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RECALLS 1 EXAM
NURSING PRACTICE 3
November 2022 Philippine Nurse Licensure Examination Review

NAME: DATE: SCORE: _____

INSTRUCTIONS: Select the correct answer for the following questions. Shade the letter of the correct answer for the corresponding question in the provided answer sheet.
STRICTLY NO ERASURES ALLOWED.

Situation: Nurse Kristian is an Operating Room nurse
preparing the necessary documents of clients for
surgery.
1. When Nurse Kristian is admitting a client for surgery, which
question is most useful in determining the client’s current
nutritional status?
A. "How is your appetite usually?"
B. "What did you eat and drink yesterday?"
C. "Have you noticed any weight loss recently?"
D. "Who does most of your shopping and cooking?"
2. A client complains of severe pain 2 days after surgery. Which
initial action should Nurse Kristian take after assessing the
character of the pain?
A. have the client rest
B. take the client’s vital signs
C. administer the prn analgesic
D. document the client’s complaint
3. A client who is scheduled for a Billroth II procedure asks the
nurse to explain what will be done during the surgery.
Which response should the nurse make?
A. "The surgeon will explain the procedure to you since
the doctor is responsible for obtaining consent."
B. "Your stomach is completely removed and the
esophagus is connected to the small intestine."
C. "The bottom part of the stomach is removed and the
remainder is attached to the small intestine."
D. "The nerves that go to your stomach are cut and a
larger opening is made for stomach emptying."
4. On the first postoperative day after an open Billroth II
procedure a client develops hiccups, 6 on a scale of 10 epigastric
pain, and a drop in blood pressure. The nurse's initial actions
should be to:
A. assess the amount of drainage from the nasogastric
(NG) tube.
B. notify the client’s physician.
C. assess the abdominal dressing.
D. administer the ordered Morphine Sulfate 4 mg IV.
5. As a Surgical Nurse management of Peri-operative clients
demand the use of knowledge, judgement and skills based on
the principles of surgical nursing practice. Which information
obtained in the postoperative assessment of a 32-year-old client
with Peritonitis will be of most concern to the nurse?
A. Bowel sounds are decreased in all four quadrants.
B. Drainage from wound drains is purulent.
C. Oxygen saturation is 90%.
D. Pain level is 6 on a scale of 10.
Situation: The postoperative care continues after the
patient’s condition stabilized as well as after the patient
is discharged from surgery facility. It is necessary for
recovery room nurses to continue evaluating the
patient’s condition to anticipate and treat
complications.
6. On the first postoperative day after an abdomino-perineal
resection, the surgical nurse notes that there is a large quantity
of serous drainage on the client's perineal dressing. The nurse
will:
A. reinforce or change the dressing.
B. notify the physician immediately.
C. irrigate the wound drain.
D. culture the drainage.
7. When developing the postoperative plan of care for a client
who has had a Cystectomy and creation of a neobladder, which
action is appropriate to include?
A. Assess the stoma every hour for the first 24 hours
after surgery.
B. Call the surgeon if the urine appears cloudy or has
clots.
C. Irrigate the urethral catheter with saline every 2 to
4 hours.
D. Change the ostomy bag when it is one-half full of
urine.
8. Which information about a client on the first postoperative
day after a total vaginal hysterectomy is most important to
communicate to the physician?
A. The client has hypotonic bowel sounds.
B. The client complains of incisional pain with coughing
rated at 8 on a scale of 10.
C. The client’s sanitary pad needs to be changed every
hour.
D. The client’s temperature is 100.3 degrees F.
9. Mrs. Melissa 47 year old is being admitted for elective surgery.
The client has a history of diabetes and hypertension. She uses
alternative therapies to assist in keeping her diabetes and
hypertension under control like taking black tea as an adjunct
therapy. The Physician is requesting her to stop ingesting black
tea in preparation for surgery. What should the nurse expect to
see with the discontinuation of the black tea?
A. Increased blood pressure
B. Increased urine output
C. Increased blood sugar
D. Increased heart rate
10. On the first postoperative day after Mrs. Melissa has had an
open cholecystectomy, the nurse notes crackles at both lung
bases, a temperature of 100” F, and complains of severe
abdominal pain. Which action should the nurse take first?
