1. A 28-month-old child with severe diarrhea is admitted.
Upon assessment, the child is feverish, has dry lips, and
irritable. What is your first nursing priority upon
admission?
a. Asses the hydration status
b. Assess the skin turgor
c. Obtain the apical-radial cardiac rate
d. Weigh the child
2. You were assigned to a patient. Upon assessment, the
patient elicited Homan’s sign. What is the nursing
priority using this assessment?
a. Encourage fluid and electrolyte balance
b. Encourage good venous circulation
c. Secure patent airway
d. Promote skincare
3. You were assigned to a patient with a nasogastric
tube attached for almost three days. It is time to irrigate
it, what is the protocol that you will follow?
a. A 30 mL sterile saline must be forcefully instilled and
provide a basin to catch the return flow.
b. A 20 mL sterile saline must be gently instilled and provide
a basin to catch the return flow.
c. Instill 30 mL sterile water and then withdraw solution.
d. Gently instill 20 mL normal saline and then withdraw
solution.
4. A nurse therapeutically responds to a patient with
AIDS when he expressed feelings of depression and
facing death with the following phrase: “Are you afraid
of dying?” What type of therapeutic technique is she
using?
a. Using open-ended question
b. Using a close-ended question
c. Using a leading question
d. Mirroring
5. What role does a nurse exhibits if she stands to
protect the needs and wishes of the patient?
a. Caregiver
b. Counselor
c. Teacher
d. Client advocate
6. A post appendectomy patient is assigned to you. You
have assessed him that he needs more knowledge
about proper wound care. What role should you apply in
this situation?
a. Role Model
b. Counselor
c. Caregiver
d. Teacher
7. While on your night rounds, you have noticed two
nursing aides placing bed sheets that they have taken
from the floor. What is the proper nursing action?
a. Confront the two nursing aides about their and actions
and call them for private counseling
b. Continue your night rounds, they have their own liabilities
on their actions.
c. Remind them the principle of medical asepsis
d. Provide a clothes basket for them
8. In a burn patient, in order to promote adequate fluid
within 24 hours, what intravenous fluid is appropriate?
a. D5 Water
b. Lactated Ringer’s Solution
c. 0.9% NaCl Solution
d. D5NSS
9. Being assigned in a pediatric ward, what is the
characteristic sign of a normal psychosocial
development of a toddler?
a. Erikson’s stage of initiative vs. guilt
b. Imaginary playmates.
c. Negative behavior
d. Demonstrations of sexual curiosity.
10. Defining stress, all of the following describes its
characteristics except:
a. Stress response is natural, productive and adaptive
b. Stress is not always a result of damage to the body
c. Stress always results in a feeling of distress
d. Stress involves the entire body as a whole
11. A one-year-old child is admitted. Looking into the
physical development of the child, what will be affected
or may have a delay?
a. Walking
b. Sitting
c. Running
d. Crawling
12. A mother is concerned about the diet of her child
that has noncomplicated acute glomerulonephritis.
What is the appropriate diet regimen you must teach as
a nurse?
a. Low-protein, low-potassium diet.
b. Regular diet, no added salt.
c. Low-sodium, low-protein diet.
d. Low-sodium, high-protein diet.
13. A patient is on Respiratory Isolation for Tuberculosis
(TB).  Which of the following would be an indicator for
the removal of Isolation Precautions?
a. Sputum Culture is negative for AFB, following a course of
INH and PAS
b. Patient has been on Anti-Tubercular Drug Therapy with
INH for one month’s time
c. Patient has no infiltrates on chest x-ray
d. Absence of adventitious breath sounds
14.A client is diagnosed to have Congestive Heart
Failure.  Upon auscultating the client’s lungs the nurse
hears crackling sounds bilaterally at the bases. What
term should you use in documenting this finding?
a. Rhonchi
b. Wheezing
c. Rales
d. Atelectasis
15. Which of the following response of a 10-year-old
patient with acute appendicitis is an alarming sign?
a. “My pain has gone away.”
b. “I am afraid to have surgery.”
c.  “I feel hot and thirsty.”
d. “I feel better with my legs up towards my chest d. Orient the patient every night before he or she sleeps

