Recalls 4 NP 2 d) hypofibrinogenemia

Situation 1- Patient Heather a gravida 1, para 0. Patient is admitted at the 9. What should the nurse prepare for the POSSIBLE order of the physician?
labor room. Her cervix is 100% effaced, and upon IE, her cervix is 3 cm a) The administration of the oxytocin
dilated, the fetus is at + 1 station. Staff Nurse Regina attends to her. b) A high- forceps birth
c) An immediate caesarean birth
1. Taken from the assessment data above that the fetus is at + station, how will d) The insertion of a fetal monitor
Nurse Regina interpret this? That the head of the fetus is .
a) Below the ischial spines 10. Abruption Placenta can cause hemorrhagic disorder which can lead to
b) Visible at the vaginal opening hypovolemic shock. What is the LATE sign of hypovolemic shock that the
c) Not yet engaged nurse should watch for?
d) Entering the pelvic inlet a) Hypertension
b) Tachycardia
2. Nurse Regina monitors the contractions of the patient. She recorded the c) hypotension
contractions as follows: started at 10:00 A.M; another began at 10:15 A.M. In d) tachypnea
MINUTES, what is the frequency of the contractions?
a) 10 Situation 3- A nurse is performing an admission assessment on Tonton a 4-
b) 9 year-old, who has been diagnosed with nephrotic syndrome.
c) 15
d) 14 11. What sign will BEST support the medical diagnosis of nephrosis?
a) Gross hematuria, tea-colored, scanty urine
3. Nurse Regina assesses the duration of the patient’s contractions by timing b) History of a streptococcal infection
them from to . c) Periorbitaledema
a) Beginning of one contraction to the beginning of the next contraction d) Anasarca
b) End of the contraction to the beginning of the next contraction
c) End of the contraction to the end of the next contraction 12. Tonton receives prednisone as the major treatment for his nephrosis.
d) Beginning of one contraction to the end of the same contraction Which of the following actions should be observed by the nurse in the
administration of prednisone?
4. After doing Leopold’s maneuvers on the patient I labor, the nurse a) All of the options.
determines that the fetus is in the ROA position. Where should the nurse place b) Administer the drug on a full stomach.
the Doppler to BEST auscultate the fetal heart tones? c) Monitor Carlo’s temperature.
a) Below the umbilicus near the left groin d) Protect Carlo from infection.
b) Below the umbilicus on the right side
c) Above the umbilicus in the midline 13. Which side effect of prednisone will be MOST prominent on Tonton and for
d) Above the umbilicus on the left on the left side which he should be prepared before its administration?
a) Hypotension
5. Patient Heather was given epidural anesthesia. This indicates late b) Decreased weight
deceleration of the fetus and so the nurse has to do important nursing c) mooning of face
interventions. ARRANGE the following nursing interventions in ORDER or d) vomiting
PRIORITY.
1) Increase intravenous fluids 14. What is the nursing diagnosis for a child with severe edema caused from
2) Change position of the patient to the left side lying nephrotic syndrome? It is risk for .
3)Reassess fetal heart rate pattern a) Impaired skin integrity
4)Document intervention and maternal/fetal response b) Constipation
a) 3 2 1 4 c) Ineffective thermoregulation
b) 3 4 1 2 d) Imbalanced nutrition more than body requirements
c) 4 2 3 1
d) 2 3 4 1 15. What will be the APPROPRIATE recommend diet for Tonton?
a) High iron, no protein
Situation 2 – Patient Helen, who is in the third trimester, arrives at the hospital b) High calorie, high protein
with vaginal bleeding. She states that she snorted cocaine approximately 2 c) High sodium, high protein
hours ago. d) Low sodium, moderate protein

6. Which defined complication is MOST likely causing the client’s vaginal Situation 4- Nurse Even works in the research unit of the Prinsesa Urduja
bleeding? Women’s Clinic. In the close monitoring of their patients using oral
a) Premature separation of normally implanted placenta contraceptives (OC), she noted several cases of myocardial infarction (MI).
b) Pregnancy outside the uterus
c) Termination of pregnancy before the age of viability 16. To establish the relationship between MI and OC, Nurse Even should make
d) Abnormal lower implantation of the placenta a research proposal for which of the following STUDY design?