A. Have the patient ambulate in the room.
B. Ask the client to deep breathe and cough.
C. Administer the ordered morphine sulfate
D. Give the prn acetaminophen (Tylenol).
Situation: The patient’s readiness for surgery is critical
to the outcome. Preoperative care focuses on preparing
the patient for surgery, interventions needed and
responding to potential anxiety.
11. The nurse in the ambulatory Preoperative unit identifies that
a client is more anxious than most clients. The nurse’s best
intervention is to:
A. attempt to identify the client’s concerns
B. report the client’s anxiety to the surgeon
C. reassure the client that the surgery is routine
D. provide privacy by pulling the curtain around the
client
12. Which is an independent nursing measure that would be
helpful in preventing the accumulation of secretions in a client

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who had general anesthesia during surgery?
A. postural drainage
B. cupping the chest
C. nasotracheal suctioning
D. frequent changes of position
13. What is the priority nursing intervention for a client during
the immediate postoperative period?
A. observe for hemorrhage
B. maintaining a patent airway
C. recording the intake and output
D. checking the vital signs every 15 minutes
14. The nurse in the postanesthesia care unit identifies that after
an abdominal cholecystectomy a client has sero-sanguineous
drainage on the abdominal dressing. What should the nurse do?
A. change the dressing
B. reinforce the dressing
C. apply an abdominal binder
D. replace the tape with Montgemery traps
15. A client has corrective surgery for a bladder laceration.
Which nursing intervention takes priority during this client’s
postoperative period?
A. turning frequently
B. raising side rails on the bed
C. providing range-of-motion exercises
D. massaging the back three times a day
Situation: A Recovery room nurse is skilled in the care of
patients with multiple –medical and surgical problems
immediately after a surgical procedure.
16. The nurse in the postanesthesia care unit is caring for a
client who has received a general anesthetic. The nurse should
notify the Physician if the:
A. client pushes the airway out
B. client has snoring respirations
C. respirations of 16 breaths/min are shallow
D. systolic blood pressure drops from 130 to 90 mm Hg
17. A client is prescribed prolonged bed rest after surgery.
Which complication does the nurse expect to prevent by
teaching the client to avoid pressure on the popliteal space?
A. cerebral embolism
B. pulmonary embolism
C. dry gangrene of a limb
D. coronary vessel occlusion
18. A postoperative client asks a nurse why it is so important to
deep breathe and cough after surgery. In formulating a
response, the nurse incorporates the understanding that
retained pulmonary secretions in a post-op client can lead to :
A. Fluid imbalance
B. Carbon dioxide retention
C. Pulmonary edema
D. Pneumonia
19. After abdominal surgery another client suddenly complains
of numbness in the right leg and “funny feeling” in the toes.
What should the nurse do first?
A. elevate the legs and tell the client to drink more
fluids
B. instruct the client to remain in bed and notify the
physician
C. rub the client’s legs to stimulate circulation and cover
the client with blanket
D. tell the client about the dangers of prolonged bed
rest and encourage ambulation
20. After a bilateral lumbar sympathectomy Mr. Harry 54-year-
old has a sudden drop in blood pressure but there is no evidence
of bleeding. What should the nurse recognize as the most likely
cause of the change in pressure?
A. inadequate fluid intake
B. after effects of anesthesia
C. increased level of epinephrine
D. reallocation of the blood supply
Situation: Pain is a subjective symptom often
experienced by clients .Therefore, nurses must
individually assessed clients when they expressed and
complains about pain. Charge Nurse Jona is a Medical
Nurse attending to the needs of clients with pain.
21. A 45-year-old male client with a history of blood clots and
degenerative joint disease in his bilateral knees is taking over-
the-counter glucosamine and chondroitin along with his
prescribed warfarin. What potential nursing diagnosis should be
a priority?
A. Risk for Impaired Circulation: arterial
B. Risk for Alteration in Comfort
C. Risk for Imbalanced Nutrition
D. Risk for Ineffective Breathing Pattern
22. Another female client with multiple lumbar muscle strains is
looking at using alternative therapies to reduce the pain. The
client seeks advice from Nurse Jona as to what type of alterative
therapy would provide the best pain relief. How should the nurse
respond?
A. "I have seen many individuals with your type of pain
be relieved of pain through the use of acupuncture."
B. "These types of therapies are more than just
therapies; they are really a mind over matter type of
event or game."
C. "Some of my other clients swear by magnet therapy
to reduce pain as it is very small and very easy to
use."
