1. Lester, a ward nurse, shows organizational and planning abilities and has 26 months of clinical experience. He is 5.

is 5. As a source of statistical data for accidents A. Exposing the lower conjunctival sac by placing the thumb or fingers of the non dominant hand on the client’s
considered to be on what stage of nursing expertise according to Benner? forehead
A. 1, 2, 3, and 5 B. Pressing on the lacrimal duct while instilling the eye drops to prevent systemic absorption
A. Advanced beginner B. None except 4 C. Instilling the eye drops into the outer third of the lower conjunctival sac
B. Expert C. 1, 3, 4 D. Instilling the eye drops from the inner canthus going towards the side of the eye
C. Competent D. All of the above
D. Proficient 20. A group of newly hired nurses were conducting a return demonstration regarding the application of eye ointment. The
11. Nurse Trevor was tasked to perform assessment on his client. The nurse instructed the client to follow the movement of head nurse should call the attention of who among the following staff nurses during the demonstration?
2. Baneng, a newly registered nurse, often wonders about what it takes to be called a professional. She is aware that nurses the penlight without moving his head. Nurse Trevor is assessing which of the following cranial nerve/s?
should act “professionally.” This implies that nurses: A. Trochlear and Optic A. Nerry, who squeezed about 2 cm of ointment and instructed the client to gently close but not squeeze the eye
B. Trochlear and Abducens B. Vanessa, who applied the ointment from the inner canthus going outward of the affected eye
A. Are dedicated and committed in the practice of their professions C. Optic and Trigeminal C. Prince, who discarded the first bead of the eye ointment before application because the tube is likely to expel
B. Consider health care cost and provide evidenced-based practice D. Occulomotor only more than the desired amount of ointment
C. Are knowledgeable, conscientious and are responsible to self and others D. Debbie, who held the tube above the conjunctival sac ensuring that the tip do not touch the conjunctiva
D. Use clinically documented evidenced-based practice in decision-making 12. Charles, a 31-year-old male, is brought to the emergency department of a tertiary hospital with an admitting diagnosis of
Traumatic Brain Injury. The nurse assigned to the patient is assessing the level of consciousness using the Glasgow coma 21. Nurse Harry started the IV infusion at 3:30 PM. When he checked Patrick at around 8:30 in the evening, he noted that the
3. Nursing is a diverse discipline that strives to meet the physiological, psychological, sociocultural, developmental, and scale. Charles opens his eyes upon pain infliction, is producing inexplicable sounds during the interaction, and is in an level of solution is at 650 mL. Nurse Harry can conclude that:
spiritual needs of clients. She conceptualized the framework for psychiatric nursing, wherein a nurse must established a abnormally flexed position. The nurse correctly assess his GCS score when he recorded as score of:
therapeutic relationship with the client: A. The solution is running on time
A. 6 B. The solution is delayed 125 mL
A. Hildegard Peplau B. 4 C. The solution is delayed by 75 mL
B. Betty Neuman C. 7 D. The solution is transfusing rapidly
C. Madeleine Leninger D. 5
D. Lydia Hall 22. Nurse Miranda is taking care of 5 patients in the female surgical ward. She started an IVinfusion of 1 liter Plain Normal
4. Athena is a medical unit staff nurse. She is aware on the importance of exercise in maintaining good health, however, due Saline Solution to Ms. Ligaya and told her that she will have to attend the needs of her other clients so she will be back
to her schedule and responsibilities at work and at home as a single parent, she is having a hard time engaging in any form after an hour. After about 30 minutes, Nurse Miranda is currently preparing medications in the Nurses’ station when Ms.
of exercise program. According to Dunn’s High Level Wellness Grid, you properly identify Athena’s situation as: 13. Nurse Angelico is working on the Out-Patient Department of a Tertiary Hospital. A client approached the nurse with Ligaya’s sister came rushing for help to check the IV infusion that was initiated. As nurse Miranda checked Ms. Ligaya,
complaints of diminished hearing on the right ear. He performed the Weber’s test and the client stated that he can hear the she found the IV site to be reddish, bulging, and the flow rate was very slow. Select and arrange in proper sequence of the
A. Poor health in an unfavorable environment sound better on his right ear. Based on the client’s response, Nurse Angelico evaluated that: interventions that Nurse Ligaya must do next.
B. Protected poor health in a favorable environment 1. Slow down the infusion
C. Emergent High A. The client may be experiencing a bone conductive hearing loss 2. Apply warm compress over the IV site
D. High B. The client has sensorineural disturbance 3. Re-site the infusion in the opposite arm
C. Cranial nerve 8 damage may be suspected 4. Document the assessment and nursing intervention
5. Monica, a student nurse is experiencing cough and colds so she was not able to attend her class today. She borrowed the D. It is a normal response to the test 5. Discontinue the infusion
notes of her classmate and asked for any home works. At home she was able to complete her school works. Based on the 6. Restart the IV distal to the former IV site
scenario, Monica is considered unhealthy in which health model? 14. Nurse Daniel is to perform the Rinne’s test to his client to assess for any hearing disturbances. He inaccurately performed
the test if he did which of the following, except A. 5,2,3,4
A. Clinical model A. Strike the tuning fork softly with the back of the hand and place it in the center of the client’s head or forehead B. 1,2,4, 3
B. Role Performance model C. 5,2,6,4
then ask the client on what ear is the sound heard better.
C. Adaptive model D. 1,5,2,4
B. Strike a tuning fork and place the prongs in front of the external auditory ear canal. Ask the client when she can
D. Eudemonistic model
no longer hear the sound. Move the base of the tuning fork on the mastoid process then ask when the client can no longer
23. Infiltration occurs when the IV cannula is dislodged from the vein which causes the IV fluid ormedication to be infused
Situation 2 –The nursing process has distinctive characteristics which include a cyclic and dynamic nature, client hear the sound. into the surrounding tissue. Nurse Brad, the outgoing nurse, has just endorsed to you a patient who has had IV infiltration
centeredness, has focus on problem solving and decision making, interpersonal and collaborative style, universal C. Strike a tuning fork and place the base of the tuning fork on the mastoid process. Ask the client when she can no as documented in his charting. Which of the following assessment findings on the patient would cause you to question
applicability and the use of critical thinking that enablethe nurse to respond to the changing health status of the client. The longer hear the sound. Remove and strike again the tuning fork and place the prongs in front of the external auditory canal. Nurse Brad’s documentation?
following questions refer to the nursing process. Ask the client when she can no longer hear the sound.
