1. A nurse instructs a client diagnosed with COPD to use purse-lip breathing.

The
client inquires the nurse about the advantage of this kind of breathing. The nurse
answers that the main purpose of purse-lip is to
A. prevent bronchial collapse
B. strengthen the intercostals muscle
C. achieve maximum inhalation
D. allows air trapping

I-clear ang pinili

2. The nurse teaches a patient about the use of respiratory inhaler. Arrange the steps
in using an inhaler chronologically. 1. Press the canister down with your fingers as you
breathe in 2. Wait one minute between puffs if more than one puff is prescribed 3.
Inhale the mist, hold your breath at least 5 to 10 seconds before exhaling 4. Remove
the cap and shake the inhaler
A. 4,1,2,3
B. 3,4,2,1
C. 4,1,3,2
D. 1,2,3,4

I-clear ang pinili

3. The physician prescribed monitoring closely of clients oxygen saturation of the

blood. Which of the following will you prepare?
A. Electrocardiogram machine
B. Spirometer
C. Pulse oximeter
D. Blood Pressure apparatus

I-clear ang pinili

4. Patients suffering from COPD are taught to avoid shifts to temperature and
humidity. It should be emphasized that heat increases body temperature and thereby
raising the: *
A. risk for infection
B. anxiety level
C. the oxygen requirements
D. fluid intake

5. COPD patients maybe taught the following pulmonary hygiene measures to improve
clearance of airway secretion, EXCEPT: *
A. effective coughing
B. measure fluid intake
C. postural drainage
D. complete bedrest

Situation 2 – Sheila, 22 years old, was brought to the hospital by her mother for chief
complaints of pallor, shortness of breath and weakness. The doctor’s impression was
anemia.
Option 1

6. The nurse knows that the BEST areas used to assess pallor that are characteristics
of anemia are the: *
A. conjunctivae and lips
B. palms and fingernails
C. lips and fingernails
D. tongue and fingers

7. To establish a diagnosis, the nurse would expect the following laboratory tests to be
ordered by the physician EXCEPT: *
A. Iron studies
B. Complete blood count
C. Bone marrow aspiration
D. Erythrocyte sedimentation rate

8. Based on the initial assessment, the nursing diagnosis identified “Activity

intolerance related to weakness and shortness of breath.” Which of the following is the
MOST relevant nursing intervention? *
A. Passive regular exercise of lower extremities
B. Maintain on high Fowler’s position
C. Auscultate lungs for abnormal breath sounds
D. Change position every two hours

9. The nurse was instructed by her senior to stay with the patient for at least 15
minutes after initiating blood transfusion PRIMARILY because of which of the following
reasons? *
A. Vital signs must be monitored every 15 minutes.
B. Transfusion reactions can occur
C. Patient needs assistance
D. It is a nursing order

10. When the nurse checked the patient’s vital signs 15 minutes after blood
transfusion was initiated, the nurse observed the blood pressure to have increased.
The nurse suspects which of the following to have occurred? *
A. Blood transfused is contaminated
B. Circulatory system could not accommodate blood volume transfused
C. Infusion of incompatible blood products
D. Hypersensitivity to the donor’s plasma proteins

Situation 3 – Potential environment hazards exist in various modalities in the

Operating room that may affect the well being of the client and healthcare workers. It
is the responsibility of the Perioperative nurse to maintain a positive environment for
all concerned.
Option 1

11. The circulating nurse is aware that many factors combine to contribute
hypothermia or hyperthermia in the surgical patients. Below are options that the
Perioperative nurse can adopt to maintain the desired temperature. Select all that
apply: 1. Adjusting the OR suite temperature 2. Limiting area of skin preparation and
surface surgical draping 3. Applying warm blankets to clients upon arrival in the OR
and after sterile drapes have been removed. 4. Keeping the OR door closed
throughout the surgical procedure 5. Limiting the exposed skin area during positioning
6. Placing rolled linen on both sides of the client during skin preparation to catch
excess water *
A. 1,2,4 and 5
B. all except 2 and 5
C. 1,2,3 and 6
D. all of these

12. During transport of postoperative clients, which of the following would you NOT
recommend to be adopted? *
A. Hanging and securing I.V. containers over the client’s head
B. Pushing the patient’s feet first avoiding rapid movement in the hallways and corners
C. Keeping the client warm with blanket
D. Elevating the side rails and using safety straps

13. The surgeon of a client for Dilatation and Curettage (D&C) who is on triple anti TB
drugs complained why his case is scheduled “last” for the day. The OR nurse offers
which of the following BEST reason? *
A. “There is no emergent need to do the case ahead of the other schedule”
B. “Your anesthesiologist preferred this time slot.”
C. “Foremost, we considered the safety of other clients.”
D. “The case is relatively short and easy.”