D. "You need to choose the alternative therapy that is
right for you based on research that supports the
intervention."
23. Charge Nurse Jona observes a new graduate RN taking all
of the following actions when assessing a client who was
admitted with abdominal pain. Which action indicates that
the new RN needs more instruction?
A. The new RN listens for bowel sounds only at the right
lower quadrant.
B. The new RN performs abdominal palpation before
auscultating the abdomen.
C. The new RN checks for rebound tenderness at the
end of the examination.
D. The new RN asks the client to bend the knees during
the examination.
24. A client tells Nurse Jona that he has severe and continuous
scrotal pain. The nurse anticipates testing for:
A. testicular cancer.
B. pyelonephritis.
C. nephrolithiasis.
D. epididymitis.
25. Nurse Jona admitted a 22-year-old client is with right lower
quadrant abdominal pain of unknown etiology rated at 7 on a
scale of 10. Which action will be included in the initial plan of
care?
A. Have client cough and deep-breathe q4h.
B. Apply heating pad to abdomen prn for pain.
C. Teach client about a high-fiber diet.
D. Place client on NPO (nothing by mouth) status.
Situation: Inadequate pain management can lead to
many consequences affecting the patient and family
members.
26. A male client is brought to the emergency department with
complaints of pain around his right scapula. The pain seems to
occur shortly after eating. This is not the first time the client has
experienced this type of pain but the pain is worse now than
ever before. What question should the nurse ask to obtain
additional information to develop a plan of care?
A. "Have you had nausea or vomiting recently?"
B. "What type of food did you have within the last 24
hours?"
C. "Have you noticed a significant weight gain or loss
recently?"
D. "Are you urinating less frequently than you were
before?"
27. The nurse is managing acute pain complained by the older
adult client during the first 24 hours after admission to the
hospital. The nurse should ensure that:
A. pain medication is ordered via the intramuscular
route
B. an order for meperidine (Demerol) is secured for
pain relief
C. patient-controlled analgesia is avoided in this
population
D. ordered PRN analgesics are administered on a
scheduled basis
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28. The nurse is working with an elderly female with complaints
of abdominal pain and nausea and vomiting. While assessing the
abdomen, the nurse notes the shape is round and the abdomen
sags. From analyzing these data, what condition should the
nurse expect?
A. Possible small bowel obstruction
B. Constipation
C. Nothing, normal aging process
D. Peptic ulcer
29. A client with intractable pain in the upper torso is admitted
to the hospital. The nurse understands that the client may be
candidate for surgery to control the pain. Which surgery should
the nurse expect to schedule?
A. rhizotomy
B. rhinotomy
C. cordotomy
D. chonderectomy
30. A client with an inflamed sciatic nerve is to have a
conventional transcutaneous electrical nerve stimulation (TENS)
device applied to the painful nerve pathway. When operating
the TENS unit, which nursing action is appropriate?
A. maintain the same dial settings every day
B. turn the machine on several times a day for 10 to 20
minutes
C. adjust the TENS dial until the client experiences relief
of pain
D. apply the color-coded electrodes anywhere it is
comfortable for the client
Situation: Tekla a 47 year old store manager is receiving
an antihypertensive drug intravenously for control of
severe hypertension. The client’s blood pressure is
unstable and is 160/94 mm Hg before the infusion.
Fifteen minutes after the infusion is started, the blood
pressure rises to 180/100 mm Hg.
31. The response to the drug is described as a/an:
A. allergic response
B. synergistic response
C. paradoxical response
D. hypersusceptibility response
32. Tekla is further being treated for hypertension reports
having a persistent hacking cough. The nurse explains that this
may be a side effect associated with:
A. ACE inhibitors
B. thiazide diuretics
C. calcium channel blockers
D. Angiotensin receptor blockers
33. What should the nurse assess to determine if Tekla is
experiencing the therapeutic effect of valsartan (Diovan), an
Angiotensin II receptor blocking agent?
A. lipid profile
B. apical pulse
C. urinary output
D. blood pressure
34. To assess the effectiveness of a vasodilator administered to
a client, what should the nurse assess?