23. What is the proper order in the physical assessment

when it comes to the examination of the abdomen?
a. Auscultation, Inspection, Percussion, Palpation
b. Inspection, Auscultation, Percussion, Palpation
16. A nurse assigned to a child with Acute c. Palpation, Percussion, Inspection, Auscultation
Glomerulonephritis is picking up doctor’s orders to put d. Inspection, Percussion, Palpation, Auscultation
in the Kardex. Which of the orders should the nurse
question?
a. Bed rest
24. In assessing the cranial nerve function, a nurse finds
b. Daily weights
out that a patient has a difficulty in determining the
c. Daily blood pressure
different scents when the eyes is closed. Which of the
d. Strict I & O
following cranial nerve had a problem?
a. CN III
17. Which of the following is an INCORRECT statement b. CN II
regarding diet therapy for a patient in renal failure? c. CN I
a. Limit dietary protein d. CN V
b. Provide a diet high in carbohydrates
c. Limit Sodium (NA) intake
25. In examining a patient with asthma in exacerbation,
d. Provide a diet high in Potassium rich food
what lung sound is predominant?
a. Crackles
18. You are assigned to speak to a group of High School b. Pleural rub
students about HIV and AIDS. In discussing c. Gurgles
transmission the nurse knows that the highest d. Wheezes
concentration of the HIV virus in infected patients is in
the:
a. Saliva
b. Cerebrospinal Fluid
c. Blood
d. Semen

19. In teaching HIV in high school students, what is the

appropriate health practice that the nurse should
emphasize?
a. Wash with antibacterial soap immediately after
intercourse.
b. Use a latex condom and water-soluble during intercourse
c. After oral sex, use anti-bacterial mouth wash to destroy
the HIV virus
d. Abstain from intercourse if the female partner is having
her menstrual period.

20. Which of the following is appropriate in a depressed

patient?
a. Using silence
b. Passive Friendliness
c. Using open-ended questions
d. Giving information

21. In a geriatric unit, you have noticed that one patient

seemed to change his behavior. Which of the following
symptoms DOES NOT indicate that the patient is going
into depression?
a. Being talkative
b. Sleeplessness
c. Complains of getting tired easily
d. Change in appetite

22. In admitting an elderly patients, it is a nurse’s goal to

orient the patient. What is the effective nursing action in
order to prevent disorientation?
a. Secure the side rails up all the time
b. Do routine rounds
c. Leave a night light

