NURSING PRACTICE I

SITUATION : A Nurse utilizes the nursing process in managing patient care. Knowledge of this
process is essential to deliver high quality care and to focus on the client’s response to their illness.

1. During the planning phase of the nursing process, which of the following is the product
developed?

A. Nursing care plan

B. Nursing diagnosis
C. Nursing history
D. Nursing notes

2. Objective data are also known as?

A. Covert data
B. Inferences
C. Overt data
D. Symptoms

3. Data or information obtained from the assessment of a patient is primarily used by nurse to:

A. Ascertain the patient’s response to health problems

B. Assist in constructing the taxonomy of nursing intervention
C. Determine the effectiveness of the doctor’s order
D. Identify the patient’s disease process

4. What is an example of a subjective data?

A. Color of wound drainage

B. Odor of breath
C. Respiration of 14 breaths/minute
D. The patient’s statement of “I feel sick to my stomach”

SITUATION : Correct application of the Nursing Process is vital in providing quality care. The nurse
must use her skills and knowledge in proper assessment, planning and evaluating to meet the
patient’s need and address the priority response of the client to his or her illness.

5. Which statement is a difference between comprehensive and focused assessment?

A. Comprehensive assessments can’t include any focus assessments

B. Focused assessments are more important than comprehensive assessments
C. Focused assessments are usually ongoing and concerning specific problems
D. Objective data are included only in comprehensive assessments

6. Two year old Ben’s mother states “Ben vomited 8 ounces of his formula this morning.” This
statement is an example of:

A. Objective data from a primary source

B. Objective data from a secondary source
C. Subjective data from a primary source
D. Subjective data from a secondary source

7. Which expected outcome is correctly written?

A. The patient will be less edematous in 24 hours

B. The patient will drink an adequate amount of fluid daily
C. The patient will identify 5 high-salt foods from prepared list by discharge
D. The patient will soon sleep well through the night

8. An expected outcome on a patient’s care plan reads: “Patient will state seven warning signs of
cancer by discharge.” When the nurse evaluates the patient progress, the patient is able to state
that a change in wart or mole, a sore that doesn’t heal and a change in bowel or bladder habits are
warning signals of cancer. Which of the following would be an appropriate evaluative statement for
the nurse to place on the patient’s nursing care plan?

A. Patient understands the warning signals of cancer

B. Goal met; Patient cited a change in wart of mole, sore that doesn’t heal and a change in bowel or
bladder habits as warning signals of cancer.
C. Goal not met
D. Goal partially met

9. A quality assurance nurse sends questionnaire to patients after discharge to determine their level
of satisfaction with the nurse care they received in the facility. What type of nursing audit is this?

A. Concurrent
B. Outcome
C. Terminal
D. Retrospective

10. The nurse makes the following entry in the patient’s record: “Goal not met; patient refuses to
attend smoking cessation classes.” Because this goal hasn’t been met, the nurse should:
A. Develop a completely new nursing care plan
B. Assign the patient to a more experienced nurse
C. Critique the steps involved in the development of the goal
D. Transfer the patient to another facility

SITUATION : Health care delivery system affects the health status of every filipino. As a Nurse,
Knowledge of this system is expected to ensure quality of life.

11. When should rehabilitation commence?

A. The day before discharge

B. When the patient desires
C. Upon admission
D. 24 hours after discharge

12. What exemplified the preventive and promotive programs in the hospital?

A. Hospital as a center to prevent and control infection

B. Program for smokers
C. Program for alcoholics and drug addicts
D. Hospital Wellness Center

13. Which makes nursing dynamic?

A. Every patient is a unique physical, emotional, social and spiritual being

B. The patient participate in the over all nursing care plan
C. Nursing practice is expanding in the light of modern developments that takes place
D. The health status of the patient is constantly changing and the nurse must be cognizant and
responsive to these changes

14. Prevention is an important responsibility of the nurse in:

A. Hospitals
B. Community
C. Workplace
D. All of the above

15. This form of Health Insurance provides comprehensive prepaid health services to enrollees for a
fixed periodic payment.

A. Health Maintenance Organization

B. Medicare
C. Philippine Health Insurance Act
D. Hospital Maintenance Organization

SITUATION : Maslow’s hierarchy of needs is an integral component of prioritization. As a nurse, you

must know the client’s needs that request for an immediate action.

16. The client with history of pulmonary emboli is scheduled for insertion of an inferior vena cava
filter. The nurse checks on the client 1 hour after the physician has explained the procedure and
obtained consent from the client. The client is lying in bed, wringing the hands, and says to the
nurse, “I’m not sure about this. What if it doesn’t work, and I’m just as bad off as before?” The nurse
addresses which of the following primary concerns of the client?

A. Fear related to the potential risk and outcome of surgery

B. Anxiety related to the fear of death
C. Ineffective individual coping related to the therapeutic regimen
D. Knowledge deficit related to the surgical procedure

17. A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies
which nursing diagnosis as the highest priority for this client?

A. Altered nutrition, less than body requirements

B. High risk for aspiration
C. High risk for fluid volume deficit
D. Diarrhea

18. A home care nurse finds a client in the bedroom, unconscious, with pill bottle in hand. The pill
bottle contained the SSRI Sertraline (Zoloft). The nurse immediately assesses the client’s:

A. Blood pressure
B. Respirations
C. Pulse
D. Urine Output

19. A nurse is caring for a client admitted to the hospital for subclavian line placement. Which
psychosocial area of assessment should the nurse address with the client?

A. Strict restrictions of neck mobility

B. Loss of ability to ambulate as tolerated
C. Possible body image disturbance
D. Continuous pain related to ongoing placement of the subclavian line
20. A hospitalized client who has a living will is being fed through a nasogastric tube. During a bolus
feeding, the client vomits and begins choking. Which of the following actions is most appropriate for
the nurse to take?

A. Clear the client’s airway

B. Make the client comfortable
C. Start CPR
D. Stop feeding and remove the NG tube

SITUATION: Health Promotion is the priority nursing reponsibility. The nurse should be able to
promote the client’s wellbeing and identify ways on improving the client’s quality of life.

21. The nurse is caring for a 16 year old female client who isn’t sexually active. The client asks if she
needs a Papanicolau test. The nurse should reply:

A. Yes, she should have a Pap test after the onset of menstruation
B. No, because she isn’t sexually active
C. Yes, because she’s 16 years old
D. No, because she is not yet 21 years old

22. The nurse is assessing a client who complains of abdominal pain, nausea and diarrhea. When
examining the client’s abdomen, which sequence should the nurse use?

A. Inspection, palpation, percussion, auscultation

B. Inspection, auscultation, percussion, palpation
C. Auscultation, inspection, percussion, palpation
D. Palpation, auscultation, percussion, inspection

23. The nurse is speaking to a group of women about early detection of breast cancer. The average
age of the women in the group is 45. Following the Philippine Cancer Society guidelines, the nurse
should recommend that the women:

A. Perform breast self examination annually

B. Have a mammogram annually
C. Have a hormonal receptor assay annually
D. Have a physician conduct a clinical examination every 2 years

24. The school nurse is planning a program for a group of teenagers on skin cancer prevention.
Which of the following instruction whould the nurse emphasize in her talk?

A. Stay out of the sun between 1 p.m and 3 p.m

B. Tanning booth are a safe alternative for those who wish to tan
C. Sun exposure is safe, provided the client wears protective clothing
D. Examine skin once per month, looking for suspicious lesions or changes in moles

25. An employer establishes a physical exercise area in the workplace and encourages all employees
to use it. This is an example of which level of prevention?

A. Primary prevention
B. Secondary prevention
C. Tertiary prevention
D. Passive prevention

SITUATION : Basic nursing skills are essential for they are vital in many nursing procedures. Such
skills are needed in order to promote health, prevent illness, cure a disease and rehabilitate
infirmities.

26. A nurse has just been told by the physician that an order has been written to administer an iron
injection to a client. The nurse plans to give the medication in the:

A. Gluteal muscle using Z-Track technique

B. Deltoid muscle using an air lock
C. Subcutaneous tissue of the abdomen
D. Anterolateral thigh using 5/8-inch needle

27. A client has just been told by the physician that a cerebral angiogram will be obtained. The nurse
then collects data from the client about which of the following pieces of information?

A. Claustrophobia
B. Excessive weight
C. Allergy to eggs
D. Allergy to iodine or shellfish

28. A client has an order for a wound culture to be performed with the next wound irrigation and
dressing change. The nurse would plan to use which of the following solutions for irrigation before
this particular procedure?

A. Providone-iodine (Betadine)
B. One-half-strength hydrogen peroxide
C. Normal saline
D. Acetic acid

29. Which of the following is the best indicator in determining that the client’s airway needs
suctioning?
A. Oxygen saturation measurement
B. Respiratory rate
C. Breath sounds
D. Arterial blood gas results

30. A nurse is planning to assist a diabetic client to perform self-monitoring of blood glucos levels.
The nurse should incorporate which of the following strategies to best help the client obtain an
adequate capillary sample?

A. Cleanse the hands beforehand using cool water

B. Let the arm hang dependently and milk the digit
C. Puncture the center of the finger pad
D. Puncture the finger as deeply as possible

SITUATION : Mastery of Intravenous therapy and all aspects that address the response of the client
to complication related to it will help the new nurse in providing quality care.

31. One hour after the IV was inserted, Nurse Net found out that the 1 liter of D5NSS was empty.
Patient was in severe respiratory distress with pinkish frothy sputum. The most probable
complication is:

A. Speed shock
B. Renal failure
C. Congestive heart failure
D. Pulmonary edema

32. When an IV of D5W is not infusing well on patient, it is best to first:

A. Pinch the rubber part to flush out clogged blood

B. Coil tube and squeeze hard
C. Lower IV to check for return flow
D. Restart the IV

33. The doctor ordered venoclysis of dextrose 5% in water one liter KVO for 24 hours as a vehicle for
IV medications. How many drops per minute should the fluid be regulated?

A. 20 drops per minute

B. 5 drops per minute
C. 10 drops per minute
D. 15 drops per minute
34. The nurse is administering I.V fluids to an infant. Infants receiving I.V Therapy are particularly
vulnerable to:

A. Hypotension
B. Fluid overload
C. Cardiac arrythmias
D. Pulmonary emboli

35. A client with severe inflammatory bowel disease is receiving TPN. When administering TPN, the
nusre must take care to maintain the prescribed flow rate because giving TPN too rapidly may cause:

A. Hyperglycemia
B. Air embolism
C. Constipation
D. Dumping syndrome

SITUATION : Teaching and learning is a nursing responsibility. The ability of a nurse to educate and
change the client’s behavior through health teaching is one important goal of nursing.

36. A client’s hypertension has been recently diagnosed. The nurse would plan to do which of the
following as the first step in teaching the client about the disorder?

A. Gather all available resource material

B. Plan for the evaluation of the session
C. Assess the client’s knowledge and needs
D. Decide on the teaching approach

37. A diabetic client who is performing self-monitoring of blood glucose at home asks a clinic nurse
why a glycosylated hemoglobin level needs to be measured. The nurse should plan to incorporate
which of the following into a response?

A. This laboratory test is done yearly to predict likelihood of long term complication
B. This laboratory test gives an indication of glycemic control over the last 3 months
C. It is done as a method of verifying the accuracy of the meter used at Home
D. It is done to predict risk of hypoglycemia with the current diet and medication regimen

38. In teaching the sister of a diabetic client about the proper use of a glucometer in determining
the blood sugar level of the client, The nurse is focusing in which domain of learning according to
bloom?

A. Cognitive
B. Affective
C. Psychomotor
D. Affiliative

39. Which of the following is the most important condition for diabetic client to learn how to control
their diet?

A. Use of pamphlets and effective teaching devices during health instruction

B. Motivation to be symptom free
C. Ability of the client to understand teaching instruction
D. Language and appropriateness of the instruction

40. When you prepare your teaching plan for a group of hypertensive clients, you first formulate
your learning objectives. Which of the following steps in the nursing process corresponds to the
writing of learning objectives?

A. Planning
B. Implementing
C. Evaluating
D. Assessing

SITUATION : Nursing is a science. It involves a wide spectrum of theoretical foundation applied in

different health care situation. The nurse must use these theories in order to deliver the most
needed quality care.

41. The theorist who believes that adaptation and manipulation of stressors are needed to foster
change is:

A. Betty Neuman
B. Dorothea Orem
C. Martha Rogers
D. Sister Callista Roy

42. The theorist whose theory can be defined as the development of a science of humankind,
incorporating the concepts of energy fields, openness, pattern and organization is:

A. Dorothy Johnson
B. Hildegard Peplau
C. Martha Rogers
D. Myra Levine

43. A theorist whose major theme is the idea of transcultural nursing and caring nursing is:
A. Dorothea Orem
B. Madeleine Leininger
C. Sister Callista Roy
D. Virginia Henderson

44. Florence Nightingale was born in

A. Italy, May 12, 1840

B. Italy, May 12, 1820
C. England, May 12, 1840
D. England, May 12, 1820

45. Smith conceptualizes this health model as a condition of actualization or realization of person’s
potential. Avers that the highest aspiration of people is fulfillment and complete developmental
actualization.

A. Clinical Model
B. Role performance Model
C. Adaptive Model
D. Eudaemonistic Model

SITUATION : Oxygen is the most important physiologic requirement of the body. Absence of this
vital element for over 6 minutes leads to irreversible brain damage. Measures that promotes
oxygenation is integral in successfully managing client’s response to illnesses.

46. The primary effect of oxygen therapy is to:

A. Increase oxygen in the tissues and cells

B. Increase oxygen carrying capacity of the blood
C. Increase respiratory rate
D. Increase oxygen pressure in the alveolar sac

47. A nurse suctions a client who has an endotracheal tube in place. Following the procedure, which
of the following would indicate to the nurse that the client is experiencing an adverse effect of this
procedure?

A. Hypertension
B. Cardiac Irregularities
C. A reddish coloration in the client’s face
D. Oxygen saturation level of 95%

48. The GAUGE size in ET tubes determines:

A. The external circumference of the tube
B. The internal diameter of the tube
C. The length of the tube
D. The tube’s volumetric capacity

49. The nurse is correct in performing suctioning when she applies the suction intermittently during:

A. Insertion of the suction catheter

B. Withdrawing of the suction catheter
C. both insertion and withdrawing of the suction catheter
D. When the suction catheter tip reaches the bifurcation of the trachea

50. The purpose of the cuff in Tracheostomy tube is to:

A. Separate the upper and lower airway

B. Separate trachea from the esophagus
C. Separate the larynx from the nasopharynx
D. Secure the placement of the tube

SITUATION : To deliver a safe and quality care, Knowledge about wound care is necessary. The nurse
will have to deal with different types of wound during practice. It is of outmost important to apply
this knowledge to ensure optimum wound healing.

51. Based on the nurse’s knowledge of surgical wounds, simple surgical incisions heal by:

A. Primary intention
B. Secondary intention
C. Tertiary intention
D. Quarternary intention

52. The nurse documents that the wound edges are approximated. When the edges of an incision
are said to be approximated, this means edges are:

A. Brought together by sutures, tapes or staples

B. Eythematous and swollen
C. Gaping and draining
D. Necrotic and draining

53. Which vitamin is most essential for collagen synthesis?

A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D

54. When assessing the client’s wound for sign of infection, the nurse should look for the presence
of which of the following?
A. Granulation tissue
B. Pink tissue
C. Purulent drainage
D. Well approximated edges

55. The nurse is changing dressing and providing wound care. Which activity should she perform
first?

A. Assess the drainage in the dressing

B. Slowly remove the soiled dressing
C. Wash hands thoroughly
D. Put on latex gloves

SITUATION : Physical examination and health assessment are important in rendering care. The nurse
must use assessment knowledge in order to determine and prioritize client’s response to his or her
illness.

56. The component that should receive the highest priority before physical examination is the:

A. Psychological preparation of the client

B. Physical Preparation of the client
C. Preparation of the Environment
D. Preparation of the Equipments

57. When inspecting a client’s skin, the nurse finds a vesicle on the client’s arm. Which description
applies to a vesicle?

