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DIAGNOSTIC EXAM
Philippine Nurse Licensure Examination 2020
NAM E:
Situation - Jaina is a fourth year nursing student currently having her
community immersion in Barangay Sto. tomas. She, together with
her professor, are is conducting a home visit with one of her
patients, who is diagnosed with an open-angle glaucoma.
1. In the middle of their conversation, the client raised a question to
Jaina. She mentioned that she has been prescribed with Latanoprost
(Xalatan) by the municipal doctor. She asks Jaina why she has to
take this. Jaina responds that this medication:
A. Dilates the affected eye
B. Moistens the affected eye
C. Decreases the angle of glaucoma in her affected eye
D. Decreases the intraocular pressure in her affected eye
2. In utilizing the IMCI protocol, the nurse should initially?
A. Observe the condition of the child
B. Ask the mother if what is the problem of the child
C. Look for danger signs
D. Identify main symptoms
Situation – 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.
3. Which of the part of body of the vendor will be the MOST affected
in terms of rabies? It is the _________.
A. Buttocks
B. Head
C. feet
D. hand
4. 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
B. 2 only
C. 3 and 4
D. 1 only
5. 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
6. 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
Situation – The Field Health Services and Information System
(FHSIS) is recording and reporting system in public health care in the
Philippines
7. 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 in-depth studies
8. 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
B. Output record
C. reporting forms
D. target/client list
9. The monthly field health service activity report is a form used
in which of the components of the FHSIS?
A. Target/client list
B. Output report
C. individual health record
D. tally report
10. 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
B. Tally report
C. target/client list
D. individual health record
Situation: As a CHN nurse, Nurse Jake is responsible for home visits
in Barangay Werpa. Thus, he needs to have a strong foundation in
blood pressure monitoring and knowledge regarding communicable
diseases such as HIV. The following questions apply.
11. In the preparatory phase of blood pressure measurement, how many
minutes should the client have been relaxed and how many minutes
should the client have not smoked or ingested caffeine?
A. 10 minutes; 15 minutes
B. 5 minutes; 30 minutes
C. 5 minutes; 15 minutes
D. 10 minutes; 30 minutes
12. In applying the BP cuff and stethoscope, how many centimeters
above the brachial artery should the nurse apply the cuff?
A. 2-3 cm.
B. 3-4 cm.
C. 4-5 cm.
D. 5-6 cm.
13. For obese persons, which part of the stethoscope is preferably used
to auscultate the pulse in obtaining the blood pressure reading?
A. The part of the stethoscope used in obtaining the BP is
irrelevant.
B. Bell
C. Diaphragm
D. Both parts are preferably used for obese people.
14. As a knowledgeable nurse, Nurse Jake knows that he should take the
mean of 2 readings of blood pressure in order to have an accurate
reading. How many minutes should be the interval between the 2
readings?
A. 5 minutes
B. 4 minutes
C. 3 minutes
D. 2 minutes
15. Which situation would require Nurse Jake to obtain a third reading?
A. If the first 2 readings differ by 15 mm Hg
B. If the first 2 readings differ by 10 mm Hg
C. If the first 2 readings differ by 5 mm Hg
D. If the first 2 readings do not have any difference
16. In handling soiled linens and clothes of a person with HIV, how
should Nurse Jake proceed?
A. Fold wet portion towards dry portion.
B. Fold dry portion towards wet portion.
C. Fold corners towards the middle.
D. Fold in a circular manner towards the middle.
17. A family member of a deceased HIV client asks Nurse Jake if it is
possible to have the body available for public viewing. As a
knowledgeable nurse, Nurse Jake answers:
A. “No, the body must be disposed immediately.”
B. “Yes, the embalmed cadaver is safe for public viewing.”
C. “Please ask the physician regarding this matter.”
D. “No, only family members should be allowed to view the
body.”
18. Which of the following sets of symptoms is characteristic of acute
stress disorder?
a. Uncontrollable worrying, significant distress or impaired
social functioning for at least 6 months.
b. Intense fear and helplessness within 1 month after
exposure to traumatic event that lasts 2 days to 4 weeks.
c. Re-experiencing of an extremely traumatic event and
numbing of responsiveness within 3 months to years after
the event.
d. Significant anxiety provoked by a specific feared object or
situation.
19. Which of the following medications are appropriate for a client
with obsessive thoughts followed by ritualistic and repeated behaviors?
A. Tacrine (Cognex)
B. Bupropion (Wellbutrin)
C. Clomipramine (Anafranil)
D. Haloperidol (Haldol)
20. A nurse found out that her patient in a medical ward was raped
by her grandfather. She appropriately reports this assessment to
which of the following agencies/departments?
A. PNP
B. DSWD
C. Bantay Bata 163
D. Nearest child protection agency
21. The following are signs that child abuse is most likely present in
a pediatric client except:
A. Child was brought to the clinic for burn injury that happened
4 days ago.
B. Mother tells that the bruises were due to home accident. The
next day she tells that it’s due to a fight with a neighbor.
C. Recurrent urinary tract infections
 D. Swelling of the forehead due to banging of head to wall as
reported by the mother.
22. Which of the following is a characteristic of a sexual abuser?
A. Only males can be sexual abusers.
B. A sexual abuser is usually a stranger to the victim.
C. He was most likely sexually abused as a child.
D. He comes from a low-income family.
23. A patient has just attempted to commit suicide by hanging. To
prevent the patient from attempting this again, which of the
following is appropriate for the nurse to do?
A. Take him to seclusion room.
B. Ask the peer to safeguard client
C. Remove one’s clothing to make sure no other items are
with the patient.
D. Ask a nurse to watch the patient constantly.
24. A manic patient needs food and fluids to maintain proper
nutrition. Which of the following is best to provide the patient?
A. Potato salad and soda
B. Beef and potato
C. Peanut butter sandwich and milk
D. Orange and iced tea
25. The nurse is caring for a patient with mania. Which of the
following activities is appropriate for the patient?
A. Cutting of paper for an art project
B. Folding of linens.
C. Playing basketball with the other patients.
D. Playing monopoly board game
26. A fundamental concept in nursing is viewing a client with unique
personality. Thus, the nurse should:
A. Consider the values of the client.
B. Focus on the client’s strengths and weaknesses.
C. Focus on the client’s behavior.
D. Refrain from labelling the client as psychiatric entity.
27. A basic concept in psychiatric nursing is that behavior _____:
A. Cannot be understood
B. Cannot be observed
C. Is the main indicator of one’s personality
D. Is meaningful and purposeful
28. The nurse interviews a patient in the health clinic. She verbalized
that she has excessive fear of gaining weight, she sees a fat girl on
the mirror despite a thin body frame, and she hasn’t had
menstruation for 6 months already. These symptoms define:
A. Binge eating disorder
B. Bulimia nervosa
C. Pica
D. Anorexia nervosa
Situation – You are a staff nurse in a rehabilitation center for
substance abuse.
29. You admitted an intoxicated patient for alcohol withdrawal.
Which of the following nursing interventions should you do to help
the client?
A. Walk the client around the unit.
B. Give the client black coffee.
C. Provide the client a quiet room to sleep in.
D. Have the client a cold shower.
30. You asked about the amount of alcohol the client consumes
daily. The client answered, “I just have a few drinks with officemates
after work.” His records show multiple cases of driving under
influence of alcohol. Which of the following would be your most
therapeutic response?
A. “That’s all the clients say at first.”
B. “Then you should have somebody driving for you.”
C. “You say you have a few drinks, but you have multiple
arrests.”
