* NLE * NCLEX * CGFNS * HAAD * PROMETRICS * DHA * MIDWIFERY * LET * RAD TECH * CRIMINOLOGY * DENTISTRY * PHARMACY *
RECALLS 1 EXAM
July 2021 Philippine Nurse Licensure Examination Review
NAME: ZAMORA, MARIA KARINA D.
Nursing Practice I
Situation 1- Quality documentation and reporting
are necessary to enhance efficient,
individualization patient care. Nurse Gigi is
assigned to Maria who is diagnosed with diabetes.
1. Nurse Gigi is aware that a record should contain
descriptive, objective observations about what
the nurse sees, hears, feels and smells. The
following describes what a record ought to be:
A. Maria is uncooperative as manifested by
her refusal to take a bath – “is” –
diniktahan ; should be “appears”
B. Maria appears depressed – “is” –
diniktahan ; should be “appears”
C. Maria is anxious as manifested by her
tossing in bed and disarrayed beddings
D. Patient states, “I wish to end my life”
– as verbalized, walang halong judgment
2. When documenting the intake-output of Maria,
Nurse Gigi should remember that she must use
precise measurements to ensure accuracy.
Which of the following reflects accuracy?
1. Maria drank an adequate amount of fluid
during the shift.
2. Maria‟s intake during the shift is 360 ml.
3. Maria‟s wound is 3 cm in length.
4. Maria‟s wound is large and gaping.
A. 1 and 3
B. 2 and 3 – should be specific
or has measurement
C. 3 and 4
D. 1 and 4
3. Another guideline for good documentation and
reporting that Nurse Gigi recalls is about
completion. When nurse Gigi administers
medications, the following should be included,
EXCEPT:
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A. Any preliminary observations – not
any, put what is only actually related
B. Preliminary observations
C. Patient‟s response
D. Nursing measure taken for negative
response
4. Nurse Gigi is making a discharge plan. The items
she needs to document and report should
include, EXCEPT:
A. Needs for referrals
B. Nurses‟ observations
C. Client‟s involvement in the care plan
D. Patient‟s goals or expected outcomes
– this is in nsg process, discharge plan is
for home care
5. Nurses are ethically obligated to information
about client‟s illness and treatment confidential.
The person who has the legitimate access to the
patient‟s record is the .
A. Husband
C. attending doctor – found in magna carta
of pt’s rights and obligations
B. Primary nurse
D. patient
Situation 2- Nurse Ben is assigned in the
outpatient department. He admits Susing, 25
years old, who is complaining of moderate to
severe abdominal pain over the right iliac region
for the last 2 days. This is accompanied by
frequent urination.
6. The FIRST STEP that nurse Ben should do is to
A. Percuss the abdomen
B. Get the vital signs
C. Palpate the right iliac region
D. Interview Susing
7. An important added data that Nurse Ben should
have if he is thinking of a urinary problem is
A. Presence of blood in the urine
B. Presence of pain on urination
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 C. When the pain appears whether at the start
or end of urination
D. Frequency, amount and burning sensation
on urination
8. An important added data that nurse ben should
ask Susing, should we consider the presence of
a gynecological problem is . B. RA 7164 – old law D. RA 9173
A. Date of menarche – if risk for Cervical CA
B. Date of last menstrual period
C. Her age and civil status – not specific to
gynecology
D. Occupation – not specific to gynecology
9. An important added data that Nurse Ben should
ask Susing, should we consider the existence of
a surgical problem is . C. Nursing Education
A. Fever – infection C. constipation
B. Vomiting D. character of pain
10. There are two important laboratory examinations
that could validate Nurse Ben‟s presumptions on
the case which are . clients?
A. CBC and stool examination
B. Urinalysis and CBC – indicates bleeding
C. Stool and urine examinations
D. Urinalysis and vaginal examinations
Situation 3- Nurse Leah has just passed the
Nursing Licensure Examination. She needs to
refresh herself regarding the law that governs the
practice of nursing in the Philippines.
11. By virtue of section 16 of the Philippine Nursing
Law, the first step she needs to do after passing
the Nursing Licensure Examination is to .
A. Take the oath of the profession before
the Professional Regulatory Board of
Nursing – no license if no oath taking
B. Apply for the Certificate of
Registration/Professional License\
C. Get an official copy of her board rating
from the PRC office
D. Apply for a Professional Identification Card
12. Which government body has the power to
revoke or suspend Leah‟s certificate of
registration/professional license, should she
commit unprofessional and unethical conduct in
the future?
A. Professional Regulatory Board of
Nursing – Quasi Judicial Power ; revoke:
confiscated ; suspended: hindi lang muna
pwede mag-work pero na sayo pa rin license
mo
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B. Philippine Nurses Association
C. Professional Regulation Commission
D. Commission on Higher Education
13. What Nursing Republic Act should Nurse Leah
refer too?
A. RA 9371 C. RA 7664
14. Since she needs to work in a hospital to get
hospital experience, which part of the Nursing
Law should Leah focus for her safe practice as a
novice nurse?
A. Scope of Nursing Practice – prevent
malpractice
B. Nursing Research
D. Nursing Personal System
15. When Leah eventually gets employed in the
hospital, she will initially be required to utilize
which of the following in rendering care to her
A. Traditional and innovative approaches
B. Therapeutic use of self
C. Health teachings
D. Nursing process
Situation 4- Alex, 15 years old, has been
complaining of sleep disturbance for the past 3
weeks. He related that he feels weak and has no
vigor in doing his school work. He is brought to
hospital B for specialization.
16. As his attending nurse, what will be the best
question to ask in order to find out Alex‟s cause
of sleep disturbance?
A. “Could you tell me what you feel about
school work?”
B. “Is there something or anyone who is
bothering you in school?”
C. “Could you share with me any major
problems that you have encountered in
school?”
D. “What is bothering you in school?” –
broad question, para makuha yung concern
niya
17. The nursing diagnosis appropriate for Alex is
A. Insomnia
B. Sleep deprivation related to problems in
school
C. Disturbed sleep pattern related to
school problem
D. Readiness for enhanced sleep
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 18. In order to help Alex go to sleep, what simple 6. Cover with thick blankets to
and inexpensive nursing intervention can the stimulate sweating
nurse provide considering the type of room Alex A. 1, 3, 5
is confined in? B. 1, 5, 6
A. Room should be well ventilated C. 2, 4, 6
B. Light should be dimmed at specific D. 2, 3, 4
time – part of sleep hygiene – things you 23. Client Jimmy wishes to know his present
have to do to have better sleep temperature in Farenheit. Nurse Yana‟s answer
C. Putting on the air conditioning unit is which of the following?
D. Putting on dark-colored curtains A. 102.2F
19. If Alex cannot sleep immediately, which of the B. 101.3F
following can be provided by the nurse? A C. 100.4F
A. glass of warm milk D. 99.5F : Celsius x 9 / 5 + 32
B. A bedside story 24. Client Jimmy complains of severe chilly
C. a sleeping pill sensation. What regulatory function of the
D. a warm bed bath hypothalamus describes his reaction?
20. In terms of nursing care, the BEST help that the A. heat production - thermogenesis
nurse can do is to B. heat promotion
A. Avoid giving round the clock medications C. heat adaptation
B. Refrain from clutter at the nurse‟s station D. heat conversation
C. Omit vital sign tasking during the sleeping 25. After client Jimmy‟s body temperature stabilized
time of Alex to normal, he began to complain of feeling hot
D. Tone down nurse’s voice and finds difficulty of adjusting to the climate
two days after. What is the APPROPRIATE
Situation 5- Client Jimmy, 66 years old, a answer to nurse Yana?
foreigner, was admitted to the hospital due to A. “Foreigners cannot adjust to hot
high fever for five days. His temperature on temperatures”
admission was 37.5 „C with flushed and warm to B. “People from cold regions have less brown
touch skin. Nurse Jana, who is his attending adipocytes”
nurse, gave him a cool sponge bath. C. “Those who lived in cold places have lower
metabolic rate than those who live in tropical
21. Cool sponge bath is an independent intervention region”
of nurse Jana aimed at D. “People from cold regions have more
A. Alleviating discomforts of client Jimmy brown adipocytes”
B. Generalizing full sponge bath care to client 26. Nurse Susan develops patient safety goals. What
Jimmy get hospital admission policy nursing goal is APPROPRIATE for safety
C. Diverting the temperature of client environment? Select all that apply.
Jimmy – conduction (solid to solid) – from 1. Reduce the risk for patient harm
person to sponge resulting from falls
D. Normalizing the vital signs of client Jimmy 2. Create a clean, orderly environment
22. The independent nursing intervention to reduce of patient
temperature of client Jimmy include which of the 3. Prevent high concentration drug
following? Select all that apply. errors
1. Monitor temperature regularly 4. Develop clean and simple signage for
2. Offer only cold drinking water directions
frequently A. 1, 2 & 3
3. Provide tepid sponge bath B. 1, 2 & 4
4. Administer Paracetamol every 4 hours C. 2, 3 & 4
5. Encourage wearing loose cotton D. 3 & 4
clothing

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 27. Nurse Susan should prevent or reduce infectious
agents PRIMARILY through the following
practices. Select all that apply.
1. Clean the room with antiseptic
solutions – antiseptic is for living,
disinfectant for non-living
2. Proper garbage disposal
3. Mandatory hand washing upon entry
to hospital
4. Improve safety administration of
medicines
A. 1, 2 & 3
B. 2, 3 & 4
C. 1 & 3
D. 1 & 4
28. Nurse Susan must comply with the policies of
health care facilities regarding isolation
precautions. The BASIC precaution in the
hospital is _______________________.
A. posting of signs of silence
B. limited visitors who are within the patient’s
age
C. private room placement
D. strict utilization of personal things
29. Nurse Susan includes air-borne precautions in
addition to Standard Precautions to be observed
at all times. These include, EXCEPT _______.
A. positioning and draping of patients
B. hand washing techniques
C. wearing of masks and gloves
D. limited patient transport
30. To protect spreading infection from one patient
to another, Nurse Susan must not forget to wash
her hands _________.
A. before and after making rounds and
endorsement of all clients
B. before and after performing procedures
and in between patient care
C. twice before and after all the procedures are
done to all the clients
D. apply alcohol before and after performing
procedures to all patients
Situation 6 - Client Alan, 33 years old, is known
for his asthma attacks. His asthma attacks
commonly occur at the change of climate in his
hometown. He was just wearing a “sando”
{sleeveless shirt} and short pants when he was
admitted to the hospital.
31. What will be Nurse Chard‟s PRIORITY
INTERVENTION?
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A. Put him near the electric fan to assist him in
breathing
B. Ask him what triggered his attack this time
C. Place him in a comfortable
environment
D. Put him near the nurse‟s station so that he
could be assessed often
32. What particular important vital sign should Nurse
Chard monitor and report to the physician?
A. Respiratory rate
B. blood pressure
C. Cardiac rate
D. Pulse rate
33. Client Alan knows that he will be given
decongestant through inhalation. What will be
the instruction of Nurse Chard? That he should
breathe and that the noozle of the NEBULIZER
should be MAINLY near his _____________.
A. Nose only
B. Face
C. Mouth only
D. Nose and mouth
34. Respiratory function is altered in clients with
asthmatic attack. Which of the following is the
cause of this alteration that Nurse Chard should
understand in order for him to make a good
nursing care plan?
A. Narrowing of the upper air passages –
cause of asthma is bronchospasm or
bronchoconstriction
B. Increased airway resistance
C. Inadequate surfactant reaction
D. Paradoxical movements of the chest wall
35. An important health teaching that Nurse Chard
must give before client Alan’s discharge is
________.
A. To avoid “sando” and shorts, if the weather
is cold
B. to use attire he is presently wearing only
during summer time
C. to watch out for climate change and
unnecessary exposure to elements of
the environment that trigger his
asthma attacks – avoid triggers
D. to be careful always because constant
asthma attacks can trigger complication and
death
Situation 7 - Andrea underwent mastectomy of
her right breast. After surgery, she was instructed
to have range of motion exercises
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 36. What is the main purpose of this type of exercise B. health care providers
for Andrea? It is to ________________. C. zumba
A. prevent pain on the site of operation D. wellness
B. prevent contracture deformity of the 42. Which is the dependent variable?
muscle of the right arm and chest A. health provider
C. improve general circulation B. wellness
D. improve breathing C. exercise
*if elevate affected arm: prevent lymphedema D. effects
37. The isotonic exercise such as Range of Motion 43. The research design of the study is
exercises are those that are initiated by the ____________
________. A. quasi-experimental
A. patient B. experimental – if “effect” usually quasi
B. physician or exp, however it was not stated that there
C. nurse was no randomization
D. relatives of the patient C. qualitative
*isometric – ex: Kegel’s ; hindi gumagalaw D. descriptive
ang joints 44. In the cause and effect relationship, which is the
38. Andrea needs some physical activity after independent variable?
operation MAINLY to improve healing of which A. Population
parts of the body? Select all that apply. B. Effect
1. Skeletal 2. Integumentary C. Relationship
3. Respiratory 4. Muscular D. Cause
A. 1 only 45. Which of the following is the appropriate
B. 4 only operational definition of wellness? Wellness is
C. 1 and 4 the state of well-being of the participants in
D. 2 and 3 Zumba on their ____________
39. A good example of isotonic exercise for Andrea’s A. social stability
arm are the following, EXCEPT ___________ B. spiritual growth
A. combing the hair C. physical health
B. brushing teeth D. mental balance
C. dressing up
D. closing and opening hand SITUATION 9 -Some teachers in an elementary
40. When doing a range of motion exercise, it is school reported that a high proportion of
important for the nurse to observe Andrea’s children‟s packed lunches contain hotdog or
________. „tocino‟, sweetened drinks and potato chips.
A. Temperature School Nurse Vivian plans to conduct health
B. Color of the skin – circulation education classes among parents on “How to
C. Blood pressure make healthy lunches and why it is important”
D. Respiratory rate
46. For this activity, Nurse Vivian considers using the
behavior change approach to encourage parents
Situation 8 - One of the thrusts of management is to adopt healthy behaviors that will lead to
to encourage more nurses to do research in order improve health. This approach is popular
to contribute to the improvement of the nursing because of the following reasons. Select all that
practice in their work setting. A group of nurses apply.
decided to conduct a study entitled, “Effects of
1. Views health as property of
Zumba as a form of exercise in promoting
individuals
wellness among the health providers in the
2. Sees people as having the
hospital setting.”
capacity to change their lifestyle
41. Which of the following is the independent 3. Assumes that if people do not act
on their health, they suffer the
variable in this study? A. Exercise
consequences
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 4. Does not consider the social and 51. The nursing process facilitates an understanding
environmental factors in which of the scope of challenges inherent in nursing
people live care of clients at risk for ___________ EXCEPT:
A. 1, 2, 3 A. Infection
B. 2, 3, 4 B. Suicide
C. 3 and 4 C. Restraint – an intervention to promote
D. 1 and 2 safety
47. Nurse Vivian finally plans to conduct parent’s D. Injury
classes using the educational approach. This 52. The clients at risk require re-assessment of their
approach is intended to _____. Select all that status on ____________
apply. A. shift basis
1. Provide information B. daily basis
2. Develop the necessary skills C. as necessary basis
3. Provide change to a particular D. injury
direction 53. When a patient is placed in a bed rest, the nurse
4. Help people make an impulsive choice must watch which part of the body most?
A. 1 and 2 A. Liver
B. 1, 2, and 3 B. Head
C. 2, 3, and 4 C. Legs
D. 2 and 3 D. Skin – bed sore
48. To start the health education class and to get 54. The Nursing Practice Standards which Nurse
the parent’s active participation, which of the Amy must let her staff follow includes, EXCEPT
following is the BEST question to ask? ___________.
A. “Did you cook your child‟s lunch today?” A. use a multidisciplinary approval to
B. “Who among you have kids who are enhance client safety as indicated – no
underweight?” need for approval
C. “Can you explain the “Plate Method”?” B. implement emergency measures during fires
D. “What food do you usually prepare and disasters
to your kids lunch?” – asking for personal C. risk elements should not be modified
experience D. use infection control practices that prevent
49. The educational approach to health education or control transmission of the pathogens
states that learning involves three aspects.
Which of the following is NOT included? SITUATION 11 - Applying therapeutic
A. Cognitive – knowledge communication skills is vital in the nurse-client
B. Affective – attitude relationship.
C. Psychomotor – skills
D. Behavioral 55. Which of the following is the BEST SEQUENCE of
50. Since your participants are adult parents, which communication techniques to use during an
of the following are appropriate strategies? assessment interview? Begin with
Select all that apply. ____________.
1. Role playing – for children A. giving a broad opening and move to asking
2. Group sharing focused questions
3. Demonstration B. Giving information and move to asking
4. Return demonstration focused questions – orient pt first
A. 2 and 3 C. 1, 2, 4 C. Asking focused questions and close-ended
questions
B. 2 and 4 D. 1, 2, 3
D. providing information and proceed to stating
observations
SITUATION 10 - Safety in any health agency is a
56. You are caring for Malou, sixteen years old,
must. Nurse Amy wants this to maintain in her
suffering from acute leukemia. You want to
unit.
actively listen to her concerns and understand

