PHILIPPINE NURSE LICENSURE EXAMINATION 2020:

DIAGNOSTIC EXAM REVIEWER

ANSWER AND EXPLANATION

1.Answer: B. Warfarin Sodium

Option B: In preoperative period, the nurse should consult with the physician about withholding
Warfarin
Sodium to avoid occurrence of hemorrhage.

2. Answer: D. Wisp of cotton

Option D: A client who is unconscious is at greater risk for corneal abrasion. For this reason, the safest
way to test the corneal reflex is by touching the cornea lightly with a wisp of cotton.

3. Answer: B. Therapeutic procedure

Option B: latrogenic infection is caused by the health care provider or is induced inadvertently by
medical treatment or procedures.

4. Answer: D. Lack of spontaneous movement

Option D: Bradykinesia is slowing down from the initiation and execution of movement.

5. Answer: B. Detached retina

Option B: This symptom is caused by stimulation of retinal cells by ocular movement.

6. Answer: D. Increased restlessness

Option D: Restlessness indicates a lack of oxygen to the brain stem which impairs the reticular activating
system.

7. Answer: C. Protects the client's head from injury

Option D: Rhythmic contraction and relaxation associated with tonic-clonic seizure can cause repeated
banging of head.

8. Answer: A. Right side-lying position or supine

Option A: Right side-lying position or supine position permits ventilation of the remaining lung and
prevent fluid from draining into sutured bronchial stump.

9. Answer: C. Decreases the effectiveness of oral contraceptives

Option C: Isoniazid (INH) interferes in the effectiveness of oral contraceptives and clients of childbearing
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age should be counseled to use an alternative form of birth control while taking this drug.

10. Answer: B. Low Fowler's

Option B: A client who has had abdominal surgery is best placed in a low Fowler's position. This relaxes
abdominal muscles and provides maximum respiratory and cardiovascular function.

11. Answer: A. Stoma is dark red to purple

Option A: Dark red to purple stoma indicates inadequate blood supply.

12. Answer: C. Reduce intestinal peristalsis

Option C: The rationale for activity restriction is to help reduce the hypermotility of the colon.

13. Answer: A. Hyperglycemia

Option A: During Total Parenteral Nutrition (TPN) administration, the client should be monitored
regularly for hyperglycemia.

14. Answer: D. Jaundice

Option D: Jaundice may be present in acute pancreatitis owing to obstruction of the biliary duct.

15. Answer: A. Tingling in the fingers

Option A: Tetany may occur after thyroidectomy if the parathyroid glands are accidentally injured or
removed.

16. Answer: D. Weight gain

Option D: Typical signs of hypothyroidism include weight gain, fatigue, decreased energy, apathy, brittle
nails, dry skin, cold intolerance, constipation, and numbness.

17. Answer. B. Thrombophlebitis

Option B: After a pelvic surgery, there is an increased chance of thrombophlebitis owing to the pelvic
manipulation that can interfere with circulation and promote venous stasis.

18. Answer. D. Steps away from the bed and make sure all others have done the same
Option D: For the safety of all personnel, if the defibrillator paddles are being discharged, all personnel
must stand back and be clear of all the contact with the client or the client's bed.
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19. Answer: D. Hard candy

Option D: Hard candy will relieve thirst and increase carbohydrates but does not supply extra fluid.

20. Answer: C. Infection

Option C: Infection is responsible for one-third of the traumatic or surgically induced death of clients
with renal failure as well as medical induced acute renal failure (ARF)

21. Answer: C. Respiratory movement

Option C: There is no respiratory movement in stage 4 of anesthesia, prior to this stage, respiration is
depressed but present.

22. Answer: B. Reduced or absent of breath sounds at the base of the lung
Option B: Compression of the lung by fluid that accumulates at the base of the lungs reduces expansion
and air exchange.

23. Answer: C. Night sweats

Option C: Assessment of a client with Hodgkin's disease most often reveals enlarged, painless lymph
node, fever, malaise and night sweats.

