November 2008 PNLE

June 2008 PNLE



Situation – Accurate computation prior to drug administration is a basic skill all nurses must have.


1. Rudolf is diagnosed with amoebiasis and is to received Metronidazole (Flagyl) tablets 1.5 gm daily in 3
divided doses for 7 consecutive days. Which of the following is the correct dose of the drug that the client
will received per oral administration?
A. 1,000 mg tid
B. 500 mg tid
C. 1,500 mg tid
D. 50 mg tid

2. Rhona, a 2 year old female was prescribed to receive 62.5 mg suspension three times a day. The
available dose is 125 mg/ml. which of the following should Nurse Paolo prepare for each oral dose?
A. 0.5 ml
B. 1.5 ml
C. 2.5 ml
D. 10 ml

3. The physician ordered Potassium Chloride (KCL) in D5W 1 liter to be infused in 24 hours for Mrs.
Gomez. Since Potassium Chloride is a high risk drug, Nurse Robert used an intravenous pump. Which of
the following should Nurse Robert do to safely administer this drug?
A. Check the pump setting every 2 hours
B. Teach the client how the infusion pump operates
C. Have another nurse check the infusion pump setting
D. Set the alarm of the pump loud enough to be heard

4. Baby Liza, 3 months old, with a congenital heart deformity, has an order from her physician: ―give 3.00
cc of Lanoxin today for 1 dose only‖. Which of the following is the most appropriate action by the nurse?
A. Clarify order with the attending physician
B. Discuss the order with the pediatric heart specialist in the unit
C. Administer Lanoxin intravenously as it is the usual route of administration
D. Refer to the medication administration record for previous administration of Lanoxin

5. When Nurse Norma was about to administer the medications of client Lennie, the relative of Lennie
told the nurse that they buy her medicines and showed the container of medications of the client. Which
of the following is the most appropriate action by the nurse?
A. Hold the nurse administration of the client‘s medication and refer to the head nurse
B. Put aside the medications she prepared and instead administer the client‘s
medications
C. Tell the client that she will inform the physician about this
D. Bring the medications of the client to the nurse‘s station and prepare accordingly

Situation – You are a newly hired nurse in a tertiary hospital. You have finished your orientation program
recently and you are beginning to assimilate the culture of the profession.

6. Using Benner‘s stages of nursing expertise, you are a beginning nurse practitioner. You will rank
yourself as a/an:
A. competent nurse
B. novice nurse
C. proficient nurse
D. advanced beginner

7. Benner‘s ―Proficient‖ nurse level is different from the other levels in nursing expertise in the context of
having:
A. the ability to organize and plan activities
B. having attained an advanced level of education
C. a holistic understanding and perception of the client
D. intuitive and analytic ability in new situations

8. As you become socialized into the nursing ―culture‖ you become a patient advocate. Advocacy is
explained by the following EXCEPT:
A. respecting a person‘s right to be autonomous
B. demonstrating loyalty to the institution‘s rights
C. shared respect, trust and collaboration in meeting health needs
D. protecting and supporting another person‘s rights

9. Modern day nursing has led to the led development of the expanded role of the nurse as seen in the
function of a:
A. Clinical nurse specialist
B. Critical care nurse
C. community health nurse
D. staff nurse

10. You join a continuing education program to help you:
A. Earn credits for license renewal
B. Get in touch with colleagues in nursing
C. Enhance your basic knowledge
D. Update your knowledge and skills related to field of interest

Situation – Mr. Jose‘s chart is the permanent legal recording of all information that relates to his health
care management. As such, the entries in the chart must have accurate data.

11. Mr. Jose‘s chart contains all information about his health care. The functions of records include all
except:
A. means of communication that health team members use to communicate their
contributions to the client‘s health care
B. the client‘s record also shows a document of how much health care agencies will
be reimbursed for their services
C. educational resource for student of nursing and medicine
D. recording of actions in advance to save time

12. An advantage of automated or computerized client care system is:
A. The nursing diagnoses for a client‘s data can be accurately determined
B. Cost of confinement will be reduced
C. Information concerning the client can b easily updated
D. The number of people to take care of the client will be reduced

13. Information in the patient‘s chart is inadmissible in court as evidence when:
A. The client‘s family refuses to have it used
B. The client objects to its use
C. The handwriting is not legible
D. It has too many abbreviations that are ―unofficial‖

14. Nursing audit aims to:
A. provide research data to hospital personnel
B. study client‘s illness and treatment regimen closely
C. compare actual nursing done to established standards
D. provide information to health-care providers

15. A telephone order is given for a client in your ward. What is your most appropriate action?
A. Copy the order on to the chart and sign the physician‘s name as close to his
original signature as possible
B. Repeat the order back to the physician, copy onto the order sheet and
indicate that it is a telephone order
C. Write the order in the client‘s chart and have the head nurse co-sign it
D. Tell the physician that you can not take the order but you will call the nurse
supervisor

Situation – Errors while providing nursing care to patients must be avoided and minimized at all time.
Effective management of available resources enables the nurse to provide safe, quality patient care.

16. In the hospital where you work, increased incidence of medication error was identified as the number
one problem in the unit. During the brainstorming session of the nursing service department, probable
causes were identified. Which of the following is process related?
A. interruptions
B. use of unofficial abbreviations
C. lack of knowledge
D. failure to identify client

17. Miscommunication of drug orders was identified as a probable cause of medication errors. Which of
the following is safe medication practice related to this?
A. Maintain medication in its unit dose package until point of actual administration
B. Note both generic and brand name of the medication in the Medication
Administration Method
C. Only officially approved abbreviations maybe used in prescription orders
D. Encourage clients to ask question about their medications.

18. The hospital has an ongoing quality assurance program. Which of the following indicates
implementation of process standards?
A. The nurses check client‘s identification band before giving medications
B. The nurse reports adverse reaction to drugs
C. Average waiting time for medication administration is measured
D. The unit has well ventilated medication room

19. Which of the following actions indicate that Nurse Jerome is performing outcome evaluation of quality
care?
A. Interviews nurses for comments regarding staffing
B. Measures waiting time for client‘s per nurse‘s call
C. Checks equipment for its calibration schedule
D. Determines whether nurses perform skin assessment every shift

20. An order for a client was given and the nurse in charge of the client reports that she has no
experience of doing the procedure before. Which of the following is the most appropriate action of the
nurse supervisor?
A. Assign another nurse to perform the procedure
B. Ask the nurse to find way to learn the procedure
C. Tell the nurse to read the procedure manual
D. Do the procedure with the nurse

Situation – Oral care is an important part of hygienic practices and promoting client
comfort.

21. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness
and presence of sores. Which of the following is BEST to use for oral care?
A. lemon glycerine
B. hydrogen peroxide
C. Mineral oil
D. Normal saline solution

22. When performing oral care to an unconscious client, which of the following is a special consideration
to prevent aspiration of fluids into the lungs?
A. Put the client on a sidelying position with head of bed lowered
B. Keep the client dry by placing towel under the chin
C. Wash hands and observe appropriate infection control
D. Clean mouth with oral swabs in a careful and an orderly progression

23. The advantages of oral care for a client include all of the following, EXCEPT:
A. decreases bacteria in the mouth and teeth
B. reduces need to use commercial mouthwash which irritate the buccal
mucosa
C. improves client‘s appearance and self-confidence
D. improves appetite and taste of food

24. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to
lungs. This can be avoided by:
A. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid
rinsing the buccal cavity
B. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs
C. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue,
lips and ums
D. suctioning as needed while cleaning the buccal cavity

25. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of
the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep
the mouth moistened by using:
A. salt solution
B. water
C. petroleum jelly
D. mentholated ointment

Situation - Mr. Martin, 71 years old was suddenly rushed to the hospital because of severe chest pain. On
admission, he was diagnosed to have acute myocardial infarction and was placed in the ICU.

26. While in the ICU, he executes the document tat list the medical treatment he chooses to refuse in
case his condition becomes severe to a point that he will be unable to make decisions for himself. This
document is:
A. living will
B. informed consent
C. last will and testament
D. power of attorney

27. After one day, the patient‘s condition worsened and feeling hopeless. He requested the nurse to
remove the oxygen. The nurse should:
A. follow the patient because it is his right to die gracefully
B. follow the patient as it is his right to determine the medical regimen he needs
C. refuse the patient and encourage him to verbalize hid feelings
D. refuse the patient since euthanasia is not accepted in the Philippines

28. Euthanasia is an ethical dilemma which confronts nurses in the ICU because:
A. the choices involved do not appear to be clearly right or wrong
B. a clients legal right co-exist with the nurse‘s professional obligation
C. decisions has to be made based on societal norms.
D. decisions has to be mad quickly, often under stressful conditions

29. A nurse who supports a patient and family‘s need to make decisions that is right for them is practicing
which of the following ethical principles?
A. Autonomy
B. confidentiality
C. privacy
D. truthfulness

30. Mr. Martin felt better after 5 days but recognizing the severity of his illness, he executes a document
authorizing the wife to transact any form of business in his behalf in addition to all decisions relative to his
confinement his document is referred to as:
A. power f attorney
B. living will
C. informed consent
D. medical records

Situation - Miss Castro was recently appointed chief nurse of a 50-bed government hospital in
Valenzuela. On her first day of duty, she tried to remember the elements of administration she learned
from her basic nursing education.

31. One of the first things Ms. Castro did was to engage her until in objective writing, formulating goals
and philosophy of nursing service. Which activities are MOST appropriately described to which elements
of administration?
A. planning
B. controlling
C. directing
d. organizing

32. In recognizing the Department of Nursing, she comes up with the organizational structure defining the
role and function of the different nursing positions and line-up the position with qualified people. This is
included in which element of administration:
A. monitoring
B. evaluation
C. organizing
D. planning

33. After one month, she and her management committee assess the regulatory measures taken and
correct whatever discrepancies are found. This is part of which element of administration:
A. monitoring
B. organizing
C. evaluation
D. planning

34. Revaluation and administrative process is BEST described as:
A. a continuing process of seeing that performance meets goals and targets
B. obtaining commitment of members to do better
C. informing personnel how well and how much improvement has been made
D. follow-up of activities that have been studied

35. In all of the various administrative functions, which of the following management skill is demanded
efficiently and effectively of Ms. Castro?
1. Decision making skills 2. Forecasting skills
3. Auditing skills 4. Communications skills

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

Situation - Health is wealth specifically in this time of the century. The nurse is trained to promote well
being of the people.

36. How does a nurse promote one‘s well being?
A. periodic travels for rest and recreation
B. faithful and observance of healthy simple lifestyle
C. run away from polluted, stressful areas
D. avoid sleepless, over fatigue nights

37. The nurse can be involved with health promotion as a significant person in helping the family:

A. become a better family
B. prevent disease
C. control their symptoms
D. modify health promotive behaviors

38. The nurse should NOT leave medication at the bedside because:
a. the bedside table is not sterile
b. it is convenient for the nurse
c. the nurse will not be able to accurately document that the patient actually took the medication
d. the patient may forget to take it.

39. Non-pharmacologic pain management includes all the following EXCEPT:
a. relaxation techniques
b. massage
c. use of herbal medicines
d. body movement

40. When assessing a client‘s blood pressure, the nurse finds it necessary to recheck the reading. How
many seconds after deflating the cuff should the nurse wait before rechecking the pressure?
a. 10
b. 30
c. 45
d. 60

Situation – The use of massage and meditation to help decrease stress and pain have
been strongly recommended based on documented testimonials.

41. Martha wants to do a study on this topic: ―Effects of massage and meditation on stress
and pain‖. The type of research that best suits this topic is:
A. Applied research
B. Qualitative research
C. Basic research
D. Quantitative research

42. The type of research design that does not manipulate independent variable is:
A. Experimental design
B. Quasi-experimental design
C. Non-experimental design
D. Quantitative design
43. This research topic has the potential to contribute to nursing because it seeks to
A. include new modalities of care
B. resolve a clinical problem
C. clarify an ambiguous modality of care
D. enhance client care

44. Martha does review of related literature for the purpose of
A. determine statistical treatment of data research
B. gathering data about what is already known or unknown about the
problem
C. to identify if problem can be replicated
D. answering the research question

45. Client‘s rights should be protected when doing research using human subjects. Martha identifies
these rights as follows EXCEPT:
A. right of self-determination
B. right to compensation
C. right of privacy
D. right not to be harmed

Situation – Richard has a nursing diagnosis of ineffective airway clearance related to
excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Mario‘s
nursing care plan is to loosen and remove excessive secretions in the airway.

46. Mario listens to Richard‘s bilateral sounds and finds that congestion is in the upper lobes of the lungs.
The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does
percussion would be:
A. Client lying on his back then flat on his abdomen on Trendelenburg position
B. Client seated upright in bed or on a chair then leaning forward in sitting
position then flat on his back and on his abdomen
C. Client lying flat on his back and then flat on his abdomen
D. Client lying on his right then left side on Trendelenburg position

47. When documenting outcome of Richard‘s treatment Mario should include the following in his
recording EXCEPT:
A. Color, amount and consistency of sputum
B. Character of breath sounds and respiratory rate before and after procedure
C. Amount of fluid intake of client before and after the procedure
D. Significant changes in vital signs

48. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would
focus on the following EXCEPT:
A. Amount of food and fluid taken during the last meal before treatment
B. Respiratory rate, breath sounds and location of congestion
C. Teaching the client‘s relatives to perform the procedure
D. Doctor‘s order regarding position restrictions and client‘s tolerance for lying flat

49. Mario prepares Richard for postural drainage and percussion. Which of the following is a special
consideration when doing the procedure?
A. Respiratory rate of 16 to 20 per minute
B. Client can tolerate sitting and lying positions
C. Client has no signs of infection
D. Time of last food and fluid intake of the client

50. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference
between the procedures is:
A. Percussion uses only one hand while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped palms
while vibration gently shakes secretion loose on the exhalation cycle
C. In both percussion and vibration the hands are on top of each other and hand
action is in tune with client‘s breath rhythm
D. Percussion slaps the chest to loosen secretions while vibration shakes the
secretions along with the inhalation of air.
Situation – A 61 year old man, Mr. Regalado, is admitted to the private ward for
observation after complaints of severe chest pain. You are assigned to take care of the
client.

51. When doing an initial assessment, the best way for you to identify the client‘s priority
problem is to:
A. Interview the client for chief complaints and other symptoms
B. Talk to the relatives to gather data about history of illness
C. Do auscultation to check for chest congestion
D. Do a physical examination while asking the client relevant questions

52. Upon establishing Mr. Regalado‘s nursing needs, the next nursing approach would be to:
A. Introduce the client to the ward staff to put the client and family at ease
B. Give client and relatives a brief tour of the physical set up the unit
C. Take his vital signs for a baseline assessment
D. Establish priority needs and implement appropriate interventions

53. Mr. Regalado says he has ―trouble going to sleep‖. In order to plan your nursing
intervention you will:
A. Observe his sleeping patterns in the next few days
B. Ask him what he means by this statement
C. Check his physical environment to decrease noise level
D. Take his blood pressure before sleeping and upon waking up

54. Mr. Regalado‘s lower extremities are swollen and shiny. He has pitting pedal edema.
When taking care of Mr. Regalado, which of the following interventions would be the most
appropriate immediate nursing approach?
A. Moisturize lower extremities to prevent skin irritation
B. Measure fluid intake and output to decrease edema
C. Elevate lower extremities for postural drainage
D. Provide the client a list of food low in sodium

55. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when
preparing a client for discharge include all EXCEPT:
A. Making a final physical assessment before client leaves the hospital
B. Giving instructions about his medication regimen
C. Walking the client to the hospital exit to ensure his safety
D. Proper recording of pertinent data

Situation – Using Maslow‘s need theory, Airway, Breathing and Circulation are the
physiological needs vital to life. The nurse‘s knowledge and ability to identify and
immediately intervene to meet these needs is important to save lives.

56. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues:
A. Carol with tumor in the brain
B. Theresa with anemia
C. Sonnyboy with a fracture in the femur
D. Brigitte with diarrhea

57. You noted from the lab exams in the chart of M. Santos that he has reduced oxygen in the blood. This
condition is called:
A. Cyanosis
B. Hypoxia
C. Hypoxemia
D. Anemia

58. You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of
insertion of the tubing for an adult would be:
A. tip of the nose to the base of the neck
B. the distance from the tip of the nose to the middle of the neck
C. the distance from the tip of the nose to the tip of the ear lobe
D. eight to ten inches

59. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by:
A. Apply suction for at least 20-30 seconds each time to ensure that all secretions
are removed
B. Using gloves to prevent introduction of pathogens to the respiratory system
C. Applying no suction while inserting the catheter
D. Rotating catheter as it is inserter with gentle suction

60. Nurse Suzie is administering 12:00 PM medication in Ward 4. Two patients have to receive Lanoxin.
What should Nurse Suzie do when one of the clients does NOT have a readable identification band?
A. Ask the client if she is Mrs. Santos
B. Ask the client his name
C. Ask the room mate if the client is Mrs. Santos
D. Compare the ID band with the bed tag

Situation – During the NUTRITION EDUCATION class discussion a 58 year old man, Mr. Bruno, shows
increased interest.

61. Mr. Bruno asks what the ―normal‖ allowable salt intake is. Your best response to Mr.
Bruno is:
A. 1 tsp of salt/day with iodine and sprinkle of MSG
B. 5 gms per day or 1 tsp of table salt/day
C. 1 tbsp of salt/day with some patis and toyo
D. 1 tsp of salt/day but no patis and toyo

62. Your instructions to reduce or limit salt intake include all the following EXCEPT:
A. eat natural food with little or no salt added
B. limit use of table salt and use condiments instead
C. use herbs and spices
D. limit intake of preserved or processed food

63. Teaching strategies and approaches when giving nutrition education is influenced by
age, sex and immediate concerns of the group. Your presentation for a group of young
mothers would be best if you focus on:
A. diets limited in salt and fat
B. harmful effects of drugs and alcohol intake
C. commercial preparation of dishes
D. cooking demonstration and meal planning

64. Cancer cure is dependent on
A. use of alternative methods of healing
B. watching out for warning signs of cancer
C. proficiency in doing breast self-examination
D. early detection and prompt treatment

65. The role of the health worker in health education is to
A. report incidence of non-communicable diseases to community health center
B. educate as many people about warning signs of non-communicable
diseases
C. focus on smoking cessation projects
D. monitor clients with hypertension

Situation – As you begin to work in the hospital where you are on probation, you are
tasked to take care of a few patients. The clients have varied needs and you are expected to provide care
for them.

66. An ambulatory client. Mr. Zosimo, is being prepared for bed. Which of the following nursing actions
promote safety for the client?
A. Turning off the lights to promote rest and sleep
B. Instructing the client about the use of call system
C. Raising the side rails
D. Placing the bed in high position


67. Mikka, a 25 year old female client, is admitted with right lower quadrant abdominal pain. The
physician diagnosed the client with acute appendicitis and an emergency appendectomy was performed.
Twelve hours following surgery, the patient complained of pain. Which of the following is the most
appropriate nursing diagnosis?
A. Impaired mobility related to pain secondary to an abdominal incision
B. Impaired movements related to pain due to surgery
C. Impaired mobility related to surgery
D. Severe pain related to surgery

68. You are preparing a plan of care for a client who is experiencing pain related to incisional swelling
following laminectomy. Which of the following should be included in the nursing care plan?
A. Encourage the client to log roll when turning
B. Encourage the client to do self-care
C. Instruct the client to do deep breathing exercises
D. Ambulate the client in ward premises every twenty minutes

69. Mr. Lozano, 50 year old executive, is recovering from severe myocardial infarction. For the past 3
days, Mr. Lozano‘s hygiene and grooming needs have been met by the nursing staff. Which of the
following activities should be implemented to achieve the goal of independence for Mr. Lozano?
A. Involving family members in meeting client‘s personal needs
B. Meeting his needs till he is ready to perform self-care
C. Preparing a day to day activity list to be followed by client
D. Involving Mr. Lozano in his care

70. Mr. Ernest Lopez is terminally ill and he choose to be at home with his family. What nursing action are
best initiated to prepare the family of Mr. Lopez?
A. Talk with the family members about the advantage of staying in the hospital for
proper care
B. Provide support to the family members by teaching ways to care for their
loved one
C. Convince the client to stay in the hospital for professional care
D. Tell the client to be with his family

Situation – Myrna, a researcher, proposes a study on the relationship between health
values and the health promotion activities of staff nurses in a selected college
of nursing.

71. In both quantitative and qualitative research, the used of a frame of reference is required. Which of
the following items serves as the purpose of a framework?
A. Incorporates theories into nursing‘s body of knowledge
B. Organizes the development of study and links the findings to nursing‘s body
of knowledge
C. Provides logical structure of the research findings
D. Identifies concepts and relationships between concepts

72. Myrna need to review relevant literature and studies. The following processes are undertaken in
reviewing literature EXCEPT:
A. locating and identifying resources
B. reading and recording notes
C. clarifying a research topic
D. using the library

73. The primary purpose for reviewing literature is to:
A. organize materials related to the problem of interest
B. generate broad background and understanding of information related to the
research problem of interest
C. select topics related to the problem of interest
D. gather current knowledge of the problem of interest

74. In formulating the research hypotheses, researcher Myrna should state the research question as:
A. What is the response of the staff nurses to the health values?
B. How is variable ―health value‖ perceived in a population?
C. Is there a significant relationship between health values and health
promotion activities of the staff nurses?
D. How do health values affect health promotion activities of the staff nurses?

75. The proposed study shows the relationship between the variables. Which of the following is the
independent variable?
A. Staff nurses in a selected college of nursing
B. Health values
C. Health promotion activities
D. Relationship between health values and health promotion activities

Situation – While working in a tertiary hospital, you are assigned to the medical ward.

76. Your client, Mr. Diaz, is concerned that he can not pay his hospital bills and professional fees. You
refer him to a:
A. Nurse supervisor
B. Social worker
C. bookkeeping department
D. physician

77. Mr. Magno has lung cancer and is going through chemotherapy. He is referred by the oncology nurse
to a self-help group of clients with cancer to:
A. receive emotional support
B. to be a part of a research study
C. provide financial assistance
D. assist with chemotherapy

78. A diabetic hypertensive client, Mrs. Linao, needs a change in diet to improve her health status. She
should be referred to a:
A. nutritionist
B. dietitian
C. physician
D. medical pathologist

79. When collaborating with other health team members, the best description of Nurse Rita‘s role is:
A. encourages the client‘s involvement in his care
B. shares and implements orders of the health team to ensure quality care
C. she listens to the individual views of the team members
D. helps client set goals of care and discharge

80. Nurse Rita is successful in collaborating with health team members about the care of Mr. Linao. This
is because she has the following competencies:
A. Communication, trust, and decision making
B. Conflict management, trust, negotiation
C. Negotiation, decision making
D. Mutual respect, negotiation and trust

Situation – The practice of nursing goes with responsibilities and accountability whether you work in a
hospital or in the community setting you main objective is to
provide safe nursing to your clients?

81. To provide safe, quality nursing care to various clients in any setting, the most important tool of the
nurse is:
A. critical thinking to decide appropriate nursing actions
B. understanding of various nursing diagnoses
C. observation skills for data collection
D. possession of in scientific knowledge about client needs

82. You ensure the appropriateness and safety of your nursing interventions while caring for various client
groups by:
A. creating plans of care for particular clientele
B. identifying the correct nursing diagnoses for clients
C. making a thorough assessment of client needs and problems
D. using standards of nursing care as your criteria for evaluation

83. The effectiveness of your nursing care plan for your clients is determined by
A. the number of nursing procedures performed to comfort the client
B. the amount of medications administered to the client as ordered
C. the number of times the client calls the nurse
D. the outcome of nursing interventions based on plan of care

84. You are assigned to Mrs. Amado, age 49, who was admitted for possible surgey. She complained of
recurrent pain at the right upper quadrant of the abdomen 1-2 hours after ingestion of fatty food. She also
had frequent bouts of dizziness, blood pressure of 170/100, hot flashes. Which of the above symptoms
would be an objective cue?
A. Blood pressure measurement of 170/100
B. Complaint of hot flashes
C. Report of pain after ingestion of fatty food
D. Complaint of frequent bouts of dizziness

85. While talking with Mrs. Amado, it is most important for the nurse to:
A. schedule the laboratory exams ordered for her
B. do an assessment of the client to determine priority needs
C. tell the client that your shift ends after eight hours
D. have the client sign an informed consent

Situation - Eileen, 45 years old is admitted to the hospital with a diagnosis of renal calculi. She is
experiencing severe flank pain, nauseated and with a temperature of 39
0
C.

86. Given the above assessment data, the most immediate goal of the nurse would be which of the
following?


A. Prevent urinary complication
B. maintains fluid and electrolytes
C. Alleviate pain
D. Alleviating nausea



87. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes
―daily urine specimen to be sent to the laboratory‖ . Eileen has a foley catheter attached to a urinary
drainage system. How will you collect the urine specimen?
A. remove urine from drainage tube with sterile needle and syringe and empty urine from the
syringe into the specimen container
B. empty a sample urine from the collecting bag into the specimen container
C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter int the
specimen container.
D. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into
the specimen container.

88. Where would the nurse tape Eileen‘s indwelling catheter in order to reduce urethral irritation?
A. to the patient‘s inner thigh
B. to the patient‘s lower thigh
C. to the patient‘
D. to the patient lower abdomen

89. Which of the following menu is appropriate for one with low sodium diet?
A. instant noodles, fresh fruits and ice tea
B. ham and cheese sandwich, fresh fruits and vegetables
C. white chicken sandwich, vegetable salad and tea
D. canned soup, potato salad, and diet soda

90. How will you prevent ascending infection to Eileen who has an indwelling catheter?
A. see to it that the drainage tubing touches the level of the urine
B. change he catheter every eight hours
C. see to it that the drainage tubing does not touch the level of the urine
D. clean catheter may be used since urethral meatus is not a sterile area

Situation – You are assigned to take care of 10 patients during the morning shift. The
endorsement includes the IV infusion and medications for these clients.

91. Mr. Felipe, 36 years old is to be given 2700 ml of D5LR to infuse for 18 hours starting at 8 am. At
what rate should the IV fluid be flowing hourly?
A. 100 ml per hour
B. 210 ml per hour
C. 150 ml per hour
D. 190 ml per hour

92. Mr. Atienza is to receive 150 ml/hour of D% W IV infusion for 12 hours for a total of
1800ml. He is also losing gastric fluid which must be replaced every two hours. Between 8 am and 10
am, Mr. Atienza has lost 250 ml of gastric fluid. How much fluid should he
receive at 11 am?
A. 350 ml/hour
B. 275 ml/hour
C. 400 ml/hour
D. 200 ml/hour

93. You are to apply a transdermal patch of nitoglycerin to your client. The following are
important guidelines to observe EXCEPT:
A. Apply to hairless clean area of the skin not subject to much wrinkling
B. Patches may be applied to distal part of the extremities like forearm
C. Change application and site regularly to prevent irritation of the skin
D. Wear gloves to avoid any medication on your hand

94. You will be applying eye drops to Miss Romualdez. After checking all the necessary
information and cleaning the affected eyelid and eyelashes, you administer the ophthalmic drops by
instilling the eye drops:
A. directly onto the cornea
B. pressing the lacrimal duct
C. into the outer third of the lower conjunctival sac
D. from the inner canthus going towards the side of the eye

95. When applying eye ointment, the following guidelines apply EXCEPT:
A. squeeze about 2 cm of ointment and gently close but not squeeze the eye
B. apply the ointment from the inner canthus going outward of the affected eye
C. discard the first bead of the eye ointment before application because the
tube is likely to expel more than desired amount of ointment
D. hold the tube above the conjunctival sac, do not let tip touch the conjunctiva

Situation – The staff nurse supervisor requests all the staff nurses to ―brainstorm‖ and
learn ways to instruct diabetic clients on self-administration of insulin. She wants to ensure that there are
nurses available daily to do health education classes.

96. The plan of the nurse supervisor is an example of
A. in service education process
B. efficient management of human resources
C. increasing human resources
D. primary prevention

97. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide
who is an unlicensed staff, Mrs. Guevarra
A. makes the assignment to teach the staff member
B. is assigning the responsibility to the aide but not the accountability for
those tasks
C. does not have to supervise or evaluate the aide
D. most know how to perform task delegated

98. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six weeks ago
when she started the job. The nurse supervisor should
A. empathize with the nurse and listen to her
B. tell her to take the day off
C. discuss how she is adjusting to her new job
D. ask about her family life

99. Process of formal negotiations of working conditions between a group of registered
nurses and employer is
A. grievance
B. arbitration
C. collective bargaining
D. strike

100. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and
required by the hospital employing you. This is
A. professional course towards credits
B. inservice education
C. advance training
D. continuing education

NP2 Nursing Board Exam June 2008 Answer Key 'Community Health Nursing and Care of Mother and
Child'
1. Which statement is correct regarding the use of cervical cap?
A. It may affect the Pap Smear result
B. It does not need to be fitted by the physician
C. It does not require the use of spermicidal
D. It must be removed within 24hours

2. 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

3. The extent of burns in children are normally assessed and expressed in terms of:
A. The amount of body surface that is unburned
B. Percentages of total body surface area (TBSA)
C. How deep the deepest burns are
D. The severity of the burns on a 1 to 5 burn scale

4. 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 (IQ)
B. An orphan
C. A victim of child neglect
D. The victim of poverty

5. Which of the following indicates the type(s) of acute renal failure?
A. Four types: hemorrhagic with and without clotting, and non hemorrhagic with and without clotting
B. One type: Acute
C. Three types: Prerenal, intrarenal, postrenal
D. Two types: Acute and subacute

6. A means of facilitating professional staff development is by building upon skills, abilities and of
experience of each practitioner is called:
A. The novice to expert model
B. Situational leadership model
C. Career enhancement
D. Clinical ladder

7. Which of the following questions by the nurse would be best fit the philosophy of the nursing mutual
participation model of care (NMPMC)?
A. ―Have you brushed your child‘s teeth today?‖
B. ―How does your child look to you today?‘
C. ―Where have you been all morning?‖
D. ―Do you think your child‘s color is worse?‖

8. There are numerous definitions of the word ―health‖. Which definition below is from Florence
Nightingale?
A. A state or a process of being and becoming an integrated and whole person
B. The state of being free from illness or injury
C. Being well and using every power the individual processes to the fullest extent
D. A state of complete physical, social, and mental well-being and not merely the absence of diasease or
infirmity.

