphetamine hydrochloride

Situation 18 - It is common that client ask the nurse personal questions.

86. Anticipation of personal questions is given adequate attention during which phase of the nurse patient relationship?

a. Orientation phase
b. Working phase
c. Pre-interaction phase
d. Termination phase

87. The client asks for the nurse's telephone number, which of these responses is NOT appropriate?

a. "it is confidential I just don't give it to anyone."

b. "What would you do with my number if I give it to you?"
c. "If I say. No to your request, what are your thoughts about it?”
d. "Are you asking for an official number of the hospital/clinic for your reference?"

88. When the client asks about the family of the nurse the MOST appropriate response is:

a. Avoid the situation and redirect the client's attention

b. Give a brief and simple response and focus on the client
c. "Why don't we talk about your family instead?"
d. Introduce another topic like the client's interests

89. When the nurse is asked a personal question, which of these reactions indicate a need her to introspect?

a. The client is simply curious

b. His/her right to privacy is being intruded
c. The client knows no other way to begin a conversation
d. Some patients are like children in seeking recognition from the nurse

90. It is 10 o'clock of your watch. The client asks, "What time is it?" The nurse's appropriate response is:

a. "Are you bored?"

b. "It is 10 o’clock."
c. "Why do you ask?"
d. "Guess, what time is it?"

Situation 19 - Ricky is a 12 year old-boy with Down’s syndrome. He stands 5' ½" and weight 100 lbs. He is slim and walks sluggishly with a limp.
He wears a neck brace as support for his neck. X - ray of cervical spine showed "subluxation of CI in relation to C2 with cord compression." He
attends a school for special education.

91. The classroom teacher consults the school for guidance on how to take care of Ricky while inside the, classroom. The nurse considers as
priority, Ricky's:

a. Physiological needs
b. Need for self-esteem
c. Needs for safety and Security
d. Needs for belonging

92. Ricky's mother visited the school nurse. She asked, " What should I do when Ricky fond his genitalia?" Appropriate response of the nurse
is for the mother to:
a. Divert Ricky's attention and engage him in satisfying activities
b. Tell Ricky that it is wrong to keep fondling his genitalia
c. Ignore Ricky's behavior because he will outgrow it later
d. Engage him in computer TV games that engage his hands

93. The nurse has one on one health education sessions with Ricky's mother. The mother understood that for her son to learn to cope and be
independent, she should constantly provide activities for Ricky to be able to:

a. socialize with people

b. eventually go to school alone
c. select and prepare his own food
d. do activities of daily living

94. All of the following activities are appropriate for Ricky EXCEPT:

a. Working with clay

b. Competitive sports
c. Preparing and cooking simple menu
d. Card and table games

95. Ricky's IQ falls within the range of 50-55. He can be expected to:

a. Profit from vocational training with moderate supervision

b. Live successfully in the community
c. Perform simple tasks in closely supervised settings
d. Acquire academic skills of 6th grade; level

Situation 20 - The abuse of dangerous drug is a serious public health concern that nurses need to address,

96. The nurse should recognize that the unit primarily responsible for education and awareness of the members of the family on the ill
effects of dangerous drugs is the:

a. law enforcement agencies

b. school
c. church
d. family

97. A drug dependent utilizes this defense mechanism and enables him to forget shame and pain.

a. repression
b. rationalization
c. projection
d. sublimation

98. This drug produces mirthfulness, fantasies, flight of ideas, loss of train of thought, distortion of size, distance and time, and "bloodshot
eyes", due to dilated pupils.

a. Opiates
b. LSD
c. Marijuana
d. Heroin

99. The nurse evaluates that-.her health teaching to a group of high school boys is effective if these students recognize which of the
following dangers of inhalant abuse.

a. Sudden death from cardiac or respiratory depression

b. Danger of acquiring hepatitis or AIDS
c. Experience of "blackout"
d. Psychological dependence after prolonged use

100. The mother of a drug dependent would never consider referring her son to a drug rehabilitation agency because she fears her son might
just becomes worse while relating with other drugs users. The mother's behavior can be described as:

a. Unhelpful
b. Codependent
c. Caretaking
d. Supportive

ANSWER KEY:
1. C
2. C
3. B
4. A
5. D
6. A
7. C
8. D
9. D
10. A
11. A
12. D
13. D
14. D
15. A
16. D
17. C
18. B
19.
20.
21.
22.
23.
24.
25. A
26. A
27. A
28. B
29. C
30. C
31. A
32. A
33. A
34. D
35. D
36. C
37. D
38. B
39. A
40. A
41. B
42. C
43. A
44. B
45. C
46.
47.
48.
49.
50.
51. D
52. B
53. B
54. A
55. A
56. A
57. C
58. D
59. A
60. B
61. A
62. B
63. D
64. D
65. D
66. B
67. D
68. C
69. C
70. C
71. C
72. B
73. B
74. A
75. B
76. B
77. B
78. C
79. B
80. C
81. B
82. B
83. D
84. D
85. D
86. B
87. A
88. B
89. D
90. B
91. C
92.
93. D
94. B
95. C
96. D
97. A
98. B
99. A
100. A

COMMUNITY HEALTH NURSING AND CARE OF THE MOTHER AND CHILD

Situation 1 - Nurse Minette is an independent Nurse Practitioner following-up referred clients in their respective homes. Here she handles a
case of POSTPARTIAL MOTHER AND FAMILY focusing on HOME CARE.

1. Nurse Minette needs to schedule a first home visit to OB client Leah. When is a first home-care visit typically made?

a. Within 4 days after discharge

b. Within 24 hours after discharge
c. Within 1 hour after discharge
d. Within 1 week of discharge

2. Leah is developing constipation from being on bed rest. What measures would you suggest she take to help prevent this?

a. Eat more frequent small meals instead of three large one daily
b. Walk for at least half an hour daily to stimulate peristalsis
c. Drink more milk, increased calcium intake prevents constipation
d. Drink eight full glasses of fluid such as water daily

3. If you were Minette, which of the following actions, would alert you that a new mother is entering a postpartial at taking-hold phase?

a. She urges the baby to stay awake so that she can breast-feed him in her
b. She tells you she was in a lot of pain all during labor
c. She says that she has not selected a name fir the baby as yet
d. She sleeps as if exhausted from the effort of labor

4. At 6-week postpartum visit what should this postpartial mother's fundic height be?

a. Inverted and palpable at the cervix

b. Six fingerbreadths below the umbilicus
c. No longer palpable on her abdomen
d. One centimeter above the symphysis pubis

5. This postpartal mother wants to loose the weight she gained in pregnancy, so she is reluctant to increase her calorin intake for breast-
feeding. By how much should a lactating mother increase her caloric intake during the first 6 months after birth?

a. 350 kcal/day
b. 5CO kcal/day
c. 200 kcal/day
d. 1,000 kcal/day

Situation 2 - As the CPES is applicable for all professional nurse, the professional growth and development of Nurses with specialties shall be
addressed by a Specialty Certification Council.
The following questions apply to these special groups of nurses.

6. Which of the following serves as the legal basis and statute authority for the Board of nursing to promulgate measures to effect the
creation of a Specialty Certification Council and promulgate professional development programs for this group of nurse-professionals?

a. R.A. 7610
b. R.A. 223
c. R.A. 9173
d. R.A. 7164
7. By force of law, therefore, the PRC-Board of Nursing released Resolution No. 14 Series of the entitled: "Adoption of a Nursing Specialty
Certification Program and Creation of Nursing Specialty Certification Council." This rule-making power is called:

a. Quasi-Judicial Power
b. Regulatory Power
c. Quasi/Legislative Power
d. Executive/Promulgation Power

8. Under the PRC-Board of Nursing Resolution promulgating the adoption of a Nursing Specialty-Certification Program and Council, which
two (2) of the following serves as the strongest for its enforcement?
(a) Advances made in science aid technology have provided the climate for specialization in almost all aspects of human endeavor and
(b) As necessary consequence, there has emerged a new concept known as globalization which seeks to remove barriers in trade, .industry and
services imposed by the national laws of countries all over the world; and
(c) Awareness of this development should impel the nursing sector to prepare our people in the services sector to meet .the above challenges;
and
(d) Current trends of specialization in nursing practice recognized by; the International Council of Nurses (ICN) of which the Philippines is a
member for the benefit of the Filipino in terms of deepening and refining nursing practice and enhancing the quality of nursing care.

a. b & c are strong justification

b. a & b are strong justification
c. a & c are strong justification
d. a & d are strong justification

9. Which of the following is NOT a correct statement as regards Specialty Certification?

a. The Board of Nursing intended to create the Nursing Specialty Certification Program as a means of perpetuating the creation of an elite force
of Filipino Nurse Professionals
b. The Board of Nursing shall oversee the administration of the NSCP through the various Nursing Specialty Boards which will eventually, be
created
c. The Board of Nursing at the time exercised their powers under R.A. 7164 in order to adopt the creation of the Nursing Specialty
Certification /council and Program
d. The Board of Nursing consulted nursing leaders of national nursing associations and other concerned nursing groups which later decided to
ask a special group of nurses of .the program for nursing specialty certification

10. The NSCC was created for the purpose of implementing the Nursing Specialty policy under the direct supervision and stewardship of the
Board of Nursing. Who shall comprise the NSCC?

a. A Chairperson who is the current President of the APO a member from .the Academe, and the last member coming from the Regulatory
Board
b. The Chairperson and members of the Regulatory Board ipso facto acts as the CPE Council
c. A Chairperson, chosen from among the Regulatory Board Members, a Vice Chairperson appointed by the BON at-large; two other members
also chosen at-large; and one representing the consumer group
d. A Chairperson who is the President of the Association from the Academe; a member from the Regulatory Board, and the last member coming
from the APO

Situation 3 - Nurse Anna is a new BSEN graduate and has just passed her Licensure Examination for Nurses in the Philippines. She has likewise
been hired as a new Community Health Nurse in one of the Rural Health Units in their City, which of the following conditions may be acceptable
TRUTHS applied to Community Health Nursing Practice.

11. Which of the following is the primary focus of community health nursing practice?

a. Cure of illnesses
b. Prevention of illness
c. Rehabilitation back to health
d. Promotion of health
12. In community health nursing, which of the following is our unit of service as nurses?

a. The Community
b. The Extended Members of every family
c. The individual members of the Barangay
d. The Family

13. A very important part of the Community Health Nursing Assessment Process includes

a. the application of professional judgment in estimating importance of facts to family and community
b. evaluation structures arid qualifications of health center team
c. coordination with other sectors in relation to health concerns
d. carrying out nursing procedures as per plan of action

14. In community health nursing it is important to take into account the family health with an equally important need to perform ocular
inspection of the areas activities which are powerful elements of:

a. evaluation
b. assessment
c. implementation
d. planning

15. The initial step in the PLANNING process in order to engage in any nursing project or parties at the community level involves:

a. goal-setting
b. monitoring
c. evaluation of data
d. provision of data

Situation 4 - Please continue responding as a professional nurse in these other health situations through the following questions.

16. Transmission of HIV from an infected individual to another person occurs:

a. Most frequency in nurses with needlesticks

b. Only if there is a large viral load in the blood
c. Most commonly as a result of sexual contact
d. In all infants born to women with HIV infection

17. The medical record of a client reveals a condition in which the fetus cannot pass through the maternal pelvis. The nurse interprets this
as:

a. Contracted pelvis
b. Maternal disproportion
c. Cervical insufficiency
d. Fetopelvic disproportion

18. The nurse would anticipate a cesarean birth for a client who has which infection present at the onset of labor?

a. Herpes simplex virus

b. Human papilloma virus
c. Hepatitis
d. Toxoplasmosia

19. After a vaginal examination, the nurse»e determines that the client's fetus is in an occiput posterior position. The nurse would anticipate
that the client will have:

a. A precipitous birth
b. Intense back pain
c. Frequent leg cramps
d. Nausea and vomiting

20. The rationales for using a prostaglandin gel for a client prior to the induction of labor is to:

a. Soften and efface the cervix

b. Numb cervical' pain receptors
c. Prevent cervical lacerations
d. Stimulate uterine contractions

Situation 5 - Nurse Lorena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PANNING CLIENTS AND INFERTILE
COUPLES. The following conditions pertain to meeting the nursing of this particular population group.

21. Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would be the best answer?

a. Prostaglandins released from the cut fallopian tubes can kill sperm
b. Sperm cannot enter the uterus, because the cervical entrance is blocked
c. Sperm can no longer reach the ova, because the fallopian tubes are blocked
d. The ovary no longer releases ova, as there is no where for them to go

22. The Dators are a couple undergoing testing for infertility. Infertility is said to exist when:

a. a woman has no uterus

b. a woman has no children
c. a couple has been trying to conceive for 1 year
d. a couple has wanted a child for 6 months

23. Another client names Lilia is diagnosed as having endometriosis. This condition interferes with the fertility because:

a. endometrial implants can block the fallopian tubes

b. the uterine cervix becomes inflamed and swollen
c. ovaries stop producing adequate estrogen
d. pressure on the pituitary leads to decreased FSH levels

24. Lilia is scheduled to have a hysterosalpingogram. Which of the following, instructions would you give her regarding this procedure?

a. She will not be able to conceive for 3 months after the procedure
b. The sonogram of the uterus will reveal any tumors present
c. Many women experience mild bleeding as an after effect
d. She may feel some cramping when the dye is inserted

25. Lilia's cousin on the other hand, knowing nurse Lorena's specialization asks what artificial insemination by donor entails. Which would be
your best answer if you were Nurse Lorena?

a. Donor sperm are introduced vaginally into the uterus or cervix

b. Donor sperm are injected intra-abdominally into each ovary
c. Artificial sperm are injected vaginally to test tubal patency
d. The husband's sperm is administered intravenously weekly

Situation 6 - There are other important basic knowledge in the performance of our task as Community Health Nurse in relation to
IMMUNIZATION these include:

26. The correct temperature to store vaccines in a refrigerator is:

a. between -4 deg C and +8 deg C

b. between 2 deg C and +8 deg C
c. between -8 deg C and 0 deg C
d. between -8 deg C and +8 deg C

27. Which of the following vaccines is not done by intramuscular (IM) injection?

a. Measles vaccine
b. DPT
c. Hepa B vaccines
d. DPT

28. This vaccine content is derived from RNA recombinants:

a. Measles
b. Tetanus toxoids
c. Hepatitis B vaccines
d. DPT

29. This is the vaccine needed before a child reaches one (1) year in order for him/her to qualify as a "fully immunized child".

a. DPT
b. Measles
c. Hepatitis B
d. BCG

30. Which of the following dose of tetanus toxoid is given to the mother to protect her .infant from neonatal tetanus and likewise provide 10
years protection for the mother?

a. Tetanus toxoid 3
b. Tetanus toxoid 2
c. Tetanus toxoid 1
d. Tetanus toxoid 4

Situation 7 - Records contain those, comprehensive descriptions of patient's health conditions and needs and at the same serve as evidences of
every nurse's accountability in the, care giving process. Nursing records normally differ from institution to, institution nonetheless they follow
similar patterns of .meeting needs for specifics, types of information. The following pertalos to documentation/records management.

31. This special form used when the patient is admitted to the unit. The nurse completes, the information in this records particularly
his/her .basic personal data, current illness, previous health history, health history of the family, emotional profile, environmental history as
well as physical assessment together with nursing diagnosis on admission. What do you call this record?

a. Nursing Kardex
b. Nursing Health History and Assessment Worksheet
c. Medicine and Treatment Record
d. Discharge Summary

32. These, are sheets/forms which provide an efficient and time saving way to record information that must be obtained repeatedly at
regular and/or short intervals, of .time. This does not replace the progress notes; instead this record of information on vital signs, intake and
output, treatment, postoperative care, postpartum care, and diabetic regimen, etc., this is used whenever specific measurements or
observations are needed to-be documented repeatedly. What is this?

a. Nursing Kardex
b. Graphic Flow sheets
c. Discharge Summary
d. Medicine and Treatment Record

33. These records show all medications and treatment provided on a repeated basis. What do you call this record?
a. Nursing Health History and Assessment Worksheet
b. Discharge Summary
c. Nursing Kardex
d. Medicine and Treatment Record

34. This flip-over card is usually kept in a portable file at the Nurses Station. It has 2-parts: the activity and treatment section and a nursing
care plan section. This carries information about basic demographic data, primary medical diagnosis, current orders of the physician to be
carried out by the nurse, written nursing care plan, nursing orders, scheduled tests and procedures, safety precautions in-patient care and
factors related to daily living activities/ this record is used in the charge-of-shift reports or during the beside rounds or walking rounds. What
record is this?

a. Discharge Summary
b. Medicine and Treatment Record
c. Nursing Health History and Assessment Worksheet
d. Nursing Kardex

35. Most nurses regard this as conventional recording of the date, time and mode by which the patient leaves a healthcare unit but this
record includes importantly, directs of planning for discharge that starts soon after the' person is admitted to a healthcare institution, it is
accepted that collaboration or multidisciplinary involvement (of all members of the health team) in discharge results in comprehensive care.
What do you call this?

a. Discharge Summary
b. Nursing Kardex
c. Medicine and Treatment Record
d. Nursing Health History and Assessment Worksheet

Situation 8 - As Filipino Professional Nurses we must be knowledgeable, about the Code of Ethics for Filipino Nurses and practice these by heart.
The next questions pertain to this Code of Ethics.

36. Which of the following is TRUE about the Code of Ethics of Filipino Nurses?

a. The Philippine Nurses Association for being the accredited professional organization was given the privilege to formulate a Code of Ethics
which the Board of Nurses promulgated
b. Code of Nurses was first formulated in 1982 published in the Proceedings of the Third Annual Convention of the PNA House of Delegates
c. The present code utilized the Code of Good Governance for the Professions in the Philippines
d. Certificate of Registration of registered nurses; may be revoked or suspended for violations of any provisions of the Code of Ethics

37. Based on the Code of Ethics for Filipino Nurses, what is regarded as the hallmark of nursing responsibility and accountability?

a. Human rights of clients, regardless of creed and gender

b. The privilege of being a registered professional nurses
c. Health, being a fundamental right of every individual
d. Accurate documentation of actions and outcomes

38. Which of the following nurses behavior is regarded as a violation of the Code of Ethics of Filipino Nurses?

a. A nurse withholding harmful information to the family members of a patient

b. A nurse declining commission sent by a doctor for her referral
c. A nurse endorsing a person running for congress
d. Nurse Reviewers and/or nurse review center managers who pays a considerable amount of cash for reviewees who would memorize items
from the Licensure exams and submit these to them after the examination

39. A nurse should be cognizant that professional programs for specialty certification by the Board of Nursing are accredited through the

a. Professional Regulation Commission

b. Nursing Specialty Certification Council
c. Association of Deans of Philippine Colleges of Nursing
d. Philippine Nurse Association

40. Mr. Santos, R.N. works in a nursing home, and he knows that one of his duties is to be an advocate for his patients. Mr. Santos knows a
primary duty of an advocate is to:

a. act as the patient's legal representative

b. complete all nursing responsibilities on time
c. safeguard the well being of every patient
d. maintain the patient's right to privacy

Situation 9 - Nurse Joanna works as an OB-Gyne Nurse and attends to several HIGH-RISK PREGNANCIES: Particularly women with preexisting of
Newly Acquired illness. The following conditions apply.

41. Bernadette is a 22-year old woman. Which condition would make her more prone than others to developing a Candida infection during
pregnancy?

a. Her husband plays gold 6 days a week

b. She was over 35 when she became pregnant
c. She usually drinks tomato juice for breakfast
d. She has developed gestational diabetes

42. Bernadette develops a deep-vein thrombosis following an auto accident and is prescribed heparin sub-Q. What should Joanna educate
her about in regard to this?

a. Some infants will be born with allergic symptoms to heparin

b. Her infant will be born with scattered petechiae on his trunk
c. Heparin can cause darkened skin in newborns
d. Heparin does not cross the placenta and so does not affect a fetus

43. The cousin of Bernadette with sickle-cell anemia alerted Joanna that she may need further instruction on prenatal care. Which statement
signifies this fact?

a. I've stopped jogging so I don't risk becoming dehydrated

b. I take an iron pull every day to help grown new red blood cells
c. I am careful to drink at least eight glasses of fluid everyday
d. 1 understand why folic acid is important for red cell formation

44. Bernadette routinely takes acetylsalicylic acid (aspirin) for arthritis. Why should she limit or discontinue this toward the end of
pregnancy?

a. Aspirin can lead to deep vein thrombosis following birth

b. Newborns develop a red rash from salicylate toxicity
c. Newborns develop withdrawal headaches from salicylates
d. Salicyates can lead to increased maternal bleeding at childbirth

45. Bernadette received a laceration on her leg from her automotive accident. Why are lacerations of lower extremities potentially more
serious in pregnant women than others?

a. Lacerations can provoke allergic responses because of gonadothropic hormone

b. Increased bleeding can occur from uterine pressure on leg veins
c. A woman is less able to keep the laceration clean because o f her fatigue
d. Healing is limited during pregnancy, so these will not heal until after birth

Situation 10 - Still in your self-managed Child Health Nursing Clinic, your encounter these cases pertaining to the CARE OF CHILDREN WITH
PULMONARY AFFECTIONS.

46. Josie brought her 3-rnonths old child to your clinic because of cough and colds. Which of the following is your primary action?
a. Give contrimoxazole tablet or syrup
b. Assess the patient using the chart on management of children with cough
c. Refer to the doctor
d. Teach the mother how to count her child's bearing

47. In responding to the care concerns of children with severe disease, referral to the hospital of the essence especially if the child manifests
which of the following?

a. Wheezing
b. Stopped bleeding
c. Fast breathing
d. Difficulty to awaken

48. Which of the following is the most important responsibility of a nurse in the prevention of necessary deaths from pneumonia and other
severe diseases?

a. Giving of antibiotics
b. Taking of the temperature of the sick child
c. Provision of Careful Assessment
d. Weighing of the sick child

49. You were able to identify factors that lead to respiratory problems in the community where your health facility serves. Your primary role
therefore in order to reduce morbidity due to pneumonia is to:

a. Teach mothers how to recognize early signs and symptoms of pneumonia

b. Make home visits to sick children
c. Refer cases to hospitals
d. Seek assistance and mobilize the BHWs to have a meeting with mothers

50. Which of the following is the principal focus on the CARI program of the Department of Health?

a. Enhancement of health team capabilities

b. Teach mothers how to detect signs and where to refer
c. Mortality reduction through early detection
d. Teach other community health workers how to assess patients

Situation 11 - You are working as a Pediatric Nurse in your own Child Health Nursing Clinic, the following cases pertain to ASSESSMENT AND
CARE OP THE NEWBORN AT RISK conditions.

51. Theresa, a mother with a 2 year old daughter asks, "at what are can I be able to take the blood pressure of my daughter as a routine
procedure since hypertension is common in the family?" Your answer to this is:

a. At 2 years you may

b. As early as 1 year old
c. When she's 3- years old
d. When she's 6 years old?