A. pulse rate
B. breath sounds
C. cardiac output
D. blood pressure
35. Nifepidine (Procardia XL) 90 mg is prescribed for another
client with Hypertension. The nurse should instruct the client to
notify the Physician if the client experiences:
A. blurred vision
B. dizziness on rising
C. excessive urination
D. difficulty breathing
Situation: Bong a Senior Nurse in a medical ward is
assessing patients, mostly those with Cardiovascular
Disease. He is reviewing and analyzing the diagnostic
results of clients for further evaluation and referral.
36. Immediately after receiving spinal anesthesia a client
experiences hypotension as a result of postural changes. To
what physiologic change does the nurse attribute the change in
BP?
A. dilation of blood vessels
B. decreased response of chemoreceptors
C. decreased strength of cardiac contractions
D. interruption of cardiac accelerator pathways
37. What should the nurse teach a client to do to minimize
orthostatic hypotension?
A. wear support hose continuously
B. lie down for 30 minutes after taking medication
C. avoid tasks that require high energy expenditures
D. sit on the edge of the bed a short time before arising
38. A 35-year-old executive secretary is hospitalized for
treatment of severe hypertension. The physician orders
captopril (Capoten) and alprazolam (Xanax). The client quickly
finds fault with the therapeutic regimen and nursing care. The
nurse identifies that this behavior is probably a manifestation of
the client’s:
A. denial of illness
B. fear of the health problem
C. response to cerebral anorexia
D. reaction to hypertensive medications
39. The Physician scheduled for an exercise electrocardiogram
(stress test). What information should the nurse include when
explaining the value of this test? Exercise stress testing is a:
A. definitive method to diagnose the cause of chest
pain
B. diagnostic modality of minimal value in planning
treatment of angina
C. noninvasive means of assessing cardiovascular
conduction and function
D. minimally invasive manner of assessing a body’s
reaction to increase in exercise
40. Ms. Gil electrocardiogram has a 12 lead electrocardiogram
taken during an episode of chest pain. A Nurse examines the
tracing for which electrocardiogram change caused by
myocardial ischemia?
A. Prolonged PR interval
B. Widened QRS complex
C. ST segment elevation or depression
D. Tall peaked T –waves
Situation: A Tertiary Hospital has a special health
program on how to control smoking and improve
lifestyle. The nurse is teaching a group of clients with
peripheral vascular disease to stop smoking.
41. Which physiologic effect of nicotine should the nurse explain
to the group?
A. constriction of the superficial vessels, dilating the
deep vessels
B. constriction of the peripheral vessels, increasing the
force of flow
C. dilation of the superficial vessels with constriction of
the collateral circulation
D. dilation of the peripheral vessels, causing a reflex
dilation of visceral vessels
42. A Nurse in a Special Health program department is assessing
the skin of a client with a history of chronic venous insufficiency.
The nurse understands that the darkening of tissue results from
the breakdown of Hemoglobin with subsequent formation of:
A. heme
B. ferric chloride
C. ferrous sulfide
D. insoluble amino acids
43. A client is admitted with chest pain unrelieved by
Nitroglycerin, an elevated temperature, decreased blood, and
diaphoresis. A Myocardial Infarction is diagnosed. Which is the
most accurate explanation for one of these clinical indicators
based on the nurse’s understanding of the disease process?
A. parasympathetic reflexes from the infracted
myocardium cause diaphoresis
B. inflammation in the myocardium causes a rise in the
systemic body temperature
C. catecholamines released at the site of the infarction
cause intermittent localized pain
D. constriction of central and peripheral blood vessels
causes a decreased in blood pressure
44. Which clinical indicator of this complication should the nurse
expect to identify when assessing the client?
A. pitting edema of the lower leg
B. ecchymotic areas of the extremity
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 C. intermittent claudication of the leg
D. localized warmth of the lower extremity
45. When caring for a client with chronic occlusive arterial
disease, what precipitating cause would the nurse most likely to
identify for development of ulceration and gangrenous lesions?
A. emotional stress, which is short-lived
B. poor hygiene and limited protein intake
C. stimulants such as coffee, tea, or cola drinks
D. trauma from mechanical, chemical, or thermal
sources
Situation: Problems in Oxygenation involves patients
with disturbances in lower and upper airways. Nurse
Bonnie a Pulmonary Nurse is attending to clients with
respiratory diseases.