9. Informal communication takes place when the individual talk and is best described by saying the
participants:
A. Are involved in a preexisting informal relationship
B. Talk with slang words
C. Have no particular agenda or protocol
D. Are relaxed

10. Tertiary care by the home health nurse is directed toward children with:
A. Problem is mobility
B. Short-term needs
C. Minor problems
D. Clinically apparent disease

11. The endometrium thickens during which phase of the menstrual cycle?
A. Secretory phase
B. Menstrual phase
C. Proliferative phase
D. Ischemic phase

12. A measurement tool to articulate the nursing workload for a specific patient or groups of patients over
a specific period of time is called:
A. Staffing pattern
B. Sill mix
C. Benchmaking
D. Patient classification

13. The mother of a 9 month-old infant is concerned that the head circumference of her baby is greater
than the chest circumference. The BEST response by the nurse is:
A. ―These circumference normally are the same, but in some babies this just differs‖
B. Perhaps your baby was small for gestational age or premature
C. ―This is normal until the age of 1 year, when the chest will be greater‖
D. ―Let me ask you a few questions, and perhaps we can figure out the cause of this difference‖

14. Which of the following approaches would work best when the nurse is communicating with an infant?
A. Use an adult voice just as you would for anyone
B. Communicate through the caregivers
C. Allow the child time to warm up to the nurse
D. Respond only after the child cries for a while

15. Evidence-based care started in medicine as a way to:
A. Promote technological advances in medicine
B. Incorporate collaboration within all health care disciplines
C. Integrate individual experience with clinical research
D. Teach medical students the art and science of medicine

16. Martina develops endometritis. What would be the best activity for her?
A. lying in bed with a cold cloth on her forehead
B. reading while resting in a trendelenburg position
C. sitting with her feet elevated while playing cards
D. walking around her room listening to music

17. 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

18. Fely has diarrhea for 2 days. She has sunken eyes, skin pinch goes back very slowly, and she is
drinking poorly and irritable. She is not able to drink and there is no blood in the stool. How will you
classify Fely‘s illness?
A. persistent diarrhea
B. some dehydration
C. severe dehydration
D. no dehydration

19. The infectious agent that causes pulmonary tuberculosis is:
A. mycobacterium tubercle
B. Hansen‘s bacillus
C. Wuchereria bancrofti
D. mycobacterium diphtheria

20. Your client, who happens to be female resident of the barangay you are covering, is an adult survivor
who states: ―Why couldn‘t I make him stop the abuse? If I were stronger person, I would have been able
to make him stop. Maybe it was my fault to be abused‖. Based on this, which would be your most
appropriate nursing diagnosis?
A. social isolation
B. anxiety
C. chronic low self-esteem
D. ineffective family coping

21. Maybelle is also scheduled to have an amniocentesis to test for fetal maturity. What instructions
would you give her before this procedure?
A. void immediately before the procedure to reduce your bladder size
B. no more amniotic fluid forms afterward, that is why only a small amount is removed
C. the intravenous fluid infused to dilate your uterus does not hurt the
fetus
D. the x-ray used to reveal your fetus position has no long-term effects

22. When planning teaching strategy for a pregnant woman, the nurse should do which of the following?
A. give information about how the woman can manage the specific problems she identifies as
relevant in her life
B. omit information related to minor pains of pregnancy to prevent the woman from developing
hypochondria
C. provide all information to the woman in a group session with other pregnant women so she can have
someone to discuss it with
D. during the first prenatal visit, teach a woman the care measures necessary for health promotion
throughout the pregnancy

23. Which of the following symptoms is LESS commonly noted in EARLY pregnancy?
A. frequency of urination
B. chills and fever
C. varicosities
D. Braxton Hicks‘ Contractions

24. Bonnie, 3 months pregnant, has reported for her first prenatal visit. The nurse should instruct her to
do which of the following?
A. eat more dairy products and green leafy vegetables to provide an additional 300 calories each day
B. increase her intake of carbohydrates-breads and sweets to prevent protein metabolism
C. eat whenever she feels hungry because her body will let her know when she needs nutrients and extra
calories
D. limit intake of amino acids to prevent development of diabetic ketoacidosis

25. The nurse is assisting Mr. and Mrs. Cruz to prepare for childbirth in the home setting. Which of the
following supplies should be readily available for the infant immediately after birth?
A. vitamin K to avoid bleeding
B. mild soap without perfume so as not to irritate the skin
C. bulb syringe to suction fluid and mucous from the mouth
D. heating lamp to avoid chilling from water evaporation

26. You were the nurse assigned to work with a child who has had whole brain radiation. You have
assessed the child to be sleeping up to 20 hours a day and is having some nausea, malaise, fever and
dysphasia. Based on this assessment, you are to work with the patients in which of the following areas.
A. Accepting a reoccurrence of the tumor
B. Dealing with the side effects of radiation therapy
C. Caring for the dying child
D. Accepting the imminent death of their child

27. The nurse is planning interventions for a child who has inflammatory bowel disease (IBD) with a
nursing diagnosis of ―Nutrition: Less than body requirements‖. Which of the following interventions will be
most helpful in resolving this nursing problem?
A. Two large meals a day instead of several minerals and snacks
B. Special IBD diet (diet that has been proven effective for crating IBD)
C. Salt free diet, high in potassium, vitamins and minerals
D. Diet as tolerated with lactose hydrolyzed milk instead of milk products and omission or highly
seasoned foods and reduction of fiber.

28. Emotional intelligence consists of a number of competencies. Some of these are listed below. Which
is NOT a characteristic of emotional intelligence?
A. Self-esteem
B. self-awareness
C. Empathy
D. Self-regulation

29. Data Collection for driving and restraining forces, including costs, desirability and feasibility is a:
A. People issue
B. Structural issue
C. Political issue
D. Technology issue

30. 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 himself for the sexual abuse and begins to withdraw and isolate
B. Newspapers and media don‘t keep sexual abuse private and accidentally or on purpose reveal the
name of the victim.
C. The child as 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


Situation – Nurse Anna is a new BSN graduate and has just passed her Licensure Examination for
Nurses in the Philippines. She has likewise been hired as a new Community Health Nurse in one of the
Rural Health Units in their City, which of the following conditions may be acceptable TRUTHS applied to
Community Health Nursing Practice.

31. Which of the following is the primary focus of community health nursing practice?
A. Cure of illnesses
B. Prevention of illnesses
C. Rehabilitation back to health
D. Promotion of health

32. In community health nursing, which of the following is our unit of service as nurses?
A. The community
B. The extended members of every family
C. The individual members of the Barangay
D. The Family

33. A very important part of the Community Health Nursing Assessment Process includes:
A. the application of professional judgment in estimating importance of
facts to family and community
B. evaluation structures and qualifications of health center team
C. coordination with other sectors in relation to health concerns
D. carrying out nursing procedures as per plan of action

34. In community health nursing it is important to take into account the family health data
coupled with an equally important need to perform ocular inspection of the area as activities
which are powerful elements of:
A. evaluation
B. assessment
C. implementation
D. planning

35. The initial step in PLANNING process in order to engage in any nursing project or
activities at the community level involves
A. goal-setting
B. monitoring
C. evaluation of data
D. provision of data

Situation – Please continue responding as a professional nurse in these other health
situations through the following questions.

36. Transmission of HIV from an infected individual to another person occurs:
A. Most frequently in nurses with needlesticks
B. Only if there is a large viral load in the blood
C. Most commonly as a result of sexual contact
D. In all infants born to women with HIV infection

37. The medical record of a client reveals a condition in which the fetus cannot pass through
the maternal pelvis. The nurse interprets this as:
A. Contracted pelvis
B. Maternal disproportion
C. Cervical insufficiency
D. Fetopelvic disproportion

38. The nurse would anticipate a cesarean birth for a client who has which infection present
at the onset of labor?
A. Herpes-simplex virus
B. Human papilloma virus
C. Hepatitis
D. Toxoplasmosis

39. After a vaginal examination, the nurse determines that the client‘s fetus is in an occiput
posterior position. The nurse would anticipate that the client will have:
A. A precipitous birth
B. Intense back pain
C. Frequent leg cramps
D. Nausea and vomiting

40. The rationales for using a prostaglandin gel for a client prior to the induction of labor is
to:
A. Soften and efface the cervix
B. Numb cervical pain receptors
C. Prevent cervical lacerations
D. Stimulate uterine contractions

Situation – Nurse Lorena 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.

41. Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would be the best
answer?
A. Prostaglandins released from the cut fallopian tubes can kill sperm
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.

42. 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

43. Another client named Lilia 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 ovaries stop producing adequate estrogen
D. pressure on the pituitary leads to decreased FSH levels

44. Lilia is scheduled to have a hysterosalphingogram. Which of the following instructions
would you give her regarding this procedure?
A. She will not be able to conceive for 3 months after the procedure
B. The sonogram of the uterus will reveal any tumors present
C. Many women experience mild bleeding as an after effect
D. She may feel some cramping when the dye is inserted

45. Lilia‘s cousin on the other hand, knowing nurse Lorena‘s specialization asks what
artificial insemination by donor entails. Which would be your best answer if you were Nurse Lorena?
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

46. A child suffers a head injury in a tumbling accident in gym class. The nurse‘s best course of action is
to:
A. Get the child up walking and makes sure he or she stays awake
B. Leave the child and go get help
C. Leave the child in the care of an older child and go get help
D. Stay with the child, keep assessing and have someone call the caregivers
47. The American Academy of Pediatrics suggests that caregivers do which of the following things in
regard to physical activities for preschoolers?
A. Push the child to practice sports activities while they are more flexible
B. Encourage a variety of physical activities in a noncompetitive environment
C. Have the child engage in competitive sports to see where they excel
D. Keep physical activities to a minimum until the child is in grade school.

48. Which of the following arrangements is generally considered to be the best for the parents of
hospitalized infant or young child?
A. Rooming in
B. Separate caregiver sleeping room on the unit
C. Day visits and sleeping at home
D. Staying at a nearby hotel or motel

49. When one person allows the conflict to be resolved at his or her own expense, this is referred in
conflict management as:
A. Losing
B. Winning while losing
C. The win-lose approach
D. The lose-win approach

50. 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 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 of the threat if force of the threat Of force without a person‘s
contact.

51. A public health nurse would instruct a pregnant woman to notify the physician immediately if which of
the following symptoms occur during pregnancy?
A. Presence of dark color in the neck
B. Increased vaginal discharge
C. Swelling of the face
D. Breast tenderness

52. A woman who is week 9 pregnant comes to the Health center with moderate bright red vaginal
bleeding. On physical examination, the physician finds the client‘s cervix 2 cm dilated. Which term best
describes the client‘s condition?
A. missed abortion
B. Incomplete abortions
C. Inevitable abortion
D. Threatened abortion

53. In a big government hospital, Nurse Pura is taking care of a woman with diagnosis of abruption
placenta. What complication of this condition is most concerned to Nurse Pura?
A. Urinary tract infection
B. Pulmonary embolism
C. Hypocalcemia
D. Disseminated intravascular coagulation

54. Which of the following findings on a newly delivered woman‘s chart would indicate she is at risk for
developing postpartum hemorrhage?
A. Post-term delivery
B. Epidural anesthesia
C. Grand multiparity
D. Premature rupture of membrane

55. Mrs. Hacienda Gracia, 35 years old postpartum client is at risk of thrombophlebitis. Which of the
following nursing interventions decrease her chances of developing postpartum thrombophlebitis?
A. Breastfeeding the newborn
B. Early ambulation
C. Administration of anticoagulant postpartum
D. Immobilization and elevation of the lower extremities

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

56. Which among the following is the primary focus of prevention of cances?
A. Elimination of conditions causing cancer
B. Diagnosis and treatment
C. Treatment at early stage
D. Early detection

57. 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 assembles
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

58. 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 under early detection
D. Those scheduled for surgery

59. Who among the following are recipients of the tertiary level of care for cancer cases?
A. Those under treatment
B. Those under supportive care
C. Those under early detection
D. Those scheduled for surgery

60. In Community Health Nursing, despite the availability and the use of many equipment and devices to
facilitate the job of the community health nurse, the best tool any nurse should be well be prepared to
apply is a scientific approach. This approach ensures quality of care even at the community setting. This
in nursing parlance is nothing less than the:
A. Nursing diagnosis
B. Nursing protocol
C. Nursing research
D. Nursing process

61. The tone and pitch of the voice, volume, inflection, speed, grunts and other vocalizations are referred
to by which of the following terms?
A. Paraverbal clues
B. Ancillary speech
C. Third element
D. Enhancements

62. The plan-do-study-act cycle begins with:
A. Four stages
B. Five agendas
C. Three questions
D. Two concepts

63. During your shift, you noted one of your pregnant clients considered as ―waiting case‖ manifests
morning sickness and which later progressed. Which assessment finding may indicate possible
developing complication?
A. Maternal pulse 90
B. Trace glucose in the urine
C. FHT 155
D. 1 + ketones in the urine

64. The nurse is working with a child who is going to have a bone marrow aspiration. The physician
orders TAC (tetracaine, adrenaline and cocaine). Which of the following is the route of administration?
A. Application to the skin, covered with a dressing prior to the procedure
B. Subcutaneous
C. IV using very slow drip over approximately 4 hours prior to procedure
D. Nasal inhalation

65. Infant head control is judged by the:
A. Ability to hold the head without support
B. Presence or absence of head lag
C. Rigidity of the neck and head
D. Amount of neck wrinkling

66. Which of the following could be included in the outcome criteria for a patient with a nursing diagnosis,
―Knowledge Deficit related to potential for altered tissue perfusion in fetus or mother related to maternal
cardiovascular‖?
A. Bedrest is maintained at home after the 36
th
wee of gestation
B. Fetal heart rate will remain between 120 and 160 beats a minute
C. Jugular vein distention is evident when lying at 45 degrees
D. Maternal blood pressure maintained above the 150 systolic

67. Pregnant women should be taught to be careful to avoid accidental injury. They are prone to falls for
which of the following reasons?
A. additional weight from pregnancy may disturb balance when walking
B. fetal activity stimulates the nerves of the legs and causes weakness
C. high levels of hormones often impair judgment resulting in reckless behavior
D. increased adrenalin released during pregnancy causes women to move faster than usual

68 . When a nurse uses the IMCI model, the IMCI chart uses illness classification, e.g. the pink row
needs:
A. no specific treatments such as antibiotics
B. urgent referral
C. appropriate antibiotics
D. no urgent measures

69. Which of the four signs of good attachment is true in this statement?
A. the chin should touch the breast while the mouth is wide open and while the lower lip is turned inward
more areola is visible above than below
B. the chin should touch the breast, the mouth is wide open while the lower lip turned outward
and more areola visible above than below
C. the chin should touch the breast while the mouth is wide open while the lower lip turned outward and
more areola visible below than above
D. the chin should touch the breast while the mouth is wide open and the lower lip turned inward, more
areola is visible above than below

70. Which type of research inquiry investigates the issues of human complexity ( e. g. understanding the
human expertise?)
A. positivism
B. quantitative research
C. logical position
D. natural inquiry

71. Carol is 15 months old and weighs 5.5 kgs and it is her initial visit. Her mother says that Carol is not
eating well and unable to breastfeed, he has no vomiting, has no convulsion and not abnormally sleepy or
difficult to awaken. Her temperature is 38.9 deg C. Using the integrated management of childhood illness
or IMCI strategy, if you were the nurse in charge of Carol, how will you classify her illness?
A. a child at a general danger sign
B. very severe febrile disease
C. severe pneumonia
D. severe malnutrition

72. Why are small for gestational age newborns at risk for difficulty maintaining body temperature?
A. their skin is more susceptible to conduction of cold
B. they are preterm so are born relatively small in size
C. they do not have as many fat stored as other infants
D. they are more active than usual so they throw off comes

73. Oxytocin is administered to Rita to augment labor. What are the first symptoms of water intoxication to
observe for during this procedure?
A. headache and vomiting
B. a swollen tender tongue
C. a high choking voice
D. abdominal bleeding and pain

74. Which of the following treatment should NOT be considered if the child has severe dengue
hemorrhagic fever?
A. use plan C if there is bleeding from the nose or gums
B. give ORS if there is skin Petechiae, persistent vomiting, and positive tourniquet test
C. give aspirin
D. prevent low blood sugar

75. In assessing the patient‘s condition using the Integrated Management of Childhood Illness approach
strategy, the first thing that a nurse should do is to:
A. ask what are the child’s problem
B. check the patient‘s level of consciousness
C. check for the four main symptoms
D. check for the general danger signs

76. A child with diarrhea is observed for the following EXCEPT:
A. how long the child has diarrhea
B. skin Petechiae
C. presence of blood in the stool
D. signs of dehydration

77. The child with no dehydration needs home treatment. Which of the following is NOT included in the
care for home management at this case?
A. give drugs every 4 hours
B. continue feeding the child
C. give the child more fluids
D. inform when to return to the health center

78. Ms. Jordan, RN, believes that a patient should be treated as individual. This ethical principle that the
patient referred to:
A. beneficence
B. nonmaleficence
C. respect for person
D. autonomy

79. When patients cannot make decisions for themselves, the nurse advocate relies on the ethical
principle of:
A. justice and beneficence
B. fidelity and nonmaleficence
C. beneficence and nonmaleficence
D. fidelity and justice

80. 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 7 – Nurse Joanna works as an OB-Gyne Nurse and attends to several HIGH-RISK
PREGNANCIES: Particular women with preexisting or Newly Acquired illness. The following
conditions apply

81. Bernadette is a 22-year old woman. Which condition would make her more prone than
others to developing a Candida infection during pregnancy?
A. Her husband plays golf 6 days a week
B. She was over 35 when she became pregnant
C. She usually drinks tomato juice for breakfast
D. She has developed gestational diabetes

82. Bernadette develops a deep vein thrombosis following an auto accident and is
prescribed heparin sub-Q. What should Joanna educate her about in regard to this?
A. Some infants will be born with allergic symptoms to heparin
B. Her infant will be born with scattered petechiae on his trunk
C. Heparin can cause darkened skin in newborns
D. Heparin does not cross placenta and so does not affect a fetus

83. The cousin of Bernadette with sickle-cell anemia alerted Joanna that she may need
further instruction on prenatal care. What statement signifies this fact?
A. I‘ve stopped jogging so I don‘t risk becoming dehydrated.
B. I take an iron pill every day to help grow new red blood cells
C. I am careful to drink at least eight glasses of fluid every day
D. I understand why folic acid is important for red cell formation

84. Bernadette routinely takes acetylsalicylic acid (aspirin) for arthritis. Why should she limit
or discontinue this toward the end of pregnancy?
A. Aspirin can lead to deep vein thrombosis following birth
B. Newborns develop a red rash from salicylate toxicity
C. Newbors develop withdrawal headaches from salicylates
D. Salicylates can lead to increased maternal bleeding at childbirth

85. Bernadette received a laceration on her leg from her automobile accident. Why are
lacerations of lower extremities potentially more serious in pregnant women than others?
A. Lacerations can provoke allergic responses because of gonadothropic hormone
B. Increased bleeding can occur from uterine pressure on leg veins
C. A woman is less able to keep the laceration clean because of her fatigue
D. Healing is limited during pregnancy, so these will not heal until after birth.