D. “I think you can’t handle a few driving.”
Situation – You are a nurse in the emergency department of Hospital
A. The following questions apply.
31. A patient who suffered from multiple trauma in the street was
seen by the nurse. She responds initially by:
A. Opening the airway.
B. Positioning properly.
C. Providing oxygen.
D. Calling emergency medical services.
32. You are supervising a staff nurse administering drug to a 3rd
degree burn client. Which of the following statements would require
immediate intervention?
A. “I shall not give tablets per orem due to the expected
paralytic ileus.”
B. “Topicalantibacterials can be applied to the wound area using
sterile technique.”
C. “Medications are given intravenously to bypass the excessive
fluid shifts.”
D. “Intramuscular injection is best because it facilitates rapid
absorption.”
Situation – As a nurse, adequate knowledge of research is integral
for the development of nursing science. The following questions
apply.
33. This refers to the integration of research findings where the
practical application is related to the original research. It utilizes the
PICO technique in answering the clinical question.
A. Research utilization
B. Research dissemination
C. Evidence-based practice
D. Cochrane Collaboration
34. You are a nurse and you wanted to study the relationship
between quality of life of seafarers and the use of social media while
on board, what is the independent variable?
A. Use of social media
B. Quality of life of seafarers
C. On board
D. Seafarers
35. Based on the question above, which is the outcome variable?
A. Use of social media
B. Quality of life of seafarers
C. On board
D. Seafarers
Situation – Nurses are accountable for documentation of nursing care
and all other significant findings of their clients. The following
questions apply.
36. The nurse is documenting nursing care for the night shift. She
writes the patient’s nursing diagnosis and problem, assessment
findings, interventions and evaluation in an FDAR format. Which of
the following documentation systems did the nurse use?
A. SOAPIE documentation
B. Narrative charting
C. Problem-oriented medical record
D. Focus charting
37. A nurse is charting her nursing care for a patient in their ward
who has been admitted for 20 days already. She documents
abnormal and significant findings only. Which documentation system
did she use?
A. Focus charting
B. Problem-oriented medical record
C. Charting by exception
D. Narrative charting
38. Most agencies have specific policies about telephone orders.
Which of the following is not true about telephone orders?
A. It is the physician’s responsibility to sign the order within 48
hours.
B. While the physician gives the order, the nurse listens
carefully, writes order, and reads back.
C. The order is transcribed to the doctor’s order sheet.
D. Orders that seem inappropriate must be questioned.
39. You are a staff nurse working in a tertiary hospital. While
charting, you see your charge nurse documenting an administered
medication even before it was given. What is your priority nursing
action?
A. Report to the head nurse promptly.
B. You are under the charge nurse. You are not entitled to
confront her.
C. Tell the charge nurse that doing so may affect her integrity
and may harm the patient.
D. Forget that you saw what the charge nurse did.
40. Nurse Gigi is aware that a record should contain descriptive,
objective observations. The following describes how record should be
except:
A. Patient states, “I wish to end my life.”
B. Maria looks anxious as manifested by her tossing in bed.
C. Maria is uncooperative as manifested by her refusal to take
a bath.
D. Maria appears depressed.
41. You observed a nurse logging into an account of another nurse
in your ward. What is your initial action?
A. Report her immediately to the chief nurse.
B. Call the attention of the head nurse.
C. Ignore the nurse. Every health care team member has the
right to know the cases of patients.
D. Immediately stop her from logging in.
Situation – Nurse Rita is a nurse in the neurosciences ward of
Toprank Hospital. She cares for several clients with various
neurologic conditions.
42. A paraplegic client is for discharge to home. The nurse correctly
includes which instruction for patient education?
A. Follow-up to this clinic if he already feels fine.
B. Maintain on bed rest for first 48 hours for further recovery.
C. Instruct to borrow crutches from a friend so he does not
need to buy.
D. Encourage home modification based on patient needs.
43. The patient with right hemiplegia asks the reason why he has to
be turned every 2 hours. The nurse’s best response is:
A. Patient’s back is encouraged to be exposed to air so
perspiration is minimized.
B. Turning is a form of exercise for a patient with paralysis
from waist down.
C. Turning prevents prolonged reduced blood flow to skin.
D. It prevents erosion of bones due to consequent immobility.
44. What type of exercise is most effective to achieve the goal of
optimal rehabilitation in a patient with paraplegia?
A. Passive ROM
B. Active ROM
C. Turn to sides q2
D. Isokinetic exercise
45. The nurse is monitoring a client who is receiving oxytocin
(Pitocin) to induce labor. Which assessment finding would cause the
nurse to immediately discontinue the oxytocin infusion?
A. Fatigue
B. Drowsiness
C. Uterinehyperstimulation
D. Early decelerations of the fetal heart rate
46. A pregnant client is receiving magnesium sulfate for the
management of preeclampsia. The nurse determines that the client is
experiencing toxicity from the medication if which finding is noted on
assessment?
A. Proteinuria of 3+
B. Respirations of 10 breaths/minute
C. Presence of deep tendon reflexes
D. Serum magnesium level of 6 mEq/L.
47. The nursing instructor asks a nursing student to describe the
procedure for administering erythromycin ointment to the eyes of the
newborn. Which student statement indicates that further teaching is
needed?
A. “I will flush the eyes after instilling the ointment.”
B. “I will clean the newborn’s eyes before instilling ointment.”
C. “I need to administer the eye ointment into each of the
newborn’s conjunctival sacs.”
D. “I will instill the eye ointment into each of the newborn’s
conjunctival sacs.”
48. Rho (D) immune globulin (RhoGAM) is prescribed for a client after
delivery and the nurse provides information to the client about the
purpose of the medication. The nurse determines that the woman
understands the purpose if the woman states that it will protect her
next baby from which condition?
A. Having Rh-positive blood
B. Developing a rubella infection
C. Developing physiological jaundice
D. Being affected by Rh incompatibility
49. The nurse assisted with the delivery of a newborn. Which nursing
action is most effective in preventing heat loss by evaporation?
A. Warming the crib pad
B. Closing the doors to the room
C. Drying the infant with a warm blanket
D. Turning on the overhead radiant warmer
50. The mother of a newborn calls the clinic and reports that when
cleaning the umbilical cord, she noticed that the cord was moist and
that discharge was present. What is the most appropriate nursing
instruction for this mother?
A. Bring the woman to the clinic.
B. This is a normal occurrence.
C. Increase the number of times that the cord is cleaned per
day.
D. Monitor the cord for another 24 to 48 hours and call the
clinic if the discharge continues.
51. The nurse is assessing a newborn after circumcision and notes
that the circumcised area is red with a small amount of bloody
drainage. Which nursing action is most appropriate?
A. Apply gentle pressure.
B. Reinforce the dressing.
C. Document the findings.
D. Contact the health care provider (HCP).
52. The postpartum nurse is providing instructions to the mother of a
newborn with hyperbilirubinemia who is being breast-fed. The nurse
should provide which most appropriate instruction to the mother?
A. Feed the newborn less frequently.
B. Continue to breast-feed every 2 to 4 hours.
C. Switch to bottle-feeding the infant for 2 weeks.
D. Stop breast-feeding and switch to bottle-feeding
permanently.
53. The nurse administers erythromycin ointment (0.5%) to the eyes
of a newborn and the mother asks the nurse why this is performed.
Which explanation is best for the nurse to provide about neonatal
eye prophylaxis?
A. Protects the newborn’s eyes from possible infections
acquired while hospitalized.
B. Prevents cataracts in the newborn born to a woman who is
susceptible to rubella.
C. Minimizes the spread of microorganisms to the newborn
from invasive procedures during labor.
D. Prevents an infection called ophtalmianeonatorum from
occurring after delivery in a newborn born to a woman
with an untreated gonococcal infection.