14. You are preparing case-assignment for the following day. Which of the following
assignment is safe for nurse Kamile who is on her 1st trimester of pregnancy? *
A. Billroth 11 under general anesthesia
B. Endoscopy room where clients are given intravenous mild sedation
C. Cast room with X-ray facilities
D. Laparoscopic cholecystectomy

15. Before the end of the shift, waste management was discussed. The different kinds
of waste and their proper disposal were presented. The following falls under the
pathologic waste category EXCEPT: *
A. specimen
B. amputated limbs
C. patients’ personal belonging
D. blood and body fluids

Situation – Mr. Sta. Rita, a post acute myocardial infarction (AMI) on his 2nd day post
attack is assigned to you, the physician said his recovery is uneventful. The following
questions apply.

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16. Morphine sulfate intravenous (I.V.) was prescribed for pain. The nurse
understands that morphine sulfate I.V. was preferred because of two reasons. These
are: 1. Bypasses the variable rates of absorption 2. Increases cardiac output 3.
Elevates enzyme levels 4. Rapid onset of action *
A. 2 and 3
B. 2 and 1
C. 3 and 4
D. 1 and 4

17. Mr. Sta. Rita is taking Aspirin, a platelet inhibitor. The client understood the
nurse’s instruction on how to take the drug if he: *
A. swallowed medicine in small amount of water
B. took the medicine two hours before meals
C. chewed and allowed the drug to dissolve with saliva
D. took the medicine with meals

18. The client’s wife observes the facial expression of Mr. Sta. Rita and interprets that
her husband is “in pain.” She asks the nurse, “What is causing the pain?” The nurse
responded that: *
A. release of tissue substances during inflammatory process can stimulate pain receptors.
B. pain is felt when the myocardial muscles contract rapidly
C. pain is triggered by the high blood pressure
D. chest pain occurs when the oxygen demand of the heart is not met

19. One of the priority nursing diagnosis is “Ineffective Tissue Perfusion.” Which of the
following would you watch for as the FIRST indication of altered perfusion? *
A. Adventitious lung sounds
B. Presence of dysrhythmias
C. Change in the level of consciousness
D. Abnormal heart sounds

20. During episodes of chest pain, which of the following procedures would the nurse
expect to be prescribed to provide assessment for myocardial infarction? *
A. Electrocardiography
B. Echocardiography
C. Radionuclide imaging
D. Angiography

Situation – You are caring for a client who is in the nasogastric tube (NGT) for feeding.

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21. Environmental control in the surgical suite is based on the principles of:1.
Measurement of exposed tube length 2. Visual assessment of aspirate 3. Auscultation
method after air injection 4. pH measurement of aspirate *
A. 2, 3 and 4
B. 1, 2 and 3
C. 1, 2 and 4
D. all except 2

22. It is important to maintain the patency of the nasogastric tube. The tube is irrigated
every 4 to 6 hours. Which solution would you use? *
A. Lactated Ringer’s
B. Normal saline
C. Bottled water
D. Tap water

23. When giving tube feedings and medications, which position of the client will reduce
risk of reflux and pulmonary aspiration? *
A. Supine position with one pillow supporting the head
B. Semi-Fowler’s position with the head elevated from 30 – 45 °
C. Supine position with the head turned to one side
D. Dorsal recumbent

24. When giving single compressed tablet medication by NGT, it should be crushed
and dissolved in water. How would the nurse APPROPRIATELY administer enteric-
coated tablet? *
A. Let the client swallow the tablet as is
B. Pulvurize the tablet finely to change the tablet form
C. Request the pharmacist to change the tablet form
D. Crush and dissolve in distilled water

25. Diarrhea is one of the most common complications of tube feeding. Which of the
following nursing actions will prevent this complication? *
A. Administer feeding by continuous drip rather than bolus
B. Dilute formula to half the concentration strength
C. Give high fiber formula
D. Instill liberal amounts of water to flush the tubing before and after feeding

Situation – Jamm, a 12 year old boy with Type I diabetes mellitus, is admitted in the
medical ward from the intensive care unit after having recovered from an episode of
diabetic ketoacidosis. Andrew has been diagnosed with type I diabetes since he was 6
years old. History showed that during the past 2 months, Andrew missed some of his
insulin injections as he got himself engrossed playing tennis.