D. Strike a tuning fork and place the base on the mastoid process. Ask the client to tell you when the sound is no A. IV site feels warm to touch
6. A 12 year old female patient was brought to the Emergency Unit by her mother due to persistent stomachache longer heard, then move the tuning fork in front of the external auditory canal. Ask the client when she can no longer hear B. Feeling of discomfort in the IV site when palpated as verbalized by the patient
accompanied by vomiting. The nurse assigned to the patient is on the assessment phase of the nursing process. During this the sound. C. (+) blanching and swelling on the skin surrounding the IV site
phase, the nurse is most concerned with: 15. The nurse conducted an assessment to several patients in the ward where she is currently assigned. Which among the D. Transfusion of the IV fluid is delayed
following assessment findings may reveal that the nurse had an inaccurate judgment?
A. Interpreting data collected from the patient 24. In intravenous therapy, it is a rule to use veins of the upper extremities first. The superficial veins of the dorsal aspect of
B. Designing nursing strategies to alleviate the discomfort of the patient the hand are the preferred site. Nurse Franco is preparing for venipuncture to his patient. Which area of the wrist is highly
A .Prince, a client with asthma who presents with high pitched and musical breath sounds heard primarily during
C. Establishing a database for references sensitive and most painful site of venipuncture and must be avoided?
D. Comparing client responses with anticipated outcomes of care expiration
B. Vanessa who is suffering from Bacterial Pneumonia with decreased tactile fremitus upon palpation
A. Lower aspect
7. Evaluating is a planned, ongoing, purposeful activity in which clients and health care professionals determine the client’s C .Dry and grating breath sounds during inspiration and expiration are heard during the auscultation of the thorax of
B. Upper aspect
progress and effectiveness of nursing care. Which of the following statements reflects outcome evaluation? Nerry, a client with Pleuritis. C. Outer aspect
D.Tympany is elicited during percussion of the stomach of Debbie, a clientwho is complaining of stomach fullness D. Inner aspect
A. Client Hazel Grace’s temperature decreased from 38 degrees Celsius to 37.4 degrees Celsius after Nurse
Augustus provides cool bath and compress. 25. The site for IV insertion is usually at back of the hand, and usually the metacarpal vein is used. Nurse Doug is about to
B. Nurse Anne always checks the client’s identification band before administration of medications. 16. A nurse in the barangay is conducting routine vaccination to children. The patient is scheduled to receive her anti-measles insert an IV cannula on an obese patient’s right metacarpal vein. He is having difficulty visualizing the vein so he decided
C. Nurse Candace noted that Adriana, a client admitted in the charity ward, has difficulty voiding using the bedpan vaccine. When preparing for a subcutaneous injection, the nurse is accurate to utilize which syringe and needle? to dilate the vein. Which of the following methods would not Nurse Doug dilating the client’s vein?
because other clients can see her.
A. Syringe 3-5 mL and needle gauge 26 to 27 A. Instruct the patient to periodically clench his right fist
D. Three clients were still admitted in the emergency ward for 5 days as the charity ward is still full and cannot yet
B. Tuberculin syringe 1 mL with needle gauge 26 or 27 B. Apply a soft non-latex tourniquet 7 inches above the insertion site
accommodate them. C. Syringe 1-2 mL and needle gauge 22 to 24
8. Nurses document evidence of the nursing process on a variety of forms throughout the clinical record. Paulo, a staff of the C. Tapping the vein site robustly
D. Syringe 1-2 mL and needle gauge 25 to D. Put the extremity in a dependent position for a few minutes below the level of the heart
quality management system of the hospital, is auditing the charts for incongruencies. He will report the following
documentation errors to his superior, aside from: 17. Nurse Carrie is conducting a teaching class to the family members of patients needing IM injections at home. One point 26. Nurse Sarah is providing morning care for her 52-year old female client. She is to perform bed and bath hygiene care to
A. Nurse Scott who documented that he charted for a co-worker and signed his name on the entry discussed by nurse Carrie is the use of Z track method. She accurately described this method if she states the following, her client. Nurse Sarah needs further instructions about the procedure if she performed which of the following, except:
except:
B. Nurse Rogue who drew a line through her mistake and wrote the word error above it 1. Checked the soiled bed linen for personal items such as eyeglasses
C. Nurse Jean who used correcting fluid to cover her mistake and made a new entry A. Z track method requires that medication be administered slowly to allow time 2. Finished care with back rub using rubbing alcohol
D. Nurse Logan who used quotes around words for tissue to expand and begin absorption of medication. 3. Put a clean gown on the strongest arm first, then the weak arm
B. In this technique, use the ulnar side of the non-dominant hand to pull the skin 4. Ensured that the temperature of the bath water is 110-115oF
9. Nurse Jane is receiving the results of the blood glucose level of her newly diagnosed diabetic patient from the laboratory to the side and pierce the skin quickly and smoothly at a 45 degree angle. 5. Washed the feet by placing them in a basin with water
over telephone. In receiving the information, Nurse Jane should: C. The Z track technique leaves a zigzag path which prevents the seepage of the 6. Observed standard precautions for exposed body fluids
medication into the SQ tissues and subsequent discomfort. 7. Washed the client’s extremities from proximal to distal
A. Repeat the results to the caller from the laboratory. Write the results on a scrap paper and then transfer the results D. This technique is usually used for IM drugs that are irritating to the tissue or 8. Performed hand hygiene after disposing of client’s linen in the soiled hamper
to the chart afterwards. drugs that cause discoloration such as iron.
