PHILIPPINE NURSING LICENSURE

EXAMINATION (PNLE)

REVIEWER
COMPILATION OF BOARD EXAM
NOVEMBER 21 & 22, 2021

SUBJECTS COVERED

NURSING PRACTICE I: Community Health Nursing

NURSING PRACTICE II: Care of Healthy/At Risk Mother and Child

NURSING PRACTICE III: Care of Clients with Physiologic and Psychosocial Alterations, Part A

NURSING PRACTICE IV: Care of Clients with Physiologic and Psychosocial Alterations, Part B

NURSING PRACTICE V: Care of Clients with Physiologic and Psychosocial Alterations, Part C

COMPILED BY: AMBAGAN

NURSING PRACTICE I: Community Health Nursing

Situation – Nurse Nona is a newly hired community Health Nurse. At the start of her
duty, she takes into consideration that she should assume numerous roles and
functions that are primarily focused on promoting a healthy community.

1. In order for Nurse Nona to become effective in her caregiving role to the different
type of clientele in the community, she should be equipped with the basic
knowledge about _______.
a. Statistics
b. Research
c. Nursing process
d. Nursing theories
In dealing with different type of clientelle, it is important to have basic knowledge
about the nursing process as it would guide the nurse into individualized care for
each family. *Im also torn between theories because it could set foundation on
care theories and transcultural theories.

2. As planner and programmer in the community setting, Nurse Nona should

understand that the PRIMARY objective of community Health Nursing is
focused on the importance of _______.
a. Curative aspect of care
b. Restoration of full function
c. Rehabilitative part of care
d. Optimum health and wellness

3. The BEST community Health Nursing principle that will guide Nurse Nona in
the effective performance of her various roles and function is focused on the
community that _____.
a. Has different health needs and problems
b. Is considered as a primary client
c. Has various structures and resources
d. Is composed of individudals and families
In CHN, the community is the primary client. Different health needs and problems does
not signify sense of community. Although it is composed of various structures and
resources, community as a primary client encompasses that. Individuals and families,
thought are basic units in the community is not the primary client

4. As health monitor, which of the following should be considered by the Nurse as

HEALTH THREATS in the community?

1. Ineffective breastfeeding x
2. Fire hazards /
3. Inadequate immunization /
4. Polluted water supply /
 a. 3,4
b. 2,3,4
c. 1,2,3,4
d. 1,2
Ineffective breastfeeding is a wellness condition
***you may consider letter C as the answer. INEFFECTIVE BF could be a health
threat as it may result in inadequate intake of breastmilk for the baby, which may
lead to poor weight gain, problems with immunity, etc. Aside from those, it may also
ineffective bf could also increase the risk for postpartum breast problems for the
mother.)
5. Which is the INITIAL task of Nurse Nona as a community organizer?
a. Formulates individuals, family groups and community care plan
b. Motivates and enhances community participation
c. Prepares and submits required reports on time
d. Coordinates with individuals, families, groups for health services
As community organizer, you facilitate community diagnosis and implementation by
motivating members of the community to participate in their own health needs

Situation – Nurse Bella takes charge of handling the Mental Health Promotion program
in the midst of the ongoing health crisis due to the COVID 19 PANDEMIC.

6. Teaching the families on promoting mental health at home in this pandemic time
should focus on the following EXCEPT:
a. Seeking community support
b. Observing open communication
c. Engaging social media the whole day
d. Reaching out to friends
Refer to Atty Rafa
7. During this pandemic time, which of the following roles of Nurse Bella should she
significantly intensify to prevent more cases of mental problems in the
community?
a. Case finder
b. Case manager
c. Researcher
d. Surveyor
Refer to Atty Rafa
8. There are individudals who are suffering from mental health challenges due to
the pandemic. The BEST nursing action is _____.
a. Refer for admission at the mental health unit
b. Help in setting up debriefing stations
c. Recommend hiring of a community psychiatrist
d. Set up a mental health program

9. Which of the following information about severity of mental illness would be

important to the mental health program in the community setting?
a. Mentally-ill patients are always dangerous
 b. Mental illness is hereditary
c. Mental illness is not curable
d. Mental illness is a global concern
The rest are stigma against mental health and must not be disseminated
10. After a webinar on the Mental Health Act, Nurse Bella realized that the
community has to change which of the following perceptions?
a. Mental illness is not hereditary
b. Community resilience is important
c. Mental illness is incurable
d. Psychosocial services should be available
Mental illness can in fact be hereditary. Some mental illnesses like ADHD and autism
may run in families. It is an interplay between the genetic predisposition and the
environment at which the client lives in.
https://www.nih.gov/news-events/nih-research-matters/common-genetic-factors-found-5
-mental-disorders
Situation - Nurse Rona recognizes the importance of the application of Epidemiology in
community health setting.

11. In priority in managing community health needs is through knowing in depth the
PREVALENCE of diseases because it indicates the _____.
a. Risks to health problems
b. Presence of health problems
c. Priority needs of the people
d. Magnitude of health problems
Magnitude of the problem refers to the number of people affected by the health
problem, case in point, the Prevalence.
12. Nurse Rona and her team has been utilizing the “EPIDEMIOLOGIC TRIAD”
model of identifying causative factors of diseases. Which of the following is not
relevant to this model? (-)
a. External agent
b. Susceptible host
c. Treatment regimen
d. Environment

e.

13. There is an outbreak of measles in some areas of the community where

investigation should Nurse Rona and her team begin?
 a. Identify and count cases 3
b. Verify diagnosis 4
c. Define and identify diagnosis 1
d. Prepare for field work 2
PIDSR Manual of Procedures: 8.4.1 Investigation (Page 82)
1. Define Cases
2. Identify all cases and contacts
3. Describe the case
4. Describe severity
5. Confirm diagnosis
6. Identify possible source of epid
7. Identify possible cause
***Based on the PHN in PH book (page 72) and on the CDC website, the first step in
conducting an OUTBREAK INVESTIGATION is to (d) Prepare for fieldwork.
Steps in Outbreak Investigation (PHN in PH, p72)
Step 1 -Prepare for field work
Step 2 -Establish the existence of an outbreak
Step 3 -Verify Diagnosis
Step 4 -Define and Identify cases
A. Establish a case definition
B. Identify and count cases
Step 5 -Perform descriptive epidemiology
Step 6 -Developing Hypotheses
Step 7 -Evaluate hypotheses
Step 8 -Refine hypotheses and execute additional studies
Step 9 -Implement control and prevention measures
Step 10 - Communicate findings
Step 11 - Follow-up Recommendations
Conducting a Field Investigation →
cdc.gov/eis/field-epi-manual/chapters/Field-Investigation.html
14. Nurse Rona is able to know the patterns of occurrence and distribution of
diseases in the community. Per record she found out there had been cases of
rabies at irregular intervals scattered in particular places. This occurrence
refers to _____.
a. Endemic
b. Epidemic
c. Pandemic
d. Sporadic

15. As an epidemiology nurse, Nurse Rona’s PRIMARY function and responsibility is

to _____.
a. Assist the epidemiologist in making reports
b. Implement public health surveillance
c. Render nursing care to sick residents
d. Follow up cases and contacts
Situation – Nurse Danica is assigned to the Health Education initiative of the health
center.

16. Nurse Danica would like to put more emphasis on healthy lifestyle in
her health education classes. Which step in the teaching-learning process should she
FIRST start?
a. Assessing health needs
b. Evaluation of learning takes place
c. Preparing learning materials
d. Developing health education plan

17. In planning for the health education program about healthy lifestyle
Nurse Danica targets to work with parents in the community. Noting different ethnics
backgrounds among them, which important consideration should be part of the plan?
a. Economic
b. Social
c. Cultural
d. Educational

18. Based on the Theory of Adult Learning by KNOWLE’S, which of the following
principles will guide the Nurse to be an effective educator?
a. Educational attainment
b. School where the participants graduated
c. Age and gender of learners
d. Environment and learner’s participation
Knowles four principles of andragony
● Adults want to participate in both the planning and evaluation attached to their
instruction.
● Experiences, both good and bad, serve as the backdrop for all learning activities.
● Adults first gravitate towards learning things that are directly relevant to their job
or personal life.
● Adult learning centers on problems, not subjects.

19. Nurse Danica plans to have the residents of the community conduct
brainstorming about their community problems. Which of the following is the
rationale of this teaching format?
a. Encourages problem solving and critical thinking skills
b. Links audience participation to the presenter’s speaking style and content
c. Allows the participants to generate ideas and discuss them in group setting
d. Offers shared experiences in a familiar setting
Adult learning is focused on problem solving rather than concept building.
20. Successful teaching and learning activities in any health care setting is
PRIMARILY fostered through _____.
a. Identifying motivating factors
 b. Using clear and concise language
c. Establishing trust and rapport
d. Setting realistic goals and objectives

Situation – Nurse Keena is alarmed with the rising number of re-emerging cases of
pulmonary tuberculosis (PTB) in the Philippines.

21. Case finding for PTB in the community requires that the nurse should identify
persons having sputum characterized as _______.
A. rusty, frothy
B. yellowish
C. Blood stained
D. Greenish

22. In the care of patients with communication diseases, Nurse Keena should know that
the feces, urine, blood and other body fluids are considered as
A. Portal of entry
B. Vehicles of transmission
C. Reservoir of agent
D. Portal of exit

23. With the onset of the rainy season, the nurses are closely monitoring the increase of
dengue cases. They should focus their health teaching on ways to prevent dengue by
_____.
A. destroying breeding places of the vector
B. using repellant lotion
C. burning of dried leaves
D. wearing of protective clothing

24. Outbreak of cases of typhoid fever occurs in the community. Nurse Keena should
inform the residents that the transmission of the disease is through ______:
A. a vector
B. food and water
C. Blood and body fluids
D. Air

25. There are several cases of Rabbies in the community. Which of the following
preventive measure should Nurse Keena teach the families?
A. Impound all dogs
B. Impose “No pets allowed” rule
C. Have the dogs vaccinated
D. Report to the authorities households 6with dog/s

Situation – As community health nurse it is expected that she is competent in

performing core competency standards on Record Management.
26. Nurse Ana is aware that the domain of record management entails which of the
following except:
A. Write in the Kardex what was to be endorsed
B. Keep human resources update at all times
C. Report to MD orally wrong use of drug
D. Ensure entries in patient record is signed

27. Improvement of Nursing service as well as patient satisfaction is also a concern of

the nurse manager. Which of the following strategies can be adopted to achieve this
goal
A. Hold regular meeting with staff
B. Make chart audit
C. Plan suggestion box
D. Conduct regular rounds of patients

28. A physician in the health facility has forgotten to change antibiotics of the patient
and make phone call order to Nurse ANA. What should be the APPROPRIATE action of
the nurse in this situation?
A. Ensure that the order will besigned by the physician as soon as heis nach to
the facility.
B. Have any physician in the facilyt sign the order
C. Carry all phone orders and bring chart to the doctor for signing
D. Call back MD to give feedback

29. If the CHN has written in the treatment record : BP 160/96, Ace inhibitor with
Diazide admistered, BP decrease at 140/88 and urine output 1200 cc for whole shift.
What type of charting is this?
A. PIE
B. AIRA
C. SOAP
D. DAR
DataL BP 160/96 Action- ACE inhibitor administered Response- BP decrease @ 140/88
and 1200cc for whole shift

30. Which of the following is PRIMARY purpose of accurate, updated and reliable
document?

A. Use from the shift report of nurse and doctor

B. Protect nurse from doctors’ reprimand
C. Serve as evidence of legal matters
D. Audit frequency of medication utilization
31. Which of the following is the rationale why team work is ESSENTIAL in health
care

A. Helping one another

B. Makes work lighter

C. Patient safety

D. Promotes camaraderie

32. What are the MAIN component of collaboration?

A. Shared vision
B. Achievement of goals
C. Working together
D. Partnership

33. Nurse Roy as member of the health team describes himself as good team player,
Which of the following is the BEST characteristics of good team player?

1. Sence of humor
2. Good listener
3. Inspires others
4. Proactive thinking
A. 1,2,3,4
B. 1,2,3
C. 1,2
D. 3,4

34. Which of the following is an ESSENTIAL element of effective collaboation?

A. Communication
B. Belong to one team
C. Networking
D. Delegation

35. Nurse Roy in his dealings with his co-workers instills collaborative partnership in
doing their task which is the aim of this type of partnership?

A. Make work faster and easier

B. Shared goals
C. Change and influence group behavior
D. Staffs’ satisfaction

Situation – Nurse Nancy is in charge of the Geriatric Care program of the barangay.
36. To plan out for the activities intended for the elderly population the nurse should
begin to______

A. do survey of the number of the elderly population

B. get informed consent
C. ask permission from barangay officials
D. tap the help of expert
Show respect to barangay officials by performing courtesy call. They have the legitimate
authority in the barangay.

37. In assessing the health condition of the older persons, which is the BEST measure
in determining their functional status?

A. Financial capability of the family

B. Age of the patient
C. Activities of daily living
D. Educational attainment

38. Which information should the nurse provide to the elderly and their families
regarding drug regimen presribed to patient?

A. Liquid medication is more convenient and safer

B. Allow them to refuse to take medicines
C. Give independence to take medicines
D. They are more vulnerable to adverse drug reaction
It must be noted that elderly are more vulnerable to adverse drug reactions due to
changes in body composition (less water), and dec in kidney and liver function which
decrease elimination of drugs, thereby having more drugs in the body.

39. Care giving to older persons can be burdensome to other members of family
who are the caregivers. During home visit to the family, the nurse should look for
symptoms of ____.
A. Agitation
B. Burnout
C. Withdrawal
D. Suicidal tendency
Long-term caregiver role strain can lead to caregiver stress and eventually cause
caregiver burnout

40. For an effective program for the elderly population, which should be the appropriate
Approach?

A. Assign to the family

B. Supervised by physician
C. Multidisciplinary
D. Under the care of barangay health workers
SITUATION – NURSE ZOE AS A PUBLIC HEALTH NURSE TOGETHER WITH
OTHER MEMBERS OF THE HEALTH TEAM ENSURE THERE IS QUALITY IN
HEALTH AND NURSING CARE, IN THEIR WORK PLACE.

41. WHICH OF THE FOLLOWING IS AN IMPORTANT TOOL OF ASSESSING

QUALITY IN THE DELIVERY OF HEALTH SERVICES?
A. RESEARCH
B. STANDARDS
C. NURSING PROCESS
D. LEGISLATION

42. CHOOSE THE KEY WORDS THAT BEST DESCRIBES QUALITY IMPROVEMENT
IN PUBLIC HEALTH.
A. STATUS QUO
B. IMPORVEMENT PROCESS
C. VERY CONVENTIONAL
D. PERFECT HEALTH FACILITY

43. CHOOSE THE DESCRIPTION THAT QUALITY EXISTS AT THE HEALTH CENTER
A. PATIENT SATISFACTION
B. SELECTED DELIVERY OF SERVICES
C. CONTROLLED BY LOCAL OFFICIALS
D. RAPID TURNOVER

44. NURSE ELISA WOULD LIKE TO ENHANCE THE PROCESS STANDARD AT THE
HEALTH CENTER. WHICH SHOULD BE HER PRIORITY NURSING INTIATIVE ?
A. REVISE MANUAL FOR OPERATION
B. HIRE MORE NEW GRADUATE
C. UPGRADE THE HEALTH EQUIPMENT
D. REDUCE OPERATIONAL EXPENSES

45. IDENTIFY TO WHOM NURSE ELISA WOULD SEEK HELP TO IMPROVE HEALTH
RESOURCES LIKE MDICINES IN ORDED TO PROVIDE QUALITY NURSING CARE
AT THE HEALTH CENTER.
A. HEAD OF THE CHURCH
B. SECRETARY OF HEALTH
C. MAYOR
D. GOVERNOR
SITUATION – NURSE ELISA HAS BEEN PROMOTED AS NURSE MANAGER IN THE
HEALTH UNIT. HER FUNCTIONS INCLUDE MANAGEMENT OF RESOURCES AND
ENVIRONMENT AND BUDGETING.

46. AS NURSE MANAGER, WHICH SHOULD SHE CONSIDER IMPORTANT WHEN

PREPARING THE BUDGET NEEDED FOR THE OPERATION OF THE UNIT.
A. ALL THINGS AND EQUIPMENT NEED TO BE NEW YEARLY
B. BUDGET IS IMPLEMENTED WITH OR WITHOUT MONEY AT HAND
C. COST EFFECTIVENESS AND EFFICIENCY ARE IMPORTANT
D. BUDGET IS NOT ESSENTIAL FOR QUALITY ASSURANCE

47. IN THE PROCESS OF PLANNING, WHICH OF THE FOLLOWING, NURSE ELISA

SHOULD USE THE PLAN THAT WOULD REVIEW THE STRENGTHS AND
WEKNESS OF THE ORGANIZATION
A. OPERATIONAL
B. NURSING CARE
C. STRATEGIC
D. PROGRAM

48. FOR COST EFFECTIVENESS MEASURE, WHICH OF THE FOLLOWING IS THE

BEST NURSING ACTION
A. ALL THINGS SHOULD BE KEPT AT THE SUPERVISORS OFFICE
B. IDENTIFY RESOURCES NEEDED TO ACCOMPLISH TASK
C. ASSIGN THE UTILITY WORKER TO KEEP TRACK
D. ALLOW EVERYONE TO TAKE RESPONSIBILITY

49. NURSE ELISA ADVOCATES FOR SAFE STAFFING PATTERN AT THE HEALTH
CENTER. WHICH BEST PRACTICE SHE SHOULD INSTILL FROM THE STAFF?
A. DELEGATE TASK
B. GIVE ALL FREEDOM TO BE HONEST IN THEIR ATTENDANCE
C. STAFFING PATTERN NOT IMPORTANT IN COMMUNITY SETTING
D. REQUIRES STAFF TO REPORT ON TIME

50. WHICH OF THE FOLLOWING IS A MEASURE OF SAFE WORK ENVIRONMENT?

1. COMPLIES WITH STANDARS
2. OBSERVE PROTOCOLS
3. ADHERES TO POLICIES
4. OBSERVE QUALITY
A. 2,3,4
B. 1,2
C. 3,4
D. 1,2,3,4

SITUATION – WHEN PRIORITIZING PROBLEM IN THE COMMUNITY, THE

PROBLEMS ARE CATEGORIZED AS HEALTH STATUS, HEALTH RESOURCES OR
HEALTH RELATED.

