NURSING PRACTICE I: FOUNDATION OF NURSING PRACTICE

SITUATION: Nursing is a profession. The nurse should have a background on the theories and foundation of nursing as it
influenced what is nursing today.

1. Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury,
alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of the
individuals, families, communities and the population. This is the most accepted definition of nursing as defined by the:

A. PNA B. ANA C. Nightingale D. Henderson

2. Advancement in Nursing leads to the development of the Expanded Career Roles. Which of the following is NOT an
expanded career role for nurses?

A. Nurse practitioner C. Nurse Researcher

B. Clinical nurse specialist D. Nurse anaesthesiologist

3. The Board of Nursing regulated the Nursing profession in the Philippines and is responsible for the maintenance of the
quality of nursing in the country. Powers and duties of the board of nursing are the following, EXCEPT:

A. Issue, suspend, revoke certificates of registration

B. Issue subpoena duces tecum, ad testificandum

C. Open and close colleges of nursing

D. Supervise and regulate the practice of nursing

4. A nursing student or a beginning staff nurse who has not yet experienced enough real situations to make judgments
about them is in what stage of Nursing Expertise?

A. Novice B. Newbie C. Advanced Beginner D. Competent

5. Benner’s “Proficient” nurse level is different from the other levels in nursing expertise in the context of having:

A. the ability to organize and plan activities

B. having attained an advanced level of education
C. a holistic understanding and perception of the client
D. intuitive and analytic ability in new situations

SITUATION: The nurse has been asked to administer an injection via Z TRACK technique. Questions 6 to 10 refer to this.

6. The nurse prepares an IM injection for an adult client using the Z track technique. 4 ml of medication is to be
administered to the client. Which of the following site will you choose?

A. Deltoid B. Rectus femoris C. Ventrogluteal D. Vastus lateralis

1
7. In infants 1 year old and below, which of the following is the site of choice for intramuscular
Injection?

A. Deltoid B. Rectus femoris C. Ventrogluteal D. Vastus lateralis

8. In order to decrease discomfort in Z track administration, which of the following is applicable?

A. Pierce the skin quickly and smoothly at a 90 degree angle

B. Inject the medication steadily at around 10 minutes per millilitre
C. Pull back the plunger and aspirate for 1 minute to make sure that the needle did not hit a blood vessel
D. Pierce the skin slowly and carefully at a 90 degree angle

9. After injection using the Z track technique, the nurse should know that she needs to wait for a few seconds before
withdrawing the needle and this is to allow the medication to disperse into the muscle tissue, thus decreasing the
client’s discomfort. How many seconds should the nurse wait before withdrawing the needle?

A. 2 seconds B. 5 seconds C. 10 seconds D. 15 seconds

10. The rationale in using the Z track technique in an intramuscular injection is:

A. It decreases the leakage of discolouring and irritating medication into the subcutaneous tissues
B. It will allow a faster absorption of the medication
C. The Z track technique prevent irritation of the muscle
D. It is much more convenient for the nurse

SITUATION: A Client was rushed to the emergency room and you are his attending nurse. You are performing a vital sign
assessment.

11. All of the following are correct methods in assessment of the blood pressure EXCEPT:

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

B. Listen to and identify the phases of Korotkoff’s sound
C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated
D. Observe procedures for infection control

12. You attached a pulse oximeter to the client. You know that the purpose is 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

13. After a few hours in the Emergency Room, The client 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:

2
 A. inconsistent
B. low systolic and high diastolic
C. higher than what the reading should be
D. lower than what the reading should be

14. Through the client’s health history, you gather that the patient smokes and drinks coffee. When taking the blood
pressure of a client who recently smoked or drank coffee, how long should 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

15. While the client has 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

16. The nurse finds it necessary to recheck the blood pressure reading. In case of such re assessment, the nurse should
wait for a period of:

A. 15 seconds B. 1 to 2 minutes C. 30 minutes D. 15 minutes

17. If the arm is said to be elevated when taking the blood pressure, it will create a:

A. False high reading B. False low reading C. True false reading D. Indeterminate

18. You are to assessed the temperature of the client the next morning and found out that he ate ice cream. How many
minutes should you wait before assessing the client’s oral temperature?

A. 10 minutes B. 20 minutes C. 30 minutes D. 15 minutes

19. When auscultating the client’s blood pressure the nurse hears the following: From 150 mmHg to 130 mmHg: Silence,
Then: a thumping sound continuing down to 100 mmHg; muffled sound continuing down to 80 mmHg and then silence.
What is the client’s blood pressure?

A. 130/80 B. 150/100 C. 100/80 D. 150/100

20. In a client with a previous blood pressure of 130/80 4 hours ago, how long will it take to release the blood pressure
cuff to obtain an accurate reading?

A. 10-20 seconds B. 30-45 seconds C. 1-1.5 minutes D. 3-3.5 minutes

Situation: Oral care is an important part of hygienic practices and promoting client comfort.

3
21. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presence of
sores. Which of the following is BEST to use for oral care?

A. lemon glycerine C. Mineral oil

B. hydrogen peroxide D. Normal saline solution

22. When performing oral care to an unconscious client, which of the following is a special consideration to prevent
aspiration of fluids into the lungs?

A. Put the client on a sidelying position with head of bed lowered

B. Keep the client dry by placing towel under the chin
C. Wash hands and observe appropriate infection control
D. Clean mouth with oral swabs in a careful and an orderly progression

23. The advantages of oral care for a client include all of the following, EXCEPT:

A. decreases bacteria in the mouth and teeth

B. reduces need to use commercial mouthwash which irritate the buccal mucosa
C. improves client’s appearance and self-confidence
D. improves appetite and taste of food

24. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to lungs. This can be
avoided by:

A. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity
B. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs
C. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and ums
D. suctioning as needed while cleaning the buccal cavity

25. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth
with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened
by using:

A. salt solution C. petroleum jelly

B. water D. mentholated ointment

Situation – Ensuring safety before, during and after a diagnostic procedure is an important responsibility of the nurse.

26. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which
of the following prior to the procedure?

A. Clenching his fist every 2 minutes

B. Breathing in and out through the nose with his mouth open
C. Tensing the shoulder muscles while lying on his back
D. Holding his breath periodically for 30 seconds

27. Following a bronchoscopy, which of the following complains to Fernan should be noted as a
possible complication:

A. Nausea and vomiting

4
B. Shortness of breath and laryngeal stridor
C. Blood tinged sputum and coughing
D. Sore throat and hoarseness

28. Immediately after bronchoscopy, you instructed Fernan to:

A. Exercise the neck muscles C. Refrain from coughing and talking

B. Breathe deeply D. Clear his throat

29. Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important function during
the procedure is to:

A. Keep the sterile equipment from contamination

B. Assist the physician
C. Open and close the three-way stopcock
D. Observe the patient’s vital signs

30. Right after thoracentesis, which of the following is most appropriate intervention?

A. Instruct the patient not to cough or deep breathe for two hours
B. Observe for symptoms of tightness of chest or bleeding
C. Place an ice pack to the puncture site
D. Remove the dressing to check for bleeding

Situation: Knowledge of the acid-base disturbance and the functions of the electrolytes is necessary to determine
appropriate intervention and nursing actions.

31. A client with diabetes milletus has a blood glucose level of 644 mg/dL. The nurse interprets that this client is at most
risk for the development of which type of acid-base imbalance?

A. Respiratory acidosis C. Respiratory alkalosis

B. Metabolic acidosis D. Metabolic alkalosis

32. In a client in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, PCO2 32 mmHg,
PO2 94 mmHg, HCO3 24 mEq/L. The nurse interprets that the client has which acid base disturbance?

A. Respiratory acidosis C. Metabolic acidosis

B. Respiratory alkalosis D. Metabolic alkalosis

33. A client has an order for ABG analysis on radial artery specimens. The nurse ensures that which of the following has
been performed or tested before the ABG specimens are drawn?

A. Guthrie test C. Romberg’s test

B. Allen’s test D. Weber’s test

34. A nurse is reviewing the arterial blood gas values of a client and notes that the ph is 7.31, Pco2 is 50 mmHg, and the
bicarbonate is 27 mEq/L. The nurse concludes that which acid base disturbance is present in this client?

A. Respiratory acidosis C. Metabolic acidosis

B. Respiratory alkalosis D. Metabolic alkalosis

5
35. Allen’s test checks the patency of the:

A. Ulnar artery C. Carotid artery

B. Radial artery D. Brachial artery

Situation 6: Eileen, 45 years old is admitted to the hospital with a diagnosis of renal calculi. She is experiencing severe
flank pain, nauseated and with a temperature of 39 0C.

36. Given the above assessment data, the most immediate goal of the nurse would be which of the following?

A. Prevent urinary complication

B. maintains fluid and electrolytes
C. Alleviate pain
D. Alleviating nausea

6
37. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes “daily
urine specimen to be sent to the laboratory” . Eileen has a foley catheter attached to a urinary drainage system.
How will you collect the urine specimen?

A. remove urine from drainage tube with sterile needle and syringe and empty urine from the
syringe into the specimen container
B. empty a sample urine from the collecting bag into the specimen container
C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the
specimen container.
D. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into the
specimen container.

38. Where would the nurse tape Eileen’s indwelling catheter in order to reduce urethral irritation?

A. to the patient’s inner thigh C. to the patient’ buttocks

B. to the patient’s lower thigh D. to the patient lower abdomen

39. Which of the following menu is appropriate for one with low sodium diet?

A. instant noodles, fresh fruits and ice tea

B. ham and cheese sandwich, fresh fruits and vegetables
C. white chicken sandwich, vegetable salad and tea
D. canned soup, potato salad, and diet soda

40. How will you prevent ascending infection to Eileen who has an indwelling catheter?

A. see to it that the drainage tubing touches the level of the urine
B. change he catheter every eight hours
C. see to it that the drainage tubing does not touch the level of the urine
D. clean catheter may be used since urethral meatus is not a sterile area

Situation: Hormones are secreted by the various glands in the body. Basic knowledge of the endocrine system is
necessary.

41. Somatocrinin or the Growth hormone releasing hormone is secreted by the:

A. Hypothalamus C. Posterior pituitary gland

B. Anterior pituitary gland D. Thyroid gland

42. All of the following are secreted by the anterior pituitary gland except:

A. Somatotropin/Growth hormone C. Thyroid stimulating hormone

B. Follicle stimulating hormone D. Gonadotropin hormone releasing hormone

43. All of the following hormones are hormones secreted by the Posterior pituitary gland except:

A. Vasopressin C. Anti diuretic hormone

B. Oxytocin D. Growth hormone

44. Calcitonin, a hormone necessary for calcium regulation is secreted in the:

A. Thyroid gland C. Parathyroid gland

B. Hypothalamus D. Anterior pituitary gland

45. While Parathormone, a hormone that negates the effect of calcitonin is secreted by the:

A. Thyroid gland C. Parathyroid gland

B. Hypothalamus D. Anterior pituitary gland

Situation: The staff nurse supervisor requests 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 classes.

46. 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

47. 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

48. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had 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
49. 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

50. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and required by the hospital
employing you. This is

A. professional course towards credits

B. inservice education
C. advance training
D. continuing education

Situation: As a nurse, you are aware that proper documentation in the patient chart is your responsibility.

51. Which of the following is not a legally binding document but nevertheless very important in the care of all
patients in any health care setting?
The
A. Bill of rights as provided in the Philippine constitution
B. Scope of nursing practice as defined by RA 9173
C. Board of nursing resolution adopting the code of ethics
D. Patient’s bill of rights

52. A nurse gives a wrong medication to the client. Another nurse employed by the same hospital as a risk
manager will expect to receive which of the following communication?

A. Incident report C. Nursing kardex

B. Oral report D. Complain report

53. Performing a procedure on a client in the absence of an informed consent can lead to which of the following
charges?

A. Fraud C. Harassment
B. Assault and battery D. Breach of confidentiality

54. Which of the following is the essence of informed consent?

A. It should have a durable power of attorney

B. It should have coverage from an insurance company
C. It should respect the client’s freedom from coercion
D. It should disclose previous diagnosis, prognosis and alternative treatments available for the client

55. Delegation is the process of assigning tasks that can be performed by a subordinate. The RN should always be
accountable and should not lose his accountability. Which of the following is a role included in delegation?
A. The RN must supervise all delegated tasks
B. After a task has been delegated, it is no longer a responsibility of the RN
C. The RN is responsible and accountable for the delegated task in adjunct with the delegate
D. Follow up with a delegated task is necessary only if the assistive personnel is not trustworthy

Situation: When creating your lesson plan for cerebrovascular disease or STROKE. It is important to include the
risk factors of stroke.

56. The most important risk factor is:

A. Cigarette smoking C. binge drinking

B. Hypertension D. heredity

57. Part of your lesson plan is to talk about etiology or cause of stroke. The types of stroke based on cause are
the following EXCEPT:

A. Embolic stroke C. diabetic stroke

B. Hemorrhagic stroke D. thrombotic stroke

58. Hemmorhagic stroke occurs suddenly usually when the person is active. All are causes of hemorrhage,
EXCEPT:

A. phlebitis C. damage to blood vessel

B. trauma D. aneurysm

59. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug is closely linked
to this?

A. Amphetamines C. shabu
B. Cocaine D. Demerol

60. A participant in the STROKE class asks what is a risk factor of stroke. Your best response is:

A. “More red blood cells thicken blood and make clots more possible.”
B. “Increased RBC count is linked to high cholesterol.”
C. “More red blood cell increases hemoglobin content.”
D. “High RBC count increases blood pressure.”

Situation: Recognition of normal values is vital in assessment of clients with various disorders.

61. A nurse is reviewing the laboratory test results for a client with a diagnosis of severe dehydration. The nurse
would expect the hematocrit level for this client to be which of the following?

A. 60% B. 47% C. 45% D. 32%

62. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 5.6
mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory value?

A. ST depression C. Prominent U wave

B. Inverted T wave D. Tall peaked T waves

63. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 3.2
mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory value?

A. U waves C. Elevated T waves

B. Absent P waves D. Elevated ST Segment

64. Dorothy underwent diagnostic test and the result of the blood examination are back. On reviewing the result
the nurse notices which of the following as abnormal finding?

A. Neutrophils 60%
B. White blood cells (WBC) 9000/mm
C. Erythrocyte sedimentation rate (ESR) is 39 mm/hr
D. Iron 75 mg/100 ml

65. Which of the following laboratory test result indicate presence of an infectious process?

A. Erythrocyte sedimentation rate (ESR) 12 mm/hr

B. White blood cells (WBC) 18,000/mm3
C. Iron 90 g/100ml
D. Neutrophils 67%

Situation: Pleural effusion is the accumulation of fluid in the pleural space. Questions 66 to 70 refer to this.

66. Which of the following is a finding that the nurse will be able to assess in a client with Pleural effusion?

A. Reduced or absent breath sound at the base of the lungs, dyspnea, tachpynea and shortness of breath
B. Hypoxemia, hypercapnea and respiratory acidosis
C. Noisy respiration, crackles, stridor and wheezing
D. Tracheal deviation towards the affected side, increased fremitus and loud breath sounds

67. Thoracentesis is performed to the client with effusion. The nurse knows that the removal of fluid should be
slow. Rapid removal of fluid in thoracentesis might cause:

A. Pneumothorax C. Cardiovascular collapse

B. Pleurisy or Pleuritis D. Hypertension
68. 3 Days after thoracentesis, the client again exhibited respiratory distress. The nurse will know that pleural
effusion has reoccurred when she noticed a sharp stabbing pain during inspiration. The physician ordered a
closed tube thoracotomy for the client. The nurse knows that the primary function of the chest tube is to:

A. Restore positive intrathoracic pressure

B. Restore negative intrathoracic pressure
C. To visualize the intrathoracic content
D. As a method of air administration via ventilator

69. The chest tube is functioning properly if:

A. There is an oscillation
B. There is no bubbling in the drainage bottle
C. There is a continuous bubbling in the waterseal
D. The suction control bottle has a continuous bubbling

70. In a client with pleural effusion, the nurse is instructing appropriate breathing technique. Which of the
following is included in the teaching?

