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CLOSED DOOR EXAMINATION

NURSING PRACTICE III
CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOLOGICAL ALTERATIONS
(PART A)
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 III” on the box provided
Situation: Nurse Eve is assigned in the morning shift of the Situation: Nurse Ricky, a nurse researcher, is studying one of
Post-Anesthesia Care Unit (PACU) and has a patient for the research priority problems in the cardiovascular unit which
admission. is the Effects of Personalized Care Management Strategies on
1. After abdominal surgery, Nurse Eve’s initial priority Stress after an acute myocardial infarction (MI).
assessment should focus on?
A. surgical site for drainage and hemorrhage 6. Nurse Ricky is planning to use a framework which states that
B. skin color and temperature humans are in constant relationship with stressors in the
C. responsiveness to painful stimuli and noise environment. In this framework, nursing is viewed as
D. respiratory function and airway interventions focused on helping the patient adjust to the
2. A patient is drowsy and still under the effect of anesthesia environment/stress. This framework is in which of the following?
post-operatively, in what position should Nurse Eve place the A. Parse' Human becoming theory
patient? B. Neuman's adaptation model
A Supine position with head bed slightly elevated. C. Peplau's psychodynamic theory
B. Prone position with a pillow under the abdomen D. Swanson's theory of caring
C. Semi-Fowler's position with the head turned to the 7. The research team decided to get their sample by choosing
right. every 5th patient who recently had MI, what sample method is
D. Left lateral position with a pillow supporting the used?
head.’ A. Simple random
3. A patient is reported to have bleeding from an arterial source B. Systematic
post-operatively, what color of blood should Nurse Eve expect? C. Stratified
A. Darkly -colored, blood flows fast. D. Cluster
B. Bright red and spurts with the heartbeat. 8. The questionnaires were given to the respondents of the
C. Slow, dark-colored, generally ooze. study without their names on it. Nurse Ricky is employing which
D.Pinkish colored- slowly flowing. ethical safeguard?
4. The PRIMARY goal of the health care team is to maintain A. Confidentiality
ventilation after surgery. Hypoxemia is the result of? B. Truthfulness
A. Excess carbon dioxide in the blood. C. Trustworthiness
B. Increasing ammonia in the blood. D. Anonymity
C. Decreased oxygen saturation 9. Nurse Ricky learned that the findings of their study is
D.Reduction of blood PH. applicable to all patients with MI under stress. What criteria of
5. A patient is undergoing blood transfusion after an abdominal research does it meet?
surgery and develops a temperature of 39.5C. Nurse Eve should A. Reliability
immediately refer the situation to the physician as this may B. Validity
indicate ____. C. Generalizability
A. abdominal tissue injury D. Transferability
B. ongoing potential infection 10. Nurse Ricky made a short but concise summary of their
C. post-anesthesia drug reaction whole research paper. This is known as the ____.
D. allergic reaction from blood transfusion A. narrative
B. abstract
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
 C. critical appraisal C. your physician will get mad, if you will not have your
D. monograph insulin injection.
Situation: One of the basic skills that should be acquired by D. let us sit down, I will explain to you, why you have
nurses is therapeutic communication. As nurses, we use this to to receive the insulin injection."
establish rapport and build a trusting/helping relationship with Situation: Diane, a 54-year-old accountant, is admitted to the
clients.2`12 General Ward. According to their family physician, she is
11. A 62-year old patient who has been in the hospital for a suspected to have Crohn’s disease.
week came up to the nurse and said "I wish that my children 16. Which of the following manifestations are expected of
will visit me today”. As a competent nurse, what would be your Crohn’s disease?
response? I. left lower quadrant abdominal pain
A. “do you have their cell phones, If you want I can II. diarrhea, unrelieved by defecation
call them" III. abdominal tenderness and spasm
B. “just relax, I am sure they will come and visit you IV. increase in weight
today" V. excessive fat in the feces
C. "you sound to be lonely, do you want me to be with A. II & III
you for a while". B. II, III & IV
D. there is so much traffic anyway it is not yet time for C. II, III & V
visiting hours" D. I & II
12. Nurse Lily has a patient who was just admitted for abdominal 17. In order to confirm the diagnosis, the nurse knows that the
pain. While the nurse is doing her assessment the patient tells examination conclusive of the presence of Crohn's disease is
"I am afraid to undergo the physical examination". Nurse Lily’s which of the following?
