NURSING PRACTICE I: FOUNDATION OF NURSING
Benner’s “Proficient” nurse level is different
PRACTICE
CAUTION: Nursing is a profession. The nurse should
have a background on the theories and foundation of
nursing as it influenced what is nursing today.
1. Nursing is the protection, promotion and
optimization of health and abilities, prevention
of illness and injury, alleviation of suffering
through the diagnosis and treatment of human
response and advocacy in the care of the
individuals, families, communities and the
population. This is the most accepted definition
of nursing as defined by the:
a. PNA
b. ANA
c. Nightingale
d. Herderson
2. Advancement in nursing leads to the
development of the Expanded Career Roles.
Which of the following is NOT an expanded
career role for nurses?
a. Nurse practitioner
b. Nurse Researcher
c. Clinical nurse specialist
d. Nurse anaesthesiologist
3. The Board of Nursing regulated the Nursing
profession in the Philippines and is responsible
for the maintenance of the quality of nursing in
the country. Powers and duties of the board of
nursing are the following, EXCEPT:
a. Issue, suspend, revoke certificates of
registration
b. Issue subpoena duces tecum, ad
testification
c. Open and close colleges of nursing
d. Supervise and regulate the practice of
nursing
4. A nursing student or a beginning staff nurse
who has not yet experienced enough real
situations to make judgments about them is in
what stage of Nursing Expertise?
a. Novice
b. Newbie
c. Advanced Beginner
d. Competent
5.
from the other levels in nursing expertise in the
context of having:
a. the ability to organize and plan activities
b. having attained an advanced level of
education
c. a holistic understanding and perception of
the client
d. intuitive and analytic ability in new
situations
SITUATION: The nurse has been asked to administer an
injection via Z TRACK technique. Questions 6 to 10 refer
to this.
6. The nurse prepares an IM injection for an adult
client using the Z track technique. 4 ml of
medication is to be administered to the client.
Which of the following site will you choose?
a. Deltoid
b. Rectus femoris
c. Ventrogluteal
d. Vastus lateralis
7. In infants 1 year old and below, which of the
following is the site of choice for intramuscular
injection?
a. Deltoid
b. Rectos femoris
c. Ventrogluteal
d. Vastus lateralis
8. In order to decrease discomfort in Z track
administration, which of the following is
applicable?
a. Pierce the skin quickly and smoothly at a
90 degree angle
b. Inject the medication steadily at around 10
minutes per milliliter
c. Pull back the plunger and aspirate for 1
minute to make sure that the needle did
not hit a blood vessel
d. Pierce the skin slowly and carefully at a 90
degree angle
9. After injection using Z Track technique, the
nurse should know that she needs to wait for a
few seconds before withdrawing the needle and
this is to allow the medication to disperse into
the muscle tissue, thus decreasing the client’s
discomfort. How many seconds should the
nurse wait before withdrawing the needle?
a. 2 seconds
 b. 5 seconds
c. 10 seconds
d. 15 seconds
10. The rationale in using the Z track technique in
an intramuscular injection is:
a. It decreases the leakage of discolouring and
irritating medication into the subcutaneous
tissues
b. It will allow a faster absorption of the
medication
c. The Z track technique prevent irritation of
the muscle
d. It is much more convenient for the nurse
SITUATION: A Client was rushed to the emergency room
and you are his attending nurse. You are performing a
vital sign assessment.
11. All of the following are correct methods in
assessment of the blood pressure EXCEPT:
a. Take the blood pressure reading on both
arms for comparison
b. Listen to and identify the phases of
Korotkoff’s sound
c. Pump the cuff to around 50 mmHg above
the point where the pulse is obliterated
d. Observes procedures for injection control
12. You attached a pulse oximeter to the client. You
know that the purpose is to:
a. Determine if the client’s hemoglobin level is
low and if he needs blood transfusion
b. Check level of client’s tissue perfusion
c. Measure the efficacy of the client’s anti-
hypertensive medications
d. Detect oxygen saturation of arterial blood
before symptoms of hypoxemia develops
13. After a few hours in the Emergency Room, The
client is admitted to the ward with an order of
hourly monitoring of blood pressure. The nurse
finds that the cuff is too narrow and this will
cause the blood pressure reading to be:
a. Inconsistent
b. low systolic and high diastolic
c. higher than what the reading should be
d. lower than what the reading should be
14. Through the client’s health history, you gather
that the patient smokes and drinks coffee. When taking
the blood pressure of a client who recently smoked or
drank coffee, how long should the nurse wait before
taking the client’s blood pressure to accurate reading?
a. 15 minutes
b. 30 minutes
c. 1 hour
d. 5 minutes
15. While the client has pulse oximeter on his
fingertip, you notice that the sunlight is shining
on the area where the oximeter is. Your action
will be to:
a. Set and turn on the alarm of the oximeter
b. Do nothing since there is no identified
problem
c. Cover the fingertip sensor with a towel or
bedsheet
d. Change the location of the sensor every
four hours
16. The nurse finds it necessary to recheck the
blood pressure reading. In case of such re
assessment, the nurse should wait for a period
of?
a. 15 seconds
b. 1 to 2 minutes
c. 30 minutes
d. 15 minutes
17. If the arm is said to be elevated when taking the
blood pressure, it will create a:
a. False high reading
b. False low reading
c. True false reading
d. Indeterminate
18. You are to assessed the temperature of the
client the next morning and found out that he
ate ice cream. How many minutes should you
wait before assessing the client’s oral
temperature?
a. 10 minutes
b. 20 minutes
c. 30 minutes
d. 15 minutes
19. When auscultating the client’s blood pressure
the nurse hears the following: From 150 mmHg
to 130 mmHg: Silence, Then: a thumping sound
continuing down to 100 mmHg; muffled sound
continuing down to 80 mmHg and then silence.
 What is the client’s blood pressure?
a. 130/80
b. 150/100
c. 100/80
d. 150/100
20. In a client with a previous blood pressure of
130/80 4 hours ago, how long will it take to
release the blood pressure cuff to obtain an
accurate reading?
a. 10-20 minutes
b. 30-45 minutes
c. 1-1.5 minutes
d. 3-3.5 minutes
SITUATION: Oral care is an important part of hygienic
practices and promoting client comfort.
21. An elderly client, 84 years old, is unconscious.
Assessment of the mouth reveals excessive
dryness and presence of sores. Which of the
following is BEST to use for oral care?
a. lemon glycerine
b. Mineral oil
c. hydrogen peroxide
d. Normal saline solution
22. When performing oral care to an unconscious
client, which of the following is a special
consideration to prevent aspiration of fluids
into the lungs?
a. Put the client on a sidelying position with
head of bed lowered
b. Keep the client dry by placing towel under
the chin
c. Wash hands and observes appropriate
infection control
d. Clean mouth with oral swabs in a careful
and an orderly progession
23. The advantages of oral care for a client include
all of the following, EXCEPT:
a. decreases bacteria in the mouth and teeth
b. reduces need to use commercial
mouthwash which irritate the buccal
mucusa
c. improves clients appearance and self
confidence
d. improves appetite and taste of food
24. A possible problem while providing oral care to
unconscious client is the risk of fluid aspiration
to lungs. This can be avoided by:
a. Cleaning teeth and mouth with cotton swabs
soaked with mouthwash to avoid rinsing the
buccal cavity.
b. swabbing the inside of the cheeks and lips,
tongue and gums with dry cotton swabs
c. use fingers wrapped with wet cotton washcloth
to rub inside the cheeks, tongue, lips and gums
d. suctioning as needed while cleaning the buccal
cavity
25. Your client has difficulty of breathing and is
mouth breathing most of the time. This causes
dryness of the mouth with unpleasant odor.
Oral hygiene is recommended for the client and
in addition, you will keep the mouth moistened
by using:
a. salt solution
b. petroleum jelly
c. water
d. metholated ointment
SITUATION – Ensuring safety before, during and after a
diagnostic procedure is an important responsibility of
the nurse.
26. To help Fernan better tolerate the
bronchoscopy, you should instruct him to
practice which of the following prior to the
procedure?
a. Cleaning his fist every 2 minutes
b. Breathing in and out through the nose with
his mouth open
c. Tensing the shoulder muscles while lying on
his back
d. Holding his breath periodically for 30
seconds
27. Following a bronchoscopy, which of the
following complains to Fernan should be noted
as a possible complication:
a. Nausea and vomiting
b. Shortness of breath and laryngeal stridor
c. Blood tinged sputum and coughing
d. Sore throat and hoarseness
28. Immediately after bronchoscopy, you instructed
Fernan to:
a. Exercise the neck muscles
b. Refrain from coughing and talking
 c. Breathe deeply
d. Clear his throat
29. Thoracentesis may be performed for cytologic
study of pleural fluid. As a nurse your most
important function during the procedure is to:
a. Keep the sterile equipment from
contamination
b. Assist the physician
c. Open and close the three-way stopcock
d. Observe the patient’s vital signs
30. Right after thoracentesis, which of the following
is most appropriate intervention?
a. Instruct the patient not to cough or deep
breath for two hours
b. Observe for symptoms of tightness of
chest or bleeding
c. Place an ice pack to the puncture site
d. Remove the dressing to check for bleeding
Situation: Knowledge of the acid-base disturbance and
the functions of the electrolytes is necessary to
determine appropriate intervention and nursing actions.
31. A client with diabetes milletus has a blood
glucose level of 644 mg/dL. The nurse interprets
that his client is at most risk for the
development of which type of acid-base
imbalance?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
32. In a client in the health care clinic, arterial blood
gas analysis gives the following results: pH 7.48,
PCO2 32mmHg, PO2 94 mmHg, HCO3 24 mEq/L.
The nurse interprets that the client has which
acid base disturbance?
a. Respiratory acidosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Metabolic alkalosis
33. A client has an order for ABG analysis on radial
artery specimens. The nurse ensures that which
of the following has been performed or tested
before the ABG specimens are drawn?
a. Guthrie test
b. Romberg’s test
c. Allen’s test
d. Weber’s test
34. A nurse is reviewing the arterial blood gas
values of a client and notes that the ph is 7.31,
pco2 is 50 mmHg, and the bicarbonate is 27
mEq/L. The nurse concludes that which acid
base disturbance is present in this client?
a. Respiratory acidosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Metabolic alkalosis
35. Allen’s test check the patency of the:
a. Ulnar artery
b. Carotid artery
c. Radial artery
d. Brachial artery
Situation 6: Eileen, 45 years old is admitted to the
hospital with a diagnostic of renal calculi. She is
experiencing severe flank pain, nauseated and with a
temperature of 39 OC.
36. Given the above assessment data, the most
immediate goal of the nurse would be which of
the following?
a. Prevent urinary complication
b. Maintains fluid and electrolytes
c. Alleviate pain
d. Alleviating nausea
37. After IVP a renal stone was confirmed, a left
nephrectomy was done. Her post-operative
order includes “daily urine specimen to be sent
to the laboratory”. Eileen has a foley catheter
attached to a urinary drainage system. How will
you collect the urine specimen?
a. Remove urine from drainage tube with
sterile needle and syringe and empty urine
from the syringe into the specimen
container
b. Empty a sample urine from the collecting
bag into the specimen container
c. Disconnect the drainage tube from the
indwelling catheter and allow urine to flow
from catheter into the specimen container
d. Disconnect the drainage from the collecting
bag and allow the urine to flow to specimen
container
 38. Where would the nurse tape Ellen’s indwelling
catheter in order to reduce urethal irritation?
a. To the patient’s inner thigh
b. To the patient’s buttocks
c. To the patient’s lower thigh
d. To the patient’s lower abdomen
39. Which of the following menu is appropriate for
one with low sodium diet?
a. Instant noodles, fresh fruits, and ice tea
b. Ham and cheese sandwich, fresh fruits anf
vegetables
c. White chicken sandwich, vegetable salad
and tea
d. Canned soup, potato salad, and diet soda
40. How will you prevent ascending infection to
Eileen who has an indwelling catheter?
a. See to it that drainage tubing touches the
level of the urine
b. Changes the catheter every eight hours
c. See to it that the drainage tubing does not
touch the level of the urine
d. Clean catheter may be used since urethal
meatus is not an sterile area
Situation: Hormones are secreted by the various glands
of the body. Basic knowledge of the endocrine system is
necessary.
41. Somatocrinin or the Growth hormone releasing
hormone is secreted by the:
a. Hypothalamus
b. Posterior pituitary gland
c. Anterior pituitary gland
d. Thyroid gland
42. All of the following are secreted by the anterior
pituitary gland except:
a. Somtotropin/Growth hormone
b. Thyroid stimulating hormone
c. Follicle stimulating hormone
d. Gonadotropin hormone releasing hormone
43. All of the following hormones are hormones
secreted by the posterior pituitary gland except:
a. Vasopressin
b. Anti-diuretic hormone
c. Oxytocin
d. Growth hormone
44. Calcitonin, a hormone necessary for calcium
Regulation is secreted in the:
a. Thyroid gland
b. Parathyroid gland
c. Hypothalamus
d. Anterior pituitary gland
45. While Parathormone, a hormone that negates
the effect of calcitonin is secreted by the:
a. Thyroid gland
b. Parathyroid gland
c. Hypothalamus
d. Anterior pituitary gland
Situation: The staff nurse supervisor requests all the
staff nurses to “brainstorm” and learn ways to instruct
diabetic clients on self-administration of insulin. She
wants to ensure that there are nurses available daily to
do health education classes.
46. The plan of the nurse supervisor is an example
of
a. In service education process
b. Efficient management of human resources
c. Increasing human resources
d. Primary prevention
47. When Mrs. Guevarra, a nurse, delegates aspects
of the clients care to the nurse-aide who is an
unlicensed staff, Mrs. Guevarra
a. makes the assignment to teach the staff
member
b. is assigning the responsibility to the aide
but not the accountability for those tasks
c. does not have to supervise or evaluate the
aide
d. most know how to perform task delegated
48. Connie, the new nurse, appears tired and
sluggish and lacks the enthusiasm she had six
weeks ago when she started the job. The nurse
supervisor should
a. Empathize with the nurse and listen to her
b. Tell her to take the day off
c. Discuss how she is adjusting to her new job
d. Ask about her family life
49. Process of formal negotiations of working
conditions between a group of registered
nurses and employer is
 a. grievance d. It should disclose previous diagnostic,
b. arbitration prognosis, and alternative treatments
c. collective bargaining available for the client
d. strike
55. Delegation is the process of assigning tasks that
50. You are attending a certification on can be performed by a subordinate. The RN
cardiopulmonary resuscitation (CPR) offered should always be accountable and should not
and required by the hospital employing you. lose his accountability. Which of the following is
This is a role included in delegation?
a. professional course towards credit a. The RN must supervise all delegated tasks
b. in-service education b. After a task has been delegated, it is no
c. advance training longer a responsibility of the RN
d. continuing education c. The RN is responsible and accountable for
the delegated task in adjunct with the
Situation: As a nurse, you are aware that proper delegate
documentation in the patient chart is your responsibility d. Follow up with a delegated task is necessary
only if the assistive personnel is not
51. Which of the following is not a legally binding trustworthy
document but nevertheless very important in
the care of all patients in any health care Situation: When creating your lesson plan for
setting? cerebrovascular disease on STROKE. It is important to
a. Bill of rights as provided in the Philippine include the risk factors of stroke.
constitution
b. Scope of nursing practice as defined by RA 56. The most important risk factor is:
9173 a. Cigarette smoking
c. Board of nursing resolution adopting the b. binge drinking
code of ethics c. Hypertension
d. Patient’s bill of rigths d. heredity

52. A nurse gives a wrong medication to the client. 57. Part of your lesson plan is to talk about etiology
Another nurse employed by the same hospital or cause of stroke. The types of stroke based on
as a risk manager will expect to receive which of cause are the following EXCEPT:
the following communication? a. Embolic stroke
a. Incident report b. diabetic stroke
b. Nursing kardex c. Hemorrhagic stroke
c. Oral report d. thrombotic stroke
d. Complain report
58. Hemorrhagic stroke occurs suddenly usually
53. Performing procedure on a client in the absence when the person is active. All are causes of
of an informed consent can lead to which of the hemorrhage, EXCEPT:
following communication? a. phlebitis
a. Fraud b. damage to blood vessel
b. Harassment c. trauma
c. Assault and battery d. aneurysm
d. Breach of confidentiality
59. The nurse emphasizes that intravenous drug
54. Which of the following is the essence of abuse carries a high risk stroke. Which drug is
informed consent? closely linked to this?
a. It should have a durable power of attorney a. Amphetamines
b. It should have coverage from an insurance b. shabu
company c. Cocaine
c. It should respect the client’s freedom from d. Demerol
coercion
 60. A participant in the Stroke class asks what is a
risk factor of stroke. Your best response is:
a. “More red blood cells thicken blood and
make clots more possible.”
b. “Increase RBC count is linked to high
cholesterol.”
c. “More red blood cell increases hemoglobin
content.”
d. “High RBC count increases blood pressure.”
Situation: Recognition of normal values is vital in
assessment of clients with various disorders.
61. A nurse is reviewing the laboratory test results
for a client with a diagnosis of severe
dehydration. The nurse would expect the
hematocrit level for this client to be which of
the following?
a. 60%
b. 47%
c. 45%
d. 32%
62. A nurse is reviewing the electrolytes result of an
assigned client and notes that the potassium
level is 5.6 mEq/L. Which of the following would
the nurse expect to note on the ECG as a result
of this laboratory value?
a. ST depression
b. Prominent U wave
c. Inverted T wave
d. Tall peaked T waves
63. A nurse is reviewing the electrolytes result of an
assigned client and notes that the potassium
level is 3.2 mEq/L. Which of the following would
the nurse expect to note on the ECG as a result
of this laboratory value?
a. U waves
b. Elevated T waves
c. Absent P waves
d. Elevated ST Segment
64. Dorothy underwent diagnostic test and the
result of the blood examination are back. On
reviewing the results the nurse notices which of
the following as abnormal finding?
a. Neutrophils 60%
b. White blood cells (WBC) 9000/mm
c. Eryhrocyte sedimentation rate (ESR) is 39
mm/hr
d. Iron 75 mg/100 ml
65. Which of the following laboratory test result
indicate presence of an infectious process?
a. Erythrocyte sedimentation rate (ESR) 12
mm/hr
b. White blood cells (WBC) 18,000/mm3
c. Iron 90 g/100ml
d. Neutrophils 67%
Situation: Pleural effusion is the accumulation of fluid in
the pleural space. Questions 66 to 70 refer to this.
66. Which of the following is a finding that the
nurse will be able to assess in a client with
pleural effusion?
a. Reduced or absent breath sound at the
base of the lungs, dyspnea, tachypnea and
shortness of breath
b. Hypoxemia, hypercapnea and respiratory
acidosis
c. Noisy respiration, crackles, stridor, and
wheezing
d. Tracheal deviation towards the affected
side, increased fremitus and loud breath
sounds.
67. Thoracentesis is performed to the client with
effusion. The nurse knows that the removal of
fluid should be slow. Rapid removal of fluid in
thoracentesis might cause:
a. Pneumothorax
b. Cardiovascular collapse
c. Pleurisy or Pleuritis
d. Hypertension
68. 3 Days after thoracentesis, the client again
exhibited respiratorydistress. The nurse will
know that pleural effusion has reoccurred when
she noticed a sharp stabbing pain during
inspiration. The physician ordered a close tube
thoracotomy for the client. The nurse knows
that the primary function of the test tube is to:
a. Restore positive intrathoracic pressure
b. Restore negative intrathoracic pressure
c. To visualize the intrathoracic content
d. As a method of air administration via
ventilator
69. The chest tube is functioning properly if:
a. There is an oscillation
b. There is no bubbling in the drainage bottle
 c. There is a continuous bubbling in the
waterseal
d. The sunction control bottle has a continuous
bubbling
70. In a client with pleural effusion, the nurse is
instructing appropriate breathing technique.
Which of the following is included in the
teaching?
a. Breath normally
b. Hold the breath after each inspiration for 1
full minute
c. Practice abdominal breathing
d. Inhale slowly and hold the breath for 3 to 5
seconds after each inhalation.
Situation: Health care delivery system affect the health
status of every Filipino. As a Nurse, knowledge of this
system is expected to ensure quality of life.
71. When should rehabilitation commence?
a. The day before discharge
b. When the patient desires
c. Upon admission
d. 24 hours after discharge
72. What exemplified the preventive and promotive
programs in the hospital?
a. Hospital as a center to prevent and control
infection
b. Program for smokers
c. Program for alcoholics and drugs addicts
d. Hospital wellness center
73. Which makes nursing dynamic?
a. Every patient is a unique physical,
emotional, social and spiritual being
b. The patient participate in the overall
nursing care plan
c. Nursing practice is expanding in the light of
modern developments that takes place
d. The health status of the patient is
constantly changing and the nurse must be
cognizant and responsive to these changes
74. Prevention in an important responsibility of the
nurse in:
a. Hospitals
b. Community
c. Workplace
d. All of the above
75. This form of Health Insurance provides
comprehensive prepaid health services to
enrollees for a fixed periodic payment.
a. Health Maintenance Organization
b. Medicare
c. Philippine Health Insurance Act
d. Hospital Maintenance Organization
Situation: Nursing ethics is an important part of the
nursing profession. As the ethical situation arises, so is
the need to have an accurate and ethical decision
making.
76. The purpose of having a nurses’ code of ethics
is:
a. Delineate the scope and areas of nursing
practice
b. Identify nursing action recommended for
specific health care situations
c. To help the public understand professional
conduct expected of nurses
d. To define the roles and functions of the
health care givers, nurses, clients
77. The principles that govern right and proper
conduct of a person regarding life, biology and
the health professionals is referred to as:
a. Morality
b. Religion
c. Values
d. Bioethics
78. A subject feeling about what is right or wrong is
said to be:
a. Morality
b. Religion
c. Values
d. Bioethics
79. Values are said to be the enduring believe about
a worth of a person, ideas and belief. If values
are going to be a part of a research, this is
categorized under:
a. Qualitative
b. Experimental
c. Quantitative
d. Non Experimental
80. The most important nursing responsibility
where ethical situations emerge in patient care
is to:
a. Act only when advised that the action is
ethically sound
 b. Not take sides, remain neutral and fair
c. Assume that ethical questions are the
responsibility of the health team
d. Be accountable for his or her own actions
81. Why is there an ethical dilemma?
a. the choices involved do not appear to be
clearly right or wrong
b. a client’s legal right co-exist with nurse’s
profession obligation
c. Decisions has to be made based on societal
norms.
d. decisions has to be made quickly, often
under stressful conditions
82. According to the code of ethics, which of the
following is the primary responsibility of the
nurse?
a. Assist towards peaceful death
b. Health is a fundamental right
c. Promotion of health, prevention of illness,
alleviation of suffering and restoration of
health
d. Preservation of health at all cost
83. Which of the following is TRUE about the code
of ethics of Filipino Nurses, except:
a. The Philippine Nurses Association for being
the accredited professional organization
was given the privilege to formulate a
Code of Ethics for Nurses which the Board
of Nursing promulgated
b. Code for nurses was first formulated in
1982 published in the proceedings of the
third Annual Convention of the PNA House
of Delegates
c. The present code utilized the code of Good
Governace for the Professions in the
Phillippines
d. Certificates of Registration of registered
nurses may be revoked or suspended for
violations of any provisions of the Code of
Ethics
84. Violation of the code of ethics might equate to
the revocation of the nursing license. Who
revokes the license?
a. PRC
b. PNA
c. DOH
d. BON
85. Base on the Code of Ethics for Filipino Nurses,
What is regarded as the hallmark of nursing
responsibility and accountability?
a. Human rights of clients, regardless of creed
and gender
b. The privilege of being a registered
professional nurse
c. Health, being a fundamental right of every
individual
d. Accurate documentation of actions and
outcomes
Situation: As a profession, nursing is dynamic and its
practice is directed by various theoretical models. To
demonstrate caring behavior, the nurse applies various
nursing models in providing quality nursing care.
86. When you clean the bedside unit and regularly
attend to the personal hygiene of the patient as
well as in washing your hands before and after a
procedure and in between patients, you indent
to facilitate the body’s reparative processes.
Which of the following nursing theory are you
applying in the above nursing action?
a. Hildegard Peplau
b. Dorothea Orem
c. Virginia Henderson
d. Florence Nightingale
87. A communication skill is one of the important
competencies expected of a nurse.
Interpersonal process is viewed as human to
human relationship. This statement is an
application of whose nursing model?
a. Joyce Travelbee
b. Martha Rogers
c. Callista Roy
d. Imogene King
88. The statement “the health status of an
individual is constantly changing and the nurse
must be cognizant and responsive to these
changes” best explains which of the following
facts about nursing?
a. Dynamic
b. Client Centered
c. Holistic
d. Art
89. Virginia Henderson professes that the goal of
nursing is to work independently with other
health care working assisting the patient to
gain independence as quickly as possible. Which of the
following nursing actions best demonstrates this theory
in taking care of a 94 year old client with dementia who
is totally immobile?
a. Feeds the patient, brushes his teeth, gives the
sponge bath
b. Supervise the watcher in rendering patient his
morning care
c. Put the patient in semi fowler’s position, set the
over bed table so the patient can eat by himself,
brush his teeth and sponge himself
d. Assist the patient to turn to his sides and allow
him to brush and feed himself only when he
feels ready
90. In the self-care deficit theory by Dorethea
Orem, nursing care becomes necessary when a
patient is unable to fulfill his physiological,
psychological and social needs. A pregnant
client needing prenatal check-up is classified as:
a. Wholly compensatory
b. Supportive educative
c. Partially compensatory
d. Non compensatory
Situation: Documentation and reporting are just as
important as providing patient care, As such, the nurse
must be factual and accurate to ensure quality
documentation and reporting.
91. Health care reports have different purposes.
The availability of patients’ record to all health
team members demonstrates which of the
following purposes:
a. Legal documentation
b. Research
c. Education
d. Vehicle for communication
92. When a nurse commits medication error, she
should accurately document client’s response
and her corresponding action. This is very
important for which of the following purposes:
a. Reasearch
b. Legal Documentation
c. Nursing Audit
d. Vehicle for communication
93. POMR has been widely used in many teaching
hospitals. One of its unique features is SOAPIE
charting. The P in SOAPIE charting should
include:
a. Prescription of the doctor to the patient’s illness
b. Plan of care for patient
c. Patient’s perception of one’s illness
d. Nursing problem and Nursing diagnosis
94. The medical records that are organized into
separate section from doctors or nurses has
more disadvantages than advantages. This is
classifies as what type of recording?
a. POMR
b. Modified POMR
c. SOAPIE
d. SOMR
95. Which of the following is the advantage of
SOMR or traditional recording?
a. Increase efficiency in data gathering
b. Reinforces the use of the nursing process
c. The caregiver can easily locate proper
section for making charting entries
d. Enhances effective communication among
health care team members.
Situations: June is a 24 year old client with symptoms of
dyspnea, absent breath sounds on the right lung and
chest x ray revealed pleural effusion. The physician will
perform thoracentesis.
96. Thoracentesis is usefulin treating all of the
following pulmonary disorders except:
a. Hemothorax
b. Hydrothorax
c. Tuberculosis
d. Empynea
97. Which of the following psychological
preparation is not relevant for him?
a. Telling him that the gauge of the needle
and anesthesia to be used
b. Telling him to keep still during the
procedure to facilitate the insertion of the
needle in the correct place
c. Allow June to express his feelings and
concerns
d. Physician’s explanation on the purpose of
the procedure and how it will be done
98. Before thoracentesis, the legal consideration
you must check is:
a. Consent is signed by the client
 b. Medicine preparation is correct
c. Position of the client is correct
d. Consent is signed by relative and physician