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26. The admitting nurse noted that Andrew is underweight and short of stature. The
nurse considers which of the following reasons BEST explain Andrew’s retarded
growth? *
A. Large amounts of protein and fat are used for energy
B. Occurrence of electrolyte imbalance leading to dehydration
C. Increased breakdown of fats for cell utilization
D. Inability to use glucose as a source of energy

27. When the nurse plans for Jamm’s insulin injection sites, which of the following
sites will the nurse NOT include in her plan? *
A. Upper outer part of dominant arm
B. Outer part of the thighs
C. Four inches above the knee of both thighs
D. Abdominal subcutaneous tissue just below the waist

28. To ensure that an injection site will not be repeated when nurses administer insulin
on Andrew, which of the following nurses’ action would be MOST effective? *
A. Have nurses record in the child’s chart the injection site
B. Every shift, verbally endorse to the receiving nurse the injection site
C. Instruct the patient to tell the nurse, the site used during the previous injection
D. Mark with a ballpen the injection site previously used

29. In the teaching plan being prepared by the nurse for Andrew, which of the
following strategies would be most relevant for Andrew to avoid overuse of an injection
site for insulin self-administration? *
A. On a teaching doll, injection sites are marked with green colored pins. After injection, the pins
are replaced with red colored pins to indicate site has been used.
B. A chart is prepared illustrating body parts where injection sites are determined for a month.
After injection, site is marked with the date and time of injection.
C. On a record book, injection sites are enumerated daily for one month. Every after injection,
date and time are recorded across the used injection site
D. “Paper doll” is constructed. Injection sites are determined for a week. Injection sites are
marked on the paper doll. Site is crossed out.

30. Which of the following statements of Jamm will the nurse consider as an indication
that Jamm is ready to self-administer his insulin? *
A. “Will you allow me to do it now?”
B. “Let me hold the syringe for you.”
C. “When I go home, I will do it myself.”
D. “Are you sure I can do it myself?”

Situation – Appropriate ethical nursing practice should always respect the patient’s
right in any health care setting. The following questions apply

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31. With the advancement of information technology, the nurse understands that
breach of confidentiality can happen LEAST in which of the following scenario? *
A. Keeping the X-ray plate hanging in the negatoscope
B. Patient’s hospital account viewed in computers placed in the hospital corridors
C. Allowing the” telephone orders” as means to transmit doctors’ order
D. Clients’ laboratory results are transmitted to the patient care unit through a “Hospital
Computerized System”

32. When restoration of health is no longer the goal of care and end-of-life care is the
goal, artificial nutrition and hydration can be prepared and continued to be
administered. The nurse can administer artificial nutrition through the following
avenues EXCEPT: *
A. intravenous (I.V.) infusion
B. nasogastric tube
C. ileostomy tube
D. gastrostomy tube

33. Nurse Sofia is in charge of an elderly client with chronic severe COPD with
complications. She recalls that hospice care might be of benefit to the client. Which of
the following statements is TRUE about hospice care? *
A. In hospice care, practical support is provided based on the wishes of a client and needs of the
family
B. Hospice care concept leads client to think that they are hopeless cases
C. Hospice care is a part of normal life and provides support for dignified individuals
D. Health care workers are not offering hospice care because they don’t like clients to think that
they are giving up on them.

34. Nurse Sofia is about to request an elderly client with emphysema to sign the
consent for thoracostomy but assesses the client as incompetent. With the client in the
hospital, is a 15 year old “Boy watcher.” Which of the following options would be
MOST ethical for the nurse to follow? *
A. Send the “Boy watcher” to fetch the client’s next-of-kin immediately
B. Call the client’s next-of-kin right away
C. Refer to the attending physician
D. Inform the head nurse

35. Health care providers need always to point to the clients and significant others that
the order of “Do not resuscitate” (DNR) means the following EXCEPT: *
A. Allow natural death to happen (AND)
B. food and food supplements are sustained
C. comfort measures are withheld
D. “no heroic measures done”

Situation – Paula, a 21 year old college student was admitted at 12 noon because of a
generalized abdominal pain which became localized after midnight on the right lower
quadrant accompanied by nausea and vomiting. In the Emergency Department the
diagnosis of Acute appendicitis was confirmed. Paula was scheduled for
Appendectomy