response is the most appropriate when she tells the patient A. Upper GI series
which of the following statement? B. Proctosigmoidoscopy
A. " I will inform the physician that you are afraid to C. Barium enema
undergo the physical examination" D. Abdominal radiography
B. "there are several patients waiting for me, the 18. One day, while at the hospital, Diane is experiencing fever,
examination has to be done now" loose bowel movement with foul smelling odor with abdominal
C. " I will call your relative to be with you, while you are pain. Considering these manifestations, the nurse should expect
being examined" what specific condition?
D. "the examination will not hurt, would you like to sit A. Hypercalcemia
down first and rest" B. Thrombocytopenia
13. What is the nurse’s best response when a student with C. Hyperbulemia
bronchial asthma, who has been going back and forth to the D. Hypokalemia
hospital, asks her, "Do you think I should stop attending my 19. Diane is going to undergo total parenteral nutrition (TPN) to
classes?” ? help with her body’s hydration and nutrition. The nurse should
A. "Well to me, that is a good decision for now, implement which of the following measures to achieve positive
especially with your asthma. patient outcomes?
B. "You said, you are thinking of stopping from I. Weighing the patient daily
attending your classes?” II. Measure intake and output
C. "Let us consult your physician, which one im better III. Provide relief of pain & discomforts
for you" IV. Monitor IV infusion rate daily
D. “Do you feel that is a good decision for you and A. I, II and III
your parents" B. I, II and IV
14. The nurse notices that the elderly patient who has been C. I, II, III, & IV
admitted a week ago looks depressed. While the nurse is taking D. II and III
the patient’s blood pressure, the patient suddenly says “Go 20. Considering the level of education of the patient, the nurse
away, leave me alone, I don't want to talk to you anymore”. The must include the following in her health teaching for home
nurse’s most therapeutic response is __. parenteral nutrition, EXCEPT?
A. "don't say that, otherwise I will not come and see A. Use of aseptic technique in changing the dressing.
you anymore” B. How to store and preparing the solution properly.
B. "I will be back in an hour, by that time, you might C. Setting up of the infusion pump safely.
want to talk to me" D. Flushing the parenteral nutrition line with
C. “If you need me, just inform your watcher for some antibiotics.
help.” Situation: Newly hired nurses in Pangasinan General Hospital
D. “don't say that, I will just attend to the other are being oriented with the legal responsibilities and
patients in the ward" accountabilities in their workplace.
15. A patient who is receiving his insulin injection tells the nurse, 21. Nurse Kyla, an ER nurse, is very busy in the morning which
“I don't want to have that insulin injection anymore." The most resulted to the administration of a penicillin injection to the
appropriate response of the nurse is _____. wrong patient. Keeping the error of nurse Kyla in mind, she can
A. you need the insulin injection, otherwise your be charged of ___.
diabetes will not be controlled. A. malpractice
B. just have your insulin injection now, I will refer you B. negligence
later to your attending physician.” C. assault
Prepared by:
Raymund Kernell Mañago Shee Ann Pagasian Adolf Yasa
Angelo Jose Molina Audrey Ayuste Darlene Joy Aquino
James Fabian Miyu Krista Miura
2 | Page
 D. battery
22. In order for nurses to perform a doctor’s order, nurses will
need to transcript the order. All of the following are considered
transcription errors, EXCEPT?
A. Illegible handwriting of the physician
B. Misinterpretation of the directions ordered
C. Use of unapproved abbreviation in the chart.
D. Wrong route of medication administration.
23. According to the 7 Rights of Drug Administration under the
category of "Right Drug", The label of the drug should be
read_______.