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RECALLS 1 EXAM Page 6
 her meanings. You know that active listening is
used to _______.
A. Treat patient‟s medical problems
B. Recognize the issue that is most
important to the client – we listen to
understand
C. Help the patient become dependent to the
nurse in addressing his concerns
D. Make conclusions regarding client‟s
perception
57. You ask your newly admitted patient, “What can
we do to help you?” You know that this
openended question will _____________.
A. result in specific information from the patient
B. allow patient to elaborate on his
response – ventilate anything under the
sun
C. allow patient to briefly answer question
D. put the patient at ease
58. As you listen to a patient, you need to provide
feedback that is __________.
A. behavior-focused and evaluative
B. well-timed and general
C. general and content-focused
D. well-timed and content-focused
59. Which of the following statements is TRUE in
relation to the use of humor?
A. Humor should focus on the client’s humanity
B. Humor is used to build rapport
C. Constant use of humor can be healing
D. Laughter increases neurotransmitters
SITUATION 11 -Mr. BC is confines in the ICU in a
provincial hospital for some complications of his
type II diabetes. He is edematous and complained
of severe chest pain. His vital signs are:
BP160/98, temperature 37.2C; PR- 90 bpm; RR-
30 bpm
60. The order of the physician is for immediate
intubation. For the priority equipment, supplies
and material to be used for the procedure, the
nurse should collaborate with the _________.
A. operating room
B. central supply unit
C. anesthesia department
D. emergency department
61. Morning care had to be done by the ________
A. nursing student
B. all the options
C. staff nurse
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D. nursing aide
62. In as much as you have not been trained in
initiating Intravenous infusion, who among the
following cannot also do it?
A. charge nurse
B. staff nurse
C. nursing aide
D. physician
63. Turning Mr. BC every two hours would be
difficult if you do it alone. In order to keep the
patient safe, the most number of nurse who can
team up with you will be ____________
A. Four
B. One
C. Two
D. Three – chest area, gitna, then feet
64. If Mr. BC would be for dialysis and you need to
bring him to the dialysis unit, who among the
following, could be the best to help you wheel
him to the area? A ______________.
A. institutional worker – or utility worker
B. member of the family
C. physician
D. nurse aide
SITUATION 12- Terry, 15 years old, and a
highschool student, visited the clinic because she
suspects that she is pregnant. Her pregnancy is
confirmed by the school physician. Terry
requested nurse Zenaida not to tell her parents
about her being pregnant. She also expressed
desire to terminate her pregnancy.
65. Which of the following ethical concepts apply to
patient Terry‟s case?
A. Bioethics
B. Deontology – means lang tinitignan ; tama
ba yung mean ; walang pakialam sa
consequence basta action tama ; kahit hindi
maganda consequence basta tama action ok
sakin yan
C. Teleology – tinitignan yung consequences,
whatever action mali man o tama, basta
consequence naging maganda ok sakin yan
D. Intuitionism
66. Nurse Zenaida should be guided by the steps in
helping Terry make an ethical decision.
Sequence the steps below.
1. Gather data
2. Make decision
3. Identify and clarify the ethical
problem
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 4. Act and assess the outcomes of
decisions
5. Identify options or alternatives
A. 3, 1, 5, 2 & 4
B. 1, 5, 2, 4 & 3 C.
1, 3, 5, 2 & 4
D. 2, 4, 1, 3 & 5
67. The INITIAL advice of nurse Zenaida to patient
Terry is which of the following?
A. Terry will inform her teacher about her
condition and to request the teacher to tell
her parents.
B. Terry will request the doctor to inform the
parents
C. Terry will choose a significant other close to
the parents to be the one to relay about her
pregnancy
D. Advise her that as a minor, her parents
should be duly informed about her
pregnancy – minor pa siya, kailangan alam
ng parents niya
68. Terry analyzed the advice of Nurse Zenaida and
realized the value of life and family. This attitude
of realization is termed as _____________
A. Justice
B. Ethics
C. Autonomy
D. Values clarification
69. Patient Terry’s decision regarding her pregnancy
is termed as _____________
A. Autonomy
B. Justice
C. Veracity
D. Fidelity
SITUATION 13 - Emma, 65 years of age, has just
been widowed a year ago. Her two children are
now all living in the U.S. She used to love cooking
but since she is now living alone, she eats meal
irregularly. Most of the time, she just watches
television. Her chief complaint is constipation.
70. When assessing Emma, Nurse Alma should ask
the following, EXCEPT:
A. Dietary and fluid intake
B. Cultural beliefs – malayo
C. Lifestyle
D. Bowel pattern
71. When auscultating the bowel sound of Emma,
the nurse should be able to hear ___________.
A. loud and gurgling sound
B. increased bowel sound
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C. decreased bowel sound – dec peristalsis
D. absent sound
72. The MOST APPROPRIATE nursing diagnosis for
Emma’s case is _________________.
A. risk of constipation related to lifestyle
B. perceived constipation related to eating
habits
C. dysfunctional gastrointestinal motility related
to lifestyle
D. constipation related to inactivity
73. Which of the following are the most simple and
cost effective interventions that the Nurse can
advise Emma to resolve constipation?
1. Encourage increased fiber in diet
2. Encourage physical activity and
regular exercise
3. Regular time for elimination
4. Laxative
A. 1, 2, & 3
B. 3 and 4
C. 1, 3 & 4
D. 2, 3 & 4
74. Health education should include which of the
following?
1. Responding to the urge to defecate
and establishing a daily pattern
2. Role of dietary fiber and fluid in
maintaining bowel function
3. Role of exercise and activity in
maintaining bowel function
4. Safe and correct use of
pharmaceutical agents
A. 2, 3 and 4
B. 1, 2, 3 and 4
C. 2 and 3
D. 1, 2 and 3
SITUATION 14 - Obesity is an emerging concern
for patients and nurses. The nurses has an
important role in assessing and evaluating
patient‟s physiological status in relation to wight
control
75. Nurse Cherry is assessing patients at the
outpatient clinic. Which of the following patients
is at risk for health complications related to
weight?
A. a thirty three year old who has a body mass
index (BMI) of 24 kg/m
B. A fifty six year old who is 6 ft (180 cm) tall
and weighs 150 lb (68 kg)
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 C. A seventy one year old who is 5 ft 4 inches
(160 cm), weighs 120 lb (55 kg), and carries
most of the weight in the thighs
D. a twenty four year old female with a
waist measurement of 30 inches (75
cm) and a hip measurement of 34
inches (85 cm) – waist hip ratio =
waist/hip × 100 ; normal Female: .8 or 80
cm
76. A patient who has been consistently following a
diet and exercise program and successfully
losing one pound weekly for several months is
weighed at the clinic. However, he has not lost
any weight for the last month. Nurse Cherry
should first _______________.
A. ask the patient whether there have
been any recent changes in exercise or
diet patterns – pag may complain, assess
muna
B. discuss the possibility that the patient has
reached a temporary weight loss plateau
C. Instruct the patient to weigh weekly and
record the weights.
D. review the diet and exercise guideline with
the patient
77. When working with an obese patient who is
enrolled in a behavior modification program,
which nursing action is APPROPRIATE?
A. Having the patient write down the caloric
intake of each meal
B. suggesting that the patient has a reward
after achieving a weight loss goal
C. encourage the patient to eat small
amounts throughout the day – focus on
routine
D. asking the patient about situations that tend
to increase appetite
78. When developing a weight-reduction plan for an
obese patient who is starting a weight loss
program, which question is MOST important for
Nurse Cherry to ask?
A. “What factors do you think led to your
obesity?”
B. “Have you been on any previous diets?”
C. “What kind of physical activities do you
enjoy?”
D. “How long have you been overweight?”
79. An obese patient asks Nurse Cherry about using
Orlistat (Xenical) for weight reduction. Nurse
Cherry advises the patient that _________.
A. drugs may be helpful in weight loss,
but weight gain is likely to recur unless
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changes in diet and exercise are
maintained – best is lifestyle change
B. the long-term effect of orlistat is not known,
and the drug may cause serious side effects
such as heart valve problems
C. this drug can cause serious depletion of
fatsoluble vitamins and should be used only
several weeks
D. weight-reduction drugs of any type are used
for only those who do not have the will
power to reduce their intake of food
SITUATION 15 - Nurse Beth is working on the
hospital‟s pediatric unit. She is assigned as a
medication and treatment nurse
80. In preparing to give medications to a
preschoolage child, which of the following
statements is an APPROPRIATE interaction by
Nurse Beth?
A. “Let me explain about the injection that you
will be getting”
B. “Do you want to take your medication
now?” – initiative vs guilt
C. “Would you like the medication with water or
juice?” – if toddler
D. “If you don‟t take the medication now, you
will not get better.”
81. To determine proper drug dosages for children,
calculations are MOST precisely made on the
basis of the child’s __________.
A. Weight – also correct but not the ideal or
best answer
B. Height
C. body surface area
D. age
82. Nurse Beth administered the intramuscular
medication of Iron by the z-tract method. This
method is used to ________________. A.
provide more even absorption of the drug
B. provide faster absorption of the drug
C. prevent the drug from irritating
sensitive tissue – displace then tissue
layers are locked > hindi magleleak and drug
> hindi maiiritate sensitive tissues
D. reduce discomfort from the needle
83. The doctor ordered to give a one year old
patient an intramuscular injection. The
appropriate and preferred muscle to select for
this child is the _______________.
A. Dorsogluteal – you could hit nerves that
could cause paralysis
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 B. Deltoid
C. Ventrogluteal
D. Vastus lateralis – either neonate or infant
SITUATION 16 - Patient Cheyenne, three years
old, was brought to the clinic by her mother due
to ear ache and low-grade fever. While
performing her physical assessment, Nurse Hazel
found Patient Cheyenne‟s right ear to be inflamed
and warm to touch. The Pediatrician ordered ear
drops to be instilled to the affected ear.
84. Nurse Hazel performs further physical
assessment on Patient Cheyenne BEFORE drug
administration, which includes the following,
EXCEPT _______________.
A. Appearance of the pinna and meatus of the
ear
B. Presence of the interference during the
drug administration
C. Type of any ear discharge
D. Location and extent of inflammation of the
ear
85. The MOST APPROPRIATE nursing action before
instilling ear drops to Cheyenne is to ______.
A. Check the medication to be within
room temperature – or warm para
comfortable
B. Refrigerate the medication for thirty minutes
C. Fill up the dropper with no more than one
millimeter
D. Clean the outer surface of the dropper
86. In installing any drug into the ears, Nurse Hazel
performs in SEQUENCE. Which of the following
steps?
1. Allow the drug to flow into the ears
slowly
2. Tilt the head away from the nurse
3. Put a small cotton loosely into the ear
4. Wait for 15 minutes before instilling
drops on the other ear – if you don’t
wait, tatapon gamot sa kabila
5. Instill the ear drops into the affected
ear
A. 1, 4, 2, 5, 3
B. 2, 5, 1, 3, 4
C. 4, 1, 5, 3, 2
D. 3, 1, 4, 5, 2
87. After instilling medications to the right ear, what
is the MOST appropriate instruction to the
mother?
A. Remain in the position for 5 minutes
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B. Pack a cotton pledge (cotton buds) tightly to
the ear
C. Have the patient remain in the position for
one hour
D. Advice the mother not to let Cheyenne drink
hot water
88. In administering otic medication, Nurse Hazel
A. Don the gloves
B. Perform hand hygiene
C. Explain procedure and postpone
D. Check identification band and proceed
Situation: Nurse Tin is assigned to care for
patients with different oxygen delivery systems.
89. As safety precautions for clients receiving
oxygen, which among these should Nurse Tin
not do?
a. Place and arrange substances like acetone,
alcohol, and oils at the bedside – oxygen is
combustible
b. Replace woolen blankets with cotton blankets.
c. Place a “No Smoking” sign on the client‟s door
and at the foot or head of the bead.
d. Ensure that all electric devices are in good
working order.
90. Nurse Tin noticed that the patient on nasal cannula
has encrustations (booger) on her nose. Which
among these is best for Nurse Tin to do first?
a. Call the physician.
b. Apply a water-soluble lubricant as ordered.
c. Tighten tubing and apply leucoplast to secure
prongs on the nares.
d. Use a sterile operating sponge to scrape of the
encrustation.
91. An oropharyngeal airway was inserted to a patient.
Assessment of the mouth may be done as appropriate
for the patient‟s condition every:
a. 1 hour c. 4 hours
b. 8 hours d. 2 hours
92. What is the common position patients are placed into
for suctioning?
a. Modified Trendelenburg
b. High-Fowler’s with head flexed
c. Semi-Fowler’s
d. Orthopneic position
93. After each suctioning for copious secretions, what
should Nurse Tin instruct a conscious patient to do?
a. Hyperventilate c. Assume a tripod position
b. Deep-breathe – when you suction, nasusuction
din ang oxygen ng pt
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 c. d. Avoid unnecessary talking
Situation: Iseminger, Levitt and Kirk (2009)
defined presencing as the term describing the art
of being present, or just being with a client during
an “existential moment”. This art of nursing
presence to promote healing was published in the
journal Nursing Clinics of North America.
94. Jimmy is a novice nurse assigned in the Cancer
Institute. He maintains his physical presence with the
patients, and attends to some of their tasks on the
patients‟ behalf. He interacts at a superficial level
with them. According to Osterman and Schwartz-
Barcott (1996), what level of being present for clients
is this?
a. Presence
b. Partial Presence – mababaw lang, not into deep
with pt
c. Total Presence
d. Transcendent Presence
95. Gigi provides emotional and spiritual presence for the
patients in the Trauma Ward. Their interactions are at
a transpersonal level, causing a transformative
experience. According to Osterman and Schwartz-
Barcott (1996), what level of being present for clients
is this?
a. Presence
b. Partial Presence
c. Total Presence
d. Transcendent Presence
96. Which of the following is not a benefit of using nurse
presence in intervening for clients who are helpless,
powerless, and vulnerable?
a. Promote healing
b. Prevent anxiety – we can’t prevent, only reduce
or maintain in a certain level
c. Create sense of safety
d. Improved client satisfaction
97. Which nursing theorist is the most relevant in using
this nursing intervention?
a. Hildegard Peplau c. Jean Watson –
Theory of Human Caring
b. Dorotea Orem d. Madeleine Lehninger
Situation: Collaboration in the unit is very essential
in relation to patient care. Management functions
are also carried out in this constant collaboration
by the nurse, in fact, one of the nurses‟ most
important role in patient care is as a collaborator.
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98. Information gathered by nurses show the importance
of nurse-physician communication. With the current
recognition that many medical errors are caused by
communication failure, which of the following is the
MOST appropriate intervention?
a. Involve a form of communication where 2
parties engage in problem solving
discussion
b. Organize a conference on medication error
participated by nurses, physicians and others
c. Develop a policy where all members of the health
team can use it as a reference
d. Conduct in-service education for nurses to
improve competencies to address the issues
99. To improve quality client care, the nurses created
“problem solving committees” headed by senior
nursing staff to review standards of care and develop
policies and procedures. Its desired outcome is best
shown in:
a. Allowing changes in staff rotation plan to
accommodate personal needs of the staff.
b. More nurses participating in doctor‟s rounds
and giving immediate information to doctors
regarding patient status
c. Continuous evaluation of nursing practice
and protocols in relation to desired patient
outcomes.
d. Increasing staff communication like providing a
bulletin board for sharing information among
personnel.
100. A new wing is being constructed in the hospital
and the Nursing Director is asked to help design it. To
achieve maximum efficiency in carrying out using
activities, the Nursing Director would consider which
of the following conditions to be most helpful?
a. Environmental factors such as current economic
status and global issues
b. How the structural plan facilities staff interaction
and the rituals the nurses use to conduct work
c. Type of equipment and technology and its effects
on how work tasks are designed and carried out
d. Work flow where equipment, medication,
and other items essential for patient care
are stored and positioned
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Nursing Practice II
Situation 1 – The family of Roxas is fond of dogs.
A vendor who entered the gate without notice is
bitten by one of the pet dogs named Bert. PHN
Cords Attends to the vendor.
1. Which of the part of body of the vendor will be
the MOST affected in terms of rabies? It is the
_________.
a. Buttocks c. feet
b. Head d. hand
2. To protect the vendor from the dangers of
rabies, PHN Cords advises him to clean the
wound thoroughly with soap and water, consult
a physician and receive anti-rabies vaccination.
Which among the following vaccines can provide
active immunity?
1. Purified vero cell
vaccine
2. Human rabies
immunoglobulin
3. Equine rabies
immunoglobulin
4. Purified duck embryo
vaccine
a. 1 and 4 c. 3 and 4
b. 2 only d. 1 only
3. The vendor acquired rabies, what will PHN Cords
do to protect those who took care of him? He
should administer____________.
a. Pre-exposure prophylactic treatment
only for the family of Bert
b. Post-exposure prophylactic
treatment only for the family of the
vendor
c. Pre-exposure prophylactic treatment to
Bert and the vendor‟s families
d. Post-exposure prophylactic treatment to
Bert and the vendor‟s families
4. PHN Cord‟s intervention to protect all residents
who own pets, especially dogs, should be done
by_______.
a. Coordinating with city/ municipal
agriculturist for immunization of all pets
b. Coordinating with city/municipal officials
to make an ordinance on stray dogs
c. Massive campaign to families not to own
pets at home
d. Massive campaign for responsible
pet ownership
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Situation 2 – The Field Health Services and
Information System (FHSIS) is recording and
reporting system in public health care in the
Philippines
5. The following are the objectives of the FHSIS,
EXCEPT:
a. Complete the picture of acute and
chronic disease
b. Ensure data recorded are useful and
accurate and disseminated in a timely,
easy to use fashion
c. Minimize recording and reporting burden
allowing more time for patient care and
promotive activities
d. Provides standardized facility-level data
base which can be used for more
indepth studies
6. As a nurse, you should know the process of how
these information are processed and
consolidated. The fundamental block of the
FHSIS system is the ______________
a. Family treatment record c. reporting
forms
b. Output record d. target/client list
7. The monthly field health service activity report is
a form used in which of the components of the
FHSIS?
a. Target/client list c. individual health
record
b. Output report d. tally report
8. In using the tally sheet, the recommended
frequency in tallying activities and services
is_______.
a. Weekly c. Monthly
b. Quarterly d. Daily
9. To monitor clients client registered in long-term
regimen such as the Multi drug Therapy, which
component of the reporting system will be most
useful?
a. Output report c. target/client list
b. Tally report d. individual health record
Situation 3 – Nurse Oscar takes care of the Ramos
extended family who resides in the house owned
by Nilda‟s mother, Marta. Nilda tends a variety
store is married to Ramon, a government
employee. They have four children: Lester, 20
years old; Gina, 18 years old; Alex, 15 years old;
and Celine, 12 years old. Lester is a working
student of his second year in computer technology
course. Gina is a high school graduate; Alex is in
third year high school and Celine is in Grade six.
There is one year old baby girl who is a daughter
of Gina. Gina, however, could not pinpoint the one
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who sired her child in as much as she had multiple
sex partners. This angered Ramon.
10. Though he recognizes the remorse of his
daughter, Ramon still feels confused regarding
the situation. He said he tried his best to support
his family and had always been considerate and
kind. He and his wife would always give them
reminders and advice calmly and never in a
nagging manner. But still they failed as parents.
The possible nursing diagnosis of Nurse Oscar of
his family is_____________.
a. Interrupted family process
b. Impaired parenting
c. Parental role conflict
d. Ineffective role performance
11. Nurse Oscar‟s conversation with Gina revealed
that the young woman still suffers from a
syndrome of failure: failure to complete one‟s
normal growth and development, failure to
complete education, failure to establish a
vocation and become independent and failure to
have a life. The nurse Oscar‟s intervention to
this problem is_____________.
a. Linear approach with regards to the
individual in the context of the family,
community and culture that will combat
shame and guilt
b. Lay down the foundation of a future by
trusting human association and
developing mutual trust initially with the
nurse, then the family, and eventually
the whole community
c. Focus on the factors that will help
protect Gina towards proximal
stimuli for healthy growth and
development to develop her
resiliency in confronting current
and future problem – pt focused
d. Transform interactions among family
members, strengthen specific roles and
functions to strengthen family system in
order to eventually cope
12. In one home visit, Nurse Oscar was approached
by the 15 year old Alex. He was asking about
condom use. He said he has a girlfriend with
whom he is madly in love with but does not
want her to get pregnant. Nurse Oscar‟s most
practical and best advice would be__________.
a. Postpone sex and suggest other ways to
expressing love
b. Explain to him the difference between
sex and love
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c. Teach him by step-to-step correct,
continuous and consistent condom
use
d. Discourage him on having a girlfriend
and focus more on his studies
13. Ramon complains to Nurse Oscar some weird
behaviour of Nilda. These past few months, she
has decreased sex drive, night‟s sweats and
mood swings. He also received weird text
message from her such as: “Do you really love
me?”, “What role do I play in your life?” “Do you
still find me attractive?” The best advice of
Nurse Oscar to Ramon should be________.
a. Give her some money for make-over to
increase her self-esteem and make her
look attractive to him
b. Accompany her to a psychiatric
c. Ignore his wife or tell her she is too old
to act like a teen-ager
d. Give reassurance that she is the
best person who came to his life –
pt is possibly experiencing menopausal
syndrome
14. Apparently, the nurse interventions have
improved family relationships. The members are
now communicating with one another and are
excited in preparing for a family affair, which is
the baptism of Beatrice. Nurse Oscar was asked
to be the godfather of the child. His best
response is_________.
a. Accept and proudly say that Beatrice will
be his 49th godchild
b. Refuse and make an alibi that he
belongs to another religion
c. Accept and express gratitude for the
trust accorded him by the family
d. Politely decline and explain that his
relationship with the family must
not go beyond professional
Situation 4 – Belinda, the PHN in the Municipality
of Tubog, learned from the residents that children
and some elderly had been suffering from
respiratory and skin ailments allegedly due to the
bad smell curly dark smoke emitting from the
factory nearby. She was invited to the community
assembly that was initiated by the barangay
council.
15. The barangay captain asked, “What can you do
to help solve the problem of Nurse Belinda?”
What would be the right response of Nurse
Belinda?
Page 13
 a. “Well, your problem is easy to solve. I
have here some cough syrup, ointments
for the skin and some antibiotics. I will
distribute this after the meeting.”
b. “Who among you here have children
who are suffering from respiratory and
skin diseases? How about the adults
who are here? Are you also having the
same problems?”
c. I suppose you gave a lot of thought
about the problem and its possible
solution. However, treating your
children and the elderly is not the
first solution. We have to go to the
root cause of the problem.”
d. “May I ask you what solution have you
identified for the community problem?”
Situation 5 – Nurse Lovely, a newly promoted
senior nurse in Obstetrics ward (OB) is attending
a seminar on management and leadership in
preparation for her work.
16. Nurse Lovely learns the five principles of goal
setting in which the senior nurse must provide
enough time for OB nurse to improve
performance. This is called__________
a. Challenge c.
feedback
b. Commitment d. task
complexity – pag complex ang task,
hindi agad matututunan – learning
curve, give time
17. The nurse also learns that continuous training is
a personal as well as an organizational goal.
Choose the statements that are true regarding
continuous training
1. Training employees is an excellent
investment and a cost to an
institution
2. Continuous training is more of a
personal responsibility than
institutional
3. Cross training and job rotation
provide on-going part-time learning
experience
4. Select the best people when hiring
employees and invest their retention
through continuous training
a. 3 and 4 c. 1 and
4 b. Pregnancy is known to accelerate the
b. 1 and 2 d. 2 and 3
18. Noting the importance of Nurse-
PatientRelationship, Nurse Lovely reviewed
Hildegard Peplau‟s Theory which identified three
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phases, the FIRST of which is when the
pregnant woman is________.
a. Feels the need to seek professional
assistance
b. Demonstrates self-reliance in caring for
herself
c. Understands the communication of
Nurse Lovely regarding the services
offered
d. Begins to have feeling belonging
19. Nurse Lovely took note that evaluating the OB
staff is an on-going function of management.
Some of the reasons for conducting evaluation
include, EXCEPT to _____________.
a. Provide an indication of the costs of poor
quality services
b. Justify the use of resources
c. Dissuade self-evaluation of OB staff
– evaluate staff reguarly ; dissuade is
opposite of persuade
d. Ensure that quality of care is provided
by the OB staff
Situation 6 - You are an OB nurse in an out
patient department of a hospital. You encounter
pregnant women with complication
20. A 35-year old woman, on her 2nd trimester of
pregnancy with insulin-dependent diabetes
mellitus, comes to you for some advice. What is
the PRIORITY message for her at this time?
a. Infants of diabetic mothers are big
which can result in more difficult delivery
b. Breastfeeding is highly recommended
and insulin use is not contraindicated
c. Achievement of optimal glycemic
control
is of utmost importance in
preventing congenital anomalies
d. Her insulin requirements will likely
increase beginning 3rd trimester of
pregnancy
21. A 30-year old G6P5 woman at 12 weeks has just
begun prenatal care. Her initial laboratory
reveals that she has human immunodeficiency
virus (HIV) infection. What would be a priority
evidence-based nurse information for this
patient?
a. Breastfeeding is still recommended due
to the great benefits to the infant
course of HIV disease in the mother
c. Medication for HIV infection is safe
and
Page 14
 can greatly reduce transmission of HIV
to the infant
d. Breastfeeding will potentiate the
transmission of HIV from the mother to
the child
Situation 7 – Nurse Dora, a nursing staff
applicant, passed both written and oral
examinations. Because she knows the head of
office, she promised to submit all her credentials
after she has “fix things up.” She was appointed
as Nurse I with a temporary status until she
submits all her credentials, including her PRC
license. Her evaluation performance was
satisfactory. After a year though, she had to
renew her PRC registration and identification (ID)
card.
22. What action must the nursing administration do
FIRST?
a. Report the matter to the head of
office who had the discretion to
appoint the nurse
b. Verify with the Professional Regulation
Commission regarding the status of
Nurse Dora
c. Confront Nurse Dora and terminate her
d. Write a letter to the Civil Service
Commission for proper action to Nurse
Dora
23. It was found out that Nurse Dora did not pass
the Nurse Licensure Examinations (NLE). What
legal action should be filled against her?
a. Dishonesty
b. Conduct unbecoming of professional
c. Malpractice
d. Misrepresentation – giving false info ;
sabi mo nurse ka pero hindi naman
talaga
24. In case Dora have medication error during her
tour of duty, the head of office can be liable
because of the law called ____________.
a. Unethical conduct
b. Respondeat superior – shared liability
c. Politicking
d. Res Ipsa Loquitur
25. All Nurses must understand that after graduation
they should pass the NLE. To be registered in
the roster, they should take the Professional
Oath with a ________, EXCEPT.
a. Member of Sangguniang Panlalawigan
b. Governor of Philippine Nurse
Association
c. Member of the Professional Regulatory
Board of Nursing
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d. Provincial Governor
Situation 8 – PHN Elfa works in barangay 14 and
15 in the Municipality of Agoho. One day, a
neighbor summons her to attend to a 7-year old
boy with high grade fever.
26. Upon reaching the house, a local herbolaria,
Nanay Isa was already attending to the boy. She
said that the boy played near the river and the
bad spirits entered his body. The MOST
appropriate remark the nurse make is
_________________.
a. “Go on. Do what you have to do,
then I will take over.” – but if there is
possibility of harm, do not allow
b. “Nanay Isa, your intervention is entirely
wrong.”
c. “It‟s good you‟re here. You can drive
away the spirits that entered the boy‟s
body.”
d. “You have to be sure that all the evil
spirits have been driven out of the boy‟s
body.”
27. After a few minutes, Nanay Isa took a big bowl
of soup and gave to the boy. The BEST remark
of the Nurse is _____________.
a. “I also drink a soup when I get sick.
How about you, Nanay Isa, do you do
the same?”
b. “The soup could have been better if you
put lemon grass on it.”
c. “Come on, tell me why soup must be
given to a child with fever
d. “That‟s correct. Increasing fluid
intake will help lower down
temperature.”
28. Finally, Nanay Isa took out from her pocket a
dried rose flower and place it on the boy‟s
forehead. How will Nurse Elsa handle this
action?
a. Tell her not to use the dried flower
again because it does not have any good
effect on the sick
b. Ask for an extra piece of fried rose
flower and promise to use it
c. Ask the herboloria the rationale for the
intervention
d. Leave the intervention as is.
Anyway the intervention is neutral:
not harmful nor beneficial
Situation 9 – The local health board established a
reproductive health clinic in the main health
center. Two nurses, Hubert and Irene, were
Page 15
assigned to handle services to address problems
related to sexuality, reproductive health and
fertility problems.
29. Nurse Hubert classifies cases according to the
major categories of reproductive tract infections.
Which of the following is NOT part of such
classification?
a. Iatrogenic infections as aftermath of
invasive procedures like catheterization
and intra-uterine device (IUD) insertion
b. Urinary tract infections among male
and female patients – urinary and
repro are not similar
c. Sexually-transmitted infections
d. Endogenous infections resulting from
poor personal hygiene
30. Irene handles the screening for gonorrhoea
every two weeks among female sex workers in
the implementation of PD 856. In differential
diagnosis of discharge among infected clients,
which of the following colors discharge will Irene
take note to identify gonorrhoea from other
causes?
a. Greenish yellow as differentiated from
mucoid white of trichomoniasis
b. Mucoid white as compared to
grayishwhite discharge of vaginosis
c. Grayish white as differentiated from
mucoid white of chlamydia
d. Yellowish white as compared to
Trichomoniasis’ greenish-yellow
31. Nurse Hubert was invited by a women‟s group
to give a lecture on healthy sexuality. In the
expectation check, he noted that there are
previous misconceptions expressed by the
participants. Which of the following statements
are correct?
a. It is the obligation of the wife to give in
to sex every time he asks for it
b. Sexuality is fluid and may change
c. Effeminate men are gays
d. Homosexuality, being gay or lesbian, is
an abnormality
32. One of the clients was positive to Gonorrhea.
Nurse Irene explained that gonorrhoea and
chlamydia, if left untreated can lead to Pelvic
Inflammatory Disease (PID). Such condition may
cause infertility due to ______.
a. Foul smelling odor discharge which can
kill the ovum
b. An unknown cause
c. Scarring which can lead to tubal
occlusion – sugat, peklat then
magbabara
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d. Purulent discharge which can kill the
sperm
33. Nurse Irene further explained that a test used to
determine tubal patency using a radiopaque
material is the __________.
a. Post-coital infetitlity test
b. Sims Huhner test
c. Friedman‟s test
d. hysterosalpingography – dye should
reach up to fallopian tube – pag naputol
agad ang dye (gitna FT or wala pa sa FT
– may bara)
Situation 10 – Ela, 21 years old, is a law graduate.
She wants to review for the Bar but thinks she is
pregnant. She said she has regular menses but
does not know when ovulation usually occurs.
This have something to do her fertility period
during her last sexual intercourse with her
husband.
34. As a nurse, what would you tell Ela regarding
ovulation? The ovulation usually corresponds to
the life of the corpus luteum which occurs
approximately _______________.
a. 14 days after the first day of the
succeeding menstrual
b. 7 days after the first day of the
succeeding menstrual
c. 7 days before the first day of the
succeeding menstrual
d. 14 days before the first day of the
succeeding menstrual
35. Ela insisted she might have been fertile during
the time of sexual intercourse. The nurse
explains that absolute period of fertility is the
span of time that a woman is likely to be
pregnant when she engages in unprotected
sex______.
a. Several days after ovulation (3-4
days)
b. During ovulation
c. Immediately after ovulation
d. Immediately before ovulation
36. The nurse proceeded to take the menstrual
history of Ela to find out if she is likely to be
pregnant. Which of the following determines the
date of onset of last menstrual period (LPM)? It
is the ___________.
a. Duration and character of the LMP
b. Implantation bleeding
c. Spotting after the LMP
d. Bleeding before the last menstrual
period (LMP)
Page 16
 37. The nurse also asked about Ela‟s secondary
amenorrhea that would most likely indicate her
pregnancy. Secondary amenorrhea is cessation
of menses for more than_______ months, after
regular menstrual cycle has been established.
a. Five c. six
b. Three d. four
*primary – 16 y/o never had menstruation
38. The nurse also asked for presence of secondary
dysmenorrhea. Which of the following conditions
is not INCLUDED under secondary
dysmenorrhea?
a. Intra-uterine device (IUD)
b. Pelvic Inflammatory Disease (PID)
c. Malposition of the cervix
d. Absence of any underlying
anatomic abnormality
39. Pediatric patients are prone to falls from hospital
beds which may result to additional cost on the part of
the hospital. Which safety measures should be instituted
to prevent such incidents?
1. Restraining them
2. Having their mothers or any significant adult
with them
3. Advising watchers to put up the bedrails at
all times
4. Telling them they will be given injection if
they will get out of bed alone
a. 3 and 4
b. 2 and 3
c. 1 and 2
d. 1 and 4
Situation: Municipality “A” made it to a local
newspaper headline because of the occurrence of
some unusual events in just 10 days: 2 pregnant
woman died giving birth at home; 2 children died
of dehydration and 2 elderly died of pneumonia.
The mayor of the town called for a meeting of the
municipal health office personnel. Public Health
Nurse Corazon was assigned to make the action
plan to prevent another similar event to happen.
40. Which of the following could have been the TOP
contributors to the situation? Select all that apply.
1. Postponement of people in seeking medical
care
2. Adherence to cultural practices and beliefs
3. Lack of ambulance and drivers
4. Delay in receiving appropriate and adequate
care
a. 2 and 3
b. 1 and 2
c. 1 and 4
d. 1 and 3
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41. Nurse Corazon and her group prepared objectives for
plan of action. The following are the characteristics of a
good objective. Choose the BEST answer.
a. Futuristic, change-oriented, dynamic
and systematic
b. Time-bound, attainable, realistic,
measureable and specific + client
centered – The client will ; CSMART
c. Flexible, accurate, top priority and
feasible
d. Time bounded, measurable, change
oriented and continuous process
42. Nurse Corazon presented the plan in a
community assembly for acceptance and approval.
Which of the following is the MOST important
criterion for the plan‟s acceptance and approval
manifested by the people?
a. Tasking the community people
b. Volunteerism and willingness of the
community people
c. Presence of the municipal health officer
in the assembly
d. Huge attendance in the community
assembly
43. To combat the delays in attending to childbirths,
Nurse Corazon adopts the Integrated Management of
Childhood Illness in the municipality. This program aims
to __________.
a. Improve and ensure the accessibility and
availability of basic and essential health
care in both public and private facilities
and services
b. Ensure the quality and affordability of
health goods and services
c. Develop, implement, monitor and
evaluate maternal and newborn
care services (exclude maternal ; IMCI
– for under 5 children)
d. Ensuring access to health care services
44. In Municipality A, like any other municipalities, one
MAJOR problem that makes any health service
program inaccessible is ___________.
a. Lack of community awareness
b. Limited number of health-oriented
programs
c. Reliance of government financial
support
d. Lack of ambulance
Situation: At 32 weeks gestation, patient
Angelica, a 16-year-old primigravid, 5 feet tall,
gained a total of 20 pounds, with a one pound
gain in the last 2 weeks. Urinalysis reveals
negative for glucose and a trace of protein. She
came to the clinic for consultation.
Page 17

