PREBOARD ANGELUS VICTUS TEST 4

Sit. 1:Recreational pursuits as well as home and work responsibilities summon people of
all ages to leave the shelter of their homes for the great outdoors.Seemingly harmless outside
activities can have associated environmental risk such as insect bites or stings, reptile bites and
environmental condition may threat a problem in the physiological balance of patients. The nurse
in the hospital is ready to face such challenge

1. A construction worker who was struck by lightning was seen in the ER and reported to be
unconscious but was revived by CPR. He was confused and reports pain to his right hand and foot
with fernlike marks. Which assssment tool is the priority for thos patient?
a. Glasgow Coma scale c. Cardiac monitor
b. Pulse oximeter d. Rule of Nine

2. Lola Basyang was found to be unconscious in her home on a hot summer day by her nephew.
The nephew reported that she had all her window shut with a fan to cool her off. The nurse place
ice on her groins and armpit to cool her off and the best nursing intervention that needs to be done
is
a. Give oxygen by mask or cannula c. Lower temperature witrh aspirin
b. Use of cooling blanket d. Monitor vital signs

3. Justin is being stung by a bee. The most appropriate measure that Cris could do is
a. Call the doctor
b. Wash the area and pull out the stinger
c. Wash the area and scrape the stinger
d. Wash the area and put calamine lotion

4. Chris is participating in a summer hike with a group of children. Suddenly the children starts
screaming, “Snake, snake”. One little girl is sitting in a tall grassy area, clutching her ankle and
crying. What is the first priority in the field of care of this child?
a. Remove any constricting clothing
b. Move the child in a safe area and encourage rest
c. Maintain extremity below level of heart
d. Keep her warm and reassurance

5. A patient was place on IV infusion of epinephrine as a result of an allergic reaction to a bee sting.
In conjunction with epinephrine injection, which action does the nurse take?
a. Place patient on continuous pulse oximetry c. Obtain an order for ECG
b. Place patient on cardiac monitor d. Obtain an order for an ABG

Sit. 2:Dindo had been admitted in the medical ward after developing edema on his eyelids,
feet and thigh. His illness was diagnosed as nephritic syndrome.

6. What type of diet would the doctor probably order for Lindo?
a. High protein with salt restriction
b. Normal diet with reduced carbohydrate
c. Low protein diet with salt restriction
d. Hypoallergenic diet with low sodium count
7. The nurse on duty was reviewing Dindo’s history. Which of the following notations might have a
bearing on his present condition?
a. Previous viral throat infection c. Brother had similar condition
b. Developed impetigo two weeks ago d. None, it is an autoimmune disorder

8. An accurate record of fluid intake and output is especially important because

a. Reliable index of infection control c. Subtle way of knowing nutritional status
b. Serve as basis of IV fluid needs d. Data for assessing kidney function

9. Furosemide was given for Dindo because of his edema. While taking the drug which of the
following should warrant immediate attention from the nurse?
a. Tetanic seizures c. Flapping tremors
b. Muscle weakness d. Blowing respirations

10. Prednisone was also prescribed because of its anti inflammatory effect on the kidney. The
nurse is aware to decrease or discontinue Dindo’s dosage if he were to develop
a. Hematuria c. Hypertension
b. Lassitude d. Anorexia

Sit. 3: The nurse is aware with the important role of the immune system in the
maintenance of physiologic integrity of every patients admitted in the ward. It is the major line of
defense in warding off harmful agents hence an understanding of its function is imperative.

11. The nurse encourages a new mother to breastfeed her infant, even for a short time, because
colostrum will provide the infant with
a. Passive immunity to diseases to which the mother has immunity
b. Active immunity to many childhood illnesses for several years.
c. Passive immunity to all childhood illnesses for several months
d. Innate immunity to diseases to which the mother is immune.

12. Which of the following gammaglobulins crosses the placenta for fetal protection and offers
partial immunity to fetus in the few months after delivery?
a. Ig M c. Ig A
b. Ig G d. Ig E

13. To prevent anaphylaxis after a patient has received allergen testing using the cutaneous scratch
method, the nurse should initially monitor the patient’s
a. Blood pressure and pulse c. Pupil size and reaction light
b. Arm at the site of skin testingd. Bilateral lung sounds

14. Which of the following white blood cells are involved in releasing histamine during an allergic
reaction?
a. Eosinophils c. Monocytes
b. Neutrophils d. Basophils

15. After teaching a patient on immunosuppressant therapy after a kidney transplant about the
posttransplant drug regimen, the nurse determines that additional teaching is needed when the patient
says,
a. “I need to be monitored closely because I have a greater chance of developing malignant
tumors.”
 b. “If I develop an acute rejection episode, I will need to have other types of drugs given IV.”
c. The drugs are given in combination because they act differently to inhibit cytokine production
and lymphocyte activity.”
d. “After a couple of years, it is likely that I will be able to stop taking the calcineurin
inhibitor.”

