Situation 1 - Mr. Ibarra is assigned to the triage area and while on duty, he assesses the condition of Mrs.

Simon who
came in with asthma. She has difficulty breathing and her respiratory rate is 40 per minute. Mr. Ibarra is asked to inject the
client epinephrine 0.3mg subcutaneously

1. The indication for epinephrine injection for Mrs. Simon is to:

a. Reduce anaphylaxis
b. Relieve hypersensitivity to allergen
c. Relieve respiratory distress due to bronchial spasm
d. Restore client's cardiac rhythm

2. When preparing the epinephrine injection from an ampule, the nurse initially:
a. Taps the ampule at the top to allow fluid to flow to the base of the ampule
b. Checks expiration date of the medication ampule
c. Removes needle cap of syringe and pulls plunger to expel air
d. Breaks the neck of the ampule with a gauze wrapped around it

3. Mrs. Simon is obese. When administering a subcutaneous injection to an obese patient. It is best for the nurse to:
a. Inject needle at a 15 degree angle over the stretched skin of the client
b. Pinch skin at the injection site and use airlock technique
c. Pull skin of patient down to administer the drug in a Z track
d. Spread skin or pinch at the injection site and inject needle at a 45-90 degree angle

4. When preparing for a subcutaneous injection, the proper size of syringe and needle would be:
a. Syringe 3ml and needle gauge 21 to 23
b. Tuberculin syringe 1 ml with needle gauge 26 or 27
c. Syringe 2ml and needle gauge 22
d. Syringe l-3ml and needle gauge 25 to 27

5. The rationale for giving medications through the subcutaneous route is;
a. There are many alternative sites for subcutaneous injection
b. Absorption time of the medicine is slower
c. There are less pain receptors in this area
d. The medication can be injected while the client is in any position

Situation 2 - The use of massage and meditation to help decrease stress and pain have been strongly recommended
based on documented testimonials.

6. Martha wants to do a study on the 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

7. 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

8. 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

9. Martha does review of related literature for the purpose of:

a. Determine statistical treatment of data research
b. Orientation to what is already known or unknown
c. To identify if problem can be replicated
d. Answering the research question

10. 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

CORRECT ANSWER: B
RATIONALE: All are the client’s rights for being the subject in a research except option B.
The following are the basic human rights of research subjects:
 Right to informed consent
 The right to refuse and/or withdraw from participation
  Right to privacy
 Right to confidentiality or anonymity of data
 Right to be protected from harm
SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10 th Edition.pp.110-111

Situation 3 - 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,

11. 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
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

12. When documenting outcome of Richard's treatment, Mario should include the following in his recording EXCEPT:
a. Color, amount and consistent 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

13. 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 restriction and client's tolerance for lying flat

14. Mario prepares Richard for postural drainage and percussion. Which of the flowing is a special consideration
when doing the procedure?
a. Respiratory rate of 16 to 20 per minute
b. Client can tolerate sitting and lying position
c. Client has no signs of infection
d. Time of last food and fluid intake of the client

15. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the
procedure is;
a. Percussion uses only one hand white 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 4 - 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.

16. 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 white asking the client relevant questions

17. 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

18. 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

19. Mr. Regalado's lower extremities are swollen and shiny. He has pitting pedal edema. When taking care of Mr.
Regalado, which of the following intervention 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
 20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client for
discharge include all EXCEPT:
a. Teaching the factors that may trigger chest pain
b. Giving instructions about his medication regimen
c. Telling the patient to see the doctor for the final instruction
d. Proper recording of pertinent data

Situation 5 - Accurate computation prior to drug administration is a basic skill all nurses must have.

21. Rudolf is diagnosed with amoebiasis and is to receive 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 receive per
oral administration?
a. 1,000 mg tid
b. 500 mg tid
c. 1,500 mg tid
d. 250 mg tid

22. 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 Paulo prepare for each oral dose?
a. .5 ml
b. 1.25 ml
c. 2.5 ml
d. 1 ml

23. A client is ordered to take Lasix, a diuretic, to be taken orally daily. Which of the following is an appropriate
instruction by the nurse?
a.Report to the physician the effects of the medication on urination
b.Take the medication early in the morning
c. Take a full glass of water with the medication
d.Measure frequency of urination in 24 hours.

Situation 6 - Mrs. Seva, 32 years old, asks you about possible problems regarding her elimination now that she is in the
menopausal stage.

24. Instruction on health promotion regarding urinary elimination is important. Which would you include?
a. Hold urine, as long as she can before emptying the bladder to strengthen her sphincters muscles
b. If burning sensation is experienced while voiding, drink pineapple-juice
c. After urination, wipe from anal area up towards the pubis
d. Tell client to empty the bladder at each voiding

25. Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical changes
predispose her to constipation?
a. inhibition of the parasympathetic reflex
b. weakness of sphincter muscles of the anus
c. loss of tone of the smooth muscles of the colon
d. decreased ability to absorb fluids in the lower intestines

26. The nurse understands that one of these factors contributes to constipation:
a. excessive exercise
b. high fiber diet
c. no regular time for defecation daily
d. prolonged use of laxatives

27. Mrs. Seva talks about her being incontinent due to a prior experience of dribbling urine when laughing or
sneezing and when she has a full bladder. Your most appropriate .instruction would be to:
a. tell client to drink less fluids to avoid accidents
b. instruct client to start wearing thin adult diapers
c. ask the client to bring change of underwear "just in case"
d. teach client pelvic exercise to strengthen perineal muscles

28. Mrs. Seva asked for instructions for skin care for her mother who has urinary incontinence and is almost always
in bed. Your instruction would focus on prevention of skin irritation and breakdown by
a. Using thick diapers to absorb urine well
b. Drying the skin with baby powder to prevent or mask the smell of ammonia
c. Thorough washing, rinsing and drying of skin area that get wet with urine
d. Making sure that linen are smooth and dry at all times

Situation 7 - 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.

29. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues?
a. Carol with a tumor in the brain
b. Theresa with anemia
c. Sonny Boy with a fracture in the femur
d. Brigette with diarrhea

30. You noted from the lab exams in the chart of Mr. Santos that he has reduced oxygen in the blood. This
condition is called:
a. Cyanosis
b. Hypoxia
c. Hypoxemia
d. Anemia

31. You will do nasopharyngeal suctioning to 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 cheek
c. the distance from the tip of the nose to the tip of the ear lobe
d. eight to ten inches

32. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by:
a. Applying 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 inserted with gentle suction

33. Myrna has difficulty breathing when on her back and must sit upright in bed to breath, effectively and
comfortably. The nurse documents this condition as:
a. Apnea
b. Orthopnea
c. Dyspnea
d. Tachypnea

Situation 8 - You are assigned to screen for hypertension: Your task is to take blood pressure readings and you are
informed about avoiding the common mistakes in BP taking that lead to 'false or inaccurate blood pressure readings.

