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CLOSED DOOR EXAMINATION

NURSING PRACTICE II
CARE OF HEALTHY AT RISK MOTHER AND CHILD
NOV 2023 Philippine Nurse Licensure Examination Review
GENERAL INSTRUCTIONS:
1. This test questionnaire contains 100 test questions
2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalid your answer.
3. AVOID ERASURES.
4. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set.
5. Write the subject title “NURSING PRACTICE II” on the box provided
Situation: Routine postpartum care is being performed by
Nurse Barbie in caring for a postpartum patient who gave birth
via normal spontaneous vaginal delivery.
1. Blood loss of _________ would lead to Nurse Barbie to
suspect that the patient is experiencing postpartum
hemorrhage.
A. More than 300ml/24 hours
B. More than 400ml/ 24 hours
C. More than 500ml/ 24 hours
D. Less than 200ml/ 24 hours
2. This is a condition caused by a markedly distended uterus and
intermittent uterine contractions within 2 to 3 days after birth?
A. Retained placenta
B. Afterpains
C. Uterine atony
D. Boggy uterus
3. Nurse Barbie observes that her patient is still adjusting to
being a mother. In line with Ramona Mercer’s Maternal Role
Attainment Theory, which statement best describes the process
of becoming a mother?
A. A woman learns mothering behavior as early as a
teenager.
B. The woman learns to become comfortable with her
role as a married individual.
C. It reflects the transitional process from being single
to raising a family.
D. It involves the dynamic transformation of a
women’s persona.
4. The mother suddenly becomes worried when a gush of blood
comes out of her vagina when she first arises from her bed. She
asks Nurse Barbie why this has occurred. Nurse Barbie is correct
when she says _________.
A. “Blood pools at the top of the uterus and passes
upon rising or sitting on the bed”
B. “This is due to the normal pooling of blood in
the vagina when the woman lies down to rest
or sleep.”
C. “Physical activity stimulates bleeding in the vagina”
D. “This is a normal physiologic occurrence where the
body attempts to eliminate excess fluids.”
5. The mother is currently having difficulty with voiding due to
her perineal edema. What can Nurse Barbie do to stimulate the
sensation of voiding?
A. Reminding her to void every hour
B. Helping the mother into the shower.
C. Insertion of a catheter
D. Running water in the sink or shower.
Situation: A postpartum mother who underwent a normal
spontaneous vaginal delivery asks the nurse when and how her
body will return to its prepregnancy state.
6. The uterus is known to return to its prepregnancy state in
____.
A. 6 weeks
B. 6 days
C. 4 weeks
D. 35 days
7. The nurse knows that the process where the uterus changes
after childbirth to return to its previous, prepregnancy state is
called __________.
A. Involution
B. Evolution
C. Subinvolution
D. Inversion
8. Among the following factors experienced by the patient
during her pregnancy and subsequent delivery, which would
most likely contribute to a slow uterine involution?
A. Full bladder during labor
B. Difficult Birth
C. Perineal Laceration
D. Gestational Hypertension
9. To assess the progression of involution, the nurse plans to
assess the uterine fundus of the mother. Which part of the
abdomen should the nurse begin with her assessment?
A. Symphysis pubis
B. Umbilicus
C. 5 cm below the xiphoid process
D. 5 cm below the umbilicus

Prepared by:
Raymund Kernell Mañago Shee Ann Pagasian Adolf Yasa
Angelo Jose Molina Audrey Ayuste Darlene Joy Aquino
James Fabian Miyu Krista Miura
1 | Page
10. The priority nursing intervention during the immediate
postpartum period is focused on ____.
A. Monitoring for signs of infection
B. Watching out for postpartum hemorrhage
C. Taking the vital signs every 2 hours
D. Assessing level of consciousness
Situation: Liza, a multigravida currently at 20th weeks of
gestation visited your clinic with complaints of dizziness, vertigo,
and heartburn. Upon assessment, it was determined that she
was malnourished.
11. She was prescribed with iron supplements and health
education was done. Which statement made by Liza would
indicate an understanding of the health instructions given?
A. “I don’t need to take these as our bodies have iron
stores.”
B. “Iron supplements may cause my stool to become
blackish green in color”
C. “The iron is best absorbed if taken on an empty
stomach.”
D. “Meat should be avoided as to ensure iron is
absorbed”
12. Liza was concerned with taking her iron supplements as she
has been taking vitamin C regularly. What will be the most
appropriate response to this?
A. “This is okay as long as you take the two supplements
1 hour apart”
B. “Stop taking Vitamin C supplements”
C. “This is okay as absorption of iron is enhanced with
Vitamin C.”
D. “This is not okay as absorption of iron is decreased by
Vitamin C.”
13. Calcium supplements were also prescribed to Liza to be
taken during the 2nd and 3rd trimesters. To help facilitate
absorption of calcium, which of the following should you advise
her to take with this?