Sit. 4: Nursing excellence nowadays can be assured by the implementation of

research and evidence based practice in the practice and management of nursing
problems.

16. What is considered the current priority area for nursing research?
a. Staffing and shortage problem
b. Problems relating to nurses professional identity
c. Improvements in patient care and patient outcomes
d. Content of nursing curricula

17. The statement, "Ninety percent (90%) of the respondents are female staff nurses
validates previous research findings (Santos, 2001; Reyes, 2005) that the nursing
profession is largely a female dominated profession is an example of"
a. Implication c. Analysis
b. Conclusion d. Interpretation

18. Which of the following tool used by qualitative researchers to enhance rigor and
reduce bias?
a. Randomness c. Reliability
b. Thick description d. Reflexivity

19.What type of nursing practice would be consider evidence based?

a. Practice that is rooted in the positivist paradigm
b. Practice that involves participation in a journal club
c. Practice that involves conducting research
d. Practice that uses research findings as basis for decision and nursing action

20. Ms. Crisotomo plans to conduct a research on the use of a new method of pain
assessment scale. Which of the following is the second step in the conceptualizing phase of
the research process?
a. Formulating the research hypothesis
b. Review related literature
c. Formulating and delimiting the research problem
d. Design the theoretical and conceptual framework

Sit. 5: On careful questioning by the nurse, Aling Ine recalled that on several
occasions during the past years she had experienced indigestion following ingestion of
fatty and fried foods. She recalls that her stools had been light colored and her skin had
been yellow on one of those occasions. The nurse suspects of cholelithiasis.
21. Aling Ine’s acholic stool suggested that
a. Gallstone were confined to the gall bladder alone
b. Stones were present in both the gall bladder and cystic duct
c. Stone had passed into and lodged in the common duct
d. Gallstone has migrated into the duct of pancreas

22. Aling Ine complained of pruritus on the arms and legs. Which of the following
measures might be most helpful in relieving her discomfort?
a. Bathing in weak sodium bicarbonate solution
b. Dusting with liberal amounts of talcum powder
c. Moistening the skin with isopropyl alcohol
d. Rubbing the skin briskly with a coarse piece of cloth

23. Aling Ine underwent cholecystogram and after the two x-rays were taken of her gall
bladder visualization studies, the nurse gave her a high fat meal in order ro
a. Restore her blood sugar level
b. Check the presence of stone by inducing colic
c. Soothe the doudenal mucosa
d. Cause the gall bladder to empty

24. Aling Ine underwent surgery and T-tube was placed on her. The function of T-tube was
to
a. Prevent bile contamination of the cystic duct stump
b. Reroute bile flow to the reconstructured cystic duct
c. Provide bile drainage while common bile duct is edematous
d. Drain blood and serum from the operative site

25. In planning Aling Ine’s post operative care, the nurse should consider that the nature
of operation has particularly disposed Aling Ine to
a. Pulmonary embolus c. Wound evisceration
b. Bronchopneumonia d. Intestinal obstruction

Sit. 6: Nurses partner with others in delivering health care services to patients.
Collaboration requires the nurse to use effective interpersonal skills, maximize
coordination of members involved in giving care services and as necessary to provide
continuity of care.

26. Maya visits her doctor with complaints of chronic diarrhea that is sometimes bloody.
She was diagnosed with ulcerative colitis. How should the nurse explain the patient’s
diagnosis to her?
a. You have inflammed sac throughout your colon
b. Your rectum and colon are inflammed and ulcerated
c. You have ulcerations and fistulas in your small bowel
d. Your colon is spastic and hypertonic
27. Which of the following laboratory tests does the nurse understand helps monitor
ulcerative colitis?
a. Electrolytes c. Amylase
b. AST and ALT d. CBC

28. Another patient Richard is diagnosed with acute diverticulitis. Which of the following
foods might Richard be instructed to avoid in his plan of care
a. Peanuts and raspberries c. Guava and apple
b. Dairy product and red meat d. Bran and whole grains