A. Breath normally
B. Hold the breath after each inspiration for 1 full minute
C. Practice abdominal breathing
D. Inhale slowly and hold the breath for 3 to 5 seconds after each inhalation

SITUATION : Health care delivery system affects the health status of every filipino. As a Nurse, Knowledge of this
system is expected to ensure quality of life.

71. When should rehabilitation commence?

A. The day before discharge

B. When the patient desires
C. Upon admission
D. 24 hours after discharge

72. What exemplified the preventive and promotive programs in the hospital?

A. Hospital as a center to prevent and control infection

B. Program for smokers
C. Program for alcoholics and drug addicts
D. Hospital Wellness Center

73. Which makes nursing dynamic?

A. Every patient is a unique physical, emotional, social and spiritual being

B. The patient participate in the over all nursing care plan
C. Nursing practice is expanding in the light of modern developments that takes place
D. The health status of the patient is constantly changing and the nurse must be cognizant and responsive
to these changes

74. Prevention is an important responsibility of the nurse in:

A. Hospitals
B. Community
C. Workplace
D. All of the above

75. This form of Health Insurance provides comprehensive prepaid health services to enrollees for a fixed periodic
payment.

A. Health Maintenance Organization

B. Medicare
C. Philippine Health Insurance Act
D. Hospital Maintenance Organization

Situation: Nursing ethics is an important part of the nursing profession. As the ethical situation arises, so is the need to
have an accurate and ethical decision making.

76. The purpose of having a nurses’ code of ethics is:

A. Delineate the scope and areas of nursing practice

B. dentify nursing action recommended for specific health care situations
C. To help the public understand professional conduct expected of nurses
D. To define the roles and functions of the health care givers, nurses, clients

77. The principles that govern right and proper conduct of a person regarding life, biology and the health
professionals is referred to as:

A. Morality
B. Religion
C. Values
D. Bioethics

78. A subjective feeling about what is right or wrong is said to be:

A. Morality
B. Religion
C. Values
D. Bioethics

79. Values are said to be the enduring believe about a worth of a person, ideas and belief. If Values are going to
be a part of a research, this is categorized under:

A. Qualitative C. Experimental
B. Quantitative D. Non Experimental

80. 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 takes 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

81. Why is there an ethical dilemma?

A. the choices involved do not appear to be clearly right or wrong

B. a clients legal right co-exist with the nurse’s professional obligation
C. decisions has to be made based on societal norms.
D. decisions has to be mad quickly, often under stressful conditions

82. According to the code of ethics, which of the following is the primary responsibility of the nurse?

A. Assist towards peaceful death

B. Health is a fundamental right
C. Promotion of health, prevention of illness, alleviation of suffering and restoration of health
D. Preservation of health at all cost

83. 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 for Nurses which the Board of Nursing promulgated
B. Code for 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. Certificates of Registration of registered nurses may be revoked or suspended for violations of any
provisions of the Code of Ethics.

84. Violation of the code of ethics might equate to the revocation of the nursing license. Who revokes the
license?

A. PRC B. PNA C. DOH D. BON

85. 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

Situation: As a profession, nursing is dynamic and its practice is directed by various theoretical models. To
demonstrate caring behaviour, the nurse applies various nursing models in providing quality nursing care.
86. When you clean the bedside unit and regularly attend to the personal hygiene of the patient as well as in
washing your hands before and after a procedure and in between patients, you indent to facilitate the body’s
reparative processes. Which of the following nursing theory are you applying in the above nursing action?

A. Hildegard Peplau C. Dorothea Orem

B. Virginia Henderson D. Florence Nightingale

87. A communication skill is one of the important competencies expected of a nurse. Interpersonal process is
viewed as human to human relationship. This statement is an application of whose nursing model?

A. Joyce Travelbee C. Martha Rogers

B. Callista Roy D. Imogene King

88. The statement “the health status of an individual is constantly changing and the nurse must be cognizant and
responsive to these changes” best explains which of the following facts about nursing?

A. Dynamic C. Client centred

B. Holistic D. Art

89. Virginia Henderson professes that the goal of nursing is to work interdependently with other health care
working in assisting the patient to gain independence as quickly as possible. Which of the following nursing
actions best demonstrates this theory in taking care of a 94 year old client with dementia who is totally
immobile?

A. Feeds the patient, brushes his teeth, gives the sponge bath
B. Supervise the watcher in rendering patient his morning care
C. Put the patient in semi fowler’s position, set the over bed table so the patient can eat by himself, brush his
teeth and sponge himself
D. Assist the patient to turn to his sides and allow him to brush and feed himself only when he feels ready

90. In the self care deficit theory by Dorothea Orem, nursing care becomes necessary when a patient is unable to
fulfil his physiological, psychological and social needs. A pregnant client needing prenatal check up is classified as:

A. Wholly compensatory C. Supportive Educative

B. Partially compensatory D. Non compensatory

Situation: Documentation and reporting are just as important as providing patient care, As such, the nurse must
be factual and accurate to ensure quality documentation and reporting.

91. Health care reports have different purposes. The availability of patients record to all health team members
demonstrates which of the following purposes:

A. Legal documentation C. Research

B. Education D. Vehicle for communication

92. When a nurse commits medication error, she should accurately document client’s response and her
corresponding action. This is very important for which of the following purposes:
A. Research C. Legal documentation
B. Nursing Audit D. Vehicle for communication

93. POMR has been widely used in many teaching hospitals. One of its unique features is SOAPIE charting. The P
in SOAPIE charting should include:

A. Prescription of the doctor to the patient’s illness

B. Plan of care for patient
C. Patient’s perception of one’s illness
D. Nursing problem and Nursing diagnosis

94. The medical records that are organized into separate section from doctors or nurses has more disadvantages
than advantages. This is classified as what type of recording?

A. POMR C. Modified POMR

B. SOAPIE D. SOMR

95. Which of the following is the advantage of SOMR or Traditional recording?

A. Increases efficiency in data gathering

B. Reinforces the use of the nursing process
C. The care giver can easily locate proper section for making charting entries
D. Enhances effective communication among health care team members

Situation: June is a 24 year old client with symptoms of dyspnea, absent breath sounds on the right lung and
chest x ray revealed pleural effusion. The physician will perform thoracentesis.

96. Thoracentesis is useful in treating all of the following pulmonary disorders except:

A. Hemothorax C. Hydrothorax
B. Tuberculosis D. Empyema

97. Which of the following psychological preparation is not relevant for him?

A. Telling him that the gauge of the needle and anesthesia to be used
B. Telling him to keep still during the procedure to facilitate the insertion of the needle in the correct place
C. Allow June to express his feelings and concerns
D. Physician’s explanation on the purpose of the procedure and how it will be done

98. Before thoracentesis, the legal consideration you must check is:

A. Consent is signed by the client

B. Medicine preparation is correct
C. Position of the client is correct
D. Consent is signed by relative and physician

99. As a nurse, you know that the position for June before thoracentesis is:
A. Orthopneic C. Low fowlers
B. Knee-chest D. Sidelying position on the affected side

100. Which of the following anaesthetics drug is used for thoracentesis?

A. Procaine 2% C. Demerol 75 mg
B. Valium 250 mg D. Phenobartbital 50 mg

NURSING PRACTICE II

Situation: Mariah is a 31 year old lawyer who has been married for 6 months. She consults you for guidance in
relation with her menstrual cycle and her desire to get pregnant.

1. She wants to know the length of her menstrual cycle. Her previous menstrual period is October 22 to 26. Her
LMB is November 21. Which of the following number of days will be your correct response?

A. 29 B. 28 C. 30 D. 31

2. You advised her to observe and record the signs of Ovulation. Which of the following signs will she likely note
down?

1. A 1 degree Fahrenheit rise in basal body temperature

2. Cervical mucus becomes copious and clear
3. One pound increase in weight
4. Mittelschmerz

A. 1,2,4 B. 1,2,3 C. 2,3,4 D. 1,3,4

3. You instruct Mariah to keep record of her basal temperature everyday, which of the following instructions is
incorrect?

A. If coitus has occurred, this should be reflected in the chart

B. It is best to have coitus on the evening following a drop in BBT to become pregnant
C. Temperature should be taken immediately after waking and before getting out of bed
D. BBT is lowest during the secretory phase

4. She reports an increase in BBT on December 16. Which hormone brings about this change in her BBT?

A. Estrogen C. Gonadotropine
B. Progesterone D. Follicle stimulating hormone

5. The following month, Mariah suspects she is pregnant. Her urine is positive for Human chorionic
gonadotrophin. Which structure produces Hcg?

A. Pituitary gland
B. Trophoblastic cells of the embryo
C. Uterine deciduas
D. Ovarian follicles

Situation: Mariah came back and she is now pregnant.

6. At 5 month gestation, which of the following fetal development would probably be achieve?

A. Fetal movement are felt by Mariah

B. Vernix caseosa covers the entire body
C. Viable if delivered within this period
D. Braxton hicks contractions are observed

7. The nurse palpates the abdomen of Mariah. Now At 5 month gestation, What level of the abdomen can the
fundic height be palpated?

A. Symphysis pubis
B. Midpoint between the umbilicus and the xiphoid process
C. Midpoint between the symphysis pubis and the umbilicus
D. Umbilicus

8. She worries about her small breasts, thinking that she probably will not be able to breastfeed her baby. Which
of the following responses of the nurse is correct?

A. “The size of your breast will not affect your lactation”

B. “You can switch to bottle feeding”
C. “You can try to have exercise to increase the size of your breast”
D. “Manual expression of milk is possible”

9. She tells the nurse that she does not take milk regularly. She claims that she does not want to gain too much
weight during her pregnancy. Which of the following nursing diagnosis is a priority?

A. Potential self esteem disturbance related to physiologic changes in pregnancy

B. Ineffective individual coping related to physiologic changes in pregnancy
C. Fear related to the effects of pregnancy
D. Knowledge deficit regarding nutritional requirements of pregnancies related to lack of information sources

10. Which of the following interventions will likely ensure compliance of Mariah?

A. Incorporate her food preferences that are adequately nutritious in her meal plan
B. Consistently counsel toward optimum nutritional intake
C. Respect her right to reject dietary information if she chooses
D. Inform her of the adverse effects of inadequate nutrition to her fetus

Situation: Susan is a patient in the clinic where you work. She is inquiring about pregnancy.

11. Susan tells you she is worried because she develops breasts later than most of her friends. Breast
development is termed as:

A. Adrenarche C. Thelarche
B. Mamarche D. Menarche

12. Kevin, Susan’s husband tells you that he is considering vasectomy After the birth of their new child.
Vasectomy involves the incision of which organ?

A. The testes C. The epididymis

B. The vas deferens D. The scrotum

13. On examination, Susan has been found of having a cystocele. A cystocele is:

A. A sebaceous cyst arising from the vulvar fold

B. Protrusion of intestines into the vagina
C. Prolapse of the uterus into the vagina
D. Herniation of the bladder into the vaginal wall

14. Susan typically has menstrual cycle of 34 days. She told you she had coitus on days 8, 10, 15 and 20 of her
menstrual cycle. Which is the day on which she is most likely to conceive?

A. 8th day C. Day 15

B. 10th day D. Day 20

15. While talking with Susan, 2 new patients arrived and they are covered with large towels and the nurse
noticed that there are many cameraman and news people outside of the OPD. Upon assessment the nurse
noticed that both of them are still nude and the male client’s penis is still inside the female client’s vagina and the
male client said that “I can’t pull it”. Vaginismus was your first impression. You know that The psychological cause
of Vaginismus is related to:

A. The male client inserted the penis too deeply that it stimulates vaginal closure
B. The penis was too large that is why the vagina triggered it’s defense to attempt to close it
C. The vagina do not want to be penetrated
D. It is due to learning patterns of the female client where she views sex as bad or sinful

Situation: Overpopulation is one problem in the Philippines that causes economic drain. Most Filipinos are
against in legalizing abortion. As a nurse, Mastery of contraception is needed to contribute to the society and
economic growth.

16. Supposed that Dana, 17 years old, tells you she wants to use fertility awareness method of contraception.
How will she determine her fertile days?

A. She will notice that she feels hot, as if she has an elevated temperature.
B. She should assess whether her cervical mucus is thin, copious, clear and watery.
C. She should monitor her emotions for sudden anger or crying
D. She should assess whether her breasts feel sensitive to cool air

17. Dana chooses to use COC as her family planning method. What is the danger sign of COC you would ask her to
report?

A. A stuffy or runny nose C. Slight weight gain

B. Arthritis like symptoms D. Migraine headache

18. Dana asks about subcutaneous implants and she asks, how long will these implants be effective. Your best
answer is:

A. One month C. Five years

B. Twelve months D. 10 years

19. Dana asks about female condoms. Which of the following is true with regards to female condoms?

A. The hormone the condom releases might cause mild weight gain
B. She should insert the condom before any penile penetration
C. She should coat the condom with spermicide before use
D. Female condoms, unlike male condoms, are reusable

20. Dana has asked about GIFT procedure. What makes her a good candidate for GIFT?

A. She has patent fallopian tubes, so fertilized ova can be implanted on them
B. She is RH negative, a necessary stipulation to rule out RH incompatibility
C. She has normal uterus, so the sperm can be injected through the cervix into it
D. Her husband is taking sildenafil, so all sperms will be motile

Situation : Nurse Lorena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY
PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting the nursing needs 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 can not 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 named Lilia is diagnosed as having endometriosis. This condition interferes with fertility
because:

A. Endometrial implants can block the fallopian tubes

B. The uterine cervix becomes inflamed and swollen
C. The ovaries stop producing adequate estrogen
D. Pressure on the pituitary leads to decreased FSH levels

24. Lilia is scheduled to have a hysterosalphingogram. 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 . You are assigned to take care of a group of patients across the lifespan.

26. Pain in the elder persons require careful assessment because they:

A. experienced reduce sensory perception

B. have increased sensory perception
C. are expected to experience chronic pain
D. have a decreased pain threshold

27. Administration of analgesics to the older persons requires careful patient assessment because older people:

A. are more sensitive to drugs

B. have increased hepatic, renal and gastrointestinal function
C. have increased sensory perception
D. mobilize drugs more rapidly

28. The elderly patient is at higher risk for urinary incontinence because of:

A. increased glomerular filtration C. decreased bladder capacity

B. diuretic use D. dilated urethra

29. Which of the following is the MOST COMMON sign of infection among the elderly?

A. decreased breath sounds with crackles C. pain

B. fever D. change in mental status
30. Priorities when caring for the elderly trauma patient:

A. circulation, airway, breathing C. airway, breathing, disability (neurologic)

B. disability (neurologic), airway, breathing D. airway, breathing, circulation

31. Preschoolers are able to see things from which of the following perspectives?
A. Their peers C. Their own and their mother’s
B. Their own and their caregivers’ D. Only their own

32. In conflict management, the win-win approach occurs when:

A. There are two conflicts and the parties agree to each one
B. Each party gives in on 50% of the disagreements making up the conflict
C. Both parties involved are committed to solving the conflict
D. The conflict is settled out of court so the legal system and the parties win

33. According to the social-interactional perspective of child abuse and neglect, four factors place the family
members at risk for abuse. these risk factors are the family members at risk for abuse. These risk factors are the
family itself, the caregiver, the child, and

A. The presence of a family crisis C. The national emphasis on sex

B. Genetics D. Chronic poverty

34. Which of the following signs and symptoms would you most likely find when assessing and infant with
Arnold-Chiari malformation?