a) Retrospective
7. The abdominal pain associated with abruption placentae may be INITIALLY b) Prospective cohort
caused by which of the following? c) incidence
a) Disseminated intravascular coagulation d) cross- sectional
b) Blood in the myometrium
c) Hemorrhagic shock 17. Since OCs are categorized into 1st, 2nd and 3rd generations, Nurse Even
d) Concealed haemorrhage decided to study not only the relationship of MI and OC but also which of the
three generations of OCs will have the highest risk for MI. Hence, which of the
8. The bleeding following severe abruption placentae is usually caused by following groups will she include in her study?
which of the following condition? a) Those who do not take OC, and those who take OC from 1st, 2nd, ad 3rd
a) Thrombocytopenia OCs.
b) Hyperglobulinemia b) All those who take OC and those who do not.
c) polycythemia c) Those who take 1st OC 2nd OC and 3rd OC.
d) Those with MI and those with no MI
18. Statistical analyses revealed odds ratio for MI among women who used
any type of OC, as compared with non-users, was .99. What does this mean?
a) Accept the null hypothesis; there is no significant relationship between MI
and OC.
b) The study focused on the three groups: 1st OC users with MI, 2nd OC
users with MI and 3rd OC users with MI.
c) There is a relationship between MI and OC and the risk of MI among users
of any type of oral contraceptive is twice that of non users.
d) The odds of getting MI among OC users and those who are not users is 1:2
c) “This is a normal reaction. It allows her to accept the reality of the birth of
your baby.”
d) “No, you should divert her attention away from her delivery.”
27. Later that day, Mrs. Pugita tells Nurse Jasmin that she has urinated four
times within the last hour but only in small amounts. What should be the
INITIAL ACTION of the nurse?
a) Explain that this is normal during the first 24 hours after delivery.
b) Palpate Mrs.Alim’s fundus to assess uterine consistency and location.
c) Catheterize Mrs.Alim immediately to expel any retained urine.
d) Begin measuring and recording and recording Mrs.Alim’s intake and output.

19. Which of the following is the independent variable of the study? 28. Which assessment finding is MOST indicative that Mrs. Pugita is
a) Highest risk developing puerperal infection?
b) Three generation of OC a) Increased pulse rate
c) OC b) Foul- smelling lochia
d) MI c) Elevated body temperature
d) A white blood cell count of 25,000/mcg
20. Identify the groups in the study that will validate the occurrence of the MI
among OC users. 29. Mrs. Pugita asks Nurse Jasmin when her menstrual period will return. The
a) Old cases of MI nurse answers that a breastfeeding patient typically resumes menstruating in
b )Prevalence of MI about .
c) old and new cases of MI a) 8 to 12 weeks
d) incidence of MI b) 3 to 6 months
c) 4 to 6 months
Situation 5- Sugar, G2 P3, is a Type I diabetes mellitus (DM) since she was 10 d) 4 to 6 weeks
years old. She is in her first trimester of pregnancy. Insu Ling is her nurse.
30. Mrs. Pugita complains of pain due to breast engorgement. What will the
21. What could be the MOST possible effect of DM to Sugar? She can have nurse do to encourage her to continue breastfeeding?
. a) Let her continue breastfeeding on schedule.
a) Ketoacidosis b) Put hot compress over the breast for 15 minutes before breastfeeding.
b) Hyperinsulinism c) Put cold compress over the breast for 15 minutes before breastfeeding.
c) Hyperglycemia d) Let her continue breastfeeding on demand.
d) Hypoglycemia
Situation 7- Nurse Jubel is collecting data from a newly admitted patient, Mrs.