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36. The development of appendicitis usually follows a pattern that correlates with the
clinical signs. The admitting nurse understands that the appendix initially becomes
distended with fluid secreted by its mucosa following: *
A. fibrotic changes in the inner wall of the appendix
B. impairment of blood supply to the appendix
C. obstruction of the appendiceal lumen
D. proliferation of microorganism inside the appendix

37. The physician noted upon palpation of the Mc Burney’s point localized and
rebound tenderness. Which of the following demonstrates this observation? *
A. Pain aggravated by coughing
B. Pain increased with internal rotation of the right hip
C. Rigid “boardlike” abdomen
D. Relief of pain with direct palpation and pain on release of pressure
38. Preoperative nursing care plan includes “potential complications related to
ruptured appendix” as one of the nursing diagnoses. Which of the following is the
nurse expected to report immediately as a possible sign of ruptured appendix? *
A. Severe nausea and vomiting
B. Sudden increase in body temperature
C. Unbearable excrutiating localized pain
D. Pain subsides

39. To prevent perforation of the inflamed appendix, which of the following will the
nurse consider as an effective intervention? *
A. Keep on NPO
B. Monitor progress of pain
C. Maintain on complete bed rest
D. Apply hot compress to abdomen

40. Postoperative medical diagnosis of the client is “Perforated appendix.” Client has a
nasogastric tube connected to continuous drainage. Which of the following is the
purpose of this intervention? *
A. Medium to cleanse the upper GI tract
B. Relieve pain due to abdominal distention
C. Drain out blood
D. Intestinal decompression

Situation - Condrado sought admission for acute gout of the right foot. Nurse Karmela
was in charge of the client.

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41. Nurse Karmela performs initial assessment. Which of the following types of joint
pain supports the physician’s diagnosis? *
a. Bilateral
b. Symmetrical
C. Polyarticular
D. Monoarticular

42. Which of the following examinations would the nurse expect to be ordered? *
a. Bone marrow aspiration
b. Knee-jerk examination
C. Synovial fluid analysis
D. Bone density

43. The client is for 24-hour urine collection for uric acid determination. To have a
reliable result, the nurse anticipates which diet prescription prior to the examination? *
a. Low fat diet
B. Low protein diet
C. Purine-free diet
D. Low-purine diet

44. During the acute attack, the pain of the affected foot can be so intense that even
the weight of the linen can be unbearable. The MOST appropriate nursing intervention
is to: *
a. Apply splint on the affected
b. Place a foot cradle on the bed
C. Elevate the affected foot
D. Apply bandage around the affected foot

45. Colchicine is prescribed during the acute attack phase. Nurse Karmela is aware
that the action of the drug is to: *
a. Provide fast symptomatic relief
b. Lower serum uric acid levels
c. Block the conduction of pain sensation
d. Interfere with the inflammation response of uric acid crystals in the joints

Situation - Henry, 65 years old underwent Transurethral Prostatectomy (TURP). He

was admitted to the Post Anesthesia Care Unit (PACU). The following questions
apply.

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46. The Operating Room (OR) nurse endorsed the ongoing intravenous infusion of
Dextrose 5% Ringer’s Lactate, 500 ml, running at 40 ml per hour at the level of 300
ml. The nurse who received the client in the PACU at 1500H, would expect the
present infusion to be consumed at: *
a. 2400H
B. 0100H
C. 2200H
D. 0300H

47. The client has an indwelling triple catheter to a continuous bladder irrigation (CBI)
with Normal Saline solution (NSS) infusing at 200 ml per hour. After four hours, the
nurse emptied the drainage bag and obtained an output at 1,080 ml. Which of the
following will the nurse record as the client’s urinary output? *
a. 180 ml
B. 1,080 ml
C. 800 ml
D. 280 ml
48. The surgeon’s order reads: “Maintain traction on the indwelling triple lumen
catheter”. Which of the following is the MOST appropriate action of the nurse? *
a. Tape the catheter to the abdomen and keep client in supine position
b. Pull the catheter taut and tape to the thigh alternately every 6 hours.
c. Instruct the client to keep both legs together and extended all the time
d. Pull the catheter taut, tape to one thigh and keep the extended all the time