45. Which will BEST describe Angelica‟s risk for
preeclampsia?
a. Proteinuria
b. Short stature
c. Total weight gain
d. Adolescent age group – less than 20,
more than 40
46. After instructing Angelica how to keep a record of
daily fetal movement counting (DFMC) at home, the
nurse determines that the teaching has been
effective when Angelica says she will count the
number of times the baby moves during which of the
spans?
a. 45-minute period after lunch each day
b. 12-hour period each day
c. 30-minute period 3 times a day
d. 1-hour period each day – should be
10 movements
47. When teaching Angelica about nutritional needs, the
nurse should emphasize ___________.
a. High residue diet
b. Low sodium diet – trigger RAAS > inc BP
c. Regular diet – even if pregnant
d. High protein diet
48. The nurse mentions some of the conditions
associated with preeclampsia. Which among the
feedbacks by Angelica to the nurse would warrant
further explanation?
a. Iron deficiency
b. Physical disability
c. Multiple pregnancy
d. Diabetes mellitus
49. Angelica was brought to the labor room for
magnesium sulfate medication. The PRIMARY
purpose for its administration is to ________.
a. Increase the central nervous system‟s
response to stimuli
b. Increase calcium absorption by the
muscles
c. Decrease neuromuscular irritability
d. Reduce peripheral vascular resistance to
lower blood pressure
*monitor BURP: BP, Urine Output, RR,
Patella reflex
50. Which of the following senses are already developed
at birth? Select those that apply.
1. Hearing.
2. Vision.
3. Taste.
4. Smell.
a. 1, 2, 3, 4
b. 1, 3, 4
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RECALLS 1 EXAM
c. 1, 2
d. 1, 2, 3
51. The body system of the newborn moves through
periods of irregular adjustment in the first six (6) hours
of life. It has two periods namely, the first and the
second periods of reactivity. The FIRST period of
reactivity consists of the following characteristics. Select
all those that apply.
1. Alertness
2. Making sucking sounds
3. Slow heartbeat
4. Slow respiratory rate (RR)
a. 1, 2
b. 3, 4
c. 1 only
d. 3 only
52. Which among the following describes Palmar
Grasp Reflex of the baby? When he ____________.
a. Is startled as his crib is shaken
b. Grasps an object and placed on his toes
c. Gets an object placed on his hand
by closing his fingers
d. Seems to spit out anything placed in his
mouth
53. One day, Baby Boy did not want to suck from
the mother’s breast. The doctor ordered intravenous
fluids. Which among these complications will Nurse Chari
anticipate to occur ALMOST IMMEDIATELY?
a. Cellulitis
b. Infiltration
c. Phlebitis
d. Burns
54. Later, the pediatrician orders Baby Boy to
undergo exchange blood transfusion because of ABO
blood incompatibility. What should be the BEST
equipment to use in as much as 50mL of blood is
ordered?
a. Syringe pump
b. Soluset with microdip
c. Pulse oximeter – do not use pumps
because blood will hemolyze ; best
answer: BT set
d. Infusion pump
Situation: Nurse Marissa is a clinical instructor
(CI) of AL University in the North. She is assigned
at the OR in a government provincial hospital.
Marissa is aware of the scope of nursing and her
responsibilities to the school and the hospital.
55. What is the FIRST STEP that Marissa should do
upon reporting to the OR with her students? She should
__________.
a. Orient the students to
the policies of the
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 OR
b. Introduce herself and
coordinate with
the head nurse
c. Greet the surgeons and
anesthesiologists
d. Orient her students to
the set-up of the Operating Room (OR)
56. Marissa understands her responsibilities to the
school she represents and the hospital she and her
students are affiliated with. Which of the following is
an INCORRECT statement about student nurses?
a. The student nurses are expected to
achieve same outcome as license
nurses, that is, to do no harm to clients
b. Although student nurses are not yet
licensed they are expected to adhere to
the same standards as the licensed
nurse
c. The student nurses are the sole
responsibility of the CI and school –
they are also resp of the hosp
d. Hospitals or health care agencies may
impose limitations on student nurses‟
practice and coordination and
collaboration by the CI and the student
nurses must always be practiced.
57. When giving case assignment to student nurses
at the OR, the CI should inform which of the following
OR personnel? Choose all that apply.
1. OR supervisor
2. Chief nurse
3. Scrub nurse
4. Circulator
a. 1, 2, 4
b. 3 and 4
c. 1 and 4
d. 1 and 2
58. If a student nurse commits a break in asepsis
while an operation is on-going, who among the following
persons can call the attention of the student nurse and
the entire team?
a. The CI only, in as much as she is the
one directly responsible over the
students.
b. The surgeon being the captain of the
ship.
c. Any member of the surgical team
who saw the infraction.
d. The scrub nurse or the circulating nurse
on-going surgery even if she did not see
the infraction.
Situation: Nurse Mitos is assigned at the Maternity
Clinic of Hospital M. Every Wednesday is pre-natal
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RECALLS 1 EXAM
day. From 8:00 o‟clock to 9:00 o‟clock in the
morning, she conducts a health education
program to pregnant women. The topic for that
day was signs and symptoms that should be
reported throughout pregnancy.
59. True labor is differentiated from failure labor
because in true labor, contractions will ____________.
a. Be relieved in the side lying position
b. Bring about progressive cervical
dilatation
c. Stop when the client is encouraged to
walk
d. Occur immediately after rupture of bag
of water
60. Based on the characteristics of the Puson family,
Nurse Olive can easily categorize which of the family‟s
developmental stage?
a. Families with pre-school children –
majority are PS
b. Family with school age children
c. Beginning family
d. Early child-bearing
61. In this particular stage, which of the following is
a most basic concern?
a. Emergence of harmony in marital and
in-law relations.
b. Child rearing
c. The couple shifts to adult social
interests.
d. Balancing time and energy to meet the
demands of work and family.
62. As a young manager, Freda knows that conflict
occurs in any organization. Which of the following
statements regarding conflict is NOT true?
a. It may result to poor performance of the
staff.
b. It can be destructive; hence, it should
not reach the highest level.
c. It is not beneficial; hence, it should
be prevented at all times.
d. It may create a new leader from among
the staff.
63. Freda tells one of the staff: “I don‟t have time to
discuss the matter with you now”, when the latter asks if
they can talk about an issue. Which of the conflict
resolution strategies did she use?
a. Avoidance
b. Smoothing
c. Compromise
d. Restriction
64. Which of the following is the BEST action that
she must take?
a. Quit her job and look for another
employment.
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 b. Disregard what she feels and continue
to work independently.
c. Identify the source of conflict and
understand the source of friction.
d. Seek help from the Director of Nursing.
65. Freda knows that one of her staff is experiencing
burnout. Which of the following is the BEST thing for
to do?
a. Remind her to show loyalty to the
institutions.
b. Ignore her observations; it will be
resolved even without intervention.
c. Let her staff ventilate her feelings
and ask how she can be of help.
d. Advise her staff to go on vacation.
66. She knows that the performance appraisal
consists of the following activities, EXCEPT
___________.
a. Setting specific standards and activities
for individual performance.
b. Using agency standards as a guide
c. Focusing activity on the correction
of identified behavior – not only on
weakness ; acknowledge also the
strengths
d. Determine areas of strengths and
weaknesses
67. Michelle is a pregnant mother living in Sta. Ana,
Manila. She has given birth to a twin, one child, and had
an abortion. Which of the statements below CORRECTLY
applies, given the obstetrical history of Michelle?
a. Since there has been a twin, Michelle is
G4P4
b. Since there was an abortion, Michelle is
G4P3
c. Michelle is Gravida 3 Para 2 (G3P2)
d. Michelle is Gravida 4 Para 2 (G4P2)
G: one twin, one child, one abortion,
plus current pregnancy
P: one twin, one child (abortion is not
included)
68. Michelle is now in her second stage of labor;
Cervix 8cm. Nurse Clemens puts her in lithotomy
position. One of the dangers of this position that Nurse
Clemens should watch for in Michelle is ___________.
a. Hyperventilation
b. Hypertension
c. Hypotension
d. Tachypnea
69. If Michelle has a long second stage of labor and
needs to be placed in Lithotomy position for a long time,
Nurse Clemens should implement the following safety
measures, EXCEPT ___________.
a. Wrap legs with elastic bandages
a. Put 2 pillows under her head
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RECALLS 1 EXAM
b. Place a small pad under her sacral area
c. Put a rolled towel under the Michelle‟s
right hip
70. Nurse Clemens understands that Michelle needs
more support and encouragement during the PEAK and
MOST painful phase of uterine contractions, which is
called ____________.
a. Decrescendo
b. Decrement
c. Increment
d. Acme
71. Before the INITIAL vaginal examination
commonly referred to as internal examination, what
must Nurse Clemens check FIRST?
a. Blood pressure for hypotension or
hypertension
b. Heart rate of Michelle for chest
compression.
c. Abdominal palpitation for signs of fetal
distress.
d. Abdominal palpitation for fetal lie and
position, and fetal heart tone.
72. Which of the following is the FIRST step that
Nurse Zyla must consider in preparing a health teaching
plan?
To know _____________.
a. Certain factors that may affect the
client‟s learning.
b. The client‟s personal values and
expectations
c. The client‟s age and educational status
d. The post partum client‟s needs
73. What resources should Nurse Zyla use in
teaching her postpartum client? Select all that apply.
1. Pamphlets
2. Audiotapes
3. Nurse specialist
4. Videotapes
a. 1, 2, 3, 4
b. 1 and 17
c. 1, 2, 18
d. 2 and 22
Situation: Sandy is a newly hired nurse at the
Neonatal Intensive Care Unit (NICU). She
received an endorsement that Baby Boy A and
Baby Girl B are ready for discharge. At 5:15 in the
afternoon she gave the babies to their mothers.
Two days after, the mother of “Baby Boy A” came
back to complain that she got the wrong baby
because she got a baby girl instead of a boy.
74. What are the elements that will prove that Nurse
Sandy committed gross negligence? Select all that
apply.
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 1. That Nurse Sandy has a duty
2. That Nurse Sandy failed to perform that duty
3. Due to that duty an injury occurred to her
patient
4. Causal relationship as regards the failure the
nurse to perform her duty and the resulting
injury.
a. 1, 2, 3
b. 3 and 4
c. 1 and 2
d. 1, 2, 3, 4
75. What could have been done to prevent the
occurrence of switching of babies?
a. Calling out the name of the mother
b. Proper identification of the baby
using name tags
c. Checking the genitalia
d. Identifying the baby by checking their
footprints
76. What is the number one element that can prove that
Sandy is incompetent? Sandy was not able to
perform her job _______________.
a. Because she is newly hired nurse
b. According to the orientation
c. Because she lacks supervision
d. According to a set standard
77. Which of the following should Sandy, being
professional nurse, understand as the primary
outcome should she be proven guilty of
incompetence?
a. That she can be delisted as member of
the APO
b. That she can be terminated from work
by her employer
c. That she can be charged in the civil
court
d. That her license to practice nursing
can
be suspended or revoked for a
period of time by the PRC
78. Which among the statements are TRUE about health
promotion? It is the process of __________.
1. Enabling individuals and communities to
increase their abilities to control and improve
their health
2. Enhancing the individuals physical,
psychologic and spiritual well-being
3. Engaging in correcting the people‟s health
behavior
4. Preventing disease from occurring and
treating it when it occurs a. 1 only
b. 3 and 4
c. 2 only
d. 1 and 2
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RECALLS 1 EXAM
79. Which of the following health behavior choices are
ESSENTIAL to promoting health and preventing disease?
a. Taking prescribed medications at the
right time and dosage.
b. Eating the right kind of food,
adequate sleep, physical exercise
and effective handling of stress
c. Refraining from travelling to countries
with high prevalence of infectious
diseases.
d. Smoking cessation and drinking alcohol
regularly.
80. What are the ESSENTIAL factors in the integrative
models of human health?
a. Intertwined and interactive, with
multiple components such as
physical, psychological and social
b. Effective only when combined and
integrated with alternative therapies
c. Generally being attributed to
psychological problems in individuals
d. Derived solely from physical
phenomenon
Situation: Mrs. Fabon, 28 years old, has been
married for 4 years. She postponed pregnancy to
pursue her career as a lawyer. One day, she went
to see an obstetrician because of vaginal spotting
and to find ways of getting her pregnant. After a
series of diagnostic examinations, she was found
to have endometriosis.
81. Which statement BEST describes endometriosis?
a. It is caused by growth of
endometrial tissues outside the
uterus.
b. It is an infection of the endometrium.
c. It is caused by abnormal proliferation of
the endometrial lining.
d. It is a major cause of primary
dysmenorrhea.
82. The nurse performs an assessment on Mrs. Fabon.
Which of the findings would be indicative of
endometriosis? Select all that apply.
1. Spotting after intercourse
2. Persistent dysmenorrhea
3. Dyspareunia
4. Menorrhagia
a. 1, 4
b. 3, 4
c. 1, 2, 3
d. 2, 3, 4
83. The physician prescribes Danazol (Danocrine) for
Mrs. Fabon. The nurse should tell her that while
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 taking this drug she will experience all these d. Pneumococcus
symptoms, EXCEPT ____________. 89. What is the MOST important advise that Nurse Flor
a. Anovulation should give Client Cedes? It is on risk of
b. Weight gain and edema ____________.
c. Diminished a. Massive bleeding
menstrual flow – eliminate A and D since b. Rupture of the uterus
they are the same c. Ectopic pregnancy
d. Cessation of her menses d. Infection
84. What is the rationale behind
endometriosis interfering with fertility? It is Situation: Mr. and Mrs. Santin have eight children who
because ____________. are all boys. How they would like to be counselled on
a. Of pressure on the pituitary that leads to family planning methods by Nurse Rem.
decreased FHS levels.
b. Of total blockage of endometrial 90. Nurse Rem explains the two forms of hormonal
tissues – pag tumubo sa ibang lugar, contraceptions which are the pill or the Oral
pwede bumara Contraceptive (OC) or the combination of Oral
c. The uterine cervix becomes inflamed Contraceptive (COC). The COC‟s compositions and
and swollen the corresponding actions are, select the TWO
d. The ovaries stop producing adequate correct answers.
estrogen 1. Estrogen acts to suppress the Follicle
Stimulating Hormone (FSH) and Leutinizing
Situation: Cedes is admitted to the hospital Hormone (LH), thus suppressing ovulation.
because of vaginal staining but without pain. Her 2. Progesterone complements the action of
obstetrical history reveals amenorrhea for the last estrogen causing the decrease in the
two months and pregnancy confirmation after her permeability of cervical mucus, thereby
first missed period. limiting sperm motility and access to ova.
3. Estrogen acts to increase FHS and LH, thus
85. Which is MOST likely be the tentative diagnosis? suppressing ovulation.
a. Threatened abortion 4. Progesterone when combined with estrogen
b. Incomplete abortion causes the increase in the permeability of
c. Missed abortion cervical mucus thereby decreasing the
d. Inevitable abortion possibility of tubal transport and
86. A few hours after admission, Client Cedes begins to implantation.
experience bearing-down sensations and expels the a. 3 and 4
products of conception in bed. What should Nurse b. 1 and 4
Flor do FIRST? c. 1 and 2
a. Notify the midwife of the hospital d. 2 and 3
b. Administer a sedative according to 91. Which of the following are the side effects of COC‟s?
physician‟s order Select the CORRECT answers.
c. Check the client’s fundus for 1. Weight gain
firmness 2. Headache
d. Transport her to the Delivery Room 3. Depression
87. Client Cedes asks what is the cause of abortion? The 4. Breast tenderness
MOST appropriate response that Nurse Flor gives is a. 3 and 4
that it is due to _____________. b. 1 and 2
a. Unresolved stress c. 1, 2, 4
b. Physical trauma d. 1, 2, 3, 4
c. Congenital defects *if lactating – progestin only pills: mapupunta sa
d. Embryonic defects baby ang estrogen > hormone replacement therapy
88. Which is the number ONE microorganism that is 92. Nurse Rem advises that the BEST way to lessen the
responsible for infection after a miscarriage? side effects of COC‟s is by __________.
a. Escherichia coli - at rectum the travel a. Changing the routine activities
somewhere else b. Consulting the physician for the side
b. Staphylococcus effects
c. Streptococcus
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RECALLS 1 EXAM Page 22
 c. Not minding it because it will just
subside
d. Using different brands of contraceptives
93. Nurse Rem also advises Mrs. Santin to notify the
health center physician/nurse for the following
symptoms, EXCEPT ______________.
a. Severe leg pain
b. Shortness of breath
c. Earache
d. Chest pain
94. Mrs. Santin expressed fear in choosing OC or
COCs. She asks about the advantages of using chemical
barriers as methods of contraception. Which of the
following are the advantages of this type of
contraception?
1. It interferes with sexual enjoyment
2. When used with another contraceptive, they
increases the other method’s effectiveness
3. Various preparations are available in the
market
4. They can be purchased without a
prescription
a. 1 and 2
b. 3 and 4
c. 1, 2, 3
d. 2, 3, 4
Situation: Mel, Kid, Emma, Gliz, and Trix are close
friends because they are almost of the same age
(8-9 years old), orphans, and out-of-school
youths. Nurse Grace from the Department of
Social Welfare and Development (DSWD) is
tasked to attend to them.
95. The nurse‟ responsibility is to check on the
children’s status/pattern. Which of the following should
be the nurse‟ PRIORITY?
a. Interaction patterns
b. Health status – general answer
c. Adaptation status
d. Developmental patterns
Situation: Essential Newborn Care is one of the best
strategies to improve newborn care and help reduce
neonatal morbidity and mortality.
96. Which off the following describes the Essential
Newborn Care protocol?
1. Series of time – bond , chronologically –
ordered, standard procedures that babies
receive at birth
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RECALLS 1 EXAM
2. Strategy to improve the health of the
newborn through interventions before
conception, at soon after birth and in
postnatal period – di pa nabubuntis
inaalagaan mo na HAHAHAHAHA
3. It aims to reduce global mortality and
morbidity associated with the major causes
of diseases in children and to contribute to
healthy growth and development of children
4. Provides an evidence- based, low cost low
technology package of interventions that will
save thousands of lives.
A. 1,2,3
B. 1,3,4
C. 1,2,4
D. 1,2,3,4
97. Interventions carried out that are done within a
prescribed period would include all except one. Which
should not be included in this category?
A. Suctioning the Infant – only when
APGAR is low
B. Drying the infant
C. Early skin t skin contact
D. Non- separation from the mother
98. Essential Newborn Care (ENC) gets away with
the usual conscientious use of evidences
incorporated into practice. Which intervention is/are
removed from practice?
1. Early Bathing
2. Routine suctioning
3. Bandaging the cord
4. Application of antiseptic in the cord
stump
A. 3.4.
B. 2,3,4
C. 1,2,3
D. 1,2,3,4
99. The Philippines is one of the 42 countries that
account for 90 % of Under Five Mortality worldwide.
More than 82,000 Filipino children under five years old
die every year .Which strategy by the department of
health is sought to attain the objectives of Essential
Newborn Care?
A. Integrated management on childhood Illness
B. Unang Yakap Campaign
C. Expanded program on Immunization
D. Basic Emergency Obstetric Care
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 NURSING PRACTICE III
Situation 1 – Nurse Louisa is employed in hospital
“X” and assigned in the Medical Ward for a year
now. The nurse supervisor ordered her to proceed
immediately to the Surgical Ward as a reliever to
another nurse who went on emergency sick leave.
She was not oriented in the Surgical Ward and
the unit was very busy.
1. Which of the following is the MOST appropriate
action of Nurse Louisa
a. Request the nurse supervisor to assign a
more experienced nurse reliever
b. Refuse the order of the nurse supervisor
and stay put in the medical ward
c. Comply with the order of the nurse
supervisor
d. Request the nurse supervisor to
give her brief orientation before
compliance
2. To qualify as an operating room nurse in the
Philippines setting, Nurse Louisa should possess
the minimum requirements of _____________.
a. Master’s degree holder with valid and
current license
b. Worked in the surgical unit for 8 hours
c. RN and has worked abroad
d. RN with valid and current license
and Surgical Ward orientation –
even without surg ward orientation
3. Nurse Louisa is a graduate in the Philippines
nursing school. As part her professional and
personal development, she should attend which
of the following program? EXCEPT___________
a. Programs by the Philippine Nurses
Association
b. Continuing Professional Development
programs by the Professional Regulation
Commission
c. Symposium and forum offered by
the school
d. Programs of international nurses
associations
4. The PRIORITY objective behind career
advancement of Nurse Louisa is ____________.
a. Increasing revenue of the service
providers
b. Renew old acquaintances and establish
camaraderie
c. Increased number of networking
activities
d. Updating one’s knowledge, skills,
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RECALLS 1 EXAM
conduct and values in professional
nursing
5. Nurse Louisa has an expired license but
promises to renew her license in due time.
Which of the following violation can she be
charged if she participated in home health care
activity?
a. Malpractice
b. Grave coercion
c. Felony
d. Negligence
*conditions wherein you’re not allowed to
work: suspended, revoked, and expired
license
Situation 2 – Health Education is an area of
nursing practice when the nurse can be creative
and independent in the work setting. The
following questions apply.
6. A nurse is developing a Teaching plan for Isabel
18 year old with Bronchial Asthma. She has an
order for discharge. Which part of the teaching
plan should be given PRIORITY?
a. Quick relief medicines as ordered
b. Avoid contact with fur-bearing pets
c. Avoid going to malls
d. Wash bed sheets in warm water
7. Mr Gilbert is for postural drainage. The nurse
should position the client‟s head at
______________.
a. No greater than a 25 degree
downward angle
b. A 30 degree lateral angle for 25 minutes
c. 25 degree at lateral angle
d. A 30 degree downward angle for 25
minutes
8. Nurse Beth is teaching Michel, an asthmatic, on
how to use the Spirometer. She should instruct
the client to have the
mouthpiece________________.
a. Place into the mouth and have regular
breathing
b. Place into the mouth and have a fast
deep breath
c. Place into the mouth and inhale
slowly
d. Place into the mouth and exhale slowly
9. Nurse Beth is teaching a client on how to use
metered dose inhaler to prevent asthmatic
attack while in the hospital. She should instruct
the client to do the following
__________________ EXCEPT.
a. Keep the head of the bed at 15
degree angle – too low, should be
semi fowler’s
Page 24
 b. Do oral care after use of the inhaler
c. Use the inhaler before she take her
meals
d. Use the inhaler as ordered
10. You are conducting health-teaching sessions to
clients with cardiovascular disorders. Client
Pedro asks you this question: “Tell me, Nurse,
what I should do with my Hypertension?” The
best response of a Nurse is____________.
a. “comply with your diet, lifestyle and
exercise”
b. “strictly follow your prescribed daily
exercise and smoking cessation”
c. “comply with your diet, life style
modification and prescribed
medicines”
d. “include garlic in your meals with
regulation of alcohol consumption”
Situation 3 - As a staff nurse in a government
hospital, you have been exposed to varied cases
of clients with endocrine problems. Your nursing
responsibility starts from admission to discharge
which is a domain of your competencies.
11. Which of the following questions should you ask
during an admission interview for a client with a
diagnosis of pheochromocytoma?
a. Do you always feel like you are
suffocating, you want to rest and sleep
b. Do you suddenly feel warm and flushed
when you get out of bed
c. Do you notice an increase in your
heart beat?
d. Do you have an increase in urination
lately?
12. When the sympathetic nervous system is
stimulated in the case of pheochromocytoma,
you expect which of the following signs?
i. Hypertension
ii. Headache
iii. Hyperhidrosis
iv. Hypermetabolism
a. 3 and 4
b. 1 only
c. 1, 2, 3, and 4 + hyperglycemia
*tumor in adrenal medulla > inc
catecholamines > inc epi, norepi
13. Which of the following drugs can induce
hypertensive crisis in Pheochromocytoma?
a. Tricyclic antidepressant
b. Corticosteroid
c. Respiratory stimulant
d. Radio iodine therapy
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RECALLS 1 EXAM
14. In the presence of pheochromocytoma, the
diagnostic test which is expected to be elevated
is ___________.
a. Serum thyroid hormone levels
b. Albumin globulin test
c. Urine cyclic adenosine mono phosphate
d. 24 hours urine collection for
vanillylmandelic acid (VMA) – urine is stored in
the refrigerator
15. Palpation, as a modality for physical examination
is AVOIDED when diagnosed with
pheochromocytoma because this
action_______________.
a. Will cause sudden release of
norepinephrine and severe hypotension
b. Will cause a sudden release of
cathecolamines and severe hypertension
c. Will displace the location of the tumor
d. Will cause sudden release of
epinephrine and severe palpitation
Situation 4 – Mr Conrado is being prepared for a
major surgery. Legal preparation for surgery
consists of checking all the required forms for the
operation. Equally important is to make sure that
the patient is physically, psychologically, and
emotionally ready for the procedure.
16. Informed consent is a process that gives the
patient opportunity involved in his or her care.
As patient advocate, the nurse ensures the
following three conditions are present to make
consent valid, EXCEPT:
a. Adequate disclosure of the diagnosis by
the physician
b. Comprehension of information by the
patient before the operation
c. Patient voluntarily giving consent
d. Forms signed by any close relative
or watcher
17. The patient asks you, “What do you think of my
surgeon?” You answered “hmmmmm… he is not
really the best one and he seems not to care for
patient...” As a result, the patient switches to
another surgeon. The latter may have grounds
to sue you for _____________.
a. Slander - spoken
b. Invasion of privacy
c. Malpractice
