Don Mariano Marcos Memorial State University

South La Union Campus

COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES
Agoo, La Union
Tel. 072.682.0663/ichams.dmmmsu-sluc.com
Embracing World Class Standards
NURSING DEPARTMENT
Care to learn, Learn to care

NAME:

Direction: Read the questions carefully. Choose the best/correct answer then give the rationale of your
answer. Please indicate your reference/s: title, author, year and page number if possible.

1. A client enters the hospital emergency department with a nosebleed. On assessment, the client tells the nurse
that the nosebleed just suddenly began. The nurse notes no obvious facial injury. Which of the following should
be the initial nursing action?
a. Prepare a nasal balloon for insertion.
b. Inert nasal packing.
c. Sit the client down, ask the client to lean forward and apply pressure to the nose for 5 to 10 minutes.
d. Place the client in a semi-Fowler’s position and apply ice packs to the nose.

Answer:
Rationale:

2. Nurse Ma. Angelica reviews the blood gas results of a client with Guillain-Barré syndrome. Nurse Ma. Angelica
analyses the results and determines that the client is experiencing respiratory acidosis. Which of the following
validates Nurse Ma. Angelica’s findings?
a. pH=7.25, PCO2=50mmHg
b. pH=7.35, PCO2=40mmHg
c. pH=7.50, PCO2=52mmHg
d. pH=7.52, PCO2=28mmHg

3. Nurse Steffany reviews the arterial blood gas results of a client and notes the following: pH is 7.45, PCO 2 of
30mmHg, and HCO3– of 22mEq/L. Nurse Steffany analyzes these results as indicating which condition?
a. Metabolic acidosis, compensated
b. Respiratory alkalosis, compensated
c. Metabolic alkalosis, uncompensated
d. Respiratory acidosis, uncompensated
4. In a postoperative client, which of the following sets of vital signs needs to be reported to the physician
immediately?
a. Temperature: 37.5OC; pulse rate: 99bpm; respiratory rate: 18cpm; blood pressure: 110/70mmHg
b. Temperature: 36.4OC; pulse rate: 121bpm; respiratory rate: 26cpm; blood pressure: 90/55mmHg
c. Temperature: 37.2OC; pulse rate: 90bpm; respiratory rate: 18cpm; blood pressure: 110/80mmHg
d. Temperature: 37.8OC; pulse rate: 101bpm; respiratory rate: 21cpm; blood pressure: 120/80mmHg

5. The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse
collects the first specimen. This specimen is then:
a. Discarded, then the collection begins.
b. Saved as part of the 24-hour collection.
c. Tested, and then discarded.
d. Placed in a separate container and later added to the collection.

6. You need a sputum specimen, but the patient has a non-productive and ineffective cough and you need to
perform tracheal suctioning. Which technique would you avoid when obtaining the specimen?
a. Administering oxygen to the patient before beginning suctioning.
b. Applying suction for 30-40 seconds then suctioning again if no sample is obtained.
c. Advance the catheter into the trachea, touching the larynx to stimulate the cough reflex.
d. Disconnecting the in-line trap from the suction tubing after suctioning and obtaining the specimen.

7. A client is placed on a four-point restraint following orders from a physician. Which of the following measures
should the nurse include in the patient’s care plan?
a. Socialize with other patients once a shift.
b. Check circulation periodically.
c. Provide stimulating diversion activities.
d. Assesses rectal temperature frequently.
8. When performing oral care to an unconscious client, which of the following is a special consideration to prevent
aspiration of fluids into the lungs?
a. Put the client on a side-lying position with head of bed lowered.
b. Keep the client dry by placing towel under the chin.
c. Wash hands and observe appropriate infection control.
d. Clean mouth with oral swabs in a careful and an orderly progression.

9. To increase venous blood return to the heart, which stroke should the nurse use when bathing the client’s
extremities?
a. Light, circular strokes from proximal to distal area.
b. Long, firm strokes from distal to proximal area.
c. Long, light strokes from proximal to distal area.
d. Rigid, circular strokes from distal to proximal area.

10. You will be applying eye drops to Miss Mendoza. After checking all the necessary information and cleaning the
affected eyelid and eyelashes, you administer the ophthalmic drops by instilling the eye drops:
a. Directly onto the cornea
b. Into the outer third of the lower conjunctiva
c. Pressing on the lacrimal duct
d. From the inner canthus going towards the side of the eye

11. All of the following statements about blood transfusion is true, except:
a. Blood typing and cross matching should be done before blood transfusion.
b. If a pack of blood is not immediately infused, the nurse should keep it in the refrigerator in the unit.
c. The blood transfusion should be administered within 30 minutes.
d. The nurse should stay with the client 30 minutes after initiating the blood transfusion to assess for
complications.

12. Being a nursing student demands insurmountable amount of effort and use of strategies. You’ve learned from
your nutrition class that which of the following would most likely help you in your studies since you memorize the
facts and loads of information because these substances greatly expedite the transmission of impulses?
a. Flavonoids particularly wine, tea and dark chocolates
b. Fruits such as apple, orange and grapes for vitamin ACE
c. Stimulants like caffeine, nicotine and marijuana
d. Vitamin B complexes

13. Which of the following should be done when inserting a nasogastric tube?
a. Insert the tube in rotating motion, head of bed elevated.
b. Check the length that will be inserted from the tip of the nose to the earlobe then xiphoid process.
c. Make sure you’ll lubricate the tip with oil lubricant to facilitate easy passage.
d. When the patient gags, remove the tube and reinsert it after 15 minutes.