Situation 8 – Still in your self-managed Child Health Nursing Clinic, you encounter these
cases pertaining to the CARE OF CHILDREN WITH PULMONARY AFFECTIONS.

86. Josie brought her 3 months old child to your clinic because of cough and colds. Which of
the following is your primary action?
A. Give cotrimoxazole tablet or syrup
B. Assess the patient using the chart on management of children with
cough
C. Refer to the doctor
D. Teach the mother how to count her child‘s breathing


87. In responding to the care concerns of children with severe disease, referral to the
hospital is of the essence especially if the child manifests which of the following?
A. Wheezing
B. Stop feeding well
C. Fast breathing
D. Difficulty to awaken

88. Which of the following is the most important responsibility of a nurse in the prevention
of unnecessary deaths from pneumonia and other severe diseases?
A. Giving antibiotics
B. Taking of the temperature of the sick child
C. Provision of Careful Assessment
D. Weighing of the sick child

89. You were able to identify factors that lead to respiratory problems in the community
where your health facility serve. Your primary role therefore in order to reduce morbidity
due to pneumonia is to:
A. Teach mothers how to recognize early signs and symptoms of pneumonia
B. Make home visits to sick children
C. Refer cases to hospitals
D. Seek assistance and mobilize the BHWs to have a meeting with mothers

90. Which of the following is the principal focus of the CARI program of the Department of
Health?
A. Enhancement of health team capabilities
B. Teach mothers how to detect signs and where to refer
C. Mortality reduction through early detection
D. Teach other community health workers how to assess patients.

Situation – Among common conditions found in children especially among poor
communities are ear infections/problems. The following questions apply.

91. A child with ear problem should be assessed for the following, EXCEPT:
A. is there any fever?
B. Ear discharge
C. If discharge is present for how long?
D. Ear pain

92. If the child does not have ear problem, using IMCI, what should you as the nurse do?
A. Check for ear discharge
B. Check for tender swellings behind the ear
C. Check for ear pain
D. Go to the next question, check for malnutrition

93. A ear discharge that has been present for more than 14 days can be classified as:
A. mastoiditis
B. chronic ear infection
C. acute ear infection
D. complicated ear infection

94. An ear discharge that has been present for less than 14 days can be classified as:
A. chronic ear infection
B. mastoiditis
C. acute ear infection
D. complicate ear infection

95. If the child has severe classification because of ear problem, what would be the best
thing that you as the nurse can do?
A. instruct mother when to return immediately
B. refer urgently
C. give an antibiotic for 5 days
D. dry the ear by wicking

Situation – If the child with diarrhea registers one sign in the pink row and one in the
yellow row in the IMCI Chart:

96. We can classify the patient as:
A. moderate dehydration
B. some dehydration
C. no dehydration
D. severe dehydration

97. The child with no dehydration needs home treatment. Which of the following is not
included in the rules for home treatment in this case:
A. continue feeding the child
B. gives oresol every 4 hours
C. know when to return to the health center
D. give the child extra fluids

98. A child who has had diarrhea for 14 days but has no sign of dehydration is classified as:
A. severe persistent diarrhea
B. dysentery
C. severe dysentery
D. persistent diarrhea

99. If the child has sunken eyes, drinking eagerly, thirsty and skin pinch goes back slowly,
the classification would be:
A. no dehydration
B. moderate dehydration
C. some dehydration
D. severe dehydration

100. Genetic testing should be performed on a child only if:
A. The parents both want it performed
B. It is in the best interest of the clinic
C. It is necessary for the child to survive
D. No one objects

NP3
Situation - One learns by doing especially when you practice the best methods.

1. Which action by a new nurse signifies a need for further teaching in infection control?
A. The nurse places the side rails the time to an unconscious patient.
B. The nurse elevates the head of the bed to check the BP
C. The nurse uses her bare hands to change the dressing
D. The Nurse applies oxygen catheter to the mouth.

2. You are a PM shift and about 5 patients are discharge. You noted that the orderly was looking through
the items of one of the patients. Which action should you pursue?
A.Call the attention of the orderly in private.
B. Ignore the situation because you are busy.
C. Report this behavior to the nurse in charge.
D. Monitor the situation and note whether any other items are reported missing.

3. What appropriate action should you do when you overhear the nursing attendant speaking harshly to
an elderly patient?
A. Try to explore the interaction with the nursing attendant concerned.
B. Change the attendant‘s assignment.
C. Initiate a group discussion with all other nursing attendants.
D. Discuss the matter with the patient‘s family.

4. Disposal of Medical Records in the Government hospital needs collaboration with which of the
following department:
A. DOH
B. MMDA
C. DILG
D. RMAO

5. You saw one colleague charting medication administration that she has not yet administered. After
talking to her, you also report the incident to the charge nurse. The charge nurse should:
A. Required the staff to submit an incident report.
B. Terminate the nurse
C. Charge the erring nurse with dishonesty.
D. Report to the Board of Nursing.

Situation - You are assigned at the PACU

6. Which nursing diagnosis has priority among the client in the PACU?
A. Acute Pain related to discomfort of wound and immobility
B. Body image disturbance of wound dressing and drains.
C. Ineffective airway clearance related to anesthesia.
D. Knowledge deficit related to lack of information because patients are all sedated.

7. Which of the following clients at the PACU will demonstrate the effectiveness of the nurse teaching?
A. The client demonstrates deep breathing, coughing, splintering and leg exercises.
B. The client manifests normal temperature.
C. The client sleeps well
D. The client has good balance I and O.

8. Which of the following remark indicates that the client‘s relative understood the discharged instructions
for would care?
A. ―If the wound is painful, I will say it is normal.‖
B. ―It is alright to use adhesive tape over the wound to keep it intact.‖
C. ―It is ok for his pet to remain at his bedside to keep him company.‖
D. It will report any redness or swelling of the wound.”

9. You must transfer out a post-op client to her room. What would your instructions to the family include to
prevent accidents?
A. Report when the IV infusion is almost finished.
B. Test the call system if functioning.
C. Keep the room lights on for 24hrs.
D. Make sure the side rails are up.

10.One of your post-op patients has a temperature of 27.9 C and was shivering. You covered him with a
blanket and later took his temperature again and it is now 38.9 C. The nursing student asked you to
explain the absence of shivering even if the temperature was higher.
A. The patient is no longer febrile thus he is no longer chilling.
B. Shivering normally disappears as temperature becomes higher.
C. The body has reached its new set point thus the absence of shivering.
D. The patient is feeling better.

Situation - Patients with chest tubes can be very challenging to new nurses.

11. The chest drainage of Tirso has continuous bubbling in the water seal drainage. After an hour you
noticed that the bubbling stops. Which of the following condition is the possible cause of the
malfunctioning sealed drainage?
A. A suction being to high
B. An air leak
C. A tube being too small
D. A tension pneumothorax

12. While you were making your endorsement, you found out the chest tube of a client was disconnected.
What would be your appropriate action?
A. Assist the client back to his bed and place him on the affected side.
B. Cover the end of the chest tube with sterilize gauze
C. Reconnect the tube to the chest tube system
D. Put the end of the chest tube into a cup of sterile normal saline

13. Dr. Reyes asked you top assist him with the removal of Tirso‘s chest tube. You would instruct the
client to:
A. Continuously breathe normally during the chest tube
B. Take a deep breath, exhale, and bear down
C. exhale upon actual removal of the tube
D. Hold breath until the chesty tube is pulled out

14. Chest tube diameter is measured or expressed in:
A. French
B. Gauge
C. Millimeters
D. Inches

15. When transporting clients with a chest tube, the system should be:
A. Disconnected
B. Closed
C. Placed lower than the patient’s chest
D. Placed between the legs of the client to prevent breakage

Situation – The preoperative nurse collaborates with the client significant others, and healthcare
providers.

16. To control environment hazards in the OR, the nurse collaborates with the following departments
EXCEPT:
A. Biomedical division
B. DOH
C. Infection control committee
D. DILG

17. Waste disposal poses a big problem for the hospital. Biological wastes (i.e. amputated limbs) disposal
should be coordinated with the following agencies EXCEPT:
A. Crematorium
B. DOH
C. MMDA
D. DILG

18. Tess, the PACU nurse discovered that Malou, who weights 110 lbs prior to surgery, is in severe pain
8 hours after cholecystectomy. Upon checking the chart, Malou found out that she has an order of
Demerol 100 mg I.M. prn for pain. Tess should verify the order with:
A. Nurse supervisor
B. Anesthesiologist
C. Surgeon
D. Intern on duty

19. Rosie, 57, who is diabetic is for debridement if incision wound. When the circulating nurse checked
the present IV fluid, she found out that there is no insulin incorporated as ordered. What should the
circulating nurse do?
A. Double check the doctor’s order and call the attending MD
B. Communicate with the ward nurse to verify if insulin was incorporated or not
C. Communicate with the client to verify if insulin was incorporated
D. Incorporate insulin as ordered


20. The documentation of all nursing activities performed is legally and professionally vital. Which of the
following should NOT be included in the patients chart?
A. Presence of prosthetic devices such as dentures, artificial limbs hearing aid, etc.
B. Baseline physical, emotional, and psychosocial data
C. Arguments between nurses and residents regarding treatment
D. Observed untoward signs and symptoms and interventions including contaminant intervening factors.

Situation – Technology and patients education has dramatically improved the management of the diabetic
client.

21. The current insulin pumps available in the market have the following capability, EXCEPT:
A. Prevent unexpected saving in blood glucose measurement
B. Detect signs and symptoms of hypoglycemia and hypercalcemia
C. Deliver a pre-meal bolus dose of insulin before each meal
D. Deliver a continuous basal rate of insulin at 5.0 units to 2.0 units per hour

22. Discharge plan of diabetic clients include injection-site-rotation. You should emphasize that the space
between sites should be:
A. 6 cm
B. 5 cm
C. 2.5 cm
D. 4 cm

23. It is critical also that a diabetic client should be educated in the possible sites if regular insulin
injection. The fastest absorption rate happens at the tissue areas of:
A. Gluteal area
B. Deltoid area
C. Anterior area
D. Abdominal area

24. Self-monitoring of blood glucose (SMBG) is recommended for patients use. You will recommend this
technology in the following diabetic patients EXCEPT:
A. Client with proliferative retinopathy
B. Unstable diabetes
C. Hypoglycemia without warning
D. Abdominal renal glucose threshold

25. It is necessary for a diabetic client to exercise regularly. What is the effect of regular exercise to a
diabetic client?
A. It burns excess glucose
B. It improves insulin utilization
C. It lowers glucose, improves insulin utilization, and decreases total triglyceride levels.
D. It will make you fit and energized.

26. Following a fracture of the forearm or tibia, complaints of sharp, deep, unrelenting pain in the hand or
foot unrelieved by analgesics or elevation of the extremity indicate which complication?
a. cast syndrome
b. compartment syndrome
c. gangrene
d. fat embolism

27. 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
b. assistant surgeon
c. x-ray technician
d. surgeon

28. Circulation must be restored within 4 minutes of cardiopulmonary arrest because:
a. the lungs fill with fluid
b. the blood begins to coagulate
c. brain cells begin to die
d. irreversible kidney failure develops

29. Benny elaborated on the concept of informed consent. He determines that the nurses need more
explanation if their response is one of the following:
a. the consent should provide a description of alternative treatments or procedures
b. the consent should offer a thorough explanation of the procedures to be done and the consequences of
it.
c. the consent should include the medical diagnosis and explanation of the patient’s condition
d. the consent should describe the prognosis if the recommended care is refused.

30. Which of the assessment findings would indicate a need for possible glaucoma testing?
a. intermittent loss of vision
b. presence of floaters
c. halos around lights
d. pruritus and erythema of the conjunctiva

31. The diabetic patient asks for a snack and something to drink. The MOST appropriate choice for this
client to meet nutritional needs would be which of the following:
a. crackers with cheese and tea
b. toast with peanut butter and cocoa
c. vanilla wafers and coffee with cream
d. graham crackers and warm milk

32. 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

33. In teaching the mother the proper administration of tetracycline eye ointment, which of the following is
MOST crucial?
a. squirt a small amount on the inside of the infected eye‘s lower lid
b. use clean, wet cloth to gently wipe away the pus
c. wash hands before medication administration
d. do not use other eye ointments or drops or put anything else in eyes.

34. The primary goal of nursing interventions after a craniotomy is:
a. avoiding need for secondary surgery
b. ensuring patient comfort
c. preventing increased intracranial pressure
d. prevention of infection

35. Mr. Salvo, a 35 year old male, has been admitted with the diagnosis of peptic ulcers. The nurse
recognizes which drugs as those MOST commonly used in these patients to decrease acid secretions?
a. erythromycin and flagyl
b. Tagamet and zantac
c. Maalox and kayexalate
d. Dyazide and carafate

36. When reading the urinalysis report, the nurse recognizes this result as abnormal:
a. red blood cells 15-20
b. turbid
c. glucose negative
d. ph 6.0

37. Mr. Hizon has had cataract surgery. Discharge teaching would include:
a. wearing eye patches for the first 72 hours
b. bending at the waist acceptable if done slowly
c. bending at the knees and keeping the head straight
d. lifting light objects is acceptable

38. 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
b. x-ray department
c. blood bank services
d. linen section

39. 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
b. chaplain
c. significant others
d. responsible caregiver

40. R.N. denotes that a nurse:
A. Has satisfactory completed with the requirements to practice nursing as set by the state.
B. Has a baccalaureate degree in nursing
C. Is professionally ready to practice nursing
D. Just a title

Situation – Joint Commission on Accreditation of Hospital Organization (JCAHO) patient
safety goals and requirements include the care and efficient use of technology in the OR and
elsewhere in the healthcare facility.

41. As the head nurse in the OR, how can you improve the effectiveness of clinical alarm
systems?
A. Limit suppliers to a few so that quality is maintained
B. Implement a regular inventory of supplies and equipment
C. Adherence to manufacturer‘s recommendation
D. Implement a regular maintenance and testing of alarm systems

42. Overdosage of medication or anesthetic can happen even with the aid of technology like
infusion pumps, sphygmomanometer and similar devices/machines. As a staff, how can you
improve the safety of using infusion pumps?
A. Check the functionality of the pump before use
B. Select your brand of infusion pump like you do with your cellphone
C. Allow the technician to set the infusion pump before use
D. Verify the flow rate against your computation

43. JCAHOs universal protocol for surgical and invasive procedures to prevent wrong site,
wrong person, and wrong procedure/surgery includes the following, EXCEPT:
A. Mark the operative site if possible
B. Conduct pre-procedure verification process
C. Take a video of the entire intra-operative procedure
D. Conduct ‗time out‘ immediately before starting the procedure

44. You identified a potential risk of pre-and postoperative clients. To reduce the risk of
patient harm resulting from fall, you can implement the following, EXCEPT:
A. Assess potential risk of fall associated with the patient‘s medication regimen
B. Take action to address any identified risks through Incident Report (IR)
C. Allow client to walk with relative to the OR
D. Assess and periodically reassess individual client‘s risk for falling

45. As a nurse, you know you can improve on accuracy of patient‘s identification by 2
patient identifiers, EXCEPT:
A. identify the client by his/her wrist tag and verify with family members
B. identify client by his/her wrist tag and call his/her by name
C. call the client by his/her case and bed number
D. call the patient by his/her name and bed number

Situation – Team efforts is best demonstrated in the OR.

