A.
Provide answer to the question of the client and include the relatives in the
SITUATIONAL
Situation 2 – Accuracy in the computation and administration of medications
ordered is extremely important when preparing medications.
6.A client is ordered to receive 20 mEq of Potassium Chloride. The bottle is
labeled KCl elixir 10 mEq/ml. How many ml should be given?
A.1.5 ml B. 2 ml C. 0.5 ml D. 1 ml
7.A client is ordered to receive Digoxin 0.325 mg OD. The stock is 0.25 mg
per tablet. How many tablets should be given to the client?
A.2 tablets B. 3 tablets C. 1.5 tablet D. ¾ tablet
8.Dilantin 5 mg/kg body weight is ordered to a client who weighs 50 lbs. The
drug is to be administered in 3 equal doses. The label reads Dilantin
suspension 125 mg/ml. How much medication should be administered to the
client?
A.1.8 ml B. 1.5 ml C. 1.0 ml D. 0.5 ml
9.A male client had exploratory laparotomy and has an order for Meperidine
Hydrochloride 50 mg IM every four hours PRN. The multiple dose vial is
labeled 50 mg/ml. What is the correct dose to be administered to this client
when he complains of pain?
A.0.5 ml B. 2 ml C. 1.0 ml D. 1.5 ml
10.An order is given to a young adult to receive 1 million units of Penicillin
IM. The stock on hand is Penicillin 500,000 units and the direction reads, add
1.3 ml to yield 2 ml. What is the correct amount to be administered?
A.3 ml B. 2 ml C. 4 ml D. 2.5 ml
Situation 6 – Nurses are expected to use critical thinking in the practice of
nursing.
26.While teaching colostomy clients to do ostomy care, the nurse does
problem solving when she:
A.Discusses diet and nutrition with the client with colostomy
B.Gives equal number of supplies to all the colostomy clients
C.Requests suppliers to give lowest price to her clients
D.Observes which among the supplies work best for the clients
27.The client tells the nurse he has less pain today that yesterday. The nurse
decides to give him Tylenol instead of Meperdine Hydrochloride (Demerol).
The nurse is using what step of the nursing process?
A.Planning C. Implementation
B. Nursing Diagnosis D. Assessment
28.Which of the following nursing diagnosis is appropriately written by the
nurse?
A.Knowledge deficit related to angiography
B.impaired gas exchange related to atelectasis
C.Acute pain related to hysterectomy
D.Need for low CHO diet related to altered nutrition
29.The nurse determines that her client has altered elimination. She identifies
the following as the possible causes for the nursing diagnosis EXCEPT?
A.Decreased mobility C. Reduced fluid intake
B.Hip replacement D. Low fiber diet
30.A nurse writing a nursing diagnosis after assessing his client. Which of the
following is the appropriate nursing diagnosis?
A.Chronic pain related to insufficient pain medication
B.Anxiety related to cardiac monitor
C.Using bedpan frequently as a result of altered elimination pattern
D.Pain related to difficulty ambulating
Situation 7 – The nurse is taking care of a client newly diagnosed with
asthma. The client tells the nurse that a relative with asthma has been
prescribed Salmotorol Xinaloate, along acting medication and wonders why
she has been prescribed. Salbutamol, a short acting drug.
31.To provide accurate information the nurse should do which of the following
activities?
A.Consult the attending physician regarding the medication prescribed
B.Refer to the head nurse the concern of the client
C.Ask the client what she knows about the action of both drugs
D.Collect the most relevant and best evidence to answer the question
32.As care the nurse conducts critical appraisal of the literature related to
client’s prescribed medication. which of the following key areas should be
addresses by the health care team to ensure relevance and transferability of the
evidence to client’s care?