d. Libel - written
18. One of your patient‟s visitors whisper to you, “I
hope you will not try to revive my dear friend if
her heart stops as she has already suffered a
lot.” The correct response is ___________.
a. “That decision is up to the physician”
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 b. “We are all trained in cardiopulmonary
resuscitation”
c. “There is a „ Do not resuscitate‟ order in
her chart”
d. “ I understand your concern, but I
can’t discuss this matter with you”
19. According to the Joint Commission, the most
frequently cited factor in sentinel (unanticipated)
events that leads to a patient‟s serious physical
or psychological injury is
______________________.
a. Confusion within the health team
b. Miscommunication among health team
members
c. Incompetence by a team member
d. Policy changes are not followed by
adequate and consistent staff education
Situation 5 – Conducting Research is one of the
major roles of the nurses both in hospital and
community settings. To be able to develop such
competencies, the nurse has to undergo an actual
conduct of the research process.
20. Which of the following statements BEST
described a researchable problem?
a. Responses of parents toward having
children with congenital heart diseases.
b. The relationship between
relaxation technique and relief of
pain of post CABG patients in the
surgical coronary care unit. –
complete: has relationship, IV, DV, and
population
c. Incidence of medication errors and
reporting practices of Health Care
Professional in a teaching hospital
d. To what extent do pre-operative
teaching affect the length of
hospitalization of patients going for
surgery
21. Nurse Joan has to undergo literature search for
her study. She can avail of this from the
following EXCEPT_____________.
a. A summary of research articles that are
relevant to the study
b. A written document published by the
investigator herself
c. Any retrieval from website that will help
her search for the subject on
investigation
d. A description of the scientific study
from
TOPRANK REVIEW ACADEMY INC.
RECALLS 1 EXAM
an information provided by a
faculty member teaching research –
only those written in formal paper
22. Weight is taken as a baseline measurement of
obese female adolescents as study subjects for a
weight reduction program. This is repeated to
note any changes. This pre-test is done
to___________________.
a. Determine whether the instrument is
defective
b. Assess if research design is appropriate
to the problem identified
c. Evaluate whether the instrument is
defective
d. Obtain preliminary data before a
treatment is conducted by the
researcher – basis for comparison
23. A Nurse researcher is using ACCU-CHEK a
monitoring kit to test presence of Diabetes
Mellitus among her study subject. How do you
classify this type of measurement?
a. Microbial
b. Cytological
c. Physiological
d. Chemical
24. Nurse Joan, wanted to conduct a study using
quasi-experimental design. This design will need
a __________.
a. Retrospective evaluation
b. Field setting for the study
c. Comparable group – or control group
d. Manipulation of the dependent variable
Situation 6 – Kenneth, 16 year old, a foreigner
was admitted in the medical ward due to
abdominal pain, nausea and vomiting by Nurse
Tessie.
25. In initiating care for patient Kenneth, which of
the following would be an APPROPRIATE
question to be asked by Nurse Tessie in her
assessment?
a. Since this is doctor’s order, you have to drink
ice water, instead of hot tea.
b. Do you have any books I could read about
people of your culture?
c. Do you need to set aside your cultural
practices, and comply with hospital rules and
regulations?
d. Is there anything I am doing that is not
acceptable to your culture?
26. Nurse Tessie respects cultural practices
integration in her nursing care plan. Which of
the following nursing action is MOST represented
of the culturally competent nurse?
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 a. Help patient Kenneth to learn and
understand the language
b. Explain and validate health knowledge
and beliefs of Patient Kenneth with that of
the hospital
c. Help Patient Kenneth identify ways to relate
more to the culture where they now resides
d. Ask patient Kenneth to help Nurse
Tessie in knowing more the culture of
his origin
27. The family of Patient Kenneth request utilization
of warm compress with banana leaves to Patient
Kenneth. Which of the following is the MOST
appropriate response of Nurse Tessie?
Alternative therapies_________.
a. Cost less than traditional therapies
b. Are use when traditional therapies are
not effective
c. Utilized natural products while
traditional therapies do not
d. Can be effective as traditional
therapies for some conditions
28. Patient Kenneth‟s family requests time for
spiritual healing process in the hospital. This is
allowed by Nurse Tessie and hospital because
it______________________.
a. Gives fulfillment and meaning to the
patient and family
b. Demonstrate people being responsible for
their life patterns
c. Is non-denominated community service
d. Formalizes a religious dogma
29. Positive Practice Environment (PPE) influences
healing process. Which of the following ways can
help Nurse Tessie create a healing environment?
a. Ensure that relatives and friends visit the
patient
b. Empower clients to make healthy decisions
for themselves
c. Place television in each room of the hospital
d. Ensure that staff nurses does not
experience burnout
Situation 7 –Julie, 28 years old, has been
diagnosed with Diabetes Mellitus. She was
advised by her family physician to be admitted to
undergo preservation for insulin therapy. Her
blood sugar ranges from 200 to 210 mg/dL. At 6
am, Nurse Cynthia administered her insulin
injection. After 2 hours, the patient complained of
cold clammy perspiration, chilly sensation and
abdominal discomfort.
30. Which of the following PRIORITY nursing actions
should the nurse perform?
TOPRANK REVIEW ACADEMY INC.
RECALLS 1 EXAM
a. Give her biscuit to eat – check CBG
1st then eat or give D5050 if too low
b. Do urine testing for sugar
c. Provide her warm blanket
d. Take blood pressure and put her on bed
rest
31. Patient Julia has been classified to have a type II
Diabetes Mellitus. Which of the following is NOT
a typical manifestation of individuals with this
condition?
a. Frequency of urination
b. Increased craving for food
c. Increased thirst
d. Weight loss
DAY 2: MAY 11, 2021
Situation 8 – Mr Dencio, 58 years old is admitted
to the pay ward because of respiratory problem.
The nurse initiated oxygen treatment by mask but
the client refuses despite the encouragement by
the wife. The client is aware of the benefits of the
treatment.
32. Which of the following should be given priority?
a. Ask the opinion of the wife
b. Conduct consensus building
c. Let the attending physician decide on
the necessity of the treatment
d. Respect the decision of the client -
autonomy
33. You are taking care of Mr Domingo who is on
the last cycle of radiation therapy for his lung
cancer. You should instruct Mr Domingo to
a. Brush teeth and gums vigorously after
meals
b. Wait one hour after treatment before
eating
c. Use mouthwash containing alcohol every
2 hours – irritate oral tissues
d. Avoid drinking hot fluids – damage
oral tissues
34. When the Nurse is assessing a client with
Congestive Heart failure with pitting edema, the
Nurse’s documentation will include which of the
following:
a. Degree of pitting edema
b. Time of indention recovery
c. Depth of edema
d. All of the options
35. Mr. Gabby is with left sided heart failure. Ime‟s
documentation of her assessment findings will
include the following, EXCEPT______________.
a. Dependent edema – RSHF:
systemic ; left if lungs
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 b. Pulmonary crackles
c. Difficulty of breathing
d. Cough
36. A client is on a diuretic therapy. Expected entry
in patient‟s chart should include the following
information, EXCEPT:
a. Serum electrolytes monitored
b. Intake and output
c. Lasix administered at 8 o‟clock
in the evening – hindi dapat sa
gabi kasi hindi na makakatulog.
However, can be given if with foley
cath because pt doesn’t need to
ambulate
d. Weight is taken before drug is given
Situation 10 – Myreen, a 42 year old teacher
with cardiac ailment, nervously informs the
doctor that her goiter is getting bigger and
distracts her while swallowing food. The
physician who examined her instructed the
nurse to admit Myreen and to prepare her for
surgery after medical clearance.
37. While interviewing Patient Myreen, she claims
that she is anxious for the coming surgery. You
expect the following signs and symptoms when
one is under stress, EXCEPT___________
a. Blood loss and weakness
b. Increases respiration rate
c. Decreased mobility
d. Pain due to tissue damage
38. Based on your knowledge, Patient Myreen, who
has a history of cardiac illness, should not be
given an enema before surgery. Which of the
following reasons inhibits the order of enema for
Patient Myreen? Enema____________
a. Paralyzes the peristalsis movement
and increases abdominal pain–
enema increases peristalsis by
distending the bowel or irritating the
intestinal mucosa
b. Produces vagal stimulation that
is dangerous to cardiac patient
– vavagal heart rate
c. Causes constipation and fecal
impaction after the surgery – on the
contrary, enemas relieve
constipation
d. Enema results to increased water
absorption in the bowels
Situation 11 – Mr MC came to the ER because
of sharp troubling pain. After his surgery, he
claimed pain is felt even he is asleep.
TOPRANK REVIEW ACADEMY INC.
RECALLS 1 EXAM
39. At what stage of pain mechanism do you classify
this pain?
a. Perception – nararamdaman niya ;
nociception
b. Modulation
c. Transmission
d. Transduction
40. When a client complains of pain less than 6
months, it is called_____________.
a. Chronic pain – more than 6 mos, usually
seen in CA
b. Persistent pain
c. Acute pain
d. Intermittent pain
41. In order for the nurse to recall the location of
pain, he has to_______________.
a. Asks for onset and duration
b. Mark the painful area in a body
diagram
c. Asks for facial expression
d. Asks verbal description using pain
intensity scale
42. As example of a drug therapy to relieve
moderate pain is_____________.
a. Codeine – others are for severe pain
b. Demerol
c. Methadone
d. Morphine sulphate
43. When a client is on prolonged pain therapy, the
nurse should watch for____________.
a. Tolerance to drug – yung dating dose
na gumagana sayo, hindi na gumagana
ngayon, kailangaan na taasan
b. Allergic reaction to drug
c. Drug resistance
d. Addiction to
Situation: The nurse at the Operating Room should
be made aware of the functions and implications of
being both a circulating and a scrub nurse. The
following questions apply.
46. The nurse was not able to completely account for the
sharps that were used during an exploratory
laparotomy. The surgeon agreed to close the suture
even if the situation was mentioned above. It was
found out that one needle was still left at the
peritoneum of the client. The surgeon was accused of
malpractice because of what happened. Which among
the following doctrines explains the scenario above?
a. Res Ipsa Loquitur – the thing speaks for itself,
kita na yung evidence
b. Force Majeure
c. Respondeat Superior
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 d. Subpoena duces tecum
47. Which among the following is considered as part of the
intraoperative phase?
a. Patient has decided to have a reconstructive
surgery
b. Induction of the anesthesia
c. Patient having two CTT after a heart transplant
d. A patient diagnosed to have a constrictive
pericarditis
48. Which part of the anesthetic ladder is the patient noted
to have increased autonomic activity?
a. Analgesia Phase
b. Delirium Phase – dec sensation
c. Surgical Phase
d. Danger Stage – overdose
49. Which among the following is NOT a principle of
surgical asepsis?
a. Always face the sterile field.
b. Sterile articles unused and unopened are still
considered sterile after the procedure.
c. The sterile field is above the waist level and on top
of the sterile field.
d. Eliminate moisture that causes
contamination – not moisture but wet
50. Which among the following post-operative
complications is characterized as the collapse of one
lung segment or the whole lobe or a number of alveolar
groups?
a. Pneumoectasis
b. Atelectasis
c. Pulmonary embolism
d. Pulmonary Shock
*if R ang affected – best heard ang sound sa L ;
tracheal deviation: sa R, kasi itutulak ni L si R
SITUATION: You are caring for a married woman
who underwent modified radical left mastectomy
51. On admission to Post-anesthesia Care Unit, you read
the OR report which indicates that estimated blood loss
during surgery was 1000mL. From the list below, select
the MOST objective indicator for the nurse to monitor
closely.
a. Changes in vital signs
b. Altered level of consciousness
c. Soaked dressing
d. Pupillary reaction to light
52. You assisted positioning the client. Her left arm should
be placed in which of the following manner?
a. Placed above the level of the heart – prev
lymphedema
b. Hyperextended away from the chest
c. Placed at the level of the heart and the hand
below the heart
TOPRANK REVIEW ACADEMY INC.
RECALLS 1 EXAM
d. Adducted and flexed
53. When the patient woke up from anesthesia, she
refuses to see her husband. She remarks that she is
“not the same person, no longer a woman; much,
much less a wife.” Which psychosocial nursing
diagnosis would best describe this situation?
a. Altered role performance r/t impaired physical
function
b. Anxiety r/t surgical removal of the breast
c. Altered body image r/t perception of
disfigurement and incapacity
d. Self-esteem disturbance r/t changing ability to
perform basic wife function
54. The client was obviously withdrawn although her
recovery from the surgery was uneventful. How can
the nurse be of best help during this period of
recovery?
a. Allowing the client to have more time to herself
b. Encouraging the client to have more time to
verbalize concerns with her family
c. Allowing the client to talk with other clients in the
ward who had the same kind of surgery
d. Allowing the patient more time to reflect about the
effects of surgery
55. During the first 8 hours postoperative, the total
drainage from the Jackson-Pratt drain attached to the
wound totaled to 25 mL. What is your next best action?
a. Do nothing as the drainage is expected
b. Empty the Jackson-Pratt device
c. Notify the surgeon stat
d. Inform the client that her wound is draining well.
56. A postmenopausal patient is scheduled for a
bonedensity scan. You instruct the patient to
______.
a. report any significant pain to the
physician at least two days before the test.
b. ingest 600 mg of calcium gluconate by
mouth for two weeks before the test
c. consume foods and beverages with a
high content of calcium for two days before the
test.
d. remove all metal objects on the day of
the scan – risk for osteoporsis ; interfere with
visualization
57. To complete the history and physical
examination of a patient diagnosed with osteoarthritis,
you should assess for presence of _____.
a. anemia
b. local joint pain
c. weight loss
d. osteoporosis
58. Ibuprofen (Motrin) 200 mg bid was prescribed
for a patient with left hip pain secondary to
osteoarthritis. To minimize gastric mucosal irritation,
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which is a side effect of the drug, what instruction would
you give the patient as to when to take it?
a. on arising
b. on an empty stomach – for faster absorption
c. immediately after a meal – could cause GI
bleeding
d. at bedtime
Situation: Nurse Sylvia is assigned in Out Patient
Department medical center. Every Wednesday of
the month, the health care services are scheduled
for patients with endocrine disorders.
59. BONUS HAHAHAHA The patient is admitted to
the private room for further work-up. You started to
develop a nursing care plan for Ms. Belen. Which of the
following nursing diagnosis is APPROPRIATE for her at
this time?
a. Disturbed thought processes R/T hyper
metabolic rate
b. Constipation R/T gastro intestinal hyper
motility
c. Imbalanced Nutrition R/T Less body
requirements
d. Activity intolerance R/T decreased metabolic
rate
60. Once Ms. Belen is confirmed to have
hypothyroidism, she might experience hematologic
compromise.Which of the following is not an expected
hematologic consequence of hypothyroidism?
a. iron and folate deficiency – anemia is d/t
dec hematocrit
b. decreased hematocrit
c. oxygen demand is decreased
d. increased Serum cholesterol
Situation: Nurse Danj admitted a new patient to
the Medicine Ward: Lianmuel, 30, complains of
diarrhea for more than two weeks prior to
consultation. The diagnosis made was Crohn‟s
Disease (CD). A plan of care was made for
Lianmuel.
56. Which of these assessments does Nurse Danj expect
to see in the patient‟s records?
i. Weight gain of 1kg/day
ii. Arthralgia
iii. 10-20 liquid, bloody stools per day
iv. Tenesmus
v. Anorexia
vi. Crampy, intermittent pain
a. i, ii, iii, iv, v, vi c. i, ii iii, iv v
b. iii, iv, v, vi d. ii, iv, v, vi
TOPRANK REVIEW ACADEMY INC.
RECALLS 1 EXAM
57. Nurse Danj should include which of the following
interventions for Lian?
a. Increase physical activity to promote intestinal
activity
b. Instruct the patient to increase intake of raw fruits
and vegetables
c. Include high-fiber food choices following the acute
phase of the condition
d. Provide Sitz bath for the skin excoriation
from bowel movements
58. What is Nurse Danj’s priority for Lian if the latter
develops fistula from his CD?
a. Fluid and electrolyte balance c. Self-esteem
needs
b. Pain management d. Skin protection
59. Which of the following signs and symptoms may
suggest presence of megacolon (d/t feces) from
antidiarrheal drug use?
a. Leukopenia c. Bradypnea
b. Fever d. Hypothermia
60. If Lian were a geriatric client, which of these is the
first indication of dehydration from fluid volume
depletion?
a. Tachycardia
b. Altered mentation – usually mental or altered
LOC
c. Hypotension
d. Fever
Situation: To carry out management functions in
any health care setting, it is necessary for the nurse
to integrate leadership skills that he/she
developed.
61. The organizational chart of a nursing department
illustrates the structure and relationships of the
nursing leaders and staff of the organization. The
following are the functions of an organizational chart,
except:
a. To illustrate centrality of control in the
organization and chain of command
b. To indicate relationship of leaders to other
management staff
c. To identify managerial levels
d. To list all functions and duties of the staff –
found in job description
62. Coercing a patient into taking medications by
threatening punishment could legally be considered
as:
a. Assault c. Malpractice
b. False imprisonment d. Battery
63. The doctor assigned to the patient was also sued
together with the nurses. When it was his turn to take
the stand during the next hearing, he was told to bring
with him a copy of the patient‟s chart. The hearing
Page 30
 officer will have to issue what legal order to bring the
patient‟s chart?
a. Writ of certiorari
b. Subpoena duces tecum – ducument
c. Subpoena ad testificandum – ikaw mag testify
d. Writ of quo warranto
64. Mr. Putanesca‟s status has declined after being
revived yesterday after suffering from arrest. Dr.
Risotto wrote a DNR order. This order implies that:
a. The patient need not be given food and water.
b. The nurse need not give due care to Mr.
Putanesca even giving bed bath.
c. The nurses and the attending physician need
not do any heroic or extraordinary measures
for the patient.
d. The patient need not be given ordinary care so
that his dying process is hastened.
65. What ethical principle applies when the surgical team
adheres to surgical asepsis during surgical procedure?
a. Justice c. Maleficence
b. Nonmaleficence d. Beneficence
Situation: Nurse Sisley is a nurse in Diliman Doctors
Hospital caring for clients with problems in the
biliary tree.
66. A patient with complaints of indigestion and RUQ pain
was diagnosed with cholecystitis and underwent an
emergency laparoscopic cholecystectomy. Which of
these should Nurse Sisley not include in her post-
operative care?
a. Instruct the client about splinting during coughing.
b. Encourage early ambulation.
c. Maintain the client flat on bed – ma-aspirate
sa sariling suka kasi may N/V ; should be semi
fowler’s
d. Assess the patient‟s O2 saturation level
frequently.
67. Which of these is the best indicator that peristalsis has
resumed after the surgery?
a. Active bowel sounds c. Drainage from NG suction
b. Passage of flatus d. Tympany upon
percussion
*paralytic ileus – absence of GI motility
68. A T-tube was inserted to maintain patency of the
common bile duct. How should Nurse Sisley position
the client for better drainage?
a. Side-lying position c. Semi-Fowler’s
b. Prone position d. Low Fowler’s
69. Rico Y. An is brought to the emergency department
because of severe and constant abdominal pain.
Nurse Sisley should conduct comprehensive nursing
interview:
a. Right upon entrance to the emergency department
b. After the vital signs have been taken
TOPRANK REVIEW ACADEMY INC.
RECALLS 1 EXAM
c. After pain is controlled – Physical exam over
nursing health hx
d. During physical examination
70. Rico Y. An was diagnosed to have acute pancreatitis
from excessive alcohol intake. Which of these is a
characteristic of the abdominal pain in acute
pancreatitis?
a. Sharp, intermittent pain
b. Intense, boring pain
c. Relieved when in supine position
d. Worsens when a fetal position is assumed
Situation: Gastrointestinal problems are rampant
in the ward Nurse Patricia is assigned in. The
following questions apply.
71. Jean is a patient admitted in the ward for her
hemorrhoid management. The following are
recommended for caring for Jean, except:
a. Tepid Sitz baths
b. Wiping to clean the anal area
c. High-fiber diet
d. Use of moistened tissues in cleaning the anal area
72. A patient with colorectal cancer and who underwent
surgery a week ago had colostomy in place. What
assessment finding of the stoma is expected?
a. It is draining bright red blood profusely.
b. It protrudes about 2 centimeters from the
abdominal wall
c. It is dark red and flaccid.
d. It is reddish pink and dry.
73. Which of these refers to the upper abdominal pain
when eating?
a. GERD c. Achalasia
b. Gastritis d. Dyspepsia
74. A patient with duodenal ulcer experiences pain that is
usually aggravated by which of the following?
i. Ingestion of food
ii. Caffeine
iii. Fried foods
iv. Spicy food
v. NSAID use
vi. Corticosteroid use
a. i, ii, iii, iv, v, vi c. i, ii, iv, v, vi
b. ii, iii, iv, v d. ii, iii, iv, v, vi
*relieved by eating – sakit nang mayayaman kasi kain
nang kain HAHAHAHAHAH pag mahirap gastic ulcer kasi
palaging gutom
75. Once peristalsis is established and confirmed after a
patient underwent surgery for (diverticulosis – just
outpouching, no inflamm) diverticulitis, which among
these does Nurse Patricia expect to be given first?
a. Mashed potato c. Plain gelatin – clear liquid
diet
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 b. Yogurt d. Pudding
Situation: You are caring for patients with various
cardiovascular problems.
76. In reading ECG tracings, which of these represents
the time required for atrial depolarization, as well as
the impulse delay in the AV node and the travel time
to the Purkinje fibers?
a. PR segment c. PR interval
b. QRS complex d. ST segment
*conduction system: SA node (pacemaker) > AV
node > Bundle of His > Purkinje fibers
*atrial repo meron pero natatabunan kasi malakas
ang QRS (ventri depo)
77. A patient with first-degree AV block will usually
manifest which of the following in his ECG reading?
a. Prolonged PR interval c. Irregular rhythm
b. Widened QRS d. Reverted P waves
Rationale: First-degree AV block occurs when all the
atrial impulses are conducted through the AV node
into the ventricles at a rate slower than normal. Rate
is usually dependent on the underlying rhythm, and
rhythm is usually regular. QRS is usually normal, with
PR interval > 0.20 seconds.
78. Which of these would characterize a third-degree AV
block?
a. Regular, rapid rhythm
b. Irregular, rapid rhythm
c. Regular, normal to slow rhythm
d. Irregular, normal to slow rhythm
Rationale: In a complete heart block, the conduction
between the atria and ventricles is absent because of
electrical block at or below the AV node. Usually, the
rhythm is regular but the atria and ventricles act
independently.
79. Which of these is your priority in caring for a client
who just had a pacemaker installed?
a. Encourage patient ambulation.
b. Minimize patient’s activity – dec cardiac
demand bec body is still adjusting to the
pacemaker
c. Increase frequency of passive ROM exercises.
d. Instruct the client to perform pursed-lip breathing
exercises.
80. Patient Elijah, who has an implanted pacemaker, is
about to enter the airport premise to be able to check
in his flight to Maldives. Knowing the dangers of the
screening devices held by the guards at the airport
entrance, what is the best thing Elijah should do?
a. Request the security personnel to exempt him
from security checking because of his pacemaker.
b. Ask if the security can inspect him manually
or through a hand search
TOPRANK REVIEW ACADEMY INC.
RECALLS 1 EXAM
c. Tell the security guard to keep his screening
device.
d. Proceed through since the handheld device will
not interfere with the pacemaker.
Situation: Hazel, 50 years old, a restaurant
business owner, smokes and drinks in a lot of
alcohol beverages especially when she is stressed
at work. She is obese and has been diagnosed to
be a borderline diabetic. Recently, she is having a
yellowish discoloration of the skin. She consulted
her private physician and was advised to be
hospitalized because of a suspected fatty liver.
86. You are the Nurse-on-duty, when she was admitted.
You conducted the initial physical examination. The
APPROPRIATE modality in examining an enlarged liver is
to:
A. Palpate the liver below the level of the right
rib of the patient
B. Percuss the liver over the right rib cage
of the patient
C. Palpate the liver above the level of the right
rib cage of the patient
D. Auscultate the liver below the level of the
right rib cage of the patient
87. Ms. Hazel was ordered to undergo liver biopsy. The
nurses responsibility includes the following except:
A. Turn the patient on supine position at right edge
of the bed.
B. Turn the patient to hold her breath while needle is
being inserted to the intercostal space
C. Turn the patient on the left side after the
procedure – apply pressure to prev bleeding
D. Secure informed consent
2 You are aware that Liver biopsy should NOT be
performed on patient Hazel if she has:
a prothrombin time of 12-15 seconds
b temperature of 37.2 degree Celsius
c normal breathing pattern
d ascites – will not obtain tissue bec of edema
3 For the first 24 hours after liver biopsy the PRIORITY
untoward reactions that you should watch for:
a change of mental status
b stages of hemorrhages – liver is highly
vascular
c signs of increasing blood pressure
d Cyanosis of the extremities
4 In planning nursing care for a patient with fatty liver,
the nursing intervention should FOCUS on:
1. Limit alcohol intake
2. Weight reduction
3. Lifestyle changes
4. Reduction of blood sugar
A. 1, 2, 3 and 4 B. 2 only
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 C. 1 and 2 D. 1,2 and 3
*if alcohol – LIMIT ; smoking - STOP
Situation: Mr. Ros, a 50 year old was admitted to
the hospital ward because of abdominal
enlargement, and is scheduled for exploratory
abdominal surgery the next day. An informed
consent has to be accomplished.
91. Who among the members of the surgical team is
responsible to explain the informed consent?
A. Surgeon C. Circulating nurse