24. Answer: A. "Is the pain sharp and continuous?"

Option A: Fractured pain is generally described as sharp, continuous, and increasing in frequency.

25. Answer: D. Presence of "hot spot on the cast

Option D: Signs and symptoms of infection under a casted area include odor or purulent drainage and
the presence of "hot spot which are areas on the cast that are warmer than the others.

26. Answer: B. Thick and immobile tympanic membrane

Option B: Otoscopic examination in a client with mastoiditis reveals a dull, red, thick and immobile
tympanic membrane with or without perforation.

27. Answer: D. Metabolic alkalosis

Option D: Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of
the loss of hydrochloric acid which is a potent acid in the body.
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28. Answer: A. Red blood cells

Option A: The adult with normal cerebrospinal fluid has no red blood cells.

29. Answer: D. Measuring urine output hourly

Option D: Measuring the urine output to detect excess amount and checking the specific gravity of urine
samples to determine urine concentration are appropriate measures to determine the onset of diabetes
insipidus.

30. Answer: B. Maintaining usual ways of accomplishing task

Option B: The nurse should focus more on developing less stressful ways of accomplishing routine task.

31. Answer: C. Client who is in danger of cardiac arrest

Option C: Autotransfusion is acceptable for the client who is in danger of cardiac arrest.

32. Answer: D. Coolness

Option D: The client with thromboembolism does not have coolness.

33. Answer: A. Position the client on the side with head flexed forward
Option A: Positioning the client on one side with head flexed forward allows the tongue to fall forward
and facilitates drainage secretions, therefore, prevents aspiration.

34. Answer: C. Monitor the site for bleeding, swelling and hematoma formation
Option C: Nursing care after bone biopsy includes close monitoring of the punctured site for bleeding,
swelling and hematoma formation.

35. Answer: D. Swimming

Option D: Walking and swimming are very helpful in strengthening back muscles for the client suffering
from lower back pain.

36. Answer: C. Sudden, severe abdominal pain

Option C: Sudden, severe abdominal pain is the most indicative sign of perforation. When perforation of
an ulcer occurs, the nurse maybe unable to hear bowel sounds at all.

37. Answer: A. Prevent an increased intraocular pressure

Option A: After surgery to correct a detached retina, prevention of increased intraocular pressure is the
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priority goal.

38. Answer: A. Constricting pupil

Option A: Miotic agent constricts the pupil and contracts cillary muscle. These effects widen the
filtration angle and permit increased outflow of aqueous humor.

39. Answer: D. Hyperoxygenate before and after suctioning

Option D: It is a priority to hyperoxygenate the client before and after suctioning to prevent hypoxia and
to maintain cerebral perfusion.

40. Answer: D. Place hand on the abdomen and feel it rise

Option D: Abdominal breathing improves lungs expansion

41. Answer: C. Limit the occurrence of drafts

Option C. A Client with burns is very sensitive to temperature changes because heat is lost in the bum
areas.

42. Answer: A. Relieve pain and promote rapid epithelialization

Option A: The graft covers the nerve endings, which reduces pain and provides framework for
granulation

43. Answer: B. Meatloaf and strawberries

Option B: Meat provides proteins and the fruit proteins vitamin C that both promote wound healing.

44. Answer: C. Absence of gastrointestinal motility

Option C: This is primarily caused by the trauma of intestinal manipulation and the depressive effects
anesthetics and analgesics.

45. Answer: D. Change in bowel habits

Option D: Constipation, diarrhea, and/or constipation alternating with diarrhea are the most common
symptoms of colorectal cancer.

46. Answer: B. Abdominal rigidity

Option B: With increased intraabdominal pressure, the abdominal wall will become tender and rigid.
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47. Answer: A. Help stop bleeding if any occurs

Option A: Pressure applied in the puncture site indicates that a billary vessel was puncture which is a
common complication after liver biopsy.