14. T3 and T4 are essential laboratory procedures particularly related to determine the rate of metabolism. Which is
considered correct?
a. Both are biologically active in the blood and are totally dependent on the iodine supplement from the diet.
b. Deficiency and excess of these may lead to goiter formation.
c. People who live in highlands have greater risk for hyperthyroidism.
d. Oversupply will lead to myxedema formation.
e. All
f. None

15. Which of the following correctly tells a nurse how to assess the residual feeding contents in a patient with NGT
before she plans to perform feeding?
a. Attach the asepto syringe to the open end of the tube, aspirate alimentary secretions. Check the pH.
b. In infants, when she aspirates 5ml she will withhold feeding.
c. Aspirate all the stomach contents and measure the amount prior to administering the feeding.
d. If 50ml or more undigested formula is withdrawn in adults, don’t continue with feeding yet.
e. A and D
f. C and D

Situation: You are the community nurse assigned in Pateros. One of your clients is Mang Tintay, a chronic chain
smoker who smokes 4 packs or more a day.
16. Mang Tintay’s habit caused him to develop emphysema and be hospitalized. His initial management included
oxygen therapy of 2 liters per minute via nasal cannula. His daughter asked you why he needs low levels of
oxygen unlike the other clients who have higher levels. Your best response would be, hypoxemia:
a. Suppresses the drive of the client to breathe.
 b. Stimulates the respiration of the client.
c. Establishes normal breathing pattern.
d. Maintains the carbon dioxide level in equilibrium.

17. Mang Tintay can now be discharged. You are teaching him and his family home care instructions including
postural drainage. They ask why postural drainage should be done. You explain to them that it is done to:
a. Improve drainage of secretions after it has been loosen by percussion.
b. Move secretions from lower to the upper segment of the lungs.
c. Enhance breathing by clearing the alveoli.
d. Aid in keeping the lungs clear by draining all the lung segments.

18. Ally is a patient admitted due to blast injury. She suffered physical trauma to the chest which needed surgery.
She is now with a closed chest drainage system. You are the nurse assigned to her. After doing an initial
assessment, you found that the fluid in the water seal chamber is intermittently fluctuating. Your next action is to:
a. Add more fluid to the suction control chamber.
b. Add more fluid to the water seal chamber.
c. Record in the chart that the system is functioning well.
d. Check for possible air leaks.

19. As an ICU nurse, you should have knowledge regarding endotracheal tube care since most patients admitted at
ICUs require complex care. You are monitoring Chelsy’s cuff pressure. To minimize her risk of mucosal necrosis,
you should keep the pressure within?
a. 10-15mmHg
b. 20-25 mmHg
c. 30-35 mmHg
d. 40-45 mmHg

20. Student nurse Sanna is assigned to Edgar, a 4-year old male, who just underwent cardiac surgery and now has
tracheostomy. Sanna is about to do tracheostomy care when Nurse Dencio reminded her to only apply suction
for 5-10 seconds while withdrawing the catheter in circulation motion. Sanna’s most appropriate action would be:
a. Suction for 5-10 seconds then rotate the catheter and withdraw.
b. Strictly follow Nurse Dencio’s reminder so that oxygen loss can be minimized and to prevent tissue trauma.
c. Inquire about the suctioning time for it is too quick for an effective suction.
d. Verify Nurse Dencio’s instruction by confirming it with the head nurse.

21. You are assigned to Yolly, a patient admitted due to severe diarrhea. Fluid and electrolyte imbalance may have
serious consequences. To prevent dehydration, IV fluid supplementation was done. You are accurately
monitoring Yolly’s response to the treatment when you are:
a. Checking Yolly’s urine output every hour.
b. Measuring Yolly’s weight every day.
c. Assessing for the presence of edema.
d. Assessing skin turgor.

22. Tetay, a patient who is for blood transfusion, is also under your care. A few minutes after the initiation of the first
unit packed RBC, Tetay showed signs of dyspnea, tachycardia, sudden anxiety and neck vein distention. Your
most appropriate intervention would be:
a. Administer IV Benadryl as ordered.
b. Collect the first post transfusion urine.
c. Position Tetay in an upright position, with the feet dependent.
d. Maintain the patency of the transfusion tubing.

23. Arterial blood gas analysis helps assess oxygenation and ventilation status and provides vital information in
managing a patient’s metabolic and respiratory disturbances. When obtaining blood samples, the nurse must
select superficial arteries which include the brachial, radial and femoral arteries. Among the following choices,
which should not be done during the ABG collection?
a. Do Allen’s test before attempting to get an arterial sample.
b. Remove the air bubbles in the syringe after blood collection.
c. Use heparinized syringe and needle and leave 0.1mL of heparin inside the syringe before obtaining blood
sample.
d. Firmly place a cotton ball over the venipuncture site for at least 5 minutes after blood collection.

24. As you are doing your rounds for the PM shift, you noticed that the father of Monique is applying a hot compress
on the child’s abdomen to relieve stomach pain. 7-year old Monique is scheduled for appendectomy the
following day. You stop what the father is doing for you know that, heat:
a. Intensifies abdominal contractions.
b. Arrests progression of the disease.
 c. Causes appendix to rupture.
d. Promotes abdominal peristalsis.