B. Anesthesiologist D. Medical Director
*kung sino ang gagawa
92. It is important that Mr. Ros is advised by the
Nurse to have nothing by mouth prior to surgery. If
this is a major operation and the schedule of
surgery is at seven in the morning, which of the
following time for fasting should be observed by the
patient?
A. 7-8 hours fasting
B. 4-5 hours fasting
C. 9-10 hours fasting
D. 3-4 hours fasting
*prev N/V, aspiration
93. As a surgical nurse, which of the following
interventions are included in your pre-operative
teaching?
A. Deep breathing exercises – prev
atelectasis
B. Hand and foot exercises
C. Valsalva Maneuver
D. None of the Above
*coughing – prev pneumonia
94. Patient asked the surgical nurse why he had an order
of nothing per mouth. Your BEST response is to prevent:
A. Shock C. nausea and vomiting
B. Aspiration D. regurgitation
95. Nurse Cleofe would like to assume a patients
advocate when the patient for surgery. Which of
the following is an example of this nursing role?
A. Nurse ensures patient is
appropriately prepared for surgery – valid
and no coercion done
B. When the consent is signed by a legal
person
C. She makes the patient understand the
benefits and risks of procedure
D. A nurse makes documentation that the
surgical procedure is needed
Situation: Documentation is an important aspect of the
nursing process. Nurse Cora is assigned in the medical
unit and responsible for a group of patients. Reporting
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and Recording is a part of her job description. The
following questions apply.
96. Nurse Cora made an entry on the patients care
plan: "Goal not Met," patient refuses to undergo breast
biopsy, patient claimed it is painful. Which of the
following should the nurse undertake as an appropriate
action guided by this recording?
A. Reassess set objectives
B. Reassure the patient
C. Notify the physician – respect or accept
then report para MD ang mag-explain
D. Reassess patients behavior
97. The nurse is measuring the patient‟s urine and
is straining it for presence of stone. Which of the
following should the Nurse record in the progress notes
as an objective data? The patient
A. States "I did not see any stone in my urine"
B. Passed out 400 mL of clear urine
C. Claims "I passed few small stones in my
urine"
D. Is complaining of flank pain during urination
98. Nurse Cora while reviewing the medication
record has observed a handwritten order, which is
unclear. What PRIORITY nursing action should the
Nurse do?
A. Call the attention of the doctor who
prescribed the drug – pa-clarify sa nagsulat
B. Refer to the nurse supervisor for the incident
report
C. Call the pharmacist who dispensed the drug
D. Read the drug reference to check the drug
99. The team leader is assessing and recording the
status of their patients for the shift. Their
documentation should reflect which of the BEST
cardinal principles?
A. Quality and timeliness of nursing care
B. Interdisciplinary communication within the
shift
C. Application of the Nursing
process – either type or form of docu,
may nsg process pa rin
D. Compliance with the documentation
standards
100. When a patient is with hematemesis, which of the
following should you read in the charting of nurse Lerma
on patient with Gastrointestinal (GI) bleeding?
A. Small amounts of blood in gastric
secretions detectable by guaiac test?
B. Bloody vomitus appearing as fresh,
bright red blood, "coffee grounds"
appearance
C. Bleeding coming from esophageal
varices observed after surgery
Page 33
 D. Black, tarry stools cause by digestion of
blood
NURSING PRACTICE IV
Situation 1 – The charge nurse in the medical unit
updates her knowledge on nursing diagnosis. She
reviews the terms used to describe clinical
adjustment.
1. A nursing diagnosis formulated when there is
insufficient evidence to support the presence of
the problem but the nurse believes the problem
is highly probable and wants to collect more
data is a/an _________:
A. Risk nursing diagnosis – complete data and
likely to happen
B. Possible nursing diagnosis – incomplete
data or evidence
C. Actual nursing diagnosis
2. Wellness nursing diagnosis Which of the
following statements is a WELLNESS nursing
diagnosis?
A. Constipation related to decreased activity
and fluid intake
B. Risk for Activity Intolerance related to
prolonged bed rest
C. Possible Self-Care Deficit; grooming related
to fatigue and muscular weakness
D. Potential for Enhanced Spiritual Well
Being
3. Which of the following statements is a
POSSIBLE nursing diagnosis?
A. Constipation related to decreased activity
and fluid intake
B. Potential for Enhanced Spiritual Well Being
C. Possible Self-Care Deficit; grooming
related to fatigue and muscular
weakness
D. Risk for Activity Intolerance related to
prolonged bed rest
4. Which of the following is a RISK nursing
diagnosis?
A. Potential for Enhanced Spiritual Well Being
B. Possible Self-Care Deficit; grooming related
to fatigue and muscular weakness
C. Risk for Activity Intolerance related to
prolonged bed rest
D. Constipation related to decreased activity
and fluid intake
5. Which of the following statements is an ACTUAL
nursing diagnosis?
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A. Possible Self-Care Deficit; grooming related
to fatigue and muscular weakness
B. Potential for Enhanced Spiritual Well Being
C. Risk for Activity Intolerance related to
prolonged bed rest
D. Constipation related to decreased
activity and fluid intake
Situation 2- The nurse provides health education
to a group of adolescents about pelvic
inflammatory disease. (PID).
6. The nurse explains that prevention of PID in
adolescents is important due to which of the
following reasons. PID ________:
A. can have devastating effects on the
reproductive tract of affected
adolescents
B. is easily prevented by compliance to any
form of contraception
C. can cause life-threating defects in infants
born to affected adolescents.
D. Is easily prevented by proper personal
hygiene
7. The nurse explains to the group of adolescents
that the most common cause of PID is _______:
A. Tuberculosis bacilli
B. Gonorrhea – tx: Ceftriaxone 250 mg +
Azithromycin 1 g
C. Staphylococcus
D. Streptococcus
8. The nurse further explains that PID presents the
following signs and symptoms, which the
adolescent should be aware of:
A. A hard painless, red and defined lesion on
the genital area.
B. Small vesicles on the genital area with
itching.
C. Lower abdominal pain and urinary tract
infection.
D. Cervical discharge with redness and edema.
9. Which of the following statements is true when
teaching adolescents about gonorrhea?
A. Gonorrhea may be contracted through
contact with a contaminated toilet seat.
B. The infectious agent for gonorrhea is
Neisseria gonorrheae.
C. Gonorrhea is most often treated by
multidose of administration of penicillin.
10. Treatment of sexual partners is an essential part
of treatment. The nurse further explains to the
adolescents that gonorrhea is highly infectious
and it ____:
A. Is limited to the external genitalia
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 B. Can lead to sterility
C. Is easily treated
D. Occurs rarely among
Situation 3- A 45 year-old female, married with
two children, is admitted in the medical
department with a diagnosis of osteoarthritis. The
nurse assists in the care of this client.
11. Which of the following signs and symptoms
should the nurse correlate with a diagnosis of
osteoarthritis?
A. Erythema and edema over the affected joints
B. Joints stiffness that decrease with
activity + but pain inc
C. Anorexia and weight loss
D. Fever and malaise
12. Which of the following factors would MOST likely
increase the joints symptoms of osteoarthritis?
A. Emotional stress
B. Obesity – naiipit ang joints
C. History of smoking
D. Alcohol abuse
13. The client asks the nurse what joints are
affected in osteoarthritis. The nurse explains that
the joints MOST likely involved in this disease
are the ________________;
A. Cervical spine and shoulder
B. Fingers and metacarpals
C. Hips and knees – weight-bearing joints
D. Ankles and metatarsals
14. The client asks the nurse what activities she can
perform to effectively decrease the pain and
stiffness in her joints before she starts her daily
routine. The nurse instructs the clients to
______?
A. Take a cold bath and rest for a few minutes
B. Perform range-of-motion exercise and
apply liniment to the affected joints.
C. Take a warm bath and rest for a few
minutes.
D. Stretch all muscle groups. – stretching all
muscle groups is not necessary to decrease
the pain and stiffness in the patient‟s joints.
15. The physical therapist prescribes a regimen of
rest, exercise and physical therapy to the client.
The nurse understand that this regimen will:
A. Provide for the return of joint motion after
prolonged immobility,
B. Help prevent the crippling effect of the
disease – limit progression or complications
C. Halt the inflammatory process.
D. Prevent arthritic pain.
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Situation 4 – The ER personnel of hospital X
receives a report that a bus traversing a hi-way
fell off the road. There were several passengers
injured. You are one of the nurses in the ER. You
assist in preparing the ER to receive the injured
passengers.
16. As an ER nurse, one of the most important
assessment skill you need is to prioritize care
utilizing the triage system. The triage system is
used to:
A. Rapidly assess clients and classify them
according to age groups,
B. Identify and categorize clients so that the
least critical are treated last.
C. Identify and categorize clients so that
the most critical are treated first
D. Rapidly assess clients and classify them
according to gender.
17. One of the injured passenger brought in was
unconscious and has multiple trauma. Using the
5-level of emergency severity index (ESI), how
SOON should the injured passenger be seen by a
physician?
A. ES4, ES5 (stable), could be delayed – one/no
resource needed
B. ES1 (unstable), immediately – requires
immediate life-saving intervention
C. ES2 (threatened), within 10 minutes – high
risk situation or
confused/lethargic/disoriented or in severe
pain/distress
D. ES3 (stable), up to one hour – many
resources are needed but no danger zone
vitals
(Reference: Agency for Healthcare Research
and Quality)
18. You do an emergency assessment of one of the
injured passengers. Which assessment should
take priority?
A. Blood pressure
B. Breathing pattern
C. Airway clearance
D. Circulatory status
19. You take the vital signs of the injured
passengers. Which of the following vital signs
indicate thatthe person is experiencing
hypovolemic shock?
A. P- 60 beats per minute; RR- 20 breaths per
minute; BP- 100/70 mmHg
B. P- 80 beats per minute; RR- 22 breaths per
minute; BP- 110/80 mmHg
C. P- 100 beats per minute; RR- 24 breaths per
minute; BP- 140/70
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 D. P- 110 beats per minute; RR- 26
breaths per minute; BP- 80/60 mmHg –
hypo tachy tachy (shock triad) interventions:
establish IV access, modified
trendenlenburg, assess 02, give inotropes –
dopa/dobu
20. One of the male passengers sustained a
concussion during the accident. He appeared to
be disoriented and restless. Which of the
following nursing diagnoses is a priority for the
care plan?
A. Sensory or perceptual alteration – health
threatening problem, medium priority problem
B. Dressing or grooming self-care deficit – requires
only minimal nursing support, low priority
problem
C. Impaired verbal communication - requires only
minimal nursing support, low priority problem
D. Risk for injury – disoriented or confused d/t
concussion (nabagok)
Situation 5 – A 30 year old male fell from a tall
building while doing construction work. He is
conscious and apparently alert but could not move
his arms and legs. His co-workers called for the
paramedics for emergency assistance.
21. When planning to move a person with possible
spinal cord injury, the primary concern of the
paramedics would be to __________:
A. Wrap and support the extremities which can
be injured easily.
B. Cushion the back with pillows to ensure
comfort
C. Move the person gently to reduce pain
D. Immobilize the head and neck to
prevent further injury.
*log roll – turn as one unit
22. The victim is brought to the emergency
department of hospital X. The physician assesses
the client. The client is confirmed to have spinal
cord injury. Which of the following would be the
MOST important nursing intervention during the
acute stage of the client‟s care?
A. Monitor vital signs – routine
intervention/assessment
B. Maintain proper alignment – this is also
crucial because improper
alignment/movement can cause further
damage and loss of neurological function.
Head flexion, rotation or extension should be
prevented (Saunders, p.2881-2882).
C. Turn and reposition client every 2 hours. –
during the acute stage, the client must be
immobilized to prevent further injury
(Saunders, p.1883).
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D. Maintain a patent airway.
23. A physical therapist prescribes passive range-
ofmotion exercises for the legs and assisted
ROM exercises for the arms as part of the
client‟s care regimen. Which observation by the
nurse would indicate that the treatment is
effective?
A. Absence of paralytic drop –
AKA foot drop
B. Free easy movement of the joints.
C. Absence of tissue ischemia over bony
prominences.
D. External rotation of the hips at rest.
24. The fracture is repaired by the orthopedic
surgeon. As soon as healing has taken place, daily
physical therapy sessions are scheduled that includes
using a tilt table. After the therapist places the client
at a 45 degree angle, the nurse should monitor the
client for which of the following? *
A. Hypertension
B. Pedal edema
C. Facial flushing
D. Dizziness – d/t orthostatic hypotension
25. After a month of therapy, the client begins to
experience muscle spasms in his legs. Which of
the following statements is accurate? The leg
spasms _____; *
A. Indicate that the damaged nerves are
healing.
B. Means eventually, the client will be able to
walk again because the damage is not
permanent.
C. It is a good sign therefore, the client should
keep on trying to move all the affected
muscles.
D. Occur from muscle reflexes and they
cannot be initiated or controlled by the
brain.
Situation 6 – Health care personnel including
nurses are part of a team trained to respond to
disasters that may occur in the community. The
following questions relate to disaster
preparedness.
26. In disaster preparedness, which of the following
is a responsibility of the nurse? The nurse
_____;
A. Assists in assigning tasks to members of the
emergency response team.
B. Serves as an advocate of the victim of disaster.
C. Assumes a leadership role in the command
center.
Page 36
 D. Assists with triage and emergency health
care needs of the injured or those involved
in the disaster.
27. A disaster preparedness plan is a formal plan of
action for coordinating the response of a health
care personnel, local government unit and other
trained personnel in the event of a disaster.
Which of the following statement is NOT TRUE
about disaster?
A. Disasters involve inter agencies working
together.
B. Disaster are natural events that causes
destruction and devastation.
C. Disasters can be controlled – can
mitigate effect only but can’t be prevented
from happening
D. Disasters result from human-made errors.
28. Which of the following concepts BEST describes
reverse triage?
A. Save scarce resource for future use.
B. Care for victim with life threatening
problems.
C. Attend to person with disabilities. –
ambulatory 1st
D. Save the ones injured who are in the most
critical condition.
29. The nurse in a disaster situation classifies victims
according to the following EXCEPT________? *
A. Urgency of treatment
B. Resources available to treat the victims
C. Severity of injury
D. Place of treatment
30. A nurse is the first responder in a disaster scene.
The nurse should FIRST________: *
A. Begin to triage the victims.
B. Wait for rescue workers to arrive at the scene.
C. Care for victim with life threatening
problems – reinforcement ang mag-triage
D. Attend to person with disabilities.
Situation 7 – Nurse Febe is a charge nurse in the
oncology unit. She applies principles of leadership
and supervision in the management of the client’s
environment.
31. Nurse Febe is aware that control of the
environment is a nurse‟s responsibility. Which
among of the following is the biggest problem of
hospitalized clients?
A. Lighting
B. Noise
C. Ventilation
D. Hospital bed
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32. An ideal environment for hospitalized
clients should be infection-free. Which of the
following infection protocol is the first line of
defense against infection?
A. Sterilization
B. Cleansing of environment
C. Disinfecting instruments
D. Hand hygiene
33. A staff nurse delegates routine morning care of a
client to a nurse aide. The person MOST
responsible for the safe performance of the care
is the___________.
A. Assistant chief nurse for the training and
education.
B. Nurse aide who perform the care.
C. Staff nurse who delegated the care
D. Charge nurse of the unit.
*5 Rights of Delegation:
1. Right Person
2. Right Task
3. Right Circumstance
4. Right Direction/Communication
5. Right Supervision
34. The most important reason why a nurse aide
must fully understand how to implement a
delegated procedure is because the nurse aide
must be able to ______________:
A. Teach another nurse aide the procedure.
B. Perform the procedure quickly.
C. Explain the procedure to the client.
D. Complete the procedure safely.
35. Nurse Febe makes the daily case assignment of
subordinates and strictly monitors their activities
and decisions. This is an example of what
leadership style?
A. Bureaucratic – the leader relies on
organizational policies and procedures for
decision-making (Saunders, p.256).
B. Democratic – based on the belief that every
group member should have input into the
development of goals and problem solving; a
democratic leader acts primarily as a
facilitator and resource person and is
concerned for each member of the group
C. Laissez-faire – a laissez-faire leader assumes
a passive, nondirective and inactive
approach and relinquishes part or all of the
responsibilities to the members of the group
(Saunders, p.256).
D. Authoritarian/Autocratic
Situation 8- A 55- year old male is brought to the
emergency ward on a wheelchair by a family
member. He complains of shortness of breath,
Page 37
dyspnea on exertion, palpitation, and cough with
frothy, blood-tinged mucus, fatigue and
weakness.
36. Based on the information presented, the nurse
formulates the nursing diagnosis. Which of the
following is MOST appropriate?
A. Activity intolerance related to compromised
oxygen transport system secondary to heart
muscle dysfunction.
B. Activity intolerance related to compromised
oxygen transport system secondary to heart
failure.
C. Anxiety related to actual threat to biological
integrity secondary to heart failure and
death.
D. Ineffective breathing patterns related
to decreased respiratory depth
secondary to pain – remove pain because
it is not stated in the situation
37. The nurse assesses the client. Which of the
following signs and symptoms would the nurse
expect of client with heart failure?
A. Strong, bounding – should be weak and
thready
B. Bradycardia
C. Murmurs
38. Normal respiratory rate The nurse administers
oxygen to the client. Which of the following
statement is TRUE about giving oxygen to
patient with heart failure?
A. Oxygen is administer thru mechanical
ventilation only.
B. Oxygen is prescribe to decrease the
work of breathing.
C. Oxygen is given to reduce anxiety.
D. Oxygen is contraindicated in heart failure.
39. The immediate management for a patient with
heart failure are the following, EXCEPT to ____:
A. Administer intravenous fluids right
away. – limit because of further congestion
B. Monitor heart rate and for dysrhythmia by
using cardiac monitor.
C. Provide reassurance of patient.
D. Assess level of consciousness.
40. The nurse is aware that the management of
heart failure requires the expertise and
consolation with other health disciplines. The
ones who can effectively implement a
therapeutic regimen to assist clients with the
psychosocial aspects that interfere with
maintaining a healthy home life and health care
network are the:
A. Physical therapists
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B. Psychiatrists
C. Social workers
D. Psychologists
Situation 9- Ms Benita is a member of ethics
committee of a training hospital. Prior to her
acceptance to the committee, she was tasked to
conduct a research.
41. Nurse Benita is guided by basic ethical guidelines
in the conduct of a research. She should apply
which of the following
principles_______________:
1. Protect the privacy of the subjects.
2. Treat the subjects fairly and justly.
3. Try to avoid injury or harm to the subjects.
4. Get the informed consent of the subjects.
A. 1 and 3
B. 2 and 3
C. All of the options
D. 2 and 4
42. Nurse Benita understands the principle which
impose a duty in the researcher to minimize
harm and maximize benefits as the principle of
_____________:
A. Confidentiality
B. Justice
C. Non-maleficence
D. Beneficence - “maximize benefits”
43. The principle of justice connotes which of the
following:
A. Fairness and equity – resources based per
need
B. Confidentiality and anonymity
C. Fairness and equality – hindi iisipin need ng
bawat isa, resources are distributed equally
D. Vulnerability and invulnerability
44. Which of the following code of conduct has
endured through the years of ages?
A. Code of Ethics for Professionals
B. Sermon on the Mount
C. Ten commandments
D. Honor Code
45. Nurse Benita is aware that the participants in a
research should give their consent. The following
are vulnerable subjects incapable of giving
informed consent EXCEPT:
A. Institutionalized persons
B. Pregnant women
C. Physically and mentally able person –
pregnant are allowed however this is the
umbrella answer
D. Children of minor age
Page 38
Situation 10- A 54 year old female was admitted
to the emergency department for crushing
substernal pain, diaphoresis and nausea. The
tentative diagnosis of the physician is myocardial
infarction.
46. The nurse in the emergency department
understand that the pain experienced by the
client is due to which of the following? A.
Myocardial ischemia.
B. Irritation of nerve endings in the
cardiac plexus.
C. Vasoconstriction because of arterial spasms.
D. Fear of impending death.
*lactic acid accumulation > metabolic acidosis
47. The initial action of the nurse to client is to
_______________:
A. Get a complete health history from the
client.
B. Prepare the client for immediate transfer to
the coronary care unit.
C. Start an intravenous infusion.
D. Administer pain medication prescribed
by the physician – morphine, analgesics
48. The nurse is aware that the area of the heart
that is most damaged in myocardial infarction
________:
A. Are the heart valves
B. Is the right ventricle.
C. Is the left ventricle – biggest ang LV,
biggest need of 02 kaya ito ang pinaka-
naapektuhan
D. Is the conduction system.
49. The nurse writes a nursing diagnosis for the
client. Which of the following is a PRIORITY
nursing diagnosis during the first twenty four
hours following a myocardial infarction? A. Fluid
volume deficit
B. Lack of knowledge about Health
Maintenance
C. Impaired Gas Exchange – d/t congestion
> pulmonary edema
D. High risk for Infection
50. The nurse admits the clients to the coronary
care unit. Which of the following actions should
be included in the admission process?
A. Contact the supervisor of the client in the
workplace.
B. Keep the client’s family informed of the
client’s progress and status.
C. Secure information about the client’s
Philhealth insurance status – B is also
correct because our approach is holistic care,
however, we are in the admission process
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that’s why it is necessary to prepare the
papers
D. Ensure the client that members of her family
can stay with her in the CCU.
Situation 11- The nurse in the emergency
department admits a 45 year old female for
vomiting blood. According to a family member
who accompanied the client, the client had gastric
ulcer for a several years. The nurse assesses that
the client is in shock.
51. Which of the following assessment findings
indicate hypovolemic shock?
A. Systolic blood pressure is less than 90
mmHg.
B. Pupils are unequally dilated.
C. Respiratory rate is more than 30
breaths per minute. – compensate (hypo
tachy tachy) ; in early stage of shock BP is
still normal
52. Pulse is less than 60 beats per minute In the
early stages of shock, the nurse expects the
result of arterial blood gas (ABG) analysis to
indicate which of the following conditions
____________:
A. Respiratory alkalosis – rapidly removing
CO2
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis
53. The physician orders intravenous infusion of
packed red blood cells and normal saline
solutions. The nurse assesses the client for
which of the following _____________:
A. Hypovolemia
B. Anaphylactic reaction – monitor for 15
mins
C. Altered level of consciousness
D. Pain
54. The nurse understands that the best indication
that fluid replacement for the client in
hypovolemic shock is adequate is when the
___________:
A. Systolic blood pressure is above 110 mmHg.
B. Diastolic blood pressure is above 90 mmHg.
C. Urine output of 20- 30 mL/Hour. – urine
output of less than 30 mL/hour is a sign of
hypovolemic shock (Brunner &Suddarth,
p.2043).
D. Urine output is greater than 30
mL/Hour. – best indicator of fluid status is
DAILY WEIGHT, however, if performing fluid
resuscitation it is URINE OUTPUT
Page 39
 55. The physician schedules the client for surgery
within six hours. The nurse minimize anxiety of
the client by answering the client‟s questions
regarding the surgery in calm manner, keeps the
client warm, advise the client to be on bed rest
and dims the lights in the room. The reason for
these interventions is to ________:
A. Increase comfort of the client and her
family. – stated na sa situation na may
anxiety siya, so psychosocial approach
B. Minimize oxygen consumption.
C. Prevent infection.
D. Stabilize fluid and electrolyte balance.
Situation 12- Nurse Simo works in the oncology
unit. She takes care of cancer patients in pain. She
is aware that cancer pain management is one of
her responsibility.
56. Nurse Simo plans care for a cancer client
experiencing pain. She is aware that an
important principle of using medication to
manage pain is to:
A. Individualize the medication therapy to the
client.
B. Provide the medication as soon as the
client requests for it.
C. Discontinue the medications periodically to
discourage the development of drug
tolerance.
D. Avoid giving client addictive medications.
57. Nurse Simo collaborates with the physician in the
development of a drug regimen for the clients.
Which of the following medications should be
avoided in the treatment of cancer pain?
A. Morphine
B. Acetaminophen (Tylenol) – for mild pain
only
C. Meperidine (Demerol)
D. Hydrocodone
58. When titrating (adjusting) a drug for the client in
pain, which of the following action is MOST
appropriate?
A. Ask the physician to include a medication
order for breakthrough pain.
B. Follow the physician‟s order for the first 24
hours.
C. Reassess the client every 8 hours for drug
effectiveness.
D. Seek a new order after 2 doses that do
not achieve a tolerable level of pain
relief.
59. One of the clients experience severe, intractable
pain and complains that the pain medication is
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not working for him. Which of the following