A. Fat-soluble vitamins
B. Water-soluble vitamins
C. Iron
D. Milk
14. Liza asks you what the main source of nutrition for her baby
is. You answer correctly by stating that it is the ______.
A. Amniotic Fluid
B. Placenta
C. Fetal Circulation
D. Small Intestines
15. You performed a health teaching session for Liza to manage
her heartburn. Which statement by Liza indicates a need for
further teaching?
A. I will lie down after eating
B. I will drink milk between meals
C. I will eat small, frequent meals
D. I will avoid fatty or spicy foods
Situation: Nurse Young was recently transferred to the
pediatric ward and was assigned to give medications for the shift
16. When giving medicine to pediatric patients, dosage varies.
Which of the following should Nurse Alicia consider?
A. Height and weight
B. Size, surface area and age
C. Size and surface area
Prepared by:
Raymund Kernell Mañago Shee Ann Pagasian
Angelo Jose Molina Audrey Ayuste
James Fabian Miyu Krista Miura
D. Size, surface area, age and weight
17.Before administering oral medications, Nurse Young is being
assessed by the head nurse on her knowledge on administering
medications for pediatric patients. Which of the following
statements shows correct understanding by Nurse Young?
A. Compared to an adult’s reaction, a child’s reaction to
the medication is more predictable
B. When giving oral medication, the child as young as two
years of age cannot be taught to swallow drugs.
C. The child should be told to place the tablet on top of
their tongue and drink water to wash down the tablet.
D. The possibility of error is greater in the giving of
medication to children than to adults.
18. Nurse Young is to administer a medication via IM injection
to an 10-month-old baby. What part should she use to reduce
the risk of nerve damage and vascular injury?
A. Gluteus maximus
B. Vastus lateralis
C. Deltoid muscle
D. Dorso-gluteal
19. Intramuscular injections have been known to produce
serious adverse effects according to research. Nurse Young
knows that the most common complication that may arise from
this is ___________.
A. Infection
B. Paralysis
C. Hematoma
D. Muscle contracture
20. Nurse Young is to administer the IM medication to the 10-
month-old baby. To ensure that the ordered medication is given
to the right patient, what will Nurse Young do first?
A. Check the patient's hospital bracelet.
B. Ask the parent/significant other to state name of
patient and birth date of patient.
C. Verify patient’s allergies with chart and with patient.
D. Compare medication order to identification bracelet.
Situation: Kim, a college student, was recently admitted to the
hospital due to having severe pre-eclampsia. Despite her
physician advising her to rest, Kim insists on continuing her work
while admitted. She currently studies around 10 hours a day and
is often visited by her peers and relatives.
21. Nurse Dani is concerned about Kim’s ability to comply with
the doctor’s instruction to rest. What appropriate action should
she take?
A. Ask her mother to explain to her why she needs to
rest.
B. Develop a routine with the patient to balance her
studies and her rest needs.
C. Tell her that she should prioritize her baby’s health
more than her studies
D. Ask her why she is not complying with the prescription
for bed rest.
22. During the interview, Patient Kim becomes irritated with the
nurse, stating “I don’t want to talk to you since you’re only a
nurse. I’ll just wait for the doctor. What would be Nurse Dani’s
best response?
A. "I do not like the way that you dismiss me."
B. “Noted. I should call your doctor.”
C. "So then you would prefer to speak with your doctor?"
D. "Your doctor prescribed this for us to do nursing care."
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 23. Due to the previous situation, Nurse Dani is now
experiencing a dilemma. This occurs when _____.
A. There is a conflict between the nurse's decision and
that of their superior
B. Choices regarding patient care are unclear
C. There is a conflict of two or more ethical principles
D. A decision must be made quickly under a stressful
situation
24. Nurse Dani knows that regardless of what just happened,
she must still abide to the ethical principle that states the nurse
is obligated to implement actions that will provide care and
benefit to the patient. What specific principle is this?
A. Beneficence
B. Justice
C. Nonmaleficence
D. Veracity
25. In providing a safe environment for the patient with
preeclampsia, what can Nurse Dani do?
A. Maintain fluid and sodium restrictions.
B. Encourage frequent visits from family and friends for
psychosocial support
C. Take the patient's vital signs every 4 hours.
D. Take off the room lights and draw the window shades.
Situation: Head Nurse Kylie is currently facilitating a training
program for newly hired nurses at Olympia Medical Center
(OMC). A key part of her training is giving scenarios for the
nurses to apply what was taught during the program. She gave
the group a situation: Patient Rosita is a pregnant woman
admitted in the OB Ward.