48. Answer: B. Working as local plumber

Option B: Hepatitis A is primarily spread via fecal-oral route. Sewage polluted water may harbor the
virus.

49. Answer: B. Serum amylase level

Option B: Amylase concentration is high in the pancreas and is elevated in the serum when the pancreas
becomes acutely inflamed and also it distinguishes pancreatitis from other acute abdominal problems.

50. Answer. A. Chloride and sodium levels

Option A: Sodium, which is concerned with the regulation of extracellular fluid volume, it is lost with
vomiting. Chloride, which balances cations in the extracellular compartments, is also lost with vomiting,
because sodium and chloride are parallel electrolytes, hyponatremia will accompany.

51. Answer: B. 02 therapy, analgesia

Option B: All the nursing interventions listed are important in the care of Mr. Duffy. However, relief of
his pain will be best achieved by increasing the O2 content of the blood to his heart and relieving the
spasm of coronary vessels.

52. Answer: C. CK peaks first (12-24 hours), followed by the SGOT (peaks in 24-36 hours) and then the
LDH (peaks 3-4 days).
Option C: Although the timing of initial elevation, peak elevation, and duration of elevation vary with
sources, current literature favors option letter c.

53. Answer: B. ventricular fibrillation

Option B: Ventricular irritability is common in the early post-MI period, which predisposes the client to
ventricular arrhythmias.
Options C and D: Heart block and atrial arrhythmias may also be seen post-MI but ventricular
arrhythmias are more common.

54. Answer: B. take his radial pulse for one minute

Option B: All options have some validity. However, option B relates best to the action of digitalis. If the
pulse rate drops below 60 or is markedly irregular, the digitalis should be held and the physician
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consulted.
Option A: Blood pressure measurement is also helpful; providing the client has the right size cuff and he
or she and/or significant other understand the technique and can interpret the results meaningfully.
Option C: Serum potassium levels should be monitored periodically in clients on digitalis and diuretics,
as potassium balance is essential for prevention of arrhythmias. However, the client cannot do this at
home.
Option D: Daily weights may make the client alert to fluid accumulation, an early sign of CHF.

55. Answer: C. tonometry

Option A: This is most often used to detect corneal lesions;
Option B: This is a test for visual acuity;
Option D: This is used to focus on layers of the cornea and lens looking for opacities and inflammation.

56. Answer: D. A gradual lessening of the power of accommodation

Option A: This defines astigmatism.
Option B: This defines myopia.
Option C: This defines hyperopia.

57. Answer: B. The area of central vision, seen on the temporal side of the optic disc, which is quite
avascular.
Options A and C: These refer to the optic disc.
Option D: This describes the color of the retina.

58. Answer: A. A pinguecula, which is normal slightly raised fatty structure under the conjunctiva that
may
gradually increase with age.
Option A: Correct by definition.

59. Answer: D. all of the above

Options A, B and C: These are potential causes of renal damage and eventually renal failure. Individuals
can live very well with only one healthy kidney.

60. Answer: B. Weakness, anorexia, pruritus

Option B: Weakness and anorexia are due to progressive renal damage; pruritus is secondary to
presence of urea in the perspiration.
Option A: Fruity-smelling breath is found in diabetic ketoacidosis.
Option C: Polyuria, polydipsia, polyphagia are signs of DM and early diabetic ketoacidosis. Oliguria is
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seen in chronic renal failure.

Option D: The skin is more sallow or brown as renal failure continues.

61. Answer: B. Drug toxicity is a major concern in uremia; individualization of therapy and often a
decrease in dose is essential.
Option B: Metabolic changes and alterations in excretion put the client with uremia at risk for
development of toxicity to any drug. Thus alteration in drug schedule and dosage is necessary for safe
care.

62. Answer: C. Apex of the heart, intercostal space, 7-9 cm to the left of the midsternal line.
Option C: The PMI is the impulse at the apex of the heart caused by the beginning of ventricular systole.
It is generally located in the 5th left ICS, 7-9 cm from the MSL or at, or just medial to, the MCL.

