Common Board Topics

Nursing Nursing Nursing Nursing Nursing

Practice I
 Drug computation
 Hearing-last sense
 Pancreatitis (Why NPO?-
reduce release of
pancreatic enzyme;
position-orthopneic)
 Location of pancreas –
right upper quadrant
behind the stomach,
lies transversely to the
upper quadrant
 Urine collection -24-hour
urine collection, clean
catch
 Delegation of task to
nursing assistant
 GCS
 Subjective data –
perception to pain
 Assistive devices- cane,
crutches
 Sleep
 Colostomy Care
 % of calories in D5W
 Incident report
 Floating nurse
 Catheterization
 NGT
 CTT
 Negligence
 Malpratice
Practice II Practice III Practice IV Practice V
Herbal medicines –  Most sensitive enzyme  Definitive enzyme for MI  Suicide
ulasimang bato, garlic, for MI  Papilledema  What will you remove in
yerba buena  IBS –cause, remove in  Pancreatitis the room of a
EINC diet, diet  Multiple sclerosis psychiatric patient?
-position of mother:  Pancreatitis  Indication of cold spots  Amphetamine
comfortable  Radiation therapy in cast  Alcohol intoxication
-drying first assigned to:  Definition of Cullen’s symptoms
-discard wet A. Experienced nurse sign  Superior vena cava
-myth and fallacies: B. Novice nurse  Responsibility of the syndrome
A. Use of enema  Radiation therapy- nurse in bivalving cast  Defense mechanisms
B. Shaving distance, time, shield  Appendicitis  Situational Crisis
C. NPO  ECG changes in acute  Position that cannot  Crisis intervention
D. IVT tissue necrosis in MI relieve edema
E. Fundal pressure  You gave NTG to a  Where to insert PICC
F. Amniotomy patient with angina,  Location of CVP
G. Suctioning after 5 minutes the  Position in increased ICP
H. Foot printing pain is still unrelieved  Cushing’s triad
I. Early bathing and you give another  Retinal detachment
J. Routine separation dose of NTG, after 5  Depression
K. All of the above minutes, the pain is  Anorexia Nervosa
RN HEALS still unrelieved. What  Bulimia
Pneumonia – most is your next NI? – give
common cause of the 3rd dose
morbidity
Pediatric nursing –
psychosocial theory
Health threat
Health deficit
The community
performed deworming
in all children –
foreseeable crisis
Most sensitive indicator
of health status of the
community –infant
mortality rate
Indicates the ideal
health status if the
community – zero
mortality rate
MOT of leptospirosis

Nursing Nursing Nursing Nursing Nursing

Practice I Practice II Practice III Practice IV Practice V
 Intravenous therapy Erik Erikson’s Stages of  Principles of Asepsis  AGN  Therapeutic
 Bioethical principles Development  Inguinal Hernia  Kidney transplant Communication
 Sleep Leprosy  Chron’s Disease  Emergency  Suicide
 Geriatric considerations Universal Precaution  IBD prioritization  Rape
 Tracheostomy Isolation  New cardio drugs  Triage  Depression
 CTT COPAR  Hyperparathyroidism  Burn assessment  Parkinson’s Disease
 Delegation Fetal milestones  Hypoparathyroidism  Burn management  Multiple sclerosis
 Prioritization Fetal positions  Abdominal Aortic  Addison’s Disease  Eye drops
 Condom Catheterization Aneurysm  Cushing’s Disease administration
 Superior Vena Cava  ROM
Syndrome  Osteoarthritis
 Rheumatoid arthritis
 Gouty Arthritis
 Research
 Crisis Intervention

Fundamentals of Nursing

Drugs and Intravenous Fluid Calculations

SITUATION. Intravenous therapy is commonly initiated for a. 25 gtts/min

several purposes like maintenance of fluid and electrolyte b. 30 gtts/min
balance, medication administration, hemodynamic functions c. 35 gtts/min
monitoring, blood transfusion, diagnostic testing, and others. d. 45 gtts/min
It is important for the nurse to possess knowledge of 2. 2, 000 mL IV saline is ordered over 15 hours. Using
intravenous infusion including vein assessment, risk and a drop factor of 15 gtts/mL, how may drops per
complications, trouble-shooting, and flow rates calculation. minute is needed to be infused?
a. 22 gtts/min
1. If an order was written to infuse a liter of Plain NSS b. 40 gtts/min
every 10 hours, at what rate would the IV pump be c. 33 gtts/min
set for? d. 35 gtts/min

1 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS

 3. You are a nurse in charge of Mr. Jesler Chio, a has about her prognosis. Considering the client’s
patient confined in the medical ward. Upon checking needs and to provide holistic care to the client, your
plan of care should focus on:
the chart, you have noticed that the IV solution is
a. Continuous assessment of her condition to
incorrect, what should you do immediately? keep her clean and comfortable
a. Notify the doctor. b. Providing support to the client as she
b. Slow the rate of flow to minimum. ambulates in the room
c. Stop the infusion. c. Ensuring that her physiologic needs are met
d. Make an incident report. especially nutrition
d. Assessing the client’s perception of her
4. The physician orders DS 500 mL with KCl 10
illness and thoughts about dying
mEq/liter at 30 mL/hr. The nurse in-charge is going
12. During the physician’s visit where he discussed the
to hang a 500 mL bag. KCl is supplied at 20 mEq/10 clients condition with Mrs. Garcia’s children, the
mL. How many milliliters of KCl will be added to the client overheard part of the conversation where the
IV solution? doctor said, “…she has short time left to live.” After
a. 0.5 mL the physician left, the client said to the nurse, “Why
b. 5 mL didn’t anyone tell me? I’m not ready to die.” What
would be your MOST appropriate response?
c. 1.5 mL
a. “This time must be very difficult for
d. 2.5 mL
you.”
5. A 10-year old child is to receive 400 mL of IV fluid in b. “If it is any consolation, everyone has to die
an 8 hour shift. The IV drip factor is 60. The IV rate sooner or later.”
that will deliver this amount is: c. “Death and birth are normal parts of the
a. 50 mL/hr cycle of life.”
d. “You will be fine, you are in good hands.”
b. 55 mL/hr
13. Mrs. Garcia’s condition worsens. She has begun to
c. 24 mL/hr
experience severe pain and manifest signs of
d. 66 mL/hr impending death. The children ask you if their
6. A client is ordered to receive 20 mEq of Potassiun mother is going to die soon. Which of the following is
Chloride. The bottle is labeled KCl elixir 10mEq/L. your MOST APPROPRIATE response?
How many mL should be given? a. “The signs do not predict the exact time of
a. 1.5 mL death.”
b. “Death is inevitable, it will come anytime
b. 2 mL
now.”
c. 0.5 mL c. “You are saddened that your mother is
d. 1 mL dying…”
7. A client is ordered to receive Digoxin 0.325 mg OD. d. “Are you worried that your mother will die?”
The stock is 0.25 mg per tablet. How many tablets 14. The client died with her family around her. The
should be given to the client? children are crying hysterically and hanging on to
their mother. What nursing action is BEST for you to
a. 2 tablets
take?
b. 3 tablets
a. Ask physician to prescribe tranquilizer for
c. 1.5 tablets the family members.
d. 3/4 tablet b. Allow the family some privacy and time
8. Dilantin 5 mg/kg body weight is ordered to a client to be with the client before doing
who weighs 50 lbs. The drug is to be administered in aftercare.
c. Allow the family to view the body then
3 equal doses. The label reads Dialntin suspension
transport the body to the hospital morgue
125 mg/mL. How much medication should be immediately.
administered to the client? d. Reassure the family that the body of their
a. 1.8 mL loved one will be cared for.
b. 1.5 mL 15. Having witnessed death of Mrs. Garcia, you become
c. 1.0 mL aware of the tears that are welling in your eyes. It is
d. 0.5 mL most appropriate to remember that when caring for
a dying client:
9. A male client had exploratory laparotomy and has an
a. The nurses’ emotional response sets an
order of meperidine hydrochloride 50 mg IM every example as to how the family should grieve.
four hours PRN. The multiple dose vial is labeled 50 b. The nurses’ own feelings and thoughts
mg/mL. What is the correct dose to be administered about death influences her ability to
to this client when he complains of pain? care for the client and the family.
a. 0.5 mL c. Any show of emotions by the nurse is
considered non-therapeutic.
b. 2.0 mL
d. The nurse should send the family out when
c. 1.0 mL bathing the body and placing identification
d. 1.5 mL tags.
10. The physician prescribed 1 liter of Dextrose 5 % in
Water to be administered at 50 mL per hour. SITUATION. Primary prevention involves health promotion
Considering the physician’s order, the intravenous as protection against disease. Activities of this type generally
apply to the health individuals before any disease or
infusion should last:
dysfunction occurs.
a. 22 hours
b. 16 hours 16. Nurses play big role in the primary level of
c. 18 hours prevention. Examples of nurse activities showing
d. 20 hours primary prevention are the following, EXCEPT:
a. Referrals to client support groups like
SITUATION. Taking care of dying clients is challenging. Mrs. those for cancer patients
Garcia, a 65 year old client, is terminally ill with stage 4 b. Teaching parents of toddlers about
cancer of the breast, right with metastasis to the cervical prevention of poisoning and accidents at
spine and lungs. She is ambulant but weak, able to perform home
her activities of daily living and has no complaints of pain. c. Family planning classes to newly weds
d. Giving immunizations to children
11. You are assigned to take care of Mrs. Garcia. She 17. Secondary prevention includes health maintenance
does not ask questions regarding her condition and activities which involves the following, EXCEPT:
her relatives do not know how much knowledge she