26. In caring for patient Rosita, Head Nurse Kylie is discussing
with Nurse Josie, a newly hired nurse, on how to utilize the
nursing process for the pregnant patient. Nurse Josie is
correct when she mentions the planning phase includes:
A. Reviewing the history of the patient during assessment
B. Prioritizing the patient’s problems
C. Identifying the nursing diagnoses
D. Collecting information of the patient’s problem has
been resolved in the evaluation phase
27. Nurse Thea, one of the assigned group leaders during the
training, is reviewing the steps of the nursing process with
the group. Nurse Thea identifies which of the following
is/are objective data? Select all that apply.
I. Respiratory rate is 22/min.
II. Feels pain after a 10-minute walk
III. Pain is rated as 3 on a scale of 10.
IV. Skin is pinkish in color, warm, and dry.
A. II and III
B. I and IV
C. III and IV
D. I and II
28. The very next day, Patient Rosita delivered an alive baby girl.
After delivery, she complained of leg pains. Nurse Josie took
hold of Patient Rosita’s chart. In the chart, an order was
provided to give PONSTAN 500 mg every 4 hours PRN for
pain. After 40 minutes, the patient felt relieved. Nurse Josie
should have conducted what step of nursing process?
A. Assessment
B. Planning
C. Evaluation
D. Intervention
Prepared by:
Raymund Kernell Mañago Shee Ann Pagasian
Angelo Jose Molina Audrey Ayuste
James Fabian Miyu Krista Miura
29. If Patient Rosita’s pain was not satisfactorily relieved after
administration of the medication, Nurse Josie should perform
which of the following actions upholding the nursing process?
A. Wait for more time for the pain reliever to take
effect
B. Collect additional data as to why the patient has not
been relieved of pain.
C. Teach the patient relaxation breathing techniques.
D. Refer to attending physician.
30. Head Nurse Kylie discusses in the training the different
elements of documentation. In order for the document to be
comprehensive and timely, it must be:
A. Complete and current
B. Accurate and concise
C. Organized
D. Factual
Situation: Mommy Oni is a 28-year-old primigravida that is
admitted to Solaris Birthing Center. She confirms to have been
in labor for the past 10 hours, having contractions 5 minutes
apart. With astute observation from Nurse Karen, she deduced
that the patient is having hypotonic contractions. Mommy Oni
also complains of more pain in her back than in her abdomen.
Sonogram was performed which showed her fetus to be
“borderline” large for gestation and in occipito-posterior
position.
31. Nurse Karen notices that Mommy Oni’s uterine contractions
are short in duration and irregular in frequency. During
contractions, Mommy Oni is screaming with pain. Nurse Karen
knows that the BEST nursing action to perform is?
A. Try to divert attention from pain.
B. Administer pain reliever as ordered.
C. Stay with the patient and offer her a back rub.
D. Document and report frequency and duration of
contractions.
32. Mommy Oni’s physician is considering augmenting her labor
with the use of oxytocin. Nurse Karen would question the use
of Oxytocin for Mommy Oni if?
A. She had an amniocentesis performed during
pregnancy
B. Her fetus is large for gestational age by a sonogram
C. Her membrane ruptured after only 1 hour of labor
D. Her blood pressure is slightly elevated above
normal
33. Nurse Karen observes that Mommy Oni’s contractions are 70
seconds long and occurring every 90 seconds when assessing
the frequency of her contractions after oxytocin was
administered. Nurse Karen’s first action should be which of
the following?
A. Give an emergency bolus of oxytocin to relax the
uterus
B. Discontinue the administration of the oxytocin
infusion.
C. Increase the rate of client’s IV infusion
D. Ask client to turn to her left side and take breaths
deeply.
34. As Nurse Karen monitors Mommy Oni, she should know which
finding shows an adequate pattern of uterine contraction?
A. Three to 5 contractions in a 10-minute period, with
resultant cervical dilatation
B. Four contractions every 5 minutes, without
resultant cervical dilatation
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Darlene Joy Aquino
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 C. One contraction every 10 minutes, without
resultant cervical dilatation
D. One contraction per minute, with resultant cervical
dilatation
35. Nurse Karen is an effective nurse when she knows which of
the nursing measures should she LEAST consider doing to
Mommy Oni having oxytocin drip?
A. Know how to recognize potential adverse reactions.
B. Administer oxytocin drug with caution
C. Monitor patient closely when infusing oxytocin
D. Inform patient about potential complication.
Situation: Madam Irene’s daughter, one-year-old Trixie, is
admitted at Sta. Teresa Medical Center due to Pneumonia. Upon
admission, she was given IV antibiotics, decongestant,
antipyretic, and vitamins. She was also subjected to oxygen
therapy.
36. As Nurse Ria gives Trixie her oral medication, she
immediately refuses, making Nurse Ria worried. Nurse Ria
will handle the situation by:
A. Leaving the child alone
B. Seeking the help of the mother in giving the oral
drug.
C. Mixing the drug with milk to cover up the
unfavorable taste.
D. Getting angry with the mother and the child.
37. With Nurse Ria’s knowledge on pediatric development, she
is aware that it is normal for one-year-old Trixie to
continuously refuse the drug because she ________.