A. Weakness of the leg muscles, loss of sensation in the legs, and restlessness
B. Difficulty swallowing, diminished or absent gag reflex, and respiratory distress
C. Difficulty sleeping, hypervigilant, and an arching of the back
D. Paradoxical irritability, diarrhea, and vomiting.

35. A parent calls you and frantically reports that her child has gotten into her famous ferrous sulfate pills and
ingested a number of these pills. Her child is now vomiting, has bloody diarrhea, and is complaining of abdominal
pain. You will tell the mother to:

A. Call emergency medical services (EMS) and get the child to the emergency room
B. Relax because these symptoms will pass and the child will be fine
C. Administer syrup of ipecac
D. Call the poison control center

36. A client says she heard from a friend that you stop having periods once you are on the “pill”. The most
appropriate response would be:

A. “The pill prevents the uterus from making such endometrial lining, that is why periods may often be scant or
skipped occasionally.”
B. “If your friend has missed her period, she should stop taking the pills and get a pregnancy test as soon as
possible.”
C. “The pill should cause a normal menstrual period every month. It sounds like your friend has not been
taking the pills properly.”
D. “Missed period can be very dangerous and may lead to the formation of precancerous cells.”

37. The nurse assessing newborn babies and infants during their hospital stay after birth will notice which of the
following symptoms as a primary manifestation of Hirschsprung’s disease?

A. A fine rash over the trunk

B. Failure to pass meconium during the first 24 to 48 hours after birth
C. The skin turns yellow and then brown over the first 48 hours of life
D. High-grade fever

38. A client is 7 months pregnant and has just been diagnosed as having a partial placenta previa. She is stable
and has minimal spotting and is being sent home. Which of these instructions to the client may indicate a need
for further teaching?

Maintain bed rest with bathroom privileges

Avoid intercourse for three days.
Call if contractions occur.
Stay on left side as much as possible when lying down.

39. A woman has been rushed to the hospital with ruptured membrane. Which of the following should the nurse
check first?

A. Check for the presence of infection

B. Assess for Prolapse of the umbilical cord
C. Check the maternal heart rate
D. Assess the color of the amniotic fluid

40. The nurse notes that the infant is wearing a plastic-coated diaper. If a topical medication were to be
prescribed and it were to go on the stomachs or buttocks, the nurse would teach the caregivers to:

avoid covering the area of the topical medication with the diaper
avoid the use of clothing on top of the diaper
put the diaper on as usual
apply an icepack for 5 minutes to the outside of the diaper

41. Which of the following factors is most important in determining the success of relationships used in delivering
nursing care?

Type of illness of the client

Transference and counter transference
Effective communication
Personality of the participants
42. Grace sustained a laceration on her leg from automobile accident. Why are lacerations of lower extremities
potentially more serious among pregnant women than other?
A. lacerations can provoke allergic responses due to gonadotropic hormone release
B. a woman is less able to keep the laceration clean because of her fatigue
C. healing is limited during pregnancy so these will not heal until after birth
D. increased bleeding can occur from uterine pressure on leg veins

43. In working with the caregivers of a client with an acute or chronic illness, the nurse would:

Teach care daily and let the caregivers do a return demonstration just before discharge
Difficulty swallowing, diminished or absent gag reflex, and respiratory distress.
Difficulty sleeping, hypervigilant, and an arching of the back
Paradoxical irritability, diarrhea, and vomiting

44. Which of the following roles BEST exemplifies the expanded role of the nurse?

Circulating nurse in surgery

Medication nurse
Obstetrical nurse
Pediatric nurse practitioner

45. According to DeRosa and Kochura’s (2006) article entitled “Implement Culturally Competent Health Care in
your workplace,” cultures have different patterns of verbal and nonverbal communication. Which difference does
NOT necessarily belong?

Personal behavior C. Subject matter

Eye contact D. Conversational style

46. You are the nurse assigned to work with a child with acute glomerulonephritis. By following the prescribed
treatment regimen, the child experiences a remission. You are now checking to make sure the child does not
have a relapse. Which finding would most lead you to the conclusion that a relapse is happening?

A. Elevated temperature, cough, sore throat, changing complete blood count (CBC) with diiferential
B. A urine dipstick measurement of 2+ proteinuria or more for 3 days, or the child found to have 3-4+
proteinutria plus edema.
C. The urine dipstick showing glucose in the urine for 3 days, extreme thirst, increase in urine output, and a
moon face.
D. A temperature of 37.8 degrees (100 degrees F), flank pain, burning frequency, urgency on voiding, and cloudy
urine.

47. The nurse is working with an adolescent who complains of being lonely and having a lack of fulfillment in her
life. This adolescent shies away from intimate relationships at times yet at other times she appears promiscuous.
The nurse will likely work with this adolescent in which of the following areas?
A. Isolation C. Lack of fulfillment
B. Loneliness D. Identity

48. The use of interpersonal decision making, psychomotor skills, and application of knowledge expected in the
role of a licensed health care professional in the context of public health welfare and safety is an example of:

A. Delegation C. Responsibility
b. Supervision D. Competence

49. The painful phenomenon known as “back labor” occurs in a client whose fetus in what position?

A. Brow position C. Breech position

B. Right Occipito-Anterior Position D. Left Occipito-Posterior Position

50. FOCUS methodology stands for:

A. Focus, Organize, Clarify, Understand and Solution

B. Focus, Opportunity, Continuous, Utilize, Substantiate
C. Focus, Organize, Clarify, Understand, Substantiate
D. Focus, Opportunity, Continuous (process), Understand, Solution

SITUATION: The infant and child mortality rate in the low to middle income countries is ten times higher than
industrialized countries. In response to this, the WHO and UNICEF launched the protocol Integrated Management
of Childhood Illnesses to reduce the morbidity and mortality against childhood illnesses.

51. If a child with diarrhea registers two signs in the yellow row in the IMCI chart, we can classify the patient as:

A. Moderate dehydration C. Severe dehydration

B. Some dehydration D. No dehydration

52. Celeste has had diarrhea for 8 days. There is no blood in the stool, he is irritable, his eyes are sunken, the
nurse offers fluid to Celeste and he drinks eagerly. When the nurse pinched the abdomen it goes back slowly.
How will you classify Celeste’s illness?

A. Moderate dehydration C. Severe dehydration

B. Some dehydration D. No dehydration

53. A child who is 7 weeks has had diarrhea for 14 days but has no sign of dehydration is classified as:

A. Persistent diarrhea C. Dysentery

B. Severe dysentery D. Severe persistent diarrhea

54. The child with no dehydration needs home treatment. Which of the following is not included in the rules for
home treatment in this case?
A. Forced fluids
B. When to return
C. Give vitamin A supplement
D. Feeding more

55. Fever as used in IMCI includes:

A. Axillary temperature of 37.5 or higher

B. Rectal temperature of 38 or higher
C. Feeling hot to touch
D. All of the above
E. A and C only

Situation: Prevention of Dengue is an important nursing responsibility and controlling it’s spread is a priority once
outbreak has been observed.

56. An important role of the community health nurse in the prevention and control of Dengue H-fever includes:

A. Advising the elimination of vectors by keeping water containers covered

B. Conducting strong health education drives/campaign directed towards proper garbage disposal
C. Explaining to the individuals, families, groups and community the nature of the disease and its causation
D. Practicing residual spraying with insecticides

57. Community health nurses should be alert in observing a Dengue suspect. The following is NOT an indicator for
hospitalization of H-fever suspects?

A. Marked anorexia, abdominal pain and vomiting

B. Increasing hematocrit count
C. Cough of 30 days
D. Persistent headache

58. The community health nurses primary concern in the immediate control of hemorrhage among patients with
dengue is:

A. Advising low fiber and non-fat diet

B. Providing warmth through light weight covers
C. Observing closely the patient for vital signs leading to shock
D. Keeping the patient at rest

59. Which of these signs may NOT be REGARDED as a truly positive signs indicative of Dengue H-fever?

A. Prolonged bleeding time

B. Appearance of at least 20 petechiae within 1cm square
C. Steadily increasing hematocrit count
D. Fall in the platelet count
60. Which of the following is the most important treatment of patients with Dengue H-fever?

A. Give aspirin for fever

B. Replacement of body fluids
C. Avoid unnecessary movement of patient
D. Ice cap over the abdomen in case of melena

Situation: Health education and Health promotion is an important part of nursing responsibility in the
community. Immunization is a form of health promotion that aims at preventing the common childhood illnesses.

61. In correcting misconceptions and myths about certain diseases and their management, the health worker
should first:

A. Identify the myths and misconceptions prevailing in the community

B. Identify the source of these myths and misconceptions
C. Explain how and why these myths came about
D. Select the appropriate IEC strategies to correct them

62. How many percent of measles are prevented by immunization at 9 months of age?

A. 80% C. 99%
B. 90% D. 95%

63. After TT3 vaccination a mother is said to be protected to tetanus by around:

A. 80% C. 99%
B. 85% D. 90%

64. If ever convulsions occurs after administering DPT, what should the nurse best suggest to the mother?

A. Do not continue DPT vaccination anymore

B. Advise mother to comeback after 1 week
C. Give DT instead of DPT
D. Give pertussis of the DPT and remove DT

65. These vaccines are given 3 doses at one month intervals:

A. DPT, BCG, TT C. OPV, HEP. B, DPT

B. DPT, TT, OPV D. Measles, OPV, DPT

Situation – With the increasing documented cases of CANCER the best alternative to
treatment still remains to be PREVENTION. The following conditions apply.

66. Which among the following is the primary focus of prevention of cancer?
 A. Elimination of conditions causing cancer
B. Diagnosis and treatment
C. Treatment at early stage
D. Early detection

67. In the prevention and control of cancer, which of the following activities is the most important function of the
community health nurse?

A. Conduct community assemblies.

B. Referral to cancer specialist those clients with symptoms of cancer.
C. Use the nine warning signs of cancer as parameters in our process of detection, control and treatment
modalities.
D. Teach woman about proper/correct nutrition.

68. Who among the following are recipients of the secondary level of care for cancer cases?

A. Those under early case detection

B. Those under post case treatment
C. Those scheduled for surgery
D. Those undergoing treatment

69. Who among the following are recipients of the tertiary level of care for cancer cases?

A. Those under early treatment C. Those under early detection

B. Those under supportive care D. Those scheduled for surgery

70. In Community Health Nursing, despite the availability and use of many equipment and devices to facilitate the
job of the community health nurse, the best tool any nurse should be wel be prepared to apply is a scientific
approach. This approach ensures quality of care even at the community setting. This is nursing parlance is
nothing less than the:

A. nursing diagnosis C. nursing research

B. nursing protocol D. nursing process

Situation – Two children were brought to you. One with chest indrawing and the other had diarrhea. The
following questions apply:

71. Using Integrated Management and Childhood Illness (IMCI) approach, how would you classify the 1st child?

A. Bronchopneumonia C. Severe pneumonia

B. No pneumonia : cough or cold D. Pneumonia

72. The 1st child who is 13 months has fast breathing using IMCI parameters he has:

A. 40 breaths per minute or more

B. 50 breaths per minute
C. 30 breaths per minute or more
D. 60 breaths per minute

73. Nina, the 2nd child has diarrhea for 5 days. There is no blood in the stool. She is irritable, and her eyes are
sunken. The nurse offered fluids and and the child drinks eagerly. How would you classify Nina’s illness?

A. Some dehydration C. Severe dehydration

B. Dysentery D. No dehydration

74. Nina’s treatment should include the following EXCEPT:

A. reassess the child and classify him for dehydration

B. for infants under 6 months old who are not breastfed, give 100-200 ml clean water as well during this period
C. Give in the health center the recommended amount of ORS for 4 hours.
D. Do not give any other foods to the child for home treatment

74. While on treatment, Nina 18 months old weighed 18 kgs. and her temperature registered at 37 degrees C.
Her mother says she developed cough 3 days ago. Nina has no general danger signs. She has 45 breaths/minute,
no chest in-drawing, no stridor. How would you classify Nina’s manifestation.

A. No pneumonia C. Pneumonia
B. Severe pneumonia D. Bronchopneumonia

76. Carol is 15 months old and weighs 5.5 kgs and it is her initial visit. Her mother says that Carol is not eating well
and unable to breastfeed, he has no vomiting, has no convulsion and not abnormally sleepy or difficult to
awaken. Her temperature is 38.9 deg C. Using the integrated management of childhood illness or IMCI strategy,
if you were the nurse in charge of Carol, how will you classify her illness?

A. a child at a general danger sign C. severe pneumonia

B. very severe febrile disease D. severe malnutrition

77. Why are small for gestational age newborns at risk for difficulty maintaining body temperature?

A. their skin is more susceptible to conduction of cold

B. they are preterm so are born relatively small in size
C. they do not have as many fat stored as other infants
D. they are more active than usual so they throw off comes

78. Oxytocin is administered to Rita to augment labor. What are the first symptoms of water intoxication to
observe for during this procedure?

A. headache and vomiting C. a high choking voice

B. a swollen tender tongue D. abdominal bleeding and pain
79. Which of the following treatment should NOT be considered if the child has severe dengue hemorrhagic
fever?

A. use plan C if there is bleeding from the nose or gums

B. give ORS if there is skin Petechiae, persistent vomiting, and positive tourniquet test
C. give aspirin
D. prevent low blood sugar

80. In assessing the patient’s condition using the Integrated Management of Childhood Illness approach strategy,
the first thing that a nurse should do is to:

A. ask what are the child’s problem C. check for the four main symptoms
B. check the patient’s level of consciousness D. check for the general danger signs

81. A child with diarrhea is observed for the following EXCEPT:

A. how long the child has diarrhea C. presence of blood in the stool
B. skin Petechiae D. signs of dehydration

82. The child with no dehydration needs home treatment. Which of the following is NOT included in the care for
home management at this case?

A. give drugs every 4 hours C. give the child more fluids

B. continue feeding the child D. inform when to return to the health center

83. Ms. Jordan, RN, believes that a patient should be treated as individual. This ethical principle that the patient
referred to:

A. beneficence C. respect for person

B. nonmaleficence D. autonomy

84. When patients cannot make decisions for themselves, the nurse advocate relies on the ethical principle of:

A. justice and beneficence C. beneficence and nonmaleficence

B. fidelity and nonmaleficence D. fidelity and justice

85. Being a community health nurse, you have the responsibility of participating in protecting the health of
people. Consider this situation: Vendors selling bread with their bare hands. They receive money with these
hands. You do not see them washing their hands. What should you say/do?

A. “Miss, may I get the bread myself because you have not washed your hands”
B. All of these
C. “Miss, it is better to use a pick up forceps/ bread tong”
D. “Miss, your hands are dirty. Wash your hands first before getting the bread”

Situation : The following questions refers to common clinical encounters experienced by an entry level nurse.

86. A female client asks the nurse about the use of a cervical cap. Which statement is correct regarding the use of
the cervical cap?

It may affect Pap smear results.

It does not need to be fitted by the physician.
It does not require the use of spermicide.
It must be removed within 24 hours.

87. The major components of the communication process are:

A. Verbal, written and nonverbal

B. Speaker, listener and reply
C. Facial expression, tone of voice and gestures
D. Message, sender, channel, receiver and feedback

88. The extent of burns in children are normally assessed and expressed in terms of:

A. The amount of body surface that is unburned

B. Percentages of total body surface area (TBSA)
C. How deep the deepest burns are
D. The severity of the burns on a 1 to 5 burn scale.