49. The nurse understands that Normal Saline Solution (NSS) is used for CBI to
prevent which of the following? *
a. Water intoxication
b. Elevation of specific urine gravity
C. Dehydration
D. Formation of stones

50. The nurse assigned to the client monitored and maintained the CBI rate of NSS at
200 ml per hour. This intervention is critical because it: *
a. Washes out remaining fragments of stones
b. Avoids postoperative infection
c. Decreases bleeding and keep the bladder free from blood clot
d. Maintains adequate hydration

Situation - Marlon, 56, was admitted to the medical ward for acute myocardial
infarction management (AMI)

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51. Marlon’s admission assessment was done by Nurse Linda. Which of the following
descriptions would the nurse consider as a classical pain of Acute Myocardial
Infarction? *
a. Pain radiates to jaw, back and left arm
b. Crushing mediastinal pain
c. Sudden chest pain associated with activity
d. Gnawing pain unrelieved by rest

52. Oxygen at 2-4 L/min via nasal cannula was prescribed. Nurse Linda understands
that the primary purpose of this order is to: *
a. Increase myocardial oxygen supply
b. Decrease cardiac workload
C. Reduce pain due to ischemia
D. Relieve difficulty of breathing
53. Morphine Sulfate was administered in intravenous boluses to reduce pain and
anxiety. Which of the following vital signs should nurse Linda monitor carefully to
specifically determine cardiac responses? *
A. Temperature
B. Pulse rate
C. Blood pressure
D. Rspiratory rate

54. Nurses must be aware that pain in MI may occur without cause primarily during
what time of the day? *
A. Anytime of the day.
B. Usually after a day’s work
C. Early at night before retiring
D. Early in the morning

55. Marlon remarked that he always carried sublingual nitroglycerin tablet for chest
pain wherever he goes. When the pain is severe he asked what he can do to enhance
the tablet’s effect. Which of the following is the CORRECT instruction of the nurse?.
Client lies supine for 15 minutes following administration. *
A. Crush the nitroglycerin tablet between the teeth and allow to dissolve with saliva.
B. Crush the nitroglycerin tablet and dissolve in ½ glass warm water then drink it.
C. Take 1 nitroglycerin tablet with ½ glass of warm water.
D. Make sure the nitroglycerin tablet is under the tongue and dissolve.

Situation – The primary goal of nursing research is to develop a scientific knowledge

base for nursing practice. Nursing research includes all studies concerning nursing
practice, nursing education, and nursing administration.

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56. Researcher Nona conducted a research of the effect of using an agent in giving
oral hygiene in the nursing care of the acutely ill surgical patients. In this type of study,
it is necessary to: *
A. Conduct a pilot study. .
B. Administer treatment.
C. Conduct interview
D. Develop a questionnaire.

57. Of the following listed designs below, which one would you allow the researcher to
have most confidence that the oral care with agent is effective in helping acutely ill
surgical client attain outcome? *
A. One-shot case study.
B. Non-equivalent control group design.
C. Post-test only control group design
D. One-group pre-test-post-test group design.

58. A team of researchers conducted a study on the relationship of the completed

surgical cases and the extent of performance of standard competencies among Level
3 nursing students assigned in the Operating Room. In correlational study, the
researcher examines the: *
A. Questionnaire used to collect data from large samples.
B. Difference between two correlated groups.
C. Relationship between or among two or more variables.
D. Cause and effect relationship.

59. The statistical tool that is used in determining the magnitude and direction of the
relationship between two variables is: *
A. Test of relationship.
B. Analysis of Variance
C. Pearson R coefficient of correlation
D. Spearman rho coefficient of correlation.

60. A researcher conducted a study on assessment of the psychosocial problems of

cancer patients in Metro Manila. Which of the following instruments was used to
collect data from large samples? *
A. Descriptive statistics
B. Inferential statistics
C. Questionnaire and interview
D. Controlled laboratory setting

Situation: The role of the Nurse is bounded by several ethico-moral responsibilities

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61. Dan Paolo, a student nurse believes that all patients should be treated as
individuals. The ethical principle that this reflect: *
a. Beneficence
b. Nonmaleficence
c. Respect for others
d. Autonomy

62. Informed consent is necessary for the treatment for involuntary clients. When this
consent cannot be obtained, permission maybe taken from the, *
a. Social Worker
b. Doctor
c. Next kin/guardian
d. Chief nurse