actions is MOST appropriate for Nurse Simo?
A. Suggest to the client to try deep breathing to
cope with the pain.
B. Explore the nature of the pain and
encourage the client to perceive it in a
different way.
C. Support the client emotionally and tell him
he will receive the next dose of medication
as soon as possible.
D. Refer the client to the attending
physician immediately and report that
the pain medication is not providing
adequate pain relief.
60. Nurse Simo assesses a client complaining of
acute pain. The MOST appropriate nursing
assessment would include which of the
following?
A. The nurses’ impression of clients’ pain.
B. The clients’ pain rating.
C. Nonverbal cues from the client.
D. Pain relief after appropriate nursing
interventions.
Situation 13- Ms. Cruz is the charge nurse of a
medical unit. She is responsible for the
management and supervision of the unit.
61. Ms. Cruz observes that one of the female staff
nurses is not performing her duties very well.
Which of the following strategies will she
implement to assist the staff nurse?
A. Discuss with the staff nurse her
performance and ways she can improve
– verbalize
B. Allow the staff nurse to select own
assignment.
C. Assign the staff nurse several clients with
various illness.
D. Ask the staff nurse to work as an assistant
charge nurse.
62. Ms. Cruz notes one of the male staff nurse is
frequently absent and his absence have
adversely affected the quality of care given to
the clients unit. Which of the following would be
the BEST approach?
A. Talk with the staff nurse regarding the
concern and remind him of the
standards of the agency – problem with
individual
B. Write the staff nurse a memorandum
regarding his absence.
C. Inform the staff nurse that his absence will
be a ground for termination.
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 D. Record the absence of the staff nurse in a
log book.
63. Ms. Cruz assigns a new staff nurse to administer
the medications of a client. Which detail of the
client‟s drug therapy is the staff nurse legally
responsible to document? The ________. A.
Peak concentration time of the drug.
B. Safe ranges of the drug.
C. Client‟s socio-economic status.
D. Client‟s reaction to the drug.
64. Ms. Cruz decides what is best for a recovering
client and acts on the decision without
consulting the client. Ms. Cruz is applying a
moral principle which is ______________.
A. Paternalism – the health care provider
decides what is best for the client and
encourages the client to act against his
or her own choices (Saunders, p.206) –
unconscious and emergency situation
B. Beneficence – the duty to do good to others
and to maintain a balance between benefits
and harms (Saunders, p.206)
C. Fidelity – the duty to do what one has
promised (Saunders, p.206)
D. Autonomy – respect for an individual‟s right
to self-determination (Saunders, p.206)
Situation 14- A 60 year old male is admitted to the
oncology unit. According to the client, he felt a
growth during a routine digital prostate
examination. He complains of pain on urination
and frequent urination.
65. The nurse understands that the function of the
prostate gland is primarily to ______;
A. Regulate the acidity and alkalinity
environment for proper sperm development.
B. Produce a secretion that aids the
nourishment and passage of sperm.
C. Secrete a hormone that stimulates the
production and maturation of sperm.
D. Store undeveloped sperm before ejaculation.
66. The nurse analyzes the laboratory values and
notes that the serum phosphate level is
elevated. This finding indicates which of the
following:
A. It confirms the diagnosis of prostate cancer.
B. The progression or regression of prostate
cancer.
C. The likelihood of metastasis to the
bones.
D. There are complications associated with
cancer.
67. The nurse knows that hormone therapy is the
mode of treatment for a client with prostate
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cancer. The goal of this form of treatment is to
______:
A. Limit the amount of circulating
androgens. – kasi lumalaki yung prostate
B. Increase prostaglandin level.
C. Increase the amount of circulating
androgens.
D. Increase testosterone level.
68. The nurse writes a nursing diagnosis of Fear and
Anxiety secondary to the diagnosis of prostate
cancer. Which of the following interventions
would be BEST for the nurse?
A. Encourage the client to keep his feelings to
himself so his family will not be affected.
B. Establish a nurse patient therapeutic
relationship.
C. Advise the client to have a positive outlook
relationship.
D. Provide spiritual support to the client –
answer always PRAY or SPIRITUAL SUPPORT
if the problem is PSYCHOSOCIAL
Situation 15- The nurse cares for a female client
who is terminally ill and is experiencing pain.
69. The nurse prepares a care plan for the client.
The overall goal for the client is ________.
The client will:
A. Achieve control of pain and discomfort.
B. Receive adequate cerebral oxygenation and
perfusion.
C. Be free from infection.
D. Receive life sustaining food and liquids.
70. The nurse is aware of the document that
expresses a client‟s wish for life sustaining
treatment in the event of terminal illness or
permanent unconsciousness. This document is
the ______;
A. No-code
B. Durable power of attorney – option of client
or proxy
C. Living will – client decides
D. Last will and testament
71. The client nears death and requests that no
medication be given that would cause a loss of
consciousness, including pain medication. The
nurse would promote the best end-of-life care
for the client by which of the following?
A. Discuss the request of the dying client with
family members and respect their wishes.
B. Comfort is the highest priority in this
situation so give medications as ordered.
C. Respect the client‟s wishes and
withhold pain medications and other
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 medications ordered. – as long as you
have explained the possible consequences
D. Be compassionate and give half of dose of
the medication ordered.
72. Which of the following statement is TRUE about
terminally ill clients?
A. Terminally ill clients require minimum
physical care.
B. Health care personnel do not understand
their own feelings about death and dying
therefore they avoid caring for terminally
clients.
C. Terminally ill clients have the right to
die with dignity.
D. Terminally ill client‟s experiences pain most
of the time.
73. The dying clients wishes to donate her eyes after
she dies. Which of the following statements is
NOT TRUE about organ donation?
A. Any individual, at least 15 years old of
age and of a sound mind may donate a
part of his body to take the effect after
transplantation needed by the
recipient. – minor pa, should be 18 &
above
B. Sharing of human organs or tissues shall be
made only through exchange programs duly
approved by the Department of Health.
C. The choice to donate an organ must be a
written document.
D. Laws do not require the consent of a family
members to retrieve organs if the donor has
expressed his last wish to donate.
Section 16- Ms. Uman is a director of the critical
care unit of hospital x. She utilizes the nursing
process to communicate care to the client.
74. She is called to the bedside of a client who is
scheduled to have laparoscopic cholecystectomy. The
client‟s pulse is slightly irregular. Ms Uman confers with
the primary nurse regarding the client’s condition, which
step of the nursing process is Ms. Uman applying?
A. Implementation
B. Evaluation
C. Planning – pag nag-uusap ibig sabihin
nagpplano
D. Assessment
75. Ms.Uman calls for a conference with the staff
members who are attending to the client. They decide to
obtain a 12-lead ECG for a more definitive picture. They
conclude that the client has no serious cardiac or
pulmonary problems. Which step of the nursing is in
effect in this situation?
A. nursing diagnosis
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B. assessment
C. evaluation
D. planning
76. Ms.Uman consults with the attending physician
and the anesthesiologist. She advises the primary nurse
to proceed with the preparations and to remain alert for
any adverse symptoms. Which step of the nursing
process is this?
A. Assessment
B. nursing diagnosis
C. planning
D. evaluation
77. Ms.Uman confers with the client‟s primary nurse
the following morning. Together they determine that the
client is ready for surgery. This step of the nursing
process is:
A. Evaluation – may napag-usapan na
B. planning
C. nursing diagnosis
D. assessment
78. Ms. Uman applies the human relations approach
in this situation. She is aware that the key to productivity
is _________________.
A. the degree of independence allowed
B. meeting the objectives of the critical care
unit
C. Firm control of the situation
D. the behavior of people under direction
Situation 17- Ms. Marcia is a nurse supervisor of
three departments in hospital X. She attends an
orientation seminar on hospital records
management.
79. Ms. Marcia understands that good client care
relies on good record keeping. Which of the following is
NOT a purpose of hospital record keeping?
A. Records provide evidence of a hospital‟s
accountability.
B. Records are a key source of data for medical
research or statistical reports.
C. Records provide data on health information
system.
D. Records provide personal information
on the physicians and nurses caring for
the clients.
80. Ms. Marcia is aware that when a client is
readmitted to a hospital, the client‟s file is retrieved
from the _______________.
A. physician‟s file
B. civil service file
C. master patient index file
D. hospital library record file
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81. Ms Marcia is aware that when a client is
discharged or dies, the following details should be
entered in the client’s record which is
the_______________.
A. Final diagnosis
B. Outcomes classification
C. Educational attainment
D. Religion
82. The following statements are true about patients
and hospital records EXCEPT:
A. Confidential records must be protected against
loss, damage , unauthorized access, modification
and disclosure
B. Patients have the right to confidential treatment
of information they provide to health
professional
C. Health records are the property of
community where the patient is treated –
property ng hosp pero ang content property ng
pt
D. Hospital records maybe released without the
patient‟s consent when required in investigation
for serious criminal offenses
Situation 18 – The nurse assists in the care of a 15
year old female experiencing anaphylaxis due to
insect bite by honeybees.
83. Upon assessment, the nurse observes the client
reacting to the insect bites. The following are common
reactions to an insect sting EXCEPT:
A. Swelling
B. Redness
C. Appearance of lesions – more of wheal
D. Pain
Situation 19 – A 21 year old male is admitted to
the burn unit of x hospital. He sustained burns on
the chest, abdomen, right arm and right leg.
1. EMERGENT PHASE
2. ACUTE PHASE
3. RECOVERY PHASE
84. The nurse assigned to his care anticipates that
the client would be particularly susceptible to which of
the following fluid and electrolyte imbalances during the
emergent phase of burn case.
A. Metabolic acidosis – d/t hyperkalemia
B. Hypernatremia
C. Hypokalemia
D. Metabolic alkalosis
85. The nurse assesses the client for fluid shifting.
During the emergent phase of a burn injury, shifts occur
due to fluid moving from the_______________.
A. Extracellular to intracellular space.
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B. Intracellular to extracellular space.
C. Vascular to interstitial space.
D. Interstitial to vascular space
86. The nurse understands that the fluid shift results
from an increase in the_____________.:
A. Total volume of intravascular plasma
B. Total volume of circulating whole blood
C. Permeability of capillary walls
D. Permeability of the kidney tubules
87. The client receives fluid resuscitation therapy.
The nurse adjusts the infusion rate by evaluating the
client’s __________:
A. Hourly urine output – N: 30-60 mL/hr
B. Daily body weight
C. Hourly urine specific gravity
D. Hourly body temperature
88. The client receives total parenteral nutrition
(TPN). The nurse understands this therapy will help the
client__________.
A. Provide adequate nutrition
B. Ensure adequate caloric and protein intake
– bawal kumain ang burn pt
C. Correct water and electrolyte imbalances
D. Allow the gastrointestinal tract to rest
Situation 20 – Nurse Merion is a staff nurse in the
oncology unit of a tertiary hospital. An activity in
the unit for continuing professional development
is to disseminate information among the
personnel and staff in the unit regarding trends
and treatment for cancer. Nurse Marion read an
article entitled “Understanding Colorectal Cancer”
which was recently published in a national
newspaper.
89. According to the Philippine Cancer Facts and
Estimates for 2010, one of the most common cancer
among men is colorectal cancer. It ranks ______ among
all the diseases:
A. First
B. Fourth
C. Second
D. Third
Situation: David is a 72 year old who is a smoker
and a social drinker. He consulted the OPD
because of rectal bleeding. His tentative diagnosis
is colorectal cancer. He was advised by the doctor
for admission.
90. Which of the following would you likely expect as
a specific complaint of the client during your initial health
history taking?
a. Projectile vomiting
b. Bouts of hematemesis
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 c. Change in bowel habits –
CAUTION US – WARNING SIGNS OF CA
d. Passing out white watery stools
91. Colonoscopy has been ordered. Which of the
following is not advisable for the client to do?
a. Has to drink the electrolyte laxatives day
before the procedure
b. Can take PRN medications when taking
electrolyte solution
c. Can have liquid diet before the
procedure.
d. Chilled electrolyte solution is allowed.
92. When assessing a client who underwent a
colostomy and the stoma appeared dusky-
purple, it indicates ______.
a. necrosis
b. anemia
c. viable stoma
d. ischemia
94. The nurse should empty the ostomy pouch before it
is 1/3 full. She should _____.
a. caution the client from straining after surgery.
b. facilitate expulsion of flatus and gas –
pwede sumabog kasi may pressure
c. prevent dislodging of the skin and ostomy
drainage
d. hasten peristalsis and evacuation of feces
95. Which of the following should the nurse report
IMMEDIATELY to the physician after colostomy?
a. Presence of pink rose to brick red stoma.
b. No flatus in 24 to 36 hours.
c. Foul smelling odor on the ostomy bag.
d. Skin slightly detached.
Situation: The TQM nurse reported to their
director that there are a lot of medication errors
committed by nurses and doctors in the hospital
for the past 3 months. They made a decision to
conduct a review of all the cases with these
errors. A clinical enhancement on drug
administration was strongly recommended by
going back to the basics. The following questions
apply:
96. Which of the following techniques in injection should
the nurse use to minimize pain when administering
imferon (Iron drugs). 1. Z_track technique
2. “Darting” needle quickly
3. Withdraw needle quickly
4. Inject medication quickly
a. 2 and 3
b. 1, 2 and 4
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c. 1 and 2
d. 1, 2, 3 and 4
97. In order to prevent error in insulin injection
which of the following safety measure should you do?
a. Leave the drug in the client refrigerator
and ask it when needed.
b. Double check with your head nurse
calculations and consider high “alert”
drugs.
c. Compute the drug, proceed to the
patient, and administer the drug.
d. Request the dietary department to keep
the drug until needed.
98. When giving injections to obese client, which of
the following needle size should you use?
a. 4 inch needle
b. 2-3 inch needle – N: 1 inch, if obese use
longer
c. 4 ½ inch needle
d. 1-1.5 inch needle
Situation: The ICU nurse assigned to a 60-year old
acutely ill client with Parkinson‟s disease who was
hospitalized frequently. The initial confinement
was due to electrolyte imbalance. The following
confinement was due to injury sustained from fall,
he became to have incontinent of stools that
further lead to development of skin irritation and
breakdown. Currently he was admitted due to
respiratory infection.
99. Related literatures included case situations
similar to the case of the client. The nurse is interested
in gaining further knowledge that can help the client at
risk for fecal incontinence. The nurse should use which
of the following method to strengthen this report?
a. Historical research method
b. Qualitative research method
c. Experimental research method
d. Quantitative research method
100. The review of literature does not only include
published research studies but also theory. In this case
which theory is least related to the study?
a. Neuman‟s system model
b. Lazarus‟ theory of stress and coping
c. Nightingale‟s environmental theory
d. Roy‟s theory of adaptation
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 Nursing Practice V
Situation 1 – You are a staff nurse at the
Neurology unit of the Pediatric Ward
1. You have a patient for admission who has been
diagnosed with Bacterial Meningitis. Which of the
following type of isolation should you
implement?
a. Contact precaution
b. Universal precaution
c. Airborne precaution
d. Droplet precaution – during 1st 24
hrs, however, after antibiotic therapy
pwede na kahit di naka-isolate
2. The attending physician of Mr M who has
Cerebral Palsy and a seizure disorder prescribed
Tegretol-XR for him. Master M has a gastrostomy
feeding tube. The medication prescribed is on
the hospital‟s “No crush list”. Which of the
following you should do in order to administer
the medication?
a. Ask the pharmacist for oral
suspension
b. Contact the attending physician to
change the order
c. Dissolve the medication in 30 ml. of
orange juice
d. Cut the medication into small pieces to
be places to be placed in the feeding
tube
3. You have been observed by your nurse manager
that when you gave the I.V. medication, you
disconnected the flush syringe first and then
clamped the intermittent infusion device. (should
be clamp > give med > flush) Which of the
following would be the most effective way to
improve this nursing practice?
a. Post an evidenced-based article on
administration of I.V. medication in
the neurological unit – best way to
convince is through research
b. Send a group e-mail discussing the
importance of clamping the device first
c. Create a poster presentation on
administration of I.V.
d. Ask each nurse if they are aware that
their practice is obsolete
4. You have a newly admitted patient with bulging
fontanels, setting-sun eyes, and lethargy. Which
of the following doctor‟s order would you
question? An order of:
a. Arterial blood draw
b. Magnetic resonance imaging
c. Computerized tomography scan
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d. Lumbar puncture (or lumbar/spinal tap)
Fatal: brain herniation
5. Your unit is reviewing national sentinel event
alerts medication and preparing
recommendations for the unit. Which strategy
would help reduce medication errors?
i. Utilized only oral syringes to
administer oral medication
ii. Eliminate the pediatric satellite
pharmacy
iii. Increase the steps in the
medical administration procedure
iv. Limit the size of I.V. fluids bags
that can be hung on small children
v. Reduce the available
concentrations or dose strengths of
high alert
a. 1, 4, 5
b. 2, 3, 4
c. 1, 2, 3
d. 3, 4, 5
6. The intervention by a psychiatric nurse that
implements the ethical principle of autonomy is
when the nurse______________.
a. Stays with the client who is
demonstrating high level of anxiety
b. Intervenes when a self-mutilating client
attempts to slash wrist
c. Explores alternative solutions with
the client, who later chooses one
alternative
d. Suggest that two clients who are
fighting be restricted to the unit
7. The nurse learns that a patient was admitted
involuntarily on the shift. What assumption can
the nurse make about the patient?
a. For the first 48 hours, he can be given
medication despite his objections
b. He can leave the ward upon demand
c. At the time of admission, he was
considered to be an imminent danger
to himself or to others
d. He has agreed to accept the treatment
and participate fully in care planning
8. A male psychiatric nurse receives a call asking
whether a certain person has been a patient in
the facility. How should the nurse respond?
Nurse_______________.
a. States that he is unable to give any
information to the caller
b. Asks the caller why the information is
being sought
c. Suggests to the caller to speak to Mr X‟s
doctor
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 d. States that Mr X has been at the facility
but gives no further information
9. A patient is about to receive electroconvulsive
therapy (ECT) when the nurse sees that the
patient has not signed a consent for treatment.
Which of the following facts should determine
the action of the nurse?
a. Verbal consent by the patient is
sufficient
b. Another patient is needed to witness the
consent form
c. Permission is granted by the patient
when he signed the hospital’s admission
form
d. Failure to obtain the patient’s
written consent can result to a
lawsuit – any invasive requires consent
10. When the nurse is told by the patient that she
consented to ECT out of fear of being
abandoned by her husband, what nursing action
is required?
a. Explain that consenting to ECT will make
her husband happy
b. Reassure the patient that her decision is
sound
c. Document the patient’s statement
d. Reprimand the husband for coercing his
wife
11. What other traits is expected from a client with
paranoid personality disorder. The client:
a. Avoids responsibility for health care
actions
b. Is afraid another person will inflict
harm – passive friendliness – wag
masyado lalapitan, if you need me I’m
here at the nurse’s station
c. Cannot follow limits set on behaviour
d. Depends on others to make important
decisions
12. The client discusses current problems with the
nurse. Which of the following interventions
should have priority in the nursing care plans.
Have the client____________.
a. Discuss the use of defense mechanisms
b. Look at the source of frustration
c. Clarify his thoughts and beliefs
about an event
d. Focus on the ways to interact with the
others
13. You noticed that the client has impaired social
skills. Which of the following short-term goals is
MOST appropriate for the client?
a. Address positive and negative feelings
about self
b. Obtain feedback from other people
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c. Identify personal feeling that
hinder social interactions –
encourage verbalization
d. Discuss anxiety-provoking situations
14. The client makes an inappropriate and
unreasonable report to you. Which of the
following principles of good communication skill
is important for you to use?
a. Use nonverbal communication to
address the issue
b. Use logic to address the client‟s
concerns
c. Tell the client that you do not share
this interpretation – present reality
d. Confront the client about the stated
misperception
15. Which of the following long-term goals is
appropriate for this client?
a. Become appropriately interdependent
with others
b. Become involved in activities that
foster social relationships
c. Verbalized a realistic view of self
d. Take steps to address disorganized
thinking
Situation 2 – As a professional nurse you take into
consideration the ethico-moral principles in
providing nursing care.
16. You released information over the phone to a
caller who identified himself as the brother of
your patient. You found out later that the
brother was out of town. Which of the following
rights did you violate?
a. Right to privacy
b. Right to continuity of care
c. Right to confidentiality
d. Right to respectful care
17. Your patient is having difficulty making decision
to undergo hip surgery. Which of the following
nursing actions BEST describes your advocacy
roles as a nurse?
a. Protect patient’s autonomy and
independence
b. Communicate patient‟s needs to the
interdisciplinary team
c. Advise the client to undergo surgery
because it is best for her
d. Actively support patient‟s decision
18. Mrs Go needs to undergo a hip surgery. She
refused to have it done even after the attending
surgeon has explained the procedure thoroughly.
Which ethical principle applies in this situation?
a. Autonomy
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 b. Justice following members will be assigned to handle
c. Non-maleficence the activity?
d. Beneficence a. The municipal health officer
19. Informed consent is one of the patient‟s bill of b. The chief of police
rights. One of its requirements is the capacity of c. The municipal mayor
the patient to give it. Which of the following d. The guidance counsellor
elements is/are related to this capacity? (SELECT 25. Which of the following has the MOST influence
ALL THAT APPLY). in the development of alcoholism among the
1. Patient is an youth?
2. He is competent to make a a. Teachers c. parents
choice b. Environment d. peer group
3. He has the freedom to make a
choice Situation 4 – You are a community health nurse
4. He can understand the doing a home visit to a patient with open-angle
consequences glaucoma. The following questions apply to this
a. 1, 2, 3 c. 1, 2, 3, 4 situation.
b. 1, 2, 4 d. 1, 3, 4
20. Another requirement of informed consent is 26. A patient is taking Latanoprost (Xalatan). She
voluntariness. It means, freedom of choice asked you why she was given this medication.
without the following conditions, Your answer is that Latanoprost__________.
EXCEPT__________. a. Moistens the affected eye
a. Force c. consequences b. Prevents the unaffected eye from
b. Fraud d. deceit developing glaucoma
c. Dilates the affected eye
Situation 3 – You are a community health nurse in d. Decreases the intraocular pressure
Municipality B where the incidence of alcoholism in her affected eye – miotic/constrict
among the youth is observed to be increasing. You
want to have an advocacy called “ALCOHOL Situation 5 – Elizabeth has been using contact
WATCH!”. lenses for the last five years. She was admitted to
the eye Unit with a diagnosis of Corneal Ulcer.
21. Initially, who would you invite to organize this
advocacy? (1) Guidance Counsellor of the public 27. Which of the following affects the ability of the
high school; (2) Officer of the local youth office eye to clearly focus? A change in the_______.
(3) Chief of police (4) Municipal health officer; a. Stroma
(5) NGO representative; (6) Parish priest b. Sensory cells of the retina
a. 1, 2, 3, 5 c. 1, 3, 5, 6 c. curvature of the cornea
b. 1, 2, 3, 4 d. 2, 3, 5, 6 d. epithelium
22. Your advocacy will operate on the following 28. Which of the following characteristics make
principle: immune defenses difficult to tend off infections
a. Individual therapy of the cornea? The cornea__________.
b. Group therapy a. Is an avascular tissue
c. Group-help b. Has three major layers
d. Self-help c. Is a vascular tissue
23. Alcohol watch! Will have for its aim: d. Is adjacent to the aqueous humor
a. One at a time step toward total 29. Which of the following is the predisposing factor
withdrawal for Elizabeth‟s condition?
b. A total abstinence from alcohol a. Bacterial infection
c. Total withdrawal from the alcohol b. Prolonged misuse of contact lenses
d. Moderate withdrawal from alcohol c. Malnutrition
*Alcoholic Anonymous (AA) – mismong d. Viral infection
alcoholics 30. Corneal ulcers are considered medical
*Al-Anon – family of alcoholics emergencies. Which of the following nursing
24. You have a plan to have a seminar on the legal actions will be your PRIORITY?
implications of substance abuse. Which of the a. Remove the contact lens