A. A flat, nonpalpable, and colored

B. Solid, elevated, and circumscribed
C. Circumscribed, elevated, and filled with serous fluid
D. Elevated, pus-filled, and circumscribed

58. When assessing a client with abdominal pain, the nurse should assess:

A. Any quadrant first

B. The symptomatic quadrant first
C. The symptomatic quadrant last
D. The sympomatic quadrant either second or third

59. To assess the client's dorsalis pedis pulse, the nurse should palpate the:

A. Medial surface of the ankle

B. Lateral surface of the ankle
C. Ventral aspect of the top of the foot
D. Medial aspect of the dorsum of the foot

60. Which of the following assessment would be a priority for a 2 year old after bronchoscopy?

A. Cardiac rate
B. Respiratory quality
C. Sputum color
D. Pulse pressure changes

61. The nurse checks the client's gag reflex. The recommended technique for testing the gag reflex is
to:

A. touch the back of the client's throat with a tongue depressor

B. observe the client for evidence of spontaneous swallowing when the neck is stroked
C. place a few milliliters of water on the client's tongue and note whether or not he swallows
D. observe the client's response to the introduction of a catheter for endotracheal suctioning

62. The nurse is evaluating a client’s lung sounds. Which of the following breath sounds indicate
adequate ventilation when auscultated over the lung fields?

A. Vesicular
B. Bronchial
C. Bronchovesicular
D. Adventitious

63. The night nurse informs the primary nurse that a client receiving intermittent gavage feedings is
not tolerating them. The primary nurse should first:

A. Change the feeding schedule to omit nights

B. Request that the type of solution be changed
C. Observe the night nurse administering a feeding
D. Suggest that the prescribed antiemetic be given first
64. A client has a chest tubes attached to a pleural drainage system. When caring for this client, the
nurse should:

A. Palpate the surrounding are for crepitus

B. Clamp the chest tubes when suctioning the client
C. Change the dressing daily using aseptic technique
D. Empty drainage chamber at the end of the shift

65. The nurse, aware of a client’s 25 year history of excessive alcohol use, would expect the physical
assessment to reveal a:

A. Liver infection
B. Low blood ammonia
C. Small liver with a rough surface
D. High fever with a generalizedrash

SITUATION : Nursing is a profession. Miss Linda is a newly appointed nurse in a hospital in Manila.
Born May 1985, Her knowledge of nursing’s professional development is required in order to project
the profession in a way that it lifts the standards of nursing.

66. Mrs. Linda defined nursing as one of the following except:

A. Assisting individual, family and community in attaining health

B. Assisting basic health needs
C. Establishing nursing diagnosis and implementing nursing care
D. Diagnosing, treating, prescribing medication and doing minor surgery

67. PNA was established in:

1. 1922
2. 1926
3. With Mrs. Rosario Delgado as first president
4. With Mrs. Anastacia Tupas as first president

A. 1,3
B. 1,4
C. 2,3
D. 2,4

68. As a national nurses association, it is characterized as follows except:

A. Both a professional body and a labor union

B. Affiliated with the International Council Of Nurses
C. Advocating for improved work and life condition of Nurses
D. Accrediting body for continuing education program

69. CPE Units per year is needed for license renewal. The number of CPE units per year should be:

A. 20 units
B. 30 units
C. 60 units
D. 100 units

70. As a nurse, R.A 1080 Exempts her from:

A. Paying her professional tax

B. Examination for civil service eligibility
C. Qualifying for the CGFNS
D. Paying business permit

71. In resigning for her job as a staff nurse, she must give advance notice of:

A. 15 days
B. 30 days
C. 45 days
D. 60 days

72. Why is there an ethical dilemma?

A. Because the law do not clearly state what is right from what is wrong
B. Because morality is subjective and it differs from each individual
C. Because the patient’s right coincide with the nurse’s responsibility
D. Because the nurse lacks ethical knowledge to determine what action is correct and what action is
unethical

73. Who among the following can work as a practicing nurse in the Philippines without taking the
Licensure examination?

A. Internationally well known experts which services are for a fee

B. Those that are hired by local hospitals in the country
C. Expert nurse clinicians hired by prestigious hospitals
D. Those involved in medical mission who’s services are for free

74. The nurse is correct in determining that a License is:

A. A personal property
B. Can be revoked by the Board of Nursing
C. A Right
D. Can be revoked by the PNA

75. A License is renewed every:

A. 1 year
B. 2 years
C. 3 years
D. 4 years

76. Which of the following persons cannot have free access to a patient’s record?

A. The patient
B. The physical therapist
C. The pharmacist
D. The lawyer

77. Ms. Linda’s license will expire in 2007, She must renew her license when?

A. January 2007
B. December 2007
C. May 2007
D. May 2008

78. The practice of Nursing in the Philippines is regulated by:

A. RA 9163
B. RA 9173
C. RA 7164
D. RA 7146

79. This quality is being demonstrated by a Nurse who raise the side rails of a confuse and
disoriented patient?

A. Autonomy
B. Responsibility
C. Prudence
D. Resourcefulness
80. Nurse Joel and Ana is helping a 16 year old Nursing Student in a case filed against the student.
The case was frustrated homicide. Nurse Joel and Ana are aware of the different circumstances of
crimes. They are correct in identifying which of the following Circumstances that will be best applied
in this case?

A. Justifying
B. Aggravating
C. Mitigating
D. Exempting

SITUATION : This is the first day of Mark, R.N. to report as a staff nurse in a tertiary hospital. As a
morning duty nurse, she is about to chart her nursing care.

81. Which of the following is not an accepted medical abbreviation?

A. NPO
B. PRN
C. OD
D. NON

82. Communication is best undertaken if barriers are first removed. Considering this statement,
which of the following is considered as deterrent factor in communication?

A. Not universally accepted abbreviation

B. Wrong Grammar
C. Poor Penmanship
D. Old age of the client

83. Which of the following chart entries are not acceptable?

A. Patient complained of chest pain

B. Patient ambulated to B/R
C. Vital signs 130/70; 84; 20
D. Pain relieved by Nitrogylcerine gr 1/150 sublingually

84. Which of the following indicates narrative charting?

A. Written descriptive nurse’s notes

B. Date recorded on nurse activity sheet
C. Use of checklist
D. Use of flowsheet
85. Being a new staff nurse, Mark remembers that information needed for daily nursing care of
clients are readily available in which of the following?

A. Kardex
B. Order sheet
C. Admission notes
D. Nurses notes

SITUATION : Mr. Orlando is assigned to Mang Carlos, A 60 years old, newly diagnosed diabetes
patient. He is beginning to write objectives for his teaching plan.

86. Which of the following is written in behavioral term?

A. Mang Carlos will know about diabetes related foot care and the techniques and equipment
necessary to carry it out
B. Mang Carlos sister will be able to determine his insulin requirement based on blood glucose
levels obtained from glucometer in two days
C. Mang Carlos daugter should learn about diabetes milletus within the week
D. Mang Carlos wife needs to understand the side effects of insulin

87. Which of the following is the best rationale for written objectives?

A. Document the quality of care

B. Facilitate evaluation of the performance of the nurse
C. Ensure learning on the part of the nurse
D. Ensure communication among staff members

88. Mang Carlos has been terminally ill for 5 years. He asked his wife to decide for him when he is no
longer capable to do so. As a Nurse, You know that this is called:

A. Last will and testament

B. DNR
C. Living will
D. Durable Power of Attorney

89. Which of the following behavior of Mang Carlos least indicates readiness to learn?

A. Talking with the nurse in charge and doctor

B. Reading brochures and pamphlets about diabetes
C. Inquiring about date of discharge
D. Asking question about diabetes milletus
90. Which of the following behaviors best contribute to the learning of Mang Carlos regarding his
disease condition?

A. Drawing him into discussion about diabetes

B. Frequent use of technical terms
C. Loosely structured teaching session
D. Detailed lengthy explanation

SITUATION : Mrs. Purificacion is now the Chief nurse of a hospital in Manila. She is carefully
reviewing different management styles and theories that will best help her in running the nursing
services in the hospital.

91. Which leadership style best empower the staff towards excellence?

A. Autocratic
B. Situational
C. Democratic
D. Laissez Faire

92. As a Nurse Manager, DSJ enjoys his staff of talented and self motivated individuals. He knew that
the leadership style to suit the needs of this kind of people is called:

A. Autocratic
B. Participative
C. Democratic
D. Laissez Faire

93. A fire has broken in the unit of DSJ R.N. The best leadership style suited in cases of emergencies
like this is:

A. Autocratic
B. Participative
C. Democratic
D. Laissez Faire

94. Mrs. Purificacion is thinking of introducing the Primary Nursing Model Approach. You
understand that this nursing model is:

A. The nurse manager assigns tasks to the staff members

B. Critical paths are used in providng nursing care
C. A single registered nurse is responsible for planning and providing individualized nursing care
D. Nursing staff are led by an RN leader in providing care to a group of clients
95. Structure, Process and Outcome are components of which step of the management process?

A. Planning
B. Organizing
C. Directing
D. Controlling

SITUATION : Nursing research is the term used to describe the evidence used to support nursing
practice. Nursing, as an evidence based area of practice, has been developing since the time of
Florence Nightingale to the present day, where many nurses now work as researchers based in
universities as well as in the health care setting.

96. Mr. DSJ Plans to undertake a research of Community 1 and 2 on how they manage their health
using Primary health care after an organization and training seminars. This type of research is:

A. Experimental
B. Historical
C. Descriptive
D. Basic

97. The independent variable is:

A. Primary Health Care

B. Community 1 and 2
C. Organization and training seminars
D. Management of their health

98. In this design, the variable that is being manipulated is

1. Independent
2. Organization and training seminars
3. Dependent
4. Management of Primary Health Care

A. 1,2
B. 1,4
C. 2,3
D. 3,4

99. In general, the research process follows the ff. ordered sequence:
1. Determination of design
2. Statement of the problem
3. Definition of variables
4. Collection and analysis of data
5. Review of related literature

A. 2,5,3,1,4
B. 3,5,4,1,2
C. 2,5,3,4,1
D. 2,5,1,3,4

100. Studies done in natural setting such as this one, posses difficulty of controlling which variable?

A. Independent
B. Dependent
C. Extraneous
D. Organismic
NURSING PRACTICE II

Situation : Nurse Macarena is a Family Planning and Infertility Nurse Specialist and currently attends
to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting
the nursing needs of this particular population group.

1. Daphne, 19 years old, asks nurse Macarena how can pregnancy be prevented through tubal
ligation. Which would be the best answer?

A. Prostaglandins released from the cut fallopian tubes will lead to permanent closure of the
vagina.
B. Sperm can not enter the uterus because the cervical entrance is blocked.
C. Sperm can no longer reach the ova, because the fallopian tubes are blocked
D. The ovary no longer releases ova as there is no where for them to go.

2. The Dators are a couple undergoing testing for infertility. Infertility is said to exist when:

A. A woman has no uterus

B. A woman has no children
C. A couple has been trying to conceive for 1 year
D. A couple has wanted a child for 6 months

3. Another client named Cindy is diagnosed as having endometriosis. This condition interferes with
fertility because:

A. Endometrial implants can block the fallopian tubes

B. The uterine cervix becomes inflamed and swollen
C. The endometrial lining becomes inflamed leading to narrowing of the cervix.
D. Inflammation of the endometrium causes release of substance P which kills the sperm.

4. Cindy submits herself to Fatima Medical Center and is scheduled to have a

hysterosalphingogram. Which of the following instructions would you give her regarding this
procedure?

A. Menstruation will be irregular for few months as an effect of the dye but it is just normal
B. The sonogram of the uterus will reveal any tumors present
C. The women may experience some itchiness in the vagina as an after effect.
D. Cramping may be felt when the dye is inserted

5. Cindy’s cousin on the other hand, knowing nurse Macarena’s specialization asks what artificial
insemination by donor entails. Which would be your best answer if you were Nurse Macarena?

A. Donor sperm are introduced vaginally into the uterus or cervix

B. Donor sperm are injected intra-abdominally into each ovary
C. Artificial sperm are injected vaginally to test tubal patency
D. The husband’s sperm is administered intravenously weekly

Situation . Nurse Dee-Lan was a graduate of Our Lady of Fatima University, he started working as a
nurse just right after he passed and topped the board exam. She was assigned to take care of a
group of patients across the lifespan.

6. Pain in geriatric clients require careful assessment because they:

A. experienced reduce sensory perception

B. have increased sensory perception
C. are expected to experience chronic pain
D. have a increased pain sensitivity

7. Administration of aminoglycosides to the older persons requires careful patient assessment

because older people:

A. are more sensitive to drugs

B. have increased hepatic, renal and gastrointestinal function
C. have increased sensory perception
D. mobilize drugs more rapidly

8. Elder clients are often at risk of having impaired skin integrity. One factor is that they often
experience urinary incontinence. The elderly patient is at higher risk for urinary incontinence
because of:

A. increased glomerular filtration C. decreased bladder capacity

B. decrease elasticity of blood vessels D. dilated urethra

9. Which of the following is the MOST COMMON sign of infection among the elderly?

A. decreased breath sounds with crackles C. pain

B. Increase body temperature D. Restlessness, confusion, irritability

10. Prioritization is important to test a nurse’s good judgment towards different situations.
Priorities when caring for the elderly trauma patient:

A. circulation, airway, breathing C. airway, breathing, disability (neurologic)

B. disability (neurologic), airway, breathing D. airway, breathing, circulation
11. The nurse assessing newborn babies and infants during their hospital stay after birth will notice
which of the following symptoms as a primary manifestation of Achalasia?

A. Olive shaped mass on abdomen

B. Failure to pass meconium during the first 24 to 48 hours after birth
C. The skin turns yellow and then brown over the first 48 hours of life
D. Effortless and non-projectile vomiting

12. A client is 7 months pregnant and has just been diagnosed as having a partial placenta previa.
She is stable and has minimal spotting and is being sent home. Which of these instructions to the
client may indicate a need for further teaching?

A. Maintain bed rest with bathroom privileges

B. Avoid intercourse for three days.
C. Call if contractions occur.
D. Stay on left side as much as possible when lying down.

13. Ms. Anna, a review assistant of the greatest nursing review center in the Philippines has been
rushed to the hospital with ruptured membrane. Which of the following should the nurse check
first?

A. Check for the presence of infection

B. Assess for Prolapse of the umbilical cord
C. Check the maternal heart rate
D. Assess the color of the amniotic fluid

14. The nurse notes that the infant is wearing a plastic-coated diaper. If a topical medication were to
be prescribed and it were to go on the stomachs or buttocks, the nurse would teach the caregivers
to:

A. avoid covering the area of the topical medication with the diaper
B.avoid the use of clothing on top of the diaper
C.put the diaper on as usual
D. apply an icepack for 5 minutes to the outside of the diaper

15. Which of the following factors is most important in determining the success of relationships
used in delivering nursing care?

A. Type of illness of the client

B. Transference and counter transference
C. Effective communication
D. Personality of the participants

16. Grace sustained a laceration on her leg from automobile accident. Why are lacerations of lower
extremities potentially more serious among pregnant women than other?
A. lacerations can provoke allergic responses due to gonadotropic hormone release
B. a woman is less able to keep the laceration clean because of her fatigue
C. healing is limited during pregnancy so these will not heal until after birth
D. increased bleeding can occur from uterine pressure on leg veins

17. You are the nurse assigned to work with a child with acute glomerulonephritis. By following the
prescribed treatment regimen, the child experiences a remission. You are now checking to make
sure the child does not have a relapse. Which finding would most lead you to the conclusion that a
relapse is happening?

A. Elevated temperature, cough, sore throat, changing complete blood count (CBC) with diiferential
B. A urine dipstick measurement of 2+ proteinuria or more for 3 days, or the child found to have
3-4+ proteinutria plus edema.
C. The urine dipstick showing glucose in the urine for 3 days, extreme thirst, increase in urine
output, and a moon face.
D. A temperature of 37.8 degrees (100 degrees F), flank pain, burning frequency, urgency on
voiding, and cloudy urine.
18. The painful phenomenon known as “back labor” occurs in a client whose fetus in what position?

A. Brow position C. Breech position

B. Right Occipito-Anterior Position D. Left Occipito-Posterior Position

Situation – With the increasing documented cases of CANCER the best alternative to
treatment still remains to be PREVENTION. The following conditions apply.