63. A mother who is pregnant and with ovarian cancer underwent a treatment. The
fetus died. What bioethical principle applies to this case? *
a. Justice
b. Double effect
c. Autonomy
d. Paternalism

64. Ms. Nenita is diagnosed to have acute MI and is recommended for admission. He
refused to be admitted and asked to be transferred to a tertiary hospital instead.
Which of the following principles should the nurse use as a guide for her actions? *
a. Justice
b. Beneficence
c. Autonomy
d. Nonmaleficence

65. A common ethical concept of nursing which reflects a professional value of

avoiding harm to the client in the executory task is: *
a. Veracity
b. Beneficence
c. Nonmaleficence
d. Autonomy

Situation : As a registered nurse, nurse Andrei will assume accountability for her
nursing actions.

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66. Doing a nursing procedure without the patient’s informed consent may bring nurse
Andrei to the court of law for this violation: *
a. Negligence
b. Assault
c. Battery
d. Tort

67. Nurse Andrei may be found negligent if:(i) A Patient is injured(ii) Nurse Andrei did
not follow nursing standards(iii) Nurse Andrei failed to do his duty(iv) The injury that
the patient sustained is foreseeable *
a. 1, 2, 3
b. All
c. 1, 2, 4
d. 2, 3, 4
68. Which of the following examples illustrates res ipsa loquitur *
a. A psychiatric patient was hit by a car a block away from the hospital
b. A comatose patient was scalded because of the hot water bag placed by nurse Andrei
c. A patient died 6 hours after the injection of antiembolic
d. A patient developed infection at the IV insertion site

69. Nurse Andrei shared with her co-worker his most recent experience about a
restless patient, which he raised the side rails up to prevent fall. Which attributes
shown by Andrei? *
a. Reliability
b. Honesty
c. Resourcefulness
d. Prudence

70. Nurse Andrei was not able to raise the side rails. His patient fell, obtained a neck
fracture and died. After due process nurse Andrei was proven guilty. Who will revoke
his license as an RN? *
a. Ombudsman
b. BON
c. DOH
d. MMDA

Situation– Nurse Monique is assigned to the pediatric surgical unit to take care of Bob
and Patrick.

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71. Bob, 18 months, was admitted for repair of hypospadias. During assessment,
which of the following will Monique expect to observe? *
A. Absence of urethral meatus
B. Termination of the urethra is in the ventral surface of the penis
C. Defect of the urethra on the dorsal surface of the penile shaft
D. Penis has 2 urethral openings located dorsally and ventrally

72. Surgery is the treatment of choice for Bob. The nurse understands that the best
time for surgery is before the child: *
A. is weaned from diapers
B. is toilet trained
C. goes to school
D. walks

73. Monique prepares a nursing care plan for Bob. Postoperatively, which of the
following is a PRIORITY nursing diagnosis? *
A. Risk for Infection
B. Alteration of fecal elimination
C. Potential malnutrition
D. Altered Body image

74. Patrick, 1 year old, was admitted to the unit from the recovery room post
cheiloplasty. Linda would place Patrick in which of the following positions? *
A. Lateral
B. Fowler’s
C. Supine
D. Prone

75. When Patrick fully recovered from anesthesia, the doctor’s ordered clear liquids as
tolerated. Which of the following is the APPROPRIATE action of the nurse? *
A. Bottle feed the infant
B. Allow infant to sip from a cup
C. Administer liquids through a medicine dropper
D. Use spoon and feed slowly and gently

Situation – The medical and surgical unit where you work just hired 3 nurses to
augment the present nursing human resources. The following questions apply.

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76. You are assigned one new nurse to work with during the shift. An admission from
the Post Anesthesia Care Unit (PACU) of a post thoracotomy with wedge resection
with a chest tube came in and you assigned the nurse to do initial assessment. Which
assessment if observed will you report to the surgeon right away? *
A. 80 ml of dark red output from the drainage bottle
B. Intermittent bubbling in the suction control
C. Intact and dry dressings
D. The drainage system is hanged at the bed side below the client’s chest

77. You put the client in Fowler’s position and explained the rationale before the client
and significant others the benefit of this position. If you were the nurse, which would
be the BEST reason for the Fowler’s position? *
A. Increases pressure on the diaphragm and allows optimal expulsion of secretion
B. Promotes deep breathing and reduces pain during inspiration
C. Reduces pressure on the diaphragm and permits optimal lung expansion
D. Relaxes the sternal muscles and enhances breathing