Situation: Badette, a 21-year old female, is admitted in the Surgical ward for multiple injuries secondary to vehicular
accident. She is placed in traction. Since then, she has not been able to get out of the bed nor do her activities of
daily living which led her to frustration.
25. All of the following is part of the principles of traction management, except:
a. A counter traction is essential to maintain an effective traction.
b. Weights should be kept resting on the floor.
c. Clients on traction need to perform active exercises.
d. Traction must be continuous to be effective in reducing and immobilizing fractures.

26. Clients sustaining multiple injuries from trauma need the management from the whole health team so that
optimal maintenance of client’s health could be achieved. Select which among the following exemplifies this kind
of intervention:
a. Nurse-initiated
b. Collaborative
c. Support system
d. Doctor-initiated

27. It is requirement that nurses know the special considerations that come with parenteral nutrition especially with
its administration and monitoring. You asked student nurse Crystal regarding this and you will correct her if she
says which of the following?
a. Kabiven solution should be infused at a constant rate.
b. Client should be weighed at the same time every day.
c. Client’s blood glucose level should be monitored every 2 hours.
d. Client’s vital signs should be assessed every 4 hours and hyperthermia should be watched out for.

28. You are taking care of Ella, a 79-year old female who has pneumonia. You attached a pulse oximeter to her to
monitor the oxygen saturation in her blood. The device started alarming and you noted a reading of 74% SpO 2.
Your initial action would be to:
a. Reposition the client.
b. Check the connections.
c. Assess the client’s vital signs and other pertinent data to have a conclusive report.
d. Contact the doctor and report the situation right away.

29. Pressure ulcers are caused by breakdown of the skin due to prolonged pressure and insufficient blood supply,
usually at bony prominences. Hydrocolloid dressings are frequently used over pressure ulcers. You are correctly
teaching the rationale behind the use of this dressing when you say:
a. It promotes easy debridement.
b. It fosters a moist environment which aids in wound healing.
c. It helps to liquefy dead wound tissue.
d. It takes up exudates which help in making the wound dry.

30. You are taking are of a patient who is prescribed with Milk of Magnesia. As part of your nursing responsibilities,
you know that:
a. It can’t be taken with meals since it impairs the absorption of fat soluble vitamins thus delaying gastric
emptying.
b. It is recommended for short term use only since it can cause toxicity.
c. It should not be administered within 1 hour of other oral medications.
d. It is the recommended laxative for those who have bowel ulceration/obstruction, dehydration and heart
failure.

31. You are a nurse in the medical-surgical ward and are taking care of Chloe, a 73-year old client diagnosed with
chronic renal failure. She presents with a BP of 160/120, has crackles in the lungs and a weight gain of 15lbs.
From the signs presented, your diagnosis is Fluid volume excess related to inability of the kidney to maintain
fluid balance. Your intervention would include all of the following, except:
a. Inspect skin for redness and blanching.
b. Educate client in maintaining high salt diet.
c. Record intake and output of client accurately.
d. Teach client to call the doctor when weight gain increases >2lbs.day.

32. Iron deficiency anemia (IDA) typically results when the intake of dietary iron is inadequate for hemoglobin
synthesis. A client with IDA usually presents with pale nail beds. Which of the following guidelines should be
advised to Irene, who is taking iron supplements?
a. Take it on full stomach to prevent gastric distress.
 b. Drink liquid form of iron using a glass to prevent teeth staining.
c. Eat foods high in fiber to minimize problems with constipation.
d. Decrease intake of vitamin C to enhance iron absorption.

33. Owen, a 27-year old male is brought to the emergency department of your hospital with admitting diagnosis of
Traumatic Brain Injury. You know that Glasgow Coma Scale (GCS) score is interpreted as: the lower the score,
the more serious the brain injury. Mr. Owen opens his eyes upon pain infliction, has no verbal response and is in
flexion. You correctly assess his GCS score when you give:
a. 7
b. 6
c. 5
d. 4

34. Changes in an individual’s mobility, depending in the cause, may be temporary or permanent. Nursing goals for
the client would be to optimize and maintain current level of functioning, prevent additional deterioration of
physical activity and promote a safe environment. You are taking care of Victor and you note that he has self-
care ability of 2 which means:
a. He can walk on his own.
b. He can walk with the use of a cane.
c. He can walk with the help of his daughter.
d. He is unable to walk.

35. Cancer can be caused by several factors such as smoking, exposure to certain chemicals and free radical
damage. Rina, a post mastectomy client inquires about the proper diet that can fight “free radicals”. You answer
Rina appropriately when you say:
a. “Citrus foods, carrots and other foods rich in beta-carotene and vitamins A, C, E appear to have properties
that fight free radicals.”
b. “Are you interested in having pamphlets about foods that fight cancer?”
c. “Consume foods that have antioxidant properties and have high levels of phytochemicals.”
d. “There are a number of herbal products in the market that you could try.”

36. You are taking care of Mrs. Viola, a comatose client. All of the following are correct interventions for her eye care
except:
a. Administer moist compress to cover the eyes every 2-4 hours.
b. Clean the eyes with saline solution and cotton calls. Wipe from outer to inner canthus.
c. Monitor the eyes for redness, exudates or ulceration.
d. If the client’s corneal reflex is absent, keep the eyes moist with artificial tears and protect the eyes with a
protective shield.