46. Nurse Bonnie observes an anxious client hyperventilating
after learning that his wife met an accident and intervenes to
prevent:
A. cardiac arrest
B. carbonic acid deficit
C. reduction in serum pH
D. excess oxygen saturation
47. Nurse Bonnie admitted another client with an arterial blood
gas report indicates the client’s pH is 7.25, Pco 2 is 35 mm Hg,
and HCO3 is 20 mEq/L. Which disturbance does the nurse
identify based on these results?
A. metabolic acidosis
B. metabolic alkalosis
C. respiratory acidosis
D. respiratory alkalosis
48. A client arterial blood gas report indicates the pH is 7.52,
Pco2 is 32 mm Hg, and HCO3 is 24 mEq/L. What imbalance does
Nurse Benjie identify as a possible cause of these results?
A. airway obstruction
B. inadequate nutrition
C. prolonged gastric suction
D. excessive mechanical ventilation
49. Nurse Bonnie understands that in the absence of pathology,
a client’s respiratory center is stimulated by:
A. oxygen
B. lactic acid
C. calcium ions
D. carbon dioxide
50. The client stated that the Physician said the tidal volume is
slightly diminished and asks the nurse what this means. What
explanation should the nurse give the client? Tidal volume is the
amount of air:
A. exhaled forcibly after a normal expiration
B. exhaled after there is a normal inspiration
C. inspired forcibly above a normal inspiration
D. trapped in the alveoli that cannot be exhaled
SITUATION: You are caring for a married woman who
underwent modified radical left mastectomy
51. On admission to Post-anesthesia Care Unit, you read the
OR report which indicates that estimated blood loss during
surgery was 1000mL. From the list below, select the MOST
objective indicator for the nurse to monitor closely.
a. Changes in vital signs
b. Altered level of consciousness
c. Soaked dressing
d. Pupillary reaction to light
52. You assisted positioning the client. Her left arm should be
placed in which of the following manner?
a. Placed above the level of the heart
b. Hyperextended away from the chest
c. Placed at the level of the heart and the hand below the heart
d. Adducted and flexed
53. When the patient woke up from anesthesia, she refuses to
see her husband. She remarks that she is “not the same
person, no longer a woman; much, much less a wife.”
Which psychosocial nursing diagnosis would best describe
this situation?
a. Altered role performance r/t impaired physical function
b. Anxiety r/t surgical removal of the breast
c. Altered body image r/t perception of disfigurement and
incapacity
d. Self-esteem disturbance r/t changing ability to perform basic
wife function
54. The client was obviously withdrawn although her recovery
from the surgery was uneventful. How can the nurse be of
best help during this period of recovery?
a. Allowing the client to have more time to herself
b. Encouraging the client to have more time to verbalize
concerns with her family
c. Allowing the client to talk with other clients in the ward who
had the same kind of surgery
d. Allowing the patient more time to reflect about the effects of
surgery
55. During the first 8 hours postoperative, the total drainage
from the Jackson-Pratt drain attached to the wound totaled
to 25 mL. What is your next best action?
a. Do nothing as the drainage is expected
b. Empty the Jackson-Pratt device
c. Notify the surgeon stat
d. Inform the client that her wound is draining well.
Situation: Samuel, 65 years old underwent partial
gastrectomy with gastrojejunostomy.
56. The nurse identified iron deficiency anemia as a potential
problem. Which of the following specifically would
predispose the patient to this problem?
a. Rapid gastric emptying due to gastrojejunostomy
b. Inadequate intake of food rich in iron
c. Excessive loss of blood during surgery
d. Inability to eat large meals
57. The nurse understands that iron deficiency anemia results
in decreased RBC which are:
a. Abnormally crescent shaped
b. Large and immature
c. Microcytic and hypochromic
d. Fragile and megaloblastic
58. The physician emphasized that Vitamin B12 levels will be
routinely monitored. Which of the following mechanism
correctly explains the possibility of the patient developing
Vitamin B12 deficiency?
a. Vitamin B12 is primarily absorbed in the duodenum
b. Fast emptying of food from the stomach interferes with
Vitamin B12 absorption
c. Intrinsic factor is necessary for absorption of Vitamin B12 is
inadequate
d. Inadequate liver storage of Vitamin b12 due to decreased
stomach size
59. Which of the following group of manifestations will the
nurse expect in case Vitamin B12 deficiency develops in the
patient?