19. Which among the following is the primary focus of prevention of cancer?

A. Elimination of conditions causing cancer

B. Diagnosis and treatment
C. Treatment at early stage
D. Early detection

20. In the prevention and control of cancer, which of the following activities is the most important
function of the community health nurse?

A. Conduct community assemblies.

B. Referral to cancer specialist those clients with symptoms of cancer.
C. Use the nine warning signs of cancer as parameters in our process of detection, control and
treatment
modalities.
D. Teach woman about proper/correct nutrition.

21. Who among the following are recipients of the secondary level of care for cancer cases?

A. Those under early case detection

B. Those under post case treatment
C. Those scheduled for surgery
D. Those undergoing treatment

22. Who among the following are recipients of the tertiary level of care for cancer cases?

A. Those under early treatment C. Those under early detection

B. Those under supportive care D. Those scheduled for surgery

23. Being a community health nurse, you have the responsibility of participating in protecting the
health of people. Consider this situation: Vendors selling bread with their bare hands. They receive
money with these hands. You do not see them washing their hands. What should you say/do?

A. “Miss, may I get the bread myself because you have not washed your hands”
B. All of these
C. “Miss, it is better to use a pick up forceps/ bread tong”
D. “Miss, your hands are dirty. Wash your hands first before getting the bread”

Situation : The following questions refers to common clinical encounters experienced by an entry
level nurse.

24. A female client asks the nurse about the use of a cervical cap. Which statement is correct
regarding the use of the cervical cap?

A. It may affect Pap smear results.

B. It does not need to be fitted by the physician.
C. It does not require the use of spermicide.
D. It must be removed within 24 hours.

25. The major components of the communication process are:

A. Verbal, written and nonverbal

B. Speaker, listener and reply
C. Facial expression, tone of voice and gestures
D. Message, sender, channel, receiver and feedback

26. The school nurse notices a child who is wearing old, dirty, poor-fitting clothes; is always hungry;
has no lunch money; and is always tired. When the nurse asks the boy his tiredness, he talks of
playing outside until midnight. The nurse will suspect that this child is:

A. Being raised by a parent of low intelligence quotient (IQ)

B. An orphan
C. A victim of child neglect
D. The victim of poverty
Situation: Mike 16 y/o has been diagnosed to have AIDS, he worked as entertainer in a cruise ship;

27. Which method of transmission is common to contract AIDS:

A. Syringe and needles A. Sexual contact

B. Body fluids B. Transfusion

28. Causative organism in AIDS is one of the following;

A. Fungus C. retrovirus
B. Bacteria D. Parasites

29. You are assigned in a private room of Mike. Which procedure should be of outmost
importance;

A. Alcohol wash C. Washing Isolation

B. Universal precaution D. Gloving technique

30. What primary health teaching would you give to mike;

A. Daily exercise C. reverse isolation

B. Prevent infection D. Proper nutrition

31. Exercise precaution must be taken to protect health worker dealing with the AIDS patients .
which among these must be done as priority:

A. Boil used syringe and needles

B. Use gloves when handling specimen
C. Label personal belonging
D. Avoid accidental wound
Situation: Michelle is a 6 year old preschooler. She was reported by her sister to have measles but
she is at home because of fever, upper respiratory problem and white sports in her mouth.

32. Rubeola is an Arabic term meaning Red, the rash appears on the skin in invasive stage prior to
eruption behind the ears. As a nurse, your physical examination must determine complication
especially:

A. Otitis media C. Inflammatory conjunctiva

B. Bronchial pneumonia D. Membranous laryngitis

33. To render comfort measure is one of the priorities, Which includes care of the skin, eyes, ears,
mouth and nose. To clean the mouth, your antiseptic solution is in some form of which one below?
A. Water C. Alkaline
B. Sulfur D. Salt

34. As a public health nurse, you teach mother and family members the prevention of complication
of measles. Which of the following should be closely watched?

A. Temperature fails to drop C. Inflammation of the nasophraynx

B. Inflammation of the conjunctiva D. Ulcerative stomatitis

35. Source of infection of measles is secretion of nose and throat of infection person. Filterable virus
of measles is transmitted by:

A. Water supply C. Food ingestion

B. Droplet D. Sexual contact

36. Method of prevention is to avoid exposure to an infection person. Nursing responsibility for
rehabilitation of patient includes the provision of:

A. Terminal disinfection C. Immunization

B. Injection of gamma globulin D. Comfort measures

SITUATION: Sexually Transmitted Diseases are important to identify during pregnancy because of
their potential effect on the pregnancy, fetus, or newborn. The following questions pertain to STD’s.

37. Ms. Reynaldita is a promiscuous woman in Manila submits herself to the clinic for certain
examinations. She is experiencing vaginal irritation, redness, and a thick cream cheese vaginal
discharge. As a nurse, you will suspect that Ms. Reynaldita is having what disease?
A. Gardnerella Vaginalis
B. Candida Albicans
C. Treponema Pallidum
D. Moniliasis

38. As a knowledgeable nurse, you know that the doctor may prescribe a certain medications for
Ms. Reynaldita. What is the drug of choice for Reynaldita’s infection?
A. haloperidol
B. miconazole
C. benzathine penicillin
D. metronidazole

39. Based on your learnings, you know that the causative agent of Reynaldita’s infection is:
A. Monistat Candida
 B. Candida Albicans
C. Albopictus Candidiasis
D. Monakiki

40. The microorganism that causes Reynaldita’s infection is a:

A. Bacteria
B. Protozoa
C. Fungus
D. Virus

41. Another client in the Maternal Clinic was Ms. Celbong. Her doctor examined Ms. Celbong’s
vaginal secretions and found out that she has a Trichomoniasis infection. Trichomoniasis is
diagnosed through which of the following method?
A. Vaginal secretions are examined on a wet slide that has been treated with potassium
hydroxide.
B. Vaginal speculum is used to obtain secretions from the cervix.
C. A lithmus paper is used to test if the vaginal secretions are infected with trichomoniasis.
D. Vaginal secretions are examined on a wet slide treated with zephiran solution.

42. Daphne who is on her first trimester of pregnancy is also infected with trichomoniasis. You know
that the drug of choice for Daphne is:
A. Flagyl
B. Clotrimazole (topical)
C. Monistat
D. Zovirax

43. Syphilis is another infection that may impose risk during pregnancy. Since we are under the
practice of health science, you know that Syphilis is caused by:
A. Treponema Syphilis
B. Neisseria gonorrhoeae
C. Chlamydia Trachomatis
D. Treponema Pallidum
44. What type of microorganism is the causative agent of syphilis?
A. Spirochete
B. Fungus
C. Bacteria
D. Protozoan
45. Under the second level of prevention, you know that one of the focuses of care is the screening
of diseases. What is the screening test for syphilis?
A. VDRL
B. Western blot
C. PSA
 D. ELISA
46. Jarisch-Herxheimer reaction may be experienced by the client with syphilis after therapy with
benzathine penicillin G. The characteristic manifestations of Jarisch-Herxheimer reaction are:
A. Rashes, itchiness, hives and pruritus
B. Confusion, drowsiness and numbness of extremities
C. sudden episode of hypotension, fever, tachycardia, and muscle aches
D. Episodes of nausea and vomiting, with bradypnea and bradycardia

47. A pregnant woman is in the clinic for consultation with regards to STD’s. She inquires about
Venereal warts and asks you about its specific lesion appearance. Which of the following is your
correct response to the client?
A. Why are you asking about it? You might be a prostitute woman.
B. The lesions appear as cauliflower like lesions.
C. It appears as pinpoint vesicles surrounded by erythema.
D. The lesions can possibly obstruct the birth canal.

48. Based on your past learnings in communicable diseases, you know that the causative agent of
venereal warts is:
A. Chlamydia Trachomatis
B. Candida Moniliasis
C. Human Papilloma Virus
D. Staphylococcus Aureus

49. As a nurse in charge for this woman, you anticipate that the doctor will prescribe what
medication for this type of infection?
A. Podophyllum (Podofin)
B. Flagyl
C. Monistat
D. Trichloroacetic acid

50. Cryocautery may also be used to remove large lesions. The healing period after cryocautery may
be completed in 4-6 weeks but may cause some discomforts to the woman. What measures can
alleviate these discomforts?
A. Kegel’s Exercise
B. Cool air
C. Topical steroids
D. Sitz baths and lidocaine cream

51. In order to prevent acquiring sexually transmitted diseases, what is the BEST way to consider?
A. Condom use
B. Withdrawal
C. vasectomy
 D. Abstinence

SITUATION: The Gastrointestinal System is responsible for taking in and processing nutrients for all
parts of the body, any problem can quickly affect other body systems and, if not adequately treated,
can affect overall health, growth, and development. The following questions are about
gastrointestinal disorders in a child.

52. Mr. & Mrs. Alcaras brought their son in the hospital for check up. The child has failure to thrive
and was diagnosed with pyloric stenosis. Which among the following statements are the
characteristic manifestations of pyloric stenosis?
A. Vomiting in the early morning
B. Bile containing vomitus immediately after meal
C. sausage shaped mass in the abdomen
D. Projectile vomiting with no bile content

53. The exact cause of pyloric stenosis is unknown, but multifactorial inheritance is the likely cause.
Being knowledgeable about this disease, you know that pyloric stenosis is more common in which
gender?
A. Male
B. Female
C. Incidence is equal for both sexes
D. None of the above

54. To rule out pyloric stenosis, the definitive diagnosis is made by watching the infant drink. After
the infant drinks, what will be the characteristic sign that will describe pyloric stenosis?
A. An olive-size lump can be palpated
B. There is gastric peristalsic waves from left to right across the abdomen
C. A hypertrophied sphincter can be seen on ultrasound.
D. A tingling sensation is felt on the lower extremities
55. Shee Jan Long a 10 months old infant was admitted to the hospital for severe abdominal pain.
The doctor found out that the distal ileal segment of the child’s bowel has invaginated into the
cecum. The nurse will suspect what disease condition?
A. Intussusception
B. Pyloric stenosis
C. Hirschprung’s disease
D. Vaginismus

56. In intussusceptions, children suddenly draw up their legs and cry as if they are in severe pain and
possibly vomit. Another manifestation of such disease is the presence of blood in the stool. What is
the characteristic stool of client with intussuscepton?
A. Coffee ground
B. Black and Tarry
 C. Currant jelly stool
D. Watery stool

57. A 4-year-old child is hospitalized because of persistent vomiting. As a nurse, you must monitor
the child closely for:
A. Diarrhea
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Hyperactive bowel sounds

58. A nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for
diarrhea. The nurse prepares to take the child’s temperature and avoids which method of
measurement?
A. Tympanic
B. Axillary
C. Rectal
D. Electronic

59. A home care nurse provides instructions to the mother of an infant with cleft palate regarding
feeding. Which statement if made by the mother indicates a need for further instructions?
A. “I will use a nipple with a small hole to prevent choking.”
B. “I will stimulate sucking by rubbing the nipple on the lower lip.”
C. “I will allow the infant time to swallow.”
D.” I will allow the infant to rest frequently to provide time for swallowing what has been placed in
the mouth.”

60. An infant has just returned to the nursing unit following a surgical repair of a cleft lip located at
the right side of the lip. The nurse places the infant in which most appropriate position?
A. On the right side
B. On the left side
C. Prone
D. Supine

61. A clinic nurse reviews the record of an infant seen in the clinic. The nurse notes that a diagnosis
of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note
which most likely sign of this condition documented in the record?
A. Severe projectile vomiting
B. Coughing at night time
C. Choking with feedings
D. Incessant crying
SITUATION: Human development is one of the important concepts that a nurse should learn to be
able to deal appropriately with their clients of different developmental stages.

62. Which statement best describes when fertilization occurs?

A. When the spermatozoon passes into the ovum and the nuclei fuse into a single cell.
B. When the ovum is discharged from the ovary near the fimbriated end of the fallopian tube.
C. When the embryo attaches to the uterine wall.
D. When the sperm and ova undergo developmental changes resulting in a reduction in the
number of chromosomes.

63. A pregnant client asks you about fetal development. At approximately what gestational age does
the fetus’s single chambered heart begin to pump its own blood cells through main blood vessels?
A. 10 weeks
B. 8 weeks
C. 5 weeks
D. 3 weeks

64. At 17 weeks gestation, a fetus isn’t considered to be ballotable. Ballotment means that:
A. The examiner feels rebound movement of the fetus.
B. The examiner feels fetal movement.
C. The client feels irregular, painless uterine contractions.
D. The client feels fetal movement.

65. Which hormone stimulates the development of the ovum?

A. Follicle stimulating hormone (FSH)
B. Human Chorionic Gonadotropin (HCG)
C. Luteinizing Hormone (LH)
D. Gonadotropin Releasing Hprmone (GnRH)

66. How long is the gestational period of a full term pregnancy?

A. Ranging from 245 days to 259 days
B. around 5,554 hours to 5,880 hours
C. More than 294 days
D. Averaging of 266 to 294 days

67. An 18 year old woman in her 18th week of pregnancy is being evaluated. Which positive sign of
pregnancy should the nurse expect to be present?
A. Fetal heart tones detectable by Doppler stethoscope
B. Fetal movement detectable by palpation
C. Visualization of the fetus by ultrasound examination.
D. Fetal heart tones detectable by a fetoscope.
68. During her prenatal visit, a 28 year old client expresses concern about nutrition during
pregnancy. She wants to know what foods she should be eating to ensure the proper growth and
development of her baby. Which step should the nurse take first?
A. Give the client a sample diet plan for a 2,400 calorie diet.
B. Emphasize the importance of avoiding salty and fatty foods.
C. Instruct the client to continue to eat a normal diet.
D. Assess the client’s current nutritional status by taking a diet history.

69. A nurse is teaching a class about the reproductive system. She explains that fertilization most
often takes place in the:
A. Ovary
B. Fallopian tubes
C. Uterus
D. vagina

70. A large number of neural tube defects may be prevented if a pregnant woman includes which
supplement in her diet?
A. Vit. A
B. Vit. E
C. Vit. D
D. Vit. B9

71. A 22 year old client is at 20 weeks gestation. She asks the nurse about the development of her
fetus at this stage. Which of the following developments occurs at 20 weeks gestation?
A. The pancreas starts producing insulin and the kidneys produce urine.
B. The fetus follows a regular schedule of turning, sleeping, sucking, and kicking.
C. Swallowing reflex has been mastered, and the fetus sucks its thumb.
D. Surfactant forms in the lungs.

SITUATION: Developing countries such as the Philippines suffer from high infant and child mortality
rates. Thus, as a management to the existing problem, the WHO and UNICEF launched the IMCI.
72. A 6 month old baby Len was brought to the health center because of fever and cough for 2 days.
She weighs 5 kg. Her temperature is 38.5 taken Axillary. Further examination revealed that she has
general rashes, her eyes are red and she has mouth ulcers non deep and non extensive, There was
no pus draining from her eyes. Most probably Baby Len has:
a. Severe complicated measles d. Measles
b. Fever: No MALARIA e. Measles with eye or mouth complications
c. Very severe febrile disease

73. The dosage of Vit. A supplement given to Baby Len would be:
d. 100,000 IU d. 200,000 IU
e. 10,000 IU e. 20,000 IU
74. Using IMCI Chart, this child can be manage with:
f. Treat the child with paracetamol and follow up in 2 days if the fever persist
g. Give the first dose of antibiotic, give Vit. A, apply Gentian Violet for mouth ulcers and refer
urgently to hospital
h. Give100, 000 international units of Vit. A
i. Give200, 000 international units of Vit. A
e. Give Vit. A, apply Gentian violet for mouth ulcers and follow up in 2 days
75. The following are signs of severe complicated measles:
j. Clouding of the cornea
k. Deep or extensive mouth ulcers
l. Pus draining from the eyes
m. A and b only
n. All of the above

76. If the child is having 2 ½ weeks ear discharges, how would you classify and treat the child:
1. Green 5. Dry the ear by wicking
2. Yellow 6. 5 days antibiotic
3. Pink 7. Urgent referral with first dose of antibiotic
4. Red

a. 4,7 b. 2,5,6 c. 1,5 d. 3,7 e. 2,5

77. The following are treatments for acute ear infections:

a. Dry the ear by wicking d. A and c only
b. Give antibiotics for 5 days e. All of the above
c. Follow up in 5 days

78. A child with ear problem should be assessed for the following, except:
a. Ear pain
b. If discharge is present for how long?
c. Ear discharge
d. Is there any fever?
e. None of the above

79. If the child does not have ear problem, using IMCI, what should you do as a nurse?
a. Go to the next question, check for malnutrition
b. Check for ear pain
c. Check for tender swelling behind the ear
d. Check for ear discharge

80. An ear discharge that has been present for more than 14 days can be classified as:
a. Complicated ear infection c. Chronic ear infection
b. Acute ear infection d. Mastoiditis

81. An ear discharge that has been present for less than 14 days can be classified as:
a. Complicated ear infection c. Chronic ear infection
b. Acute ear infection d. Mastoiditis

82. If the child has severe classification because of ear problem, what would be the best thing that
you should do as a nurse?
a. Dry the ear by wicking
b. Give an antibiotic for 5 days
c. Refer urgently
d. Instruct mother when to return immediately

Situation: Primary Health Care (PHC) is defined by the WHO as essential health care made
universally accessible to individuals, families and communities.