54. The nurse develops a plan of care for a woman with human
immunodeficiency virus infection and her newborn. The nurse should
include which intervention in the plan of care?
A. Monitoring the newborn’s vital signs routinely
B. Maintaining standard precautions at all times while caring
for the newborn
C. Initiating referral to evaluate for blindness, deafness,
learning problems, or behavioral problems
D. Instructing the breast-feeding mother regarding the
treatment of the nipples with nystatin ointment
55. The nurse is planning care for a newborn of a mother with
diabetes mellitus. What is the priority nursing consideration for this
newborn?
A. Developmental delays because of excessive size.
B. Maintaining safety because of low blood glucose levels.
C. Choking because of impaired suck and swallow reflexes
D. Elevated body temperature because of excess fat and
glycogen
56. Which statement reflects a new mother’s understanding of the
teaching about the prevention of newborn abduction?
A. “I will place my baby’s crib close to the door.”
B. “Some health care personnel won’t have name badges.”
C. “It’s OK to allow the unlicensed assistive personnel to carry
my newborn to the nursery.”
D. “I will ask the nurse to attend to my infant if I am napping
and my husband is not here.”
57. The nurse prepares to administer a vitamin K injection to a
newborn, and the mother asks the nurse why her infant needs the
injection. What best response should the nurse provide?
A. “Your newborn needs vitamin K to develop immunity.”
B. “The vitamin K will protect your newborn from being
jaundiced.”
C. “Newborns have sterile bowels, and vitamin K promotes
the growth of bacteria in the bowel.”
D. “Newborns are deficient in vitamin K, and this injection
prevents your newborn from bleeding.”
58. The nurse is monitoring a client in the immediate postpartum
period for signs of hemorrhage. Which sign, if noted, would be an
early sign of excessive blood loss?
A. A temperature of 38 ° C
B. An increase in the pulse rate from 88 to 102 beats/minute
C. A blood pressure change from 130/88 to 124/80 mm Hg
D. An increase in the respiratory rate from 18 to 22
breaths/minute
59. The nurse is providing instructions about measures to prevent
postpartum mastitis to a client who is breast-feeding her newborn.
Which client statement would indicate a need for further instruction?
A. “I should breast-feed every 2 to 3 hours.”
B. “I should change the breast pads frequently.”
C. “I should wash my hands well before breast-feeding.”
D. “I should wash my nipples daily with soap and water.”
60. The postpartum nurse is assessing a client who delivered a
healthy infant by cesarean section for signs and symptoms of
superficial venous thrombosis. Which sign would the nurse note if
superficial venous thrombosis were present?
A. Paleness of the calf area
B. Coolness of the calf area
C. Enlarged, hardened veins
D. Palpable dorsalispedis pulses
61. A client in a postpartum unit complains of sudden sharp chest
pain and dyspnea. The nurse notes that the client is tachycardic and
the respiratory rate is elevated. The nurse suspects a pulmonary
embolism. Which should be the initial nursing action?
A. Initiate an intravenous line.
B. Assess the client’s blood pressure.
C. Prepare to administer morphine sulfate.
D. Administer oxygen, 8 to 10L/minute, by face mask.
62. On assessment of a postpartum client, the nurse notes that the
uterus feels soft and boggy. The nurse should take which initial
action?
A. Elevate the client’s legs.
B. Document the findings.
C. Massage the fundus until it is firm.
D. Push on the uterus to assist in expressing clots.
63. The nurse is teaching a postpartum client about breast-feeding.
Which instruction should the nurse include?
A. The diet should include additional fluids.
B. Prenatal vitamins should be discontinued.
C. Soap should be used to cleanse the breasts.
D. Birth control measures are unnecessary while breast-
feeding.
64. A nurse is preparing to assess the uterine fundus of a client in
the immediate postpartum period. After locating the fundus, the
nurse notes that the uterus feels soft and boggy. Which nursing
intervention would be most appropriate?
A. Elevate the client’s legs.
B. Massage the fundus until it is firm.
C. Ask the client to turn on her left side.
D. Push on the uterus to assist in expressing clots.
65. The nurse is caring for four 1-day postpartum clients. Which
client would require further nursing action?
A. The client with mild afterpains
B. The client with a pulse rate of 60 beats/minute
C. The client with colostrum discharge from both breasts
D. The client with lochia that is red and has a foul-smelling
odor
66. When performing a postpartum assessment on a client, a nurse
notes the presence of clots in the lochia. The nurse examines the
clots and notes that they are larger than 1 cm. Which nursing action
is most appropriate?
A. Document the findings.
B. Reassess the client in 2 hours.
C. Notify the health care provider.
D. Encourage increased oral intake of fluids.
67. The nurse is assessing a pregnant client in the second trimester
of pregnancy who was admitted to the maternity unit with a
suspected diagnosis of abruptio placentae. Which assessment finding
should the nurse expect to note if this condition is present?
A. Soft abdomen
B. Uterine tenderness
C. Absence of abdominal pain
D. Painless, bright red vaginal bleeding
68. The maternity nurse is preparing for the admission of a client in
the third trimester of pregnancy who is experiencing vaginal bleeding
and has a suspected diagnosis of placenta previa. The nurse reviews
the health care provider’s prescriptions and should question which
prescription?
A. Prepare the client for an ultrasound.
B. Obtain equipment for a manual pelvic examination.
 C. Prepare to draw a hemoglobin and hematocrit blood
sample.
D. Obtain equipment for external electronic fetal heart rate
monitoring.
69. An ultrasound is performed on a client at term gestation who is
experiencing moderate vaginal bleeding. The results of the
ultrasound indicate that abruptio placentae is present. On the basis
of these findings, the nurse should prepare the client for which
anticipated prescription?
A. Delivery of the fetus
B. Strict monitoring of intake and output
C. Complete bed rest for the remainder of the pregnancy
D. The need for weekly monitoring of coagulation studies until
the time of delivery
70. The nurse is monitoring a client who is in the active stage of
labor. The client has been experiencing contractions that are short,
irregular, and weak. The nurse documents that the client is
experiencing which type of labor dystocia?
A. Hypotonic
B. Precipitous
C. Hypertonic
D. Preterm labor
71. The nurse in a labor room is preparing to care for a client with
hypertonic uterine contractions. The nurse is told that the client is
experiencing uncoordinated contractions that are erratic in their
frequency, duration, and intensity. What is the priority nursing
action?
A. Provide pain relief measures.
B. Prepare the client for an amniotomy.
C. Promote ambulation every 30 minutes.
D. Monitor the oxytocin (Pitocin) infusion closely.
72. The nurse has developed a plan of care for a client experiencing
dystocia and includes several nursing actions in the plan of care.
Which is the priority nursing action?
A. Providing comfort measures
B. Monitoring the fetal heart rate
C. Changing the client’s position frequently
D. Keeping the significant other informed of the progress of
labor
73. The nurse in the postpartum unit is caring for a client who has
just delivered a newborn infant following a pregnancy with a
placenta previa. The nurse reviews the plan of care and prepares to
monitor the client for which risk associated with placenta previa?
A. Infection
B. Hemorrhage
C. Chronic hypertension
D. Disseminated intravascular coagulation
74. The nurse in a labor room is performing a vaginal assessment on
a pregnant client in labor. The nurse notes the presence of the
umbilical cord protruding from the vagina. What is the first nursing
action with this finding?
A. Gently push the cord into the vagina.
B. Place the client in Trendelenburg’s position.
C. Find the closest telephone and page the health care
provider stat.
D. Call the delivery room to notify the staff that the client will
be transported immediately.
75. The nurse is caring for a client in labor. Which assessment
finding indicates to the nurse that the client is beginning the second
stage of labor?