22. Which of the following would require an increased dose of medication once Jaclyn, who is pregnant with twins. She has a healthy 3-year-old child who
Sugar is in the second half of pregnancy? was delivered at 38 weeks. She also revealed that she does not have a history
a) Insulin of abortion nor fetal demise. Her last menstrual period began February 7,
b) Pancreatic enzymes 2017 and ended February 12, 2017.
c) estrogenic hormone
d) antihypertensives 31. What is the GTPAL for Mrs. Jaclyn?
a) G = 1, T = 1 , P = 1, A = 0, L = 1
23. What is the route of administration for insulin during pregnancy? b) G = 2, T = 0 , P = 0, A = 0, L = 1
a) Intravenous c) G = 3, T = 2 , P = 0, A = 0, L = 1
b) Subcutaneous d) G = 2, T = 1 , P = 0, A = 0, L = 1
c) oral
d) shot with flex pen 32. What is the expected change in the hematologic system that occurs during
the END of the first trimester of pregnancy that Nurse Jubel should recognize?
24. Considering Sugar’s condition, Nurse Insu Ling will anticipate what effect to a) An increase in hematocrit
the fetus? The condition will be . b) A decrease in WBC’s
a) Large for gestational age c) An increase in blood volume
b) Macrosomia d) A decrease in sedimentation rate
c) Intrauterine growth retardation (IUGR)
d) Meningomyelocele 33. Mrs. Jaclyn asks about the functions of placenta. Which of the following
items should Nurse Jubel include in the teaching plan?
25. On the first postpartum day, which of the following requirements for insulin 1) The placenta filters the fetal urine.
will be anticipated by the nurse to be ordered by the physician? 2) Fetal and maternal blood mix in the placenta to exchange nutrients.
a) Remain unchanged 3)The placenta filters the alcohol from the mother’s blood.
b) Decrease sharply and suddenly 4) Substances are exchanged by the placenta without mixing the maternal and
c) Increase rapidly fetal blood.
d) Decrease slowly and steady 5) Fetal respiration, nutrition and excretion are carried out by the placenta.
a) 1, 2, 3
Situation 6- Mrs. Pugita, gravida 3 para 3003, is admitted to the postpartal unit b) 4, 5
after an uncomplicated labor and vaginal delivery. She opted to breastfeed her c) 3, 4, 5
baby. Nurse Jasmin is around to take care of her. d) 1, 2

26. The first day after delivery, Mr. Pugita tells the nurse that his wife has been 34. Mrs. Jaclyn asks “When will be my expected date of delivery (EDD)?”
talking constantly about her recent delivery experience. He asks if this is a Based on her knowledge of Naegeles’ Rule, which should be the CORRECT
sign of postpartal blues. What should be the BEST response of the nurse? answer of Nurse Margie?
a) “Do you feel uncomfortable about her talking on her delivery experience?” a) November 14, 2017
b) “Yes, it’s clear sign of post-partum blues. She may need a psychiatric b) October 14, 2017
evalution.” c) October 19, 2017
d) November 19, 2017
35. Nurse Jubel Explained the chronological order of the growth and
development of the fetus as it occurs in pregnancy which is the following
. regarding the procedure for the administration of digoxin (Lanoxin). Which
a. Ovum, zygote, morula, embryo, fetus, infant
b. Morula, zygote, ovum, fetus, embryo, infant
c. Morula, ovum, embryo, zygote, fetus, infant
d. Zygote, ovum, morula, embryo, fetus, infant
Situation 8- Nurse Korinna attends to Patient Cha Hin who is three months
pregnant when a pelvic sonogram was conducted on her revealing the fetus’
weak cardiac pulsation. Nurse Korinna advised the patient to have a follow up
visit to their clinic after a week but it was only after two weeks that the patient
returned when she started to suffer from severe abdominal pains. Upon
examination, the doctor found out that there was a dead fetus in her womb.
The patient underwent hysterectomy and as a result, she had no more chance
to bear a child.
36. Cha Hin filed legal charges against all people concerned regarding the
outcome of the procedure done to redress the damages caused by the
procedure. Who among the following will be accountable to the patient?
a) None, all members of the health care team performed their professional
duties on the patient.
b) Only Dr. A but not the nurse because the latter was just following orders
from the physician.
c) Dr. A and the nurse because of their failure to perform their perspective
duties with diligence and care.
d) Dr. A and the hospital administrator because of command responsibilities on
the treatment and care to the patient.