83. The WHO held a meeting in this place where Primary health Care was discussed. What is this
place?
A. Alma Ata
B. Russia
C. Vienna
D. Geneva
Situation: The national objective for maintaining the health of all Filipinos is a primary responsibility
of the DOH.

84. The following are mission of the DOH except:

a. Ensure accessibility
b.Quality of health care
c.Health for all Filipinos
d.Quality of Life of all Filipinos
e. None of the above

85. The basic principles to achieve improvement in health include all BUT:
a. Universal access to basic health services must be ensured
b. The health and nutrition of vulnerable groups must be prioritized
c. Performance of the health sector must be enhanced
d. Support the frontline workers and the local health system
e. None of the above

86. Which of the following is not a primary strategy to achieve health goals:

a. Support of local health system development

b. Development of national standards for health
c. Assurance of health care for all
d. Support the frontline workers
e. None of the above

87. According to the WHO health is:

A. state of complete physical, mental and social well being not merely the absence of disease
B. A science and art of preventing disease and prolonging life
C. A science that deals the optimum level of functioning of the Individual, family and community
D. All of the above
88. Assistance in physical therapy of a trauma patient is a:
Primary level of prevention
B. Secondary level of prevention
C. Tertiary level of prevention
D. Specialized level of prevention

89. Local health boards were established at the provincial, city and municipal levels. At the
municipal level,the chairman of the board is the:

A.Rural Health physician

B.Governor
C.Mayor
D.Chairman of the Committee on Health
90. The emphasis of community health nursing is on:

A. Treatment of health problems

B. Preventing health problems and promoting optimum health
C. Identification and assessment of health problems
D. Illness end of the wellness-illness continuum.

91. In asking the mother about her child’s problem the following communication skills should be
used except:
a. Use words that the mother understand
b. Give time for the mother to answer the questions
c. Listen attentively
d. Ask checking questions
e. None of the above

92. Which of the following is the principal focus of the CARI program of the Department of Health?
a. Teach other community health workers how to assess patients
b. Mortality reduction through early detection
c. Teach mothers how to detect signs and where to refer
d. Enhancement of health team capabilities

93. You were able to identify factors that lead to respiratory problems in the community where your
health facility serves. Your primary role therefore in order to reduce morbidity due to pneumonia is
to?
a. Seek assistance and mobilize the BHW’s to have a meeting with mothers
b. Refer cases to hospitals
c. Make home visits to sick children
d. Teach mothers how to recognize early signs and symptoms of pneumonia

94. Which of the following is the most important responsibility of a nurse in the prevention of
unnecessary deaths from pneumonia and other severe disease?
a. Weighing of the child
b. Provision of careful assessment
c. Taking of the temperature of the sick child
d. Giving of antibiotics

95. A 4-month-old child was brought to your clinic because of cough and colds. Which of the
following is your primary action?
a. Teach the mother how to count her child’s breathing?
b. Refer to the doctor
c. Assess the patient using the chart on management of children with cough
d. Give cotrimoxazole tablet or syrup
e. All of the above

96. In responding to the care concerns to children with severe disease, referral to the hospital is of
the essence especially if the child manifests which of the following?
a. Stopped feeding well c. Wheezing
b. Fast breathing d. Difficulty to awaken

Elvira Magalpok is a 26 year old woman you admit to a birthing room. She’s been having
contractions 45 seconds long and 3 minutes apart for the last 6 hours. She tells you she wants to
have her baby “naturally” without any analgesia or anesthesia. Her husband is in the Army and
assigned overseas, so he is not with her. Although her sister lives only two blocks from the hospital,
Elvira doesn’t want her called. She asks if she can talk to her mother on the telephone instead. As
you finish assessing contractions, she screams with pain and shouts, “Ginagawa ko na ang lahat ng
makakaya ko! Kailan ba matatapos ang paghihirap kong ito?”

97. Elvira didn’t recognize for over an hour that she was in labor. A sign of true labor is:
A. Sudden increase energy from epinephrine release
B. “Nagging” but constant pain in the lower back.
C. Urinary urgency from increased bladder pressure.
D. “Show” or release of the cervical mucus plug.

98. Elvira asks you which fetal position and presentation are ideal. Your best answer would be:
A. Right occipitoanterior with full flexion.
B. Left transverse anterior in moderate flexion.
C. Right occipitoposterior with no flexion.
D. Left sacroanterior with full flexion.

99. Elvira is having long and hard uterine contractions. What length of contraction would you report
as abnormal?
A. Any length over 30 seconds.
B. A contraction over 70 seconds in length.
C. A contraction that peaks at 20 seconds.
D. A contraction shorter than 60 seconds.

100. You assess Elvira’s uterine contractions. In relation to the contraction, when does a late
deceleration begin?
A. Forty-five seconds after the contraction is over.
B. Thirty seconds after the start of a contraction.
C. After every tenth or more contraction.
D. After a typical contraction ends.
NURSING PRACTICE III

SITUATION: Mang Roberto was long diagnosed with chronic renal failure. You are his nurse and the
following question assesses your knowledge in the different fluid and electrolyte imbalances that
are associated with chronic renal failure.

1. Disequilibrium syndrome is always a risk in all clients undergoing hemodialysis for chronic renal
failure. The nurse should assess Mang Roberto for which of the following sign and symptom
associated with Disequilibrium syndrome?

A. Hypertension, Tachycardia and Fever

B. Imbalance, gait abnormality and inability to stand up
C. Restlessness, irritability and generalized weakness
D. Headache, deteriorating level of consciousness and twitching

2. After Mang Roberto completed his hemodialysis, The nurse should use which indicators to
evaluate the client’s status after dialysis?

A. Potassium level and weight C. Blood Urea Nitrogen and Creatinine level
B. Vital signs and Blood Urea Nitrogen D. Vital signs and weight

3. Mang Roberto’s chronic renal failure was caused by a crush injury to the lower leg right after an
accident. The acute renal failure progresses to chronic renal failure until now, his case is irreversible.
The nurse is correct in determining that the cause of Mang Roberto’s Acute renal failure before was:

A. Pre renal B. Post renal C. Renal D. Extra renal

4. Mang Roberto misses 2 sessions of hemodialysis. Blood was drawn and is sent for analysis. Which
electrolyte disturbance is expected in a client with chronic renal failure?

A. Hypernatremia B. Hyperkalemia C. Hypokalemia D. Alkalemia

5. In Mang Roberto’s ECG tracing, you would expect to find:

A. Depressed T wave C. A peaked T wave

B. Presence of U wave D. Inverted T wave

6. The main indicator of the need for hemodialysis is:

A. Ascites B. Acidosis C. Hypertension D. Hyperkalemia

7. To gain access to the vein and artery, an AV shunt was used for Mang Roberto. The most serious
problem with regards to the AV shunt is:

A. Septicemia B. Clot formation C. Exsanguination D. Vessel sclerosis

8. When caring for Mang Roberto’s AV shunt on his right arm, you should:

A. Cover the entire cannula with an elastic bandage

B. Notify the physician if a bruit and thrill are present
C. User surgical aseptic technique when giving shunt care
D. Take the blood pressure on the right arm instead

9. Mang Roberto Complains of tingling in the finger and twitching of the muscles. This is caused by:

A. Acidosis C. Calcium Depletion

B. Potassium retention D. Sodium chloride depletion

10. Which of the following is an appropriate instruction for Mang Roberto?

A. Follow a high potassium diet

B. Strictly follow the hemodialysis schedule
C. Use salt substitute instead of the normal table salt
D. Use alcohol on the skin to clean it due to integumentary changes

SITUATION: Mang Roberto’s condition continues to worsen and the doctor suggested Kidney
Transplantation.

11. Mang Roberto has just received a renal transplant and has started cyclosporine therapy to
prevent graft rejection. Which of the following condition is a major complication of this drug
therapy?

A. Depression C. Infection
B. Hemorrhage D. Peptic ulcer disease

12. Which of the following is the rationale why Azathioprine (Imuran), Prednisone or Cyclosporine
(SandImmune) is given in a client that has undergone Kidney Transplantation?

A. To enhance the immune system preventing rejection

B. To suppress the immune system preventing rejection
C. To enhance kidney function
D. To protect the newly transplanted kidney from invading pathogens
13. Immunosuppression following Kidney transplantation is continued:

A. For life C. A week after transplantation

B. 24 hours after transplantation D. Until the kidney is not anymore rejected

14. Steroids, if used following kidney transplantation would cause which of the following side
effects?

A. Alopecia C. Orthostatic Hypotension

B. Increase Cholesterol Level D. Increase Blood Glucose Level

15. Mang Roberto was readmitted to the hospital with acute graft rejection. Which of the following
assessment finding would be expected?

A. Hypotension C. Decreased WBC

B. Normal Body Temperature D. Elevated BUN and Creatinine

SITUATION: Nanette was rushed to the hospital due to burns. Witnesses told the emergency team
that Nanette fell asleep while she is holding her cigarette thus, burning the bed sheets and herself.
2nd and 3rd degree burns are on the face, neck, anterior and posterior trunk as well as the anterior of
the left leg and the whole right arm was burned. First degree burns are located on the anterior
portion of the right leg and the anterior portion of the right and left arm. Nanette is a 110 lbs female
client.

16. The priority nursing intervention for Nanette is to:

A. Assess airway, breathing and circulation C. Apply ointment over the burned surface
B. Check Nanette’s Vital Signs D. Administer oxygen inhalation

17. Using the rule of nine, the percentage of the burned area on Nanette’s skin is:

A. 63% B. 81% C. 90% D. 72%

18. The rationale in giving IV fluids for Miss Nanette is to prevent:

A. Cardiogenic shock C. Hypovolemic shock

B. Septic Shock D. Neurogenic Shock

19. A second degree burn on Nanette is characterized by:

A. Eschars C. Blisters and Edema

B. Broken skin with fat exposed D. Insensate wound draining purple fluid
20. During the first 48 hours, Burn victims is observed for metabolic acidosis resulting from loss of
bicarbonate ions that arises from:

A. Potassium loss C. Sodium loss

B. Calcium loss D. Magnesium loss

21. IV fluid that is commonly used in clients with dehydration, diarrhea and burns is:

A. Lactated Ringers C. Normal Saline Solution

B. D5 NSS D. NSS Plus potassium

22. The doctor uses Parkland/Baxter formula in computing the amount of fluid needed for Nanette’s
resuscitation. You would expect that the doctor will order how many milliliters of IV fluids?

A. 6 liters during the first 8 hours, 3 liters on the next 8 hours and another 3 liters on another 8
hours.
B. 12 liters during the first 8 hours and another 12 liters on the succeeding 16 hours
C. 8 liters during the first 8 hours, 4 liters on the next 8 hours and another 8 liters on another 8
hours
D. 10 liters during the first 8 hours and another 10 liters on the succeeding 16 hours

23. During the emergent phase of burn, which of the following is an expected finding on Nanette?

A. Decreased heart rate C. Increased blood pressure

B. Elevated hematocrit levels D. Increased urinary output

24. Which electrolyte disturbance is the most lethal in client with burn?

A. Hyponatremia C. Hyperkalemia
B. Hypercalcemia D. Hypokalemia

25. The priority consideration for Nanette during the early phase of burn is:

A. Pain C. Fluid status

B. Body Image D. Infection of the wound

SITUATION: Joanna Marie, a 40 year old client was diagnosed with breast cancer.

26. The nurse is instruction Joanna about breast self examination. The nurse instructs Joanna to
perform Breast Self Examination:
A. At the onset of menstruation C. Every month during ovulation
B. 1 week after menstruation begins D. Weekly at the same time each day

27. Joanna is taking Adriamycin together with tamoxifen. You know that Adriamycin works by:

A. Inhibiting DNA Synthesis C. Changing the osmotic gradient of the cell

B. Preventing Folic acid synthesis D. Increase cell wall permeability

28. Joanna’s tumor is said to be ERP+. You know that Estrogen receptor positive tumor is:

A. A good indicator of the possibility of breast reconstruction

B. A good indicator for giving an estrogen replacement therapy to decrease the tumor size
C. An indicator that the client might respond to tamoxifen
D. An indicator that metastasis has already occured

29. Which of the following maybe use to her post operatively?

A. Cystoclysis bottle C. Jackson Pratt Drain

B. 3 way bottle system D. Pleural drainage

30. All of the following are applicable nursing diagnosis for Joanna except:

A. Pain upon lying down C. Potential for sexual dysfunction

B. Body Image Disturbance D. Self care deficit r/t immobility of the arm

31. Rationale for elevating the arm of Joanna post operatively is to:

A. Improve coping ability C. Improve Edema

B. Prevent infection D. Decrease bleeding and drainage

32. After Modified radical mastectomy, which assessment finding indicates that Joanna is
experiencing a complication related to surgery?

A. Sanguineous drainage in the Jackson Pratt drain

B. Pain at the incision site
C. Complaints of decrease sensation in the operative site
D. Arm edema on the operative arm

33. Allowing Joanna to perform deep breathing exercise will prevent:

A. Pneumonia C. Atelectasis
B. Bronchitis D. Lymph edema

34. The nurse is teaching the sisters of Joanna about Mammography, The nurse tells the client that:

A. Mammography takes about 1 hour

B. To avoid the use of deodorant, powders and creams on the day of the test
C. There is no discomfort associated with the procedure
D. To maintain an NPO status 8 hours before the procedure

35. Joanna was brought to the hospice. During your visit, Joanna expresses that “If I can just live a
little longer to see my 3 sons finish college, I will be ready to die.” Which phase of the grieving
process Is Joanna experiencing?

A. Denial B. Bargaining C. Depression D. Anger

36. In the Philippines, The use of this method is strongly suggested and recommended than any
other methods to decrease death due to breast cancer:

A. BSE B. Mammography C. Breast Biopsy D. Sugery

37. The nurse is teaching a group of women to perform breast self-examination. The nurse should
explain that the purpose of performing the examination is to discover:

A. Thickness and Fullness

B. Malignant or Benign Lumps
C. changes from previous self-examinations.
D. Fibrocystic masses

38. Anita, Joanna’s sister is performing BSE and she stands in front of the Mirror. The rationale for
standing in front of the mirror is to check for:

A. Unusual discharges coming out from the breast

B. Any obvious malignancy
C. The Size and Contour of the breast
D. Thickness and lumps in the breast

39. The nurse puts a folded towel under the Left shoulder of the Client to be examined for clinical
BSE. Why is this so?

A. To make the left shoulder nearer to the hands of the clinician for palpation
B. To make the pectoralis muscle prominent, toning the breast tissue for better palpation
C. To put the breast in a more lateral position to better ease the palpation
D. To balance and spread the breast tissue thus easing palpation

40. 30. A 52-year-old female tells the nurse that she has found a painless lump in her right breast
during her monthly self-examination. Which assessment finding would strongly suggest that this
client's lump is cancerous?