A. The contractions are regular.
B. The membranes have ruptured.
C. The cervix is dilated completely.
D. The client begins to expel clear vaginal fluid.
76. The nurse in the labor room is caring for a client in the active
stage of the first phase of labor. The nurse is assessing the fetal
patterns and notes a late decelaration on the monitor strip. What is
the most appropriate nursing action?
A. Administer oxygen via face mask.
B. Place the mother in a supine position.
C. Increase the rate of the oxytocin (Pitocin) intravenous
infusion.
D. Document the findings and continue to monitor the fetal
patterns.
77. The nurse is reviewing the record of a client in the labor room
and notes that the health care provider has documented that the
fetal presenting part is at the -1 station. This documented finding
indicates that the fetal presenting part is located at which area?
A. 1 inch below the coccyx
B. 1 inch below the iliac crest
C. 1 cm above the ischial spine
D. 1 fingerbreadth below the symphysis pubis
78. A client arrives at a birthing center in active labor. Her
membranes are still intact, and the health care provider prepares to
perform an amniotomy. What will the nurse relay to the client as the
most likely outcome of the amniotomy?
A. Less pressure on her cervix
B. b, Decreased number of contractions
C. Increased efficiency of contractions
D. The need for increased maternal blood pressure
monitoring
79. The nurse is monitoring a client in labor. The nurse suspects
umbilical cord compression if which is noted on the external
monitoring tracing during a contraction?
A. Variability
B. Accelerations
C. Early decelerations
D. Variable decelerations
Situation:The Ebola Virus causes an acute serious illness which is
often fatal if untreated. Ebola Virus first appeared in 1976 in two
simultaneous outbreaks, one was in Sudan and one was in Congo.
The outbreak which occurred in 2014 in West Africa was the largest
and most complex Ebola outbreak since the virus was first
discovered.
80. The incubation period is the time interval from the infection with
the virus to the onset of symptoms. For Ebola Virus Disease, this is?
A. 5-20 days
B. 3-7 days
C. 10-12 days
D. 2-21 days
81. The Ebola Virus is primarily transmitted through?
A. Airborne transmission
B. Droplet transmission
C. Direct contract transmission
D. Hereditary
82. The following are signs and symptoms of the Ebola Virus
Disease. Select all that apply:
i. Sudden onset of fever
ii. Splenomegaly
iii. Fatigue and muscle pain
iv. Bleeding (Internal and external)
v. Tinnitus
vi. Decreased level of consciousness
A. i, iii, iv, v c. iii, iv, v, vi
B. ii, iv, v, vi d. i, iii, iv, vi
83. The following basic nursing interventions can aid increase the
chances of survival EXCEPT:
A. Provide symptomatic care.
B. Strictly follow the schedule for the prescribed antibiotics.
C. Administer oral or intravenous fluids, as ordered.
D. Monitor oxygen saturation and blood pressure.
84. Which of the following is true regarding the prevention and
control of the spread of Ebola Virus?
A. Prompt and safe burial of the dead must be observed.
B. Male survivors should practice safe sex and hygiene for 12
months from convalescence or until their semen tests
negative thrice for Ebola virus.
C. There are no special precautions in terms of handling
animal products (e.g. blood and meat).
D. Susceptible people should be vaccinated.
Situation -Nurse Karla is working in an obstetric unit in Hospital Y.
She cares for female clients in their puerperium. The following
questions apply.
85. What is the primary presenting symptom in a client with placenta
previa?
A. Bright red bleeding
B. Concealed hemorrhage
C. Rupture of membranes
D. Abdominal pain
86. The mother consulted to Sta. Monica Health Center as she
suspects that she is pregnant after having no menstruation this
month. She told the nurse that she had her menses last March 11,
2018. The mother asked when will she deliver the baby. The nurse
correctly replies:
A. December 18, 2018
B. November 29, 2018
C. November 14, 2018
D. December 11, 2018
87. A pregnant mother, 32 weeks gestation, was admitted to the OB
ward for significant bleeding in different mucosal areas. The
physician found out that she has disseminated intravascular
coagulation. What could be the reason for the condition?
A. Placenta previa
B. Fetal demise
C. Premature rupture of membranes
D. Endometriosis
88. The nurse in the labor room monitors a patient in her transitional
phase for duration of contractions. She measures this:
A. From the beginning of one to the beginning of the next
contraction.
B. From the start of a contraction to the end of the same
contraction.
C. From the end of a contraction to the beginning of the next
contraction.
D. From the beginning of one contraction to the end of the
next contraction.
89. In the labor room, a pregnant patient was being assessed for
cervical dilation and uterine contraction. Which of the following
findings tells the nurse that the patient is on the transitional phase?
A. 3cm dilated, contractions every 15-30 mins
B. 7cm dilated, contractions every 3-5 mins
C. 8cm dilated, contractions every 3-5 mins
D. 9cm dilated, contractions every 2-3 mins
90. Which of the following is not true about progesterone?
A. It helps maintain pregnancy.
B. Its release is stimulated by the luteinizing hormone.
C. It maintains and supports continued growth of
endometrium.
D. Progesterone levels increase when Gn-RH decreases.
91. A pregnant patient at 32 weeks’ gestation came to the health
center for consult. It was found out that the fetal position is LOA.
Where does the nurse expect to hear the fetal heart tone?
 A. Umbilical area C. Inconclusive
B. Left lower abdomen D. Need for repeat testing
C. Left upper abdomen 103. A client with acquired immunodeficiency syndrome (AIDS)
D. Suprapubic area has histoplasmosis. Nurse Awra should assess the client for which
92. Nurse Awra is performing an assessment on a client with expected finding?
pheochromocytoma. Which assessment data would indicate a A. Dyspnea
potential complication associated with this disorder? B. Headache
A. A coagulation time of 5 minutes. C. Weight gain
B. A urinary output of 50 mL/hour D. Hypothermia
C. A blood urea nitrogen level of 20 mg/dL 104. Nurse Awra is giving discharge instructions to a client with
D. A heart rate that is 90 beats/minute and irregular pulmonary sarcoidosis. Nurse Awra concludes that the client
93. Nurse Awra is providing discharge instructions to a client who understands the information if the client indicates to report which
has Cushing’s syndrome. Which client statement indicates that sign of exacerbation?
instructions related to dietary management are understood? A. Fever
A. “I will need to limit the amount of protein in my diet.” B. Fatigue
B. “I should eat foods that have a lot of potassium in them.” C. Weight loss
C. “I am fortunate that can eat all the salty foods I enjoy.” D. Shortness of breath
D. “I am fortunate that I do not need to follow any special 105. Nurse Awra is conducting an educational session with
diet.” community members regarding the symptoms associated with
94. Nurse Awra is caring for a client who is 2 days post-operative tuberculosis. Which is one of the first manifestations associated with
following an abdominal hysterectomy. The client has a history of tuberculosis?
diabetes mellitus and has been receiving regular insulin according to A. Dyspnea
capillary blood glucose testing four times a day. A carbohydrate- B. Chest pain
controlled diet has been prescribed but the client has been C. A bloody, productive cough
complaining of nausea and is not eating. On entering the client’s D. A cough with the expectoration of mucoid sputum
room, Nurse Awra finds the client to be confused and diaphoretic. 106. The low-pressure alarm sounds on a ventilator. Nurse Awra
Which action is most appropriate at this time? assesses the client and then attempts to determine the cause of the
A. Call a code to obtain needed assistance immediately. alarm. If unsuccessful in determining the cause of the alarm, Nurse
B. Obtain a capillary blood glucose level and perform a Awra should take what initial action?
focused assessment. A. Administer oxygen
C. Ask the unlicensed assistive personnel (UAP) to stay with B. Check the client’s vital signs
the client while obtaining 15 to 30 g of a carbohydrate C. Ventilate the client manually
snack for the client to eat. D. Start cardiopulmonary resuscitation.