I. three (3) times.
II. before removing from the shelf.
III, before measuring actual dose
IV. before opening a unit dose-container
A. II and III
B. I and II
C. I, II and III
D. I, II, III and IV
24. The nurse is handling a restless patient admitted to the
medical ward and decided to put the patient into a body restraint
without the doctor’s order. Which of the following torts could
the nurse be liable for?
A. invasion of privacy
B. assault
C. battery
D. neglect
25. Due to a Jeepney strike, a lot of the nurses during the night
shift was absent. The nurse supervisor decides to allocate most
nurses to the PRIORITY wards to address this concern. What
type of ethical principle is the nurse supervisor using?
A. Beneficence
B. Non-maleficence
C. Justice
D. Fidelity
Situation: Ricky, a 50-year-old patient is having episode of
Bronchial asthma and was examined in the ER by the physician
and ordered to be admitted.
26. The watcher of Ricky observes that he is having difficulty
breathing. The watcher immediately called Nurse Berna. Upon
auscultation, Ricky’s breath sounds are diminished. The first
nursing action she should implement is?
A. Position him on bed in semi-fowler's position.
B. Administer oxygen therapy as order.
C. Instruct patient to nebulize self if available.
D. Administer bronchodilator as ordered.
27. Nurse Berna interviews Ricky for a comprehensive health
history. The nurse discovers that he worked in a cement factory.
Which occupational hazard can bring about an asthmatic trigger
to Ricky?
A. Contactant C. infiltrant
B. Inhalant D. ingestant
28. Theophylline was administered to the patient in order to
relieve the patient's asthmatic attack. Among the following
mechanisms of action of the drug (Theophylline), which is
INCORRECT?
A. Regulating the immune system of the body
B. Relaxing the smooth tissue of the bronchial
airways.
C. reducing inflammation of the airways of the lungs
D. relaxing the skeletal muscle of the bronchial
airways.
Prepared by:
Raymund Kernell Mañago Shee Ann Pagasian
Angelo Jose Molina Audrey Ayuste
James Fabian Miyu Krista Miura
29. The nurse should observe the patient taking Theophylline by
mouth for what adverse effect of the drug?
A. dry mucosal membrane
B. inability to sleep
C. irregular heartbeat
D. increased blood pressure
30. The patient is about to be discharged with bronchodilator
drugs. The nurse informs him that the bronchodilator drug is
considered effective if it lessens what symptom?
A. allergic reaction
B. breath sounds
C. body temperature
D. wheezing
Situation: Rica, a 66-year -old patient was admitted to the
medical ward due to chronic back pain, general weakness and
difficulty of breathing. One day, Nurse Susan observed the
patient being anxious and restless. He was tentatively diagnosed
with impending respiratory insufficiency secondary to hypoxia.
31. Nurse Susan is trying to correctly record restlessness caused
by pain and that of hypoxia. Nurse Susan knows that
restlessness caused by pain should be accurately recorded as
_________?
A. Difficulty of breathing.
B. Increased respiratory rate and blood pressure.
C. Increased heart rate
D. Increased perspiration and change of position.
32.Nurse Susan documented: "Refused to eat and fell from bed"
in the nurse’s notes. The statement is incomplete because it
lacks which of the following?
A. Time of complaint, foods missed and reaction on
fall incurred.
B. Referrals made on fall, medications given and
reasons of falling.
C. Contents of complaints, reasons of refusing meal
and nature of fall.
D. Time of eating, medications for back pain and
intense of pain.
33. The patient’s chart is sometimes used in court proceedings.
Which of the following entries recorded would be MOST
justifiable in court?
A. Large bruises on thigh upon assessment.
B. Patient fell out of bed when reaching out for
medication.
C. Burn on the back area observed upon auscultation.
D. Patient drunk when seen in the emergency room.
34. Which of the following charting rules are considered to make
documentation legally safe? Select all that apply.
I. Documenting worries and all concerns as verbalized by
the patient.
II. Charting at the end of the shift only.
III. Discussing recorded cases and diagnosis of the patient.
IV. Recording all information verbalized by patient and
family
A. III, IV
B. I, III
C. I
D.II
35. Patient Rica was reading his own chart and she asks the
nurse why “(-) smoking and (-) liquor” were recorded when she
does not smoke or drink alcohol. The nurse knows that the
MOST accurate response is?