B. Point out to the caller that she, as a nurse, cannot receive results from the laboratory tests over the telephone and A. 1, 2, 5, 6, 7
asks the laboratory personnel to bring the written results to the nurse’s station instead. 18. Nurse Jesse is to apply a transdermal patch of Nitroglycerine to a male client with Chronic Angina. The following are B. 1, 4, 5, 6, 8
C. Write down the result, read back the results to the caller from the laboratory and receive confirmation from the important guidelines to be observed by Nurse Jesse, aside from: C. 2, 3, 5, 6, 8
caller. D. 2, 4, 6, 7, 8
D. Request that the laboratory send the results via email to transfer to the client’s chart. A. If the body area has hair, clip the hair prior to application of the patch
B. Patches may be applied to distal part of the extremities like forearm 27. The nurse conducted an assessment to Mrs. Tasya, an 83 year old unconscious client. Assessment of the mouth reveals
10. Aside from reporting unusual occurrences, Nurse Kenji is aware that the incident report also offers many advantages. He C. Change application and site regularly to prevent irritation of the skin excessive dryness and presence of sores. Which of the following should the nurse use to provide oral care for Mrs. Tasya?
states that the benefits derived from an incident report are the following except: D. Wear gloves during application to prevent drug absorption
A. Mineral oil
1. For potential legal allegations 19. The nurse is to apply eye drops to Mr. Rivera prior to his surgery to correct Cataract. After checking all the necessary B. Lemon glycerine
2. To alert the risk management committee information and cleaning the affected eyelid and eyelashes, the nurse manager should not intervene if the nurse administer C. Half strength hydrogen peroxide
3. To find ways to prevent similar incident in the future the ophthalmic drops by: D. Regular mouthwash - containing alcohol can irritate the oral mucosa and cause dryness
4. To chastise the individual involved
 48. Home oxygen therapy services are readily available in most communities. Safety precautions are essential during oxygen
28. Nurse Echo is to provide oral care to his client who is currently unconscious. He is aware that this intervention imposes 38. Blood products should be infused through administration sets designed specifically for blood.Nurse Tris overhears a therapy. Although oxygen by itself will not burn or explode, it facilitates combustion . Hazel Grace is prescribed to have
a great risk of fluid aspiration to the lungs. Because of this knowledge, nurse Echo should perform which of the physician stating that Mr. Waters, another client is in hypovolemic shock and requires plasma expansion. Nurse Tris home oxygen therapy. What safety precaution is not essential in having oxygen administration at home, except?
following to avoid the said risk? anticipates receiving an order to transfuse which of the following blood products to Mr. Waters?
1. For home oxygen use or when facility permits smoking, teach family members and roommates
A. Use fingers wrapped with wet cottons and wash cloths to rub inside the cheeks, tongue, lips and gums. A. Cryoprecipitate to smoke only outside or in provided smoking rooms near from the client and the oxygen
B. Swab the inside of the cheeks and lips, tongue and gums with dry cotton. B. Albumin equipment.
C. Clean the teeth and mouth with cotton swabs soaked with mouth wash to avoid rinsing the buccal cavity. C. Packed red blood cells 2. Place cautionary signs reading “No Smoking: Oxygen in Use” on the client’s door, foot of the
D. Suction as needed while cleaning the buccal cavity. D. Whole Blood bed and on the oxygen equipment
3. Instruct clients and visitor on the hazards of smoking with oxygen in use.
29. Massage is a comfort measure that can aid relaxation, decrease muscle tension and ease anxiety because the physical 39. Bone marrow biopsy is the removal of a specimen of bone marrow for laboratory study. Ms. Lancaster has been suspected 4. Make sure that electric devices are in good working conditions to prevent the occurrence of
contact between the nurse and the client communicates care. The nurse plans to provide back massage to her client who of having leukemia. Her physician orders for a bone marrow biopsy to rule out the disease via the posterior superior iliac short-circuit sparks. Avoid materials that generate static electricity like cotton blankets. Woolen
always expresses anxiety towards her incoming surgical procedure. The nurse decided to use Effleurage, she is aware that crest. In educating Ms. Lancaster about the procedure, which of the following should not be included? blankets and synthetic fiber blankets should be used.
this massage technique involves: 5. Avoid use of volatile, flammable materials, such as oils, grease, alcohol, ether, and acetone near
A. “A local anesthesia around the biopsy site will be used, and a sedative may also be administered.” clients receiving oxygen
A. The use of long, slow, gliding strokes B. “You will be asked to hold still for the duration of the procedure while in a supine position.” 6. Be sure electric equipment, devices and machines are all not electrically grounded
B. A firm, quick taps or strikes all over the body C. “You will hear a crunching sound as the needle is pushed through the bone.” 7. Make known the location of fire extinguishers, and make sure personnel are trained in their use.
C. Kneading the body by squeezing the soft tissues D. “The procedure usually lasts for about 15-30 minutes.”
D. The use of short, slow, circular strokes A. 2, 3, 4 and 7
40. Paracentesis is the removal of peritoneal fluid from the abdominal cavity, usually for ascites or for diagnostic purposes. B. 1, 2, 3 and 4
30. Mr. Morrison is diagnosed of having Obstructive sleep apnea. His physician recommended multiple therapies and Nurse Filomena is caring for a patient with liver cirrhosis who is about to undergo paracentesis. Which of the following C. 2, 3, 5 and 7
interventions to resolve the problem. The nurse conducted health teaching about alcohol and smoking cessation but is actions by Nurse Filomena can jeopardize the patient’s safety? D. 3, 4, 5 and 6
aware that these actions are still not enough to prevent apnea episodes. The treatment of choice for Mr. Morrison is:
A. Nurse Filomena instructs the patient to void immediately before the procedure 49. A client suddenly complained of difficulty breathing. The physician ordered oxygen therapy via a nasal cannula for the
A. Low flow oxygen therapy B. Nurse Filomena instructs the patient to remain still while the trocar with cannula is inserted midway between the client. The nurse understands that this method of oxygen delivery does which of the following?
