* NLE * NCLEX * CGFNS * HAAD * PROMETRICS * DHA * MIDWIFERY * LET * RAD TECH * CRIMINOLOGY * DENTISTRY * PHARMACY

*
RECALLS 1 EXAM
NURSING PRACTICE 4
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: The Gastrointestinal System is susceptible to nursing action should be included in the plan of care at this time?
many health problems, impaired motility and infection. A. Keep head of bed elevated to 30 degrees.
Nurse Mich is admitting a client with Gastroesophageal B. Initiate tube feedings at 30 mL/hr.
Reflux. C. Reposition nasogastric tube as needed for abdominal
distention.
1. Management of Gastroesohageal reflux (GERD) begins on D. Report bloody nasogastric drainage to the physician
teaching the client to avoid situations that cause decrease lower stat.
esophageal sphincter pressure and esophageal irritation. Which 8. Which information about a client who is taking a full liquid
statement by a client who has received education about GERD diet 6 days after an Esophagogastrectomy should nurse Josie
indicates that the nurse may need to provide additional report immediately to the Physician?
teaching? A. The client refuses to take more than 100 mL.
A. "I will take antacids before I eat." B. The client has hypotonic bowel sounds.
B. "I should have my big meal at lunchtime." C. The client’s blood pressure is 88/46 mm Hg.
C. "I am going to quit smoking today." D. The client has bibasilar fine lung crackles.
D. "I should use two pillows to sleep on at night." 9. Phia a charge nurse is preparing the client with a Peptic Ulcer
2. Which snack choice by a client with gastroesophageal reflux and has Ranitidine (Zantac) scheduled for 10:00 AM. What time
disease (GERD) indicates that the nurse's teaching about should Nurse Phia administer the ordered 30 mL of calcium
appropriate diet has been effective? carbonate–magnesium carbonate (Mylanta)?
A. Chocolate pudding A. 9:00 AM C. 10:00 AM
B. Peppermint tea B. 9:30 AM D. 11:00 AM
C. Cheese sandwich 10. Nurse Phia has another client with duodenal ulcer. Which
D. Dried apples information about a client admitted with a Duodenal ulcer should
3. Boy, 54 years old is diagnosed of Esophageal Cancer. Which the Nurse Angel report immediately to the Physician?
information about a client who has Esophageal cancer being A. The client’s abdomen is rigid and painful.
admitted for an Esophagogastrectomy is of most concern to the B. The client is complaining of intermittent nausea.
nurse? C. The client’s NG drainage has a coffee-ground
A. The client complains of odynophagia. appearance.
B. The client has difficulty swallowing soft foods. D. The client reports drinking approximately 10 beers
C. The client has had radiation for 6 weeks. every day.
D. The client’s serum albumin level is 1.7 mg/dL.
4. Another client who was admitted with Acute Gastritis with Situation: Cancer ranks third in the leading cause of
nausea and vomiting has been on NPO (nothing by mouth) for morbidity and mortality in our country. Early detection
2 days. The client has a new "diet as tolerated" order. What increases the survival rate. Lani an Oncology nurse is
should the nurse offer to the client? responsible for screening and educating clients with
A. Tomato juice Cancer.
B. Tossed salad
C. Cherry gelatin 11. A client who has been diagnosed with gastric cancer tells
D. Nonfat milk nurse Lani, "I am so afraid!" Which response by the nurse is
5. Nurse Mich received a new female client. Fifteen minutes after most appropriate?
eating, a client who has had a Gastrojejunostomy complains of
abdominal cramping and palpitations. Which action should the A. "Can you tell me more about why you are afraid?"
nurse take? B. "Do you think that an anti-anxiety medication would
A. Administer prn metoclopramide (Reglan). help?"
B. Have the client lie down. C. "Perhaps talking to a clergyman would help decrease
C. Place the client on NPO status for 24 hours. your fear."
D. Notify the physician. D. "It is quite common for people with your diagnosis to
be fearful."