34. When taking blood pressure reading the cuff should be:
a. deflated fully then immediately start second reading for same client
b. deflated quickly after inflating up to 180 mmHg
c. large enough to wrap around upper arm of the adult client 1 cm above brachial artery
d. inflated to 30 mmHg above the estimated systolic BP based on palpation of radial or brachial artery

35. Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of death worldwide and
is a preventable disease. The primary cause of COPD is:
a. tobacco hack
b. bronchitis
c. asthma
d. cigarette smoking

36. In your health education class for clients with diabetes you teach, them the areas for control Diabetes
which include all EXCEPT:
a. regular physical activity
b. thorough knowledge of foot care
c. prevention of infection
d. proper nutrition

37. You teach your clients the difference between, Type I (IDDM) and Type II (NDDM) Diabetes.
Which of the following is true?
a. both types of diabetes mellitus clients are all prone to develop ketosis
b. Type II (NIDDM) is more common and is also preventable compared to Type I (IDDM) diabetes which is genetic in
etiology
c. Type I (IDDM) is characterized by fasting hyperglycemia
d. Type II (IDDM) is characterized by abnormal immune response

38. Lifestyle-related diseases in general share common risk factors. These are the following except
a. physical activity
b. smoking
c. genetics
d. nutrition

Situation 9 - Nurse Rivera witnesses a vehicular accident near the hospital where she works. She decides to get involved
and help the victims of the accident.

39. Her priority nursing action would be to:

a. Assess damage to property
b. Assist in the police investigation since she is a witness
c. Report the incident immediately to the local police authorities
d. Assess the extent of injuries incurred by the victims, of the accident
 40. Priority attention should be given to which of these clients?
a. Linda who shows severe anxiety due to trauma of the accident
b. Ryan who has chest injury, is pale and with difficulty of breathing
c. Noel who has lacerations on the arms with mild-bleeding
d. Andy whose left ankle swelled and has some abrasions

41. In the emergency room, Nurse Rivera is assigned to attend to the client with lacerations on the arms,
while assessing the extent of the wound the nurse observes that the wound is now starting to bleed profusely.
The most immediate nursing action would be to:
a. Apply antiseptic to prevent infection
b. Clean the wound vigorously of contaminants
c. Control and reduce bleeding of the wound
d. Bandage the wound and elevate the arm

42. The nurse applies pressure dressing on the bleeding site. This intervention is done to:
a. Reduce the need to change dressing frequently
b. Allow the pus to surface faster
c. Protect the wound from micro organisms in the air
d. Promote hemostasis

43. After the treatment, the client is sent home and asked to come back for follow-up care. Your responsibilities
when the client is to be discharged include the following EXCEPT:
a. Encouraging the client to go to the, outpatient clinic for follow up care
b. Accurate recording, of treatment done and instructions given to client
c. Instructing the client to see you after discharge for further assistance
d. Providing instructions regarding wound care

Situation 10 - While working in the clinic, a new client, Geline, 35 years old, arrives for her doctor's appointment. As the
clinic nurse, you are to assist the client fill up forms, gather data and make an assessment.

44. The nurse purpose of your initial nursing interview is to:

a. Record pertinent information in the client chart for health team to read
b. Assist the client find solutions to her health concerns
c. Understand her lifestyle, health needs and possible problems to develop a plan of care
d. Make nursing diagnoses for identified health problems

45. While interviewing Geline, she starts to moan and doubles up in pain, She tells you that this pain occurs
about an hour after taking black coffee without breakfast for a few weeks now. You will record this as follows:
a. Claims to have abdominal pains after intake of coffee unrelieved by analgesics
b. After drinking coffee, the client experienced severe abdominal pain
c. Client complained of intermittent abdominal pain an hour after drinking coffee
d. Client reported abdominal pain an hour after drinking black coffee for few weeks now

46. Geline tells you that she drinks black coffee frequently within the day to "have energy and be wide awake"
and she eats nothing for breakfast and eats strictly vegetable salads for lunch and dinner to lose weight.
She has lost weight during the past two weeks, in planning a healthy balanced diet with Geline, you will:
a. Start her off with a cleansing diet to free her body of toxins then change to a vegetarian, diet and drink
plenty of fluids
b. Plan a high protein, diet; low carbohydrate diet for her considering her favorite food
c. Instruct her to attend classes in nutrition to find food rich in complex carbohydrates to maintain daily
high energy level
d. Discuss with her the importance of eating a variety of food from the major food groups with plenty of fluids

47. Geline tells you that she drinks 4-5 cups of black coffee and diet cola drinks. She also smokes up to a
pack of cigarettes daily. She confesses that she is in her 2nd month of pregnancy but she does not want
to become fat that is why she limits her food intake. You warn or caution her about which of the following?
a. Caffeine products affect the central nervous system and may cause the mother to have
a "nervous breakdown"
b. Malnutrition and its possible effects on growth and development problems in the unborn fetus
c. Caffeine causes a stimulant effect on both the mother and the baby
d. Studies show conclusively that caffeine causes mental retardation

48. Your health education plan for Geline stresses proper diet for a pregnant woman and the prevention of
non-communicable diseases that are influenced by her lifestyle these include of the following EXCEPT:
a. Cardiovascular diseases
b. Cancer
c. Diabetes Mellitus
d. Osteoporosis

Situation 11 - Management of nurse practitioners is done by qualified nursing leaders who have had clinical experience
and management experience.

49. An example of a management function of a nurse is:

a. Teaching patient do breathing and coughing exercises
b. Preparing for a surprise party for a client
c. Performing nursing procedures for clients
d. Directing and evaluating the staff nurses

50. Your head nurse in the unit believes that the staff nurses are not capable of decision making so she makes
the decisions for everyone without consulting anybody. This type of leadership is:
a. Laissez faire leadership
b. Democratic leadership
c. Autocratic leadership
d. Managerial leadership

51. When the head nurse in your ward plots and approves your work schedules and directs your work,
she is demonstrating:
a. Responsibility
b. Delegation
c. Accountability
d. Authority

52. The following tasks can be safely delegated by a nurse to a non-nurse health worker EXCEPT:
a. Transfer a client from bed to chair
b. Change IV infusions
c. Irrigation of a nasogastric tube
d. Take vital signs

53. You made a mistake in giving the medicine to the wrong client. You notify the client's doctor and write an
incident report. You are demonstrating:
a. Responsibility
b. Accountability
c. Authority
d. Autocracy

Situation 12 - Mr. Dizon, 84 years old, is brought to the .Emergency Room for complaint of hypertension flushed face,
severe headache, and nausea. You are doing the initial assessment of vital signs.