B. CPAP device umbilicus and symphysis pubis
C. Hypnosis C. Nurse Filomena will drain 1,700 mL during the entire session as ordered A. Delivers a constant concentration of oxygen
D. Cognitive therapy D. Nurse Filomena makes sure that the fluid will be drained slowly B. Delivers a high concentration of oxygen
C. Mixes room air with oxygen
31. Ms. Akira is scheduled to have her blood drawn today for laboratory work ups. Before collecting the blood, you decided to Situation 9 –Determining the need for safety measures is viewed as an independent nursing function. One intervention D. Restricts the client from coughing and talking while wearing the device
perform Allen’s test. You are doing the Allen’s test erroneously if you perform which of the following? employed in the setting to ensure safety of patients is the application of restraints. However, because restraints restrict the
individual's freedom, their use has legal implications. Nurses need to know their agency's policies and the state laws about 50. An endotracheal tube is inserted by physicians. It is inserted through the mouth and into the trachea with the guide of a
A. Applies direct pressure over the client’s ulnar and radial arteries simultaneously restraining clients. The following questions apply. laryngoscope. The nurse is assigned to care for a patient who underwent endotracheal intubation four hours ago. All of
B. While applying pressure, asks the client to open and close the hand repeatedly the following measures must be observed in providing care to this patient, aside from:
C. Releases pressure from the ulnar artery while compressing the radial artery and assesses the color of the 41. The nurse decided to apply restraints to an aggressive patient admitted in the ward. To avoid legal implications, the nurse
extremity distal to the pressure point is aware that which of the following is an incorrect statement about the use of restraints? A. Ensure that the head of the bed is elevated 30 degrees, if not contraindicated.
D. Withdraws blood if the pinkness of the hand returns within 15 seconds B. Be certain to move the oral endotracheal tube to the opposite side of the mouth every 4 hours.
A. Physician must sign the order for restraints within 24 hours. C. Monitor closely and maintain a cuff pressure of 23 mmHg
32. An arterial blood gas test measures the acidity and the oxygen and carbon dioxide levels in the blood from an artery. When B. Bony prominences are padded before application of restraints D. Assess for client’s respiratory status and skin integrity every 2 hours.
obtaining blood samples, the nurse must select superficial arteries such as the brachial, radial and femoral arteries. Nurse C. Check client’s skin integrity and neurologic status once every four hours
Jacob is to collect blood sample for ABG testing. He incorrectly performs the test if he does which of the following: D. Secure the restraint using a clove hitch knot Situation 11 –Paulo has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for
infection because of retained secretions. Part of Nurse Logan’s nursing care plan is to loosen and remove excessive
A. Perform Allen’s test before attempting to get an arterial sample. 42. Restraints are protective devices used to limit the physical activity of a client or to immobilize a client or extremity. They secretions in the airway. The following questions apply.
B. Use a heparinised syringe and needle. Leave 0.5 mL of heparin inside the syringe before obtaining blood sample. are used to protect the client, allow for treatment in a safe environment, and reduce the risk of injury to others. Before
C. After blood collection, apply cotton ball and pressure for at least 5 minutes on the site. Nurse Augustus asks for an order for restraints for his client with dementia, the following alternatives could first be 51. Nurse Logan listens to Paulo’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate
D. Remove the air bubbles in the syringe after blood collection. utilized, except: position to drain the anterior and posterior apical segments of the lungs when Nurse Logan performs percussion would be:

33. Nurse Cedier eviews an ABG result of one of his patients hooked to a mechanical ventilator and notes the following: pH A. He positioned the bed at its lowest level A. Paulo lying on his back then flat on his abdomen on Trendelenburg position.
of 7.43, PCO2 of 30 mmHg, and HCO3 of 20mEq/L. Nurse Cedie analyzes these results as indicating: B. Assign the client in a room away from the nurse’s station to prevent overstimulation B. Paulo seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his
C. He provided a rocking chair for his client to use. abdomen.
A. Metabolic acidosis, compensated D. He placed large plants on the boundary where his client is only allowed to go. C. Paulo lying flat on his back and then flat on his abdomen.
B. Metabolic alkalosis, compensated D. Paulo lying on his right then left side on Trendelenburg position.
C. Respiratory alkalosis, compensated 43. An adolescent client diagnosed with schizophrenia screams noisily after routine assessment. The nurse caring for the client
D. Respiratory acidosis, uncompensated threatened to restraint the client if she does not stop shouting. The nurse shall be liable for: 52. Nurse Logan will now proceed to percussion and vibration of Paulo’s thorax. Nurse Logan demonstrated sufficient
knowledge about the difference of these procedures if he stated that:
34. A 24-year old female client was rushed to the Emergency Department because of intentional aspirin overdose. The patient A. Battery B. Assault C. Fraud D. Defamation
appears confused, pale with complaints of dizziness. Arterial blood gases are drawn and the nurse reviews the results, 44. A crime is an act committed in violation of public law and punishable by a fine or imprisonment. A crime does not have to A. In percussion, only one hand is used while in vibration, both hands are used.
expecting to note which of the following to patients suffering from ASA overdose? be intended in order to be a crime. A nurse is caring for a client with colon cancer. The client tells the nurse, “You are B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose
useless. None of your actions help me”. The nurse suddenly slaps the clients face. The client filed a complaint and charged on the exhalation cycle
A. A decreased pH and an increased CO2 - respiratory acidosis the nurse with: C. In both percussion and vibration, the hands are on top of each other and hand action is in tune with client’s breath
B. An increased pH with an increased HCO3 - metabolic alkalosis A. Felony B. Manslaughter C. Misdemeanor D. Gross negligence rhythm
C. An increased pH and a decreased CO2- respiratory alkalosis D. Percussion involves striking of the chest with cupped hands to loosen secretions while vibration shakes the
D. A decreased pH and a decreased HCO3 45. Anticoagulants are drugs used to prolong bleeding time and thereby preventing blood clot formation. They are widely used secretions along with the inhalation of air
in the treatment of thromboembolic disease. Mrs. Timberlake, a 42-year old patient with DVT, is on the out-patient unit
35. Obtaining capillary blood specimen is done to determine blood glucose levels of clients at risk for hyper/hypoglycemia. for follow-up after a week’s therapy of warfarin (Coumadin). Which of the following clotting parameters would indicate 53. After the procedure, Nurse Logan needs to document the outcome of Paulo’s treatment, Nurse Logan should include the
Daniel, 28 years old, will have his blood glucose taken for routine monitoring. Which of the following steps if done by the the need to increase Mrs. Timberlake’s current dose of warfarin? following in his recording, except:
nurse will hinder a successful reading?