63. Answer: A. Tricuspid

Option A: The sound created by closure of the tricuspid valve is heard at the 5th LICS at the LSB.
Option B: Pulmonic closure is best heard at the 2nd LICS, LSB.
Option C: Aortic closure is best heard at the 2nd RICS, RSB.
Option D: Mitral valve closure is best heard at the PMI landmark (apex)

64. Answer: B. S2
Option A: S1 is caused by mitral and tricuspid valve closure;
Option B: S2 is caused by the aortic and pulmonic valve closure;
Options C and D: S3 and S4 are generally considered abnormal heart sounds in adults and are best
heard at the apex.

65. Answer: D. the left coronary artery has two main branches, the left anterior descending and left
circumflex: both supply the left ventricle
Option D: The right and left coronary arteries are the only branches off the ascending aorta; blood
enters these arteries mainly during diastole; the right coronary artery also often supplies a small portion
of the left ventricle
Options A, B, and C: The other objective findings may be seen in chronic mitral stenosis with episodes of
atrial fibrillation and right heart failure.

66. Answer: C. pulmonary hypertension

Option C: Pulmonary congestion secondary to left atrial hypertrophy causes these symptoms.
Option D: The left ventricle does not hypertrophy in mitral stenosis.
Option B: Right heart failure would cause abdominal discomfort and peripheral edema.
Option A: Pericardial thickening does not occur.
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67. Answer: D. chest x-ray showed left ventricular hypertrophy

Option D: Evidence of left atrial enlargement may be seen on chest x-ray and ECG.

68. Answer: C. papillary muscle ischemia and dysfunction

Option A: Ventricular ischemia does not occur with prolapsed mitral valve.
Options B and D: These are not painful conditions in themselves.

69. Answer: B. cancer of the lung

Option B: The incidence of lung cancer is also rapidly rising in women.

70. Answer: B. squamous cell carcinoma (epidermoid)

Option B: Textbooks of medicine and nursing classify primary pulmonary carcinoma somewhat
differently. However most agree that squamous cell or epidermoid carcinoma is always associated with
cigarette smoking.

71. Answer: B. Explaining that the reactions to chemotherapy are minimal

Option B: There are numerous severe reactions to chemotherapy such as stomatitis, alopecia, bone
marrow depression, nausea and vomiting.
Options A, C, and D: These are important nursing considerations.

72. Answer: A. Pneumonectomy: removal of the entire lung

Option B: Wedge resection is the removal of part of a segment of the lung.
Option C: Decortication is the removal of a fibrous membrane that develops over the visceral pleura.
Option D: Thoracoplasty is the removal of ribs or sections of ribs.

73. Answer: B. TIA's or transient ischemic attacks

Option B: A TIA is a temporary reduction in blood flow to the brain, manifesting itself in symptoms like
those Mr. Liberatore experiences.
Options C and D: Although hypoglycemia and hyperglycemia can cause some drowsiness and/or
disorientation, the episodes Mr. Liberatore experiences fit the pattern of TIA because of his quick
recovery with no sequelae and no treatment.

74. Answer: B. visual loss

Option B: Visual field loss is
common side effect of CVA. In right-handed persons the speech center
(Broca's area) is most commonly in the left brain.
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Option A: Because of the crossover of the motor fibers, a CVA in the left brain will produce a right-sided
hemiplegia.
Option C: Thus, Mr. Liberatore will probably have some speech disturbance and right-sided paralysis.
Option D: Often bladder control is diminished following CVA.

75. Answer: A. spastic paralysis, hyperreflexia, presence of babinski reflex

Options B, C, and D: These describe lower motor neuron disease.

76. Answer: B. the aura and headache of migraine

Option B: The warning sign or aura is associated with migraine although not everyone with migrane has
an aura. Migraine is usually unilateral and described as pounding. Julie's symptoms are most compatible
with migraine.