51. NURSE MARIS IS CORRECT IN IDENTIFYING, WHICH OF THE FOLLOWING IS

A HEALTH RESOURCE PROBLEM ?
A. FEUD BETWEEN THE MIDWIFE AND HEAD OF THE BARANGAY SANITATION
COMMITTEE
B. HIGH MATERNAL MORTALITY RATE
C. ABSENCE OF MIDWIFE IN THE COMMUNITY TO RENDER HEALTH SERVICES
D. INCREASE IN NUMBER OF DEATHS FROM PNEUMONIA
Human Resource is part of health resources

52. THERE ARE FIVE CRITERIA IN PRIORITIZING COMMUNITY HEALTH

PROBLEMS. IF BNURSE MARIS IS ESTIMATING THE PROPORTION OF THE
POPULATION AFFECTED BY THE PROBLEM, SHE IS USING WHAT CRITERION IN
PRIORITIZATION?
A. MAGNITUDE OF THE PROBLEM
B. SOCIAL CONCERN
C. NATURE OF THE PROBLEM
D. MODIFIABILITY OF THE PROBLEM

53. SELECT A BARRIER TO GOAL SETTING BETWEEN THE NURSE AND THE
FAMILY.
A. EDUCATIONAL ATTAINMENT
B. SOCIO ECONOMIC STATUS
C. NATURE OF EMPLOYMENT
D. FAILURE OF FAMILY TO PERCEIVE EXISTENCE OF PROBLEM

54. WHICH IS THE MOST APPROPRIATE INTERVENTION SHOULD THE NURSE

DO TO HELP FAMILY PERFORM THE HEALTH TASKS?
A. REFER FAMILY TO BARANGAY OFFICIALS FOR GUIDANCE
B. HELP THE FAMILY RECOGNIZE THE PROBLEM
C. ALLOW FAMILY TO DECIDE TO USE HEALTH RESOURCES
D. LEAVE THE FAMILY WHAT ACTION TAKE ON THEIR PROBLEM
55. CHOOSE THE STEP OF NURSING PROCESS THAT IDENTIFIES THE FAMILY
HEALTH SEEKING BEHAVIOR
A. IMPLEMENTATION
B. EVALUATION
C. ASSESSMENT
D. PLANNING

SITUATION – NURSE OSCAR IS IN CHARGE OF THE OSTEOPOROSIS CONTROL

PROGRAM OF THE HEALTH CENTER

56. NURSE OSCAR INFORM THE OTHER MEMBERS OF THE TEAM ABOUT
OSTEOPOROSIS. WHICH OF THE FOLLOWING IS TRUE OF THE DISEASE IN THE
PHILIPPINES
A. THERE ARE ONLY FEW CASES IN THE COUNTRY
B. THE DISEASE IS NOT ALARMING
C. FILIPINOS ARE AWARE OF THE INCIDENCE OF OSTEPOROSIS
D. FILIPINOS HAVE LOW AWARENESS ABOUT THE DISEASE
Osteoporosis is a silent disease
57. WHICH IS THE MOST IMPORTANT RISK FACTOR TO OSTEOPOROSIS
A. MENOPAUSE
B. BEING MALE
C. WITH HISTORY OF PREVIOUS FRACTURE
D. SHORT IN HEIGHT
Being female >50 or during menopause, the patient is 4x more likely to have
osteoporosis

58. WHICH OF THE FOLLOWING IS THE PREVENTIVE MEASURE TO

OSTEOPOROSIS DEVELOPMENT
A. I justRON RICH FOOD
B. CALCIUM RICH FOOD AND SUPPLEMENT
C. DAILY JOGGING
D. VIGORIOUS EXERCISE

59. WHICH OF THE FOLLOWING IS TRUE ABOUT OSTEOPOROSIS

A. IT IS A SILENT DISEASE
B. IT IS MORE COMMON IN MEN
C. IT IS NOT THAT ALARMING
D. IT IS ONLY DISCOVERED AFTER A FRACTURE
60. THE DIAGNOSTIC EXAMINATION FOR OSTEOPOROSIS IS GEARED
TOWARDS MEASURING
A. BONE DENSITY
B. BLOOD VOLUME
C. WEIGHT
D. HEIGHT

Situation - Nurse Telly is planning to conduct a qualitative research about the life
experiences of teenage mothers in the community.

61. Which “APPROPRIATE” research design Nurse Telly should use in her planned
study?
A. Grounded theory
B.Phenomenology
C.Case study
D.Etnography

62. After shed has decided to conduct the study, which of the following nursing action
she should do next?
a. create conceptual framework
b.make a research proposal
c.decide for the data analysis
d.plan for data collection

63. Which is the “APPROPRIATE” means to present qualitative data?

A.Themes
B.BAR graph
C.Pie graph
D.Linear graph

64. Which of the following nursing actions Nurse Telly must do in doing data
saturation of qualitative data
A.Do resurvey
B.Use case study
C.Do interview more than once
D.Seek advice of expert

65. One of the study questions in the proposed study is about needs of teenage
mothers.In choosing framework to make the topice more stable,which theory Nurse
Telly should adopt in her study?
A.Roy
B.Maslows
C.Orem
D.Kings

Situation - Nurse Rina had been working as public health nurse,In working with families
she valules the importance of family care plan, and other concepts about community
health nursing

66. Nurse Rica is in charge of the Animal bite program fo the health center.Which of
the following is the causative agent of rabies?
A.Parasite
B.Virus
C.Bacteria
D.Fungi

67. Which is the BEST strategy to control incidence of Rabies in the community?
A.Impound dogs
B.Kill stray dogs
C.Responsible pet owner
D.Fine the owners

68. Which BEST advice the nurse should give in case of dogbite?
A.Wash wound with garlic
B.Do not feed the dog
C.Bleed the bitten area
D.Wash thoroughly with running water

69. What advice should be given to the owner of the dog in case of dogbite
A.Give away animal
B.Impound the dog
C.Kill the dog
D.Feed well and observe (+)

70. Which IMPORTANT information the nurse should inform the public about rabies?
A.It could be prevented
B.It is an ordinary disease
C.Rabies is not deadly
D.It kills
Situation - Nurse Erica is fully aware that being a public health nurse her work is guided
by ethico-moral principles.

71. Which is the 'MAIN' goal of ethical practice of the nrusing profession including the
community setting?
A.To protect the nurse and co workers
B.To prevent reprimand from physicians
C.For the patients family satisfaction
D.Centered on the welfare of clients and protect their rights

72. As public health nurse Nurse Erica makes sure all the supplies and medicines
needed for the care of community are available. This is an example of the principle of
______________.
A.Justice
B.Respect
C.Fair treatment
D.Benificence

73. Select nurses action in keeping with principle of confidentiality

A.Hides identitt of patient
B.Shares information from patients chart in public
C.Keeps all matters about the patient as a secret
D.Discusses the case of patient with others

74. Nurse Erica is always guided by the principle of benificence in all that she does
to all her patients. Which of the following nursing action is aligned with principle of
beneficence.
A. Equal and fair allocation of resources to all
B.Getting informed consent
C.Keep records of patients from public viewing
D.Promoting patients safety at all times

75. Nurse Erica tap all the newly hired nurses to be members of her new prohect.
She is observing the ethical principle of __________.
A. Justice
B.Autonomy
C.Nonmaleficence
D.Respect
Situation – Nurse Henie uses the Family coping index in assessing family health needs
and problems of particularly of families who are vulnerable to illness.

76. Which of the following is an evidence of a poor family coping index related to
healthcare attitudes?
A.A parent who washes the wound of the child with running water. (+)
B.The family who observes the habit of cleaning surroundings. (+)
C.A young mother who introduced solid food to her three-month old baby.
D.A mother who brings her child to be vaccinated for measles.(+)

77. Which of the following is the BEST evidence of a family whose family coping
index on therapeutic competence is rated as coping well?
A.Shows positive interpersonal relationship
B.Participates in the weekly clean and green program of the community
C.Maintain clean and organized household ambiance
D.Visits the clinic frequently well or sick.
Therapeutic competence index includes all the procedures or treatment prescribed for
the care of ill, such as giving medication, dressings, exercise and relaxation, special
diets.
https://www.rnpedia.com/nursing-notes/community-health-nursing-notes/family-coping-i
ndex/
78. Which of the following tools used by nurses in the community setting for
assessing health needs and problems of families that is similar to family coping index
A.Nursing theories
B.Vital statistics
C.Case study
D.Nursing diagnosis

79. In utilizing family coping index nurses should be knowledgeable that the focus of
this tool is identifying the family's _____________.
A.strategies to deal with stressful situations
B.manner of interaction
C.ways of managing health needs and challenges
D.patterns of health habits

80. Nurse Myrna is taking care of a firmly whose there young children are sick with
malnutrition particularly protein deficiency. Which of the following behaviors is indicative
of the family's positive coping index
A.Observing erratic mealtime due to work schedule of parents.
B.Bringing children to health center for consult only when needed.
C.Serving foods that children like but high in carbohydrates.
D.Cooking foods in variety that include meat,dairy products and beans.
Torn between B and D but B has a “only when needed” so maybe D is a better answer?
I also think that if you cook a variety of food, it means that you give time for choosing
and cooking food, indicating a positive coping index

Situation – Ms. Sandra is a newly assigned school nurse in the elementary school of the
barangay. She planned to do physical examination of every child.

81. In assessing the health condition of school children, which of the following would
be the findings common to this age group?

A. Cancer and other malignancies

B. Anemia and other blood disorders

C. Lice and parasites
D. Fracture and injuries
Fracture occur in 40% of girls and 50% of boys. Head lice and parasites occur in 6-12
million.

82. In the performance of her roles and functions as a school nurse, which guiding
principle should she consider very important?

A. Health is an integral part of the education process.

B. The nurse is in full authority over the children.
C. The local health authority supervises the school health.
D. School nursing is more focused on socialization.

83. Choose how many times at least the nurse conducts physical assessment to school
children.

A. Thrice a year
B. Every semester
C. Every quarter
D. Once a year
PHN Book- Every school child should be examined once a year and as the need arises
like during pandemics

84. Who should Nurse Sandra consider as a priority for home visitation?

A. Pedro 9 years old whose parents are both working.

B. Melissa 10 years old with stunted growth for her age.
C. Cindy 7 years old who has been absent due to skin lesions.
D. Mike 8 years old who often sleeps during class hour.
Students with stunted growth may indicate malnourishment and must be further
investigated. Although there is a need to visit a student absent d/t skin condition, it
does not say that it was frequent absenteeism or not.
The following are some cases needing home visitation:
● Students with parents afraid of some medical procedure
● Students re-infected d/t home condition
● People suffering from communicable disease
● Students who are absent frequent because of sickness
● Students who are malnourished
85. Which of the indicators BEST describes an effective outcome of school nursing
programs and initiatives.
A. Zero absenteeism and tardiness of pupils.
B. teachers are observers of school health program.
C. Limited information in school of health initiatives.
D. Constant and visits and phone calls of parents.

Situation - Nurse Cris is about to start her community organizing activities. Together with
her core group, their goal is to be successful in community organization through
effective communication.

86. Nurse Cris would like to communicate to the people the health problems they had
identified. In reaching out every household in the community which is the BEST
strategy the nurse should employ?

A. Call for general assembly

B. Use social media
C. Send memorandum
D. Write a letter to residents

87. Which communication techniques should Nurse Cris employ in order to

successfully capture the details of the meeting?

A. Summarizing

B. Restating
C. Reassuring

D. Validating

88. Nurse Cris received information from some community residents who suspect that a
neighbor is abusing his young child. Which should be the PRIORITY nursing action?
A. Report to police authorities.
B. Notify the social worker.
C. Ignore the information.
D. Validate the information

89. In organizing the community in the midst of a major health crisis, which STRATEGY
should the Nurse Cris employ to effectively communicate the importance of health
and safety protocol?

A. Send letter compelling everyone to follow.

B. Use social media to spread the information.
C. Request an elder residents to inform everyone.
D. Place poster and flyer in dialect in strategic places.

90. In order for Nurse Cris to facilitate the recognition of the community of the existence
of their health problems, which nursing action would yield BETTER results?

A. Asks the barangay head to make the report.

B. Set the ground rule that presence of problem is valid

C. Allows people’s participation to confirm the health.

D. Acts as an expert to communicate to residents.

Situation – Nurse Bea engages in both formal and informal learning activities to
enhance her knowledge about Nursing theories and other concept in Nursing.

91. Nurse Bea recall the theory of Nursing as caring by _____________.

A. Orem- self care

B. Watson
C. Kings- Goal Attainmentf
D. Banners- novice to expert

92. Which of the following is the central theme of Sr. Calista Roys theory.

A. Self-care deficit

B. Adaptation

C. Nursing as caring
D. Transcultural

93. This theory categorizes professionals as Novice to Expert is by ____________.

A. Benner

B. Abdellah

C. Pender

D. Kings

94. Nurse Bea reviewed the elements of nursing as a profession. Which of the following
is an important element that characterizes Nursing as a profession?

A. Has Members
B. Possess body of knowledge
C. Service oriented
D. A calling

95. Nurse Bea wants to pursue higher education in Nursing for her career
advancement. Aside from enrolling in graduate school, which of the following she
could enhance her career?

A. participates in professional organization

B. Attends seminars
C. Conducts research
D. Attend symposium

Situation - Nurse Levy reviews all pertinent laws that affects public health nursing.

96. RA 9173 is otherwise known as the Philippine Nursing Act of 2002. Which is the
primary aim of this law?

A. To enhance the competence of professional nurses.

B. To regulate practice of professional nursing in the country
C. To facilitate mobility of nurses to other countries
D. To promote well – being of health workers.
97. The nurse closely monitors the work she delegated to the barangay health worker.
She is legally guided by his principle

A. Respondent superior
B. The good Samaritan
C. Res ipsa loquitor
D. Jurisprudence

98. This law promotes the wellbeing and living conditions of health workers especially
those from the government managed facilities ________.

A. Continuing professional development

B. Magna Carta for health workers
C. Philippine qualifications framework
D. Local government code

99. It mandates the compulsory immunization of children below 8 years

A. PD 996
B. RA 11223
C. RA 8173
D. RA 10912
new law is RA 10152- up to 5 years old

100. This law allows every Filipino to avail of affordable medicines.

A. Local Government Code

B. Primary health care
C. Universal Health Care
D. Generic Drug Act

NURSING PRACTICE II: Care of Healthy/At Risk

Mother and Child
Situation - Nurse Kathy is caring for a postpartum patient. Routine postpartum care is
rendered to the patient.

1. Which assessnebt finding would lead the nurse to suspect a postpartum

hemorrhage? Blood loss of __

A. less than 300 ml/24 houf6rs

B. more than 400 ml/24 hours
C. less than 200 ml/24 hours
D. more than 500 ml/24 hours
Postpartum hemorrhage (PPH), defined as blood loss of 500 mL or more within 24
hours after birth that results in signs and symptoms of hemodynamic instability
https://doh.gov.ph/sites/default/files/publications/TR_Carbetocin.pdf

2. Which of the following is caused by the markedly distended uterus and intermittent
uterine contractions within 2 to 3 days after birth?
A. Retained placenta
B. Uterine atony
C. After pains
D. Boggy uterus

3. The nurse prepares a care plan for the patient. Based on Ramona Mercer’s
becoming a mother (BAM) theory, which of the following statements foster the process
of becoming a mother?
A. The woman becomes comfortable with her identity as a married individual.
B. It encompasses the dynamic transformation and evolution of a woman’s persona.
C. A woman learns mothering behavior prior as early as a teenager.
D. It accurately reflects the transitional process from being single to a married
relationship.

4. The mother asks why she has a gush of blood coming out from the vagina that
occurs when she first arises from bed. The nurse’s CORRECT response should be
_______:
A. “Blood pools at the top of the vagina and forms clots that are passed upon rising or
sitting on the toilet.”
B. “Positioning causes blood to flow out when she stand.”
C. “Because of the normal pooling of blood in the vagina when the woman lies down to
rest or sleep.”
D. “Normal physiologic occurrence that results as the body attempts to climinate excess
fluids.”

5. Some postpartum mothers will experience difficulty voiding because of the edema
and trauma of the perineum. Which PRIORITY nursing measures stimulate the
sensation of voiding?
A. Encouraging her to avoid.
B. Running water in the sink or shower.
C. Helping the mother into the shower.
D. Providing cold tea or fluids of choice.

Situation - A postpartum mother newly delivered her baby per vagina. She keeps on
asking the nurse when the basic physiologic changes occur as her body returns to a
prepregnant state.

6. The nurse explains to the mother that the uterus will return to its prepregnancy state
in ___ weeks.
A. six
B. three
C. four
D. five

7. In her capacity to teach, the nurse describes the changes of the uterus after childbirth
to return to a nonpregnant state as ____.
A. catabolism
B. subinvolution
C. contraction of muscle fibers
D. Involution

8. Which of the following conditions does the nurse explain to the patient the
contributory factor that slows uterine involution?
A. Full Bladder during labor
B. Difficult birth
C. Prolonged labor
D. Infection during pregnancy

9. The nurse assesses the uterine funds of the mother. Which part of the abdomen will
nurse begin?
A. Symphysis pubis
B. Midline
C. Umbilicus
D. Sides of the abdomen

10. The FIRST PRIORITY nursing intervention during the immediate postpartum period
is focused on ___.
A. Monitoring urinary output
B. Taking the vital signs every 4 hours
C. Observing postpartum hemorrhage
D. Checking level of responsiveness
Situation - Evelyn a multigravida, in her 20th weeks of generation visited the community
clinic with complains of dizziness, vertigo, and heartburn. After the physical
assessment, Nurse Harper finds the patient as malnourished.

11. Iron supplementation was prescribed because of her low hemoglobin level. Which
statement, if made by Evelyn, would indicate an understanding of health instruction?
A. “My body has all the iron it needs and I don’t need to take supplements.”
B. “Meat does not provide iron and should be avoided.”
C. “The iron is best absorbed if taken on an empty stomach.”
D. “Iron supplements will give green color to my stool.”

12. Evelyn was given iron as supplemental vitamin to prevent maternal anemia. She
asks if it will not be affected because she is regularly taking vitamins C. Which of the
following would be the BEST response of the nurse?
A. “Take two other vitamins separately.”
B. “Take the iron after a full meal.”
C.”Absorption of iron is enhanced with Vit C.
D. “Drink milk when taking the iron supplement.”