1. Non capsulated mass

2. Fixed, irregular and hard
3. Presence of Orange peel skin
4. Soft and mobile

A. 1,2,3 B. 1,2 C. 1,2,4 D. 1,3,4

SITUATION: Agnes, a client with Leukemia is in the clinic for her routine check up.

41. Which finding is unlikely when assessing Agnes?

A. Small abdomen C. Increased WBC Counts

B. Bruises and Petechiae D. Dyspnea during exercise or exertion

42. The most appropriate diagnostic examination for Agnes is:

A. RBC Exam C. Complete Blood Count

B. WBC Count D. Bone Marrow Aspiration

43. What should you encourage her to use in order to maintain her oral hygiene?

A. Use regular toothbrush C. Use cotton pledget only

B. Gargle with mouthwash only D. Use soft toothbrush

44. Which of the following complications are the three main consequence of leukemia?

A. Bone deformities, Infection and Anemia

B. Anemia, Infection and Bleeding tendencies
C. Leukopenia, Thrombocytopenia and Anemia
D. Leukocytosis, Thrombocytosis and Polycythemia

45. You noticed that Agnes’ nose is bleeding, You would instruct Agnes to:

A. lie supine with his neck extended. C. blow his nose and then put lateral pressure on his
nose.
B. sit upright, leaning slightly forward. D. hold his nose while bending forward at the waist.
SITUATION: Mr. Ramos is a 60 year old male client admitted to the hospital with the diagnosis of
pneumonia. He complains of pain when coughing.

46. What action should the nurse take in assisting Mr. Ramos in doing deep breathing and coughing
exercise?

A. Recognize that the patient is too sick to cough at this time

B. Splint the patient’s chest while he coughs
C. Turn Mr. Ramos to the unaffected side and ask him to cough
D. Encourage her to cough and then give her pain medication as ordered

47. A sputum specimen was collected from Mr. Ramos for culture and sensitivity. This study is to
ascertain which of the following facts?

A. The virulence of microorganism involved

B. The antibiotics which would be most helpful
C. The patients probably reaction to the causative microorganism
D. The patient’s sensitivity to antibiotics

48. Laboratory reports shows RBC : 2,000,000, WBC: 5,000 and Platelets : 300,000. Considering the
above findings which of the following clinical manifestation is the most likely manifestation Mr.
Ramos is to exhibit?

A. Decrease respiration and increase pulse C. Increase respiration and normal pulse
B. Normal Respiration and increase pulse D. Increase pulse and increase respiration

49. Because of these laboratory findings, the nurse is aware that her most appropriate action is to
prevent which of the following?

A. Infections and cross contamination

C. Injury might lead to bleeding
B. Over activity that might lead to exhaustion
D. Hypercoagulation that might lead to thrombus formation

50. Upon discharge, the health teaching of the nurse to Mr. Ramos should include which of the
following except:

A. Avoid fatigue C. Maintain the usual exercise

B. Maintain hygiene D. Avoid drafts

SITUATION: Blood transfusion was ordered for Andre after an episode of severe bleeding.
51. Before blood transfusion, The nurse priority is to assess Andre for which of the following?

A. Clotting time B. Vital Signs C. Sodium D. Weight

52. Before administering the transfusion, The nurse must start an IV infusion of which of the
following?

A. Sterile water B. NSS C. D5W D. D5LR

53. Which of the following is an appropriate needle for Blood transfusion?

A. A butterfly needle C. A 25 gauge angiocatheter

B. An 18 gauge angiocatheter D. A 21 gauge angiocatheter

54. Which of the following is not expected to be done by the nurse in case of a whole blood
transfusion?

A. Assess the venipuncture for any signs of bleeding or hematoma

B. Prepare the blood transfusion using a microdrip tubing
C. Assess the patient closely for any reaction
D. Make sure that the drip chamber of the IV fluid is partially filled with blood

55. Which of the following is the recommended flow rate for the first 20 minutes of blood
transfusion?

A. 10 B. 20 C. 40 D. 60

56. Solutions that are said to be compatible with the osmolarity of the body are called:

A. Isotonic
B. Hypotonic
C. Normosol
D. Hypertonic

57. Which of the following are signs of hemolytic reaction during blood transfusion?

A. Itching, urticaria and wheezing

B. Cough, dyspnea, pulmonary congestion
C. High fever and chills
D. Fever and backache
58. In any event of an adverse hemolytic reaction during blood transfusion, Nursing intervention
should focus on:

A. Slow the infusion, Call the physician and assess the patient
B. Stop the infusion, Assess the client, Send the remaining blood to the laboratory and call the
physician
C. Stop the infusion, Call the physician and assess the client
D. Slow the confusion and keep a patent IV line open for administration of medication

59. The nurse knows that after receiving the blood from the blood bank, it should be administered
within:

A. 1 hour B. 2 hours C. 4 hours D. 6 hours

60. During blood administration, the nurse should carefully monitor adverse reaction. To monitor
this, it is essential for the nurse to:

A. Stay with the client for the first 15 minutes of blood administration
B. Stay with the client for the entire period of blood administration
C. Run the infusion at a faster rate during the first 15 minutes
D. Tell the client to notify the staff immediately for any adverse reaction

SITUATION : John Mark is a 21 year old male client who was rushed following an automobile
accident. He is very anxious, dyspneic and in severe pain.

61. The nurse notices that John’s chest tube was dislodged from the chest. The most appropriate
nursing intervention is to:

A. Notify the physician

B. Cover the insertion site with petrolatum gauze
C. Immersed the tube into a bottle of sterile water
D. Clamp the tube

62. To ensure that the system is functioning effectively, the nurse should:

A. Observe for intermittent bubbling in the water seal chamber

B. Flush the chest tube with 30 to 60 ml of NSS every 4 hours
C. Maintain the client in a sidelying position always
D. Strip the chest tube in the direction towards the client

63. JM’s chest tube is said to be functioning correctly when which of the following is observed?
A. Continuous bubbling in the water seal chamber
B. Fluctuation in the water seal chamber
C. Suction tubing attached to the wall unit
D. Vesicular breath sounds heard in all lung fields

64. He is intubated with an endotracheal tube and is placed on a mechanical ventilator. Which
findings alerts the nurse to an additional problem with regards to the respiratory function?

A. Dull of percussion in the 3rd to 5th intercostals space, midclavicular line

B. Decreased paradoxical motion
C. Louder breath sounds on the right chest
D. Vesicular breath sound heard at the lung bases

65. The right chest wall of peter moves in during inspiration and balloons out when he exhales. He is
very dyspneic. The nurse understands that this symptom is indicative of:

A. Hemothorax B. Flail Chest C. Atelectasis D. Pleural effusion

SITUATION : Rene is a 3 y/o boy brought to the health center for fever and cough. You noted grayish
pinpoint dots located at the buccal mucosa. A maculopapular rash was noted on his face. Questions
20-25 refer to this.

66. The patient’s disease is most likely:

A. Rubeola C. Rubella
B. Diptheria D. Pneumonia

67. The lesion in his buccal mucosa is called:

A. Forchheimer’s spot C. Ghon’s tubercle

B. Pseudomembrane D. Koplik’s spot

68. What is the exanthem of measles?

A. Maculopapular rash B. Forchheimer’s spot

B. Pseudomembrane D. Koplik’s spot

69. The nurse knows that the most common complication of Measles is:

A Pneumonia and larynigotracheitis

B. Encephalitis
C. Otitis Media
D. Bronchiectasis

70. Measles vaccine is given at how many months?

A. At birth B. 1 ½ months C. 6 months D. 9 months

71. All of the following are necessary household management in preventing the spread of Measles
at home except:

A. Boil foods that are not eaten by the patient

B. Separate eating utensils of the patient from that of other members of the family
C. Isolate the patient when symptoms start to appear
D. Children should be watch out for complications of the disease

72. A client suspected of having tetanus asks the nurse about immunizations against tetanus. The
nurse explains that the major benefit in using tetanus antitoxin is that it:

A. Stimulates plasma cells directly

B. Provides a high titer of antibodies
C. Provide immediate active immunity
D. Stimulates long-lasting passive immunity

73. Miss Kate is a bread vendor and you are buying a bread from her. You noticed that she receives
and changes money and then hold the bread without washing her hand. As a nurse, What will you
say to Miss Kate?

A. Miss, Don’t touch the bread I’ll be the one to pick it up

B. Miss, Please wash your hands before you pick up those breads
C. Miss, Use a pick up forceps when picking up those breads
D. Miss, Your hands are dirty I guess I’ll try another bread shop

74. The Causative agent of Tuberculosis is said to be:

A. Mycobacterium Tuberculosis
B. Hansen’s Bacilli
C. Bacillus Anthraces
D. Group A Beta Hemolytic Streptococcus

75. A client who was exposed to hepatitis A is given gamma globulin to provide passive immunity
which:

A. Increases the production of short lived antibodies

B. Provides antibodies that neutralize the antigen
C. Accelerates antigen-antibody union at the hepatic sites
D. Stimulates the lymphatic system to produce large number of antibodies

76. They are the proteins in the body that are produced in response to the invasion to pathogens
and microorganisms.

A. Antigen
B. Amino Acids
C. Agglutinogen
D. Antibody

77. A nursing instructor asks a nursing student to describe human immunoglobulin. The student
correctly states that these types of vaccine are:

A. Vaccine that have their virulence diminished so as to not produce a full blown clinical illness
B. Vaccine that contains pathogens made inactive by either chemicals or heat
C. Bacterial toxins that have been made inactive by either chemicals or heat
D. Vaccines collected from pooled blood of people and provide antibodies to variety of diseases

78. Mode of transmission of leprosy aside from skin contact is by:

A. Oral fecal C. Borrowing utensil

B. Sexual contact D. Droplet infection

79. Which of the following is not a late sign and symptoms of leprosy?

A. Paralysis C. Madarosis
B. Contractures D. Gynecomastia

80. Which among the following person is most susceptible to leprosy?

A. Mark, 21 year old athlete

B. Arvinn, 16 year old student
C. JC, 12 year old student
D. Clarence, 9 year old student

81. The nurse is documenting her care for a client with iron deficiency anemia. Which of the
following nursing diagnoses is most appropriate?

A. Impaired gas exchange C. Ineffective airway clearance

B. Deficient fluid volume D. Ineffective breathing pattern
82. The nurse walks into the room of a client who has had surgery for testicular cancer. The client
says that he'll be undesirable to his wife, and he becomes tearful. He expresses that he has spoiled a
happy, satisfying sex life with his wife, and says that he thinks it might be best if he would just die.
Based on these signs and symptoms, which nursing diagnosis would be most appropriate for
planning purposes?

A. Situational low self-esteem C. Social isolation

B. Unilateral neglect D. Risk for loneliness

83. A 92-year-old client with prostate cancer and multiple metastases is in respiratory distress and is
admitted to a medical unit from a skilled nursing facility. His advance directive states that he doesn't
want to be placed on a ventilator or receive cardiopulmonary resuscitation. Based on the client's
advance directive, the nursing plan of care should include which intervention?

A. Check on the client once per shift.

B. Provide mouth and skin care only if the family requests it.
C. Turn the client only if he's uncomfortable.
D. Provide emotional support and pain relief.

84. Which of these findings is an early sign of bladder cancer?

A. Painless Hematuria C. Nocturia

B. Occasional Polyuria D. Dysuria

85. During a late stage of acquired immunodeficiency syndrome (AIDS), a client demonstrates signs
of AIDS-related dementia. The nurse should give the highest priority to which nursing diagnosis?

A. Bathing or hygiene self-care deficit C. Dysfunctional grieving

B. Ineffective cerebral tissue perfusion D. Risk for injury

86. When assessing a client with partial thickness burns over 60% of the body, which of the
following should the nurse report immediately?

A. Complaints of intense thirst C. Urine output of 70 ml the 1st hour

B. Moderate to severe pain D. Hoarseness of the voice

87. A client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse's
primary concern should be:

A. fluid resuscitation. C. body image.

B. infection. D. pain management.
88. client is admitted to the hospital following a burn injury to the left hand and arm. The client's
burn is described as white and leathery with no blisters. Which degree of severity is this burn?

A. First degree burn C. Third degree burn

B. Second degree burn D. Fourth degree burn

89. A client with end-stage liver cancer tells the nurse he doesn't want extraordinary measures used
to prolong his life. He asks what he must do to make these wishes known and legally binding. How
should the nurse respond to the client?

A. Tell him that it's a legal question beyond the scope of nursing practice.
B. Give him a copy of the client's bill of rights.
C. Provide information on active euthanasia.
D. Discuss documenting his wishes in an advance directive.

90. A client is admitted to the hospital with an exacerbation of her chronic systemic lupus
erythematosus (SLE). She gets angry when her call bell isn't answered immediately. The most
appropriate response to her would be:

A. "You seem angry. Would you like to talk about it?"

B. "Calm down. You know that stress will make your symptoms worse."
C. "Would you like to talk about the problem with the nursing supervisor?"
D. "I can see you're angry. I'll come back when you've calmed down."

SITUATION: Consider the following hypothesis: “The Job turnover rate and job dissatisfaction levels
of graduate nurses who have worked less than 2 years is higher than for those graduate nurses who
have worked for more than 2 years”

91. A systematic, objective, process of analyzing phenomena importance to nursing is termed as:

A. Nursing research C. Scientific research

B. Research D. Research process

92. The major reason for conducting nursing research is to:

A. Improve nursing care for clients

B. Promote the growth of the nursing profession
C. Document to cost effectiveness of nursing care
D. Ensure accountability of nursing practice

93. Which is you independent variable?

A. Job dissatisfaction C. Job dissatisfaction and Job turn over rate
B. Job turn over rate D. Length of employment

94. Which is your dependent variable?

A. Job dissatisfaction C. Job dissatisfaction and Job turn over rate

B. Job turn over rate D. Length of employment

95. The type of hypothesis in this situation is classified as:

A. Simple, Directional C. Complex, Directional

B. Simple, Non Directional D. Complex, Research

96. The problem that a researcher would like to give emphasis “Is there a relationship between
timing of the administration of psychological support and feelings of wellbeing among terminally ill
patients”. The appropriate null hypothesis for this problem is:

A. Feelings of wellbeing of terminally ill patients who received psychological support is similar to the
feelings of wellbeing of those terminally ill patients who did receive said psychological support.
B. There is no relationship between the timing of administration of psychological support and
feelings of well-being among terminally ill patients
C. Factors are not appropriate to determine any desired results
D. There is no relationship between the timing of the administration of psychological support and
feelings of adequacy among terminally ill patients

97. In the above number, your dependent variable is:

A. Terminally ill patients C. Timing of psychological support

B. Feelings of wellbeing D. Time

98. In the recent technological innovations, which of the following describe researches that are
made to improve and make human life easier?

A. Pure research C. Basic research

B. Applied research D. Experimental research

99. After the researcher has determined and read relevant literature, she has to:

A. Write down the review

B. Organized the relevant literature
C. Analyze potential literature
D. Integrate the review of literature

100. The final product of review of related literature is:

A. Pool of related literature

B. Organized relevant literature
C. Analyzed potential literature
D. Written review of literature
NURSING PRACTICE IV
Situation : Cancer of the prostate is the leading cancer in Men other than skin cancer. The following
questions will assess your knowledge and theoretical foundation in dealing with clients with
prostate cancer.

1. Among the following population group, who has a higher risk in the development of prostate
cancer?

A. African-American C. Asian
B. Caucasian D. Hispanics

2. Which among the following is NOT a risk factor for prostate cancer?

A. A family member with prostate cancer C. High fat and diet high in red meats
B. Advancing age D. Smoking

3. Mr. Juan Jose Rodrigo has been diagnosed with prostate cancer just a few hours ago. Which of the
following sign would alert the nurse that the cancer is already advanced?