D. Stay with the client and ask the UAP to call the health care 107. A client has undergone esophagogastroduodenoscopy.
provider (HCP) for a prescription for intravenous 50% Nurse Awra should place highest priority on which item as part of the
dextrose. client’s care plan?
95. Nurse Awra is caring for a client with pheochromocytoma who is A. Monitoring the temperature
scheduled for adrenalectomy. In the preoperative period, what B. Monitoring complaints of heartburn
should the nurse monitor as the priority? C. Giving warm gargles for a sore throat
A. Vital signs D. Assessing for the return of the gag reflex
B. Intake and output 108. Nurse Awra has taught the client about an upcoming
C. Blood urea nitrogen results endoscopic retrograde cholangiopancreatography procedure. Nurse
D. Urine for glucose and ketones Awra determines that the client needs further information if the client
96. A client has just been admitted to the nursing unit following makes which statement?
thyroidectomy. Which assessment is the priority for this client? A. “I know I must sign the consent form.”
A. Hypoglycemia B. “I hope the throat spray keeps me from gagging.”
B. Level of hoarseness C. “I’m glad I don’t have to lie still for this procedure.”
C. Respiratory distress D. “I’m glad some IV medication will be given to relax me.”
D. Edema at the surgical site 109. The health care provider has determined that a client with
97. A client being hemodialyzed suddenly becomes short of breath hepatitis has contracted the infection from contaminated food. Nurse
and complains of chest pain. The client is tachycardic, pale, and Awra understands that this client is most likely experiencing what
anxious and Nurse Awra suspects air embolism. What is the priority type of hepatitis?
nursing action? A. Hepatitis A
A. Monitor vital signs every 15 minutes for the next hour. B. Hepatitis B
B. Discontinue dialysis and notify the health care provider C. Hepatitis C
(HCP). D. Hepatitis D
C. Continue dialysis at a slower rate after checking the lines 110. Nurse Awra is caring for a client with a diagnosis of chronic
for air. gastritis. Nurse Awra monitors the client knowing that this client is at
D. Bolus the client with 500 mL of normal saline to break up risk of which vitamin deficiency?
the air embolus. A. Vitamin A
98. A client is admitted to the emergency department following a fall B. Vitamin B12
from a horse and the health care provider (HCP) prescribes insertion C. Vitamin C
of a Foley catheter. While preparing for the procedure, Nurse Awra D. Vitamin E
notes blood at the urinary meatus. Nurse Awra nurse should take 111. Nurse Awra is assessing a client 24 hours following a
which action? cholecystectomy. Nurse Awra notes that the T-tube has drained 750
A. Notify the HCP. mL of green-brown drainage since the surgey. Which nursing
B. Use a small-sized catheter. intervention is most appropriate?
C. Administer pain medication before inserting the catheter. A. Clamp the T-tube.
D. Use extra povidone-iodine solution in cleansing the meatus. B. Irrigate the T-tube.
99. Nurse Awra is assessing the patency of a client’s left arm C. Document the findings.
arteriovenous fistula prior to initiating hemodialysis. Which finding D. Notify the health care provider.
indicates that the fistula is patent? 112. Nurse Awra would evaluate that defibrillation of a client
A. Palpation of a thrill over the fistula was most successful if which observation was made?
B. Presence of a radial pulse in the left wrist A. Arousable, sinus rhythm, BP 116/72 mm Hg
C. Absence of a bruit on auscultation of a fistula B. Nonarousable, sinus rhythm, BP 88/60 mm Hg
D. Capillary refill less than 3 seconds in the nail beds of the C. Arousable, marked bradycardia, BP 86/54 mm Hg
fingers on the left hand D. Nonarousable, supraventricular tachycardia, BP 122/60 mm
100. Nurse Awra is assessing a client with epididymitis. The Hg
nurse anticipates which findings on physical examination? 113. Nurse Awra is evaluating a client’s response to
A. Fever, diarrhea, groin pain, and ecchymosis cardioversion. Which observation would be of highest priority to
B. Nausea, vomiting, scrotal edema, and ecchymosis Nurse Awra?
C. Fever, nausea, vomiting, and painful scrotal edema A. Blood pressure
D. Diarrhea, groin pain, testicular torsion, and scrotal edema B. Status of airway
101. A hemodialysis client with a left arm fistula is at risk for C. Oxygen flow rate
arterial steal syndrome. Nurse Awra should assess the client for D. Level of consciousness
which manifestations of this complication? 114. Nurse Awra is caring for a client who has just had
A. Warmth, redness, and pain in the left hand implantation of an automatic internal cardioverter-defibrillator. Nurse
B. Aching pain, pallor, and edema of the left arm Awra immediately would assess which item based on priority?
C. Edema and reddish discoloration of the left arm A. Anxiety level of the client and family
D. Pallor, diminished pulse, and pain in the left hand B. Presence of a Medic-Alert card for the client to carry
102. A client who is human immunodeficiency virus (HIV)- C. Knowledge of restrictions of postdischarge physical activity
positive has had a tuberculin skin test (TST). Nurse Awra notes a 7- D. Activation status of the device, heart rate cutoff, and
mm area of induration at the site of the skin test and interprets the number of shocks it is programmed to deliver.
result as which finding? 115. Nurse Awra is assessing the neurovascular status of a
A. Positive client who returned to the surgical nursing unit 4 hours ago after
B. Negative undergoing aortoiliac bypass graft. The affected leg is warm, and
Nurse Awra notes redness and edema. The pedal pulse is palpable
and unchanged from admission. How should Nurse Awra correctly
interpret the client’s neurovascular status?
A. The neurovascular status is normal because of increased
blood flow through the leg.
B. The neurovascular status is moderately impaired, and the
surgeon should be called.
C. The neurovascular status is slightly deteriorating and
should be monitored for another hour.
D. The neurovascular status is adequate from an arterial
approach, but venous complications are arising.
116. Nurse Awra is caring for a client who had a reaction of an
abdominal aortic aneurysm yesterday. The client has an intravenous
infusion at a rate of 150 mL/hour, unchanged for the last 10 hours.
The client’s urine output for the last 3 hours has been 90, 50, and 28
mL (28 mL most recent). The client’s blood urea nitrogen level is 35
mg/dL and the serum creatinine level is 1.8 mg/dL, measured this
morning. Which nursing action is the priority?
A. Check the urine specific gravity.
B. Call the health care provider (HCP).
C. Check to see if the client had a sample for a serum albumin
level drawn.
D. Put the intravenous (IV) line on a pump so that the
infusion rate is sure to stay stable.
SITUATION: A nurse is caring for an ambulatory 60 y/o male patient
who has overflow urinary incontinence secondary to benign prostatic
hypertrophy (BPH). The physician orders external catheter
application for the patient.
117. The nurse is aware that the following are the purposes of
condom catheter application BUT:
A. To collect urine and control urinary incontinence
B. To permit physical activity of the patient
C. To promote relaxation of the urinary bladder
D. To prevent skin irritation
118. During condom catheter application, the nurse must follow
these standards apart from:
A. Roll the condom outward onto itself
B. Roll the condom over the penis, leaving 2.5-inch distance
from the tip of the penis to the connecting tube
C. Make sure that the tip of the penis is not touching the
condom and that the condom is not twisted.
D. Instruct the client to keep the drainage below the level of
the condom and avoid loops or kinks in the tubing.
119. The nurse is aware that she should attach the urinary
drainage bag of the condom catheter to the:
A. Side rails
B. Bed frame
C. Patient’s gown
D. Patient’s leg
120. The nurse is knowledgeable that how often should she
assess the penis of the patient?