13. Evelyn was advised to take calcium supplements on the 2nd and 3rd trimester of
pregnancy. Which of the following would ENCHANCE her intestinal absorption of
calcium?
A. Fat-soluble vitamins
B. Proteins
C. Minerals
D. Water soluble vitamins

14. Nurse Harper observed Evelyn has knowledge deficit regarding fetal nutrition. Nurse
Narper has to explain that the MAIN SOURCE of nutrition for the baby is which of the
following?
A. Amniotic Fluid
B. Uterus
C. Placenta
D. Chorionic Villi

15. Nurse Harper provides health instruction to the patient experiencing heartburn.
Which Statement by the patient indicates a NEED for further instruction? I have to
_____.
A. drink milk between meals
B. eat small, frequent meals
C. avoid fatty or spicy foods
D. lie down after eating

Situation - The giving of medication to a pediatric patient is a serious responsibility of a

nurse. Nurse Imelda has just been assigned to the Pediatric Wards.
16. When giving medicine to pediatric patients, dosage varies. Which of the following
should Nurse Imelda consider?
A. Height and surface area
B. Size, Surface area & age
C. Size, surface area, age & height
D. Size & surface area

17. The Headnurse checks Nurse Imelda’s knowledge on administering oral medication
to pediatric patients. Which of the following statements below should she choose as
CORRECT?
A. A child’s reaction to a dose ordered by a physician is not less predictable than
adult’s reaction.
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 plate the tablet in the middle of his 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. In Infants and toddlers, which part should Nurse Imelda often use for intramuscular
injection to reduce the risk of vascular and peripheral nerve injuries?
A. Gluteus maximus
B. Dorso-gluteal
C. Deltoid muscle
D. Vastus lateralis

19. Administering medication intramuscularly can produce a variety of serious adverse

effects has been revealed in comprehensive surveys of research reports. When asked
by the Headnurse what is the MOST common complication that may arise, Nurse
Imelda should mention ____.
A. abscess
B. herve palsies and paralysis
C. hematoma
D. muscle contracture

20. Prior to administering the drugs ordered by the Pediatrician, Nurse Imelda needs to
know if she is giving the ordered medication to the right patient. The FIRST step is
__________.
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 – Alaia, a patient with nevere proeclampsia, is admitted to the hospital. She is
a student from one of the local universities, she insists of continuing her studies while in
the hospital despite being instructed to rest. The patient studies approximately 10 hours
a day and has numerous visits from fellow students, family, and friends.

21. Nurse Isabelle is concerned about the patient’s welfare and her ability to comply
with the doctor’s instructions. What should be the APPROPRIATE action?

A. Include a significant other in helping the patient

understand the need for rest.
B. Instruct the patient that the baby’s health is more
important than her studies at this time.
C. Develop a routine with the patient to balance her studies
and her rest needs.
D. Ask her why she is not complying with the prescription for bed rest.

22. Patient Alaia, who seems to be irritated with the nurse, said, “I don’t want to talk to
you because you’re only a nurse. I will wait for my doctor.” Which of the following is an
APPROPRIATE response by the nurse?

A. “I’m angry with the way you dismiss me.”

B. “So then you would prefer to speak with your doctor?”
C. “I understand. I should call your doctor.”
D. “Your doctor prescribed this for us to do nursing care.”

23. Nurse Alaia is now in a dilemma. This occurs when .

A. there is a conflict between the nurse’s decision and that of his/her superior193
B. choices are unclear
C. there is a conflict of two or more ethical principles
D. a decision had to be made quickly under a stressful
situation

24. Which of the ethical principles stipulates that the nurse is responsible for providing
all patients with are, attention and information?

A. Beneficence C. Nonmaleficence
 B. Advocacy D. Veracity

25. Which action by the nurse provides a safe environment for a preeclamptic patient?

A. Maintain fluid and sodium restrictions.

B. Take off the room lights and draw the window shades.
C. Encourage visits from family and friends for psychological
support.
D. Take the patient’s vital signs every four hours.

Situation – Part II of the training is the giving of the hypothetical situation for the
application of what was taken during the didactic. A group was given a scenario of a
pregnant woman in the OB ward.

26. The scenario states that the nurse is discussing the nursing process with a newly
hired nurse. Which of the following describes the planning phase of the nursing
process?

A. Identify the nursing diagnoses

B. Gather information if the patient’s problem has been resolved in the evaluation
phase
C. Review the patient’s history during assessment
D. Prioritize patient problems

27. Nurse Jezyl one of the group leaders reviewed the steps of the nursing process with
the group. Which of the following date should the nurse identify as 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 C. III and IV
B. I and IV D. I and II

28. On the second day, the patient delivered an alive baby girl. She complains of leg
pain. The nurse took hold of the patient’s CHART. Ponstan 500 mg every 4 hours PRN
for pain was ordered and was given. After 40 minutes, the patient was relieved. What
step of the nursing process should the nurse have conducted?
A. Assessment C. Evaluation
B. Planning D. Intervention

29. According to the nursing process, which of the following actions the nurse takes if
the pain does not satisfactorily relieve?
A. Wait for more time for the pain reliever to take effect.
B. Collect additional data as to why the patient has not been relieve of pain.
C. Teach the patient relaxation breathing techniques.
D. Refer to attending physicians.

30. The nurse Trainor discusses the elements of documentation. Which of the following
refers to being comprehensive and timely?
A. Complete and current C. Organized
B. Accurate and concise D. Factual

Situation – Patient Ellie, a 28-year-old primigravida, is admitted to a birthing center. She

has been in labor with an interval of 5 minutes apart from 10 hours now. Hypotonic
contractions are observed by Nurse Nora. She feels more pain in her back than in her
abdomen, sonogram shows her fetus is “borderline” large for gestation and in
occipito-posterior position.

31. Nurse Nora observes that the Ellie’s uterine contraction are irregular in frequency
and short in duration. Ellie screams in pain during contractions. Which of the following
actions is considered BEST for the nurse platform?
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 contraction.

32. The physician is considering augmenting her labor with oxytocin. What would make
Nurse Nora question the use of oxytocin for patient Ellie?
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 Nora notices patient’s uterine contractions are 70 seconds long and occur
every 90 seconds when assessing the frequency of her contractions after she receives
oxytocin. What would be the nurse’s FIRST action?
A. Give an emergency bolus of oxytocin to relaxed 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 breathe deeply

34. Nurse Nora monitors the patient, knowing that which indicates an adequate
contraction pattern?
A. Three to 5 contractions in a 10-minute period, with
resultant cervical dilatation
B. Four contractions every 5 minutes, without resultant
cervical dilatation
C. One contraction every 10 minutes, without resultant cervical dilatation
D. One contraction per minute, with resultant cervical dilatation

35. Which of the following nursing measures would the nurse LEAST CONSIDERS to
Patient Ellie with 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 complications

Situation – Miriam on one year of age, is admitted due to pneumonia. She has IV
antibiotics, antipyretic, decongestant and vitamins as medications. She also is under
oxygen therapy.

36. Nurse Messy has been worried about Miriam’s refusal to take her oral drugs. How
will she handle the situation?
A. Leave the child alone
B. Seek the help of the mother in giving the oral drug.
C. Mix the drug with milk to cover up the unfavorable taste.
D. Get angry with the mother and the child.

37. As one-year-old child, Nurse Messy understands the reason (s) why Miriam
continuously refuse to take her drugs. It is because it is normal for her age to .
A. have separation anxiety.
 B. internalize the attitudes of others.
C. utilize magical thinking.
D. be negativistic in all matters.

38. The BEST way to administer oxygen on Miriam is by .

A. hood C. Incentive Spirometer
B. face mask D. nasal catheter

39. For the IV antibiotic therapy of Miriam, the MOST common gauge used for IV
cannula is gauge .
A. 20 C. 22
B. 24 D. 18

40. What IMPORTANT evaluation parameter should Nurse Messy observe that would
show improvement in Miriam’s condition?
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 - Ashley a postpartum patient, who has delivered a stillborn wants to leave the
hospital without a physician’s order. The patient is still hooked to an intravenous
fluid(IVF) and is on closed postpartum monitoring.

41.To avoid liability, which of the following is an APPROPRIATE action by nurse

Valerie?
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 the transportation plans from the hospital.

42.Nurse Valarie informs patient Ashley on the need for early ambulation. Which of the
nurse’s instruction on ambulation is INCORRECT?
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.While waiting for a feedback from the nurse supervisor regarding the [patient’s desire
to go home, nurse Valerie opted to check on the patient. Upon entering the room, she
discovers that the waste basket on fire. Sequence the nurse’s actions in the options
below.

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 the fire was put off, the patient was found to have absconded. What is the
ethico-legal responsibility of the attending nurse?
A. Autonomy
B. Nonmaleficence
C. Beneficence
D. Justice

45. Absconding is inevitable in any health care facility. Who will be informed
IMMEDIATELY if the patient found out the absconded?
A. Attending physician
B. Security guard on duty
C. Resident on duty
D. Nursing staff

Situation - Catherine,5 years of age, is admitted to the Pediatric Ward due to severe
otalgia, fever and irritability. The mother informed Nurse Selma that patient had upper
respiratory infection three weeks prior to admission. The admission diagnosis is acute
otitis media (AOM).

46. Nurse Selma conducts her INITIAL assessment on Catherine. The patient keeps on
crying and constantly pulls her right ear. What is her MOST APPROPRIATE action?
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. Nurse Selma is preparing to administer Ofloxacin eardrop on Catherine per Doctor’s
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. After washing her hands and gently cleaning any discharge that can be removed
easily from the outer ear, Nurse Selma positions the child. Which of the following steps
follows?
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 knowledge on otitis media, nurse Selma recalls that children are
predisposed to AOM due to the following risk factors, EXCEPT ______.
A. absence of breastfeeding
B. swimming
C. exposure to cigarette smoke
D. poor hygiene

50. To promote drainage and reduce pressure from fluid, Nurse Selma’s nursing
intervention is to have the child 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 Ester is rotated to the Pediatrics Ward. As such, she needs to review
the principles and concepts of human growth and development to better appreciate her
role as a professional nurse.

51. Being assigned to care for pediatric patients, Nurse Ester should remember which of
the following statements?
A. Toddler period ranges from 12 to 36 months
B. An infant’s tongue is smaller than adult
C. Early childhood period ranges from 3 to 7 years
D. Breast milk provides complete infant nutrition
52. While Nurse Ester was taking the temperature of the Baby Chooka, the mother
asked Nurse Ester when growth and development become more rapid. Her answer
should be, during at _______months of life.
A. ten
B. nine
C. twelve
D. eleven

53. It is vital for Nurse Ester to give concrete example of activities to stimulate gross and
fine motor development. Examples are, 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 & 2
B. 2 & 3
C. 3 & 4
D. 1,2,3 & 4

54. According to the World Health Organization (WHO), suicide has become a global
phenomenon. When taking care of emotionally disturbed adolescent patients, Nurse
Ester should be alerted with warning signs which often occur for at least one month
before a suicide attempt, EXCEPT____.
A. increase in initiative
B. verbalization of suicidal thoughts
C. crying
D. sleep disturbances

55. During one of the nursing rounds, the Pediatric Ward Headnurse asked Nurse Ester
the inclusive ages considered as the transition from childhood to adulthood but
sometimes extending until college graduation. Her CORRECT answer should be _____.
A. 15 to 18
B. 12 to 16
C. 11 to 18
D. 13 to 18
Situation - In a birthing station, five postpartum mothers delivered 2 hours, 4 hours, and
6 hours ago, respectively. All of them are multigravida patients, Adalynn, the nurse
educator opted to conduct health education on a postpartum hemorrhage.

56. Nurse Adalynn explains to the mother that early indication for hypovolemia caused
by postpartum hemorrhage 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. The Nurse educator Adalynn reviewed the risk factors for postpartum hemorrhage
for the mothers. Which of the following factors IS NOT included ____?
A. ruptured uterus
B. uterine atony
C. overdistended uterus
D. retroversion of the uterus

58. During the normal postpartum course, when would the nurse expect to note the
fundal assessment that will be in line with the umbilicus?
A. Immediately after the delivery
B. 4 days after the delivery
C. When the client’s bladder is full
D. The day after the delivery

59. A postpartum patient asks nurse Adalynn when she may safely resume sexual
activity. Which of the following information should the nurse tell the patient on
resumption of sexual activity?
A. In 2 to 4 weeks
B. At any time
C. After the 6-week physician check-up
D. When her normal menstrual period has resumed

60. Nurse Adalynn discusses the possibilities of future postpartum hemorrhage with the
patients. Which of the following increases the absorption of vitamin k?
A. Proteins
B. Carbohydrates
C. Minerals
D. Fats
Situation - During the nurse’s rounds, the head nurse noticed that the Intake & Output
sheets have not been filled up.

61.Based on the findings, what should the head nurse do?

A. Ask the staff nurses the reason 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.The head nurse decided to coach her staff nurses. One of the questions she raised
was what fluids should be excluded in the I & O flow sheet.
The CORRECT response should be, which of the following?
A. Intravenous fluids
B. Gelatin
C. Solid foods
D. Beverages

63.The head nurse emphasized to the staff nurses what NOT to be included under the
output list. The answer should be, which of the following?
A. Drainage from tubes
B. Solid/hard feces
C. Urine
D. Vomitus

64.The BEST time to record the intake & Output is ______________.

A. During endorsement
B. After endorsement
C. Right before endorsement
D. Any time before duty

65.A patient’s I & O is vital for patients with Chronic Heart Failure. The MAIN purpose of
recording accurately the
I & O of such patient is to _________.
A. Determine is 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 - The group of nurses assigned in the delivery room is interested in conducting
a study on the experiences of pregnant women in labor. they are thinking of qualitative
research.

66.In the presentation of results of qualitative research, the nurse research uses as a
reference in the write-up _____ person.
A. first
B. second
C. fourth
D. third

67.Nursing, as a human science, deals with the critical and fundamental differences in
attitude toward 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.The group was observant as to the activities taking place in the delivery room. one of
the activities Involved social processes, which can be better explored. 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 data analysis of their study, experiences of pregnant women in labor, they
returned to the participants to determine the accuracy of the emerged themes. which
criteria of trustworthiness in the group doing?
A. Confirmability
B. Credibility
C. Transferability
D. Dependability

70.The group used an audio record to capture what transpired during the interview. after
the transcription, which of the following action is APPROPRIATE for the group to do with
audiotape?
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 other to listen.

Saturation - Marie OB-GYN head nurse, conducted an in-service program on staff

development.

71.Head nurse Marie discussed that the MOST frequently neglected area in
management is _____.
A. Managerial knowledge
B. Professional development
C. Clinical skills
D. Successful communication
72.A critical component of the supervisory process is delegation. which of the following
in the MOST empowering to staff?
A. Effective delegation does not require nurses to know the abilities and weakness of
their staff.
B. Delegation frees the manager to do other tasks while empowering staff.
C. Delegation fosters the responsibility of staff while increasing professional growth.
D. Delegation starts at top management down to subordinates.

73.Head nurse Marie discussed negotiation. the focus of negotiation is to create

a___________.
A. soothing situation
B. third-party consultation
C. trade-off
D. win-win situation

74.Supervision occurs after delegation. what is the PRIMARY purpose of supervision?

A. Influences the organization’s approach in recruitment promotion, and personnel
evaluation.
B. Improves staff compliance with policy and procedures individual.
C.Assigns appropriate work tasks to the best-qualified individual.
D.Enhances the delivery of quality nursing care.

75.delegation involves the transfer of care to an individual. what is the BEST criterion
when delegating staff?
A. Responsibility C. Flexibility
B. Adaptability D. Competence

Situation - Therapeutic communication promotes understanding between the sender

and receiver. Nurse Gary should be abreast with the common therapeutic techniques if
he wants his nursing care to be effective and achievable.

76.When a patience says,” I am not sure if I should undergo colonoscopy or not as I am

scared. “Which of the following is the MOST appropriate communication technique that
Nurse Gary should use?
A. Touch C. Restating
B. Clarifying D. Silence

77.When a patient “Whenever I see my husband visit me, I feel depressed”. Nurse Gary
says. “Your husband depresses you? “The therapeutic communicate is which of the
following?
A. Restatement C. Focusing
B. Focusing D. Seeking clarification
78.When a Nurse Gary says to the patient, “tell me more about your experience when
you had the colonoscopy.”, which of the following therapeutic techniques is Nurse Gary
using?
A. Focusing C. Encouraging
elaboration
B. Clarifying D. Restating

79.When Nurse Gary, “tell me more the experience. I wish to hear about. “Which of the
following therapeutic communication techniques is Nurse Gary using?
A. Restating C. Open-ended
question
B. Seeking clarification D. Summarizing

80.When nurse Gary tells the patient, “You will be wheeled in to the OR and will be
hooked to man IVF where the anesthesia will be given intravenously.” Which of the
following therapeutic communication techniques is Nurse Gary using?
A. Clarification C. Giving information
B. Summarizing D. Reflection

Situation - A pediatric patient, 12 years old is admitted to the Private Room with a
tracheostomy tube.

81. Since the staff nurse assigned to the patient does not have any experience in
caring for a patient with tracheostomy tube, Who among the following should NOT do
the care?

A. Medical Resident

B. Medical Intern

C. Charge Nurse

D. Mother of a Child with care of tracheostomy tube experience

82. The otolarhyngologist arrives to change the tracheostomy tube, which of the
following should the nurse collaborate for the appropriate equipment/supplies need in
changing the tracheostomy tube.

A. Emergency department

B. Central supply unit

C. Anesthesia department

D. Operating Room Department

83. To assure that nurse mica will learn the proper way of caring for patient with
tracheostomy tube, the heanurse should collaborate with, who among the following
personnel for the training?

A. Assistant Chief nurse clinical

B. Chief of unit

C. Asst. Chief nurse for education and training

D. Chief of clinics

84. The otolarhyngologist ordered a change for tracheostomy tube ties? Who among
the following should the doctor collaborate with?

A. Medical intern

B. Medical resident

C. Nurse Aide

D. Staff Nurse

85. The skill of suctioning using a single use catheter for tracheostomy is more safely
performed with which of the number of assistant?

A. Four

B Two

C. Three

D. One
Situation - josophine a multiparous patient is admitted due to labor pains which started
an hour ago, During the vaginal examination, the nurse noted the complete dilatation of
the cervix and effacement is 100 percent, the patient is in the true labor pains

86. Which of the following problems with labor and delivery is completed in less than 3
hours?

A. Precipitous

B. Preterm

C. Induced

D. Prolonged

87. Patient Josephine was referred to the physician, routine blood examinations were
taken, after reviewing the serum electrolyte levels an isotonic intravenous iv infusion
was prescribed. Which iv solution should the nurse prepare ?

A. 5 % dextrose in water

B. 0.45 percent sodium chloride solution.

C. 10% dextrose in water

D. 3% sodium chloride solution

88. The patient during labor would anticipate some emotional support. Which of the
following nursing interventions should nurse sarah provide to keep the patient calm?