a. Pallor, weakness, spoon shaped nails, smooth sore tongue
b. Progressive weakness, shortness of breath, palpitations,
cheilosis
c. Fatigue, irritability, pallor, painful swelling of hands
d. Slight jaundice, fatigue, paresthesia, glossitis
60. Priority nursing diagnosis is identified by the nurse for
Samuel is “Imbalanced nutrition related to patients’
inadequate intake of food.” Which of the following is an
appropriate intervention?
a. Based on list of patient’s choice of food, prepare diet plan
b. Plan diet with family members in consultation with dietician
c. Prepare a diet plan taking into consideration the patients
preferred eating pattern
d. Have physician order a specific diet for the patient
Situation: The nurse at the Operating Room should be made
aware of the functions and implications of being both a
circulating and a scrub nurse. The following questions apply.
61. The nurse was not able to completely account for the
sharps that were used during an exploratory laparotomy.
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 The surgeon agreed to close the suture even if the situation
was mentioned above. It was found out that one needle 70. If Allan were a geriatric client, which of these is the first
was still left at the peritoneum of the client. The surgeon indication of dehydration from fluid volume depletion?
was accused of malpractice because of what happened. a. Tachycardia c. Hypotension
Which among the following doctrines explains the scenario b. Altered mentation d. Fever
above?
a. Res Ipsa Loquitur Situation: Gastrointestinal problems are rampant in the ward
b. Force Majeure Nurse Kaye is assigned in. The following questions apply.
c. Respondeat Superior
d. Subpoena duces tecum 71. Malou is a patient admitted in the ward for her hemorrhoid
management. The following are recommended for caring
62. Which among the following is considered as part of the for Malou, except:
intraoperative phase? a. Tepid Sitz baths
a. Patient has decided to have a reconstructive surgery b. Wiping to clean the anal area
b. Induction of the anesthesia c. High-fiber diet
c. Patient having two CTT after a heart transplant d. Use of moistened tissues in cleaning the anal area
d. A patient diagnosed to have a constrictive pericarditis
72. A patient with colorectal cancer and who underwent surgery
63. Which part of the anesthetic ladder is the patient noted to a week ago had colostomy in place. What assessment
have increased autonomic activity? finding of the stoma is expected?
a. Analgesia Phase a. It is draining bright red blood profusely.
b. Delirium Phase b. It protrudes about 2 centimeters from the abdominal wall.
c. Surgical Phase c. It is dark red and flaccid.
d. Danger Stage d. It is reddish pink and dry.

64. Which among the following is NOT a principle of surgical 73. Which of these refers to the upper abdominal pain when
asepsis? eating?
a. Always face the sterile field. a. GERD c. Achalasia
b. Sterile articles unused and unopened are still considered b. Gastritis d. Dyspepsia
sterile after the procedure.
c. The sterile field is above the waist level and on top of the 74. A patient with duodenal ulcer experiences pain that is
sterile field. usually aggravated by which of the following?
d. Eliminate moisture that causes contamination. i. Ingestion of food
ii. Caffeine
65. Which among the following post-operative complications is iii. Fried foods
characterized as the collapse of one lung segment or the iv. Spicy food
whole lobe or a number of alveolar groups? v. NSAID use
a. Pneumoectasis vi. Corticosteroid use
b. Atelectasis a. i, ii, iii, iv, v, vi c. i, ii, iv, v, vi
c. Pulmonary embolism b. ii, iii, iv, v d. ii, iii, iv, v, vi
d. Pulmonary Shock
75. Once peristalsis is established and confirmed after a patient
Situation: Nurse Becky admitted a new patient to the underwent surgery for diverticulitis, which among these
Medicine Ward: Allan, 30, complains of diarrhea for does Nurse Kaye expect to be given first?
more than two weeks prior to consultation. The a. Mashed potato c. Plain gelatin
diagnosis made was Crohn’s Disease (CD). A plan of care b. Yogurt d. Pudding
was made for Allan.