52. You typically gag children to inspect the back of their throat. When is it important NOT to solicit a gag reflex?

a. when a girl has a geographic tongue

b. when a boy has a possible inguinal hernia
c. when a child has symptoms of epiglottitis
d. when children are under 5 years of age

53. Baby John was given a drug at birth to reverse the effects of a narcotic given to his mother in' labor. What drug is commonly used for
this?
a. Naloxone (Narcan)
b. Morphine Sulfate
c. Sodium Chloride
d. Penicillin G

54. Why are small-for-gestational-age newborns at risks for difficulty maintaining body temperature?

a. They do not have as many fat stores as other infant’s

b. They are more active than usual so throw off covers
c. Their skin is more susceptible to conduction of cold
d. They are preterm so are born relatively small in size

55. Baby John develops hyperbilirubinemia. What is a method used to treat hyperbilirubinemia in a newborn?

a. Keeping infants in a warm arid dark environment

b. Administration of a cardiovascular stimulant
c. Gentle exercise to stop muscle breakdown
d. Early feeding to speed passage of meconium

Situation 12 - You are the nurse in the Out-Patient-Department and during your shift you encountered multiple children's condition. The
following questions apply.

56. You assessed a child with visible severe wasting, he has:

a. edema
b. LBM
c. kwashiorkor
d. marasmus

57. Which of the following conditions is NOT true about contraindication to immunization?

a. do not give DPT2 or DPT3 to a child who has convulsions within 3 days of DPT1
b. do not give BOG if the child has known hepatitis .
c. do not give OPT to a child who has recurrent convulsion or active neurologic disease
d. do not give BCG if the child has known AIDS

58. Which of the following statements about immunization is NOT true:

a. A child with diarrhea who is due for OPV should receive the OPV and make extra dose on the next visit
b. There is no contraindication to immunization if the child is well enough to go home
c. There is no contraindication to immunization if the child is well enough to go home and a child should be immunized in the health center
before referrals are both correct
d. A child should be immunized in the center before referral

59. A child with visible severe wasting or severe palmar pallor may be classified as:

a. moderate malnutrition/anemia
b. severe malnutrition/anemia
c. not very tow weight no anemia
d. anemia/very low weight

60. A child who has some palmar pallor can be classified as:

a. moderate anemia/normal weight

b. severe malnutrition/anemia
c. anemia/very low weight
d. not very low eight to anemia

Situation 13 - Nette, a nurse palpates the abdomen of Mrs. Medina, a primigravida. She is unsure of the date of her last menstrual period.
Leopold's Maneuver is done. The obstetrician told mat she appears to be 20 weeks pregnant. .

61. Nette explains this because the fundus is:

a. At the level the umbilicus, and the fetal heart can be heard with a fetoscope
b. 18 cm, and the baby is just about to move
c. is just over the symphysis, and fetal heart cannot be heard
d. 28 cm, and fetal heart can be heard with a Doppler

62. In doing Leopold's maneuver palpation which among the following is NOT considered a good preparation?

a. The woman should lie in a supine position wither knees flexed slightly
b. The hands of the nurse should be cold so that abdominal muscles would contract and tighten
c. Be certain that your hands are warm (by washing them in warm water first if necessary)
d. The woman empties her bladder before palpation

63. In her pregnancy, she experienced fatigue and drowsiness. This probably occurs because:

a. of high blood pressure

b. she is expressing pressure
c. the fetus utilizes her glucose stores and leaves her with a Sow blood glucose
d. of the rapid growth of the fetus

64. The nurse assesses the woman at 20 weeks gestation3 and expects the woman to report:

a. Spotting related to fetal implantation

b. Symptoms of diabetes as human placental lactogen is released
c. Feeling fetal kicks
d. Nausea and vomiting related HCG production

65. If Mrs. Medina comes to you for check-up on June 2, her EDO is June 11, what do you expect during assessment?

a. Fundic ht 2 fingers below xyphoid process, engaged

b. Cervix close, uneffaced, FH-midway between the umbilicus and symphysis pubis
c. Cervix open, fundic ht. 2 fingers below xyphoid process, floating .
d. Fundic height at least at the level of the xyphoid process, engaged

Situation 14: - Please continue responding as a professional nurse in varied health situations through the following questions.

66. Which of the following medications would the nurse expect the physician to order for recurrent convulsive seizures of a 10-year old child
brought to your clinic?

a. Phenobarbital
b. Nifedipine
c. Butorphanol
d. Diazepam

67. RhoGAM is given to Rh-negative women to prevent maternal sensitization from occurring. The nurse is aware that in addition to
pregnancy, Rh-negative women would also receive this medication after which of the following?

a. Unsuccessful artificial insemination procedure

b. Blood transfusion after hemorrhage
c. Therapeutic or spontaneous abortion
d. Head injury from a car accident
68. Which of the following would the nurse include when describing the pathophysiologv of gestational diabetes?

a. Glucose levels decrease to accommodate fetal growth

b. Hypoinsulinemia develops early in the first trimester
c. Pregnancy fosters the development of carbohydrate cravings
d. There is progressive resistance to the effects of insulin

69. When providing prenatal education to a pregnant woman with asthma, which of the following would be important for the nurse to do?

a. Demonstrate how to assess her blood glucose

b. Teach correct administration of subcutaneous bronchodilators
c. Ensure she seeks treatment for any acute exacerbation
d. Explain that she should avoid steroids during her pregnancy

70. Which of the following conditions would cause an insulin-dependent diabetic client the most difficulty during her pregnancy?

a. Rh incompatibility
b. Placenta previa
c. Hyperemesis gravidarum
d. Abruption placentae

Situation 15 - One important toot a community health nurse uses in the conduct of his/her activities is the CHN Bag. Which of the following
BEST DESCRIBES the use of this vital facility for our practice?

71. The Community/Public Health Bag is:

a. a requirement for home visits

b. an essential and indispensable equipment of the community health nurse
c. contains basic medications and articles used by the community health nurse
d. a tool used by the Community health nurse is rendering effective nursing procedure during a home visit

72. What is the rationale in the use of bag technique during home visit?

a. It helps render effective nursing care to clients or other members of the family
b. It saves time and effort of the nurse in the performance of nursing procedures
c. It should minimize or prevent the spread of infection from individuals to families
d. It should not overshadow concerns for the patient

73. Which among the following is important in the use of the bag technique during home visit?

a. Arrangement of the bag's contents must be convenient to the nurse

b. The bag should contain all necessary supplies and equipment ready for use
c. Be sure to thoroughly clean your bag especially when exposed to communicable disease cases
d. Minimize if not totally prevent the spread of infection

74. This is an important procedure of the nurse during home visits?

a. protection of the CHN bag

b. arrangement of the contents of the CHM bag
c. cleaning of the CHN bag
d. proper handwashing

75. In consideration of the steps in applying the bag technique, which side of the paper lining of the CHN bag is considered clean to make a
non-contaminated work area?

a. The lower lip

b. The outer surface
c. The upper lip
d. The inside surface

Situation 16 - As a Community Health Nurse relating with people in different communities, and in the implementation of health programs and
projects you experience vividly as well the varying forms of leadership and management from the Barangay Level to the Local
Government/Municipal City Level.

76. The following statements can correctly be made about Organization and management?

A. An organization (or company) is people. Values make people persons: values give vitality, meaning and direction to a company. As the people
of an organization value, so the company becomes.
B. Management is the process by which administration achieves its mission, goals, and objectives
C. Management effectiveness can be measured in terms of accomplishment of the purpose of the organization while management efficiency is
measured in terms of the satisfaction of individual motives
D. Management principles are universal therefore one need not be concerned about people, culture, values, traditions and human relations.

a. B and C only
b. A, B and D only
c. A and D only
d. B, A, and C only

77. Management by Filipino values advocates the consideration of the Filipino goals trilogy according to the Filipino priority-values which
are:

a. Family goals, national goals, organizational goals

b. Organizational goats, national goals, family goals
c. National goals, organizational goals, family goals
d. Family goals, organizational goals, national goals

78. Since the advocacy for the utilization of Filipino value-system in management has been encouraged, the Nursing sector is no except,
management needs to examine Filipino values and discover its positive potentials and harness them to achieve:

a. Employee satisfaction
b. Organizational commits .ants, organizational objectives and employee satisfaction
c. Employee objectives/satisfaction, commitments and organizational objectives
d. Organizational objectives, commitments and employee objective/satisfaction

79. The following statements can correctly be made about an effective and efficient community or even agency managerial-leader.
A. Considers the achievement and advancement of the organization she/he represents as well as his people
B. Considers the recognition of individual efforts toward the realization of organizational goals as well as the welfare of his people
C. Considers the welfare of the organization above all other consideration by higher administration
D. Considers its own recognition by higher administration for purposes of promotion and prestige

a. Only C and D are correct

b. A, C and D are correct
c. B, C, and D are correct
d. Only A and B are correct

80. Whether management at the community or agency level, there are 3 essential types of skills managers must have, these are:
A. Human relation skills, technical skills, and cognitive skills
B. Conceptual skills, human relation/behavioral skills, and technical skills
C. Technical skills, budget and accounting skills, skills in fund-raising
D. Manipulative skills, technical skills, resource management skills

a. A and D are correct

b. B is correct
c. A is correct
d. C and D are correct

Situation 17 - You are actively practicing nurse who just finished your Graduate Studies. You earned the value of Research and would like to
utilize the knowledge and skills gained in the application of research to Nursing service. The following questions apply to research.

81. Which type of research Inquiry investigates the issue of human complexity (e.g. understanding the human expertise)

a. Logical position
b. Naturalistic inquiry
c. Positivism
d. Quantitative Research

82. Which of the following studies is based on quantitative research?

a. A study examining the bereavement process in spouses of clients with terminal cancer
b. A study exploring factors influencing weight control behavior
c. A study measuring the effects of sleep deprivation on wound healing
d. A study examining client's feelings before, during and after a bone marrow aspiration

83. Which of the following studies is based on qualitative research?

a. A study examining clients reactions to stress after open heart surgery

b. A study measuring nutrition and weight, loss/gain in clients with cancer
c. A study examining oxygen levels after endotracheal suctioning
d. A study measuring differences in blood pressure before during and after a procedure

84. An 85 year old client in a nursing home tells a nurse, "I signed the papers for that research study because the doctor was so insistent and
I want: him to continue taking care of me." Which client right is being violated?

a. Right of self determination

b. Right to privacy and confidentiality
c. Right to full disclosure
d. Right not to be harmed

85. "A supposition or system of ideas that is proposed to explain a given phenomenon," best defines:

a. a paradigm
b. a concept
c. a theory
d. a conceptual framework

Situation 18 - Nurse Michelle works with a Family Nursing Team in Calbayog Province specifically handling a UNICEF Project for Children. The
following conditions pertain, to CARE OP THE FAMILIES PRESCHOOLERS.

86. Ronnie asks constant questions. How many does a typical 3-year-old ask in a day's time?

a. 1,200 or more
b. Less than 50
c. 100-200
d. 300-400

87. Ronnie will need to change to a new bed because his baby sister will need Ronnie's old crib. What measure would you suggest that his
parents take to help decrease sibling rivalry between Ronnie and his new sister?

a. Move him to the new bed before the baby arrives

b. Explain that new sisters grow up to become best friends
c. Tell him he will have to share with the new baby
d. Ask him to get his crib ready for the new baby

88. Ronnie's parents want to know how to react to him when he begins to masturbate while watching television. What would you suggest?

a. They refuse to allow him to watch television

b. They schedule a health check-up for sex-related disease
c. They remind him that some activities are private
d. They give him "timeout" when this begins

89. How many words does a typical 12-month-old infant use?

a. About 12 words
b. Twenty or more words
c. About 50 words
d. Two, plus "mama" and "dada"

90. As a nurse. You reviewed infant safety procedures with Bryan's mother. What are two of the most common types of accidents among
infants?

a. Aspiration and falls

b. Falls and auto accidents
c. Poisoning and burns
d. Drowning and homicide

Situation 19 - Among common conditions found in children especially among poor communities are ear infection/problems. The following
questions apply.