37. Since nurses are always in contact with clients, we should practice basic personal hygiene. Who among the
following nurses practice this?
a. Nurse Karina, who uses brown nail polish to protect her nails from infectious materials.
b. Nurse Faye, who ties her hair neatly so that it doesn’t fall to her face.
c. Nurse Raisa, who makes herself smell good and fresh by putting on cologne.
d. Nurse Veronica, who uses big and beautiful accessories to make herself pleasing to her clients and co-
workers.

38. You are giving a talk to the nurse during their monthly ward meeting. You inform them that generally, clients in
the Intensive Care Unit (ICU) have higher chances of contracting hospital acquired infections than those
admitted in ordinary wards. Which of the following explanations is true?
a. ICU staff adheres less to guidelines of asepsis since clients are on antibiotics all the time.
b. Several activities and procedures performed at the ICU expose clients to more pathogens.
c. Clients are highly critical and very vulnerable to infections.
d. ICUs are never vacant and clients can’t be transferred that easily making disinfection area difficult.

39. Nurses should practice standard precaution at all times. Nurse Tina is demonstrating this when she:
a. Performs proper hand washing including washing of used hand gloves.
b. Wears a mask if working within 3 feet of the client.
c. Wears clean gloves when touching blood, body fluids, secretions and contaminated items.
d. Places the client in a private room that has negative air pressure.

40. Chingkay, a community health nurse visits the slum areas of Barangay Dali-dali once a week. In order to
promote secondary prevention of malnutrition in children in the community, Nurse Chingkay must do which of the
following?
a. Assess the home for risk factors for malnutrition.
b. Inform the mothers about the schedule of the deworming of their children.
 c. Provide the mothers with a list of activities or behaviors that could lead to malnutrition.
d. Perform a fecal screening test to determine if eggs of worms are present.

41. Jessica, a pediatric nurse notices that her 4-year old client is showing signs and symptoms of pain. She then
validates the pain using the Wong-Baker Faces Pain Rating Scale. When the child points to the 4th cartoon face,
it means that the child’s description of pain is:
a. Hurts a little more
b. Hurts even more
c. Hurts whole lot
d. Hurts more

42. Many disasters are happening in different parts of the world today. Recently, Japan has suffered the grave
consequences of earthquakes and tsunamis. Disasters are classified by the resultant anticipated necessary
response. A level 3 disaster indicates:
a. Local and regional assets are overwhelmed; statewide or federal assistance is required.
b. National efforts are insufficient. Aid from other countries is needed.
c. Regional efforts and aid from surrounding communities are sufficient to manage the effects of the disaster.
d. Local emergency response personnel and organizations can contain effectively manage the disaster and its
aftermath.

43. Sleep is needed by the body to recover from all the stress it encountered during the day. There are differences
between patterns of sleeping of different generations. Which of the following would best describe the sleep of
middle age group?
a. There is increased night awakenings and decreased satisfaction with quality of sleep.
b. Sleep pattern fluctuates as middle age groups experience stress from jobs and parenting responsibilities.
c. There is circadian synchronization.
d. There is increased satisfaction with quality of sleep as an individual is approaching middle age group.

44. You are having a conversation with Fernanda, your 66-year old client when you noticed that she is not wearing
her hearing aid. To make sure that she can hear you, you should:
a. Face client, enunciate and exaggerate your lip movement.
b. Talk in slow manner, directly facing the client.
c. Speak close to the client’s better ear as appropriate.
d. Speak in slowly and loudly in a high pitched voice.

45. Mina is admitted to a semi-private room. She has been the only client in the room for 4 days until Becky was
admitted. Mina asks you about Becky’s health condition. Your best response would be:
a. Explain that you are not allowed to disclose Becky’s information due to confidentiality.
b. Describe to Ms. Mina the health status of Becky.
c. Take note of what Ms. Mina would want to know regarding Becky.
d. Advise Ms. Mina to ask Becky herself.

Situation: Nurse Sandy is assigned in the Pediatric Intensive Care Unit (PICU). She is preparing the medication of
her client who weighs 52.8lbs. The doctor ordered amoxicillin 125mg qid. Her drug guide states that the safe range
for the drug is 20-40mg/kg/day.
46. She computed the correct minimum safe dose if she obtained:
a. 1056mg/day
b. 960mg/day
c. 500 mg/day
d. 480 mg/day

47. She knows that what the doctor ordered us a safe dose since the total daily dose is:
a. 1056mg/day
b. 960mg/day
c. 500 mg/day
d. 480 mg/day

48. Marty, a 5-year old boy, diagnosed with vitamin B deficiency is to be given 30mL/hour of D5LR. Nurse Zy will be
using an infusion set calibrated at 60gtts/min. How many drops per minute would the nurse regulate the IV?
a. 30 gtts/min
b. 15 gtts/min
c. 10 gtts/min
d. 7.5 gtts/min
49. Mang Honorario is about to undergo prostate surgery. As surgical prophylaxis, ceftazidime is ordered. Since it is
his first time to receive the drug, skin testing should be initially done. You prepare the drug using a tuberculin
syringe with gauge 25 needle. The procedure is correctly done if you:
a. Pinch the area over the site and inject the medication slowly and carefully.
b. Put a cotton ball above the injection site and leave it for at least 5 minutes.
c. Massage the site after the injection.
d. Stretch the skin over site and insert the needle slowly at 10 to 15 degree angle.