77. Answer: B. dilation of cerebral arteries

Option B: The vascular theory best explains migraine and often diagnosis is confirmed through a trial of
ergotamine, which constricts the dilated, pulsating vessels.

78. Answer: A. seasonal allergies

Option A: Sinus headache often accompanies seasonal allergies.
Option C: Many factors may contribute to migraine. Usually the client comes from a family that has
migrated, which may have been called "sick headache" due to accompanying nausea and vomiting.
Option D: Often there is an aura.
Option B: Stress, diet, hormonal changes, and fatigue may all be implicated in migraine.

79. Answer: D. feeling of tightness bitemporally, occipitally, or in the neck

Options A and B: These describe sinus headache; option A may also be compatible with headache
secondary to eyestrain; option B is also compatible with migraine.
Option C: This would be correct if stated a bandlike "tightness" around the head instead of "burning"

80. Answer: B. gliomas are usually benign

Option B: Gliomas are malignant tumors.

81. Answer: C. CN8

Option C: CN8, the acoustic nerve or vestibulocochlear nerve, is the most commonly affected CN in
acoustic neuroma.
Options A and B: As the tumor progresses, CN5 and CN7 can be affected.
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82. Answer: D. increased pulse rate, drop in blood pressure

Option D: As ICP increases, the pulse rate decreases and the BP rise. However, as ICP continues to rise,
vital signs may vary considerably.

83. Answer: B. Straining to evacuate the enema might increase the intracranial pressure
Option B: Any activity that increases ICP could possibly cause brain herniation. Straining to expel an
enema is one example of how the increased ICP can be further aggravated.

84. Answer: A. Keeping his head flat

Option A: Postoperatively clients who have undergone craniotomy usually have their heads elevated to
decrease local edema and also decrease ICP.

85. Answer: B. extracranial hemorrhage

Option B: Hemorrhage is predominantly intracranial, although there may be some bloody drainage on
external dressings.
Option A: Increased ICP may result from hemorrhage or edema.
Option D: CSF leakage may result in meningitis.
Option C: Seizures are another postoperative concern.

86. Answer: B. the incision in gallbladder surgery is in the subcostal area, which makes the client
reluctant to take a deep breath and cough
Option A: This is true: the rationale for deep breathing and coughing is to prevent postoperative
pulmonary complications such as pneumonia and atelectasis.
Option B: The risk of pulmonary problems is somewhat increased in clients with biliary tract surgery
because of their high abdominal incisions.
Option C: This assumes the stereotype of the person with gallbladder disease - fair, fat and forty - which
is not necessarily the case. Splinting the incision with the hands or a pillow is very helpful in controlling
the pain during coughing.

87. Answer: A. to notify the surgeon at once; this is an elevated WBC indicating an inflammatory
reaction
Option A: A WBC count of 15,000 probably indicates acute cholecystitis, especially considering Mrs.
Hogan's new pain. The surgeon should be called as he/she may treat the acute attack medically and
delay the surgery for several days, weeks, or months.

88. Answer: B. allow her family to be with her before the medication takes effect
Options A, C, and D: These should all take place prior to administration of the drugs. The family may also
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be involved earlier but certainly should have that time immediately after the medication is given and
before it takes full effect to be with their loved ones. Good planning of nursing care can facilitate this.

89. Answer: C. immediately report signs of shock to the head nurse and/or surgeon and monitor VS
closely
Option C: These are signs of impending shock, which may be true shock or a reaction to anesthesia. Your
most appropriate action is to report your findings quickly and accurately and to continue to monitor
Mrs. Hogan carefully.

90. Answer: D. stat

Option D: Leg exercises, deep breathing and coughing, moving, and turning should begin as soon as the
client's condition is stable.
Option B: The family can be extremely helpful in encouraging the client to do them, in supporting the
incision, etc.
Option A: A doctor's order is not necessary - this is a nursing responsibility.