A. “I have difficulty starting my urination”

B. “My backs and hips are painful and my right leg is slightly larger than the other”
C. “My urine is bloody”
D. “My urine is bouncing”

4. At the initial sign and symptoms of prostate cancer, before diagnosis, the physician can perform a
screening test to detect a characteristic “STONY HARD” prostate and nodules at the prostate area
using:

A. Cytoscopy C. DRE
B. PSA D. MRI

5. To diagnose the presence of prostate cancer, the physician will perform:

A. Transrectal needle biopsy of the prostate

B. Test to identify the PSA levels
C. Transrectal ultrasound
D. Radiolabeled monoclonal antibody capromab penetide with indium-111

6. After the removal of the prostate tissue, The physician soaked the solution in formaldehyde in a
sterile specimen container and asked you to send the specimen immediately. Which of the following
is a correct nursing action?
A. “Dr. Ruiz, I don’t think this specimen is acceptable. Please redo the procedure and do not soak the
specimen in any medium.”
B. “Dr. Ruiz, I just want you to know that you soaked the specimen in formaldehyde wherein, it
should not be soaked in any medium at all.”
C. Accept the specimen because there is nothing wrong with the physician’s action
D. “Dr. Ruiz, it should be soaked in NSS not formaldehyde. I am going to report you to the board of
medicine for this could lead to a false result.”

7. In any biopsy, the specimen is sent to the:

A. Radiologist B. Nearest of Kin C. Pathologist D. Medical

Technologist

8. PSA is used not for the detection but to know if the cancer is responding to treatment or
advancing. The nurse knows that the abbreviation PSA stands for:

A. Prostate specific antibody C. Prostate specified antibody

B. Prostate specific antigen D. Prostate specified antigen

9. In testing for the PSA, the nurse will collect which specimen?

A. Blood B. Urine C. Feces D. Prostatic fluid

10. Mr. Rodrigo said that he has difficulty voiding. Which of the following is the best nursing action
to encourage voiding in any clients with voiding difficulties?

A. Encourage the client to drink plenty of fluids to promote urination

B. Bring the client to the bathroom and stay with him when the sensation to void is felt by the client
C. Catheterize the client
D. Encourage the use of bathroom or commode rather than bedpans

Situation : Care of clients with tracheotosmy is often a challenge to a beginning nurse. The following
questions will test your knowledge on Tracheostomy and its related care.

11. You know that when rendering tracheotosmy care, the priority consideration is always to keep
the airway patent and also to prevent infection at the site. The nurse knows the technique used in
rendering Tracheostomy care is:

A. Clean B. Disinfected C. Sterile D. Medical

12. Prior to the suctioning or removal of the inner cannula, the nurse knows that the client is
prepared and positioned in:

A. High fowlers B. Semi fowlers position C. Left side lying D. Sims

13. In cleaning the inner cannula or other parts of the tracheotosmy tube, The best cleansing
mediums are:

A. Hydrogen peroxide and Sterile NSS

B. Providone Iodine and Sterile NSS
C. Alcohol and Sterile NSS
D. Alcohol and Hydrogen Peroxide

14. In contrary with Tracheostomy tubes, sizes of chest tubes are expressed in terms of:

A. French B. Gauge C. M2 D. Diameter

15. Which of the following is NOT true with regards to securing the Tracheostomy?

A. The cuff provides sufficient securing

B. The Tracheostomy can be sutured in place
C. The Tracheostomy can be stapled in place
D. Tie or Velcro tie are used to generally secure the Tracheostomy around the client

16. The nurse knows that in Tracheostomy creation, 1% Lidocaine and 1:100,000 Epinephrine is
injected at the incision site. The purpose of Lidocaine is mainly to provide anesthetic effect while the
Epinephrine is needed to:

A. Relax the bronchus and dilate the airway for easier insertion
B. To promote faster healing
C. To prevent the Vasovagal reflex that might cause bradycardia
D. For Hemostasis

17. Which of the following is not considered as a regular part of a Tracheostomy tube?

A. The outer cannula C. The obturator

B. The inner cannula D. The cuff

18. Which of the following is the reason why will a surgeon select a cuffed tube over a non cuffed
Tracheostomy tube?

A. Cuffed tube offers efficient securing C. Cuff tube offers excellent attachment
B. Cuffed tube is mainly used to prevent coughing D. For mechanical ventilation

19. The size of the Tracheostomy tube is denoted in terms of:

A. French C. Units
B. Gauge D. Size / mmID

20. The function of the obturator is:

A. To direct the outer cannula to traverse the curvature of the trachea for easier insertion
B. In cases of emergency, when outer cannula accidentally dislodges
C. To facilitate dilation of the stoma for the insertion of the outer cannula
D. To prevent too much pressure on the jugular vein after the tie has been placed

Situation : Organ donation is a new form of treatment that provides multiple complication such as
rejection.

21. Organ donation to save life was initially with the first transplant done by:

A. Dr. Christian Barnard of the Union of South Africa

B. Dr. Christian of the U.S.A.
C. Dr. Christian Barnard of Soviet Union
D. Dr. Christian Barnard of U.K.

22. In 1983, The FDA approved the first anti-rejection drug by the name of:

A. Cyclosporine B. Prednisone C. Imuran D. Azathioprine

23. You would expect that in cases of organ donation, you would expect that the
immunosuppressant medications such as Cyclosporine, Prednisone and Imuran are taken:

A. For 2 years C. When rejection is not anymore viable

B. When the suture heals D. For the rest of the client’s life

24. Which of the following is a sign that the transplanted kidney is being rejected?

A. Fever and Weight Gain C. Chills, Fever, Polyuria

B. Fever and Weight Loss D. Anuria, Fever, Weight Gain and Hematuria

25. Among children candidates for organ transplant, when all selected children have appropriate
tissue matches for the same donated organ, the basis for the decision as to which child gets the
organ is given to the child who:
A. will receive the most benefit from the new organ
B. is most likely to die without the transplant
C. is selected by the lottery system for available organs
D. is at the top of the list and has waited the longest time

Situation: In a client with widespread colon cancer, A colectomy is the surgical procedure of choice
instead of an Abdominal perineal resection.

26. Ileostomy is performed after a colectomy. The nurse will expect that the stool of the client will
be:

A. Mushy B. Spicy C. Liquid D. Soft

27. When should the teaching about ileostomy care commence?

A. Immediately after the operation, when the anesthesia is wearing off

B. 72 hours after operation
C. When readiness and interest is observed
D. As soon as the patient is admitted

28. Which of the following indicates a need for further teaching in client’s with ileostomy?

A. “I am expecting a change in my diet.”

B. “I can remove the appliance during sleep.”
C. “I can still swim”
D. “I am prone to dehydration because of the ileostomy”

29. For the client’s stool to be more “formed” which of the following food are added to the client’s
diet?

A. Boiled rice
B. Spaghetti and macaroni
C. Cheese
D. Bran

30. An expert nurse in the field of colostomy and ileostomy is called as a/an:

A. Enterostomal Therapy Nurse C. Nurse oncologist

B. Ostomy nurse D. Nurse Enterostomist

Situation: During surgical operation, it is inevitable to utilize sutures. The nurse should know the
basic principles in suturing as well as knowledge in selecting sutures and caring for clients with
sutures.

31. Steel has the highest tensile strength among sutures in the non absorbable category. When you
say tensile strength, it refers to:
A. The amount of weight or force necessary to break the suture
B. The cross sectional size of the suture
C. The ability of the suture to absorb fluid
D. The force necessary to cause the knot to slip

32. In suturing the internal organs such as kidneys, liver, spleen, pancreas and stomach, the nurse
knows that the type of suture material that the physician will most likely use is:

A. Steel B. Vicryl C. Cotton D. Silk

33. If the suture is removed to soon, the nurse knows that it could lead to failed healing of the
wound as well as infection. If the suture is removed too late, which of the following can occur?

A. Itching B. Swelling C. Scarring D. Pain

34. The nurse noticed that there are yellow and brown crustings around the area of the suture.
Which of the following is the best cleansing medium to remove such crusting?

A. Hydrogen Peroxide B. Providone Iodine C. NSS D. Alcohol

35. If the suture is performed on the client’s face. The nurse will reinforce the teaching that the
client should return when for suture removal?

A. After 7 days C. After 10 days

B. After 3 to 4 Days D. The next day

36. Sizes of sutures denotes the diameter. The physician will perform a corneal transplant and will
suture the eye. The nurse will prepare which of the following suture size?

A. 7 B. 5 C. 3 D. 9-0

37. Who holds the packet flaps of sutures to open it and place it in the sterile table for use?

A. Scrub nurse B. Circulating nurse C. Assistant surgeon D. Surgeon

38. Non absorbable suture material such as cotton, nylon and silk are best used in suturing which of
the following abdominal layer?

A. Skin B. Peritoneum C. Fascia D. Muscle

39. When least amount of trauma is desired, or when the client is prone to keloid formation, the
nurse should prepare which type of the needle?

A. Swaged B. Round C. Blunt D. Taper

40. Another alternative “suture” for skin closure is the use of ____________
A. Staple
 B. Therapeutic glue
C. Absorbent dressing
D. Invisible suture

Situation: The following are questions with regards to the OPERATING ROOM.

41. The operating room is divided into three areas, The unrestricted, the semi restricted and the
restricted areas. Where is the operating room?

A. Restricted B. Unrestricted C. Semi restricted D. PACU

42. What OR attires are worn in the restricted area?

ub suit, OR shoes, head cap

ad cap, scrub suit, mask, OR shoes
sk, OR shoes, scrub suit
, mask, gloves, shoes

43. What OR attires are worn in the semi-restricted area?

A. scrub suit only

B. scrub suit, shoe cover, mask
C. scrub suit and head cap, with or without the shoe cover
D. head cap, mask, shoe cover only

44. One of the hidden dangers in the OR is missing instruments. What is the appropriate approach to
this happening?

A. correct labeling
B. “a place for everything and everything in its place”
C. install a flush sterilizer in the OR
D. increase instrument inventory

45. PACU Vital signs monitoring is performed every:

A. 5 minutes B. 10 minutes C. 15 minutes D. 30 minutes

46. Mr. T.O. has undergone surgery for lyses of adhesions. He is transferred from Post Anesthesia
Care Unit (PACU) to the Surgical floor, the nurse should obtain blood pressure, pulse and respiration
every:

A. 3 minutes C. 15 minutes
B. 30 minutes D. 20 minutes
47. Another worthy study is the compliance to the principles of aseptic technique among the sterile
OR team. Who does NOT belong to the sterile OR team?

A. scrub nurse C. x-ray technician

B. assistant surgeon D. surgeon

48. The patient demonstrates knowledge of the psychological response to the operation and other
invasive procedure when she asks about:

A. Who will be with me in the OR?

B. How is the post operative pain over the site like?
C. Will I be naked during the operation?
D. Is it cold inside the?

49. Endoscopic minimally invasive surgery has evolved from diagnostic modality to a widespread
surgical technique. What department should the nurse collaborate which is unusual in conventional
surgery?

A. engineering department C. blood bank services

B. x-ray department D. linen section

50. When the client is discharged from the hospital and is not capable of doing the needed care
services, the following can assume the role, EXCEPT:

A. family members C. significant others

B. chaplain D. responsible caregiver

Situation: Anesthesia is used even during the Ancient times. In its evolution, modern marvels in the
use of anesthesia enables the nurses to develop a more competitive approach in patient care.

51. An anesthesia delivered directly to the spinal canal is known as:

A. Epidural C. General
B. Intrathecal D. Local

52. After spinal anesthesia, 30% of the patient develops spinal headache. This is due to:

A. Severe hypotension associated with Vasodilation due to the anaesthetics.

B. Increase volume of the cerebrospinal fluid due to anesthesia induction.
C. Cerebral edema due to rapid absorption of the anaesthetics.
D. CSF leakage due to the puncture created by the spinal needle in the membrane that surrounds
the spinal cord.
53. Before the induction of spinal anesthesia, the client is placed in which of the following preferred
position to widen the vertebral space:

A. Quasi fetal position C. Flat on bed supine position

B. Prone position D. Sidelying position affected side

54. After spinal anesthesia, to prevent spinal headache, the client is placed on which of the following
position?

A. Sitting position C. Flat on bed, supine

B. Sidelying position affected side D. Flat on bed, prone

55. Another way to prevent spinal headache is by the use of the correct needle gauge. If the client is
an adult client, the anaesthesiologist might order a pink spinal set. The nurse knows that the pink
spinal set has a gauge of:

A. 12 B. 16 C. 22 D. 26

Situation: The nurse utilizes the theoretical foundation basic to perioperative nursing in the various
nursing scenarios:

56. In medical and nursing practice, code means a call for:

A. DNR state C. clinical case

B. call to order D. cardiopulmonary resuscitation

57. The OR team collaborates from the first to the last surgical procedure. Who monitors the
activities of each OR suite?

A. scrub nurse C. circulating nurse

B. anesthesiologist D. surgeon

58. In patients with acute pancreatitis, the administration of the analgesic morphine may cause:

A. addiction C. paralytic ileus

B. urinary retention D. spasms of the sphincter of Oddi

59. Who is responsible in daily monitoring the standards of safe, nursing practice in the operating
suite?

A. surgeon C. OR nurse supervisor

B. perioperative nurse D. chief nurse

60. During surgery, movement of personnel should be:

A. kept to a minimum C. monitored

B. restricted D. eliminated when possible

61. The patient has a right to information regarding the operation or other invasive procedure and
potential effects. This right is achieved through:

A. Enlightened Consent C. charting

B. preoperative visit D. doctor’s rounds

62. Which statement about a person’s character is evident in the OR team?

A. it assists in the control of feelings, thoughts and emotions in the face of difficulty
B. it reflects the moral values and beliefs that are used as guides to personal behavior and actions
C. it encourages the constructive use of the pleasure of the senses
D. it refers to the quality of being righteous, correct, fair and impartial

63. You continuously evaluate the client’s adaptation to pain. Which of the following behaviors
indicate appropriate adaptation?

A. The client reports pain reduction and decreased activity

B. The client denies existence of pain
C. The client can distract himself during pain episodes
D. The client reports independence from watchers

64. Pain in ortho cases may not be mainly due to the surgery. There might be other factors such as
cultural or psychological that influence pain. How can you alter these factors as the nurse?

A. Explain all the possible interventions that may cause the client to worry
B. Establish trusting relationship by giving his medication on time
C. Stay with the client during pain episodes
D. Promote client’s sense of control and participation in control by listening to his concerns

65. In some hip surgeries, Fentanyl analgesia is given. What is your nursing priority care in such a
case?

A. Instruct client to observe strict bed rest

B. Check for epidural catheter drainage
C. Administer analgesia through epidural catheter as prescribed
D. Assess respiratory rate carefully
Situation: Mrs. Diaz is assigned in the female surgical ward. While on duty, an 15 year old client,
married, was admitted for CS. The informed consent for the operation has to be obtained.

66. The person legally responsible for taking the informed consent is:

A. The OR nurse who is going to assist with the operation

B. Any doctor assigned with the team
C. The doctor who is going to perform the procedure
D. The ward nurse where the patient stayed before the operation

67. Mr. Diaz has to remember the following with regard to the IC:

A. Because the patient is a minor, the parents should be asked to sign the consent.
B. The informed consent should be signed either by the patient or her 20 year old husband if
patient is unconscious
C. Nurses has the responsibility to obtain the informed consent prior to surgery
D. Legal guardian should sign the consent since the client is 15 year old

68. The medical intern who assisted in the operation gave post operative orders. In this case,
Mrs.Diaz should:

A. Validate the order from the surgeon and request him to counter sign
B. Follow the order as long as they are within the scope of nursing practice
C. Clarify from the medical intern those that are ambiguous
D. Refuse to follow the order because it is not legal

69. After one year, Mrs. Diaz was rotated to the delivery room. As a DR Nurse, the Obstetrician
ordered her to administer spinal anesthesia because the anaesthesiologist did not arrive at the
scene. The nurse would:

A. Give the anesthesia if the supervising nurse approves it

B. Give the anesthesia if the OB supervises her
C. Give the anesthesia if the doctor writes the order
D. Do not follow

70. Which of the following should the nurse remember when a doctor requests them to administer
anesthesia?

A. The nurse has the right to refuse it, if the doctor’s order is unlawful
B. Doctor’s order should always be written
C. The nurse may render medical procedure if the doctor supervises him
D. The staff nurse can be accused of insubordination if she does not follow the doctor’s order

Situation: Miss Matias, found out that Mang Carding, newly admitted patient, has terminal cancer
and that his nurse has not yet informed him of the diagnosis.
71. Initially, Miss Matias should:

A. Tell the doctor the Mang Carding hinted that he feels he has Cancer
B. Be available to listen when the patient decides to discuss his illness
C. Call in the family and the team to prepare Mang Carding about his impending death
D. Inform Mang Carding about his Diagnosis

72. On the second day, the wife of Mang Carding shows signs of grieving, The stages of Grieving
identified by Elizabeth Kubler-Ross Are:

A. Numbness, Anger, Resolution and Reorganization

B. Denial, Anger, Bargaining, Disorganization, Acceptance
C. Denial, Anger, Bargaining, Depression, Resolution
D. Denial, Anger, Bargaining, Depression, Detachment

73. Which of the following will be the most helpful therapy for the Grieving family?

A. Watching the video of the dying client over and over to encourage moving on
B. A course on death and dying
C. Psychotherapy
D. Group meeting with other grieving families

74. the nurse, when dealing with the relatives of a dying patients must be sensitive to their
emotional reactions. A family member who blames herself for the condition of the dying patient
indicates that she:

A. Has major issues

B. is oversensitive
C. Has neurotic tendencies
D. Is potentially risk for suicide

75. In caring of a dying client during post mortem, the most important thing that the nurse should
remember is:

A. Treat the body with outmost dignity

B. Close the eyes immediately before the onset of rigor mortis
C. Verify that the client is really dead by checking the ABC and double checking the death notice
D. Close the mouth, straighten the body, elbows and knees before the onset of rigor mortis

Situation : The patients chart is a legal documentation the is admissible in the court. In working with
the client, The protection of the information on the chart and patient’s privacy is one of the priority.
You are caring for Ana, a 12 year old grade 6 pupil from manila and is one of the daughters of Maria,
A 38 year old mother of 12.