29. The nurse is aware that the diagnostic test typically ordered for acute diverticulitis do
not include a barium enema. The reason for this is that a barium enema
a. Minimal diagnostic value in diverticulitis
b. Would greatly increase the patient’s pain
c. Lengthy procedure for the patient to tolerate
d. Can perforate an intestinal abscess

30. Luke has an history of inguinal hernia and was seen in the hospital with complaints of
sudden severe abdominal pain, vomiting and abdominal distention. Based on these
assessment findings, the nurse suspects that which of the following complications has
developed?
a. Peritonitis c. Strangulated hernia
b. Incarcerated hernia d. Intestinal perforation

Sit. 7: Because shock is a manifestation of a pathologic condition rather than a disease

state, its causes vary and nurses are aware that more than one type of shock can be present at the
same time. The changing condition of patient’s hemodynamic stability poses a greater challenge to
nurses who works in critical care areas.

31.The nurse recognizes which patient with a disorder is at greatest risk for hypovolemic shock?
a. Burns c. Myopathies
b. Sepsis d. Pericarditis

32. The nurse in the ICU monitors a patient for which manifestation as a compensatory mechanism
to the initial stage of shock?
a. Vascular dilation c. Increased heart rate
b. Reduce mean arterial pressure d. Elevated body temperature

33. The nurse knows that the rationale in giving Dopamine, a positive inotropic drug to patient on
a cardiogenic shock is to
a. Increase heart rate c. Increase oxygen consumption
b. Increase cardiac contractilty d. Increase cellular metabolism

34. A young student nurse was admitted for septic shock secondary to an illegal abortion induced
by unlincensed midwife. While reviewing the her CBC, which of the following is indicative of septic
shock?
a. Increase platelet count c. Increase amount of immature erythrocytes
b. Decreased hemoglobin d. Decreased neutrophil count
35. In providing health education to a group of nursing students in the ICU, which of the following
may be a risk factor for the development of sepsis among patients?
1. Cardiomyopathy 3.History of anaphylaxis 5. Age older than 65
2. Low serum albumin levels 4. Corticosteroid use

a. 1,3 and 5 b. 2,4 and 5 c. 1,2 and 4 d. 3,4 and 5

Sit. 8: Maricar works in the burn unit and is assigned to take care several patients
with varying degree of injury.

36. Maricar is aware that endotracheal or tracheostomy tube are usually placed in
patients who have experienced
a. Electrical burns on the hands and arms causing arrythmia
b. Thermal burns to the head, face resulting in hypoxia
c. Chemical burns on the chest and abdomen
d. Secondhand smoke inhalation

37. In the acute phase of care, oral fluids were withheld among burn patients because of
which of the following the patients may be particularly prone to
a. Aspiration and pneumonia c. Hyperistalsis and diarrhea
b. Vomiting and abdominal distention d. Gagging and strangulation

38. During morning report, Maricar learns she will be caring for a patient who is in stage
III burn care. What care can the nurse anticipate providing during the shift?
a. Dressing changes c. Pain management
b. Exercises d. Debridement

39. A newly admitted patient has a second degree burn encircling her left thigh from a
motorcycle accident. When Maricar enters her room, the patient was anxious and agitated.
The nurse should do first which of the following interventions?
a. Evaluate the condition of her pulses on the leg
b. Check the burn dressing for an increase in drainage
c. Immediately give some pain medications as ordered
d. Assess the cause of patient’s anxiety

40. Which of the following adjustments in bed making procedure would most decrease a
patient’s discomfort following skin grafting of a burn on the right lower extremity?
a. Placing a large plastic square on the grafted area to protect it from drafts
b. Leaving off the upper sheet until wounds on thigh have ceased to weep
c. Using bed cradle to prevent the sterile upper sheet from touching the body
d. Elevating the knee gatch of the bed to relieve tension on the skin of the thighs

Sit. 9: Dysebel, a 46 year old mother of five grown children had ceased to
menstruate one year before, but was admitted to the hospital with heavy vaginal bleeding
of two days duration. A Papanicolaou smear and punch biopsy revealed carcinoma of the
cervix

41. The nurse read in the literature which says that by the time cervical cancer is diagnosed 50-
75% have already involvement of the upper pelvic wall. As many as 30% have gross distant
metastasis and as few as 30% of patients have underlying vaginal bleeding. Which of the following
is the appropriate interpretation of these research findings?
a. 20 out of 30 women positive with cervical cancer has involvement of upper pelvic wall
b. Out of 20 women who were diagnosed with cervical cancer only 5 have metastasis
c. If there were 10 women diagnosed with cervical cancer, 3 have upper pelvic wall
involvement
d. Vaginal bleeding was identified on 8 out of 30 women positive for cervical cancer