A.Result of the study, validity of the result and facilitate the study report to the
client
B.Practicality and validity of the search materials to answer the clinical
question
C.Applicability and generality of the search materials that may benefit the
client
D.Search materials should provide related information that substantiate the
client’s question
33.On the basis of pieces of evidence from the literature search related to the
client’s prescribed medication, the nurse’s MOST appropriate intervention is
to:
discussion
B.Talk with the attending physician the result of the literature search
C.Call a meeting with the nursing staff for a presentation of literature search
D.Discuss plan of care and the client’s concern with the health care team
34.The nurse is ready to implement the decision of the health care team on the
prescribed medication to the client. Which of the following should be
considered?
1.integrate the evidence found from the literature search with the health care
provider
2.expertise in the clinical assessment of the client
3.available health care resources
4.preferences and values of the client
A.1, 2, 3, and 4 C. 2, 3, and 4
B.1 and 2 D. 1 and 4
35.The treatment plan has been implemented. Which of the following is the
MOST appropriate action based on clinical decision?
A.Ask the client what he feels about the treatment
B.Conduct physical assessment and gather more data
C.Evaluate how effective the clinical decision is with the client
D.Generate more information by doing literature search
Situation 8 – Nurse’s communication skills are often put to test when
interacting with clients assigned to them.
36.A 70 year old client is admitted to the hospital for difficulty of breathing
and chest pain. He is accompanied by his son who asks the nurse what he
should do about his father’s hearing problem. Which of the following
responses by the nurse reflects therapeutic communication?
A.“I will ask your father for more information”
B.“What kind of hearing problems does your father have?”
C.“Your father will be referred to a specialist after a hearing test is done.”
D.“Hearing problems occur as people get older.”
37.While conducting nursing rounds, the nurse found a 30 year old, post
mastectomy client lying on her side facing the wall. When the nurse
approached her, she says “leave me alone, I need rest.” The nurse responds by
saying:
A.“I understand you.” C.“You sound upset.”
B.“I will be back.” D.“Don’t worry you can cover up the loss.”
38.While waiting for three hours to be called in the doctor’s clinic, a client
suddenly shouts “Why is this taking so long? I have been waiting for several
hours and nobody attends to us?” What should be the initial response of the
nurse?
A.Approach client and tell her that there are other clients to be attended to
B.Instruct the client to be quiet and assure her that she will be attended to soon.
C.Talk to the client and determine her immediate needs
D.Pacify the client and send her to the adjacent room
39.A 26 year old mother of 8 month old twins brought one infant to the
doctor’s clinic for fever and cough. She tells the nurse, “I can’t handle this
anymore with other children to attend to, this is overwhelming for me.” Which
of the following is the best initial response by the nurse?
A.“You will survive this crisis, just like other mothers in similar situations.”
B.“I will refer you to the social services for assistance.”
C.“You should know what is best for the infant.”
D.What seems to be the problem? It must be tough having other children to
attend to.”
40.The day prior to surgery, a 40 year old client says to the nurse, “I’m
nervous. Is the doctor competent in this kind of surgery” How should the nurse
best respond?
A.“Several clients who have undergone similar surgery always recover.”
B.Do you want to talk with the client who has similar surgery and has fully
recovered?”
C.“You seem concerned about the surgery.”
D.“Your doctor is very competent”
Situation 9 – Urethral catheterization requires a physician’s order. Special
care and strict aseptic technique must be observed for clients with indwelling
catheter.