A. 30 minutes after condom catheter application, then q 4
hours
B. 1 hour after condom catheter application, then q shift
C. 30 minutes after condom catheter application, then q 24
hours
D. 1 hour after condom catheter application, then q 2 days
121. The nurse is aware that how often should she change the
condom device?
A. Every 8 hours
B. Every 16 hours
C. Every 24 hours
D. Every 32 hours
122. The nurse has changed the old condom catheter of the
patient. She demonstrates understanding of the procedure if she
tapes the new condom catheter in what manner?
A. Vertically
B. Horizontally
C. Diagonally
123. The nurse wants to delegate the application of a condom
catheter to a nursing aide. What must the nurse assess prior to
delegating this task?
A. Assess whether the client has unique needs.
B. Measure the client’s intake.
C. Assist the client out of bed to a chair.
D. Assess changes in the client’s mobility status.
124. The nursing aide has applied a condom catheter to a
client. The nurse should document what information about this
procedure?
1. Number of mL of fluid used to inflate the balloon
2. Location of the drainage bag
3. Name of the UAP who applied the device
4. Time and date that the condom catheter was applied
5. Integrity of the penis
A. 1,2,3
B. 3,4
C. 4,5
D. 1,2
SITUATION: A male patient was rushed into the Emergency Room
after being involved with motor vehicular accident. Assessment
reveals sucking anterior and mid-axillary chest wounds. The
physician on duty orders emergency thoracic operation with chest
tube insertion connected to a three-way bottle system.
125. Nurse Maureen, an OR nurse has assisted the physician
with the insertion of a chest tube. She monitors the client and notes
oscillation of the fluid level in the water seal chamber after the tube
is inserted. Based on this assessment, which action would be
appropriate?
A. Inform the physician
B. Continue to monitor the client
C. Reinforce the occlusive dressing
D. Encourage the client to deep-breathe
126. The patient’s operation was successful and is now being
transferred to surgical ward. Nurse Hiromi who is currently caring for
this patient, notes continuous gentle bubbling in the suction control
chamber. What action is appropriate?
A. Do nothing, because this is an expected finding
B. Immediately clamp the chest tube and notify the physician
C. Check for an air leak because the bubbling should be
intermittent
D. Increase the suction pressure so that the bubbling
becomes vigorous
127. Nurse Hiromi also assessed the patient's chest tube
insertion site. She noticed a fine crackling sound and feeling upon
palpating the area. What action should the she take?
A. Discontinue the chest tube suction.
B. Collaborate with the client's physician.
C. Mark the area involved and remove the tube.
D. Reinforce the chest tube dressing.
128. The patient becomes irritable and restless. He incessantly
turns from side to side. Unfortunately, the chest tube accidentally
disconnects. The initial nursing action of Hiromi is to:
A. Call the physician
B. Place the end of the tube in a bottle of sterile water
C. Immediately replace the chest tube system
D. Place a sterile occlusive dressing over the disconnection
site
129. The patient’s water seal drainage stopped bubbling. After
checking the patient and the bottle system, nurse Hiromi found no
unusual findings. The doctor was notified and ordered for chest X-
ray. The result reveals re-expansion of the patient’s affected lung.
The physician finally orders removal of the chest tube. While
assisting the doctor during chest tube removal, she should instruct
the patient to:
A. Exhale slowly with pursed lips
B. Inhale deeply and hold breath
C. Inhale and exhale quickly
D. Exhale and hold breath
Situation – Nurse Paul is caring for several pediatric clients in a
pediatric ward in Hospital X. The following questions apply.
130. At 1 month, what health teaching must be communicated
to parents to promote optimum safety?
A. Remove small objects from floor.
B. Remove poisonous substances from low areas.
C. Provide head gear for temper tantrums.
D. Raise side rails high.
131. The parents are planning to give their child fresh oregano
leavesfor cough. How will the nurse respond best?
A. Please wait. I will just get a prescription for that.
B. It is not prescribed by the physician.
C. I will allow as long as it does not harm the child.
D. It is better to give child lagundi syrup than fresh oregano
leaves.
132. Which is the very first deciduous tooth that erupts during a
child’s life?
A. Lower lateral incisor
B. Lower central incisor
C. Upper lateral incisor
D. Upper central incisor
133. An 8-year old child is sick and is recovering at home.
Which of the following is helpful for faster recovery of the child?
A. Call the classmates to visit him at home.
B. Encourage him to watch television if he wants to.
C. Ask him his interests.
D. The child stays with the parents.
134. A 6-year old asked is mother, “When I die, how many days
will you wait until you wake me up?” What does the nurse infer from
the child’s question?
A. Child’s anxiety levels manifest by asking about his own
death.
B. The child’s concept of death is still not completely
developed.
C. He has a fear of body mutilation.
D. He needs the presence of his parents at this developmental
stage.
135. What is the appropriate response to a mother who is
anxious to have her child undergo pyloromyotomy?
A. You cannot do anything about it.
B. How do you feel about the procedure?
C. The case is an emergency. If he does not undergo surgery
he will die.
D. Why do you feel that way? Please tell me.
Situation – Nurses should be knowledgeable regarding the laws and
policies that surround the nursing practice.
136. Which of the following is an example of unintentional tort?
A. The nurse did not come to the patient’s room upon turning
of the call light. Patient suffered frommyocardial infarction.
B. Two nurses are talking about a patient in a cafeteria when
another nurse heard the conversation.
C. The nurse threatens the child that he will not be fed if he
will not take the medicine.
 D. A nurse checks on the health records of a patient she is not
assigned to.
137. The nurse entered a patient’s room to perform blood
extraction. The patient refused the attempt, but the nurse continued
to insert the intravenous catheter. The nurse has committed what
tort?
A. Assault
B. Battery
C. False imprisonment
D. Invasion of privacy
Situation – Nurse Buboy is being considered as a nursing supervisor
in one of their hospital departments. He must be equipped with
principles of leadership and management before being committed to
his position.
138. Which of the following conflict resolution strategies lead to
a lose-lose situation?
A. Accommodating
B. Compromise
C. Collaborating
D. Competing
139. Which of the following should be delegated to an
unlicensed nursing assistant?
A. Discuss about stroke.
B. Teaching on physical rehabilitation for stroke.
C. Administration of mannitol.
D. Turning every 2 hours.
140. The charge nurse is managing a group of staff nurses for
the night shift. Which of the following actions by the charge nurse
demonstrates the most important communication skill?
A. Shares jokes with the staff nurses during break time.
B. Being assertive and firm with her requests.
C. Assertive and directive only during emergency events in
the ward.
D. Listening attentively to what the nursing staff verbalize.
141. A nurse from nursing service department is evaluating the
performance of staff in a neurosciences unit. Which of the following
is must be done for proper evaluation?
A. Observe the nurses from afar to avoid Hawthorne effect
B. Review the records of recently discharged patients.
C. Interview patients and their significant others’ randomly.
D. Use of measurable standards
142. Among which of the following is not a sophisticated
technology?
A. Magnetic resonance imaging
B. Pulse oximeter
C. Chest X-ray
D. Vein finder
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.
143. 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 – results from accumulation of
metabolites, hyponatremia and hyperkalemia. Primarily, it
is due to hyponatremia. Since sodium is unavailable
because it is trapped in the edema fluids, bicarbonate
produced by the kidneys will be excreted (Udan, p.570).
B. Hypernatremia
C. Hypokalemia
D. Metabolic alkalosis
144. 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.