1. Answer: A
The most critical part upon admission is the hydration status
of the patient. While all the answers were correct and
important, the first objective is the hydration status of the
child.
2. Answer: B
Promoting venous return flow may prevent thrombophlebitis.
A sign that a patient may suffer from thrombophlebitis is
called Homan’s sign. The other goals are not well indicated
in the assessment.
3. Answer: D
The proper way to irrigate the nasogastric tube is to use
gentle pressure during the instillation of the normal saline
solution. Withdrawing the solution afterward can end the
procedure. Gentle pressure is needed in order to preserve
the integrity of the stomach walls.
4. Answer: A
Open-ended questions can help the patient verbalize his
feelings. It helps the nurse explore the thoughts of the
patient in order to provide a means of nursing care in terms
of psychological support and as an active listener.
5. Answer: D
As a client advocate, the nurse protects the interests of the
client. She represents the patient when the patient is not
able to voice out his or her needs. She may also relay
information to the physician when the patient is not able to
represent himself.
6. Answer: D.
Being a teacher in this situation means that you must allow
the patient to learn proper wound care on his own. As a
teacher, the nurse helps the client to learn about their health
and health care procedures.
7. Answer: C
As a part of the healthcare team, nurses should be able to
know that they have responsibility for the situation above. In
order to correct the behavior of the two nursing aides, they
must understand the reason to change the beddings. Giving
them information about germ transmission is the appropriate
approach.
8. Answer: B
Lactated Ringer’s Solution must be used within the first 24
hours. Colloids such as D5Water and D5 NSS increase
capillary permeability which may increase the risk of
pulmonary edema.
9. Answer: C
Assertion of automony is seen in 2 to 21/2-year-old toddlers
as they begin their language and social development. The
stage of initiative vs. guilt (2) is more common in the
preschool-age child, 3 to 6 years. At 3 to 4 years of age,
children have imaginary playmates (1).
10. Answer: C
Stress does not always result in feelings of distress such as
harmful or unpleasant stress. The others options definitely
describe stress.
11. Answer: A
A 1-year-old child normally learns to walk. Any interruption
on this development such as physical stress and
hospitalization can affect the normal development. The child
should sit (4) by 6 months and should already be crawling
(1) by 1 year of age.
12. Answer: B
A regular diet with moderate sodium is suggested for
children who are in acute glomerulonephritis. If the client’s
condition progresses to renal failure, sodium, potassium, and
protein are restricted
13. Answer: A
Clients who have been on anti-TB drug regimes for at least
2-3 weeks and have absence of AFB in at least two
successive sputum cultures, no longer need to be on
Respiratory Isolation.  Taking medication alone, or the
absence of adventitious breath sounds such as rhonchi,
rales, etc, or the absence of infiltrates on chest x-ray, usually
seen with Pneumonia would not be a reason to D/C
Isolation, making choices (b), (c), and (d) incorrect.
14. Answer: C
Rales are defined as abnormal lung sounds which is
crackling in nature. Rhonchi is characterized by dry coarse
sounds which is present when the patient coughs. Wheezes
is common upon expiration and denotes narrowed
passages.
15. Answer: A
The classic finding when an appendix ruptures is a sudden
cessation of pain. Options b, c and dare expected findings
for a child of this age who is diagnosed with acute
appendicitis.
16. Answer: C.
Blood pressure elevation signals a frequent complication
associated with Acute Glomerulonephritis. The nurse should
expect to assess blood pressure every 2 to 4 hours with vital
signs.  Options a, b and d are appropriate orders for a child
with Acute Glomerulonephritis
17. Answer: D
Patients with renal failure should have a diet that provides
(high biologic value) proteins rich foods such as eggs, dairy
products and meats.  These are necessary to maintain a
positive nitrogen balance.  Foods high in calories are also
necessary, and sodium intake should be limited. Foods high
in Potassium should be AVOIDED due to decreased ability
of the kidney(s) to filter and excrete Potassium
18. Answer: C
The HIV virus has been found and isolated in all of the
above body fluids, as well as in the stool and urine.
However, the highest concentration is found in the blood of
infected individuals.
19. Answer: B
Although abstinence is still the best protection against the
spread of the HIV virus, the use of a latex condom with an
H20 soluble lubricant is the most effective means. Other
choices do not give assurance of preventing acquiring the
HIV virus.
20. Answer: C.
Using open-ended questions can allow the patient with
depression to voice out his or her problems or what is
bothering him or her. Using silence at this time is not
appropriate as well as with the other options.
21. Answer: A
Being talkative indicates that the patient may be developing
dementia.
22. Answer: D
Elderly patients are at a higher risk for sustaining injuries,
especially in unfamiliar surroundings. While other choices
are potential interventions that the nurse could implement,
choice (c.) would allow the patient to better visualize the
surroundings, delimiting possible accidents or falls. 
Orienting the patient, as well as checking the patient, and
keeping side rails up are also important , each patient must
be assessed individually to determine which measure(s)
should be employed
23. Answer: B
Percussion is first done in order to assess all the quadrants
and the next is palpation which involves direct pressure. This
step can also elicit pain or dullness.
24. Answer: C
The cranial nerve I or olfactory nerve is responsible to take
in the scents and send signals to the brain.
25. Answer: D
Wheezes is continuous, lengthy, musical heard during
inspiration or expiration. It is common to those with asthma
since there is an active narrowing of the bronchioles.