91. A child with ear problem should be assessed for the following EXCEPT:

a is there any fever?

b. ear discharge
c. if discharge is present for how long?
d. ear pain

92. If the child does not have ear problem, using IMCI, what should you as the nurse do?

a. Check for ear discharge

b. Check for tender swellings, behind the ear
c. Check for ear pain
d. Go to the next question, check for malnutrition

93. An ear discharge that has been present for more than 14 days can be classified as:

a. mastoditis
b. chronic ear infection
c. acute ear infection
d. complicated ear infection

94. An ear discharge that has been present for jess than 14 days can be classified as:

a. chronic ear infection

b. mastoditis
c. acute ear infection
d. complicated ear infection

95. If the child has severe classification because of ear problem, what would be the best thing that you as the nurse can do?
a. instruct mother when to return immediately
b. refer urgently
c. give an antibiotic for 5 days
d. dry the ear by wicking

Situation 20 - If a child with diarrhea registers one sign in the pink row and one in the yellow; row in the IMCI Chart.

96. We can classify the patient as:

a. moderate dehydration
b. some dehydration
c. no dehydration
d. severe dehydration

97. The child with no dehydration needs home treatment Which of the following is not included the rules for home treatment in this case:

a. continue feeding the child

b. give oresol every 4 hours
c. know when to return to the health center
d. give the child extra fluids

98. A child who has had diarrhea for 14 days but has no sign of dehydration is classified as:

a. severe persistent diarrhea

b. dysentery
c. severe dysentery b. dysentery
d. persistent diarrhea

99. If the child has sunken eyes, drinking eagerly, thirsty and skin pinch goes back slowly, the classification would be:

a. no dehydration
b. moderate dehydration
c. some dehydration
d. severe dehydration

100. Carlo has had diarrhea for 5 days. There is no blood in the stool, he is irritable. His eyes are sunken the nurse offers fluid to Carlo and he
drinks eagerly. When the nurse pinched the abdomen, it goes back slowly. How will you classify Carlo’s illness?

a. severe dehydration
b. no dehydration
c. some dehydration
d. moderate dehydration

ANSWER KEY:
1. A
2. B
3. A
4. C
5. B
6. D
7. C
8. D
9. A
10. B
11. D
12. D
13. A
14. B
15. A
16. C
17. D
18. A
19. B
20. D
21. C
22. C
23. A
24. C
25. A
26. B
27. A
28. C
29. B
30. D
31. B
32. B
33. D
34. D
35. A
36. C
37. C
38. A
39. B
40. C
41. D
42. D
43. B
44. D
45. B
46. B
47. D
48. C
49. A
50. C
51. C
52. C
53. A
54. A
55. D
56. D
57. B
58. A
59. B
60.
61. A
62. B
63. D
64. C
65. A
66. A
67. C
68. D
69. C
70. C
71. B
72. A
73. D
74. D
75. B
76. D
77. D
78. D
79. D
80. C
81. B
82. C
83. A
84. A
85. C
86. D
87. A
88. C
89. A
90. A
91. A
92. D
93. B
94. C
95. B
96. D
97. B
98. D
99. C
100. C

FOUNDATION OF PROFESSIONAL NURSING PRACTICE

Situation 1 - Mr. Ibarra is assigned to the triage area and while on duty, he assesses the condition of Mrs. Simon who came in with asthma. She
has difficulty breathing and her respiratory rate is 40 per minute. Mr. Ibarra is asked to inject the client epinephrine 0.3mg subcutaneously

1. The indication for epinephrine injection for Mrs Simon is to:

a. Reduce anaphylaxis
b. Relieve hypersensitivity to allergen
c. Relieve respirator distress due to bronchial spasm
d. Restore client’s cardiac rhythm

2. When preparing the epinephrine injection from an ampule, the nurse initially:

a. Taps the ampule at the top to allow fluid to flow to the base of the ampule
b. Checks expiration date of the medication ampule
c. Removes needle cap of syringe and pulls plunger to expel air
d. Breaks the neck of the ampule with a gauze wrapped around it

3. Mrs. Simon is obese. When administering a subcutaneous injection to an obese patient, it is best for the nurse to:

a Inject needle at a 15 degree angle' over the stretched skin of the client
b. Pinch skin at the Injection site and use airlock technique
c. Pull skin of patient down to administer the drug in a Z track
d. Spread skin or pinch at the injection site and inject needle at a 45-90 degree angle

4. When preparing for a subcutaneous injection, the proper size of syringe and needle would be:

a. Syringe 3-5ml and needle gauge 21 to 23

b. Tuberculin syringe 1 mi with needle gauge 26 or 27
c. Syringe 2ml and needle gauge 22
d. Syringe 1-3ml and needle gauge 25 to 27

5. The rationale for giving medications through the subcutaneous route is;

a. There are many alternative sites for subcutaneous injection

b. Absorption time of the medicine is slower
c. There are less pain receptors in this area
d. The medication can be injected while the client is in any position

Situation 2 - The use of massage and meditation to help decrease stress and pain have been strongly recommended based on documented
testimonials.

6. Martha wants to do a study on, this topic. "Effects of massage and meditation on stress and pain." The type of research that best suits this
topic is:

a. applied research
b. qualitative research
c. basic research
d. quantitative research

7. The type of research design that does not manipulate independent variable is:

a. experimental design
b. quasi-experimental design
c. non-experimental design
d. quantitative design

8. This research topic has the potential to contribute to nursing because it seeks to:

a. include new modalities of care

b. resolve a clinical problem
c. clarify an ambiguous modality of care
d. enhance client care

9. Martha does review of related literature for the purpose of:

a. determine statistical treatment of data research

b. gathering data about what is already known or unknown
c. to identify if problem can be replicated
d. answering the research question

10. Client’s rights should be protected when doing research using human subjects. Martha identifies these rights as follows EXCEPT:

a. right of self-determination
b. right to compensation
c. right of privacy
d. right not to be harmed
Situation 3 - Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of
retained secretions. Part of Nurse Mario's nursing care plan is to loosen and remove excessive secretions in the airway,

11. Mario listens to Richard's bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain
the anterior and posterior apical segments of the lungs when Mario does percussion would be:

a. Client lying on his back then flat on his abdomen on Trendelenburg position
b. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdomen
c. Client lying flat on his back and then flat on his abdomen
d. Client lying on his right then left side on Trendelenburg position

12. When documenting outcome of Richard's treatment Mario should include the following in his recording EXCEPT:

a. Color, amount and consistent of sputum

b. Character of breath sounds and respirator/rate before and after procedure
c. Amount of fluid intake of client before and after the procedure
d. Significant changes in vital signs

13. When assessing Richard for chest percussion or chest vibration and postural drainage Mario would focus on the following EXCEPT:

a. Amount of food and fluid taken during the last meal before treatment
b. Respiratory rate, breath sounds and location of congestion
c. Teaching the client's relatives to perform 'the procedure
d. Doctor's order regarding position restriction and client's tolerance for lying flat

14. Mario prepares Richard for postural drainage and percussion. Which of the flowing is a special consideration when doing the procedure?

a. Respiratory rate of 16 to 20 per minute

b. Client can tolerate sitting and lying position
c. Client has no signs of infection
d. Time of fast food and fluid intake of the client

15. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedure is;

a. Percussion uses only one hand white vibration uses both hands
b. Percussion delivers cushioned blows to the chest with cupped palms while gently shakes secretion loose on the exhalation cycle
c. In both percussion and vibration the hands are on top of each other and hand action is in tune with client's breath rhythm
d. Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the inhalation of air

Situation 4 - A 61 year old man, Mr. Regalado, is admitted to the private ward for observation; after complaints of severe chest pain. You are
assigned to take care of the client.

16. When doing an initial assessment, the best way for you to identify the client’s priority problem is to:

a. Interview the client for chief complaints and other symptoms

b. Talk to the relatives to gather data about history of illness
c. Do auscultation to check for chest congestion
d. Do a physical examination white asking the client relevant questions

17. Upon establishing Mr. Regalado's nursing needs, the next nursing approach would be to:

a. introduce the client to the ward staff to put the client and family at ease
b. Give client and relatives a brief tour of the physical set up the unit
c. Take his vital signs for a baseline assessment
d. Establish priority needs and implement appropriate interventions

18. Mr. Regalado says he has "trouble going to sleep". In order to plan your nursing intervention you will.
a. Observe his sleeping patterns in the next few days
b. Ask him what he means by this statement
c. Check his physical environment to decrease noise level
d. Take his blood pressure before sleeping and upon waking up

19. Mr. Regalado's lower extremities are swollen and shiny. He has pitting pedal edema. When taking care of Mr. Regalado, which of the
following intervention would be the most appropriate immediate nursing approach.

a. Moisturize lower extremities to prevent skin irritation

b. Measure fluid intake and output to decrease edema
c. Elevate lower extremities for postural drainage
d. Provide the client a list of food low in sodium

20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client for discharge include all EXCEPT:

a. Making a final physical assessment before client leaves the hospital

b. Giving instructions about his medication regimen
c. Walking the client to the hospital exit to ensure his safety
d. Proper recording of pertinent data

Situation 5 - Nancy, mother of 2 young kids. 36 years old, had a mammogram and was told that she has breast cysts and that she may need
surgery. This causes her anxiety as shown by increase in her pulse and respiratory rate, sweating and feelings of tension.

21. Considering her level of anxiety, the nurse can best assist Nancy by:

a. Giving her activities to divert her attention

b. Giving detailed explanations about the treatments she will undergo
c. Preparing her and her family in case surgery is not successful
d. Giving her clear but brief information at the level of her understanding

22. Nancy blames God for her situation. She is easily provoked to tears and wants to be left alone, refusing to eat or talk to her family. A
religious person before, she now refuses to pray or go to church stating that God has abandoned her. The nurse understands that Nancy is
grieving for her self and is in the stage of:

a. bargaining
b. denial
c. anger
d. acceptance

23. The nurse visits Nancy and prods her to eat her food. Nancy replies "what's the use? My time is running out. The nurse's best response
would be:

a. "The doctor ordered full diet for you so that you will be strong for surgery."
b. "I understand how you fee! but you have 1o try for your children's sake."
c. "Have you told your, doctor how you feel? Are you changing your mind) about surgery?"
d. "You sound like you are giving up."

24. The nurse feels sad about Nancy's illness and tells her head nurse during the end of shift endorsement that "it's unfair for Nancy to have
cancer when she is still so young and with two kinds. The best response of the head nurse would be:

a. Advise the nurse to "be strong and learn to control her feelings"
b. Assign the nurse to another client to avoid sympathy for the client
c. Reassure the nurse that the client has hope if she goes through all statements prescribed for her
c. Ask the other nurses what they feel about the patient to find out if they share the same feelings

25. Realizing that she feels angry about Nancy's condition, the nurse Seams that being self-aware is a conscious process that she should do in
any situation like this because:

a. This is a necessary part of the nurse -client relationship process

b. The nurse is a role model for the client and should be strong
C. How the nurse thinks and feels affect her actions towards her client and her work
d. The nurse has to be therapeutic at all times and should not be affected

Situation 6 – Mrs. Seva, 32 years old, asks you about possible problems regarding her elimination now that she is in the menopausal stage.

26. Instruction on health promotion regarding urinary elimination is important. Which would you include?

a. Hold urine, as long as she can before emptying the bladder to strengthen her sphincters muscles
b. If burning sensation is experienced while voiding, drink pineapple-juice
c. After urination, wipe from anal area up towards the pubis
d. Jell client to empty the bladder at each voiding

27. Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical changes predispose her to constipation?

a. inhibition of the parasympathetic reflex

b. weakness of sphincter muscles of the anus
c. loss of tone of the smooth muscles of the color
d. decreased ability to absorb fluids in the lower intestines

28. The nurse understands that one of these factors contributes to constipation:

a. excessive exercise
b. high fiber diet
c. no regular tine for defecation daily
d. prolonged use of laxatives

29. Mrs. Seva talks about rear of being incontinent due to a prior experience of dribbling urine when laughing or sneezing and when she has
a full bladder. Your most appropriate .instruction would be to:

a. tell client to drink less fluids to avoid accidents

b. instruct client to start wearing thin adult diapers
c. ask the client to bring change of underwear "just in case"
d. teach client pelvic exercise to strengthen perineal muscles

30. Mrs. Seva asked for instructions for skin care for her mother who has urinary incontinence and is almost always in bed. Your instruction
would focus on prevention of skin irritation and breakdown by

a. Using thick diapers to absorb urine well

b. Drying the skin with baby powder to prevent or mask the smell of ammonia
c. Thorough washing, rising and during of skin area that get wet with urine
d. Making sure that linen are smooth and dry at all times

Situation 7 - Using Maslow's need theory, Airway, Breathing and Circulation are the physiological needs vital to life. The nurse's knowledge and
ability to identify and immediately intervene to meet these needs is important to save lives.

31. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues:

a. Carol with a tumor in the brain

b. Theresa with anemia
c. Sonny Boy with a fracture in the femur
d. Brigette with diarrhea

32. You noted from the lab exams in the chart of Mr. Santos that he has reduced oxygen in the blood.
This condition is called:

a. Cyanosis
b. Hypoxia
c. Hypoxemia
d. Anemia

33. You will nasopharyngeal suctioning Mr. Abad. Your guide for the length of insertion of the tubing for an adult would be:

a. tip of the nose to the base of the .neck

b. the distance from the tip of the nose to the middle of the cheek
c. the distance from the tip of the nose to the tip of the ear lobe
d. eight to ten inches

34. While doing nasopharyngeal suctioning on .Mr. Abad, the nurse can avoid trauma to the area by:

a. Apply suction for at least 20-30 seconds each time to ensure that all secretions are removed
b. Using gloves to prevent introduction of pathogens to the respiratory system
c. Applying no suction while inserting the catheter
d. Rotating catheter as it is inserted with gentle suction

35. Myrna has difficulty breathing when on her back and must sit upright in bed to breath, effectively and comfortably. The nurse documents
this condition as:

a. Apnea
b. Orthopnea
c. Dyspnea
d. Tachypnea

Situation 8 - You are assigned to screen for hypertension: Your task is to take blood pressure readings and you are informed about avoiding the
common mistakes in BP taking that lead to 'false or inaccurate blood pressure readings.

36. When taking blood pressure reading the cuff should be:

a. deflated fully then immediately start second reading for same client
b deflated quickly after inflating up to 180 mmHg
c. large enough to wrap around upper arm of the adult client 1 cm above brachial artery
d. inflated to 30 mmHg above the estimated systolic BP based on palpation of radial or bronchial artery

37. Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of death worldwide and is a preventable disease. The
primary cause of COPD is:

a. tobacco hack
b. bronchitis
c. asthma
d. cigarette smoking

38. In your health education class for clients with diabetes you teach, them the areas, for control . Diabetes which include all EXCEPT:

a. regular physical activity

b. thorough knowledge of foot care
c. prevention nutrition
d. proper nutrition

39. You teach your clients the difference between, Type I (IDDM) and Type II (NDDM) Diabetes. Which of the following is true?

a. both types diabetes mellitus clients are all prone to developing ketosis
b. Type II (NIDDM) is more common and is also preventable compared to Type I (IDDM) diabetes which is genetic in etiology
c. Type I (IDDM) is characterized by fasting hyperglycemia
d. Type II (IDDM) is characterized by abnormal immune response

40. Lifestyle-related diseases in general share areas common risk factors. These are the following except
a. physical activity
b. smoking
c. genetics
d. nutrition

Situation 9 - Nurse Rivera witnesses a vehicular accident near the hospital where she works. She decides to get involved and help the victims of
the accident.

41. Her priority nursing action would be to:

a. Assess damage to property

b. Assist in the police investigation since she is a witness
c. Report the incident immediately to the local police authorities
d. Assess the extent of injuries incurred by the victims, of the accident

42. Priority attention should be given to which of these clients?

a. Linda who shows severe anxiety due to trauma of the accident

b. Ryan who has chest injury, is pate and with difficulty of breathing
c. Noel who has lacerations on the arms with mild-bleeding
c. Andy whose left ankle swelled and has some abrasions

43. In the emergency room, Nurse Rivera is assigned to attend to the client with .lacerations on the arms, while assessing the extent of the
wound the nurse observes that the wound is now starting to bleed profusely. The most immediate nursing action would be to:

a. Apply antiseptic to prevent infection

b. Clean the wound vigorously of contaminants
c. Control and. reduce bleeding of the wound
d. Bandage the wound and elevate the arm

44. The nurse applies pressure dressing on the bleeding site. This intervention is done to:

a. Reduce the need to change dressing frequently

b. Allow the pus to surface faster
c. Protect the wound from micro organisms in the air
d. Promote hemostasis

45. After the treatment, the client is sent home and asked to come back for follow-up care. Your responsibilities when the client is to be
discharged include the following EXCEPT:

a. Encouraging the client to go to the, outpatient clinic for follow up care

b. Accurate recording, of treatment done and instructions given to client
c. Instructing the client to see you after discharge for further assistance
d. Providing instructions regarding wound care

Situation 10 - While working in the clinic, a new client, Geline, 35 years old, arrives for her doctor's appointment. As the clinic nurse, you are to
assist the client fiil up forms, gather data and make an assessment.

46. The nurse purpose of your initial nursing interview is to:

a. Record pertinent information in the client chart for health team to read
b Assist the client find solutions to her health concerns
c. Understand her lifestyle, health needs and possible problems to develop a plan of care
d. Make nursing diagnoses for identified health problems

47. While interviewing Geline, she starts to moan and doubles up in pain, She tells you that this pain occurs about an hour after taking black
coffee without breakfast for a few weeks now. You will record this as follows:

a. Claims to have abdominal pains after intake of coffee unrelieved by analgesics

b. After drinking coffee, the client experienced severe abdominal pain
c. Client complained of intermittent abdominal pain an hour after drinking coffee
d. Client reported abdominal pain an hour after drinking black coffee for three weeks now

48. Geline tells you that she drinks black coffee frequently within the day to "have energy and be wide awake" and she eats nothing for
breakfast and eats strictly vegetable salads for lunch and dinner to lose weight. She has lost weight during the past two weeks, in planning a
healthy balanced diet with Geline, you will:

a. Start her off with a cleansing diet to free her body of toxins then change to a vegetarian, diet and drink plenty of fluids
b. Plan a high protein, diet; low carbohydrate diet for her considering her favorite food
c. Instruct her to attend classes in nutrition to find food rich in complex carbohydrates to maintain daily high energy level
d. Discuss with her the importance of eating a variety of food from the major food groups with plenty of fluids

49. Geline tells you that she drinks 4-5 cups of black coffee and diet cola drinks. She also smokes up to a pack of cigarettes daily. She
confesses that she is in her 2nd month of pregnancy but she does not want to become fat that is why she limits her food intake. You warn or
caution her about which of the following?

a. Caffeine products affect the central nervous system and may cause the mother to have a "nervous breakdown"
b. Malnutrition and its possible effects on growth and development problems in the unborn fetus
c. Caffeine causes a stimulant effect on both the mother and the baby
d. Studies show conclusively that caffeine causes mental retardation

50. Your health education plan for Geline stresses proper diet for a pregnant woman and the prevention of non-communicable diseases that
are influenced by her lifestyle these include of the following EXCEPT:

a. Cardiovascular diseases
b. Cancer
c. Diabetes Mellitus
d. Osteoporosis

Situation 11 - Management of nurse practitioners is done by qualified nursing leaders who have had clinical experience and management
experience.

51. An example of a management function of a nurse is:

a. Teaching patient do breathing and coughing exercises

b. Preparing for a surprise party for a client
c. Performing nursing procedures for clients
d. Directing and evaluating the staff nurses

52. Your head nurse in the unit believes that the staff nurses are not capable of decision making so she makes the decisions for everyone
without consulting anybody. This type of leadership is:

a. Laissez faire leadership

b. Democratic leadership
c. Autocratic leadership
d. Managerial leadership

53. When the head nurse in your ward plots and approves your work schedules and directs your work, she is demonstrating:
a. Responsibility
b. Delegation
c. Accountability
d. Authority

54. The following tasks can be safely delegated' by a nurse to a non-nurse health worker EXCEPT:

a. Transfer a client from bed to chair

b. Change IV infusions
c. Irrigation of a nasogastric tube
d. Take vital signs

55. You made a mistake in giving the medicine to the wrong client You notify the client’s doctor and write an incident report. You are
demonstrating:

a. Responsibility
b. Accountability
c. Authority
d. Autocracy

Situation 12 – Mr. Dizon, 84 years old, is brought to the .Emergency Room for complaint of hypertension flushed face, severe headache, and
nausea. You are doing the initial assessment of vital signs.

56. You are to measure the client’s initial blood pressure reading by doing all of the following EXCEPT:

a. Take the blood pressure reading on both arms for comparison

b. Listen to and identify the phases of Korotkoff’s sounds
c. Pump the cuff up to around 50 mmHg above the point where the pulse is obliterated
d. Observe procedures for infection control

57. A pulse oximeter is attached to Mr. Dizon’s finger to:

a. Determine if the client’s hemoglobin level is low and if he needs blood transfusion
b. Check level of client’s tissue perfusion
c. Measure the efficacy of the client’s anti hypertensive medications
d. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops

58. After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an order of hourly monitoring of blood pressure. The
nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be:

a. Inconsistent
b. low systolic and high diastolic pressure
c. higher than what the reading should be
d. lower than what the reading should be

59. Through the client’s health history, you gather that Mr. Dizon smokes and drinks coffee. When taking the blood pressure of a client who
recently smoked or drank coffee, how long should be the nurse wait before taking the client’s blood pressure for accurate reading?

a. 15 minutes
b. 30 minutes
c. 1 hour
d. 5 minutes

60. While the client has the pulse oximeter on his fingertip, you notice that the sunlight is shining on .the area where the oximeter is. Your
action will be to:

a. Set and turn on the alarm of the oximeter

b. Do nothing since there is no identified problem
c. Cover the fingertip sensor with a towel or bedsheet
d. Change the location of the sensor every four hours

Situation 13 - The nurse's understanding of ethico-legal responsibilities will guide his/her nursing practice.

61. The principles that .govern right and proper conducts of a person regarding life, biology and the health professions is referred to as:

a. Morality
b. Religion
c. Values
d. Bioethics

62. The purpose of having nurses’ code of ethics is:

a. Delineate the scope and areas of nursing practice

b. Identify nursing action recommended for specific healthcare situations
c. To help the public understand professional conduct, expected of nurses
d. To define the roles and functions of the health care giver, nurses, clients

63. The most important nursing responsibility where ethical situations emerge in patient care is to:

a. Act only when advised that the action is ethically sound

b. Not take sides remain neutral and fair
c. Assume that ethical questions are the responsibility: of the health team
d. Be accountable for his or her own actions

64. You inform the patient about his rights which include the following EXCEPT:

a. Right to expect reasonable continuity of care

b. Right to consent to or decline to participate in research studies or experiments
c. Right to obtain information about another patient
d. Right to expect that the records about his care will be treated as confidential

65. The principle states that a person has unconditional worth and has the capacity to determine his own destiny.

a. Bioethics
b. Justice
c. Fidelity
d. Autonomy

Situation 14 – Your director of nursing wants to improve the quality of health care offered in the hospital. As a staff nurse in that hospital you
know that this entails quality assurance programs.

66. The following mechanisms can be utilized as part of the quality assessment program of your hospital EXCEPT:

a. Patient satisfaction surveys provided

b. Peer review clinical records of care of client
c. RO of the Nursing Intervention Classification
d.