A. Get the chart from him and reprimand him from
reading the chart
Adolf Yasa
Darlene Joy Aquino
3 | Page
 B. The sign of negative before the word means he is
not drinking alcohol or smoking cigarette.
C. Ask patient Miko to apologize for reading the chart.
D. Tell Noel that alcohol and liquor are important
factors in diagnosing his ailment
Situation: Ethical dilemma is becoming a common scenario in
the health care delivery system brought about by the advanced
technological changes in health care.
36. A competent nurse knows that which of the following
situations is considered to be an ethical dilemma?
A. A nurse providing demonstration of the possible
risk if a chest tube drainage of a patient is pulled out.
B. Family members having ambivalent feelings
whether their father will undergo amputation of a
diabetic leg.
C. A nurse is overheard by the daughter that if her
mother will not take her insulin injection she will not
serve her food tray.
D. The physician signs the medical directives of
terminally-ill patient admitted in the hospital with his
spouse.
37. The physician suggested that a pacemaker be inserted to
correct the symptoms of a 78-year-old patient with bradycardia
and palpitation, but the patient voluntarily decided not to have
it inserted. The family respects the decision of the patient.
Which ethical principle is being applied?
A. Beneficence
B. Autonomy
C. Fidelity
D. Justice
38. A physician ordered pain medication for a pediatric patient.
The nurse clarifies the prescription of the physician. The ethical
principle being observed by the nurse is _______?
A. Fidelity
B. Truthfulness
C. Justice
D. Non-maleficence
39. Which ethical principle is being used when a nurse promises
a post- surgical patient that he would come back to assist in the
patient’s ambulation after carrying out a physician's order?
A. Beneficence
B. Justice
C. Autonomy
D. Fidelity
40. Which ethical principle is being observed by a nurse who
aids for the patient’s welfare in relation to health, safety and
personal rights?
A. Responsibility
B. Accountability
C. Confidentiality
D. Advocacy
Situation: In the Philippines, endocrine disorders are of high
prevalence. Cynthia is a 48-year-old patient who was diagnosed
with Graves’ disease. Based on her health history she has been
having insomnia, palpitation and heat intolerance.
41. Which of the following manifestations is a classic finding
expected of Cynthia’s diagnosis?
A. Decreased libido
B. Exophthalmos
C. Infertility
D. Hoarseness of the voice
Prepared by:
Raymund Kernell Mañago Shee Ann Pagasian
Angelo Jose Molina Audrey Ayuste
James Fabian Miyu Krista Miura
42. Which of the following laboratory findings will confirm
Cynthia’s diagnosis?
I. Decreased TSH levels
II. Elevated free thyroxin levels
III. Increased TSH levels
IV. Decreased free thyroxin levels
A. II and IV
B. III and IV
C. I and II
D. II and III
43. One of the managements for Graves’ disease is through
medication. In order to inhibit the synthesis of thyroid hormones
and block the conversion of T3 and T4, which of the following
drugs should be given?
A. adrenergic blockers (Inderal)
B. radioactive iodine (RAI)
C. sevothyroxine (Synthroid)
D. propyl thiouracil (Propyl Thyracil)
44. The nurse is teaching Cynthia about hyperthyroidism and
her nutritional needs that require attention. The nurse knows
that the diet MOST appropriate for Cynthia is?
A. high fibrous, low protein, high CHO
B. high caloric, high CHO and high protein
C. high caloric, high CHO and low protein
D. high protein, low Vitamin A and C
45. Numbness of the fingers, toes and twitching of the mouth
is felt by Cynthia 7 hours after her thyroid is removed. This
manifestations are MOST probably caused by?
A. thyrotoxic crisis
B. hypoparathyroidism
C. hypo thyroidism
D. infection
Situation- Ely was rushed in the emergency room appearing
with jaundice, dyspnea and an enlarged abdomen. The
physician suspects that he has a liver disorder and beginning
esophageal varices. Based on history acquired, Ely was a smoker
and alcoholic.