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 b. Prompt referral to the ophthalmologist
for treatment
c. Administer eyedrops
d. Pressure dressing applied to both eyes
for comfort
*surgery: Penetrating keratoplasty (PKP) /
corneal transplant
Situation 6 – Joseph is an 11-year old Grade IV
pupil in a private school was diagnosed to have an
attention-deficit hyperactivity disorder
(ADHD)
31. Which of the following is NOT a MAIN
characteristics of ADHD?
a. Passivity c. hyperactivity
b. Inattention d. impulsivity
32. His teacher has observed joseph to have
difficulty waiting for his tutor often batting into
conversations and blurts out answers without
waiting for questions to be finished. These are
manifestations of_________.
a. Hyperactivity c. passivity
b. Inattention d. impulsivity
33. Which of the following is the most important
nursing consideration in caring for Joseph and
his family?
a. Establishing a therapeutic
relationship with Joseph and his
family – 1st way to work with pt
b. Seeking information regarding mother‟s
course of pregnancy with Joseph
c. Teaching them instructions on giving
Joseph‟s medication
d. Giving them instructions on giving
Joseph‟s medication
Situation 7 – Mrs H, a 58-yearold female was
brought in the Emergency Room with the chief
complaint of sudden severe headache, numbness
of the right side of her body and difficulty in
speaking. Oxygen was administered at once to
Mrs H.
34. The rationale for administering oxygen to
suspected stroke patient is __________.
a. To prevent further respiratory deficit
b. To prevent hypoxia (O2 constricts
blood vessels) and hypercapnia
(dilates)
c. To prevent further neurologic deficits
d. To increase the respiratory function
35. Which of the following risk of complications is
lessened through oxygen administration to
patient suspected of having a stroke?
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a. Increased intracranial pressure
b. Rebleeding
c. Fluid accumulation in the lungs
d. Pulmonary emboli
36. A non-contrast computed tomography (CT) scan
was ordered for Mrs H. The purpose of this
diagnostic test is to determine___________.
a. The patency of Mrs H’s airway
b. The treatment for Mrs H
c. The extent of damage to Mrs H’s motor
function
d. If the event is ischemic or
hemorrhagic
37. Which of the following is the focus of INITIAL
assessment for Mrs H.?
a. Visual acuity c. motor functions
b. Emotional status d. airway patency
38. You read in the physician’s notes that Mrs H. has
contralateral deficits. This means ___________.
a. Both sides of the body are involved
b. A right cerebral vessel is involved
c. A left cerebral vessel is involved –
opposite side
d. Deficits will be present below the level of
the stroke
Situation 8 – You are a community health nurse in
Municipality C. You want to improve the primary
prevention activities in the municipality in relation
to mental health.
39. In the public health model, which of the
following is considered the “patient”? The
___________.
a. Community c. individual
b. Country d. family
40. In assessing mental health needs of the
community, one of the technique used is
epidemiological studies which examine the
incidence and prevalence of mental disorders in
a defined population. Incidence is the number of
__________.
a. People at risk for mental disorder
b. Existing cases of mental disorder in the
total population at a specified point in
the time
c. New cases of mental disorder in a
population over a specified period
of time
d. New cases of specific illness in the total
population
*Prevalence – old and new cases
41. Promoting mental health is a primary prevention
activity which is consistent with the principle
of________
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 a. Interdisciplinary care
b. Autonomy
c. multidisciplinary care
d. self-help
42. The purpose of primary prevention is to lower
the incidence of mental disorder. This can be
done through____________.
a. Reducing the rate at which new cases of
mental disorders develop
b. Early treatment of new cases of mental
disorders
c. Case-finding for population group at risk
for mental disorder
d. Program development and
intervention for older adults – others
are secondary
Situation 9 – You are a staff nurse in a
government hospital being transferred to the
Psychiatric Unit. You were required to equip
yourself by attending the enhancement program
on Crisis Intervention. To assess your knowledge
and skills on the subject you were given a pretest.
43. A crisis that is acute but temporary and due to
external source is__________.
a. Developmental
b. Transitional
c. Traumatic
d. Dispositional
*crisis lasts for less than 6 weeks
44. Which of the following nursing interventions is
the most appropriate for a client who is in the
early state of crisis?
a. Encourage client to express feeling
and emotions related to crisis
b. Require client to be actively involved in
establishing goals
c. Encourage client to begin the
development of insight
d. Ask client to evaluate the situation
45. Which of the following is NOT an assumption in
the concept of crisis?
a. Crisis is acute and resolved within a
short period of time
b. All individuals experience a crisis
c. Crisis is a growth-retarding factor
to the emotional development of a
person
d. Specific identifiable events precipitate a
crisis
46. The MAIN objective of crisis intervention is
to_____________
a. Make the person realize his/her
mistakes
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RECALLS 1 EXAM
b. Ensure patient‟s safety
c. Return the person to the root of the
crisis to identify the cause
d. Eliminate the stressor
Situation 10 – Documentation is a registered
nurse‟s accountability legal and ethical actions.
47. Charting done by a nurse provides a
comprehensive, sequential notes of the following
EXCEPT:
a. Procedures performed
b. Patient medical diagnosis
c. Information about patient‟s health
status
d. Relevant health data
48. BONUS HAHAHAHA TAMA LAHAT The following
are the importance of proper documentation.
(SELECT ALL THAT APPLY): 1) facilitates
interdisciplinary communications; 2) holds vital
information about the patient; 3) reflects quality
and timeliness of nursing care; 4) evidence of
care provided by the doctor and nurses; 5)
utilized as a legal document in a court litigation
a. 1, 2, 4 c. 1, 3, 4
b. 2, 3, 4 d. 1, 4, 5
49. “Compliant with standards” is one of the
characteristics of good documentation. This
means___________.
a. A particular order for effective and
efficient care is followed
b. It presents exact and correct details of
nursing care provided
c. Specified protocols are dutifully
followed
d. Timely information is provided
50. Which of the following guidelines in
documentation applies when you administer
drugs prepared by another nurse?
a. Document immediately drug given to
avoid medication errors
b. Document that you administered the
drug but somebody prepared it
c. There must be existing institutional
policy that must be observed in
relation to this situation – docu what
you only prepared, however, depends on
hosp policy
d. Do not document at all
Situation 11 – Nelson, a 26-year old construction
worker, arrives in the Ear Clinic riding a Honda
Motorcycle. He is wearing a headset with Mp3
player hooked to his belt. Nelson is for hearing
assessment.
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 51. Pure Tone Audiometry is ordered for Nelson.
Which of the following does this procedure
measure?
a. Vestibular portion of the auditory nerve
b. Ear canal volume
c. Structure of the cars
d. Hearing acuity
52. Nelson was found to have Mastoiditis. Which of
the following ear structure is affected?
a. Tympanic membrane
b. Pinna
c. Eustachian tube
d. Mastoid air cells
53. Which of the following is the most common
cause of Mastoiditis?
a. Bone tumor
b. Untreated Otitis Media (inflamm of
middle ear)
c. Meningitis
d. Mastoid diseases
54. Antibiotics have limited use in the actual
treatment of Mastoiditis because________.
a. Tissue destruction is extensive
b. It is a long-term treatment
c. Antibiotics do not easily penetrate
the infected bony structure of the
mastoid
d. Culture has to be done to identify which
antibiotic is most effective for the
treatment of Mastoiditis
55. Which of the following is the most common
treatment for Mastoiditis?
a. Mastoidectomy only
b. Mastoidectomy with tympanoplasty
c. Antibiotics with tympanoplasty
d. Antibiotics
Situation: In the PGH Ear Unit, the staff nurse is
attending to several outpatient clients seeking
follow-up care.
56.The nurse assists in an ear irrigation. Which of the
following statements by the nurse is correct?
a. “Tilt the head towards the
unaffected ear.”
b. “Direct the stream of
irrigate at the sides of the ear
canal.” – wag sa gitna > damage to
eardrum
c. “After the procedure, lie on the
unaffected side to allow the irrigate to
soften any hardened mass.”
d. “This procedure is allowed for
otitis media to clean the canal.”
57. In administering ear drops, the nurse observes which
of the following principles?
a. In a child, pull pinna upward and backward.
b. Let the ear drops fall on the middle space of the
canal.
c. Lie on the unaffected side to facilitate
absorption.
d. Position unaffected ear uppermost.
58. Otosclerosis, a disorder of labyrinth function,
constitutes which type of hearing loss?
a. Perceptive loss c. Sensorineural loss
b. Conductive loss d. Mixed loss
*Conductive – reversible, problem sa dinadaanan ng
sound (bara/rigid na)
*Sensorineural – damage to CN 8 (Vestibulocochlear)
irreversible ; ototoxic drugs: Streptomycin,
Furosemide
59. Which of the following is a characteristic sign of acute
otitis media in children?
a. Jumping in pain c. Painless
inflammation
b. Ear tugging d. Difficulty awakening
60. What makes children more predisposed to chronic
otitis media?
a. Shorter Eustachian tube
b. Horizontal orientation of the ear canal
c. Primary diaphragmatic breathing
d. Both A and B
Situation: Addiction disorders are unnecessarily
common in the modern lifestyle of Filipinos,
especially with the rise of establishments selling
products with caffeine. Because of the various
“improvements” in performance, this industry is
still unwavering.
61. Which of the following do not have the potential of
addiction, if consumed frequently and in large
amounts?
a. Chocolate-flavored Cola c. Green tea
b. Apple juice d.
Common cold preparations
62. Caffeine greatly affects which part of the heart, as
reflected in an ECG?
a. Atrium c. Purkinje fibers
b. Ventricles d.
Interventricular septum
63. The nurse suspects caffeine intoxication in a young
professional if he notes which finding?
a. Decreased flow of thought and speech
b. Psychomotor agitation – agitated dapat pag
withdrawal
c. Urinary retention
d. Pale face