99. As a nurse, you know that the position for June

before thoracentesis is:
a. Orthopedic
b. Low fowlers
c. Knee-chest
d. Sidelying position on the affected side

100. Which of the following anaesthetics

drug is used for thoracentesis?
a. Procaine 2%
b. Demerol 75 mg
c. Valium 250 mg
d. Phenobartbital 50 mg
NURSING PRACTICE II
Situation: Mariah is a 31 year old lawyer who has been
married for 6 months. She consults you for guidance in
relation with her menstrual cycle and her desire to get
pregnant.
1. She wants to know the length of her menstrual
cycle. Her previous menstrual period is October
22 to 26. Her LMB is November 21. Which of the
following number of days will be your correct
response?
A. 29
B. 28
C. 30
D. 31
2. You advised her to observe and record the signs
of ovulation. Which of the following signs will
she likely note down?
1. A 1 degree Fahrenheit rise in basal body
temperature
2. Cervical mucus becomes copious and clear
3. One pound increase in weight
4. Mittelschmerz
A. 1, 2 , 4
B. 1, 2 , 3
C. 2, 3, 4
D. 1, 3, 4
3. You instruct Mariah to keep record of her basal
temperature every day, which of the following
instructions is incorrect?
A. If coitus has occurred; this should be
reflected in the chart
B. It is best to have coitus on the evening
following a drop in BBT to become pregnant
C. Temperature should be taken immediately
after waking and before getting out of bed
D. BBT is lowest during the secretary phase
4. She reports an increase in BBT on December
16. Which hormone brings about this change in
her BBT?
A. Estrogen
B. Gonadotropin
C. Progesterone
D. Follicle stimulating hormone
5. The following month, Mariah suspect she is
pregnant. Her urine is positive for Human
Chorionic Gonadotropin. Which structure
produces Hcg?
A. Pituitary gland
B. Trophoblastic cells of the embryo
C. Uterine deciduas
D. Ovarian follicle
Situation: Mariah came back and she is now pregnant.
6. At 5 month gestation, which of the following
fetal development would probably be achieve?
A. Fetal movement are felt Mariah
B. Vernix caseosa covers the entire body
C. Viable if delivered within this period
D. Braxton hicks contractions are observed.
7. The nurse palpates the abdomen of Mariah.
Now at 5 month gestation, what level of the
abdomen can the fundic height be palpated?
A. Symphysis pubis
B. Midpoint between the umbilicus and the
xiphoid process
C. Midpoint between the symphysis pubis and
the umbilicus
D. Umbilicus
8. She worries about her small breasts, thinking
that she probably will not be able to breastfeed
her baby. Which of the following responses of
the nurse is correct?
A. “The size of your breast will not affect your
lactation”
B. “You can switch to bottle feeding”
C. “You can try to have exercise to increase
the size of your breast”
D. “Manual expression of milk is possible”
9. She tells the nurse that she does not take milk
regularly. She claims that she does not want to
gain too much weight during her pregnancy.
Which of the following diagnosis is a priority?
A. Potential self-esteem disturbance related to
physiologic changes in pregnancy
B. Ineffective individual coping related to
physiologic changes in pregnancy
C. Fear related to the effects of pregnancy
D. Knowledge deficit regarding nutritional
 requiremnts of pregnancies related to lack of
information sources
10. Which of the following interventions will likely
ensure compliance of Mariah?
A. Incorporate her food preferences that are
adequately nutritious in her meal plan.
B. Consistently counsel toward optimum
nutritional intake
C. Respect her right to reject dietary
information if she chooses
D. Inform her of the adverse effect of
inadequate nutrition to her fetus
Situation: Susan is a patient in the clinic where you
work. She is inquiring about pregnancy.
11. Susan tell you she is worried because she
develops breasts later than most of her friends.
Breast development is termed as:
A. Adrenarche
B. Thelarche
C. Mamarche
D. Menarche
12. Kevin, Susan’s husband tells you that he is
considering vasectomy after the birth of their
new child. Vasectomy involves the incision of
which organ?
A. The testes
B. The epididymis
C. The vas deferens
D. The scrotum
13. On examination, Susan has been found of
having a cystocele. A cystocele is:
A. A sebaceous cyst arising from the vulvar
fold
B. Protrusion of intestines into the vagina
C. Prolapse of the uterus into the vagina
D. Herniation of the bladder into the vaginal
wall
14. Susan typically has menstrual cycle of 34 days.
She told you she had coitus on days 8, 10, 15
and 20 of her menstrual cycle. Which is the day
on which she is most likely to conceive?
A. 8th day
B. Day 15
C. 10th day
D. Day 20
15. While talking with Susan, 2 new patients arrived
and they are covered with large towels and the
nurse noticed that there are many cameraman
and news people outside of the OPD. Upon
assessment the nurse noticed that both of them
are still nude and the male client’s penis is still
inside the female client’s vagina and the male
client said “I can’t pull it”. Vaginismus was your
first impression. You know that the
psychological cause of Vaginismus is related to:
A. The male client inserted the penis too
deeply that it stimulates vaginal closure
B. The penis was too large that is why the
vagina triggered its defense to attempt to
close it
C. The vagina does not want to be penetrated
D. It is due to learning patterns of the female
client where she views sex as bad or sinful
Situation: Overpopulation is one problem in the
Philippines that causes economic drain. Most Filipinos
are against in legalizing abortion. As a nurse, Mastery of
contraception is needed to contribute to the society and
economic growth.
16. Supposed that Dana, 17 years old, tells you she
wants to use fertility awareness method of
contraception. How will she determine her
fertile days?
A. She will notice that she feels hot, as if she
has an elevated temperature.
B. She should assess whether her cervical
mucus is thin, copious, clear and watery
C. She should monitor her emotions for
sudden anger or crying
D. She should assess whether her breasts feel
sensitive to cool air
17. Dana chooses to use COC as her family planning
method. What is the danger sign of COC you
would ask her to report?
A. A stuffy or runny nose
B. Slight weight gain
C. Arthritis like symptoms
D. Migraine headache
18. Dana asks about subcutaneous implants and
she asks, how long will these implants be
effective. Your best answer is:
A. One month
 B. Five years
C. Twelve months
D. 10 years
19. Dana ask about female condoms. Which of the
following is true with regards to female
condoms?
A. The hormone the condom releases might
cause mild weight gain
B. She should insert the condom before any
penile penetration
C. She should coat the condom with
spermicide before use
D. Female condoms, unlike male condoms, are
reusable
20. Dana has asked about GIFT procedure. What
makes her a good candidate for GIFT?
A. She has patent fallopian tubes, so fertilized
ova can be implanted on them
B. She is RH negative, a necessary stipulation
to rule out RH incompatibility
C. She has normal uterus, so the sperm can be
injected through the cervix into it
D. Her husband is taking sildenafil, so all
sperms will be motile.
Situation: Nurse Lorena is a family planning and
Infertility Nurse Specialist and currently attends to
FAMILY PLANNING CLIENTS AND INFERTLE COUPLES.
The following conditions pertain to meeting the nursing
needs of this particular population group.
21. Dina, 17 years old, asks you how a tubal ligation
prevents pregnancy. Which would be the best
answer?
A. Prostaglandins released from the cut
fallopian tubes can kill sperm
B. Sperm cannot enter the uterus because the
cervical entrance is blocked.
C. Sperm can no longer reach the ova,
because the fallopian tubes are blocked
D. The ovary no longer releases ova as there is
nowhere for them to go.
22. The Dators are a couple undergoing testing for
infertility. Infertility is said to exist when:
A. A woman has no uterus
B. A woman has no children
C. A couple has been trying to conceive for 1
year
D. A couple has wanted a child for 6 months
23. Another client named Lilia is diagnosed as
having endometriosis. This condition interferes
with fertility because:
A. Endometrial implants can block the
fallopian tubes.
B. The uterine cervix becomes inflamed and
swollen
C. The ovaries stop producing adequate
estrogen
D. Pressure on the pituitary leads to decreased
FSH level
24. Lilia is scheduled to have a
hysterosalphingogram. Which of the following
instructions would you give her regarding this
procedure?
A. She will not be able to conceive for 3
months after the procedure
B. The sonogram of the uterus will reveal any
tumors present
C. Many women experience mild bleeding as
an after effect
D. She may feel some cramping when the dye
is inserted
25. Lilia’s cousin on the other hand, knowing Nurse
Lorena’s specialization ask what artificial
insemination by donor entails. Which would be
your best answer if you were Nurse Lorena?
A. Donor sperm are introduced vaginally into
the uterus or cervix
B. Donor sperm are injected intra
abdominally into each ovary
C. Artificial sperm are injected vaginally to test
tubal patency
D. The husband’s sperm is administered
intravenously weekly
Situation: You are assigned to take care of a group of
patients across the lifespan.
26. Pain in the elder persons requires careful
assessment because they:
A. experienced reduce sensory perception
B. have increased sensory perception
C. are expected to experience chronic pain
D. had a decreased pain threshold
27. Administration of analgesics to the older
persons requires careful patient assessment
because older people:
A. are more sensitive to drugs
 B. have increased hepatic, renal and
gastrointestinal function
C. have increased sensory perception
D. mobilize drugs more rapidly
28. The elderly patient is at higher risk for urinary
incontinence because of:
A. increased glomerular filtration
B. decreased bladder capacity
C. diuretic use
D. dilated urethra
29. Which of the following is the MOST COMMON
sign of infection among the elderly?
A. decreased breath sounds with crackles
B. pain
C. fever
D. change in mental status
30. Priorities when caring for the elderly trauma
patient:
A. circulation, airway, breathing
B. airway, breathing, disability (neurologic)
C. disability (neurologic), airway, breathing
D. airway, breathing, circulation
31. Preschoolers are able to see things from which
of the following perspectives?
A. Their peers
B. Their own and their mother’s
C. Their own and their caregivers’
D. Only their own
32. In conflict management, the win-win approach
occurs when:
A. There are two conflicts and the parties
agree to each other
B. Each party gives in on 50% of the
disagreements making up the conflict
C. Both parties involved are committed to
solving the conflict
D. The conflict is settled out of court so the
legal system and the parties win.
33. According to the social-interactional perspective
of child abuse and neglect, four factors place
the family members at risk for abuse. These risk
factors are the family itself, the caregiver, the
child, and
A. The presence of a family crisis
B. The national emphasis on sex
C. Genetics
D. Chronic poverty
34. Which of the following signs and symptoms
would you most likely find when assessing and
infant with Arnold-Chiari malformation?
A. Weakness of the leg muscles, loss of
sensation in the legs, and restlessness
B. Difficulty swallowing, diminished or absent
gag reflex, respiratory distress
C. Difficulty sleeping, hyper vigilant, and an
arching of the back
D. Paradoxical irritability, diarrhea, and
vomiting
35. A parent calls you and frantically reports that
her child has gotten into her famous ferrous
sulfate pills and ingested a number of these
pills. Her child is now vomiting, has bloody
diarrhea, and is complaining of abdominal pain.
You will the mother to:
A. Call emergency medical services (EMS) and
get the child to the emergency room
B. Relax because these symptoms will pass
and the child will be fine.
C. Administer syrup of ipecac
D. Call the poison control center
36. A client says she heard from a friend that you
stop having period once you are on the “pill”.
The most appropriate response would be:
A. “The pill prevents the uterus from making
such endometrial lining that is why periods
often be scant or skipped occasionally”.
B. “If your friend has missed her period, she
should stop taking pills and get a pregnancy
test a soon as possible”.
C. “The pill should cause a normal menstrual
period every month. It sounds that your
friend not taking the pills properly”.
D. “Missed period can be very dangerous and
may lead to the formation of precancerous
cells”.
37. The nurse assessing new born babies infants
during their hospital stay after birth will notice
Which of the following symptoms as a primary
manifestation of Hirschsprung’s disease?
A. A fine rush over the trunk
B. Failure to pass meconium during the first
24 to 48 hours after birth
 C. The skin turns yellow and then brown over
the first 48 hours of life
D. High-grade fever
38. A client is 7 months pregnant and has just been
diagnosed as having a partial placenta Previa.
She is stable and has minimal spotting and is
being sent home. Which of these instructions to
the client may indicate a need for further
teaching?
A. Maintain bed rest with bathroom
privileges
B. Avoid intercourse for 3 days
C. Call if contractions occur
D. Stay on left side as much as possible when
lying down
39. A woman has been rushed to the hospital with
ruptured membrane. Which of the following
should the nurse check first?
A. Check for the presence of infection
B. Assess for prolapse of the umbilical cord
C. Check the maternal heart rate
D. Assess the color of the amniotic fluid
40. The nurse notes that the infant is wearing a
plastic-coated diaper. If a topical medication
were to be prescribed and it were to go on the
stomachs or buttocks, the nurse would teach
the caregivers to:
A. Avoid covering the area of topical
medication with the diaper
B. Avoid the use of clothing on top of the
diaper
C. Put the diaper on as usual
D. Apply an icepack for 5 minutes to the
outside of the diaper
41. Which of the following factors is most
important in determining the success of
relationships used in delivering a nursing care?
A. Type of illness of the client
B. Transference and counter transference
C. Effective communication
D. Personality of the participants
42. Grace sustained a laceration on her leg from
automobile accident. Why are lacerations of
lower extremities potentially more serious
among pregnant women than other?
A. lacerations can provoke allergic responses
due to gonadotropic hormone
release
B. a woman is less able to keep the laceration
clean because of her fatigue
C. healing limited during pregnancy so these
will not heal until after birth
D. increased bleeding occur from uterine
pressure on leg veins.
43. In working with the caregivers of a client with
an acute or chronic illness, the nurse would:
A. Teach care daily and let the caregivers do a
return demonstration just before discharge
B. Difficulty swallowing, diminished or absent
gag reflex, and respiratory distress
C. Difficulty sleeping, hypervigillant, and an
arching of the back
D. Paradoxical irritability, diarrhea and
vomiting
44. Which of the following roles BEST exemplifies
the expanded role of the nurse?
A. Circulating nurse in surgery
B. Medication nurse
C. Obstetrical nurse
D. Pediatric nurse practitioner
45. According to DeRosa and Kochura’s (2006)
article entitled “Implement Culturally
Competent Health care in your workplace”,
cultures have different patterns of verbal and
nonverbal communication. Which difference
does?
A. NOT necessarily belong
B. Personal behavior
C. Subject matter
D. Conversational style
46. You are the burse assigned to work with a child
with acute glomerulonephritis. By following the
prescribed treatment regimen, the child
experiences a remission. You are now checking
to make sure the child does not have a relapse.
Which finding would most lead you to the
conclusion that a relapse is happening?
A. Elevated temperature, cough, sore throat,
changing complete blood count (CBC) with
differential
B. A urine dipstick measurement of 2+
proteinuria or more for 3 days, or the child
found to have 3-4+ proteinuria plus
edema.

C. The urine dipstick showing glucose in the
urine for 3 days, extreme thirst, increase in
urine output, and a moon face.
D. A temperature of 37.8 degrees (100 degrees
F), flank pain, burning frequency, urgency
on voiding, and cloudy urine.
47. The nurse is working with an adolescent who
complains of being lonely and having a lack of
fulfillment in her life. The adolescent shies away
from intimate relationships at times yet at other
times she appears promiscuous. The nurse will
likely work with this adolescent in which of the
following areas?
A. Isolation
B. Lack of fulfillment
C. Loneliness
D. Identity
48. The use of interpersonal decision making,
psychomotor skills, and application of
knowledge expected in the role of a license
health care professional in the context of public
health welfare and safety is an example of:
A. Delegation
B. Responsibility
C. Supervision
D. Competence
49. The painful phenomenon known as “back labor”
occurs in a client whose fetus in what position?
A. Brow position
B. Breech position
C. Right Occipito- anterior position
D. Left Occipito- posterior position
50. FOCUS methodology stands for:
A. Focus, Organize, Clarify, Understand and
Solution
B. Focus, Opportunity, Continuous, Utilize,
Substantiate
C. Focus, Organize, Clarify, Understand,
Substantiate
D. Focus, Opportunity, Continuous (process),
Understand, Solution
Situation: The infant and child mortality rate in the low
middle income countries is ten times higher than
industrialized countries. In response to this, the WHO
and UNICEF launched the protocol integrated
management of Childhood Illness to reduce the
morbidity and mortality against childhood illnesses.
51. If a child with diarrhea registers two signs in the
yellow row in the IMCI chart, when can classify
the patient as:
A. Moderate dehydration
B. Severe dehydration
C. Some dehydration
D. No dehydration
52. Celeste has had diarrhea for 8 days. There is no
blood in the stool, he is irritable, his eyes are
sunken, and the nurse offers fluid to Celeste
and the drinks eagerly. When the nurse pinched
the abdomen it goes back slowly. How will you
classify Celeste’s illness?
A. Moderate Dehydration
B. Severe dehydration
C. Some dehydration
D. No dehydration
53. A child who is 7 weeks has had a diarrhea for 14
days but has no sign of dehydration is classified
as:
A. Persistent diarrhea
B. Dysentery
C. Severe Dysentery
D. Severe Persistent Diarrhea
54. The child with no dehydration needs home
treatment. Which of the following is not
included in the rules for home treatment in this
case?
A. Forced Fluids
B. When to return
C. Give vitamin A supplement
D. Feeding more
55. Fever as used in IMCI includes:
A. Axillary temperature of 37.5 or higher
B. Rectal temperature of 38 or higher
C. Feeling hot to touch
D. All of the above
E. A and C only
Situation: Prevention of Dengue is an important nursing
responsibility and controlling its spread is a priority
once outbreak has been observed.
56. An important role of the community health
nurse in the prevention and control of dengue
H-Fever includes:
A. Advising the elimination of vectors by
keeping water containers covered
 B. Conducting strong health education drives/
campaign directed towards proper garbage
disposal
C. Explaining to the individuals, families,
group and community the nature of the
disease and its causation
D. Practicing residual spraying with insecticides
57. Community health nurses should be alert in
observing a Dengue suspect. The following is
not an indicator for hospitalization of H-Fever
suspects?
A. Marked anorexia, abdominal pain and
vomiting
B. Increasing hematocrit count
C. Cough of 30 days
D. Persistent headache
58. The community health nurses’ primary concern
in the immediate control of hemorrhage among
patients with dengue is:
A. Advising low fiber and Non- fat diet
B. Providing warmth through light weight
covers
C. Observing closely the patient for vital signs
leading to shock
D. Keeping the patient at rest
59. Which of these signs may NOT be REGARDED as
a truly positive signs indicative of Dengue H-
Fever?
A. Prolonged bleeding time
B. Appearance of at least 20 petechiae within
1cm square
C. Steadily increasing hematocrit count
D. Fall in the platelet count
60. Which of the following is the most important
treatment of patients with Dengue H-fever?
A. Give aspirin for fever
B. Replacement of body fluids
C. Avoid unnecessary movement of patient
D. Ice cap over the abdomen in case of melena
Situation: Health education and Health Promotion is an
important part of nursing responsibility in the
community. Immunization is a form of health promotion
that aims at preventing the common childhood
illnesses.
61. In correcting misconceptions and myths about
certain diseases and their management, the
health worker should first:
A. Identify the myths and misconceptions
prevailing in the community
B. Identify the source of these myths and
misconceptions
C. Explain how and why these myths came
about
D. Select the appropriate IEC strategies to
correct them
62. How many percent of measles are prevented by
immunization at 9 months of age?
A. 80%
B. 99%
C. 90%
D. 95%
63. After TT3 vaccination a mother is said to be
protected to tetanus by around:
A. 80%
B. 99%
C. 85%
D. 90%
64. If ever convulsions occur after administering
DPT, what should the nurse best suggest to the
mother?
A. Do not continue DPT vaccination anymore
B. Advise mother to comeback after 1 week
C. Give DT instead of DPT
D. Give pertussis of the DPT and remove DT
65. These vaccines are given 3 doses at one month
intervals:
A. DPT, BCG, TT
B. OPV, HEP. B, DPT
C. DPT, TT, OPV
D. Measles, OPV, DPT
Situation: with the increasing of documented cases of
CANCER the best alternative to treatment still remains
to be PREVENTION. The following conditions apply:
66. Which among the following is the primary focus
of prevention of cancer?
A. Elimination of conditions causing cancer
B. Diagnosis and treatment
C. Treatment at early age
D. Early detection
67. In the prevention and control of cancer, which
of the following activities is the most important
function of the community health nurse?
 A. Conduct community assemblies
B. Referral to cancer specialist those clients
with symptoms of cancer
C. Use the nine warning signs of cancer as
parameters in our process of detection,
control and treatment modalities
D. Teach woman about proper/correct
nutrition
68. Who among the following are recipients of the
secondary level of care for cancer cases?
A. Those under early case detection
B. Those under post case treatment
C. Those scheduled for surgery
D. Those undergoing treatment
69. Who among the following are recipients of the
tertiary level of care for cancer cases?
A. Those under early treatment
B. Those under early detection
C. Those under supportive care
D. Those scheduled for surgery
70. In community health nursing, despite the
availability and use of many equipment and
devices to facilitate the job of the community
health nurse, the best tool any nurse should be
will be prepared to apply is a scientific
approach. This approach ensures quality of care
even at the community setting. This is nursing
parlance is nothing less than the:
A. Nursing diagnosis
B. Nursing Research
C. Nursing Protocol
D. Nursing Process
Situation: Two children were brought to you. One with
Chest in drawing and the other had diarrhea. The
following question apply:
71. Using integrated Management and Childhood
Illness (IMCI) approach, how would you classify
the 1st child?
A. Bronchopneumonia
B. Severe pneumonia
C. No pneumonia: cough or cold
D. Pneumonia
72. The 1st child who is 13 month has fast breathing
using IMCI parameters he has:
A. 40 breaths per minute or more
B. 50 breaths per minute
C. 30 breaths per minute or more
D. 60 breaths per minute
73. Nina, the 2nd child has diarrhea for 5 days. There
is no blood in the stool. She is irritable, and her
eyes are sunken. The nurse offered fluid and the
child drinks eagerly. How would you classify
Nina’s illness?
A. Some dehydration
B. Severe dehydration
C. Dysentery
D. No dehydration
74. Nina’s treatment should include the following
EXCEPT:
A. Reassess the child and classify him for
dehydration
B. For infants under 6 months old who are not
breast feed, give 100-200 ml clean water as
well during this period
C. Give in the health center the recommended
amount of ORS for 4 hours
D. Do not give any other foods to the child for
home treatment
75. While on treatment, Nina 18 months old
weighted 18kgs. And her temperature
registered at 37 degrees C. Her mother says she
developed cough 3 days ago. Nina has no
general danger signs. She has 45 breath/minute,
no chest in drawing, no stridor. How would you
classify Nina’s manifestation?
A. No Pneumonia
B. Pneumonia
C. Severe pneumonia
D. Bronchopneumonia
76. Carol is 15 months old and weight 5.5kgs. and it
is her initial visit. Her mother says that Carol is
not eating well and unable to breastfeed, he is
no vomiting, has no convulsion and not
abnormally sleepy or difficult to awaken. Her
temperature is 38.9 deg. C. Using the integrated
management of childhood illness or IMCI
strategy, if you were the nurse in charge of
carol, how will you classify her illness?
A. a child at a general danger sign
B. severe pneumonia
C. very severe febrile disease
D. severe malnutrition
77. Why are small for gestational age newborns at
risk for difficulty maintaining body temperature?
A. their skin is more susceptible to conduction of
cold
B. they are preterm so are born relatively small in
size
C. they do not have as many fast stored as other
infants
D. they are more active than usual so they throw
off comes
78. Oxytocin is administered to Rita to augment
labor. What are first symptoms of water
intoxication to observe for during this
procedure?
A. headache and vomiting
B. a high choking voice
C. a swollen tender tongue
D. abdominal bleeding and pain
79. Which of the following treatment shout NOT be
considered if the child has severe dengue
Hemorrhagic Fever?
A. use plan C is there is bleeding from the nose
or gums
B. give ORS if there is skin Petechiae,
persistent vomiting, and positive tourniquet
test
C. give aspirin
D. prevent low blood sugar
80. In assessing the patient’s condition using the
integrated management of Childhood illness
approach strategy, the first thing that a nurse
should do is to:
A. ask what are the child’s problem
B. check for the four main symptoms
C. check the patients level of consciousness
D. check for the general danger signs
81. A child with diarrhea is observed for the
following EXCEPT:
A. how long the child has diarrhea
B. presence of blood in the stool
C. skin petechiae
D. signs of dehydration
82. The child with no dehydration needs home
treatment. Which of the following is NOT
included in the care for home management at
this case?
A. give drugs every 4 hours
B. give the child more fluids
C. continue feeding the child
iInform when to return to the health center
83. Ms. Jordan, RN, believes that a patient should
be treated as individual. This ethical principle
that the patient referred to:
A. beneficence
B. respect for person
C. nonmaleficence
D. autonomy
84. When patients cannot make decisions for
themselves, the nurse advocate relies on the
ethical principle of:
A. justice and beneficence
B. beneficence and nonmaleficence
C. fidelity and nonmaleficence
D. fidelity and justice
85. Being a community health nurse, you have the
responsibility of participating in protecting the
health of people. Consider this situation:
Vendors selling bread with their bare hands.
They receive money with these hands. You do
not see them washing their hands. What should
you say/do?
A. “miss, may I get the bread myself because
you have not washed your hands
B. All of these
C. “Miss, it is better to use a pick up
forceps/bread tong”
D. “miss, your hands are dirty. Wash your
hands first before getting the bread.
Situation: The following questions are refer to common
clinical encounters experienced by an entry level nurse.
86. A female client ask the nurse about the use of a
cervical cap. Which statement is correct
regarding the use of the cervical cap?
A. It may affect Pap smear results.
B. It does not need to be fitted by the
physician.
C. It does not require the use of spermicide.
D. It must be removed within 24 hours.
87. The major components of the communication
process are:
A. Verbal, Written and nonverbal
B. Speaker, listener and reply
 C. Facial expression, tone of voice, and
gestures
D. Messages, sender, channel, receiver, and
feedback
88. The extent of burns in children are normally
assessed and expressed in terms of:
A. The amount of body surface that is
unburned
B. Percentages of total body surface area
(TBSA)
C. How deep the deepest burns are
D. The severity of the burns on a 1 to 5 burn
scale.
89. The school nurse notices a child who is wearing
old, dirty, poor fitting clothes; is always hungry;
has no lunch money; and is always tired. When
the nurse ask the boy his tiredness, he talks of
playing outside until midnight. The nurse will
suspect that this child is:
A. Being raised by a parent of low intelligence
quotient (IQ)
B. An Orphan
C. A victim of child neglect
D. The victim of poverty
90. Which of the following indicates the type(s) of
accurate renal failure?
A. Four types: hemorrhagic with and without
clotting, and nonhemorrhagic with and
without clotting
B. One type: acute
C. Three types: prerenal, intrarenal, and
postrenal
D. Two types: acute and subacute
Situation: Mike 16 y/o has been diagnosed to have
AIDS; he worked as entertainer in a cruise ship;
91. Which method of transmission is common to
contract AIDS?
A. Syringe and needles
B. Sexual contact
C. Body fluids
D. Transfusion
92. Causative organism in AIDS is one of the
following:
A. Fungus
B. Retrovirus
C. Bacteria
D. Parasites
93. You are assigned in a private room of mike.
Which procedure should be of outmost
importance;
A. Alcohol wash
B. Washing isolation
C. Universal precaution
D. Proper nutrition
94. What primary health teaching would you give to
mike;
A. Daily exercise
B. Reverse isolation
C. Prevent infection
D. Proper nutrition
95. Exercise precaution must be taken to protect
health worker dealing with the AIDS patients.
Which among these must be done as priority:
A. Boil used syringe and needles
B. Use gloves when handling specimen
C. Label personal belonging
D. Avoid accidental wound
Situation: Michelle is a 6 years old preschooler. She was
reported by her sister to have a measles but she is at
white home because of fever, upper respiratory
problem, and white sports in her mouth.
96. Rubeola is an Arabic term meaning red, the rash
appears on the skin in invasive stage prior to
eruption behind the ears. As a nurse, your
physical examination must determine
complication especially:
A. Otitis media
B. Inflammatory conjunctiva
C. Bronchial pneumonia
D. Membranous laryngitis
97. To render comfort, measure is one of the
priorities, which includes care of the skin, eyes,
ears, mouth, and nose. To clean the mouth your
antiseptic solution is in some form of which one
below?
A. Water
B. Alkaline
C. Sulfur
D. Salt
98. As a public health nurse, you teach mother and
family members the prevention of complication
of measles. Which of the following should be
Closely watched?
A. Temperature fails to drop
B. Inflammation of the nasophraynx
C. Inflammation of the conjunctiva
D. Ulcerative stomatitis

99. Source of infection of measles is secretion of

nosse and throat of infection person. Filterable
virus of measles is transmittedby:
A. Water supply
B. Food ingestion
C. Droplet
D. Sexual contact
100. Method of prevention is to avoid
exposure to an infection person. Nursing
responsibility for rehabilitation of patient
includes the provision of:
A. Terminal disinfection
B. Immunization
C. Injection of gamma globulin
D. Comfort measures
NURSING PRACTICE III
c. 50 days
d. 14 days
Situation: Leo lives in the squatter area. He goes to
nearby school. He helps his mother gather molasses Situation: as a nurse researcher you must have a very
after school. One day, he was absent because of fever, good understanding of the common terms of concept
malaise, anorexia, and abdominal discomfort. used in research.