2 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS

 a. Nursing care to maintain skin integrity of
diabetic client
b. Giving medications and treatments to
discharge clients
c. Proper positioning of clients with
disability in the home setting
d. Smoking cessation program
18. When teaching your clients about nutrition, you
include the following food as rich sources of good
cholesterol, EXCEPT:
a. Fish c. Soya
b. Beef d. Olive oil
19. A community based hospital offers acute care in
addition to adult outpatient services, exercises and
yoga classes for young and old. This hospital
provides which type of services?
a. Tertiary and illness prevention
b. Primary and tertiary
c. Secondary and tertiary
d. Primary and secondary
20. Mr. Peralta, 48 years old, is attending a smoking
cessation program to be held at the nearby high
school conducted by the school nurse. This program
is classified as:
a. Diagnosis and treatment
b. Health restoration
c. Rehabilitation
d. Health promotion
SITUATION. Client’s record is a structured device where all
tasks concerning the diagnostic and treatment process done
on the client are documented. An account of what has
occurred between the client or the health care team has to be
recorded once interaction has been undertaken.
21. An entry in the nurses notes for a client with urinary
tract infection states: “Encouraged fluid intake to
2,500 ml per day.” Which description of the nurse’s
statements applies?
a. It describes the amount of fluid
intake desired.
b. It establishes accuracy using an exact
measurement.
c. It is incorrect as it lacks accuracy of
measurement.
d. It does not specify fluid allowed.
22. The nurse is recording the treatments administered
to her clients. The following information should be
included in her charting, EXCEPT:
a. Health teaching.
b. Client’s response compared to previous
treatment,
c. Time administered.
d. Equipment used.
23. A male nurse is giving a change of shift report for all
clients in the medical unit at the nurses’ station.
During this reporting the nurse is expected to:
a. Review the condition of the client by reading
the documented information.
b. Report the condition of the client and
compare with what the incoming staff need
to know.
c. Provide significant information about
the client as baseline for the next shift.
d. Read the data about the client objectively.
24. The nurse is preparing Mr. Jovan Manantan for
transfer from the Intensive Care Unit to his private
room. To promote continuity of care what
information should be included in the transfer
report?
1. Clients name, age, physical and
medical diagnosis and allergies.
2. Correct health status of the client at the
time of transfer.
3. Any critical observation and
intervention to help the receiving
nurse.
4. Need for special equipment
a. 1 and 2 c. 1, 2, 3 and 4
b. 3 and 4 d. 1, 2 and 4
25. Mr. Christian Peralta, a 55 year old executive,
requests the nurse if he can read his medical records
3 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
upon discharge. What is the MOST appropriate action
of the nurse?
a. Allow the client to read his chart because of
his client’s right.
b. Tell the client that he is not allowed to read
his chart.
c. Ask the client to write a written
request.
d. Refer the request of the client to the
physician.
SITUATION. A number of clients in your unit are at risk of
developing pressure sores. As a precaution, the supervisor
emphasizes the nurse’s responsibility in ensuring proper care
of clients with problem of immobility.
26. While changing linen of Aling Kassandra, a comatose
patient, the nursing aide reports that she noticed a
reddened area in the left buttock of the client. Upon
inspection, you noted that the area blanches and is
the size of a peso coin. Your MOST appropriate
immediate nursing approach would be to:
a. Measure the size of the reddened area for
proper documentation.
b. Instruct the nursing aide to finish bed
making using dry fresh linen.
c. Endorse a schedule for turning and
positioning the client round the clock.
d. Position the client on her right side.
27. To decrease the occurrence of pressure sores on
Aling Kassandra, the nursing team’s goal is to reduce
pressure points. The MOST appropriate nursing
intervention would be:
a. Elevate the head part of the bed as
little as possible.
b. Massage over the bony prominences.
c. Use a “donut” cushion while the client is
seated.
d. Place the client on a side lying position.
28. While assessing the clients assigned to your care,
you observe that the client with the greatest risk for
developing a “bedsore” or pressure sore would be:
a. 4 year old girl in Buck’s traction.
b. 40 year old unconscious client.
c. 82 year old client who has had mild stroke.
d. 70 year old client with type 2 diabetes.
29. While assessing the pressure sore of a 75 year old
client, the nurse documents that healing is taking
place when she observes the presence of:
a. Eschar
b. Exudates
c. Granulation tissue
d. Ragged edges around the wound
30. In a nurse’s meeting in the ward, the senior nurse
discusses prevention of pressure sores. She
identifies practices that are most likely to
cause shearing injury to the skin and should
therefore be avoided. Of the following practices,
which one causes the LEAST harm to the client?
a. Failure to use a draw/lift sheet when
moving client to the head of the bed
b. Failure to lower the head part of the bed
before moving the client upward
c. Positioning an immobilized client without
help from staff
d. Dragging the heels of the client in bed
as he is being positioned
SITUATION. Mr. Tan, 54 years old, is admitted to the
medical unit for executive check-up. His admitting notes
reveal: temperature: 36.8 degrees C; pulse rate: 86/min;
respiratory rate: 18/min; BP: 160/90 mmHg.
31. When admitting Mr. Tan, your most important
INITIAL nursing action would be to:
a. Take him around the ward to show him the
unit set up
b. Introduce Mr. Tan to the other staff in the
unit
c. Obtain Mr. Tan’s nursing history
d. Identify needs of Mr. Tan that may
require immediate management
 32. The charts admission notes state that Mr. Tan has
bi-pedal edema. During assessment, you VERIFY this
as:
a. Doing palpation
b. Interviewing the client
c. Doing inspection
d. Checking the results of laboratory tests
33. Mr. Tan asks you what he should do to help reduce
swelling of his feet and ankles. Your most
appropriate response would be the following,
EXCEPT:
a. Elevate his feet while seated or while lying
in bed
b. Reduce intake of salty food
c. Requests the doctor for diuretics
d. Inform him that edema is caused by
problem with his kidney
34. Mr. Tan had blood extraction for hematology, blood
chemistry, lipid profile, FBS. The laboratory results
are in. Of the following, which is NOT within normal?
a. Cholesterol: 4.28 mmol/L
b. HBA1C: 5.7%
c. FBS: 6.5 mmol/L
d. Hematocrit: 39.7/L
35. You are planning Mr. Tan’s discharge from your unit.
Your nursing responsibilities include all, EXCEPT:
a. Making a final assessment of the client
b. Replying to queries regarding his
hospital bill
c. Giving instructions regarding his home
medications
d. Arranging for his transportation home
SITUATION. Nurses in the medical unit are finding ways to
improve collaborative relationship with the physicians. Efforts
to identify factors that foster or impede nurse-physician
collaboration are thoroughly examined. A review of the
antecedent environmental factors was undertaken.
36. A variety of factors collected have been linked to the
quality of nurse-physician collaboration. Given this
information, which of the following measures is
appropriate to foster nurse-physician collaboration?
a. Present collected data to the physicians are
those involved in health care
b. Nurse and physician should be willing to
consider each other’s position
c. Consider both environmental and
professional factors
d. Arrange a meeting to discuss issues and
concerns with the physician and other
members of the health team
37. Information gathered by nurses show the importance
of nurse-physician communication. With the current
recognition that many medical errors are caused by
communication failure, which of the following is the
MOST appropriate intervention?
a. Conduct in-service education for nurses to
improve competencies to address the issues
b. Organize a conference on medication error
participated by nurses, physicians and
others
c. Involve a form of communication
where 2 parties engage in problem
solving discussion
d. Develop a policy where all members of the
health team can use it as a reference
38. There are other problems that were identified during
the gathering of data but at the moment do not have
ready solutions. In this situation, which of the
following is the MOST appropriate action to be
undertaken?
a. Nurse and physician should identify types of
problems amendable to collaboration
b. Give priority to these problems because
they are good candidates for collaboration
c. Immediate action must be done to assist
the clients in their health problems
d. Prioritize problems needing immediate
attention and solution
39. Given the above situation, which of the following
actions should be done by both parties?
a. Continuous conference to keep track of the
concerns of the clients
4 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
b. Conduct weekly conference for continuity of
medical management
c. Encourage open communication for
effective collaboration
d. Design condition to support desired levels of
collaboration more effectively
40. Of the following nursing service staff, who are MOST
likely to engage in problem solving communication
with the physician to ensure the quality of
communication and outcomes?
a. Nurses who are on the managerial level
to ensure effective problem solving
with the physician
b. A team of experienced nurses with less
experienced staff nurses
c. Any staff available for the conference with
collaboration
d. Nurses assigned to the clients with
identified problems
SITUATION. Mr. Bandong, 52 years old, known diabetic
(TYPE 2) is admitted with symptoms of high blood pressure
190/100 mmHg, an unhealed wound on his right big toe and
has bi-pedal edema. He is on insulin. Co-management by the
health team Is recommended in the care of Mr. Bandong.
41. Based on the presenting condition of the client upon
admission, the nurse would immediately refer Mr.
Bandong to a/an:
a. Endocrinologist for management of
diabetes mellitus
b. Dietitian for nutritional management
c. Cardiologist to stabilize blood pressure
d. Diabetes nurse educator for self
management of symptoms
42. The head nurse calls for a meeting of the staff
nurses to plan care management for Mr. Bandong.
The priority nursing action in the care of the client
would be:
a. Blood glucose monitoring
b. Monitoring of blood pressure
c. Accurate measurement of fluid intake and
output
d. Accurate insulin administration
43. Upon assessment of the client’s lower extremities,
the nurses notes the unhealed condition of the
client’s infected toe wound. The nurse would:
a. Prepare equipment to wash and disinfect
the affected toe
b. Refer to attending physician for proper
wound management
c. Call the head nurse for assistance as the
nurse starts wound debridement
d. Call relative to gather information about
cause of wound infection
44. The nurse learns that the client does not regularly do
blood glucose monitoring and still has not learned
how to do self-administration of insulin. To learn
these, you will refer the client to:
a. Pharmacist
b. Advance practice nurse
c. Diabetes nurse educator
d. Medical intern
45. Mr. Bandong’s condition improves and discharge
planning is initiated. This includes planning his
nutritional regimen to encourage compliance. The
client will MOST likely be referred to:
a. Nutritionist
b. Endocrinologist
c. Dietitian
d. Cardiologist
SITUATION. A nurse is assigned to several clients and her
functions include giving intravenous (IV) medications and
fluids. During the end of shift endorsement, she receives
incoming doctor’s orders to run some IV fluids for clients
assigned to her.
46. Mr. Jocson, 49 years old, has a doctor’s order to
receive 1 liter of normal Saline solution to run for 24
hours. The nurse would set the intravenous fluid to
infuse at how many milliliters (ml) per hour and how
many drops per minute if the drop rate of the IV
tubing is 15 drops/ml?
 a. 42 ml/hr, 10 drops/minute
b. 48 ml/hr, 15 drops/minute
c. 50 ml/hr, 18 drops/minute
d. 36 ml/hr, 7 drops/minute
47. Brand, 8 years old, has an order for D5 Lactated
Ringers 250 ml to infuse for 4 hours, starting at 8
am, using IV tubing set with a drop factor of 60
microdrops (gtts)/ml. What should be the rate of
flow if the IV is to be consumed at 12 noon?
a. 48 gtts/min c. 43 gtts/min
b. 63 gtts/min d. 58 gtts/min
48. While reading the doctor’s orders for the other
clients, you will seek clarification from the doctor for
which of the following orders?
a. Infuse 0.9% normal saline to keep vein
open (KVO)
b. Incorporate 20 mEq potassium chloride in 1
liter of D5 Water at 50 ml/hr
c. Flush peripherally inserted central catheter
(PICC) with 10 ml normal saline every 6
hours
d. Infuse 500 ml of normal saline for 2 hours
49. Mr. Manangan is newly admitted to the ward and
before administering IV medications, you read in his
chart that he has a peripherally inserted central
catheter (PICC) that is now 4 weeks old. Upon
examination, you observed that the site is clean and
free from manifestations of infiltration, irritation and
infection. Your MOST appropriate action would be to:
a. Document observation in the nurses
notes to inform the physician and other
nurses
b. Discontinue the PICC line since it is 4 weeks
old
c. Administer the medication as ordered
d. Give medications through oral or
intramuscular route
50. While assessing Mr. Salinga’s IV site, you noticed
swelling and tenderness above the site. Your MOST
appropriate nursing action would be:
a. Apply cold compress to the IV site
b. Stop infusing IV fluids
c. Flush the catheter with normal saline
solution
d. Elevate extremity to facilitate drainage by
gravity
SITUATION. While in the ward, you are assigned to clients
with problems related to the gastrointestinal tract.
51. The nurse is preparing Mr. Ashi for cleansing enema.
When administering enema, the maximum height at
which the enema can should be held from the level
of the bed is:
a. 14 inches c. 16 inches
b. 10 inches d. 12 inches
52. While administering the enema, Mr. Ashi complains
of abdominal cramps. Which of the following would
be the MOST appropriate action of the nurse?
a. Clamp the tubing a few minutes till the
cramps subside, then continue
b. Pull the rectal tube slowly till the cramps
subside
c. Stop the procedure and refer to the
attending physician
d. Lower the enema can to slow down the
inflow of the enema solution
53. Following the surgery, Mrs. Castillo developed
abdominal distension. The physician ordered a rectal
tube insertion to relieve distention. To achieve
maximum effectiveness, how long should the rectal
tube be left in place?
a. 5 minutes
b. 15 minutes
c. 30 minutes
d. 60 minutes
54. After ensuring that the nasogastric tube (NGT) is in
place, the nurse prepares to feed Mrs. Castillo using
the open system. With a 30 ml syringe, the nurse
proceeds with the feeding following this sequence:
1. Hold the NGT high to prevent backflow
and then clamp
5 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
2. Open clamp and raise or lower the
syringe to regulate flow of formula
3. Remove the plunger of the syringe and
attach to NGT
4. Fill up the syringe with feeding formula
5. Add 30 to 60 ml of water to irrigate
syringe allowing it to run down the NGT
a. 2, 3, 4, 1, 5
b. 1, 3, 2, 5, 4
c. 3, 4, 2, 5, 1
d. 4, 3, 1, 2, 5
55. The nurse is to perform gastric gavage. What should
the best position of the client while the gastric tube
is being insterted?
a. Supine position
b. High fowler’s position
c. Trendelenburg position
d. Low fowler
SITUATION. Proper nutrition and elimination are important
to health and the nurse has an important role to play in
assisting people from various age groups obtain proper
information
56. Audie, 36 years old, is diagnosed with peptic ulcer
and asks you what food is best to add to his diet so
as not to exacerbate his symptoms. Your BEST
response would be for him to take:
a. Leafy green vegetable dishes
b. Citrus fruit juices or shakes
c. Mocha, café latte and other similar drinks
d. Milk regularly 3-4 times daily
57. You are assigned to Mrs. Femmie, a client with an
order for cleansing enema. While doing the
procedure, the client groans and complains of
abdominal cramping. Your MOST appropriate initial
nursing action would be:
a. Reduce the flow of the fluid by
clamping the enema tubing
b. Instruct the client to relax, inhale and
exhale slowly
c. Lower the height of the enema container
d. Push the rectal tube further in by 2 inches
58. An elderly client you are taking care of has fecal
incontinence for 3 days now. He is able to tolerate
food but has no control of his bowel movement. He
has soft watery stools and uses adult diapers. While
caring for this client, you will watch out closely for
risk of:
a. Increased abdominal cramping
b. Perineal and anal skin breakdown
c. Malnutrition and weight loss
d. Falls when he tries to go to the bathroom
59. Jarred, 5 years old, is brought to the hospital for
severe diarrhea. You are aware that a major problem
that may develop that will adversely affect Jarred
would be:
a. Severe abdominal cramping
b. Excessive passing of flatus
c. Severe fluid electrolyte imbalance
d. Irritation of the anal sphincter
60. Miss Sharry, a client who had abdominal surgery
under general anesthesia, is still in the recovery
room. You are aware that clients who went through
general anesthesia will most likely experience:
a. Absence of peristalsis
b. Tolerance for soft diet immediately after
operation
c. Immediate return of gastrointestinal motility
d. Excessive gas formation noted upon
auscultation
SITUATION. Nurse Krrychia is conducting a clinical
assessment of Naneng, 40 year old female client, admitted
for chronic renal disease.
61. Nurse Krrychia utilizes the most reliable indicators of
Naneng’s fluid balance status which include the
following, EXCEPT:
a. Her daily weight record
b. The measurement of intake and output
c. Complete blood count
d. Results of urinalysis
 62. While assessing Naneng’s skin, nurse Krrychia noted
that the skin flattens more slowly after the pinch is
released. This is an indication that the client is
manifesting sign of:
a. 2+ pitting edema c. FVD
b. Shift of body fluids d. FVE
63. Nurse Krrychia continues with the assessment of the
neck and instructed the client to lie flat on bed. With
the presenting complaints, the nurse expects to note
which of the following?
a. Neck warm to touch
b. Collapse of neck veins
c. Jugular venous distention
d. Difficulty in moving the neck
64. During the planning phase, nurse Krrychia prioritizes
nursing interventions to support client’s achievement
of expected outcome. In this case, the goal of care
for the client should be:
a. Proper fluid balance of intake and
output is attained
b. IV site should be free from infection
c. Prevent depletion of fluids
d. Relief from vomiting and diarrhea
65. The following nursing interventions to prevent or
correct fluid, electrolyte, and acid base imbalances
include the following, EXCEPT:
a. Fluid and blood products
b. Allaying of anxiety
c. Modification of fluid intake
d. Appropriate patient and family teaching
SITUATION. Vanj, a staff nurse in the surgical ward, has
been assigned to take care of Mrs. Reyginia, a 58 year old
client who has an endotracheal tube.
66. Nurse Vanj’s objective is to improve client’s
respiration after she noted thickened, tenacious
secretions. To loosen the secretions, the MOST
appropriate nursing intervention is to:
a. Instill mucomyst into the endotracheal tube
and frequently turn clients unless
contraindicated
b. Administer humidified oxygen and place in
side lying or prone position unless
contraindicated
c. Increase fluid intake and ask client to
deep breathing and coughing exercise
d. Assess client’s respiratory status and
perform clapping to loosen secretions
67. Nurse Vanj performs endotracheal suctioning. The
nurse appropriately does the suctioning procedure
when she performs which of the following:
a. Rotates the catheter gently and
suctions for not more than 10 seconds
each time.
b. Observes and records the amount and
character of the secretions after each
suctioning
c. Assesses the respiratory and circulatory
status after a cluster of 5-8 times suctioning
d. Observes how long the client tolerates the
catheter during the suctioning process
68. In the care of this client, the nurse monitors the cuff
pressure and takes care to reduce the risk of
tracheal tissue necrosis by maintaining the cuff
pressure to:
a. 30-55 mmHg c. 40-45 mmHg
b. 10-15 mmHg d. 20-25 mmHg
69. When taking care of Mrs. Reyginia, nurse Vanj
performs oral and nasal care every 2 to 4 hours to
promote hygiene and comfort. As a precautionary
measure for possible biting down of the oral
endotracheal tube, the nurse should:
a. Request an assistant to hold the patient
down
b. Use an oropharyngeal airway
c. Provide humidified air prior to the procedure
d. Place the client on side lying position
70. The head nurse reminds Nurse Vanj about measures
that must be strictly observed when suctioning the
client through the endotracheal tube. This measure
is:
6 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
a. Turning on the suctioning apparatus during
catheter insertion
b. Suction by rotating 2 to 3 times before
withdrawing the catheter
c. Always use rubber gloves when suctioning
to prevent infection
d. Hyperoxygenating the client before and
after the procedure
SITUATION. It is rainy season and the pediatric clinic where
you are assigned is filled with children and mothers waiting
for attention and treatment
71. Many children in the clinic have upper Respiratory
Tract Infection (URTI). Kersee has two children with
her at the clinic. To prevent spread of URTI, the
BEST instruction to give mothers like Kersee will be
to:
a. Teach child to use sleeves to wipe off nasal
charges
b. Instruct mother and child to wear protective
masks at all times
c. Wipe off child’s nasal discharge so that no
mucous crust forms on the nostrils
d. Wash hands thoroughly with soap and
water after handling mucous
discharges
72. The nurse teaches Kersee and the other parents that
URTI spreads through droplets after coughing and
sneezing. Your health instructions are effective when
the parents do the following EXCEPT:
a. Deposit sputum in tissue and discard used
tissue in a trash can
b. Cover mouth and nose when coughing or
sneezing
c. Wash and dry hands by using a towel
provided in the lavatory
d. Wash hands thoroughly after contact with
mucous secretions
73. Following the nurse’s instructions on how to prevent
spread of infection, Kersee teaches her children how
to prevent infecting their playmates when they have
URTI. Which of the following actions would be
considered INEFFECTIVE in preventing spread of
infection?
a. Washing hands after blowing nasal
discharges
b. Covering mouth and nose when sneezing or
coughing with their skirt or shirt
c. Covering nose and mouth with hands
when sneezing then continue playing
d. Pinning a handkerchief or face towel to wipe
off mucus secretions or cover nose
74. You demonstrate proper hand washing technique to
the parents in the clinic as a step to prevent spread
of infection. The parents perform the practical
procedure correctly when they:
a. Rub hands together, in between
fingers, using soap and rinse with
running water
b. Rub hands together for friction under
running water
c. Wash fingers with soap and rinse with water
in a basin
d. Wash hands with antimicrobial soap, apply
rubbing alcohol, dry hands by allowing
alcohol to evaporate
75. At home, Kersee observes principle of infection
control when she:
a. Avoids shaking linen, clothes and
towels used by a sick child
b. Keeps kitchen utensils and plates in
cupboards where leftover food are stored
c. Places handbags and baskets on food
preparation areas
d. Avoids shaking and stores used clothes and
linen in the clothes cabinet
SITUATION. Nurse Jazel is coping with transition from
student nurse to a professional nurse. Along with an
accumulation of knowledge, skills and competencies she is
leaving enough space for her unique personality to develop.
Using Benner’s Stages from Novice to Expert, the following
questions apply:
 2. Visual assessment of aspirate
76. Which of the following stages begins in nursing 3. Auscultation method after air injection
school? 4. pH measurement of the aspirate
a. Expert c. Proficient a. 2,3 and 4 b. All except 2
b. Novice d. Advanced beginner c. 1, 2 and 3 d. 1, 2 and 4
77. As a new graduate nurse, Jazel begins nursing 82. It is important to maintain patency of the
practice as a/an: nasogastric tube. The tube is irrigated every 4 to 6
a. Novice c. competent hours. Which solution would you use?
b. Proficient d. Advanced beginner a. Tap water b. Bottled water
78. Nurse Jazel’s performance as a new graduate is c. Normal saline d. Lactated Ringer’s
characterized as: 83. When giving tube feedings and medications, whivh
a. Having feeling of mastery position of the client will reduce risk of reflux and
pulmonary aspiration.
b. Processing intuitive grasps a. Supine position with one pillow supporting the
head
c. Formulating principles b. Semi-Fowler’s position with the head
d. Exhibiting rule-governed behavior elevated from 30 to 45 degrees.
79. Nurse Jazel successfully passed the Nurse Licensure c. Supine position with the head turned to one side
Examination. She is now employed as staff nurse in d. Dorsal recumbent
a General Hospital. How long will it take 84. When giving simple compressed tablet medication by
approximately for nurse Jazel to achieve the NGT, it should e crushed and dissolved in the water.
competent level? How would the nurse APPROPRIATELY administer
a. 12 months enteric-coated tablet?
b. 18 months a. Let the client swallow the tablet as is
c. 6 months b. Pulvurize the tablet finely to change the tablet
d. 30 months form
80. In order to attain the expert level, nurse Jazel’s c. Request the pharmacist to change the
experience should be: tablet form
a. Innovative d. Crush and dissolve in distilled water
b. State-of-the art 85. Diarrhea is one of the most common complications of
c. Extensive tube feeding. Which of the following nursing actions
d. Varied will prevent this complication?
SITUATION. You are caring for the client who is with a. Administer feeding by continuous drip
nasogastric tube (NGT) for feeding. rather than bolus
b. Give high fiber formula
81. When assessing for the NGT placement, which three c. Dilute formula to half the concentration strength
methods are often recommended? d. Instill liberal amounts of water to flush the
1. Measurement of exposed tube length tubing before and after feeding
c. Leave the anaesthesiologist to follow the
Professional Adjustment and Nursing Jurisprudence order
90. The surgeon is such in a hurry to “close” because of
SITUATION. Nurse Sandara is preparing GD, a 28- year old the deteriorating condition of the client. The
newlywed for surgery for a repair of multiple trauma from a perioperative nurses cannot account for an operating
car accident. GD is in severe pain and comforted by his wife sponge. Which is the most appropriate action of the
and significant others. scrub nurse at this point?
a. hands the suture for closing and tell the surgeon
86. There exists a hierarchy who should sign the consent that one OS cannot be accounted for.
to be legally valid if the client is not competent. Rank
b. The scrub nurse asks the circulating nurse to
the following next-of-kin who shall sign the consent
recheck the sponges one more time.
for GD’s surgery.
1. Grandparents from paternal or maternal side c. The scrub informs the surgeon that one OS
2. Adult competent children cannot be accounted for.
3. Brother or sister d. Obligingly, the scrub nurse hands the suture to
4. Legitimate spouse close and continue to locate the missing OS
5. Guardian whether appointed by court or not
SITUATION. Appropriate and ethical nursing practice should
a. 4,5,3,2 and 1 b. 4,3,1,2 and 5 always respect the patient’s right in any health care setting.
c. 4,2,1,3, and 5 d. 5,3,4,2 and 1 The following questions apply.
87.Legally, nurse Sandara shall assume which role
during the signing of the consent? 91. With the advancement of information technology, the
a. advocate nurse understands that breach of confidentiality can
b. Witness happen LEAST in which of the following scenario?
c. Interpreter a. Keeping the X-ray plate hanging in the
d. Counselor negatoscope
b. Clients laboratory results are transmitted to the
patient care unit through a “HOSPITAL
88. GD underwent exploratory laparotomy for multiple
COMPUTERIZED SYSTEM.”
organ injuries in his abdomen. Which Doctrine is
c. Allowing “telephone orders” as means to
applied when the surgeon is held liable when there is
transmit doctors’ order
an incorrect surgical count?
d. Patient’s hospital account viewed in the
a. Res ipsa loquitor
computers placed in the hospital corridors.
b. Captain of the ship
c. Doctrine of Vicarous liability 92. When restoration of health is no longer the goal of
d. Doctrine of independent contractor care and end-of-life care is the goal, artificial
nutrition and hydration can be prepared and
89. During the surgery, the client was profusely bleeding
continued to be administered. The nurse can
that prompted the surgeon to verbally order
administer artificial nutrition through the following
“Transfuse all available blood.” Which if the following
avenues EXCEPT:
options would the nurse talk so that she will not be
a. IV infusion
held liable if the blood complications occur?
b. Nasogastric tube
a. Document as ordered and have the
c. Ileostomy tube
surgeon sign as soon as feasible
d. gastrostomy tube
b. Transfuse the blood with the
anaesthesiologist 93. Nurse Sofia is in charge of an elderly client with
chronic severe COPD with cimplications. She recalls