A. has separation anxiety.
B. internalizes the attitudes of others.
C. utilizes magical thinking.
D. is negativistic in all matters.
38. Nurse Ria knows that in giving Trixie oxygen effectively, the
best way to administer it is through the use of _______.
A. hood
B. face Mask
C. Incentive Spirometer
D. nasal catheters
39. With Trixie being given IV Antibiotic therapy, Nurse Ria
should give the MOST common gauge used for IV cannula
for her age which is gauge ____.
A. 20
B. 24
C. 22
D. 18
40. Nurse Ria is monitoring Trixie for improvement of her
condition. An IMPORTANT evaluation parameter that she
should watch out is ____.
A. Absence of fever.
B. Absence of chest indrawing.
C. Respiratory rate of 45 beats per minute,
D. Respiratory rate of 55 beats/ minute.
Situation: Patient Boa Hancock is a postpartum patient
admitted at Marineford General Hospital where she delivered a
stillborn. She is hooked to an intravenous fluid (IVF) and is
currently being monitored postpartum. She tells her nurse,
Nurse Luffy, that she wants to leave the hospital. However, she
doesn’t have an order from Dr. Chopper to be discharged from
the hospital.
Prepared by:
Raymund Kernell Mañago Shee Ann Pagasian
Angelo Jose Molina Audrey Ayuste
James Fabian Miyu Krista Miura
41. Given that Nurse Luffy is aware of the ethico-legal concerns
regarding Boa Hancock’s request, he has to avoid liabilities.
Which of the following actions is APPROPRIATE for Nurse
Luffy to do?
A. Notify nursing supervisor of the patient’s plans to
leave
B. Arrange medication prescriptions at the patient’s
preferred pharmacy.
C. Notify directly the attending obstetrician.
D. Ask the patient about transportation plans from the
hospital.
42. With Patient Boa Hancock being on postpartum, Nurse Luffy
reminds her on the importance and need of early
ambulation. As per Nurse Luffy’s instruction, which of the
following is INCORRECT in doing ambulation?
A. Assist the patient from sitting to standing position.
B. Raise the head of the bed slowly to achieve sitting
position of the patient.
C. Allow the patient to rise from the bed to a standing
position unassisted.
D. Assist patient to rise from lying to sitting position.
43. As Nurse Luffy is waiting for an update from Nurse Rayleigh,
his supervisor, regarding Boa Hancock’s request to go
home, he proceeds to check his patient. As he entered the
room, he discovers that the basket containing wastes
caught on fire. In response to the emergency, Nurse Luffy
calmly recalled that the correct steps to do in this situation
is:
I. Rescue the patient.
II. Activate the fire alarm.
III. Close the door to confine the fire.
IV. Put off the fire with fire extinguisher.
A. IV, II and I
B. I, II, III and IV
C. I, II and IV
D. II, IV and I
44. After Nurse Luffy put out the fire, he noticed that Boa
Hancock has absconded. What is the ethico-legal
responsibility of Nurse Luffy?
A. Autonomy
B. Nonmaleficence
C. Beneficence
D. Justice
45. Nurse Rayleigh told Nurse Luffy that absconding is
inevitable in any health care facility. If the patient suddenly
absconded, Nurse Luffy should IMMEDIATELY inform which
of the following?
A. Attending physician
B. Security guard on duty
C. Resident on duty
D. Nursing staff
Situation: Patient Anya Forger is a 5-year-old child currently
admitted at the pediatric ward of Ostania Medical Memorial
Center (OMMC). She was admitted due to having severe otalgia,
irritability, and fever. Yor Forger, her mother, informed Nurse
Fiona that Patient Anya developed Upper Respiratory Infection
three weeks prior to admission. The admitting diagnosis of
Patient Anya is Acute Otitis Media (AOM).
46. Nurse Fiona performs her initial assessment on Anya. She
notices that Patient Anya keeps crying and constantly
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 pulling her right ear. Being Patient Anya’s nurse, she knows
that the MOST APPROPRIATE action to do is:
A. Request parent to carry the child
B. Take Catherine's vital signs.
C. Refer to the attending physician.
D. Assess the description and frequency of pain.
47. Patient Anya’s physician gives a doctor’s order to administer
Ofloxacin eardrop on Patient Anya. As Nurse Fiona prepares
to administer the order, she needs to hold the bottle with
her hands to warm up the solution to prevent dizziness for
______.
A. 5-6 minutes
B. 1 to 2 minutes
C. 3-4 minutes
D. 6-7 minutes
48. Nurse Fiona washed her hands and gently started cleaning
any discharges that can be removed easily from the outer
ear. As Nurse Fiona positions Patient Anya, she vividly
remembers that the next step in the procedure is to:
A. Gently press the tragus of the ear four times in a
pumping motion.