89. The school nurse notices a child who is wearing old, dirty, poor-fitting clothes; is always hungry; has no lunch
money; and is always tired. When the nurse asks the boy his tiredness, he talks of playing outside until midnight.
The nurse will suspect that this child is:

A. Being raised by a parent of low intelligence quotient (IQ)

B. An orphan
C. A victim of child neglect
D. The victim of poverty

90. Which of the following indicates the type(s) of acute renal failure?

A. Four types: hemorrhagic with and without clotting, and nonhemorrhagic with and without clottings
B. One type: acute
C. Three types: prerenal, intrarenal and postrenal
D. Two types: acute and subacute
Situation: Mike 16 y/o has been diagnosed to have AIDS, he worked as entertainer in a cruise ship;

91. Which method of transmission is common to contract AIDS:

A. Syringe and needles A. Sexual contact

B. Body fluids B. Transfusion

92. Causative organism in AIDS is one of the following;

A. Fungus C. retrovirus
B. Bacteria D. Parasites

93. You are assigned in a private room of Mike. Which procedure should be of outmost importance;

A. Alcohol wash C. Washing Isolation

B. Universal precaution D. Gloving technique

94. What primary health teaching would you give to mike;

A. Daily exercise C. reverse isolation

B. Prevent infection D. Proper nutrition

95. Exercise precaution must be taken to protect health worker dealing with the AIDS patients . which among
these must be done as priority:

A. Boil used syringe and needles

B. Use gloves when handling specimen
C. Label personal belonging
D. Avoid accidental wound

Situation: Michelle is a 6 year old preschooler. She was reported by her sister to have measles but she is at home
because of fever, upper respiratory problem and white sports in her mouth.

96. Rubeola is an Arabic term meaning Red, the rash appears on the skin in invasive stage prior to eruption
behind the ears. As a nurse, your physical examination must determine complication especially:

A. Otitis media C. Inflammatory conjunctiva

B. Bronchial pneumonia D. Membranous laryngitis

97. To render comfort measure is one of the priorities, Which includes care of the skin, eyes, ears, mouth and
nose. To clean the mouth, your antiseptic solution is in some form of which one below?
A. Water C. Alkaline
B. Sulfur D. Salt

98. As a public health nurse, you teach mother and family members the prevention of complication of measles.
Which of the following should be closely watched?

A. Temperature fails to drop C. Inflammation of the nasophraynx

B. Inflammation of the conjunctiva D. Ulcerative stomatitis

99. Source of infection of measles is secretion of nose and throat of infection person. Filterable virus of measles is
transmitted by:

A. Water supply C. Food ingestion

B. Droplet D. Sexual contact

100. Method of prevention is to avoid exposure to an infection person. Nursing responsibility for rehabilitation of
patient includes the provision of:

A. Terminal disinfection C. Immunization

B. Injection of gamma globulin D. Comfort measures

NURSING PRACTICE III

Situation: Leo lives in the squatter area. He goes to nearby school. He helps his mother gather molasses after
school. One day, he was absent because of fever, malaise, anorexia and abdominal discomfort.

1. Upon assessment, Leo was diagnosed to have hepatitis A. Which mode of transmission has the infection agent
taken?

A. Fecal oral B. Droplet C. Airborne D. Sexual contact

2. Which of the following is concurrent disinfection in the case of Leo?

A. Investigation of contact
B. Sanitary disposal of faeces, urine and blood
C. Quarantine of the sick individual
D. removing all detachable objects in the room, cleaning lighting and air duct surfaces in the ceiling, and cleaning
everything downward to the floor

3. Which of the following must be emphasized during mother’s class to Leo’s mother?

A. Administration of Immunoglobulin to families

B. Thorough hand washing before and after eating and toileting
C. Use of attenuated vaccines
D. Boiling of food especially meat

4. Disaster control should be undertaken when there are 3 or more hepatitis A cases. Which of these measures is
a priority?

A. Eliminate faecal contamination from foods

B. Mass vaccination of uninfected individuals
C. Health promotion and education to families and communities about the disease it’s cause and transmission
D. Mass administration of Immunoglobulin

5. What is the average incubation period of Hepatitis A?

A. 30 days B. 60 days C. 50 days D. 14 days

Situation: As a nurse researcher you must have a very good understanding of the common terms of concept used
in research.

6. The information that an investigator collects from the subjects or participants in a research study is usually
called;

A. Hypothesis C. Variable
B. Data D. Concept

7. Which of the following usually refers to the independent variables in doing research

A. Result C. output
B. Cause D. Effect

8. The recipients of experimental treatment is an experimental design or the individuals to be observed in a non
experimental design are called;

A. Setting C. Treatment
B. Subjects D. Sample

9. The device or techniques an investigator employs to collect data is called;

A. Sample C. hypothesis
B. Instrument D. Concept

A. The use of another persons ideas or wordings without giving appropriate credit results from inaccurate or
incomplete attribution of materials to its sources. Which of the following is referred to when another persons
idea is inappropriate credited as one’s own;

A. Plagiarism C. assumption
B. Quotation D. Paraphrase

Situation – Mrs. Pichay is admitted to your ward. The MD ordered “Prepare for thoracentesis this pm to remove
excess air from the pleural cavity.”

11. Which of the following nursing responsibilities 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

12. Mrs. Pichay who is for thoracentesis is assigned by the nurse to which of the following positions?

A. Trendelenburg position
B. Supine position
C. Dorsal Recumbent position
D. Orthopneic position

13. 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

14. To prevent leakage of fluid in the thoracic cavity, how will 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
15. Chest x-ray was ordered after thoracentesis. When your 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: A computer analyst, Mr. Ricardo J. Santos, 25 was brought to the hospital for diagnostic workup after
he had experienced seizure in his office.

16. Just as the nurse was entering the room, the patient who was sitting on his chair begins to have a seizure.
Which of the following must the nurse do first?

A. Ease the patient to the floor

B. Lift the patient and put him on the bed
C. Insert a padded tongue depressor between his jaws
D. Restraint patient’s body movement

17. Mr. Santos is scheduled for CT SCAN for the next day, noon time. Which of the following is the correct
preparation as instructed by the nurse?

A. Shampoo hair thoroughly to remove oil and dirt

B. No special preparation is needed. Instruct the patient to keep his head still and stead
C. Give a cleansing enema and give fluids until 8 AM
D. Shave scalp and securely attach electrodes to it

18. Mr. Santos is placed on seizure precaution. Which of the following would be contraindicated?

A. Obtain his oral temperature

B. Encourage to perform his own personal hygiene
C. Allow him to wear his own clothing
D. Encourage him to be out of bed

19. Usually, how does the patient behave after his seizure has subsided?

A. Most comfortable walking and moving about

B. Becomes restless and agitated
C. Sleeps for a period of time
D. Say he is thirsty and hungry

20. Before, during and after seizure. The nurse knows that the patient is ALWAYS placed in what position?

A. Low fowler’s C. Side lying

B. Modified trendelenburg D. Supine
Situation: Mrs. Damian an immediate post op cholecystectomy and choledocholithotomy patient, complained of
severe pain at the wound site.

21. Choledocholithotomy is:

A. The removal of the gallbladder

B. The removal of the stones in the gallbladder
C. The removal of the stones in the common bile duct
D. The removal of the stones in the kidney

22. The simplest pain relieving technique is:

A. Distraction C. Deep breathing exercise

B. Taking aspirin D. Positioning

23. Which of the following statement on pain is TRUE:

A. Culture and pain are not associated

B. Pain accompanies acute illness
C. Patient’s reaction to pain Varies
D. Pain produces the same reaction such as groaning and moaning

24. In pain assessment, which of the following condition is a more reliable indicator?

A. Pain rating scale of 1 to 10

B. Facial expression and gestures
C. Physiological responses
D. Patients description of the pain sensation

25. When a client complains of pain, Your initial response is:

A. Record the description of pain

B. Verbally acknowledge the pain
C. Refer the complaint to the doctor
D. Change to a more comfortable position

Situation: You are assigned at the surgical ward and clients have been complaining of post pain at varying
degrees. Pain as you know, is very subjective.

26. 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
27. Pentoxidone 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

28. The client complained of abdominal distention 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

29. Surgical pain might be minimized by which nursing action in the O.R.

A. Skill of surgical team and lesser manipulation

B. Appropriate preparation for the scheduled procedure
C. Use of modern technology in closing the wound
D. Proper positioning and draping of clients

30. Inadequate anesthesia is said to be one of the common cause of pain both in intra and post op patients. If
General anesthesia is desired, it will involve loss of consciousness. Which of the following are the 2 general types
of GA?

A. Epidural and Spinal

B. Subarachnoid block and Intravenous
C. Inhalation and Regional
D. Intravenous and Inhalation

Situation: Nurse’s attitudes toward the pain influence the way they perceive and interact with clients in pain.

31. Nurses should be aware that older adults are at risk of underrated pain. Nursing assessment and
management of pain should address the following beliefs EXCEPT:

A. Older patients seldom tend to report pain than the younger ones
B. Pain is a sign of weakness
C. Older patients do not believe in analgesics, they are tolerant
D. Complaining of pain will lead to being labeled a ‘bad’ patient

32. Nurses should understand that when a client responds favorably to a placebo, it is known as the ‘placebo
effect’. Placebos do not indicate whether or not a client has:
A. Conscience C. Disease
B. Real pain D. Drug tolerance

33. You are the nurse in the pain clinic where you have client who has difficulty specifying the location of pain.
How can you assist such client?

A. The pain is vague

B. By charting-it hurts all over
C. Identify the absence and presence of pain
D. As the client to point to the painful are by just one finger

34. What symptom, more distressing than pain, should the nurse monitor when giving opioids especially among
elderly clients who are in pain?

A. Forgetfulness C. Drowsiness
B. Constipation D. Allergic reactions like pruritis

35. Physical dependence occurs in anyone who takes opiods over a period of time. What do you tell a mother of
a ‘dependent’ when asked for advice?

A. Start another drug and slowly lessen the opioid dosage

B. Indulge in recreational outdoor activities
C. Isolate opioid dependent to a restful resort
D. Instruct slow tapering of the drug dosage and alleviate physical withdrawal symptoms

Situation: The nurse is performing health education activities for Janevi Segovia, a 30 year old Dentist with Insulin
dependent diabetes Miletus.

36. Janevi is preparing a mixed dose of insulin. The nurse is satisfied with her performance when she:

A. Draw insulin from the vial of clear insulin first

B. Draw insulin from the vial of the intermediate acting insulin first
C. Fill both syringes with the prescribed insulin dosage then shake the bottle vigorously
D. Withdraw the intermediate acting insulin first before withdrawing the short acting insulin first

37. Janevi complains of nausea, vomiting, diaphoresis and headache. Which of the following nursing intervention
are you going to carry out first?

A. Withhold the client’s next insulin injection

B. Test the client’s blood glucose level
C. Administer Tylenol as ordered
D. Offer fruit juice, gelatine and chicken bouillon

38. Janevi administered regular insulin at 7 A.M and the nurse should instruct Jane to avoid exercising at around:
A. 9 to 11 A.M C. Between 8 A.M to 9 A.M
B. After 8 hours D. In the afternoon, after taking lunch

39. Janevi was brought at the emergency room after four month because she fainted in her clinic. The nurse
should monitor which of the following test to evaluate the overall therapeutic compliance of a diabetic patient?

A. Glycosylated hemoglobin C. Ketone levels

B. Fasting blood glucose D. Urine glucose level

40. Upon the assessment of Hba1c of Mrs. Segovia, The nurse has been informed of a 9% Hba1c result. In this
case, she will teach the patient to:

A. Avoid infection C. Prevent and recognize hyperglycaemia

B. Take adequate food and nutrition D. Prevent and recognize hypoglycaemia

41. The nurse is teaching plan of care for Jane with regards to proper foot care. Which of the following should be
included in the plan?

A. Soak feet in hot water

B. Avoid using mild soap on the feet
C. Apply a moisturizing lotion to dry feet but not between the toes
D. Always have a podiatrist to cut your toe nails; never cut them yourself

42. Another patient was brought to the emergency room in an unresponsive state and a diagnosis of
hyperglycaemic hyperosmolar nonketotic syndrome is made. The nurse immediately prepare to initiate which of
the following anticipated physician’s order?

A. Endotracheal intubation
B. 100 unites of NPH insulin
C. Intravenous infusion of normal saline
D. Intravenous infusion of sodium bicarbonate

43. Jane eventually developed DKA and is being treated in the emergency room. Which finding would the nurse
expect to note as confirming this diagnosis?

A. Comatose state
B. Decreased urine output
C. Increased respiration and an increase in pH
D. Elevated blood glucose level and low plasma bicarbonate level

44. The nurse teaches Jane to know the difference between hypoglycaemia and ketoacidosis. Jane demonstrates
understanding of the teaching by stating that glucose will be taken if which of the following symptoms develops?

A. Polyuria B. Shakiness C. Blurred Vision D. Fruit breath odor

45. Jane has been scheduled to have a FBS taken in the morning. The nurse tells Jane not to eat or drink after
midnight. Prior to taking the blood specimen, the nurse noticed that Jane is holding a bottle of distilled water.
The nurse asked Jane if she drink any, and she said “yes.” Which of the following is the best nursing action?

A. Administer syrup of ipecac to remove the distilled water from the stomach
B. Suction the stomach content using NGT prior to specimen collection
C. Advice to physician to reschedule to diagnostic examination next day
D. Continue as usual and have the FBS analysis performed and specimen be taken

Situation: Elderly clients usually produce unusual signs when it comes to different diseases. The ageing process is
a complicated process and the nurse should understand that it is an inevitable fact and she must be prepared to
care for the growing elderly population.

46. Hypoxia may occur in the older patients because of which of the following physiologic changes associated
with aging.

A. Ineffective airway clearance

B. Decreased alveolar surfaced area
C. Decreased anterior-posterior chest diameter
D. Hyperventilation

47. The older patient is at higher risk for incontinence because of:

A. Dilated urethra
B. Increased glomerular filtration rate
C. Diuretic use
D. Decreased bladder capacity

48. Merle, age 86, is complaining of dizziness when she stands up. This may indicate:

A. Dementia C. Functional decline

B. A visual problem D. Drug toxicity

49. Cardiac ischemia in an older patient usually produces:

A. ST-T wave changes C. Chest pain radiating to the left arm

B. Very high creatinine kinase level D. Acute confusion

50. The most dependable sign of infection in the older patient is:

A. Change in mental status

B. Fever
C. Pain
D. Decreased breath sounds with crackles

Situation – 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 of patient delivery outcome.

51. 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

52. Surgeries like I and D (incision and drainage) and debridement 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 anaesthesiologist
D. According to the surgeon’s preference

53. 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 anesthesiologist are in tandem
C. strap made of strong non-abrasive materials 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

54. 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 ID
D. check baseline vital signs

55. Some lifetime habits and hobbies affect postoperative respiratory function. If your client smokes 3 packs of
cigarettes a day for the past 10 years, you will anticipate increased risk for:

A. perioperative anxiety and stress

B. delayed coagulation time
C. delayed wound healing
D. postoperative respiratory infection
Situation: Sterilization is the process of removing ALL living microorganism. To be free of ALL living microorganism
is sterility.

56. There are 3 general types of sterilization use in the hospital, which one is not included?

A. Steam sterilization C. Physical sterilization

B. Chemical sterilization D. Sterilization by boiling

57. Autoclave or steam under pressure is the most common method of sterilization in the hospital. The nurse
knows that the temperature and time is set to the optimum level to destroy not only the microorganism, but also
the spores. Which of the following is the ideal setting of the autoclave machine?