7 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS

 that the 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 an d needs of the
family
b. Health care workers are not offering hospice
care because they don’t like clients to think that
they are giving up on them.
c. Hospice care is a part of the normal life and
provides support for the dignified
individuals
d. Hospice care concept leads client to think that
they are hopeless cases.
94. 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
95. Health care providers need always to point out 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. Comfort measures are withheld
c. Food and food supplements are sustained
d. “ no heroic measures” done
SITUATION. Nurses have a responsibility to understand the
current legal and ethical guidelines that govern the practice of
the nursing profession.
96. A new registered nurse is being interviewed for a
staff position in a private hospital. Which of the
following statements indicates her understanding of
the practice of nursing in the Philippines as provided
for in the nursing law?
a. “Only professional licensed nurses can
practice nursing in the Philippines.”
b. “A registered nurse can practice
professional nursing in the hospital and
community settings.”
c. “A nurse is certified to practice nursing in
the Philippines.”
d. “A registered nurse license provides basis
for professional nursing practice”
97. A nurse assigned in the surgical unit visited the
mother of her friend confined in the medical unit.
She was observed by the staff nurse in the unit
reading the chart of the client. In this situation, the
action of the nurse is described as:
a. Acceptable because she is known to the
client
b. Unethical because of possible breach of
confidentiality
c. Appropriate because she is part of the
nursing staff of the hospital
d. Inappropriate because she is not assigned
in the unit
98. The nurse is concerned about the medical care of her
client who has been confined in the hospital for 2
weeks. She has a physician friend not connected
with the agency whose opinion she asked regarding
the treatment of care. In this case, the nurse acted:
a. In accordance with hospital policies and
regulations
b. In violation of the principle of
confidentiality
c. Following the appropriate chain of command
d. Based on what is good for the client
99. A nursing student asks permission from the head
nurse to photocopy the record of the client she is
presently taking care of. She is to present a case
study and needed information to substantiate her
data. Which of the following should be appropriate
action of the head nurse?
a. Tell the nursing student to ask permission
from the attending physician
8 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
b. Allow her to photocopy the pages related to
the information needed
c. Allow her to write down pertinent but
no identifying information
d. Do not allow photocopying due to
confidentiality
100. A nurse researcher is conducting a research study on
the concerns of the elderly regarding hospitalization.
An elderly client was offered to participate in the
study. She signed the consent but later decided to
withdraw from the project. In this situation, the
elderly client:
a. May withdraw as long as the family requests
withdrawal
b. May withdraw at any time of the study
c. Cannot withdraw since the consent is a legal
document and has been signed
d. Cannot withdraw since the study has
started
SITUATION. To carry out management functions in any
health care setting it is necessary for the nurse to integrate
leadership skills that he/she developed.
101. To improve quality client care, the nurse created
“problem solving committees” headed by senior
nursing staff to review standards of care and develop
policies and procedures. Its desired result is best
seen in:
a. Continuous evaluation of nursing
practice/protocols in relation to
desired patient outcomes
b. Allowing changes in staff rotation plan to
accommodate personal needs of the staff
c. Increasing staff communication like
providing a bulletin board for sharing
information among personnel
d. More nurses participating in doctor’s rounds
and giving immediate information to doctors
regarding patient status
102. The nursing department’s organizational chart
illustrates structure and relationships of the nursing
leaders and staff of the organization. The following
are the functions of an organizational chart EXCEPT:
a. List functions and duties of the staff
b. Illustrates centrality of control in the
organization and chain of command
c. Indicates relationship of leaders to other
management staff
d. Identifies managerial levels
103. A hospital is constructing a new wing and the
Director of Nursing is asked to help design it. To
achieve maximum efficiency in caring out nursing
activities, the Director of Nursing would consider
which of the following conditions to be MOST helpful?
a. Environmental factors such as current
economic, legal, technological and social
influences that the organization must
consider
b. How the structural plan facilitates staff
interaction and the rituals the nurse
use to conduct work
c. Work flow where equipment, medication
and other items essential for patient care
are stored and positioned
d. Type of equipment and technology and its
effects on how work tasks are designed and
carried out
104. Time management is important to provide quality
and prioritize work. The nurse finds the following
practices helpful in managing time for patient care
EXCEPT:
a. Keeping telephone communication short
b. Blocking out time to accomplish important
activities
c. Doing time and motion study to determine
time utilization
d. Dealing with interruption openly and
directly
105. The Director of Nursing wants to improve the quality
of health care in the hospital. The following activities
are examples of quality assurance measurements
EXCEPT:
 a. Evaluating outcomes or end results of care
provided to client
b. Asking clients to accomplish client
satisfaction survey forms
c. Measuring quality of care against
established standards of nursing care
d. Checking if emergency carts or
medications are properly stock
106. Coercing a patient into taking medications by
threatening punishment could legally be considered
as:
a. assault
b. false imprisonment
c. battery
d. probable cause
107. The doctor assigned to the patient was also sued
together with the nurses. When it was his turn to
take the stand during the next hearing, he was told
to bring with him a copy of the patient’s chart. The
hearing officer will have to issue what legal order to
bring the patient’s chart?
a. Injunction
b. subpoena ad testificandum
c. subpoena duces tecum
d. injunction
108. Mr. John Jeriko De Leon has declining condition after
being revived yesterday after suffering from arrest.
Dr. Rean Fesico wrote a DNR order. This order
implies that:
a. The patient need not be given food and water.
b. The nurses and the attending physician
should not do any heroic or extraordinary
measures for the patient.
c. The patient need not be given ordinary care so
that his dying process is hastened.
d. The nurse need not give due care to Joshua
even giving bed bath.
109. The nurse must observe the principle of privileged
communication. Confidentiality of information can be
revealed only in which case?
a. When the attending physician allows
b. When the patient consents
c. In any court case involving the client
d. Civil case
110. During the investigation, it was decided to call the
watcher to testify on what she knows about the case.
The watcher can be compelled to be present in the
next hearing if the investigation body issues which of
the following?
a. subpoena duces tecum
b. subpoena ad testificandum
c. warrant
d. injunction
111. Nurse Supervisor Beah oriented Nurse Madel, the
new staff nurse of Makati Medical Center-Critical
Care Unit concerning the hospital’s medication
administration protocol. Supervisor Beah evaluated
Nurse Madel’s comprehension of the instructions by
asking which among these practices below is NOT
SAFE regarding medication administration. Nurse
Madel selects:
a. The nurse educates the client about the purpose
of the medications, its common possible side
effects, and important considerations.
b. The nurse administers the medications that
the unit head nurse prepared.
c. The nurse records in the patient’s chart known
allergies of the patient and notified the
attending physician.
d. The nurse who is uncertain with her calculations
asked another nurse to double-check it.
112. A patient is admitted to the emergency from a
vehicular accident. Because of the possibility of
developing shock, Nurse Romeo explained to the
patient the need for starting IV infusion. However,
the patient did not consent to the procedure. Despite
the patient’s refusal, Nurse Romeo continued
inserting the catheter. He can be sued for:
a. Assault
b. Negligence
9 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
c. Malpractice
d. Battery
113. Which of the following actions violates responsible
protection of the client’s confidentiality?
a. Posting of the client’s name on the room
door.
b. Lowering voice levels when giving a report
during doctor’s rounds.
c. Providing a password for each client’s electronic
chart, if appropriate.
d. Putting printed copies of patient chart in a
nonpublic location.
114. Few weeks after an exploratory laparotomy
procedure, the patient showed systemic signs of
infection including generalized fever and redness and
pain in the surgical site. The attending physician
ordered for an X-ray of the patient’s abdomen and
the plate revealed an operating sponge left in the
abdomen. Based on the presented scenario, the
surgical team can be held liable in view of which
doctrine?
a. Doctrine of respondeat superior
b. Doctrine of res ipsa loquitor
c. Doctrine of Captain of the Ship
d. None of the above options applies
115. The most important legal consideration prior to
performing surgical procedure is:
a. To make sure that the surgical patient had been
educated by the surgeon about the surgery,
preparations, possible complications,
expectations after the surgery, and other
relevant information
b. To ensure that a correct operative consent
form was signed by the patient before he
was given preoperative medications
c. To double check the preoperative checklist
d. To secure operative consent from the patient
116. What ethical principle
applies when the surgical team
adheres to surgical asepsis during surgical
procedure?
a. Justice
b. Nonmaleficence
c. Beneficence
d. Autonomy
117. You are to witness a surgical consent form signing. A
patient’s relative informed you and the surgeon that
his father already signed a consent form when he
was brought to the hospital due to abdominal pain
and was advised for confinement after series of
diagnostic works and evaluation by the physician-on-
duty at the emergency room. The patient’s daughter
asked you why his father needs to sign a new
consent. Which of the following response is most
appropriate?
a. “Anything that you worry about?”
b. “The surgeon will secure from you another
consent form for your surgery. The consent
form that you signed at the emergency
room is the consent for admission.”
c. “Haven’t you been informed by the morning shift
nurse?”
d. The above statements are inappropriate.
118. The four elements of a professional negligence claim
are:
a. professional relationship, intentional wrongful
act, proximate cause, and damage to the client
b. professional responsibility, fault, harm to the
client and wrongful act
c. duty, fulfillment of duty, professional
relationship and wrongful act
d. duty, breach of duty, causation,
harm/injury and damages
119. The least consideration in obtaining informed
consent before surgery is:
 a. completing the informed consent papers 1
hour after preoperative medication is given
b. completing the informed consent papers before
all preoperative test results are in the patient’s
chart
c. completing the informed consent papers the
evening before the surgery
d. completing the informed consent papers with a
family member present
120. Don Roberto was about to die due to nosocomial
pneumonia. He has a platinum bracelet and verbally
told to the nurse that he wanted to give it as a gift to
his son Bryce. This has a legal term which is/are:
a. Bobot mortis
b. C and D
c. Donation causa mortis
d. Gifts causa mortis
Ethical and Moral Principles
SITUATION. Nurses are obliged to fulfill their responsibility
and provide ethical and moral care that demonstrates respect
for others.
121. The nurse manager is preparing staff development
classes for new nurses. Which of the following should
be included in relation to ethical decision making?
a. Ethical decisions arrived at for client care
are based on the recommendation of family
and significant others
b. Ethical decision making is based on
knowledge, facts and strong
commitment to right or wrong
c. Ethical decision making is the responsibility
of the nurse alone
d. Ethical decision making is based on the
philosophy of individual values and beliefs
122. Steph, daughter of the client, refuses to inform her
father about his diagnosis. The nurse is concerned
about whether or not she will tell the client about his
diagnosis. This is an example of an ethical:
a. Conflict c. Dilemma
b. Concern d. Issue
123. After the client was informed by the physician that
he is positive for stage IV cancer of the prostate, he
requested the nurse to withhold the information from
his wife and children. Which of the following is an
appropriate action of the nurse?
a. Encourage the client to tell his wife
b. Refuse to do the request but offer support
and guidance
c. Pretend not to have understood the request
and consult supervisor
d. Ask patient to give her time to think
about it and refer to the physician
124. When the nurse finished performing foot care on the
client, she was requested to come back to change
the linen. The nurse changed the linen as requested
by the client. The nurse is demonstrating which of
the following ethical rules?
a. Nonmaleficence
b. Confidentiality
c. Justice
d. Fidelity
125. The morning shift is over and the outgoing nurse
was about to leave the unit when the relative of the
client called because the client fell out of the bed.
The nurse hurriedly went to the client’s room to
attend to the client. Which of the following ethical
principles illustrate the action of the nurse?
a. Justice c. Beneficence
b. Autonomy d. Nonmaleficence
126. When the nurse is providing care to the patient using
a multidisciplinary team approach with other health
care workers, this process is called:
a. proactive care
b. dynamic care
c. collaborative care
d. reactive care
127. Rechecking that the drug dose was correctly
computed to avoid over-dosage is:
a. Justice
10 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
b. Respect
c. Beneficence
d. Loyalty
128. The Catholic Church in the Philippines always
pursues life and life alone. Abortion has never been
accepted because this act kills from the belief of a
fetus is already a life. Which of the following
statements is TRUE of abortion in the Philippines?
a. A nurse who performs induced abortion will have
no legal accountability if the mother requested
that the abortion done on her
b. Abortion maybe considered acceptable if the
mother is unprepared for the pregnancy
c. Induced abortion is both a criminal act and
an unethical act for the nurse
d. Induced abortion is allowed in cases of rape and
incest
129. A collision of two buses on Roman Super Highway in
Balanga City left three persons dead and 36 others
injured. The nurse used triaging in attending to the
casualties. What ethical principle does the situation
represent?
a. Autonomy
b. Fidelity
c. Beneficence
d. Justice
130. Hospitals put up triage schemes to determine who
should be served first. It was taught by ER head
nurse to Nurse Karl and this follows?
a. Deontology
b. Beneficence
c. Non-maleficence
d. Justice
131. When Herminia, a manic patient went berserk, she
was restrained because the doctor cannot be
contacted. Which moral principle applies to the
situation?
a. Two-fold effect
b. Totality
c. Epikia
d. Golden Rule
132. Anonymity is the name given to the procedure that
ensures subjects that their responses:
a. Cannot be identified by anyone
b. Will not be shared with anyone
c. Will not be destroyed at the end of the study
d. Will be kept under lock and key
133. The use of another person’s idea or wordings without
giving appropriate credit results from inaccurate or
incomplete attribution to when another person’s idea
is inappropriately credited as one’s own?
a. Assumption
b. Plagiarism
c. Quotation
d. Paraphrase
Nursing Research
SITUATION. Gab, a newly registered nurse, applied for work
as a research assistant. A thorough understanding of the
steps in the research process is important when doing a
study.
134. Nurse Gab knows that defining the purpose of the
research project serves which function?
a. States the focus of the research study
b. Identifies population group to be used
c. Determines statistical treatment needed
d. Explains why the problem is significant
to study
135. During his job interview, Nurse Gab was asked which
type of research is intended to gain insight by
discovering “meaning”? Her best reply is:
a. A phenomenological research
b. Qualitative research
c. Quantitative research
d. Anthropology based research
 136. When another nurse tells Gab that he performs hand
washing eight times a day but can’t explain why
except to say “I’ve always done it this way”, her
answer is an example of:
a. Scientific knowledge
b. Unsubstantiated knowledge
c. Authoritative knowledge
d. Traditional knowledge
137. Nurse Gab is doing research on the effect of
cholesterol on blood pressure. Blood pressure is what
type of variable?
Community Health Nursing
Community Organizing Participatory Action Research
SITUATION. People empowerment is an important purpose
why Community Participatory Active Research (COPAR) was
created, it encourages the community to generate community
participation in development activities.
139. The following are facts about COPAR, which one is
not?
a. It is a social development approach that aims to
transform the apathetic, individualistic and
voiceless poor into dynamic, participatory and
politically responsive community
b. It is a process by which community identifies its
needs and objectives, develops confidence to
take action in respect to them and in doing so,
tends and develops cooperative and
collaborative attitudes and practices in the
community
c. It is a continuous and sustained process of
educating the people to understand and
develop their critical awareness of their
existing conditions, working with the
people collectively and efficiently on their
immediate problems toward solving their
day-to-day survival needs
d. It is a collective, participatory, transformative,
liberative, sustained and systematic process of
building people’s organizations by mobilizing and
enhancing the capabilities and resources of the
people for the resolution of their issues and
concerns towards effective change in their
existing oppressive and exploitative conditions.
140. In COPAR, people of the community are being
prepared as managers of development programs in
the future. All of the following but one are
considered as principles of COPAR
a. Community resources are identified and
mobilized for the poor, the powerless and
the oppressed
b. People, especially the most oppressed, exploited
and deprived sectors are open to change, have
the capacity to change and are able to bring
about change
c. COPAR should be based on the interests of the
poorest sectors of the society
d. COPAR should lead to a self-reliant community
and society.
141. COPAR is people-based it is focused towards the
powerless and the oppressed. Which developmental
approach is related to participatory?
a. Immediate or spontaneous response to
ameliorate the manifestation of poverty,
especially on the personal level
b. The process of empowering the poor so
that they can pursue a more just and
humane society
c. Abandoning the traditional methods of doing
things and must adopt the technology of
industrial countries
d. Introduction of whatever resources are lacking
in the community adopting technological
development
142. Jacobson defined Community Health Nursing as:
a. a service rendered by a professional nurse with
communities, groups, families, individuals at
home and in health centers
b. a learned practice of discipline with the
ultimate goal of contributing, as individuals
11 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
a. Intervening variable
b. Exploratory variable
c. Independent variable
d. Dependent variable
138. The term used to refer to information collected in
research is:
a. Abstract
b. Mean
c. Data
d. Subject
and in collaboration with others, to the
promotion of the client’s optimum level of
functioning through teaching and delivery
of care
c. The science and art of preventing disease,
prolonging life and promoting health.
d. a special field of nursing that combines the skills
of nursing, public health and some phases of
social assistance and functions as part of the
total public health program for the promotion of
health, the improvement of the conditions in the
social and physical environment, rehabilitation of
illness and disability
143. The following statements do not relate to
community development, but one?
a. In participatory approach, then nurse must
devotedly adhere to what people want
b. If the people are not attending to the
services offered by the health staff, the
team must reassess the needs of the
people
c. In a peasant community where people are
fighting for land ownership, the nurse must not
participate as this is not a health concern
d. Nurses must not join protests action as nurses
should always be neutral at all times
Integrated Management of Childhood Illnesses
SITUATION. The Philippines witnessed the rise in the
incidences of DENGUE in various parts of the country starting
2009. The following situations affecting children apply.
144. In a Barangay in Iloilo where there were high
incidences of malaria, a child was brought by her
mother with on and off feeling of dryness and warm
skin, temperature reached 37.50C and above, the
child has no general danger signs, with stiff neck, no
runny nose, no measles, and no other obvious
causes of fever. The child may be classified as
having
a. Malaria
b. Fever, no malaria
c. Fever, malaria unlikely
d. Severe febrile disease/Malaria
145. It is understood that if a child were living in a “no
malaria risk area” but who has presenting signs of
stiff neck. The child may be classified as having
a. Severe febrile disease
b. Fever no malaria
c. Malaria
d. Sever malaria
146. You attended to a 3-year old child with measles and
with eye complications. This child should be treated
with the following EXCEPT:
a. Apply gentian violet
b. Apply tetracycline ointment
c. Give Vitamin A
d. Follow up in 2 days
147. In classifying dengue cases, which of the following is
NOT possible classification of dengue hemorrhagic
fever?
a. None of these
b. Severe dengue hemorrhagic fever
c. Dengue hemorrhagic fever unlikely
d. Dengue hemorrhagic fever
148. You are attending to 5 cases of dengue in 2 clusters
of barangays assigned to you. Which of the following
 treatment modalities SHOULD NOT be considered if
the children you are attending to has severe dengue
hemorrhagic fever?
a. Give aspirin
b. Give ORS if there is skin petechiae
c. Apply alternative plan if there is bleeding from the
nose or gums
d. Prevent low blood sugar
SITUATION. The Integrated Management of Childhood
Illnesses (IMCI) has been established as an approach to
strengthen the provision of comprehensive and essential health
package to the children.
149. The core of the IMCI strategy is integrated case
management of the most common childhood
problems, with a focus on the important causes of
death. Which one is not a main component in IMCI
strategy?
a. Improvements in the case management skills of
heath staff through the provision of locally
adapted guidelines on IMCI and through
activities to promote their use
b. Improvement of the public’s acceptance of
IMCI
c. Improvements in the health system required for
effective management of childhood illness
d. Improvements in family and community
practices
150. The clinical guidelines, which are based on expert
clinical opinion and research result, are designed for
the management of:
a. Sick children aged 1 week up to 5 years
b. Sick children aged 1 month up to 5 years
c. Sick children aged 1 year up to 5 years
d. Sick children aged 1 day up to 5 years
151. Which of the following is wrong about IMCI?
a. Integrated case management relies on case
detection
b. The treatments are developed according to
action oriented classification rather than exact
diagnosis
c. The guidelines give instructions for how to
routinely assess a child for general danger signs
d. The treatments are developed according to
diagnosis rather than action oriented
classifications
152. The complete lMCl case management process
involves the following elements:
1. Assess a child by checking first for danger signs
2. Classify a child's illnesses using a color-coded
triage system.
3. Identify specific treatments for the child.
4. Provide practical treatment instructions
a. 1, 2, 3
b. 1, 3, 4
c. 2, 3, 4
d. All of these
153. In utilizing the IMCI protocol, the nurse should
initially?
a. Observe the condition of the child
b. Ask the mother if what is the problem of
the child
c. Look for danger signs
d. Identify main symptoms
154. Urgent referral should be suggested with the
presence of danger signs. Which of the following are
considered as general danger signs to a sick young
child?
I. Stridor, chest in-drawing and low fever with
clouding of the cornea and deep extensive
mouth ulcers
II. High fever, lethargy and inability to drink
III. Stiff neck with high fever and tender
swelling behind the ear
IV. Unable to breastfeed and difficulty to awaken
V. Visible severe wasting, edema of both feet
and severe palmar pallor with diarrhea
12 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
a. III, IV
b. II, III, IV, V
c. II, IV
d. II, III, IV
155. Baby Sabri an 11 month old infant, has cough with
wheezing and an RR of 57 per minute. The nurse
gave him a trial of rapid-acting inhaled
bronchodilators. After 3 cycles, the child has 53
breaths per minute. The nurse would:
a. Administer another bronchodilators and return in
25 days if cough is still present
b. Give an IM Benzyl Penicillin 10,000 units/lbs and
Gentamicin 7.5 mg/lbs and refer right away.
c. Give amoxicillin 2 capsules three times daily for
five days
d. Administer amoxicillin 15ml two times daily
for three day
156. If inhaler is not available, the nurse should do which
of the following?
a. Refer the child for assessment for TB or asthma
b. Consider oral salbutamol as the second
choice
c. Tell the mother to bring the child for a follow up
check after 5 days
d. Soothe the throat and relieve cough with a safe
remedy
SITUATION. Nikko, 3 years old is brought to the clinic due to
fever, cough and difficulty of breathing. You suspect that this is
a case pneumonia.
157. Your basic assessment of Nikko should include:
a. Looking for signs of ear infection
b. Looking signs of dehydration
c. All of these
d. Looking for intercostals and subcostal
retractions
158. Nikko is diagnosed of having pneumonia you expect
his respiratory rate to be:
a. 60 breaths per minute
b. 50 breathsp er minute
c. 40 breaths per minute
d. 20 breathsper minute
159. Nikko is on antibiotic therapy which of the following
statements indicates that the mother needs further
teaching?
a. “l can slop giving the antibiotics he seems
better.”
b. “He needs to finish the 5 day treatment even if
he seems better”
c. “l’ll continue feeding my son as usual or add
more if needed during the treatment”
d. “l’ll bring back my son to the health center in 2
days or sooner if his condition worsens.”
160. In order to check whether the mother understands
and will be able to carry out the instructions given
her, which of the following will you do:
a. Ask the mother to demonstrate what she has
heard
b. Ask the mother to repeat the instructions to
correct any misinformation
c. Ask them other what problems she might have
in giving the antibiotics
d. Any of these
SITUATION. IMCI also is used to manage one of the most
common causes of morbidity in the Philippines among children
which is Diarrhea.
161. Andoy, has diarrhea for 5 days. Upon assessment,
you noted that there is no blood in her stool and that
she is irritable and her eyes are sunken. You offered
her fluids and the child drank eagerly. How would
you classify Andoy’s illness?
a. Some dehydation
b. Dysentery
c. Severe dehydration
d. No dehydration
162. You know that Andoy’s treatment includes the
following EXCEPT:
a. Reassess the child and classify him for
dehydration
 b. Give in the health center the recommended 171. What is the appropriate temperature for the freezer
amount of ORS for 4 hours of the refrigerator in storing vaccines
c. Use the PLAN A: Treat Diarrhea at home a. +2 to + 8C
d. Use the PLAN B: Treat Some Dehydration with b. +15 to + 25C
ORS c. -2 to -8C
163. Upon taking the informaton you find out that Andoy d. -15 to -25C
is 2 years old and weighed 16 kg. Based on the 172. BCG is a:
treatment plan for Andoy, how much amount of ORS a. Bacterial toxin
must be given to him for the first 4 hours b. Plasma derivatives
considering the following data? c. killed bacteria
a. 200-400 ml ORS d. live attenuated bacilli
b. 400-700 ml ORS 173. Measles vaccine is a:
c. 900 ml ORS a. Bacterial toxin
d. 900- 1400 ml ORS b. Plasma derivatives
c. killed bacteria
SITUATION. One of the trending news today is about the d. live attenuated virus
Reproductive health bill. The following questions are about
the Philippine Reproductive Health.
174. Diptheria vaccine is a:
a. Toxoids
b. Plasma derivatives
164. The main objectives of Philippine Reproductive
c. killed bacteria
Health includes the following: d. live attenuated bacilli
1. Reduce the maternal mortality rate
2. Reducing the child mortality
175. Hepa B vaccine is a:
a. Bacterial toxin
3. Halting and reversing the spread of HIV/AIDS
b. Plasma derivatives
4. Increasing access to Reproductive health
c. killed bacteria
information services
d. live attenuated bacilli
5. Reduce paternal mortality to prostate cancer
176. What type of immunoglobulin is passed to the baby
a. All of the above during breastfeeding?
b. All except 5 a. IgG
c. All except 4 b. IgM
d. All except 3 c. IgA
165. According to this framework, the foremost d. IgE
intervention in attaining reproductive health is:
SITUATION. Nurse Dang Castillo, initiated the
a. Family planning
organizing of the “Caring Frontiers Nursing Service
b. Counselling
Company” in Leyte. This was envisioned to deliver health
c. Safe Sex Campaign Drive
care and various nursing services through home health
d. Maternal and Child Health and Nutrition
care services well within the scope of nursing practice.
166. Because of insufficient technical readiness and
availability of resources, the DOH has focused in
177. Nurse Lanie is one of their Registry Officials and acts
as a liaison between families and communities
addressing the health concerns on the first four
served by the company to actively engage on policy
priority elements of the reproductive health namely:
and social change that will support and promote
1. Adolescent Reproductive health
family health in their Province. Nurse Dang Castillo is
2. Family Planning
performing what role?
3. Prevention and Management of Reproductive
a. Care Provider
Tract Infection Including STIs and HIV/AIDS
b. Counselor
4. Maternal and Child Health and Nutrition
c. Client Advocate
5. Prevention of Infertility and sexual Dysfunction
d. Facilitator
a. All except 5 178. Formulating and implementing a supervisory plan,
b. 1,3,4,5 monitoring, and evaluating beginning nurse
c. 2,3,4,5 practitioners’ performance in the implementation of
d. 1,2,4,5 public health programs are what functions of the
public health nurse?
Immunization/Vaccination a. Trainer
b. Coordinator
SITUATION. PD 996 was created to eradicate preventable c. Supervisor
diseases in Filipino Children. d. Manager
179. As an advocate, Registry Nurse Lanie places her
167. Nurse Maria knows that Measles is given at what client’s rights as priority. She is aware that advocacy
particular time? work involves which of the following?
a. 6 weeks a. Influencing public opinion
b. Anytime after birth b. Obtaining a general information about the
c. 9 months community
d. 1 month after birth c. Coordination with the health team
d. Prioritizing health conditions and problems
168. Measles vaccine is given at what route? 180. According to the World Health Organization, one of
a. I.D the leading causes of mortality in the Philippines is
b. SQ which of the following?
c. I.M a. Leukemia
d. P.O b. Heart Disease
169. Measles vaccine is prepared as? c. Malignant Neoplasm
D. Lower respiratory tract infections
a. Plasma derivative
b. Weakened Toxin 181. Registry Nurse Lanie is conducting a community
c. freeze dried diagnosis composed of Demographic variables,
d. live attenuated socioeconomic variables, health, and illness patterns,
170. In following the cold chain principle, Nurse Miranda health resources and political/leadership patterns.
What type of community diagnosis is Nurse Lanie
knows the appropriate temperature for the body of
conducting?
the refrigerator in storing vaccines.
a. Individualized Nursing diagnosis
a. +2 to + 8C
b. Population Focused Diagnosis
b. +15 to + 25C
c. Comprehensive Community Diagnosis
c. -2 to -8C
d. Problem Oriented Community Diagnosis
d. -15 to -25C