46. All of the following signs/symptoms indicates a hepatic
disorder, EXCEPT?
A. Indigestion
B. Diarrhea
C. Nausea and vomiting
D. Abdominal bloating
47. The physician ordered a liver function test for Ely. Which of
the following is/are the expected results for a patient with
damaged liver?
I. Prothrombin time is prolonged.
II. Albumin level is increased.
III. Globulin level is decreased.
IV. Ammonia level is decreased.
A. I and II
B. I, II and III
C. I only
D. I, II, II and IV
48. Ely has developed esophageal varices and it began bleeding,
the doctor immediately ordered Sengstaken-Blakemore tube to
stop bleeding. After a few hours, the patient is observed to have
difficulty breathing. What is the priority action of the nurse?
A. Monitor vital signs
B. Asked client to take a deep breath
C. Deflate the esophageal balloon
D. Call the physician at once
Adolf Yasa
Darlene Joy Aquino
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49. A competent nurse knows which intervention to anticipate
when a patient develops esophageal varices?
A. Monitoring progression of anxiety
B. Observing signs of epistaxis
C. Monitoring urine output
D. Preparing client for blood transfusion
50. The nurse anticipates which of the following drugs to be
ordered by the physician to help stop the bleeding caused by
esophageal varices?
A. Neperidine C. Aldactone
B. Furosemide D. Vasopresisn
Situation: Patient Bennett is in the Intensive Care unit after
incurring a severe head injury and is under the care of nurse
Barbara. Upon assessment, nurse Barbara suspects that patient
Bennett may have a basilar fracture and prepares for the
patient’s ordered NGT insertion. She recalls the principles
related to NGT insertion.
51. Patient Bennett’s basilar fracture would present with what is
known as Battle’s sign. Nurse Barbara would be correct if she
notes this as?
A. Blood leaks from the patient’s nose
B. Bruising in the periorbital region
C. Swelling in the periorbital region
D. The area behind the ear is bruised
52. Fischl, patient Bennett’s guardian, asks nurse Barbara about
the purpose of inserting a nasogastric tube. Nurse Barbara
would be correct if she states that the primary purpose of a
nasogastric tube is?
A. Administration of medication
B. Decompression of the stomach
C. Collection of gastric specimen for further testing
D. Administration of nutritional requirements
53. Which of the following actions is the most appropriate for
Nurse Barbara to perform for the patient?
A. Place the patient in semi-Fowler’s position with a
pillow for head support
B. Assess the patency of the patient’s airway before
inserting the nasogastric tube
C. Check the gastric aspirate for blood
D. Advance the tube with its natural curve upward the
nostril of the patient
54. Nurse Barbara further establishes her knowledge regarding
NGT insertion when she considers which of the following actions
as most appropriate?
A. Ask the physician for the use of an oral gastric tube
instead
B. Advance the NGT to reach the duodenum
C. Check the gastric aspirate for blood
D. Ensure extra lubrication upon the insertion of the
nasogastric tube
55. As nurse Barbara carefully proceeds with each step of NGT
insertion, she knows that which of the following actions is not a
part of the procedure? Select all that apply.
I. Identify the patient through his name and birthday
II. Measure the tube length to be inserted and mark the
location
III. Elevate the patient’s head to 45 degrees
IV. Instruct the patient to breathe and swallow
throughout the procedure
V. Assess the amount of gastric residual during tube
feeding
A. II, III, V
Prepared by:
Raymund Kernell Mañago Shee Ann Pagasian
Angelo Jose Molina Audrey Ayuste
James Fabian Miyu Krista Miura
B. II, IV
C. III, V
D. III only
56. In what position should nurse Barbara place the patient
upon insertion of the NGT?
A. Low-Fowler’s C. Fowler’s
B. Semi-Fowler’s D. High-Fowler’s
57. Resistance is met as the nasogastric tube is being inserted
into the patient. Which of the following actions would be most
appropriate for the nurse to do?