50. You will be guiding a student nurse in administering a drug to your client using the Z track method. You inform
her the following guidelines, except:
a. This method requires that medication be administered slowly to allow time for tissue to expand and begin
absorption of medication.
b. In this technique, use the ulnar side of the non-dominant hand to pull the skin to the side and pierce the skin
quickly and smoothly at a 45 degree angle.
c. This technique leaves a zigzag path which prevents the seepage of the medication into subcutaneous
tissues and subsequent discomfort.
d. This technique is used for intramuscular drugs that are irritating to the tissue or drugs that cause
discoloration such as iron.

51. According to studies, medication errors constitute a large percentage of deaths that could have been prevented
in hospitals. The 12 rights of medication administration have been set as a guide to nurses to address this
problem. Nurse Kim is about to administer 1 liter of D5LR for 6 hours to her client. Which safety measure should
she consider to ensure that the right dose is given to the right client?
a. Never give a medication that you haven’t prepared.
b. Confirm client’s identification before administering medication.
c. Use proper measuring device.
d. Follow strictly the time of medication administration.

52. Body mechanics describe the efficient, coordinated and safe use of the body to move objects and carry out the
activities of daily living. When lifting objects, you observe proper body mechanic when you:
a. Carry an object as far away as possible from your body to keep the body’s center of gravity.
b. Carry objects not more than 55lbs by yourself.
c. Bend over while standing to pick up an object.
d. Use the major muscle groups of your thigh, knees, upper and lower arms, abdomen ad pelvis to prevent
back strain.

53. Interviewing a client is a part of the routine assessment done by nurses. Who among the following nurses
conduct an interview incorrectly?
a. Nurse Bebe who stands beside the client’s bed and looks down towards the client when asking questions.
b. Nurse Rico who is maintaining 2-3 feet distance while interviewing the client.
c. Nurse Vladimir who conducts the interview in a well-lighted and well-ventilated place.
d. Nurse Lyza who translates medical terminologies into layman’s terms so that the client could understand
what the topic is.

54. Diagnosing is the second phase of the nursing process. There are several formats of nursing diagnosis. Which
of the following is an incorrect nursing diagnosis?
a. Constipation related to prolonged laxative use
b. Situational low self-esteem related to feelings of rejection by husband as manifested by hypersensitivity
c. Impaired has exchange related to pneumonia
d. Potential complication of head injury: increased ICP

55. Nurse Amor is trying to contact the physician to report a change in the status of her client, Loyda. However, the
physician is on a meeting and is unable to answer the call. His secretary called Amor back after an hour and
relayed the doctor’s verbal order. Which is nurse Amor’s best intervention?
a. Keep on asking for the doctor.
b. Note the order of the doctor and let him sign the chart when he does the rounds.
c. Don’t accept the order from the secretary.
d. Transcribe the phone order as it comes from the doctor and document appropriately.

56. Proper incident reporting in a health care institution holds the promise of isolating problem areas, procedures
and personnel within an institution thus making corrective action easier. It can also serve as a weapon in
defense of law suits brought against the institution. Nurse Mila is doing an incident report which of the following
should she not include in the report?
a. Account of the important factors associated with the incident
b. Intervention done after the incident
c. Disparaging remarks given by the client
 d. Narration of the incident as factual as possible

57. Health models are helpful in assisting care providers to meet the health and wellness needs of individuals. Who
among the following individuals illustrates the definition of health according to the clinical model?
a. Gino, a father of 8 who is able to send all of his children to school.
b. Hector, who is healthy because he does not have any injury.
c. Daniel who is still able to live a normal life despite 1 kidney.
d. Cedrick who dreamt to be a doctor is now a resident physician.

58. Nursing went on through different periods in history. Which of the following statements most characterize the
period of Apprentice Nursing?
a. Nursing is performed out of compassion and is for women only.
b. Nursing is influenced by trends resulting from wars.
c. Nursing is performed without formal education.
d. It is when licensure examination of nurses started.

59. Your cousin is aspiring to be a nurse in the near future. You advise her that the first step in becoming a
registered nurse in the Philippines is through the completion of:
a. A bachelor’s degree completed in a hospital setting and eligibility to take the licensure exam.
b. A BS Nursing degree and eligibility to take the licensure exam.
c. A formal four-year college course that leads to BS Nursing.
d. Basic science courses that include theoretical and clinical courses.

60. Nurses have different roles to fulfill. We are flexible and we adjust our role according to our client’s needs. Nurse
Sheila is taking care of a diabetic client. She assumes the role of a change agent when she:
a. Provides client with information about benefits of proper diet and exercise.
b. Assists the client in modifying the eating habits and physical activity.
c. Informs the physician of the client’s health needs.
d. Regularly monitors the client’s blood glucose.

61. Aging, the normal process of time-related change, begins with birth and continues throughout life. In the local
setting, it is observed that the elderly population is oftentimes hospitalized. All of the following are correct
descriptions of the theories of aging except:
a. The activity theory proposes that life satisfaction in normal aging requires maintaining the active lifestyle of
middle age.
b. All types of intelligence (e.g. spatial perception, retention of non-intellectual information, verbal
comprehension and mathematical skills) decline in the aging population.
c. The ability to learn and acquire new skills and information decreases in the older adult, particularly after the
seventh decade of life.
d. Despair results when older person feels dissatisfied and disappointed with his or her life and would live
differently if given another chance.

62. While the family of Mr. Gordon, your client with a terminal condition is inside his hospital room, Mr. Gordon died.
Your best nursing action would be:
a. Give time for the family to be with Mr. Gordon.
b. Allow the family to grieve.
c. Return Mr. Gordon’s things to his family.
d. Give reassurance to the family that utmost care will be given to Mr. Gordon’s body.