1. Upon assessment, Leo was diagnosed to have 6. The information that an investigator collects
hepatitis a. Which mode of transmission has the from the subjects or participants in a research
infection agent taken? study is usually called;
A. Fecal-oral a. Hypothesis
B. Droplet b. Variable
C. Airborne c. Data
D. Sexual contact d. Concept

2. Which of the following is concurrent 7. Which of the following usually refers to the
disinfection in the case of Leo? independent variables in doing research
a. Investigation of contact a. Result
b. Sanitary disposal of faeces, urine and b. Output
blood c. Cause
c. Quarantine of the sick individual d. Effect
d. Removing all detachable objects in the
room, cleaning lighting and air duct surfaces 8. The recipients of experimental treatment is an
in the ceiling, and cleaning everything experimental design or the individuals to be
downward to the floor. observed in a non experimental design are
called;
3. Which of the following must be emphasized a. Setting
during mother’s class to Leo’s mother? b. Treatment
a. Administration of immunoglobulin to c. Subjects
families d. Sample
b. Thorough hand washing before and after
eating and toileting 9. The device or techniques an investigator
c. Use of attenuated vaccines employs to collect data is called;
d. Boiling of food especially meat a. Sample
b. Hypothesis
4. Disaster control should be undertaken when c. Instrument
there are 3 or more hepatitis A cases. Which of d. Concept
these measures is a priority?
a. Eliminate faecal contamination from foods 10. The use of another person’s ideas or wrong
b. Mass vaccination of uninfected individuals doings without giving appropriate credit result
c. Health promotion and education to from inaccurate or incomplete attribution of
families and communities about the materials to its sources. Which of the following
disease it’s cause and transmission is referred to when another person’s idea is
d. Mass administration of immunoglobulin inappropriate credited as one’s own;
a. Plagiarism
5. What is the average incubation period of b. Assumption
Hepatitis A? c. Quotation
a. 30 days d. Paraphrase
b. 60 days
Situation- Mrs. Pichay is admitted to your ward. The MD
ordered “prepare for thoracentesis this pm to remove
excess air from the pleural cavity.
 11. Which of the following nursing responsibilities is
essential in Mrs. Pichay who will undergo
thoracentesis?
a. Support and reassure client during the
procedure
b. Ensure that informed consent has been
signed
c. Determine if client has allergic reaction to
local anesthesia
d. Ascertain if chest x-rays and other tests n
have been prescribed and completed
12. Mrs. Pichay who is for thoracentesis is assigned
by the nurse to which of the following position?
a. Trendelenburg position
b. Supine position
c. Dorsal recumbent position
d. Orthopneic position
13. During thoracentesis, which of the following
nursing intervention will be most crucial?
a. Place patient in a quiet and cool room
b. Maintain strict aseptic technique
c. Advise patient to sit perfectly still during
needle insertion until it has been
withdrawn from the chest
d. Apply pressure over the puncture site as
soon as the needle is withdrawn
14. To prevent leakage of fluid in the thoracic
cavity, how will you position the client after
thoracentesis?
a. Place flat in the bed
b. Turn on the unaffected side
c. Turn on the affected side
d. On bed rest
15. Chest X-ray was ordered after thoracentesis.
When your client asks what is the reason for
another chest x-ray, you will explain:
a. To rule out pneumothorax
b. To rule out any possible perforation
c. To decongest
d. To rule out any foreign body
Situation: A computer analyst, Mr. Ricardo J. Santos, 25
was brought to the hospital for diagnostic workup after
he had experienced seizure in his office.
16. Just as the nurse was entering the room, the
patient who was sitting on his chair begins to
have a seizure. Which of the following must the
nurse do first?
a. Ease the patient to the floor To rule out
pneumothorax
b. Lift the patient and put him on the bed
c. Insert a padded tongue depressor between
his jaws
d. Restraint patient’s body movement
17. Mr. Santos is scheduled for CT SCAN for the
next day, noon time. Which of the followingis
the correct preparation as instructed by the
nurse?
a. Shampoo hair thoroughly to remove oil and
dirt
b. No special preparation is needed. Instruct
the patient to keep his head still and stead
c. Give a cleansing enema and give fluids until
8 AM
d. Shave scalp and securely attach electrodes
to it
18. Mr. Santos is placed on seizure precaution.
Which of the following would be
contraindicated?
a. Obtain his oral temperature
b. Encourage to perform his own personal
hygiene
c. Allow him to wear his own clothing
d. Encourage him to be out of bed
19. Usually, how does the patient behave after his
seizure has subsided?
a. Most comfortable walking and moving
about.
b. Becomes restless and agitated
c. Sleeps for a period of time
d. Say he is thirsty and hungry
20. Before, during and after seizure. The nurse
knows that the patient is ALWAYS placed in
what position?
a. Low fowler’s
b. Side lying
c. Modified trendelenburg
d. Supine
Situation: Mrs. Damian an immediate post op
cholecystectomy and choledocholithotomy patient,
complained of severe pain at the wound site.
21. Choledocholithotomy is:
a. The removal of the gallbladder
b. The removal of the stones in the gallbladder
c. The removal of the stones in the
common bile duct
d. The removal of the stones in the kidney
22. The simplest pain relieving technique is:
a. Distracton
b. Deep breathing exercise
c. Taking aspirin
d. Positioning
23. Which of the following statement on pain is
TRUE?
a. Culture and pain are not associated
b. Pain accompanies acute illness
c. Patient’s reaction to pain Varies
d. Pain produces the same reaction such as
groaning and moaning
24. In pain assessment, which of the following
condition is a more reliable indicator?
a. Pain rating scale of 1 to 10
b. Facial expression and gestures
c. Physiological responses
d. Patient’s description of the pain sensation
25. When a client complains pain, your initial
response is:
a. Record the description of pain
b. Verbally acknowledge the pain
c. Refer the complaint to the doctor
d. Change to a more comfortable position
Situation: You are assigned at the surgical ward and
Clients have been complaining of post pain at varying
Degrees. Pain as you know, is very subjective.
26. A one-day postoperative abdominal surgery
client has been complaining of severe throbbing
abdominal pain described as 9 in a 1-10 pain
rating. Your assessment reveals bowel sounds
on all quadrants and the dressing is dry and
intact. What nursing intervention would you
take?
a. Medicate client as prescribed
b. Encourage client to do imagery
c. Encourage deep breathing and turning
d. Call surgeon stat
27. Pentoxidone 5 mg IV every 8 hours was
Prescribed for post abdominal pain. Which will
be your priority nursing action?
a. Check abdominal dressing for possible
swelling
b. Explain the proper use of PCA to alleviate
anxiety
c. Avoid overdosing to prevent
dependence/tolerance
d. Monitor VS, more importantly RR
28. The client complained of abdominal distention
and pain. Your nursing intervention that can
alleviate pain is:
a. Instruct client to go to sleep and relax
b. Advice the client to close the lips and avoid
deep breathing and talking
c. Offer hot and clear soup
d. Turn to sides frequently and avoid too
much talking
29. Surgical pain might be minimized by which
nursing action in the O.R.
a. Skill of surgical team and lesser
manipulation
b. Appropriate preparation for the scheduled
procedure
c. Use of modern technology in closing the
wound
d. Proper positioning and draping of clients
30. Inadequate anesthesia is said to be one of the
common cause of pain both in intra and post op
patients. If general anesthesia is desired, it will
involve loss of consciousness. Which of the
following are the 2 general types of GA?
a. Epidural and Spinal
b. Subarachnoid block and intravenous
c. Inhalation and regional
d. Intravenous and inhalation
Situation: Nurse’s attitude toward the pain influence
The way they perceive and interact with clients in pain.
31. Nurses should be aware that older adults are at
risk of underrated pain. Nursing assessment and
management of pain should address the
following beliefs EXCEPT:
a. Older patient seldom tend to report
pain than the younger once
b. Pain is a sign of weakness
c. Older patients do not believe in
analgesics, they are tolerant
d. Complaining of pain will lead to being
labelled a ‘bad’ patient
32. Nurse should understand that when a client
responds favourable to a place, it is known as
the ‘placebo effect’. Placebos do not indicate
 Whether or not a client has:
a. Conscience
b. Disease
c. Real pain
d. Drug tolerance
33. You are the nurse in the pain clinic where you
have client who has difficulty specifying the
location of pain. How can you assist such client?
a. The pain is vague
b. By charting- it hurts all over
c. Identify the absence and presence of pain
d. As the client to point to the painful are by
just one finger
34. What symptom, more distressing than pain,
should the nurse monitor when giving opioids,
especially among elderly clients who are in
pain?
a. Forgetfulness
b. Drowsiness
c. Constipation
d. Allergic reactions like pruritis
35. Physical dependence occurs in anyone who
takes opioids over a period of time. What do
you tell a mother of a ‘dependent’ when asked
for advice?
a. Start another drug and slowly lessen the
opioid dosage
b. Indulge in recreational outdoor activities
c. Isolate opioid dependent to a restful resort
d. Instruct slow tapering of the drug dosage
and alleviate physical withdrawal
symptoms
Situation: The nurse is performing health education
activities for Janevi Segovia, a 30 year old Dentist with
insulin dependent Diabetes Miletus.
36. Janevi is preparing a mixed dose of insulin. The
nurse is satisfied with her performance when
she:
a. Draw insulin from the vial of clear insulin
first
b. Draw insulin from the vial of the
intermediate acting insulin first
c. Fill both syringe with the prescribed insulin
dosage then shake the bottle vigorously
d. Withdraw the intermediate acting insulin
first before withdrawing the short
Acting insulin first
37. Janevi complains of nausea, vomiting,
diaphoresis and headache. Which of the
following nursing intervention are you going to
carry out first?
a. Withhold the client’s next insulin injection
b. Test the client’s blood glucose level
c. Administer Tylenol as ordered
d. Offer fruit juice, gelatine and chicken
bouillon
38. Janevi administered regular insulin at 7 am and
the nurse should instruct Jane to avoid
exercising at around:
a. 9 to 11 A.M
b. Between 8 A.M to 9 A.M
c. After 8 hours
d. In the afternoon, after taking lunch
39. Janevi was brought at the emergency room
after four month because she fainted in her
clinic. The nurse should monitor which of the
following test to evaluate the overall
therapeutic compliance of a diabetic patient?
a. Glycosylated haemoglobin
b. Ketone levels
c. Fasting blood glucose
d. Urine glucose level
40. Upon the assessment of Hba1c of Mrs. Segovia,
the nurse has been informed of a 9% Hba1c
result. In this case, she will teach the patient to:
a. Avoid infection
b. Prevent and recognize hyperglycaemia
c. Take adequate food and nutrition
d. Prevent and recognize hypoglycaemia
41. The nurse is teaching plan of care for Jane with
regards to proper foot care. Which of the
following should be included in the plan?
a. Soak feet in hot water
b. Avoid using mild soap on the feet
c. Apply a moisturizing lotion to dry feet but
not between the toes
d. Always have a podiatrist to cut your toe
nails; never cut them yourself
42. Another patient was brought to the emergency
room in an unresponsive state and a diagnosis
of hyperglycaemia hyperosmolar nonketotic
syndrome is made. The nurse immediately
 prepares to initiate which of the following
anticipated physician’s order?
a. Endotracheal intubation
b. 100 unites of NPH insulin
c. Intravenous infusion of normal saline
d. Intravenous infusion of sodium
bicarbonate
43. Jane eventually developed DKA and is being
treated in the emergency room. Which finding
would the nurse expect to note as confirming
this diagnosis?
a. Comatose state
b. Decreased urine output
c. Increased respiration and an increase in pH
d. Elevated blood glucose level and low
plasma bicarbonate level
44. The nurse teaches Jane to know the difference
between hypoglycaemia and ketoacidosis. Jane
demonstrates understanding of the teaching by
stating the glucose will be taken if which of the
following symptoms develops?
a. Polyuria
b. Shakiness
c. Blurred Vision
d. Fruity breath odour
45. Jane has been scheduled to have FBS taken in
the morning. The nurse tells Jane not to eat or
drink after midnight. Prior to taking the blood
specimen the nurse noticed that Jane is holding
a bottle of distilled water. The nurse asked Jane
if she drink any, and she said “yes.” Which of
the following is the best nursing action?
a. Administer syrup of ipecac to remove the
distilled water from the stomach
b. Suction the stomach content using NGT
prior to specimen collection
c. Advice a physician to reschedule to
diagnostic examination next day
d. Continue as usual and have the FBS
analysis performed and specimen be taken
Situation: Elderly clients usually produce unusual signs
When it comes to different diseases. The ageing process
is a complicated process and the nurse understand that
it is an inevitable fact and she must be prepared to care
for the growing elderly population.
46. Hypoxia may occur in the older patient because
of which of the following physiologic changes associated
with aging.
a. Ineffective airway clearance
b. Decreased alveolar surfaced area
c. Decreased anterior-posterior chest diameter
d. Hyperventilation
47. The older patient is at higher risk for
incontinence because of:
a. Dilated urethra
b. increased glomerular filtration rate
c. Diuretic use
d. Decreased bladder capacity
48. Merle, age 86, is complaining of dizziness when
she stand up. This may indicate:
a. Dementia
b. Functional decline
c. A visual problem
d. Drug Toxicity
49. Cardiac ischemia in an older patient usually
produces:
a. ST-T wave changes
b. Chest pain radiating to the left arm
c. Very high creatinine kinase level
d. Acute confusion
50. The most dependable sign of infection in the
older patient is:
a. Change in mental status
b. Fever
c. Pain
d. Decreased breath sounds with crackles
Situation – In the OR, there are safety protocols that
should be followed. The OR nurse should be well versed
with all these to safeguard the safety and quality of
patient delivery outcome.
51. Which of the following should be given highest
priority when receiving patient in the OR?
a. Assess level of consciousness
b. Verify patient identification and informed
consent
c. Asses vital signs
d. Check for jewellery, gown, manicure, and
dentures
52. Surgeries like I and D (incision and drainage
and debridement are relatively short
procedures but considered ‘dirty cases’ when
are these procedures best scheduled?
 a. Last case
b. In between cases
c. According to availability of
anaesthesiologist
d. According to the surgeon’s preference
53. Or nurses should be aware that maintaining the
client’s safety is the overall goal of nursing care
during the intraoperative phase. As the
circulating nurse, you make certain that
throughout the procedure…
a. The surgeon greets his client before
induction of anaesthesia
b. The surgeon and anaesthesiologist are in
tandem
c. Strap made of strong non-abrasive
materials are fastened securely around the
joints of the knees and ankles and around
the 2 hands around an arm board.
d. Client is monitored throughout the surgery
by the assistant anaesthesiologist
54. Another nursing check that should not be
missed before the induction of general
anaesthesia is:
a. Check for presence underwear
b. Check for presence dentures
c. Check patient’s ID
d. Check baseline vital signs
55. Some lifetime habits and hobbies affect
postoperative respiratory function. If your client
smokes 3 packs of cigarettes a day for the past
10 years, you will anticipate increased risk for:
a. Perioperative anxiety and stress
b. Delayed coagulation time
c. Delayed wound healing
d. Postoperative respiratory infection
Situation: Sterilization is the process of removing ALL
living microorganism. To be free of ALL loiving
microorganism is sterility.
56. There are 3 general types of sterilization use in
the hospital, which one is not included?
a. Steam sterilization
b. Physical sterilization
c. Chemical sterilization
d. Sterilization by boiling
57. Autoclave or steam under pressure is the most
common method of sterilization in the hospital.
The nurse knows that the temperature and time is set
to the optimum level to destroy not only the
microorganism, but also the pores. Which of the
following is the ideal setting of the autoclave machine?
a. 10,000 degree Celsius for 1 hour
b. 5,000 degree Celsius for 30 minutes
c. 37 degree Celsius for 15 minutes
d. 121 degree Celsius for 15 minutes
58. It is important that before a nurse prepare the
material to be sterilized, a chemical indicator
strip should be placed above the package,
preferably, Muslim sheet. What is the color of
the striped produced after autoclaving?
a. Black
b. Blue
c. Gray
d. Purple
59. Chemical indicators communicate that:
a. The items are sterile
b. That the items had undergone sterilization
process but not necessarily sterile
c. The items are disinfected
d. That the items had undergone disinfection
process but not necessarily disinfected
60. If a nurse will sterilize a heat and moisture labile
instruments, it is according to AORN
recommendation to use which of the following
method of sterilization?
a. Ethylene oxide gas
b. Autoclaving
c. Flash sterilizer
d. Alcohol immersion
Situation: Nurses hold a variety of roles when providing
care to a perioperative patient.
61. Which of the following role would be the
responsibility of the scrub nurse?
a. Assess the readiness of the client prior to
surgery
b. Ensure that the airway is adequate
c. Account for the number of sponges,
needles, supplies, used during the surgical
procedure
d. Evaluate the type of anaesthesia
appropriate for the surgical client
 62. As a perioperative nurse, how can you best
meet the safety need of the client after
administering preoperative narcotic?
a. Put side rails up and ask the client not to
get out of bed
b. Send the client to OR with the family
c. Allow client to get up to go to the comfort
room
d. Obtain consent form
63. It is the responsibility of the pre-op nurse to do
skin prep for patients undergoing surgery. If hair
at the operative site is not shaved, what should
be done to make suturing easy and lessen
chance of incision infection?
a. Draped
b. Pulled
c. Clipped
d. Shampooed
64. It is also the nurse’s function to determine
when infection is developing in the surgical
incision. The perioperative nurse should
observe for what signs of impending infection?
a. Localized heat and redness
b. Serosanguinous exudates and skin
blanching
c. Separation of the incision
d. Blood clots and scar tissue are visible
65. Which of the following nursing interventions is
done when examining the incision wound and
changing the dressing?
a. Observe the dressing and type and odor
of drainage if any
b. Get patient’s consent
c. Wash hands
d. Request the client to expose the incision
wound
Situation - The preoperative nurse collaborates with the
Client significant others, and healthcare providers.
66. To control environmental hazards in the Or, the
nurse collaborates with the following
departments EXCEPT:
a. Biomedical division
b. Infection control committee
c. Chaplaincy services
d. Pathology department
67. An air crash occurred near the hospital leading
to a surge of trauma patient. One of the last
patients will need surgical amputation but there no
sterile surgical equipments. In this case, which of
the following will the nurse expect?
a. Equipments needed for surgery need not be
sterilized if this is an emergency necessitating
life saving measures
b. Forwarding the trauma client to the nearest
hospital that has available sterile equipment is
appropriate
c. The nurse will need to sterilize the item before
using it to the client using the regular
sterilization setting at 121 degree Celsius in 15
minutes
d. In such cases, Flash sterilizer will be use at 132
degree Celsius in 3 minutes
68. Tess, the PACU nurse, discovered that Malou,
who weighs 110lbs prior to surgery, is in severe
pain 3 hrs after cholecystectomy. Upon
checking the chart, Malou found out that she
has an order of Demerol 100 mg I.M prn for
pain. Tess should verify the order with:
a. Nurse supervisor
b. Surgeon
c. Anaesthesiologist
d. Intern on duty
69. Rosie, 57 who is diabetic is for debridement if
incision wound. When the circulating nurse
checked the present IV fluid, she found out that
there is no insulin incorporated as ordered.
What should the circulating nurse do?
a. Double check the doctor’s order and call
the attending MD
b. Communicate with the ward nurse to verify
if insulin was incorporated or not
c. Communicate with the client to verify if
insulin was incorporated
d. Incorporate insulin as ordered
70. The documentation of all nursing activities
performed is legally and professionally vital.
Which of the following should NOT be included
in the patient’s chart?
a. Presence of prosthetoid devices such as
dentures, artificial limbs hearing aid, etc.
b. Baseline physical , emotional, and
psychosocial data
c. Arguments between nurses and residents
regarding treatments
d. Observed untoward signs and symptoms
and interventions including contaminant
intervening factors
Situation- Team efforts is best demonstrated in the OR.
71. If you are the nurse in charge for scheduling
surgical cases, what important information do
you need to ask the surgeon?
a. Who is your internist
b. Who is your assistant and
anaesthesiologist, what is your preferred
time and type of surgery?
c. Who are your anaesthesiologist, internist,
and assistant
d. Who is your anaesthesiologist
72. In the OR, the nursing tandem for every surgery
is:
a. Instrument technician and circulating nurse
b. Nurse anaesthetist, nurse assistant, and
instrument technician
c. Scrub nurse, nurse anaesthetist
d. Scrub and circulating nurse
73. While team effort is needed in the OR for
efficient and quality patient care delivery, we
should limit the number of people in the room
for infection control. Who comprise this team?
a. Surgeon, anaesthesiologist, scrub nurse,
radiologist, orderly
b. Surgeon, assistants, scrub nurse, circulating
nurse, anaesthesiologist
c. Surgeon, assistant surgeon,
anaesthesiologist, scrub nurse, pathologist
d. Surgeon, assistant surgeon,
anaesthesiologist, intern, scrub nurse
74. Who usually act as an important part of the OR
personnel by getting the wheelchair or
stretcher, and pushing/pulling them towards
the operating room?
a. Orderly/clerk
b. Nurse supervisor
c. Circulating nurse
d. Anaesthesiologist
75. The breakdown in teamwork is often times a
failure in:
a. Electricity
b. Inadequate supply
c. Leg work
d. Communication
Situation: Basic knowledge on Intravenous solution is
necessary for care of clients with problems with fluids
and electrolytes
76. A client involved in a motor vehicle crash
presents to the emergency department with
severe internal bleeding. The client is severely
hypotensive and unresponsive. The nurse
anticipates which of the following intravenous
solutions will most likely be prescribed to
increase intravascular volume, replace
immediately blood loss and increablood
pressure?
a. 0.45% sodium chloride
b. 0.33% sodium chloride
c. Normal saline solution
d. Lactated ringer’s solution
77. The physician orders the nurse to prepare an
isotonic solution. Which of the following IV
solution would the nurse expect the intern to
prescribe?
a. 5% dextrose in water
b. 0.45% sodium chloride
c. 10% dextrose in water
d. 5% dextrose in 0.9% sodium chloride
78. The nurse is making initial rounds on the
nursing unit to assess the condition of assigned
clients. The nurse notes that the client’s IV site
is cool, pale and swollen and the solution is not
infusing. The nurse concludes that which of the
following complications has been experienced
by the client?
a. Infection
b. Phlebitis
c. Infiltration
d. Thrombophlelibitis
79. A nurse reviews the clients electrolyte
laboratory report and notes that the potassium
level is 3.2 mEq/L. Which of the following
complications has been experienced by the
client?
a. U waves
b. Absend P waves
c. Elevated T waves
d. Elevated ST segment
80. One patient had a “runaway’ IV of 50%
dextrose. To prevent temporary excess of
insulin or transient hyperinsulin reaction what
solution you prepare in anticipation of doctor’s
 Order?
a. Any IV solution available to KVO
b. Isotonic solution
c. Hypertonic solution
d. Hypotonic solution
81. An informed consent is required for:
a. Closed reduction of a fracture
b. Irrigation of the external ear canal
c. Insertion of intravenous catheter
d. Urethral catheterization
82. Which of the following is not true with regards
to be informed consent?
a. It should describe different treatment
alternatives
b. It should contain a thorough and detailed
explanation to the procedure to be done
c. It should describe the clients diagnosis
d. It should give an explanation of the client’s
prognosis
83. You know that the hallmark of nursing
accountability is the:
a. Accurate documentation and reporting
b. Admitting your mistakes
c. Filling an incident report
d. Reporting a medication error
84. A nurse is assigned to care for a group of clients.
On review of the client’s medical records, the
nurse determines that which client is at risk for
excess fluid volume?
a. The client taking diuretics
b. The client with renal failure
c. The client with an ileostomy
d. The client who requires gastrointestinal
suctioning
85. A nurse is assigned to care for a group of clients.
On review of the client’s medical records, the
nurse determines that which client is at risk for
deficient fluid volume?
a. A client with colostomy
b. A client with congestive heart failure
c. A client with decreased kidney function
d. A direct receiving frequent wound irrigation
Situation: as a perioperative nurse, you are aware of the
correct processing methods for preparing instruments
and other devices for patient use to prevent infection.
86. As an OR nurse, what are your foremost
considerations for selecting chemical agents for
disinfection?
a. Material compatibility and efficiency
b. Odor and availability
c. Cost and duration of disinfection process
d. Duration of disinfection and efficiency
87. Before you use a disinfected instrument it is
essential that you:
a. Rinse with tap water followed by alcohol
b. Wrap the instrument with sterile water
c. Dry the instrument thoroughly
d. Rinse with sterile water
88. You have a critical heat labile instrument to
sterilize and are considering to use high level
disinfectant. What should you do?
a. Cover the soaking vessel to contain the
vapour
b. Double the amount of high level
disinfectant
c. Test the potency of a high level disinfectant
d. Prolong the exposure time according to
manufacturer’s direction
89. To achieve sterilization using disinfectants,
which of the following is used?
a. Low level disinfectants immersion in 24
hours
b. Intermediate level disinfectants immersion
in 12 hours
c. High level disinfectants immersion in 1 hour
d. High level disinfectant immersion in 10
hours
90. Bronchoscope, thermometer, Endoscope, ET
tube, Cytoscope are all BEST sterilized using
which of the following?
a. Autoclaving at 121 degree Celsius in 125
minutes
b. Flash sterilizer at 132 degree Celsius in 3
minutes
c. Ethylene oxide gas aeration for 20 hours
d. 2% Glutaraldehyde immersion for 10 hours
Situation: The OR is divided into three zones to control
traffic flow and contamination.
 91. What OR attires are worn in the restricted area?
a. Scrub suites, OR shoes, head cap
b. Head cap, scrub suit, mask, OR shoes
c. Mask, OR shoes, scrub suit
d. Cap, mask, gloves, shoes
92. Nursing intervention for a patient on low dose
IV insulin therapy includes the following
EXCEPT:
a. Elevation of serum ketones to monitor
ketosis
b. Vital signs including BP
c. Estimate serum potassium
d. Elevation of blood glucose levels
93. The doctor ordered to incorporate 1000”u”
insulin to the remaining on –going IV. The
strength is 500/ml. how much should you
incorporate into the IV solution?
a. 10ml
b. 0.5ml
c. 2 ml
d. 5ml
94. Multiple vial-dose-insulin when in use should be
a. Kept at room temperature
b. Kept in narcotic cabinet
c. kept in the refrigerator
d. store in the freezer
95. Insulins using insulin syringe are given using
how many degrees off needle insertion?
a. 45
b. 180
c. 90
d. 15
Situation: Maintenance of sterility is an important
function a nurse should perform in any OR setting.
96. Which of the following is true with regards to
sterility?
a. Sterility is time related, items are hot
considered sterile after a period of 30 days
of being not use.
b. For 9 months, sterile items are considered
sterile as long as they are covered with
sterile muslin cover and stored in a dust
proof covers.
c. Sterility is event related, not time related
d. For 3 weeks, items double covered with
muslin are considered sterile as long as they
have undergone the sterilization process
97. 2 organizations endorsed that sterility are
affected by factors other than the time itself,
these are:
a. The PNA, and the PRC
b. AORN and JCAHO
c. ORNAP and MCNAP
d. MMDA and DILG
98. All of these factors affect the sterility of the OR
equipment, these are the following except:
a. The material used for packaging
b. The handling of the materials as well as its
transport
c. Storage
d. The chemical or process used in sterilizing
the material
99. When you say sterile, it means:
a. The material is clean
b. The material as well as the equipment are
sterilized and had undergone a rigorous
sterilization process
c. There is black stripe on the paper indicator
d. The material has no microorganism nor
spores present that might cause an
infection
100. In using liquid sterilizer versus autoclave
machine, which of the following is true?
a. Autoclave is better in sterilizing OR supplies
versus liquid sterilizer
b. They are both capable of sterilizing the
equipments, however, it is necessary to
soak supplies in the liquid sterilizer for a
longer period of time
c. Sharps are sterilizes using autoclave and not
cidex
d. If liquid sterilizer is used rinsing it before
using is not necessary
NURSING PRACTICE IV
Situation: After an abdominal surgery, the circulating
and scrub nurses have critical responsibility about
sponge and instrument count.
1. Counting is performed thrice: during the
preincision phase, the operative phase and
closing phase. Who counts the sponges, needles
and instruments?
a. The scrub nurse only
b. The circulating nurse only
c. The surgeon and the assistant surgeon
d. The scrub nurse and the circulating nurse
2. The layer of the abdomen is divided into 5.
Arrange the following from the first layer going
to the deepest layer:
1. Fascia
2. Muscle
3. Peritoneum
4. Subcutaneously
5. Skin
a. 5,4,3,2,1
b. 5,4,1,3,2
c. 5,4,2,1,3
d. 5,4,1,2,3
3. When is the first sponge/instrument count
reported?
a. Before closing the subcutaneous layer
b. Before peritoneum is closed
c. Before closing the skin
d. Before the fascia is sutured
4. Like any nursing interventions, counts should be
documented. To whom does the scrub nurse
report any discrepancy of counts so that
immediate and appropriate action is instituted?
a. Anaesthesiologists
b. Surgeon
c. OR nurse supervisor
d. Circulating nurse
5. Which of the following are 2 interventions of
the surgical team when an instrument was
confirmed missing?
a. MRI and Incidence report
b. CT Scan, MRI, incidence report
c. X-RAY and Incidence report
d. CT Scan and Incidence report
Situation: An entry level nurse should be able to apply
theoretical knowledge in the performance of the basic
nursing skills.
6. A client has an indwelling urinary catheter and
she is suspected of having urinary infection.
How should you collect a urine specimen for
culture and sensitivity?
a. Clamp tubing for 60 minutes and insert a
sterile needle into the tubing above the
clamp to aspirate urine
b. Drain urine from the drainage bag into the
sterile container
c. Disconnect the tubing from the urinary
catheter and let urine flow into a sterile
container
d. Wipe the self-sealing aspiration port with
antiseptic solution and insert a sterile
needle into the self-sealing port
7. To obtain specimen for sputum culture and
sensitivity, which of the following instruction is
best?
a. Upon waking up, cough deeply and
expectorate into container
b. Cough after pursed lip breathing
c. Save sputum for two days in covered
container
d. After respiratory treatment, expectorate
into a container
8. The best time for collecting the sputum
specimen for culture and sensitivity is:
a. Before retiring at night
b. Anytime of the day
c. Upon waking up in the morning
d. Before meals
9. When suctioning the endotracheal tube, the
nurse should:
a. Explain procedure to patient; insert
catheter gently applying sunction.
Withdrawn using twisting motion
b. Insert catheter until resistance is met and
then withdraw slightly, applying suction
intermittently as catheter is withdrawn
c. Hyperoxygenate client insert catheter using
back forth motion
d. Insert suction catheter four inches into the
tube, suction 30 seconds using
 twirling motion as catheter is withdrawn
10. The purpose of NGT IMMEDIATELY after an
operation is:
a. For feeding or gavage
b. For gastric decompression
c. For lavage, or the cleansing of the
Stomach content
d. For the rapid return of peristalsis
Situation – Mr. Santos, 50, is to undergo cystoscopy de
to multiple problems like scantly urination, hematuria
and dysuria.
11. You are the nurse in charge in Mr. Santos. When
asked are the organs to be examined dring
cystoscopy, you will enumerate as follows:
a. Urethra, kidney, bladder, urethra
b. Urethra, bladder wall, trigone, urethral
opening
c. Bladder wall, uterine wall and urethral
opening
d. Urethral opening, ureteral opening
bladder
12. In the OR, you will position Mr. Santos who is
cystoscopy in:
a. Supine
b. Lithotomy
c. Semi-fowler
d. Trendelenburg
13. After cystoscopy, Mr. Santos asked you to
explain why there is no incision of any kind.
What do you call him?
a. “Cystoscopy is direct visalization and
examination bu urologist”.
b. “Cystoscopy is done by x-ray
visualization of the urinary tract”.
c. “Cystoscopy is done by using laser on the
urinary tract”.
d. “Cystoscopy is an endoscopic procedure
of the urinary tract”.
14. Within 24-48 hours post cystoscopy, it is normal
to observe one of the following:
a. Pink-tinged urine
b. Distended bladder
c. Signs of infection
d. Prolonged hematuria
15. Leg cramps are NOT uncommon post
cystoscopy.
Nursing intervention includes:
a. Bed rest
b. Warm moist soak
c. Early ambulation
d. Hot sitz bath
Situation – Mang Felix, a 79 year old man who is brought
to the Surgical Unit from PACU after a transurethral
resection. You are assigned to receive him. You noted
that he has a 3-way indwelling urinary catheter for
continuous fast drip bladder irrigation which is
connected to a straight drainage.
16. Immediately after surgery, what would you
expect his urine to be?
a. Light yello
b. Bright red
c. Amber
d. Pinkish to red
17. The purpose of the continuous bladder
irrigation is to:
a. Allow continuous monitoring of the fluid
output status
b. Provide continuous flushing of clots and
debris from the bladder
c. Allow for proper exchange of
electrolytes and fluid
d. Ensure accurate monitoring of intake
and output
18. Mang Felix informs you that he feels some
discomfort on the hypogastric area and he has
to void. What will be your most appropriate
action.
a. Remove his catheter then allow him to
avoid on his own
b. Irrigate his catheter
c. Tell him to “Go ahead and void. You have
an indwelling catheter.”
d. Assess color and rate of outflow, if
there is changes refer to urologist for
possible irrigation.
19. You decided to check on Mang Felix’s IV fluid
infusion. You noted a change in flow rate, pallor
and coldness around the insertion site. What is
your assessment finding?
a. Phlebitis
b. Infiltration to subcutaneous tissue
c. Pyrogenic reaction
d. Air embolism
 20. Knowing that proper documentation of
assessment findings and interventions are
important responsibilities of the nurse during first
post-operative day, which of the following is the
LEAST relevant to document in the case of Mang
Felix?
a. Chest pain and vital signs
b. Intravenous infusion rate
c. Amount, color, and consistency of
bladder irrigation dranaige
d. Activities of daily living started
Situation: Melamine contamination in milk has brought
worldwide crisis both in the milk production sector as
well as the health and economy. Being aware of the
current events is one quality that a nurse should
possess to prove that nursing is a dynamic profession
that will adapt depending on the patient’s need.
21. Melamine is a synthetic resin used for
whiteboards, hard plastics and jewellery box
covers due to its fire retardant properties. Milk
and food manufacturers add melamine in order
to:
a. It has a bacteriostatic property leading to
increase food and milk life as a way of
preserving foods
b. Gives a glazy and more edible look on
foods
c. Make milks more tasty and creamy
d. Create an illusion of a high protein
content on their production
22. Most of the milk contaminated by melamine
came from which country?
a. India
b. China
c. Philippines
d. Korea
23. Which government agency is responsible for
testing the melamine content of foods and food
products?
a. DOH
b. MMDA
c. NBI
d. BFAD
24. Infants are the most vulnerable to melamine
poisoning. Which of the following is NOT a sign
of melamine poisoning?
a. Irritability, back ache, Urolithiasis
b. High blood pressure, fever
c. Anuria, Oliguria or Hematuria
d. Fever, Irritability and a large output of
diluted urine
25. What kind of renal failure will melamine
poisoning cause?
a. Chronic, Prerenal
b. Chronic, Intrarenal
c. Acute, Postrenal
d. Accute, Prerenal
Situation: Leukemia is the most common type of
childhood cancer. Acute lymphoid leukemia is the cause
of almost 1/3 of all cancer that occurs in children under
age 15.
26. The survival rate for Acute Lymphoid Leukemia
is approximately:
a. 25%
b. 40%
c. 75%
d. 95%
27. Whereas acute nonlymphoid leukemia has a
survival rate of:
a. 25%
b. 40%
c. 75%
d. 95%
28. The three main consequence of leukemia that
cause the most danger is:
a. Neutropenia causing infection, anemia
causing impaired oxygenation and
thrombocytopenia leading to bleeding
tendencies
b. Central nervous system infiltration,
anemia causing impaired oxygenation
and thrombocytopenia leading to
bleeding tendencies
c. Splenomegaly, hepatomegaly, fractures
d. Invasion by the leukemic cells to the
bone causing severe bone pain
29. Gold standard in the diagnostic of leukemia is
by which of the following
a. Blood culture and sensitivity
b. Bone marrow biopsy
c. Blood biopsy
d. CSF aspiration and examination
30. Adriamycin, Vincristine, Prednisone, and L
asparaginase are given to the client for long
term therapy. One common side effect
 Especially of adriamcycin is alopecia. The child
ask: “Will I get my hair back once again?”The
nurse best respond is by saying:
a. “Don’t be silly, of course you will get
your hair back
b. “ We are not sue, let’s hope it’ll grow
c. “This side effect is usually permanent.
But I will get the doctor to discuss it for
you”
d. “You hair will regrow in 3 to 6 months
but of different color, usually darker
and of different texture
Situation: Breast cancer is the 2nd most common type of
cancer after lung cancer and 99% of which, occurs in
woman. Survival rate is 98% if this is detected early and
treated promptly. Carmen is a 53 year old patient in the
high risk group for break cancer was recently diagnosed
with Breast cancer.
31. All of the following are factors that said to
contribute to the development of breast cancer
except:
a. Prolonged exposure to estrogen such as
an early menarche or late menopause,
nulliparity and childbirth after age 30
b. Genetics
c. Increasing age
d. Prolonged intake of Tamoxifen
(Nolvadex)
32. Protective factors for the development of
breast cancer includes which of the following
except:
a. Exercise
b. Breast feeding
c. Prophylactic Tamoxifen
d. Alcohol intake
33. A patient diagnosed with breast cancer has
been offered the treatment choices of breast
conservation surgery with radiation or a
modified radical mastectomy. When questioned
by the patient about these options, the nurse
informs the patient that the lumpectomy with
radiation:
a. Reduces the fear and anxiety that
accompany the diagnosis and treatment
of cancer
b. Has about the same 10-year-survival rate
as the modified radical mastectomy
c. Provides a shorter treatment period with
a few long term complications
d. Preserves the normal appearance and
Sensitivity of the breast.
34. Carmen, who is asking the nurse the most
appropriate time of the month to do her self-
examination of the breast. The MOST
appropriate reply by the nurse would be:
a. The 26th day of the menstrual cycle
b. 7 to 8 days after conclusion of the
menstrual period
c. During the menstruation
d. The same day each month
35. Carmen being treated with radiation therapy.
What should be included in the in the plan of
care to minimize skin damage from the
radiation therapy?
a. Cover the areas with thick clothing
materials
b. Apply a heating pad to the size
c. Wash skin with water after the therapy
d. Avoid applying creams and powders to
the area
36. Based on the DOH and World Health
Organization (WHO) guidelines, the mainstay
for early detection method for breast cancer
that is recommended for developing counties is:
a. A monthly breast self-examination (BSE)
and an annual health worker breast
examination (HWBE)
b. An annual hormone receptor assay
c. An annual mammogram
d. A physician conduct a breast clinical
examination every 2 years
37. The purpose of performing the breast self-
examination (BSE) regularly is to discover:
a. Fibrocystic masses
b. Area of thickness or fullness
c. Cancerous lumps
d. Changes from previous BSE
38. If you are to instruct a postmenopausal woman
about BSE, when would you tell her to do BSE:
a. On the same day of each month
b. On the first day of her menstruation
c. Right after the menstrual period
d. On the last day of her menstruation
39. During breast self- examination, the purpose of
standing in front of the mirror is to observe the
breast for:
a. Thickening of the tissue
 b. Lumps in the breast tissue
c. Axillary lymphnodes
d. Change in size and colour
40. When preparing to examine the left breast in a
reclining position, the purpose of placing a small
folded towel under the clients left shoulder is
to:
a. Bring the breast closer to the examiner’s
right hand
b. Tense the pectoral muscle
a. Balance the breast tissue more evenly
on the chest wall
b. Facilitate lateral positioning of the
breast
Situation- Radiation therapy is another modality of
cancer management. With emphasis on
multidisciplinary management you have important
responsibilities as nurse.
41. Albert is receiving external radiation therapy
and he complains of fatigue and malaise. Which
of the following nursing interventions would be
most helpful to Albert?
a. Tell him that sometimes these feelings
can be psychogenic
b. Refer him to the physician
c. Reassure him that these feelings are
normal
d. Help him plan his activities
42. Immediately following the radiation
teletherapy, Albert is
a. Considered radioactive for 24 hours
b. Given a complete bath
c. Placed on isolation for 6 hours
d. Free from radiation
43. Albert is admitted with a radiation induced
thrombocytopenia. As a nurse you should
observe the following symptoms:
a. Petechiae, ecchymosis, epistaxis
b. Weakness, easy fatigability, pallor
c. Headache, dizziness, blurred vision
d. Severe sore throat, bacteremia,
hepatomegaly
44. What nursing diagnosis should be of highest
priority?
a. Knowledge deficit regarding
thrombocytopenia precautions
b. Activity intolerance
c. Impaired tissue integrity
d. Ineffective tissue perfusion, peripheral,
celebral, cardiovascular,
gastrointestinal, renal
45. What intervention should you include in your
care plan?
a. Inspect his skin for petechiae, bruising,
GI bleeding regularly
b. Place albert on stick isolation precaution
c. Provide rest in between activities
d. Administer antipyretics if his
temperature exceeds 38C
Situation: Burn are cause by transfer of heat source to
the body. It can be thermal, electrical, radiation, or
chemical
46. A burn characterized by pale white appearance,
charred or with fat exposed and painlessness is:
a. Superficial partial thickness burn
b. Deep partial thickness burn
c. Full thickness burn
d. Deep full thickness burn
47. Which of the following BEST describe superficial
partial thickness burn or first degree burn?
a. Structures beneath the skin are damage
b. Dermis is partially damaged
c. Epidermis and dermis are both damaged
d. Epiderm is damaged
48. A burn that said to be“WEEPING”is classified as:
a. Superficial partial thickness burn
b. Deep partial thickness burn
c. Full thickness burn
d. Deep full thickness burn
49. During the acute phase of the burn injury,
which of the following is a priority?
a. Wound healing
b. Emotional support
c. Reconstructive surgery
d. Fluid resuscitation
50. While in the emergent phase, the nurse knows
that the priority is to:
a. Prevent infection
b. Prevent deformities and contractures
c. Control pain
d. return the hemodynamic stability fluid
resuscitation
51. The MOST effective method of delivering pain
medication during the emergent phase is:
a. intramuscularly
b. orally
c. subcutaneously
d. intravenously
52. When a client accidentally splashes chemicals to
his eyes, the initial priority care following the
chemical burn is to:
a. irrigate with normal saline for 1-15
minutes
b. transport to a physician immediately
c. irrigate with water for 15 minutes or
longer
d. cover the eyes with sterile gauze
53. Which of the following can be a fatal
complication of upper airway burns?
a. stress ulcers
b. shock
c. hemorrhage
d. laryngeal spasms and swelling
54. When a client rush towards you and he has a
burning clothes on, it is your priority to do
which of the following first?
a. log roll on the grass/ground
b. slap the flames with his hands
c. try to remove the burning clothes
d. splash the client with 1 bucket of cool
water
55. Once the flames are extinguished, it is most
important to:
a. cover client with warm blanket
b. give him sips of water
c. calculate the extent of his burns
d. assess the Sergio’s breathing
56. During the first 24 hours after the thermal
injury, you should assess Sergio for:
a. hypokalemia and hypernatremia
b. hypokalemia and hyponatremia
c. hyperkalemia and hyponatremia
d. hyperkalemia and hypernatremia
57. A client was sustained deep partial thickness
and full thickness burns of the face, whole
anterior chest and both upper extremities two
days ago begins to exhibit extreme restlessness.
You recognize that this most likely indicates that
The client is developing:
a. Celebral hypoxia
b. Metabolic acidosis
c. Hypervolemia
d. Renal failure
58. 1 165 lbs trauma client was rushed to the
emergency room with full thickness burns on
whole face, right and left arm, and at the
anterior upper chest sparing the abdominal
area. He also has superficial partial thickness
burn at the posterior trunk and at the half
upper portion of the left leg. He is at the
emergency phase of burn. Using the parkland’s
formula, you know that during the first 8 hours
of burn, the amount of fluid will be given is:
a. 5,400 ml
b. 9,450 ml
c. 10,800 ml
d. 6,750 ml
59. The doctor incorporated insulin on the client’s
fluid during the emergency phase. The nurse
knows that insulin is given because:
a. Client with burn also develops metabolic
acidosis
b. Client with burn also develops
hyperglycemia
c. Insulin is needed for additional energy
and glucose burning after the stressful
incidence to hasten wound healing,
regain of consciousness and rapid return
of hemodynamic stability
d. For hyperkalemia
60. The IV fluid of choice for burn as well as
dehydration is:
a. 0.45% NaCI
b. Sterile water
c. NSS
d. D5LR
Situation: ENTEROSTOMAL THERAPY is now considered
specialty in nursing. You are participating in the
OSTOMY CARE CLASS.
61. You plan to teach Fermin how to irrigate the
colostomy when:
a. The perineal wound heals and Fermin
can sit comfortably on the commode
b. ‘fermin can lie on the side comfortably,
about the 3rd postoperative day
c. The abdominal incision is closed and
 Contamination is no longer a danger
d. The stools starts to become formed,
around the 7th postoperative day
62. When preparing to teach Fermin how to irrigate
colostomy, you should plan to do the
procedure:
a. When Fermin would have normal bowel
movement
b. At least 2 hours before visiting hours
c. Prior to breakfast and monitoring care
d. After Fermin accepts alteration in body
image
63. When observing a return demonstration of a
colostomy irrigation, you know that more
teaching is required if Fermin:
a. Lubricates the tip of the catheter prior to
inserting into the stoma
b. Hangs the irrigating bag on the
bathroom door cloth hook during fluid
insertion
c. Discontinues the insertion of fluid after
500 ml of fluid has been instilled
d. Clamps of the flow of fluid when felling
uncomfortable.
64. You are aware that teaching about colostomy
care is understood when Fermin states “I will
contact my physician and report:
a. If I have any difficulty inserting the
irrigating tub into the stoma.”
b. If I noticed a loss sensation to touch in
the stoma tissue.”
c. The expulsion of flatus while the
rrigating fluid is running out.”
d. When mucus is passed from the stoma
between the irrigations.”
65. You would know after teaching Fermin that
dietary instruction for him is effective when he
states “It is important that I eat:
a. Soft food that is easily digested and
absorbed by my large intestines.”
b. Bland food so that my intestines do not
become irritated.”
c. Food low in fiber so that there are fewer
stools.”
d. Everything that I ate before the
operation while avoiding foods that
cause gas.”
Situation: Based on studies of nurses working in special
units like intensive care unit and coronary care unit
It is important for nurses to gather as much information
to be able to address their needs for nursing care.
66. Critically ill patients frequently complain about
which of the following when hospitalized?
a. Hospital food
b. Lack of privacy
c. Lack of blankets
d. Inadequate nursing staff
67. Who of the following is at greatest risk of
developing sensory problem?
a. Female patient
b. Transplant patient
c. Adolescent
d. Unresponsive patient
68. Which of the following factors may inhibit
learning in critically ill patients?
a. Gender
b. Educational level
c. Medication
d. Previous knowledge of illness
69. Which of bthe following statements does not
apply to critically ill patients?
a. Majority need extensive rehabilitation
b. All have been hospitalized previously
c. Are physically unstable
d. Most have chronic illness
70. Families of critically ill patients desire which of
the following needs to be met first by the
nurse?
a. Provision of comfortable space
b. Emotional support
c. Updated information on clients status
d. Spiritual counselling
Situation: Johnny, sought consultation to the hospital
because of fatigability, irritability, iittery and he has
been experiencing this sign and symptoms for the past 5
months.
71. His diagnosis was hyperthyroidism, the
following are expected symptoms except:
a. Anorexia
b. Fine tremors of the hnad
c. Palpitation
d. Hyper alertness
72. She has to take drugs to treat her
hyperthyroidism. Which of the following will
you NOT expect that the doctor will prescribe?
 a. Colace (Docusate)
b. Tapazole (Methimazole)
c. Cytomel (Liothyronine)
d. Synthroid(Levothyroxine)
73. The nurse knows that Tapazole ha which of the
following side effect that will warrant
immediate withholding of the medication?
a. Death
b. Hyperthermia
c. Sore throat
d. Thrombocytosis
74. You asked questions as soon as she regained
consciousness from thyroidectomy primarily to
assess the evidence of :
a. Thyroid storm
b. Damage to the laryngeal nerve
c. Mediastinal shift
d. Hypocalcaemia tetany
e.
75. Should you check for haemorrhage, you will:
a. Slip your hand under the nape of her
neck
b. Check for hypotension
c. Apply neck collar to prevent
haemorrhage
d. Observe the dressing if it is soaked with
blood
76. Basal metabolic rate is assessed on Johnny to
determine his metabolic rate. In assessing the
BMR using the standard procedure, you need to
tell Johny that:
a. Obstructing his vision
b. Restraining his upper and lower
extremities
c. Obstructing his hearing
d. Obstructing his nostrils with a clamp
77. The BMR is based on the measurement that:
a. Rate of respiration under different
condition of activities and rest
b. Amount of oxygen consumption under
resting condition over a measured
period of time
c. Amount of oxygen consumption under
stressed condition over a measured
period of time
d. Ratio of respiration to pulse rate over a
measured period of time
78. Her Physician ordered lugol’s solution in order
To:
a. Decrease the vascularity and size of the
thyroid gland
b. Decrease the size of the thyroid gland
only
c. Increase the vascularity and size of the
thyroid gland
d. Increase the size of the thyroid gland
only
79. Which of the following is a side effect of lugol’s
solution?
a. Hypokalemia
b. Enlargement of the thyroid gland
c. Nystagmus
d. Excessive salivation
80. In administering Lugol’s solution, the
precautionary measure should include:
a. Administer with glass only
b. Dilute with juice and administer with a
straw
c. Administer it with milk and dink it
d. Follow it with milk magnesia
Situation: Pharmacological treatment was not effective
for Johnny’s hyperthyroidism and now, he is scheduled
for thyroidectomy.
81. Instrument in the surgical suite for surgery is
classified as either CRITICAL, SEMI CRITICAL, and
NON CRITICAL. If the instruments are
introduced directly into the blood stream or
into any normally sterile cavity or area of the
body it is classified as:
a. Critical
b. Non Critical
c. Semi Critical
d. Ultra critical
82. Instruments that do not touch the patient or
have contact only to intact skin is classified as:
a. Critical
b. Non critical
c. Semi critical
d. Ultra critical
83. If an instrument is classified as Semi Critical, an
acceptable method of making the instrument
ready for surgery is through:
a. Sterilization
b. Disinfection
c. Decontamination
 d. Cleaning
84. While critical items and should be:
a. Clean
b. Sterilized
c. Decontaminated
d. Disinfected
85. As a nurse, you know that intact skin acts as an
effective barrier to most microorganisms.
Therefore, items that come in contact with the
intact skin or mucus membranes should be:
a. Disinfected
b. Clean
c. Sterile
d. Alcoholized
86. You are caring for Johnny who is scheduled to
undergo total thyroidectomy because of a
diagnosis of thyroid cancer, prior to total
thyroidectomy, you should instruct Johnny to:
a. Perform range and motion exercise on
the head and neck
b. Apply gentle pressure against the
incision when swallowing
c. Cough and deep breathe every 2 hours
d. Support head with the hands when
changing position
87. As Johnny’s nurse, you plan to set up
emergency equipment at her bedside following
thyroidectomy, You should include:
a. An airway and rebreathing tube
b. A trancheostomy set and oxygen
c. A crush cart with bed board
d. Two ampoules of sodium bicarbonate
88. Which of the following nursing interventions is
appropriate after a total thyroidectomy?
a. Place pillows under your patient’s
shoulder
b. Raise the knee-gatch to 30 degrees
c. Keep you patient in a high-fowler’s
position
d. Support the patient’s head and neck
with pillows and sandbags
89. If there is an accidental injury to the
parathyroid gland during a thyroidectomy which
of the following might Leda develops
postoperatively?
a. Cardiac arrest
b. Respiratory failure
c. Dyspnea
d. Tetany
90. After surgery Johnny develops peripheral
numbness, tingling and muscle twitching and
spasm. What would you anticipate to
administer?
a. Magnesium sulphate
b. Potassium iodide
c. Calcium gluconate
d. Potassium chloride
Situation: Budgeting is an important part of a nurse
Managerial activity. The correct allocation and
distribution of resources is vital in the harmonious
operation of the financial balance of the agency.
91. Which of the following best defines Budget?
a. Plan for the allocation of resources for
future use
b. The process of allocating resources for
future use
c. Estimate cost of expenses
d. Continous process in seeing that the
goals and objective of the agency is met
92. Which of the following is best defines Capital
Budget?
a. Budget to estimate the cost of direct
labour, number of staff to be hired and
necessary number of workers to meet
the general patient needs
b. Includes the monthly and daily expenses
and expected revenue and expenses
c. Theses are related to long term
planning and includes major
replacement or expansion of the plant,
major equipment and inventories
d. These are expenses that are not
dependent on the level of production or
sales, They tend to be time-related, such
as salaries nor rents being paid per
month
93. Which of the following best described
Operational Budget?
a. Budget to estimate the cost of direct
labour, number of staff to be hired and
necessary number of workers to meet
the general patient needs
b. Includes the monthly and daily
expenses and expected revenue and
expenses
c. these are related to long term planning
and includes major replacement or
 expansion of the plant, major equipments
and inventories.
d. These are expenses that are not
dependent on the level of production or
sales. They tend to be time-related,such as
rent
94. Which of the following accurately describes a
Fixed Cost in budgeting?
a. There are usually the raw materials and
labour salaries that depend on the
production or sales
b. These are expenses that change in
proportion to the activity of a business
c. These are expenses that are not
dependent on the level of production or
sales. They tend to be time-related, such
as rent
d. This is the summation of the Variable Cost
and the Fixed Cost
98. Which of the following is true with the Triad
seen in head injuries?
a. Narrowing of Pulse pressure, Cheyne
stokes respiration, Tachycardia
b. Widening Pulse pressure, Irregular
respiration, Bradycardia
c. Hypertension, Kussmaul’s respiration,
Tachycardia
d. Hypotension, Irregular respiration,
Bradycardia
99. In a client with a cheyne stokes respiration,
Which of the following is the most appropriate
nursing diagnosis
a. Ineffective airway clearance
b. Impaired gas exchange
c. Ineffective breathing pattern
d. Activity Intolerance