A. Pull the tube slightly then carefully advance the tube
forward
B. Advance the tube more slowly and as much as the
client can tolerate
C. Withdraw, relubricate, and reinsert the NGT in
another nostril
D. Withdraw the tube and repeat insertion when no
resistance is met
58. The patient coughs and presents difficulty of breathing as
the nasogastric tube is being inserted. Which of the following is
the best nursing action?
A. Withdraw the tube completely and reinserting it
when difficulty of breathing has subsided
B. Advance the tube more slowly and as much as the
client can tolerate since this is normal
C. Stop advancing the tube for a few seconds then
continue as tolerated
D. Pull the tube slightly then carefully advance forward
59. Nurse Barbara knows that she can confirm a correct
placement of a nasogastric tube by checking the gastric aspirate
of its pH. What pH value should nurse Barbara obtain?
A. pH 6.7 C. pH 8.7
B. pH 5.7 D. pH 7.7
60. Before removing a nasogastric tube, which of the following
actions would be the priority?
A. Push 50mL of air into the tube
B. Slowly and carefully withdraw the tube
C. Ask the client to take a deep breath and hold it
D. Disconnect the nasogastric tube from the suction
apparatus
Situation: Nurse Jean comes into a patient’s room where she
finds the latter lying on the floor next to the bed. Nurse Jean
brought the client back to bed, assessed for any injuries, and
notified the physician.
61. Nurse Jean who found the client lying on the floor knows
that she should:
A. Be suspended due to the incident
B. Report the incident to the nursing board
C. Record the incident in her employee file
D. Write an incident report
62. Nurse Jean knows that which of the following is the primary
purpose of submitting an incident report?
A. Provide clients the treatment they need to stabilize
their condition
B. Measure the effectiveness of interventions relating
to outcomes
C. Immediate documentation of the incident
D. It is the correct method of reporting to local,
regional, and national units
63. Which of the following is an important principle when filing
an incident report?
A. It is not included in the patient’s chart
Adolf Yasa
Darlene Joy Aquino
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 B. Record in the client’s chart that an incident report 73. As the nurse reviews the progress notes, she notices that
was accomplished there is an unintentionally left blank space. The nurse should do
C. Create a copy of the incident report for the the following except?
healthcare provider A. Place a signature at the end
D. Place the incident report with the client’s medical B. Draw a horizontal line through the space
chart C. Input the nurse’s credentials in the last part
64. The following are not appropriate for nurse Jean to include D. Allow the space to be filled in later
in the incident report except? 74. A charting method consisting of written notes stating the
A. A suspicion of what might have caused the incident routine care, findings and problems found in a client is known
B. How the nurse saw the client and what she did for as narrative charting and is a traditional part of which
the client documentation system?
C. The statement of the client about the incident A. PIE charting that includes progress notes and flow
D. The extenuating circumstances involved in the sheets
situation. B. Focus charting that utilizes the FDAR
65. All of the following are to be included in the incident report C. Source-oriented record where information about a
except? particular problem is distributed throughout the
A. All witnesses to the incident record
B. The time, date, and place of incident D. Problem-oriented record that consists of a list of
C. The client’s own account of the incident problems, a care plan, progress notes, and a
D. Daily medications of the client database
66. The incident report must be completed within what time 75. A documentation system that documents only abnormal or
frame? significant findings related to the patient is known as Charting
A. 24 hours C. 1 week By Exception (CBE). It has three main elements which include
B. 72 hours D. 2 weeks the following except?
67. What should Nurse Jean do next when she has accomplished A. Standards of nursing care
the incident report? B. Nurse’s station access to chart forms
A. Secure the incident report with the client’s chart C. Bedside access to chart forms
B. Inform the family about the incident D. Flow sheets
C. Avoid mentioning the incident in the chart Situation: Student Nurse Eula is dedicating all of her time into
documentation studying in the library for the Philippine Nursing Licensure
D. Submit the incident report to the head nurse Examination. Her study buddy, Amber, asks Eula a few
68. Head nurse Lisa receives the incident report from nurse questions related to Maternal and Child nursing as this Amber’s
Jean. Where should head nurse Lisa to store the incident report? weakest nursing subject. The following are the questions Amber