13 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS

SITUATION. A nurse is assigned to a community health
center where the variety of experiences and the culture of the
community influences the care she gives to the clients.
182. While in the community health center, you note
various practices among the families you serve.
Which of the following situations will be of concern to
you as the nurse?
a. Mang Tomas weans a copper bracelet for his
rheumatoid arthritis
b. Mang Andoy gives his son various herbs
everyday
c. Aling Pat applies Vicks VapoRub to the chest and
back of her grandson with colds
d. Aling Mika uses Atis seeds on the hair of her
granddaughter to treat lice.
183. Mr. Curz, diagnosed with Alzheimer’s Disease is
brought to the center by his daughter to seek help
regarding home care. In planning the care of Mr.
Cruz , priority should focus on
a. Providing food rich in fiber to prevent constipation
b. Protecting the client from possible injury in
his environment
c. Assisting the client to perform ADL
d. Assisting all family members deal with the
challenges of long term care of this client.
184. You are following up a client who has cataract. The
most important nursing action/instruction to
implement would be
a. Advise the client to wear glasses indoors and
outdoors to guard versus sun glare
b. provide adequate lighting at home at all
times
c. Instruct family not to change furniture
arrangement at home
d. Advise the client to have cataract removed
185. While on duty at the community health center, some
clients are brought for consultation. Based on your
assessment, the FIRST client to attend to would be
a. Alling Juana with Dementia who wanders in the
streets every morning
b. Mang Sixto, 65 year old with congestive heart
failure and 3+ pitting edema
c. Aling Maria, 65 year old, terminal client with
weight loss (15 lbs) last month
d. Mang Ramon, 70 year old with Parkinson’s
disease and started hallucinating
186. You are visiting a newly discharged cerebrovascular
accident client currently confined to a wheelchair for
long periods of time. Your most appropriate priority
intervention would be to
a. Ask the client to move his buttocks every two
hours to increase blood circulation to the area
b. Prevent skin breakdown by putting a
pressure relieving cushion in the seat of the wheelchair
c. Refer to physical therapist to teach client to
transfer from bed to wheelchair
d. Instruct family to feed client high protein diet for
better skin integrity
SITUATION. Documentation is an important aspect of every
nurse’s activity. This is a major area of responsibility which
helps facilitate continuity of work within a 24 hour cycle.
187. A 26 year old mother was admitted for hyperemesis
gravidarum. While taking the history of this client, it
would be MOST important to report which of the
following?
a. The client has cool lower extremity bilaterally
b. The client has diminished palpable peripheral
pulses
c. The client is anxious about the effect of her
condition to the baby
d. The client has allergy to shellfish
188. You are on duty and you received report from the
previous shift. Which of the following client should
you attend to FIRST?
a. A client who is reveiving ciprofloxacin and
complains of a fine macular rash
b. A client who is receiving blood transfusion and
complains of a dry mouth
c. A client who is scheduled to receive heparin and
the PTT is 70 seconds
d. A client who is receiving IV potassium and
complains of burning at the IV site
14 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
189. You are reviewing the nurse’s notes in your client’s
chart. You would be MOST concerned by which of the
following entries?
a. “Foley catheter draining clear urine and the pH is
6.5”
b. “The client drinks 3 glasses of orange juice
everyday.”
c. “The client’s skin is blanched over the
scapular areas.”
d. “Vital signs are within normal limits.”
190. You are attending to clients in your clinic. As you
return to your desk, you find 4 phone messages.
Which of the following messages should you return
FIRST?
a. A client is nauseated and has vomited 6
times in the previous 24 hours.
b. A client with stage II decubitus ulcer at home
reports that the dressing has come off.
c. A client is complaining of leg pain after walking
half a mile.
d. A client with cold symptoms has an oral
temperature of 39.4 0C
191. At approximately 6 PM, a nurse deployed for duty in
one of the affiliate hospitals, begin to open the
nurses’ notes for the evening shift. The last entry is
noted for 1PM, and there is no signature. The MOST
appropriate nursing response is to
a. Begin charting on the next line below the last
entry, inform the day nurse to make a late entry to complete
the chart
b. Do not enter anything until the day nurse
has been notified of the problem and returns to the unit
to complete her charting
c. review with the client the activities after 1PM and
enter what are determined to be the activities after 1PM
d. Leave approximately 3 or 4 lines for the day nurse
to enter some of her missed entries and sign the chart
SITUATION. Myths and fallacies as pertain care of the
birthing mothers and their newborn have been debunked
resulting in the development of hwat is now known as
Essential Intrapartum Newborn Care or EINC. The following
applies:
192. On December 7, 2009, the Department of Health
issued as Administrative Order implementing the
ENC protocol with the goal of rapidly reducing the
number of newborn deaths in the Philippines. With
internationall standards integrated in the Intrapartal
care program has now evolved into the EINC
program under the guidance of the WHO. Now
considered as myths and fallacies include
1. Use of enema to reduce the risk of infections and
shorten the duration of labor
2. Shaving the pubic hair of women in labor as a
hygienic practice to minimize infection
3. Restricted intake of food and fluid during active
labor for possible risk of aspirating gastric contents due to
anesthesia
4. Application of IV therapy to hydrate women due to
food and drink restrictions
5. Use of fundal pressure to help the mother in the
expulsion of her fetus
6. Early amniotomy and oxytocin augmentation in
order to prevent operative delivery
a. 4, 5, and 6 b. none of these c. 1, 2,
and 3 d. all of these 6
193. In the immediate care of the newborn, there are also
practices which were debunked as practices based on
false beliefs. Which are they?
1. Routine suctioning believed to be necessary to
clear the baby’s airway and stimulate him to breathe
2. Foot printing as a means of identification of
newborn
3. Early bathing and washing as a form of hygienic
practice
4. Routine separation (baby in the nursery while
mother is in her room)
5. Continuance to providing artificial feeding (starts
with pre-lacteals then artificial milk substitutes)
a. 2 and 5 b. 1, 3, and 4 c. only 2
d. all 5 are taken now as wrong beliefs
194. On the INTRAPARTAL CARE, one among 5
recommended practices include MATERNAL
 POSITIONING especially during the 1 st stage of labor.
The recommended practice now is
a. Allow women to assume an upright position versus
the former recumbent (supine/semi-recumbent and lateral)
b. Strictly follow the traditional medical model of
labor and delivery
c. Encourage women to take up the position
they find most comfortable to them
d. Allow women to assume any other upright position
(walking, standing, sitting, kneeling) versus recumbent
195. On the ESSENTIAL CARE OF THE NEWBORN, the
three new major RECOMMENDED PRACTICES are
1. Practice Rooming-in
2. Skin to skin contact
3. Strict handwashing of carers handing the newborn
child
4. Use of partograph
5. Properly timed cord clamping
6. Initiation of breastfeeding
a. 1, 3, and 4 b. 4, 6, and 2
c. 2, 5, and 6 d. 4, 5, and 1
196. Essential Intrapartum Newborn Care (EINC) is our
country’s instrument in health addressing the
challenge of the United Nations 2 out of 8 Millenium
Development Goals (MDGs) targeted to achieved by
2015. Which are these 2 MDGs?
a. MDGs 3 and 6 b. MDGs 4 and 5
c. MDGs 1 and 2 d. MDGs 7 and 8
SITUATION. You are newly passed and registered nurse
applying for beginning nursing job. While waiting you heard
your Parish Priest calling for volunteers for a Parish-Based
Health Program, you signed up to help and practice your
profession. Among the health conditions you would normally
encounter are obstetrical cases.
197. A 22 year old mother missed 2 of her regular
menstrual periods. The Parish Medical Volunteer
confirms an early, intrauterine pregnancy. This is her
1st pregnancy. To determine her expected due date,
which of the following assessments is most
important?
a. Date of last menstrual period
b. Date of last intercourse
c. Age of menarche
d. Dates of her 1st menstrual period
198. The action of hormones during pregnancy affects the
body by:
a. Blocking the release of insulin from the pancreas
b. Raising resistance to insulin utilization
c. Enhancing the conversion of food to glucose
d. Preventing the liver from metabolizing glycogen
199. You opt that all Fridays are Family Care Nursing
clinic HOLIDAYS. On Fridays, you prefer to do
personal visits. You follow up patients in their
homes, do volunteer health work in schools, or visit
industries within the vicinity. In a student health
clinic, a client confides to you that her boyfriend
informed her that he tested positive for hepatitis B.
Which of the following is your BEST response?
a. “You will receive the hepatitis B immunoglobulin
(HB1G).”
b. “Have you had sex with your boyfriend?”
c. “That must be real shocking to you.”
d. “You should also be tested for hepatitis B.”
200. An eye surgeon aware of your “Friday-Visit” Program
called on you one day and referred a 4-year old
client whom he scheduled for an eye surgery. When
you met her mother she asks how best to prepare
her daughter for the eye surgery, which of the
following actions would be BEST?
a. Draw a picture of the eye and explain what will
happen during the surgery.
b. Help the mother explain to the child how to get
ready for surgery using dolls.
c. Instruct the mother to tell her daughter that the
surgery will only take an hour.
d. Guide the mother to read her daughter an
age-appropriate illustrated book about eye surgery.
201. You are back on your usual Nursing Clinic duties, it is
a Tuesday and a woman at 38-weeks gestation
comes to you with problems of vaginal bleeding.
Which of the following remarks, if made by the client
15 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
would suggest PLACENTA PREVIA as a potential
cause of bleeding?
a. “I feel fine, but the bleeding scares me.”
b. “I’ve been experiencing severe abdominal
cramps.”
c. “I feel nauseated more during the past few
weeks.”
d. “The bleeding started after I carried 4 bags
of groceries.”
SITUATION. Having a privately owned, community-situated
nursing care facility makes the nurse develop rapport with
greater number of community residents. She can become a
vital community resource with her nursing skills and
knowledge. BUT with the nature of the nurses’ work, it is
necessary to be conscious about legal considerations.
202. Alvin, a 5-year old boy and his mother are your
regular clients in your Nursing Clinic. You
accompanied them to a nearby hospital for referral
of what you suspected as an acute case of
appendicitis. Alvin’s parents have been legally
separated for 5 years now but both enjoy “joint legal
custody”. The nurse on duty sought your assistance
in asking the mother for her informed consent for
immediate surgery. Together with the nurse-on-
duty, which of the following would be the BEST
action?
a. Have the mother sign the consent and continue
the child’s preoperative preparation
b. Contact the father to obtain consent
c. Have the mother sign the consent and inform the
surgery
d. Have the mother sign the consent and inform
the surgeon right away
203. Another of your pediatric patients named Duke got
rushed to the hospital with sustained bruises and
lacerations, and a fractured arm. As Duke was being
treated in the ER, his mother requested for you to
come and assist them and the nurse-on-duty (NOD)
was informed of your coming as their family nurse.
Upon arrival, you coordinated with the NOD and later
you were able to obtain Duke’s confession that he
got involved in a “frat” fight outside school. You and
the NOD agreed on which priority actions?
a. Ensure documentation on the Duke’s chart
b. Share the information with the hospital social
worker
c. Share only this information with fellow health
professionals
d. Call for the Police and report the findings
204. You got invited as speaker in a class of nursing
students to share your experiences and
understanding on the handling of potential legal
cases while in practice. Which acts would constitute
battery?
a. When you administer an injection to a
schizophrenic patient who refuses to take the
medication because he believe it is poison.
b. When on doctor’s order you restrain an agitated
patient inside the ER
c. When you chase a patient who tries to run away
while taking a walk with you around the hospital
d. When you hold the arm of a manic patient who
strikes you
205. Nathan, a 10 year old boy and his family are your
clients. He was admitted to the hospital for a skin
graft surgery. You went to visit him and when you
came he is being rolled back from surgery, He is on
D5W infusing into his left arm and you introduced
yourself then checked with the NOD and got the
following information, he weighs 50 lbs (23.6 kg)
and the physician’s order was “D5W 2, 000 cc/24
hours”. At this instance you opted to engage the
NOD to
a. Set the IV infusion pump controller to run at 84
gtts/min
b. Monitor the patient for fluid and electrolyte
balance
c. Call the physician to clarify the IV order
d. Ensure accurate records of the patient’s intake
and output.
206. You visited one of your family client, a 26-year old
mother whose son died of Sudden Infant death
 Syndrome (SIDS). As you were conversing it is
sound for you to
a. Ask how her son was positioned in bed while in
the hospital at the time of his death
b. Allow the mother to cry and talk about her
son and related concerns
c. Ask about her other children at home
d. Explain the cause of SIDS
SITUATION. Mary, a 12-month old infant, was brought to
the health center for her regular well baby check up. Her
mother is concerned with her child’s growth and
development. She expressed her desire to learn more about
this concern.
207. The child’s birth weight was 8 lbs. Upon assessment
the child now weighs 18 lbs. In documenting the
result, you know that this weight is:
a. Appropriate for the child’s age
b. below the expected weight
c. above the expected weight
d. Individualized and thus unpredictable
208. In formulating the nursing diagnosis regarding the
mother’s concern, which of the following should you
consider?
a. Health seeking behavior
b. Anxiety
c. Knowledge deficit
d. Altered health maintenance
209. In planning care for the infant, you should advise the
mother that the best way to help her child complete
the development task for the first year is to
a. respond to her consistently
b. expose her to many caregivers to help her learn
variability
c. keep her stimulated with may toys
d. talk to her at a special time each day
210. To relieve teething discomfort which measure would
you suggest an infant’s mother to use?
a. provide her with a fluid diet for 2 days
b. Offer her Apergum to chew
c. Ask her pediatrician for a sedative for her
d. Give her a cold teething ring to chew
211. In evaluating the health teaching on breastfeeding,
which of the following observations made by the
mother would reveal correct understanding of
breastfed infants?
a. Breastfed infants usually have fewer stools than
bottle-fed infants
b. Stools of breastfed infants tend to have a strong
odor
c. Breastfed infants usually have soft stools
than bottle-fed infants
d. Stools of breastfed infants are usually harder than
those of bottle-fed infants
Medical-Surgical Nursing
SITUATION. Ginger, 45 years old male, diagnosed with
gastric cancer was admitted to the Post Anesthesia Care Unit
(PACU) post partial gastrectomy and gastrojejunostomy.
Though still sedated, patient responds to commands.
217. The nurse who admitted the patient performed an
initial “head to be” assessment is done FIRST by the
nurse?
a. Assess level of consciousness
b. Determine level of discomfort and pain
c. Observe general appearance
d. Take vital signs
218. When the patient has been stabilized, the PACU
nurse transferred the patient to private room. While
endorsing, the receiving nurse in the private room
performed her initial assessment, and noticed that
the nasogastric tube of the patient was out of place.
Which of the following will the receiving nurse do
FIRST? She will:
a. Remove the NGT and report to the surgeon
b. Secure the NGT with tape and refer to the
surgeon
c. Ask the PACU nurse to validate her observation
d. Document observation and report to the
surgeon
16 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
SITUATION. Good and comprehensive nursing assessment
among infants and children is an important aspect of
determining appropriate, safe and quality nursing care
interventions. The following apply:
212. A 4-week old infant with symptoms of pyloric
stenosis was brought by her mother to your clinic.
Which of the following statements would you expect
the mother to make about her son’s symptoms?
a. “My son’s bowel movements have turned black
and sticky”
b. “My son spits green liquid after feeding”
c. “My son seems hungry all the time”
d. “I really have to encourage my son to suck the
bottle”
213. A teenager comes to your clinic with problems of
fatigue, sore throat, and flu-like symptoms in the
last 2 weeks. Physical examination reveals enlarged
lymph nodes and temperature of 37.9C. Which pf the
following statements do you BEST make?
a. “Stay in your room until all of your symptoms are
gone.”
b. “Do not share your drinking glass or silverware
with anybody.”
c. “Eat in separate room away from your family.”
d. “Cover your mouth and nose when you
sneeze or cough.”
214. You are caring for a 2-month old infant to which a PH
probe test indicated “reflux.” Which nursing action is
MOST appropriate?
a. Raise the head of infant’s bed
b. Do not give the next feeding
c. Instruct properly the mother how to do CPR
d. Keep a normal feeding schedule
215. You are visiting a 3-month old child whom you
previously saw in your clinic. He is now on Bryant’s
Traction for development dysplasia of the hips.
Which of the following toys would be appropriate for
you to offer the infant to keep him occupied while
hospitalized?
a. Colorful, plastic non-toxic blocks
b. A toy rattle
c. A stuffed toy animal
d. Nursery rhymes played on tape
216. One early morning as you were opening your nursing
clinic, a 5 year old boy was rushed to you in an
emergeny after ingesting a bottle of baby aspirin.
You are to observe the boy for which signs and
symptoms?
a. Tinnitus and gastric distress
b. Dysrhythmia and hypoventilation
c. Nausea and vertigo
d. Epistaxis and paralysis
219. The nurse understands that the immediate
postoperative intervention that PREVENTS disruption
of the gastric suture lines post partial gastrectomy
and gastrojejunostomy is maintaining?
a. Pressure dressing
b. Fluid and electrolyte balance
c. Complete bed rest
d. Nasogastric tube to drainage system
220. In the nursing care plan, the nurse identified
dumping syndrome as a potential problem when the
patient starts to take clear liquids. Which of the
following symptoms should the nurse watch for as a
result of peristaltic stimulation?
a. Nausea and vomiting, epigastric pain, and
borborygmus
b. Tachycardia, diaphoresis and hypoglycaemia
c. Abdominal cramping, light headedness, and
confusion
d. Orthostatic hypotension, dizziness, palpitations
221. To promote adequate nutrition, which of the
following intervention would be LEAST helpful for the
client?
a. Liquids and solids are taken at separate time
b. Meals should be small and more frequent
c. Assume recumbent position for 30 minutes post
meal
 d. Increase intake of carbohydrate
SITUATION. Marissa, 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. Marissa was scheduled for appendectomy.
222. The development of the appendicitis usually follows a
pattern that correlates with the clinical signs. The
admitting nurse understands that the appendix
initially becomes distended with fluid secretd by its
mucosa following:
a. Fibrotic changes in the inner walls of the
appendix
b. Obstruction of the appendiceal lumen
c. Impairment of blood supply to the appendix
d. Proliferation of the microorganism inside the
appendix
223. The physician noted upon palpation of the
Mcburney’s point localized and rebound tenderness.
Which of the following demonstrate 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
release of pressure
224. 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 a ruptured appendix?
a. Severe nausea and vomiting
b. Unbearable excruciating localized pain
c. Sudden increase in body temperature
d. Pain subsides
225. 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 bedrest
d. Apply hot compress to the abdomen
226. Post operative 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. Reliever pain due to abdominal distention
c. Drain out blood
d. Intestinal decompression
SITUATION. You are assigned in the medical unit and
assigned to take care of 5 patients with various
cardiovascular conditions. One of your initial activities is to
gather data about your patients.
227. During a physical examination of Anna, you palpated
the PMI(point of maximum impulse)
In the fifth intercostal space lateral to the midclavicular line.
Which of the following is the MOST appropriate action for you
to do?
a. Asses Anna fir symptoms of left ventricular
hypertrophy
b. Ask Anna about risk factors for coronary artery
disease
c. Auscultate both carotids arteries for a bruit
d. Document that the PMI is in the normal
location
228. You are admitting a new patient, Bernie, for coronary
artery disease and started to obtain his health
history. Which of the following questions would you
use when obtaining subjective data related to
Bernie’s health perception-health management
functional health pattern?
a. “How often do you have your cholesterol
level and blood pressure checked?”
b. “Have you had any episode of fever, sore throat,
or streptococcal onfections?”
c. “Are there any symptom that seems to occur
when you’re feeling very low?”
17 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
d. “Do you ever experience any discomfort or
indigestion resulting from exercise or any
activity?”
229. While doing a physical examination on Maria who is a
thin 72 year old patient, you observe pulsation of the
abdominal aorta in the epigastric area just below the
xiphoid process. You inform Maria that this is:
a. An indication that an abdominal aortic
aneurysm has probably developed
b. Related to normal elevated systemic arterial
pressure
c. Most likely due to age-related sclerosis and
inelasticity of the aorta
d. A normal assessment finding for a thin individual
230. While doing assessment on Grace, who has heart
failure, you note that she has jugular venous
distention (JVD) when lying flat in bed. Your next
action will be to:
a. Palpate the jugular veins and compare the
volume and pressure on both sides.
b. Use a centimetre ruler to measure and
document accurately the level of the JVD.
c. Elevate Grace gradually to an upright
position and continue to examine the JVD.
d. Ask her to perform the valsalva maneuver and
observe the jugular veins.
231. A nursing student is assigned to Lucia, who is one of
your patients, and she is doing a physical
assessment. You will need to intervene
IMMEDIATELY if the nursing student:
a. Palpates both carotid arteries
simultaneously to compare pulse quality
b. Uses the palm of the hand to assess extremity
skin temperature
c. Places Lucia in the left lateral position to check
for the PMI
d. Presses on the skin over the tibia for 10m
seconds to check for edema.
SITUATION. Nurse Daisy has three discharged client during
early part of the PM shift. The senior nurse assigned her to
take charge of any admission during the shift. A lethargic
female client came in for thyroid work-up.
232. As prescribed by the attending physician, the nurse
instructed the client to undergo Radioactive iodine
uptake test the following morning. The client asks to
be educated on the test. Nurse Daisy would explain
that the purpose of the test is to:
a. Demonstrate the extent of damage/compression
rendered by the nodule to the trachea.
b. Detect if the thyroid nodule is malignant or benign
c. Determine the functional activity of the thyroid
gland and differentiate pituitary from thyroid
function
d. Measure the ability of the thyroid gland to remove
and concentrate iodine from the blood.
233. Before the radioactive iodine uptake test, the nurse
should verify which of the following would affect the
result of the test?
a. Over the counter drug intake
b. Sleeping habits
c. Height and weight
d. Food preference
234. The doctor prescribed levothyroxine sodium 0.15
mg. per orem daily after the diagnosis of
hypothyroidism was confirmed. Nurse Daisy
administers the medication at which time to obtain
the drug optimum therapeutic level?
a. In the morning before breakfast
b. At the patient’s most convenient time
c. At various times of the day
d. Before bedtime
235. Nurse Daisy included in her health instruction about
foods that inhibit thyroid secretions.
1, Spinach
2. Cauliflower
3. Squash
4. Raddish
5. Strawberries
6. Guavas
a. All except 3 and 6 c. All except 2 and 4
b. All of these d. All except 1 and 5
 236. Nurse Daisy would include in her discharge plan for
the client and significant others the regular intake of
which product that would ensure iodine intake.
a. Lugol’s solution c. Warm salt solution gargle
b. Seafood d. Iodized salt
SITUATION. Maricar, a staff nurse assigned in the medical
ward reports during the morning shift. All clients assigmed to
Maricar are ongoing IV therapy. To ensure safe and quality
nursing care, Maricar implements policies, procedures and
guidelines set by the hospital regarding intravenous therapy.
237. After incorporating 20 mEq Potassium chloride into
the dextrose 5% in the Water 1000ml bag, the nurse
AVOIDS doing which of the following nursing
interventions?
a. Shake the IV bag
b. Place calibration label on the IV bag
c. With a pen marker, label the IV bag with
incorporated drug
d. Check for color changes in the IV bag
238. When Maricar checked on the intravenous infusion of
one of her clients, she noted a label attached to the
intravenous tubing with the date 6/23/12. She
understands that the venous set will be changed on:
a. 6/25/12 c. 6/24/12
b. 6/27/12 d. 6/27/12
239. The client with ongoing intravenous infusion of
Dextrose 5% lactated Ringers solution rings the call
bell and when
He nurse approached her, she pointed to her intravenous (IV)
site.
When the nurse assessed the IV site, she noted that phlebitis
has developed. The nurse does the following nursing
intervention EXCEPT:
a. Restart an IV line in a proximal portion of the
same arm
b. Reinstruct the clients what not to do while IV
infusion
c. Applies cold moist compress over the IV site
d. Elevate the affected arm on a pillow
240. An elderly client with an ongoing IV infusion of
DEXTROSE 5% an NaCL 0.9% 1000 ml hung at 1545
H was assessed to be slightly dyspneic, chilling and
with increased pulse rate. The IV has 400ml
remaining and it was 1630 H. The nurse should take
which IMMEDIATE nursing action?
a. Refer to the attending physician STAT
b. Remove the IV cannula
c. Slow down the IV infusion
d. Put the client in a sitting position
SITUATION. Andrew, a 12 year old boy with type 1 DM, is
admitted in the medical ward from the Intensive Care Unit
after having recovered from the episode of diabetic
ketoacidosis. Andrew has been diagnosed with type 1
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.
241. The admitting nurse noted 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 cell utilization
d. Inability to use glucose as a source of energy.
242. When the nurse plans for Andrew’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 above the knee of both
thighs
d. Abdominal subcutaneous tissue just below the waist
243. To ensure that injection site will not be repeated
when nurse administer insulin on Andrew, wjich of
the following nurse’s action would MOST effective?
a. Have nurses record on the child’s chart the
injection site
b. Every shift, verbally endorse the receiving nurse the
injection site
c. Instruct the patient to tell the nurse, the site used
during the previous injection
18 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
d. Mark with a ballpen the injection site previously used
244. 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 injection.
a. On a teaching doll, injection site are mared with
green colored pins. After injection, the pins are
replaced with red colored pins t 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
245. Which of the following statements of Andrew will the
nurse consider as an indication that Andrew is ready
to self-administer his insulin?
a. “Will you allow me to do it?”
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. The medical and surgical unit where you work
justhired 3 nurses to augment the present nursing human
resources. The following questions apply:
246. You are assigned one new nurse t 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 bedside
below the client’s chest
247. 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 fowler’s
position?
a. Relaxes the sterna muscles and enhances
breathing
b. Promotes deep breathing and reduces pain
during inspiration
c. Reduces pressure on the diaphragm and
permits optimal lung expansion
d. Increases pressure on the diaphragm and allows
optimal expulsion of secretion
248. 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
clot
b. Clamp the tubing every time the client coughs
c. Milk feeding
d. Empty the drainage tube prn
249. 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
is to:
a. clamp the tubing at once.
b. Place the open end of the tubing in sterile water
c. Pull out the tubing and apply an air tight
dressing to the site
d. Immediately reconnect the tube
 250. The senior nurse was emphasizing to the new nurse
that intermittent bubbling of 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. Nurse Diane is assigned to the pediatric surgical
unit to take care of Jason and Gessa.
251. Jason, 18 months, was admitted for repair of
hypospadias. During assessment, which of the
following will Diane 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 uretha on the dorsal surface of the
penile shaft
d. Penis has 2 urethral openings located dorsally
and ventrally
252. Surgery is the treatment of choice for Jason. The
nurse understands that the best time for surgery is
before the child:
a. Is weaned from diapers c. Goes to school
b. Is toilet trained d. walks
253. Diane prepares a nursing care plan for Jason.
Postoperatively, which of the following is a PRIORITY
nursing diagnosis?
a. Risk for infection c. Potential malnutrition
b. alteration of fecal elimination d. Altered body
image
254. Gessa, 1 year old was admitted to the unit from the
recovery room post cheiloplasty. Diane would place
Gessa in which of the following positions?
a. Lateral b. Fowler’s
c. Supine d. Prone
255. When Gessa fully recovered from anesthesia, the
doctor ordered clear liquids as tolerated. Which of
the following is the appropriate action of the nurse?
a. Allow infant to sip from cup
b. Use spoon and feed slowly and gently
c. Administer liquids through a medicine
dropper
d. Bottle feed the infant
SITUATION. Editha, 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.
256. The nurse knows that the BEST areas used to assess
pallor that are characteristics of anemia are the:
a. Conjunctivae and lips c. Lips and fingernails
b. palms and fingernails d. Tongue and fingers
257. To establish a diagnosis the nurse would expect the
following laboratory tests to be ordered by the
physician except:
a. Iron studies c. Bone marrow aspiration
b. complete blood count d. ESR
258. 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. Change position every 2 hours
c. Auscultation lungs for abnormal breath sounds
d. Maintain on high Fowler’s position
259. 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 reason?
a. Vital signs must be monitored every 15 minutes
b. Patient needs assistance
c. Transfusion reaction can occur
d. It is a nursing order
260. When the nurse checked the patient’s vital signs 15
minutes after blood transfusion was initiated, the
nurse observed the blood pressure to have
19 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
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. Nursing practice act require nurses to maintain
a safe environment for their clients.
Nurses must act to identify and minimize risks to clients.
261. A nurse is taking care of Mr. Louie Martinez who is
receiving oxygen therapy. A watcher approached her
saying there is fire burning in the trash basket inside
the medication room in the nurse’s station. What
INITIAL action should the nurse do?
a. Turn off the oxygen and remove all
clients from the room.
b. Get the fire extinguisher to put off the
fire.
c. Calm the clients and escort them to a
safe area.
d. Ask for help from the visitors.
262. What nursing action is essential when Mr. Martinez is
to have oxygen administration at home?
a. Assist the client and family check
all electrical appliances in the
vicinity for extension cords.
b. Turn off all electrical devices inside the
room of the client.
c. Instruct the clients to install a carpet
inside the room.
d. Instruct relatives to have fire
extinguisher ready.
263. Joy,a charge nurse in the pediatric unit, is assessing
the area for fire hazards. The following situation is
considered the GREATEST fire hazard:
a. Cleaning supplies and cardboard boxes
stored in the room with oxygen tank.
b. Closet of clients filled with clothing and
newspapers.
c. Personal items of clients kept under the
bed.
d. Some staff smoking in the rest
room.
264. While doing her rounds, the nurse passed through a
private room and saw flames and smelled smoke.
Which of the following should be the INITIAL action
of the nurse?
a. Evacuate all the clients in the building.
b. Ask for assistance.
c. Evacuate the clients out of the
burning room.
d. Evacuate the weakest clients first.
265. The nurse is explaining universal precaution to the
client. The primary purpose of universal precaution
as part of maintaining safe environment is to:
a. Prevent health workers from acquiring
communicable diseases.
b. Reduce the spread of the disease.
c. Prevent nosocomial infection.
d. Prevent the spread of communicable
diseases.
Acid-Base Balance
SITUATION. Acid-base disturbances are classified as
respiratory or metabolic. Normally, the kidneys regulate the
bicarbonate level in the ECF while the lungs, under the control
of the medulla, control the carbon dioxide and thus the
carbonic acid content of the ECF. When alterations in these
regulatory mechanism occur, these result in either acidosis or
alkalosis.
 266. Ms.Jennilyn Abad, a 25-year old depressed woman 275. Compute for the amount to be given for the second 8
was admitted to Bataan General Hospital due to hours?
overdose of Diazepam. An arterial blood gas is a. 8, 856 mL
drawn. Which of the following ABG findings would be b. 7, 380 mL
most significant? c. 3, 321 mL
a. pH 7.47; paCO2 23 mm Hg; HCO3- 25 mEq/L d. 10, 332 mL
b. pH 7.26; paCO2 47 mm Hg; HCO3- 27 mEq/L 276. If thedrop factor is 15 gtts/mL, what is the flow rate
c. pH 7.37; paCO2 40 mm Hg; HCO3- 24 mEq/L of the fluid in the first 8 hours?
d. pH 7.47; paCO2 48 mm Hg; HCO3- 29 mEq/L a. 277 gtts/min
267. Mr. Rex Medina, 84-year old farmer was diagnosed b. 323 gtts/min
with chronic renal failure. Which of the following ABG c. 231 gtts/min
findings would be expected? d. 208 gtts/min
a. respiratory acidosis 277. If thedrop factor is 15 gtts/mL, what is the flow rate
b. respiratory alkalosis of the fluid in the second 8 hours?
c. metabolic acidosis a. 104 gtts/min
d. metabolic alkalosis b. 138 gtts/min
268. Theclient’s arterial blood gas results are: pH 7.47, c. 115 gtts/min
paCO2 47 mmHg; HCO3- 27 mEq/L. The nurse knows d. 161 gtts/min
that the client is experiencing which acid-base
imbalance? SITUATION. Joey, a 171.6 pound-man suffered burn injury
a. metabolic acidosis involving the face, chest, right forearm, right leg, and left
thigh.
b. metabolic alkalosis
c. respiratory acidosis
278. What is the Total Body Surface Area (TBSA)?
d. respiratory alkalosis
a. 72 %
269. A client comes to the emergency department b. 67.5 %
experiencing shortness of breath and chest c. 45 %
tightness. An arterial blood gas is ordered. Which of d. 54 %
the following ABG data indicates respiratory 279. What is the total amount of fluid to be given for 24
alkalosis? hours?
a. 7 020 mL
a. pH 7.48, paCO2 46 mmHg; HCO3- 28 mEq/L
b. 3 510 mL
b. pH 7.26, paCO2 32 mmHg; HCO3- 21 mEq/L c. 30 888 mL
c. pH 7.47, paCO2 34 mmHg; HCO3- 21 mEq/L d. 14 040 mL
d. pH 7.30, paCO2 47 mmHg; HCO3- 29 mEq/L 280. Compute for the amount to be given for the first 8
270. Acongestive heart failure patient is in Furosemide hours?
therapy. Which of the following ABG results reflects a a. 7 020 mL
potential complication of this drug? b. 3 510 mL
c. 30 888 mL
a. pH 7.48, paCO2 46 mmHg; HCO3- 28 mEq/L
d. 14 040 mL
b. pH 7.26, paCO2 32 mmHg; HCO3- 21 mEq/L
281. If the drop factor is 15 gtts/mL, what is the flow rate
c. pH 7.47, paCO2 34 mmHg; HCO3- 21 mEq/L of the fluid in the first 8 hours?
d. pH 7.30, paCO2 47 mmHg; HCO3- 29 mEq/L a. 40 gtts/min
271. Aclient is admitted to the emergency department b. 60 gtss/min
due to fever. Which of the following ABG results is c. 220 gtts/min
most significant? d. 150 gtts/min
a. pH 7.34, paCO2 33 mmHg; HCO3- 19 mEq/L
282. How much fluid is to be given for the first twelve
b. pH 7.48, paCO2 46 mmHg; HCO3- 28 mEq/L
(12) hours?
c. pH 7.46, paCO2 33 mmHg; HCO3- 19 mEq/L a. 8 775 mL
d. pH 7.29, paCO2 48 mmHg; HCO3- 27 mEq/L b. 8 755 mL
272. A 60 year-old client is admitted to the hospital c. 8 577 mL
presenting shortness of breath, fever, and a d. 8 757 mL
productive cough. Which ABG outline is most related
SITUATION. Domeng, a 56 year-old farmer was admitted in
in the diagnosis of COPD?
the Emergeny Department (ED) because of hematemesis
a. metabolic acidosis accompanied by hematochezia. Domeng is an alcoholic and is
b. metabolic alkalosis under treatment for cirrhosis of the liver. His abdomen is
c. respiratory acidosis enlarged and his lower extremities are edematous. Admitting
d. respiratory alkalosis physician’s initial diagnosis is ruptured esophageal varices.