A. Giving praise to her the sense of satisfaction regard quick labor

B. Support in maintaining a sense of control

C. Explanation of the effect of labor on the new born

D. Allowing the patient to Express pain ang anxiety

89. Patient josephine ask why her labor is so much shorter compared to her previous
deliveries. Which of the following is the best RESPONSE?
A. Consent of contraction was gradual

B. Multigravida has shorter labor.

C. Cervical lengthening was longer

D. Induction of labor was done

90. Nurse sarah reads the physician's prescription to administer methylergonovine

maleate( Methergen) IM after delivery. The rationale giving this medication is which of
the following?

A. Reduces the amount of lochia drainage

B. Prevents postpartum hemorrhage

C. Decreases uterine contractions

D. Maintains normal blood pressure.

Situation - Jose 10 yrs old has bronchitis he needs oxygenation 4L/m per doctors order.

91. The first standard step in oxygen therapy that the nurse should do is which of the
following.

A. Prepare the patient for oxygen treatment

B. Check the chart for orderedq flow rate, and oxygen delivery method

C. Gather all the equipments and supply

D. Assess patients condition

92. In planning for Jose's oxygen therapy the nurse should consider which of the
following?

A. Need for a humidifier

B. Length the tubing determine the sge of jose

C. Determine the sge of jose

D. Manner of administering oxygen

93. The PRIORITY action of the nurse for jose due to oxygen therapy is ___________

A. Attach the humidifier and connecting 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. What PRIORITY Precautionary measure should be done by the nurse during the
oxygen therapy?

A. Limit visitors

B. Attach "No Smokong" signage

C. Check humidifiers water regularly

D. Connect belt to oxygen tank

95. One evening, jose complained of dyspnea despite continue oxygen therapy. What
should be nurse initial intervention?

A. Give PRN medication

B. Refer patient to the physician

C. Assess the latency of the tubing

D. Re-assess the patient

Situation - Headnurse Wilma has been encountering errors in documenting and records
management based on her reviewe of the nurses notes in the patients chart, to solve
the issue, she decided to conduct a lecture on proper nursing documentation and
management of records.
96. At the start of her lecture, Headnurse Wilma ask the purpose of the nursing process,
which of the following purposes is the CORRECT answer?

A. Reduce the number of forms of the chart

B. List the patients health problems

C. Record the patients progress

D. Provide the confidentiality of the chart

97. One of the staff nurses was asked about the principles to be observed when
charting patients progress accurately, which of the following principles would be the
CORRECT answer?

A. Statements are qualified by the use of "seems" and "appear"

B. Assumptions and conclusions are reported

C. Specific and definite words or phrases are used

D. General statements and measurements are used

98. Which of the following is NOT a characteristic of charting?

A. Complete

B. Subjective

C. Objective

D. Accurate

99. During nursing endorsement, the kardex used. Which of the following statement is
NOT correct? It is____________

A. Kept up to date.

B. A quick reference to current information about the client.

C. Consists of folded card for each patient.

D. Part of the medical record.

100. A sample of an error in charting was shown by headnurse wilma. Which of the
following is the CORRECT solution to remedy the error?

A. Recopy the sheet and destroy the original sheet.

B. Use a single line to cross out the error, then 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.

NURSING PRACTICE III: Care of Clients with Physiologic and Psychosocial Alterations,
Part A

Situation - Nurse G is assigned in the morning shift of the Post- Anesthesia Care Unit
(PACU) and has a patient for admission.

1. The INITIAL priority assessment performed by the nurse, when admitting a patient in
the unit after abdominal surgery is to check for _______________.

A. surgical site for drainage and hemorrhage

B. skin color and temperature
C. responsiveness to painful stimuli and noise
D. respiratory function and airway

2. How should the nurse position the patient who is in a somnolent status and still under
the effect of anesthesia?
A. Supine position with head bed slightly elevate
B. prone position with a pillow under the abdomen
C. Semi-fowler’s with the head turned to the right
D. Left lateral position with a pillow supporting the head
3. When a patient has bleeding after surgery, the PACU nurse, expects which color if
coming from arterial source?
A. Darkly-colored , blood flows fast
B. Bright red and spurts with the heartbeat
C. slow, dark-colored, generally ooze.
D. Pinkish colored-slowly flowing

4. During the immediate post-operative phase, the PRIMARY goal of the health care
team is to maintain ventilation. Which of the following situations should be observed as
a result of hypoxemia?
A. Excess carbon dioxide in the blood
B. increasing ammonia in the blood
C. Decreased oxygen saturation
D. reduction of blood PH

5. When a patient develops a temperature of 39.8 degree centigrade after an abdominal

surgery with an ongoing blood transfusion, the PACU nurse should notify the surgeon
as this may indicate___________.
A. abdominal tissue injury
B. ongoing potential infection
C. post –anesthesia drug reaction
D. allergic reaction from blood transfusion

Situation - Nurse Sandy is a member of the research team in a cardiovascular health

facility. One of the research priority problems in her unit is on the “Effects of
Personalized Care management Strategies on stress after an acute myocardial infection
(MI)

6. Nurse Sandy selected a framework which focuses “ that humans are in constant
relationship with stressors in the environment and that nursing is keeping the patient’s
system adjust to wellness which is BEST reflected in _________.

A. Parse’s Human Becoming theory

B. Neuman’s adaptation model
C. Peplau’s psychodynamic Theory
D. Swanson’s theory of caring

7. What type of sampling while Nurse Sandy adopts if when every third (3rd) patients
with MI are selected after a random start?
A. Simple random
B. Systematic
C. Stratified
D. Cluster
8. Nurse Sandy distributed the coded questionnaires to the respondents of the study
without their names on it. What ethical safeguard is being employed in this practice?
A. Confidentially
B. Truthfulness
C. Trustworthiness
D. Anonymity

9. When the findings of the study can be applied to all patients with MI under stress
patients in the whole Philippines, it satisfied which of the following criteria in research?
A. Reliability
B. Validity
C. Generalizability
D. Transferability

10. Nurse Sandy has completed the study and started to make a report to the Research
department. A written brief summary is submitted which is known as _________.
A. narrative
B. abstract
C. critical appraisal
D. monograph

Situation – Communication is a basic competency needed by the nurse in the health

care delivery system as a means of building relationships with patients and significant
others.

11. Mrs. Lim, 52 year old has been in the hospital for almost a week. She approached
Nurse Alma who was doing her rounds and said “ I wish that my children will visit me
today” Your BEST response to the patient is ________.

A. “do you have their cell phones, if you want I can call them”.
B. “just relax, I am sure they will come and visit you today”
C. “you sound to be lonely, do you want me to be with you for a while”
D. there is so much traffic, anyway it is not yet time for visiting hours”.

12. Nurse Linda observed that her patient, who was just admitted for abdominal pain,
looks tense and quite restless. The patient tells the nurse “I am afraid to undergo the
physical examination”. The BEST response of Nurse Linda is ________.
A. “I will inform the physician that you are afraid to undergo the physical examination”
B. “there are several patients waiting for me, the examination has to be done now”
C. “I will call your relative to be with you, while you are being examined”
D. “the examination will not hurt, would you like to sit down first and rest”
13. Ms. Cynthia, a college student is being admitted on and off in the hospital for
Bronchial asthma verbalizes to the nurse “Do you think I should stop attending my
classes? What is the BEST response of the nurse?
A.” Well to me, that is a good decision for now especially with your asthma.
B. You said, you are thinking of stopping form attending your classes?
C. “Let us consult your physician, which one is better for you”
D.” Do you feel that is a good decision for you and your parents”

14. An elderly patient looks depressed, tells the nurse while her blood pressure is being
taken, ”Go away, leave me alone, I Don’t want to talk to you anymore”. The Nurse BEST
response is _________.
A. “Don’t say that, otherwise I will not come and see you anymore”
B. “I will be back in an hour, by that time, you might want to talk to me”
C. “ If you need me, just inform your watcher for some help.”
D. “don’t say that, I will just attend to the other patients in the ward”

15. Patient Alma, is receiving insulin injection for her diabetes. She tells the nurse “ I
don’t want to have that insulin injection anymore.” The MOST therapeutic response of
the nurse is __________.
A. you need the insulin injection now, I will refer you later will not be controlled.”
B. just have your insulin injection now, I will not, I will refer you later to your attending
physician.”
C. you physician will get mad, if you will not have your insulin injection.”
D. let us sit down, I will explain you you, why you have to receive the insulin injection.”

Situation – Nurse Lina is assigned in the Medical ward and has admitted patient Sonia,
a 52 year old accountant, Who was suspected to have of Crohn’s Disease by her
Family physician.

16. Nurse Lina should assess the patient for the presence of _______.

I left lower quadrant abdominal pain

II diarrhea, Unrelieved by defecation
III abdominal tenderness and spasm
IV increase in weight
V excessive fat in the feces
A. II & III
B. II, III & IV
C. II, III, & V
D. I & II

17. The physician in-charge of the patient ordered laboratory and diagnostic studies in
order to confirm its diagnosis. This of the following examination is conclusive of the
presence of Crohn’s Disease?
A. Upper GI series
B. Proctosigmoidoscopy
C. Barium Enema
D. Abdominal radiography

18. During Ms. Sonia’s hospitalization, she had fever, loose bowel movement with foul
smelling odor with abdominal pain. Considering these manifestations, Nurse Lina
should monitor the patient on what specific condition?
A. Hypocalcemia
B. Thrombocytopenia
C. Hyperbulemia
D. Hypokalemia

19. Ms. Sonia was ordered by her physician to have total parenteral nutrition (TPN) to
improve her hydration, skin turgor and improve the overall well being of the patient.
Which of the following nursing measures should Nurse Lina implement to facilitate
positive patients outcome?

I Weighing the patient daily

II Measure intake and output
III Provide relief of pain & discomforts
IV Monitor IV Infusion rate Daily
A. I, II & III
B. I & III
C. I, II, III & IV
D. I & IV

20. The patients is preparing to go home in few days time. What specific health teaching
on HOME PARENTERAL NUTRITION (PN) should be given considering the level of
education of the patient. These include the following EXCEPT _________.
A. use of aseptic technique in changing the dressing.
B. how to store & preparing the solution properly.
C. setting up of the infusion pump safely.
D. flushing the parenteral nutrition line with antibiotics

Situation - In today’s nursing practice, roles have been expanded to include legal
responsibilities and accountability in workplace.

21. Nurse Lina is on duty at the ER and has been very busy that morning resulting to
the administration of penicillin injection which is ordered to another patient. With this
error, the nurse can be charged of ______.
A. malpractice
B. negligence
C. assault
D. Battery

22. Transcription of doctor’s order is a nurse’s responsibility to put the order into action.
Which of the following principles of medication safety is NOT considered to belong to
transcription error?
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. In order for nurses to encounter legal problems in drug administration which of the
following 7 Rights of drug administration, should be implemented under the category of
“Right Drug”? Read the label of the drug ________.
I. three (3) times.
II. before removing from the shelf.
III. Before measuring actual dose.
IV. before opening unit dose -container.
A. II & III C. I, II & III
B. I & II D. I, II, III & IV

24. Nurse edna admits a patient from the ER to the medical unit. The patient is very
restless with IV lines and a urinary catheter. She was put to bed and the nurse
applied a body restraint without the doctor’s order. Nurse Edna’s action can be
liable for ______.
A. invasion of privacy C. Battery
B. Non- maleficence D. neglect

25. Ms. Cruz is a supervisor of the hospital on night shift. Several nurses did not report
due to jeepney strike. When the supervisor is executing proper allocation of nurses
to the priority wards to address this concern, she is observing what type of principle?
A. Beneficence C. Justice
B. non- maleficence D. Fidelity

Situation – Mr. JC 50–year-old is having episode of bronchial asthma and was

examined in the ER by the physician and ordered to be admitted.

26. Nurse Tita admitted the patient and was observed to be dyspneic. Breadth sounds
are diminished upon auscultation. Which INITIAL nursing action should she implement
first?
A. Position him on bed in semi- fowler’s position.
B. Administered oxygen therapy as ordered.
C. Instruct patient to nebulize self if available.
D. Administer bronchodilator as ordered.
27. Based on the health history, the patient is working in a cement factory. This
occupational hazard can bring about asthmatic trigger as a/ an _______.
A. contactant C. infiltrant
B. inhalant D. ingestant

28. The physician ordered Theophylline 300mg. Per day to relieve patient’s asthmatic
attack. Which of the following is NOT mechanism of action of this drug?
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 airway.

29. Select from the following potential ADVERSE effects of theophylline, the nurse
should observe when the drug is taken orally_____.
A. dry mucosal membrane C. irregular heartbeat
B. inability to sleep D. increased blood pressure

30. The patient is preparing to go home with his bronchodilator drugs. He ask the nurse,
how will I know if the drug is effective? Her APPROPRIATE response is, “ there will
be an initial decreased in _______”.
A.allergic reaction C. body temperature
B. breadth sounds D. wheezing

Situation - Noel, a 67 year- old, male, anxious and restless with his condition, was
admitted by Nurse Chona in the medical ward due to chronic back pain, general
weakness and difficulty of breathing. He was attended by the physician and was
tentatively diagnosed with impending respiratory insufficiency secondary to hypoxia.

31. It is important that Nurse Chona records accurately the restlessness caused by pain
and that of hypoxia. Which of the following should be recorded as the restlessness
caused by pain?
A. Difficulty of breathing.
B. Increased respiratory rate and blood pressure.
C. Increased heart rate.
D. increased perspiration and change of position.

32. Nurse Chona read in one nurse’s notes chart this documentation: “ refused to eat
and fell from bed”. Which of the following is lacking in this documentation?
A. Time of complaint, foods missed and reaction on fall incurred.
B. Refferals 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. Charting are important documents that are used in court proceedings Nurse Chona
should take note that the following entry recorded would be MOST defensible 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 emergency room.

34. Which of the following charting rules will keep the nurse legally safe?
I. Documenting worries and all concerns as verbalized by the patient.
II. Charting at the end of the shift only.
III. Discussing of recorded cases and diagnosis of the patient.
IV. Recording all information verbalized by patient and family.
A. III, IV C. I
B. I, III D. II

35. Nurse Chona saw patient Noel reading hid own chart and questions the nurse
why(-) smoking and (-) liquor was recorded when he does not smoke and drink
alcohol? What is the INITIAL explanation of Nurse Chona on the record?
A. Get the chart from and reprimand him from reading the chart.
B. The sign of negative before and the word means he is not drinking alcohol or
smoking cigarettes .
C. Ask patient Noel to apologize 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 advance technological changes on health care.

36. Which of the following is the example of 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 a terminally- ill patient admitted in the
hospital with his spouse.
37. A 70- year- old has been rushed to the hospital due to bradycardia and palpitation.
The physician suggested that pacemaker be inserted to correct the symptoms.
The patient voluntarily decides not to have the pacemaker inserted. This is respected by
the family. This is an example of what ethical principle?
A. Beneficence C. Fidelity
B. Autonomy D. Justice

38. The Er nurse clarifies the doctor’s prescription on the dose of the pain medication
base on the pain scale assessment and patient’s age. Which ethical principle is
applied?
A. Fidelity C. Justice
B. Truthfulness D. Non- maleficence

39.Nurse Pat promised to a post- surgical team, that she would come back to assist in
his ambulation after carrying out the physician’s order. This follows the principle
of______.
A. Beneficence C. Autonomy
B. Justice D. Fidelity

40. When a nurse supports the welfare of the patient in relation to health , safety and
personal rights, the ethical principle followed is ______.
A. Responsibility C. Autonomy
B. Accountability D. Advocacy

Situation - Nurses Dina is caring for several patients in the medical unit mostly
sufferings from endocrine disorders Evelyn, is a 45 years old, government employee
who has been diagnosed by their doctor to be suffering from graves disease. Based on
her health history she has been having insomia, , palpitation and heat intolerance.

41. A classic finding that Nurse Dina would expect to find in addiction to the above
complaints which is SPECIFIC to her condition is ____

A. Decreasead libido C. Infertility

B. Exopthalmos D. Hoarseness of the voice

42. Select the two (2) primary laboratory test findings ordered by his physician that will
confirm that patient evelyn has graves diseases.

1 decreased TSH levels

11 Elevated free thyroxine levels
111 increased TSH levels
1V. Decreased free throxin levels

A.11 &1V C. 1 &11

B. 111 &1V D. 11 & 111

43. Choose from the listed drug therapy that should be administered to Ms. Evelyn in
order to inhibit the synthesis of thyroid hormones and block the conversion of T3 and
T4___
A. Adrenergic blockers (inderal)
B. Radioactive iodine (RAI)
C. Sevothyroxine (synthroid)
D. Propyl thiouracil (Propyl Thyracil)

44. While Ms. Evelyn is being prepared physically and physiologically for possible
thyroid surgery, her nutritional needs was also being met wit a die that is__

A. High fibrous, low protein, high CHO

B. High caloric, high CHO, low protien

C. High caloric, high CHO, and protien

D. High protein, low Vitamin A &C

45. MS Evelyn underwent thyroidectomy she complained of numbness of the finders,

toes and twitching of the mouth, this is likely caused by __

A. Thyrotoxic crisis C. Hypo thyroidism

B. Hypo parathyroidism D. Infection

Situation - Mr. Santi a salesman was admitted because of severe abdominal pain.
Based on the data gathered, he smoke and drink 3-4 bottles of beer every day. He
appeared jaundice, dyspeic with enlarged abdomen. The physician suspected that he
has a liver disorder abdomen. The physician suspected that he has a liver disorder and
beginning esophageal varice.

46. Which of the following clinical manifestation is not included in client with hepatic
disorder?

A. Indigestion C. Nausea and vomiting

B Diarrhea D. Abominal bloating

47. Liver function test was ordered. In a damaged liver the following tests will reveal

1. Prothrombine time is prolong.

11. Albumin level is ordered

111. Globulin level is decreased

1V. Amonia level is decreased

A. 1 and 11 C. 1 only
B. 1.11 and 111 D. 1.11.111 and 1V

48. Mr. Santos esophageal varices bleed. His doctor ordered sengstaken- blakemore
tube to stop bleeding. Two hours after, the client develop difficulty of breathing. What
PRIORITY action should the nurse undertake?