A. Physician’s record asked to Eula:
B. Secured cabinet 76. What is the site of fertilization or conception?
C. Nurse’s notes A. Ampulla C. Cervix
D. Patient’s medical record B. Uterus D. Isthmus
69. What will prove that Nurse Jean’s interventions have been 77. What is the site of implantation?
carried out? A. Ampulla C. Cervix
A. Determining the nurse’s need for assistance B. Uterus D. Isthmus
B. Supervision over delegated or assigned care 78. Amber can’t remember what to call the lowest point of the
C. Implementation of the nursing interventions pelvis and the site that is being assess during a culdoscopy. Eula
D. Documentation of the procedures is correct if she calls this the:
70. When obtaining factual information, which of the following A. Cervix
will be the best source for the healthcare team? B. Isthmus
A. The patient’s chart C. Pouch of Douglas
B. The nurse’s notes D. Ampulla
C. The physician’s records 79. What is the site of tubal ligation or female sterilization?
D. The nurse’s incident report A. Ampulla
71. The following chart recordings violate the legal guidelines of B. Pouch of Douglas
proper documentation except? C. Cervix
A. Patient had a good day and moved around the room D. Isthmus
B. Patient’s condition unchanged 80. What is the site for Pap Smears and Spinnbarkeit sampling?
C. The attending physician made an error A. Ampulla
D. Dr. Kaeya was called to clarify the order for B. Pouch of Douglas
antibiotics C. Cervix
72. A nurse makes an error while doing her documentation. D. Isthmus
Which of the following should the nurse not do? 81. Nurse Sage palpates patient Jett’s edematous limbs and
A. Obtain a new nurse’s notes and rewrite the entries finds that upon palpation, a pit 6mm deep appears and
B. Write the word “error” above the error disappears after a while. Nurse Sage knows that this pitting
C. Draw a single line through the error edema is under what grading?
D. Sign your name or initials and date of the error A. 1+ C. 3+
B. 2+ D. 4+
Prepared by:
Raymund Kernell Mañago Shee Ann Pagasian Adolf Yasa
Angelo Jose Molina Audrey Ayuste Darlene Joy Aquino
James Fabian Miyu Krista Miura
6 | Page
82. After an hour, nurse Sage conducts another assessment. 90. On her first day, she cares for baby Kazuha who is 3-month-
She palpated the edematous limbs and found moderate old infant. Nurse Ayaka is correct if she knows baby Kazuha can
indentation of the edema. Nurse Sage would interpret this is as start eating solid foods at what month?
what grading? A. 6 months C. 8 months
A. 1+ C. 3+ B. 7 months D. 9 months
B. 2+ D. 4+ 91. Among the following table foods, nurse Ayaka would be
83. Being a prudent nurse, nurse Sage knows that the cause correct if she selects which food to introduce last?
and nature of edema is related to what mechanism? A. Scrambled eggs
A. There is an increase in kidney tubular reabsorption B. Whole-grain bread
B. There is an increase in glomerular filtration rate C. Steamed vegetables
C. There is a decrease in glomerular membrane D. Cereals
permeability 92. Nurse Ayaka recalls that toddlers have a tendency to only
D. There will only be edema in the ankle want the same foods prepared in the same way for every meal
84. Client Jett’s ankle clonus has been observed to have 3 of the day but forgot what it was called. Her colleague, nurse
involuntary movements which would be interpreted as? Ayato, states that this is:
A. None C. Moderate A. Pica C. Food selectiveness
B. Mild D. Severe B. Picky eating D. Food jag
85. Client Jett’s patellar reflex has been brisker than usual. Situation: Patient Peppa, an obese adolescent with type 1
Nurse Sage would be correct to grade this as? diabetes mellitus, goes to the clinic and is assessed by nurse