A. 10,000 degree Celsius for 1 hour

B. 5,000 degree Celsius for 30 minutes
C. 37 degree Celsius for 15 minutes
D. 121 degree Celsius for 15 minutes

58. It is important that before a nurse prepares the material to be sterilized, A chemical indicator strip should be
placed above the package, preferably, Muslin sheet. What is the color of the striped produced after autoclaving?

A. Black B. Blue C. Gray D. Purple

59. Chemical indicators communicate that:

A. The items are sterile

B. That the items had undergone sterilization process but not necessarily sterile
C. The items are disinfected
D. That the items had undergone disinfection process but not necessarily disinfected

60. If a nurse will sterilize a heat and moisture labile instruments, It is according to AORN recommendation to use
which of the following method of sterilization?

A. Ethylene oxide gas B. Autoclaving C. Flash sterilizer D. Alcohol immersion

Situation 5 – Nurses hold a variety of roles when providing care to a perioperative patient.

61. 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

62. 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 the client not to get out of bed
B. Send the client to OR with the family
C. Allow client to get up to go to the comfort room
D. Obtain consent form

63. 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

64. 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

65. Which of the following nursing interventions 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 – The preoperative nurse collaborates with the client significant others, and healthcare providers.

66. To control environmental hazards in the OR, the nurse collaborates with the following departments EXCEPT:

A. Biomedical division C. Infection control committee

B. Chaplaincy services D. Pathology department

67. An air crash occurred near the hospital leading to a surge of trauma patient. One of the last patients will need
surgical amputation but there are no sterile surgical equipments. In this case, which of the following will the
nurse expect?

A. Equipments needed for surgery need not be sterilized if this is an emergency necessitating life saving measures
B. Forwarding the trauma client to the nearest hospital that has available sterile equipments is appropriate
C. The nurse will need to sterilize the item before using it to the client using the regular sterilization setting at 121
degree Celsius in 15 minutes
D. In such cases, flash sterlizer will be use at 132 degree Celsius in 3 minutes

68. Tess, the PACU nurse, discovered that Malou, who weights 110 lbs prior to surgery, is in severe pain 3 hrs
after cholecystectomy. Upon checking the chart, Malou found out that she has an order of Demerol 100 mg I.M.
prn for pain. Tess should verify the order with:

A. Nurse supervisor C. Surgeon

B. Anesthesiologist D. Intern on duty

69. Rosie, 57, who is diabetic is for debridement if incision wound. When the circulating nurse checked the
present IV fluid, she found out that there is no insulin incorporated as ordered. What should the circulating nurse
do?

A. Double check the doctor’s order and call the attending MD

B. Communicate with the ward nurse to verify if insulin was incorporated or not
C. Communicate with the client to verify if insulin was incorporated
D. Incorporate insulin as ordered.

70. The documentation of all nursing activities performed is legally and professionally vital. Which of the
following should NOT be included in the patient’s chart?

A. Presence of prosthetoid devices such as dentures, artificial limbs hearing aid, etc.
B. Baseline physical, emotional, and psychosocial data
C. Arguments between nurses and residents regarding treatments
D. Observed untoward signs and symptoms and interventions including contaminant intervening factors

Situation – Team efforts is best demonstrated in the OR.

71. 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 anaesthesiologist, and what is your preferred time and type of surgery?
C. Who are your anaesthesiologist, internist, and assistant
D. Who is your anaesthesiologist

72. In the OR, the nursing tandem for every surgery is:

A. Instrument technician and circulating nurse

B. Nurse anaesthetist, nurse assistant, and instrument technician
C. Scrub nurse and nurse anaesthetist
D. Scrub and circulating nurses
73. 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, anaesthesiologist, scrub nurse, radiologist, orderly

B. Surgeon, assistants, scrub nurse, circulating nurse, anaesthesiologist
C. Surgeon, assistant surgeon, anaesthesiologist, scrub nurse, pathologist
D. Surgeon, assistant surgeon, anaesthesiologist, intern, scrub nurse

74. Who usually act as an important part of the OR personnel by getting the wheelchair or stretcher, and
pushing/pulling them towards the operating room?

A. Orderly/clerk
B. Nurse Supervisor
C. Circulating Nurse
D. Anaesthesiologist

75. The breakdown in teamwork is often times a failure in:

A. Electricity
B. Inadequate supply
C. Leg work
D. Communication

Situation: Basic knowledge on Intravenous solutions is necessary for care of clients with problems with fluids and
electrolytes.

76. A client involved in a motor vehicle crash presents to the emergency department with severe internal
bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates which of the following
intravenous solutions will most likely be prescribed to increase intravascular volume, replace immediate blood
loss and increase blood pressure?

A. 0.45% sodium chloride C. 0.33% sodium chloride

B. Normal saline solution D. Lactated ringer’s solution

77. The physician orders the nurse to prepare an isotonic solution. Which of the following IV solution would the
nurse expect the intern to prescribe?

A. 5% dextrose in water C. 0.45% sodium chloride

B. 10% dextrose in water D. 5% dextrose in 0.9% sodium chloride

78. The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse
notes that the client’s IV Site is cool, pale and swollen and the solution is not infusing. The nurse concludes that
which of the following complications has been experienced by the client?
A. Infection B. Phlebitis C. Infiltration D. Thrombophelibitis

79. A nurse reviews the client’s electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L.
Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value?

A. U waves B. Absend P waves C. Elevated T waves D. Elevated ST segment

80. One patient had a ‘runaway’ IV of 50% dextrose. To prevent temporary excess of insulin or transient
hyperinsulin reaction what solution you prepare in anticipation of the doctor’s order?

A. Any IV solution available to KVO

B. Isotonic solution
C. Hypertonic solution
D. Hypotonic solution

81. An informed consent is required for:

A. closed reduction of a fracture C. irrigation of the external ear canal

B. insertion of intravenous catheter D. urethral catheterization

82. Which of the following is not true with regards to the informed consent?

A. It should describe different treatment alternatives

B. It should contain a thorough and detailed explanation of the procedure to be done
C. It should describe the client’s diagnosis
D. It should give an explanation of the client’s prognosis

83. You know that the hallmark of nursing accountability is the:

A. accurate documentation and reporting

B. admitting your mistakes
C. filing an incidence report
D. reporting a medication error

84. A nurse is assigned to care for a group of clients. On review of the client’s medical records, the nurse
determines that which client is at risk for excess fluid volume?

A. The client taking diuretics

B. The client with renal failure
C. The client with an ileostomy
D. The client who requires gastrointestinal suctioning
85. A nurse is assigned to care for a group of clients. On review of the client’s medical records, the nurse
determines that which client is at risk for deficient fluid volume?

A. A client with colostomy

B. A client with congestive heart failure
C. A client with decreased kidney function
D. A client receiving frequent wound irrigation

Situation: As a perioperative nurse, you are aware of the correct processing methods for preparing instruments
and other devices for patient use to prevent infection.
86. As an OR nurse, what are your foremost considerations for selecting chemical agents for disinfection?

A. Material compatibility and efficiency

B. Odor and availability
C. Cost and duration of disinfection process
D. Duration of disinfection and efficiency

87. Before you use a disinfected instrument it is essential that you:

A. Rinse with tap water followed by alcohol

B. Wrap the instrument with sterile water
C. Dry the instrument thoroughly
D. Rinse with sterile water

88. You have a critical heat labile instrument to sterilize and are considering to use high level disinfectant. What
should you do?

A. Cover the soaking vessel to contain the vapor

B. Double the amount of high level disinfectant
C. Test the potency of the high level disinfectant
D. Prolong the exposure time according to manufacturer’s direction

89. To achieve sterilization using disinfectants, which of the following is used?

A. Low level disinfectants immersion in 24 hours

B. Intermediate level disinfectants immersion in 12 hours
C. High level disinfectants immersion in 1 hour
D. High level disinfectant immersion in 10 hours

90. Bronchoscope, Thermometer, Endoscope, ET tube, Cytoscope are all BEST sterilized using which of the
following?

A. Autoclaving at 121 degree Celsius in 15 minutes

B. Flash sterilizer at 132 degree Celsius in 3 minutes
C. Ethylene Oxide gas aeration for 20 hours
D. 2% Glutaraldehyde immersion for 10 hours
Situation: The OR is divided into three zones to control traffic flow and contamination

91. What OR attires are worn in the restricted area?

A. Scrub suit, OR shoes, head cap

B. Head cap, scrub suit, mask, OR shoes
C. Mask, OR shoes, scrub suit
D. Cap, mask, gloves, shoes

92. Nursing intervention for a patient on low dose IV insulin therapy includes the following, EXCEPT:

A. Elevation of serum ketones to monitor ketosis

B. Vital signs including BP
C. Estimate serum potassium
D. Elevation of blood glucose levels

93. The doctor ordered to incorporate 1000”u” insulin to the remaining on going IV. The strength is 500 /ml. How
much should you incorporate into the IV solution?

A. 10 ml C. 0.5 ml
B. 2 ml D. 5 ml

94. Multiple vial-dose-insulin when in use should be

A. Kept at room temperature C. Kept in narcotic cabinet

B. Kept in the refrigerator D. Store in the freezer

95. Insulins using insulin syringe are given using how many degrees of needle insertion?

A. 45 B. 180 C. 90 D. 15

Situation : Maintenance of sterility is an important function a nurse should perform in any OR setting.

96. Which of the following is true with regards to sterility?

A. Sterility is time related, items are not considered sterile after a period of 30 days of being not use.
B. for 9 months, sterile items are considered sterile as long as they are covered with sterile muslin cover and
stored in a dust proof covers.
C. Sterility is event related, not time related
D. For 3 weeks, items double covered with muslin are considered sterile as long as they have undergone the
sterilization process

97. 2 organizations endorsed that sterility are affected by factors other than the time itself, these are:
A. The PNA and the PRC
B. AORN and JCAHO
C. ORNAP and MCNAP
D. MMDA and DILG

98. All of this factors affect the sterility of the OR equipments, these are the following except:

A. The material used for packaging

B. The handling of the materials as well as its transport
C. Storage
D. The chemical or process used in sterililzing the material

99. When you say sterile, it means:

A. The material is clean

B. The material as well as the equipments are sterilized and had undergone a rigorous sterilization process
C. There is a black stripe on the paper indicator
D. The material has no microorganism nor spores present that might cause an infection

100. In using liquid sterilizer versus autoclave machine, which of the following is true?

A. Autoclave is better in sterilizing OR supplies versus liquid sterilizer

B. They are both capable of sterilizing the equipments, however, it is necessary to soak supplies in the liquid
sterilizer for a longer period of time
C. Sharps are sterilized using autoclave and not cidex
D. If liquid sterilizer is used, rinsing it before using is not necessary

NURSING PRACTICE IV

Situation: After an abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge
and instrument count.

1. Counting is performed thrice: During the preincision phase, the operative phase and closing phase. Who counts
the sponges, needles and instruments?

A. The scrub nurse only

B. The circulating nurse only
C. The surgeon and the assistant surgeon
D. The scrub nurse and the circulating nurse

2. The layer of the abdomen is divided into 5. Arrange the following from the first layer going to the deepest
layer:

1. Fascia
2. Muscle
3. Peritoneum
4. Subcutaneous/Fat
5. Skin

A. 5,4,3,2,1 C. 5,4,1,3,2
B. 5,4,2,1,3 D. 5,4,1,2,3

3. When is the first sponge/instrument count reported?

A. Before closing the subcutaneous layer

B. Before peritoneum is closed
C. Before closing the skin
D. Before the fascia is sutured

4. Like any nursing interventions, counts should be documented. To whom does the scrub nurse report any
discrepancy of counts so that immediate and appropriate action is instituted?

A. Anaesthesiologists
B. Surgeon
C. OR nurse supervisor
D. Circulating nurse

5. Which of the following are 2 interventions of the surgical team when an instrument was confirmed missing?

A. MRI and Incidence report

B. CT Scan, MRI, Incidence report
C. X-RAY and Incidence report
D. CT Scan and Incidence report

Situation: An entry level nurse should be able to apply theoretical knowledge in the performance of the basic
nursing skills.

6. A client has an indwelling urinary catheter and she is suspected of having urinary infection. How should you
collect a urine specimen for culture and sensitivity?

A. clamp tubing for 60 minutes and insert a sterile needle into the tubing above the clamp to
aspirate urine
B. drain urine from the drainage bag into the sterile container
C. disconnect the tubing from the urinary catheter and let urine flow into a sterile container
D. wipe the self-sealing aspiration port with antiseptic solution and insert a sterile needle into the self sealing
port

7. To obtain specimen for sputum culture and sensitivity, which of the following instruction is best?
A. Upon waking up, cough deeply and expectorate into container
B. Cough after pursed lip breathing
C. Save sputum for two days in covered container
D. After respiratory treatment, expectorate into a container

8. The best time for collecting the sputum specimen for culture and sensitivity is:

A. Before retiring at night C. Anytime of the day

B. Upon waking up in the morning D. Before meals

9. When suctioning the endotracheal tube, the nurse should:

A. Explain procedure to patient; insert catheter gently applying suction. Withdrawn using twisting motion
B. Insert catheter until resistance is met, then withdraw slightly, applying suction intermittently as catheter is
withdrawn
C. Hyperoxygenate client insert catheter using back and forth motion
D. Insert suction catheter four inches into the tube, suction 30 seconds using twirling motion as catheter is
withdrawn

10. The purpose of NGT IMMEDIATELY after an operation is:

A. For feeding or gavage

B. For gastric decompression
C. For lavage, or the cleansing of the stomach content
D. For the rapid return of peristalsis

Situation - Mr. Santos, 50, is to undergo cystoscopy due to multiple problems like scantly urination,
hematuria and dysuria.

11. You are the nurse in charge in Mr. Santos. When asked what are the organs to be examined
during cystoscopy, you will enumerate as follows:

A. Urethra, kidney, bladder, urethra

B. Urethra, bladder wall, trigone, ureteral opening
C. Bladder wall, uterine wall, and urethral opening
D. Urethral opening, ureteral opening bladder

12. In the OR, you will position Mr. Santos who is cystoscopy in:

A. Supine
B. Lithotomy
C. Semi-fowler
D. Trendelenburg

13. After cystoscopy, Mr. Santos asked you to explain why there is no incision of any kind. What do you tell him?
A. “Cystoscopy is direct visualization and examination by urologist”.
B. “Cystoscopy is done by x-ray visualization of the urinary tract”.
C. “Cystoscopy is done by using lasers on the urinary tract”.
D. “Cystoscopy is an endoscopic procedure of the urinary tract”.

14. Within 24-48 hours post cystoscopy, it is normal to observe one the following:

A. Pink-tinged urine
B. Distended bladder
C. Signs of infection
D. Prolonged hematuria

15. Leg cramps are NOT uncommon post cystoscopy. Nursing intervention includes:

A. Bed rest
B. Warm moist soak
C. Early ambulation
D. Hot sitz bath

Situation – Mang Felix, a 79 year old man who is brought to the Surgical Unit from PACU after a transurethral
resection. You are assigned to receive him. You noted that he has a 3-way indwelling urinary catheter for
continuous fast drip bladder irrigation which is connected to a straight drainage.

16. Immediately after surgery, what would you expect his urine to be?

A. Light yellow C. Bright red

B. Amber D. Pinkish to red

17. The purpose of the continuous bladder irrigation is to:

A. Allow continuous monitoring of the fluid output status

B. Provide continuous flushing of clots and debris from the bladder
C. Allow for proper exchange of electrolytes and fluid
D. Ensure accurate monitoring of intake and output

18. Mang Felix informs you that he feels some discomfort on the hypogastric area and he has to void. What will
be your most appropriate action?