42. When surgical removal is not feasible for Dyesebel, ionizing radiation may often be used to
treat malignant tumors in deep tissues because
a. Healthy cells are completely unaffected by ionizing radiation
b. Blood supply to normal tissues nullifies radiation effects
c. Immature cells are the most susceptible to radiation injury
d. Ionization converts abnormal cellular growth substances to normal ones

43. Dyesebelwas assigned to a private room during the period of radium application. The nurse
should arrange the furniture in Dyesebel’s room so that
a. Dyesebel’s bed and bedside stand are just inside the room, one on either side of hall door
b. Dyesebel’s bed is just inside the hall door and her stand on the far side of the room
c. Dyesebel’s bed and stand are parallel on the far sideof the room
d. Both Dyesebel’s bed and bedside stand are as far from the hall door as possible

44. The nurse should instruct Dyesebel to maintain which of the following bed positions during the
48 hours of radium application?
a. Supine with both hips and knees slightly flexed
b. Recumbent with the lower extremities fully extended
c. Side lying with the upper leg flexed sharply
d. Prone with the hips elevated over the foot gatch

45. The nurse is teaching the sisters of Donna about mammography, the nurse tells them correctly
that
a. The examination will takes about 1 hour
b. Avoid the use of deodorant and powders on day of the test
c. There is no discomfort associated with the procedure
d. Maintain an NPO status 6 hours prior to the procedure

Sit. 10: Care of the aging individual presents one of the greatest challenges for nurses. Julia
is aware that aging individuals experience many losses and vulnerable to depression and feelings
of low self worth. Lolo Teryo was seen by a nurse in the ER who was reported to becoming
increasingly withdrawn. He eats little food and has lost some weight. His wife died 6 years ago and
attended the funeral of his best friend a month ago and after which behavioral changes began.
46. In her admission, the nurse observes an open sore on Lolo Teryo’s arm. When asked about it
he says he scraped it on the fence 2 weeks ago and the lesion was smaller than it was. The nurse
may analyze the data as
a. He might be trying to commit suicide
b. Delay in healing might indicate super imposed skin cancer
c. Diminished inflammatory response in elderly
d. Age related changes on the skin and maldistribution of fats

47. Lolo Teryo is deaf on his right side. Which is the most appropriate nursing intervention for
communicating with Lolo Teryo?
a. Speak loudly to his ear
b. Speak to him from a position on his left side
c. Speak face-to face in a low pitched voice
d. Speak face-to-face in a high pitched voice

48. Why it is important to have the nurse check the temperature of water before Lolo Teryo takes
a shower?
a. He may catch cold if the water temperature is too low
b. He may burn himself because of a higher pain threshold
c. Has difficulty of discriminating between hot and cold
d. He might have lower pain threshold

49. The nurse encouraged Lolo Teryo to attend early morning exercise. He becomes tired and
short of breath. The nurse interprets this as
a. Age related changes in the cardiovascular system
b. Attributed to his sedentary lifestyle
c. Effects of his depression on his stamina
d. Medication the doctor might give him

50. According to studies and literature, which of the following is most important for Lolo Teryo to
maintain a healthy, adaptive old age?
a. To remain socially interactive
b. To disengage slowly in preparation to last stage of life
c. To move in with his son and family
d. To maintain total independence and accept help

Sit. 11: Professional nursing must recruit and sustain a cadre of engaged, spirited and
involved leaders; nurse leaders ready to face the unprecedented challenges and opportunities in
the 21st century. Engaged leaders create an atmosphere of attention to work as well as match the
talents and strengths of their staff with their assigned work.

51. The duty of a nurse leader filling the role of change agent revolves around which process?
a. Patient safety issues c. Staff safety issues
b. Organizational structures d. Workforce culture

52. A nurse leader provides orientation to an upcoming change in wound care procedures. The
leader builds relationships and supports the staff in implementing the new procedures. Which
type of approach is the leader using to manage resistance to change?
a. Normative re-educative c. Country club
b. Power coercive d. Rational-emperical
53. A nurse reports in a staff meeting about being unaware of the status of the planned changed on
the nursing unit. Which strategy should the nurse leader use to resolve this problem?
a. Remain open and flexible to hearing the staff’s concerns about change
b. Maintain close contact with resisters to facilitate buy in to the change
c. Communicate with the staff more frequently
d. Acknowledge negative consequences to resisting the change

54. A nurse leader determines the effectiveness of the plan of change and modifies the plan. Which
step in the change process does this represent?
a. Evaluation c. Implementation
b. Planning d. Organization

55. The nurse leader who is working to be a change agent on the nursing unit would be sure to do
which of the following?
a. Have firm, inflexible thoughts about how the change should progress
b. Communicate with staff in a vague manner
c. Aggressively pursue getting buy in from the staff
d. Articulate to the staff a vision of the change

Sit. 12: Nurse Bryle works in Clinika Dermatologika and had been having large volume of
patients for check up.