A. Carefully choose a vascular puncture site such as the earlobe or the side of the finger, and gently squeeze it A. aPTT is two times the patient’s baseline level A. Color, amount and consistency of sputum
towards the site. B. INR is 1 B. Character of breath sounds and respiratory rate before and after procedure
B. Hold the reagent strip under the puncture site until there is adequate blood, and smear the indicator square with it. C. PT remains at the patient’s baseline level C. Amount of fluid intake of client before and after the procedure
C. After pricking, wipe away the first drop of blood with a cotton ball, as serous fluid can alter test results. D. PT is two times the patient’s baseline level D. Significant changes in vital signs
D. After collecting adequate blood, ask client to apply pressure to the puncture site to assist homeostasis.
Situation 10 - Threats to fire safety are referred to as fire hazards. A fire hazard may include a situation that increases the 54. Maintaining a patent airway is one of the priorities of a nurse in an unconscious patient. After assessment of his
Situation 8 - Nurse Tris is a medical-surgical nurse taking care of patient Four who was diagnosed of having Chronic Renal likelihood a fire may start or may impede escape in the event a fire occurs. unconscious patient, the nurse determines that oral suctioning is needed. Which of the following principles in performing
Failure a week ago. Two units of packed red blood cells were ordered to be transfused for 4-6 hours each unit. suctioning should he follow?
46. To maintain safety in the workplace, fire extinguishers should be present in each room. The mother of the client admitted
36. Nurse Tris measured the temperature of patient, Four, before hanging the packed red blood cells and it was found to be in the hospital suddenly called the attention of the nurse and reported that there room is on fire. The nurse hurriedly A. Oral suctioning using a suction catheter can be delegated because it is not necessarily a sterile technique but
101.80F orally. Nurse Tris must do which of the following as the most apt nursing action? checked the emergency and noted that the fire begun because of grounded electrical wirings. In this case, the best fire requires only clean technique
extinguisher to use is: B. Apply suction intermittently in a rotating manner as the suction catheter is gently inserted
A. Administer diphenhydramine as ordered and begin the transfusion C. Hyperoxygenate the patient with 100% oxygen for 15 minutes before and after the procedure
B. Give Four two tablets of paracetamol and begin the transfusion A. Water Fire Extinguisher (RED) D. Use petroleum jelly to lubricate the suction catheter before and in between suctioning
C. Start the transfusion as prescribed B. Powder Fire Extinguisher (BLUE)
D. Delay hanging the blood and notify the physician C. Foam Fire Extinguisher (BLACK)
D. Carbon Dioxide Fire Extinguisher (RED) 55. A nurse is suctioning fluids from a client through an endotracheal tube. During the suctioning procedure, the nurse notes
37. Nurse Tris enters patient Four’s room to assess him after receiving the first unit of packed red blood cells 45 minutes on the monitor that the heart rate decreases. Which of the following is the most appropriate nursing intervention?
earlier. Patient Four appears flushed and dyspneic. On assessment, Nurse Tris auscultates the presence of crackles in the 47. Since the fire started inside the room of the client, the goals of the nurse are to stop the fire and if not to slow down the
lung bases. Nurse Tris determines that patient Four most likely is experiencing which of the following complications of spread of the fire. To achieve these goals, the nurse should keep in mind: A. Continue to suction, a decrease in the heart rate is a normal response to suctioning
blood transfusion therapy? B. Ensure that the suction is limited to 15 seconds
A. Rescue the client, start the alarm, contain the fire where it started, and extinguish the fire. C. Stop the procedure and reoxygenate the client
A. Hypovolemia B. Contain the fire, rescue the patient, call the fire Department, and gather evidence as to where the fire started D. Notify the physician immediately
B. Fluid overload C. Call the fire department, set the alarm and rescue the client
C. Transfusion reaction D. Find the cause of the fire, extinguish the fire, rescue the client, and notify the fire department
D. Bacteremia
Situation 12 –Clients who need airway support due to a temporary or permanent condition may have a tracheostomy. A. Collect a specimen of urine during midstream D. Managers focus on systems and structures while leaders develops vision and strategies
Nurse Chichay is assigned to various patients in the Medical-Surgical Unit. Mrs. Tampipi, one of the patients assigned to B. attempt to void when a urinary catheter is in place
her has just been inserted with a tracheostomy tube. C. void after a urinary catheter is inserted and removed 74. Power is the ability to do or act and results in the achievement of desired results. Power causes things to happen. The
D. empty the bladder before a urinary catheter is inserted charge nurse on the unit guides the other personnel’s actions by demonstrating care expected from the other nurses. The
56. Nurse Chichay was demonstrating tracheostomy care to a small group of student nurses. After cleaning the inner cannula 65. Continuous bladder irrigation is a medical procedure which is usually performed for one of two reasons. First, it is other nurses recognize the charge nurse’s knowledge and expertise. Which of the following types of power is the charge
with hydrogen peroxide and rinsing it with NSS, Nurse Chichay is now returning it to the tracheostomy site. She performed to minimize the chances of blood clots forming in the bladder following certain types of surgery. Second, it is nurse using?
demonstrates proper returning of the cannula by performing which of the following: a means of injecting medication into the bladder to fight an infection or for some other reason. When caring for a client
with continuous bladder irrigation, the nurse should: A. Reward Power
A. Inserting the flange of the tube and rotating it in a clockwise motion until it clicks into place B. Coercive Power
B. Returning the inner cannula following the curvature of the tube, locking by rotating the external ring a. Monitor drainage for amount only. C. Expert Power
counterclockwise until it clicks into place b. Empty the bag frequently so it does not exceed three-fourths full D. Connection Power
c. Subtract irrigant from output to determine urine volume
C. Securing the flange of the inner cannula to the outer cannula using a sterile twill tape
d. Include irrigating the solution in any 24-hour urine tests ordered 75. Nurse Vanessa performs her tasks with excellence at the unit she is assigned to. She is also efficient in performing nursing
D. Replacing the inner cannula following the curve of the tube, locking by rotating the external ring clockwise until
procedures and is effective in dealing with patients. Contrary to this, she does not share the same vision as the nurse
it clicks into place.
Situations 14 – Nurses have a responsibility for ethical considerations to patients, employing agency, and physicians. The manager in her unit. She does not voice out her opinion or share her expertise with the nurse manager. Nurse Vanessa can
following questions apply. be considered as what type of follower?