Situation: To carry out management functions in any
66. Which of these assessments does Nurse Becky expect to health care setting, it is necessary for the nurse to
see in the patient’s records? integrate leadership skills that he/she developed.
i. Weight gain of 1kg/day
ii. Arthralgia 76. The organizational chart of a nursing department illustrates
iii. 10-20 liquid, bloody stools per day the structure and relationships of the nursing leaders and
iv. Tenesmus staff of the organization. The following are the functions of
v. Anorexia an organizational chart, except:
vi. Crampy, intermittent pain a. To illustrate centrality of control in the organization and chain
a. i, ii, iii, iv, v, vi c. i, ii iii, iv v of command
b. iii, iv, v, vi d. ii, iv, v, vi b. To indicate relationship of leaders to other management staff
c. To identify managerial levels
67. Nurse Becky should include which of the following d. To list all functions and duties of the staff
interventions for Allan?
a. Increase physical activity to promote intestinal activity 77. Coercing a patient into taking medications by threatening
b. Instruct the patient to increase intake of raw fruits and punishment could legally be considered as:
vegetables a. Assault c. Malpractice
c. Include high-fiber food choices following the acute phase of b. False imprisonment d. Battery
the condition
d. Provide Sitz bath for the skin excoriation from bowel 78. The doctor assigned to the patient was also sued together
movements with the nurses. When it was his turn to take the stand
during the next hearing, he was told to bring with him a
68. What is Nurse Becky’s priority for Allan if the latter develops copy of the patient’s chart. The hearing officer will have to
fistula from his CD? issue what legal order to bring the patient’s chart?
a. Writ of certiorari c. Subpoena ad testificandum
a. Fluid and electrolyte balance c. Self-esteem needs b. Subpoena duces tecum d. Writ of quo warranto
b. Pain management d. Skin protection
79. Mr. Waldo’s status has declined after being revived
69. Which of the following signs and symptoms may suggest yesterday after suffering from arrest. Dr. Gordon wrote a
presence of megacolon from antidiarrheal drug use? DNR order. This order implies that:
a. Leukopenia c. Bradypnea a. The patient need not be given food and water.
b. Fever d. Hypothermia

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b. The nurse need not give due care to Mr. Waldo even giving 86. The nurse in the ambulatory Preoperative unit identifies that
bed bath. a client is more anxious than most clients. The nurse’s best
c. The nurses and the attending physician need not do any intervention is to:
heroic or extraordinary measures for the patient. A. attempt to identify the client’s concerns
d. The patient need not be given ordinary care so that his dying B. report the client’s anxiety to the surgeon
process is hastened. C. reassure the client that the surgery is routine
D. provide privacy by pulling the curtain around the
80. What ethical principle applies when the surgical team client
adheres to surgical asepsis during surgical procedure? 87. Which is an independent nursing measure that would be
a. Justice c. Maleficence helpful in preventing the accumulation of secretions in a client
b. Nonmaleficence d. Beneficence who had general anesthesia during surgery?
A. postural drainage
Situation: Mar is a nurse assigned in the Medical Ward B. cupping the chest
of Bataan Hospital. The following questions pertain to C. nasotracheal suctioning
nursing care of patients with Diabetes Mellitus. D. frequent changes of position
88. What is the priority nursing intervention for a client during
81. A middle-age male client has recently been started on the immediate postoperative period?
insulin therapy. During one of Nurse Mar’s rounds, the client A. observe for hemorrhage
asked whether drinking alcohol would be possible. How B. maintaining a patent airway
should Mar respond? C. recording the intake and output
a. "Alcohol is a fast-acting sugar that will increase your blood D. checking the vital signs every 15 minutes
sugar rapidly." 89. The nurse in the post-anesthesia care unit identifies that
b. "The calories from alcohol must be figured into the daily plan after an abdominal cholecystectomy a client has sero-
to prevent weight gain." sanguineous drainage on the abdominal dressing. What should
c. "Alcohol can impair the client’s ability to recognize and treat the nurse do?
hypoglycemia." A. change the dressing
d. "Alcohol does not require insulin for absorption so B. reinforce the dressing
hypoglycemia may be a problem." C. apply an abdominal binder
D. replace the tape with Montgomery traps
82. A female client is asking about sugar substitutes. She knows 90. A client has corrective surgery for a bladder laceration.
that she needs to reduce her calorie intake to reduce her Which nursing intervention takes priority during this client’s
weight to avoid complications associated with diabetes. postoperative period?