56. Nure Bryle prepares for a patient with acute cellulitis of the lower leg. The nurse anticipates
that which of the following will prescribed for the patient?
a. Cold compress to the affected area
b. Warm compress to the affected area
c. Intermittent heat lamp treatments four times daily
d. Alternating hot and cold compresses continuously

57. Nielzon was diagnosed with psoriasis. Nurse Brylee understands that which characteristic is
associated with this skin disorder?
a. Red purplish scaly lesions c. Silvery white scaly patches
b. Clear, thin nail beds d. Oily skin and with desquamated plaques

58. A patient who is taking azithromycin (Zithromax) tells the nurse that the information provided
by the pharmacy indicates this drug causes photosensitivity. The patient asks Nurse Brylee what
will happen with exposure to sunlight while taking the drug. The best response by the nurse is that
a. Heat from the sun is readily absorbed by the body and may lead to problems with heat
intolerance
b. Most common effect of photosensitivity is corneal damage because the drug causes
corneal absorption of UV light
c. Photosensitivity causes abnormal melanocyte activity on exposure to UV light, resulting
in splotchy, abnormally dark tanning
d. Sun exposure may cause an exaggerated sunburn with redness, swelling, and blistering
on exposed areas

59. The health care provider diagnoses impetigo and prescribes penicillin for a patient who has
crusty vesicopustular lesions over the lower face and skin creases in the neck. Which information
will be included in the teaching plan for this patient?
 a. How to clean the infected areas with soap and water
b. Appropriate use of alcohol-based lotions to decrease skin bacteria
c. Daily use of a multiple vitamin with a high dose of vitamin A to improve skin integrity
d. Use of petroleum jelly (Vaseline) to soften crusty areas

60. When NurseBrylee examined a patient’s oral cavity, the nurse notes the presence of white
lesions that resemble milk curds. Which question by the nurse is appropriate at this time?
a. How often do you brush your teeth?
b. Are you taking any medications at present?
c. Do you have a productive cough?
d. Have you ever had an oral herpes infection?

Sit. 13: Drawing on a comprehensive knowledge base, nurses are cognizant of a host factors
that influence physical health as they provide care to support optimal physiologic function. Efforts to
restore or improve function includes basic care and comfort. End of shift
reports/endorsements/referrals are important in assisting the nurses plan and implement care to the
clients assigned to them.

61. The nurse is preparing to give drug after receiving the morning endorsement. Which medication should
the nurse administer first?
a. Loop diuretic of patient with serum potassium level of 3.2mEq/l
b. Rapid acting insulin to a diabetic patient who has breakfast tray in room
c. Stimulant laxative to a patient who has not had bowel movement in 3 days
d. Proton pump inhibitor of a patient on NPO to be given IV

62. The nurse is preparing patients for surgery. Which patient has the greatest potential for experiencing
complications?
a. Leona scheduled for D and C who smokes marijuana on daily basis
b. Karen scheduled for open cholecystectomy smokes 2 packs per day
c. Joe scheduled for surgery on aneurysm and has history of elevated BP
d. Nielzon for left knee arthroscopy who reports chewing tobacco daily

63. Grace is caring for a patient with flail chest who has had chest tube for three days. The nurse notes there is no
fluctuation in the water seal compartment. Which intervention should the nurse implement first?
a. Check the tubing for any dependent loops
b. Auscultate the patient’s posterior breath sounds
c. Prepare to remove the patient’s chest tubes
d. Notify the doctor that the lungs have re-expanded

64. The female patient in the preholding area tells the nurse that she had reaction to a latex
diaphragm. Which intervention should the nurse perform first?
a. Label the patient’s chart with allergy
b. Place a red allergy band on the patient
c. Inform the patient to tell all doctor of the allergy
d. Notify the operating room personnel

65. The morning duty nurse has received the end shift of report from the outgoing night duty
nurse. Among the clients endorsed to the morning duty nurse, who should she assess FIRST?
a. Female client who has been turning on the call light frequently because her care has been
neglected
b. Male client who has just been brought to the floor from the emergency room with no
 report of complaints
c. Male client who will have cardiac catheterization in the morning and has been allowed to
use the bathroom once
d. Female client who received pain medications 30 minutes ago for pain at level 8

Sit. 14: Miggy consulted his private physician concerning of episodes of pressing, choking
chest pain. On the basis of examination, the doctor made a diagnosis of atherosclerosis heart
diasese with angina pectoris.