B. Gently pull the outer ear
C. Drop the medicine into the ear canal.
D. Keep the ear up for five minutes.
49. Based on her previous knowledge on otitis media, Nurse
Selma remembers that children like Patient Anya are
predisposed to Acute otitis media due to the following risk
factors, EXCEPT _____.
A. absence of breastfeeding
B. Swimming
C. exposure to cigarette smoke
D. poor hygiene
50. Nurse Fiona’s nursing interventions to promote drainage
and reduce pressure from fluid from is to have Patient Anya
assume any of the following positions, EXCEPT?
A. tilt head to side if sitting up
B. lie on the affected area
C. put the pillows behind the head
D. lie on the non-affected ear
Situation: Nurse May is a nurse that is currently rotated in the
Pediatrics Ward of Kawayan Medical Center. To better
appreciate her role as a professional nurse in the area, she
needs to review the principles and concepts of human growth
development.
51. As she was assigned to provide care to pediatric patients,
Nurse May should recall which of the following correct
information?
A. Toddler period ranges from 12 to 36 months.
B. An infant's tongue is smaller than the adult.
C. Early childhood period ranges from 3 to 7 years.
D. Breast milk provides complete infant nutrition.
52. Nurse May is checking Baby Janjan’s temperature when her
mother asks about what age does growth and development
become more rapid. Nurse May knows that rapid growth
and development occurs during which time?
A. Ten
B. Nine
C. Twelve
D. Eleven
53. The mother of Baby Janjan further asked Nurse May how
to determine if her baby is at the right age of her
development. Nurse May explained that one of the key
Prepared by:
Raymund Kernell Mañago Shee Ann Pagasian
Angelo Jose Molina Audrey Ayuste
James Fabian Miyu Krista Miura
determinants of the baby’s development is her gross and
fine motor development. She emphasized further that there
are actions that can stimulate and growth and fine motor
movement, such as which of the following?
1. Push/pull
2. Use of scissors and pencil appropriately
3. Poking straws into holes
4. Stand on tiptoes if shown first
A. 1 and 2
B. 2 and 3
C. 3 and 4
D.1, 2, 3 and 4
54. According to the World Health Organization (WHO), suicide
has become a global phenomenon. As a pediatric nurse that
deals with different children from toddler to adolescent,
Nurse May is bound to take care of adolescents who are
emotionally disturbed. As such, it is vital for Nurse May to
have prior knowledge of warning signs of suicide which
occur for at least a month before an attempt. Which of the
following warning signs should NOT alert Nurse May?
A. increase in initiative
B. verbalization of suicidal thoughts.
C. Crying
D. Sleep disturbances
55. Head Nurse Jona regularly performs rounds in the Pediatric
Ward. In one of her nursing rounds, she asked Nurse Ester
about the age inclusivity where a person transitions from
childhood to adulthood or graduation. Nurse Ester knows
that the CORRECT age range is from ________.
A. 15 to 18
B. 12 to 16
C. 11 to 18
D. 13 to 18
Situation: Nurse Elle is working in the Birthing station of Maayo
General Hospital, where five postpartum mothers delivered 2
hours, 4 hours, and 6 hours ago, respectively. Upon their
obstetric history, she discovered that all of them have had past
pregnancies. Nurse Elle, being a nurse educator, opted to
conduct health education about postpartum hemorrhage which
would deem vital to all postpartum mothers present.
56. Nurse Elle explains to the mothers about early indications for
hypovolemia caused by postpartum hemorrhage. She is
CORRECT when she states that early signs and symptoms that
can be observed is:
A. increasing pulse and decreasing blood pressure
B. altered mental status and level of consciousness
C. dizziness and increasing respiratory rate
D. cool, clammy skin, and pale mucous membranes
57. Nurse Elle further discussed with the mothers that there are
risk factors that can lead to postpartum hemorrhage. Nurse
Elle correctly explains that the following are risk factors
EXCEPT:
A. ruptured uterus
B. uterine atony
C. overdistended uterus
D. retroversion of the uterus
58. Nurse Elle reviews the normal postpartum course and expects
to note sexual activity during:
A. After weeks from the delivery
B. 4 days after the delivery
C. When the client's bladder is full
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 D. The day after the delivery
59. During the health education session, one mother asked Nurse
Elle if sexual activity will return if no complications develop.
Nurse Elle explains that through a normal postpartum course,
they would expect the return of sexual activity during what
time?
A. In 4 to 6 weeks
B. At any time
C. After the 6-week physician check-up
D. When her normal menstrual period has resumed
60. Nurse Elle instructs the postpartum mothers that there may
be possibilities of them experiencing postpartum hemorrhage
in the future. Nurse Elle emphasizes that proper nutrition and
diet may prevent or lessen the occurrence of hemorrhage. An
example would be the inclusion of Vitamin K intake to lessen
the bleeding itself. Nurse Elle knows that the patient should
take Vitamin K with _______ for easier absorption.