Situation: A client with a history of Peptic Ulcer disease 12. Fecal occult blood testing (FOBT) is indicated as part of the
is admitted to the emergency department with massive routine colon cancer screening for a client in the outpatient
vomiting of blood. clinic. For FOBT, the nurse will plan to:
A. perform testing on stool obtained during the rectal
6. Nurse Josie prepares which of the following diagnostic studies examination.
to confirm the real cause of the problem: B. schedule the client for multiple clinic appointments.
A. an esophagogastroduodenoscopy (EGD). C. teach the client how to do home guaiac-based testing.
B. an upper gastrointestinal (GI) tract x-ray series. D. test stool samples for carcinoembryonic antigen (CEA)
C. blood testing for Helicobacter pylori. levels.
D. stool testing for occult blood.
7. Nurse Josie is caring for a client who returned to the nursing 13. A client calls the outpatient surgery department the day after
unit 6 hours ago after having an Esophagogastrectomy. Which having Cryosurgery for Cervical Cancer in situ. Which

1 | Page
information about the client is of most concern to the nurse?
A. The client is very anxious about the cancer diagnosis.
B. The client complains of cramping abdominal pain.
C. The client has serous vaginal discharge.
D. The client’s temperature is 101.9 degrees F.
14. A client has been told she needs a Hysterectomy for Cervical
Cancer is upset about being unable to have more children. What
should the nurse do?
A. evaluate her willingness to pursue adoption
B. encourage her to focus on her own recovery
C. emphasize that she does have two children already
D. ensure that all treatment options have been explored
15. When a 32-year-old woman has a family history of breast
cancer, the most appropriate intervention by Nurse Lani is to:
A. emphasize the importance of genetic testing.
B. teach the client that she should avoid oral
contraceptives.
C. discuss the reasons for frequent breast screening
examinations.
D. educate the client about the effects of hormone
replacement therapy (HRT).
Situation: Chemotherapy is used to cure and to increase
the survival time.
16. When caring for a male client who is to receive
Chemotherapy for a cancerous condition, the nurse understands
that spermatogenesis occurs:
A. at the time of puberty
B. at any time after birth
C. immediately following birth
D. during embryonic development
17. After receiving the results of a breast biopsy that was
positive for cancer, the nurse observes that Mrs. Fe, 49 years
old does not mention the biopsy results when talking with her
husband. Which initial response by the nurse is appropriate?
A. Obtain a mental health referral from the client’s
physician.
B. Suggest that the client ask her physician for an
antidepressant.
C. Ask the client if she understands what the biopsy
results mean.
D. Offer to assist the client in discussing the results with
her husband.
18. In order to help determine the effectiveness of therapy for
Mrs. Fe with stage III Metastatic Breast cancer, the nurse plans
to monitor:
A. CA-125 levels.
B. mammogram findings.
C. BRCA1 and BRCA2 results.
D. level of HER-2/neu expression.
19. Mrs. Fe is admitted to the hospital after 6 months with
metastatic cancer and is experiencing abdominal pain, a
temperature of 100.4°F, and distended abdomen. The client
asks the nurse, “Do you think that I’m going to have surgery?”
The statement by the nurse that best helps to establish a
therapeutic relationship is:
A. “You seem concerned about having surgery.”
B. “Some people with your problem have surgery.”
C. “I really don’t know. You’ll have to ask your doctor.”
D. “Has someone talked to you about your scheduled
surgery?”
20. Another client with chronic Myelogenous Leukemia (CML)
has a white blood cell (WBC) count of 322,000. The nurse
anticipates the need to prepare the client for:
A. splenectomy.
B. leukapheresis.
C. red blood cell transfusion.
D. stem cell transplant.
Situation: Mr. Noli is an Emergency room nurse and he
is treating an old woman for soft-tissue injuries that the
medical team suspects might be caused by physical
abuse. The daughter-in-law states that her mother-in-
law is forgetful and confused and that she fell.