Burns 283. Assessment reveals signs and symptoms of early

compensatory hemorrhagic shock. If you were the
nurse who admitted Domeng, which of the following
SITUATION: Mr. Joseph Villaruel, a 180.4-pound man
will you consider as the compensatory mechanism
suffered burn injury involving the chest, right lower arm, responsible for the increased heart rate and
inner portion of the right leg, and left leg. respiartory rate?
a. Stimulation of the sympathetic nervous system
273. What is the Total Body Surface Area (TBSA)? b. Increase in size of the vascular bed due to peripheral
vasodilation
a. 63 %
c. Renin-angiotensin response
b. 45 % d. Release of adrenocorticotropic hormone from the
c. 40.5 % hypothalamus
d. 54 % 284. To restore hemodynamic stability on the client,
274. Whatis the total amount of fluid to be given for 24 which of the following will the nurse expect to be
hours? done FIRST?
a. Insertion of central arterial and venous
a. 20, 664 mL
catheters
b. 13, 284 mL
b. Endoscopic ligation of rupture varices
c. 14, 760 mL c. Blood transfusion for blood repalcement
d. 17, 712 mL d. Administration of vasoactive and inotropic drugs
20 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
 285. Hemodynamics measurement revealed stable vital
signs and increased cardiac output. The physician
ordered treatment of the esophageal varices. Which
of the following procedures will teh nurse expect to
be done?
a. Upper endoscopy
b. Intrahepatic portal systemic shunt
c. Exploratory laparotomy
d. Coagulation therapy
286. In the intensive care unit, nursing orders required all
nurses to assess regularly for early manifestations of
portal systemic encephalopathy. Which of the
following will the nurse note during her observation?
a. Occurrence of asterexis
b. Development of disorientation and incoherence
c. Signs and symptoms of increased intracranial
pressure
d. Presence of papilledema
287. Serum ammonia level of the client remained to be
elevated. The following may be considered by the
nurse to be TRUE regarding this obsevation EXCEPT:
a. Ammonia is formed as proteins and amino acids are
broken down by intestinal bacteria.
b. Ammonia accumulates in the blood due to
inability of the kidney to excret ammonia.
c. Due to bleeding, blood in the intestinal tract is
digested as protein, therby increasing serum
ammonia.
d. Since liver function is destroyed, ammonia can no
longer be converterd to a less toxic form.
SITUATION. Panchito, 5 yrs. old, has idiopathic nephrotic
syndrome. He has generalized edema with a puffy face,
distended abdomen and edematous legs. Blood pressure is
normal. Blood tests show hypoalbuminemia.
288. The nurse is aware that generalized edema is due to
hypoalbuminemia which lead primarily to which of
the following?
a. Increased secretion of antidiuretic hormone
b. Reduced intravascular volume
c. Decreased plasma osmotic pressure
d. Stimulation of the renin-angiotensis system
289. The nurse closely monitors the urine output of the
patient. Which of the following characteristics of a
urine sample will the nurse expect?
a. Fruity odor c. Urine is frothy
b. Increased amount d. Blood in urine
290. The attending physician of Panchito prescribed renal
biopsy. When the nurse palns for the nursing care of
Panchito after the biopsy, which of the following will
be a PRIORITY intervention to prevent bleeding?
a. Observe for abdominal pain and tenderness
b. Monitor vital signs
c. Place on complete bed rest
d. Closely watch urine output
291. Corticosteroid therapy is prescribed. Which of the
following is the MOST relevant nursing intervention
to address complications of the therapy?
a. Weigh daily to monitor fluid balance
b. Closely monitor for changes in body
temperature
c. Maintain on a salt restricted diet
d. Offer small frequent meals
292. When the nurse prepares her health instruction for
the mother of Panchito, which of the following side
effects of the drug will the nurse include in her plan?
1. Diuresis
2. Hirsutism
3. Abdominal distention
4. Loss of appetite
5. Rounding of the face
a. 3, 4, 5
b. b. 2, 3, 5
c. c. 1, 2, 5
SITUATION. Miggy, 8 years old, has two chest tubes
d. d. 1, 2, 3
connected to a disposable water sealed drainage system
because of chest injuries from a vehicular accident.
SITUATION. The declining of patient satisfaction related to
nursing service per survey results as well as increased
incidences of hospital acquired infection during the past 6
months caused the nursing service division to push the
nursing units to explore quality improvement projects.
21 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
293. The intensive care unit (ICU) quality improvement
team decided to gather data to determine probable
causes of central line infection among the ICU
patients. If you were the member of the quality
improvement team, which of the following data will
you consider as MOST appropriate to yield the most
probable cause of central line infection?
A. Nurses’ notes on hourly assessment of sites of
central line.
B. Performed central line care interventions as
observed.
C. Daily every shift report of central line care measures
from bedside nurses.
D. Incidence of central line infection as reported
by infection control nurse.
294. The highest incidence of fall among the
hospitalization patients is in the medical unit. The
medical unit’s quality improvement team has
identified the probable causes of the incidences of
fall among their hospitalization patients. With the
data analyzed and findings organized, which of the
following should the quality improvement team do
FIRST?
A. Implement fall prevention measures identified to be
effective
B. Propose a list of nursing actions intended to identify
fall risks and preventive measures.
C. Do a pilot study of the fall prevention measures to a
small group of patients.
D. Brainstorm for a plan for an appropriate action
for change.
295. Another group of quality improvement team in the
ICU conducted a project on ventilator associated
pneumonia incidences among ICU patients. If you
are a member of this team, which of the following
measures will you consider as the MOST appropriate
to be implemented in collaboration with the
respiratory therapist?
A. Perform regularly assessment of the client’s
readiness to be extubated.
B. Consider orotracheal as preferred route of
endotrachealintubalation.
C. Maintain head elevation at 30-45 degrees.
D. Suction endotracheal tube as prescribed in the
manual of procedures.
296. Noise level in the ICU has always been a complaint in
the patient satisfaction survey. Which of the
following tools can be recommended to the quality
improvement team as most appropriate to determine
level of noise in the ICU.
A. Questionnaire with clients and patients as
respondents
B. Observation checklist
C. Measurement device
D. Interview schedule form with nurses, clients and
relatives as interviewees.
297. During a group discussion, probable factors
responsible for urinary tract infection incidences
among the hospitalization clients in the medical unit
were being explored. Which of the following will you
consider as the group of data which would be LEAST
helpful?
1. Diameter and length of Foley catheter
2. Length of time Foley catheter has been kept
indwelling
3. Age and sex of client
4. Daily physical activities of the client
5. Relevant data regarding need for continuing
indwelling catheter
A. 1,2,4
B. 3,4,5
C. 1,2,3
D. 2,3,4
298. The nurse observed that the drainage from the chest
tubes have not increased from the previous shift
report. Which of the following is the PRIORITY action
of the nurse?
A. Check the chest tube for kinks.
B. Assess for breath sounds.
 C. Document observation of the patient
D. Change position of the patient.
299. Frequent assessment of the closed drainage system
is important to ensure appropriate functioning. The
nurse observes that water level fluctuates with
respiratory effort. The nurse considers this as sign
of:
A. Trapped air
B. An inefficient system
C. Patent tubes
D. Air leaks
300. The nurse works with a nursing aide. Which of the
following is a CORRECT action of the nurse? The
nurse directed the nursing aide to:
A. Always check that clamp is available at the bedside.
B. Observe regularly the amount and color of drainage
from chest tubes.
C. Report signs of patient’s discomforts at the site of
the chest tubes.
D. Turn the patient regularly and maintain
connections of the tubes.
301. While the nurse was turning the patient during bed
bath, one of the chest tubes was pulled out from its
site. Which of the following will the nurse do FIRST?
A. Reinsert the chest tube
B. Disconnect chest tube from the drainage system
C. Cover wound site occlusively
D. Clamp the chest tube
302. To determine if chest tubes are in place and
pneumothorax is corrected, which of the following
will the nurse expect the physician to order?
A. Tidal volume measurement
B. Arterial blood gas analysis
C. Chest radiograph
D. Thoracentesis
SITUATION. A group of intensive care unit nurses decided to
conduct a research study to describe the relationship between
the frequency of endotracheal sunctioning and the incidence
of infection among ventilator assisted patients. The team
selected the non-experimental design specifically the
prosprective approach.
303. If you are a member of the research team, which of
the following will you consider as the research
study’s independent variable when you formulate the
research problem?
A. Incidence of infection
B. Relationship of endotracheal sunctioning
and incidence of infection
C. Dependence of clients on mechanical
ventilation
D. Frequency of endotracheal sunctioning
304. Data regarding the study’s dependent variable will be
collected by the research team through which of the
following?
A. Self report techniques
B. In vitro measures
C. Projective techniques
D. Available data In the patient’s chart
305. The research team is fully aware that measurement
of variables is a vey important consideration in
obtaining quality data in the study. Which of the
following statements will you accept as TRUE?
A. Reliability quality of an instrument is
independent of its validity
B. An instrument can be valid without being reliable
C. A measuring device which is unreliable can be valid
D. High reliability of an instrument provides no evidence
of its validity
306. Taking into consideration the content of the written
informed consent, which of the following reflects the
research team’s recognition of the participant’s right
to privacy?
A. Right to withdraw and withhold information
B. Confidentiality pledge
C. Voluntary consent
D. Potential benefits and risks
307. The research team decided to conduct the study for
3 months. Utilizing the prospective approach, which
of the following will the researcher appropriately do?
A. Participants will be assigned to the experimental and
control group and incidence of infection in the two
groups will be compared.
22 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
B. During the period of 3 moths, those ventilator
assisted patients who developed infection will be
include in the study
C. On the last day of the 3rd month, charts of
participants will be reviewed and data collected
regarding frequency of endotracheal suction and
incidence of infection
D. From day one to the last day of the 3rd month,
data regarding frequency of endotracheal
suctioning and incidence of infection will be
collected.
SITUATION. Ryzza, 4 years old is positive for Bacterial
meningitis
308. From the history obtained from the mother, which of
the following could be the possible method by which
the infection was transmitted to the patient?
A. Drinking water in the community was contaminated
B. Contract with respiratory secretions of an
infected person
C. Hand of caregiver was contaminated with the fecal
discharges
D. Eating utensils of the child were contaminated
309. The physician prescribed lumbar tap. When the
nurse reads the laboratory results, which of the
following reflects positive results indicative of
bacterial meningitis.
A. Decreased white blood cells, decreased proteins,
high glucose
B. Normal white blood cells count, increased proteins,
high glucose
C. Increased white blood cells, increased proteins,
low glucose
D. Increased white blood cells, decreased proteins, low
glucose
310. Assessment findings reveal positive Brudzinski’s
sign. When the nurse flexed the child’s neck forward,
which of the following behavior indicated a positive
Bruzdinski’s sign?
A. Hip flexed and knee extended
B. Knee extended and ankle flexed
C. Leg extended with resistance
D. Hip, knee and ankle flexed
311. In the nursing care plan prepared bi the nurse, “Pain
related to meningeal irritation” is a priority nursing
diagnosis. Which of the following should the nurse
avoid to do to prevent pain when positioning the
patient?
A. Extend leg
B. Flex the neck forward
C. Hyperextend the neck
D. Flex the hip
312. “Infeffective tissue perfusion related to increased
intracranial pressure” is another nursing diagnosis
formulated by the nurse. Which of the following
assessment data specific to eye changes would the
nurse interpret as normal intracranial pressure?
A. Positive sunset eye signs
B. Positive strabismus
C. Positive nystagmus
D. Positive doll’s eye reflex
SITUATION. EMERGENCY – triage trauma to facilitate care of
clients in the emergency room, various management
strategies have been devised to addresss the survival needs
of patients. As an ER nurse you should be equipped with
knowledge, skills and attitude to cope with unexpected
problems.
313. You are assigned as the triage nurse in the ER. Four
patients injured in a vehicular accident were brought
to the emergency room at the same time. To whom
will you assign the HIGHEST priority?
A. Rusty, with maxillofacial injury and gurgling
respiration
B. Zenia,with severe head injury but with
no perceptible blood pressure
C. Harriet, with lumbar spinal cord injury with
lower extremity paralysis
D. Bell, 8 months pregnant with premature
labor contractions
314. Reynold, was sideswiped by a motor cycle while he
was waiting for a bus. His head hit the concrete
pavement. According to a winess Reynold was
unconscious for a while but regained hiss
 consciousness as of nothing happened. However,
after a while he complained of severe headache and
asked to be brought to the nearest emergency room.
You are the nurse in the emergency room. If
increased intracranial pressure is suspected, what
would be the sign?
A. Involuntary posturing
B. Irregular breathing pattern
C. Papillary asymmetry
D. Alteration in level of consciousness
315. You are caring for Raymond who sustained multiple
injuries following an automobile accident. Your initial
assessment revealed that he is oriented to person
and place but is rather confused as to time. He
complains of severe headache and drowsiness. His
pupils are both equal and reactive to light. Your
critical nursing intervention would be:
A. Prevent unnecessary movement
B. Prepare to administer MDiannitol
C. Keep Raymond alert and responsive
D. Monitor for signs of increased intracranial
pressure
316. Janeth is admitted into the emergency room
following an assault where she was beaten in the
face and head. Based on Janeth’s history, which of
the following interventions should be performed
first?
A. Insert an oral or nasopharyngeal airway
B. Give 100% oxygen by mask
C. Insert an intravenous catheter
D. Obtain arterial blood gases
317. Dionisia losses consciousness. You should prepare
for which of the following FIRST?
A. Endotracheal intubation or surgical airway
placement
B. CT scan on the head
C. Place a nasogastric tube
D. Place a second IV line
SITUATION. Jillian is an emergency department nurse
working during the morning shift. A newly hired nurse was
assigned to work with her as part of the orientation program.
318. A 41 year old victim of gunshot wound is being
assessed closely for signs of hypovolemic shock.
Which of the following instructions of jillian to the
newly hired nurse is LEAST intended to obtain data
regarding hypovolemic shock?
A. “Talk to the patient.”
B. “Note skin color of the patient”.
C. “report to me changes in vital signs”
D. “maintain pressure on the wound.”
319. The newly hired nurse observed jillian perform
assessment on a 50 year old female who sustained
partial and full thickness burns on both lower
extremities to due to fie. Which of the following
questions asked by jillian will the newly hired nurse
consider as an attempt to determine full thickness
burns?
A. “Can you move both extremities?”
B. “How long you were your extremities exposed
to the flames?”
C. “Did you cover your extremities with any material
like a blanket?”
D. “Do you experience pain?”
320. Jillian administered as prescribed, antivenom and
tetanus toxoid to a client admitted with history of
snakebite. If you were the newly hired nurse, which
of the following statements will you consider
INCORRECT?
A. Tetanus toxoid enhances effect of anti-venom
B. Amount of anti-venim is dependent on the severity
of reaction than weight of the client
C. Complications induced may be prevented by tetanus
toxoid
D. Anti-venom is an antidote for snakebite
321. Jillian instructed the newly hired nurse to inform the
client with congestive heart failure to avoid Valsalva-
type maneuvers. The newly hired nurse understands
that these include the following EXCEPT:
A. Walking to and from the bathroom
B. Coughing and straining
C. Moving from supine to lateral position
D. Getting out of bed to a wheelchair
23 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
322. When appraising the performance of the newly hired
nurse during the shift, which of the following
behaviors will Jillian consider as reflective of a
responsibility to improve evaluation ability?
A. Seeks clarifications regarding deviations from
standard procedures
B. Organizes reference materials on medication
prescriptions
C. Questions appropriately data obtained from the
client
D. Asks for supervision on performance of a new
procedure
SITUATION. Victoria , the staff nurse is preparing a teaching
plan for Mrs. Santos, a 75 year old who is recovering from an
episode of Acute Bronchitis which exacerbated her diabetes.
Mrs. Santos is hard oh hearing and arthritic but alert and
oriented.
323. In developing the teaching for Mrs. Santos , which of
the following steps is done after Victoria has
identified the learning of her client?
A. Determine content C. Set learning outcomes
B. Set priorities for teaching D. organize the learning
experiences
324. Which of the following behavioral objectives is MOST
appropriate before Mrs. Santos is expected to self-
administer medications prescribed by the physician?
A. Write the names of the drugs
B. Identify all the medications
C. Select the prescribed medications
D. Organize the medication
325. During assessment, which of the following is best for
Victoria to do to be able to determine the learning
style preferred by Mrs. Santos? Ask Mrs. Santos:
A. The things she usually do
B. How she learned best in the past
C. For changes she is willing to do
D. Who will be interested to learn with her
326. Which of the following will be the MOST effective
when Victoria uses the “one on one” discussion
method of teaching?
A. Frequently rephrase statements to facilitate
understanding
B. Use printed materials with all capital letters for easy
reading
C. Allow Mrs. Santos to recommend a schedule of
drug administration
D. Limit to verbal instructions
327. During the discussion, Victoria asked Mrs. Santos to
repeat what she just taught. Mrs. Santos did not
respond. Which of the following is BEST for Victoria
to say?
A. “Are there things which I did not say clearly?”
B. “Mrs. Santos, did you hear what I asked you?”
C. “Did you understand what I have just taught you?”
D. “I asked you to repeat what I have just said. Mrs.
Santos”.
SITUATION. You are assigned in the cancer institute and
caring for 5 patients with varying types of cancer.
328. Hector, with non-Hodgkin’s lymphoma, develops a
platelet count of 10,000/µl during chemotherapy.
Based on these findings, an appropriate nursing
intervention is to;
A. Encourage fluids to 3000ml/day
B. Check all stools for occult blood
C. Check the temperature q 4 hr.
D. Provide oral hygiene q 2 hr
329. Fannie, a 26-year old teacher with stage II Hodgkin’s
lymphoma asks you, “ How long do I have to live?” –
Your BEST response is;
A. “Most patients with your stage if Hodgkin’s disease
are treated successfully.”
B. “It will depend on how your disease to
radiation, but most patients do well”
C. “You know , no one can predict how long someone
will live, so try to focus on the present”.
D. “With ongoing maintenance chemotherapy, the 10-
year old survival rate is very good”
330. Debra , who has ovarian cancer tells you, “I don’t
think my husband cares about me anymore. He
rarely visits me.” During the visit of debra’s husband
you greeted him and he told you ‘I just could not
 stand to see my wife so ill and I don’t know what to
say to her” what will be you APPROPRIATE nursing
diagnosis in this situation?
A. Interrupted family processes related to effect
of illness on family members
B. Compromised family coping related to disruption in
lifestyle and role changes
C. Risk for caregiver role strain related to burdens of
care giving responsibilities
D. Impaired home maintenance related to perceived
role changes
331. Jenny a 40 – year old single mother of two school-
age children is hospitalized with metastic cancer of
the ovary. You find her crying, and she tells you that
she does not know what will happen to her children
when she dies. Your MOST appropriate response is:
A. “For now you need to concentrate on getting well.
Don not worry about your children.”
B. “Why don’t we talk about the options you have
for the care of your children?”
C. “Many patients with cancer live for a long time , so
there’s a time to plan for your children”
D. “Perhaps you ex-husband will take the children when
you can’t care for them”.
332. When assessing Lerma’s needs for psychologic
support after she has been diagnosed with stage I
cancer of the colon, which questions will you ask to
give the MOST information?
A. “ Are you familiar with the stages of emotional
adjustments to a diagnosis like cancer of the colon.”
B. “ How long ago were you diagnosed with this
cancer?”
C. “How do you feel about having a possible terminal
illness?
D. “Can you tell me what has been helpful to you
in the past when coping with stressful events?”
SITUATION. Jinggoy Estrada has been diagnosed with End-
Stage Renal disease. The physician prescribed dietary
teaching and outpatient hemodialysis three times a week
333. Jinggoy asks the nurse to tell him the purpose of the
treatment. Which of the following is the MOST
appropriate response of the nurse?
A. “Hemodialysis removes excess fluids and waste
products and restores electrolyte balance.
B. “Hemodialysis uses the principles of diffusion
andultrafiltration to remove electrolytes.
C. “Blood is pumped through a semipermeable capillary
in a hemodialyxer”.
D. “Hemodialysis is one of several renal replacement
therapy.”
334. An arteriovenous fistula has been created.
Postoperatively, which of the following will the nurse
include as a PRIORITY nursing intervention to
promote circulation?
A. Auscultate for bruit every 4 hours
B. Elevate the affected arm
C. Pbserve finger tips for cuanosis
D. Keep dressing intact
335. Which of the following pre0dialysis care is done by
the nurse to be able to determine effectiveness of
treatment with regards to excess fluid volume?
A. Assess integumentary status
B. Assess vascular site
C. Have patient empty bladder prior to treatment
D. Record weight and vital signs
336. Nutrition therapy of Jinggoy includes control of
protein. Dietary prescription states that jinggoy is
allowed 0.8 gram of protein per kg per day. If
Jinggoy weighs 120 lbs, how much is his daily
protein allowance?
A. 57.9 g.
Pscyhiatric Nursing
Therapeutic Communication
SITUATION. Therapeutic communication forms a connection
between the client and the nurse. Furthermore, it facilitates
the establishment of the nurse-client relationship and fulfills
the purpose of nursing:
24 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
B. 43.6 g.
C. 81.7 g.
D. 96 g.
337. Jinggoy claims he loves to eat raisins. The nurse
instructs the patient to avoid this food because it is
rich in which of the following?
A. Sodium
B. Potassium
C. Magnesium
D. Phosphorus
SITUATION. Joey De Leon, 58 years old, post total
thyroidectomy with modified neck dissection due to papillary
carcinoma of the thyroid gland with lymph node metastasis
was admitted for ratdioactive iodine therapy.
338. Prior to admission, the client underwent a scan with
a test amount of radioactive iodine. If you were the
nurse who admitted the client, which of the following
will you consider as the reason for this intervention?
A. To determine existence of known distant
metastatic tumor.
B. To measure size of remaining thyroid tissue
C. To explore the operative site for baseline data
D. To mark the site where the radioactive iodine will be
administered
339. In the nursing care plan prepared for the client,
which of the following nursing interventions is LEAST
relevant to ensure a safe environment once
treatment has started?
A. Utilize preferably only disposable items for patient’s
personal use
B. Provide hand sanitizers in the corridor outside
the client’s room
C. Dispose appropriately garbage bags marked
radioactive
D. Have all frequently handled items in the room
covered with absorbent material.
340. As the nurse assigned to the client, you understand
that after radioactive iodine has been administered,
excess iodine not absorbed by the thyroid tissue will
leave the body PRIMARILY through which of the
following?
A. Sweat
B. Urine
C. Feces
D. Saliva
341. To ensure effectiveness of the radioactive iodine
therapy, you expect the physician will prescribe low
iodine diet during which of the following?
A. Day of administration of the radioactive iodine until
day of discharge
B. Two weeks before, during and until 2 days after
the treatment
C. The day before the scan until the first day after the
treatment
D. Upon admission in the hospital until a week after the
treatment.
342. When planning discharge, which of the following
instructions will you consider for reduction of
radioactive exposure to others?
1. Use private toilet facilities and flush 2-3 times after
use
2. Wash eating utensils separately from others
3. Drink normal intake of fluids
4. Bathe daily and wash hands frequently
5. Stay in isolation at home two weeks after the
treatment.
A. All except 3
B. 2,3 and 5
C. 2, 4 and 5
D. 1,2 and 4
343. Mrs. Catherine Ang, 45 years old, has terminal
cancer of the breast. She cries and tells the
nurse, “Why do I have to suffer this kind of illness?”
There is no cure for this and I wish my family would
not hope for a cure.” Which of the following is the
MOST appropriate response of the nurse?
a. “Is your family ready to accept your
condition?”
 b. “You feel angry that your family hopes
for a cure for your illness?”
c. “You sound like you are likely to die.”
d. “I think you and your family should discuss
your condition with your physician.”
344. While on your way to the cafeteria, you were greeted
by a friend who happens to be visiting a client under
your care. She asks about the client’s condition.
Which of the following would be the most
appropriate response of the nurse?
a. “I am not in a position to discuss her
condition but you are my friend, I can tell
you that she is on her way to recovery.”
b. “If you want to know her condition, why
don’t you talk to her attending physician.”
c. “I cannot discuss the status of the
client with you.”
d. “Confidentially, I can tell you that her
condition is unstable.”
345. An 18 year old client has been in the hospital for 3
days with infection of clamydia. While administering
her 12:00 noon medication, the client tells the nurse
that she has a secret which she wants the nurse to
know but asked the nurse not to tell anybody. Which
of the following is the MOST appropriate response of
the nurse?
a. “What you will tell me will be properly
documented.”
b. “Yes, I promise to protect you when
entrusting your secret with me.”
c. “Yes, you can trust me not to divulge your
secret.”
d. “I cannot promise to keep a secret if it
affects your health.”
346. A depressed client tells the nurse that she is very
disappointed following her loss of job. “I’m a failure
and cannot perform my work right.” The following
are appropriate responses of the nurse EXCEPT:
a. Provide experiences that will enhance
her self-esteem
b. Reassure the client that everything will get
better soon
c. Stay with the client and listen to what she
says
d. Motivate the client by giving positive
support and encouragement
347. The nurse is interacting with a client who verbalized
that she is hearing voices telling her that “she is a
bad girl.” Which of the following responses is the
MOST appropriate?
a. “I understand what you feel but keep calm.”
b. “Nobody is around except the two of
us.”
c. “Don’t worry, it will not harm you.”
d. “It’s difficult for you to understand all that
you are experiencing right now.”
Suicide
SITUATION. Zoshima was rushed to the emergency room
when she was discovered to have taken over dosage of
sleeping pills.
348. Myths surround suicide but which of these should the
nurse take as reality?
A. All suicide behavior should be taken
seriously. It is a cry for help
B. Only psychotic persons try to kill themselves
C. The suicide risk is over when improvement
follows a suicide crisis
D. Suicide attempts are manipulative plays
349. Zoshima is on antidepressant treatment and was
placed on the “Suicide Watch List”. The nurse must
be alert that among depressed patients, suicide is
likely to be committed when:
A. There is a traumatic experience that serves as a
precipitating event
B. Antidepressant medication begins to raise
mood
C. Depression is at its peak
D. The patient is depressed anytime
350. The primary nursing diagnosis of Zoshima is:
25 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
A. Risk for suicide C. spiritual distress
B. Loss of self-control D. ineffective coping
351. All of these are basic suicide precautions except:
A. Allow the client to have visitors and telephone
calls
B. Stay with the client with all medications are
taken
C. Isolate the suicidal patient
D. Search the client belongingness in his/her
presence for potentially harmful objects
352. Which of these should be taken out of Zosima’s room
A. Throw pillow C. coke in can
B. String bracelet D. book
SITUATION. Ms. Carlos, the psychiatric nurse at the family
section of the Out-Patient Department follows up families of
discharged schizophrenic patients. These follow up visits
provide opportunities for psychosocial treatment of patients
and their families.
353. To ensure maximum participation of family members
in follow up sessions with Ms. Carlos, which of these
elements of effective family intervention is basic?
a. Family social support
b. Improvement in family communication
c. Training in problem solving
d. Mutually agreed upon goals
354. The primary goal of psychosocial treatment of
families of discharged psychiatric patients is:
a. Provide gainful employment
b. Ameliorate poverty and social ills in the
community
c. Provide education on medication
management
d. Enhance coping efforts and reduce stressful life
events
355. Which of the following is a cultural factor that is a
barrier to avail of family intervention?
a. Resources and time
b. Unresponsive government policies
c. Shame and stigmatization
d. Traditional practices
356. All of these are within the scope of the generalist
nurse’s role, EXCEPT:
a. Social skills training
b. Individual and family assessments
c. Family therapy
d. Health education on psychotropic drugs
357. Cognitive behavior principles are utilized in
psychosocial treatment. In such interventions,
patients who are rehabilitating from schizophrenia
are:
a. Taught to unlearn maladaptive behaviors
through desensitization
b. Assisted to work through their unconscious
internal conflicts
c. Taught to reframe psychotic symptoms as
coping attempts rather than signs that they
are crazy or weak
d. Made to recognize the importance of
psychotropic drugs to combat delusions and
hallucinations
SITUATION. Jose, 30 years old was admitted to the
Psychiatry Ward because of changes in behaviour such as
neglect of self care, withdrawal from relations with people,
talking to himself and beliefs taht he is being persecuted. He
has been diagnosed with Schizophrenia disorder.
358. Nurse Dina was assigned to take care of Jose. She
approached and greeted Jose and sat with him to
start an interaction. He moved back to distantiate
himself and evaded eye contact. Nurse Dina
recognized that in order to establish a nurse-patient
relationship, it is important for Joe to have:
a. Self-confidence
b. Self-worth
c. Rapport
d. Trust
359. Nurse Dina observed that Jose kept mumbling
unintelligible words which made no sense to her
accompanied with inappropriate facial grimaces as if
he talking to someone. He claims he is in a prison
camp. Nurse Dina interprets these behaviors as:
a. Depersonalization
 b. b. Anhedonia
c. Lack of insight
d. Ambivalence
360. The multidisciplinary team shared observations of
Jose and discussed plans for treatment. Nurse Dina
anticipates that from evidenced based practice, the
MOST likely treatment plan to be initiated is:
a. Behavior modification c. Remotivation therapy
b. Relationship therapy d. Pharmacotherapy
361. A socialization program is scheduled for the day. A
therapeutic intervention of Nurse Dina is:
a. Minimize environment stimuli and have Jose
engage in a less stimulating activity