A. Monitor vvital siign

B. Asked client to take a deep breath

C. Defflate the esophagel baloon

D. Call the physician at once

49. In client with esophagel varices which of the following doctors order do you
anticipate?

A. Monitoring progression of anxiety

 B. Observe signs of epistaxis

C. Monitoring urine output

D. Preparing client for blood transfusion

50. Which of the following medication is likely to be given to quickly stop bleeding from
esophageal varices____

A. Neperidine C. Aldactone

B. Furosemide D. Vasopressin

Situation - Mr. leo, an insurance agent was ordered by his physician to be admitted to
the hospital for coronary artery Bypass Graft (CABG) due to three vessels blockage.

51. As a nurse, you are aware that cardiac surgery is a source of stress to the patient
and family. Which of the following strategies should the nurse implement FIRST to
overcome this stress?

A. Identity ccoping mechanism helpful to the patient and family embers

B. Recognize fears and concern regarding surgery and future health status.

C. Explore support system available during the entire hospitalization period

D. Reinforced understanding of the surgical procedure, hospitalizaton and recovery

52. Mr Leo, underwent an invasive diagnostic test to determine the location of the
blockage which is needed for his CABG. Thi procedure is ___

A. Cardic CT scan

B. Carotid doppler

C. Magnetic resonance imaging

D. Cardiac catherization
53. The nurse is teaching breathing exercise to Mr. leo At what phase of the peri-
operative care is this best performed?

A. After surgery when an in inside the recovery room

B. Immediately after he has signed the informed consent

C. During the briefing period prior to the surgical procedure.

D. When he is back to his room from the recovery unit

54. Which of the following is a blood thinning drug and temporarily stopped by the
physician prior to CABG due to possible bleeding?

A. Prodexal C.Aspirin

B. Ibuprofen D. Toradol

55. The nurse formulate a nursing diagnosis Decreased cardiac output R/T Blood loss
which of the following is the highest priority nursing action?

A. Auscultate for heart sound and rhythm

B.assess peripheral pulses, pedal , tibial, and radial

C. Monitor EKG pattern for cardiac dysrhythmia

D. Assess arterial blood pressure every 15 min. Until stable

Situation - Venus, 32 year old a government employee has been having abdominal pain
which was on and off for almost 6 months. She has been having flatulence, and recently
lost weight because of vomiting. She consulted their office physician and she was
suspected to be suffering from chronic pancreatitis. She was advice to be hospitalized
for further work-up.

56. You are the admitting nurse when Ms. Venus arrived in the hospital. When doing a
comprehensive pain assessment, you should conduct the procedure during the ___

A. Evaluation of nursing pain management

B. Initial contact with the patient

C. Course of pain management

D. The time the physician instructed you to do

57. When a patient is having pain due to pancreatitis, you expect that the pain is located
in the ___

A. Hypogastrium, right upper quadrant of the abdomen radiating to the left lumbar area

B. Epigastrium, right upper quadrant of the abdomen radiating to the left lumbar area

C. Hypogastrium, left upper quadrant of the abdomen radiating to the left lumbar area

D. Epigastrium, left upper quadrant of the abdomen radiating to the left lumbar area

58. You are aware of several manifestation when a patient is in pain. Which of the
following is a behavioral response to pain?

A. Changes in skin color

B. Increase in blood pressure

C. Depth in respiration

D. Moaning and grimacing

59. When a patient is ordered corticosteroids, which of the following drugs will produce
therapeutic effects of reducing pain?

A. Spironolactone C. Atropine S04

B. Diazepam D. Prednisone

60. When severe vomiting occurs in this patient, it results to what particular condition?

A. Hyperkalemia C. Alkalosis

B. Hypocalcemia D. Acidosis
Situation - Collaboration and team work are critical to the success of health care
operations

61. Which of the following statements is INCORRECT of collaboration in health care

setting?

A. Trust and respect are core values of a collaborative organization.

B.A shared vision is essential for collaboration in any health care operations.

C. Successful conflict resolution can help collaborative teams overcome differences.

D. Inter professional Collaboration multidisciplinary collaboration can be used

interchangeably.

62. Nurse Lyn Received an order from attending physician Of patient pillar who was
having a severe abdominal pain of almost a double dose of morphine SO4 the nurse
consulted her and tell the manager and the pharmacist regarding the order which was
also questioned. The nurse called the attention of the physician regarding the dose of
the drug and changed the order to an acceptable level what relevant principle of
collaboration is applied in this case?

I.Shared vision

ll.respect and trust

lll.communication

lV.Interpersonal relationship

A.I,ll,lll, and lV

B.lll, and lV

C.l and ll

D.I,ll, and lll

63. In a tertiary hospital Where Gio works as unit manager, An interdisciplinary team
model is adopted on collaboration of care, With this type of model how is decision
making made?

A. Shared responsibility of the group for the problem solving final decision

B. One person makes the final decision for the treatment.

C. Partnership with the patient and team for the final decision.

D. All members work together for both alternative and final decision.

64. Nurse Ime, Is a member of the quality assurance team of the hospital and has been
always rated as very assertive which of the following is Not a characteristic of an
assertive person?

A. Intervene with the situation calmly and confidenty

B. She stands up with what she believes and push control on others

C. Articulate clearly the importance of nursing perspective.

D. Use “I” when Stating thought and feeling and “you” when persuading others.

65. A patient is going for a coronary artery bypass graft (CABG) due to a 4 black arterial
blood vessels.A Surgical team has been formed with the cardiac surgeon as the head
who is a member of the health team that prepares the preoperative orders for the
patient?

A. Cardiologist

B. Anesthesiologist

C. Surgeon

D. Medical internist

Situation - Roy, 65 years old came to the outpatient clinic due to dyspnea,fever And on
and off productive cough he smokes one pack of cigarettes per day for the last 30
years.The doctor ordered sputum examination, chest x-ray and blood culture.
66. In collecting sputum specimen The nurse should it should instruct Roy to

A. Breath slowly cough and expectorate into the specimen

B.Breath deeply and cough expectorate into the sputum container

C.Cough and expectorate saliva into the specimen container

D. Cough and expectorate Into the specimen container

67. The patient’s diagnostic test revealed he was Positive for bacterial pneumonia the
most like the causative Organism of this type of pneumonia is

A. Legionella pneumoniae

B.Mycoplasma pneumoniae

C.Streptococcus pneumonia

D. Hemophilus pneumoniae

68. The nurse did an admission procedure the best position to be assumed by Roy is

A. Left lateral position with the affected side inferior

B. Sime fowler position at least 30 degrees

C. Dorsal position with pillows under the chest

D. Lying on his side the affected side of the lungs should be superior

69. When a patient is diagnosed to have pneumonia the breath sound detected by the
nurse on auscultation of the affected area would be

A. Wheezing sounds

B. Stridor

C. Fine crackles

D. deep and low-pitched breath sounds

70. When there is respiratory depression resulting from drug overdose the nurse have
to watch for which of the following?

A. Hyperventilation

B. Tachypnea

C. Biot’s respiration

D. bradypnea

Situation - Ms bel 66 years old consulted the opd due to changes in energy level fatigue
and not able to tolerate performance of activities of daily living the physician suspected
that she has hypothyroid disorder and advised admission for further work-up.

71. When a patient is with hypothyroidism the assessment findings of the nurse that is
not present is

A. Brittle nails

B.Hair loss

C.dry skin

D. Fine tremors of hands

72. In assessing the thyroid gland for size, shape symmetry, consistency and a
presence of tenderness, the most appropriate examination modality is

A. Auscultation

B.percussion

C.palpation

D.inspection

73. After several thyroid diagnostic tests,Ms bel was ordered to take thyroid hormone(
levothyroxine). Which of the following nursing actions is not advisable in Administering
this drug? the nurse should give?

A. A single dose daily before breakfast.

 B.A single dose daily after breakfast

C.it with a full glass of water

D.it without mixing with fruit juices

74. In monitoring the effectiveness of the drug therapy which of the following is not
expected as a positive patient outcome?

A. Regular bowel function

B. excessive sweating at night time

C. Participates in self care activities

D. Metabolism returns to normal

75. The nurse in developing a nursing care plan for Ms Bel if the nursing diagnosis is
“activity intolerance related to fatigue and depressed cognitive process which of the
following is an appropriate intervention?

A. Increase mobility through early ambulation

B. Allow self care activities with active Exercises

C. Space nursing activities to promote rest and sleep

D. Avoid a stimulating interesting conversation

Situation - Resources in healthcare delivery system are one of the challenging concerns
of nursing leadership in the country today. nurse gayle is a unit manager in a tertiary
hospital and conducts meeting regularly every two weeks to her staff to address priority
affecting their services.

76. Which of the following statements indicate an effective communication technique

used by the unit manager to her staff?

A. “We need to improve our nursing services otherwise top management will take over”
B. “Let’s limit requesting supplies and equipment our budget for our promotion might be
affected”

C.” There are a lot of redundant positions in our unit there is a need to retrench some
stuff”

D. “We need to discuss strategic approaches to facilitate delivery of nursing services

with less expense on our consumers”

77. For the past six months several nurses are resigning some have verbalized in the
exit interview that there are not happy anymore which of the following descriptions
manifest best a nurse who has job satisfaction?

A. Competitive, self centered euphoric

B. Empowered, enthusiastic,ethical

C. Loner,egoistic,reactive.

D. Outgoing ,sensitive ,competitive

78. Delegation is A critical component of leadership and governance Which of the

following empowering Activities should the unit manager applies in delegation?

A. In delegation facilitating professional growth and development of a staff is necessary.

B. When delegating I responsibility to a nursing staff modification of standards of care

is permitted.

C. Delegation of responsibility in patient care has to start from top management to the
staff nurse level.

D. Delegation requires responsibility with corresponding accountability of staff nurse.

79.Nurse gayle is guided that the initial step of delegation is?

A. Demonstrate the task and let the staff continue the next activities

B. Assess the capability of the staff change him if not performing

C.Determine the competency level of the staff-for the task being given
D.Explain the the task to be done with the companying job description

80. The unit manager is planning to take her regular official business leave for the
year-she has written a letter of recommendation to her immediate supervisor for her
assistant unit manager to assume her position while she is on leave. This is example of
delegation by______:

A.Rank

B.authority

C.succession

D. Authority

Situation – Nurse Adela is on duty in the medical unit and has two patients for
discharge.
Eliza, 38 years old diagnosed with Diabetes Mellitus and on insulin therapy for the first
time and Aileen, 42 years old who had myocardial infarction (MI)

81. When preparing a teaching plan for patient Eliza, the following are the instructions
provided to patients with Diabetes Mellitus. Which ONE of the teaching plan is
considered NOT a PRIORITY concern when discussing the list with the patient?
A. Dient and genetic counselling.
B. Exercise in extreme heat and cold.
C. Regular exercise, diet and medications.
D. Monitoring of blood sugar and urine ketones.

82. Eliza was taught by Nurse Adela on how to administer self-injection insulin and
rotation sites with the use of the chart every day till her discharge.The following is the
procedure for the Self – injection of Insulin. Which of the following are the CORRECT
sequence in the self administration of the drug?

I. Inject the insulin, push the plunger all the way in

II. With one hand stabilize the skin by spreading a large area
III. Pull the needle straight out of the skin & press cotton ball over injection site
IV. Pick-up syringe with the other hand, hold and insert needle to the skin.
V. Dispose syringe in the hard plastic container.

A. I, IV, III, & V C. III, II, I, V & IV

B. II, IV,I, III & V D. IV, III, I, V & II
83. The doctor ordered a low- saturated fat, low- cholesterol diet to patient Eileen who
was also going home. From the following list of foods, which meals has to be included in
the instructional plan of Nurse Adela to her patient?

A. Pork steak, mixed vegetables with butter and cheese.

B. Hamburger, macaroni salad and milk shake.
C. Fried chicken, green beans, and skim milk.
D. Baked fish, green beens, coffee

84. Considering that patient Eileen is a post MI patient, she was taught by the nurse on
home exercises on leg movements while resting on bed. The expected goal of this
intervention is to______:

A. facilitate better digestion is to _____.

B. Prevent stasis of urine and stone formation
C. facilitate circulation for skin integrity
D. prevent venous stasis in the lower extremities

85. The resumption of sexual activity is an important activity that has to be included in
the home instructions to be given to patient Eileen together with her husband.Which of
the following is the SAFE period for an complicated MI to resume sexual activity?

A. One month after MI

B. 12 to 14 days after MI
C. Two months after MI
D. 7 to 10 days after MI

Situation – MO, a 22 –yr old nurse graduate, passed the November 2018 Philippine
Nurse Licensure Examination before her birthday which is November 16. The scheduled
oath-taking ceremony was set on January 6, 2019.

86. To obtain her license to practice, she must do the following, EXCEPT:

A. Must take the oat to any government official

B. Must Register in the registration division of the PRC
C. Must take the oath of professional before any member of the PRBON
D. Must be issued a certificate of Registration(COR) and profession identification
card (PIN)

87. Nurse Merle has to renew her license on before ______.

A. January 6, 2021 C. November 16, 2021

B. November 16, 2022 D. January 6, 2022

88. For the Nurse Merle to continually practice nursing, she must satisfy the
requirements set by the PRC and comply how many units of CPD upon renewal?
 A. 45 units C. 25 units
B. 10 units D. 15 units

89. After 3 years being assigned in the Operating Room, Merle in interested to actively
join which appropriate professional organization?

A. ORNAP
B. NLGN
C. ADPCN
D. APO

90. What would Merle do to keep abreast with the latest trends in peri-operative
nursing?

A. Attend training and seminars

B. Perform researches
C. All of these
D. Pursue graduate studies.

Situation – A computer analyst of a company, was rushed to the Emergency room due
to
abdominal pain, nausea and vomiting, ascites and shallow breathing due to enlarged
abdomen. The physician suspected that the patient is suffering from peritonitis and was
advised to be admitted for further workout.

91. In assessing a patient suffering from peritonitis, which of the following

manifestation is NOT likely to be present?

A. Rebound tenderness
B. Abdominal gas
C. Abdominal guarding
D. Abdominal regidity

92. The overall goals set by the members of the heath team once the patient is admitted
include Which of the following?

I. Relief of the abdominal pain

II. Resolution of inflammation
III. Provision of normal nutritional status
IV. Prevention from complications

A. I, II, III
B. I & II
C. II & III
 D. I, II, III, & IV

93. Diagnostic test were ordered to the patient which included: complete blood count
(CBC) and abdominal CT scan. The primary purpose for ordering CT scan is to
determine PRESENCE of_______.

A. Amylasse content
B. Bacteria
C. Fluid shifts
D. Abscess

94. Which of the following drugs do you expect be ordered by the physician for severe
acute pain?
A. Acetaminophen (Tylenol)
B. Levorphanol (Levo-Dromoran)
C. Percodan (Aspirin)
D. Codeine (Ambenyl)

95. The physician ordered the patient for paracentesis. Which of the following
pre-procedure nursing actions should the nurse perform EXCEPT______.

A. place him in upright position on the edge of the bed.

B. place him in low-lying position with knees straight
C. Check for the signed consent form
D. Instruct patient to urinate to empty bladder

Situation – Jen is an active member of the Quality Assurance (AQ) team in a health
facility Where the major role is setting Quality Standards.

96. Which of the following statements is TRUE of Quality Improvement?

A. Focuses on the organizational structure than patient care.

B. Continually improve every process in the organization.
C. Centered on people rather than processes.
D. An approach that is externally driven by the stakeholders.

97.As a QA nurse, which of the following can Nurse Jen adopts as a concurrent
evaluation of patient’s outcomes in the unit?

I. Direct observation of patient’s condition.

II. Patient’s interview in the unit.
III. Face to Face interview with nursing staff.
IV. Nursing audit from the patient’s chart.

A. III & IV
B. I, II, & III
 C. I, II, III,& IV
D. I, & II

98. Nurse Jen, distributed the patient satisfaction form to the admitted patients in the
hospital, this tool is in complience to the ______ quality standards.

A. human resource
B. organizational structure
C. patient care
D. legal – ethical

99. The QA team was alerted by the Administration, that they have to anticipate for a
possible Earthquake in the forthcoming days. As part of the Safe Practice Environment
(SPE)
standards, which of the following are to be given PRIORITY attention by the team?

I. Electrical Wires
II. Combustible materials of the building
III. Entry , Exit
IV. Infected waste materials

A. I, II, III, & IV

B. II, . & II
C. I, & II
D. I, II, & III

100. The QA team has bombared by complaints of patients on their long waiting period
in the OPD , before the health care professionals are examining them. In response to
this concern, which type of quality assessment should the team implement?

A. Outcome evaluation
B. Process evaluation
C. Ongoing evaluation
D. Structure evaluation
NURSING PRACTICE IV: Care of Clients with Physiologic and Psychosocial Alterations, Part B

Situation - Research is a vital endeavor nurses must engage into in order to contribute
to nursing science

1. When the nurse researcher collects data at more than one point over an extended
period, which design is applied?
A. Cross-sectional
B. Time-related
C. Time sequenced
D. Longitudinal

2. If a research study involves an intervention and “blinding” which research design

is being referred to?
A. Non-descriptive
B. Phenomenological
C. Experimental
D. Descriptive

3. Which of the following statements is LEAST descriptive of a qualitative research

design?
A. Researchers become involved.
B. Gather data from one collection strategy.
C. It is flexible and elastic.
D. Strives for an understanding of the whole strategy.

4. Qualitative researchers should choose their participants who can best meet the
objectives of the study. Who of the following BEST qualifies? (PURPOSIVE
SAMPLING)
A. Cooperative person in the community
B. Those readily available thus convenient for the researcher.
C. Able to articulate and reflect on the phenomenon that they experienced.
D. Parsons referred by friends.

5. A “full understanding” in research should be understood by the nurse researcher

as___.
A. ensuring that participants are not placed at risk
B. explaining the study including risks and benefits
C. the right to decide voluntarily
D. not exploiting information shared by participants
Situation – Management of records is very vital in any health care facility. The nurse
must ensure there is due diligence in the task.

6. Nurse Gay is assigned in the Medical Unit. She is guided that in documentation, she
should use abbreviation that is ____.
A. used automatically to save precious time.
B. reduced to the minimum in all units.
C. approved standard list by the hospital.
D. not used at all because it can be misinterpreted.

7. One error in record-keeping is illegible handwriting. What is the APPROPRIATE

action by the nurse in this situation?
A. Request the senior nurse to read the order for you.
B. Let the resident-on-duty in the nurses station interpret it.
C. Call the physician who made the order.
D. Report the lapse to the Quality Assurance Committee.

8. When a nurse commits an error in the progress notes the BEST action she should do
is to _____.
A. cross the error many times to ensure it could no longer be read and sign.
B. delete the erroneous phrase or sentence using correction fluid and sign.
C. put a line across the sentence, Make the correction over it, and sign.
D. erase whatever is in error using a rubber eraser and sign.