63. Who among the following nurses practice disease prevention under the secondary level?
a. Gondar, who refers a homeless schizophrenic to a mental institution.
b. Slardar, who performs risk assessment for specific types of cancer.
c. Barathrum, who performs monthly testicular self-exam.
d. Huskar, who performs environmental sanitation along with other BHWs.

64. Theory is defined as a supposition or system of ideals that is proposed to explain a phenomenon, like nursing.
This nursing theorist conceptualized the nurse’s role as assisting the sick or healthy individuals to gain
independence in meeting the 14 fundamental needs. Who is this theorist?
a. Virginia Henderson
b. Florence Nightingale
c. Madeleine Leininger
d. Sister Callista Roy

65. Proton pump inhibitors reduce acid secretion in the stomach. It is used in the treatment of peptic ulcer disease
(PUD). Mr. Yohan has been diagnosed of PUD and is prescribed with omeprazole (Prilosec). Which of the
following health teachings should not be included in doing patient education?
 a. Therapy is limited to up to 2 months because long-term use has been associated with gastric cancer.
b. Immediately report diarrhea and abdominal pain.
c. Take the medication with meals.
d. It should never be crushed, broken or chewed.

66. Wearing of personal protective equipment (PPE) is an effective method of infection control. PPE typically consist
of gloves, gown, mask and eyewear. Which of the following principles regarding donning and removing of PPEs
is incorrect?
a. After washing the hands, the gown is put on first then the mask, eyewear and lastly the gloves.
b. In donning clean disposable gloves, the open method of gloving should be followed at all times.
c. In removing soiled PPE, the gloves are removed first then the eyewear, gown and lastly the mask.
d. The mask is removed at the doorway to the patient’s room.

67. In opening a sterile package, special aseptic techniques must be followed to maintain sterility. Nurse Purist is
about to open several packages in which sterile items are wrapped. Which of the following actions would make
the items unsterile?
a. Open the flap by grasping the inner surface of the wrapper with thumb and index finger.
b. Before opening a wrapped package, make sure that the top flap opens away from you.
c. Reach around the package in opening flaps.
d. Make sure that the inner surface of the wrapper does not touch any unsterile object or surface.

68. Surgical handwashing is done usually before any surgery or when performing sterile techniques. Nurse Mangix
is about to perform insertion of an indwelling foley catheter to one of his patients. He is about to perform surgical
handwashing. Which of the following guidelines is correct when performing surgical handwashing?
a. The faucet handle is turned off after handwashing by using a towel to grasp the handle.
b. A single towel is used to dry both hands after handwashing.
c. Water is allowed to flow from arms to fingertips when wetting the hands.
d. Ordinary soap may be used.

69. The Guaiac or fecal occult blood tests determines the presence of blood in the stool. Mr. Azwraith, a 54-year old
male is a high risk candidate for colorectal cancer. The physician orders Guaiac test. You are the nurse assigned
to assist Mr. Azwraith with the test. You are correct when you state that which of the following would not produce
a false positive reading?
a. The patient ate radishes and turnips yesterday.
b. The patient takes 500mg ascorbic acid tablet daily.
c. The patient ate beef caldereta yesterday.
d. The patient takes 300mg ferrous sulfate tablet OD HS.

70. Paracentesis is the removal of peritoneal fluid from the abdominal cavity, usually or ascites or for diagnostic
purposes. Nurse Rikki is caring for a patient with liver cirrhosis who is about to undergo paracentesis. Which of
the following actions by Nurse Rikki can jeopardize the patient’s safety?
a. Nurse Rikki instructs the patient to void immediately before the procedure.
b. Nurse Rikki instructs the patient to remain still while the trocar with cannula is inserted midway between the
umbilicus and symphysis pubis.
c. Nurse Rikki will drain 1,700mL during the entire session as ordered.
d. Nurse Rikki makes sure that the fluid will be drained slowly.

71. There are a number of support devices that are available for maintaining good body alignment of clients. The
doctor of your post total hip replacement surgery patient wants to maintain the patient’s legs in abduction and
orders which of the following support devices?
a. Trochanter rolls
b. Wedge pillow
c. Bed board
d. Foot boots

72. Due to dynamic and improving health care service worldwide, nurses are fulfilling expanded career roles to meet
the demands of health care. Nurse Mangix has completed advanced education program on gerontology nursing
and is currently employed in a community-based home care facility for the aged where they cater to older adult
patients with chronic illnesses. Nurse Mangix is a:
a. Clinical nurse specialist
b. Nurse practitioner
c. Nurse entrepreneur
d. Nurse administrator

73. Nurses today currently face the national issue of unemployment and underemployment. Although there are job
vacancies, most Filipino nurses do not qualify for such positions because of lack of experience. Most hospitals
 abroad require a nurse to have at least 2 years of clinical experience. According to the stages of nursing
expertise, most hospitals abroad require a nurse to be a/an:
a. Expert
b. Proficient
c. Competent
d. Advanced beginner

74. Mrs. Darcy has been diagnosed of having stage 2 lung carcinoma for about 4 months now. She reports that she
still provides for her family well as she is the primary breadwinner and that she can still accomplish the tasks at
the accounting firm that she works in. when asked, she says that she considers herself healthy. What health
model would tell the nurse that she is indeed healthy?
a. Adaptive model
b. Role performance model
c. Eudemonistic model
d. Clinical model

75. Proper stethoscope use during BP taking ensures an accurate reading. Student nurse Abadon is taking the vital
signs of his patient while you, his clinical instructor are watching him. He is currently taking the patient’s blood
pressure. You would immediately call his attention when he:
a. Places the diaphragm of the stethoscope over the brachial site.
b. Uses an antiseptic wipe to clean the earpieces.
c. Tilts the earpieces slightly forward before inserting them into the ears.
d. Places the amplifier of the stethoscope directly on the skin over the brachial artery.