A. Remove his catheter then allow him to void on his own

B. Irrigate his catheter
C. Tell him to “Go ahead and void. You have an indwelling catheter.”
D. Assess color and rate of outflow, if there is a change refer to urologist for possible irrigation.

19. You decided to check on Mang Felix’s IV fluid infusion. You noted a change in flow rate,
pallor and coldness around the insertion site. What is your assessment finding?

A. Phlebitis
B. Infiltration to subcutaneous tissue
C. Pyrogenic reaction
D. Air embolism

20. Knowing that proper documentation of assessment findings and interventions are important
responsibilities of the nurse during first post operative day, which of the following is the LEAST relevant to
document in the case of Mang Felix?

A. Chest pain and vital signs

B. Intravenous infusion rate
C. Amount, color, and consistency of bladder irrigation drainage
D. Activities of daily living started

Situation: Melamine contamination in milk has brought world wide crisis both in the milk production sector as
well as the health and economy. Being aware of the current events is one quality that a nurse should possess to
prove that nursing is a dynamic profession that will adapt depending on the patient’s needs.

21. Melamine is a synthetic resin used for whiteboards, hard plastics and jewellery box covers due to its fire
retardant properties. Milk and food manufacturers add melamine in order to:

A. It has a bacteriostatic properties leading to increase food and milk life as a way of preserving the foods
B. Gives a glazy and more edible look on foods
C. Make milks more tasty and creamy
D. Create an illusion of a high protein content on their products

22. Most of the milks contaminated by Melamine came from which country?

A. India B. China C. Philippines D. Korea

23. Which government agency is responsible for testing the melamine content of foods and food products?

A. DOH B. MMDA C. NBI D. BFAD

24. Infants are the most vulnerable to melamine poisoning. Which of the following is NOT a sign of melamine
poisoning?

A. Irritability, Back ache, Urolithiasis

B. High blood pressure, fever
C. Anuria, Oliguria or Hematuria
D. Fever, Irritability and a large output of diluted urine

25. What kind of renal failure will melamine poisoning cause?

A. Chronic, Prerenal C. Chronic, Intrarenal

B. Acute, Postrenal D. Acute, Prerenal

Situation: Leukemia is the most common type of childhood cancer. Acute Lymphoid Leukemia is the cause of
almost 1/3 of all cancer that occurs in children under age 15.

26. The survival rate for Acute Lymphoid Leukemia is approximately:

A. 25% B. 40% C. 75% D. 95%

27. Whereas acute nonlymphoid leukemia has a survival rate of:

A. 25% B. 40% C. 75% D. 95%

28. The three main consequence of leukemia that cause the most danger is:

A. Neutropenia causing infection, anemia causing impaired oxygenation and thrombocytopenia leading to
bleeding tendencies
B. Central nervous system infiltration, anemia causing impaired oxygenation and thrombocytopenia leading to
bleeding tendencies
C. Splenomegaly, hepatomegaly, fractures
D. Invasion by the leukemic cells to the bone causing severe bone pain

29. Gold standard in the diagnosis of leukemia is by which of the following?

A. Blood culture and sensitivity

B. Bone marrow biopsy
C. Blood biopsy
D. CSF aspiration and examination

30. Adriamycin,Vincristine,Prednisone and L asparaginase are given to the client for long term therapy. One
common side effect, especially of adriamycin is alopecia. The child asks: “Will I get my hair back once again?” The
nurse best respond is by saying:

A. “Don’t be silly, ofcourse you will get your hair back”

B. “We are not sure, let’s hope it’ll grow”
C. “This side effect is usually permanent, But I will get the doctor to discuss it for you”
D. “Your hair will regrow in 3 to 6 months but of different color, usually darker and of different texture”
Situation: Breast Cancer is the 2nd most common type of cancer after lung cancer and 99% of which, occurs in
woman. Survival rate is 98% if this is detected early and treated promptly. Carmen is a 53 year old patient in the
high risk group for breast cancer was recently diagnosed with Breast cancer.

31. All of the following are factors that said to contribute to the development of breast cancer except:

A. Prolonged exposure to estrogen such as an early menarche or late menopause, nulliparity and childbirth after
age 30
B. Genetics
C. Increasing Age
D. Prolonged intake of Tamoxifen (Nolvadex)
32. Protective factors for the development of breast cancer includes which of the following except:

A. Exercise C. Breast feeding

B. Prophylactic Tamoxifen D. Alcohol intake

33. A patient diagnosed with breast cancer has been offered the treatment choices of breast conservation
surgery with radiation or a modified radical mastectomy. When questioned by the patient about these options,
the nurse informs the patient that the lumpectomy with radiation:

A. reduces the fear and anxiety that accompany the diagnosis and treatment of cancer
B. has about the same 10-year survival rate as the modified radical mastectomy
C. provides a shorter treatment period with a fewer long term complications
D. preserves the normal appearance and sensitivity of the breast.

34. Carmen, who is asking the nurse the most appropriate time of the month to do her self-examination of the
breast. The MOST appropriate reply by the nurse would be:

A. the 26th day of the menstrual cycle

B. 7 to 8 days after conclusion of the menstrual period
C. during her menstruation
D. the same day each month

35. Carmen being treated with radiation therapy. What should be included in the plan of care to minimize skin
damage from the radiation therapy?

A. Cover the areas with thick clothing materials

B. Apply a heating pad to the site
C. Wash skin with water after the therapy
D. Avoid applying creams and powders to the area

36. Based on the DOH and World Health Organization (WHO) guidelines, the mainstay for early detection method
for breast cancer that is recommended for developing countries is:

A. a monthly breast self examination (BSE) and an annual health worker breast examination (HWBE)
B. an annual hormone receptor assay
C. an annual mammogram
D. a physician conduct a breast clinical examination every 2 years

37. The purpose of performing the breast self examination (BSE) regularly is to discover:

A. fibrocystic masses C. areas of thickness or fullness

B. cancerous lumps D. changes from previous BSE
38. If you are to instruct a postmenopausal woman about BSE, when would you tell her to do BSE:

A. on the same day of each month C. on the first day of her menstruation
B. right after the menstrual period D. on the last day of her menstruation

39. During breast self-examination, the purpose of standing in front of the mirror it to observe the breast for:

A. thickening of the tissue C. lumps in the breast tissue

B. axillary lymphnodes D. change in size and contour

40. When preparing to examine the left breast in a reclining position, the purpose of placing a small folded towel
under the client’s left shoulder is to:

A. bring the breast closer to the examiner’s right hand

B. tense the pectoral muscle
C. balance the breast tissue more evenly on the chest wall
D. facilitate lateral positioning of the breast

Situation – Radiation therapy is another modality of cancer management. With emphasis on multidisciplinary
management you have important responsibilities as nurse.

41. Albert is receiving external radiation therapy and he complains of fatigue and malaise. Which of the following
nursing interventions would be most helpful for Albert?

A. Tell him that sometimes these feelings can be psychogenic

B. Refer him to the physician
C. Reassure him that these feelings are normal
D. Help him plan his activities

42. Immediately following the radiation teletherapy, Albert is

A. Considered radioactive for 24 hrs

B. Given a complete bath
C. Placed on isolation for 6 hours
D. Free from radiation

43. Albert is admitted with a radiation induced thrombocytopenia. As a nurse you should observe the following
symptoms:

A. Petechiae, ecchymosis, epistaxis

B. Weakness, easy fatigability, pallor
C. Headache, dizziness, blurred vision
D. Severe sore throat, bacteremia, hepatomegaly
44. What nursing diagnosis should be of highest priority?

A. Knowledge deficit regarding thrombocytopenia precautions

B. Activity intolerance
C. Impaired tissue integrity
D. Ineffective tissue perfusion, peripheral, cerebral, cardiovascular, gastrointestinal, renal

45. What intervention should you include in your care plan?

A. Inspect his skin for petechiae, bruising, GI bleeding regularly

B. Place Albert on strict isolation precaution
C. Provide rest in between activities
D. Administer antipyretics if his temperature exceeds 38C

Situation: Burn are cause by transfer of heat source to the body. It can be thermal, electrical, radiation or
chemical.

46. A burn characterized by Pale white appearance, charred or with fat exposed and painlessness is:

A. Superficial partial thickness burn

B. Deep partial thickness burn
C. Full thickness burn
D. Deep full thickness burn

47. Which of the following BEST describes superficial partial thickness burn or first degree burn?

A. Structures beneath the skin are damage

B. Dermis is partially damaged
C. Epidermis and dermis are both damaged
D. Epidermis is damaged

48. A burn that is said to be “WEEPING” is classified as:

A. Superficial partial thickness burn

B. Deep partial thickness burn
C. Full thickness burn
D. Deep full thickness burn

49. During the Acute phase of the burn injury, which of the following is a priority?

A. wound healing C. emotional support

B. reconstructive surgery D. fluid resuscitation

50. While in the emergent phase, the nurse knows that the priority is to:
A. Prevent infection C. Prevent deformities and contractures
B. Control pain D. Return the hemodynamic stability via fluid resuscitation

51. The MOST effective method of delivering pain medication during the emergent phase is:

A. intramuscularly C. orally
B. subcutaneously D. intravenously

52. When a client accidentally splashes chemicals to his eyes, The initial priority care following the chemical burn
is to:

A. irrigate with normal saline for 1 to 15 minutes

B. transport to a physician immediately
C. irrigate with water for 15 minutes or longer
D. cover the eyes with a sterile gauze

53. Which of the following can be a fatal complication of upper airway burns?

A. stress ulcers C. shock

B. hemorrhage D. laryngeal spasms and swelling

54. When a client will rush towards you and he has a burning clothes on, It is your priority to do which of the
following first?

A. log roll on the grass/ground

B. slap the flames with his hands
C. Try to remove the burning clothes
D. Splash the client with 1 bucket of cool water

55. Once the flames are extinguished, it is most important to:

A. cover clientwith a warm blanket

B. give him sips of water
C. calculate the extent of his burns
D. assess the Sergio’s breathing

56. During the first 24 hours after the thermal injury, you should asses Sergio for:

A. hypokalemia and hypernatremia

B. hypokalemia and hyponatremia
C. hyperkalemia and hyponatremia
D. hyperkalemia and hypernatremia
57. A client who sustained deep partial thickness and full thickness burns of the face, whole anterior chest and
both upper extremities two days ago begins to exhibit extreme restlessness. You recognize that this most likely
indicates that the client is developing:

A. Cerebral hypoxia C. metabolic acidosis

B. Hypervolemia D. Renal failure

58. A 165 lbs trauma client was rushed to the emergency room with full thickness burns on the whole face, right
and left arm, and at the anterior upper chest sparing the abdominal area. He also has superficial partial thickness
burn at the posterior trunk and at the half upper portion of the left leg. He is at the emergent phase of burn.
Using the parkland’s formula, you know that during the first 8 hours of burn, the amount of fluid will be given is:

A. 5,400 ml C. 9, 450 ml
B. 10,800 ml D. 6,750 ml

59. The doctor incorporated insulin on the client’s fluid during the emergent phase. The nurse knows that insulin
is given because:

A. Clients with burn also develops Metabolic acidosis

B. Clients with burn also develops hyperglycemia
C. Insulin is needed for additional energy and glucose burning after the stressful incidence to hasten wound
healing, regain of consciousness and rapid return of hemodynamic stability
D. For hyperkalemia

60. The IV fluid of choice for burn as well as dehydration is:

A. 0.45% NaCl C. Sterile water

B. NSS D. D5LR

Situation: ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the
OSTOMY CARE CLASS.

61. You plan to teach Fermin how to irrigate the colostomy when:

A. The perineal wound heals And Fermin can sit comfortably on the commode
B. Fermin can lie on the side comfortably, about the 3rd postoperative day
C. The abdominal incision is closed and contamination is no longer a danger
D. The stools starts to become formed, around the 7th postoperative day

62. When preparing to teach Fermin how to irrigate colostomy, you should plan to do the procedure:

A. When Fermin would have normal bowel movement

B. At least 2 hours before visiting hours
C. Prior to breakfast and morning care
D. After Fermin accepts alteration in body image
63. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if
Fermin:

A. Lubricates the tip of the catheter prior to inserting into the stoma
B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
C. Discontinues the insertion of fluid after 500 ml of fluid has been instilled
D. Clamps of the flow of fluid when felling uncomfortable

64. You are aware that teaching about colostomy care is understood when Fermin states, “I will contact my
physician and report:

A. If I have any difficulty inserting the irrigating tub into the stoma.”
B. If I noticed a loss of sensation to touch in the stoma tissue.”
C. The expulsion of flatus while the irrigating fluid is running out.”
D. When mucus is passed from the stoma between the irrigations.”

65. You would know after teaching Fermin that dietary instruction for him is effective when he states, “It is
important that I eat:

A. Soft food that is easily digested and absorbed by my large intestines.”

B. Bland food so that my intestines do not become irritated.”
C. Food low in fiber so that there are fewer stools.”
D. Everything that I ate before the operation, while avoiding foods that cause gas.”

Situation: Based on studies of nurses working in special units like the intensive care unit and coronary care unit, it
is important for nurses to gather as much information to be able to address their needs for nursing care.

66. Critically ill patients frequently complain about which of the following when hospitalized?

A. Hospital food C. Lack of privacy

B. Lack of blankets D. Inadequate nursing staff

67. Who of the following is at greatest risk of developing sensory problem?

A. Female patient C. Transplant patient

B. Adoloscent D. Unresponsive patient

68. Which of the following factors may inhibit learning in critically ill patients?

A. Gender C. Educational level

B. Medication D. Previous knowledge of illness

69. Which of the following statements does not apply to critically ill patients?
A. Majority need extensive rehabilitation
B. All have been hospitalized previously
C. Are physically unstable
D. Most have chronic illness

70. Families of critically ill patients desire which of the following needs to be met first by the nurse?

A. Provision of comfortable space

B. Emotional support
C. Updated information on client’s status
D. Spiritual counselling

Situation: Johnny, sought consultation to the hospital because of fatigability, irritability, jittery and he has been
experiencing this sign and symptoms for the past 5 months.

71. His diagnosis was hyperthyroidism, the following are expected symptoms except:

A. Anorexia C. Fine tremors of the hand

B. Palpitation D. Hyper alertness

72. She has to take drugs to treat her hyperthyroidism. Which of the following will you NOT expect that the
doctor will prescribe?

A. Colace (Docusate) C. Tapazole (Methimazole)

B. Cytomel (Liothyronine) D. Synthroid (Levothyroxine)

73. The nurse knows that Tapazole has which of the following side effect that will warrant immediate withholding
of the medication?

A. Death C. Hyperthermia
B. Sore throat D. Thrombocytosis

74. You asked questions as soon as she regained consciousness from thyroidectomy primarily to assess the
evidence of:

A. Thyroid storm C. Damage to the laryngeal nerve

B. Mediastinal shift D. Hypocalcaemia tetany

75. Should you check for haemorrhage, you will:

A. Slip your hand under the nape of her neck

B. Check for hypotension
C. Apply neck collar to prevent haemorrhage
D. Observe the dressing if it is soaked with blood

76. Basal Metabolic rate is assessed on Johnny to determine his metabolic rate. In assessing the BMR using the
standard procedure, you need to tell Johnny that:

A. Obstructing his vision

B. Restraining his upper and lower extremities
C. Obstructing his hearing
D. Obstructing his nostrils with a clamp

77. The BMR is based on the measurement that:

A. Rate of respiration under different condition of activities and rest

B. Amount of oxygen consumption under resting condition over a measured period of time
C. Amount of oxygen consumption under stressed condition over a measured period of time
D. Ratio of respiration to pulse rate over a measured period of time

78. Her physician ordered lugol’s solution in order to:

A. Decrease the vascularity and size of the thyroid gland

B. Decrease the size of the thyroid gland only
C. Increase the vascularity and size of the thyroid gland
D. Increase the size of the thyroid gland only

79. Which of the following is a side effect of Lugol’s solution?

A. Hypokalemia C. Enlargement of the Thryoid gland

B. Nystagmus D. Excessive salivation

80. In administering Lugol’s solution, the precautionary measure should include:

A. Administer with glass only

B. Dilute with juice and administer with a straw
C. Administer it with milk and drink it
D. Follow it with milk of magnesia

Situation : Pharmacological treatment was not effective for Johnny’s hyperthyroidism and now, he is scheduled
for Thyroidectomy.