76. Who cannot access the client’s chart?

A. Maria C. Member of the health care team

B. The patient D. The nurse from the nearby hospital

77. Who owns the patient chart?

A. The patient C. The hospital

B. The doctor in charge D. The government

78. If the court issues an investigation necessitating the utilization of Ana’s chart, you know that the
chart will not be admissible IF:

A. Maria refuses C. The chart is not legible

B. Ana refuses D. The chart is missing

79. The research teams from other countries are interested in investigating Ana’s case. They want to
read and gather information about Ana and the manifestation of her condition. For the sake of
improving knowledge and the development of a cure, the nurse knows that research is very
important. Permission in this case will be taken from:

A. Ana C. The hospital management

B. Maria D. The doctor in charge

80. If Ana reaches the age of majority, 18 years of age, and Maria asks for her chart, which of the
following is the best nursing action?

A. Ignore Maria’s request

B. Decline Maria’s request
C. Give the chart to the Mother of Ana
D. Tell Maria to ask permission from Ana

Situation 6 – Infection can cause debilitating consequences when host resistance is compromised
and virulence of microorganisms and environmental factors are favorable. Infection control is one
important responsibility of the nurse to ensure quality of care.

81. Honrad, who has been complaining of anorexia and feeling tired, develops jaundice, after a
workup he is diagnosed of having Hepatitis A. his wife asks you about gamma globulin for herself
and her household help. Your most appropriate response would be:

A. “Don’t worry your husband’s type of hepatitis is no longer communicable”

B. “Gamma globulin provides passive immunity for hepatitis B”
C. “You should contact your physician immediately about getting gammaglobulin.”
D. “A vaccine has been developed for this type of hepatitis”

82. Voltaire develops a nosocomial respiratory tract infection. He ask you what that means? Your
best response would be:

A. “You acquired the infection after you have been admitted to the hospital.”
B. “This is a highly contagious infection requiring complete isolation.”
C. “The infection you had prior to hospitalization flared up.”
D. “As a result of medical treatment, you have acquired a secondary infection.’

83. As a nurse you know that one of the complications that you have to watch out for when caring
for Omar who is receiving total parenteral nutrition is:

A. stomatitis
B. hepatitis
C. dysrhythmia
D. infection

84. A solution used to treat Pseudomonas wound infection is:

A. Dakin’s solution
B. Half-strength hydrogen peroxide
C. Acetic acid
D. Betadine

85. Which of the following is the most reliable in diagnosing a wound infection?

A. Culture and sensitivity

B. Purulent drainage from a wound
C. WBC count of 20,000/μL
D. Gram stain testing

Situation : Respiration is one of the most important vital sign. This is usually the first Vital sign to be
assessed more than anything for it is easily altered by the patient’s consciousness. The nurse should
be aware of the different changes and alteration in respiration.

86. Another name for an abnormal breath sound is:

A. Adventurous breath sound

B. Excursion
C. Adventitious breath sound
D. Dyspnea

87. In a client with diabetic ketoacidosis, Kussmauls respiration is exhibited. This is evidence that
there is the presence of:
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis

88. If the nurse will auscultate the base of the lungs, it is expected that she will hear:

A. Bronchovesicular B. Tubular C. Vesicular D. Crackles

89. The respiratory center is found in the:

A. Pons B. Hypothalamus C. Medulla D. Lungs

90. Initially in asthma, you are expecting that the client’s acid base disturbance is:

A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis

Situation: Carbon Monoxide poisoning is said to be the 2nd leading cause of poison death. It is said to
be the leading cause of inhalation poisoning. Mang edgardo was rushed to the hospital after being
unconscious inside an enclosed parking lot. Carbon monoxide poisoning is suspected.

91. The pulse oximetry reading of Mang edgardo is 100%. This suggests that:

A. There is no danger of hypoxia

B. There is no carbon monoxide poisoning, it should be ruled out
C. This is not a reliable sign to rule out carbon monoxide poisoning, further assessment is required
D. That the client has an improved chance of surviving, since the client is well oxygenated

92. Which of the following is a sign the nurse will expect to see on Mang edgardo?

A. Cherry-red skin
B. Pale skin
C. Cyanotic
D. Restlessness

93. Initially, in patient with suspected inhalation poisoning, the most important intervention at the
scene of poisoning is:

A. Assess the patient’s airway breathing and circulation

B. Conduct a head to toe physical assessment
C. Administer oxygen and loosen the client’s clothing
D. Carry the client on the fresh air immediately opening all windows and doors if this is enclosed

94. Which of the following laboratory result is constantly checked in clients undergoing treatment
for carbon monoxide poisoning?

A. Oxygen saturation C. Skin color

B. RBC count D. Carboxyhemoglobin level

95. If a client demonstrates psychoses, visual disturbance, ataxia, amnesia and confusion even after
completion of resuscitation and the return of normal oxygenation, this will indicate that:

A. The client suffered from an irreversible brain damage

B. That the client still needs to be evaluated for this is evidence that resuscitation is not yet
complete
C. That the client will need a longer rehabilitation to go back to the previous functioning
D. That the client is exhibiting secondary gains

Situation: The physician has ordered 3 units of whole blood to be transfused to WQ following a
repair of a dissecting aneurysm of the aorta.

96. You are preparing the first unit of whole blood for transfusion. From the time you obtain it from
the blood bank, how long should you infuse it?

A. 6 hours C. 4 hours
B. 1 hour D. 2 hours

97. What should you do FIRST before you administer blood transfusion?
A. verify client identity and blood product, serial number, blood type, cross matching results,
expiration date
B. verify client identity and blood product serial number, blood type, cross matching results,
expiration date with another nurse
C. check IV site and use appropriate BT set and needle
D. verify physician’s order

98. As WQ’s nurse, what will you do AFTER the transfusion has started?

A. add the total amount of blood to be transfused to the intake and output
B. discontinue the primary IV of Dextrose 5% Water
C. check the vital signs every 15 minutes
D. stay with WQ for 15 minutes to note for any possible BT reactions

99. WQ is undergoing blood transfusions of the first unit. The EARLIEST signs of transfusion reactions
are:

A. oliguria and jaundice C. hypertension and flushing

B. urticaria and wheezing D. headache, chills, fever
100. In case WQ will experience an acute hemolytic reaction, what will be your PRIORITY
intervention?

A. immediately stop the blood transfusion, infuse Dextrose 5% in Water and call the physician
B. stop the blood transfusion and monitor the patient closely
C. immediately stop the BT, infuse NSS, call the physician, notify the blood bank
D. immediately stop the BT, notify the blood bank and administer antihistamines
NURSING PRACTICE V

Situation : Mrs. Andres brought his son, Juanito, age 3 to the Pediatric clinic. She noticed that her
son is not speaking and tend to repeat everything she says. The mother also told the nurse that
Juanito prefers to be alone, will cry when someone will come near him and tend to rock himself
from morning till he will fell asleep.

1. An essential clinical feature of autistic disorder is:

A. Inability to concentrate in any task

B. Easily Distracted
C. Stereotyped motor behaviors
D. Poor motor skills

2. Headbanging is a common manifestation of an autistic child. A relevant nursing diagnosis would

be:

A. Activity intolerance C. Risk for Injury

B. Impaired physical mobility D. Impaired skin integrity

3. According to freud, Juanity is at what psychosexual stage?

A. Anal B. Oral C. Phallic D. Latency

4. Typically, if there is a change in the environment, the child will manifest which of the following?

A. Clinging behavior C. Suicide

B. Temper tantrums D. Talks incoherently

5. The best treatment approach for autistic children is encouraging their desired behavior through
positive reinforcement. This is:

A. Milieu Therapy B. Psychoanalysis C. Play Therapy D. Behavior Therapy

6. There is no definite cause identified for autism, but a strong link has been found on:

A. Environmental factors C. Upbringing

B. Genetic factors D. MMR vaccination

7. Which of the following is true about Autism?

A. Autism is common among boys than girls
B. Autism is common among girls than boys
C. MMR vaccination has been strongly linked in the development of Autism
D. Autistic children usually develops normal social skills

8. The mother of Juanito asked the nurse, When is autism diagnose? The nurse will respond:

A. Autism is diagnosed after 3 years old

B. Autism is diagnosed after 6 years old
C. At 4 years old, Autism is diagnosed
D. Autism is diagnosed before 3 years old

9. If a child with autism develops destructive behavior, The drug of choice that the nurse will expect
that the physician will give to control self injury is:

A. Chlorpromazine [Thorazine] C. Time-out

B. Methylphenidate [Ritalin] D. Valium, Librium or other Anxiolytic

10. Chlorpromazine was given to the child. Which is true with regards to this medication?

A. Expect that the child will be unusually alert and hyperactive during the therapeutic period
B. The mother should decrease the fluid intake of the child as this drug causes fluid retention
C. That the drug is given in order to decrease the child’s hyperactivity
D. The mother should avoid overexposing the child to sunlight for the child might develop rashes
due to photosensitivity

Situation : Mastery of Psychotropic medications is necessary for the therapeutic improvement in the
health of the psychiatric clients.

11. Lithium is only given:

A. P.O B. IM C. IV D. SQ

12. The nurse should expect that a client who cheeks the medication is a non-complaint patient.
Knowing the non compliance is the single most important factor for exacerbation and
rehospitalisation, the doctor ordered Prolixin [Fluphenazine Decanoate]. The nurse knows that is it
given:

A. Orally B. Sublingually C. IV D. IM

13. Which of the following is an antidepressant?

A. Serenace (Haloperidol)
B. Valium (Diazepam)
C. Tofranil (Imipramine HCl)
D. Trilaton (Pherpenazine)

14. The nurse knows that the relationship between sodium and lithium is that:

A. When lithium increases, sodium also increases

B. When sodium increases, lithium also increases
C. They are inversely proportional
D. They are directly proportional

15. Which of the following class of antidepressant is the least sedating?

A. SSRI B. MAOI C. TCA D. Neuroleptics

Situation : Mang Cardo, Age 72, is a widower with moderate Alzheimer’s disease. Was brought to
the home for the Aged by his married daughter. On admission, she says to the nurse, “I never
thought this would happen to us. I really feel guilty about bringing him here, I can’t bear to part with
him.”

16. The nurse’s therapeutic response to Mang Carlos’ daughter is:

A. “You have indeed made a sound decision, Your father needs professional care which you cannot
provide at home.”
B. “Why are you feeling guilty bringing him here?”
C. “I know that his has been a difficult time for you. You seemed troubled about bringing him
here.”
D. “You have done well everything for your father, Do not be upset. We will take care of him.”

17. Initially, the nursing diagnosis would be:

A. Impaired communication C. Altered thought process

B. Impaired social interaction D. Altered family process

18. To guide the nurse in planning activities for Mang Carlos, The nurse should prioritize soliciting
which information?

A. Support system from the significant others

B. Coping mechanism
C. Routine activities at home
D. The extent of memory impairment

19. Cardo appears to be awake and restless throughout the night, Which of the following is the
medication you are expecting to be given?

A. Diazepam [Valium] C. Imipramine [Tofranil]

B. Chlorpromazine [Thorazine] D. Lithium [Lithane]
20. One morning, Mang Cardo has difficulty putting his pyjamas. In Alzheimer’s disease, this is
known as:

A. Aphasia B. Agnosia C. Apraxia D. Anomia

21. Which of the following is the cause of Dementia of the Alzheimer’s type?

A. Unknown C. Increasing Age

B. Decreased Acetylcholine D. Senile plaques deposition

22. The initial sign of Dementia is:

A. Aphasia C. Confusion
B. Forgetfullness D. Restlessness

23. Mang Cardo has been talking about how he got his scratch on his left arm, he told you that it
was caused by a shard of glass that touches his skin accidentally. The next day, he told you that the
scratch was caused by a knife he did not see that it fell from the table towards his arms. The next
day, he said it was bitten by an ant and he scratched it because it was itchy. This is a symptom seen
in Dementia known as:

A. Confusion B. Altercation C. Aphasia D. Confabulation

24. Tacrine was given to the client and the nurse knows that which of the following enzyme is
periodically checked?

A. ALT B. Creatinine C. AST D. BUN

25. A client with Alzheimer's disease mumbles incoherently and rambles in a confused manner. To
help redirect the client's attention, the nurse should encourage the client to:

A. fold towels and pillowcases. C. play cards with another client.

B. participate in a game of charades. D. perform an aerobic exercise.

Situation : A nurse is working with an aggressive client in the psychiatric unit.

26. All of the following concepts are true EXCEPT:

A. Hostility is destructive
B. Frustration develops in response to unmet needs, wants and desire
C. Anger is always incompatible with love
D. Aggression can be expressed in a constructive as well as a destructive manner.
27. Carlo is acting out hostile and aggressive feeling by kicking the chairs in the room. the MOST
effective way to deal with Carlo’s behavior is initially to:

A. Set limits on the behavior by verbal command

B. Administer PRN tranquilizer
C. Remove the chairs from the room
D. Restrain the patient and place him in the “Isolation Room”

28. Mrs. Dizon was visiting her son at the Psychiatry Ward. Which of the following items will the
nurse not allow to be brought inside the ward?

A. String rosary bracelet C. Bottle of coke

B. Box of cake D. Rubber shoes

29. Which of the following will probably be most therapeutic for a patient on a behavioral
modification ward?

A. If the client is agitated, discuss the feelings especially anger

B. Insist to stop obscene language by verbal reprimand
C. Give client support and positive feedback for controlling use of obscene language
D. Provide a punching bag as an alternative to express upset emotions

30. Which of the following must be considered while planning activities for the depressed patient?

A. Activities which require exertion of energy

B. Challenging activities to get him out of his depression
C. Structured activities that the client can participate
D. Variety of unstructured activities

31. To maintain a therapeutic eye contact and body posture while interacting with angry and
aggressive individual, the nurse should:

A. keep an eye contact while staring at the client

B. keep his/her hands behind his/her back or in one’s pockets
C. fold his/her arms across his/her chest
D. keep an “open” posture, e.g. Hands by sides but palms turned outwards

32. A patient in the ward suddenly slapped you in the face and spitted on your face and is obviously
agitated and violent. Which of the following is the best nursing action?