54. You are to measure the client's initial blood pressure reading by doing all of the following EXCEPT:
a. Take the blood pressure reading on both arms for comparison
b. Listen to and identify the phases of Korotkoff's sounds
c. Pump the cuff up to around 50 mmHg above the point where the pulse is obliterated
d. Observe procedures for infection control

55. A pulse oximeter is attached to Mr. Dizon's finger to:

a. Determine if the client's hemoglobin level is low and if he needs blood transfusion
b. Check level of client's tissue perfusion
c. Measure the efficacy of the client's anti hypertensive medications
d. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops

56. After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an order of hourly
monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure
reading to be:
a. Inconsistent
b. low systolic and high diastolic pressure
c. higher than what the reading should be
d. lower than what the reading should be

57. Through the client's health history, you gather that Mr. Dizon smokes and drinks coffee. When taking the
blood pressure of a client who recently smoked or drank coffee, how long should be the nurse wait before
taking the client's blood pressure for accurate reading?
a. 15 minutes
b. 30 minutes
c. 1 hour
d. 5 minutes

58. While the client has the pulse oximeter on his fingertip, you notice that the sunlight is shining on the area
where the oximeter is. Your action will be to:
a. Set and turn on the alarm of the oximeter
b. Do nothing since there is no identified problem
c. Cover the fingertip sensor with a towel or bedsheet
d. Change the location of the sensor every four hours

Situation 13 - The nurse's understanding of ethico-legal responsibilities will guide his/her nursing practice.

59. The principles that -govern right and proper conducts of a person regarding life, biology and the health
professions is referred to as:
a. Morality
b. Religion
c. Values
d. Bioethics

60. The purpose of having nurses' code of ethics is:

a. Delineate the scope and areas of nursing practice
b. Identify nursing action recommended for specific healthcare situations
c. To help the public understand professional conduct, expected of nurses
d. To define the roles and functions of the health care giver, nurses, clients

61. Potassium chloride (KCL) was ordered by a physician. The nurse administered it by directive push.
The patient died instantly of ventricular fibrillation. She is liable for.
a.Negligence
b.Malpractice
c. Battery
d.Assault

62. You inform the patient about his rights which include the following EXCEPT:
a. Right to expect reasonable continuity of care
b. Right to consent to or decline to participate in research studies or experiments
c. Right to obtain information about another patient
d. Right to expect that the records about his care will be treated as confidential

63. The principle states that a person has unconditional worth and has the capacity to determine his own destiny.
a. Bioethics
b. Justice
c. Fidelity
d. Autonomy

Situation 14 - Your director of nursing wants to improve the quality of health care offered in the hospital. As a staff nurse
in that hospital you know that this entails quality assurance programs.

64. A legislative enactment that serves as a defense to malpractice is the Good Samaritan statute.
The following statements are correct, except:
a.It protects health care provides from civil liability that may be incurred in stopping to render aid at
the scene of an accident.
b.It also applies to hospital care given to a client as long it is of an emergency nature
c. Health care professionals may still be sued by an injured victim for gross negligence.
d.Health care provides should not charge the patient during an emergency if they want to be covered
by the statute.

65. Standards of nursing practice serve as guide for:

a.Nursing practice in the different fields of nursing
b.Proper nursing approaches and techniques
c. Safe nursing care and management
d.Evaluation of nursing cared rendered

66. You are taking care of critically ill client and the doctor in charge calls to order a DNR (do not resuscitate)
for the client. Which of the following is the appropriate action when getting DNR order over the phone?
a. Have the registered nurse, family spokesperson, nurse supervisor and doctor sign
b. Have two nurses validate the phone order, both nurses sign the order and the doctor should sign his
order within 24 hours.
c. Have the registered nurse, family and doctor sign the order
d. Have 1 nurse take the order and sign it and have the doctor sign it within 24 hours

67. To ensure the client safety before starting blood transfusion the following are needed before the procedure
can be done EXCEPT:
a. take baseline vital signs
b. blood should be warmed to room temperature for 30 minutes before blood transfusion is administered
c. have two nurses verify client identification, blood type, unit number and expiration date of blood
d. get a consent signed for blood transfusion

68. Part of standards of care has to do with the use of restraints. Which of the following statements is NOT true?
a. Doctor's order for restraints should be signed within 24 hours
b. Remove and reapply restraints every two hours
c. Check client's pulse, blood pressure and circulation every four hours
d. Offer food and toileting every two hours

Situation 15 - During the NUTRITION EDUCATION class discussion a 58 year old man, Mr. Bruno shows increased
interest.

69. 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 not patis or toyo
 70. 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

71. Which of the following behaviors by a client indicates to the nurse that learning in cognitive domain has
taken place?
a.Physically demonstrating how to cook low sodium dish
b.Actively demonstrating the new skill
c. Telling the nurse that he has accepted the illness and its effects on lifestyle
d.Explaining the need to have low sodium diet

72. The nurse determines that dietary teaching has been effective when a client states that which of the
following food items has the highest sodium content?
a. milk
b. fresh fruits
c. meats
d. chocolate pudding

73. The role of the health worker in health education is to:

a. report incidence of non-communicable disease 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 16 - You are assigned to take care of 10 patients during the morning shift. The endorsement includes the IV
infusion and medications for these clients.

74. Mr- Felipe, 36 years old is to be given 2700ml of D5RL to infuse for 18 hours starting at 8am.
At what rate should the IV fluid be flowing hourly?
a. 100 ml/hour
b. 210 ml/hour
c. 150 ml/hour
d. 90 ml/hour

75. Mr. Lagro is to receive 1 liter of D5LR to run for 12 hours. The drop factor of the IV infusion set is
10 drops per minute. Approximately, how many drops per minute should the IV is regulated?
a. 13-14 drops
b. 17-18 drops
c. 10-12 drops
d. 15-16 drops

76. You are to apply a transdermal patch of nitroglycerin to your client. The following important guidelines
to observe EXCEPT:
a. Apply to clean hairlines of the skin that are not subject to too 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 of your hand

77. 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 on the lacrimal duct
c. into the outer third of the upper conjunctival sac
d. from the inner canthus going towards the side of the eye

78. When applying eye ointment, the following guidelines apply EXCEPT:
a. squeeze about 2 cm of ointment and gently close but not squeeze eye
b. apply 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 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 17 - Nursing management is performing leadership functions of governance and decision-making within
organizations employing nurses.

79. The unit manager is meeting with the director of nursing for the unit manager’s yearly performance review.
The director of nursing states that the unit manager needs to improve leadership skills. In differentiating
leadership from management, the nurse manager recognizes that which of the following approaches will apply?
a. The manager works more one-on-one with staff
b. A leader seeks a higher position on an organizational chart
c. A good leader uses managerial principles
d. A manager is not required to use leadership principles
 80. 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

81. A staff nurse is responsible for the care of the assigned client from admission to discharge. When the
staff nurse is not on duty, others provide care based on instructions left by the staff nurse. Which type
of nursing assignment does this represent?
a.Case management
b.Team
c. Primary
d.Functional

82. 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

83. You are attending a certification program on cardiopulmonary resuscitation (CPR) offered and required by
the hospital employing you. This is;
a. professional course towards credits
b. in-service education
c. advance training
d. continuing education

Situation 18 - There are various developments in health education that the nurse should know about.

84. The nurse is preparing a client for a magnetic resonance imaging (MRI). Which of the following client
statements indicates to the nurse that teaching has been successful?
a. “The dye used in the test will turn my urine green for about 24 hours.”
b. “This procedure will take about 90 minutes to complete. There will be no discomfort.”
c. “I will be put to sleep for this procedure. I will return to my room in two hours.”
d. “The wires that will be attached to my head and chest will not cause me any pain.”