b. Present the plan for the day and have Jose decided
c. Have a friendly patient invite Jose to the socialization
program to overcome his withdrawal from social
relations
d. Refer the matter to the occupational therapist
362. A therapeutic attitude in dealing with Jose is by
being:
a. Lenient and have no demands
b. Actively friendly with him
c. Passively friendly with him
d. Simply objective and businesslike
SITUATION. Nurse Florida, the Community Health Nurse,
attended the a Barangay meeting where problem of “Troubled
teenagers who are delinquents, possible drug and alcochol
abusers and get involved in occasional violence...” was
discussed. She approached Gerry, the President of the
Sanggunian Kabataan and they talked about developing a
strategy which resulted in series of meetings with teenagers
in the barangay.
363. An informal first meeting with some teenagers was
held in basketball court. In order to engage the
teenagers to talk about their concerns, it is essential
for Nurse Florida and SK Jerry to:
a. Establish a contract with them
b. Ensure confidentiality of their discussions
c. Avoid bringing any gadget that the teenagers
can get suspicious of
d. Just listen more than talk
364. On the third meeting, 20 teenagers showed up. The
teenagers started to talk about their problems and
about ‘marijuana, acid exoerimenters, frequent
users, pushers, etc...’ At this point, it would be
therapeutic for Nurse Florida and Jerry to:
a. Make effort to offer solutions or answers to their
problems
b. Practice moralistic judgment
c. Maintain active listening
d. Translate to the teenagers what is going on in
their world
365. The themes of the conversations with the teenagers
centered around, “No one ever listens,” and “We
treid to talk with our teacher, then the guidance
counselor, the other teachers, the coach and still
othes but they just don’t have time...” The nurse
infers that these young people:
a. Are having reaction formation
b. Primarily want to avoid prison sentences
c. Desperately want relationships with adults
d. Worry about parental punishment
366. During the fourth meeting, 40 adolescents attended,
all eager to talk, share experiences and offer ideas.
The adolescents asked about the personal lives of
Nurse Florida and Jerry and who they had shared
information about their situations. This must be
taken as cue to:
a. Develop objectivity
c. Deepen trust in the relationship
b. Maintain professionalism
d. Establish control of the situation
367. After the fourth meeting, Nurse Florida and Jerry
explored ideas about future directions. In bringing in
a community leader to listen and talk to these
teenager, the priority objective of such meeting
would be to:
a. Avoid confinement in mental hospitals
b. Explore options and solve problems
c. Circumvent heavy prisonsentences
d. Do health screening among the teenagers
26 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
SITUATION. The nurse is caring for an elderly client who has
severe hearing impairment.
368. Which of the following is the MOST important of
assessing a client with hearing loss?
a. Change in style of communication
b. History of a client
c. Weariness or unexpalined irritability
d. Use of simple noninvasive way to test hearing
369. The nurse is preparing a nursing history. In
communicating with the client, which of the following
is the MOST appropriate method to be used by the
nurse?
a. Speak loud enough to be heard
b. Sit beside the client with the affected ear
c. Speak directly and clearly facing the clie
d. Use cardboard when asking question
370. The nurse is performing a physical exam on the
client. Which of the following is the MOST
appropriate method to be used by the nurse?
a. Bone conduction
b. Whisper Test
c. Audiogram
d. Otoscope
371. An elderly client asked the nurse why older adults
are more prone to conductive hearing loss and
tinnitus. The nurse addresses appropriately the
query of the client when she states that it is
important to INITIALLY rule out:
a. Injury to the middle ear
b. Hardened cerumen lodged in the external
ear
c. Recurrent otitis media
d. Damage to the tympanic membrane
372. Which of the following is an appropriate nursing
intervention for the client with hearing impairment?
a. Get an interpreter every time the nurse makes
contact with the client
b. Prepare set of questions and write responses of
client
c. Minimize environment noise before
speaking with the client
d. Place the client in a quiet well ventilated room
SITUATION. Kath is 9 years old. Horribly sexually abused by
her father, she had developed a way of behaving: she strips
naked, urinates on the floor and hit and kick on the staff, and
then asks sweetly for a hug. She is one of the kids on the
Child and Adolescent Unit of the hospital.
373. From the family history of Kath the nurse infers that
a fundamental issue is Kath’s:
a. Lack of maternal care and warmth
b. Feelings of hostility of own family
c. Inconsistent emotional and physical
relationships
d. Inability to trust relationships
374. With other behaviorally disturbed children in the
unit, Kath smiles with glee watching adult staff
struggle to take time to fix the place and put things
in order every time these kids create chaos. This
pattern of behaviour is:
a. Hostile
b. Assaultive
c. Manipulative
d. Demanding
375. Kath has developed hostile attitudes as shown in
her hitting and kicking behaviour. The
psychodynamics of Kaths’s behaviour MOST likely
would point to:
a. Inability to cope with conflict and
frustration
b. Lack of role models in her growing up
c. Cry for plea for protection of children’s rights
d. Inability to to discern what is acceptable from
unacceptable behaviuor
376. In creating a therapeutic environment for kath and
kids of the same situation, it is FOREMOST to:
a. Develop a positive image of self
b. Provide therapeutic limit setting
c. Provide values education
d. Observe physical hygiene and adequate nutrtion
377. In the unit, it is not uncommon to hear loud bangs
and thuds with yelling, screaming and cursing of
 these children with the company of Kath. A
therapeutic activity that the staff can provide is:
a. Sports that foster cooperation and teamwork
b. Painting and art work
c. Active ball games that are not competitive
d. Organizing scrapbook clubs
SITUATION. Psychiatric nursing practice has evolved from
an institutionalized setting to a more humane approach. Ideas
about mental illness, human natureand the
environmentcontinueto challenge roles of nurses.
378. Psychiatric treatment encourages client’s
independence. The nurse recognized which these
setting to be LEAST restictive.
a. Half-way homes
b. State hospitals
c. Family of orientation
d. Nursing homes
379. As the date for discharge approaches, a client
becomes increasingly anxious and regresses, thus
delaying staff’s decision to discharge client. The
client’s behavior, following this decision, improve and
this pattern gets repeated. The staff’s decision to
delay discharge acts as a:
a. Negative reinforce
b. b. Conditioner
c. Punishment
d. Positive reinforcer
380. Chronic schizophrenic patients are assisted to learn
self-helo behaviors by way of tokens for good
grooming, which in turn are used to present at
dinner to be served their meals. This an intervention
used in:
a. Social therapy
b. Behavior modification
c. Relationship therapy
d. Community involvement
381. Client is psychotic and confused. Priority in planning
is to:
a. Provide structural controls
b. Maintain safety of other patients
c. Maintain client safety
d. Avoid damage to environment
382. Which of these opportunities will the nurse create to
teach clients a sense of responsibility and learn the
consequences of their actions?
a. Remotivation groups
b. Client government
c. Activity groups
d. Discussion groups
SITUATION. The following are behavioral interactions which
have occurred within the ward milieu in which patient and
staff has encounters.
383. While the patients were gathering in the gym for the
morning exercise, Jennylyn approached the nurse
and reported about a “bad” behaviour of another
patient. The nurse observed Jennylyn’s repeated
pattern of bringing messages about misbehaving
patients. The nurse interprets this correctly as a/an:
a. Compulsive behaviour
b. Policing behaviour which helps to ensure
discipline in the ward
c. Attempt to enhace her power with the
nurse
d. Matter of fact behaviour that does not
necessarily have any intended meaning
384. During the ward meeting, Danny interrupts to ask
the nurse, “What time is it?” even though the wall
clock is visible to everybody. It is BEST for the nurse
to:
a. Have him refer to the clock
b. Respond, “Am I your time keeper?”
c. Ignore this behavior
d. Simply tell the time
385. During the nurse-patient interaction, the patient
remarked without trigger, “It bothers me” as he
showed disturbed behaviour. The nurse responds
therapeutically when she:
a. Observes and remains silent.
b. Asks, “When you say ‘it’ what are you talking
about?”
c. Verbalizes observation of the disturbed
behaviour
27 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
d. Reflects back, “You are bothered?”
386. Jacob has been noted to have the repeated pattern
of relating his thoughts as “You know” or “Everybody
knows.” It is BEST for the nurse to:
a. Interrupt as this may lead to obsessive thinking
b. Take this as simply a matter of expression
c. Observe for ideas of reference
d. Respond by asking for details
387. Virgie, a newly admitted patient exclaimed, “They
are talking about me” as he began to be upset and
irritable. A therapeutic response of the nurse would
be to:
a. Ask, “Who are they?”
c. Inquire on what is being talked about
b. Say, “Tell me what is upsetting you?”
d. Allow him to continue his
thought process
SITUATION. The nurse wants to develop a client education
program to increase the outpatient client’s knowledge and
skill regarding medication management.
388. Effectiveness of this program is BEST demonstrated
with the client’s:
a. Rigidly follow doctor’s orders regarding drug
intake
b. Self-reliant, self-care behaviours and
responsible use of prescribed medications
in the community setting
c. Religiously recording the intake for their
medications
d. Increased frequency of communication with the
health care team to consult for any problem that
may arise
389. The INITIAL goal of this program would be to:
a. Create a more productive alliance between
the client and members of the
interdisciplinary mental health care team
b. Increase treatment compliance
c. Impart the information necessary for
independent medication management
d. Teach responsible problem solving and decision
making skills regarding medication skills
390. Which of the following steps reflects the client’s
awareness of the first step in the correct procedure
to be used when taking medications?
a. Open the bottle and pour the correct amount
into the bottle cap or other container
b. Read the label or the doctor’s orders
carefully
c. Take the medication with a full glass juice or
water
d. Close the bottle tightly and double check the
doctor’s order
391. Which of the following offer social support regarding
medication compliance?
a. Use a calendar to track medication usage
b. Keep a journal or record of taking medications
c. Have the doctor recommend the use of
affordable generic medications
d. Have family and friends attend a
medication education group with the client
SITUATION. Management of the spinal cord injuries vary
from the acute management phase through rehabilitation.
The nurse faces challenges how to maximize health status to
preserve quality.
392. Nurse Carrie is assigned in the Neurological Ward.
She is taking of Bob with spinal cord injury. The
goals of managementfor Bob should include which of
the following:
a. Skeletal fracture reduction and traction, and
pharmacological therapy
b. Continuous monitoring of vital signs and
immobility
c. Prevent further injury and observe for
symptoms of progressive neurological
deficit
d. Pharmacological and physical therapy
393. Nurse Carrie is testing the motor ability of Bob. She
performs this procedure by:
a. Asking the client to move his upper and lower
extremities
b. Using a wasp of cotton from the shoulder down
the lower extremities
 c. Gently pincing the skin with a tongue bleda
starting at the shoulder level down to both lower
extremities
d. Asking the client to sppread the fingers,
squeeze the nurse’s hand and move the
toes or turn the feet
394. In taking care of clients with sopinal cord injury, the
nurse MUST observe which of the following nursing
interventions?
a. Promoting adequate breathing, improving
mobility, adaptation to sensory and
perceptual alteration, maintaining skin
integrity and elimination, providing comfort
measures
b. Maintaining immobility, adequate nutrition and
elimination, comfort measures, pharmacological
and respiratory therapy and adapting to sensory
and perceptual alterations
c. Improving elimination, adapting to sensory and
perceptual alteration, pharmacological and
respiratory therapy and maintaining skin
integrity
d. Adapting to sensory and perceptual function,
maintaining immobility, providing comfort
measures and improving bowel functions
395. one of the clients assigned to nurse Carrie is
Norman, who is in Halo Traction. While administering
the 8:00am medication, she notices that one of the
pins was detached. Which of the following should be
her INITIAL action?
a. Ask assistance from the other staff nurses to
immobilize the client
b. Leave the client in his position and call for help
with other staff
c. Call the neurosurgeon
d. Stabilize the head in a neutral position and
ask another nurse to notify the
neurosurgeon
396. Nursing care of Norman with Halo Traction requires
meticulous care under the halo vest. Which of the
following nursing measures MUST be done in
providing care to Norman?
a. Inspect for excessive perspiration, redness
and skin blistering, wash the torso and
change liner periodically
b. Inspecting the skin for redness and blistering,
and open the vest periodically to promote
comfort
c. Wash the torso and leave the liner in the body of
the client and apply powder especially on the
bony prominences
d. Applying powder inside the vest to prevent skin
breakdown after washing the torso
SITUATION. An orientation and training program was
developed for beginning nurse who chose a professional
career as psychiatric mental health nurses. During the course
of this program, a common concern was on challenges in
handling concern to discuss client situations during a
treatment planning conference.
397. Feelings of helplessness, powerlessness fear and
anger are common when patients threaten to strike
the nurse. A priority step in developing a plan to
manage patients threatening verbal communication
is for the nurse to:
A. Keep distance from the patient
C. Observe strict security protocol
B. Acknowledge the powerful feelings
D. have the client on the “watch list”
398. Nurse Rosanna reported that one of their male client
would often comment on how she puts on her make-
up that appears unbecoming of her. It is best for
Nurse Rosanna to:
A. Secretly go to the bathroom to check on how
she looks
B. Regard the client as lacking in personal values
C. Reprimand client that such is an unacceptable
behavior
D. Recognize this as manipulative behavior
399. The team recognized that threatening verbal
behaviors is a way of discharging feeling of
frustration. Disrupting the physical environment or
actually physically attacking someone can be best
prevented through:
28 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
A. Release of pent-up feelings in a nurse-
client relationship
B. Provision of adequate social support from the
team
C. Constant and consistent coaching from the team
D. Anticipation how to meet client’s needs in a
structured environment
400. The client, reacting to an authority figure shouted.
“You stupid nurse!” Attending Nurse Amanda
responded with a surge of anger, reliving an
experience with a former teacher who embarrassed
her by calling her stupid in class. It is most
important to have:
A. Recognize her feelings of anger
C. Dissociate from the past
B. Put herself in clients situation
D. Sympathize with the client
401. There are patients who engage in maladaptive
behaviors such as ridiculing and name calling staff
members like “obese, old, bitchy, bossy…etc.” in
order for the nurse to share such comments to the
team it is most important to have:
A. Respect and self –adequacy
B. Trust and courage
C. Self –confidence and self-worth
D. Love and belonging
402. The nurse concludes the client understands the
desired effects and major side effects of trazodone
(Desyrel) when he makes which of the following
statements?
a. “I know I will be able to get up and go
downstairs to the bathroom during the night as
long as I leave a nightlight on.”
b. “I am drinking more fluids now that I am taking
this medication so it will work the way it is
supposed to.”
c. “This medicine should help me sleep
without my having to worry about
becoming addicted to it, and if I have a
problem with priapism, I will notify my
doctor immediately.”
d. “I will feel more energetic after 3 or 4 weeks of
taking this medication, and I understand I must
take it only as prescribed so that I will not
become addicted to it.”
403. If an overdose of benzodiazepines is suspected, the
nurse obtains which of the following medications to
reverse that drug’s effects as ordered?
a. Diazepam (Valium)
b. Triazolam (Halcion)
c. Fluvoxamine (Luvox)
d. Flumazenil (Romazicon)
SITUATION. Nurse Riza is dealing with psychiatric clients.
She knows that therapeutic communication is essential for an
effective nurse-patient interaction.
404. Nurse Riza enters a client’s room to obtain an
admission history, moves the chair to the top of the
bed by the client’s head, and sits down to better
hear the client. The client draws back and moves to
the opposite side of the bed. What is the best
response by Nurse Riza?
a. Move the chair a foot or two away from the
bed and observe the client’s response.
b. Say, “I will come back later when you are ready
to talk to me.”
c. Ignore the behavior and continue with the
interview, observing the client for depression.
d. Lean over and touch the client to convey
reassurance.
405. During the nursing assessment of an elderly female
client, Nurse Riza enhances communication by doing
which of the following?
a. Speaking loudly and using many gestures
b. Interviewing the client quickly to converse the
client’s energy
c. Interviewing the client with family present to
verify responses to questions
d. Restating terms or phrases in different
ways if the client does not understand
406. Nurse Riza would use which of the following
statements when trying to encourage a client to
 express her feelings and allow her to genuinely
respond to those feelings?
a. “You mentioned that you broke your leg last
year. Can you tell me more about how that
happened?”
b. “You shared with me a lot of information about
your history of depression. It sounds as though
medication alone may not be controlling your
symptoms as you hoped.”
c. “You mentioned that your back pain has
never gone away since your surgery. How
difficult has it been to adapt to having pain
during everyday activities?”
d. “You told me that you have had asthma since
you were 11 years old and that medication
therapy requires adjustment every 8 to 10
months or so. Is that right?”
407. Which of the following would be the most
appropriate time for the use of confrontation as a
therapeutic technique for communication with an
assigned client?
a. When a good relationship exists and the
client’s anxiety level is low
b. During periods when the client is noncompliant
c. After client has had time to reflect on his or her
behavior
d. Immediately after a negative behavior has
occurred
408. Nurse Riza observes a client who is fidgeting,
wringing the hands, and has body tenses and a
wrinkled brow. What is the best way for her to
interpret these non-verbal cues?
a. Say, “You look tense. Can you tell me if
something is making you afraid or
nervous?”
b. Ask, “You look upset. Would you like some
medication to help you become calmer?”
c. Say, “You look worried. Is something bothering
you?”
d. Ask, “Why are you so nervous and jumpy?”
SITUATION. Nurse Ivy is assigned in a rehabilitation facility
and is caring for clients with addiction.
409. Nurse Ivy is caring for a client with alcohol
dependence. During the admission process, the
client verbalizes occasional sexual performance
problems. Then he says, “It’s nothing a little alcohol
can’t fix.” Nurse Ivy provides education about the
effect of alcohol on sexual functioning by which of
the following?
a. Increased desire and performance ability
b. Headache and the “too tired syndrome”
c. Hyperarousal and premature ejaculation for men
and anorgasmia for women
d. Decreased desire and ability to perform
410. A physician just wrote an order for a client to take
naltrexone (ReVia). What would be the greatest
concern of Nurse Ivy while getting ready to
administer this medication?
a. The medication blocks the euphoric feeling from
narcotics and alcohol.
b. Whether the physician provided good medication
teaching.
c. The medication can precipitate withdrawal
if the client is not completely detoxified.
d. The client will not be able to experience
pleasurable sensations.
411. Nurse Ivy observes a family visit on the unit and
recognizes that the family is suffering with effects of
addiction and codependence. What long-lasting
interpersonal problems might Nurse Ivy expect
family members to manifest?
a. Lowered self-esteem
b. Impatience
c. Frustration tolerance
d. Being argumentative
412. A client is transitioning to a less intensive level of
outpatient treatment for addiction. The client
statement that most reflects risk for relapse is:
a. Dreaming about gambling or engaging in
compulsive sex.
b. Not feeling happy.
c. Feeling hungry or tired.
29 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
d. Keeping thoughts of using a secret.
SITUATION. Nurse Nicole is assigned in psychiatric unit and
is handling a client who frequently demonstrates aggressive
behavior.
413. When conducting assessment of the client within the
unit for the potential for violent or aggressive
behavior, it is important for Nurse Nicole to:
a. Reassure the client that everything will be all
right, and the staff will make sure nothing
untoward happens.
b. Reinforce that the client is solely
responsible for his or her own actions and
will experience the consequences of acting
out.
c. Explain that violence is not acceptable, and the
staff will not allow the client to act out.
d. Reassure the client that limited acting out will be
allowed but only in a controlled setting.
414. Nurse Nicole would use which of the following as the
most restrictive intervention when responding to
clients who display the potential for violence?
a. Meeting in a quiet room to reduce stimulation
b. Administering a PRN medication to reduce
anxiety
c. Providing physical interventions, such as two-
person escort out of a program area
d. Using restraints, such as four-point
restraint
415. Which of the following is the most important
intervention by Nurse Nicole when a client does not
respond to less restrictive interventions and is
rapidly escalating toward violence?
a. Cease negotiation with a client and
implement plan of intervention to control
and provide safety.
b. Bargain with client to determine what can be
done to prevent assaultive behavior.
c. Offer a PRN medication to reduce anxiety.
d. Ask client to move to a less stimulating, private
area and spend some time alone.
416. The client who became violent on the psychiatric unit
had restraints applied at 10:00 am. Nurse Nicole
makes a note to release the restraint at no later than
which of the following times?
a. 10:15 am
b. 11:00 am
c. 12:00 nn
d. 02:00 pm
417. After a staff member has been involved in a
particularly violent episode with a client, debriefing
should occur:
a. After the staff had the opportunity to calm.
b. Immediately to facilitate processing of
feelings.
c. Only until the staff requests such intervention.
d. After a 3-day time-off period.
SITUATION. Nurse Paula is caring for Aling Ibyang, a 73-
year-old client suspected to have Dementia of the Alzheimer’s
type.
418. Which of the following approaches would be best for
Nurse Paula who is communicating with the
cognitively impaired client?
a. Loud and precise
b. Simple and direct
c. As nonverbal as possible
d. Sign language
419. Which of the following should be given the first
priority when planning the care of a client with
dementia?
a. Preventing further deterioration
b. Finding suitable nursing home placement
c. Supporting family caregivers
d. Preventing injury
420. Nurse Paula would include the overall goal for
nursing care is which of the following?
a. Reorient the client to reality.
b. Keep the loss of capacity for self-care to a
minimum.
c. Assist the client with tasks of daily living.
d. Maintain adequate hydration and nutrition.
 421. Which of the following nursing interventions would
support optimal memory function for a client with
dementia?
a. Develop stimulating and meaningful
therapeutic activities.
b. Remind the client of forgotten events.
c. Orient the client to reality.
d. Restrain the client when agitated.
SITUATION. Nurse Julie is assigned in a psychiatric unit
handling clients with anxiety disorders.
422. Nurse Julie is assessing a client whom verbalizes
feeling of “a sudden, intense fear for no apparent
reason”. Which of the following should the nurse
assess the client for other symptoms compatible with
this?
a. Agoraphobia
b. Obsessive compulsive disorder
c. Panic disorder
d. Posttraumatic stress disorder
423. Nurse Julie has been told that a client’s anxiety is at
the panic level. The following symptoms is expected:
a. Dizziness, palpitations, and nausea
b. Feelings of “butterflies” in the stomach
c. Feelings of fatigue and inability to remain awake
d. Obsessive thought and compulsive behavior
424. The underlying assumption behind cognitive therapy
in treating anxiety disorder is:
a. Mental health problems are learned and can be
corrected through relearning.
b. Mental health problems are illnesses that may
be inherited and/or caused by chemical
imbalances.
c. Distorted conceptualizations and
dysfunctional beliefs can lead to mental
health problems.
d. Goup tasks can set the stage to allow important
group interactions to occur.
425. Which type of therapy exposes the client to
imaginary or real-life stress-provoking stimuli for an
extended period of time, and session is terminated
when client’s anxiety decreases?
a. Response prevention
b. Systematic desensitization
c. Implosion therapy
d. Thought-stopping
SITUATION. Nurse Rosa is a psychiatric nurse working at
National Center for Mental Hospital and is caring for clients
with Dissociative Disorders.
426. One of the clients whom Nurse Rosa is caring for
reports depersonalization experiences that have
been frightening to him. Which of the following is the
most therapeutic response by Nurse Rosa?
a. “It must be very scary for you. Tell me
more about how they occur.”
b. “Don’t worry; you will always come back
together.”
c. “Being in the hospital must be very frightening.”
d. “Let’s focus on the stress in your life.”
427. A client with dissociate identity disorder (DID) who
has just been admitted with several fresh burns on
her ankles and wrists is refusing to attend group
therapy. What should be the priority nursing
diagnosis by Nurse Rosa?
a. Self-care deficit
b. Impaired sensory perception
c. Risk for self-mutilation
d. Noncompliance
428. The most appropriate outcome of care by Nurse Rosa
for a male client who has experienced a dissociative
fugue is that the client will do which of the following?
a. Remember what occurred during his fugue
stage.
b. Gain additional coping skills to deal with
his current problems.
c. Report no feelings of being detached from his
body.
d. State the positive aspects about himself.
429. Which coping technique for dissociative disorders
focuses on external environment rather than on
30 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
internal feelings, thoughts, or sensations that can
lead to “spacing out”?
a. Progressive muscle relaxation
b. Physical exercise
c. Grounding
d. Distraction
SITUATION. Nurse Dianne is assigned as Community Mental
Health Nurse in municipality of Hagonoy. She is dealing with
various families in the said community.
430. Nurse Dianne constructing a family genogram for an
adult client would not necessarily include which of
the following family members mentioned by the
client?
a. 28-year-old brother
b. 4-year-old stepson
c. 43-year-old aunt
d. 91-year-old great grandmother
431. Nurse Dianne notes during a client interview that
which of the following client data could indicate a
potential problem with the functioning of the client’s
family and warrants further assessment?
a. The client and spouse resolve an argument on
their own, although it often takes a few hours.
b. The client visits her aging mother and father
who live an hour away every other week.
c. The client takes a weekly art class and a weekly
dance class.
d. The client often “grounds” the children for
misbehavior in an attempt to raise them
“the right way.”
SITUATION. Nurse Marie is assigned in caring for clients
with various types of cast applied.
432. A client has a fiberglass (nonplaster) cast applied to
the lower leg. The client asks the nurse when the
client will be able to walk using the casted leg. The
nurse replies that the client will be able to bear
weight on the casted leg:
a. In 48 hours
b. In 24 hours
c. In about 8 hours
d. Within 20 to 30 minutes of application
433. A nurse is assessing the casted extremity of a client.
The nurse would assess for which of the following
signs and symptoms indicative of infection?
a. Dependent edema
b. Diminished distal pulse
c. Presence of “hot spot” on the cast
d. Coldness and pallor of the extremity
434. A client has sustained a closed fracture and just had
a cast applied to the affected arm. The client is
complaining of intense pain. The nurse elevates the
limb, applies an ice bag, and administers an
analgesic, with little relief. The nurse interprets that
this pain may be caused by:
a. Infection under the cast
b. The anxiety of the client
c. Impaired tissue perfusion
d. The recent occurrence of the fracture
435. A nurse has conducted teaching with a client in an
arm cast about signs and symptoms of compartment
syndrome. The nurse determines that the client
understands the information if the client states that
he or she could report which of the following early
symptoms of compartment syndrome?
a. Cold, bluish-colored fingers
b. Numbness and tingling in the fingers
c. Pain that increases when the arm is dependent
d. Pain relived only by oxycodone and aspirin
436. A nurse is admitting client with multiple trauma to
the nursing unit. The client has a leg fracture and
had a plaster cast applied. In positioning the casted
leg, the nurse should:
a. Keep the leg in a level position.
b. Elevate the leg for 3 hours and put it flat for 1
hour.
c. Keep the leg level for 3 hours and elevate it for
1 hour.
d. Elevate the leg on pillows continuously for
24 to 48 hours.
 437. A nurse has given a client with a leg cast instructions
on cast care at home. The nurse would evaluate that
the client needs further instruction if the client
makes which of the following statements?
a. “I should avoid walking on wet, slippery floors.”
b. “I’m not supposed to scratch the skin
underneath the cast.”
c. “It’s okay to wipe dirt off the top of the cast with
a damp cloth.
d. “If the cast gets wet, I can dry it with a
hair dryer turned to the warmest setting.”
438. A client is complaining of skin irritation from the
edges of a cast applied the previous day. The nurse
should take which of the following actions?
a. Petal the cast edges with adhesive tape.
b. Massage the skin at the rim of the cast.
c. Use a rough file to smooth the cast edges.
d. Apply lotion to the skin at the rim of the cast.
439. A client is being discharged to home after application
of a plaster leg cast. The nurse determines that the
client understands proper care of the cast if the
client states that he or she should:
a. Avoid getting the cast wet.
b. Cover the casted leg with warm blankets.
c. Use the fingertips to lift and move the leg.
d. Use a padded coat hanger end to scratch under
the cast.
SITUATION. Nurse Mina is assigned in Orthopedic Ward and
is caring for clients under skin and skeletal tractions.
the nurse notes a small amount of bleeding around
the pin insertion sites. The nurse should take which
action?
a. Notify the surgeon.
b. Recheck in 1 hour.
c. Check the client’s vital signs.
d. Place a small pressure dressing at the
bleeding site.
445. The nurse is assigned to care for a client who is in
traction. The nurse prepares a plan of care for the
client and includes which nursing action in the plan?
a. Monitor the weights to be sure that they are
resting on a firm surface.
b. Check the weights to be sure that they are
off of the floor.
c. Make sure that the knots are at the pulleys.
d. Make sure the head of the bed is kept at a 45-
to 90-degree angle.
446. The nurse has developed a plan of care for a client
who is in traction and documents a nursing diagnosis
of self-care deficit. The nurse evaluates the plan of
care and determines that which of the following
observations indicates a successful outcome?
a. The client allows the nurse to complete the care
on a daily basis.
b. The client assists the family to assist in the care.
c. The client refuses care.
d. The client assists in self-care as much as
possible.