67. The nurse of the Standards of Nursing Practice is important in the hospital. Which of the following statements best describes what it is?

a. These are statements that describe the maximum or highest level of acceptable performance in nursing practice.
b. It refers to the scope of nursing as defined in Republic Act 9173
c. It is a license issued by the Professional Regulation Commission to protect the public from substandard nursing practice.
d. The Standards of care includes the various steps of the nursing process and the standards of professional performance.
68. You are taking care of critically ill client and the doctor in charge calls to order a DNR (do not resuscitate) for the client. Which of the
following is the appropriate action when getting DNR order over the phone?

a. Have the registered nurse, family spokesperson, nurse supervisor and doctor sign
b. Have two nurses validate the phone order, both nurses sign the order and the doctor should sign his order within 24 hours.
c. Have the registered nurse, family and doctor sign the order
d. Have 1 nurse take the order and sign it and have the doctor sign it within 24 hours

69. To ensure the client safety before starting blood transfusion the following are needed before the procedure can be done EXCEPT:

a. take baseline vital signs

b. blood should be warmed to room temperature for 30 minutes before blood transfusion is administered
c. have two nurses verify client identification, blood type, unit number and expiration date of blood
d. get a consent signed for blood transfusion

70. Part of standards of care has to do with the use of restraints. Which of the following statements is NOT true?

a. Doctor’s order for restraints should be signed within 24 hours

b. Remove and reapply restraints every two hours
c. Check client’s pulse, blood pressure and circulation every four hours
d. Offer food and toileting every two hours

Situation 15 – During the NUTRITION EDUCATION class discussion a 58 year old man, Mr. Bruno shows increased interest.

71. Mr. Bruno asks what the "normal" allowable salt intake is. Your best response to Mr. Bruno is:

a. 1 tsp of salt/day with iodine and sprinkle of MSG

b. 5 gms per day or 1 tsp of table salt/day
c. 1 tbsp of salt/day with some patis and toyo
d. 1 tsp of salt/day but not patis or toyo

72. Your instructions to reduce or limit salt intake include all the following EXCEPT:
a. eat natural food with little or no salt added
b. limit use of table salt and use condiments instead
c. use herbs and spices
d. limit intake of preserved or processed food

73. Teaching strategies and approaches when giving nutrition education is influenced by age, sex and immediate concerns of the group. Your
presentation for a group of young mothers would be best if you focus on:

a. diets limited in salt and fat

b. harmful effect on drugs and alcohol intake
c. commercial preparation of dishes
d. cooking demonstration and meal planning

74. Cancer cure is dependent on

a. use of alternative methods of healing

b. watching out for warning signs of cancer
c. proficiency in doing breast self-examination
d. early detection and prompt treatment

75. The role of the health worker in health education is to:

a. report incidence of non-communicable disease to community health center

b. educate as many people about warning signs of non-communicable diseases
c. focus on smoking cessation projects
d. monitor clients with hypertension

Situation 16 – You are assigned to take care of 10 patients during the morning shift. The endorsement includes the IV infusion and medications
for these clients.

76. Mr. Felipe, 36 years old is to be given 2700ml of D5RL to infuse for 18 hours starting at 8am. At what rate should the IV fluid be flowing
hourly?

a. 100 ml/hour
b. 210 ml/hour
c. 150 ml/hour
d. 90 ml/hour

77. Mr. Atienza is to receive 150mg/hour of D5W IV infusion for 12 hours for a total of 1800ml. He is also losing gastric fluid which must be
replaced every two hours. Between 8am to 10am. Mr. Atienza has lost 250ml of gastric fluid. How much fluid should he receive at 11am?

a. 350 ml/hour
b. 275 ml/hour
c. 400 ml/hour
d. 200 ml/hour

78. You are to apply a transdermal patch of nitroglycerin to your client. The following important guidelines to observe EXCEPT:

a. Apply to hairlines clean are of the skin not subject to much wrinkling
b. Patches may be applied to distal part of the extremities like forearm
c. Change application and site regularly to prevent irritation of the skin
d. Wear gloves to avoid any medication of your hand

79. You will be applying eye drops to Miss Romualdez. After checking all the necessary information and cleaning the affected eyelid and
eyelashes you administer the ophthalmic drops by instilling the eye drops.

a. directly onto the cornea

b. pressing on the lacrimal duct
c. into the outer third of the lower conjunctival sac
d. from the inner canthus going towards the side of the eye

80. When applying eye ointment, the following guidelines apply EXCEPT:

a. squeeze about 2 cm of ointment and gently close but not squeeze eye
b. apply ointment from the inner canthus going outward of the affected eye
c. discard the first bead of the eye ointment before application because the tube likely to expel more than desired amount of ointment
d. hold the tube above the conjunctival sac do not let tip touch the conjuctiva

Situation 17 – The staff nurse supervisor request all the staff nurses to “brainstorm” and learn ways to instruct diabetic clients on self-
administration of insulin. She wants to ensure that there are nurses available daily to do health education classess.

81. The plan of the nurse supervisor is an example of

a. in service education process

b. efficient management of human resources
c. increasing human resources
d. primary prevention

82. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an unlicensed staff, Mrs. Guevarra.

a. makes the assignment to teach the staff member

b. is assigning the responsibility to the aide but not the accountability for those tasks
c. does not have to supervise or evaluate the aide
d. most know how to perform task delegated

83. Connie, the-new nurse, appears tired and sluggish and lacks the enthusiasms she give six weeks ago when she started the job. The nurse
supervisor should:

a. empathize with the nurse and listen to her

b. tell her to take the day off
c. discuss how she is adjusting to her new job
d. ask about her family life

84. Process of formal negotiations of working conditions between a group of registered nurses and employer is:

a. grievance
b. arbitration
c. collective bargaining
d. strike

85. You are attending a certification program on cardiopulmonary resuscitation (CPR) offered and required by the hospital employing you.
This is;

a. professional course towards credits

b. in-service education
c. advance training
d. continuing education

Situation 18 - There are various developments in health education that the nurse should know about.

86. The provision of health information in the rural areas nationwide through television and radio programs and video conferencing is
referred to as:

a. Community health program

b. Telehealth program
c. Wellness program
d. Red cross program

87. A nearby community provides blood pressure screening, height and weight measurement smoking cessation classes and aerobics class
services. This type of program is referred to as:

a. outreach program
b. hospital extension program
c. barangay health center
d. wellness center

88. Part of teaching client in health promotion is responsibility for one’s health. When Danica states she need to improve her nutritional
status this means:

a. Goals and interventions to be followed by client are based on nurse's priorities

b. Goals and intervention developed by nurse and client should be approved by the doctor
c. Nurse will decide goals and, interventions needed to meet client goals
d. Client will decide the goals and interventions required to meet her goals

89. Nurse Beatrice is providing tertiary prevention to Mrs. De Villa. An example of tertiary provestion is:

a. Marriage counseling
b. Self-examination for breast cancer
c. Identifying complication of diabetes
d. Poison, control

90. Mrs. Ostrea has a schedule for Pap Smear. She has a strong family history of cervical cancer. This is an example of:

a. tertiary prevention
b. secondary prevention
c. health screening
d. primary prevention

Situation: 19 - Ronnie has a vehicular accident where he sustained injury to his left ankle. In the Emergency Room, you notice how anxious he
looks.

91. You establish rapport with him and to reduce his anxiety you initially

a. Take him to the radiology, section for X-ray of affected extremity

b. Identify yourself and state your purpose in being with the client
c. Talk to the physician for an order of Valium
d. Do inspection and palpation to check extent of his injuries

92. While doing your assessment, Ronnie asks you "Do I have a fracture? I don't want to have a cast.” The most appropriate nursing
response would be:

a. "You have to have an X-ray first to know if you have a fracture."

b. "Why do you; sound so scared? It is just a cast and it's not painful"
c. "You seem to be concerned about being in a cast."
d. "Based on my assessment, there doesn’t seem to be a fracture."

ANSWER KEY
1. C
2. B
3. D
4. D
5. B
6. B
7. C
8. D
9. B
10. B
11. B
12. C
13. C
14. D
15. A
16. A
17. C
18. B
19. A
20. C
21. D
22. C
23. D
24. D
25. C
26. D
27. C
28. D
29. D
30. C
31. B
32. C
33. C
34. C
35. B
36. D
37. D
38. B
39. B
40. C
41. D
42. B
43. D
44. D
45. C
46. C
47. D
48. D
49. B
50. D
51. D
52. C
53. D
54. B
55. B
56. C
57. D
58. C
59. B
60. C
61. D
62. C
63. D
64. C
65. D
66. D
67. A
68. D
69. D
70. C
71. B
72. B
73. D
74. D
75. B
76. C
77. -
78. B
79. B
80. C
81. C
82. B
83. C
84. C
85. B
86. B
87. A
88. D
89. C
90. B
91. B
92. C

Situation 1 - Concerted work efforts among members of the surgical team is essential to the success of the surgical procedure.

1. The sterile nurse or sterile personnel touch only sterile supplies and instruments. When there is a need for sterile supply which is not in
the sterile field, who hands out these items by opening its outer cover?

a. Circulating nurse
b. Anesthesiologist
c. Surgeon
d. Nursing aide

2. The OR team performs distinct roles for one surgical procedure to be accomplished within a prescribed time frame and deliver a standard
patient outcome. White the surgeon performs the surgical procedure, who monitors the status of the client like urine output, blood loss?

a. Scrub nurse
b. Surgeon
c. Anesthesiologist
d. Circulating nurse

3. Surgery schedules are communicated to the OR usually a day prior to the procedure by the nurse of the floor or ward where the patient is
confined. For orthopedic cases, what department is usually informed to be present in the OR?

a. Rehabilitation department
b. Laboratory department
c. Maintenance department
d. Radiology department

4. Minimally invasive surgery is very much into technology. Aside from the usual surgical team who else to be present when a client
undergoes laparoscopic surgery?

a. Information technician
b. Biomedical technician
c. Electrician
d. Laboratory technicial

5. In massive blood loss, prompt replacement of compatible blood is crucial. What department needs to be alerted to coordinate closely
with the patient's family for immediate blood component therapy?

a. Security Division
b. Chaplaincy
c. Social Service Section
d. Pathology department

Situation 2 - You are assigned in the Orthopedic Ward where clients are complaining of pain in varying degrees upon movement of body parts.

6. Troy is a one day post open reduction and internal fixation (ORIF) of the left hip and is in pain. Which of the following observation would
prompt you to call the doctor?
a. Dressing is intact but partially soiled
b. Left foot is cold to touch and pedal pulse is absent
c. Left leg in limited functional anatomic position
d. BP 114/78, pulse of 82 beats/minute

7. There is an order of Demerol 50 mg I.M. now and every 6 hours p r n. You injected Demerol at 5 pm. The next dose of Demerol 50 mg I.M.
is given:

a. When the client asks for the next dose

b. When the patient is in severe pain
c. At 11pm
d. At 12pm

8. You continuously evaluate the client's adaptation to pain. Which of the following behaviors-indicate appropriate adaptation?

a. The client reports pain reduction and decreased activity

b. The client denies existence of pain
c. The client can distract himself during pain episodes
d. The client reports independence from watchers

9. Pain in Ortho cases may not be mainly due to the surgery. There might be other factors such as cultural or psychological that influence
pain. How can you alter these factors as the nurse?

a. Explain all the possible interventions that may cause the client to worry.
b. Establish trusting relationship by giving his medication on time
c. Stay with the client during pain episodes
d. Promote client's sense of control and participation in pain control by listening to his concerns

10. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?

a. Instruct client to observe strict bed rest

b. Check for epidural catheter drainage
c. Administer analgesia through epidural catheter as prescribed
d. Assess respiratory rate carefully

Situation 3 - Records are vital tools in any institution and should be properly maintained for specific use and time.