37. Under the situation, if the physician and the nurse are liable over the
consequence of the treatment and care of the patient, what applicable legal
doctrine will this be?
a) Respondeat Superior
b) Captain of Ship Doctrine
c) Patient’s Proximate Negligence
d) Res Ipsa Loquitor
38. If the nurse is called to testify on the alleged surgical procedure performed
to the patient to determine whether there was lack of necessary care and
diligence, the nurse should testify only on matters which are .
a) Within her personal knowledge
b) Documented in the chart
c) Advised by her lawyer
d) Being asked by the court
39. Medical records have legal implications. In as much as the nurse failed to
chart the discharge instructions, what principle in records management was
violated?
a) “If it was not documented, it was not done.”
b) “Completion of chart should be within 48 hours.”
c) “No document, no discharge.”
d) “Not all documented data are true.”
40. Hospital A practices clinical pharmacy. Physician writes the order of
medications, pharmacist prepares it and the nurse administers it. Who then
will be liable for any drug overdose administered intravenously by the nurse?
a) Pharmacist
b) Nurse and Physician
c) Nurse
d) nurse and pharmacist
Situation 9- Joseph, 3 years old, who underwent ventricular septal defect
repair, is placed on a maintenance dosage of digoxin (Lanoxin) elixir. Nurse
Hannah, complete with the knowledge of the disease, is assigned to him.
41. The dosage is 0.07 mg/kg/day, and the client’s weight is 7.2 kg. The
physician orders the Digoxin to be given twice daily. How much Digoxin should
Nurse Hannah prepare to administer at each dose?
a) 2.5 mg
b) 0.5 mg
c) 0.37 mg
d) 0.25 mg
42. Nurse Rita provides home care instructions to the parents of Joseph
statement, if made by the parent, indicated the need for further instructions?
a) “If the child vomits after medication administration, I will repeat the dose.”
b) “If more than one dose is missed, I will call the physician.”
c) “I will take the child’s pulse before administering the medication.”
d) “I will not mix the medication with any food and drinks.”
43. Which of the following instructions about ORAL pediatric medications is
TRUE as these interfere with milk and milk products or food eaten by young
children? Oral medication should be given .
a) With meals always
b) On an empty stomach
c) ½ hour after meals
d) With the night time formula
44. Joseph has a blood pressure of 92/78; resting pulse of 60; respirations 28
and a potassium level of 4.8 mEg/L. He is irritable and has vomited twice
since the morning dose of digoxin. Which finding is most indicative of digoxin
toxicity?
a) Vomiting
b) Lethargy
c) Bradycardia
d) Irritability
45. Considering Joseph’s age, which of the following is the BEST approach by
the nurse when administering medication?
a) “You will feel better if you take your medication.”
b) “Would you like to take your medicine from a spoon or a cup?”
c) “Do you want to take this pretty red medicine?”
d) This is your medicine and you must take it all right now.”
Situation 10- Hani, a 5- year- old child, is admitted to the hospital for
abdominal pain. The mother reports that the child has been pale, tires easily
and has hematomas in the arms and legs. On physical examination,
lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are
being performed on the child because acute lymphocytic leukemia is
suspected.
46. Which of the following procedures will confirm this diagnosis?
a) A lumbar puncture
b) A platelet count
c) Bone marrow biopsy
d) White blood cell count
47. Based on the instructions of the nurse, which of the following activities
should NOT be done by the parents in monitoring possible infection on Hani?
a) Taking the rectal temperature daily
b) Inspecting the skin daily for redness
c) Inspecting the mouth daily for lesions
d) Performing proper hand washing techniques
48. What is the PRIMARY effect of leukemia on the bone marrow?
a) a selective reduction in the number of neutrophils
b) Leucopenia, thrombocytopenia, and anemia
c) The crowding out of normal cells on the site
d) Proliferation of cells producing blood components
49. The patient’s parents asked why her child has hematomas and anemia.
Which of the following should be the explanation of Nurse Jean Ralffio?
a) Hematomas and anemia are related to the child’s inactivity.”
b) “All blood cells are made in the bone marrow. Hematomas and anemia are
due to decreased RBC and platelet count.”
c) “Hematomas and anemia are indicative that the end is near.”
d) “the anemia is because the child hasn’t been eating well; the hematomas
are from the multiple needle sticks.”