95. Which of the following accurately describes
Variable Cost in budgeting?
a. These are related to long term planning
and include major replacement or
expansion of the plant, major equipments
and inventories
b. These are expenses that changes in
proportion to the activity of a business
c. These are expenses that are not
dependent on the level of production or
sales. They tend to be time-related, such
as rent
d. This is the summation of the Variable Cost
and the Fixed Cost
100. You know the apnea is seen in client’s
with cheyne stokes respiration, APNEA is
defined as:
a. Inability to breathe in a supine position
so the patient sits up in the bed to
breathe
b. The patient is dead, the breathing stops
c. There is an absence of breathing for a
period of time, usually 15 seconds or
more
d. A period of hypercapnea and hypoxia
due to the cessation of respiratory effort
inspite of normal respiratory functioning

Situation – Andrea is admitted to the ER following an

assault where she was hit in the face and head. She was
brought to the ER by a police woman. Emergency
measures were started.

96. Andrea’s respiration is described as waxing and

waning. You know that this rhythm of respiration
is defined as waxing and waning. You know that
this rhythm of respiration is defined as:
a. Biot’s
b. Cheyne Strokes
c. Kussmaul’s
d. Eupnea

97. What do you call the triad of sign and symptoms

seen in a client with increasing ICP?
a. Virchow’s Triad
b. Nursing triad
NURSING PRACTICE V
c. The Chinese Triad
d. Charcot’s Triad
Situation: Understanding different models of acre is a
necessary part of the nurse patient relationship.
1. The focus of this therapy is to have a positive
environmental manipulation, physical and social
to effect a positive change.
a. Milleu
b. Psychotherapy
c. Behavior
d. Group
2. The client asks the nurse about milleu therapy.
The nurse responds knowing that the primary
focus of milleu therapy can be best described by
which of the following?
a. A form of behavior modification therapy
b. A cognitive approach of changing the
behaviour
c. A living, learning or working environment
d. A behavioural approach to changing
behaviour
3. A nurse is caring for a client with phobia who is
being treated for thw condition. The client is
introduced to short periods of exposure to the
phobic object while in relaxed state. The nurse
understands that this form of behavior
modification can be best described as
a. Systematic desensitization
b. Self-control therapy
c. Aversion Therapy
d. Operant conditioning
4. A client with major depression is considering
cognitive therapy. The client say to the nurse,
“How does this treatment works?” the nurse
responds by telling the client that:
a. N
b. “This type of treatment helps you examine
how your past life has contributed to your
problems.”
c. “This type of treatment helps you to
confront your fears by exposing you to the
feared object abruptly”
d. “This type of treatment will help you relax
and develop new coping skills.”
5. A client state, “I get down on myself when I
make mistake.” Using cognitive therapy
approach, the nurse should:
a. Teach the client relaxation exercise to
diminish stress
b. Provide the client with Mastery experience
to boost self esteem
c. Explore the client’s past experience that
causes the illness
d. Help client modify the belief that anything
less than perfect is horrible
6. The most advantageous therapy for a preschool
age child with a history of physical and sexual
abuse would be:
a. Play
b. Psychoanalysis
c. Group
d. Family
7. An 18 year old client is admitted with the
diagnosis of anorexia nervosa. A cognitive
behavioural approach is used as part of her
treatment plan. The nurse understand that the
purpose of this approach is to:
a. Help the client identify and examine
dysfunctional thoughts and beliefs
b. Emphasize social interaction with clients
who withdraw
c. Provide a supportive environment and a
therapeutic community
d. Examine Intrapsychic conflict and past
events in life
8. The nurse is preparing to provide reminiscence
therapy for a group of client. Which of the
following clients will be nurse select for this
group?
a. A client who experiences profound
depression with moderate cognitive
impairment
b. a catatonic, Immobile client with moderate
cognitive impairment
c. An undifferentiated schizophrenic client
with moderate cognitive impairment
d. A client with mild depression who exhibits
who demonstrates normal cognition
9. Which intervention would be typical of a nurse
using cognitive-behavioral approach to a client
experiencing low self-esteem?
 a. Use of unconditional positive regard c. refer the client to the psychiatrist
b. Analysis of free association d. refer the matter to the police
c. Classical conditioning
d. Examination of negative thought patterns Situation: Rose seeks psychiatric consultation because
of intense fear of flying in an airplane which has gently
10. Which of the following therapies has been affected her chances of successful in her job.
strongly advocated for the treatment of post-
traumatic stress disorders? 16. The most common defense mechanism used by
a. ECT phobic client is:
b. Group Therapy a. Supression
c. Hypnotherapy b. Denial
d. Psychoanalysis c. Rationalization
d. Displacement
11. The nurse knows that im group therapy, the
maximum number of members to include is: 17. The goal of the therapy in phobia is:
a. 4 a. Change her lifestyle
b. 8 b. Ignore tension producing situation
c. 10 c. Change her reaction towards anxiety
d. 16 d. Eliminates fear producing situations

12. The nurse is providing information to a client 18. The therapy most effective for client’s with
with the use of disulfiram (antabuse) for the phobia is:
treatment of alcohol abuse. The nurse a. Hypnotherapy
understands that this form of therapy works on b. Cognitive therapy
what principle? c. Group therapy
a. Negative Reinforcement d. Behavior therapy
b. Operant conditioning
c. Aversion therapy 19. The fear and anxiety related to phobia is said to
d. Gestait therapy be abruptly decreased when the patient is
exposed to what is feared through:
13. A biological or medical approach in treating a. Guided Imagery
psychiatric patient is: b. Systematic desensitization
a. Million therapy c. Flooding
b. Behavioral therapy d. Hypotherapy
c. Somatic therapy
d. Psychotherapy 20. Based on the presence of symptom, the
appropriate nursing diagnosis is:
14. Which of these nursing actions belong to the a. Self-esteem disturbance
secondary level of preventive intervention? b. Activity intolerance
a. Providing mental health consultation to c. Impaired adjustment
health care providers d. Ineffective individual coping
b. Providing emergency psychiatric services
c. Being politically active in relation to mental Situation: Mang Jose, 39 year old farmer, unmarried had
health issues been confined in the National center for mental health
d. Providing mental health education to for three years with a diagnosis of Schizophrenia.
members of the community
21. The most common defense mechanism used by
15. When the nurse identifies a client who has a paranoid client is:
attempted to commit suicide the nurse should: a. Displacement
a. call a priest b. Rationalization
b. counsel the client c. Suppression
d. Projection
 22. Nursing…..
a. Kdknf
b. Nfdjnvgj
c. Bvxnbv
d. Nbnbvf
23. A relevant nursing diagnosis for clients with
auditory hallucination is:
a. Sensory perceptual alteration
b. Altered thought process
c. Impaired social interaction
d. Impaired verbal communication
24. During mealtime, Jose refused to eat telling that
the food was poisoned. The nurse should:
a. gnore his remark
b. Offer him food in his own container
c. Show him how irrational his thinking is
d. Respect his refusal to eat
25. When communicating with Jose, The nurse
considers the following except:
a. Be warm and enthusiastic
b. Refrain from touching Jose
c. Do not argue regarding his hallucination
and delusion
d. Use simple, clear language
e.
Situation: Gringo seeks psychiatric counseling for his
ritualistic behaviour of counting his money as many as
10 times before leaving home.
26. An initial appropriate are nursing diagnosis is:
a. Impaired social interaction
b. Ineffective individual coping
c. Impaired adjustment
d. Anxiety moderate
27. Obsessive compulsive disorder is BEST described
by:
a. Uncontrollable impulse to perform an act or
ritual repeatedly
b. Persistent thoughts
c. Recurring unwanted and disturbing though
alternation with a behavior
d. Pathological persistence of unwilled
thought, feeling or impulse
28. The defense mechanism used by persons with
obsessive compulsive disorder is undoing and it
Is best described in one of the following statements:
a. Unacceptable feelings or behavior are kept out
of awareness by developing the opposite
behavior or emotion
b. Consciously unacceptable instinctual drives are
diverted into personally and socially acceptable
channels
c. Something unacceptable already done
d. Transfer of emotions associated with a
particular person, object or situation to another
less threatening person, object or situation
29. To be more effective, the nurse who cares for
persons with obsessive compulsive disorder
must posses one of the following qualities:
a. Compassion
b. Patience
c. Consistency
d. Friendliness
30. Persons with OCD usually manifest:
a. Fear
b. Apathy
c. Suspiciousness
d. Anxiety
Situation: The patient who is depressed will undergo
electroconvulsive therapy:
31. Studies on biological depression support
electroconvulsive therapy as mode of treatment.
That rationale is:
a. ECT produces massive brain damage which
destroys the specific area containing
memories related to the events surrounding
the development of psychotic condition
b. The treatment serve as a symbolic
punishment for the client who feels guilty
and worthless
c. ECT relieves depression psychologically by
increasing the norepinephrine level
d. ECT is seen as a life-threatening experience
and depressed patients mobilized all their
bodily defences to deal with this attack
32. The preparation of a patient for ECT ideally is
MOST similar to preparation for a patient for:
a. Electroencephalogram
 b. General anaesthesia
c. X-ray
d. Electrocardiogram
33. Which of the following is a possible side effect
which you will discuss with the patient?
a. Haemorrhage with the brain
b. Encephalitis
c. Robot-like body stiffness
d. Confusion, disorientation and short term
memory loss
34. Informed consent is necessary for the treatment
for involuntary clients. When this cannot be
obtained, permission may be taken from the:
a. social worker
b. next of kin or guardian
c. doctor
d. chief nurse
35. after ECT, the nurse should do this action before
giving the client fluids, food or medication:
a. assess the grag reflex
b. next of kin or guardian
c. assess the sensorium
d. check 02 sat with a pulse oximeter
Situation: Mrs Ethel Agustin 50 y/o, teacher is afflicted
with myasthenia gravis.
36. Looking at Mrs Agustin, your assessment would
include the following except:
a. Nystagmus
b. Difficulty of hearing
c. Weakness of the levator palpebrae
d. Weakness of the ocular muscle
37. In an effort to combat complications which
might occur relatives should he taught;
a. Checking cardiac rate
b. Taking blood pressure reading
c. Techniques of oxygen inhalation
d. Administration of oxygen inhalation
38. The drug of choice for her condition is;
a. Prostigmine
b. Morphine
c. Codeine
d. Prednisone
39. As her nurse, you have to be cautious about
administration of medicine, if she is under
medicated this can cause;
a. Emotional crisis
b. Cholinergic crisis
c. Menopausal crisis
d. Myasthenia crisis
40. If you are not extra careful and by chance you
give over medication, this would lead to:
a. Cholinergic crisis
b. Menopausal crisis
c. Emotional crisis
d. Myasthenia crisis
Situation: Rosanna 20 y/o unmarried patient believes
that the toilet for the female patient in contaminated
with AIDS virus and refuses to use it unless she flushes it
three times and wipes the seat same number of times
with antiseptic solution.
41. ??
a. Adjust to a strange environment
b. Express her anxiety
c. Develop the sense of trust in other person
d. Control unacceptable impulses or feelings
42. Assessment data upon admission help the nurse
to identify this appropriate nursing diagnosis
a. Ineffective denial
b. Impaired adjustment
c. Ineffective individual coping
d. Impaired social interaction
43. An effective nursing intervention to help Rosana
is;
a. Convincing her to use the toilet after the
nurse has used it first
b. Explaining to her that AIDS cannot be
transmitted by using the toilet
c. Allowing her to flush and clear the toilet
seat until she can manage her anxiety
d. Explaining to her how AIDS is transmitted
44. The goal for treatment for Rosana must be
directed toward helping her to;
a. Walk freely about her past experience
b. Develop trusting relationship with others
c. Gain insight that her behaviour is due to
feeling of anxiety
d. Accept the environment unconditionally
 45. Psychotherapy which is prescribed for Rosana is
described as;
a. Establishing an environment adapted to an
individual patient needs
b. Sustained interaction between the therapist
and client to help her develop more
functional behaviour
c. Using dramatic techniques to portray
interpersonal conflicts
d. Biologic treatment for mental disorder
Situation: Dennis 40 y/o married man, an electrical
engineer was admitted with the diagnosis of paranoid
disorder. He has become suspicious and distrustful 2
months before admission. Upon admission, he kept on
saying, “my wife has been planning to kill me.”
46. A paranoid individual who cannot accept the
guilt demonstrate one of the following defense
mechanism;
a. Denial
b. Projection
c. Rationalization
d. Displacement
47. One morning, Dennis was seen tilting his head as
if he was listening to someone. An appropriate
nursing intervention would be;
a. Tell him to socialize with other patient to
divert his attention
b. Involve him in group activities
c. Address him by name to ask if he is hearing
voice again
d. Request for an order of antipsychotic
medicine
48. When he says, “These voices are telling me my
wife is going to kill me.” A therapeutic
communication of the nurse is which one of the
following;
a. “i do not hear the voices you say you hear”
b. “are you really sure you heard those
voices?”
c. “I do not think you heard those voices?”
d. “whose voices are those?”
49. The nurse confirms that Dennis is manifesting
auditory hallucination. The appropriate nursing
diagnosis she identifiesis;
a. Sensory perceptual alteration
b. Self-esteem disturbance
c. Ineffective individual coping
d. Defensive coping
50. Most appropriate nursing intervention for a
client with suspicious behaviour is one of the
following;
a. Talk to the client constantly to reinforce
reality
b. Involve him in competitive activities
c. Use Non Judgemental and Consistent
approach
d. Project cheerfulness in interacting with the
patient
Situation: clients with Bipolar disorder receives a very
high nursing attention due to the increasing rate of
suicide related to the illness.
51. The nurse is assigned to care for a recently
admitted client who has attempted suicide.
What should the nurse do?
a. Search the client’s belongings and room
carefully for items that could be used to
attempted suicide.
b. Express trust that the client won’t cause
self-harm while in the facility.
c. Respect the client’s privacy by not
searching any belongings.
d. Remind all staff members to check on
the client frequently.
52. In planning activities for the depressed client,
especially during the early stages of
hospitalization, which of the following plan is
best?
a. Provide an activity that is quiet and solitary
to avoid increased fatigue such as working
on a puzzle and reading a book.
b. Plan nothing until the client asks to
participate in the milieu
c. Offer the client a menu of daily activities and
ask the client to participate in all of them
d. Provide a structured daily program of
activities and encourage the client to
participate
53. A client with a diagnosis of major depression,
recurrent with psychotic features is admitted to
the mental health unit. To create a safe
environment for the client, the nurse most
 Importantly devises a plan of care that deals
specifically with the clients:
a. Disturbed thought process
b. Imbalanced nutrition
c. Self-care deficit
d. Deficient knowledge
54. The client is taking a tricyclic anti-depressant,
which of the following is an example of TCA?
a. Paxil
b. Nardil
c. Zoloft
d. Pamelor
55. The client visits the physician’s office to seek
treatment for depression, feelings of
hopelessness, poor appetite, insomnia, fatigue,
low self-esteem, poor concentration, and
difficulty in making decisions. The client states
that these symptoms began at least 2 years ago.
Base on this report, the nurse suspects:
a. Cyclothymic disorder
b. Bipolar disorder
c. Major depression
d. Dysthymic disorder
56. The nurse is planning activities for a client who
has bipolar disorder, which aggressive social
behaviour. Which of the following activities
would be most appropriate for this client?
a. Ping pong
b. Linen delivery
c. Chess
d. Basketball
57. The nurse assesses a client with admitted
diagnosis of bipolar affective disorder, mania.
The symptoms presented by the client that
requires the nurse’s immediate intervention is
the client’s:
a. Outlandish behaviour and inappropriate
dress
b. Grandiose delusion of being a royal
descendant of king arthut
c. Nonstop physical activity and poor
nutritional intake
d. Constant incessant talking that includes
sexual topics and teasing the staff
58. A nurse is conducting a group therapy session
and during the session, A client with mania
consistently talks and demonstrate the group.
The behaviour is disrupting the group interaction.
The nurse would initially:
a. Ask the client to leave the group session
b. Tell the client that she will not be
allowed to attend any more group
sessions.
c. Tell the client that she needs to allow
other client in a group time to talk
d. Ask another nurses to escort the client
out of the group session.
59. A professional artist is admitted to the
psychiatric unit for treatment of bipolar disorder.
During last 2 weeks, the client has created 154
paintings, slept only 2 to 3 hours every 2 days,
and lost 18 lb (8.2 kg). Based on Maslow’s
hierarchy of needs, what should the nurse
provide this client with first?
a. The opportunity to explore family dynamics
b. Help with re-establishing a normal sleep
pattern
c. Experiences that build self-esteem
d. Art materials and equipment
60. The physician orders lithium carbonate
(Lithonate) for a client who’s in the manic phase
of bipolar disorder. During lithium therapy, the
nurse should watch for which adverse reactions?
a. Anxiety, restlessness, and sleep disturbance
b. Nausea, diarrhea, tremor, and lethargy
c. Constipation, lethargy, and ataxia
d. Weakness, tremor, and urine retention
Situation – Annie has a morbid fear of heights. She asks
the nurse what desensitization therapy is:
61. The accurate information of the nurse of the
goal of desensitization is:
a. To help the client relax and progressively
work up a list of anxiety provoking
situations through imagery
b. To provide corrective emotional experiences
through a one-to-one intensive relationship
c. To help clients in a group therapy setting to
take on specific roles and re-enact in front of
an audience, situation in which interpersonal
conflict is involved
d. To help clients cope with their problems by
learning behaviors that are more functional
and be better equipped to face reality and
make decisions.
 62. It is essential in a desensitization for the patient Problem. After the identification of the research
to: problem, which of the following should be done?
a. Have rapport with the therapist a. Methodology
b. Use deeps breathing or another relaxation b. Acknowledgment
technique c. Review of related literature
c. Assess one’s self for the need of an anxiolytic d. Formulate hypothesis
drug
d. Work through unresolved unconscious 68. Which of the following communicate the results
conflicts of the research to the readers. They facilitate the
description of the data.
63. In this level of anxiety, cognitive capacity a. Hypothesis
diminishes. Focus becomes limited and client b. Research problem
experiences tunnel vision. Physical signs of c. Statistics
anxiety become more pronounced. d. Tables and graphs
a. Severe anxiety
b. Mild anxiety 69. In quantitative date, which of the following
c. Panic described as the distance in the scoring unites of
d. Moderate anxiety the variable from highest to the lower?
A. Frequency
64. Antianxiety medications should be used with B. Median
extreme caution because long term use can lead C. Mean
to: D. Range
a. Parkinson like syndrome
b. Hepatic failure 70. The expresses the variability of the data in
c. Hypertensive crisis reference to the mean. It provides as with a
d. Risk of addiction numerical estimate of how far, on the average
the separate observation are from the mean:
65. The nursing management of anxiety related with a. Mode
post- traumatic stress disorder includes all of the b. Median
following EXCEPT: c. Standard deviation
a. Encourage participation in recreation of d. Frequency
sports activities
b. Reassure client’s safety while touching Situation: Survey and Statistics are important part of
client research that is necessary to explain the characteristics
c. Speak in a calm soothing voice of the population.
d. Remain with the client while fear level is
high 71. According to the WHO statistics on the homeless
population around the world, which of the
SITUATION: you are fortunate to be chosen as part of following groups of people in the world
the research team in the hospital. A review of the disproportionately represents the homeless
following IMPORTANT nursing concepts was made. population
a. Hispanics
66. As a professional, a nurse can do research for b. Asians
varied reason except: c. African Americans
a. Professional advancement through research d. Caucasians
participation
b. To validate results of new nursing modalities 72. All but one of the following is not a measure of
c. For financial gains Central Tendency:
d. To improve nursing care a. Mode
b. Standard deviation
67. Each nurse participants was asked to identify a c. Variance
d. Range
73. In the value: 87, 85, 88, 92, 90; what is the a. There is a control group
mean? b. There is an experimental group
a. 88.2 c. Selection of subjects in the control group is
b. 88.4 randomized
c. 87 d. There is a careful selection of subjects in the
d. 90 experimental group