C. 1+ C. 3+ George.
D. 2+ D. 4+ 93. Nurse George asks patient Peppa what she does in the
Situation: Student Nurse Sana has been reviewing Nursing administration of her insulin. Nurse George should correct her if
Research in preparation for the NLE as this was the subject she she states that she:
almost failed in college. Today, she tries to differentiate A. Injects the prepared insulin 5-15 minutes after
deductive and inductive research. preparation
B. Does not aspirate after inserting the needle to
86. Student Nurse Sana knows that the focus of inductive herself
research is the following except? C. Administer some her of insulin intravenously
A. Interacting with the participants that results in D. Shakes the bottle of insulin
findings 94. As a result of her high total triglyceride, cholesterol, and LDL
B. Knowing that reality is multiple and subjective levels, a low-fat diet was prescribed for patient Peppa which
C. Building predictions for testing unfortunately proved ineffective. Her physician then prescribed
D. Testing predictions that were already built a cholesterol-reducing agent. Nurse George knows that if this
87. Student Nurse Sana also knows that the focus of deductive medication therapy proves ineffective as well, patient Peppa will
research is following except? then be prescribed with what drug?
A. Building predictions for testing A. Atorvastatin (Lipitor)
B. Being independent from the participants B. Bempedoic acid (Nexletol)
C. A real world exists that is driven by real natural C. Cholestyramine (Questran)
causes D. Icosapent ethyl (Vascepa)
D. Testing predictions that were already built Situation: Future nurse Dahyun is currently reviewing maternal
Situation: Patient Lyney comes into the clinic and states that and child nursing and tries to recall the different placental
he was diagnosed with a complicated UTI. Nurse Lynette functions to the fetus.
assesses patient Lyney’s condition. 95. Future Nurse Dahyun knows that the placenta is responsible
for the “respiration” of the developing fetus by transferring
88. Patient Lyney asks about the difference between a oxygen and carbon dioxide to their respective places. She would
complicated and an uncomplicated UTI. Nurse Lynette would be also be correct if she states that these gases readily cross the
correct if she states that an uncomplicated UTI: placenta by?
A. Affects only the ureters A. Active transport
B. Is associated with an underlying disease B. Pinocytosis
C. Occurs in a normal urinary tract C. Simple diffusion
D. Occurs in a urinary tract with structural or D. Passive diffusion
functional problems 96. Future Nurse Dahyun also knows that maternal IgG
89. Nurse Lynette asks the patient about the medications he antibodies can cross placentally despite the fact that most
uses for his condition. She would be correct to expect which proteins are too large to do this. She is correct if she states that
medication for complicated UTI? these antibodies provide passive immunity and pass through the
A. Amoxicillin placenta by:
B. Ampicillin A. Active transport
C. Ciprofloxacin B. Pinocytosis
D. Trimethoprim/Sulfamethoxazole C. Simple diffusion
Situation: During her rotation in the pediatric ward, nurse D. Passive diffusion
Ayaka is expected to be well-versed with the care and nutrition 97. Nurse Rosaria knows that post-partum hemorrhage often
of pediatric clients. leads to hypovolemia and would present with early signs and
symptoms such as?
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
 A. Dizziness and lethargy
B. Rapid weak pulses and falling blood pressure
C. Pale mucous membranes
D. Decreasing level of consciousness
98. One of nurse Rosaria’s patient was worried and asked nurse
Rosaria if she was at risk for post-partum hemorrhage. Nurse
Rosaria would be correct if she does not include which of the
following as a risk factor?
A. Anteverted uterus
B. Retained tissue
C. Uterine atony
D. Trauma
99. Another patient of nurse Rosaria is one day post-partum and
is having her uterus palpated. Nurse Rosaria is correct if she
knows that at this time, the uterus is normally be located at:
A. At the level of the umbilicus
B. 1 cm below the umbilicus
C. 1 inch below the umbilis
D. Midway of the umbilicus and symphysis pubis
100. As nurse Rosaria is making rounds, one of her patients talks
to her about post-partum discharges the patient has been
having. All of the following statements requires no correction
except?
A. This lochia is quite annoying to manage, but I know
why it occurs
B. I should alert the nurse when there are color
changes in my lochia
C. I use tampons to makes it easier to manage my
lochia just like my period
D. If I change perineal pads, I make sure to wash my
hands before handling the baby

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