A. Proteins
B. Carbohydrates
C. Minerals
D. Fats
Situation: Nurse Sherry is the head nurse of the OB/GYN ward
of Marianas General Hospital. In one of her nursing rounds, she
noticed that there is a lack of data filled up in the Intake &
Output sheets of various patients of the ward.
61. Based on the discovered findings, what would be the most
appropriate action for Head Nurse Sherry to do?
A. Ask the staff nurses the reasons for the failure to
properly fill up the Intake & Output flow sheet.
B. Give the staff nurses first warning.
C. Conduct a needs assessment.
D. Review the Orientation Program.
62. With the presenting issue in the ward, Head Nurse Sherry
decided to coach her staff nurses. One of the questions she
asked was what fluids should not be included in documenting
the Intake/Output flowsheet. The staff nurse is correct if she
said:
A. Intravenous Fluids
B. Gelatin
C. Solid Foods
D. Beverages
63. Head Nurse Sherry also emphasized to the staff nurses that
which of the following should be EXCLUDED in documenting
the Output list?
A. Drainage from tubes
B. Solid/hard feces
C. Urine
D. Vomitus
64. Another question asked by Head Nurse Sherry is about the
time to record the Intake and Output. The staff nurse is
correct when she said that the BEST TIME to record the
intake and output is:
A. During endorsement
B. After endorsement
C. Right before endorsement
D. Any time before duty
65. Mommy Mathilda, a pregnant patient in the ward, is also
diagnosed with Chronic Heart Failure. In patients with
chronic heart failure, monitoring intake and output is
considered vital. The MAIN purpose of recording accurate
Prepared by:
Raymund Kernell Mañago Shee Ann Pagasian
Angelo Jose Molina Audrey Ayuste
James Fabian Miyu Krista Miura
data on intake and output of these patients is to
_____________.
A. determine if client is improving or not
B. find out if there is still water retention in the
interstitial cells
C. detect cardiac overload
D. determine weight gain/loss
Situation: Nurse Melanie and her fellow staff nurses assigned
in the delivery room of Pandacan Medical Center, is interested
in conducting a research study on the experiences of pregnant
women in labor. They are planning on making it qualitative
research to yield accurate results, with Nurse Melanie as the lead
researcher.
66. In the presentation of results and discussion portion of the
qualitative study, Nurse Melanie should use as a reference
in the write-up the ______ person.
A. First
B. Second
C. Fourth
D. Third
67. Nursing is always regarded as both an art and a science. In
the field of human science, nursing deals with the critical
and fundamental differences in attitude towards their
respective phenomena. Which of the following is an aim of
human sciences?
A. Construct prediction
B. Seek causal explanation
C. Sets control
D. makes meaningful interpretation
68. Nurse Melanie’s research group is observing the activities
occurring in the delivery room. One of the activities
happening involves social processes, which can be further
explored. To explore this, which of the following qualitative
research method should be used?
A. Grounded theory
B. Historical research
C. Descriptive Phenomenology
D. Case study
69. After the research group is done analyzing the data of their
study about experiences of pregnant women in labor, they
proceed to return to the participants in order to determine
the accuracy of the emerged themes. The research group
is doing which criteria of trustworthiness?
A. Confirmability
B. Credibility
C. Transferability
D. Dependability
70. While conducting the interview as their method of data
collection in the study, the research group utilized audio
recording devices to capture what transpired in the
interview session. After transcribing the data, the research
group is aware that the APPROPRIATE action to do with the
audio tape is:
A. Keep the audiotape in a vault and dispose of it a year
after.
B. Submit the audiotape to their research adviser.
C. Throw it in the trash bin immediately after it was
used
D. Post the recording on their university research
website for others to listen.
Adolf Yasa
Darlene Joy Aquino
6 | Page
Situation: Nurse Christine is the head nurse of the OB/GYN following therapeutic communication technique is the
area at Santa Monica General Hospital. To increase better MOST appropriate for Nurse Dan to use?
performance in the area, she conducted an in-service program A. Touch
on staff development. B. Clarifying
C. Restating
71. Head Nurse Christine discussed with the nurses in the area D. Silence
that the MOST frequently neglected area in management is 77. When Karylle said, "Whenever I see my husband visit me,
__________. I feel depressed,” Nurse Dan replied, “Your husband
A. Managerial knowledge depresses you?” Nurse Dan responded with which
B. Professional development therapeutic communication technique?
C. Clinical skills A. Restatement
D. Successful communication B. Focusing
72. Being the head nurse in the area, Nurse Christine knows C. Focusing
that a vital component in the process of supervising is D. Seeking clarification
delegation of tasks. She knows that the delegation is MOST 78. As Nurse Dan continued to converse with Patient Karylle,
empowering to the staff because: he said, “Tell me more about your experience when you
A. Effective delegation does not require nurses to know had the colonoscopy” Which therapeutic communication
the abilities and weaknesses of their staff technique is Nurse Dan utilizing?