57. Nurse Chichayis changing the tapes on the tracheostomy tube of Mrs. Tampipi. The client coughs and the tube is
dislodged. The priority nursing action is to:
66. A 45-year-old male client returns from surgery with a diagnosis of cancer. The physician informs the staff to avoid telling A. Politician
A. Cover the tracheostomy site with a sterile dressing to prevent infection the client the diagnosis. Upon awakening the client asks if he has cancer. Which among the following is the nurse’s most B. Partner
appropriate response? C. Subordinate
B. Call the physician to reinsert the tube
C. Grasp the retention sutures to spread the opening D. Contributor
A. “Sorry, but I still don’t know the results of the test”
D. Call the respiratory therapy department to reinsert the tracheostomy
B. “I will call the physician and have him speak with you” 76. In an Acute Care General Hospital, the organization chart is composed of the Board of Trustees who are giving orders to
58. A metered-dose inhaler (MDI), a handheld nebulizer, is a pressurized container of medication that is used to release the C. “How are you feeling now?” the president. Under the president are four vice presidents classified in different departments: finance, administration,
medication by forcing the medication through a nosepiece or mouthpiece into finer particles forming a mist or spray. D. “The results show that you may be suffering from cancer” medicine and nursing who reports to the president. There are middle managers under each vice president who are given
Lester, a 7-year old patient was diagnosed of asthma and was prescribed a bronchodilator to be delivered by MDI. In direct orders to first-line managers, who are above the service providers. What type of organizational structure is described
teaching the proper use of a MDI, arrange the following steps in order: 67. Nurse Billy is the ER nurse who is triaging the incoming patients. A mother comes up to him and complains that they have in the situation?
1. Hold breath for 10 seconds been waiting there for more than an hour already with her child who has a sprained ankle. She complains that they were
2. Rinse mouth with tap water among the first in line and yet a couple of patients who just came in were attended to immediately by the physician. Nurse A. Centralized structure
3. Exhaled slowly through pursed lips Billy is following what ethical principle? B. Decentralized structure
4. Shake the canister vigorously for 3-5 seconds C. Matrix structure
5. Hold the canister upside down and press down once on the MDI and inhale slowly the mist A. Justice D. Complex structure
6. Exhale comfortably as in a normal breath B. Beneficence
C. Veracity 77. Nurse Jesse notices on the organizational chart that there are two staff nurses per shift who report to the nurse manager of
A. 4, 1, 5, 6, 3, 2 D. Nonmaleficence the maternity unit. This means that there are a total of six staff nurses who are under the nurse manager of the unit. This
demonstrates which of the following:
B. 2, 4, 5, 1, 6, 3
C. 4, 6, 5, 1, 3, 2 68. Informed consent is an agreement by a client to accept a course of treatment or a procedure after being provided
complete information, including the benefits and risks of treatment, alternatives to the treatment, and prognosis if not A. Chain of command
D. 2, 3, 5, 1, 6, 2
treated by a healthcare provider. A 32-year-old unmarried client with cervical cancer has been advised to undergo B. Unity of command
hysterectomy. When obtaining the consent for surgery, the nurse should initially do which of the following? C. Span of control
59. The incentive spirometer is also issued to patients recovering from rib damage to help minimize the chance of fluid build-
D. All of the above
up in the lungs. Nurse Carlota is supervising Mr. Manansala during spirometry. Which of the following actions when made
by the patient would indicate that the health teaching regarding correct incentive spirometer use has been ineffective? A. Prepare the client by telling her what to expect before and after the surgery
B. Ensure the client that there are still other treatment options 78. This statement identifies the organizations constituency and addresses its position regarding ethics, principles and
C. Witness the client’s signature on the form standards of practice.
A. Immediately after taking a slow, deep inhalation, the patient exhales slowly and steadily
B. The patient avoid brisk or quick inhalations D. Verify that the client has enough information to sign the consent
A. Mission
C. When the patient has difficulty breathing through the mouth only, he uses a nose clip
69. An individual has the right to understand the choices being offered around medical treatment and the right to voluntarily B. Vision
D. Mr. Manansala holds the device in an upright position
agree or refuse treatment. The family of a comatose client complains that the nurse failed to obtain a signed consent before C. Philosophy
inserting an indwelling catheter. The nurse’s action is considered to be: D. Objectives
60. Chest tubes may be inserted to drain fluid or air from any of the three compartments of the thorax.During the nurse’s
rounds, Nurse Ylvis found Yves in the bathroom and his tubing was dislodged from his chest. Upon assessment, the nurse
A. Wrong, the nurse should have secured a signed consent before initiating the procedure 79. The patient care classification system (PCCS) is a method of grouping patients according to the amount and complexity of
heard air coming out of the incision site. The nurse’s priority action would be:
B. Correct, IFC insertion does not need a separate consent form nursing care requirement and the nursing time and skill they require. It serves to determine the amount of nursing care
C. Wrong, the nurse should have asked the physician to secure a consent first required in 24 hours as well as the category of nursing personnel who should provide the care. Which of the following
A. Cover chest insertion site with a non-occlusive sterile gauze
D. Justifiable, the client needs accurate monitoring of hourly output. statements regarding PCCS is incorrect?
B. Immerse the tip of the tubing in a saline container with sterile water
C. Place a sterile gauze with petrolatum gauze over the insertion site
70. An advance health care directive, also known as living will, personal directive, advance directive, or advance decision, is a A. Level I is known as the Self-Care or Minimal Care
D. Assist the client in her bed then notify the physician
set of written instructions that a person gives that specify what actions should be taken for their health if they are no longer B. Level IV requires constant attention of at least every 15-30 minutes by the nurse with hourly urine output
able to make decisions due to illness or incapacity. Mr. Hilton has been suffering from advanced stage lung cancer and C. Level II requires complete assistance in ADLs
Situation 13 –Elimination of the waste products of digestion from the body is essential to health. Failure to meet this
wants his wife, Mrs. Hilton to be his primary health care decision-maker in the event he becomes mentally incapacitated. D. Level III requires close observation at least every 30 minutes
function can greatly affect the total functioning of the client. The following questions apply.
This is related to which of the following advanced care directive?