A. Tell the client: “Because of that, you are not going to eat your lunch, dinner and breakfast
anymore.”
B. Slap the client back and say “I am your nurse, you are a patient and you have no right to hurt me.”
C. Prepare a 5 member team to restraint the client
D. Respond by saying “You are losing control of yourself, you slapped me and you spitted on me and
you are way out of control”

33. Which of the following is an accurate way of reporting and recording an incident?

A. “When asked about his relationship with his father, client became anxious.”
B. “When asked about his relationship with his father, client clenched his jaw/teeth,
made a fist and turned away from the nurse.”
C. “When asked about his relationship with his father, client was resistant to respond”
D. “When asked about his relationship with his father, his anger was suppressed”

34. To encourage thought, which of the following approaches is NOT therapeutic?

A. “Why do you feel angry?”

B. “When do you usually feel angry?”
C. “How do you usually express anger?”
D. What situations provoke you to be angry?”

35. A patient grabs and about to throw it. The nurse best responds saying.

A. “Stop! Put that chair down.”

B. “Don’t be silly.”
C. “Stop! The security will be here in a minute.”
D. “Calm down.”

Situation: In your professional nursing role, it is essential to establish a meaningful nurse-patient

relationship.

36. A helping nurse patient relationship is characterized by which of the following?

A. Recovery promoting C. Mutual interaction

B. Growth facilitating D. Health enhancing

37. Demonstrating a helping relationship enables you to establish in the patient:

A. Compliance to treatment
B. Positive response to illness
C. Gratitude to your services
D. Some sense of trust in you

38. Therapeutic communication begins with:

A. Knowing the patient C. Interacting with the patient

B. Trust D. Knowing yourself
39. Which of the following approaches will most likely make your patient accept your help?

A. Attending to all his needs C. Demonstrating a relaxed and attending attitude

B. Calling him by first name D. Asking personal questions for health information

40. The client said “I am troubled that my Son is starting to use drugs.” The nurse replied, “It’s
troubling and painful for you, I feel sorry about this.” The nurse’s reply is an example of:

A. Empathy B. Sympathy C. Telepathy D. Self awareness

41. Preparation for termination of the nurse-patient relationship begins during the:

A. Termination phase C. Pre-orientation phase

B. Working phase D. Orientation phase

42. The client’s past reactions to ending relationships is withdrawal. The nurse assists her to
practice better ways of coping termination by providing opportunities to:

A. Test new patterns of behavior C. Conceptualize her problem

B. Plan for alternatives D. Value and find meaning in experience

9. A male nurse reminds the client that is already time for group activities, The client responded by
yelling to the nurse “You are always telling me what to do! Just like my father!” This is an example
of:
A. Symbolization C.Reaction Formation
B. Transference D. Counter Transference

44. The longest and the most productive phase of the NPR is:

A. Termination phase C. Pre-orientation phase

B. Working phase D. Orientation phase

45. The objection of the nurse-patient relationship is to provide an opportunity of the patient to:

A. Clarify problems C. Have a corrective emotional experience

B. Develop insights D. Develop interpersonal relationship

Situation: Mental Retardation is an increasingly common childhood disorder that impairs learning.

46. Mental retardation is:

A. a delay in normal growth and development caused by an inadequate environment
B. a lack of development of sensory abilities
C. a condition of subaverage intellectual functioning that originates during the developmental
period and is associated with impairment in adaptive behavior
D. a severe lag in neuromuscular development and motor abilities

47. An important principle for the nurse to follow in interacting with retarded children is:

A. seen that if the child appears contented, his needs are being met
B. provide an environment appropriate to their development task as scheduled
C. treat the child according to his chronological age
D. treat the child according to his developmental level

48. The child was classified as having an IQ of 55. This is said to be:

A. Mild Mental Retardation C. Severe Mental Retardation

B. Moderate Mental Retardation D. Profound Mental Retardation

49. Which of the following is true with regards to Mild Mental Retardation?

A. Trainable, Can reach up to 2nd grade and can reach the maturity of a 7 year old
B. Custodial and barely trainable
C. Requires total care throughout life, Mental age of a young infant
D. Educable, can reach up to grade 6 and has a maturity of a 12 year old

50. A child with an IQ of 35-49 is:

A. Barely trainable C. Educable

B. Trainable D. Requires total care

51. Which of the following is true with regards to mental retardation?

A. Mental retardation is always accompanied by physical features

B. Hereditary and perinatal factors do not result to mental retardation
C. Mental retardation is a mental illness
D. Hereditary and perinatal factors are known to result to impaired intellectual functioning

52. The onset of mental retardation is before the child reaches what particular age?

A. 17 B. 16 C. 15 D. 18
53. The possible nursing diagnosis for a mentally retarded child who is hyperactive is:

A. Impaired physical mobility

B. Potential for injury
C. Impaired social adjustment
D. Ineffective coping

54. A tranquilizing agent given in calming a hyperactive mentally retarded is:

A. Chlorpromazine [Thorazine] C. Imipramine [Tofranil]

B. Haloperidol [Haldol] D. Diazepam [Valium]

55. This form of psychotherapy allows the child to experience and express intense or troubling
emotion in a safe environment with a caring individual:

A. Play therapy C. Behavior therapy

B. Milieu therapy D. Gestalt therapy

Situation : Margie has been diagnosed with Bipolar I disorder. The client demonstrates extreme
psychomotor agitation, flight of ideas, loud talking and elated mood.

56. Which of the following is true about manic reaction?

A. It is an expression of destructive impulse

B. A means of coping with frustrations and disappointments
C. A means of ignoring reality
D. An attempt to ward of feelings of underlying depression

57. Nursing care plan for a client with Mania like Margie should give priority to:

A. Discourage him from manipulating the staff

B. Prevent him from assaulting other patient
C. Protect him against suicidal attempts
D. Provide adequate food and fluid intake

58. During a nurse patient interaction, Margie jumps rapidly from one topic to another, This is
known as:

A. Flight of Ideas C. Ideas of reference

B. Clang association D. Neologism

59. Which of the following is a suitable activity that a nurse should assign for a Manic client?

A. delivering supply of linen to other rooms

B. conducting a drama workshop
C. engaging in activity therapy and group exercises
D. painting a mural with other patients

60. The doctor ordered lithium. You know that this is indicated in patients with:

A. Depression C. Schizophrenia
B. Mania D. Anxiety disorders

61. Lithium has a narrow therapeutic range of:

A. 0.1 to 1.0 mEq/L C. 10 to 50 mEq/L

B. 0.6 to 1.2 mEq/L D. 50 to 100 mEq/L

62. Which of the following is a side effect of lithium toxicity?

A. Anuria C. Sudden burst of muscle strength

B. Oliguria D. Polyuria

63. What specimen is taken from a client when checking the lithium level of the body?

A. Blood B. Stool C. Urine D. Sweat

64. Which of the following is NOT a drug use to augment lithium toxicity?

A. Urea B. Mannitol C. Aminophylline D. Acetylcysteine

65. The nurse has a standing order of Lithium for Margie. If the lithium level is 1.5 mEq/L, the nurse
knows that she should:

A. Administer the next dose and continue monitoring the client

B. Report this to the physician
C. Recheck the lithium level and validate first before doing any action
D. Withhold the next dose and notify the physician

Situation : Nursing informatics is a way of using information technology, computers and the internet
in the improvement of nursing care. The first nursing informatics conference was held during 1977.

66. The ANA recognized nursing informatics heralding its establishment as a new field in nursing
during what year?

A. 1992 B. 1994 C. 2001 D. 2004

67. When is the first certification of nursing informatics given?

A. 1992-1993 B. 1994-1995 C. 2001-2002 D. 2004-2005

68. Which of the following is the 3 integrated components of the nursing informatics?

1. Nursing science 3. Health science

2. Computer science 4. Information science

A. 1,2,3 B. 1,3,4 C. 1,2,4 D. 3,4,5

69. A textbook publisher wants to store large amount of data in a computer format that cannot be
changed by other people. Which of the following would best serve this purpose?

A. CD ROM B. Floppy disk C. RAM D. Network

70. The challenge most associated with the utilization of an electronic record system is which of the
following?

A. Cost B. Accuracy C. Privacy D. Curability

71. A client insists that the practitioner use a treatment method discovered on an internet data
base. Which of the following response is most appropriate?

A. “The treatment must be examine to see if it is appropriate”

B. “Most website treatments have not been studied or researched”
C. “The person establishing the website is the only one who can use it on clients”
D. “Websites are like advertising, they are biased and may not be legitimate.”

72. This is a type of a computerized recording system that enables hospitals to organize various data
such as admission, records, clinical laboratory, pharmacy, inventory and finance.

A. Management information system

B. Hospital information system
C. University information system
D. Government information system

73. A nurse, who is proficient in computers and information technology that uses these advantages
to promote effective and secured use of computerized record is referred to as:

A. Information technician C. Nursing information technician

B. Nursing IT D. Nurse Informaticist

74. One advantage of a computerized recording system is that:

The nursing diagnoses for a client’s data can be accurately determined

Cost of confinement will be reduced
Information concerning the client can be easily updated
The number of people to take care of the client will be reduced

75. You are to research the different types of oxygen delivery system. From the nasal cannula up to
the venturi mask. Using nursing informatics, you found out different sources of information. One of
the question that needs to be answered in your research is “What type of oxygen delivery system is
the most comfortable?” you will answer:

A. Nasal cannula, according to the American journal of nursing and medicine

B. Face masks, according to a nursing blog site
C. Venturi mask, according to Wikipedia
D. Oxygen tents, according to a personal website from yahoo search engine

Situation: Celina age 25, a ramp model, suddenly became blind after her boyfriend broke off with
her. A thorough work up did not reveal any pathological findings.

76. The loss or alteration of physical functioning without organize cause bit is an expression of a
psychological needs is known as:

A. Somatization C. Hypochondriasis
B. Depersonalization D. Conversion

77. Initially, the relevant nursing diagnosis the nurse includes in her care plan is:

A. Self esteem disturbance

B. Impaired adjustment
C. Ineffective individual coping
D. Ineffective denial

78. The defense mechanism commonly used by these clients is:

A. Projection C. Repression
B. Rationalization D. Sublimation

79. An appropriate nursing intervention which can help Celina is:

A. Establishing a trusting relationship

B. Encourage her to verbalize her feelings
C. Reinforce reality
D. Accept her limitation as a person

80. An effective modality of treatment for Celina would be:

A. Milieu therapy
B. Systematic desensitisation
C. Cognitive-Behavioral therapy
D. Psychopharmacology
Situation : Records and Records management is one of the core of professional nursing
practice.

81. The National Archives of the Phils. (NAP) is mandated by R.A. 9470 of 2007 to plan, formulate
and implement records management and archival administration program for the efficient action,
utilization, maintenance, retention, preservation, conservation and disposal of public records
including the adoption of security measures and vital records protection program for the
government and give technical assistance to all branches of government. Hospitals should safe keep
their record and coordinate with which of the following agency for its disposal?

A. National Archives of the Philippines

B. Metropolitan Manila Development Authority
C. Record Management and Archive Office
D. Department Of Health

82. If The research team finished the research about Ana’s case and they are done disseminating
data and after the report has been completed and written, Pre-processed data about Ana should be:

A. Preserved C. Stored for future use

B. Destroyed by Burning or Shredding D. Keep in a private file nobody can access

83. All of the following are purposes of the chart EXCEPT:

A. To document the quality of care

B. A vehicle for communication
C. For the prerecording of nursing actions
D. For research and education

84. What is an example of a subjective data?

A. Color of wound drainage

B. Odor of breath
C. Respiration of 14 breaths/minute
D. The patient’s statement of “I feel sick to my stomach”

85. Charting should be legible and include only standard abbreviations. Which of the
following is NOT a standard abbreviation?

A. PRN C. NNO
B. OD D. NPO

Situation: A nurse should be aware that some problems in the emergency setting are not always
physiologic. Sometimes, Crisis can affect the patient in an emergency setting.
 86. Which of the following statements best describes acquaintance rape?

A. Sexual intercourse when one person engaging in the activity is unsure about wanting to do so
B. When two people don’t love each other and engage in sexual activities
C. When someone on a date tricks the other person into having sexual intercourse
D. Sexual intercourse committed with force or the threat of force without a person’s consent

87. Male to male rape is also another problem that a nurse can encounter. The nurse knows that in
male to male rape, The perpetrator is usually:

A. An effeminate male homosexual C. A heterosexual who believes that he is superior

B. A young, newcomer heterosexual male D. A passive homosexual male

88. An 18 year old male client was rushed to the hospital due to burns, bruises and cuts on the face
and body. The teenager confessed that he was raped by 4 of his classmates, all of which are also
male. Male to male rape also occurs and the nurse must know that:

A. If there is an erection, the male victim also consents to the rape itself.
B. That all male to male rape cases occurs at home, which is statutory most of the time.
C. That male rape victims are usually homosexuals. Which are very much deserving to be raped.
D. Most victims of male to male rapes never dare to report the incident.

89. One of four factors describing the experience of sexually abused children and the effect it has on
their growth and development is stigmatization. Stigma will occur when:

A. A child blames him or herself for the sexual abuse and begins to withdraw and Isolate
B. Newspapers and the media don’t keep sexual abuse private and accidentally or on purpose reveal
the name of the victim
C. The child has been blamed by the abuser for his or her sexual behaviors, saying that the child
asked to be touched or did not make the abuser to stop
D. The child’s agony is shared by other members of the family or friends when the
sexual abuse becomes public knowledge

90. Which of the following is an example of hostile environment in terms of sexual harassment?

A. the boss assures you of a big promotion if you go out on a couple of dates with him
B. your supervisor makes masturbatory gestures every time you walk pass him
C. the personnel manager hints that the job will be yours if you cooperate sexually with him
D. your boss suggests that your “raise” is dependent upon having sex with him

Situation : You are a nurse working in the medical ward.

91. Mr. E.O. age 52 had a laryngectomy due to cancer of the larynx. Discharge instructions are given to
Mr.F.O. and his family. Which response by written communication from Mr. F.O. or verbal response
from the family, will be a signal to the nurse that the instructions need to be reclarified?
a. it is acceptable to take over-the-counter medications now that condition is stable
b. the suctioning at home must be a clean procedure, not sterile.
c. report swelling, pain or excessive drainage
d. cleans skin around stoma BID, use hydrogen peroxide and rinse with water, pat dry.

92. Dr. Tuazon scheduled Mrs. Poe for a right breast mass incision with frozen section and possible
mastectomy on Monday, first case. As the nurse in-charge for scheduling you will collaborate with
the following departments EXCEPT:

a. pathology c. anesthesia
b. dietary d. surgery

93. A mother who is pregnant and has ovarian cancer has to undergo surgery to treat the cancer. In
the process the fetus died. The doctrine that justifies the death of the fetus is:

a. justice c. exception to the role

b. anatomy d. double effect

94. A nurse is waiting for a report to be sent by fax. The machine activates but instead of the report,
the nurse received a sexually oriented photograph. The MOST appropriate nursing action is to:

a. call the nursing supervisor and report the incident

b. cut the photograph and throw it away.
c. call the police
d. call the unit who sent it and ask for the name of person who sent the photograph

95. Ms. F.X.. has been admitted with right upper quadrant pain and has been placed on a low fat diet.
Which of the following trays would be acceptable for her?

a. liver, fried potatoes and avocado

b. whole milk, rice and pastry
c. ham, mashed potatoes, cream peas
d. skim milk, lean fish, tapioca pudding

Situation : Some equipments and materials in our hospital are color coded, this is to increase the
safety and proficiency of rendering patients care.

96. If a nurse has been ordered to prepare a spinal set gauge 16, the nurse knew that the color for that
spinal set is coded at:

A. Red B. Pink C. Yellow D. Blue

97. If the anaesthesiologist asked for a 22 gauge spinal set, the nurse knew that the color of the set
that she will obtain is:

A. Red B. Pink C. Yellow D. Blue

98. For pediatric patients, the spinal set is coded with color:

A. Red B. Pink C. Yellow D. Blue

99. An anesthesiologist is preparing to do a spinal anesthesia to a 220 lb, 30 year old athlete she
request the circulating nurse to prepare a pink spinal set with another blue set as stand by. What
gauge spinal sets will make available in the OR suite?
A. Gauge 16 and 22
B.Gauge 18 and 16
C.Gauge 16 and 20
D. Gauge 5 and 22

100. Medical gases are used a lot in the OR. Some gases are used to operate equipment and some are
used to administer general anesthesia through inhalation. What is the identifying color of the tank
which contains ‘laughing gas’?

A. Yellow B. Green C. Black D. Blue