81. Instruments in the surgical suite for surgery is classified as either CRITICAL, SEMI CRITICAL and NON CRITICAL.
If the instrument are introduced directly into the blood stream or into any normally sterile cavity or area of the
body it is classified as:

A. Critical B. Non Critical

B. Semi Critical D. Ultra Critical
82. Instruments that do not touch the patient or have contact only to intact skin is classified as:

A. Critical B. Non Critical

B. Semi Critical D. Ultra Critical

83. If an instrument is classified as Semi Critical, an acceptable method of making the instrument ready for
surgery is through:

A. Sterilization C. Disinfection
B. Decontamination D. Cleaning

84. While critical items and should be:

A. Clean C. Sterilized
B. Decontaminated D. Disinfected

85. As a nurse, you know that intact skin acts as an effective barrier to most microorganisms. Therefore, items
that come in contact with the intact skin or mucus membranes should be:

A. Disinfected C. Clean
B. Sterile D. Alcoholized

86. You are caring for Johnny who is scheduled to undergo total thyroidectomy because of a diagnosis of thyroid
cancer. Prior to total thyroidectomy, you should instruct Johnny to:

A. Perform range and motion exercise on the head and neck

B. Apply gentle pressure against the incision when swallowing
C. Cough and deep breath every 2 hours
D. Support head with the hands when changing position

87. As Johnny’s nurse, you plan to set up an emergency equipment at her bedside following thyroidectomy. You
should include:

A. An airway and rebreathing tube

B. A tracheostomy set and oxygen
C. A crush cart with bed board
D. Two ampules of sodium bicarbonate

88. Which of the following nursing interventions is appropriate after a total thyroidectomy?

A. Place pillows under your patient’s shoulders.

B. Raise the knee-gatch to 30 degrees
C. Keep you patient in a high-fowler’s position.
D. Support the patient’s head and neck with pillows and sandbags.

89. If there is an accidental injury to the parathyroid gland during a thyroidectomy which of the following might
Leda develop postoperatively?

A. Cardiac arrest C. Respiratory failure

B. Dyspnea D. Tetany

90. After surgery Johnny develops peripheral numbness, tingling and muscle twitching and spasm. What would
you anticipate to administer?

A. Magnesium sulfate C. Potassium iodide

B. Calcium gluconate D. Potassium chloride

Situation: Budgeting is an important part of a nurse managerial activity. The correct allocation and distribution of
resources is vital in the harmonious operation of the financial balance of the agency.

91. Which of the following best defines Budget?

A. Plan for the allocation of resources for future use

B. The process of allocating resources for future use
C. Estimate cost of expenses
D. Continuous process in seeing that the goals and objective of the agency is met

92. Which of the following best defines Capital Budget?

A. Budget to estimate the cost of direct labour, number of staff to be hired and necessary number of workers to
meet the general patient needs
B. Includes the monthly and daily expenses and expected revenue and expenses
C. These are related to long term planning and includes major replacement or expansion of the plant, major
equipments and inventories.
D. These are expenses that are not dependent on the level of production or sales. They tend to be time-related,
such as salaries or rents being paid per month

93. Which of the following best described Operational Budget?

A. Budget to estimate the cost of direct labour, number of staff to be hired and necessary number of workers to
meet the general patient needs
B. Includes the monthly and daily expenses and expected revenue and expenses
C. These are related to long term planning and includes major replacement or expansion of the plant, major
equipments and inventories.
D. These are expenses that are not dependent on the level of production or sales. They tend to be time-related,
such as rent

94. Which of the following accurately describes a Fixed Cost in budgeting?

A. These are usually the raw materials and labor salaries that depend on the production or sales
B. These are expenses that change in proportion to the activity of a business
C. These are expenses that are not dependent on the level of production or sales. They tend to be time-related,
such as rent
D. This is the summation of the Variable Cost and the Fixed Cost

95. Which of the following accurately describes Variable Cost in budgeting?

A. These are related to long term planning and include major replacement or expansion of the plant, major
equipments and inventories.
B. These are expenses that change in proportion to the activity of a business
C. These are expenses that are not dependent on the level of production or sales. They tend to be time-related,
such as rent
D. This is the summation of the Variable Cost and the Fixed Cost

Situation – Andrea is admitted to the ER following an assault where she was hit in the
face and head. She was brought to the ER by a police woman. Emergency measures were started.

96. Andrea’s respiration is described as waxing and waning. You know that this rhythm of
respiration is defined as:

A. Biot’s C. Cheyne stokes

B. Kussmaul’s D. Eupnea

97. What do you call the triad of sign and symptoms seen in a client with increasing ICP?

A. Virchow’s Triad C. Cushing’s Triad

B. The Chinese Triad D. Charcot’s Triad

98. Which of the following is true with the Triad seen in head injuries?

A. Narrowing of Pulse pressure, Cheyne stokes respiration, Tachycardia

B. Widening Pulse pressure, Irregular respiration, Bradycardia
C. Hypertension, Kussmaul’s respiration, Tachycardia
D. Hypotension, Irregular respiration, Bradycardia

99. In a client with a Cheyne stokes respiration, which of the following is the most appropriate nursing diagnosis?

A. Ineffective airway clearance C. Impaired gas exchange

B. Ineffective breathing pattern D. Activity intolerance
100. You know the apnea is seen in client’s with cheyne stokes respiration, APNEA is defined as:

A. Inability to breath in a supine position so the patient sits up in bed to breathe

B. The patient is dead, the breathing stops
C. There is an absence of breathing for a period of time, usually 15 seconds or more
D. A period of hypercapnea and hypoxia due to the cessation of respiratory effort inspite of normal respiratory
functioning.

NURSING PRACTICE V

Situation : Understanding different models of care is a necessary part of the nurse patient relationship.

1. The focus of this therapy is to have a positive environmental manipulation, physical and social to effect a
positive change.

A. Milieu B. Psychotherapy C. Behaviour D. Group

2. The client asks the nurse about Milieu therapy. The nurse responds knowing that the primary focus of milieu
therapy can be best described by which of the following?

A. A form of behavior modification therapy

B. A cognitive approach of changing the behaviour
C. A living, learning or working environment
D. A behavioural approach to changing behaviour

3. A nurse is caring for a client with phobia who is being treated for the condition. The client is introduced to
short periods of exposure to the phobic object while in relaxed state. The nurse understands that this form of
behaviour modification can be best described as:

A. Systematic desensitization C. Self control therapy

B. Aversion Therapy D. Operant conditioning

4. A client with major depression is considering cognitive therapy. The client say to the nurse, “How does this
treatment works?” The nurse respond by telling the client that:

A. “This type of treatment helps you examine how your thoughts and feelings contribute to your difficulties”
B. “This type of treatment helps you examine how your past life has contributed to your problems.”
C. “This type of treatment helps you to confront your fears by exposing you to the feared object abruptly.
D. “This type of treatment will help you relax and develop new coping skills.”

5. A Client state, “I get down on myself when I make mistake.” Using Cognitive therapy approach, the nurse
should:

A. Teach the client relaxation exercise to diminish stress

B. Provide the client with Mastery experience to boost self esteem
C. Explore the client’s past experiences that causes the illness
D. Help client modify the belief that anything less than perfect is horrible

6. The most advantageous therapy for a preschool age child with a history of physical and sexual abuse would be:

A. Play B. Psychoanalysis C. Group D. Family

7. An 18 year old client is admitted with the diagnosis of anorexia nervosa. A cognitive behavioural approach is
used as part of her treatment plan. The nurse understands that the purpose of this approach is to:

A. Help the client identify and examine dysfunctional thoughts and beliefs
B. Emphasize social interaction with clients who withdraw
C. Provide a supportive environment and a therapeutic community
D. Examine intrapsychic conflicts and past events in life

8. The nurse is preparing to provide reminiscence therapy for a group of clients. Which of the following clients
will the nurse select for this group?

A. A client who experiences profound depression with moderate cognitive impairment

B. A catatonic, immobile client with moderate cognitive impairment
C. An undifferentiated schizophrenic client with moderate cognitive impairment
D. A client with mild depression who exhibits who demonstrates normal cognition

9. Which intervention would be typical of a nurse using cognitive-behavioral approach to a client experiencing
low self esteem?

A. Use of unconditional positive regard C. Analysis of free association

B. Classical conditioning D. Examination of negative thought patterns

10. Which of the following therapies has been strongly advocated for the treatment of post traumatic stress
disorders?

A. ECT B. Group Therapy C. Hypnotherapy D. Psychoanalysis

11. The nurse knows that in group therapy, the maximum number of members to include is:

A. 4 B. 8 C. 10 D. 16

12.The nurse is providing information to a client with the use of disulfiram (antabuse) for the treatment of
alcohol abuse. The nurse understands that this form of therapy works on what principle?

A. Negative Reinforcement C. Operant Conditioning

B. Aversion Therapy C. Gestalt therapy

13. A biological or medical approach in treating psychiatric patient is:

A. Million therapy C. Behavioral therapy

B. Somatic therapy D. Psychotherapy

14. Which of these nursing actions belong to the secondary level of preventive intervention?

A. Providing mental health consultation to health care providers

B. Providing emergency psychiatric services
C. Being politically active in relation to mental health issues
D. Providing mental health education to members of the community

15. When the nurse identifies a client who has attempt to commit suicide the nurse should:

A. call a priest
B. counsel the client
C. refer the client to the psychiatrist
D. refer the matter to the police

Situation: Rose seeks psychiatric consultation because of intense fear of flying in an airplane which has greatly
affected her chances of success in her job.

16. The most common defense mechanism used by phobic clients is:

A. Supression C. Denial
B. Rationalization D. Displacement

17. The goal of the therapy in phobia is:

A. Change her lifestyle

B. Ignore tension producing situation
C. Change her reaction towards anxiety
D. Eliminate fear producing situations
18. The therapy most effective for client’s with phobia is:

A. Hypnotherapy C. Cognitive therapy

B. Group therapy D. Behavior therapy

19. The fear and anxiety related to phobia is said to be abruptly decreased when the patient is exposed to what is
feared through:

A. Guided Imagery
B. Systematic desensitization
C. Flooding
D. Hypotherapy

20. Based on the presence of symptom, The appropriate nursing diagnosis is:

A. Self esteem disturbance

B. Activity intolerance
C. Impaired adjustment
D. Ineffective individual coping

Situation: Mang Jose, 39 year old farmer, unmarried, had been confined in the National center for mental health
for three years with a diagnosis of schizophrenia.

21. The most common defense mechanism used by a paranoid client is:

A. Displacement C. Rationalization
B. Suppression D. Projection

22. When Mang Jose says to you: “The voices are telling me bad things again!” The best response is:

A. “Whose voices are those?”

B. “I doubt what the voices are telling you”
C. “I do not hear the voice you say you hear”
D. “Are you sure you hear these voices?”

23. A relevant nursing diagnosis for clients with auditory hallucination is:

A. Sensory perceptual alteration

B. Altered thought process
C. Impaired social interaction
D. Impaired verbal communication

24. During mealtime, Jose refused to eat telling that the food was poisoned. The nurse should:

A. Ignore his remark

B. Offer him food in his own container
C. Show him how irrational his thinking is
D. Respect his refusal to eat
25. When communicating with Jose, The nurse considers the following except:

A. Be warm and enthusiastic

B. Refrain from touching Jose
C. Do not argue regarding his hallucination and delusion
D. Use simple, clear language

Situation: Gringo seeks psychiatric counselling for his ritualistic behavior of counting his money as many as 10
times before leaving home.

26. An initial appropriate nursing diagnosis is:

A. Impaired social interaction

B. Ineffective individual coping
C. Impaired adjustment
D. Anxiety Moderate

27. Obsessive compulsive disorder is BEST described by:

A. Uncontrollable impulse to perform an act or ritual repeatedly

B. Persistent thoughts
C. Recurring unwanted and disturbing thought alternating with a behavior
D. Pathological persistence of unwilled thought, feeling or impulse

28. The defense mechanism used by persons with obsessive compulsive disorder is undoing and it is best
described in one of the following statements:

A. Unacceptable feelings or behavior are kept out of awareness by developing the opposite behavior or emotion
B. Consciously unacceptable instinctual drives are diverted into personally and socially acceptable channels
C. Something unacceptable already done is symbolically acted out in reverse
D. Transfer of emotions associated with a particular person, object or situation to another less threatening
person, object or situation

29. To be more effective, the nurse who cares for persons with obsessive compulsive disorder must possess one
of the following qualities:

A. Compassion C. Patience
B. Consistency D. Friendliness

30. Persons with OCD usually manifest:

A. Fear B. Apathy C. Suspiciousness D. Anxiety

Situation : The patient who is depressed will undergo electroconvulsive therapy.

31. Studies on biological depression support electroconvulsive therapy as a mode of treatment. The rationale is:
A. ECT produces massive brain damage which destroys the specific area containing memories related to
the events surrounding the development of psychotic condition
B. The treatment serves as a symbolic punishment for the client who feels guilty and worthless
C. ECT relieves depression psychologically by increasing the norepinephrine level
D. ECT is seen as a life-threatening experience and depressed patients mobilize all their bodily defenses
to deal with this attack.

32. The preparation of a patient for ECT ideally is MOST similar to preparation for a patient for:

A. electroencephalogram C. general anesthesia

B. X-ray D. electrocardiogram

33. Which of the following is a possible side effect which you will discuss with the patient?

A. hemorrhage within the brain

B. encephalitis
C. robot-like body stiffness
D. confusion, disorientation and short term memory loss

34. Informed consent is necessary for the treatment for involuntary clients. When this cannot be obtained,
permission may be taken from the:

A. social worker C. next of kin or guardian

B. doctor D. chief nurse

35. After ECT, the nurse should do this action before giving the client fluids, food or medication:

A. assess the gag reflex C. next of kin or guardian

B. assess the sensorium D. check O2 Sat with a pulse oximeter

Mrs. Ethel Agustin 50 y/o, teacher is afflicted with myasthenia gravis.

36. Looking at Mrs. Agustin, your assessment would include the ff except;

A. Nystagmus
B. Difficulty of hearing
C. Weakness of the levator palpebrae
D. Weakness of the ocular muscle

37. In an effort to combat complications which might occur relatives should he taught;
A. Checking cardiac rate
B. Taking blood pressure reading
C. Techniques of oxygen inhalation
D. Administration of oxygen inhalation

38. The drug of choice for her condition is;

A. Prostigmine
B. Morphine
C. Codeine
D. Prednisone

39. As her nurse, you have to be cautious about administration of medication, if she is undermedicated this can
cause;

A. Emotional crisis
B. Cholinergic crisis
C. Menopausal crisis
D. Myasthenia crisis

40. If you are not extra careful and by chance you give over medication, this would lead to;

A. Cholinergic crisis
B. Menopausal crisis
C. Emotional crisis
D. Myasthenia crisis

Rosanna 20 y/o unmarried patient believes that the toilet for the female patient in contaminated with AIDS virus
and refuses to use it unless she flushes it three times and wipes the seat same number of times with antiseptic
solution.