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64. In the previous situation of the young professional
intoxicated with caffeine, he suddenly was unable to
take any caffeine source for 24 hours already. The
nurse expects to note the following findings, except?
a. Headache
b. Difficulty in stimulating
c. Nausea and vomiting
d. Muscle pain
65. The following are the reasons why many people abuse
caffeine. Choose the exception.
a. Relieve fatigue
b. Increase mental alertness
c. Both A and B
d. Neither A nor B
Situation: Nurse Fe had been working as a head
nurse in the Mental Health pavilion of Davao City.
For the past years she had been challenged to cater
to the needs of different mentally ill patients of
across the continuum of care.
66. A staff nurse in the psychiatric ward is upset about
the new female charge nurse who just sits in her office
all day. One of the staff member informs Nurse Fe
about the situation. Which statement by Nurse Fe
indicates a laissez faire leadership style?
a. “I will schedule a meeting to discuss the concern
of the charge nurse”
b. “I hired the new charge nurse and she is doing
what I told her to do”
c. “I will talk to the charge nurse about your
concerns and get back to you”
d. “You and the staff really should take care of
this situation on your own”
67. A volunteer nurse on the ward tells the nurse that one
of the patients on the ward is a neighbor and asks
about the patient‟s condition. Which information
should the nurse discuss with the volunteer?
a. Determine how well she knows the patient before
talking with the volunteer
b. Tell the volunteer the patient‟s condition in
layman‟s term
c. Ask the patient if it is all right to talk with the
volunteer
d. Explain that patient information is on the
need to know basis only
68. The psychiatric ward is governed by a system of
shared governance. Which statement best describes
an advantage of this system?
a. It guarantees that union will not be able to come
into the hospital
b. It makes the manager responsible for sharing
information with the staff
c. It involves staff nurses in the decision
making process of the unit
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RECALLS 1 EXAM
d. It is a system used to represent the nurses in
labor disputes
69. A nurse is able to assess that a depressed patient is
bleeding from a wrist cut. She immediately direct
another staff nurse to call the doctor and send the
nurse aide to gather specific materials to implement
measures to control bleeding. Which style of
leadership did the nurse use in this situation?
a. Autocratic
b. Democratic
c. Facilitative
d. Laissez-faire
70. Which strategy should the nurse leader use to
facilitate the performance appraisal conference?
a. Interview with other staff about the employee‟s
performance
b. Begin the evaluation interview with an
openended question
c. Include personal feelings in the comment
sections of the tool for clarity
d. Refrain from adding comments to the evaluation
form
Situation: The nurse is caring for patients with
issues in gender and sexuality. The following
situations will apply.
71. A nurse was approached by a 23-year-old male who
confessed that he has romantic and sexual affinity
towards lesbians, gays, transsexuals, bisexuals, a
straight male and a straight female. The nurse will
help the man identify himself as a? a. Transsexual c.
Pansexual
b. Asexual d. Polysexual
72. Chester, a 25-year-old male, has been decided that
he wants a gender reassignment surgery. He asks the
nurse as to whom should he ask help regarding his
concern. The nurse will help the client correctly if the
nurse refers him to a?
a. Endocrinologist – d/t hormones c. Psychiatrist
b. Psychologist d. Surgeon
73. Which among the following individuals is
characterized by either a male or a female who
dresses like a male or a female?
a. Transvestite c. Cross-dresser
b. Transgender d. Transsexual
74. Lea, a 22-year-old lesbian, has decided to have a
gender reassignment surgery and is currently on
hormone replacement therapy as she wait for her
surgery. Which among the following features are
noticeably the effect of the hormone replacement
therapy?
a. Decreasing heart rate
b. Increased production of body hairs on areas
with
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 less body hairs than before
b. Ovarian atrophy
c. Linea nigra
75. After his gender reassignment surgery, Reston felt
that he is not as sexually satisfied as that of when he
was still a male by genitalia. Which among the
following disorders have been noted to be highest
across males and females who had gender
reassignment surgery?
a. Manic Disorders
b. Depression
c. Schizophrenia
d. Bipolar Disorder
Situation: In the Psychiatric ward nurses are
discussing the other factors that caused of
Alzheimer‟s disease (AD). And they all agree that it
is a degenerative disease of the brain caused by
gradual death and loss of brain cells resulting to
progressive and irreversible Dementia.
76. Which of the following nursing intervention is most
helpful in meeting the needs of an older adult
hospitalized with the diagnosis of Dementia of the
Alzheimer‟s type?
a. providing a nutritious diet high in carbohydrates
and protein
b. simplifying the environment as much as
possible while eliminating the need for
choices
c. developing a consistent nursing plan with fixed
time schedules to provide for emotional needs
d. providing an opportunity for many alternative
choices in the daily schedule to stimulate interest
77. The nurse recognizes that Dementia of the
Alzheimer‟s type is characterized by:
a. aggressive acting-out behavior
b. periodic remissions and exacerbations
c. hypoxia of selected areas of brain tissue
d. areas of brain destruction called senile
plaques
78. A 75-year-old man with the diagnosis of Dementia has
been cared for by his wife for 5 years. For the past 2
years he has not spoken and incontinent of urine and
feces. During the last month he has changed from
being placid and easygoing to agitated and
aggressive. He is admitted to a Psychiatric hospital for
treatment with Psychopharmacology. Which is the
priority nursing care while this client is in the
psychiatric facility?
a. managing his behavior
b. preventing further deterioration
c. focusing on the needs of the wife
d. establishing on the needs of the wife
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RECALLS 1 EXAM
79. When attempting to understand the behavior of an
older adult diagnosed with Vascular Dementia, the
nurse recognizes that the client is probably:
a. not capable of using any defense mechanisms
b. using one method of defense for every situation
c. making exaggerated use of old,
familiar mechanism
d. attempting to develop new defense mechanism to
meet the current situation.
*alam pa ang past nila, ang nawawala ay ang recent
memory
80. The Nurse develops a nursing diagnosis of self care
deficit for an older client with Dementia. Which of the
following is the most appropriate goal for this client?
a. The client will be admitted to a long care facility to
have activities of daily living needs met
b. The client will function at the highest level
of independence possible – laging mali ang
magiging dependent sayo ang pt
c. The client will complete all activities of daily living
independently within one (1 ) hour time frame
d. The Nursing staff will attend to all the client‟s
activities of daily living needs during the
hospitalization
Situation: The diverse Neurologic disorders
present a unique challenges of nursing care. The
Nurse must have a clear understanding of the
pathologic processes for appropriate nursing
management. Nurse Marco is attending to clients
in the ward with Multiple Sclerosis.
81. Which statement by a client with Multiple Sclerosis
(demyelination of myelin sheaths) indicates to Nurse
Marco that the client needs further teaching?
a. “I use a straw to drink liquids.”
b. “I will take a hot bath to help relax my
muscles.” – pwedeng nasusunog ka na, hindi mo
pa alam
c. “I plan to use an incontinence pad when I go out.”
d. “I may be having a rough time now, but I hope
tomorrow will be better.”
82. A recently hospitalized client with Multiple Sclerosis is
concerned about generalized weakness and a
fluctuating physical status. What is the priority nursing
intervention for this client? a. encourage bed rest
b. space activities throughout the day
c. teach the limitations imposed by the disease
d. have one of the client‟s relatives stay at the
bedside
83. Marco is excited to be assigned in a Neuro –Ward after
his extensive training. He is preparing to conduct a
Neurologic examination. What nursing intervention is
anticipated for a client in the plateau phase of Guillain-
Barre syndrome?
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 a. providing a straw to stimulate the facial muscles 89. Which of the following is the first line treatment
b. inserting an indwelling catheter to monitor for acute mania?
urinary output A. Imipramine
c. encouraging aerobic exercises to avoid muscle B. Sodium valproate
atrophy C. Electro-convulsive therapy
d. administering antibiotic medication to prevent D. Lithium carbonate
pneumonia *normal range: 0.5-1.5
84. Mr. Rod a 48 year old client carpenter admitted after *therapeutic range: 0.6-1.2
a spinal cord injury and the Physician indicates that a 90. Which of the following statements best describes
client is a Paraplegic. The family asks Nurse Marco severe depression?
what this means. What explanation should the nurse A. Anxiety and panic attack are characteristics of
give to the family? other condition
a. upper extremities are paralyzed B. Sonia wakes up early
b. lower extremities are paralyzed C. Sonia's depression is less in the morning
c. one side of the body is paralyzed but worsens toward the end of the day
d. both lower and upper extremities are paralyzed D. Delusion and hallucinations do not occur
85. Which clinical indicator does Nurse Marco identify
when assessing a client with hemiplegia? Situation: You are a nurse in Psychiatric Unit. The
a. paresis of both lower extremities use of therapeutic touch is an effective
b. paralysis of one side of the body intervention in caring for your patience.
c. paralysis of both lower extremities
d. paresis of upper and lower extremities 91. Which type of therapeutic touch is used when
you assess skin turgor of the patient during physical
Situation: Sonia is a 28 year old graduate school assessment?
student in a leading private university. She came A. Friendship C. Social
in a psychiatric unit due to sleeplessness but B. Love D. Functional
claiming she is still overactive. She revealed she 92. You gently guide a patient in going to her room.
has a history of depression when she was 18 This is the type of:
years old and was into drugs. Further evaluation A. Social B. Love
revealed Sonia is suffering from a Bipolar
C. Friendship D. Sexual
disorder, rapid cycling mood disorder
93. You put your arms around the shoulders of an
classification.
elderly patient. Which type of touch is this?
A. Love C. Social
86. Which of the following characterizes Rapid Cycling
Mood disorder? (not lke bipolar) B. Functional D. Friendship
A. Exaggerately energetic behavior 94. What type of touch is used when it involves tight
hugs and kisses between relatives?
B. Depressive episodes alternating with at least
one manic episode A. Love C. Social
C. Hypomanic episodes alternating with B. Friendship D. Functional
depressive episode of two years duration 95. Which of the following is NOT a type of
D. Two or more mood episodes of two therapeutic touch used by the nurse in providing care to
years duration psychiatric patients?
87. In your interview with Sonia, she said "I have special A. Social C. Sexual
power that's why I was sent by God to make this world B. Friendship D. Love
a better place." This is a manifestation of:
A. Paranoia Situation: Nurse Honeylet wants to improve in her
B. Delusion of persecution care for patient Mar, who is an alcoholic. She asks
C. Delusion of grandeur help from her head nurse Amanda.
D. Denial
88. You heard of Sonia telling another nurse, - there are 96. Honeylet goes to Mar's bedside to greet him.
people who wants to harm me because I have special Amanda corrects Honeylet of her greeting which is NOT
power." This is a manifestation of what behavior? appropriate to Mar
A. Mania C. Hallucination A. "Hi, Mar!„ so you got drunk last night"
B. Delusion of grandeur D. Delusion of B. "Hi, Mar!, I heard you enjoyed yourself last
persecution night"

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RECALLS 1 EXAM Page 53
 C. "Hi, Mar!, I heard you had a drinking
spree last night"
D. "Hi, Mar!, How was your drinking affair
last night"

97. Mar turned his back away from Nurse Honeylet,

saying "It's none of your business, you ugly duckling."
The appropriate response of Nurse Honeylet would be:
A. "What you said hurt me, you alcoholic!"
B. "You beast, you are as ugly as I am"
C. "You really arc a drunkard"
D. "I don't think you mean what you have
just said. Do You?"

98. Amanda wished that Honeylet should have used

a/ an:
A. non-verbal communication
B. therapeutic communication
C. emphatic communication
D. casual communication

99. Amanda suggested that Honeylet should use

communication technique appropriate for the condition
of Mar such as:
A. Concluding C. questioning
B. Analyzing D. rephrasing

100. Honeylet should have used according to

Amanda, which kind of attitude?
A. motherly C. passive
B. friendly D. matter of fact

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RECALLS 1 EXAM Page 54