66. When developing a teaching plan for Miggy with all these risk factors for coronary artery
disease, the nurse will focus on
a. Family history of heart disease c. Increased risk associated with ethnicity
b. Incidence on advancing age d. Low activity level the patient reports

67. In the clinic the nurse monitors Miggy’s heart sounds and a murmur is heard at the second left
intercostal space along the left sternal border. Which valve is most likely be involved?
a. Pulmonic c. Aortic
b. Mitral d. Tricuspid

68. Miggy was scheduled for coronary angiography and possible percutaneous coronary
intervention (PCI).When caring for Miggy who has returned to the coronary care unit after having
a PCI, the nurse obtains these assessment data. Which data indicate the need for immediate
intervention by the nurse?
a. Heart rate 100 beats /min c. Chest pain level 8 on a 10 point scale
b. Blood pressure 90/60 mmHg d. Pedal pulse of +2

69. Verapamil (Isoptin) is ordered for Miggy with newly diagnosed Prinzmetal’s (variant) angina.
When teaching the patient, the nurse will include the fact that the drug will
a. Help prevent clotting in the arteries
b. Increase the force of myocardial contraction
c. Decrease spasms of the coronary arteries
d. Reduce the “fight or flight “ response

70. Miggy developed ST-segment elevation in several ECG leads is admitted to the ED and diagnosed as
having an AMI. Which question should the nurse ask to determine whether the patient is a candidate for
fibrinolytic therapy?
a. “What time did your chest pain begin?”
b. “Can you describe the quality of your chest pain?”
c. “Do you take aspirin on a daily basis?”
d. “Is there any family history of heart disease?”

Sit. 15: A "disaster" is a large-scale emergency—even a small emergency left unmanaged

may turn into a disaster. Disaster preparedness is crucial and is everybody's business. There are
agencies that are in charge of ensuring prompt response. Comprehensive Emergency Management
(CEM) is an integrated approach to the management of emergency program and activities for all
four emergency phases (mitigation, preparedness, response, and recovery), for all type of
emergencies and disasters (natural, man-made, and attack) and for all levels of government and
the private sector.

71. Several patients come to the emergency department with suspected contamination by MERS
Corona virus. What should the nurse do?
 1. Quarantine all contacts
2. Restrict visitors form the emergency department
3. Call housekeeping for diulted household bleach
4. Isolate all suspected patients in one area
5. Call extra staff to assist with the possibility of more patiens with same problems

a. 1,2 and 4 b. 2,3 and 4 c. 1,3 and 5 d. 1,2,4 and 5

72. A MERS corona virus infection was suspected in the area and as patients are admitted to the
hospital what type of precautions should the nurse implement?
a. Enteric precaution c. Reverse isolation
b. Hand washing precaution d. Standard precaution

73. As a member of a volunteer disaster medical asistance team, the nurse would be expected to
a. Triage casualties that hit the local community
b. Assist with implementing the hospital’s emergency response plan
c. Train citizens of communities how to respond to mass casualties event
d. Deploy to local or other communities with disaster to provide medical assistance

74. According to Joint Commission on Accreditation of Healthcare Organizations, all hospital must
perform which of the following task?
a. Develop a disaster plan and send it to all nurse managers in the unit
b. Develop a disaster plan, hold drills once a year and regularly evaluate
c. Select a disaster representative from the ER who is responsible for all activities
d. Develop a disaster plan, and hold a disaster drill twice each year

75. Which of the four phases of emergency management is defined as "sustained action that
reduces or eliminates long-term risk to people and properly from natural hazards and the effect"?
a. Recovery c. Mitigation
c. Response d. Preparedness

Sit. 16: Nurse Lance is an Emergency Department nurse working during the morning shift.
A newly hired nurse was assigned to work with him as part of the orientation program. He was
happy to act as a preceptor of the new nurse.