41.A day after the insertion of the urinary retention catheter, the client
complains of discomfort in the bladder and urinary meatus. The initial action
of the nurse would be to:
A.Establish patency of the catheter
B.Milk the catheter towards the collecting receptacle
C.Check the bladder of distended
D.Inform the head nurse
42.The nurse is preparing to irrigate the indwelling urinary catheter of the
client. As ordered by the physician, the client is to have closed intermittent
catheter irrigation. The nurse performs the procedure in the following order:
1.aspirate sterile solution into the syringe
2.using aseptic technique, put sterile solution in sterile graduated cup
3.clamp indwelling retention catheter
4.withdraw syringe, leave solution for around 20 minutes
5.slowly inject sterile irrigant into the catheter and bladder
6.remove the clam and allow irrigant to drain into the collection bottle/bag
A.2, 1, 3, 5, 4, 6 C. 2, 3, 1, 4, 5, 6
B.3, 2, 1, 4, 5, 6 D. 1, 2, 3, 4, 5, 6
43.When a client has a retention catheter, the nurse is expected to:
A.Clean the urinary meatus and adjacent skin periodically
B.Encourage liberal amount of fluid intake
C.Flush the catheter as needed
D.Perform perineal flushing as needed
44.An order to discontinue catheterization of the client was implemented. She
complains of difficulty in her first attempt to urinate. The nurse explains that
this is due to:
A.Attempt of the body to adjust to normal reflex mechanism
B.Fluid and electrolyte imbalance
C.Irritation of the urethra
D.Irritation of the urinary bladder
45.When considering the safety needs of a client with a urinary catheter, which
of the following should the nurse observe?
A.Keep a closed sterile drainage system
B.Irrigate the catheter daily
C. Keep the bag lower than the bed
D. Measure intake and output daily
Situation 10 – The nurse noted encrustations around the stoma of a client
with tracheostomy. The client is due for routine tracheostomy care.
46.The nurse informs the client about the procedure then prepares the
equipment needed. When cleaning the tracheostomy tube site, which of the
following should the nurse observe to reduce the transmission of
microorganisms?
A.Wash hands thoroughly
B.Use eye protection and mask
C.Wear clean gown
D.Wash hands, don clean disposable gloves and mask
47.In addition to observing appropriate infection control measures the nurse
should do which of the following interventions prior to the removal of the
inner cannula?
A.Open small sterile brush package
B.Suction tracheostomy prior to cleaning
C.Open sterile supplies as needed
D.Remove oxygen source
48.The nurse is correctly performing the removal of the inner cannula when
he/she:
A.Rinses the neck plate of the tracheostomy tube then pulling the inner
cannula gently in line with its curvature
B.Pulls gently the inner cannula clockwise
C.Unlocks inner cannula by turning counterclockwise and gently withdrawing
in line with its curvature
D.Picks up the inner cannula with glove that is considered sterile.
49.After thoroughly cleansing the lumen and the entire inner cannula in
hydrogen peroxide solution the nurse is now ready to return the cannula to the
tracheostomy site. To ensure that the cannula is in place the nurse should:
A.Replace the inner cannula following the curve of the tube, lock by rotating
the external ring clockwise until it clicks in place.
B.Insert the flange of the tube and lock it until it clicks into place
C.Secure the flange of the inner cannula to the outer cannula
D.Return the inner cannula, lock by rotating the external ring counterclockwise
until it clicks into place
50.The nurse is changing the tracheostomy ties of the client. The most
appropriate technique to follow when changing soiled tracheostomy ties is to:
A.Bring ties together on both sides of the neck and pull tight
B.Insert one end of tape on the other side of the tracheostomy from back to
front
C.Thread end of tie through trach flange then thread through slit in tie and pull
tight
D.Tie the two ends of the tape with square knot at the side of neck
Situation 11 – The nurse is taking care of clients who have varied nutritional
needs. The nurse should have adequate knowledge of nutrition and how it
promotes health, affects growth and development and healing of clients in any
setting.
51.In a health education class at the health center, the nurse informs the clients
that certain food substances are related to non-communicable diseases. An
example of this is:
A.Obstructive pulmonary disorder due to increased fast food intake, increased
calcium and salt intake, low fiber intake
B.Obesity linked to increased intake of processed/fast food high in fat, salt and
inadequate fiber
C.Hypertension linked to increased intake of caffeinated products, processed
food intake, artificial flavorings and refined sugars
D.Diabetes due to increased salt intake, increased processed food intake, low
fiber intake.