74. In the value: 80, 80, 80, 82, 82, 90, 90, 100; 80. The researcher implemented a medication
What is the mode? regimen using a new type of combination drug
a. 80 to manic patients while another group of manic
b. 82 patient receives the routine drugs. The
c. 90 researcher however handpicked the
d. 85.5 experimental group for they are the clients with
multiple episodes of bipolar disorder. The
75. In the value: 80, 80, 10 10, 25, 65, 100, 200; researcher utilized which research design?
What is the median? a. Quasi- experimental
A. 71.25 b. Phenomenological
B. 22.5 c. Pure experimental
C. 10 and 25 d. Longitudinal
D. 72.5
Situation 19: as a nurse, you are expected to participate
76. Draw lots, lottery table of random numbers or a in initiating or participating in the conduct of research
sampling that ensures that each element of the studies to improve nursing practice. You to be updated
population has an equal and independent on the latest trends and issues affected the professional
chance of being chosen is called: and the best practices arrived at by the profession.
a. Cluster
b. Stratified 81. You are interested to study the effects of
c. Simple mediation and relaxation on the pain
d. Systematic experienced by cancer patients. What type of
variable is pain?
77. An investigator wants to determine some of the a. Dependent
problems that are experienced by diabetic b. Independent
clients when using an insulin pump. The c. Correlational
investigator went into a clinic where the d. Demographic
personally knows several diabetic clients having
problem with insulin pump. The type of sampling 82. You would like to compare the support system of
done by the investigator is called: patient with chronic illness to those with acute
a. Probability illness. How will you best state your problem?
b. Snowball a. A descriptive study to compare the support
c. Purposive system of patients with chronic illness and
d. Incidental those with acute illness in terms of
demographic data and knowledge about
78. If the researcher implemented a new structured intervention
counselling program with a randomized group of b. The effects of the types of support system
subject and a routine counselling with another of patient with chronic illness and those
randomized group of subject, the research is with acute illness
utilizing which design? c. A comparative analysis of the support
a. Quasi Experimental system of patients with chronic illness and
b. Comparative those with acute illness
c. Experimental d. A study to compare the support system of
d. Methodological
patients with chronic illness and those with
acute illness.
79. Which of the following is not true about a pure
experimental research?
 e. What are the differences of the support
system being received by patient with
chronic illness and patients with acute
illness?
83. You would like to compare the support system
o0f patients with chronic illness to those with
acute illness. Considering that the hypothesis
was: “Clients with chronic illness have lesser
support system than clients with acute illness.”
What type of research is this?
a. Descriptive
b. Correlational, Non Experimental
c. Experimental
d. Quasi Experiemental
84. In any research study where individual persons
are involved, it is important that an informed
consent of the study is obtained. The following
are essential information about the consent that
you should disclose to the prospective subjects
except:
a. Consent to incomplete disclosure
b. Description of benefits, risks, and
discomforts
c. Explanation of procedure
d. Assurance of anonymity and confidentiality
85. In the Hypothesis: “The utilization of technology
in teaching improves the retention and
attention of the nursing students. “Which is the
dependent variable?
a. Utilization of technology
b. Improvement in the retention and
attention
c. Nursing students
d. teaching
Situation: you are actively practicing nurse who has just
finished you graduate studies. You learned the value of
research and would like to utilize the knowledge and
skills gained in the application of research to the nursing
service. The following question apply to research.
86. Which type of research inquiry investigates the
issues of human complexity (e.g. understanding
the human expertise)
a. Logical Position
b. Positivism
c. Naturalistic inquiry
d. Quantitative research
87. Which of the following studies is based on
quantitative research?
a. A study examining the bereavement process
in spouse of clients with terminal cancer
b. A study exploring the factors influencing
weight control behaviour
c. A study measuring the effects of sleep
deprivation on wound healing
d. A study examining client’s feelings before,
during and after bone marrow aspiration.
88. Which of the following studies is based on the
qualitative research?
a. A study examining clients reaction to stress
after open heart surgery
b. A study ,measuring nutrition and weight
loss/gain in clients with cancer
c. A study examining oxygen levels after
endotracheal suctioning
d. A study measuring difference in blood
pressure before, during and after procedure
89. An 85 year old client in a nursing home tells a
nurse “ I signed the papers of that research study
because the doctor is so insistent and I want him
to taking care of me.” Which client right is being
violated?
a. Right of self determination
b. Right to full disclosure
c. Right to privacy and confidentiality
d. Right not to be harmed
90. A supposition or system od idea that is proposed
to explain a given phenomenon best defines:
a. A paradigm
b. A theory
c. A concept
d. A conceptual framework
Situation: Mastery of research design determination is
essential in passing the NLE.
91. Ana wants to know if the length of time she will
study for the board examination is proportional
to her board rating. During the June 2008 board
examination, she studied for 6 months and
gained 68% , on the next board exam, she
studied for 6 months again for a total of 1 year
and gained 74%, on the third board exam, she
studied for 6 months for a total of 1 and a half
 Year and gained 82%. The research design she Collected 100 random individuals and determine
used is: who is their favourite comedian actor. 50% said
a. Comparative Dolphy, 20% said Vic Sotto, while some answered
b. Experimental Joey De Leon, Allan K, Michael V. Tonyo conducted
c. Correlational what type of research study ?
d. Qualitative a. Phenomenological
b. Non experimental
92. Anton was always eating high fat diet. You want c. Case study
to determine if what will be the effect of high d. Survey
cholesterol food to Anton in the next 10 years.
You will use: 98. Jane visited tribe located somewhere in China, it
a. Comparative is called the Shin Jea tribe. She studied the way
b. historical of life, tradition and the societal structure of
c. correlational these people. Jane will best use which research
d. longitudinal design?
a. Historical
93. community A was selected randomly as well as b. Phenomenological
community B, nurse Edna conducted teaching to c. Case study
community A and assess if community A will d. ethnograpic
have a better status that community B. this is an
example of: 99. Anjoe researched on TB. Its transmission,
a. comparative causative agent and factors, treatment sign and
b. experimental symptoms as well as medication and all other in
c. correlational depth information about tuberculosis. This study
d. qualitative is best suited for which research design?
a. Historical
94. Ana researched on the development of a new b. Phenomenological
way to measure intelligence by creating a 100 c. Case study
item questionnaire that will assess the cognitive d. Ethnographic
skills of an individual. The design best suited for
this study is: 100. Diana is to conduct study about the relationship
a. Historical of the number of family members in the
b. Survey household and the electricity bill. Which of the
c. Methodological following is the best research design suited for
d. Case study this study?
1. Descriptive
95. Gen is conducting a research study on how mark, 2. Exploratory
an AIDS client lives his life. A design sited for this 3. Explanatory
study is: 4. Correlational
a. Historical 5. Comaparative
b. Phenomenological 6. Experimental
c. case study a. 1,4
d. ethnographic b. 2,5
c. 3,6
96. Marco is to perform a study about how nurses d. 1,5
perform surgical asepsis during World War II. A e. 2,4
design best for this study is:
a. Historical
b. Phenomenological
c. Case study
d. Ethnographic

97. Tonyo conducts sampling at barangay 412. He

TEST I- Foundation of Professional Nursing Practice
1. The nurse In- charge in labor and deliver unit
administered a dose of terbutaline to a client
without checking the client’s pulse. The
standard that would be used to determine if the
nurse was negligent is:
a. The physician’s order
b. The action of a clinical nurse specialist who
is recognized expert in the field
c. The statement in the drug literature about
administration of terbutaline
d. The action of a reasonably prudent nurse
with similar education and experience.
2. Nurse Trish is caring for a female client with a
history of GI Bleeding, sickle cell disease, and a
platelet count of 22,000/ul. The female client is
dehydrated and receiving dextrose of 5% in haf
normal saline solution at 150 ml/hr. the client
complains of severe bone pain and is scheduled
to receive a dose of morphine sulphate, In
administering the ,medication, Nurse Trish
should avoid which routine?
a. I.V
b. I.M
c. Oral
d. S.C
3. Dr. Garcia writes the following order for the
client who has been recently admitted
“Digoxin .125 mg P.O. once daily.” To prevent a
dosage error, how should the nurse document
this order onto the medication administration
record?
a. “Digoxin .1250 mg P.O. once daily.”
b. “Digoxin 0.1250 mg P.O. once daily.”
c. “Digoxin 0.125 mg P.O. once daily.”
d. “Digoxin .125 mg P.O. once daily.”
4. A newly admitted female client was diagnosed
with deep vein thrombosis. Which nursing
diagnosis should receive the highest priority?
a. Ineffective peripheral tissue perfusion
related to venous congestion
b. Risk for injury related to edema.
c. Excess fluid volume related to peripheral
vascular disease
d. Impaired gas exchange related to increased
blood flow.
5. Nurse Betty is assigned to the following clients.
The client that the nurse would see first after
endorsement?
a. A 34 year-old- post-operative
appendectomy client of five hours who is
complaining of pain.
b. A 44 year old myocardial infarction (MI)
client who is complaining of nausea
c. A 26 year old client admitted for
dehydration whose intravenous (IV) has
infiltrated
d. A 63 year old post operative’s abdominal
hysterectomy client of three days whose
incisional dressing is saturated with
serosanguinous fluid.
6. Nurse Gail places a client in a four point
restraint following orders from the physician.
The client care plan should include:
a. Assess temperature frequently
b. Provide diversional activities
c. Check circulation every 15-30 minutes
d. Socialize with other patients once a shift
7. A male client who has severe burns is receiving
H2 receptor antagonist therapy. The nurse in-
charge knows the purpose of this therapy is to:
a. Prevent stress ulcer
b. Block prostaglandin synthesis
c. Facilitate protein synthesis
d. Enhance gas exchange
8. The doctors order hourly urine output
measurement for a postoperative male client.
The nurse Trish records the following amounts
of output for 2 consecutive hours: 8 a.m:50ml;
9a.m: 60ml. Based on these amounts, which
action should the nurse take?
a. Increase the I.V fluid infusion rate
b. Irrigate the indwelling urinary catheter
c. Notify the physician
d. Continue to monitor and record hourly
urine output
9. Tony, a basketball player twist his right ankle
while playing on the court and seeks care for
ankle pain and swelling. After the nurse applies
ice to the ankles for 30minutes, which
statement by Tony suggests that ice application
has been effective?
a. “Many ankle look less swollen now”
b. “My ankle feels warm”
c. “My ankle appears redder now”
 d. “I need something stringer for pain relief”
10. The physician prescribes a loop diuretic for a
client. When administering this drug, the nurse
anticipates that the client may develop which
electrolyte imbalance?
a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia
11. She finds out that some managers have
benevolent-authoritative style of management.
Which of the following behaviours will she
exhibit most likely?
a. Have condescending trust and confidence in
their subordinates.
b. Gives economic and ego awards
c. Communicates downwards to staffs
d. Allows decision making among
subordinates
12. Nurse Amy is aware that the following is true
about functional nursing
a. Provides continuous, coordinated and
comprehensive nursing activities
b. One to one nurse patient ratio
c. Emphasize the use of group collaboration
d. Concentrates on tasks and activities
13. Which type of medication order might read
“Vitamin K10 mg I.M daily x3 a day?”
a. Single order
b. Standard written order
c. Standing order
d. Stat order
14. A female client with a fecal Impaction
frequently exhibits which clinical manifestation?
a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools
15. Nurse Linda prepares to perform an otoscopic
examination on a female client. For proper
visualization, the nurse should position the
client’s ear by:
a. Pulling the lobule down and back
b. Pulling the helix up and forward
c. Pulling the helix up and back
d. Pulling the lobule down and forward
16. Which instruction should nurse Tom give to a
male client who is having external radiation
therapy:
a. Protect the irritated skin from sunlight
b. Eat 3 to 4 hours before treatment
c. Wash the skin over the regularly
d. Apply lotion or oil to the radiated area
when it is red or sore.
17. In assisting a female client for immediate
surgery , the nurse in-charge is aware that she
should:
a. Encourage the client to avoid following
preoperative medication.
b. Explore the client’s fears and anxieties
about the surgery
c. Assist the client in removing dentures and
nail polish
d. Encourage the client drink water prior to
surgery
18. A male client is admitted and diagnosed with
acute pancreatitis after a holiday celebration of
excessive food and alcohol. Which assessment
finding reflects this diagnosis?
a. Blood pressure above normal range
b. Presence of crackles in both lung fields
c. Hyperactive bowel sounds
d. Sudden onset of continuous epigastric and
back pain
19. Which dietary guidelines are important for
Nurse Oliver to implement in caring for the
client with burns?
a. Provide high- fiber, high-fat diet
b. Provide high-protein, high- carbohydrate
diet
c. Monitor intake to prevent weight gain
d. Provide ice chips or water intake
20. Nurse Hazel will administer a unit of whole
blood, which priority information should the
nurse have about the client?
a. Blood Pressure and pulse rate
b. Height and weight
c. Calcium and potassium level
d. Hgb and Hct Levels
21. Nurse Michelle witnesses a female client sustain
a fall and suspects that the leg may be broken.
The nurse takes which priority action?
a. Takes a set of vital signs
 b. Call the radiology department for X-ray
c. Reassure the client that everything will be
alright
d. Immobilize the leg before moving the client
22. A male client is being transferred to the nursing
unit for admission after receiving a radium
implant for bladder cancer. The nurse-in charge
would take which priority action in the care of
this client?
a. Place client on reverse isolation
b. Admit the client into the private room
c. Encourage the client to take frequent rest
periods
d. Encourage family and friends to visit
23. A newly admitted female client was diagnosed
with agranulocytosis. The nurse formulates
which priority nursing diagnosis?
a. Constipation
b. Diarrhea
c. Risk of infection
d. Deficient knowledge
24. A male client is receiving total perenteral
nutrition suddenly demonstrates signs and
symptoms of an air embolism. What is the
priority action by the nurse?
a. Notify the physician
b. Place the client on the left side in the
trendelenburg position
c. Place the client in high- fowlers position
d. Stop the total parenteral nutrition
25. Nurse May attends an educational conference
on leadership styles. The nurse is sitting with a
nurse employed at a large trauma center who
states that the leadership style at the trauma
center is task-oriented and directive. The nurse
determines that the leadership style used at the
trauma center is:
a. Autocratic
b. Laissez-faire
c. Democratic
d. Situational
26. The physician orders DS 500 cc with KCI 10
mEq/liter at 30cc/hr. the nurse in- charge is
going to hang a 500 cc bag. KCI will be added to
the IV solution.
a. .5cc
b. 5cc
c. 1.5cc
d. 2.5cc
27. A child of 10 years 400 cc of IV fluid in an 8 hour
shift. The IV drip factor is 60. The IV rate that
will deliver ths amount is:
a. 50 cc/ hour
b. 55 cc/ hour
c. 24 cc/ hour
28. The nurse is aware that the most important
nursing action when a client returns surgery is:
a. Assess the IV for type of fluid and rate of
flow.
b. Assess the client for presence of pain
c. Assess the foley catheter for patency and
urine output
d. Assess the dressing for damage
29. Which of the following vital sign assessment
that may indicate cardiogenic shock after
myocardial infraction?
a. BP- 80/60, Pulse – 110 irregular
b. BP- 90/50, Pulse – 50 regular
c. BP- 130/80, Pulse- 100 regular
d. BP- 180/100, Pulse- 90 irregular
30. Which is the most appropriate nursing action in
obtaining a blood pressure measurement
a. Take the proper equipment, place the
client in the comfortable position, and
record the appropriate in information in
the client’s chart
b. Measure the client’s arm, if you are not
sure of the size of cuff to use.
c. Have the client recline or sit comfortably in
a chair with the forearm at the level of the
heart.
d. Document the measurement, which
extremity was used, and the position that
the client was in during the measurement.
31. Asking the questions to determine if the person
understands the health teaching provided by
the nurse would be included during which step
of the nursing process?
a. Assessment
b. Evaluation
c. Implementation
 d. Planning and goals
32. Which of the following item is considered the
single most important factor in assisting the
health professional in arriving at a diagnosis or
determining the person’s need.
a. Diagnostic test result
b. Biographical date
c. History of present illness
d. Physical examination
33. In preventing the development of an external
rotation deformity of the hip in a client who
must remain in bed for any period of time, the
most appropriate nursing action would be to
use:
a. Trochanter roll extending from the crest
b. Pillows under the lower leg
c. Footboard
d. Hi-abductor pillow
34. Which stage of pressure ulcer development
does the ulcer extend into the subcutaneous
tissue?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
35. When the method of wound healing is one in
which wound edges are not surgically
approximated and integumentary continuity is
restored by granulations, the wound healing is
termed:
a. Second intention healing
b. Primary intention healing
c. Third intention healing
d. First intention healing
36. An 80 year old male client is admitted to the
hospital with a diagnosis of pneumonia. Nurse
Oliver learns that the client live alone and
hasn’t been eating or drinking. When assessing
him for dehydration, nurse Oliver would expect
to find:
a. Hypothermia
b. Hypertension
c. Distended neck veins
d. Tachycardia
37. The physician prescribes meperidine (Demerol),
75mg I.M every 4 hours as needed, to control a
client’s postoperative pain. The package insert
“meperidine, 100mg/ml”. How many millilitres of
meperidine should the client receive?
a. 0.75
b. 0.6
c. 0.5
d. 0.25
38. A male client with diabetes mellitus is receiving
insulin. Which statement correctly describes an
insulin unit?
a. It’s a common measurement in metric
system
b. It’s the basis for solids in the avoid drupois
system
c. It’s the smallest measurement in the
apothecary system
d. It’s a measurement of effect, not a standard
measure of weight or quantity.
39. Nurse Oliver measures a client’s temperature
102F. What is the equivalent centigrade
temperature?
a. 40.1 degree Celsius
b. 38.9 degree Celsius
c. 48 degree Celsius
d. 38 degree Celsius
40. The nurse is assessing a 48 year old client who
has come to the physician’s office for his annual
physical exam. One of the first physical signs of
aging is:
a. Accepting limitations while developing
assets
b. Increasing loss of muscle tone.
c. Failing eyesight, especially close vision
d. Having more frequent aches and pain
41. A physician insert a chest tube into a female
client to treat a pneumothorax. The tube is
connected to water-seal drainage. The nurse in-
charge can prevent chest tube air leaks by:
a. Checking and taping all connections
b. Checking patency of the test tube
c. Keeping the head of the bed slightly
elevated
d. Keeping the chest drainage system below
the level of the chest
42. Nurse Trish must verify the client’s identity
before administering medication. She is aware
that the safest way to verify identity is to:
a. Check the client’s identification band
b. Ask the client to state his name
 c. State the client’s name out loud and wait a
client to repeat it
d. Check the room number and the client’s
name on the bed
43. The physician orders dextrose 5% in water,
1000 ml to be infused over 8 hours. The I.V
tubing delivers 15drops/ml. Nurse John should
run the I.V infusion at a rate of:
a. 30 drops/minute
b. 32 drops/minute
c. 20 drops/minute
d. 18 drops/minute
44. If a central venous catheter becomes
disconnected accidentally, what should the
nurse in-charge do immediately?
a. Clamp the catheter
b. Call another nurse
c. Call the physician
d. Apply a dry sterile dressing to the site.
45. A female client was recently admitted. She has
fever, weight loss, and watery diarrhea is being
admitted to the facility. While assessing the
client, nurse hazel inspect the client’s abdomen
and notice that it is slightly concave. Additional
assessment should proceed in which order?
a. Palpitation, auscultation, and percussion
b. Percussion, Palpitation and auscultation
c. Palpitation, percussion, and auscultation
d. Auscultation, percussion and palpitation
46. Nurse Betty is assessing tactile fremitus in a
client with pneumonia. For this examination,
nurse Betty should use the:
a. Fingertips
b. Finger pads
c. Dorsal surface of the hand
d. Ulnar surface of the hand
47. Which type of evaluation occurs continually
throughout the teaching and learning process?
a. Summative
b. Informative
c. Formative
d. Retrospective
48. A 45 year old client, has no family history of
breast cancer or other risks factors for this
disease. Nurse John should instruct her to have
mammogram how often?
a. Twice per year
b. Once per year
c. Every 2 years
d. Once, to establish baseline
49. A male client has the following arterial blood
gas values: pH7.30;Pao2 89mmHg; Paco2 50
mmHg; and HCO3 26mLq/L. Based on thses
values, Nurse Patricia should exoect which
condition?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
50. Nurse Len refers a female client with terminal
cancer to a local hospice. What is the goal of
this referral?
a. To help the client find appropriate
treatment options
b. To provide support for the client and family
in coping with termila illness
c. To ensure that the client gets counselling
regarding health care costs
d. To teach the client and family about cancer
and its treatment.
51. When caring for a male client with a 3 –cm
stage I pressure ulcer on the coccyx, which of
the following actions can the nurse institute
independently?
a. Massaging the area with an astringent every
2 hours
b. Applying an antibiotic cream to the area
three times a day
c. Using normal saline solution to clean the
ulcer and applying protective dressing as
necessary
d. Using a povidone-iodine wash on ulceration
three times per day
52. Nurse Oliver must apply an elastic bandage to a
client’s ankle and calf. He should apply the
bandage beginning Aat the client’s :
a. Knee
b. Ankle
c. Lower thigh
d. Foot
53. A 10 year old child with type 1 diabetes develops
diabetic ketoacidosis and receives a continuous
insulin infusion. Which condition represents the
greatest risk to this child?
a. Hypernatremia
b. Hypokalemia
c. Hyperphosphatemia
 d. Hypercalcemia
54. Nurse Len is administering sublingual
nitrglycerin (Nitrostat) to the newly admitted
afterward, the client may experience:
a. Throbbing headache or dizziness
b. Nervousness or paresthesia
c. Drowsiness or blurred vision
d. Tinnitus or diplopia
55. Nurse Michelle hears the alarm sound on the
telemetry monitor. The nurse quickly looks at
the monitor and notes that a client is in a
ventricular tachycardia. The nurse rushes to the
client’s room. Upon reaching the client’s
bedside, the nurse would take which action
first?
a. Prepare for cardioversion
b. Prepare to defibrillate the client
c. Call a code
d. Check the client’s level of consciousness
56. Nurse Hazel is preparing to ambulate a female
client. The best and safest position for the nurse
in assisting the client is to stand:
a. On the unaffected side of the client
b. On the affected side of the client
c. In front of the client
d. Behind the client
57. Nurse Janah is monitoring the ongoing care
given to the potential organ donor who has
been diagnosed with brain death. The nurse
determines that the standard of acre had been
maintained if which of the following data is
observed?
a. Urine output: 45 ml/hr
b. Capillary refill: 5 seconds
c. Serum pH: 7.32
d. Blood pressure: 90/48 mmHg
58. Nurse Amy has an order to obtain a urinalysis
from a male client with an indwelling urinary
catheter. The nurse avoids which of the
following. Which contaminate the specimen?
a. Wiping the port with an alcohol swab
before inserting the syringe
b. Aspiring a sample from the port on the
drainage bag
c. Clamping the tubing of the drainage bag
d. Obtaining the specimen from the urinary
drainage bag.
59. Nurse Meredith is in process of giving a client a
bed bath. In the middle of the procedure, the
unit secretary calls the nurse on the intercom to
tell the nurse that the there is an emergency
phone call. The appropriate nursing action is to:
a. Immediately walk out of the client’s room
and answer the phone call
b. Cover the client, place the call light
c. Finish the bed bath before answering the
phone call
d. Leave the client’s door open so the client
can be monitored and the nurse can answer
the phone
60. Nurse John is collecting a sputum specimen for
culture and sensitivity testing from a client
who has a productive cough. Nurse Janah plans
to implement which intervention to obtain the
specimen?
a. Ask the client to expectorate a small
amount of sputum into the emesis basin.
b. Ask the client to obtain the specimen after
breakfast
c. Use a sterile plastic container for obtaining
the specimen
d. Provide tissues for expectoration and
obtaining the specimen
61. Nurse Ron is observing a male client using a
walker. The nurse determines that the client is
using the walker correctly if the client:
a. Puts all the four points of the walker flat on
the floor, puts weight on the hand pieces,
and then walks into it.
b. Puts weight on the hand pieces , moves the
walker forward, and then walk into it
c. Puts weight on the hand pieces, slides the
walker forward, and then walks into it
d. Walks into the walker, puts weight on the
hand pieces and then puts all four points of
the walker flat on the floor.
62. Nurse Amy has documented an entry regarding
client care in the client’s medical record. When
checking the entry, the nurse realizes that
 Incorrect information was documented. How does the
nurse correct this error? a. Prone with head turned toward the side
a. Erases the error and writes in the correct supported by a pillow
information b. Sim’s position with the head of the bed
b. Uses correction fluid to cover up the incorrect flat
information and writes in the correct c. Right side-lying with the head of the bed
information. elevated 45 degrees.
c. Draws one line to cross out the incorrect d. Left side-lying with the head of the bed
information and then initials the change. elevated 45 degrees.
d. Covers up the incorrect information completely
using a black pen and writes in the correct 67. Nurse John develops methods for data
information gathering. Which of the following criteria of a
good instrument refers to the ability of the
63. Nurse Ron is assisting with transferring a client instrument to yield the same results upon its
from the operating room table to a stretcher. To repeated administration?
provide safety to the client , the nurse should: a. Validity
a. Moves the client rapidly from the table to b. Specificity
the stretcher c. Sensitivity
b. Uncover the client completely before d. Reliability
transferring to the stretcher.
c. Secures the client safety belts after 68. Harry knows that he has to protect the rights of
transferring to the stretcher human research subjects. Which of the following
d. Instructs the client to move self from the actions of Harry ensures anonymity?
table to the stretcher. a. Keep the identities to the subject secret
b. Obtain informed consent
64. Nurse Myrna is providing instruction to a c. Provide equal treatment to all the subjects
nursing assistant assigned to give a bed bath to of the study.
a client who is contact precautions. Nurse d. Release findings only to the participants of
Myrna instructs the nursing assistant to use the study.
which of the following protective items when
giving bed bath? 69. Patient’s refusal to divulge information is a
a. Gown and goggles limitation because it is beyond the control of
b. Gown and gloves Tiffany”. What type of research is appropriate
c. Gloves and shoe protectors for this study?
d. Gloves and goggles a. Descriptive- correlational
b. Experiment
65. Nurse Oliver is caring for a client with impaired c. Quasi- experiment
mobility that occurred as a result of a stroke. The d. Historical
client has right sided arm and leg weakness. The
nurse would suggest that the client use which of 70. Nurse Ronald is aware that the best tool for
the following assistive devices that would provide data gathering is?
the best stability and ambulating? a. Interview schedule
a. Crutches b. Questionnaire
b. Single and straight legged cane c. Use of laboratory data
c. Quad core d. Observation
d. Walker
71. Monica is aware that there are times when only
66. A male client with a right pleural effusion noted manipulation of study variables is possible and
on a chest X-ray is being prepared for the elements of control or randomization are
thoracentesis. The client experiences severe not attendant. Which type of research is
dizziness when sitting upright. To provide a safe referred to this?
environment, the nurse assists the client to a. Field study
which position for the procedure? b. Quasi- experiment
 c. Solomon- four group design
d. Post-test only design
72. Cherry notes down ideas that were derived
from the description of an investigation written
by the person who conducted it. Which type of
reference source refers to this?
a. Footnote
b. Bibliography
c. Primary source
d. Endnotes
73. When nurse Trish is providing care to his
patient, she must remember that her duty is
bound no to do doing any action that will cause
the patient harm. Ti is the meaning of the
bioethical principle:
a. Non-malaficence
b. Beneficence
c. Justice
d. Solidarity
74. When a nurse in-charge causes an injury to a
female and the injury caused becomes the
proof of the negligent act, the presence of the
injury is said to exemplify the principle of:
a. Force majeure
b. Respondeat superior
c. Res ipsa loquitor
d. Holdover doctrine
75. Nurse Myrna is aware that the Board of Nursing
has quasi-judicial power. An example of this
power is:
a. The Board can issue rules and regulation
that will govern the practice of nursing
b. The Board can investigate violations of the
nursing law and code of ethics
c. The Board can visit a school applying for a
permit in collaboration with CHED
d. The Board prepares the board
examinations.
76. When the license of nurse Krina is revoked, it
means that she:
a. Is no longer allowed to practice the
profession for the rest of her life
b. Will never have her/hi license re-issued
since it has been revoked
c. May apply for re-issuance of his/her license
based on certain condition stipulated in RA
9173
d. Will remain unable to practice professional
nursing
77. Ronald plans to conduct a research on the use
of a new method of pain assessment scale.
Which of the following is the second step in the
conceptualizing phase of the research process?
a. Formulating the research hypothesis
b. Review related literature
c. Formulating and delimiting the research
problem
d. Design the theoretical and conceptual
framework
78. The leader of the study knows that certain
patients who are in specialized research setting-
tend to respond psychologically to the
conditions of the study. This referred to as:
a. Cause and effect
b. Hawthorne effect
c. Halo effect
d. Horns effect
79. Mary finally decides to use judgment sampling
on her research. Which of the following actions
of is correct?
a. Plans to include whoever is there during his
duty
b. Determines the different nationality of
patients frequently admitted and decides to
get representations samples from each.
c. Assigns numbers for each of the patients,
place these in a fishbowl and draw 10 from
it.
d. Decides to get 20 samples from the
admitted patients.
80. The nursing theorist who developed
transcultural nursing theory is:
a. Florence Nightingale
b. Madeleine Leininger
c. Albert Moore
d. Sr. Callista Roy
81. Marion is aware that the sampling method that
gives equal chance to mall units in the
population to get picked is:
a. Random
b. Accidental
c. Quota
d. Judgment
 d. Sim’s left lateral
82. John plans to use a Likert Scale to his study to 89. Nurse Marian is preparing to administer a blood
determine the: transfusion. Which action should the nurse take
a. Degree of agreement and disagreement first?
b. Compliance of expected standards a. Arrange for typing and cross matching of
c. Level of satisfaction client’s blood
d. Degree of acceptance b. Compare the client’s identification
wristband with the tag on the unit of blood.
83. Which of the following theory addresses the c. Start an I.V infusion of normal saline
four modes of adaption? d. Measure the client’s vital signs.
a. Madeleine Leininger
b. Sr. Callista Roy 90. A 65 year old male client request s his
c. Florence Nightingale medication at 9 p.m. instead of 10 p.m. so that
d. Jean Watson he can go to sleep earlier. Which type of nursing
intervention is required?
84. Ms. Garcia is responsible to the number of a. Independent
personnel reporting to her. This principle refers b. Dependent
to: c. Interdependent
a. Span of control d. Intradependent
b. Unity of command
c. Downward communication 91. A female client is to be discharged from an
d. Leader acute care facility after treatment for right leg
thrombophlebitis. The Nurse Betty notes that
85. Ensuring that there is an informed consent on the client’s leg is pain-free, without redness or
the part of the patient before a surgery is done, edema. The nurse’s actions reflect which step of
illustrates the bioethical principle of: the nursing process?
a. Beneficence a. Assessment
b. Autonomy b. Diagnosis
c. Veracity c. Implementation
d. Non-maleficence d. Evaluation