9. Which is NOT a correct statement regarding record-keeping?

A. Failure to do it could be evidence of professional misconduct
B. It is an optional task to be done when circumstances allow.
C. It is a tool in professional practice that helps provide quality care.
D. it is part of the professional duty of the nurse.

10. The QA nurse conducts a regular audit of the medical records. The PRIMARY
purpose of conducting an audit in a health facility is to _____.
A. identify errors made by health personnel.
B. identify areas for improvement
C. ensure that standards are met.
D. promote risk management.
Situation – Health Education to Bong and his family is set up prior to surgery. A program
of weight gain aims for a high protein and high calorie diet. The nurse prepares the
health education plan.

11. The nurse ensures, which of the following should be present and be cooperative in
the educational program?
A. Patient, student nurses and interns
B. Patient, family and significant others
C. Head nurse and family
D. New staff nurses and nursing aides of the unit

12. The nurse must include in the education plan, which of the following components?
(select all that apply.)

I. Objectives
II. Content and time allotment
III. Teaching and learning resources
IV. Evaluation parameters
A. II, III, and IV
B. I, III, and IV
C. I, II, III and IV
D. I, II, and III

13. To have a simplified and more understandable implementation of the plan, the nurse
presents it with use of ____.
A. printed content in cartolina
B. a lecturer
C. a co-worker
D. colored pictures

14. Before the education plan of the staff nurse can be finalized and implemented, it is
BEST that it is reviewed by the _____.
A. Nurse supervisor
B. Medical Director
C. Head Nurse
D. Chief Nurse

15. During the implementation process, the nurse should ensure a____ for a better
assimilation of the teaching.
A. serious lecturer
B. Lecture to start at 11:00Am
C. conducive time and place
D. neophyte as sharer

Situation - Nursing student Myra decides to do a qualitative phenomenological study on

how the stigma of AIDS affects the patients. She has previously identified 6 participants
3 teenage boys and 3 teenage girls.

16. What is the BEST way for Myra to collect data from these participants?
A. Focus group discussion
B. Survey, questionnaire
C. Individual interview
D. Observation

17. What kind of sampling method should she apply?

A. Network
B. Random
C. Stratified
D. Purposive

18. The statements of the findings of the study that will be formulated by Myra should be
by_______.
A. summarizing the sharings of the participants of both sexes
B. identifying the answers of the males and the females
C. describing answers of the males and females by percentages
D. extracting meanings and themes from significant statements

19. Informed consent in this study will be obtained by Myra from the______.
A. six participants only
B. parents only
C. six participants and available relative
D. six participants and their parents

20. What is NOT important for Myra to do when listening to tape recordings?
A. Do the listening as soon as possible after the interview.
B. Note for the voice tone and voice inflection.
C. Listen when she feels the motivation for a more productive time.
D. Take notice of the pauses of the participants.
Situation - Communication is very important in a nurse-patient interaction relationship.

21. It is not enough for the nurse to listen, but she also has to validate what she has
heard. The importance of validation are the following, EXCEPT __________.
A. perceptions influence the interpretation of a message
B. most patients are cognitively impaired
C. Eye contact does not necessarily send the same message
D. assists clarifying thoughts

22. To be more responsible, a nurse needs to understand the elements of the

communication process. When she initiates interpersonal communication, the element
involved is __________.
A. referent
B. sender
C. message
D. channel

23. Should the nurse encounter patients who are stresses due to their health condition,
the BEST way to communicate is through which one of the following?
A. Sympathizing
B. Empathizing
C. Sharing
D. Listening

24. The reasons for the nurse wishing to enhance his/her communication skills is to be
able to establish Rapport, EXCEPT __________.
A. brings about change to promote well-being of patients
B. decreased incidents of legal problems
C. gets better evaluation rating of care and delivery
D. generates threat between the nurse and the patient

25. When the nurse interacts with patients face-to-face such as in getting information
during the assessment phase of the nursing process, the level of communication is
which of the following?
A. Intrapersonal
B. Interpersonal
C. Public communication
D. Verbal
Situation – It is necessary that records are well-recorded and properly kept if they are to
serve the organization and the requesting public well.

26. Incident Reports (IRs) shall be collected for the day and due investigation, the IRs
_____.
A. must be completed and stored on the open cabinet
B. can be stored on the table top for easy retrieval
C. must be summarized monthly and stored in a secured cabinet
D. classified by date so they can be easily accessibility

27. The patient record (charts) are collected every three nights from the various
departments. The night nurse is EXPECTED to do the following, EXCEPT, _____.
A. ensure t he correct order of the chart
B. see to the completeness of the chart pages
C. bind the charts as they are
D. tape or repair torn pages

28. When patient record reach the Medical Records, the assigned staff will _____.
A. store the charts in their respective shelves
B. separate the medico-legal chats
C. check the completeness of the charting of the doctors and nurses
D. bind the chart immediately

29. The charts are stored in the Medical Records or storage room for at least
_____years.
A. 3 – 5 years
B. 1 – 5 years
C. 5 – 10 years
D. 1 – 3 years

30. How many years are medico-legal charts stored?

A. 8 years
B. 10 years after the case is closed
C. 5 years
D. 10 years

Situation - Health education on HIV-AIDS has been massive in the years prior, yet
patients and their relative still have a number of queries and misconceptions about it.
Lerma, a young mother of 34, has been recently diagnosed of the disease.
31. Lerma is aware that there is mother-to-child transmission of HIV-1. She becomes
concerned and asks the nurse when it specifically happens. The nurse answers that it
can occur in the following circumstances, EXCEPT _____.
A. during breastfeeding
B. during casual contact
C. at the time of delivery
D. In utero

32. Lerma would like to know how she could limit further exposure to more HIV virus by
using preventive measures. The nurse inform her that the use of a highly effective male
condom that can decrease the transmission of HIV is _____.
A. Non-latex
B. Latex
C. polyurethrane
D. lambskin

33. Patient Lerma has a CD4 lymphocyte count which is below 200 cells/cumm. She
then asks what it means. The nurse answers that _____.
A. the result still falls within normal limits
B. she is in Stage 3 HIV-AIDS
C. it is slightly below normal but there is nothing to worry
D. it is worrisome result but immediate attention is not necessary

34. The nurse counsels Lerma that the prevention of HIV infection that is usually NOT
REALISTIC is which one of the following?
A. HIV testing
B. Behavioral interventions to reduce risks
C. Total abstinence
D. Linkage to a treatment center

35. Nurses are at risk for HIV exposure. Post exposure prophylaxis (PEP) DOES NOT
include one of the following?
A. Take 2 – 3 anti – retroviral drugs, as prescribed.
B. Drugs must be taken for 28 days
C. Drugs must be taken for at least a week
D. Take the medicine within 72 hours of exposure.

Situation – The Quality Department has received numerous complaints, some of them
on patient falls.
36. Nonah who is an 86-year-old patient is admitted for fever fell from the bed despite
the presence of a watcher. The Head Nurse was concerned since a fall protocol has
been formulated for some time now. To avoid similar incident, which of the following is
MOST effective?
A. Interview the patient
B. Interview the nurse-on-duty
C. Investigate everyone
D. Do a root cause analysis

37. The nurse informed the Head Nurse that the lock in the side rails does not work
properly at times and might have gotten loose in the night thus the incident of fall. What
is the APPROPRIATE thing for the Head Nurse to do in this regards?
A. Penalized all the nurses for not having reported such defect.
B. Make a memo to the Maintenance Department to check involved bed and the rest of
the beds.
C. Punish the nurse-on-duty for not reporting such observation before the incident.
D. Warn every one this is not going to be tolerated in the future.

38. The Quality Improvement Officer – in – charge of the unit plans to conduct a
meeting with the staff. The MOST important thing to tackle is to _____.
A. inform them of their punishment
B. review the protocol
C. inform them their lapses
D. scold those involved

39. What is the INITIAL action that the nurse should do immediately after the fall
mitigate the situation?
A. Document the incident right away.
B. Phone the Head Nurse to report the incident
C. Wait for the Head Nurse’s advice.
D. Have a doctor assess the patient immediately.

40. What lesson will the nurse learn from this incident?
A. Tell the others to cover her up.
B. Safety first – report even trivial but relevant observation.
C. Deny any error or omission.
D. Never get caught in her omissions.
Situation – Nilda, 58 years of age, was brought to the ER because of numbness on her
left face and arm and a confused mental state. The ER doctor made an initial
impression of ischemic stroke.

41. Nilda wonders how she developed the manifestation of ischemic stroke. The nurse
explains that there is _____.
A. extravasation of blood into the brain.
B. possible presence of a cerebral aneurysm.
C. vascular occlusion to the brain
D. inability to understand spoken language

42. The nurse knows that visual-perceptual disturbances can occur in stroke. When
patient Nilda manifests hemianopsia, she has _____.
A. inability to perform everyday movements and gestures.
B. blindness in half of the visual field
C. difficulty speaking
D. inability to understand spoken language

43. The nurse knows that initial diagnostic test that is ordered for stroke is _____.
A. Carotid ultrasound
B. 12-lead ECG
C. Magnetic Resonance Imaging (MRI)
D. CT scan

44. The ER nurse anticipates that a thrombolytic agent would be ordered to treat
ischemic attacks. knowing the action of thrombolytic, the nurse must particularly be alert
for which adverse reaction?
A. Formation of blood clots
B. Bleeding
C. Early onset of infection
D. Allergies

45. Patient Nilda complains of shoulder pain. The nurse is aware that she is prone to
have adduction of the shoulder. A nursing intervention for this is to _____.
A. position distal joint higher than proximal joint
B. place a pillow under the arm to keep the arm close to the chest
C. position the fingers so that they are barely flexed
D. place one pillow in the axilla to keep the arm away from the chest.
Situation – Emmy, 22 years of age is a midwife in the OB ward is now complaining of
contact dermatitis from gloves.

46. Patients like Emmy who have experienced delayed hypersensitivity to latex
FREQUENTLY complains of _____.
A. flushing, bronchospasm
B. urticaria, laryngeal edema
C. rhinitis, conjunctivitis, blisters
D. papules, vesicles, pruritus

47. The nurse knows that the diagnosis of contact latex allergy is based on history and
_____.
A. Latex specific IgE
B. finding IgE in serum
C. skin patch test
D. ELISA

48. Latex allergy can be a type I IgE-mediated immediate hypersensitivity to plant

proteins from the latex of rubber. It can manifest in its MOST sever form as _____.
A. Pruritus, erythema and swelling
B. Asthma
C. Anaphylaxis
D. Blisters and other skin lesions

49. Type I IgE-mediated immediate hypersensitivity reaction is promptly manged with

_____.
A. theophylline
B. epinephrine
C. corticosteroid
D. dephenhydramine

50. The best prevention management of contact latex allergy is _____.

A. applying lotion before gloving
B. avoidance of latex products
C. avoiding rubberized goods
D. resigning from the job

Situation - Sins of omission and commission may be committed by the nurse the
course of her duty. She must therefore be extra careful.
51. The patient for breast biopsy is very anxious and seemed not to understand her
ordered surgery, radical mastectomy. What is the APPROPRIATE action by the
nurse?
A. Call the supervisor to explain the procedure.
B. Have the available resident explain the surgery further.
C. Request the doctor to give the patient more information.
D. Supply the information missed to be explained by the doctor

52. The patient refused his intramascular injection but the nurse proceeded to
administer it anyway. What con the nurse be accused of?
A. Moral distress
B. Trespass to person
C. Assault
D. Battery

53. The staff nurse was doing prescribed modified steam inhalation to a pediatric patient
which resulted to burns. What is NOT a RELEVANT statement to establish negligence?
A. There is a duty to care.
B. There is a breach in the standard.
C. The breach caused the harm.
D. It was a verbal order by the physician.

54. Staff nurse A told her co-workers that staff B is suffering from gonorrhea. What can
staff A sued for?
A. Defamation
B. Slander
C. Discrimination
D. Libel

55. The surgical patient, a Jehovah’s witness, reiterated non-acceptance to a blood

transfusion. The nurse defied it and the patient was transfused intraoperatively. What
case can be filed by the patient?
A. Moral distress
B. Battery
C. Trespass to person
D. Assault

Situation – Nurses must closely adhere to the ethical principles and rules, and not only
to the laws.
56. When the nurse ensures that patients have consented to all treatments and
procedure, she is TRUE to which ethical principle?
A. Fidelity
B. Beneficence
C. Veracity
D. Autonomy

57. If the nurse will refuse to perform duties for which she is not qualified, she is
practising _____.
A. veracity
B. beneficence
C. respect
D. non-maleficence

58. The Code of Ethics stipulates that human life is inviolable. Which statement
CORRECTLY translates the principle to the situation of the Filipino nurse as a
professional?
A. It is okay to participate in euthanasia provided there is a doctor’s order.
B. Participation is permissible when patient, family, and doctor’s order.
C. After the patient, doctor and hospital administrator have agreed, nurses may choose
to participate
D. Nurses shall not participate in euthanasia.

59. When the physician insists that his cancer patient undergoes radiation, in addition to
chemotherapy which is CONTRARY to the patient’s and family’s wishes,
the physician is exercising _____.
A. veracity
B. autonomy
C. fidelity
D. paternalism

60. An Iranian was admitted to the hospital for kidney transplantation. He claims his
donor is a Filipino relative as required by the law. However, it was discovered later
that his claim was not true. Should the doctor fail to act accordingly to the wrong
information, the nurse is obligated to refer the case to, which of the following?
A. Medical Director
B. Administrator
C. Chief Executive Officer
D. Ethics Committee
Situation – The nurse conducts health education on common types of allergy with the
parents of allergic children and adults with hypersensitivity issues.

61. During the conduct of the health education class, which communication skill involves
active listening that is being used by nurse to gain an understanding of the patient’s
message?
A. Clarifying
B. Responding
C. Attending
D. Confronting

62. The nurse must be alert about BARRIERS to communication during the health
education class so that she can ______.
A. use them when communicating
B. communicate much better
C. use them to enhance interactions
D. rationalize wrong styles of communication

63. The mother of the atopic dermatitis patient is very concerned about scarring that
will result from the child’s frequent scratching. How will the nurse BEST communicate
her reassurance?
A. Asking the mother what she prefers for the child to have scars or he be unable to
sleep?
B. Telling the mother matter of fact that scars will lighten as the child grows older
anyway.
C. Tapping the hand of the mother while explaining that scarring occurs only when
lesions get infected.
D. Reminding the mother that beauty is only secondary to comfort derived from
scartching.

64. Because of the presence of skin lesions, atopic dermatitis affects the patient’s
self-esteem and his willingness to interact with others. The nurse communicates her
nursing intervention by _____.
A. instructing the patient to go back to the primary physician
B. giving instructions and counseling on preventive measures and treatments.
C. referring the patient to the dermatologist
D. referring the patient to the psychologist

65. The adult patient who was receiving diphenhydramine (Benadryl) verbalized he was
always sleepy and fears he would sleep on the job and will get fired. The nurse
will BEST calm the patient by assuring him that his physician can readily change his
medicine to _____.
A. chlorpheniramine (Acrifed)
B. brompheniramine (Dimetapp)
C. loratadine (Allerta)
D. dimenhydrinate (Dramamine)

Situation – Susie, 5 years old, is diagnosed with nephrotic syndrome and is manifesting
massive proteinuria massive proteinuria resulting to decreased albumin in the blood.

66. The nurse understands that the passage of protein in the urine is the result of
_____.
A. inherited kidney disorder
B. increased glormuerular permeability
C. rise in the production of albumin
D. intrinsic kidney disease

67. Upon clinical assessment, the nurse observes that the OUTSTANDING
manifestation of the patient is _____.
A. weight gain
B. obesity
C. emaciation
D. edema

68. The physical appearance of the urine of the patient with nephrotic syndrome is
COMMONLY _____.
A. cloudy
B. clear
C. whitish
D. Frothy

69. The patient with nephrotic syndrome is ordered corticosteroids. Who of the following
are NOT ALLOWED in the patient’s
A. Parents with diabetes
B. Relatives with upper respiratory tract infection.
C. Visitors with mild asthma.
D. Personnel with allergy

70. Corticosteroids are one of the main therapies for nephrotic syndrome. Which of the
following COMMON side effects should the nurse watch for?
A. Loss of appetite
B. Increase in body hair
C. Loss of weight
D. Lowering of blood pressure

Situation - Patient Reno, 53 years of age, is pale and complains of easy fatigability. He
has undergone Complete Blood Count (CBC) where abnormal cells were found. He was
diagnosed with acute lymphocytic leukemia (ALL).

71. The nurse ensure that the isolation procedure APPROPRIATE for Reno is _____.
A. standard
B. airborne precaution
C. strict
D. protective

72. Which of the following diagnostic procedures will definitely establish the diagnosis
for patient Reno?
A. White Blood Cell count
B. Complete Blood Count
C. Bone marrow biopsy
D. Hemoglobin and hematocrit counts

73. When the thrombocyte count falls below 20,000/cu mm, the nurse will expect that
the physician will order _____.
A. complete bed rest
B. strict aseptic technique
C. platelet transfusion
D. “limit visitors”

74. On the basis of his leukocyte count, the nurse instructs the patient NOT to do, which
one of the following?
A. Limit number of staff entering the room.
B. Be in a private room with the door closed always.
C. Receive immunization with a live attenuated virus.
D. Use antimicrobial soap when bathing.

75. During the period of exacerbation, the patient’s hemoglobin is markedly decreased.
What instruction by nurse is APPROPRIATE?
A. Allow exercise as long as tolerated.
B. Let patient be dependent on self-care.
C. Perform only activities of daily living.
D. Serve pork and liver barbecue.

Situation – Nurses must continually grow as a person and as a professional.

76. As a newly licensed nurse employed in a tertiary hospital, you are required to attend
Continuing Professional Development (CPD) program. When the training program is for
the enhancement of the competencies of nurses employed in the hospital, it is called
_____.
A. self-directed
B. In-service training program
C. informal training program
D. formal education program

77. The professional career development of a nurse can be achieved through various
ways, such as_____.
A. Participating in political rallies
B. Attending culinary courses
C. Attendance in socio-civic activities
D. Engaging in CPD programs

78. When nurses are projected in a television advertisement as sex symbols, what
APPROPRIATE action is expected from a concerned nurse?
A. Go to the street to manifest displeasure of the nurses’ portrayal.
B. Report to the concerned agency
C. Condemn the issues in the radio program.
D. Keep your silence, it is the television station’s prerogative.