76. The echocardiogram showed a patient has pericardial effusion. When assessing the patient
with pericardial effusion, Nurse Lance will check for pulsus paradoxus, which is characterized by
a:
a. Diastolic blood pressure that is lower during exhalation
b. Diastolic blood pressure that is higher during inhalation
c. Systolic blood pressure that is higher during exhalation
d. Systolic blood pressure that is lower during inhalation

77. Immedietely the doctor on duty scheduled an emergency pericardiocentesis. When assessing
the patient after a pericardiocentesis that was performed for cardiac tamponade, Nurse Lance is
aware that the cardiac tamponade has been relieved when the following assessment findings are
present:
a. Decrease in central venous pressure and increase in blood pressure
b. Decrease in central venous pressure and decrease in blood pressure
c. Increase in central venous pressure and increase in blood pressure
 d. Increase in central venous pressure and decrease in blood pressure

78. A young teenager was brought to the hospital with a suspected lead poisoning and a chelation
therapy was prescribed. Nurse Lance caring for the patient would prepare to administer which of
the following medications?
a. Calcium disodium edetate c. Ipecac syrup
b. Activated charcoal d. Sodium bicarbonate

79. Nurse Lance is assessing a patient on respiratory distress from a house fire and inhalation
injury is suspected. The nurse monitors which of the following for the presence of carbon
monoxide poisoning?
a. Pulse oximetry c. Sputum carbon levels
b. Urine myoglobin d. Serum carboxyhemoglobin levels

80. A patient on cardiogenic shock has an order of IV nitroglycerine for control of chest pain and to
increase myocardial perfusion. Nurse Lance understands that the nitroglycerin must be prepared
by mixing the medication
a. Under a laminar flow hood c. Every hours because of its unstable nature
b. Solution in a glass bottle d. Solution that is in a plastic bag

Sit. 17: Nursing leaders have an obligation to address legal problems and ethical dilemmas
as they arise in the different clinical nursing practice

81. A nurse seeking to maintain ethical personal behavior would focus on doing which of the
following in clinical practice?
1. Use of ethical principles 4. Refer decisions to ethics committee
2. Evaluate personal morals 5. Familiarize self with Code of Ethics
3. Uses standard methods of practice

a. 1,2,4 and 5 b. 1,2 and 5 c. 1,3,4 and 5 d. 1,2,3,4 and 5

82. The nurse does not act when a patient becomes hypotensive after surgery. The patient
requires emergency surgery to stop postoperative bleeding later that night. Which type of
prosecution does the nurse potentially face for failing toa act?
a. Tort law c. Felony
b. Statutory law d. Misdeamenor

83. Based upon the request made by the patient’s spouse and children, a doctor ask the nurse to
discontinue feeding a debilitated comatose patient. The nurse understands the legal basis for
carrying out the order and first checks the patient’s record for documentation of
a. Court approval to stop the treatment
b. Approval by the institutional Ethics committee
c. Written order by the physician to remove the tube
d. Authorization by the family to discontinue the treatment

84. A new staff nurse is being evaluated by the nurse supervisor for knowledge skills and attitudes
at work. One aspect being rated is responsibility. Which action of the nurse denotes
responsibility?
a.The staff nurse offers suggestions for improvement in the nursing unit
b. The staff nurse adheres to the standards of nursing practice
 c. The staff nurse questions the policies of the administration
d. The staff nurse shares her positive views with the rest of the staff

85. A nurse gives a patient the wrong medication. After assessing the patient, the nurse completes
an incident report. Which statement describes what will occur next?
a. The incident will be reported to the Board of Nursing for disciplinary action
b. The incident will be documented in the nurse’s personnel file
c. Medication error will result in the nurse being suspended and possibly terminated
d. The report will be used to promote quality care and risk management

Sit. 18: Nurses often encounters patients undergoing disfiguring surgeries that may alter
normal physiologic function. It entails adjustment both physical and psychological and nurse plays
a very integral role in such circumstances.

86. The major improvement in body image following a modified radical mastectomy in a patient
with breast cancer usually is related to the
a. Feeling that the patient looks whole
b. Fact that something is done to help
c. Patient’s improved functional abilities
d. Acceptance received from others

87. A patient has a surgical creation of a colostomy for cancer of the colon. When comparing the
procedures of colostomy irrigation and an enema, the nurse understands than an intervention that
is unique to a colostomy irrigation is
a. Using cone shaped tip for the end of the instillation catheter
b. Clearing the tubing of air before insertion of irrigating solution
c. Lubricating the catheter tip with a water soluble jelly
d. Positioning the patient for evacuation of the bowel