21. A mental examination indicates that the client is properly
oriented when it comes to person, place, and time, and the client
does not make any comment when asked directly how the
bruises and abrasions occurred. The nurse should now:
A. recommend that the client be admitted for further
assessment of the situation
B. believe the daughter-in-law until further data prove her
information to be untrue
C. act on instinct and report the abuse to the appropriate
state agency for investigation
D. refer the client’s record to the hospital ethics
committee for analysis and recommendations
22. After 30 minutes another client is brought to the emergency
room a 35-year-old client for a bee sting. The client has a history
of allergies to bees and is having trouble breathing. The nurse
is aware that this client could die from:
A. ischemia C. lactic acidosis
B. asphyxia D. antihistamines
23. Nurse Noli admitted another client who is allergic to peanuts
and he understands that the symptoms experienced by a client
during an anaphylactic reaction to peanuts are the result of:
A. increased cardiac output and hypertension
B. respiratory depression and cardiac standstill
C. constriction of capillaries and decreased cardiac output
D. bronchial constriction and decreased peripheral
resistance
24. Another client with benign prostatic hyperplasia (BPH)
arrives at the hospital at 8:00 AM for his scheduled transurethral
resection of the prostate (TURP). Which information about the
client is most important to communicate to the Physician before
surgery? The client:
A. Ate dinner last night at 7 PM.
B. Takes one Aspirin daily.
C. Has a family history of BPH.
D. Has had hematuria.
25. A 40-year-old man who wishes to have children has a
decreased urinary stream and nocturia caused by Benign
Prostatic Hyperplasia (BPH). When the client is considering
surgery for this disorder, the nurse anticipates teaching that:
A. retrograde ejaculation caused by all surgeries for BPH
causes decreased fertility.
B. open surgical procedures cause fewer problems with
erectile dysfunction.
C. transurethral resection of the prostate (TURP) does not
affect fertility.
D. infertility is less likely with transurethral incision of the
prostate (TUIP).
Situation: Immediately after a storm has passed, the
rescue team with which the nurse is working is
searching for injured people. A victim lying next to a
broken natural gas main is not breathing and is bleeding
heavily from a wound on the foot.
26. Based on the Principles of Disaster Management the nurse’s
first step should be to:
A. treat the victim for shock
B. start rescue breathing immediately
C. apply surface pressure to the foot wound
D. remove the victim for the immediate vicinity
27. The nurse is responding to the needs of victims at the
collapsed building soon after an earthquake. The principle that
guides the nurse’s priorities during this disaster is:
A. hemorrhage necessitates immediate care to save the
most lives
B. those requiring minimal care are treated first so that
they can help others
C. clients with head injuries should be treated first
because the care is most complex
D. children should receive the highest priority because
they have the greatest life expectancy
28. The emergency department triage nurse admits the
following four clients. Which one is the highest priority for rapid
evaluation and treatment by the Physician?
A. A 21-year-old with the sudden onset of severe scrotal
pain
B. A 34-year-old with scrotal bruising and pain after
vasectomy
C. A 45-year-old with an ulcerated lesion on the glans of
the penis
D. A 60-year-old with hematuria after a prostatectomy a
week ago
2 | Page
29. During intravenous emergency fluids are given to clients to
correct electrolytes imbalance. The Physician has prescribed
35mEq if Potassium Chloride to be added to a primary
intravenous infusion of 1000ml of D5W and run for 24 hours.
The vial of potassium chloride is labelled 40 mEq=10 ml. The
factor of infusion set is 10. How many ml of Potassium Chloride
40 mEq /10ml should be added to the 1000ml of D5 Water?
A. 9.9.ml C. 7.7. ml
B. 8.8. ml D. 6.6 ml
30. What is the hourly rate of absorption should be?
A. 22 ml/ hour C. 42 ml/ hour
B. 32 ml / cc D. 52 ml / cc
Situation: In a Medical ward there are clients with
potential or actual disorders of fluids and electrolytes
disturbance and homeostatic mechanisms.
31. The nurse is caring for a client with chronic kidney failure.
The nurse understands that ammonia is normally exerted by the
kidney to help maintain:
A. osmotic pressure of the blood
B. acid-base balance of the body
C. low bacterial level in the urine
D. normal red blood cell production
32. Which finding best suggests that nursing interventions for a
client with an excess fluid volume have been effective?
A. clear breath sounds
B. positive pedal pulses
C. normal potassium level
D. increased urine specific gravity
33. The nurse understands that a client with albuminuria has
edema because of:
A. fall in tissue hydrostatic pressure
B. rise in plasma hydrostatic pressure
C. rise in tissue colloid osmotic pressure
D. fall in plasma colloid oncotic pressure
34. When the nurse uses the clamp on the administration set to
manually adjust the flow of IV fluid into a client by gravity, what
change in energy takes place?