50. Patients Hani is not expected to survive. Hani says to her mother, “Will you
take care of me when I am dead the way you do now?” the child’s mother asks
Nurse Jean Ralffio how to answer her child. The nurse’s response should be
based on which of the following understanding of the child’s behaviour.
a) “Children of this age do not understand the finality of death.”
b) “The child is denying that he has a terminal illness.”
c) “Most 5-year-old children have a great fear of mutilation.”
d) “the child may be having visual and auditory hallucinations.”
Situation 11- a 13-year-old- girl named Zelda tells the nurse at the pediatric
clinic that she took a pregnancy test and it was positive. She tells the nurse
that her grandfather, with whom she, her younger siblings, and her mother
live, has repeatedly molested her for the past 3 years. When the nurse asks
the girl if she has told this to anyone, she replies: “Yes, my mother.”
a) Keep crib rails up to the highest position.
b) Cover electric outlets with safety plugs.
c) Remove poisonous substances from low areas.
d) Remove small objects from the floor.
59. When teaching a mother how to prevent accidents while caring for her 6-
month-old infant, Nurse Von should emphasize that at this age, the infant can
already do which of the following developmental milestone?
a) Stand while holding on to furniture.
b) Crawl short distances. 9 months
c) Roll over from back to abdomen.
d) Sit up without assistance. 8 months

51. As the nurse’s legal responsibility, which is the APPROPRIATE agency 60. Nurse Von assesses the oral cavity of a 6-month-old child and finds out
should she notify FIRST? that the tooth that buds first is the .
a) City Health Office to do a vaginal examination to confirm the pregnancy a) Upper molars
b) DSWD for notifying the girl’s mother about the pregnancy test positive b) Lower central incisor
result. c) Canines
c) Board members of Child Protective Services for proper intervention d) Lower molars
d) Philippine National Police concerning a possible sex crime
Situation 13- Nurse Karl is caring for a mother- infant dyad. The mother has
52. If Zelda is really a victim of incest and the agency opts that she be admitted just given birth to a baby boy two days ago. Today, the charge nurse us doing
in the hospital, where should she be placed? a chart audit to determine whether the nursing process was properly done
a) With an older friendly child from prenatal to postnatal periods. The laboratory results of the mother and
b) In a room near the nurse’s station baby boy are shown below. Mrs. Gloria Lim: Prenatal Laboratory Results.
c) With another 5 year old Type: RH -A Negative Rubella
d) In a private room Titer- 1: 8 RPR/VDRL- Negative
HB Sag- Negative
53. The abusive parent usually manifests one of the following characteristics HIV- Negative
EXCEPT Hgb/Hct-11/33
a) History of severe mental illness PKU-Negative
b) History of drug abuse Baby Boy Lim: Day 2 of Life
c) Belongs to low-income group Laboratory Test Results
d) Low tolerance for frustration Blood Glucose-50
Total Bilirubin-10mg
54. When a patient, who allegedly has been sexually abused, the nurse should Blood Type-1 Negative
be aware that legal proceedings may be necessary. Because of this possibility, HCT-50
which of the following actions is MOST important to be done by the nurse?
a) Determining if there are other injuries such as bruises and hematomas. 61. Using the chart data, which nursing intervention was CORRECTLY done by
b) Asking the parents for their approval for diagnostic examinations for the Nurse Karl for Mrs. Gloria Lim? *
child.
c) Assessing the child’s physical, intellectual and emotional developmental a. Rubella vaccination
levels. b. Rhogam injection
d) Documenting physical findings and interactions during admission. c. Neonatal 50% glucose infusion
d. Maternal blood transfusion
55. What typical assessment findings are observed to a patient who is a victim
of sexual abuse 62. Nurse Karl charted an IMPORTANT plan of care for Mrs. Lim. He indicated
a) Recurrent UTI in her charting that the patient should report immediately signs and symptoms
b) Fracture and bruises of a virus-causing- disease which may affect the cardiovascular system of the
c) Enuresis fetus during which of the period of pregnancy?
d) Failure to thrive syndrome a) First month Organogenesis
b) Third month
Situation 12- Nurse Von is assigned at the Under Five Clinic. Mostly of her c) Second Month
patients are infants, so she took the opportunity to have a mother’s class on d) Fourth Month
the care of infants.