41. The fear of using “contaminated” toilet seat can be attributed to Rosanna’s inability to;

A. Adjust to a strange environment

B. Express her anxiety
C. Develop the sense of trust in other person
D. Control unacceptable impulses or feelings

42. Assessment data upon admission help the nurse to identify this appropriate nursing diagnosis

A. Ineffective denial
B. Impaired adjustment
C. Ineffective individual coping
D. Impaired social interaction

43. An effective nursing intervention to help Rosana is;

A. Convincing her to use the toilet after the nurse has used it first
B. Explaining to her that AIDS cannot be transmitted by using the toilet
C. Allowing her to flush and clear the toilet seat until she can manage her anxiety
D. Explaining to her how AIDS is transmitted

44. The goal for treatment for Rosana must be directed toward helping her to;

A. Walk freely about her past experience

B. Develop trusting relationship with others
C. Gain insight that her behaviour is due to feeling of anxiety
D. Accept the environment unconditionally

45. Psychotherapy which is prescribed for Rosana is described as;

A. Establishing an environment adapted to an individual patient needs

B. Sustained interaction between the therapist and client to help her develop more functional behaviour
C. Using dramatic techniques to portray interpersonal conflicts
D. Biologic treatment for mental disorder

Dennis 40 y/o married man, an electrical engineer was admitted with the diagnosis of paranoid disorders. He has
became suspicious and sitrustful 2 months before admission. Upon admission, he kept on saying, “my wife has
been planning to kill me.”

46. A paranoid individual who can not accept the guilt demonstrate one of the following defense mechanism;

A. Denial
B. Projection
C. Rationalization
D. Displacement

47. One morning, Dennis was seen tilting his head as if he was listening to someone. An appropriate nursing
intervention would be;

A. Tell him to socialize with other patient to divert his attention

B. Involve him in group activities
C. Address him by name to ask if he is hearing voices again
D. Request for an order of antipsychotic medicine
48. When he says, “ this voices are telling me my wife is going to kill me.” A therapeutic communication of the
nurse is which one of the following;

A. “i do not hear the voices you say you hear”

B. “ are you really sure you heard those voices?”
C. “ I do not think you heard those voices?”
D. “Whose voices are those?”

49. The nurse confirms that Dennis is manifesting auditory hallucination. The appropriate nursing diagnosis she
identifiesis;

A. Sensory perceptual alteration

B. Self esteem disturbance
C. Ineffective individual coping
D. Defensive coping

50. Most appropriate nursing intervention for a client with suspicious behavior is one of the following;

A. Talk to the client constantly to reinforce reality

B. Involve him in competitive activities
C. Use Non Judgmental and Consistent approach
D. Project cheerfulness in interacting with the patient

Situation: Clients with Bipolar disorder receives a very high nursing attention due to the increasing rate of suicide
related to the illness.

51. The nurse is assigned to care for a recently admitted client who has attempted suicide. What should the
nurse do?

A. Search the client's belongings and room carefully for items that could be used to attempt suicide.
B. Express trust that the client won't cause self-harm while in the facility.
C. Respect the client's privacy by not searching any belongings.
D. Remind all staff members to check on the client frequently.

52. In planning activities for the depressed client, especially during the early stages of hospitalization, which of
the following plan is best?

A. Provide an activity that is quiet and solitary to avoid increased fatigue such as working on a puzzle and
reading a book.
B. Plan nothing until the client asks to participate in the milieu
C. Offer the client a menu of daily activities and ask the client to participate in all of them
D. Provide a structured daily program of activities and encourage the client to participate
53. A client with a diagnosis of major depression, recurrent with psychotic features is admitted to the mental
health unit. To create a safe environment for the client, the nurse most importantly devises a plan of care that
deals specifically with the clients:

A. Disturbed thought process C. Imbalanced nutrition

B. Self Care Deficit D. Deficient Knowledge

54. The client is taking a Tricyclic anti depressant, Which of the following is an example of TCA?

A. Paxil C. Nardil
B. Zoloft D. Pamelor
55. A client visits the physician's office to seek treatment for depression, feelings of hopelessness, poor
appetite, insomnia, fatigue, low self-esteem, poor concentration, and difficulty making decisions. The client
states that these symptoms began at least 2 years ago. Based on this report, the nurse suspects:

A. cyclothymic disorder. C. Bipolar disorder

B. major depression. D. dysthymic disorder.

56. The nurse is planning activities for a client who has bipolar disorder, which aggressive social behaviour.
Which of the following activities would be most appropriate for this client?

A. Ping Pong B. Linen delivery C. Chess D. Basketball

57. The nurse assesses a client with admitted diagnosis of bipolar affective disorder, mania. The symptom
presented by the client that requires the nurse’s immediate intervention is the client’s:

A. Outlandish behaviour and inappropriate dress

B. Grandiose delusion of being a royal descendant of king arthut
C. Nonstop physical activity and poor nutritional intake
D. Constant incessant talking that includes sexual topics and teasing the staff

58. A nurse is conducting a group therapy session and during the session, A client with mania consistently talks
and dominates the group. The behaviour is disrupting the group interaction. The nurse would initially:

A. Ask the client to leave the group session

B. Tell the client that she will not be allowed to attend any more group sessions
C. Tell the client that she needs to allow other client in a group time to talk
D. Ask another nurse to escort the client out of the group session

59. A professional artist is admitted to the psychiatric unit for treatment of bipolar disorder. During the last 2
weeks, the client has created 154 paintings, slept only 2 to 3 hours every 2 days, and lost 18 lb (8.2 kg).
Based on Maslow's hierarchy of needs, what should the nurse provide this client with first?

A. The opportunity to explore family dynamics

B. Help with reestablishing a normal sleep pattern
C. Experiences that build self-esteem
D. Art materials and equipment

60. The physician orders lithium carbonate (Lithonate) for a client who's in the manic phase of bipolar disorder.
During lithium therapy, the nurse should watch for which adverse reactions?
A. Anxiety, restlessness, and sleep disturbance
B. Nausea, diarrhea, tremor, and lethargy
C. Constipation, lethargy, and ataxia
D. Weakness, tremor, and urine retention

Situation – Annie has a morbid fear of heights. She asks the nurse what desensitization therapy is:

61. The accurate information of the nurse of the goal of desensitization is:

A. To help the clients relax and progressively work up a list of anxiety provoking situations through imagery.
B. To provide corrective emotional experiences through a one-to-one intensive relationship.
C. To help clients in a group therapy setting to take on specific roles and reenact in front of an audience,
situations in which interpersonal conflict is involved.
D. To help clients cope with their problems by learning behaviors that are more functional and be better
equipped to face reality and make decisions.

62. It is essential in desensitization for the patient to:

A. Have rapport with the therapist

B. Use deep breathing or another relaxation technique
C. Assess one’s self for the need of an anxiolytic drug
D. Work through unresolved unconscious conflicts

63. In this level of anxiety, cognitive capacity diminishes. Focus becomes limited and client experiences tunnel
vision. Physical signs of anxiety become more pronounced.

A. Severe anxiety C. Mild anxiety

B. Panic D. Moderate anxiety

64. Antianxiety medications should be used with extreme caution be cause long term use can lead to:

A. Parkinsonian like syndrome C. Hepatic failure

B. Hypertensive crisis D. Risk of addiction

65. The nursing management of anxiety related with post traumatic stress disorder includes all of the following
EXCEPT:

A. Encourage participation in recreation or sports activities

B. Reassure client’s safety while touching client
C. Speak in a calm soothing voice
D. Remain with the client while fear level is high
SITUATION: You are fortunate to be chosen as part of the research team in the hospital. A review of the following
IMPORTANT nursing concepts was made.

66. As a professional, a nurse can do research for varied reason except:

A. Professional advancement through research participation

B. To validate results of new nursing modalities
C. For financial gains
D. To improve nursing care

67. Each nurse participants was asked to identify a problem. After the identification of the research problem,
which of the following should be done?

A. Methodology C. Acknowledgement
B. Review of related literature D. Formulate hypothesis

68. Which of the following communicate the results of the research to the readers. They facilitate the description
of the data.

A. Hypothesis C. Research problem

B. Statistics D. Tables and Graphs

69. In Quantitative date, which of the following is described as the distance in the scoring unites of the variable
from the highest to the lower?

A. Frequency C. Median
B. Mean D. Range

70. This expresses the variability of the data in reference to the mean. It provides as with a numerical estimate of
how far, on the average the separate observation are from the mean:

A. Mode C. Median
B. Standard deviation D. Frequency

Situation: Survey and Statistics are important part of research that is necessary to explain the characteristics of
the population.

71. According to the WHO statistics on the Homeless population around the world, which of the following groups
of people in the world disproportionately represents the homeless population?

Hispanics C. African Americans

Asians D. Caucasians
72. All but one of the following is not a measure of Central Tendency:

A. Mode C. Standard Deviation

B. Variance D. Range

73. In the value : 87, 85, 88, 92, 90; What is the mean?

A. 88.2 B. 88.4 C. 87 D. 90

74. In the value : 80, 80, 80, 82, 82, 90, 90, 100; What is the mode?

A. 80 B. 82 C. 90 D. 85.5

75. In the value: 80,80,10,10,25,65,100,200; What is the median?

A. 71.25 B. 22.5 C. 10 and 25 D. 72.5

76. Draw Lots, Lottery, Table of random numbers or a sampling that ensures that each element of the population
has an equal and independent chance of being chosen is called:

A. Cluster C. Stratified
B. Simple D. Systematic

77. An investigator wants to determine some of the problems that are experienced by diabetic clients when using
an insulin pump. The investigator went into a clinic where he personally knows several diabetic clients having
problem with insulin pump. The type of sampling done by the investigator is called:

A. Probability C. Snowball
B. Purposive D. Incidental

78. If the researcher implemented a new structured counselling program with a randomized group of subject and
a routine counselling program with another randomized group of subject, the research is utilizing which design?

A. Quasi experimental C. Comparative

B. Experimental D. Methodological

79. Which of the following is not true about a Pure Experimental research?

A. There is a control group

B. There is an experimental group
C. Selection of subjects in the control group is randomized
D. There is a careful selection of subjects in the experimental group
80. The researcher implemented a medication regimen using a new type of combination drugs to manic patients
while another group of manic patient receives the routine drugs. The researcher however hand picked the
experimental group for they are the clients with multiple episodes of bipolar disorder. The researcher utilized
which research design?

A. Quasi-experimental C. Phenomenological
B. Pure experimental D. Longitudinal

Situation 19: As a nurse, you are expected to participate in initiating or participating in the conduct of research
studies to improve nursing practice. You to be updated on the latest trends and issues affected the profession
and the best practices arrived at by the profession.

81. You are interested to study the effects of mediation and relaxation on the pain experienced by cancer
patients. What type of variable is pain?

A. Dependent C. Independent
B. Correlational D. Demographic

82. You would like to compare the support system of patient with chronic illness to those with acute illness. How
will you best state your problem?

A. A descriptive study to compare the support system of patients with chronic illness and those with acute illness
in terms of demographic data and knowledge about intervention.
B. The effects of the types of support system of patients with chronic illness and those with acute illness.
C. A comparative analysis of the support system of patients with chronic illness and those with acute illness.
D. A study to compare the support system of patients with chronic illness and those with acute illness.
E. What are the differences of the support system being received by patient with chronic illness and patients
with acute illness?

83. You would like to compare the support system of patients with chronic illness to those with acute illness.
Considering that the hypothesis was: “Client’s with chronic illness have lesser support system than client’s with
acute illness.” What type of research is this?

A. Descriptive B. Correlational, Non experimental

C. Experimental D. Quasi Experimental

84. In any research study where individual persons are involved, it is important that an informed consent of the
study is obtained. The following are essential information about the consent that you should disclose to the
prospective subjects except:

A. Consent to incomplete disclosure

B. Description of benefits, risks and discomforts
C. Explanation of procedure
D. Assurance of anonymity and confidentiality

85. In the Hypothesis: “The utilization of technology in teaching improves the retention and attention of the
nursing students.” Which is the dependent variable?

A. Utilization of technology
B. Improvement in the retention and attention
C. Nursing students
D. Teaching

Situation: You are actively practicing nurse who has just finished you graduate studies. You learned the value of
research and would like to utilize the knowledge and skills gained in the application of research to the nursing
service. The following questions apply to research.

86. Which type of research inquiry investigates the issues of human complexity (e.g understanding the human
expertise)?

A. Logical position C. Positivism

B. Naturalistic inquiry D. Quantitative research

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

A. A study examining the bereavement process in spouse of clients with terminal cancer
B. A study exploring the factors influencing weight control behaviour
C. A Study measuring the effects of sleep deprivation on wound healing
D. A study examining client’s feelings before, during and after bone marrow aspiration.

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

A. A study examining clients reaction 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 procedure

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

A. Right of self determination C. Right to full disclosure

B. Right to privacy and confidentiality D. Right not to be harmed

90. A supposition or system of ideas that is proposed to explain a given phenomenon best defines:
A. A paradigm C. A theory
B. A Concept D. A conceptual framework

Situation: Mastery of research design determination is essential in passing the NLE.

91. Ana wants to know if the length of time she will study for the board examination is proportional to her board
rating. During the June 2008 board examination, She studied for 6 months and gained 68%, On the next board
exam, she studied for 6 months again for a total of 1 year and gained 74%, On the third board exam, She studied
for 6 months for a total of 1 and a half year and gained 82%. The research designed she used is:

A. Comparative C. Experimental
B. Correlational D. Qualitative

92. Anton was always eating high fat diet. You want to determine if what will be the effect of high cholesterol
food to Anton in the next 10 years. You will use:

A. Comparative C. Historical
B. Correlational D. Longitudinal

93. Community A was selected randomly as well as community B, nurse Edna conducted teaching to community
A and assess if community A will have a better status than community B. This is an example of:

A. Comparative C. Experimental
B. Correlational D. Qualitative

94. Ana researched on the development of a new way to measure intelligence by creating a 100 item
questionnaire that will assess the cognitive skills of an individual. The design best suited for this study is:

A. Historical C. Survey
B. Methodological D. Case study

95. Gen is conducting a research study on how mark, an AIDS client lives his life. A design suited for this is:

A. Historical C. Phenomenological
B. Case Study D. Ethnographic

96. Marco is to perform a study about how nurses perform surgical asepsis during World War II. A design best for
this study is:

A. Historical C. Phenomenological
B. Case Study D. Ethnographic
97. Tonyo conducts sampling at barangay 412. He collected 100 random individuals and determine who is their
favourite comedian actor. 50% said Dolphy, 20% said Vic Sotto, while some answered Joey de Leon, Allan K,
Michael V. Tonyo conducted what type of research study?

A. Phenomenological C. Non experimental

B. Case Study D. Survey

98. Jane visited a tribe located somewhere in China, it is called the Shin Jea tribe. She studied the way of life,
tradition and the societal structure of these people. Jane will best use which research design?

A. Historical C. Phenomenological
B. Case Study D. Ethnographic

99. Anjoe researched on TB. Its transmission, Causative agent and factors, treatment sign and symptoms as well
as medication and all other in depth information about tuberculosis. This study is best suited for which research
design?

A. Historical C. Phenomenological
B. Case Study D. Ethnographic

100. Diana is to conduct a study about the relationship of The number of family members in the household and
the electricity bill. Which of the following is the best research design suited for this study?

1. Descriptive
2. Exploratory
3. Explanatory
4. Correlational
5. Comparative
6. Experimental

A. 1,4 B. 2,5 C. 3,6 D. 1,5 E. 2,4