B. Delegation frees the manager to do other task while A. Focusing
empowering staff. B. Clarifying
C. Delegation fosters the responsibility of staff while C. Encouraging elaboration
increasing professional growth. D. Restating
D. Delegation starts at top management down to 79. When Nurse Dan says, “Tell me more about about your
subordinates experience. I wish to hear about…” He is displaying which
73. During the in-service program, Head Nurse Christine therapeutic communication technique?
discussed one of the common conflict resolution methods A. Restating
which is negotiation. She asked one staff what the focus of B. Seeking clarification
negotiation is. The staff answered correctly if she said C. Open-ended questions
negotiation creates a ________. D. Summarizing
A. Soothing situation 80. Nurse Dan tells the patient, “You will be wheeled in to the
B. Third party consultation OR and will be hooked to an IVF where the anesthesia will
C. Trade-off be given intravenously." The therapeutic communication
D. Win-win situation technique that Nurse Dan used is ____________.
74. Head Nurse Christine emphasized that after delegation of A. Clarification
duty comes supervision. She stated that the PRIMARY B. Summarizing
purpose of supervision is it: C. Giving information
A. Influences the organization’s approach in D. Reflection
recruitment, promotion and personnel evaluation.
B. Improves staff compliance with policy and Situation: Patient Sheena is a 12-year-old pediatric patient
procedures. admitted at Calantag Hospital Private Room, where she was
C. Assigns appropriate work tasks to the best-qualified equipped with a tracheostomy tube. Nurse Kenny is the person
D. Enhances the delivery of quality nursing care. assigned to care of Sheena.
75. Head Nurse Christine reinforced that Delegation involves
transferring of nursing care to an individual. She stated that 81. Nurse Kenny is a newly registered nurse, so he does not
when delegating care to the staff, there are various criteria have the experience and skill caring for Patient Sheena who
to observe. What is considered the BEST criterion when has a tracheostomy tube. As an inexperienced nurse, he
delegating staff? can ask for anyone of the following to perform the care,
A. Responsibility EXCEPT:
B. Adaptability A. Medical Resident
C. Flexibility B. Medical Intern
D. Competence C. Charge Nurse
D. Mother of child with care of tracheostomy tube
Situation: Therapeutic Communication is an important aspect experience
in providing better rapport as it promotes understanding 82. Dr. Dizon, the otolaryngologist, arrived at the room to
between the sender and receiver. Nurse Dan, a staff nurse in perform the changing of tracheostomy tube. He asked
the Medical-Surgical ward of Taginting Medical Center, should Nurse Kenny to prepare for the appropriate equipment and
be abreast with common therapeutic communication techniques supplies needed for the procedure. Nurse Kenny is aware
if he wants to have an effective and achievable nursing care. that the CORRECT department to collaborate with is:
A. Emergency Department
76. Karylle, a patient with gastrointestinal problems explicitly B. Central Supply Unit
says, “I am not sure if I should undergo colonoscopy or not C. Anesthesia Department
as I am scared.” To give a proper response, which of the D. Operating Room Department

Prepared by:
Raymund Kernell Mañago Shee Ann Pagasian Adolf Yasa
Angelo Jose Molina Audrey Ayuste Darlene Joy Aquino
James Fabian Miyu Krista Miura
7 | Page
 83. Nurse Kenny informed his head nurse, Jane, that he still
does not have the skill and experience to perform this
procedure. To assure that Nurse Kenny learns the proper
way of caring for patients with tracheostomy tube, Head
Nurse Jane knows to collaborate with who among the
following personnel?
A. Asst. Chief Nurse for Clinical
B. Chief of Unit
C. Asst. Chief Nurse to Education & Training
D. Chief of Clinics
84. Dr. Dizon ordered a change of the tracheostomy tube ties for
Patient Sheena. Among the following, which should Dr. Dizon
collaborate with in performing this task?
A. Medical Intern
B. Medical Resident
C. Nursing Aide
D. Staff Nurse
85. Dr. Dizon is going to perform suctioning on patient Sheena
using a single-used catheter for tracheostomy. To perform the
skill of suctioning using a single-used catheter for
tracheostomy safely, he needs how many assistants?
A. Four
B. Two
C. Three
D. One
Situation: Madellaine, a multipara patient is admitted at
Nicanor Buenavente General Hospital due to having labor pain
that started an hour ago. Upon performing the vaginal
examination, Nurse Patricia noted that the cervix is completely
dilated and 100% effaced. With this assessment, Patient
Madellaine is experiencing true labor pains.