63. Looking at the medication sheet, the charge nurse noted that Nurse Karl
56. Which of the following will Nurse Von EMPHASIZE regarding the used the CORRECT ROUTE in the administration of the vaccine, which
importance of play during infancy? Play enhances development. was .
a) Cognitive a) Rectal
b) Emotional b) Intradermal
c) Physical c) Subcutaneous
d) Social d) Intramuscular

57. Which among the infants would show signs that he/she is experiencing 64. After administration of the vaccine, health teaching was also charted by the
maternal deprivation? staff nurse. Which of the following is the CORRECT one?
a) Hyperactive a) Immediate follow-up check up
b) Overweight b) Nothing Per Orem
c) prone to illness c) No pregnancy for 3 months Rubella virus can pass through the placenta and
d) responsive to stimuli affect the baby
d) Avoid exposure to Rubella
58. What should Nurse Von include in the accident prevention teaching plan for
a mother with 4-month-old infant?
65. Nurse Karl should also include in his charting an additional health
education to Mrs. Lim that is: rubella virus can be transmitted via the placenta
by the process of . 73. Geneva went to see a nutritionist. She is overweight for her height. What is
a) Simple diffusion
b) Pinocytosis
c) Active Transport
d) Facilitated Diffusion
Situation 14- Breastfeeding is one of the major responsibilities of OPD Nurse
Pau. Along this line, she gathers pregnant women to provide them health
education about the topic.
66. Nurse Pau explains that exclusive breastfeeding is giving the
baby . c) Carbohydrates, fats and salts
a) Breast milk and introducing solids at one month
b) Breast milk with drops of syrup
c) Breast milk alternating with sips of boiled water
d) Only breast milk for 6 months
67. She further explains that the specific objectives of exclusive and extended
breastfeeding from 2005 to 2010 are the following EXCEPT . c) Take weight reducing pills.
a) 50% of infants are exclusively breastfeeding up to 6 months
b) 90% of infants are started on complementary feeding by 6 months of age.
c) 70% of newborns are initiated to breastfeeding within an hour after birth.
d) 12 months is the median duration of breastfeeding.
68.A mother questioned Nurse Pau in the event that she does not produce
milk, what should she do? The BEST answer of Nurse Pau would
be . following should be Nurse Peninah’s ACCURATE explanation?
a) “If it is difficult on your part, then you can use local herbs said to help the
production of the breast milk.”
b) “That’s a big problem ma’am, but you can still try again.”
c) “Just continue breastfeeding. This will stimulate the hypothalamus in the
production of breast milk.”
d) I empathize with you. I too, do not have breast milk.”
69. Malou, one of the pregnant women, asked Nurse Pau to teach her the
proper positioning of the baby while breastfeeding. Among Nurse Pau’s
answers, which one is NOT CORRECT?
a) The baby can lie down perpendicularly with the mother to promote better
bonding.
b) The baby’s face should be towards the mother’s breast to have an eye to
eye contact.
c) The baby’s head and body should be aligned to promote better swallowing.
d) The baby’s tummy should be close to the mother’s tummy for better
support.
70. To convince the pregnant mothers to breastfeed their newborns upon
delivery, the BEST thing that Nurse Pau must do is to
a) Explain the hospital policy on “No breastfeeding; No admission”
b) Relate her own experience on breastfeeding
c) Prepare the mothers physically, emotionally and psychologically
d) Ask other mothers to convince them to breastfeed
Situation 15- Geneva is now 15 years old. She goes to an exclusive school but
she seldom interacts with her classmates nor is interested to join school
activities. Her mother brought her to an adolescent specialist and was
diagnosed of malnutrition.