A. potential energy is converted to kinetic energy
B. kinetic energy is converted to potential energy
C. chemical energy is converted to kinetic energy
D. potential energy is converted to chemical energy
35. The client with which condition has an increased risk for
developing Hyperkalemia?
A. Crohn’s disease
B. Cushing’s syndrome
C. Chronic heart failure
D. End-stage renal disease
Situation: Nurse Gringo is attending to varied clients
with fluids and electrolytes problems.
36. The nurse adds potassium chloride 20 mEq to the IV solution
of a client with Diabetic Ketoacidosis. What is the primary
purpose for administering this drug?
A. treatment for hyperpnea
B. prevention of flaccid paralysis
C. replacement of excessive losses
D. treatment of cardiac dysrhythmias
37. The nurse is caring for a client with fluid and electrolyte
imbalance. Which is the most important means of maintaining
fluid and electrolyte balance that should be understood by the
nurse?
A. aldosterone
B. the urinary system
C. the respiratory system
D. antidiuretic hormone
38. Which of the following nursing actions included in the plan
of care for a client with Gastroenteritis will the Head nurse
delegate to the nursing aid?
A. Apply a moisture barrier to the perianal skin.
B. Advance the client’s diet as tolerated.
C. Teach the client handwashing technique.
D. Monitor the appearance of the stools.
39. Another 65 year old male client has Ascites and is
experiencing shortness of breath. This a form of edema that
accumulates in the peritoneal cavity. Nurse Gringo understands
that Ascites can be related to which problem?
A. portal hypertension
B. kidney malfunction
C. diminished plasma protein levels
D. decreased production of potassium
40. While a client with Ascites is receiving albumin, the planned
therapeutic effect will be greater if the nurse regulates the
infusion to flow:
A. slowly, and restrict fluid intake
B. rapidly, and withholds fluid intake
C. rapidly, and encourages fluid intake
D. slowly, and encourages liberal fluid intake
Situation: Mr. Pao, emergency room nurse assumes
responsibility for systematically assessing the needs of
the patients when disaster and crisis occurs. The nurse
may treat clients who experience hysteria first.
41. Which of the following person or persons to be cared for
immediately?
A. Panic C. Euphoria
B. Coma D. Depression
42. A client with hypothermia is brought to the emergency
department. Nurse Pao should explain to the family members
that treatment will include:
A. core rewarming with warm fluids
B. ambulation to increase metabolism
C. frequent oral temperature assessment
D. gastric tube feedings to increase fluids
43. A 72-year old unresponsive man is admitted to the
emergency department after playing tennis on a hot, humid day.
The initial nursing assessment reveals that he has hot, dry skin;
a RR= 36 breaths/min; and a HR= 128 beats/min. Which is
Nurse Pao’s initial action?
A. suction the airway C. offer cool oral fluids
B. remove all clothing D. prepare for intubation
44. Nurse Donayre is working in a busy Emergency department
on a hot summer day and four near-drowning victims are
admitted. Which near – drowning victim should the nurse assess
for signs of Hypovolemia?
A. 72-year-old rescued from a lake
B. 2-year-old rescued from a bath tub
C. 50-year-old rescued from the ocean
D. 17-year-old rescued from a backyard pool
45. Nurse Pao has been notified that a client who has suffered
large full-thickness burns is expected to arrive at the hospital in
about 1 minute. Which equipment is most important to obtain?
A. Intravenous catheter C. Morphine sulfate
B. Retention catheter D. Nasogastric tube
Situation: The Immune system functions as the body’s
defense mechanism against invasion of
microorganisms. The nurse is caring for a client with an
impaired immune system.