86. During the shift, Nurse Patricia is keeping watch of Patient
Madellaine’s labor. She is aware that one of the problems that
can occur with labor is that the labor and delivery can be
completed in less than 3 hours. This is usually termed as
________ labor.
A. Precipitous
B. Preterm
C. Induced
D. Prolonged
87. Patient Madellaine is referred to the physician, Dr. Matthew.
Upon doctor’s recommendation, routine blood examinations
were taken. After reviewing the serum electrolyte levels, Dr.
Matthew ordered IV infusion of Isotonic fluid as prescribed.
With Nurse Patricia’s knowledge on IV fluids, which IV solution
should she prepare?
A. 5 percent dextrose in water
B. 0.45 percent sodium chloride solution
C. 10 percent dextrose in water
D. 3 percent sodium chloride solution
88. Patient Madellaine, having been in labor, would anticipate
some emotional support. To keep Patient Madellaine calm
during labor, Nurse Patricia should perform which of the
following nursing intervention?
A. Giving praise for her the sense of satisfaction
regarding quick labor.
B. Support in maintaining a sense of alcohol
C. Explanation of the effect of labor on the newborn.
D. Allowing the patient to express pain and anxiety.
Prepared by:
Raymund Kernell Mañago Shee Ann Pagasian
Angelo Jose Molina Audrey Ayuste
James Fabian Miyu Krista Miura
Situation: Jonah, a multiparous patient experiencing true labor
pains, is noted to have complete dilatation of the cervix and
effacement of 100 percent.
89. A nursing student asks the nurse why Patient Jonah’s labor
now is much shorter compared to her previous deliveries. Which
of the following is the BEST RESPONSE?
A. Onset of contraction was gradual.
B. Multigravida patient has shorter labor.
C. Cervical lengthening was longer.
D. Induction of labor was done.
90. Methylergonovine maleate (Methergin) is prescribed by the
physician and was administered intramuscularly after delivery.
What is the primary action of this medication?
A. Reduces the amount of lochia drainage.
B. Prevents postpartum hemorrhage
C. Decreases uterine contractions.
D. Maintains normal blood pressure.
Situation: A doctor ordered oxygenation of 4 liters per minute
for Joseph, a 10-year-old child with bronchitis.
91. What is the first standard step in oxygen therapy?
A. Prepare the patient for the oxygen treatment
B. Check the chart for ordered flow rate and oxygen
delivery method.
C. Gather all the equipment and supplies.
D. Assess patient's condition.
92. All of the following needs to be considered when
administering oxygen therapy, EXCEPT _____.
A. need for a humidifier.
B. length of tubing.
C. determine the age of Joseph.
D. manner of administering oxygen, continuous or
intermittent.
93. The nurse knows that the PRIORITY nursing action when
administering oxygen therapy is to ______.
A. attach the humidifier and connect tubing to the
oxygen delivery device.
B. connect the flow meter to the pipe in oxygen outlet
C. turn on the oxygen
D. check the flow.
94. Which precautionary measure done by the nurse is
PRIORITY during oxygen therapy?
A. Limit visitors.
B. Attach "No Smoking" signage
C. Check humidifier's water regularly
D. Connect belt to oxygen tank.
95. Joseph, while on continuous oxygen therapy, still complains
of having difficulty breathing. The nurse's INITIAL intervention
is to ______.
A. Give PRN medication.
B. Refer patient to the physician
C. Assess the patency of the tubing.
D. Re-assess the patient.
Situation: Due to an increasing number of errors in regard to
documentation and record management, Head nurse Levi is
conducting a lecture on proper nursing documentation and
management of records in her ward.
Adolf Yasa
Darlene Joy Aquino
8 | Page
96. Head nurse Levi asked the staff nurses about the purpose
of nursing process. The purpose of the nursing process is
to__________ ?
A. Reduce the number of forms of the chart
B. List the patients’ health problems.
C. Record the patient's progress.
D. Provide confidentiality of the chart.
97. When charting patient's progress accurately, which of the
following principles should be followed?
A. Statements are qualified by the use of "seems' and
"appears"
B. Assumptions and conclusions are reported
C. Specific and definite words or phrases are used.
D. General statements and measurement are used.
98. All of the following are characteristics of a chart, EXCEPT?
A. Complete
B. Subjective
C. Objective
D. Accurate
99. Kardex is used during nursing endorsements. Which of the
following is NOT true about Kardex?
A. kept up to date
B. a quick reference for current information about the
client.
C. consists of folded card for each patient.
D. part of the medical record.
100. When an error is made during charting, what should the
nurse do?
A. Recopy the sheet and destroy the original sheet
B. Use a single line to cross out the error, the write
the date, time and sign the correction made.
C. Use correction fluid to erase the error
D. Use eraser to remove the wrong entry

Prepared by:
Raymund Kernell Mañago Shee Ann Pagasian Adolf Yasa
Angelo Jose Molina Audrey Ayuste Darlene Joy Aquino
James Fabian Miyu Krista Miura
9 | Page