46. If you are the nurse in charge for scheduling surgical cases, what important information
do you need to ask the surgeon?
A. Who is your internist
B. Who is your assistant and anesthesiologist, and what is your preferred
time and type of surgery?
C. Who are your anesthesiologist, internist, and assistant
D. Who is your anesthesiologist

47. In the OR, the nursing tandem for every surgery is:
A. Instrument technician and circulating nurse
B. Nurse anesthetist, nurse assistant, and instrument technician
C. Scrub nurse and nurse anesthetist
D. Scrub and circulating nurses

48. While team effort is needed in the OR for efficient and quality patient care delivery, we
should limit the number of people in the room for infection control. Who comprise this
team?
A. Surgeon, anesthesiologist, scrub nurse, radiologist, orderly
B. Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist
C. Surgeon, assistant surgeon, anesthesiologist, scrub nurse, pathologist
D. Surgeon, assistant surgeon, anesthesiologist, intern, scrub nurse

49. When surgery is on-going, who coordinates the activities outside, including the family?
A. Orderly/clerk
B. Nurse Supervisor
C. Circulating Nurse
D. Anesthesiologist

50. The breakdown in teamwork is often times a failure in:
A. Electricity
B. Inadequate supply
C. Leg work
D. Communication
Situation – Colostomy is a surgically created anus. It can be temporary or permanent,
depending on the disease condition.\

51. Skin care around the stoma is critical. Which of the following is not indicated as a skin
care barriers?
A. Apply liberal amount of mineral oil to the area
B. Use karaya paste and rings around the stoma
C. Clean the area daily with soap and water before applying bag
D. Apply talcum powder twice a day

52. What health instruction will enhance regulation of a colostomy (defecation) of clients?
A. Irrigate after lunch everyday
B. Eat fruits and vegetables in all three meals
C. Eat balanced meals at regular intervals
D. Restrict exercise to walking only

53. After ileostomy, which of the following condition is NOT expected?
A. Increased weight
B. Irritation of skin around the stoma
C. Liquid stool
D. Establishment of regular bowel movement

54. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT:
A. Increase the irrigating solution flow rate when abdominal cramps is felt
B. Insert 2-4 inches of an adequately lubricated catheter to the stoma
C. Position client in semi-Fowler
D. Hang the solution 18 inches above the stoma

55. What sensation is used as a gauge so that patients with ileostomy can determine how
often their pouch should be drained?
A. Sensation of taste
B. Sensation of pressure
C. Sensation of smell
D. Urge to defecate

Situation – As a nurse, you should be aware and prepared of the different roles you play.

56. What role do you play when you hold all client‘s information entrusted to you in the
strictest confidence?
A. Patient’s advocate
B. Educator
C. Patient‘s Liaison
D. Patient‘s arbiter

57. As a nurse, you can help improve the effectiveness of communication among healthcare
givers by:
A. Use of reminders of ‗what to do‘
B. Using standardized list of abbreviations, acronyms, and symbols
C. One-on-one oral endorsement
D. Text messaging and e-mail

58. As a nurse, your primary focus in the workplace is the client‘s safety. However, personal
safety is also a concern. You can communicate hazards to your co-workers through the use
of the following EXCEPT:
A. Formal training
B. Posters
C. Posting IR in the bulletin board
D. Use of labels and signs

59. As a nurse, what is one of the best way to reconcile medications across the continuum
of care?
A. Endorse on a case-to-case basis
B. Communicate a complete list of the patient‘s medication to the next provider of
service
C. Endorse in writing
D. Endorse the routine and ‗stat‘ medications every shift

60. As a nurse, you protect yourself and co-workers from misinformation and
misrepresentations through the following EXCEPT:
A. Provide information to clients about a variety of services that can help alleviate
the client‘s pain and other conditions
B. Advising the client, by virtue of your expertise, that which can contribute to the
client‘s well-being
C. Health education among clients and significant others regarding the use of
chemical disinfectant
D. Endorsement thru trimedia to advertise your favourite disinfectant
solution

Situation – You were on duty at the medical ward when Zeny came in for admission for
tiredness, cold intolerance, constipation, and weight gain. Upon examination, the doctor‘s
diagnosis was hypothyroidism.

61. Your independent nursing care for hypothyroidism includes:
A. administer sedative round the clock
B. administer thyroid hormone replacement
C. providing a cool, quiet, and comfortable environment
D. encourage to drink 6-8 glasses of water

62. As the nurse, you should anticipate to administer which of the following medications to
Zeny who is diagnosed to be suffering from hypothyroidism?
A. Levothyroxine
B. Lidocaine
C. Lipitor
D. Levophed

63. Your appropriate nursing diagnosis for Zeny who is suffering from hypothyroidism would
probably include which of the following?
A. Activity intolerance related to tiredness associated with disorder
B. Risk to injury related to incomplete eyelid closure
C. Imbalance nutrition to hypermetabolism
D. Deficient fluid volume related to diarrhea

64. Myxedema coma is a life threatening complication of long standing and untreated
hypothyroidism with one of the following characteristics.
A. Hyperglycemia
B. Hypothermia
C. Hyperthermia
D. Hypoglycemia

65. As a nurse, you know that the most common type of goiter is related to a deficiency of:
A. thyroxine
B. thyrotropin
C. iron
D. iodine

Situation – Mr. Santos, 50, is to undergo cystoscopy due to multiple problems like scantly

66. You are the nurse in charge of Mr. Santos. When asked what are the organs to be examined during
cystoscopy, you will enumerate as follows:
A. Urethra, Kidney, Bladder
B. Urethra, Bladder wall, trigone, urethral opening
C. Bladder wall, uterine wall and urethral opening
D. Urethral opening, urethral opening bladder.

67. You are the nurse in charge of Mr. Santos. When asked what are the organs to be examined during
cystoscopy in:
A. Supine
B. Lithotomy
C. Semi-fowler
D. Trendelenburg

68. After cystoscopy, Mr. Santos asked you to explain why there is no incision of any kind. What do you
yell him?
A. Cystoscopy is direct visualization and examination by urologist
B. Cystoscopy is done by x-ray visualization of the urinary tact
C. Cystoscopy is done by using lasers on the urinary tract
D. Cystoscopy is an endoscopic procedure of the unrinary tract

69. Within 24-48 hours post cystoscopy, it is normal to observe one of the following:
A. Pink-tinged urine
B. Distended bladder
C. Signs of infection
D. Prolonged hematuria
70. Leg cramps are NOT uncommon post cystoscopy. Nursing intervention includes:
A. Bed rest
B. Warm moist soak
C. Early ambulation
D. Hot sitz bath

Situation – A specimen is a piece of tissue of body fluid taken from the disease body organ or tissue to
aid the health care team in diagnosis and effective treatment.

71. Carmen is suspected to have a left breast CA. She is scheduled in your room on 5 for frozen section.
How will you prepare the specimen for laboratoty?
A. Refrigerator and send it along with the day‘s specimen
B. Send to pathology immediately without soaking solution
C. Soak it in NSS
D. Soak it in formalin

72. How will you label this specimen? What information was essential in the label?
A. Name of the client, age, sex, hospital number
B. Name of the client, age, sex
C. Name, age, site, type of specimen, hospital number, doctor
D. Name, doctor, type of specimen, hospital number

73. Foreign body extracted from the body like pins, needles, seeds or bullets are also considered as a
specimen. You assisted in the multiple gunshot wound exploration. During the surgey send the specimen
to:
A. The department of pathology
B. The national bureau of investigation
C. The OR head nurse
D. Client‘s family

74. A post dilation and curettage (D and C) client is for discharge. Follow-up of lab result should be part of
the discharge plan. You will instruct the client to follow up result at the:
A. Medical record
B. Laboratory
C. Doctor’s clinic
D. Nurse‘s station

75. You are the circulating nurse in OR 2. You have 4 thyroidectomy cases for the day. How do, you
prevent switching of specimens?
A. Send specimens to laboratory right away after the operation with the proper labels
B. Collect all specimens and send to laboratory at the end of the day
C. Label specimen at once
D. Prepare 4 specimen vials first thing in the morning

76. 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

77. Negligence in the practice of nursing can be a ground for:
a. revocation of license by the Ombudsman
b. revocation of license by the BON
c. revocation of license by the DOH
d. revocation of license by the Nursing Department

78. One way of verifying that the right message/doctor‘s order was communicated effectively is by:
a. phrasing intelligently
b. repeating the order message
c. documenting
d. speaking distinctly using enough volume

79. Maria is administering a cleansing enema to a patient with fecal impaction. Before administering the
enema, she should place the patient in which of the following positions?
a. on the right side of the body with the head of the bed elevated 45 degrees
b. left Sim’s position
c. on the left side of the body with the head of the bed elevated 45 degree
d. right Sim‘s position

80. The functionality and integrity of instruments and medical devices used in surgical procedure, is the
responsibility of the:
a. surgeon
b. bio-med technician
c. OR nurse
d. scrub nurse

81. Maria will be preparing a patient for thoracentesis. She should assist the patient to which of the
following positions for the procedure?
a. prone with the head turned to the side and supported by a pillow
b. lying in bed on the affected side with the head of the bed elevated 45 degrees
c. Sim‘s position with the head of the bed flat
d. Lying in bed on the unaffected side with the head of the bed elevated 45 degrees

82. When a patient comes to the clinic for an eye examination, the ophthalmologists administers
phenylephrine 2.5% drops to:
a. dilate retinal blood vessels
b. anesthetize the cornea
c. dilate the pupil
d. removed any obstruction on the cornea

83. Which of the following statements by Ms. S.O. a chemotherapy patient with a low WBC count, a low
platelet count and a hemoglobin measurement of 5.6 g would indicate the need for further teaching?
a. ―My lips are dry an d cracking. I need some lubricant‖
b. ―My husband and I have been using vaginal lubrication before my intercourse‖
c. ―I check my mouth and teeth after each meal‖
d. “I’ve been very constipated and need an enema”

84. Patients undergoing surgery display different levels of anxiety. This is researchable. At present, it has
been found out that music can decreases anxiety. What other factors can reduce anxiety that is currently
done among postoperative cases?
a. pre-anesthetic drugs
b. pre-operative visit
c. shower prior to surgery
d. presence of any members of the family

85. A heavily researched topic in infection control is about the single most important procedure for
preventing hospital-acquired infections. What is this procedure called?
a. handwashing
b. use of scrub suite
c. use of facemask
d. brain washing

86. A most critical strategy in nursing communication is:
a. non-verbal communication
b. giving stereotyped comments
c. verbal communication
d. active listening

87. 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
b. 30 minutes
c. 15 minutes
d. 20 minutes

88. Mr. K, age 13, is diagnosed with chronic bronchitis. He is very dyspneic and must sit up to breath. An
abnormal condition in which there is discomfort in breathing in any bed or sitting position is:
a. Cheyne-stokes
b. orthopnea
c. eupnea
d. dyspnea

89. The nurse recognizes that the MOST common causative organism in pyelonephritis is:
a. E.Coli
b. Klebsiella
c. Candida Albicans
d. Pseudomonas

90. Mr. WT is cleaning the garage and splashes a chemical to his eyes. The initial priority care following
the chemical burn is to:
a. irrigate with normal saline for 1 to 15 minutes
b. transport to a physician immediately
c. irrigate with water for 15 minutes or longer
d. cover the eyes with a sterile gauze

91. Licensed nurses from foreign countries can practice nursing in the Philippines in the following
condition:
a. employed in state colleges and universities
b. special projects with hospitals with a fixed fee
c. employees by private hospitals
d. medical mission whose services are free

92. A patient diagnosed with breast cancer has been offered the treatment choices of breast conservation
surgery with radiation or a modified radical mastectomy. When questioned by the patient about these
options, the nurse informs the patients that the lumpectomy with radiation.
A. Reduces the fear and anxiety that accompany the diagnosis and treatment of cancer
B. Has about the same 10 years survival rate as the modified radical mastectomy
C. Provides shorter treatment period with a fewer long term complications
D. Preserves the normal appearance and sensitivity of the breast

93. The patient has a right to information regarding the operation or other invasive procedure and potential
effects. This right is achieved through:
a. informed consent
b. preoperative visit
c. charting
d. doctor‘s rounds

94. 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

95. Mrs. XP underwent D and C for dysfunctional bleeding. What is inserted vaginally to prevent
postoperative bleeding?
a. perineal pad
b. vaginal packing
c. vaginal suppository
d. gelfoam

Situation – Mrs. Pichay is admitted to your ward. The MD ordered ―Prepare for
thoracentesis this pm to remove excess air from the pleural cavity.‖

96. Which of the following nursing responsibilities is essential in Mrs. Pichay who will
undergo thoracentesis?
A. Support and reassure client during the procedure
B. Ensure that informed consent has been signed
C. Determine if client has allergic reaction to local anesthesia
D. Ascertain if chest x-rays and other tests have been prescribed and
completed
97. Mrs. Pichay who is for thoracentesis is assigned by the nurse to which of the following
positions?
A. Trendelenburg position
B. Supine position
C. Dorsal Recumbent position
D. Orthopneic position
98. During thoracentesis, which of the following nursing intervention will be most crucial?
A. Place patient in a quiet and cool room
B. Maintain strict aseptic technique
C. Advice patient to sit perfectly still during needle insertion until it has
been withdrawn from the chest
D. Apply pressure over the puncture site as soon as the needle is withdrawn

99. To prevent leakage of fluid in the thoracic cavity, how will you position the client after
thoracentesis?
A. Place flat in bed
B. Turn on the unaffected side
C. Turn on the affected side
D. On bed rest

100. Chest x-ray was ordered after thoracentesis. When your client asks what is the reason
for another chest x-ray, you will explain:
A. to rule out pneumothorax
B. to rule out any possible perforation
C. to decongest
D. to rule out any foreign body

Situation – Ensuring safety is one of your most important responsibilities. You will need to provide
instructions and information to your clients to prevent complications.

1. Randy has chest tubes attached to a pleural drainage system. When caring for him you should:
A. empty the drainage system at the end of the shift
B. clamp the chest tube when suctioning
C. palpate the surrounding areas for crepitus
D. change the dressing daily using aseptic techniques

2. Fanny, came in from PACU after pelvic surgery. As Fanny‘s nurse you know that the sign that would be
indicative of a developing thrombophlebitis would be:
A. a tender, painful area on the leg
B. a pitting edema of the ankle
C. a reddened area at the ankle
D. pruritus on the calf and ankle

3. To prevent recurrent attacks on Terry who has acute glumerulonephritis, you should instruct her to:
A. seek early treatment for respiratory infections
B. take showers instead of tub bath
C. continue to take the same restrictions on fluid intake
D. avoid situations that involve physical activity

4. Herbert had a laryngectomy and he is now for discharge. He verbalized his concern regarding his
laryngectomy tube being dislodged. What should you teach him first?
A. Recognize that prompt closure of the tracheal opening may occur
B. Keep calm because there is no immediate emergency
C. Reinsert another tubing immediately
D. Notify the physician at once

5. When caring for Larry after an exploratory chest surgery and pneumonectomy, yourpriority would be
to maintain:
A. supplementary oxygen
B. ventilation exchange

C. chest tube drainage
D. blood replacement

Situation – As a nurse you need to anticipate the occurrence of complications of stroke so that life
threatening situations can be prevented.

6. Wendy is admitted to the hospital with signs and symptoms of stroke. Her Glasgow Coma Scale is 6 on
admission. A central venous catheter was inserted an I.V. infusion was started. As a nurse assigned to
Wendy what will be your priority goal?
A. Prevent skin breakdown
B. Preserve muscle function
C. Promote urinary elimination
D. Maintain a patent airway

7. Knowing that for a comatose patient hearing is the last sense to be lost, as Judy‘s nurse, what should
you do?
A. Tell her family that probably she can‘t hear them
B. Talk loudly so that Wendy can hear you
C. Tell her family who are in the room not to talk
D. Speak softly then hold her hands gently

8. Which among the following interventions should you consider as the highest priority when caring for
June who has hemiparesis secondary to stroke?
A. Place June on an upright lateral position
B. Perform range of motion exercises
C. Apply antiembolic stockings
D. Use hand rolls or pillows for support

9. Ivy, age 40, was admitted to the hospital with a severe headache, stiff neck and photophobia. She was
diagnosed with a subarachnoid hemorrhage secondary to ruptured aneurysm. While waiting for surgery,
you can provide a therapeutic environment by doing which of the following?
A. honoring her request for a television
B. placing her bed near the window
C. dimming the light in her room
D. allowing the family unrestricted visiting privileges

10. When performing a neurologic assessment on Walter, you find that his pupils are fixed and dilated.
This indicated that he:
A. probably has meningitis
B. is going to be blind because of trauma
C. is permanently paralyzed
D. has received a significant brain injury

Situation – With the improvement in life expectancies and the emphasis in the quality of life it is important
to provide quality care to our older patients. There are frequently encountered situations and issues
relevant to the older patients.