46. When caring for this client, the nurse understands that the
blood protein associated with the immune system is:
A. albumin C. thrombin
B. globulin D. hemoglobin
47. A client who was exposed to Hepatitis A is given Gamma
Globulin. The nurse understands that this will provide passive
immunity because it:
A. increases production of short-lived antibiotics
B. provides antibodies that neutralize the antigen
C. accelerates antigen-antibody union at the hepatic sites
D. stimulates the lymphatic system to produce large
numbers of antibodies
48. Another client is admitted to the emergency department
with a contaminated wound. The client is poor historian, and is
impossible to determine whether the client is immunized against
Tetanus. Which of the following is the preparation of choice that
will permit this client to produce passive immunity for several
weeks with minimal danger of allergic reactions?
A. DTaP vaccine
B. tetanus toxoid
C. tetanus antitoxin
D. tetanus immune globulin
49. Last December, Manila experienced a very cold climate. A
homeless person is brought to the emergency department after
3 | Page
prolonged exposure to cold weather. The nurse should assess
the client for hypothermia, which is manifested by:
A. Stupor C. Increased anxiety
B. Erythema D. Rapid respirations
50. A client with Rheumatoid Arthritis asks the nurse why the
Physician is going to inject Hydrocortisone into the knee joint.
The nurse explains that the most important reason for the
injection is to:
A. lubricate the joint
B. reduce inflammation
C. provide physiotherapy
D. prevent ankylosis of the joint
Situation: Autoimmune disorders, such as SLE, need
astute nursing skills in order to manage the care needed
for these patients.
51. The nurse will expect which of the following assessment
findings in a patient with SLE, except:
a. Positive antinuclear antibody test
b. Malar rash
c. Elevated erythrocyte sedimentation rate
d. Positive Tzanck smear
52. In teaching the client with SLE about self-care, the nurse
advices the client against:
a. Consumption of high vitamin and high iron diet
b. Use of mild soap and prescribed ointments/creams
c. Consumption of high protein diet
d. Use of visor during exposure to sunlight
53. Which of the following is the single most important
medication available for treatment of SLE?
a. Antimalarial agents c. Alkylating medications
b. Corticosteroids d. Monoclonal Antibodies
54. The nurse refers the patient to the nutritionist for
counseling about:
a. Diabetic Plate Method c. DASH diet
b. Low Protein Diet d. BRAT diet
55. CREST syndrome is a variety of symptoms experienced by
patients with:
a. Scleroderma
b. Polymyositis
c. Rheumatoid arthritis
d. Systemic lupus erythematosus
Situation: EMERGENCY- Triage Trauma to facilitate care
of clients in the emergency room, various management
strategies have been devised to address the survival
needs of patients. As an ER nurse you should be
equipped with knowledge, skills and attitude to cope
with unexpected problems.
56. You are assigned as the triage nurse in the ER. Four
patients injured in a vascular accident were brought to the
Emergency room at the same time. To whom will you assign
the highest priority?
a. Lorna, with maxillofacial injury and gurgling respiration
b. Alba, with severe head injury but no perceptible blood
pressure
c. Harriet, with lumbar spinal cord injury with lower extremity
paralysis
d. Bibi, 8 months pregnant with premature labor contractions
57. Waltz, a MERALCO wireman, fell from a height of 5 meters.
His head hit the concrete pavement. According to a witness,
Waltz was unconscious for a while but regained his
consciousness as if nothing happened. 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. Pupillary asymmetry
d. Alteration in level of consciousness
58. You are the nurse caring for Waltz who sustained multiple
injuries following a fall. Your initial assessment revealed
that he is oriented to a 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 furosemide
c. Keep Waltz alert and responsive
d. Monitor for signs of increased intracranial pressure
59. She is admitted into the Emergency room following as
assault where she was beaten in the face and head. Based
on She’s history, which of the following interventions should
be performed first?
a. Immediate intubation of the patient
b. Give 100% oxygen mask
c. insert an intravenous catheter
d. Obtain arterial blood gases
60. Lawrence loses consciousness after he had seizures. You
should prepare for which of the following first?
a. Place nasogastric tube
b. CT scan on the head
c. Endotracheal intubation or surgical airway management
d. Place a second IV line
SITUATION: Laryngeal cancer is common among
patients who have abusive behaviors to their throat. The
following situations apply.