85. In preparing a teaching plan regarding colostomy irrigations, the nurse should include which of the following?
a.The colostomy needs to be irrigated at the same time every day
b.Irrigate the colostomy after meals to increase peristalsis
c. Insert the catheter about 10 inches into the stoma
d.The solution should be very warm to increase dilation and flow

86. Part of teaching client in health promotion is responsibility for one's health, when Danica states she need
to improve her nutritional status this means:
a. Goals and interventions to be followed by client are based on nurse's priorities
b. Goals and intervention developed by nurse and client should be approved by the doctor
c. Nurse will decide goals and, interventions needed to meet client goals
d. Client will decide the goals and interventions required to meet her goals

87. Nurse Beatrice is providing tertiary prevention to Mrs. De Villa. An example of tertiary prevention is:
a. Marriage counseling
b. Self-examination for breast cancer
c. Teaching complications of diabetes
d. Poison control

88. Mrs. Ostrea has a schedule for Pap smear. She has a strong family history of cervical cancer. This is an
example of:
a. tertiary prevention
b. secondary prevention
c. health screening
d. primary prevention

Situation 19 - Ronnie has a vehicular accident where he sustained injury to his left ankle. In the Emergency Room, you
notice how anxious he looks.

89. You establish rapport with him and to reduce his anxiety you initially
a. Take him to the radiology, section for X-ray of affected extremity
b. Identify yourself and state your purpose in being with the client
c. Talk to the physician for an order of Valium
d. Do inspection and palpation to check extent of his injuries

90. While doing your assessment, Ronnie asks you "Do I have a fracture? I don't want to have a cast."
The most appropriate nursing response would be:
a. "You have to have an X-ray first to know if you have a fracture."
b. "Why do you; sound so scared? It is just a cast and it's not painful"
c. "You seem to be concerned about being in a cast."
d. "Based on my assessment, there doesn't seem to be a fracture."

Situation 20 - You are taking care of Mrs. Leyba, 66 years old, who is terminally ill with ovarian cancer stage IV.

91. When caring for a dying client you will perform which of the following activities?
a. Encourage the client to reach optimal health
b. Assist client perform activities of daily living
c. Assist the client towards a peaceful death
d. Motivate client to gain independence

92. The client prepares for eventual death and discusses with the nurse and her family how she would like
her funeral to look like and what dress she will use. This client is in the stage of:
a. acceptance
b. resolution
c. denial
d. bargaining

Situation 21 - 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.

93. 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

94. 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

95. The nurse checks for placement of a nasogastric (NG) tube before beginning a tube feeding for a client.
Which of the following results would indicate to the nurse that the tube feeding can begin?
a. A small amount of white mucus is aspirated from the NG tube
b. The pH of the contents removed from the NG tube is 3
c. No bubbles are seen when the nurse inverts the NG tube in water
d. The client says he can feel the NG tube in the back of his throat

96. The nurse in the outpatient clinic assists with the application of a cast to the left arm of a five-year old girl.
After the cast is applied, the nurse should
a. petal the edges of the cast to prevent irritation
b. elevate the client’s left arm on two pillows
c. apply cool, humidified air to dry the cast
d. ask the client to move her fingers to maintain mobility

97. A nurse teaches a health class at the local library to a group of senior citizens. Which of the following
behaviors should the nurse emphasize to facilitate regular bowel elimination?
a.Avoid strenuous activity
b.Eat more foods with increased bulk
c. Decrease fluid intake to decrease urinary losses
d.Use oral laxatives so that a bowel pattern emerges

98. An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client
a. in semi-Fowler’s position
b. prone, with the head turned to the side
c. with the head of the bed elevated 45° and the neck extended
d. supine, with the head in the midline position

99. The nurse is reviewing procedures with the health care team. The nurse should intervene if an
RN staff member makes which of the following statements?
a.“It is my responsibility to ensure that the consent form has been signed and is attached to the patient’s chart.”
b.“It is my responsibility to witness the signature of the patient before surgery is performed.”
c. “It is my responsibility to explain the surgery and ask the patient to sign the consent form.”
d.“It is my responsibility to answer questions that the patient may have before surgery.”

100. For a client with a neurological disorder, which of the following nursing assessments will be MOST
helpful in determining subtle changes in the client’s level of consciousness?
a.Client posturing
b.Glasgow coma scale
c. Client thinking pattern
d.Occurrence of hallucinations
___________________________________________________________________________________
Situation 1 - Nurse Minette is an independent Nurse Practitioner following-up referred clients in their respective homes.
Here she handles a case of POSTPARTAL MOTHER AND FAMILY focusing on HOME CARE.

1. Nurse Minette needs to schedule a first home visit to OB client Leah, when is a first home-care visit typically
made?
a.Within 4 days after discharge
b.Within 24 hours after discharge
c. Within 1 hour after discharge
d.Within 1 week of discharge

2. Leah is developing constipation from being on bed rest, what measures would you suggest she take to help
prevent this?
a. Eat more frequent small meals instead of three large one daily
b. Walk for at least half an hour daily to stimulate peristalsis
c. Drink more milk, increased calcium intake prevents constipation
d. Drink eight full glasses of fluid such as water daily

3. If you were Minette, which of the following actions, would alert you that a new mother is entering a postpartal
at taking-hold phase?
a. She urges the baby to stay awake so that she can breast-feed him in her
b. She tells you she was in a lot of pain all during labor
c. She says that she has not selected a name for the baby as yet.
d. She sleeps as if exhausted from the effort of labor

4. At 6-week postpartum visit what should this postpartal mother's fundic height be?
a. Inverted and palpable at the cervix
b. Six fingerbreadths below the umbilicus
c. No longer palpable on her abdomen
d. One centimeter above the symphysis pubis

4. This postpartal mother wants to loose the weight she gained in pregnancy, so she is reluctant to increase
her caloric intake for breast-feeding. By how much should a lactating mother increase her caloric intake during
the first 6 months after birth?
a.350 cal/day
b.500 cal/day
c. 200 cal/day
d.1,000 cal/day

Situation 2 – Nurse Lisa manages her own Reproductive and Children’s Nursing Clinic in Sorsogon and necessarily she
attends to health conditions of mothers and children. The following questions pertains to the growing fetus.

5. Obstetrical client Marichu asks how much longer Nurse Lisa will refer to the baby inside her as an embryo.
What would be your best explanation?
a. Her baby will be a fetus as soon as the placenta forms
b. From the time of implantation until 5 to 8 weeks, the baby is an embryo
c. After the 20th week of pregnancy, the baby is called a zygote
d. This term is used during the time before fertilization

6. Marichu is worried that her baby will be born with a congenital heart disease. What assessment of a fetus
at birth is important to help detect congenital heart defect?
a. Determining that the color of the umbilical cord is not green
b. Assessing whether the umbilical cord has two arteries and one vein
c. Assessing whether the Wharton’s jelly of the cord has a pH higher than 7.2
d. Measuring the length of the cord to be certain that it is longer than 3 feet

7. Additionally, Nurse Lisa would gather more information about Marichu’s worry about what may threaten the
health of her baby. What would Nurse Lisa hope to find?
a. Has Marichu been overly anxious about something
b. Has Marichu suffered from any communicable/contagious disease at the time of her early stage of pregnancy
c. Has Marichu engage in sexual activity during the fetal development state of her child
d. Has Marichu engaged in any detrimental activities during the fetal development stage (e.g. smoking, drinking,
taking drugs, a bad fall, or attempts to terminate pregnancy.)