11. During a meal a client with hepatitis B dislodge her IV line and bleeds on the surface of the over-the-
bed table. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with:
A. Alcohol
B. Acetone
C. Ammonia
D. Bleach

12. Nino is being treated with radiation therapy. What would be included in the plan of care to minimize
skin damage from the radiation therapy?
A. Cover the areas with thick clothing materials
B. Apply a heating pad to the site
C. Wash skin with water after the therapy
D. Avoid applying creams and powders to the area

13. You are assigned to the following patients. Which of the following patients is most at risk for metabolic
alkalosis?
A. Grace, 30 years old post surgical patient who has continuous nasogastric suction
B. Rachel, 55 year old who has just experienced a stroke
C. Helen, 70 year old with altered level of consciousness who is unable to access water freely.
D. Mary Jane a 2 year old infant receiving isotonic sodium chloride IV solution

14. Studies have shown that the highest incidence of Hodgkin‘s disease is common among young adults.
Juana, 20 years old approaches you and tells you ―I am worried about the mass on my neck. What should
you do as a nurse?
A. Tell her there is nothing to worry if it does not bother her
B. Palpate Juana‘s neck and explain the possible cause
C. Tell her Hodgkin‘s disease is common among young adults like her
D. Tell her to see a doctor

15. As a nurse, you accidentally administer 40mg of Propanolol (Inderal) to a client instead of 10mg
although the client exhibits no adverse reactions to the larger dose, you should:
A. Complete an incident report
B. Call the hospital attorney
C. Inform the client‘s family
D. Do nothing because the client‘s condition is stable

Situation – Radiation therapy is another modality of cancer management. With emphasis on
multidisciplinary management you have important responsibilities as a nurse

16. Albert is receiving external radiation therapy and he complains of fatigue and malaise. Which of the
following nursing interventions would be most helpful for Albert?
A. Tell him that sometimes these feelings can be psychogenic
B. Refer him to the physician
C. Reassures him that these feelings are normal
D. Help him plan his activities

17. Immediately following the radiation teletherapy, Albert is:
A. Considered radioactive fro 24hours
B. Given a complete bath
C. Placed on isolation for 6 hours
D. Free from Radiation

18. Albert is admitted with a radiation induced thrombocytopenia. As a nurse you should observe the
following symptoms:
A. Petechiae, ecchymosis, epistaxis
B. Weakness, easy fatigability, pallor
C. Headache, dizziness, blurred vision
D. Severe sore throat, bacteremia, hepatomegaly

19. What nursing diagnosis should be the highest priority?
A. Knowledge deficit regarding thrombocytopenia precautions
B. Activity intolerance
C. Impaired tissue integrity
D. Ineffective tissue perfusion, peripheral, cerebral, cardiovascular, gastrointestinal, renal

20. What intervention should you include in your care plan?
A. Inspect his skin for petechiae, bruising, GI bleeding regularly
B. Place Albert on strict isolation precaution
C. Provide rest in between activities
D. Administer antipyretics if his temperature exceeds 38 C

Situation - You are assigned to take care of four patients with different conditions.

21. KJ, who is to have a kidney transplant asks you how long will he take azathioprime (Imuran),
cyclosporine and prednisone? You recognized that KJ understood the teaching when he states, ―I must
take these medications:
A. until the anastomosis heals
B. during the preoperative period
C. until the supply is over
D. for the rest of my life

22. After the kidney transplant, you must observe KJ for signs of rejection which includes:
A. fever and weight gain
B. hematuria and seizure
C. polyuria and jaundice
D. moon face and muscle atrophy

23. FB, 28 years old with chronic renal disease plans to receive a kidney transplant. Recently, FB was
told by his physician that he was a poor candidate for transplant because of his hypertension and
diabetes mellitus. Now, FB tells you ―I want to go off dialysis, I‘d rather not live than to be in this treatment
the rest of my life‖. How would you respond to him?
A. leave the room and allow him to collect his thoughts
B. tell FB that ― We all have days when we don‘t feel like going on‖
C. tell FB that ― Treatments are only three times a week, you can live with that‖
D. take a sit next to him and sit quietly

24. DS signed a consent form for participation in a clinical trial for implantable cardioverter defibrillators.
Which statement by DS indicates the need for further teaching before true informed consent can be
obtained?
A. ―a wire from the generator will be attached to my heart‖
B. ―the physician will make a small incision in my chest wall and place the generator there‖
C. “I wonder if there is another way to protect these bad rhythms”
D. ―this implanted defibrillator will protect me from those bad rhythms my heart goes into‖

25. KP is participating in a cardiac study in which his physician is directly involved. Which statement by
KP indicates a lack of understanding about his rights as a research study participant?
A. ―My confidentiality will not be compromised in this study‖
B. ― I understand the risk associated in this study‖
C. ―I can withdraw from the study anytime‖
D. “ I’ll have to find a new physician if I don’t complete this study”

Situation - Foot care among patients with peripheral vascular problems is very important.

26. When teaching a client with peripheral vascular disease about foot care, you should include which
instructions:
A. avoid wearing canvas shoes
B. avoid using a nail clipper to cut toe nails
C. avoid use of cornstarch on the foot
D. avoid wearing cotton socks

27. FT, who has no known history of peripheral vascular disease, comes to the emergency room
complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses,
paresthesia and a mottled, cyanotic, cold, cadaverous left calf. While the physician determines the
appropriate management, you should:
A. shave the affected leg in anticipation of surgery
B. place a healing pad around the calf
C. keep the affected leg level or slightly dependent
D. elevate the affected calf as high as possible

28. Peripheral neuropathies primarily affect:
A. sensory functions
B. vascular functions
C. optic functions
D. motor functions

29. Peripheral neuropathy can BEST be controlled by:
A. good glucose control
B. steroid therapy
C. vitamin supplement
D. nothing, there is no slowing the process

30. In addition to clients with diabetes mellitus you must be aware that acute hypoglycemia can also
develop in a client with:
A. hypertension
B. hyperthyroidism
C. liver disease
D. diabetes insipidus

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.

31. 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
B. 1 hour
C. 4 hours
D. 2 hours

32. 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

33. 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

34. WQ is undergoing blood transfusions of the first unit. The EARLIEST signs of transfusion reactions
are:
A. oliguria and jaundice
B. urticaria and wheezing
C. hypertension and flushing
D. headache, chills, fever

35. 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

Situation - The kidneys have very important excretory, metabolic, erythropoietic functions. Any disruptions
in the kidney‘s functions can cause disease. As a nurse it is important that you understand the rationale
behind the treatment regimen used.

36. PL, who is in acute renal failure, is admitted to the Nephrology Unit. The period of oliguria usually
lasts for about 10 days. Which assessment parameter for kidney function will you use during the oliguric
phase?
A. urine output directly related to the amount of IV fluid infused
B. urine output is less than 400 ml/24 hours
C. urine output of 30-60 ml/hour
D. no urine output, kidneys in a state of suspension

37. During the shock phase, what is the effect of the rennin-aldosterone-angiotensin system on renal
function?
A. increased urine output, increased absorption of sodium and water
B. decreased urine output, decreased absorption of sodium and water
C. increased urine output, decreased absorption of sodium and water
D. decreased urine output, increased absorption of sodium and water

38. As you are caring for PL who has acute renal failure, one of the collaborative interventions you are
expected to do is to start hypertonic glucose with insulin infusion and sodium bicarbonate to treat:
A. hyperkalemia
B. hypercalcemia
C. hypokalemia
D. hypernatremia

39. BN, 40 year old with chronic renal failure. An arteriovenous fistula was created for hemodialysis in his
left arm. What diet instructions will you need to reinforce prior to his discharge?
A. drink plenty of water
B. restrict your salt intake
C. monitor your fruit intake and eat plenty of bananas
D. be sure to eat meat every meal

40. BN, is also advised not to use salt substitute in the diet because:
A. salt substitute contain potassium which must be limited to prevent arrhythmias
B. limiting salt substitutes in the diet prevents a buildup of waste products in the blood
C. fluid retention is enhanced when salt substitutes are included in the diet
D. a substance in the salt substitute interferes with fluid transfer across the capillary membrane

Situation – With the improvement in life expectancies and the emphasis in the quality of life it is
important to provide quality care to our older patients. There are frequently encountered situations and
issues relevant to the older patients.

41. Hypoxia may occur in the older patients because of which of the following
physiologic changes associated with aging.
A. Ineffective airway clearance
B. Decreased alveolar surfaced area
C. Decreased anterior-posterior chest diameter
D. Hyperventilation

42. The older patient is at higher risk for incontinence because of:
A. dilated urethra
B. increased glomerular filtration rate
C. diuretic use
D. decreased bladder capacity

43. Merle, age 86, is complaining of dizziness when she stands up. This may
indicate:
A. dementia
B. a visual problem
C. functional decline
D. drug toxicity

44. Cardiac ischemia in an older patient usually produces:
A. ST-T wave changes
B. Very high creatinine kinase level
C. Chest pain radiating to the left arm
D. Acute confusion

45. The most dependable sign of infection in the older patient is:
A. change in mental status
B. fever
C. pain
D. decreased breath sounds with crackles

Situation – A ―disaster‖ is a large-scale emergency—even a small emergency left unmanaged may turn
into a disaster. Disaster preparedness is crucial and is everybody‘s business. There are agencies that are
in charge of ensuring prompt response. Comprehensive Emergency Management (CEM) is an integrated
approach to the management of emergency programs and activities for all four emergency
phases (mitigation, preparedness, response, and recovery), for all types of emergencies and disasters
(natural, man-made, and attack) and for all levels of government and the private sector.

46. Which of the four phases of emergency management is defined as ―sustained action that reduces or
eliminates long-term risk to people and property from natural hazards and their effects.‖?
A. Recovery
B. Mitigation
C. Response
D. Preparedness

47. You are a community health nurse collaborating with the Red Cross and working with disaster relief
following a typhoon which flooded and devastated the whole province. Finding safe housing for survivors,
organizing support for the family, organizing counseling debriefing sessions and securing physical care
are the services you are involved with. To which type of prevention are these activities included:
A. Tertiary prevention
B. Primary prevention
C. Aggregate care prevention
D. Secondary prevention

48. During the disaster you see a victim with a green tag, you know that the person:
A. has injuries that are significant and require medical care but can wait hours with
threat to life or limb
B. has injuries that are life threatening but survival is good with minimal
intervention
C. indicates injuries that are extensive and chances of survival are unlikely even
with definitive care
D. has injuries that are minor and treatment can be delayed from hours to
Days

49. The term given to a category of triage that refers to life threatening or potentially life threatening injury
or illness requiring immediate treatment:
A. Immediate
B. Emergent
C. Non-acute
D. Urgent

50. Which of the following terms refer to a process by which the individual receives education about
recognition of stress reaction and management strategies for handling stress which may be instituted
after a disaster?
A. Clinical incident stress management
B. Follow-up
C. Debfriefing
D. Defusion

Situation – As a member of the health and nursing team you have a crucial role to play in ensuring that
all the members participate actively is the various tasks agreed upon.

51. While eating his meal, Matthew accidentally dislodges his IV lines and bleeds. Blood oozes on the
surface of the over-bed table. It is most appropriate that you instruct the housekeeper to clean the table
with:
A. Acetone
B. Alcohol
C. Ammonia
D. Bleach

52. You are a member of the infection control team of the hospital. Based on a feedback during the
meeting of the committee there is an increased incidence of pseudomonas infection in the Burn Unit (3
out of 10 patients had positive blood and wound culture). What is your priority activity?
A. Establish policies for surveillance and monitoring
B. Do data gathering about the possible sources of infection (observation,
chart review, interview).
C. Assign point persons who can implement policies.
D. Meet with the nursing group working in the burn unit and discuss problem with
them.

53. Part of your responsibility as a member of the diabetes core group is to getreferrals from the various
wards regarding diabetic patients needing diabetes education. Prior to discharge today, 4 patients are
referred to you. How would you start prioritizing your activities?
A. Bring your diabetes teaching kit and start your session taking into consideration
their distance from your office
B. Contact the nurse in-charge and find out from her the reason for the referral
C. Determine their learning needs then prioritize
D. Involve the whole family in the teaching class

54. You have been designated as a member of the task force to plan activities for the Cancer
Consciousness Week. Your committee has 4 months to plan and implement the plan. You are assigned
to contact the various cancer support groups in your hospital. What will be your priority activity?
A. Find out if there is a budget for this activity
B. Clarify objectives of the activity with the task force before contacting the
support groups
C. Determine the VIPs and Celebrities who will be invited
D. Find out how many support groups there are in the hospital and get the contact
number of their president

55. You are invited to participate in the medical mission activity of your alumni association. In the planning
stage everybody is expected to identify what they can do during the medical mission and what resources
are needed. You thought it is also your chance to share what you can do for others. What will be
your most important role where you can demonstrate the impact of nursing in health?
A. Conduct health education on healthy life style
B. Be a triage nurse
C. Take the initial history and document findings
D. Act as a coordinator

Situation – One of the realities that we are confronted with is our mortality. It is important for us nurses
to be aware of how we view suffering, pain, illness, and even our death as well as its meaning. That way
we can help our patients cope with death and dying.

56. Irma is terminally ill, she speaks to you in confidence. You now feel that Irma‘s family could be helpful
if they knew what Irma has told to you. What should you do first?
A. Tell the physician who in turn could tell the family
B. Obtain Irma’s permission to share the information in the family
C. Tell Irma that she has to tell her family what she told you
D. Make an appointment to discuss the situation with the family

57. Ruby who has been told she has terminal cancer, turns away and refuses to respond to you. You
can best help her by:
A. Coming back periodically and indicating your availability if she
would like you to sit with her
B. Insisting that Ruby should talk with you because it is not good to keep
everything inside
C. Leaving her alone because she is uncooperative and unpleasant to be
with
D. Encouraging her to be physically active as possible

58. Leo, who is terminally ill and recognizes that he is in the process of losing everything and everybody
he loves, is depressed. Which of the following would best help him during his depression?
A. Arrange for visitors who might cheer him
B. Sit down and talk with him for a while
C. Encourage him to look at the brighter side of things
D. Sit silently with him

59. Which of the following statements would best indicate that Ruffy, who is dying, has accepted his
impending death?
A. “I’m ready to go.”
B. ―I have resigned myself to dying.‖
C. ―What‘s the use?‖
D. ―I‘m giving up‖

60. Marla, 90 years old has planned ahead for her death-philosophically, socially, financially and
emotionally. This is recognized as:
A. Acceptance that death is inevitable
B. Avoidance of the true situation
C. Denial with planning for continued life
D. Awareness that death will soon occur

Situation – Andrea is admitted to the ER following an assault where she was hit on the face and head.
She was brought to the ER by a police woman. Emergency measures were stated.