440. A client with a hip fracture asks the nurse why SITUATION. You are the nurse caring for Elisa, a 3-year-old
Buck’s extension traction is being applied for female client diagnosed with seizure disorder.
surgery. The nurse’s response is based on the
understanding that Buck’s extension traction 447. The main difference between simple and complex
primarily: partial seizure is that the former:
a. Allows bony healing to begin before surgery a. Does not involve impairment in
b. Provides rigid immobilization of the fractured consciousness
site b. Accompanies impairment in consciousness
c. Lengthens the fractured leg to prevent severing c. Has automatisms
of blood vessels d. Has cognitive symptoms
d. Provides comfort by reducing muscle 448. You are reviewing the guidelines for seizure care.
spasms and provides fracture Which of the following nursing care during a seizure
immobilization is incorrect?
441. A client has Buck’s extension traction applied to the a. Ease the patient to the floor, if possible
right leg. The nurse would plan which of the b. Loosen constrictive clothing
following interventions to prevent complications of c. Protect the head with a pad to prevent injury
the device? d. Attempt to pry open jaws that are clenched
a. Give pin care once a shift. in a spasm
b. Massage the skin of the right leg with lotion 449. Which of the following nursing care is appropriate
every 8 hours. after a seizure event?
c. Inspect the skin on the right leg at least a. Keep the patient on side-lying position
once every 8 hours. b. Place bed in highest position possible with
d. Release the weights of the right leg for daily two to three side rails up and padded
range-of-motion exercises. c. Orient the patient upon awakening
442. The nurse is preparing a plan of care for the client in d. Use calm persuasion and gentle restraint when
skin traction. The nurse includes in the plan that a the patient becomes agitated
priority intervention is to assess the client frequently 450. The patient had a series of generalized seizures that
for: occurred without full recovery of consciousness
a. The presence of bowel sounds between attacks lasting for 30 minutes. The nurse
b. Signs of infection around the pins sites documents this as:
c. Signs of skin breakdown a. Status epilepticus
d. Urinary incontinence b. Petit mal seizure
443. A nurse is evaluating the pin sites of a client in c. Tonic-clonic seizure
skeletal traction. The nurse would be least concerned d. Atonic seizure
with which of the following findings? 451. The priority intervention in caring for patient with
a. Inflammation seizure disorder is:
b. Serous drainage a. Improving coping mechanisms
c. Pain at pin site b. Reducing fear of seizures
d. Purulent drainage c. Preventing injury
444. A client returns to the nursing unit following the d. Providing patient and family education
application of skeletal leg traction. Upon assessment,