76. The nurse is tasked to assess the rate, depth and rhythm of the patient’s respiration. You are a newly hired
nurse assigned to the female surgical ward. Nurse Raijin is the senior nurse of the ward and is orienting you of
the basic procedures done in the ward, one of which is taking respirations. Which of the following statements
made by Nurse Raijin would produce an inaccurate reading?
a. “You should count one inhalation and one exhalation as one respiration or breath.”
b. “Place the client’s arm across the chest and observe for the chest movements while supposedly taking the
radial pulse.”
c. “Count the respirations for 1 full minute then multiplied by two if the rhythm is irregular.”
d. “Making sure that the patient is not aware that he is counting the respirations.”

77. The apical pulse site is located at the point of maximum impulse (PMI) just above the heart’s apex. You are the
nurse assigned in the surgical ward. You are about to assess the vital signs of the 3 patients assigned under
your care. Which of the following conditions would not prompt you to obtain a pulse rate from the apical pulse
site?
a. The patient is an 11-month old male who have just undergone cleft palate surgery.
b. The patient is currently taking nifedipine (Adalat).
c. The patient is suspected of having premature ventricular contractions (PVCs).
d. None of the above

78. In the medical-surgical department, the nurse patient ratio is 2:75. Nurse Dianne, the charge nurse, prepared the
drugs to be administered at 12pm. Unexpectedly, Nurse Dianne cannot leave a patient who is having a seizure
activity so she requested Nurse Ruby to administer what she prepared. How should Nurse Ruby respond?
a. “Don’t worry; I’ll finish the job for you.”
b. “You administer the medicine and I’ll stay with the patient with seizure for you.”
c. “Leave the patient first, administer the medicine then come back later.”
d. “I’ll give diazepam 5mg IV then I’ll just tell the physician to check on the patient.”

79. You’re unable to establish emergency IV access in a child who requires rapid fluid administration. You attempt
intraosseous access. You know that you’ve reached the bone marrow because you feel a soft pop and a
decrease in resistance. Which of the following sites is recommended for use in children?
a. Iliac crest
b. Sternum
c. Proximal tibia
d. Distal femur

80. The generic name is the official or non-proprietary name for the drug. This name is not owned by any
pharmaceutical company and is universally accepted. An orphan drug is a drug that:
a. Has failed to go through the approval process.
b. Is available in foreign country but not in this country.
c. Has been discovered but is not financially viable and therefore has not been adopted by any drig company.
d. Is available without prescription.
81. A placebo is a benign substance given to ease non-specific, often psychosomatic symptoms when the patient
thinks she’s receiving an actual treatment. The success of a placebo stems from the patient’s belief that she’s
receiving a treatment. When giving placebos, nurses must remember the following guidelines, except:
a. It requires a doctor’s order.
b. The patient’s request not to receive placebo can be disregarded.
c. Defer placebo when another treatment is indicated.
d. Use a placebo only after careful diagnosis.

82. A child weighing 76lbs is ordered to receive 150mg of clindamycin (Tidact) q6 hours. The pediatric drug
handbook states the recommended dose is 8-20mg/kg/day in four divided doses. The clindamycin is supplied in
100mg scored tablets. Is this a safe dose?
a. Too low
b. Too high
c. Within the safe dosage range
d. Not enough details is given to guarantee the safe dose

83. A nurse is conducting a community surveillance study for the purpose of communicable disease control. The
nurse knows that an active surveillance method of assessment is best because it:
a. Relies solely on the initiative of health care providers to report cases.
b. Results in detection of a more accurate number of cases.
c. Reflects an upward swing if a certain disease is current news.
d. Always results in clear indicators for interventions.

84. The physician orders intralipids fat emulsion, given intravenously for a client. The nurse should consult with the
physician before administering the fat emulsion solution if which of the following is noted in the client’s record?
a. The client is receiving parenteral nutrition (PN).
b. The client has an allergy to iodine.
c. The client has a blood glucose level of 120mg/dL.
d. The client has an allergy to egg yolks.

85. A nurse is reviewing the laboratory results of a client who is receiving magnesium sulfate by intravenous infusion.
The nurse notes that the magnesium level is 7mEq/L. On the basis of this laboratory result, the nurse would
expect to note which of the following in the client?
a. No specific signs or symptoms because this value is a normal level.
b. Tremors
c. Respiratory depression
d. Hyperactive reflexes

86. Nurse Carl is caring for a client with hypocalcemia would expect to note which of the following changes on the
electrocardiogram (ECG)?
a. Widened T wave
b. Prominent U wave
c. Prolonged QT interval
d. Shortened ST segment

87. A nurse is giving a bed bath to a client and discovers that an additional wash cloth and towel are needed. Which
of the following is the appropriate action to take to obtain the needed items?
a. Ask the unit secretary to get the needed items.
b. Wash hands, leave the client’s room and obtain the needed items.
c. Borrow the client’s roommate’s wash cloth and towel.
d. Ask a family member to obtain the needed items.