88. Miguel has an above the knee amputation because of a gangrenous leg ulcer. After the second
postoperative day, to prevent deformities the nurse should
a. Keep the patient’s residual limb elevated on a pillow
b. Encourage the patient to lie on a prone position
c. Place an abduction pillow between the patient’s leg
d. Teach the patient to press the residual limb against a hard surface

89. The nurse should be aware that sensory restriction in a patient who is blind can
a. Lead to use of permanent neurotic behavior
b. Decrease the patient’s restlessness and lethargy
c. Heighten the patient’s ability to make decisions
d. Increase the use of daydreaming and fantasy

90. Mrs. Damaso undergoes emergency treatment related to acute coronary syndromes. The
patient has little sleep over the past 24 hours. Which assessment finding is consistent with sleep
deprivation?
a. Slowing of thought process c. Hyperventilation
b. Cool extremities d. Apnea lasting greater than 5 seconds
 Sit. 19: Marco, a 43 year old owner of a sari sari store developed business worries
and chronic epigastric pain. He consulted a doctor when nausea and vomiting case him to
lose sleep at night. The nurse suspects duodenal ulcer

91. In preparation for Marco for his test, the nurse should tell him to expect that UGIS will include
a. Taking serial pictures as he assumes different position
b. Ingestion of numerous liquids and semi soft meals in quick succession
c. Removal of stomach secretions through a nasogastric tube
d. Administration of radiopaque drugs intramuscularly or intravenously

92. As part of his treatment , drugs was given to Marco. Which of the following prescribed
medication will most likely reduce acid production on his stomach?
a. Nizatidine c. Esomeprazole
b. Maalox d. Propantheline bromide

93. On another room, another patient Alberto’ was with cirrhosis and his condition deteriorated
during his first week in the hospital. He became more drowsy and icteric and developed an
offensive breath odor with flapping tremors. The nurse is suspecting he is developing hepatic
encephalopathy. Which of the following nursing diagnoses warrants the highest priority in the
plan of care by the nurse?
a. Potential for injury c. Alteration in comfort
b. Self care deficit d. Alteration in nutrition

94. A nurse caring for the Alberto with hepatic encephalopathy assesses for asterixis. To confirm
this, the nurse would
a. Extend arm anddorsiflex the wrist and extend fingers of patient.
b. Ask client to sign his name on a piece of paper
c. Check for the stools for the color of his stools
d. Tie the arm with BP cuff and note tremors at the fingers

95. Based on Alberto’s history, the nurse should evaluate him for signs and symptoms of which of
the following complications?
a. Circulatory overload c. Bleeding tendencies
b. Respiratory distress d. Urinary tract infection

Sit. 20: Nurse Hector was hired as a beginning nurse in a tertiary specialty hospital
who specializes in vascular diseases and was assigned with several patients in one ordinary
day.

96. Nurse Hector performing an assessment with a patient who has chronic peripheral arterial
disease (PAD) of the legs would expect to find
a. Swollen, dry, scaly ankles c. Positive Homan’s sign
b. Prolonged capillary refill d. Draining ulcer on the heel

97. A patient with a history of a 4-cm abdominal aortic dissecting aneurysm is admitted to the
emergency department with severe back pain and bilateral flank ecchymoses. The vital signs are
blood pressure (BP) 90/58, pulse 138, and respirations 34. The nurse plans interventions for the
patient based on the expectation that treatment will include
a. Immediate surgery
 b. STAT angiogram
c. Paracentesis when vital signs are stabilized with fluid replacement
d. Admission to intensive care for observation and diagnostic testing

98. A patient recovering on a general surgical unit from an aortic valve replacement 1 week ago
develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. The nurse should
notify the health care provider and
a. Elevate the left leg on a pillow
b. Apply an elastic wrap to the leg
c. Keep patient in bed in the supine position
d. Assist the patient in gently exercising the leg

99. When the nurse is planning expected outcomes for the patient, which outcome has the highest
priority for this patient who has a history of thromboangiitis obliterans (Buerger’s disease) is
admitted to the hospital with a gangrenous lesion of the right small toe?
a. Cessation of smoking c. Maintenance of appropriate weight
b. Control of serum lipid levels d. Demonstration of meticulous foot care

100. The nurse has identified the collaborative problem of potential complication: pulmonary
embolism for a patient with left-calf DVT. Which nursing action is appropriate to include in the
plan of care?
a. Maintain bed rest as ordered c. Administer oxygen to keep O2 saturation 90%
b. Apply compression stockings d. Remind to dorsiflex the feet