52.The nurse teaches healthy nutrition practices to clients to prevent or
decrease the incidence of non-communicable lifestyle related diseases. These
include the following, EXCEPT:
A.alcohol intake and smoking
B.Consume meat or dried beans
C.Use iodized salt but avoid excessive intake of salty food
D.Eating regularly of food from different food groups of normal growth
53.As a ___________ at surgery, a client has lost more than 20% of his body
weight. The nurse wants to ensure that the client’s nutritional needs are met at
home. The nurse should:
A.Provide the client a written recommendation of what food to eat using the
food pyramid guide
B.Refer the client to a nutritionist in the health center of the barangay
C.Suggest to the family that they buy a cookbook that will include the client’s
favorite food
D.Instruct the family to make a weekly menu plan and show it to the
community health nurse
54.The doctor orders clear liquid diet for a post surgery client. The food
allowed include which of the following?
A.Milk, coffee, fruit juice C. Tea, cola drinks, gelatin
B.Water, tea, ice cream D. Milk, gelatin, cream soup
55.A client practices Islam and his diet must consider his religious practices
and beliefs. You are aware that this client would avoid which of the following
food?
1.Shrimps and crabs 4. Pork products like bacon
2.Wine and alcoholic drinks 5. Caffeinated products like cola drinks
3.Fish with scales
A.2, 4, and 5 B. 1, 4, and 5 C. 3, 4, and 5 D. 1, 2, and 4
Situation 13- You are conducting a class on proper nutrition as part of health
promotion.
61.Part of your teaching plan that helps address nutrition problems in the
community include all EXCEPT:
A.building healthy nutrition related practices
B.aiming for ideal body weight in all age brackets
C.choosing food wisely focusing on food pyramid guide
D.eating small meals frequently
62.Through health education, the nurse disseminates information about
nutrition related problems that could lead to serious non-communicable
diseases (NCD). The nurse discourages this eating practice to avoid NCD:
A.Skipping meals then binging on favorite food
B.Eating single food diets for long periods
C.Increased salt and increased processed food intake
D.Early introduction of child to cow’s milk and solid food
63.The nurse observes that childhood is more common now. The frequent
cause of this is the Filipino parent’s belief that:
A.Cheese and hotdogs are good meals rich in protein
B.A fat child is healthy, a thin child is sickly
C.Fast food is nutritious and convenient
D.Colorful food has more nutritional value
64.In nutrition education, your targeted participants include all EXCEPT:
A.Food handlers C. Food service people
B.Young children D. Mothers
65.One mother asks the nurse “why eating food cooked in vegetable oil” is
considered healthy. The nurse’s most appropriate response is that:
A.Gravy has fat drippings and is very tasty
B.Vegetable oil is “safer” than animal oil
C.Food rich saturated fat is generally good
D.Vegetable oil increases energy intake and helps prevent vitamin A deficiency
Situation 14 – The nurse’s understanding of death as a natural part of man’s
life cycle allows her to help her clients.
66.A client, 37 years old, married and mother of two children ages ten (10) and
eight (8), was diagnosed with advanced metastatic breast cancer. She is
depressed and expressed concern about the welfare of her family. Which of the
following actions should the nurse plan to do first for a client who is
experiencing depression?
A.Provide recreational activities
B.Allow the client to spend time with her family
C.Assist the patient to express feelings, beliefs and values
D.Refer the client to the priest or minister
67.The nurse ensures that the client is treated with dignity and assists her in
determining her own physical, psychological and social priorities. Part of the
nurse’s challenge that should be incorporated in the plan of care is:
A.Focusing on the client’s needs
B.Assisting daily activities of daily living
C.Providing measures related to physical changes
D.Supporting the client’s will and hope
68.To provide a sense of dignity for the client, the nurse should aim for the
client to achieve which of the following?
A.Acceptance of the diagnosis
B.Hopefulness in cancer treatment
C.Manifestation of physical wellness during the treatment
D.Cooperation during the treatment
69.While the nurse is assisting the client in her care, the client starts to cry and
strikes her. The behavior that the client is manifesting best describes which of
the following stages of death and dying?