80. There are four methods commonly used to organize and deliver nursing care to clients. These include: Case system,
61. A client has an order for “enemas until clear” before major bowel surgery. After preparing the equipment and solution, the
A. Instructive directive Functional nursing, Team and Primary Nursing. The Nurse Manager of the Medical-Surgical unit plans to adapt the case
nurse assists the client into which of the following positions to administer small volume enema?
B. Living will method in delivering care to clients. Which of the following is considered as an advantage of this patient care modality of
A. Right side-lying with the head of the bed elevated 45 degrees.
C. Proxy Directive care delivery?
B. Left-lateral sim’s position
D. Holographic will A. The consistency of one individual caring for patients for an entire shift
C. Right-lateral sim’s position
B. The nurse may not have the same patients from day to day
D. Left side-lying with the head of the bed elevated 45 degrees.
Situations 15 – Nurses are leaders who make a difference. They belong to one profession where they are able to touch C. Care can be delivered to a large number of patients
people’s lives in intimate and profound ways. D. To a patient, care may be disjointed
62. Nurse Islao is assigned to care for Mr. Ingo, a 62-year old accountant scheduled for low volume enema in the morning.
The nurse noted that Mr. Ingo was admitted due to a gastrointestinal disorder and flatulence as the chief complaint.
71. You considered Mrs. Estafada, chief nurse of One Direction Medical Center, a traditional and bureaucratric leader. Which Situation 17 – Effective management inspires teamwork among the members of the organization. Nurse Managers must be
Considering Mr. Ingo’s chief complaint, which of the following will Nurse Islao expect to administer to the patient?
of the following statements about bureaucratic leader approach is true? able to maintain a good working relationship with their subordinates for the client’s safety not to be compromised.
1. Retention enema
2. Cleansing enema
A. Guiding policiesare accentuated 81. In any strategic planning process, there are steps to be followed. It is equally important when developing an
3. Carminative enema
B. Mrs. Estafada is always in control organizational, unit, or program plan to progress in a systematic manner. The nurse manager should initially perform
4. Return-flow enema
C. Judgmentmaking is participative which of the following in a strategic planning process?
A. 1 and 2
B. 2 only D. Specialization of tasks is normal
A. Administering questionnaire in the unit
C. 3 and 4
72. Leadership is a dynamic phenomenon which has been defined in many different ways. Because of this, theories were B. Evaluate the planned action
D. 3 only
developed in an attempt to describe and understand the phenomena. Which among the following theories states that a C. Identify planning goals and objectives
leader has to be from the noble class and has to be a male in order for him to qualify as a leader? D. Collect data
63. Colostomy irrigation is done to help establish the patient’s regularity of bowel movement especially during the early
weeks after a colostomy is done. Mr. Spektor is about to undergo colostomy irrigation for the first time. All of the A. Traits Theory
B. Transformational Theory 82. Mariposa is a nurse manager and is making a staffing and scheduling task including manpower pooling. Knowing the
following are incorrect guidelines while performing irrigation except:
C. Great Man Theory different management process and function, which of the functions of management does Mariposa’s activity fall into?
A. Hang the irrigation reservoir approximately at the level of the patient’s sternum D. Transactional Theory
A. Controlling
B. Lubricate the cone/catheter tip with water-soluble lubricant and advance for 5 inches into the patient’s stoma
73. Nurse leaders, regardless of the position they hold in an organization, are the individuals who continually question the B. Directing
C. If catheter does not advance easily, allow water to flow slowly while advancing catheter, or use the gloved,
status quo, offer suggestions about how to improve patient care, and entice (not demand or require) colleagues to work C. Organizing
lubricated index finger to dilate the stoma
toward a new level of excellence. All but one of the following descriptions correctly depicts the difference between a D. Planning
D. In choosing the irrigating tip, a cone tip is preferred over a soft catheter tip
manager and a leader.
83. An essential part of the nurse’s professional accountability is evaluation of the quality of nursing care they provide to their
64. A urine test checks different components of urine, a waste product made by the kidneys. A regular urine test may be done
A. Leaders motivate people to abide by the guiding policies of the organization clients. Nurse Sam is assigned to a Britain2client in the private ward. In their first interaction, the client asked Nurse Sam
to help find the cause of symptoms. A nurse is caring for a 62-year-old male client diagnosed with benign prostatic
B. Managers operate within organizational rules, regulations, policies and procedures while leaders initiate change. about the mission and vision of the hospital. Nurse Sam correctly answered the client as he has learned this by heart. The
hypertrophy. The physician orders a residual urine test. The nurse instructed the client to do which of the following?
C. Leaders rely on trust while managers rely on control. head nurse evaluates Nurse Sam’s action and classifies this under:
 D. All of the above
A. Structure
B. Process 92. A mental health nurse is conducting a study on the effects of new method in teaching among Autistic Children on their
C. Outcome reading abilities based on their actual competencies. What variable is being manipulated in this study?
D. Quality Evaluation
A. Effects of new teaching method
84. Delegating is the process by which a manager assigns specific tasks or duties to workers. By delegating tasks, the nurse B. Number of nurses
manager is freed of valuable time that can be well spent on other more important things. Which of the following activities C. Teaching method
of the nurse manager can be delegated to subordinates? D. Reading abilities

A. Accountability for poor completion of activities in the unit 93. A hypothesis may be based on astute observation of some phenomenon within the environment. The researcher predicts
B. Authority to sign the nurse manager’s name that “Drug addicts are more prone to HIV infection than those who do not take drugs”. What type of hypothesis was made
C. Taking corrective or disciplinary action for a staff’s poor performance by the researcher?
D. Maintaining the morale of the staff, especially to the new ones
A. Simple hypothesis
85. Quality Assurance is a process of evaluation that is applied to the health care system and the provision of health care B. Complex hypothesis
services by health workers. If promotes collegial and sharing relationships among workers instead of a feeling of threat C. Directional hypothesis
when observed and evaluated.The Chief Nurse wants to improve the quality of health care in the hospital. She intends to D. Non-directional hypothesis
measure the quality of health care services. The following activities are examples of quality assurance measurements,
except: 94. A nurse researcher is interested in engaging their department in developing a phenomenological research. Which of the
following questions is answered by this type of qualitative research?