78. The new nurse reads the doctor’s order: “Maintain patent chest tube and closed
drainage. Milk tubing prn.” The APPROPRIATE nursing action is: *
A. pinch the tubing alternately towards the drainage chamber if there is visible fibrin or clots
B. clamp the tubing every time the client coughs
C. milk feeding
D. empty the drainage tube prn

79. The new nurse encouraged the client to assume a comfortable position while
maintaining body alignment despite the presence of the drainage system. While the
patient was looking for a more comfortable position, the tubing was accidentally
disconnected. The INITIAL and APPROPRIATE action of the nurse is to: *
A. clamp the tubing at once
B. place the open end of the tubing in a sterile water
C. pull out the tubing and apply an airtight dressing to the site
D. immediately reconnect the tube

80. The senior nurse was emphasizing to the new nurse that intermittent bubbling of
the water seal chamber is normal but should continuous bubbling be observed, this
can indicate: *
A. presence of air leak
B. that pressure is equal to the water seal
C. no more air is leaking into the pleural cavity
D. negative pressure in the mediastinal cavity

Situation: COPAR is an important tool for community development and people

empowerment as this helps the community workers to generate community
participation in development activities. COPAR prepares people/clients to eventually
take over the management of a development programs in the future.

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81. In a phenomenological research, the research team understands that the

experience of being isolated will be: *
A. explained by the researcher to the participant
B. interpreted by the researcher for the participant
C. interpreted by the researcher with the participant
D. interpreted by the participant for the researcher

82. When determining adequate number of participants, the research team will
consider which of the following? *
A. Sample size of the participant will be determined before the study
B. Number of participants will be adequate when data obtained are saturated.
C. Participants should be representative of the target population
D. The convenience type of sampling will be the most appropriate sampling method
83. The research team planned to utilize audio-recorded interviews as their method of
collecting data. Which of the following techniques would ensure that data obtained will
be adequately analyzed? 1. Simultaneously listen to the recording and read the written
transcript, then note observations 2. Repeatedly listen to the audio-tape recordings 3.
Make notations while listening to the audio-tape recordings 4. Transcribe audio-
recorded interview word for word *
A. 1 only
B. 1 and 4
C. 1, 3 and 4
D. all of these

84. After the research team has “dwelled with the data” the team decided to conduct
data reduction. Which of the following is the team expected to do? *
A. Identify patterns in the obtained data
B. Eliminate data which are not related
C. Break text down into subparts and label accordingly
D. Classify the data based on a theoretical perspective

85. During the interpretation phase, the research team is expected to answer which of
the following questions? *
A. What do the findings show?
B. What is going on?
C. What is the meaning of the experience of isolation?
D. Are the themes justifiable and grounded from the data?

Situation – Nurse Gel is preparing Ike, a 28 year old newly-wed for surgery for a repair
of multiple trauma from a car accident. Ike is in severe pain and comforted by his wife
and significant others.

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86. There exist a hierarchy who should sign the consent to be legally valid if the client
is not competent. Rank the following next-of-kin who shall sign the consent for Ike’s
surgery. 1. Grandparents from paternal or maternal side 2. Adult competent children 3.
Brother or sister4. Legitimate spouse5. Guardian whether appointed by court or not *
A. 4,5,3,2 and 1
B. 4,3,1,2 and 5
C. 4,2,1,3 and 5
D. 5,3,4,2 and 1

87. Legally, nurse Gel shall assume which role during the signing of the consent? *
A. Advocate
B. Witness
C. Interpreter
D. Counselor

88. Ike underwent exploratory laparotomy for multiple organ injuries in his abdomen.
Which Doctrine is applied when the surgeon is held liable when there is an incorrect
surgical count? *
A. Res Ipsa Loquitor
B. Captain of the Ship
C. Doctrine of Vicarious Liability
D. Doctrine of Independent Contractor

89. During the surgery, the client was profusely bleeding that prompted the surgeon to
verbally order “Transfuse all available blood.” Which of the following options would the
nurse take so that she will not be liable if blood transfusion complications occur? *
A. Document as ordered and have the surgeon sign as soon as feasible.
B. Transfuse the blood with the anesthesiologist
C. Send the blood for proper cross-matching and transfuse immediately after
D. Leave the anesthesiologist to follow the order

90. The surgeon is such in a hurry to “close” because of the deteriorating condition of
the client. The Perioperative nurses cannot account for an operating sponge (OS).
Which is the MOST appropriate action of the scrub nurse at this point? *
A. Hands the suture for closing and tell the surgeon that one OS cannot be accounted for
B. The scrub nurse asks the circulating nurse to recheck the sponges one more time
C. The scrub nurse informs the surgeon that one OS cannot be accounted for
D. Obligingly, the scrub nurse hands the suture to close and continue to locate the missing OS

ation – Nurse Kenneth is caring for Jonathan, 40 year old 3rd day post bowel
resection, NPO with D5LR IV 1000 ml at 125 ml/hr. Laboratory findings show a
hemoglobin level of 8 g/dl and hematocrit of 30 %.