91. Answer: E. All of the above.

Option E: An oropharyngeal airway should be used in an unconscious patient. In a conscious or
semiconscious patient, its use may cause laryngospasm or vomiting. An oropharyngeal airway that is too
long may push the epiglottis into a position that obstructs the airway. It is often used with an ETT to
prevent biting and occlusion. It is usually inserted upside down and then rotated into the correct
orientation as it approaches full insertion.

92. Answer: B. Reduces the risk of aspiration of gastric contents.

Option A: This is wrong because an attempt should not last longer than 30 seconds.
Option C: Unless the injury is suspected the neck should be slightly flexed and the head extended the
'sniffing position'.
Option D: After securing an airway and successfully ventilating the patient with two breaths you should
then check for a pulse. If there is no pulse begin chest compressions. Intubation is part of the secondary
survey ABC's.

93. Answer: C. Cricoid pressure may prevent gastric inflation during ventilations.
Option C: Cricoid pressure may prevent gastric inflation during ventilations and may also prevent
regurgitation by compressing the esophagus.
Option A: This may cause gastric insufflation thus increasing the risk for regurgitation and aspiration.
With adults, breaths should be delivered slowly and steadily over 2 seconds.
Option B: Effective ventilation using bag-valve mask usually requires at least two well-trained rescuers.
Option D: A frequent problem with bag-valve mask ventilations is the inability to provide adequate tidal
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volumes.

94. Answer: D. Pull the tube back and listen again.

Option D: Most likely you have a right mainstern bronchus intubation. Pulling the tube back a few
centimeters may be all you need to do.

95. Answer: D. Should not be used with a conscious person, pediatric patients, or patients who have
swallowed caustic substances.
Option A: EOA insertion should only be attempted by persons highly proficient in their use.
Option B: Moreover, since visualization is not required the EOA may be very useful in patient's when
intubation is contraindicated or not possible.
Option C: Vomiting and aspiration are possible complications of insertion and removal of an EOA.

96. Answer: A. A patient may have a normal appearing ECG.

Option A: Which is why a normal ECG alone cannot be relied upon to rule out an MI.
Option B: Chest pain does not always accompany an MI. This is especially true of patients with diabetes.
Option C: A targeted history is often crucial in making the diagnosis of acute MI.
Option D: The chest pain associated with an acute MI is often described as heavy, crushing pressure,
like an elephant sitting on my chest.'

97. Answer: C. Ventricular fibrillation

Option C: Moreover, ventricular fibrillation is 15 times more likely to occur during the first hour of an
acute MI than the following twelve hours which is why it is vital to decrease the delay between onset of
chest pain and arrival at a medical facility. First-degree heart block is not a lethal arrhythmia.

98. Answer: B. It may cause a drop in blood pressure.

Option B: Verapamil usually decreases blood pressure, which is why it is sometimes used as an
antihypertensive agent.
Option A: Verapamil may be lethal if given to a patient with V-tach, therefore it should not be given to a
tachycardic patient with a wide complex QRS.
Option C: Verapamil is a calcium channel blocker and may actually cause PEA if given too fast
intravenously or if given in excessive amounts. The specific antidote for overdose from verapamil, or any
other calcium channel blocker, is calcium.
Option D: Verapamil may cause hypotension.

99. Answer: C. Has a maximum total dosage of 0.03-0.04 mg/kg IV in the setting of cardiac arrest.
Option A: Only give atropine for symptomatic bradycardias. Many physically fit people have resting
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heart rates less than 60 bpm.

Option B: Atropine may be given via an endotracheal tube.
Option D: Administering atropine slowly may cause paradoxical bradycardia

100. Answer: A. True

Option A: Asystole is not amenable to correction by defibrillation. But there is a school of thought that
holds that asystole should be treated like V-fib, i.e., defibrillate it. The thinking is that human error or
equipment malfunction may result in misidentifying V-fib as asystole. Missing V-fib can have deadly
consequences for the patient because V-fib is highly amenable to correction by defibrillation.