B. Intracellular to extracellular space.
C. Vascular to interstitial space.
D. Interstitial to vascular space
145. 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
146. The client receives fluid resuscitation therapy. The nurse adjusts
the infusion rate by evaluating the client’s __________:
A. Hourly urine output
B. Daily body weight
C. Hourly urine specific gravity
D. Hourly body temperature
147. 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
C. Correct water and electrolyte imbalances
D. Allow the gastrointestinal tract to rest
Situation - The nurse cares for a female client who is terminally ill
and is experiencing pain.
148. 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.
149. 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 order – DNR is an order written by a HCP when a
client has indicated a desire to be allowed to die if the client
suffers cardiac or respiratory arrest (Saunders, p.234).
B. Durable power of attorney – appoints a person (health care
proxy) chosen by the client to make health care decisions
on the client’s behalf when the client can no longer make
decisions (Saunders, p.234).
C. Living will – lists the medical treatment that a client chooses
to omit or refuse if the client becomes unable to make
decisions and is terminally ill (Saunders, p.234).
D. Last will and testament
150. 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 medications ordered.
D. Be compassionate and give half of dose of the medication
ordered.
151. 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.
152. 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.
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.
Situation – The charge nurse in the medical unit updates her
knowledge on nursing diagnosis. She reviews the terms used to
describe clinical adjustment.
153. 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
B. Possible nursing diagnosis –
C. Actual nursing diagnosis
D. Wellness nursing diagnosis
154. Which of the following statements is a WELLNESS nursing
diagnosis?
A. Constipation related to decreased activity and fluid intake –
actual ndx
B. Risk for Activity Intolerance related to prolonged bed rest –
risk ndx
C. Possible Self-Care Deficit; grooming related to fatigue and
muscular weakness – possible ndx
D. Potential for Enhanced Spiritual Well Being – wellness ndx
155. Which of the following statements is a POSSIBLE nursing
diagnosis?
A. Constipation related to decreased activity and fluid intake –
actual ndx
B. Potential for Enhanced Spiritual Well Being – wellness ndx
C. Possible Self-Care Deficit; grooming related to fatigue and
muscular weakness – possible ndx
D. Risk for Activity Intolerance related to prolonged bed rest –
risk ndx
156. Which of the following is a RISK nursing diagnosis?
A. Potential for Enhanced Spiritual Well Being – wellness ndx
B. Possible Self-Care Deficit; grooming related to fatigue and
muscular weakness – possible ndx
C. Risk for Activity Intolerance related to prolonged bed rest –
risk ndx
D. Constipation related to decreased activity and fluid intake –
actual ndx
157. Which of the following statements is an ACTUAL nursing
diagnosis?
A. Possible Self-Care Deficit; grooming related to fatigue and
muscular weakness – possible ndx
B. Potential for Enhanced Spiritual Well Being – wellness ndx
C. Risk for Activity Intolerance related to prolonged bed rest –
risk ndx
D. Constipation related to decreased activity and fluid intake –
actual ndx
Situation – Mrs. Astral, 66-year old hypertensive was admitted to the
hospital complaining of chest discomfort, orthopnea, pedal edema,
and productive cough.
158. Hypertension is regarded as an afterload disturbance B. Airborne-droplet method through coughing or sneezing
resulting to a decrease in cardiac output. His usual cardiac rate is C. Contaminated food and water
62/min with a stroke volume of 80mL per contraction and CVP of D. Prolong skin to skin contact
2mmhg . His cardiac output is approximately: 170. The physician prescribed an anti-tuberculosis drug to the
A. 9920 mL/min client. The nurse is aware that one of the listed drugs can cause
B. 160 mL/min damage of the eighth cranial nerve. Which of the following is this
C. 4, 960 mL/min drug?
D. 124 mL/min A. Aminosalicylic acid (ASA)
159. Decreased cardiac output results to a decrease in tissue B. Streptomycin sulfate
perfusion. A decrease in renal perfusion results to which of these C. Isoniazid (INH)
compensatory mechanisms? D. Ethambutol
A. Enlargement of the left ventricle Situation – Nurse Jasmine is assigned to the central ICU where she
B. Hypertrophy of the ventricular myocardium. cares for several acutely ill clients.
C. Release of hormone erythropoietin to stimulate RBC 171. A nurse is assisting in the care of a client who is to be
production. defibrillated. The nurse plans to set the defibrillator to which to
D. Release of renin to cause an angiotensin-aldosterone which of the following starting energy range levels, depending on the
response. specific physician order?
160. The most comfortable position of a client with pulmonary A. 50 to 100 joules
edema is: B. 120 to 200 joules
A. Semi-fowlers C. 250 to 300 joules
B. Side-lying D. 350 to 400 joules
C. Right lateral 172. Other than CPR, drugs are commonly used for cardiac
D. Sitting upright arrest. Which of the following does not correspond to their action or
161. One of the parameters considered in the diagnosis and purpose?
progress of a disease is the central venous pressure (CVP). Which of A. Sodium bicarbonate to reverse acidosis.
the following statements about CVP is incorrect? B. Lidocaine to suppress ventricular arrhythmias.
A. Normal pressure is 4 to 10 cmH2O. C. Dobutamine to increase cardiac contractility while
B. A decrease indicates that IV fluid infusion is adequate. promoting peripheral vasodilation.
C. An increase indicates that there is circulatory overloading. D. Atropine sulfate to reduce tracheobronchial and salivary
D. To ensure accuracy, nurse positions manometer at the secretions.
level of the client’s right atrium.
162. Auscultation of the lungs will reveal which of the following 173. Which of the following are assessment findings in the early
breath sounds in a client with pulmonary edema? stages of shock?
A. Wheeze A. Cool, pale, moist skin, weak and fast heartbeat, restlessness
B. Rhonchi B. Warm, dry, pink skin, bradycardia, bradypnea, stupor
C. Friction rub C. Restlessness and apprehension, cyanosis, unconsciousness
D. Rales D. All of the above
163. A patient admitted to the hospital with myocardial 174. To improve venous return to the heart without impending
infarction develops severe pulmonary edema. Which of the following respiration, the shock client is placed in which position?
symptoms should the nurse expect the patient to exhibit? A. Trendelenburg
A. Slow, deep respirations B. Left Lateral
B. Stridor C. Modified Trendelenburg
C. Dyspnea D. Sims’ position
D. Bradycardia 175. While caring for the client, the nurse maintains continuous
164. A patient is experiencing knife-like chest pain which assessment of which of the following parameters?
aggravates during inspiration. Which of the following is most likely its A. Vital signs, hourly urine output, skin color and
origin? temperature, level of consciousness
A. Cardiac B. Vital signs, hourly urine output, skin color and temperature
B. Gastrointestinal C. Vital signs and urine output
C. Respiratory D. Skin color and level of consciousness
D. Musculoskeletal 176. Sodium nitroprusside (Nipride), a vasodilator, was infused.
165. A nurse assesses a patient with bronchitis in a medical This is administered as an IV drip to:
ward. He coughs thick, tenacious sputum and feels fatigued to walk A. Relieve chest pain.
to the bathroom. Which of the following nursing diagnoses takes B. Increase cardiac contractility.
priority? C. Decrease resistance and cardiac workload.
A. Ineffective breathing pattern D. Lower blood pressure.
B. Ineffective airway clearance 177. The nurse enters the room and observes that the Cynthia
C. Fatigue is restless, breathing difficulty, develops rashes and has flushed
D. Activity intolerance appearance. She suspects anaphylaxis. Which nursing action takes
Situation –A 65-year old male is examined by a private physician priority?
diagnosed as possible pulmonary tuberculosis. A. Administer diphenhydramine as ordered.