FUNDAMENTALS OF NURSING – FINAL COACHING SET B KEY ANSWER

1. C 8. B 15. D 22. C 29. C
2. B 9. A 16. D 23. D 30. A
3. C 10. B 17. B 24. D 31. D
4. C 11. A 18. B 25. C 32. C
5. D 12. A 19. D 26. B 33. A
6. B 13. C 20. C 27. B 34. C
7. C 14. A 21. D 28. B 35. A

31 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS

 36. C 52. A 68. D 84. C 100. B
37. A 53. A 69. B 85. B 101. D
38. C 54. B 70. D 86. B 102. D
39. B 55. A 71. C 87. C 103. B
40. D 56. B 72. A 88. B 104. C
41. C 57. B 73. B 89. B 105. D
42. C 58. B 74. A 90. B 106. A
43. C 59. D 75. A 91. C 107. C
44. C 60. C 76. D 92. C 108. A
45. A 61. B 77. B 93. C 109. D
46. C 62. D 78. B 94. A 110. A
47. B 63. C 79. C 95. C 111. A
48. D 64. A 80. A 96. B 112. B
49. C 65. B 81. C 97. C
50. B 66. B 82. B 98. C
51. B 67. C 83. A 99. C

113.

Donor-Recipient Relationships
DONORS
O A B AB
PATIENT

AB Yes Yes Yes Yes

B Yes No Yes No
A Yes Yes No No
O Yes No No No

Universal Blood

BLOOD TYPE COMMONLY KNOWN AS RATIONALE

O- Universal Donor O+ May cause allergic reactions of Rh -
recipients
AB+ Universal recipient AB – may be allergic to blood of Rh+ donors

Blood Transfusion

COMMON BOARD EXAM QUESTION ANSWER RATIONALE

Gauge 18 G – 20 G The preferred needle sizes; bigger
needles allow passage of blood contents
Solution NSS only at KVO Other solutions may be incompatible and
may cause lysis of RBC. Initiate another
IV line if the main line is incompatible
Blood stay 30 minutes Blood is left in the room for no more than
30 minutes before starting the blood
transfusion to prevent further
deterioration of the red blood cells
Height 1 meter/3 feet/36 in. Distance of the container above the
venipuncture site
Method 15-15-15-15 15 drops for the first 15 minutes; stay
with the patient for the first 15 minutes
and monitor vital signs every 15 minutes
for the first hour, then every our
thereafter
Completion Time 4 hours Packed RBC should not hang for more
than 4 hours. The risk for sepsis
increases if blood hangs for a longer
period
Tubings 1-2 units Blood tubing must be changed of
transfusion of 1-2 units of blood
Reactions BT reactions Febrile, non-hemolytic is the most
common reaction. Acute hemolytic is the
most dangerous reaction
Pre-medications Antihistamines Reduce chances of allergic reactions.
Give 30 minutes before BT

Intravenous Fluid Therapy

 IV Insertion

CUE CONSIDERATION
Wash hands At least 20 seconds
Vein Use distal veins of the non-dominant hand
Tourniquet 2-6 inches above the site of IV insertion
Cleanse site Alcohol swab 3 to 4 inches
Disinfect Use povidone iodine swab to disinfect skin, 3 to 4 inches
Insert 15-30 degree angle , bevel up
32 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS
Continuous Bladder Irrigation (Cystoclysis)

 FAST FACTS
1. Purpose
2. Physician’s order
3. Urinary catheter
4. Insertion procedure
5. Saline solution
6. Measurement
7. Danger
8. Needed equipment
 COMMON CONCERNS
1. Output < Input
2. Pt complains of pain Pain rating scale, bladder palpation, tubings kinks assessment, drainage observation, intake and
3. Bloody/clotty drainage
4. Catheter leaks
5. Documentation
To maintain the patency of the urinary catheter and tubing
Foley catheter insertion and cystoclysis
3-way catheter: (1) From irrigating solution, (2) to bladder, (3) from bladder to urine
bag
Sterile to avoid infection and occlusion
Store at room temperature to prevent bladder spasms
Strict intake and output for all patients
Bladder perforation
Sterile NSS for irrigation (3L/bag), 3 way catheter, large urine drainage bag
NURSING ACTION
S: Stop and recalculate the Intake and Output
A: Assess the tubing for kinks and loops
P: Palpate for bladder distention
I: Irrigate manually if obstruction is suspected (Instill slowly at least 60 ml of sterile
NSS. Do not force if resistance is met. Allow irrigation to flow back freely)
N: Notify physician if previous measures are unsuccessful
output measurement and avoidance of cold solution
Increase rate of irrigation as ordered, perform manual irrigation, inform physical if large
amount of blood or clots persists
Assess for spasm, obstruction, infection, may administer Buscopan as ordered
C: Comfort/pain scale of the patient
C: Color and appearance of drainage
C: Clots and fragments noted
C: Calculation of urine > CBI infused – foley output = True urine
C: Concerns of patient like bladder spasms
C: Client teaching performed

Condom Catheterization

 Preparation Details the patient, inspect and cleanse the penis

 Secure condom
 Tape the condom
 Connect
 Attach
 Changing time
Leave 1 inch space between penis and the plastic connecting tube
Secure elastic tape around the base of the penis over the condom
Check for penile oxygenation within 30 minutes
Connect condom to the urinary drainage system
Ambulatory Patient: Attach the bag to the patient’s leg
On complete bedrest: Attach the bag to the bedframe
Change condom catheter everyday, wash penis with soap and water, then dry

Urinary Catheterization

 Fast Facts
1. Sizes of Catheter CHILD ADULT MALE
Fr 8-10 Fr 14-16 Fr 18
2. Length of Catheter FEMALE: 22 cm MALE: 40 cm
3. Types of Catheter STRAIGHT: Inserted to drain the bladder and then removed immediately
RETENTION: Remains in the bladder to drain urine
COUDE’: More rigid than straight catheters; has tapered and curved tip
(Commonly used for men with prostatic hypertrophy; it is more easily controlled and
less traumatic on insertion)
3-WAY CATHETER: For patients who may require bladder irrigation
4. Catheter Materials MATERIAL DURATION
Plastic catheter 1 week or less (inflexible)
Rubber/Silastic 2-3 weeks
Siliconized Rubber 2-3 months
They create less encrustation at the meatus
(expensive)
Polyvinyl chloride (PVC) 1-1 ½ months
They soften at body temperature to conform
with urethra
 Differences in Male-Female Catheterization

PATIENT MALE FEMALE

Position Supine: Thighs slightly abducted Dorsal recumbent: Feet at about 2 feet
apart
Depth of insertion 6-9 inches 2-3 inches
RN’s 1 hand Grab the penis 90 degrees higher Retract the labia
Cleaning method Circular Front to back
Insertion instruction Inhale through the mouth and exhale as Inhale through the mouth and exhale as
the nurse inserts the cath the nurse inserts the cath
Attach Lower abdomen Inner thigh

Rectal Tube Insertion

 Purpose Remove excessive air in the intestines

 Pt’s position Left-lateral position with upper leg bent over the lower leg
 Lubricate 4 inches of the rectal tube
 Insert 4 inches towards the umbilicus

33 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS

  Rectal tube French 20-30
 Duration 20 minutes
 Brainsticker: 4-4, 20-20 (4 inches lubrication, 4 inches insertion, French 20, for 20 minutes

Colostomy Care

 Colostomy Surgical creation of an opening of the colon onto the surface of the abdomen
 Colostomate Person with colostomy
 ET Nurse Enterostomal Therapy nurse: one who figures out best location of the stoma
 CWOCN Certified Wound, Ostomy, Continence Nurse
The nurse who teaches the patient about the rationale and general principles of ostomy care
 Risk Low rectal surgery risks: Post-operative sexual dysfunction and urination incontinence due to
possible nerve damage
 Stoma Appearance: Pink to bright red (shiny), appears warm and moist and secretes mucus, protrudes
at about ¾ inch or 2 cm
After operation: Slightly edematous
Stoma normally shrinks: 6-8 weeks after surgery
Stoma shape: Round to oval
 Function Colostomy usually functions: 3 to 6 days post-operatively
 Measure Stoma measurement: Done at least once a week for the first post-op 6-8 weeks
 Education Teach patient to report:
M: Mucocutaneous separation (breakdown of sutures)
U: Unusual loss of sensation (initially, it has no sensation)
S: Signs of ischemia and necrosis (dark red, purplish or black color; dry, firm or flaccid
S: Stenosis (inability to pass the catheter/cone into the stoma)
T: Terrible bleeding
 Cleaning Colostomy cleaning: Use mild soap and water, moist and soft cloth (gauze dressing can cover the
stoma)
 Soap Soap to avoid: Irritating, harsh and moisturizing soap (lubricants in moisturizing soap interferes
adhesion of appliance)
 Complication Most common complication: Hernia
 Types Types of colostomy according to duration:
Short – term (temporary): Allows healing process
Long – term (permanent): Created when distal colon portion is made to permanently rest
(descending/sigmoid colostomy; the only colostomy that can be controlled)
 Types Types of colostomy according to location:
Ascending colostomy: Liquid stool (Rarely used because ileostomy is better if the discharge is
liquid)
Transverse colostomy: Semi-formed stool (Change: No more than once a day and not less than
once every 3-4 days)
Descending colostomy: Formed stool (Most often, stool can be controlled)
Sigmoid colostomy: The most common type of colostomy, bowel movement: 2-3 days
Note: After cleansing the skin, the patient pats the skin completely dry with a gauze pad, taking care not to rub the area. The patient
can lightly dust nystatin (Mycostatin) powder on the peristomal skin if irritation or yeast growth is present.

Changing an Ostomy Appliance

 Duration Ostomy appliance is changed every 3-7 days

 Empty Empty the colostomy bag when it is 1/3 to ¼ full
 Time Not close to meal or visiting hours (before meals is advisable)
Not immediately after meals (2-4 hours after meals is ideal)
Not immediately after administration of drugs that may stimulate patient to defecate
 Pt Position Bed: Sitting or lying position
Ambulatory: Sitting or standing in the bathroom facing the toilet
 Steps Empty contents: if pouch is drainable
Remove the pouch: if non-drainable
Cleanse periostomal skin and stoma with warm water and mild soap and wash cloth
Dry the area by patting with towel
 Skin barrier Measure the stoma using the stoma guide
Trace circle at the back of the skin barrier
Make an opening 1/8 inch larger than the stoma
Remove the paper backing and apply skin barrier, press for 30 seconds
Apply pouch

Colostomy Irrigation

 Tip Same time each day, after a meal or after a hot/warm drink
 Irrigation Lukewarm (tepid tap) water, 500-1000 ml
 Temperature 100oF (37.8oC)
 Bag height Pt. is standing: Bottom of container, levels the shoulder when patient is seated
Pt. is supine: 12-18 inches above the stoma
 Position Sit on the toilet or stand up straight
 Time 5 minutes/1000 ml
 Cramps Cramps and nausea: Signs of too fast administration; too much water; or too cold fluids
Management: Temporarily stop the infusion (clamp) and have the patient take deep breaths
Resume instilling the water when cramps have subsided

Enema

 Fast Facts about Enema

1. Mechanism Distend the intestine or sometimes, irritate the intestinal mucosa
2. Temperature 100 – 105 oF (37.8 to 40.6 oC)

34 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS

 3. Child Enema temperature: 37.8 oC to prevent burning the rectal tissues
4. Pt.’s position Left-lateral Sim’s position
5. Insertion 1-1 ½ inches, infant
2-3 inches, child
3-4 inches, adult

Note: High-flow (large volume) enema is given to cleanse as much of the colon as possible
Low-flow (small volume) enema is given to cleanse the rectum and sigmoid colon only

 Enema Administration Tips

1. Lubricate 2 inches of the rectal tube
2. Pt. position Left lateral with the right leg acutely flexed
3. Insert Smoothly and slowly into the rectum towards the umbilicus
4. Depth 3-4 inches (places the tip of the tube beyond the anal sphincter; anal canal is about 1-2 in.)
5. Resistance If there is resistance, instruct the pt to take a deep breath and run small amount of solution to
relax the rectal and anal sphincter
6. Height 12 inches: Low enema; 18 inches: High enema
7. Complaint If patient complains of fullness or pain:
Lower the container or use the clamp to temporarily stop the flow for 30 seconds; then restart
the flow at a slower rate
8. Retention At least 5-10 minutes for cleansing enema
At least 30 minutes for retention enema

 Types of Enema

TYPES PURPOSE CONTENT RETENTION TIME

Cleansing Enema Pre-op Soapsuds Hold (5-10 minutes)
Oil-retention enema Soften feces 4-8oz of olive/mineral oil 1-3 hours
Carminative enema Expel flatus 3 oz H2O, 2 oz glycerin, 1 oz 5-10 mins
Epsom
Fleets enema Decrease constipation 4 oz H2O, hypertonic saline 2-5 mins
Return-flow enema Expel flatus 100-200 ml alternating fluid Repeated 5-6 times

Transfer Techniques

 Moving Client Up in Bed

1. Bed Flat or as low as the patient can tolerate
2. Bed height At nurse’s waist level
3. Bed wheels Must be locked
4. All pillows Are removed (Place one against head o bed to protect patient)
5. Patient 3 ways: (1) Grasp the head of the bed; (2) Raise upper body on elbows and push; or (3)
grasp the overhead trapeze
6. Nurse Near arm: Under the client’s thighs
Far arm: Push down on the mattress
7. Weak Patient Patient: Flex hips, knees and neck with arms across the chest
Nurse: One hand under back-shoulders, one hand under thighs, then push the pt.
 Turning Client to Lateral or Prone Position
1. Move patient To the side of the bed opposite the side the patient will face when turned
2. Patient Near arm: Is placed across his chest
Near leg: Is placed across his far leg

 Assisting Client to Sit on the Side of the Bed

1. Patient Lateral position facing the nurse
2. Bed Raise head of the bed slowly to its highest position
3. Nurse Stand near head of the bed, facing towards the foot of the bed
Arm: Around pt’s shoulders and beneath pt’s thighs
Assist patient to a sitting position
 Transferring Patient Between Bed and Chair
1. Bed Lowest position (so that pt’s feet will rest flat on the floor)
2. Head of bed Is raised to a sitting position (or as tolerated by patient)
3. Wheelchair Placed on side of the bed (placed on the stronger side of the patient)
Parallel to bed (as close as possible to the bed); 45 degree angle to the bed
Put chair next to the head part of the bed (facing the foot of the bed)
4. Nurse Assist patient to sit on edge of bed
Assess balance problems (allow pt’s legs to dangle for a few minutes)
Wrap gait belt around the patient’s waist (based on assessed need)
Face pt, spread feet about shoulder width apart, and flex hips and knees
Keep back straight; avoid twisting
5. Patient Hands on bed or on the nurse’s shoulder
Should not grasp the nurse’s neck for support (masasakal ang nurse)
6. Nurse and pt Nurse’s foot positioned on the outside of the patient’s foot
Assist patient to stand, instruct to push back foot and rock to forward foot
Nurse pushes patient with forward foot and rocks to the back foot
Note: If without belt, place your hands on the side of the chest, not at the axillae of the patient
 Transferring Patient Between Bed and Stretcher
1. Bed Flat and slightly higher than stretcher
2. Nurse Instruct client to flex neck and place arms across chest, then move pt using draw sheet

Ambulation-Related Skills

35 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS

  Walkers
1. Candidate pt Upper extremities: Adequate upper body strength
Lower extremities: Partial weight-bearing
2. Usage BOTH LEGS ARE WEAK ONE LEG IS WEAKER
Walker-> Right -> Left Leg Followed by the good leg
3. Safety tips Do not step too close, do not consistently watch your step, walk slowly
4. Sitting Sitting with a walker
(1) Position yourself, (2) Place stronger leg behind, (3) Use both arms as your support as you sit
5. Stair Going upstairs with a walker
(1) Prepare to climb, (2) Fold the walker, (3) Walker then the good leg, (4) then the bad leg, (5)
upon reaching the last stair step, unfold the walker, and (6) move the good leg
6. Stair Going downstairs with a walker
(1) Prepare and fold the walker, (2) walker first, (3) followed by the bad leg, (4) then good leg,
(5) unfold the walker, (6) then continue with bad leg

MEDICATION

ROUTE NEEDLE GAUGE SYRINGE ANGLE EFFECT SITE EXAMPLE

ID ¼ - 3/8 inch 27 G 1 ml 15o Local effect Lightly pigmented areas
SubQ ½-5/8 inch 1-3 ml 1-3 45o Slow-systemic Fat pads in the abdomen and
thighs
IM 1-2 inch/es 22 G 3-5 ml 90o Rapid-systemic Vastus lateralis, Deltoid,
Ventro/dorsogluteal

IM SITE AGE DETAILS

Vastus Lateralis 1 year and younger Divide upper leg to 9 areas
Inject in the outer middle third

Ventrogluteal Over 1 year Inject between iliac crest and antero-

superior iliac supine
Dorsogluteal 3 years old and above Site is not used until a child has learned to
walk for at least 1 year

WHAT IS YOUR GOAL?

TO TOP THE BOARD EXAM!!!

36 CLOSED DOOR COACHING: FOCUS ON COMMON BOARD QUESTIONS