11. The patient's medical record can work as a double-edged swords. When can the medical record become the doctor's/nurse worst
enemy?

a. When the record is voluminous

b. When a medical record is subpoenaed in court
c. When it is missing
d. When the medical record is inaccurate, incomplete, and inadequate

12. Disposal of medical records in government hospitals/institutions must be done in close coordination with what agency?

a. Department of Interior and Local Government (DILG)

b. Metro Manila Development Authority (MMDA)
c. Records Management Archives Office (RMAO)
d. Depart of Health (DOH)

13. In the hospital, when you need-the medical record of a discharged patient for research, you will request permission through:

a. Doctor in charge
b. The hospital director
c. The nursing Service
d. Medical records section

14. You readmitted a client who was in another department a month ago. Since you will need the previous chart, from whom do you request
the old chart?

a. Central supply section

b. Previous doctor's clinic
c. Department where the patient was previously admitted
d. Medical records section

15. Records Management and Archives Offices of the DOH is responsible for implementing its policies on record, disposal. You know that
your institution is covered by this policy it;

a. Your hospital is considered tertiary

b. Your hospital is in Metro Manila
c. It obtained permit to operate from DOH
d. Your hospital is Philhealth accredited

Situation 4 - In the OR, there are safety protocols that should be followed. The OR nurse should be well versed with all these to safeguard the
safety and quality to patient delivery outcome.

16. Which of the following should be given highest priority when receiving patient in the OR?

a. Assess level of consciousness

b. Verify patient identification and informed consent
c. Assess vital signs
d. Check for jewelry, gown, manicure and dentures

17. Surgeries like I and D (incision and drainage) and debribement are relatively short procedures but considered ‘dirty cases’. When are
these; procedures best scheduled?

a. Last case
b. In between cases
c. According to availability of anesthesiologist
d. According to the surgeon's preference

18. OR nurses should be aware that maintaining the client's safety is the overall goal of nursing care during the intraoperative phase. As the
circulating nurse, you make certain that throughout the procedure...

a. the surgeon greets his client before induction of anesthesia

b. the surgeon and anestheriologist are in tandem
c. strap made of strong non-abrasive material are fastened securely around the joints of the knees and ankles and around the 2 hands around
an arm board
d. client is monitored throughout the surgery by the assistant anesthesiologist

19. Another nursing check that should not be missed before the induction of general anesthesia is:

a. check for presence underwear

b. check for presence dentures
c. check patient's
d. check baseline vital signs

20. Some different habits and hobbies affect postoperative respiratory function. If your client smokes 3 packs of cigarettes a day for the part
10 years, you will anticipate increased risk for:

a. perioperative anxiety and stress

b. delayed coagulation time
c. delayed wound healing
d. postoperative respiratory function

Situation 5 - Nurses hold a variety of roles when providing care to a perioperative patient.

21. Which of the following role would be the responsibility of the scrub nurse?

a. Assess the readiness of the client prior to surgery

b. Ensure that the airway is adequate
c. Account for the number of sponges, needles, supplies, Used during the surgical procedure
d. Evaluate the type of anesthesia appropriate for the surgical client

22. As a perioperative nurse, how can you best meet the safety need of the client after administering preoperative narcotic?

a. Put side rails up and ask client not to get out of bed
b. Send the client to ORD with the family
c. Allow client to get up to go to the comfort room
d. Obtain consent form

23. It is the responsibility of the pre-op, nurse to do skin prep for patients undergoing surgery. If hair at the operative site is not shaved,
what should be done to make suturing easy and lessen chance of incision infection?

a. Draped
b. Pulled
c. Clipped
d. Shampooed

24. It is also the nurse's function to determine when infection is developing in the surgical incision. The perioperative nurse should observe
for what signs of impending infection?

a. Localized heat and redness

b. Serosanguinous exudates and skin blanching
c. Separation of the incision
d. Blood clots and scar tissue are visible

25. Which of the following nursing intervention is done when examining the incision wound and changing the dressing?

a. Observe the dressing and type and odor of drainage if any

b. Get patient's consent
c. Wash hands
d. Request the client to expose the incision wound

Situation 6 - Carlo, 16 years old, comes to the ER with acute asthmatic attack. RR is 46/min and he appears to be in acute respiratory distress.

26. Which of She following nursing actions should be initiated first?

a. Promote emotional support

b. Administer oxygen at 6L/min
c. Suction the client every 30 min
d. Administer bronchodilator by nebulizer

27. Aminophylline was ordered for acute asthmatic attack. The mother asked the nurse, what its indication the nurse will say is:

a. Relax smooth muscles of the bronchial airway

b. Promote expectoration
c. Prevent thickening of secretions
d. Suppress cough
28. You will give health instructions to Carlo, a case of bronchial asthma. The health instruction will include the following EXCEPT:

a. Avoid emotional stress and extreme temperature

b. Avoid pollution like smoking
c. Avoid pollens, dust seafood
d. Practice respiratory isolation

29. The asthmatic client asked you what breathing technique he can best practice when asthmatic attack starts. What will be the best
position?

a. Sit in high-Fowler's position with extended legs

b. Sit-up with shoulders back
c. Push on abdomen during exhalation
d. Lean forward 30-40 degrees with each exhalation

30. As a nurse you are always alerted to monitor status asthmaticus who will likely and initially manifest symptoms of:

a. metabolic alkalosis
b. respiratory acidosis
c. respiratory alkalosis
d. metabolic acidosis

Situation 7 - Joint Commission on Accreditation of Hospital Organization (JCAHP) patient safety goals and requirements include the care and
efficient use of technology in the OR arid elsewhere in the healthcare facility.

31. As the head nurse in the OR, how can you improve the effectiveness of clinical alarm systems?

a. limit suppliers to a few so that quality is maintained

b. implement a regular inventory of supplies and equipment
c. Adherence to manufacturer's recommendation
d. Implement a regular maintenance and testing of alarm systems

32. Over dosage of medication or anesthetic can happen even with the aid of technology like infusion pump, sphymomanometer, and similar
devices/machines. As a staff, how can you improve the safety of using infusion pumps?

a. Check the functionality of the pump before use

b. Select your brand of infusion pump like you do with your cellphone
C. Allow the technician to set the; infusion pump before use
d. Verify the flow rate against your computation

33. JCAHOs universal protocol for surgical and invasive procedures to prevent wrong site, wrong person, and wrong procedures/surgery
includes the following EXCEPT:

a. Mark the operative site if possible

b. Conduct pre-procedure verification process
c. Take a video of the entire intra-operative procedure
d. Conduct time out immediately before starting the procedure

34. You identified a potential risk of pre and post operative clients. To reduce the risk of patient harm resulting from fall, you can implement
the following EXCEPT:

a. Assess potential risk of fail associated with the patient's the following EXCEPT: medication regimen
b. Take action to address any identified risks through Incident Report (IR)
c. Allow client to walk with relative to the OF?
d. Assess and periodically reassess individual client's risk for falling
35. As a nurse you know you can improve on accuracy of patient's identification by 2 patient identifiers, EXCEPT:

a. identify the client by his/her wrist tag and verify with family members
b. identify client by his/her wrist tag and call his/her by name
c. call the client by his/her case and bed number
d. call the patient by his/her name and bed number

Situation 8 - Team efforts is best demonstrated in the OR

36. If you are the nurse in charge for scheduling surgical cases, what important information do you need to ask the surgeon?

a. Who is your internist

b. Who is your assistant and anesthesiologist, and what is your preferred time and type of surgery?
c. Who are your anesthesiologist, internist, and assistant
d. Who is your anesthesiologist.

37. In the OR, the nursing tandem for every surgery is:

a. Instrument technician and circulating nurse

b. Nurse anesthetist, nurse assistant, and instrument technician
c. Scrub nurse and nurse anesthetist
d. Scrub and circulating nurses

38. While team effort is needed in the OR for efficient and quality patient care delivery, we should limit the number of people in the room
for infection control. Who comprise this team?

a. Surgeon, anesthesiologist, scrub nurse, radiologist, orderly

b. Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist
c. Surgeon, assistant surgeon, anesthesiologist, scrub nurse, pathologist
d. Surgeon, assistant surgeon, anesthesiologist, intern, scrub nurse

39. When surgery is on-going, who coordinates the activities outside, including the family?

a. Orderly/clerk
b. Nurse supervisor
c. Circulating nurse
d. Anaesthesiologist

40. The breakdown in teamwork is often times a failure in:

a. Electricity
b. Inadequate supply
c. Leg work
d. Communication

Situation 9 - Colostomy is a surgically created anus- It can be temporary or permanent, depending on the disease condition.

41. Skin care around the stoma is critical. Which of the following is not indicated as a skin care barriers?
a. Apply liberal amount of mineral oil to the area
b. Use karaya paste and rings around the stoma
c. Clean the area daily with soap and water before applying bag
d. Apply talcum powder twice a day

42. What health instruction will enhance regulation of a colostomy (defecation) of clients?

a. Irrigate after lunch everyday

b. Eat fruits and vegetables in all three meals
c. Eat balanced meals at regular intervals
d. Restrict exercise to walking only

43. After ileostomy, which of the following condition is NOT expected?

a. increased weight
b. Irritation of skin around the stoma
c. Liquid stool
d. Establishment of regular bowel movement

44. The following are appropriate nursing interventions during colostomy irrigation EXCEPT:

a. Increase the irrigating solution flow rate when abdominal cramps is felt
b. Insert 2-4 inches of an adequately lubricated catheter to the stoma
c. Position client in semi-Fowler
d. Hand the solution 18 inches above the stoma

45. What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained?

a. Sensation of taste
b. Sensation of pressure
c. Sensation of smell
d. Urge to defecate

Situation 10 - As a beginner in research, you are aware that sampling is an essential element of the research process.

46. What does a sample group represent?

a. Control group
b. Study subjects
c. General population
d. Universe

47. What is the most important characteristics of a sample?

a. Randomization
b. Appropriate location
c. Appropriate number
d. Representativeness

48. Random sampling ensures that each subject has:

a. Been selected systematically

b. An equal change of selection
c. Been selected based on set criteria
d. Characteristics that match other samples

49. Which of the following sampling methods allows the use of any group of research subject?

a. Purposive
b. Convenience
c. Snow-bail
d. Quota

50. You decided to include 5 barangays in your municipality and chose a sampling method that would get representative samples from each
barangay. What should be the appropriate method for you to use in this care?
a. Cluster sampling
b. Random sampling
c. Stratifies sampling
d. Systematic sampling

Situation 11 -After an abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge and Instrument count.

51. When is the first sponge/instrument count reported?

a. Before closing the subcutaneous layer

b. Before peritoneum is closed
c. Before dosing the skin
d. Before the fascia is sutured

52. What major supportive layer of the abdominal wall must be sutured with long tensile strength such as cotton or nylon or silk suture?

a. Fascia
b. Muscle
c. Peritoneum
d. Skin

53. Like sutures, needles also vary in shape and uses. If you are the scrub nurse for a patient who is prone to keloid formation and has a low
threshold of pain, what needle would you prepare?

a. Round needle
b. A traumatic needle
c. Reverse cutting needle
d. Tapered needle

54. Another alternative "suture" for skin closure is the use of _______________:

a. Staple
b. Therapeutic glue
c. Absorbent dressing
d. invisible suture

55. Like any nursing interventions, counts should be documented. To whom does the scrub nurse report any discrepancy of country so that
immediate 'and appropriate action in instituted?

a. Anesthesiologist
b. Surgeon
c. Or nurse supervisor
d. Circulating nurse

Situation 12 - As a nurse, you should be aware and prepared of the different roles you play.