61. In the carcinogenesis of laryngeal cancer, which of the
following will result to the damage of the DNA?
a. Smoking c. GERD
b. Blunt trauma d. Thick mucus secretions
62. Which among the following is not an early sign of laryngeal
cancer?
a. Hoarseness of voice
b. Cough and hemoptysis
c. Dysphagia
d. Enlarged inguinal lymph nodes
63. A singer approached the nurse and asks what could be the
reason why she developed laryngeal cancer. The nurse’s
best response would be?
a. Singing with no rests in between concerts
b. Drinking cold water after a show
c. Singing very high notes
d. Singing in varying voice registers
64. Which among the following phases of the carcinogenesis of
laryngeal cancer causes permanent conversion of laryngeal
tissues to malignant tissues?
a. Initiation c. Malignant conversion
b. Promotion d. Progression
65. Mang Bert, a 50 packs/year smoker, approached a nurse
and was asking what would be the end point of medical
intervention in the event that he will have a laryngeal
cancer. The nurse’s best response would be?
a. Permanent placement of a tracheostomy tube
b. Radiation Therapy
c. Chemotherapy
d. Endotracheal tube insertion
SITUATION: You are assigned to take care of Saira who
will be receiving a radium implant. You should be aware
of the safety and protective measures to prevent
untoward incidents.
66. While caring for Saira who has an implant, the following
protective factors can easily be controlled except
a. Time spent with Saira c. Shielding used
b. Distance kept from Saira d. Your physical status
67. As you care for Saira, you should remember that:
a. No special handling techniques are required for linen or
equipment
b. Special radiation resistant linen must be used
c. Rubber gloves must be used while in contact with the
bed linen and Irma
d. Linen and equipment should not be removed from Saira’s
room until it is free from radiation contamination
68. Where should Saira be placed in?
a. Double room with her bed against an internal wall
b. Single room with her bed against an external wall
c. Double room with her bed located away from the other
patient
d. Single room with her bed located near the hall
69. What type of diet should Saira receive?
a. High fiber c. Full-liquid
b. Low residue d. Clear liquid
4 | Page
70. While caring for the client, your most important nursing
intervention is to keep
a. Any visitor three feet way from Saira
b. The lead container in Saira’s room
c. The radium source in place
d. Saira as comfortable as possible
Situation: Clients with renal and urinary problems are
admitted in the ward.
71. The doctor ordered a straight catheterization be done for
Mr. Zantua, who was unable to void for the past 24 hours.
During the process, the nurse ensures that the bladder is
emptied gradually to prevent
a. Possible shock
b. Atrophy of bladder musculature
c. Abdominal cramping
d. Renal failure
72. Leo, diagnosed with End Stage Renal Disease, 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 and
ultrafiltration to remove electrolytes.”
c. “Blood is pumped through a semipermeable capillary in
a hemodialyzer.”
d. “Hemodialysis is one of several renal replacement
therapy.”
73. Which of the following pre-dialysis care is done by the nurse
to be able to determine the 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
74. The nurse understands that a client with albuminuria has
edema because of:
a. fall in tissue hydrostatic pressure
b. rise in plasma hydrostatic pressure
c. rise in tissue colloid osmotic pressure
d. fall in plasma colloid oncotic pressure
75. Prior to insertion of the catheter for peritoneal dialysis, what
instruction should the nurse give to the patient?
a. Limit food intake for at least 8 hours prior to the dialysis.
b. Splint the abdomen and perform diaphragmatic
breathing.
c. Empty the bladder and bowel.
d. Inhale and hold breath until the catheter is inserted
through the peritoneum.
Situation: Isolated emergency cases are rampant in the
communities. Though not involving the mass
population, prompt treatment is still considered to
prevent the emergency case from progressing to a life-
threatening situation.
76. A patient with suspected massive hemorrhage was brought
to the ED of your institution. Which of these actions done
by the ER nurse would require you to intervene?
a. Using two large-gauge intravenous catheters for fluid
resuscitation.
b. Initiating transfusion of PRBCs directly from the
commercialized cooler.
c. Inserting an indwelling catheter if not contraindicated
d. Maintaining the patient in supine position until
hemodynamic stability is achieved.