A. Evaluating outcomes or end results of care provided to client
B. Delegating routine tasks to nursing assistants A. “What is the way of life if this cultural group?”
C. Asking clients to accomplish client satisfaction survey forms B. “What is the effect of the intervention to the dependent variable?”
D. Measuring quality of care against established standards of nursing care C. “What is the essence of the phenomenon is as experienced by these people?”
D. “What is the core category that is central in explaining what is going on in that social scene?”
86. Among the following situations, which one does not exemplify negligence?
95. Nurse Paolo is interested in the increasing incidences of HIV/AIDS in the province of Benguet. In choosing the
A. Nurse Ejay did not report to the physician nor document in the chart that he observed the patient’s toes were respondents, he first picked 3 cities/towns of Benguet, and picked 20 respondents from each. What sampling technique did
cyanotic and cold to touch. The patient had a leg cast. The leg later became gangrenous and had to be amputated. he employ?
B. Nurse Vanessa mistakenly administers a drug to the wrong patient. She later documents this error and filed an
incident report. A. Systematic random sampling
C. Nurse Prince has mistakenly given the dose of Morphine to his patient. The doctor’s order was 10mg, but he B. Snowballing
administered 100mg. The patient later developed severe respiratory depression and had to be put on ICU for C. Quota sampling
mechanical ventilation. D. Cluster sampling
D. Nurse Nerry did not raise the side rails of her elderly patient who had dementia. During her rounds, she saw the
patient lying on the floor unconscious. X-ray later revealed that the patient broke his pelvis. Situation 20 – Statistical tests are procedures for testing research hypotheses and evaluating the believability of the findings.

87. Mr. Moose is the eldest son of a terminal cancer patient. He has been persuading Nurse Mila and Nurse Mika to assist with 96. The types of mathematical calculations that can be made with data depend on the level of measurement of the data.
the euthanasia of his father. He said that he cannot bear to see his father suffer anymore, although he is still conscious and Gender, religious affiliation, and marital status are considered to be in what level of measurement?
can still communicate to others. This is the reason why he and his siblings have decided to put the patient to a “permanent
sleep” by giving a large dose of Morphine Sulfate. After much persuasion, the two nurses agree. Nurse Mira was the nurse A. Nominal
on duty that night. She allowed Nurse Mika to enter the patient’s room. Nurse Mika prepares the morphine in the syringe B. Ordinal
and injects it via IV push. Nurse Mila later discards the ampules of morphine as well as the syringe used. The patient later C. Interval
died of respiratory arrest. The principal/s in the crime was/ were: D. Ratio

A. Mr. Moose 97. Frequency distributions are a good way to organize data and clarify patterns. These impose an order on raw data, numeric
B. Nurse Mika values are ordered from lowest to highest, accompanied by a count of the number (or percentage) of times each value was
C. Nurse Mira obtained. The following statements are true about mean, except:
D. Both A and B 98.
E. Both B and C A. It is familiar to most people and intuitively clear.
B. It is not affected by extreme values in a set of data.
88. A contract is a meeting of minds between two or more persons whereby one binds himself, with respect to the others, to C. Data does not have to be arranged from highest to lowest.
give something or to render some service. Nurse Peter agreed to extend his duty to cover for Nurse Nathan’s absence. In D. It can be easily calculated and unique since every data set has one and only one mean.
doing this, Nurse Nathan shall also act as Nurse Peter’s replacement on his scheduled leave. This is an example of which
contract? 99. A group of researchers collected the raw data they needed for their study. They were able to come up with the following
sequence of value: 80, 80, 10, 10, 25, 65, 100 and 200. The researchers do not need further teaching if they stated that the
A. Do ut des median of the data is:
B. Facio ut facias A. 71. 25
C. Facio ut des B. 10 and 25
D. Do ut facias C. 22. 5
D. 72. 5
89. Mrs. Lorenzana underwent exploratory laparotomy for multiple organ injuries in her abdomen. According to this doctrine,
the surgeon is held liable when there is an incorrect surgical count? 99. Six ethical principles guide the protection of prospective research participants: beneficence, non-maleficence, fidelity,
justice, veracity and confidentiality.The nursing department of CBRC General Hospital is to conduct a research. The nurse
A. Force majeure manager wants to ensure that she does not violate the moral and ethical rights of their participants. All of the following are
B. Doctrine of Vicarious Liability considered true, except:
C. Captain of the Ship A. Being honest with informing them of all known potential risks and benefits
D. Doctrine of Independent Contractor B. If a researcher is conducting interviews, the researcher should maintain anonymity
C. Providing benefits to research participants such as access to experimental therapies
90. A professional nurse is a person who has completed a basic nursing education program and is licensed in his country or D. Building rapport with the research participants
state to practice professional nursing within the scope of nursing practice.HeadNurse Valentine is very particular with the
duties and responsibilities of a nurse within the scope of nursing practice. Because of his utmost respect to the law and the 100. Nurse Researcher Carlito is interested in studying the research question: “What are the differentiations and the similarities
nursing profession, he will report which of the following for jeopardizing the profession? between an aggressive and a nonaggressive cognitively impaired elderly admitted in a specialized institution?”
A. Nurse TonTon who stopped his clinical practice to enroll in a master’s program. Investigation of cognitively impaired individuals presented some ethical dilemmas, which of the following protocol would
B. Nurse Darlene who sutured a lacerated perineum after acquiring special training for it. be considered unethical?
C. Nurse Darren who accepted consultation services from families in the barangay. A. Recording interaction with the elderly with their permission
D. Nurse Earl who carefully performed internal examination to a patient with vaginal spotting. B. Verbal permission from the subjects is unnecessary
C. Data coded and recorded solely by the investigator
91. Research process has five major phases namely; Conceptual, Design and Planning, Empirical, Analytical, and D. A written consent from the institution and a significant other
Dissemination phase. Fabia et.al group is now working collaboratively in the initial phase of the research process. Which
among the following major steps are included in this phase?
1. Determining the purpose of the study
2. Acknowledging the limitations of the study
3. Conducting a pilot study
4. Formulating and delimiting the problem
5. Formulating the hypothesis
6. Developing protocols
7. Specifying the method to measure the research variables

A. 1, 2, 4
B. 1,2,4,6
C. 1,2,4,5