8. Marichu is scheduled to have an ultrasound examination. What instruction would you give her before her
examination?
a. You can have medicine for pain for any contraction caused by the test
b. Drink at least 3 glassess of fluid before the procedure
c. The intravenous fluid infused to dilate your uterus does not hurt the fetus
d. Void immediately before the procedure to reduce your bladder size

9. Marichu is scheduled to have an amniocentesis to test for fetal maturity. What instruction would you give
her before this procedure?
a. The x-ray used to reveal your fetus position has no long term effects
 b. The intravenous fluid infused to dilate your uterus does not hurt the fetus
c. No more amniotic fluid form afterward, which is why only a small amount is removed
d. Void immediately before the procedure to reduce your bladder size.

Situation 3 - 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.

11. Which of the following is the primary focus of community health nursing practice?
a.Cure of illnesses
b.Prevention of illness
c. Rehabilitation back to health
d.Promotion of health

12. 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

13. 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 arid 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

14. In community health nursing it is important to take into account the family health with an equally important
need to perform ocular inspection of the areas activities which are powerful elements of:
a.evaluation
b.assessment
c. implementation
d.planning

15. The initial step in the PLANNING process in order to engage in any nursing project or parties at the community
level involves:
a.goal-setting
b.monitoring
c. evaluation of data
d.provision of data

16. Transmission of HIV from an Infected Individual to another person occurs:

a.Most frequently in nurses with needle sticks
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

17. 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.Cephalopelvic disproportion

18. 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.Toxoplasmosia

19. 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

20. 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 cervical1 pain receptors
c. Prevent cervical lacerations
d. Stimulate uterine contractions
Situation 4 - 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.

21. 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 cannot 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

22. 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

23. Another client names Lilia is diagnosed as having endometriosis. This condition interferes with the
fertility because:
a. endometrial implants can block the fallopian tubes
b. the uterine cervix becomes inflamed and swollen
c. ovaries stop producing adequate estrogen
d. pressure on the pituitary leads to decreased FSH levels

24. Lilia is scheduled to have a hysterosalpingogram. 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

25. 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

Situation 5 - There are other important basic knowledge in the performance of our task as Community Health Nurse in
relation to IMMUNIZATION these include:

26. The correct temperature to store vaccines in a refrigerator is:

a.between -4 deg C and +8 deg C
b.between 2 deg C and +8 deg C
c. between -8 deg C and 0 deg C
d.between -8 deg C and +8 deg C

27. Which of the following vaccines is not done by intramuscular (IM) injection?
a.Measles vaccine
b.DPT
c.Hep B vaccines
d.DPT

28. According to the new EPI Routine Schedule of immunization, when is Hepa B vaccine first given?
a. 6 weeks
b. 9 months
c. 12 months
d. at birth

29. This is the vaccine needed before a child reaches one (1) year in order for him/her to qualify as a "fully
immunized child".
a. DPT
b. Measles
c. Hepatitis B
d. BCG

30. Which of the following dose of tetanus toxoid is given to the mother to protect her .infant from neonatal
tetanus and likewise provide 10 years protection for the mother?
a. Tetanus toxoid 3
b. Tetanus toxoid 2
c. Tetanus toxoid 1
d. Tetanus toxoid 4

Situation 6 - Records contain those comprehensive descriptions of patient's health conditions and needs and at the same
serve as evidences of every nurse's accountability in the care giving process. Nursing records normally differ from
institution to, institution nonetheless they follow similar patterns of .meeting needs for specifics, types of information. The
following pertains to documentation/records management.

31. This special form used when the patient is admitted to the unit. The nurse completes the information in this
records particularly his/her basic personal data, current illness, previous health history, health history of the
family, emotional profile, environmental history as well as physical assessment together with nursing diagnosis
on admission, what do you call this record?
a. Nursing Kardex
b. Nursing Health History and Assessment Worksheet
c. Medicine and Treatment Record
d. Discharge Summary

32. These, are sheets/forms which provide an efficient and time saving way to record information that must be
obtained repeatedly at regular and/or short intervals of time. This does not replace the progress notes;
instead this record of information on vital signs, intake and output, treatment, postoperative care, postpartum
care, and diabetic regimen, etc., this is used whenever specific measurements or observations are needed
to-be documented repeatedly. What is this?
a. Nursing Kardex
b. Graphic Flow sheets
c. Discharge Summary
d. Medicine and Treatment Record

33. These records show all medications and treatment provided on a repeated basis. What do you call this record?
a. Nursing Health History and Assessment Worksheet
b. Discharge Summary
c. Nursing Kardex
d. Medicine and Treatment Record

34. This flip-over card is usually kept in a portable file at the Nurses Station. It has 2-parts: the activity and
treatment section and a nursing care plan section. This carries information about basic demographic data,
primary medical diagnosis, current orders of the physician to be carried out by the nurse, written nursing
care plan, nursing orders, scheduled tests and procedures, safety precautions in-patient care and factors
related to daily living activities/ this record is used in the charge-of-shift reports or during the beside rounds
or walking rounds. What record is this?
a. Discharge Summary
b. Medicine and Treatment Record
c. Nursing Health History and Assessment Worksheet
d. Nursing Kardex

35. Most nurses regard this as conventional recording of the date, time and mode by which the patient leaves
a healthcare unit but this record includes importantly, directs of planning for discharge that starts soon
after the" person is admitted to a healthcare institution, it is accepted that collaboration or multidisciplinary
involvement (of all members of the health team) in discharge results in comprehensive care, what do
you call this?
a.Discharge Summary
b.Nursing Kardex
c. Medicine and Treatment Record
d.Nursing Health History and Assessment Worksheet

Situation 7 - Health instructions are essentially given to pregnant mothers.

36. 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

37. A woman who is 9 weeks 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 abortion
c. Inevitable abortion
d. Threatened abortion

38. In a big government hospital, Nurse Pura is taking care of a woman with a diagnosis of abruptio placenta.
What complication of this condition is of most concern to Nurse Pura?
a.Urinary tract infection
b.Pulmonary embolism
c. Hypocalcemia
d.Disseminated intravascular coagulation

39. Which of the following findings on a newly delivered woman’s chart would indicate she is risk for
 developing postpartum hemorrhage?
a.Post-term delivery
b.Epidural anesthesia
c. Grand multiparity
d.Premature rupture of membrane

40. Mrs. Hacienda Gracia 35 years old postpartum client is at risk of thrombophlebitis. Which of the following
nursing interventions decreases her chance 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 8 - Nurse Joanna works as an OB-Gyne Nurse and attends to several HIGH-RISK PREGNANCIES: Particularly
women with preexisting of Newly Acquired illness. The following conditions apply.