61. As Andrea‘s nurse, what will be your priority interventions?
A. Insert and intravenous catheter
B. Insert an oral or nasopharyngeal airway
C. Obtain arterial blood gases
D. Give 100% oxygen

62. Andrea‘s arterial blood gases respiratory acidosis. This most likely related to:
A. Partially obstructed airway
B. Ineffective breathing pattern
C. Head injury
D. Pain

63. Andrea loses consciousness. You should prepare for which of the following FIRST?
A. Placement of nasogastric tube
B. Placement of a second IV line
C. Endotracheal intubation or surgical airway placement
D. CT scan of head

64. Andrea‘s physician gives an order of Mannitol 0.25 g/kg IV bolus for increased ICP. This is given to:
A. Promote cerebral-tissue fluid movement
B. Promote renal perfusion
C. Correct acid-base imbalances
D. Enhance renal-excretion of drugs

65. As Andrea‘s nurse your goal is to prevent increased Intracranial Pressure (ICP). Which of the
following independent nursing interventions is NOT suited for her?
A. Do oropharyngeal suction every 15 minutes to prevent pulmonary aspiration?
B. Keep ahead of bed 30-35 degrees elevated
C. Maintain Andrea‘s head in straight alignment and prevent hip flexion
D. Prevent constipation and increases in intra-abdominal pressure

66. Andrea‘s respiration is described as waxing and waning. You know that this rhythm of respiration is
defined as:
A. Biot‘s
B. Kussmaul‘s
C. Cheyne Stokes
D. Eupnca

67. What do you call the triad of sign and symptoms seen in a client with increasing ICP?
A. Virchow‘s Triad
B. The Chinese triad
C. Cusching’s Triad
D. Charcot‘s Triad

68. Which of the following is true with the Cushing‘s Triad seen in head injuries?
A. Narrowing of Pulse Pressure, Cheyne strokes respiration, Tachycardia
B. Widening Pulse pressure, Irregular respiration, Bradycardia
C. Hypertension, Kussmaul‘s respiration, Tachycardia
D. Hypotension, Irregular respiration, Bradycardia

69. In a client with a Cheyne stokes respiration, which of the following is the most appropriate nursing
diagnosis?
A. Ineffective airway clearance
B. Ineffective breathing pattern
C. Impaired gas exchange
D. Activity Intolerance

70. You know the apnea is seen in client‘s with cheyne stoke respiration, APNEA is defined as:
A. Inability to breath in a supine position so the patient sits up in bed to breathe.
B. The patient is dead, the breathing stops
C. There is an absence of breathing for a period of time usually 15 seconds or more
D. A period of hypercapnea and hypoxia due to cessation of respiratory effort inspite of normal respiratory
functioning

Situation - Specific surgical interventions may be done when lung cancer is detected early. You have
important peri-operative responsibilities in caring for patients with lung cancer.

71. Horace underwent lobectomy. Which of following is the purpose of Horace‘s closed chest drainage
post lobectomy:
a. expansion of the remaining lung
b. facilitation of coughing
c. prevention of mediastinal shift
d. promotion of wound healing

72. Which of the following observations indicates that the closed chest drainage system is functioning
properly?
A. absence of bubbling in the suction-control bottle
B. the fluctuating movement of fluid in the long tube of the water-seal bottle during inspiration
C. intermittent bubbling through the long tube of the suction control bottle.
D. less than 25 ml drainage in the drainage bottle

73. Following lobectomy, you can BEST help Horace to reduce pain during the deep breathing and
coughing exercises by:
A. placing the patient on his/her operative side during exercises
B. splinting the patient’s chest with both hands during the exercises
C. administering the prescribed analgesic immediately prior to exercises
D. providing rest for 6 hours before exercises

74. Peter underwent pneumonectomy. During the immediate post operative period, deep tracheal suction
should be done with extreme caution because:
A. Peter will not be able to tolerate coughing
B. the tracheobronchial trees are dry
C. the remaining normal lung needs minimal stimulation
D. the bronchial suture line maybe traumatized

75. On which of the following positions should you place Peter who just underwent pneumonectomy?
A. Prone position
B. On his abdomen or on the side opposite the surgery
C. On his back or on the side of surgery
D. Any position is acceptable

Situation – Mang Felix, a 79 year old man who is brought to the Surgical Unit from PACU after a
transurethral resection. You are assigned to receive him. You noted that he has a 3-way indwelling
catheter for continuous fast dip bladder irrigation which is connected to a straight drainage.

76. Immediately after surgery, what would you expect his urine to be?
A. Light yellow
B. Amber
C. Bright red
D. Pinkish to red

77. The purpose of the continuous bladders irrigation is to:
A. Allow continuous monitoring of the fluid output status
B. Provide continuous flushing of clots and debris from the bladder
C. Allow for proper exchange of electrolytes
D. Ensure accurate monitoring of intake and output

78. Mang Felix informs you that he feels some discomfort on the hypogastric area and he has to void.
What will be your most appropriate action?
A. Remove his catheter then allow him to void his own
B. Irrigate his catheter
C. Tell him ―Go ahead and void. You have an indwelling catheter‖
D. Assess color and rate of outflow, if there is a change refer to urologist for possible irrigation

79. You decided to check on Mang Felix‘s IV fluid infusion. You noted in flow rate, pallor and coldness
around the insertion site. What is your assessment finding?
A. Phlebitis
B. Infiltration to subcutaneous tissue
C. Pyrogenic reaction
D. Air embolism

80. Knowing that proper documentation of assessment findings and interventions share important
responsibilities of the nurse during first post operative days, which of the following is the LEAST relevant
to document in the case of Mang Felix?
A. Chest pain and vital signs
B. Intravenous infusion rate
C. Amount, color and consistency of bladder irrigation drainage
D. Activities of daily living started

Situation – Many hospitals from bioethical review committees to ensure quality of life of patients. You are
invited by the nursing service departments to participate in their bioethical review committee. You are
expected to know the purpose and apply bioethical principles.

81. Which of the following is the purpose of the ethical review committee?
A. Promote implementation of general standards
B. Enhance health care providers liability
C. Increase individuals responsibility
D. Decrease Public security of health care provider‘s action

82. Daria who is admitted to the hospital with autoimmune thrombocytopenia and a platelet count of
20,000/ml develops epistaxis and melena. Treatment with corticosteroid and immunoglobulin has not
been successful. Her physician recommend splenectomy. Daria states ―I don‘t need surgery. This will go
away on its own‖.
A. Beneficence
B. Justice
C. Autonomy
D. Advocacy

83. Zorayda is terminally ill and is experiencing sever pain. She has bone and liver metastasis. She has
been on morphine for several months now. Zorayda is aware that they are having financial problems. She
decides to sign DNR form,. What ethical principle did Zorayda and her family utilize as basis for their
decision to sign a DNR.
A. Justice
B. Autonomy
C. Advocacy
D. Beneficence

84. Tricia, a staff nurse working in a cancer unit, is considered a role model not only by her colleagues but
also by her patients. She goes out of her way to help other. She is very active in their professional
organization and he practices what she teaches. What ethical principles is she practicing?
A. Beneficence
B. Justice
C. Autonomy
D. Advocacy

85. You are commuting to work riding the LRT. An older person collapsed and nobody seems to notice
her. The security guard tried to make ker sit down but she remained unconscious. You saw what
happened and you decided to help. With help, you brought the patient to the nearest hospital. You
learned later that woman was diabetic. She was on her way To the diabetes clinic to have fasting blood
sugar tested. She developed hypoglycemia. You were able to save a life. You felt good. What principle
was applied?
A. Advocacy
B. Beneficence
C. Justice
D. Autonomy


Situation – Ensuring safety before, during, and after a diagnostic procedure is an important responsibility
of the nurse

86. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the
following prior to the procedure?
A. Clenching his fist every 2 minutes
B. Breathing in and out through the nose with his mouth open
C. Tensing the shoulder muscles while lying on his back
D. Holding his breath periodically for 30 seconds

87. Following bronchoscopy, which of the following complains to Fernan should be noted as possible
complication:
A. Nausea and vomiting
B. Shortness of breath and laryngeal stridor
C. Blood tinged sputum and coughing
D. Sore throat and hoarseness

88. Immediately after bronchoscopy, you instructed Fernan to:
A. Exercise the neck muscles
B. Breathe deeply
C. Retrain from coughing and talking
D. Clear his throat

89. Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important
function during procedure is to:
A. Keep the sterile equipment from contamination
B. Assist the physician
C. open and close the three-way stopcock
D. Observe the patient’s vital signs

90. Right after thoracentesis, which of the following is most appropriate intervention?
A. Instruct the patient not to cough or deep breathe for two hours
B. Observe for symptoms of tightness of chest or bleeding
C. Place an ice pack to the puncture site
D. Remove the dressing to check for bleeding

Situation – Brain tumor, whether malignant or benign, has serious
management implications. As a nurse, you should be able to understand the consequences of the
disease and the treatment.

91. You are caring for Conrad who has a brained tumor and increased Intracranial Pressure (ICP). Which
intervention should you include in your plan to reduce ICP?

A. Administer bowel softener
B. Position Conrad with his head turned toward the side of the tumor
C. Provide sensory stimulation
D. Encourage coughing and deep breathing

92. Keeping Conrad‘s head and neck alignment results in:
A. increased inthrathoracic pressure
B. increased venous outflow
C. decreased venous outflow
D. increased intrabdominal pressure

93. Which of the following activities may increase intracranial pressure (ICP)?
A. Raising the head of the bed
B. Manual hyperventilation
C. Use of osmotic diuretics
D. Valsalva’s maneuver

94. After you asses Conrad, you suspected increased ICP. Your most appropriaterespiratory goal is to:
A. maintain partial pressure of arterial O2 (PaO2) above 80 mmHg
B. lower arterial pH
C. prevent respiratory alkalosis
D. promote CO2 elimination

95. Conrad underwent craniotomy. As his nurse, you know that drainage on a craniotomy dressing must
be measured and marked. Which findings should you report immediately to the surgeon?
A. Foul-smelling drainage
B. Yellowish drainage
C. Greenish drainage
D. Bloody drainage

Situation – As a nurse you are expected to be competent in utilizing the nursing process in the care of
your clients.

96. Getty is receiving chemotherapy for cancer. You review Getty‘s laboratory report and note that he has
anemia. To which nursing diagnosis should you give the highest priority?
A. Activity intolerance
B. Impaired oral mucous membrane
C. Impaired tissue perfusion, cerebral, cardiovascular, gastrointestinal
D. Impaired tissue integrity

97. An immediate objective for nursing care of an overweight mildly hypertensive client with ureteral colic
and hematuria is to decrease:
A. Hypertension
B. Pain
C. Hematuria
D. Weight

98. A difficult problem to deal with when caring for a patient with a partial thickness burns sustained 3
days ago is:
A. Alteration in body image
B. Maintenance of sterility
C. Frequent dressing change
D. Severe pain

99. Which outcome criterion would be appropriate for a client with a nursing diagnosis of effective airway
clearance?
A. Continued use of oxygen when necessary
B. Breath sound clear on auscultation
C. Respiratory rate of 24/min
D. Presence of congestion

100. Which assessment would be most supportive of the nursing diagnosis, impaired skin integrity related
to purulent drainage?
A. Heart rate of 88 beats/min
B. Dry and intact wound dressing
C. Oral temperature
D. Wound healing by first intention
NURSING PRACTICE V - NURSING CARE OF CLIENT WITH PHYSIOLOGICAL AND
PSYCHOSOCIAL ALTERATIONS (Part C)

Situation - Felisa has a ritualistic pattern of constantly washing her hands with soap and water followed
by rubbing alcohol.

1. This behavior is categorized as:
A. delusional
B. normal
C. neurotic
D. psychotic

2. A therapeutic intervention in this situation is:
A. avoid limits on her behavior to release her anxiety
B. call attention to her ritualistic pattern
C. provide alternative behaviors to deal with increased anxiety
D. ignore her behavior totally

3. The anxiety of Felisa is disabling and interferes with her job performance, interpersonal relationships
and other activities of daily living. To minimize such problems, she is likely to be given:
A. diazepam ( Valium )
B. haloperidol ( Haldol )
C. imipramine Hcl ( Tofranil )
D. chlorpromazine ( Thorazine )

4. Felisa understands the effects of her medicine when expresses:
A. ―I should watch out for signs of sore lips or sore throat‖
B. ―I might have constipation‖
C. ―I might feel changes in my body temperature‖
D. “ I should not drive or operate machines”

5. The level of anxiety that Felisa is experiencing is:
A. Panic
B. Severe
C. Mild
D. Moderate

Situation - The nurse recognizes the need to learn to cope with stress and change. She becomes
interested to practice natural ways to enhance well being.

6. Lifestyle modification begins with:
A. minimizing eating in fast food restaurants
B. having an exercise regimen to follow regularly
C. recognizing the impact of unhealthy habits
D. avoiding pollutants in the environment

7. All of these are the behavior intervention to stress management. EXCEPT:
A. guided imagery
B. pharmacotherapy
C. meditation
D. progressive muscle relaxation

8. Basic to progressive muscle relaxation is:
A. focusing on an image to relax
B relaxing muscles from tension
C. use of industrial equipment
D. stopping disturbing thoughts

9. Dietary practices are very important to the health of the Filipino family. The nurse needs to assess this
lifestyle because:
A. the nurse wants to change the eating patterns of the Filipino family
B. the nurse knows that being overweight is a major health hazard
C. the nurse wants to stop all the mainstream weight-loss diets
D. the nurse has to find out what people are eating

10. A young overweight adult smokes 5-10 sticks of cigarettes/day, ambitious, looks at life as challenging
and perfect and never considers change in his lifestyle, initially needs:
A. commitment
B. information
C. skills to attempt change
D. motivation

Situation - Bernie and John in their late 40‘s have been married for 20 years and at the peak of their
careers. Suddenly, Bernie discovered that her husband was falling in love with another woman. Shaken
by this situation, she started to have problems sleeping and could not function well at work and at the risk
of losing her job. John asked forgiveness and regret very much the hurt his wife was going through and
suffered guilt feelings:

11. Bernie and John are going through a:
A. situational crisis
B. developmental crisis
C. anticipated crisis
D. both developmental and situational crisis

12. All of these are characteristics of crisis EXCEPT:
A. a hazardous or threatening event occurs
B. it has a growth promoting potential
C. usual problem solving methods and coping mechanisms produce a
solution
D. anxiety or depression continue to increase

13. The nurse employs this approach in crisis intervention:
A. problem-solving
B. behavior modification
C. role-playing
D. nurse-patient relationship

14. Assessment data of the nurse include all the following EXCEPT:
A. coping mechanisms
B. situational support
C. perception of the event
D. repressed problems

15. The duration of crisis usually lasts several days and usually:
A. 2 – 4 weeks
B. 1 – 2 weeks
C. 1 – 2 months
D. 4 – 6 weeks

Situation - The community health nurse encounters special children in the community.

16. An individual with antisocial personality disorder lacks remorse, shame and guilt in going against the
norms of society. Psychodynamically, this defect in the personality reflects a disturbance of the:
A. ego
B. super ego
C. ego ideal
D. id

17. The nurse teaches parents about children‘s beginning concepts of right and wrong by emphasizing
child rearing attitude and practices during the:
A. school age
B. toddler age
C. infancy period
D. latency period

18. It is BEST for parents to teach healthy interpersonal relationships to their children by:
A. modeling to their children
B. encouraging their children to attend secondary school
C. encouraging their children at home to behave properly
D. teaching their children good manners and right conduct

19. 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


20. 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

Situation - As a professional, it is imperative that the nurse is accountable to oneself hence the
importance of personal and professional development.

21. Nurse: ― I feel personally involved with my client‘s problems‖ demonstrates:
A. counter transference
B. empathy
C. transference
D. sympathy

22. The nurse has achieved self-awareness in which of the following verbalizations?
A. every time people around me yell, I feel upset and withdrawn
B. when the patient yelled at me I became speechless
C. with the patients tone of voice and stare, I got reminded of how my father would be so angry
and this made me anxious
D. I thought it was rude for the patient to yell hence I kept quiet

23. An accepting attitude requires being:
A. aware of ones biases
B. tolerant of the faults of others
C. non judgmental
D. in control of tendency to blame

24. Self-awareness, knowledge and understanding of human behavior and communication skills define
what is essential in caring for every nurse to be able to demonstrate:
A. positive self-projection
B. assertiveness
C. therapeutic use of self
D. self-mastery

25. Considering that man is by nature social, it is BEST for the nurse to gain self-awareness by:
A. participating in intensive group experiences
B. individual psychotherapy
C. hypnotherapy
D. writing an autobiography for self introspection

Situation – Ninety year old Purita is confined at the medical unit for respiratory ailment for which a
breathing apparatus is prescribed for her to use while she sleeps. She refuses to wear continuously
though she full understands the medical indication for it:

26. Which of these ethical principles can guide the nurse in her action?
A. Beneficence
B. Fidelity
C. Autonomy
D. Nonmaleficence

27. Purita has six children who already adults. They differ in their opinion whether or not to allow their
mother to decide for her. The nurse would encourage family conference for:
A. The eldest child‘s opinion to be given priority.
B. Majority of the children to decide
C. Allowing the medical staff to decide in their behalf
D. Consensus building

28. Breathing treatments are to be given to Purita. In anticipation that Purita might refuse. Dinio, one of
the children requests that he be the one to sign the consent in behalf of their mother. The nurse explains
that Purita is rational in her thinking and which of this client‘s right must be regarding?
A. Right to refuse treatment
B. Right to privacy
C. Right to informed consent
D. Right of habeas consent

29. Which of these would be the nurse‘s priority following the treatment principle of least restrictive
alternative?
A. One on one staffing
B. Use of on site guard/watcher
C. Physical restraint
D. Seclusion

30. Purita talks about her joy in having responsible and accomplished children and recalls challenging
career as a lawyer. She is demonstrating a sense of:
A. Ego integrity
B. Industry
C. Generativity
D. Autonomy

Situation – The supervising nurse received report that a staff nurse is displaying frequent irritation, anger,
and even indifference toward clients and co-workers.