71. Which of the following is NOT a CORRECT statement about malnutrition?
Malnutrition is for .*
a) Both the urban and rural areas
b) Both the poor and the rich
c) The underweight as family income increases
d) The overweight as family income increases
72. Advertisement (ads) on television is said to be a contributory factor for
obesity. What could be a GOOD advice to adolescents like Geneva regarding
these ads that can be contributory to malnutrition?
a) “Check nutritional contents before buying foods.”
b) “Follow your desire for food and drinks.”
c) “What you see is what you get.”
d) “There is no truth in advertisements.”
the normal weight, in POUNDS, for Geneva who is 5 feet tall?
a)90
b)75
c) 85
d) 80
74. How can Geneva be helped to reduce her weight? She can be advised to
cut intake of which of the following?
a) Salt, protein and fats
b) Carbohydrates, vitamins and salts
d) Fats, protein and sweets
75. Which of the following can Geneva do to help her with her obesity
problem?
a) Skip one full meal a day.
b) Drink 6 glasses of water every day.
d) Exercise 30 minutes three times a week.
Situation 16- Baby Boy Christian, 6 months old, was diagnosed as having
communicating hydrocephalus. Nurse Peninah is planning nursing care for
this baby who is a candidate for ventriculo- peritoneal shunting.
76. When helping the parents understand the baby’s problem, which of the
a) “The CSF is prevented from adequate absorption by a blockage in the
ventricles of the brain.”
b) “Too much Cerebro Spinal Fluid (CSF) is produced within the ventricles of
the brains.”
c) “The flow of CSF through the brain cells does not empty effectively into the
spinal cord.”
d) “There is a part of the brain surface that usually absorbs CSF after its
production that is not functioning adequately.
77. Nurse Peninah understands that hydrocephalus, if left untreated, can
cause mental retardation because of which of the following rationales?
a) Hypertonic CSF disturbs normal plasma concentration, depriving nerve
cells of vital nutrients.
b) Gradually increasing size of the ventricles presses the brain against the
bony cranium; anoxia and decreased blood supply result.
c) Increasing head size necessitates more oxygen and nutrients than normal
blood flow can supply.
d) CSF dilutes blood supply, causing cells to atrophy.
78. What is the IMPORTANT nursing care of an infant with increased
intracranial pressure?
a) Check the infant’s reflexes at regular intervals.
b) Monitor the infant’s level of consciousness by stimulating frequently.
c) Weight the infant daily before feeding.
d) Elevate the infant’s head higher than the hips.
79. Baby Boy Christian just had a ventriculoperitoneal shunt. His parents were
worried about the prognosis. What information should Nurse Peninah give to
the parents to allay their worry? *
a) The shunt may need to be revised as the child grows older.
b) If any brain damage has occurred, it is reversible during the first year of life.
c) Hydrocephalus usually is self- limiting by 2 years of age and then the shunt
is removed.
d) The prognosis is excellent and the valve is permanent.
80. What is the drug that will lessen CSF production that Nurse Peninah will
anticipate the doctor to order?
a) Spironolactone
b) Lasix
c) Mannitol
d) Diamox Carbonic anhydrase (Acetazolamide)
Situation 17- Nurse Vincent assists in the in-service training of nurses in St.
James Hospital. Based from the needs assessment, the nurses need to be
trained on patient’s safety. The first lecture was on medication administration.
Nurse Vincent gave the following problems for the nurse to solve.
81. An eight-year-old- patient is to receive Aminophylline 3 mg/kg TID. If the
girl weights 25 kg, how much Aminophylline should she receive daily?
a) 125 mg
b) 225 mg
c) 200 mg
d) 100 mg
82. Mrs. Delos Santos is to receive Digoxin 0.325 mg p.o. because of her heart
ailment. The stock is 0.250 mg per tablet. How many TABLETS should the
nurse request for 7 days supply for the patient?
a)9
b) 7
c) 10
d) 8
temperature during ovulation is shown in which of the following observations?
The temperature .
a) Drops markedly and remains lower
b) Rises markedly and remains high
c) Drops slightly and then rises again
d) Rises suddenly and then falls down
90. In response to a client’s question on the chief function of progesterone,
which of the following would be the CORRECT answer? It
.
a) Stimulates the follicles for ovulation to occur
b) Establishes the secondary male sex characteristics
c) Prepares the uterus to receive a fertilized ovum
d) Develops the female reproductive organs
Situation 19- Janna, 3 years old, was admitted to Pediatrics Ward because of
watery stools four times in 30 minutes accompanied by vomiting, abdominal
pain and temperature of 38.1 degrees centigrade. Nurse Gel was the one who
was the admitting nurse.