41. 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 gold 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

42. 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 the placenta and so does not affect a fetus

43. The cousin of Bernadette with sickle-cell anemia alerted Joanna that she may need further instruction on
prenatal care. Which 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 grown new red blood cells
c. I am careful to drink at least eight glasses of fluid everyday
d. I understand why folic acid is important for red cell formation

44. 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 salicylates toxicity
c. Newborns develop withdrawal headaches from salicylates
d. Salicylates can lead to increased maternal bleeding at childbirth

45. Bernadette received a laceration on her leg from her automotive 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 o f her fatigue
d. Healing is limited during pregnancy, so these will not heal until after birth

Situation 9 - Still in your self-managed Child Health Nursing Clinic, you encounter these cases pertaining to the CARE
OF CHILDREN WITH PULMONARY INFECTIONS.

46. Josie brought her 3-rmonths 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 bearing

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

48. Which of the following is the most important responsibility of a nurse in the prevention of necessary deaths
from pneumonia and other severe diseases?
a. Giving of antibiotics
b. Taking of the temperature of the sick child
c. Provision of Careful Assessment
d. Weighing of the sick child
 49. A child of 2 months is considered manifesting fast breathing if:
a. 50 breaths/min
b. below 50 breaths/min
c. 50 breaths/minute or more
d. 40 breaths/minute or more

50. Which of the following is the principal focus on 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 10 - You are working as a Pediatric Nurse in your own Child Health Nursing Clinic, the following cases pertain
to ASSESSMENT AND CARE of THE NEWBORN AT RISK conditions.

50. Theresa, a mother with a 2 year old daughter asks, "at what age can I be able to take the blood pressure
of my daughter as a routine procedure since hypertension is common in the family?" Your answer to this is:
a. At 2 years you may
b. As early as 1 year old
c. When she's 3- years old
d. When she's 6 years old?

52. You typically gag children to inspect the back of their throat. When is it important NOT to solicit a gag reflex?
a. when a girl has a geographic tongue
b. when a boy has a possible inguinal hernia
c. when a child has symptoms of epiglottitis
d. when children are under 5 years of age

53. Baby John was given a drug at birth to reverse the effects of a narcotic given to his mother in labor.
What drug is commonly used for this?
a. Naloxone (Narcan)
b. Morphine Sulfate
c. Sodium Chloride
d. Penicillin G

54. Why are small-for-gestational-age newborns at risks for difficulty maintaining body temperature?
a. They do not have as many fat stores as other infant's
b. They are more active than usual so throw off covers
c. Their skin is more susceptible to conduction of cold
d. They are preterm so are born relatively small in size

55. Baby John develops hyperbilirubinemia, what is a method used to treat hyperbilirubinemia in a newborn?
a. Keeping infants in a warm arid dark environment
b. Administration of a cardiovascular stimulant
c. Gentle exercise to stop muscle breakdown
d. Early feeding to speed passage of meconium

Situation 11 - You are the nurse in the Out-Patient-Department and during your shift you encountered multiple children's
condition. The following questions apply.

56. You assessed a child with visible severe wasting, he has:

a. edema
b.LBM
c. kwashiorkor
d.marasmus

57. Which of the following conditions is NOT true about contraindication to immunization?
a. do not give DPT2 or DPT3 to a child who has convulsions within 3 days of DPT1
b. do not give BCG if the child has known hepatitis .
c. do not give OPT to a child who has recurrent convulsion or active neurologic disease
d. do not give BCG if the child has known AIDS

58. Which of the following statements about immunization is NOT true?

a. A child with diarrhea who is due for OPV should receive the OPV and make extra dose on the next visit
b. There is no contraindication to immunization if the child is well enough to go home
c. There is no contraindication to immunization if the child is well enough to go home and a child should be
immunized in the health center before referrals are both correct
d. A child should be immunized in the center before referral

59. A child with visible severe wasting or severe palmar pallor may be classified as:
a. moderate malnutrition/anemia
b. severe malnutrition/anemia
c. not very tow weight no anemia
d. anemia/very low weight
 60. A child who has some palmar pallor can be classified as:
a. moderate anemia/normal weight
b. severe malnutrition/anemia
c. anemia/very low weight
d. not very low eight to anemia

Situation 12 - Nette, a nurse palpates the abdomen of Mrs. Medina, a primigravida. She is unsure of the date of her last
menstrual period. Leopold's Maneuver is done. The obstetrician told her that she appears to be 20 weeks pregnant. .

61. Nette explains this because the fundus is:

a. At the level the umbilicus and the fetal heart can be heard with a fetoscope
b. 18 cm, and the baby is just about to move
c. is just over the symphysis, and fetal heart cannot be heard
d. 28 cm, and fetal heart can be heard with a Doppler

62. In doing Leopold's maneuver palpation which among the following is NOT considered a good preparation?
a. The woman should lie in a supine position with her knees flexed slightly
b. The hands of the nurse should be cold so that abdominal muscles would contract and tighten
c. Be certain that your hands are warm (by washing them in warm water first if necessary)
d. The woman empties her bladder before palpation

63. In her pregnancy, she experienced fatigue and drowsiness. This probably occurs because:
a. of high blood pressure
b. she is expressing pressure
c. the fetus utilizes her glucose stores and leaves her with a low blood glucose
d. of the rapid growth of the fetus

64. The nurse assesses the woman at 20 weeks gestation and expects the woman to report:
a. Spotting related to fetal implantation
b. Symptoms of diabetes as human placental lactogen is released
c. Feeling fetal kicks
d. Nausea and vomiting related HCG production

65. If Mrs. Medina comes to you for check-up on June 2, her EDC is June 11, what do you expect during
assessment?
a. Fundic ht 2 fingers below xyphoid process, engaged
b. Cervix close, uneffaced, FH-midway between the umbilicus and symphysis pubis
c. Cervix open, fundic ht. 2 fingers below xyphoid process, floating.
d. Fundic height at least at the level of the xyphoid process, engaged

Situation 13 - Please continue responding as a professional nurse in varied health situations through the following
questions.

66. Which of the following medications would the nurse expect the physician to order for recurrent convulsive
seizures of a 10-year old child brought to your clinic?
a. Phenobarbital
b. Nifedipine
c. Butorphanol
d. Diazepam

67. RhoGAM is given to Rh-negative women to prevent maternal sensitization from occurring. The nurse is aware
that in addition to pregnancy, Rh-negative women would also receive this medication after which of the following?
a. Unsuccessful artificial insemination procedure
b. Blood transfusion after hemorrhage
c. Therapeutic or spontaneous abortion
d. Head injury from a car accident

68. Which of the following would the nurse include when describing the pathophysiology of gestational diabetes?
a. Glucose levels decrease to accommodate fetal growth
b. Hypoinsulinemia develops early in the first trimester
c. Pregnancy fosters the development of carbohydrate cravings
d. There is progressive resistance to the effects of insulin

69. When providing prenatal education to a pregnant woman with asthma, which of the following would be
important for the nurse to do?
a. Demonstrate how to assess her blood glucose
b. Teach correct administration of subcutaneous bronchodilators
c. Ensure she seeks treatment for any acute exacerbation
d. Explain that she should avoid steroids during her pregnancy

70. Which of the following conditions would cause an insulin-dependent diabetic client the most difficulty during
her pregnancy?
a. Rh incompatibility
 b. Placenta previa
c. Hyperemesis gravidarum
d. Abruptio placenta

Situation 14 - One important tool a community health nurse uses in the conduct of his/her activities is the CHN Bag.
Which of the following BEST DESCRIBES the use of this vital facility for our practice?