31. The initial action of the supervisor would be to:
A. Post guidelines on proper decorum of nurse in the bulletin board.
B. Write a memo of warning to the house
C. Request anecdotal report from the nurse‘s co-workers
D. Call the nurse for a one on one conference

32. The nurse expressed increasing feelings of dissatisfaction. The supervising nurse intervenes
therapeutically by taking the role of:
A. Administrator by relieving her of responsibilities
B. Therapist by delving into the nurse‘s internal conflict
C. Counselor by actively listening
D. Educator by reorienting her of role as a nurse.

33. Coupled with poor work performance, mental and physical fatigue and actual withdrawal from client
contact and nursing duties. The nurse can be said to be suffering from:
A. Psychotic anxiety
B. Staff burn-out
C. Personality maladjustment
D. Neurotic depression

34. A priority in the nurse‘s personal development would be to:
A. Address her physical well-being
B. Boost her self-confidence
C. Provide social support
D. Help her find value and meaning in her work

35. The most relevant professional program for her would be:
A. Assertiveness training
B. Stress management
C. Group dynamics and team building
D. Behavior modification


Situation – A nurse assigned in the neurologic unit is taking of clients with varying degrees of generative
disorders.

36. Mr. A with Myasthenia Gravis is having difficulty speaking. What communication strategies should the
nurse avoid when interacting with Mr. A?
A. Repeating what the client says for better understanding
B. Using paper and pencil in communicating with the client
C. Encouraging the client to speak slowly
D. Encouraging the client to speak quickly

37. When planning for nursing care for Mr. B who has Parkinson‘s disease. Which of the following goals
would be most appropriate?
A. To improve muscle tone
B. To start rehabilitation as much as possible
C. TO treat the disease
D. TO maintain optimal body function

38. For the past 10 years, Alma, 42 years old has had multiple sclerosis. Client with multiple sclerosis
experience many different symptoms. As part of the rehabilitation planned for Alma, the nurse suggested
therapy and hobbies to help her.
A. Strengthen muscle coordination
B. Establish routine
C. Develop perseverance and motivation
D. Establish good health habits

39. On his second day of hospitalization, Mr. Santos was unable to stand and is having difficulty
swallowing and talking. Which of the following is the priority of the nurse in assisting Mr. Santos?
A. To prevent bladder distention
B. To prevent decubitus ulcer
C. To prevent contracture
D. To prevent aspiration pneumonia

40. The wife of a seventy two year old man with a diagnosis of Alzheimer‘s disease begins to cry and tells
the nurse, ―I could not understand my husband anymore. He has changed drastically.‖ ―Which of the
following responses of the nurse is MOST appropriate?
A. The physician and the staff will make sure that your husband will be comfortable and safe here.
B. This has been a difficult time for you. Let us walk and find a quiet place where we can talk.
C. He will soon recover in his condition.
D. You need not worry, we are doing the best we could.

Situation – Annie has a morbid fear of heights. She asks the nurse what desensitization therapy is:

41. The accurate information of the nurse the goal of desensitization is:
A. To help the clients relax and progressively work up a list of anxiety provoking situations through
imagery
B. To provide corrective emotional experiences through a one-to-one intensive relationship
C. To help clients in a group therapy setting to take on specific roles and reenact in front of an
audience, situations in which interpersonal conflict is involved.
D. To help clients cope with their problems by learning behaviors that we are more functional
and be better equipped to face reality and make decisions.

42. It is essential in desensitization for the patient to:
A. Have a rapport with therapist
B. Use deep breathing or another relaxation technique
C. Assess one‘s self for the need of anxiolytic drug
D. Work through unresolved unconsciousness conflicts

43. In this level of anxiety, cognitive capacity diminishes. Focus becomes limited and client experiences
turned vision. Physical signs of anxiety become more pronounced.
A. Severe anxiety
B. Panic
C. Mild anxiety
D. Moderate anxiety

44. Anti-anxiety medication should be used with extreme caution because long term use can lead to.
A. Parkinsonian like syndrome
B. Hypertensive crisis
C. Hepatic failure
D. Risk of addiction

45. The nursing management of anxiety related with post traumatic stress disorder includes all of the
following EXCEPT:
A. Encourage participation in recreation or sport activities
B. Reassurance client’s safety while touching client
C. Speak in calm soothing voice
D. Remain with the client while fear level is high

Situation – The nurse is often met with the following situations when clients become angry and
aggressive individual, the nurse should:

46. 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

47. During the pre-interaction phase of the N-P relationship, the nurse recognizes thisnormal INITIAL
reaction to an assaultive or potentially assaultive person.
A. To remain and cope with the incident
B. Display empathy towards the patient
C. To call for help from other members of the team
D. To stay and fight or run away

48. 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‖

49. 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?‖

50. 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 – A vehicle hit some pedestrian while waiting for a bus ride. Some of the victims suffered injuries
in different part of the body. The victims were brought to the nearby hospital. One of the victims,
Josephine was confirmed to have a fractured left arm. While waiting for plaster cast to be applied,
Josephine appears to be anxious.

51. To reduce anxiety, the nurse teaches the procedure to the client, which of the following topics should
NOT be included in the teaching plan?
A. Leave the cast uncovered to promote drying
B. Bear weight on the plaster for one hour. A stockinet will be placed
over the left arm to be placed in the cast.
C. Handle hardening cast with palm of hands.
D. Trim and reshape finish cast with knife or cutter.

52. Cast was applied on Josephine‘s left arm. In assessing the neurovascular status of the client, which of
the following assessment findings should be reported to the physician?
A. Pain on the left arm
B. Swelling of the fingers
C. Skin abrasion on the edges of the plaster cast
D. Nail bed capillary refill time of 10 seconds

53. One of the victims a sixty year old woman sustained hip fracture. Prior to surgery, a Buck‘s extension
traction is to be applied. The rationale of traction is primarily based the understanding that Buck‘s
extension traction:
A. Reduces muscle spasms and helps to immobilize the fracture
B. Allows reduction of the fracture site for bone healing.
C. Secures the fracture site to prevent damage to the muscle tissues
D. Secures the fracture site for rigid immobilization

54. Philip was placed in skeletal leg traction with an overbed frame. He is not allowed to move from side
to side. Which of the following nursing interventions is useful in maintaining.
A. Assist the client by holding the trapeze and raising hips of the bed.
B. Check the apparatus that weights hang free and knots in the rope
are tied securely.
C. Suspend a trapeze within easy reach of the client
D. Support the affected extremity while the weights are removed.

55. To prevent complication when a child is in Buck‘s traction, the nurse should:
A. Clean the extremity and keep the skin dry
B. Assess any skin and circulatory disturbances
C. Clean the pin sites as necessary
D. Provide high fiber small meals.

56. The following concept are true EXCEPT:
A. Hostility is destructive
B. Frustration develops in response to unmet needs, wants and desire
C. Anger is incompatible with love
D. Aggression can be expressed in a constructive as well as a destructive
Manner

57. 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‖

58. Mrs. Dizon was visiting her son at the Psychiatry Ward. Which of the following items will the nurse
NOT allow to brought inside the ward?
A. String rosary bracelet
B. Box of cake
C. Bottle of coke
D. Rubber shoes

59. 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.

60. Which of the following must be considered while planning activities for the depressed client?
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

Situation - The nurse works with Mina to help her work through termination of the nurse-patient
relationship.

61. Preparation for termination of the nurse-patient relationship begins during the:
A. termination phase
B. working phase
C. pre-orientation phase
D. orientation phase

62. Mina‘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
B. plan for alternatives
C. conceptualize her problem
D. value and find meaning in experience

63. During the early part of the interaction, the nurse asked after a period of silence. ―Perhaps we would
talk about my leaving‖. The nurse utilized which communication technique:
A. encouraging
B. suggesting
C. focusing on client
D. understanding

64. The longest and the most productive phase of the NPR is:
A. Termination phase
B. Working phase
C. Pre-orientation phase
D. Orientation phase

65. The objection of the nurse-patient relationship is to provide an opportunity of the patient to:
A. clarify problems
B. develop insights
C. have a corrective emotional experience
D. develop interpersonal relationship

Situation - As a program manager, the mental health psychiatric nurse is tasked to provide general
patient management.

66. The nurse is aware that identifying the aspects of general patient management and identifying
interventions for meeting these basic needs are distinctions of:
A. psychotherapy
B. therapeutic milieu
C. pharmacotherapy
D. behavior therapy

67. In order to get active participation of the clients to carry out the objective of the program, it is BEST for
the nurse to conduct a/an:
A. community meeting
B. survey
C. observation
D. selective interview of patients

68. Through the nurse‘s role modeling of effective communication, the clients learned new ways of
dealing with authority figures. This gives the clients a venue to:
A. communicate
B. socialize
C. identify their problems
D. test new patterns of behavior

69. This element of communication facilitates evaluation of the program:
A. receiver
B. message
C. sender
D. feedback

70. The nurse‘s style of leadership in milieu therapy is:
A. autocratic
B. laissez-faire
C. democratic
D. benevolent

Situation - Loretta is a 28 years old, unemployed patient, admitted to the psychiatric unit with a diagnosis
of chronic undifferentiated schizophrenia. She described herself as the ―Virgin Mary‖ and her mission is to
propagate peace. She was observed laughing and talking to herself. Her thought processes were
profoundly disorganized. She was also fearful and suspicious of others.

71. Loretta‘s claim of being the ―Virgin Mary‖ is a/an:
A. imagination
B. delusion
C. hallucination
D. obsession

72. Her mission to propagate peace is:
A. a serious call for a need of transformation
B. an attempt to overcome low self-esteem
C. realistic and laudable
D. an advocacy that she can participate in

73. Which of this intervention would NOT be therapeutic in decreasing Loretta‘s anxiety?
A. joke about her thought to help her feel at ease
B. listen to her thoughts and feelings
C. simply accept
D. do not convince her that her perception is unreal

74. The nurse evaluates that Loretta‘s ready for a rehabilitation program when she:
A. approaches the nurse at frequent intervals
B. ceases to talk about “Virgin Mary”
C. goes to the coffee shop alone more often
D. carries a book ―The Purpose Driven Life‖

75. The nurse is leading a group meeting of patients to prepare them to be discharged. An appropriate
goal for the group members is to develop:
A. attitudes of society towards the mentally ill
B. skills for maintaining daily living
C. awareness of interpersonal patterns of interactions
D. insight into personal problems

Situation - A group of adult chronic schizophrenic patients were recommended to undergo social skills
training.

76. The following are the objectives of a social skills training program EXCEPT:
A. explore deep seated intrapsychic conflicts
B. practice skills in relating with people
C. help build self esteem and self confidence
D. develop and practice general coping skills

77. Social skills training is NOT primarily indicated for psychiatric patients who are:
A. in acute stage of illness
B. having difficulties starting and maintaining interpersonal relationships
C. having chronic episodes of stress and anxiety while interacting with others
D. experiencing recurrence of symptoms in front of particular people or among
people in general

78. The focus of the group interaction is ―here and now‖. An appropriate topic would be:
A. ways to celebrate Valentine‘s Day in February
B. how to spend the summer vacation
C. an unforgettable experience as a child
D. how to tell a joke

79. An appropriate technique for the participants to practice how to communicate effectively is through/a:
A. lecture
B. seminar
C. role play
D. psychodrama

80. Considering that it is BEST to learn by example, it is MOST practical to:
A. model good social skills throughout the session
B. relate successful past experiences
C. invite a resource person
D. watch a movie

Situation - Andy, 30 years old, was admitted to the Psychiatric Ward because of religious preoccupation,
deterioration in self-care and disturbed thoughts. He believes that he has committed a lot of sins. He is
threatened by people reaching out to him. His fasting for several days was not sufficient for him to feel
forgiven.

81. Andy is demonstrating:
A. religious delusion
B. delusion of grandeur
C. somatic delusion
D. delusion of being controlled

82. A delusion is:
A. psychomotor disturbance
B. mood disturbance
C. disturbance of thought
D. disturbance of perception

83. The nursing goal for Andy is to:
A. have him see a priest for confession
B. encourage him to pray to atone for his sins
C. help him develop a positive self image
D. socialize him with a group to keep him in touch with reality

84. As Andy talks about his sins that he believes make people look down upon him. It is BEST to:
A. agree with him and sympathize how sinful he has really been
B. explore the nature of his sins
C. explain that he is depreciating himself too much
D. acknowledge how he feels and focus on reality oriented topics

85. Which of the following drugs will most likely to decrease Andy‘s hallucination?
A. Chlorpromazine (Thorazine)
B. Chlomipramine (Anafranil)
C. Fluoxetine (Prozac)
D. Carbamazepine (Tegretol)

86. Which of this client situation appropriately illustrate horticulture therapy?
A. the therapist brings bongos, tambourine, and bells and encourages client
participation
B. Tommy, Karen, Jon and Pia play scrabble every night after supper
C. every afternoon, Vic goes in the garden where he work with plants,
seedlings, tree planting and watering them
D. Paul finds sketching relaxing and rewarding

87. The beginning professional nurse can do mental health counseling with the following clients EXCEPT:
A. Actively psychotic patients
B. Out of school adolescents
C. Parents with child rearing concerns
D. School children with behavioral problem

88. A professional responsibility of the mental health psychiatric nurse is to provide a safe and therapeutic
environment. This is BEST reflected in:
A. restraining patients who violates policies and do not follow schedule of
activities.
B. maintaining a closed door policy to prevent patients from absconding.
C. keeping a restrictive environment to prevent patients from becoming
assaultive and hostile
D. ensuring physical safety and maintaining therapeutic attitude
towards the patients

89. The foundation of the therapeutic process is the therapeutic relationship. What is the essential
component that the nurse must bring to the relationship?
A. humor
B. empathy
C. reframing
D. confrontation

90. Which of these people, the highest in population groups that would need priority mental health
therapy?
A. adults going through active skills
B. single elderly with no social support
C. young professionals entering the workplace
D. women preparing for overseas employment

Situation - The nurse observed that Marie, age 28 years old had not been participating in activity
therapies.

91. Which of the following remarks from the nursing attendants indicates a need for further teaching and
observation?
A. Marie made no response to an invitation to play
B. Marie preferred to sit at the bench and watch the ballgame
C. Marie is aloof and indifferent to co-patients
D. Marie read a book while other patients played a ballgame

92. Marie said ―I don‘t like to be a part of it. Look, they are being laughed at because they are singing and
acting like children‖. The nurse notes that in order for the activity therapy to be therapeutic:
A. the staff should decide solely what activities to be done and what rules
apply
B. patients should be allowed solely to decide what they want to do on their
own
C. ballgames should be limited to male patients only
D. age and needs of patient should be considered in the choice of
games

93. To encourage active participation among patients, it is BEST to plan activities they can engage in
through a:
A. one to one interaction
B. community meeting
C. checklist
D. feedback evaluation forum

94. In planning activities for the patients, it is essential to consider FOREMOST:
A. safety and security
B. variety and fun
C. novelty and creativity
D. excitement and challenge

95. Adults, ― singing and acting like children‖ is a form of:
A. displacement
B. regression
C. sublimation
D. compensation

Situation – Nursing care for the elderly

96. In planning care for a patient with Parkinson‘s disease, which of these nursing diagnoses should have
priority?
A. potential for injury
B. altered nutritional state
C. ineffective coping
D. altered mood state

97. The frequent use of the older client‘s name by the nurse is MOST effective in alleviating which of the
following responses to old age?
A. Loneliness
B. Suspicion
C. Grief
D. Confusion

98. An elderly who has lots of regrets, unhappy and miserable is experiencing:
A. Crisis
B. Despair
C. Loss
D. Ambivalence

99. The pre-morbid personality of a schizophrenic elderly client is:
A. Schizoid
B. Extrovert
C. Ambivert
D. Cycloid

100. Schizophrenia is a/an:
A. Anxiety disorder
B. Neurosis
C. Psychosis
D. Personality disoder