What sugar substitute would be best? A. turning frequently
a. a. Fructose c. Sorbitol B. raising side rails on the bed
b. b. Sucrose d. Sucralose C. providing range-of-motion exercises
D. massaging the back three times a day
83. Nurse Mar is preparing to administer insulin to a client with
a blood sugar level of 124 mg/dL. He compared the result Situation: Jesi, a 44 year old Bank manager is receiving
to the medication record and the physician's order and an antihypertensive drug intravenously for control of
noted that the client is ordered Novolog insulin. He acquired severe hypertension. The client’s blood pressure is
the appropriate amount of insulin and then went to the unstable and is 160/94 mm Hg before the infusion.
client's room to administer the medication. The meal tray is Fifteen minutes after the infusion is started, the blood
due in 30 minutes. What should he do? pressure rises to 180/100 mm Hg.
a. Give the insulin immediately after the client has finished the
entire meal. 91. The response to the drug is described as a (n):
b. Administer the insulin immediately to coincide the A. allergic response
medication’s onset with the time of the meal. B. synergistic response
c. Administer the insulin because the blood glucose is high C. paradoxical response
enough to prevent hypoglycemia. D. hyper-susceptibility response
d. Hold the medication until the meal tray is in front of the client. 92. Jesi is further being treated for hypertension reports having
a persistent hacking cough. The nurse explains that this may be
84. Another patient in the unit was recently diagnosed with a side effect associated with:
Type 1 Diabetes. Nurse Mar is providing education on what A. ACE inhibitors
is termed as "survival skills." Which of the following skills B. thiazide diuretics
should he prioritize to teach the client? C. calcium channel blockers
a. Treatment of hypoglycemia D. Angiotensin receptor blockers
b. Sick day management 93. What should the nurse assess to determine if Jesi is
c. Insulin self-injection technique experiencing the therapeutic effect of valsartan (Diovan), an
d. Basic dietary information Angiotensin II receptor blocking agent?
A. lipid profile
85. A 23-year-old woman is asking Nurse Mar regarding the B. apical pulse
preparation of mixed dose of insulin. Which of the following C. urinary output
instructions should he not give to the patient? D. blood pressure
a. When drawing the insulin, turn the vial and syringe upside 94. To assess the effectiveness of a vasodilator administered to
down. a client, what should the nurse assess?
b. Inject air into the bottle of insulin equivalent to the number
of units of insulin to be withdrawn. A. pulse rate
c. Draw the needed amount of NPH before drawing the needed B. breath sounds
amount of regular insulin. C. cardiac output
d. Do not shake the vial of insulin. Instead, roll it in between D. blood pressure
your hands or palms. 95. Nifepidine (Procardia XL) 90 mg is prescribed for another
client with Hypertension. The nurse should instruct the client to
Situation: The patient’s readiness for surgery is critical to the notify the Physician if the client experiences:
outcome. Preoperative care focuses on preparing the patient for A. blurred vision
surgery, interventions needed and responding to potential B. dizziness on rising
anxiety. C. excessive urination
D. difficulty breathing

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Situation: Problems in Oxygenation involves patients
with disturbances in lower and upper airways. Nurse
Bong, a Pulmonary Nurse is attending to clients with
respiratory diseases.

96. Nurse Bong observes an anxious client hyperventilating after

learning that his wife met an accident and intervenes to prevent:
A. cardiac arrest
B. carbonic acid deficit
C. reduction in serum pH
D. excess oxygen saturation
97. Nurse Bong admitted another client with an arterial blood
gas report indicates the client’s pH is 7.25, Pco 2 is 35 mm Hg,
and HCO3 is 20 mEq/L. Which disturbance does the nurse
identify based on these results?
A. metabolic acidosis
B. metabolic alkalosis
C. respiratory acidosis
D. respiratory alkalosis
98. A client arterial blood gas report indicates the pH is 7.52,
Pco2 is 32 mm Hg, and HCO3 is 24 mEq/L. What imbalance does
Nurse Bong identify as a possible cause of these results?
A. airway obstruction
B. inadequate nutrition
C. prolonged gastric suction
D. excessive mechanical ventilation
99. Nurse Bong understands that in the absence of pathology,
a client’s respiratory center is stimulated by:
A. oxygen
B. lactic acid
C. calcium ions
D. carbon dioxide
100. The client stated that the Physician said the tidal volume is
slightly diminished and asks the nurse what this means. What
explanation should the nurse give the client? Tidal volume is the
amount of air:
A. exhaled forcibly after a normal expiration
B. exhaled after there is a normal inspiration
C. inspired forcibly above a normal inspiration
D. trapped in the alveoli that cannot be exhaled

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