71. The Community/Public Health Bag is:

a. a requirement for home visits
b. an essential and indispensable equipment of the community health nurse
c. contains basic medications and articles used by the community health nurse
d. a tool used by the Community health nurse is rendering effective nursing procedure during a home visit

72. What is the rationale in the use of bag technique during home visit?
a. It helps render effective nursing care to clients or other members of the family
b. It saves time and effort of the nurse in the performance of nursing procedures
c. It should minimize or prevent the spread of infection from individuals to families
d. It should not overshadow concerns for the patient

73. Which among the following is important in the use of the bag technique during home visit?
a. Arrangement of the bag's contents must be convenient to the nurse
b. The bag should contain all necessary supplies and equipment ready for use
c. Be sure to thoroughly clean your bag especially when exposed to communicable disease cases
d. Minimize if not totally prevent the spread of infection

74. This is an important procedure of the nurse during home visits?

a. protection of the CHN bag
b. arrangement of the contents of the CHN bag
c. cleaning of the CHN bag
d. proper handwashing

75. Which of the following is not found inside the public health bag?
a. apron
b. test tube holder
c. alcohol lamp
d. sphygmomanometer and stethoscope

Situation 15 - As a community health nurse, you may realize that the family is faced with a number of health and
nursing problems which cannot be taken up all at the same time considering the available resources of both the family
and the nurse. The following questions pertain in prioritizing health problems.

76. In identifying and prioritizing health problems of the family in the community setting, the following factors
are identified except:
a. Nature of the problem
b. Cost of resources
c. Salience
d. Modifiability

77. According to the factors affecting priority setting, which of the following situations would be classified as a
health threat that needs immediate attention?
a.G2P1 mother with history of pre-eclampsia
b.School age children below normal weight
c. Mothers who have no knowledge on caring for the young
d.Community with 100 people suffering from scabies

78. A health deficit refers to preventable health problems brought about by lack of knowledge to handle situation.
Which of the following is not a health deficit?
a.Family size beyond family’s resources
b.Malnutrition
c. Unsanitary waste disposal
d.Cases of malaria

79. In formulating goals for family health nursing, there are barriers which the nurse has to identify. Which of the
following situation is an identified barrier?
a.Family accepts the existence of the problem
b.Nurse and family develops a working relationship
c. Family perceives problem but belittles it.
d.Goals set by both family and nurse is attainable

80. In planning nursing care in the community health setting, the nurse has to consider the different concepts
of planning except:
a. Planning is a set and standardized and rigid
b. Planning is dynamic and continuous
c. Planning entails a systematic process
d. Planning is futuristic.
Situation 16 - You are actively practicing nurse who just finished your Graduate Studies. You earned the value of
Research and would like to utilize the knowledge and skills gained in the application of research to nursing service. The
following questions apply to research.

81. Which type of research inquiry investigates the issue of human complexity (e.g. understanding the human
expertise)
a. Logical position
b. Naturalistic inquiry
c. Positivism
d. Quantitative Research

82. Which of the following studies is based on quantitative research?

a. A study examining the bereavement process in spouses of clients with terminal cancer
b. A study exploring factors influencing weight control behavior
c. A study measuring the effects of sleep deprivation on wound healing
d. A study examining client's feelings before, during and after a bone marrow aspiration

83. Which of the following studies is based on qualitative research?

a. A study examining clients reactions to stress after open heart surgery
b. A study measuring nutrition and weight, loss/gain in clients with cancer
c. A study examining oxygen levels after endotracheal suctioning
d. A study measuring differences in blood pressure before during and after a procedure

84. An 85 year old client in a nursing home tells a nurse, "I signed the papers for that research study because
the doctor was so insistent and I want him to continue taking care of me." Which client right is being violated?
a. Right of self determination
b. Right to privacy and confidentiality
c. Right to full disclosure
d. Right not to be harmed

85. "A supposition or system of ideas that is proposed to explain a given phenomenon," best defines:
a. a paradigm
b. a concept
c. a theory
d. a conceptual framework

Situation 17 - Nurse Michelle works with a Family Nursing Team in Calbayog Province specifically handling a UNICEF
Project for Children. The following conditions pertain, to CARE OP THE FAMILIES PRESCHOOLERS.

86. Ronnie asks constant questions. How many does a typical 3-year-old ask in a day's time?
a. 1,200 or more
b. Less than 50
c. 100-200
d. 300-400

87. Ronnie will need to change to a new bed because his baby sister will need Ronnie's old crib, what measure
would you suggest that his parents take to help decrease sibling rivalry between Ronnie and his new sister?
a. Move him to the new bed before the baby arrives
b. Explain that new sisters grow up to become best friends
c. Tell him he will have to share with the new baby
d. Ask him to get his crib ready for the new baby

88. Ronnie's parents want to know how to react to him when he begins to masturbate while watching television,
what would you suggest?
a. They refuse to allow him to watch television
b. They schedule a health check-up for sex-related disease
c. They remind him that some activities are private
d. They give him "timeout" when this begins

89. How many words does a typical 12-month-oId infant use?

a. About 12 words
b. Twenty or more words
c. About 50 words
d. Two, plus "mama" and "dada"

90. As a nurse, you reviewed infant safety procedures with Bryan's mother. What are two of the most common
types of accidents among infants?
a. Aspiration and falls
b. Falls and auto accidents
c. Poisoning and burns
d. Drowning and homicide

Situation 18 - Among common conditions found in children especially among poor communities are ear infection/
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. An ear discharge that has been present for more than 14 days can be classified as:
a. mastoditis
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. mastoditis
c. acute ear infection
d. complicated 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 19 - If a 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 the rules for home
treatment in this case:
a. continue feeding the child
b. give 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 b. 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. Carlo has had diarrhea for 5 days. There is no blood in the stool, he is irritable. His eyes are sunken the
nurse offers fluid to Carlo and he drinks eagerly. When the nurse pinched the abdomen, it goes back slowly.
How will you classify Carlo's illness?
a. severe dehydration
b. no dehydration
c. some dehydration
d. moderate dehydration

CORRECT ANSWER: C
RATIONALE: The manifestations of the client are of some dehydration. Other manifestation under the
classification is restlessness.
OPTION A: Two of the following should be manifested in order to be classified as severe dehydration:
 Abnormally sleepy or difficult to awaken
 Sunken eyes
 Skin pinch goes back very slowly
 OPTION B: if not enough signs to classify as some or severe dehydration.
OPTION D: not part of the classification
SOURCE: IMCI manual Page 24

Situation 1 - Concerted work efforts among members of the surgical team is essential to the success of the surgical
procedure.