56. What role do you play, when you hold all clients’ information entrusted to you in the strictest confidence?

a. Patient's advocate
b. Educator
c. Patient's Liaison
d. Patient's arbiter

57. As a nurse, you can help improve the effectiveness of communication among healthcare givers

a. Use of reminders of what to do

b. Using standardized list of abbreviations, acronyms, and symbols
c. One-on-one oral endorsement
d. Text messaging and e-mail

58. As a nurse, your primary focus in the workplace is the client's safety. However, personal safety is also a concern. You can communicate
hazards to your co-workers through the use of the following EXCEPT:

a. Formal training
b. Posters
c. Posting IR in the bulletin board
d. Use of labels and signs

59. As a nurse, what is one of the best way to reconcile medications across the continuum of care?

a. Endorse on a case-to-case basis

b. Communication a complete list of the patient's medication to the next provider of service
c. Endorse in writing
d. Endorse the routine and 'stat' medications every shift

60. As a nurse, you protect yourself and co-workers from misinformation and misrepresentations through the following EXCEPT:

a. Provide information to clients about a variety of services that can help alleviate the client's pain and other conditions
b. Advising the client, by virtue of your expertise, that which can contribute to the client's well-being
c. Health education among clients and significant others regarding the use of chemical disinfectant
d. Endorsement thru trimedia to advertise your favorite disinfectant solution

61. A one-day postoperative abdominal surgery client has been complaining of severe throbbing abdominal pain described as 9 in a 1-10
pain rating. Your assessment reveals bowel sounds on all quadrants and the dressing is dry and intact. What nursing intervention would you
take?

a. Medicate client as prescribed

b. Encourage client to do imagery
c. Encourage deep breathing and turning
d. Call surgeon stat

62. Pentoxicodone 5 mg IV every 8 hours was prescribed for post abdominal pain. Which will be your priority nursing action?

a. Check abdominal dressing for possible swelling

b. Explain the proper use of PCA to alleviate anxiety
c. Avoid overdosing to prevent dependence/tolerance
d. Monitor VS, more importantly RR .

63. The client complained of abdominal and pain. Your nursing intervention that can alleviate pain is:

a. Instruct client to go to sleep and relax

b. Advice the client to close the lips and avoid deep breathing and talking
c. Offer hot and clear soup
d. Turn to sides frequently and avoid too much talking

64. Surgical pain might be minimized by which nursing action in the OR:

a. Skill of surgical team and lesser manipulation

b. Appropriate preparation For the scheduled procedure
c. Use of modem technology in closing the wound
d. Proper positioning and draping of clients

65. One very common cause of postoperative pain is:

a. Forceful traction during surgery
b. Prolonged surgery
c. Break in aseptic technique
d. Inadequate anesthetic

Situation 14 - You were on duty at the medical ward when Zeny came in for admission for tiredness, cold intolerance, constipation, and weight
gain. Upon examination, the doctor's diagnosis was hypothyroidism.

66. Your independent nursing care for hypothyroidism includes:

a. administer sedative round the clock

b. administer thyroid hormone replacement
c. providing a cool, quiet, and comfortable environment
d. encourage to drink 6-8 glasses of water

67. As the nurse, you should anticipate to administer which of the following medications to Zeny who is diagnosed to be suffering from
hypothyroidism?

a. Levothyroxine
b. Lidocaine
c. Lipitor
d. Levophed

68. Your appropriate nursing diagnosis for Zeny who is suffering from hypothyroidism would probably include which of the following?

a. Activity intolerance related to tiredness associated with disorder

b. Risk to injury related to incomplete eyelid closure
c. Imbalance nutrition related to hypermetabolism
d. Deficient fluid volume related to diarrhea

69. Myxedema coma is a life threatening complication of long standing and untreated hypothyroidism with one of the following
characteristics.

a. Hyperglycemia
b. hypothermia
c. hyperthermia
d. hypoglycemia

70. As a nurse, you know that the most common type of goiter is related to a deficiency

a. thyroxine
b. thyrotropin
c. iron
d. iodine

Situation 15 - Mrs. Pichay is admitted to your ward. The MD ordered "Prepared for thoracentesis this pm to remove excess air from the pleural
cavity."

71. Which of the following nursing responsibility is essential in Mrs. Pichay who will undergo thoracentesis?

a. Support, and reassure client during the procedure

b. Ensure that informed consent has been signed
c. Determine if client has allergic reaction to local anesthesia
d. Ascertain if chest x-rays and other tests have been prescribed and completed

72. Mrs. Pichay who is for thoracentesis is assisted by the nurse to any of the following positions, EXCEPT:
a. straddling a chair with arms and head resting on the back of the chair
b. lying on the unaffected side with the bed elevated 30-40 degrees
c. lying prone with the head of the bed lowered 15-30 degrees
d. sitting on the edge of the bed with her feet supported and arms and head on a padded overhead table

73. During thoracentesis, which of the following nursing intervention will be most crucial?

a. Place patient in a quiet and cool room

b. Maintain strict aseptic technique
c. Advice patient to sit perfectly still during needle insertion until it has been withdrawn from the chest
d. Apply pressure over the puncture site as soon as the needle is withdrawn

74. To prevent leakage of fluid in the thoracic cavity, how wilt you position the client after thoracentesis?

a. Place flat in bed

b. Turn on the unaffected side
c. Turn on the affected side
d. On bed rest

75. Chest x-ray was ordered after thoracentesis. When you client asks what is the reason for another chest x-ray, you will explain:

a. to rule out pneumothorax

b. to rule out any possible perforation
c. to decongest
d. to rule out any foreign: body

Situation 16 - In the hospital, you are aware that we are helped by the .use of a variety of equipment/devices to enhance quality patient care
delivery;

76. You are initiate an IV line to your patient, Kyle, 5, who is febrile. What IV administration set will you prepare?

a. Blood transfusion set

b. Macroset
c. Volumetric chamber
d. Microset

77. Kyle is diagnosed to have measles. What will your protective personal attire include?

a. Gown
b. Eyewear
c. Face mask
d. Gloves

78. What will you do to ensure that Kyle, who is febrile, will have a liberal oral fluid intake?

a. Provide a glass of fruit every meal

b. Regulate his IV to 30 drops per minute
c. Provide a calibrated pitcher of drinking water and juice at the bedside and monitor intake and output
d. Provide a writing pad to record his intake

79. Before bedtime, you went to ensure Kyle's safety in 'bed. You will do which of the following:

a. Put the lights on

b. Put the side rails up
c. Test the call system
d. Lock the doors
80. Kyle's room is fully mechanized. What do you teach the watcher and Kyle to alert the nurse for help?

a. How to lock side rails

b. Number of the telephone operator
c. Call system
d. Remote control

Situation 17 - Tony, 11 years old, has 'kissing tonsils' and is scheduled for tonsillectomy and adenoidectomy or T and A.

81. You are the nurse of Tony who will undergo T and A in the morning. His mother asked you if Tony will be put to sleep. Your teaching will
focus on:

a. spinal anesthesia
b. anesthesiologist’s preference
c. local anesthesia
d. general anesthesia

82. Mothers of children undergoing tonsillectomy and adenoidectomy usually ask what food prepared and give their children after surgery.
You as the nurse will say:

a. balanced diet when fully awake

b. hot soup when awake
c. ice cream when fully awake
d. soft diet when fully awake

83. The RR nurse should monitor for the most common postoperative complication of:

a. hemorrhage
b. endotracheal tube perforation
c. esopharyngeal edema
d. epiglottis

84. The PACU nurse will maintain postoperative T and A client in what position?

a. Supine with neck hyperextended and supported with pillow

b. Prone with the head on pillow and tuned to the side
c. Semi-Fowler's with neck flexed
d. Reverse trendelenburg with extended neck

85. Tony is to be discharged in the afternoon of the same day after tonsillectomy and adenoidectomy. You as the RN will make sure that the
family knows to:

a. offer osteorized feeding

b. offer soft foods for a week to minimize discomfort while swallowing
c. supplement his diet with vitamin C rich juices to enhance heating
d. offer clear liquid for 3 days to prevent irritation

Situation 18 - Rudy was diagnosed to have chronic renal failure. Hemodialysis is ordered that an A-V shunt was surgically created.

86. Which of the following action would be of highest priority with regards to the external shunt?

a. Avoid taking BP or blood sample from the arm with shunt

b. Instruct the client not to exercise the arm with the shunt
c. Heparinize the shunt daily
d. Change dressing of the shunt daily

87. Diet therapy for Rudy, who has acute renal failure, is tow-protein, low potassium and sodium. The nutrition instruction should include:
a. Recommend protein of high biologic value like eggs, poultry and lean meat
b. Encourage client to include raw cucumbers, carrot, cabbage, and tomatoes
c. Allowing the client cheese, canned foods, and other processed food
d. Bananas, cantaloupe, orange and other fresh fruits can be included in the diet

88. Rudy undergoes hemodialysis for the first time and was scared of disequilibrium syndrome. He asked you how this can be prevented.
Your response is:

a. maintain a conducive comfortable and cool environment

b. maintain fluid and electrolyte balance
c. initial hemodialysis shall be done for 30 minutes only so as not to rapidly remove the waste from the blood than from the brain
d. maintain aseptic technique throughout the hemodialysis

89. You are assisted by a nursing aide with the care of the client with renal failure. Which delegated function to the aide would you
particularly check?

a. Monitoring and recording I and O

b. Checking bowel movement
c. Obtaining vital signs
d. Monitoring diet

90. A renal failure patient was ordered for creatinine clearance. As the nurse you will collect

a. 48 jour urine specimen

b. first morning urine
c. 24 hour urine specimen
d. random urine specimen

Situation 19 - Fe is experiencing left sharp pain and occasional hematuria. She was advised to undergo IVP by her physician.

91. Fe was so anxious about the procedure and particularly expressed her low pain threshold. Nursing health instruction will include:

a. assure the client that the pain is associated with the warm sensation during the administration of the Hypaque by IV
b. assure the client that the procedure painless
c. assure the client that contrast medium will be given orally
d. assure the client that x-ray procedure like IVP is only done by experts

92. What will the nurse monitor and instruct the client and significant others, post IVP?

a. Report signs and symptoms for delayed allergic reactions

b. Observe NPO for 6 hours
c. Increase fluid intake
d. Monitor intake and output

93. Post IVP, Fe should excrete the contrast medium. You instructed the family to include more vegetables in the diet and

a. increase fluid intake

b. barium enema
c. cleansing enema
d. gastric lavage

94. The IVP reveals that Fe has small renal calculus that can be passed out spontaneously. To increase the chance of passing the stones, you
instructed her to force fluids and do which of the following?

a. Balanced diet
b. Ambulance more
c. Strain all urine
d. Bed rest

95. The presence of calculi in the urinary tract is called:

a. Colelithiasis
b. Nephrolithiasis
c. Ureterolithiasis
d. Urolithiasis

Situation 20 - At the medical-surgical ward, the nurse must also be concerned about drug interactions.

96. You have a client with TPN. You know that in TPN, like blood transfusion, there should be no drug incorporation. However, the MD's
order read; incorporate insulin to present TPN. Will you follow the order?

a. No, because insulin will induce hyperglycemia in patients with TPN

b. Yes, because insulin is chemically stable with TPN and can enhance blood glucose level
c. No, because insulin is not compatible with TPN
d. Yes, because it was ordered by the MD

97. The RN should also know that some drugs have increased absorption when infused in PVC container. How will you administer drugs such
as insulin, nitroglycerine hydralazine to promote better therapeutic drug effects?

a. Administer by fast drip

b. Inject the drugs as close to the IV injection site
c. Incorporate to the IV solution
d. Use volumetric chamber

98. One patient has a 'runaway' IV of 50% dextrose. To prevent temporary excess of insulin transient hyperinsulin reaction, what solution
should you prepare in anticipation of the doctors order?

a. Any IV solution available to KVO

b. Isotonic solution
c. Hypertonic solution
d. Hypotonic solution

99. How can nurse prevent drug interaction including absorption?

a. Always flush with NSS after IV administration

b. Administering drugs with more diluents
c. Improving on preparation techniques
d. Referring to manufacturer's guidelines

100. In insulin administration, it should be understood that our body normally releases insulin according to our blood glucose level. When is
insulin and glucose level highest?

a. After excitement
b. After a good night's rest
c. After an exercise
d. After ingestion of food

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