166. The client asks the nurse why the physician suspects that he B. Maintain open airway.
has tuberculosis. The nurse explains that a diagnosis of C. Provide oxygen support via face mask.
tuberculosis may take some weeks to confirm. Which of the D. Call the physician.
following statements support the answer of the nurse? 178. Cynthia reported a history of allergy as triggered by
A. A positive smear will have to have a positive culture to seafood. Which drug is most appropriate to be given to her when
confirm diagnosis. his?
B. A positive reaction to a tuberculosis skin test indicates that A. Diphenhydramine
the client has active tuberculosis even if negative sputum B. Cetirizine
smear is obtained. C. EpiPen
C. A positive sputum culture would take at least 3 weeks D. Loratadine
because of the slow reproduction of tubercle bacilli. Situation – Nurse Elyzeis assigned to the operating room complex.
D. Chest X-rays need to be repeated during several 179. Nausea and vomiting in which client is of greatest concern
consecutive weeks because the small lesions are difficult to to the nurse?
detect.” A. Client receiving cisplatin and 5-fluorouracil
167. The nurse is aware that in pulmonary tuberculosis, there B. Client with vertigo
is a decreased surface area for gaseous exchange in the lungs. C. Client with severe gastric ulcer
Oxygen and carbon dioxide are exchanged in the lungs by the D. Client postoperative craniotomy
process of: 180. A patient status post-myocardial infarction must be given
A. Diffusion what medication to prevent cardiac complications?
B. Filtration A. Atropine (Isopto Atropine)
C. Active transport B. Psyllium husks (Metamucil)
D. Osmosis C. Loperamide (Imodium)
168. The client noted in his chart the term “hemoptysis” and D. Milk of Magnesia
asked the nurse what it means. The nurse correctly responds by 181. A 30-year old female underwent right modified radical
saying that: mastectomy. How should the nurse position the patient’s arm?
A. Hemoptysis is the presence of blood in your urine. A. Right arm abducted and internally rotated.
B. It is the vomiting of gastric contents which contains blood. B. Left arm is adducted and placed over the abdomen
C. Hemoptysis is the coughing up of blood. C. Right arm is elevated using stacked towels.
D. It is the rupture of blood vessels and pooling of blood into D. A pillow is placed under right arm.
the interstitial space. 182. A client needs surgery to relieve an intestinal obstruction.
169. The client asks the nurse how he got infected with PTB. The nurse receives the following set of orders for the client. Which of
The nurse explains that the mode of transmission is one of the the following orders should the nurse question before performing?
following: A. Tap water enemas until clear.
A. Exposure to tuberculosis cattle by ingestion of B. Out of bed as tolerated.
unpasteurized milk C. Neomycin sulfate 1 g P.O. every 4 hours.
 D. Betadine scrub to abdomen. C. Increased urine specific gravity
183. Which among the following findings will the nurse expect D. Elevated BUN and Crea
to find in the patient with osteomyelitis at the right tibia? 196. The client’s blood urea nitrogen(BUN) level is elevated. This
A. Cold to touch most likely resulted from:
B. Loss of hair A. Hemolysis of RBC
C. Decreased pulse grade B. Reduced renal blood flow
D. Pain that intensifies with movement C. Below normal metabolic rate
Situation –Patients with metabolic problems were admitted in the D. Destruction of kidney cell
medical ward of Hospital A. The following questions apply.
184. The nurse should include which instruction when teaching 197. The client’s serum potassium is elevated, and the nurse
a client about insulin administration? administers sodium polystyrene sulfonate (Kayexalate). The drug is
A. Administer insulin after the first meal of the day. administered because of its ability to:
B. Administer insulin at 45-degree angle into the deltoid A. Exchange sodium and potassium ions in the colon
muscle. B. Increase potassium excretion from the colon
C. Shake the vial of insulin vigorously before withdrawing the C. Increase calcium absorption in the colon
medication. D. Exchange potassium into the colon and sodium to the feces
D. Draw up regular insulin first when mixing two types of 198. If the client’s potassium level continues to rise, the nurse should
insulin in one syringe. be prepared for which of the following emergency situations:
A. Myocardial damage
185. A client admitted with a serum glucose level of 618 mg/dL. B. Cardiac atrophy
The client is awake and oriented, with hot, dry skin, temperature of C. Ventricular hyperstimulation
100.6 F (38.1C), pulse rate of 116 bpm, and BP of 108/70 mmHg. D. Circulatory collapse
Based on these findings, which nursing diagnosis should receive the 199. A high carbohydrate, low protein diet is prescribed for the client.
highest priority? The rationale for high carbohydrate diet is that carbohydrates will:
A. Fluid volume deficit related to osmotic diuresis. A. Act as a diuretic
B. Decreased cardiac output related to increased heart rate. B. Help maintain urine acidity
C. Altered nutrition less than body requirements related to C. Prevent the development of ketosis
insulin deficiency. D. To prevent accumulation of toxic substances
D. Ineffective thermoregulation related to dehydration. 200. The client has an external cannula inserted in her forearm for
186. A client has just been diagnosed with Type 1 (insulin- hemodialysis. Which of the following measures should the nurse
dependent) diabetes mellitus. Which client comment correlates best avoid when caring for the client?
with this disorder? A. Using the unaffected arm for blood pressure
A. “I was thirsty all the time. I just couldn’t get enough measurements.
drink.” B. Performing venipuncture on the arm with fistula.
B. “It seemed like I had no appetite. I had to make myself C. Auscultating the cannula for bruits every 4 hours.
eat.” D. Checking of bleeding at the needle insertion site.
C. “I had a cough and cold that just didn’t seem to go away.”
D. “I notice I had pan when I went to the bathroom.”
187. The nurse should expect a client with hypothyroidism to
report which of these health concerns?
A. Increased appetite and weight loss
B. Puffiness of the face and hands
C. Nervousness and tremors
D. Increasing exopthalmus
188. A client with hypothyroidism is receiving levothyroxine
sodium (Synthroid) 50 mcg po daily. Which of these findings should
the nurse recognize as an adverse drug effect?
A. Dysuria
B. Leg cramps
C. Tachycardia
D. Blurred vision
189. A client’s arterial blood gas values are pH: 7.12; paCO2: 40
mmHg; HCO3: 15 mEq/L. Which disorder does these ABG values
suggest?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis
190. A client is being returned to the room after a subtotal
thyroidectomy. Which piece of equipment is most important for the
nurse to bring to this client’s bedside?
A. Indwelling urinary catheter kit
B. Tracheostomy set
C. Cardiac monitor
D. Humidifier
191. The nurse should expect to administer which of these drugs to a
client with diabetes insipidus?
A. Vasopressin
B. Furosemide
C. Regular insulin
D. 10% dextrose
192. Which outcome indicates that treatment has been effective for a
client with diabetes insipidus?
A. Fluid intake of less than 2, 500 mL in 24 hours
B. Urine output of more than 200 cc/hour
C. Blood pressure of 90/50 mmHg
D. Pulse rate of 126 bpm
193. Which nursing diagnosis is most appropriate for a client
with Addison’s disease?
A. Ineffective stress coping
B. Fluid volume excess
C. Impaired bladder patters: Urinary retention
D. Fluid and electrolyte imbalance related to Hypokalemia
Situation – A 60-year old developed shock after a severe myocardial
infarction. He now has acute renal failure
194. The client’s family asks the nurse why the client developed
acute prerenal failure. The nurse should base the respond on the
knowledge that there is:
A. An obstruction of flow from the kidneys
B. A surge of the blood flow into the kidneys
C. A prolonged episode of inadequate cardiac output
D. Histologic damage to the kidney resulting in acute tubular
necrosis
195. The most significant sign of acute renal failure is:
A. Decreased urine output
B. Decreased filtration rate