86. Nurse Reese is teacher a female client with
peripheral vascular disease about foot care;
nurse Reese should include which instruction?
a. Avoid wearing cotton socks.
b. Avoid using a nail clipper to cut toenails
c. Avoid wearing canvas shoes.
d. Avoid using cornstarch on feet.
87. A client is admitted with multiple pressure
ulcers. When developing the client’s diet plan,
the nurse should include:
a. Fresh orange slices
b. Steamed broccoli
c. Ice cream
d. Ground beef patties
88. The nurse prepares to administer a cleansing
enema. What is the most common client
position used for this procedure?
a. Lithotomy
b. Supine
c. Prone
92. Nursing care for a female client includes
removing elastic stockings once per day. The
Nurse Betty is aware that the rationale for this
intervention?
a. To increase blood flow to the heart
b. To observe the lower extremities
c. To allow the leg muscles to stretch and
relax
d. To permit veins in the legs to fill with
blood
93. Which nursing intervention takes highest
priority when caring for a newly admitted client
who’s receiving a blood transfusion?
a. Instructing the client to report any itching,
swelling, or dyspnea
b. Informing the client that the transfusion
usually take 1 ½ to 2 hours.
c. Documenting blood administration in the
client care record.
 d. Assessing the client’s vital signs hen the d. 30 minutes after administering the next
transfusions ends. dose.

94. A male client complains of abdominal
discomfort and nausea while receiving tube
feedings. Which intervention is most
appropriate for this problem?
a. Give the feedings at room temperature.
b. Decrease the rate of feedings and the
concentration of the formula.
c. Place the client in semi-fowler’s position
while feeding.
d. Change the feeding container every 12
hours.
95. Nurse Patricia is reconstituting a powdered
medication in a vial. After adding the solution to
the powder, she nurse should:
a. Do nothing
b. Invert the vial and let it stand for 3 to 5
minutes
c. Shake the vial vigorously.
d. Roll the vial gently between the palns.
99. Nurse May is aware that the main advantage of
using a floor stock system is:
a. The nurse can implement medication orders
quickly.
b. The nurse receives input from the
pharmacist.
c. The system minimizes transcription errors.
d. The system reinforces accurate circulations
100. Nurse Oliver is assessing a client’s
abdomen. Which finding should the nurse
report as abnormal?
a. Dullness over the liver.
b. Bowel sounds occurring every 10
seconds.
c. Shifting dullness over the abdomen.
d. Vascular sounds heard over the renal
arteries.

96. Which intervention should the nurse Trish use

when administering oxygen by face mask to a
female client?
a. Secure the elastic band tightly around the
client’s head.
b. Assist the client to the semi-fowler position
if possible.
c. Apply the face mask from the client’s chin
up over the nose
d. Loosen the connectors between the oxygen
equipment and humidifier.

97. The maximum=m transfusion time for a unit of

packed red blood cells (RBCs) is:
a. 6 hours
b. 4 hours
c. 3 hours
d. 2 hours

98. Nurse Monique is monitoring the effectiveness

of a client’s drug therapy. When should the
nurse Monique obtain a blood sample to
measure the trough drug level?
a. 1 hour before administering the next dose
b. Immediately before administering the next
dose
c. Immediately after administering the next
dose
Answer and Rationale – Foundation of Professional
Nursing Practice
1. Answer: (D) the actions of a reasonably prudent
nurse with similar education and experience.
Rationale: The standard of care is determined
by the average degree of skill, care and
diligence by nurses in similar circumstances.
2. Answer: (B) I.M
Rationale: With a platelet count of 22,000/ul,
the clients tends to bleed easily. Therefore, the
nurse should avoid using the I.M. route because
the area is a highly vascular and can bleed
readily when penetrated by a needle. The
bleeding can be difficult to stop.
3. Answer: (C) “Digoxin 0.125 mg P.O once daily”
Rationale: The nurse should always place a zero
before a decimal point so that no one misreads
the figure, which could result in a dosage error.
The nurse should never insert a zero at the end
of a dosage that includes a decimal point
because this could be misread, possibly leading
to a tenfold increase in the dosage.
4. Answer: (A) Ineffective peripheral tissue
perfusion related to venous congestion.
Rationale: Ineffective peripheral tissue
perfusion related to venous congestion takes
the highest priority because venous
inflammation and clot formation impede blood
flow in a client with deep vein thrombosis.
5. Answer: (B) A 44 year-old myocardial infarction
(IM) client who is complaining of nausea.
Rationale: Nausea is a symptom of impending
myocardial infarction (MI) and should be
assessed immediately so that treatment can be
instituted and further damage to the heart is
avoided.
6. Answer: (C) Check circulation every 15-30
minutes.
Rationale: Restraints encircle the limbs, which
place the client at risk for circulation every 15-
30 minutes will allow the nurse to adjust the
restraints before injury from decreased blood
flow occurs.
7. Answer: (A) Prevent stress ulcer
Rationale: Curling’s ulcer occurs as a generalized stress
response in burn patients. The results in a decreased
production of mucus and increased secretion of gastric
acid. The best treatment for this prophylactic use of
antacids and H2 receptor blockers.
8. Answer: (D) Continue to monitor and record
hourly urine output
Rationale: Normal urine output for an adult is
approximately 1 ml/minute (60ml/hour).
Therefore, this client’s output is normal. Beyond
continued evaluation, no nursing action is
warranted.
9. Answer: (B) “My ankle feels warm”.
Rationale: Ice application decreases pain and
swelling. Continued or increased pain, redness
and increased warmth are signs of inflammation
that shouldn’t occur after ice application.
10. Answer: (B) Hyperkalemia
Rationale: A loop diuretic removes water and,
along with it, sodium and potassium. This may
result in hypokalemia, hypovolemia, and
hyponatremia.
11. Answer: (A) Have condescending trust and
confidence in their subordinates
Rationale: Benevolent-authoritative managers
pretentiously show their trust and confidence
to their followers
12. Answer: (A) Provides continuous, coordinated
and comprehensive nursing services.
Rationale: Functional nursing is focused tasks
and activities and not on the care of the
patients.
13. Answer: (B) Standard written order
Rationale: This is a standard written order.
Prescribers write a single order for medications
given only once. A stat order is written for
medications given immediately for an urgent
client problem. A standing order, also known as
a protocol, establishes guidelines for treating a
particular disease or set of symptoms in special
care areas such as the coronary care unit.
Facilities also may institute medication
protocols that specifically designate drugs that a
nurse may not give.
14. Answer: (D) Liquid or semi liquid stools
rationale: Passage of liquid or semi liquid stools
result from seepage of unformed bowel
contents around the impacted stool in the
return. Clients with fecal impaction don’t pass
hard, brown, formed stools because the feces
can’t move past the impaction. These
Clients typically report the urge to defecate
(although they can’t pass stool) and a decreased
appetite.
15. Answer: ( C) Pulling the helix up and back
Rationale: to perform an otoscopic examination
on an adult, the nurse grasps the helix of the
ear and pulls it up and back to straighten the
ear canal. Pulling the lobule in any direction
wouldn’t straighten the ear canal for
visualization.
16. Answer: (A) Protect the irritated skin from
sunlight.
Rationale: irradiated skin is very sensitive and
must be protected with clothing or sunblock.
The priority approach is the avoidance of strong
sunlight.
17. Answer: (C) Assist the client in removing
dentures and nail polish.
Rationale: Dentures, hairpins, and combs must
be removed. Nail polish must be removed so
that cyanosis can be easily monitored by
observing the nail beds.
18. Answer: (D) sudden onset of continuous
epigastric and back pain.
Rationale: The auto digestion of tissue by the
pancreatic enzymes results in pain from
inflammation, edema, and possible
hemorrhagre. Continuous unrelieved epigastric
or back pain reflects the inflammatory process
in the pancreas.
19. Answer: (B) provide high-protein, high-
carbohydrate diet.
Rationale: A positive nitrogen balance is
important for meeting metabolic needs, tissue
repair, and resistance to infection. Caloric goals
may be as high as 500 calories per day.
20. Answer: (A) Blood pressure and pulse rate.
Rationale: The baseline must be established to
recognize the signs of an anaphylactic or
haemolytic reaction to the transfusion.
21. Answer: (D) immobilize the leg before moving
the client.
Rationale: If the nurse suspects a fracture,
splinting the area before moving the client is
imperative. The nurse should call for emergency
help if the client is not hospitalized and call for a
physician for the hospitalized client.
22. Answer: (B) Admit the client into a private
room.
Rationale: The client who has a radiation. Implant is
placed in a private room and has a limited number of
visitors. This reduces the exposure of others to the
radiation.
23. Answer: ( C ) Risk for infection
Rationale: Agranulocytosis is characterized by a
reduced number of leukocytes (leucopenia) and
neutrophils (neutropenia) in the blood. The
client is at high risk for infection because of the
decreased body defences against
microorganism. Deficient knowledge related to
the nature of the disorder may be appropriate
diagnosis but is not the priority.
24. Answer: (B) Place the client on the left side in
the tredelenburg position.
Rationale: Lying on the left side may prevent air
from flowing into the pulmonary veins. The
trendelenburg position increases intrathoracic
pressure, which decreases the amount of blood
pulled into the vena cava during aspiration.
25. Answer: (A) Autocratic
Rationale: The autocratic style of leadership is a
task- oriented and directive.
26. Answer: (D) 2.5cc
Rationale: 2.5 cc is to be added, because 500
bag of solution is being medicated instead of a 1
liter.
27. Answer: (A) 50cc/hour
Rationale: A rate of 50cc/hr. The child is to
receive 400cc over a period of 8 hours =
50cc/hr.
28. Answer: (B) Assess the client for presence of
pain.
Rationale: assessing the client for pain is a very
important measure. Postoperative pain an
indication of complication. The nurse should
also asses the client for pain to provide for the
client’s comfort.
29. Ansewer: (A) BP- 80/60, Pulse- 110 irregular.
Rationale: The classic signs of cardiogenic shock
are low blood pressure, rapid and weak
irregular pulse, cold, clammy skin, decreased
urinary output, and clebral hypoxia.
30. Answer: (A) Take the proper equipment, place
the client in a comfortable position. And record
the appropriate information in the cleint’s
chart.
Rationale: It is a general or comprehensive
statement about the correct procedure and it
indicates the basic ideas which are found in the
other options.
31. Answer: (B) Evaluation 43.

44.

32. No question

33. No question

34. No question

35. No question

36. No question

37. No question

38. No question

39. No question

40.

41.

42. Mnmnm 45.

46. Answer: (D) Ulnar Surface of the hand
Rationale: The nurse uses the ulnar surface, or
ball of the hand to assess tactile fremitus, thrills
and vocal vibrations through the chest wall. The
fingertips and finger pads best distinguish text
and shape. The dorsal surface best feels
warmth.
47. Answer: (C) Formative
Rationale: Formative (or concurrent) evaluation
occurs continuously throughout the teaching
and learning process. One benefit is the nurse
can adjust teaching strategies as necessary to
enhance learning. Summative or retrospective,
evaluation occurs at the conclusion of the
teaching and learning session. Informative is not
type of evaluation.
48. Answer: (B) Once per year
Rationale: yearly mammograms should begin at
age 40 and continue for as long as the woman is
in good health. If health risk, such as family
history, genetic tendency or past breast cancer,
exist more frequent examinations may be
necessary.
49. Answer: (B) Respiratory Acidosis
Rationale: The client has a below-normal (acidic)
blood pH value and an above-normal partial
pressure of arterial carbon dioxide (Paco2) value,
indicating respiratory acidosis. In respiratory
alkalosis, the pH value is below normal. In
metabolic acidosis, the pH and bicarbonate (Hco3)
values are below normal. In metabolic alkalosis,
the pH and Hco3 values are above normal.
50. Answer: (A) To provide support for the client and
family in coping with terminal illness.
Rationale: Hospices provide supportive care for
terminally ill clients and their families. Hospice
care doesn’t focus on counselling regarding health
care costs. Most client referred to hospices have
been treated for their disease without success and
will receive only palliative care in the hospice.
51. Answer: (C ) Using normal saline solution to clean
the ulcer and applying a protective dressing as
necessary.
Rationale: washing the area with normal saline
solution and applying a protective dressing are
within the nurse’s realm of
Interventions and will protect the area. Using
povidone-iodine wash and an antibiotic cream
require a physician’s order. Massaging with an
astringent can further damage the skin.
52. Answer: (D) Foot
Rationale: An elastic bandage should be applied
form the distal area to the proximal area. This
method promotes venous return. In this case,
the nurse should begin applying the bandage at
the client’s foot. Beginning at the ankle, lower
thigh or knee does not promote venous return.
53. Answer: (B) Hypokalemia
Rationale: Insulin administration causes glucose
and potassium to move into the cells, causing
hypokalemia.
54. Answer: (A) Throbbing headache or dizziness
Rationale: Headache and dizziness often occur
when nitroglycerin is taken at the beginning
therapy. However, the client usually develops
tolerance.
55. Answer: (D)Check the client’s level of
consciousness
Rationale: Determining unresponsiveness is the
first step assessment action to take. When a
client is in ventricular tachycardia, there is a
significant decrease in cardiac output. However,
checking the unresponsiveness ensures
whether the client is affected by the decreased
cardiac output.
56. Answer: (B) On the affected side of the client
Rationale: When walking with clients, the nurse
should stand on the affected side and grasp the
security belt in the midspine area of the small of
the back. The nurse should position the free
hand at the shoulder area so that the client can
be pulled toward the nurse in the event that
there is a forward fall. The client is instructed to
look up and outward rather than at his or her
feet.
57. Answer: (A) Urine output: 45ml/hr
Rationale: Adequate perfusion must be
maintained to all vital organs in order for the
client to remain visible as an organ donor. A
urine output of 45ml per hour indicates
adequate renal perfusion. Low blood pressure
and delayed capillary refill are circulatory
system indicators of inadequate perfusion. A
serum pH of 7.32 is acidotic, which adversely
affects all body tissues.
58. Answer: (D) Obtaining the specimen from the
urinary drainage bag.
Rationale: A urine specimen is not taken from the
urinalysis drainage bag. Urine undergoes chemical
changes while sitting in the bag and does not necessarily
reflect the current client status. In addition, it may
become contaminated with bacteria from opening the
system.
59. Answer: (B) cover the client, place the call light
within reach, and answer the phone call.
Rationale: Because telephone call is an
emergency, the nurse may need to answer it.
The other appropriate action is to ask another
nurse to accept the call. However, is not one of
the options. To maintain privacy and safety, the
nurse covers the client and places the call light
within the client’s reach. Additionally, the
client’s door should be closed or the room
curtains pulled around the bathing area.
60. Answer: (C) Use a sterile plastic container for
obtaining the specimen.
Rationale: Sputum specimens for culture and
sensitivity testing need to be obtained using
sterile techniques because the test id done
determine the presence of organisms. If the
procedure for obtaining the specimen is not
sterile, then the specimen is not sterile, then
the specimen would be contaminated and the
results of the test would be invalid.
61. Answer: (A) Puts all the four points of the
walker flat on the floor, puts weight on the
hand pieces , and then walks into it.
Rationale: When the client uses a walker, the
nurse stand adjacent to the affected side. The
client is instructed to put all four points of the
walker to 2 feet forward flat on the floor before
putting weight on hand pieces. This will ensure
client safety and prevent stress cracks in the
walker. The client is then instructed to move
the walker forward and walk into it.
62. Answer: ( C) Draws one illness to cross out the
incorrect information and then initials the
change.
Rationale: To correct an error documented in a
medical record, the nurse draws one line
through the incorrect information and then
initials the error. An error is never erased and
correction fluid is never used in the medical
record.
63. Answer: ( C ) Secures the client safety belts after
transferring to the stretcher.
Rationale: During the transfer the client after
the surgical procedure is complete. The nurse
should avoid exposure of the client
Because of the risk for potential heat loss.
Hurried movements and rapid changes in the
position should be avoided because these
predispose the client to hypotension. Sat the
time of the transfer from the surgery table to
the stretcher, the client is still affected by the
effects of the anaesthesia; therefore, the client
should not move self. Safety belts can prevent
the client from falling off the stretcher.
64. Answer: (B) Gown and gloves
Rationale: Contact precautions require the use
of gloves and a gown if direct client contact is
anticipated. Googles are not necessary unless
the nurse anticipates the splashes of blood,
body fluids, secretions, or excretions may occur.
Shoe protectors are not necessary
65. Answer: (C ) Quad Cane
Rationale: Crutches and a walker can be difficult
to manuever for a client with weakness on one
side. A cane is better suited for client with
weakness of the arm and leg on one side.
However, the Quad cane would provide the
most stability because of the structure of the
cane and because a quad cane ha sfour legs.
66. Answer: (D) Left side lying with the head of the
bed elevated 45 degrees.
Rationale: To facilitate removal of fluid from the
chest wall, the client is poisoned sitting at the
edge of the bed leaning over the bedside table
with the feet supported on a stool. If the client
is unable to sit up, the client is positioned lying
in bed on the unaffected side with the head of
the bed elevated 30 to 45 degrees.
67. Answer: (D) Reliability
Rationale: Reliability is consistency of the
research instrument. It refers to the
repeatability of the instrument in extracting the
same responses upon its repeated
administration.
68. Answer: (A) Keep the identities of the subject
secret
Rationale: Keeping the identities of the research
subject secret will ensure anonymity because
this will hinder providing link between the
information given to whoever is its source.
69. Answer: (A) Descriptive-Correlational
Rationale: Descriptive-correlational study is the
most appropriate for this study because it
studies the variables that could be the
antecedents of the increased incidence of
nosocomial infection.
70. Answer: (C ) Use of laboratory data
Rationale: Incidence of nosocomial infection is
best collected through the use of biophysiologic
measures, particularly in vitro measurements,
hence laboratory data is essential.
71. Answer: (B) Quasi-Experimental
Rationale: Quasi-Experimental is done when
randomized and control of the variables are not
possible.
72. Answer: (C ) Primary Source
Rationale: This refers to a primary source which
is a direct account of the investigation done by
the investigator. In contrast to this is a
secondary source, which is written by someone
other than the original researcher.
73. Answer: (A) Non-maleficence
Rationale: Non-maleficence means do not cause
harm or do any action that will cause any harm
to the patient/client. To do good is referred as
beneficence.
74. Answer: (C ) Res ipsa loquitor
Rationale: Res ipsa loquitor literraly means the
thing speaks for itself. This means in operational
terms that the injury caused is the proof that
there was a negligent act.
75. Answer: (B) The board can investigate violence
of the nursing law and code of ethics
Rationale: Quasi-judicial power means that the
board of nursing has the authority to investigate
violations of the nursing law and can issue
summons, subpoena, or subpoena duces
tecumas needed.
76. Answer: ( C) May apply for re-issuance of
his/her license based on certain conditions
stipulated in RA 9173
Rationale: RA 9173 sec. 24 states that for equity
and justice, a revoked license maybe re-issued
provided that the following conditions are met:
a) the cause for revocation of license has
already been corrected or removed; and b) at
atleast four years has elapsed since the license
has been revoked.
77. Answer: (B) Review related literature
Rational: after formulating and delimiting the
research problem, the researcher conducts a
review of a related literature to determine the
extent of what has been done 0n the study by
previous researcher.
78. Answer: (B) Hawthorne effect
Rational: Hawthorne effect is based on the
study of Elton mayo and company about the
effect on an intervention done to improve
the working conditions of the workers on their
productivity. It resulted to an increased
productivity but not due to the intervention but
due to the psychological effects of being
observed. They performed differently because
they were under observation.
79. Answer: (B) Determines the different nationality
of patients frequently admitted and decides to
get representation samples from each.
Rationale: Judgment sampling involves including
samples according to the knowledge of the
investigator about the participants in the study.
80. Answer: (B) Madeleine Leininger
Rationale: Medeleine Leininger developed the
theory on transcultural theory based on her
observations on the behaviour of selected
people within a culture.
81. Answer: (A) Random
Rationale: Random sampling gives equal chance
for all the elements in the population to be
picked as part of the sample.
82. Answer: (A) Degree of agreement and
disagreement
Rationale: Likert Scale is a 5 point summated
scale used to determine the degree of
agreement or disagreement of the respondents
to a statement in a study.
83. Answer: (B) Sr. Callista Roy
Rationale: Sr. Callista Roy developed the
adaptation model which involves the
physiologic mode, self-concept mode, role
function mode and dependence mode.
84. Answer: (A) Span of control
Rationale: Span of control refers to the number
of workers who report directly to a manager.
85. Answer: (B) Autonomy
Rationale: Informed consent means that the
patient fully understand about the surgery,
including the risks involved and the alternative
solution. In giving consent it is done with
knowledge and is given freely. The action of
allowing the patient to decide whether a
surgery is to be done or not exemplifies the
bioethical principle of anatomy
86. Answer: (C) Avoid wearing canvas shoes.
Rationale: The client should be instructed to
avoid wearing canvas shoes. Canvas shoes
cause the feet to perspire, which may, in turn,
cause skin irritation and breakdown. Both
cotton and corn starch absorb perspiration.
 The client should be instructed to cut toenails
straight across with nail clippers.
87. Answer: (D) Ground beef patties
Rationale: Meat is an excellent source of
complete protein, which this client needs to
repair the tissue breakdown caused by pressure
ulcers. Oranges and broccoli supply vitamin C
but not protein. Ice cream supplies only some
incomplete protein, making it less helpful in
tissue repair.
88. Answer: (D) Sim’s left lateral
Most common position used to administer a
cleansing anema because it allows gravity to aid
the flow of fluid along the curve of the sigmoid
colon. If the client assume this position nor has
poor sphincter control, the dorsal recumbent or
right lateral position may be used. The supine
and prone positions are inappropriate and
uncomfortable for the client.
89. Answer: (A) Arrange for typing and cross
matching of the clients blood.
Rationale: The nurse first arranges for typing
and cross matching of the clients blood to
ensure compatibility with donor blood. The
other options, although appropriate when
preparing to administer a blood transfusion,
come later.
90. Answer: (A) Independent
Rationale: Nursing interventions are classified
as independent, interdependent, or dependent.
Altering the drug schedule to coincide with the
client’s daily routine represents an indepedents
intervention, whereas consulting with the
physician and pharmacist to change a client’s
medication because of adverse reactions
represents an interdependent intervention.
Administering an already-prescribed drug on
time is a dependent intervention. An
intradependent nursing intervention doesn’t
exist.
91. Answer: (D) Evaluation
Rationale: The nursing actions described
constitute evaluation of the expected
outcomes. The finding shows that the expected
outcomes have been achieved. Assessment
consist of a client’s history, physical
examination, and laboratory studies. Analysis
consist of considering assessment information
to derive the appropriate nursing diagnosis.
Implementation is the phase of the
Nursing process where the nurse puts the plan
to care into action.
92. Answer: (B) To observe the lower extremities
Rationale: Elastic stockings are used to promote
venous return. The nurse needs to remove
them once per day to observe the condition of
the skin underneath the stockings. Applying the
stockings increases blood flow to the heart.
Where the stockings are in place, the leg
muscles can still stretch and relax, and the veins
can fill with blood.
93. Answer: (A) Instructing the client to report any
itching, swelling or dyspnea.
Rationale: Because administration of blood or
blood products may cause serious adverse
effects such as allergic reactions, the nurse must
monitor the client for these effects. Signs and
symptoms of life-threatening allergic reaction
include itching, swelling, and dyspnea. Although
the nurse should inform the client of the
duration of the transfusion and should
document its administration, these actions are
less critical to the client’s immediate health. The
nurse should assess vital signs at least hourly
during the transfusion.
94. Answer: (B) Decrease the rate of feedings and
the concentration of the formula.
Rationale: Complaints of abdominal discomfort
and nausea are common in clients receiving
tube feedings. Decreasing the rate of the
feeding and the concentration of the formula
should decrease the client’s discomfort.
Feedings are normally given at room
temperature to minimize abdominal cramping.
To prevent aspiration during feeding, the head
of the client’s bed should be elevated at least
30 degrees. Also, to prevent bacterial growth,
feeding containers should be routinely changed
every 888 to 12 hours.
95. Answer: (D) Roll the vital gently between the
palms.
Rationale: Rolling the vital gently between the
palms produces heat, which help dissolve the
medication. Doing nothing or inverting the vial
wouldn’t help dissolve the medication. Shaking
the vial vigorously could cause the medication
to breakdown, altering its action.
96. Answer: (B) Assist the client to the semi-fowler
position if possible.
Rationale: by assisting the client to semi-fowler
position, the nurse promotes easier chest
expansion, breathing and oxygen intake.
 The nurse should secure elastic band so that the
face mask fits comfortably and snugly rather
than tightly, which could lead to irritation. The
nurse should apply the face mask from the
client’s nose down to the chin- not vice versa.
The nurse should check the connectors
between the oxygen equipment and humidifier
to ensure that they are airtight; loosened
connectors can cause loss of oxygen.
97. Answer: (B) 4 hours
Rationale: A unit of packed RBCs may be giver
over a period of between 1 and 4 hours. It
shouldn’t refuse for longer than 4 hours
because the risk of contamination and sepsis
increases after that time. Discard or return to
the blood bank any blood not given within this
time, according to facility policy.
98. Answer: (B) immediately before administering
the next dose.
Rationale: Measuring the blood drug
concentration helps determine whether the
dosing has achieved the therapeutic goal. For
measurement of the trough, or lowest, blood
level of a drug, the nurse draws a blood sample
immediately before administering the next
dose. Depending on the drug’s duration of
action and half-life, peak blood drug levels
typically are drawn after administering the next
dose.
99. Answer: (A) The nurse can implement
medication orders quickly.
Rationale: A floor stock system enables the
nurse to implement medication orders quickly.
It doesn’t allow for pharmacist input, nor does it
minimize transcription errors or reinforce
accurate calculations.
100. Answer: (C ) Shifting dullness over the
abdomen
Rationale: Shifting dullness over the abdomen
indicates ascites, an abdominal finding. The
other options are normal abdominal findings.
TEST II- Community Health Nursing and Care of the
Mother and Child
1. May arrives at the health care clinic and tells the
nurse that her last menstrual period was 9
weeks ago. She also tells the nurse that a home
pregnancy test was positive but she began to
have mild cramps and is now having moderate
vaginal bleeding. During the physical
examination of the client, the nurse notes that
May has a dilated cervix. The nurse determines
that May is experiencing which type of abortion?
a. Inevitable
b. Incomplete
c. Threatened
d. Septic
2. Nurse Reese is reviewing the record of a
pregnant client for her first prenatal visit. Which
of the following data, if noted on the client’s
record, would alert the nurse that the client is
at risk for a spontaneous abortion?
a. Age of 36 years
b. History of syphilis
c. History of genital herpes
d. History of diabetic mellitus
3. Nurse Hazel is preparing to care for a client who
is newly admitted to the hospital with a possible
diagnosis of ectopic pregnancy. Nurse Hazel
develops a plan of care for the client and
determines that which of the following nursing
actions is the priority?
a. Monitoring weight
b. Assessing for edema
c. Monitoring apical pulse
d. Monitoring temperature
4. Nurse Oliver is teaching a diabetic pregnant
client about nutrition and insulin needs during
pregnancy. The nurse determines that the client
understand dietary and insulin needs if the
client states that the second half of pregnancy
requires:
a. Decreased caloric intake
b. Increased caloric intake
c. Decreased insulin
d. Increase insulin
5. Nurse Michelle is assessing a 24 year old client
with a diagnosis of hydatidiform mole. She is
aware that one of the following us unassociated
with his condition?
a. Excessive fetal activity.
b. Larger than normal uterus for gestational
age
c. Vaginal bleeding
d. Elevated levels of human chorionic
gonadotropin.
6. A pregnant client is receiving magnesium sulfate
for severe pregnancy induced hypertension
(PIH). The clinical findings that would warrant
use of the antidote, calcium gluconate is:
a. Urinary output 90cc in 2 hours.
b. Absent patellar reflexes
c. Rapid respiratory rate above 40/min.
d. Rapid rise in blood pressure
7. During vaginal examination of Janah who is in
labor, the presenting part is at station plus two.
Nurse, correctly interprets it as:
a. Presenting part is 2 cm above the plane of the
ischial spines
b. Biparietal diameter is at the level of the
ischial spines
c. Presenting part in 2 cm below the plane of
the ischial spines.
d. Biparietal diameter is 2 cm above the
ischial spines.
8. A pregnant client is receiving oxytocin (Pitocin)
for induction of labor. A condition that warrant
the nurse in-charge to discontinue I.V infusion
of Pitocin is:
a. Contractions every 1 ½ minutes lasting 70-
80 seconds.
b. Maternal temperature 101.2
c. Early decelerations in the fetal heart rate.
d. Fetal heart rate baseline 140-160 bpm.
9. Calcium gluconate is being administered to a
client with pregnancy induced hypertension
(PIH). A nursing action that must be initiated as
the plan of care throughout injection of the
drug is:
a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR
10. A trial for vaginal delivery after an earlier
caesarian, would likely to be given to a gravida,
who had:
 a. First low transverse caesarian was for active
herpes type 2 infections; vaginal culture at
39 weeks pregnancy was positive
b. First and second caesarian were for
cephalopelvic disproportion
c. First caesarian through a classic incision as a
result of severe fetal distress.
d. First low transverse caesarian was for
breech position. Fetus in this pregnancy is in
a vertex presentation.
11. Nurse Ryan is aware that the best initial
approach when trying to take a crying toddler’s
temperature is:
a. Talk to the mother first and then to the
toddler
b. Bring extra help so it can be done quickly.
c. Encourage the mother to hold the child
d. Ignore the crying and screaming.
Infant looks for it. The nurse is aware that estimated
age of the infant would be:
a. 6 months
b. 4 months
c. 8 months
d. 10 months
16. Which of the following is the most prominent
feature to public health nursing?
a. It involves providing home care to sick
people who are not confined in the
hospital.
b. Services are provided free of charge to
people within the catchments area.
c. The public health nurse functions as part of
a team providing a public health nursing
services.
d. Public health nursing focuses on preventive,
not curative, services.