79. To enhance the personality of the graduate nurse, she/he may attend which of the
following programs?
A. Gymnastics
B. Marathon training
C. Social graces and physical fitness
D. Scuba diving

80. The nurse’s application to Canada has finally been approved and she was advised
to depart in three months. She is currently enrolled in the graduate school. Moreover,
her mother has just been discharged from the hospital. Which of the following actions
is BEST?
A. Inform family that the money spent in graduate school can be easily earned in
Canada.
B. Inform the agency that she could go anytime as they wish.
C. Share with friends that this is her escape from her sad life with her family.
D. Request the recruiter to give her more time to settle her personal concerns.

Situation - Patient Narding is diagnosed with stroke and suffers from a number of
deficits as a result of injury to his brain. His rehabilitation may be long, depending on
the extent of brain injury.

81. Narding has been urinating on and off in bed which is possibly related to a flaccid
bladder and difficulty in communicating. The nurse becomes concerned because he is
showing signs and symptoms of pressure sores due to his immobility and the frequently
wet beddings. The nurse decides to refer the patient to the _____.
A. Resident on duty
B. Attending Physician
C. Infectious doctor specialist
D. Supervisor – in – charge

82. Narding becomes unduly silent and keeps to himself after his stroke left him with
left-sided weakness. The nurse observes that the patient seems really sad and shares
the information to the physician, who refers the patient to a ______.
A. psychiatrist
B. neurologist
C. psychologist
D. physiotherapist

83. The patient shared his concern about being able to father a child after the stroke,
especially that he has one child, a girl. He would like to have two boys but he doubts
his present sexual capacity. Who can BEST help him along this area?
A. Primary consultant
B. Nurse
C. Supervisor in charge
D. Urologist

84. The patient should be assisted back to normal mobility after his stroke partially
incapacitated him. The referral that will be done by the attending physician must be to
which professional?
A. Occupational Therapist
B. Resident physician
C. Physical therapist
D. Primary consultant

85. Narding seems forgetful, inattentive, and not answering appropriately to some
questions posed. The nurse anticipates that the consultant will need to ask the
professional help of the _____ for cognitive improvement.
A. psychologist
B. psychiatrist
C. family doctor
D. neurologist

(95-100, refer to atty rafa’s ratio)

95. Nurses may be privy to very personal information of patients and should make every
effort to make it confidential, otherwise she can be charged of _____.
A. negligence
B. malpractice
C. invasion of privacy
D. defamatioin

Situation – Quality improvement must be embraced by every health institution if ti aims

for safe and quality care. The Medical Director of Camiguin Medical Center made
random rounds for five consecutive days to all areas of the hospital to assess its
services.

96. Which of the following is NOT a characteristic of quality improvement that the
medical director is interested in?
A. The leader is the empowered
B. Problem-solving is by everyone
C. The employees are treated as customers
D. Reacts to correct or bad situation

97. A risk is any event that causes problems or benefits on the healthcare institution.
The Medical Director knows that potential risks must be identified across the hospital in
order to prevent the following, EXCEPT _____.
A. financial loss
B. incident reports
C. accidents
D. injuries
98. Based on patient survey, a number of complaints have been tracked. Which of the
following is NOT a preventive activity in the practice of the Medical Director’s risk
management?
A. Fostering good administration-personnel relations.
B. Providing safe environment every time.
C. Tracking patient complaints at irregular intervals.
D. Satisfying patient needs and desires.

99. The Medical Director, with the Chief Nurse and other officers, of the hospital believe
that Patient Relations is impotant in risk management which is NOT the way to handle
complaints?
A. Let the patient express himself
B. Be sure to rebut the patient point by point
C. Staff should not be defensive.
D. Listen to the patient’s cue carefully.

100. Nurses usually complain they have no personal life because of rating shifts. The
following are three major ways to create personal time, EXCEPT _____.
A. delegate work to others
B. fill every moment with tasks or chores
C. eliminate tasks that add no value
D. hire someone else to do the work
NURSING PRACTICE V: Care of Clients with Physiologic and Psychosocial Alterations, Part C

SITUATION – NURSES INFORM PATIENTS TAKING ANTIPSYCHOTIC

MEDICATIONS ABOUT THE TYPES OF SIDE EFFECTS THAT MAY OCCUR. SHE
ENCOURAGES PATIENTS TO REPORT INSTEAD OF DISCOUNTING THE
MEDICATIONS. FOLLOWING ARE RELATED TO PATIENT TEACHINGS.

1. WHEN TAKEN ANTIANXIETY DRUGS LIKE BENZODIAZOPINES, WHICH

APPROPRIATE HEALTH TEACHING SHOULD THE NURSE EMPHASIZE?
a. ANTIANXIETY DRUGS CAN TREAT THE UNDERLYING PROBLEM
b. PATIENT SHOULD NOT DRINK ALCOHOL BECAUSE IT POTENTIATES
ITS EFFECT
c. PATIENT CAN DISCONTINUE THE DRUG ABRUPTLY EVEN WITHOUT
ORDERS.
d. PATIENT CAN STILL DRIVE HIS CAR CAUSE OF DELAYED RESPONSE
TIME

2. WHEN TAKING ANTICONVULSANT DRUGS LIKE LITHIUM, WHICH

APPROPRIATE HEALTH TEACHING SHOULD THE NURSE EMPHASIZE?
a. TIME OF LAST DOSE MUST BE ACCURATE SO THAT BLOOD LEVEL
MONITORING BE ACCURATE
b. PATIENT CAN TAKE DRUGS EVEN WITHOUT FOOD INTAKE
c. PATIENT WILL NOT EXPERIENCE POLYURIA AND POLYDIPSIA
d. PATIENT WILL HAVE CONSTIPATION, THUS HE HAS TO INCREASE
FLUID INTAKE

3. WHICH OF THE FOLLOWING DOES NOT SIGNIFY EXTRAPYRAMIDAL

SYMPTOMS (EPS) HALDOL?
a. ACUTE DYSTONIA c. PSEUDO PARKINSONISM
b. AKATHISIA d. INCREASED LIBIDO
4. THE PATIENT OFTEN APPEARS RESTLESS, ANXIOUS, AGITATED WITH
RIGID POSTURE AND LACK OF SPONTANEOUS GESTURES. WHICH OF
THE FOLLOWING DESCRIBES THIS PATIENT WITH INTENSE NEED TO
MOVE ABOUT?
a. WITHDRAWAL c. DYSTONIA
b. DYSKINESIA d. AKATHISIA
 5. WHEN TAKING SSRI (SELECTIVE SEROTONIN REUPTAKE INHIBITORS),
WHICH APPROPRIATE HEALTH TEACHING SHOULD THE NURSE
EMPHASIZE?
a. AGED CHEESE MAYBE ALLOWED
b. PATIENT SHOULD TAKE THE DRUG FIRST THING IN THE MORNING
c. PEANUTS ARE ALLOWED
d. TYRAMISE FREE DIET CAN LOWER BLOOD PRESSURE

SITUATION – REMEDIOS, A 65-YEAR-OLD HOUSEWIFE HAS BEEN DIAGNOSED

WITH RHEUMATOID ARTHRITIS BOTH HANDS AND KNEES.

6. ON A VISIT TO THE CLINIC, A PATIENT REPORTS THE ONSET OF EARLY

SYMPTOMS OF RHEUMATOID ARTHRITIS. WHAT WILL BE THE NURSE
FOCUSED ASSESSMENT DURING PATIENT INTERVIEW?
a. ENLARGED NODULES
b. EARLY MORNING STIFFNESS OF THE LOWER EXTREMITIES
c. LIMITED MOTION OF JOINTS OF UPPER EXTREMITIES
d. DEFORMED JOINTS OF THE HANDS
7. PATIENT REMEDIOS COMPLAINS SHE COULD NOT DO HOUSEHOLD
CHORES AND HER KNEES HURT WHENEVER SHE WALKS. WHICH
NURSING DIAGNOSIS WOULD BE MOST APPROPRIATE?
a. A SELF-CARE DEFICIT RELATED TO INCREASING JOINT PAIN
b. ACTIVITY INTOLERANCE RELATED TO FATIGUE AND JOINT PAIN
c. DISTURBED BODY IMAGE RELATED TO FATIGUE AND JOINT PAIN
d. INEFFECTIVE COPING RELATED TO INCREASED JOINT PAIN
8. FOR A PATIENT IN THE ACUTE PHASE OF RHEUMATOID ARTHRITIS,
WHICH OF THE FOLLOWING SHOULD THE NURSE IDENTIFY AS LOWEST
PRIORITY IN THE PLAN OF CARE?
a. PRESERVING JOINT c. RELIEVING PAIN
FUNCTION d. MAINTAINING USUAL TASK
b. PREVENTING JOINT
DEFORMITY
9. A PATIENT WITH OSTEOARTHRITIS DEVELOPS COAGULOPATHY
SECONDARY TO LONG-TERM NONSTEROIDAL ANTI-INFLAMMATORY
DRUG (NSAID) USE. THE COAGULOPATHY IS MOST LIKELY THE RESULT
OF _____.
a. DECREASED PLATELET ADHESIVENESS
b. BLOCKED PROTHROMBIN CONVERSION
c. IMPAIRED VITAMIN K SYNTHESIS
d. FACTOR VIII DESTRUCTION
 10. A NURSE IS TEACHING A PATIENT WITH OSTEOARTHRITIS ABOUT
LIFESTYLE CHANGES. THE NURSE KOWS THE PATIENT UNDERSTAND
THE TEACHING WHEN SHE STATES THAT SHE WILL ____.
a. ABSTAIN FROM ALCOHOL c. LOSS WEIGHT
b. AVOID EXERCISE d. RESTRICT CAFFEINE

SITUATION – EIGHTEEN YEAR OLD CHIMEYA AND HER FATHER CAME TO CLINIC
FOR POSSIBLE DEPRESSION. SHE HAS A NUMBER OF FEARS OF GETTING SICK
AND DYING FROM COVID-19. SHE EATS LESS AND SLEEPS RESTLESSLY. SHE
HAS NOT TAKEN A BATH FOR A WEEK, ALWAYS TALKS ABOUT HER MISSING
MOTHER WHO DIED DUE TO COVID-19 INFECTION.

11. WORKING WITH A DEPRESSED CHIMEYAM THE NURSE SHOULD

UNDERSTAND THAT DEPRESSION IS MOST DIRECTLY RELATED TO A
PERSON’S ______.
a. REMEMBERING HER CHILDHOOD
b. STAGE IN LIFE
c. HAVING EXPERIENCED A SENSE OF LOSS
d. EXPERIENCING POOR INTERPERSONAL RELATIONSHIPS WITH
OTHERS
12. EARLY IDENTIFICATION AND TREATMENT ARE ESSENTIAL TO PREVENT
LONG TERM DEPRESSION. PREVENTIVE MEASURES DO NOT INCLUDE
____.
a. MEDICATION AS A TREATMENT ALONE
b. PROVIDING A STABLE HOME LIFE
c. PRACTICING OPEN AND HONEST COMMUNICATION
d. FACILITATING A STRONG SENSE OF SELF TRUST, RESILIENCE AND
SELF-ESTEEM
13. CHIMEYA WAS ADMITTED IN THE HOSPITAL FOR TREATMENT OF HER
DEPRESSION. WHICH ANTIDEPRESSANT DRUG IS COMMONLY USED?
a. NORFRAMIN c. PROZAC
b. ELAVIL d. TOFRANIL
14. TO PREVENT THE RECURRENCE OF DEPRESSION, HOW LONG SHOULD
THE PATIENT TAKE THE ANTI DEPRESSANT DRUGS?
a. SIX MONTHS TO TWO c. ONE YEAR TO THREE
YEARS YEARS
b. TWO MONTHS TO ONE d. ONE TO THREE MONTHS
YEAR
 15. THREE DAYS AFTER THE ADMISSION OF CHIMEYA, THE NURSE
OBSERVES SHE HAS TAKEN A BATH, WORN A CLEAN DRESS, AND
COMBED HER HAIR. WHAT IS THE APPROPRIATE REACTION OF THE
NURSE TO THE BEHAVIORAL CHANGE IN CHIMEYA?
a. “SOMETHING IS DIFFERENT ABOUT YOU TODAY. WHAT IS IT?”
b. “OH. I’M SO PLEASED THAT YOU FINALLY PUT ON A CLEAN DRESS”
c. “I SEE THAT YOU HAVE WORN A CLEAN DRESS AND HAVE COMBED
YOUR HAIR”
d. “THAT’S GOOD. YOU HAVE ON A CLEAN DRESS AND HAVE COMBED
YOUR HAIR.”

SITUATION – NURSES PROVIDE THEIR PATIENTS INFORMATION THEY NEED TO

GIVE INFORMED CONSENT, ONLY IF IT IS WITHIN THEIR SCOPE OF NURSING
PRACTICE AND NURSING KNOWLEDGE. CONSENT IS THE PATIENTS
ACKNOWLEDGEMENT AND ACCEPTANCE OF MEDICAL TREATMENT.

16. IN EMERGENCY SITUATION WHEN A PATIENT IS UNABLE TO GIVE

CONSENT FOR LIFE SAING TREATMENT, WHAT TYPE OF CONSENT
ALLOWS TO ASSUME APPROPRIATE MEDICAL TREATMENT?
a. IMPLIED CONSENT c. EXPRESS CONSENT
b. INFORMED CONSENT d. INVOLUNTARY CONSENT
17. WHICH OF THE FOLLOWING ARE ESSENTIAL COMPONENTS OF
INFORMED CONSENT?
i. EXPLANATION OF THE PROCEDURE AND ALTERNATIVES TO THE
PROCEDURE
ii. DISCUSSION OF POTENTIAL RISKS AND BENEFITS OF THE
PROCEDURE
iii. CONFIRMATION THAT THE PATIENT UNDERSTANDS THE RISKS,
BENEFITS, AND ANY ALTERATIONS
a. I, III c. II, III
b. I, II d. I, II, III
18. TREATMENT OF A PATIENT WITHOUT CONSENT CAN CONSTITUTE
______, WHICH IS DEFINED AS INTENTIONAL AND UNWANTING
TOUCHING.
a. BATTERY c. NEGLIGENCE
b. SLANDER d. TORT
19. WHOSE RESPONSIBILITY IS IT TO OBTAIN INFORMED CONSENT?
a. NURSE MANAGER d. MIDWIFE
b. ANESTHESIOLOGIST
c. PHYSICIAN
 20. BIOETHICAL ISSUE SHOULD BE DESCRIBE AS _______________________.
a. THE WITHHOLDING OF FOOD AND TREATMENT AT THE REQUEST OF THE PATIENT
IN A WRITTEN ADVANCE DIRECTIVE GIVEN BEFORE A PATIENT ACQUIRED
PERMANENT BRAIN DAMAGE FROM AN ACCIDENT
b. THE PHYSICIAN’S MAKING ALL DECISIONS OF CLIENT MANAGEMENT WITHOUT
GETTING INPUT FROM THE PATIENT
c. AFTER THE PATIENT GIVES PERMISSION, THE PHYSICIAN’S DISCLOSING ALL
INFORMATION TO THE FAMILY FOR THIS SUPPORT IN THE MANAGEMENT OF THE
PATIENT
d. A RESEARCH PROJECT THAT INCLUDED TREATING ALL REGULAR EMPLOYED
PERSONNEL AND NOT TREATING ALL CASUAL EMPLOYED TO COMPARE THE
OUTCOMES OF SPECIFIC DRUG THERAPY

Situation – Rosie, a new staff nurse, was assigned in the Psychiatric Unit A depressed patient
assigned to her fell from her bed. Her head nurse asked her to submit an Incident Report (IR).

21. The purpose why the head nurse asked Nurse Rosie to submit an IR is to _____.
A. note patterns of incidence in the same unit
B. place it in Nurse Rosie’s201 file
C. document immediately the incident
D. evaluate Nurse Rosie’s performance

22. In writing the IR, which of the following in NOT included?

A. Who was / were involved?
B. What daily medications are given to the patient
C. What happened?
D. Who witnessed the incident?

23. What guideline is IMPORTANT in relation to incident report (IR)? It is _____.

A. not made part of the patient’s chart
B. placed in the nurse’s 201 file
C. filed in the nurses station
D. filed in the Records Section of the hospital

24. Which of the following would prove that the nurse action carried out met the standards of care on
falls?
A. Utilizing the nursing process in providing safe, quality nursing care
B. Documenting the procedures done
C. Carrying out the doctor’s order
D. Performing physical assessment

25. Should the investigation of the fall go further, which of the following is the best source of factual
information?
A. incident report
 B. nurse’s notes in the chart
C. anecdotal record
D. process recording

Situation – Mrs. Del, 70-year-old retired teacher is diagnosed of Dementia. She lives with her
24-year-old granddaughter. Nurse Maxie attends to her when she goes for her OPD checkups.

26. Mrs. Del must be aware that the MOST common chronic incidence that brings about injury among
elderly persons is _____.
A. rheumatic fever C. gallbladder
B. hip fracture D. urinary tract infection

27. Nurse Maxie should recognized that the MOST common psychogenic disorder among elderly
persons is ______.
A. depression C. decreased appetite
B. sleep disturbance D. inability to concentrate

28. Which of the following is the most common cause of dementia among elderly persons?
A. Parkinson’s disease
B. Alzhiemer’s disease
C. Amyotrophic lateral sclerosis
D. Multiple sclerosis

29. Which of the following symptoms is COMMON to both the presenile and senile dementia
associated with Alzheimer’s disease?
A. Increased appetite
B. Loss of short-term memory
C. Inappropriate behavior
D. Inability to provide self-care

30. Patient with dementia suffers from “sundown syndrome”. Which nursing action should be included
in this patient’s care plan?
A. Maintain consistent schedule and sequence of daily activities.
B. Integrate patient’s cultural preferences in to the care provided.
C. Serve warm beverage and snack in the early evening.
D. Provide opportunities for patient to learn and practice new skills.

Situation – Nurse Annie is assigned to Sherry, a junior high school student, who is treated for her
Bulimia.

31. Bulimia is best defined as a / an ______.

A. disorder of the unknown origin associated with starving oneself
 B. pathological disorder of binging and vomiting
C. phobic disorder of fear of obesity
D. eating disorder associated with vomiting

32. What condition is NOT likely to develop in Sherry?

A. Hyperkalemia C. Gastric ulcer
B. Tooth decay D. Rectal bleeding

33. Which of the following conditions may lead to death in a bulimic patient like Sherry?
A. Hypokalemia and cardiac arrhythmias and arrest
B. Metabolic acidosis and renal failure
C. Hyponatremia and circulatory collapse
D. Hypernatremia and congestive heart failure

34. Endocrine changes often result in a bulimic patient. Which of the following would be an expected
change in Sherry?
A. Delayed Thyroid Stimulating Hormone response to Hormone Replacement Therapy
B. Increased production of Follicle Stimulating Hormone
C. Hypopituitarism
D. Decreased Adrenocorticotropic Hormone in response to cortisone

35. Amitriptyline, an anti-depressant is the drug of choice in treating Bulimia. What is a COMMON
side effect of this drug?
A. Anticholinergic effects C. Urinary frequency
B. Cholinergic effects D. Diarrhea

Situation - Mr. Rollan is diagnosed to have chronic schizophrenia.