77. Which of these would indicate proper insertion of an
oropharyngeal airway?
a. Oropharyngeal airway should measure from the nose to
the ear.
b. The artificial airway should be inserted with the tip facing
down, facing the tongue, until it reaches the uvula.
c. The distal end of the oropharyngeal airway should be in
the hypopharynx, and the flange is approximately at the
patient’s lips.
d. Displace the tongue by rotating the airway 90 degrees
during insertion into the pharynx.
78. A client goes unconscious to the floor after minutes of
choking on an obstruction from his meal. You perform
Heimlich maneuver correctly by which of these actions?
Select all that apply.
i. Turn the client to prone position before the
maneuver.
ii. Kneel close to the patient’s thighs, facing his head
iii. Place the heel of one hand directly on the xiphoid
process with the other hand on top of it
iv. Press the abdomen with an inward and downward
thrust.
a. iii c. ii, iii
b. ii, iv d. ii
79. A patient who sustained a snake bite approximately one
hour ago was brought to the ER. Which of these is your
priority action?
a. Administer IV prednisone to reduce inflammation.
b. Immobilize and elevated the affected extremity above
the level of the heart.
c. Apply cold compress on the bite and the area around it.
d. Instruct the patient to remain lying down.
80. Antivenin polyvalent was prescribed for the patient who had
a snake bite. Which of these signs and symptoms should
alert you for a possible serum sickness that may lead to
neuropathy?
a. Arthralgia c. Vomiting
b. Increased lethargy d. Diarrhea
Situation: The Gastrointestinal System is susceptible to
many health problems, impaired motility and infection.
Nurse Mak is admitting a client with Gastroesophageal
Reflux.
81. Management of Gastroesohageal reflux (GERD) begins on
teaching the client to avoid situations that cause decrease lower
esophageal sphincter pressure and esophageal irritation. Which
statement by a client who has received education about GERD
indicates that the nurse may need to provide additional
teaching?
A. "I will take antacids before I eat."
B. "I should have my big meal at lunchtime."
C. "I am going to quit smoking today."
D. "I should use two pillows to sleep on at night."
82. Which snack choice by a client with gastroesophageal reflux
disease (GERD) indicates that the nurse's teaching about
appropriate diet has been effective?
A. Chocolate pudding
B. Peppermint tea
C. Cheese sandwich
D. Dried apples
83. Emmy, 54 years old is diagnosed of Esophagel Cancer.
Which information about a client who has Esophageal
cancer being admitted for an Esophagogastrectomy is of most
concern to the nurse?
A. The client complains of odynophagia.
B. The client has difficulty swallowing soft foods.
C. The client has had radiation for 6 weeks.
D. The client’s serum albumin level is 1.7 mg/dL.
84. Another client who was admitted with Acute Gastritis with
nausea and vomiting has been on NPO (nothing by mouth) for
2 days. The client has a new "diet as tolerated" order. What
should the nurse offer to the client?
A. Tomato juice
B. Tossed salad
C. Cherry gelatin
D. Nonfat milk
85. Nurse Mak received a new female client. Fifteen minutes
after eating, a client who has had a Gastrojejunostomy
complains of abdominal cramping and palpitations. Which action
should the nurse take?
A. Administer prn metoclopramide (Reglan).
B. Have the client lie down.
C. Place the client on NPO status for 24 hours.
D. Notify the physician.
Situation: Mr. Bob is an Emergency room nurse and he
is treating an old woman for soft-tissue injuries that the
medical team suspects might be caused by physical
5 | Page
abuse. The daughter-in-law states that her mother-in-
law is forgetful and confused and that she fell.