12. Baby Tina a 3months old infant just had a cleft 17. When the nurse determined whether resources
lip and palate repair. What should the nurse do were maximized in implementing Ligtas Tigdas,
to prevent trauma to operative site? she is evaluating
a. Avoid touching the suture line, even when a. Effectiveness
cleaning b. Efficiency
b. Place the baby in prone position. c. Adequacy
c. Give the baby a pacifier. d. Appropriateness
d. Place the infant’s arms in soft elbow
restraints. 18. Vangie is a new B.S.N. graduate. She wants to
become a Public Health Nurse. Where should
13. Which action should nurse Marian include in she apply?
the care plan for a 2 month old with heart a. Department of Health
failure? b. Provincial Health office
a. Feed the infant when he cries. c. Regional Health Unit
b. Allow the infant to rest before feeding. d. Rural Health Unit
c. Bathe the infant and administer
medications before feeding. 19. Tony is aware the Chairman of the Municipal
d. Weigh and bathe the infant before feeding. Health Board is:
a. Mayor
14. Nurse Hazel is teaching a mother who plans to b. Municipal Health Officer
discontinue breast feeding after 5months. The c. Public Health Nurse
nurse should advise her to include which foods d. Any qualified physician
in her infant’s diet?
a. Skim milk and baby food 20. Myra is the public health nurse in a municipality
b. Whole milk and baby food with a total population of about 20,000. There
c. Iron-rich formula only are 3 rural health midwives among the RHU
d. Iron-rich formula and baby food personnel. How many more midwife items will
the RHU need?
15. Mommy Linda is playing with her infant, who is a. 1
sitting securely alone on the floor of the clinic. b. 2
The mother hides a toy behind her back and the c. 3
d. The RHU does not need any more midwife
item.
21. According to freeman and Heinrich, community
health nursing is a developmental service.
Which of the following best illustrates this
statement?
a. The community health nurse continuously
develops himself personally and
professionally.
b. Health education and community organizing
are necessary in providing community
health services.
c. Community health nursing is intended
primarily for the health promotion and
prevention and treatment of disease
d. The goal of community health nursing is to
provide nursing services to people in their
own places of residence.
22. Nurse Tina is aware that the disease declared
through Presidential Proclamation No. 4 as a
target for eradication in the Philippines is?
a. Poliomyelitis
b. Measles
c. Rabies
d. Neonatal tetanus
23. May knows that the step in community
organizing participation. What is the primary
goal of community organizing?
a. Integration
b. Community organization
c. Community study
d. Core group formation
24. Beth a public health nurse takes an active role
in community participation. What is the primary
goal of community organizing?
a. To educate the people regarding community
health problems
b. To mobilize the people to resolve community
health problems
c. To maximize the community’s resources in
dealing with health problems.
d. To maximize the community’s resources in
dealing with health problems.
25. Tertiary prevention is needed in which stage of
the natural history is disease?
a. Pre-pathogenesis
b. Pathogenesis
c. Prodromal
d. Terminal
26. The nurse is caring for a primigravid client in the
labor and delivery area. Which condition would
place the client at risk for disseminated
intravascular coagulation (DIC)?
a. Intrauterine fetal death.
b. Placenta accreta.
c. Dysfunctional labor
d. Premature rupture of the membranes
27. A fullterm client is in labor. Nurse Betty is aware
that the fetal heart rate would be:
a. 80 to 100 beats/minute
b. 100 to 120 beats/minute
c. 120 to 160 beats/minute
d. 160 to 180 beats/minute
28. The skin in the diaper area of a 7 month old
infant is excoriated and red. Nurse Hazel should
instruct the mother to:
a. Change the diaper more often.
b. Apply talc powder with diaper changes.
c. Wash the area vigorously with each diaper
change.
d. Decrease the infant’s fluid intake to
decrease saturating diapers.
29. Nurse Carla knows that the common cardiac
anomalies in the children with Down Syndrome
(trisomy 21) is:
a. Atrial septal defect
b. Pulmonic stenosis
c. Ventricular septal defect
d. Endocardial cushion defect
30. Malou was diagnosed with severe preeclampsia
is now receiving I.V. magnesium sulfate. The
adverse effects associated with magnesium
sulfate is:
a. Anemia
b. Decreased urine output
c. Hyperreflexia
d. Increased respiratory rate
31. A 23 year old client is having her menstrual
period every 2 weeks that last for 1 week. This
type of menstrual patter is best define by:
a. Menorrhagia
b. Metrorrhagia
c. Dyspareunia
d. Amenorrhea
32. Jannah is admitted to the labor and delivery
unit. The critical laboratory result for this client
would be:
a. Oxygen saturation
b. Iron binding capacity
c. Blood typing
d. Serum calcium
33. Nurse Gina is aware that the most common
condition found during the second-trimester of
pregnancy is:
a. Metabolic alkalosis
b. Respiratory acidosis
c. Mastitis
d. Physiologic anemia
34. Nurse Lynette is working in the triage area of an
emergency department. She sees that several
pediatric clients arrive simultaneously. The
client who needs to be treated first is:
a. A crying 5 year old child with a laceration on
his scalp.
b. A 4 year old child with barking coughs and
flushed appearance.
c. A 3 year old child with Down Syndrome who
is pale and asleep in his mother’s arms
d. A 2 year old infant with stridorous breath
sounds, sitting up in his mother’s arms and
drooling.
35. Maureen in her third trimester arrives at the
emergency room with painless vaginal bleeding.
Which of the following conditions is suspected?
a. Placenta previa
b. Abruption placentae
c. Premature labor
d. Sexually transmitted disease
36. A young child named Richard is suspected of
having pinworms. The community nurse collects
a stool specimen to confirm the diagnosis. The
nurse should schedule the collection of this
specimen for:
a. Just before bedtime
b. After the child has been bathe
c. Any time during the day
d. Early in the morning
37. In doing a child’s admission assessment, Nurse
Betty should be alert to note which signs or
symptoms of chronic lead poisoning?
a. Irritability and seizures
b. Dehydration and diarrhea
c. Bradycardia and hypotension
d. Petechiae and hematuria
38. To evaluate a woman understands about the
use of diaphragm for family planning. Nurse
Trish asks her to explain how she will use the
appliance. Which response indicates a need for
further health teaching?
a. “I should check the diaphragm carefully for
holes every time I sue it”
b. “I may need a different size of diaphragm if I
gain or lose weight more than 20 pounds”
c. “The diaphragm must be left in place for
atleast 6 hours after intercourse”
d. “I really need to use the diaphragm and jelly
most during the middle of my menstrual
cycle.”
39. Hypoxia is a common complication of
laryngotracheobronchitis. Nurse Oliver should
frequently asses a child with
laryngotracheobronchitis for:
a. Drooling
b. Muffled voice
c. Restlessness
d. Low-grade fever
40. How should Nurse Michelle guide a child who is
blind to walk to the playroom?
a. Without touching the child, talk
continuously as the child walks down the
hall.
b. Walk one step ahead, with the child’s hand
on the nurse’s elbow.
c. Walk slightly behind, gently guiding the
child forward.
d. Walk next to the child, holding the child’s
hand.
41. When assessing newborn diagnosed with
ductus arteriosus, Nurse Olivia should expect
that the child most likely would have an:
a. Loud, machinery-like murmur.
b. Bluish color to the lips.
c. Decreased BP reading in the upper
extremities.
d. Increased BP reading in the upper
extremities.
42. The reason nurse May keeps the neonate in a
neutral thermal environment is that when a

newborn becomes too cool, the neonate requires
a. Less oxygen, and the newborn’s metabolic rate
increases.
b. More oxygen, and the newborn’s metabolic
rate decreases.
c. More oxygen, and the newborn’s metabolic
rate increases.
d. Less oxygen, and the newborn’s metabolic rate
decreases.
43. Before adding potassium to an infant’s I.V. line,
Nurse Ron must be sure to assess whether this
infant has:
a. Stable blood pressure
b. Patant frontanelles
c. Moro’s reflex
d. Voided
44. Nurse Carla should know that the most
common causative factor or dermatitis in
infants and younger children is:
a. Baby oil
b. Baby lotion
c. Laundry detergent
d. Powder with cornstarch
45. During tube feeding, how far above an infant’s
stomach should the nurse hold the syringe with
formula?
a. 6 inches
b. 12 inches
c. 18 inches
d. 24 inches
46. In a mother’s class, Nurse Lynnete discussed
childhood diseases such as chicken pox. Which
of the following statements about chicken pox
is correct?
a. The older one gets, the more susceptible he
becomes to the complications of chicken
pox.
b. A single attack of chicken pox will prevent
future episode, including conditions such as
shingles.
c. To prevent an outbreak in the community,
quarantine may be imposed by health
authorities.
d. Chicken pox vaccine is best given when
there is impending outbreak in the
community.
47. Barangay Pinoy had an outbreak of German
measles. To prevent congenital rubella, what is
the BEST advice that you can give to women in
the first trimester of pregnancy in the barangay
Pinoy?
a. Advise them on the signs of German
measles.
b. Avoid crowded places, such as markets and
movie houses.
c. Consult at the health center where rubella
vaccine may be given
d. Consult a physician who may give them
rubella immunoglobulin.
48. Myrna a public health nurse knows that to
determine possible sources of sexually
transmitted infections, the BEST method that
may be undertaken is:
a. Contact tracing
b. Community survey
c. Mass screening tests
d. Interview of suspects
49. A 33-year old female client came for
consultation at the health center with the chief
complaint of fever for a week. Accompanying
symptoms were muscle pains and body malaise.
A week after the start of fever, the client noted
yellowish discoloration of his sclera. History
showed that he waded in flood waters about 2
weeks before the onset of symptoms. Based on
her history, which disease condition will you
suspect?
a. Hepatitis A
b. Hepatitis B
c. Tetanus
d. Leptospirosis
50. Mickey a 3-year old client was brought to the
health center with chief complaint of severe
diarrhea and the passage of “rice water” stools.
The client is most probably suffering from which
condition?
a. Giardiasis
b. Cholera
c. Amebiasis
d. Dysentery
51. The most prevalent form of meningitis among
children aged 2 months to 3 years is caused by
which microorganism?
a. Hemophilus influenzea
b. Morbillivirus
 c. Streptococcus pnuemoniae
d. Neisseria meningitides
52. The student nurse is aware that the
pathognomonic sign of measles is Koplik’s spot
and you may see Koplik’s spot by inspecting the:
a. Nasal mucosa
b. Buccal mucosa
c. Skin on the abdomen
d. Skin on neck
53. Angel was diagnosed as having Dengue fever.
You will say that there is slow capillary refill
when the color of the nailbed that you pressed
does not return within how many seconds?
a. 3 seconds
b. 6 seconds
c. 9 seconds
d. 10 seconds
54. In Integrated Management of Childhood Illness,
the nurse is aware that the severe conditions
generally require urgent referral to a hospital.
Which of the following severe conditions DOES
NOT always require urgent referral to a hospital?
a. Mastoiditis
b. Severe dehydration
c. Severe pneumonia
d. Sever febrile disease
55. Myrna a public health nurse is will conduct
outreach immunization in a barangay Masay
with a population of about 1500. The estimated
number of infants in the barangay would be:
a. 40 infants
b. 50 infants
c. 55 infants
d. 65 infants
56. The community nurse is aware that the
biological used in Expanded Program on
Immunization (EPI) should NOT be stored in the
freezer?
a. DPT
b. Oral polio vaccine
c. Measles vaccine
d. MMR
57. It is the most effective way of controlling
schistosomiasis in an endemic area?
a. Use of molluscicides
b. Building of foot bridges
c. Proper use of sanitary tolilets
d. Use of p[protective footwear, such as
rubber boots
58. Several clients is newly admitted and diagnosed
with leprosy. Which of the following clients
should be classified as a case of multibacillary
leprosy?
a. 3 skin lesion, negative slit skin smear
b. 3 skin lesions, positive slit skin smear
c. 5 skin lesions, negative slit skin smear
d. 5 skin lesions, positive slit skin smear
59. Nurses are aware that diagnosis of leprosy is
highly dependent on recognition of symptoms.
Which of the following Is an early sign of
leprosy?
a. Mascular lesions
b. Inability to close eyelids
c. Thickened painful nerves
d. Sinking of the nosebridge
60. Marie brought her 10 month old infant for
consultation because of fever, started 4 days
prior to consultation. In determining malaria
risk, what will you do?
a. Perform a tourniquet test.
b. Ask where the family resides
c. Get a specimen for blood smear.
d. Ask if the fever is present every day.
61. Susie brought her 4 years old daughter to the
RHU because of cough and colds. Following the
IMCI assessment guide, which of the following is
a danger sign that indicates the need for urgent
referral to a hospital?
a. Inability to drink
b. High grade fever
c. Signs of severe dehydration
d. Cough for more than 30 days
62. Jimmy a 2-year old child revealed “baggy
pants”. As a nurse, using the IMCI guidelines,
how will you manage jimmy?
a. Refer the child urgently to a hospital for
confinement.
b. Coordinate with the social worker to enroll
the child in a feeding program.
c. Make a teaching plan for the mother,
focusing on the menu planning for her child.
d. Assess and treat the child for health
problems like infections and intestinal
parasitism.
63. Gina is using Oresol in the management of
diarrhea of her 3-year old child. She asked you
what to do if her child vomits. As a nurse you
will tell her to:
a. Bring the child to the nearest hospital for
further assessment.
b. Bring the child to the health center for
intravenous fluid therapy.
c. Bring the child to the health center for
assessment by the physician.
d. Let the child rest for 10 minutes then
continue giving Oresol more slowly.
64. Nikki a 5-month old infant was brought by his
mother to the health center because of diarrhea
for 4 to 5 times a day. Her skin goes back slowly
after a skin pinch and her eyes are sunken.
Using the IMCI guidelines, you will classify this
infant in which category?
a. No signs of dehydration
b. Some dehydration
c. Severe dehydration
d. The data is insufficient.
65. Chris a 4-month old infant was brought by her
mother to the health center because of cough.
His respiratory rate is 42/minute. Using the
Integrated Management of Child Illness (IMCI)
guidelines of assessment, his breathing is
considered as:
a. Fast
b. Slow
c. normal
d. insignificant
66. Mylene had just received her 4th dose of tetanus
toxoid. She is aware that her baby will have
protection against tetanus for
a. 1 year
b. 3 years
c. 5 years
d. Lifetime
67. Nurse Ron is aware that unused BCG should be
discarded after how many hours of
reconstitution?
a. 2 hours
b. 4 hours
c. 8 hours
d. At the end of the day
68. The nurse explains to a breastfeeding mother
that breast milk is sufficient for all the baby’s
nutrient need only up to:
a. 5 months
b. 6 months
c. 1 year
d. 2 years
69. Nurse Ron is aware that the gestational age of a
conceptus that is considered viable (able to live
outside the womb) is:
a. 8 weeks
b. 12 weeks
c. 24 weeks
d. 32 weeks
70. When teaching parents of a neonate the proper
position for the neonate’s sleep, the nurse
Patricia stresses the importance of placing the
neonate on his back to reduce the risk of which
of the following?
a. Aspiration
b. Sudden infant death syndrome (SIDS)
c. Suffocation
d. Gastroesophageal reflux (GER)
71. Which finding might be seen in baby James a
neonate suspected of having infection?
a. Flushed cheeks
b. Increased temperature
c. Decreased temperature
d. Increased activity level
72. Baby jenny who is small-for-gestation is at
increased risk during the transitional period for
which complication?
a. Anemia probably due to chronic fetal
hyposia
b. Hyperthermia due to decreased glycogen
stores
c. Hyperglycemia due to decreased glycogen
stores
d. Polycythemia probably due to chronic fetal
hypoxia
73. Marjorie has just given birth at 42 weeks’
gestation. When the nurse assessing the
neonate, which physical finding is expected?
a. A sleepy, lethargic baby
b. Lanugo covering the body
c. Desquamation of the epidermis
d. Vernix caseosa covering the body
74. After reviewing the Myrna’s maternal history of
magnesium sulfate during labor, which
condition would nurse Richard anticipate as a
potential problem in the neonate?
a. Hypoglycemia
b. Jitteriness
c. Respiratory depression
d. Tachycardia
75. Which symptom would indicate the Baby
Alexandra was adapting appropriately to extra-
uterine life without difficulty?
a. Nasal flaring
b. Light audible grunting
c. Keep the cord dry and open air
d. Wash the cord with soap and water each
day during a tub bath
76. When teaching umbilical cord care for Jennifer
a new mother, the nurse Jenny would include
which information?
a. Apply peroxide to end the cord with each
diaper change
b. Cover the cord with petroleum jelly after
bathing
c. Keep the cord dry and open to air
d. Wash the cord with soap and water each
day during a tub bath.
77. Nurse John is performing an assessment on a
neonate. Which of the following findings is
considered common in the healthy neonate?
a. Simian crease
b. Conjunctival hemorrhage
c. Cystic hygroma
d. Bulging fontanelle
78. Dr. Esteves decides to artificially rupture the
membranes of a mother who is on labor.
Following this procedure, the nurse hazel
checks the fetal heart tones for which of the
following reasons?
a. To determine fetal well-being
b. To assests for prolapsed cord
c. To assess fetal position
d. To prepare for an imminent delivery.
79. Which of the following would be least likely to
indicate anticipated bonding behaviors by new
parents?
a. The parent’s willingness to touch and hold
the new born.
b. The parent’s expression if interest about
the size of the new born.
c. The parents’ indication that they want to
see the newborn.
d. The parents’ interaction with each other.
80. Following a precipitous delivery, examination of
the client’s vagina reveals a fourth-degree
laceration. Which of the following would be
contraindicated when caring for this client?
a. Applying cold to limit edema during the first
12 to 24 hours.
b. Instructing the client to use two or more
peripads to cushion the area.
c. Instructing the client on the use of sitz bath
if ordered.
d. Instructing the client about the importance
of perineal (kegel) exercise.
81. A pregnant woman accompanied by her
husband, seeks and admission to the labor and
delivery area. She states that she’s in labor and
says she attended the facility clinic for prenatal
care. Which question should the nurse Oliver
ask her first?
a. “Do you have any chronic illness?”
b. “Do you have any allergies?”
c. “What is your expected due date?”
d. “Who will be with you during labor?”
82. A neonate begins to gag and turns a dusky
color, what should the nurse do first?
a. Calm the neonate
b. Notify the physician
c. Provide oxygen via face mask as ordered
d. Aspirate the neonate’s nose and mouth
with a bulb syringe.
83. When a client states that her “water broke,”
which of the following actions would be
inappropriate for the nurse to do?
a. Observing the pooling of straw-colored
fluid.
b. Checking vaginal discharged with nitrazine
paper
c. Conducting a bedside ultrasound for an
amniotic fluid index.
d. Observing for flakes of vernix in the vaginal
discharge.
84. A baby girl is born 8 weeks premature. At birth
she has no spontaneous respiration but is
successfully resuscitated. With several hours
she develops respiratory grunting, cyanosis,
tachypnea,nasal falring, and retractions. She’s
diagnosed with respiratory distress syndrome,
intubated, and placed on a ventilator. Which
nursing action should be include in the baby’s
plan of care to prevent retinopathy of
prematurity?
a. Cover his eyes while receiving oxygen.
b. Keep her body temperature low.
c. Monitor partial pressure of oxygen (pao2)
levels.
d. Humidify the oxygen.

85. Which of the following is normal newborn

calorie intake?
a. 110 to 130 calories per kg.
b. 30 to 40 calories per lb of body weight.
c. Atleast 2 ml per feeding
d. 90 to 1oo calories per kg.

86. Nurse John is knowledgeable that usually

individual twins will grow appropriately and at
the same rate as singletons until how many
weeks?
a. 16 to 18 weeks
b. 18 to 22 weeks
c. 30 to 32 weeks
d. 38 to 40 weeks
87. Which of the following classification applies to
monozygotic twins for whom the cleavage of
the fertilized ovum occurs more than 13 days
after fertilization?
a. Conjoined twins
b. Diamniotic dichorionic twins
c. Diamniotic monochorionic twins
d. Monoamniotic monochorionic twins

88.