88. A clinic nurse has obtained a throat culture specimen from a client who is suspected of having a throat infection.
The nurse calls the laboratory to have the specimen picked up and is told that the laboratory is short-staffed and
that the laboratory assistant will pick up the specimen in 2 hours. Which of the following is the appropriate
nursing action?
a. Tell the client to return in 1 hour for a repeat throat culture.
b. Refrigerate the specimen.
c. Tell the laboratory that someone needs to pick up the specimen immediately.
d. Contact the physician who ordered the specimen.

89. A clinic nurse has provided instructions regarding home care measures to a female client diagnosed with pelvic
inflammatory disease (PID). Which of the following statements if made by the client indicates an understanding
of these measures?
a. “I need to douche once in the morning and once in the evening.”
b. “I need to wear tampons instead of sanitary pads when I have my menstrual period.”
 c. “I need to see the physician to get an intrauterine device for birth control.”
d. “I need to avoid tight-fitting clothing.”
90. A nurse is supervising a nursing assistant performing mouth care in an unconscious client. The nurse should
intervene if the nursing assistant is observed doing which of the following?
a. Turning the client’s head to one side.
b. Using a gloved finger to open the client’s mouth.
c. Placing an emesis basin under the client’s mouth.
d. Using small volumes of fluid to rinse the mouth.

91. Nurse Janine plans care for a client receiving total parenteral nutrition (TPN), understanding that which of the
following statements regarding TPN and peripheral parenteral nutrition (PPN) is true?
a. TPN is usually indicated for clients needing long-term nutritional support, whereas PPN is for short-term
support.
b. TPN is used to deliver isotonic or mildly hypertonic solutions, whereas PPN is used to deliver highly
hypertonic solutions.
c. PPN is indicated for clients needing more than 2000cal, whereas TPN is indicated for clients needing less
than 2000cal.
d. PPN is indicated for clients who are NPO, whereas TPN is indicated for clients who need to supplement oral
intake.

92. A client is receiving nutrition by means of parenteral nutrition (PN). Nurse Heidi monitors the client for
complications of the therapy and assesses the client for which of the following signs of hyperglycemia?
a. Fever, weak pulse and thirst.
b. Nausea, vomiting and oliguria.
c. Sweating, chills and abdominal pain.
d. Weakness, thirst and increased urine output.

93. Nurse Tamayo is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the
solution. Nurse Tamayo takes which of the following actions?
a. Rolls the bottle of solution gently.
b. Obtains a different bottle of solution.
c. Shakes the bottle of solution vigorously.
d. Runs the bottle of solution under warm water.

94. Nurse Ferreria is making initial rounds on the nursing unit to assess the condition of assigned clients. Nurse
Ferreria notes that a client’s intravenous (IV) site is cool, pale and swollen and the solution is not infusing. Nurse
Ferreria concludes that which of the following complications has been experienced by the client?
a. Infection
b. Phlebitis
c. Infiltration
d. Thrombosis

95. A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. Nurse Estoque
assesses the site and determines that the client has developed phlebitis. Nurse Estoque avoids which action in
the care of this client?
a. Notifies the physician.
b. Applies warm moist packs to the site.
c. Discontinues the IV catheter at that site.
d. Starts a new IV line in proximal portion of the same vein.

96. A physician tells a client that the client needs a blood transfusion and that a blood sample must be drawn first for
blood typing and crossmatching. After the physician leaves, the client asks the Nurse Barba, “What exactly is a
blood type, anyway?” Nurse Barba responds with which of the following statements?
a. “The blood type represents an antigen founds on the surface of the red blood cell.”
b. “The blood type represents an antibody found on the surface of the red blood cell.”
c. “The blood type represents an antibody that normally circulates in the blood plasma.”
d. “The blood type represents an antigen that normally circulates in the blood plasma.”
97. A client is brought to the emergency room having experienced blood loss related to an arterial laceration. Fresh
frozen plasma (FFP) is ordered and transfused to replace fluid and blood loss. Nurse Domondon understands
that the rationale for transfusing FFP in this client is to:
a. Treat the loss of platelets.
b. Promote rapid volume expansion.
c. That the transfusion must be done slowly.
d. That it will increase the hemoglobin and hematocrit levels.
98. Nurse Galen enters the nursing lounge and discovers that a chair is on fire. He activates the alarm, closes the
lounger door and obtains the fire extinguisher to extinguish the fire. Nurse Galen pulls the pin on the fire
extinguisher. The next appropriate action for the use of the fire extinguisher is to:
a. Aim at the base of the fire.
b. Squeeze the handle on the extinguisher.
c. Sweep the fire from side to side with the extinguisher.
d. Sweep the fire from top to bottom with the extinguisher.

99. When performing a surgical dressing change of a client’s abdominal dressing, Nurse Elli notes an increase in the
amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. Nurse Elli
should do which of the following in the initial care of this wound?
a. Leave the incision open to the air to dry the area.
b. Irrigate the wound and apply a sterile dry dressing.
c. Apply a sterile dressing soaked with normal saline.
d. Apply sterile dressing soaked in povidone iodine (Betadine).

100.A nurse is caring for a client with a sever burn who is scheduled for an autograft to be placed on the lower
extremity. The nurse develops a postoperative plan of care for the client and includes which of the following in
the plan?
a. Maintain the client in a prone position.
b. Elevate and immobilize the grafted extremity.
c. Maintain the surgical extremity in a flat position.
d. Keep the surgical extremity covered with a blanket.