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91. During the physician’s rounds, Dr. Lorenzo made the following orders:
-Gentamycin 80 mg IV piggy back in 50 ml D5 Water over 30 minutes -Ranitidine 50
mg IV in 50 ml D5 water piggy back in 30 minutes -Packed red blood cells (RBC) 250
ml to run for 3 hours How many milliliters should Nurse Kenneth document as the total
intake for the 8 hour shift? *
A. 1000 ml
B.1300 ml
C. 1350 ml
D. 350 ml

92. While reading Jonathan’s chart, you read the laboratory findings as: -serum
potassium 2.2 mEq/L -sodium 129 mEq/L -Calcium 7.5 mg/L The nurse would
anticipate / prepare which of the following IV solutions to be prescribed? *
A. Sodium Chloride 0.45 %
B. Dextrose 5% in water
C. Dextrose 5% in Lactated Ringers solution
D. Normosol

93. Nurse Kenneth continued to monitor Jonathan who has an ongoing IV and packed
red blood cells (PRBC) transfusion. The client complains of headache, backache and
the temperature began to spike. Rank the action of the nurse according to PRIORITY:
1. refer to the attending physician 2. assess the client 3. close the roller clamp of the
PRBC4. keep the vein open with NSS5. document observation and intervention *
A. 2,3,4,1 and 5
B. 3,2,1,4 and 5
C. 3,4,2,1 and 5
D. 1,2,3,4 and 5

94. Nurse Kenneth identifies risk for wound complications. In case of wound
evisceration, the IMMEDIATE action of the nurse is to: *
A. Instruct the client to stay quiet in bed as you call for help
B. Apply clean abdominal binder and place the pillow on top of the wound
C. Cover the wound with sterile gauze wet with sterile NSS
D. Call for the surgeon stat

95. Jonathan has been NPO since he was operated and asks the nurse when he can
have food. Nurse Kenneth’s most APPROPRIATE response is: *
A. “The dietitian will make their rounds in a while to assess you and other postoperative clients.”
B. “The surgeon will make their rounds to assess your readiness to take in your preferred diet.”
C. “Clear soup will be served as soon as you have bowel sounds”
D. “You can have sips of water for the mean time”

Situation – Mrs. Yu, a 47 year old teacher sought admission to the hospital for
hemorrhage due to diverticulitis.

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96. Nurse Paz read the order of the attending physician, “Start Blood transfusion of 2
units compatible blood to run for four hours each unit. Monitor closely and report
untoward reactions.” The nurse prepared for cross matching. Which of the following is
an APPROPRIATE action of the nurse? *
A. Obtain blood transfusion set from the supply room.
B. Have blood sample extracted by the medical technologist.
C. Start intravenous infusion of normal saline solution.
D. Call blood bank for the prescribed blood.

97. Nurse Paz is successful in collaborating with the rest of the team if she
understands that the diverticulum may bleed due to: *
A. severe inflammation of the sigmoid
B. irritable bowel syndrome
C. prolonged constipation
D. erosion of the adjacent blood vessel by a fecalith

98. Additionally, the physician ordered to assess for evidence of lower intestinal
bleeding. The nurse does which of the following? *
A. Visual examination of the stool
B. Accurate measuring hourly output
C. Guaiac testing of stool for occult blood
D. Routine stool examination

99. When collaborating with the health team members, which of the following BEST
describe the nurse’s role? *
A. Shares and implements doctor’s order effectively
B. Encourages participation of the client in the total care
C. Listens to the different views of the “significant others”
D. Helps client understand the treatment plan

100. Total parenteral nutrition was started. The nurse understands that the caloric
nutrient content and amount of this intervention is determined by the following
EXCEPT: *
A. pharmacist
B. nutritionist
C. physician
D. nurse