86. A mental examination indicates that the client is properly
oriented when it comes to person, place, and time, and the client
does not make any comment when asked directly how the
bruises and abrasions occurred. The nurse should now:
A. recommend that the client be admitted for further
assessment of the situation
B. believe the daughter-in-law until further data prove her
information to be untrue
C. act on instinct and report the abuse to the appropriate
state agency for investigation
D. refer the client’s record to the hospital ethics
committee for analysis and recommendations
87. After 30 minutes another client is brought to the emergency
room a 35-year-old client for a bee sting. The client has a history
of allergies to bees and is having trouble breathing. The nurse
is aware that this client could die from:
A. ischemia C. lactic acidosis
B. asphyxia D. antihistamines
88. Nurse Bob admitted another client who is allergic to peanuts
and he understands that the symptoms experienced by a client
during an anaphylactic reaction to peanuts are the result of:
A. increased cardiac output and hypertension
B. respiratory depression and cardiac standstill
C. constriction of capillaries and decreased cardiac output
D. bronchial constriction and decreased peripheral
resistance
89. Another client with benign prostatic hyperplasia (BPH)
arrives at the hospital at 8:00 AM for his scheduled transurethral
resection of the prostate (TURP). Which information about the
client is most important to communicate to the Physician before
surgery? The client:
A. Ate dinner last night at 7 PM.
B. Takes one Aspirin daily.
C. Has a family history of BPH.
D. Has had hematuria.
90. A 40-year-old man who wishes to have children has a
decreased urinary stream and nocturia caused by Benign
Prostatic Hyperplasia (BPH). When the client is considering
surgery for this disorder, the nurse anticipates teaching that:
A. retrograde ejaculation caused by all surgeries for
BPH causes decreased fertility.
B. open surgical procedures cause fewer problems with
erectile dysfunction.
C. transurethral resection of the prostate (TURP) does not
affect fertility.
D. infertility is less likely with transurethral incision of the
prostate (TUIP).
Situation: In a Medical ward there are clients with
potential or actual disorders of fluids and electrolytes
disturbance and homeostatic mechanisms.
91. The nurse is caring for a client with chronic kidney failure.
The nurse understands that ammonia is normally exerted by the
kidney to help maintain:
A. osmotic pressure of the blood
B. acid-base balance of the body
C. low bacterial level in the urine
D. normal red blood cell production
92. Which finding best suggests that nursing interventions for a
client with an excess fluid volume have been effective?
A. clear breath sounds
B. positive pedal pulses
C. normal potassium level
D. increased urine specific gravity
93. The nurse understands that a client with albuminuria has
edema because of:
A. fall in tissue hydrostatic pressure
B. rise in plasma hydrostatic pressure
C. rise in tissue colloid osmotic pressure
D. fall in plasma colloid oncotic pressure
94. When the nurse uses the clamp on the administration set to
manually adjust the flow of IV fluid into a client by gravity, what
change in energy takes place?
A. potential energy is converted to kinetic energy
B. kinetic energy is converted to potential energy
C. chemical energy is converted to kinetic energy
D. potential energy is converted to chemical energy
95. The client with which condition has an increased risk for
developing Hyperkalemia?
A. Crohn’s disease
B. Cushing’s syndrome
C. Chronic heart failure
D. End-stage renal disease
Situation: A mother with the diagnosis of AIDS states
that she has been caring for her baby even though she
has not been feeling well.
96. What important information should the nurse determine?
A. is she has kissed the baby
B. if the baby is breastfeeding
C. when the baby last received antibiotics
D. how long she has been caring for the baby
97. The nurse is planning to provide discharge teaching to the
family of a client with AIDS. Which statement should the nurse
include in the teaching plan?
A. “Wash the dishes in hot soap as you usually do.”
B. “Let the dishes soak in hot water overnight before
washing.”
C. “You should boil the client’s dishes for 30 minutes after
use.”
D. “have the client eat from paper plates so they can be
discharged.”
98. During an AIDS education class a client states, “Vaseline
works great when I use condoms.” Which conclusions about the
client’s knowledge of condom use can the nurse draw this
statement?
A. an understanding of safer sex
B. an ability to assume self-responsibility
C. ignorance concerning correct condom use
D. ignorance concerning the transmission of HIV
99. The client with AIDS is experiencing nausea and vomiting.
The Nurse would make which of the following dietary alterations
for this client to enhance nutritional intake?
A. Avoid dairy products and red meat
B. Plan large nutritious meals
C. Add spices to food to enhance flavor
D. Serve foods while they are warm
100. The Physician orders a Paracentesis. How should the nurse
instruct the client to prepare for the radiograph?
A. void before the procedure
B. a laxative the evening before the procedure
C. nothing by mouth for 8 hours before the procedure
D. a low soapsuds enema the morning of the procedure
6 | Page