83. In giving insulin to an OB diabetic patient, the nurse must use an 91. Which of the following should be the PRIMARY consideration by the nurse
APPROPRIATE needle size and length, which among the following will this when charting the Chief Complaint? The .
be? a) Number of significant accompanying symptoms
a) 23 G, 3/8 b) Objective symptom presented
b) 22 G, 2/8 c) Subjective symptom presented
c) 24 G, 4/8 d) Significant reason for the child’s hospitalization
d) 25 G, ⅝
92. Using the FDAR (Focus Data Action and Response) Charting, which of the
84. Nurse Vincent emphasized that patient safety is . following presenting data would be PRIMARY “Focus”
a) Preventing errors and adverse reactions to patients associated with health a) Vomiting in small amount
care b) Watery stools 4x in 30 minutes
b) Being careful in caring for patients at all times c) Generalized abdominal pain
c) Providing treatment and care to patients and documenting the same d) Temperature of 38.1 centigrade
d) Being mindful of the needs of others at all times
93. When getting the data on the subjective symptom of the abdominal pain,
85. Nurse Vincent has provided instructions that all care provided by nurses which of the following should the nurse RELY on?
must be documented, as one of their legal responsibilities. In case errors a) Mother’s verbal complaint
occur, which is the correct way of documenting it? b) Result of the abdominal percussion
a) Wrong medicine given to wrong patient. Physician notified. Patient c) Patient’s verbal complaint
observed d) Result of auscultation of the abdomen
b) Medication inadvertently omitted. Supervisor notified.
c) Medication given to patient A instead to patient B. Patient advised. 94. The “response” should be based from which of the following categories of
d) Wrong dose of medicine administered to patient. Sorry. the FDAR?
a) Intervention made
Situation 18- one of the responsibilities of a nurse in fertility specialist’s office b) Laboratory Findings
is to provide health teaching to the patient in relation to timing of intercourse to c) Focus
achieve pregnancy. d) Assessment

86. Which instruction to patient addresses the BEST time to achieve a 95. Which of the following can be the LEAST source of data for this case?
pregnancy? a) Vital signs
a) 14 days before the next period is expected b) Laboratory Findings
b) Immediately after menses end c) Intake and output
c) Midway between periods d) Immunization record
d) 14 days after the beginning of the last period
Situation 20- Nurses are guided by bio-ethical principles as they practice their
87. With regards to sexual functioning, the nurse explained the ovulation chosen profession.
occurs on which of the following conditions? 96. What bio- ethical principle guides the nurses when taking care and being
a) Chorionic gonadotropin level is high responsible for patients?
b) Luteinizing hormone level is high GnRh → FSH & LH → ↑ Estrogen → ↑ LH a) Solidarity
c) Oxytocin level is high b) Fidelity
d) Progesterone level is high c) Totality
d) Stewardship
88. After ovulation has occurred, the nurse teaches women in the fertility clinic
that the ovum is through to remain viable for many HOURS? 97. Each person has a responsibility to take care of his/her body. In case a part
a) 24 to 36 is defective, it can be removed for the benefit of the remaining parts. What bio-
b) 12 to 18 ethical principle is this?
c) 48 to 72 a) Totality
d) 1 to 6 b) Stewardship
c) Solidarity
89. When teaching clients to determine the time of ovulation by taking the d) Fidelity
basal temperature, the nurse explains that the change in the basal
98. As member of the health team, nurses are expected to collaborate with
other health care professionals for unity and cooperation. What bio- ethical
principle is this?
a) Fidelity
b) Stewardship
c) Solidarity
d) Totality

99. When another person or entity intrudes in the affairs of the patient to
promote justice and welfare, what bio- ethical principle does he/she promotes
a) Welfare
b) Stewardship
c) Justice
d) Paternalism

100. As a means to solve any crisis or scarcity in any health care systems,
providing an equitable distribution of resources is based on what bio- ethical
principle?
a) Paternalism
b) Justice
c) Fidelity
d) Stewardship