A.Bargaining B. Depression C. Anger D. Denial
70.When planning for the care of dying person, the essential elements that the
nurse should consider are the following EXCEPT?
A.Maintain the client’s confidentiality
B.Schedule time to be available with the client
C.Help in clarifying distorted pattern
D.Provide factual information to queries of client and families

Situation 15 – Bed rest is a therapeutic intervention that achieves beneficial

effect. However, prolonged bed rest can be counterproductive to a client’s
recovery. The inactivity imposed by bed rest may cause structural changes in
joints and shorten muscles. Moving, turning and positioning of clients are
essential aspects of nursing care.
71.A nurse is giving the 8:00AM medication to a client who happens to have
slid down the bed from the Fowler’s position. Which of the following
interventions is most effective when the nurse repositions the client?
A.Raise the head of the bed to the height of the center of gravity
B.Remove all pillows then place against the head of the bed
C.Ask the client to flex the hips and knees and position the feet for effective
pushing up
D.Adjust the head of the bed to a flat position or as low as the client can
tolerate
72.Using an overhead trapeze for repositioning client can be accomplished by
instructing the client to grasp the:
A.Overhead trapeze with one hand and push with the heels upward
B.Head of the bed with one hand and maneuvering for an upward movement
C.Head of the bed with one arm and the overhead trapeze with the other arm
then lift and pull upward
D.Overhead trapeze with both hands and lift and pull during the move
73.A client on bed rest is rolled to a lateral position by the nurse. The nurse is
negotiating the move correctly when he:
A.Positions himself at the midpart of the bed and places both hands at the back
of the client and roll client onto side.
B.Places one hand on the client’s far hip and the other on the client’s far
shoulder rock backward and roll onto side of the body facing him.
C.Assumes a broad stance with the foot nearest the bed placing his arms under
the client’s thighs and shoulder and roll client onto side
D.Supports the back and buttocks of the client and shifts his own weight from
the forward to the backward foot and roll onto his side.
74.A client with injured left is sitting on the bed preparing to transfer to a
wheelchair. The nurse is assisting the client and positions the wheelchair on
the:
A.Foot part of the bed C. Client’s right side
B.Head part of the bed D. Client’s left side
75.A client has difficulty walking and needs a wheelchair to facilitate
performance of daily activities. Anticipating the needs of the client, the nurse
should have the wheelchair ready by placing it at:
A.60-degree angle to the bed C. 90-degree angle to the bed
B.45-degree angle to the bed D. 30-degree angle to the bed

Situation 20 – The physician prescribed 1 liter of Dextrose 5% in Water to be

administered at 50ml per hour.
96.Considering the physician’s order, the intravenous infusion should last?
A.22 hours B. 16 hours C. 18 hours D. 20 hours
97.The intravenous infusion was started at 10:00am. When the nurse checked
the patient at 2:00pm, she noted the level of the solution to be 850 ml. How
much solution should have been infused at this time?
A.200 ml B. 150 mlC. 250 mlD. 100 ml
98.The nurse is analyzing the remaining fluid of 850 ml. Based from the
amount to be consumed at 50 ml/hr, the nurse assessed that the infusion is:
A.Running fast C. within the prescribed time
B.Delayed D. slightly ahead of time
99.Maintaining the prescribed flow rate of 50 ml/hr, in how many hours should
the remaining 850 ml of 5% Dextrose in Water be consumed?
A.17 hours B. 16 hours C. 18 hours D. 15
hours
100.At 10:00am, maintaining the prescribed flow rate of 50 ml/hr and
considering the remaining 850 ml, how many drops per minute should the
nurse regulate the IV infusion if the drop factor is 15 drops/ml?
A.20 drops/min C. 10 drops/min
B.16 drops/min D. 13 drops/min

GOOD LUCK AND GOD BLESS!!!