36. To prevent relapses of schizophrenia with Mr. Rollan , which of the following Nurse Anna should
NOT encouraged Mr. Rollan and his family?
A. Keep any troubling side effects of medications with nurses.
B. Practice stress reduction techniques.
C. To follow the medication regimen accurately.
D. Participate regularly in any other forms of treatment.

37. Choose one nursing strategy Nurse Anna should NOT use.
A. Speak in a low, calm tone of voice.
B. Let him interact with you while he is hallucinating.
C. Maintain a nonthreatening stance, keep a physical distance.
D. Maintaining safety for herself and Mr. Rollan.

38. Choose on LEAST Anna’s nursing action while communicating with Mr. Rollan.
A. “Please let me know if I can be helpful.”
 B. Check his use of ordered PRN medication.
C. “I’ll let you sit here quietly and I will be at the nurse station.”
D. “I’m just checking in with you to see if there is anything you need right now.”

39. Which of the following strategies would the nurse instruct the patient to do as a measure to
prevent relapse?
A. Report changes in sleeping, eating and mood.
B. Block hallucinations during daily activities.
C. Take additional medications on days when Mr. Rollan is “feeling bad”.
D. Take stress management class.

40. Which of the following identified ability of Mr. Rollan that he can now effectively participate in
rehabilitation?
A. Ability to concentrate. C. Ability to talk.
B. Ability to think. D. Ability to do listen.

Situation – Mrs. Labrador, 75 years old, is in the clinic for the treatment of acute closed-angle
glaucoma.

41. The physician would like to measure the intraocular pressure with non-contract (air puff)
tonometer. While preparing patient for her examination, the nurse inform the patient that _____.
A. after the examination, a slight pain will experienced
B. before the examination, a medication will be given
C. it is a painless procedure that has no side effects
D. during the ocular fundoscopy, atropine eye drop will be instilled

42. Which symptoms are ASSOCIATED with acute-closed angle glaucoma?

A. Diplopia and photophobia
B. Blurred vision and colored rings around lights
C. Episodic blindness and no pain
D. Sensation of curtain drawn across the visual field

43. The physician has prescirbed Pilocarpine one percent eye drops every six hours. The expected
OUTCOME for this medication is to _____.
A. dilate the pupil by paralyzing the ciliary muscle
B. prevent dryness of the cornea and conjunctiva
C. promote drainage of aqueous humor from anterior chamber
D. reduce inflammation of the iris and choroid

44. The physician recommends peripheral iridectomy to relieve intraocular pressure. He prescribed
Meperidine Hydrochloride (Demerol) 50mg and Atropine Sulfate 0.3mg IM as the preoperative
medications. The nurse should _____.
A. recognize that atropine sulfate is given preoperatively to dilate the pupil
B. recognize this as a usual preoperative medication and administer it
C. realize that the atropine sulfate is being given to dry up secretion
D. notify the physician and question the order

45. Which of these nursing diagnoses should the nurse give PRIORITY for an elderly patient who has
impaired vision due to glaucoma?
A. High risk for injury
B. Impaired physical mobility
C. Grooming self-care deficit
D. Feeding self-care deficit

Situation – Rizal, a 50 – year old house painter, came in with the chief complaints of slurred speech,
blurring of vision, and hallucinations. Upon evaluation of his case, it revealed volatile substance
intoxication.

46. The predisposing factor in Rizal’s case is his _____.

A. Age
B. Occupation
C. Home environment
D. Community

47. Volatile Substance Abuse is considered the most dangerous among the abused psychoactive
substances because of the RISK of _____.
A. violence
B. developing schizophrenia
C. irreversible damage to the bone marrow, brain, liver, kidney
D. malnutrition

48. The nurse heard Rizal saying, “My mother visited me last night and reminded me to take care of
myself.” This is manifestation of _____.
A. auditory hallucination
B. visual hallucination
C. delusion
D. reaction formation

49. Substance abuse affects not only the user but also the other members of the family. Which of the
following is the MOST APPROPRIATE nursing diagnosis in the care of Rizal?
A. Impaired social interactions.
B. Impaired parenting
C. Dysfunctional family processes
D. Ineffective coping

50. Sever intoxication to volatile substances may lead to unconsciousness or even death. The
PRIORITY nursing intervention in caring for such patient is monitoring the _____.
A. mental status
B. neurological functions
C. nutritional status
D. vital signs

Situation – Darwin, 35-year-old engineer met a vehicular accident while going to work. He suffered
head injury, responsive and admitted at the intensive care unit for close monitoring and management.

51. During nursing assessment, Darwin speaks a rambling manner and is unable to repeat words
spoken to him. Which are of the brain MOST likely is affected?
A. Wernicke’s area
B. Broca’s area
C. Foramen magnum
D. Brodmann’s area

52. The physician orders a computerized transverse axial tomogram (CAT) scan. Nursing preparation
of the patient for this procedure includes:
A. Explaining that the vital signs will be monitored for 2 hours after the examination.
B. Reassuring that CAT scanning is a noninvasive procedure.
C. Explaining that a spinal tap will be done so that a radioactive isotope can be injected.
D. Telling patient that a radiopaque dye is injected into artery in the arm.

53. The physician order to observe for EARLY signs of increased intracranial pressure which includes
_____.
A. restlessness and change in level of consciousness
B. elevated temperature and decerebrate posturing
C. rising blood pressure and bradycardia
D. widening pulse pressure and dilated pupils

54. All of the following signs indicate increased intracranial pressure EXCEPT?
A. Decreased level of consciousness
B. Tachycardia
C. Papilledema
D. Vomiting

55. The nurse noticed dressing is wet. Which action by the nurse can be safely used to determine if
the drainage contains cerebrospinal fluid (CSF)? What is the attending nurse should do?
A. Blot the drainage with sterile gauze pad and look for a clear wet ring around the spot of blood.
B. Swab the orifice of the ear with a sterile applicator and send the specimen to the laboratory.
C. Obtain a negative reading for sugar after testing CSF with Tes-Tape.
D. Gently suction the ear and send the specimen to the laboratory.

Situation – Nurse Manager participates in quality improvement projects to increase awareness and
achieve better performance of nursing team.

56. A professional practice system that manages clinical care of patients across a continuum using
managed care concepts and tools is called _____.
A. modular nursing
B. differentiated practice
C. case management
D. primary nursing

57. What is the outcome of having a sound clinical care management by professional healthcare
team?
A. It decreases patients’ length of stay
B. It diminishes collegiality between health care providers
C. It increases cost of hospitalization
D. It contributes to duplication of services

58. During a staff meeting, the nurse manager presents his own analysis of problems and proposals
for actions to the staff, inviting critique and comments. Which answer indicates the manager’s
leadership style?
A. Laissez-faire
B. Autocratic
C. Participative leadership
D. Democratic

59. Which of the following is often associated with the concept of decentralized decision making in
management?
A. Team nursing
B. Interdisciplinary practice model
C. Shared governance
D. Primary nursing

60. Some decisions are best made by a group rather than by the nurse alone. What is an advantages
of group decision making?
A. Promote collective contribution of ideas
B. Different ideas and opinions
C. Individual opinions are influenced by others
D. Dependency is fostered

Situation - Glory, a 23 year old evening cashier of Seven Eleven 24 hours convenience store, was
sexually abused by a jeepney driver while on her way home from work one evening. She was
brought to the ER with bruises all over body. She was crying uncontrollably and appears to be
anxious.

61. Which of the following therapeutic communication should Nurse Ann say for Glory?
A. “You are upset, calm yourself first Glory. I can’t understand you.”
B. “can you identify your abuser?”
C. “I know something terrible and horrifying happened to you.”
D. “Would you like to relate to me what happened?”
62. In providing nursing care for Glory during her acute stress reaction to rape trauma, Nurse Ann
may apply, which of the following?
A. Physical assessment
B. Collaborate with community agencies
C. Crisis intervention techniques
D. Teaching and learning principles

63. Glory’s physical assessment is complete and physical evidence has been collected. After three
days, Nurse Ann noted Glory to be withdrawn, confused and at times physically immobile. How
should Nurse Ann interpret these behaviors?
A. Evidence that the client is a high suicide risk
B. Signs of depression
C. Indicative of the need for longer hospital admission
D. Normal reactions to a devastating event

64. Emergency care to be given for rape victims are as follows:

I. If victim calls the hospital, tell her not to take a bath, wash or change clothes, just go directly to the
hospital.
II. Provide privacy and be-judgmental
III. Stay with the victim, focus on physical safety and emotional security
IV. Assist on pelvic examination to collect evidence as semen stains
A. I, III, IV C. II, III, IV
B. I, II, III D. I, II, IV

64. Nurse Ann wanted to become a patient advocate to rape victims. Which of the following
RESPONSIBILITIES should she note?
A. Isolate the patient first to provide privacy while attending to other patients.
B. Call the press since this is a legal case.
C. Perform thorough physical assessment and document objectively all evidence of rape.
D. Postpone the physical examination until the patient is calm.

Situation – Head Nurse Alona ensures teamwork and collaboration in her until to achieve efficient
shared decision-making and open communication to provide safe patient care.

66. A nurse returns from vacation and finds a new model of I.V. pump attached to her patient’s I.V.
How should the nurse proceed?
A. Read the I.V. pump manual before caring for the patient.
B. Refuse to care for the patients
C. Inform the charge nurse and ask her to provide a teaching session about how to use the pump.
D. Use the pump because it is somewhat like the old pumps on the unit.

67. A nurse is caring for a 72-year-old male patient who requires insertion of a central venous
catheter. Who is responsible for obtaining informed consent?
A. Physician who will insert the catheter
B. Charge nurse
C. Attending physician
D. The nurse assisting with the procedure

68. A nurse reports that a patient coughs frequently after taking anything by mouth. The dietitian
recommends a swallow evaluation for the patient in which the physician participating in the team
rounds writes the order. This is an example of collaboration of client care _____.
A. with the ancillary care providers
B. between the physician and the dietary deparment
C. with the risk management team because of risk for aspiration
D. among members of the multidisciplinary group

69. Before delegating to a new nurse the task of giving a shower to a paraplegic elderly, the charge
nurse should FIRST ensure that the new nurse _____.
A. has demonstrated competency for the task
B. has received the assignment during endorsement time
C. is supervised at all times
D. provides companion to the patients

70. Which of the following tasks would be APPROPRIATE for the nurse to delegate to nursing
aide?
A. Assist a new postoperative patient to the bathroom
B. Teach a patient how to administer discharge medications.
C. Change a central line dressing.
D. Assist the patient during meal time.

Situation – Mr. Ferrer, 42 years old, is admitted to the hospital in a semi-conscious state diagnosed
with cerebrovascular accident.

71. The nurse obtains history of patient’s present illness from his family. What significant information
can the nurse gather from the patient’s family?
A. consistent hypertension and dizziness
B. palpitations and hypotension
C. family history about illness
D. emotional response to past illness

72. The PRIORITY nursing care for Mr. Ferrer during the acute phase is to _____.
A. provide sensory stimulation
B. maintain respiratory and cardiac function
C. prevent contracture and deformities
D. maintain optimal nutrition

73. Part of nursing care plan is to observe Mr. Ferrer for signs of increased intracranial pressure.
Which of the following clinical manifestations would INDICATE this condition?
A. Tachycardia and drop in blood pressure
B. Bradycardia and rising blood pressure
C. Bradycardia and drop in blood pressure
D. Tachycardia and rising blood pressure

74. Which of the following positions will be MOST APPROPRIATE to Mr. Ferrer’s care?
A. Head of bed elevated in a lateral position
B. Head of bed elevated in a supine position
C. Right lateral position
D. Left lateral position

75. Mr. Ferrer’s wife is very upset asks if there is any hope to recover from his condition? Which of
the following is the MOST APPROPRIATE reply by the nurse?
A. “You must be patient, let’s hope for the best outcome.”
B. “You should never lose hope”
C. “It is too soon to tell what the outcome will be.”
D. “Actually, manifestations may even get worse.”

Situation – Liela, 5 years old, was diagnosed as autistic since she was 1 year old.

76. What behavior will Nurse Raffy observe as characterized by Liela?

A. Inappropriate behavior, poor attention span with impulsivity
B. Negativistic hostile and defiant behavior
C. Failure to develop interpersonal skills
D. Anxiety induced involuntary stereotype motor movements

77. At her age, Liela is in what stage of social development?

A. Initiative vs Guilt
B. Trust vs Mistrust
C. Industry vs Inferiority
D. Autonomy vs Shame and Doubt

78. Nurse Raffy reconnizes which of the following as a COMMON behavioral sign of autism?
A. Clinging behavior towards parent
B. Early language development
C. Indifference to being hugged or held
D. Creative imaginative play with peers

79. The BEST nursing intervention that Nurse Raffy can use to provide trusting relationship with an
autistic Liela is to _____.
A. convey warmth through touch
B. Early language development
C. Indifference to being hugged or held
D. Creative imaginative play with peers

80. Which pharmacologic treatment is APPROPRIATE for Liela’s temper tantrum, aggressiveness,
self injury and stereotyped behavior?
A. Clonidine (Catapres) C. Clomipramine (Anafranil)
B. Naltrexone (Re Via) D. Haloperidol (Haldol)

Situation - Patient safety remains a global health care challenge. There are basic principles of
infection control. These include standard precautions and transmission based precautions. The
following are transmission based precaution question.

81. Which one of the following is considered the MOST important intervention in infection control?
A. personal protective clothing
B. prevention of infection associated with catheter
C. safe use and disposal of sharps
D. hand hygiene of healthcare staff

82. Which mode of infection transmission is due to splashes of blood / body fluids into the mucosa or
contamination of non intact skin with infected blood and body fluids?
A. ingestion C. inoculation
B. airborne D. direct / indirect contact

83. Which mode of infection transmission is due to microorganism being transferred to other patients
from contaminated equipments and via the hands of nurses?
A. ingestions C. inoculation
B. airborne D. direct / indirect contact

84. What mode of transmission is due to contaminated food and water being consumed?
A. Inoculation C. Ingestion
B. Direct / indirect contact D. Airborne

85. Which of the following is NOT a standard precaution?

A. respiratory hygiene C. personnel protective equipment
B. injection safety D. hand hygiene

Situation – The nurse abides with ethico moral principles.

86. When the nurse placed the patient in restraints before using other methods of intervention, she/he
violated the patient’s rights to _____.
A. receive confidential and respectful care
B. provide informed consent
C. receive treatment in the least restrictive environment
D. refuse treatment

87. Which of the following actions is a violation of a psychiatric patient’s rights?

A. Paranoid patient with delusions about his family is told that if he makes a will, it might not be valid.
B. The nurse confiscated the cellphone from patient’s room and tell him it is being locked in the vault.
C. Staff members confiscated written letters done by patients addressed to local newspaper.
D. Patient is paid minimum wage for helping in the hospital kitchen.
88. Which of the following in NOT covered in Patient’s Bill of Rights?
A. Refusal to treatment C. Right to treatment
B. Informed consent D. Civil commitment

89. A patient has been advised by the psychiatrist that he needs inpatient hospitalization. The patient
agrees, signs the admission forms, and agrees to receive treatment. What type of admission is this?
A. Formal C. Informal
B. Voluntary D. Involuntary

90. Disclosure of client information beyond the interdisciplinary team without consent of the client is a
breach of _____.
A. confidentiality C. duty
B. beneficence D. veracity

Situation – Nursing research is conducted to answer a question or resolve problems on the relevance
of the nursing profession.

91. The nurse develops the following hypothesis: Elderly women receive less aggressive treatment
for terminally-ill spine patients than younger women. Which variable would be considered to be the
independent variable?
A. Degree of treatment received
B. Age of the patients
C. Use of inpatient treatment
D. Type of complications being treated

92. The following are considered qualitative research process EXCEPT.

A. Sample C. Hypothesis
B. Literature review D. Data collection

93. Which of the following is an example of a PRIMARY source in a research study?

A. A textbook of medical-surgical nursing
B. A doctoral dissertation that critiques all research in the area of attention deficit disorder
C. A published commentary on the findings of another study.
D. A journal article about a study that used large, previously unpublished databases generated.

94. What is the BEST source to use when conducting a level one (1) systematic meta-analysis of the
literature?
A. An electronic database and doctoral dissertations
B. An electronic database
C. Doctoral dissertations
D. The Cochrane Statistical Methods

95. Which type of research allows researchers to be neutral observers?

A. Quantitative research C. Case studies
 B. Ethnographic research D. Qualitative researcher

Situation – Mrs. Gomez, 63-year-old admitted for cataract extraction. Nurse Lucy is assigned to
prepare the patient for surgery.

96. Mrs. Gomez tells the nurse that she does not want to know about her surgery. What would be the
BEST response of the nurse?
A. “I must go over certain information with you.”
B. “You are right; do not worry yourself tonight.”
C. “You really sound quite concerned about your surgery.”
D. “Well, I could talk to your son about this instead.”

97. What should the nurse do before giving pre-operative teaching to the patient?
A. Determine Mrs. Gomez anxieties, level of understanding and expectations.
B. Research the surgical procedure so as to give step-to-step explanation.
C. Schedule teaching to begin 2-3 hours before surgery.
D. Give Mrs. Gomez general information because specifics might be treatening.

98. While doing health teaching to Mrs. Gomez, the attending nurse can BEST recognize that her
patient is learning by _____.
A. demonstrating a positive change in her behavior
B. constant verbal reaffirmations that she understands
C. her ability to repeat what was discussed
D. nonverbal acknowledgment that she understands, such as nodding.

99. The nurse prepare Mrs. Gomez for discharge. What would be the nurse MOST important post
cataract surgery instruction to her patient?
A. Avoid the use of laxative
B. Use an eye shield at night
C. Avoid to touch the eye dressing
D. Curtail most heavy activities

100. After discharge, Mrs. Gomez attends the eye clinic for follow-up visit. When she received her
cataract glasses, it is important that the nurse advise her that _____.
A. magnification by the lens is only about 10 percent
B. daily eye drops are required with eyeglasses
C. her peripheral vision will be increased
D. objects will appear closer than they really are