1. The sterile nurse or sterile personnel touch only sterile supplies and instruments. When there is a need for
sterile supply which is not in the sterile field, who hands out these items by opening its outer cover?
a. Circulating nurse
b. Anesthesiologist
c. Surgeon
d. Nursing aide

2. The OR team performs distinct roles for one surgical procedure to be accomplished within a prescribed time
frame and deliver a standard patient outcome. Who monitors the status of the client like urine output, blood loss
while the surgeon performs the surgical procedure?
a.Scrub nurse
b.Surgeon
c. Anesthesiologist
d.Circulating nurse

3. The following are members of the sterile team EXCEPT for one.
a.Surgeon
b.Surgical Assistant
c. Anesthetist
d.Scrub nurse

4. Before blood transfusion, the nurse started an IV infusion as ordered. Which of the following is commonly
ordered before BT?
a. Sterile water solution
b. D5LR
c. Dextrose 5% in water
d. Normal saline solution

Situation 2 - You are assigned in the Orthopedic Ward where clients are complaining of pain in varying degrees upon
movement of body parts.

5. Troy is a one day post open reduction and internal fixation (ORIF) of the left hip and is in pain. Which of the
following observation would prompt you to call the doctor?
a.Dressing is intact but partially soiled
b.Left foot is cold to touch and pedal pulse is absent
c. Left leg in limited functional anatomic position
d.BP 114/78, pulse of 82 beats/minute

6. There is an order of Demerol 50 mg I.M. now and every 6 hours prn, You injected Demerol at 5 pm. The next
dose of Demerol 50 mg I.M. is given:
a. When the client asks for the next dose
b. When the patient is in severe pain
c. At 11 pm
d. At 12 pm

7. A patient is in pain following surgery. Which of the following instructions should the nurse give to the patient
regarding pain management?
a.“Try to bear the pain as long as you can.”
b.“Pain should be reported in the early stages.”
c. “Higher levels of pain are easier to reduce than lower levels.”
d.“Our goal is to keep you pain free.”

8. When assessing a patient for pain, the nurse observes facial grimacing with movement, and blood pressure
and pulse elevation. Which of the following measures should the nurse take next?
a.Realize that patient has the right to refuse medication.
b.Explain the reasons for taking pain medication.
c. Tell the patient to notify the nurse when the pain becomes severe.
d.Leave the medication at the bedside in case the patient desires it later.

9. In some hip surgeries, an epidural catheter for fentanyl epidural analgesia is given. What is your nursing
priority care in such a case?
a.Instruct client to observe strict bed rest
b.Check for epidural catheter drainage
c. Administer analgesia through epidural catheter as prescribed
 d.Assess respiratory rate carefully

Situation 3 – Rita just retired from government service and was admitted for pneumonectomy.

10. As the nurse on duty, you should check for the medical clearance of your client for surgery among other
pre-op requirements. This clearance primarily covers:
a.Stress-coping mechanism of the client
b.Socio-economic status of the client
c. Smoking and eating habits of the client
d.Cardio-pulmonary system

11. Preoperative tests were done. Particularly, the nurse should assess the lung capacity by checking the:
a.Serum creatinine level
b.Chest x-ray
c. Serum protein levels
d.Arterial blood gas

12. The main objective in postoperative pneumonectomy is to:

a.Maintain a patent airway
b.Provide maximum remaining lung capacity
c. Provide early rehabilitation measures
d.Recognize early symptoms of complications

13. There is an order of central venous pressure (CVP) reading. As a nurse, you should know that this is a measure
observing signs of:
a.Hypoxia
b.Hypovolemia
c. Hypothermia
d.Hypoxemia

14. Pulmonary edema is a potential danger that we nurses should monitor in post pneumonectomy. This is
usually due to:
a.Cardiac output goes to the remaining lung
b.Liberal fluid intake
c. Rapid infusion of IV fluids
d.Fluid retention due to prolonged bed rest

Situation 4 - In the OR, there are safety protocols that should be followed. The OR nurse should be well versed with all
these to safeguard the safety and quality to patient delivery outcome.

15. Which of the following should be given highest priority when receiving patient in the OR?
a. Assess level of consciousness
b. Verify patient identification and informed consent
c. Assess vital signs
d. Check for jewelry, gown, manicure and dentures

17. In the OR, you will position a patient for TURP in:
a.Supine
b.Lithotomy
c. Semi-fowler
d.Trendelenburg

18. OR nurses should be aware that maintaining the client's safety is the overall goal of nursing care during the
intraoperative phase. As the circulating nurse, you make certain that throughout the procedure:
a. the surgeon greets his client before induction of anesthesia
b. the surgeon and anesthesiologist are in tandem
c. strap made of strong non-abrasive material are fastened securely around the joints of
the knees and ankles and around the 2 hands around an arm board
d. client is monitored throughout the surgery by the assistant anesthesiologist

19. You refer postoperative patients under general anesthesia to the doctor when he has:
a.Cold clammy skin and filiform pulse
b.Snoring respiration and rapid pulse
c. Accidental removal of the airway
d.A drop in blood pressure and rapid pulse

20. Some different habits and hobbies affect postoperative respiratory function. If your client smokes 3 packs
of cigarettes a day for the part 10 years, you will anticipate increased risk for:
a. perioperative anxiety and stress
b. delayed coagulation time
c. delayed wound healing
d. postoperative respiratory function

CORRECT ANSWER: D
 RATIONALE: Patients who smoke are encouraged to stop 2 months before surgery. These patients should be
counseled to stop smoking at least 24 hours prior to surgery. Research suggest that counseling has a positive
effect on the patient’s smoking behavior 24 hors preceding surgery, helping reduce the potential for adverse effect
associated with smoking such as increased airway reactivity, decreased mucocilliary clearance, as well as
physiologic changes in the cardiovascular and immune systems.
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 403

Situation 5 - Nurses hold a variety of roles when providing care to a perioperative patient.

21. Which of the following role would be the responsibility of the scrub nurse?
a. Assess the readiness of the client prior to surgery
b. Ensure that the airway is adequate
c. Account for the number of sponges, needles, supplies, Used during the surgical procedure
d. Evaluate the type of anesthesia appropriate for the surgical client

22. As a perioperative nurse, how can you best meet the safety need of the client after administering preoperative
narcotic?
a. Put side rails up and not leaving the sedated patient
b. Send the client to OR with the family
c. Allow client to get up to go to the comfort room
d. Obtain consent form

23. It is the responsibility of the pre-op nurse to do skin prep for patients undergoing surgery. If hair at the
operative site is not shaved, what should be done to lessen chance of incision infection?
a. Draped
b. Pulled
c. Clipped
d. Shampooed

24. A nurse is assessing the operative site in a client who underwent a breast reconstruction. The nurse is
inspecting the flap and the areola of the nipple and notes that the areola is a deep red color around the edge.
The nurse takes which action first?
a.Document the findings
b.Elevate the breast
c. Encourage nipple massage
d.Notify the physician

25. When performing a surgical dressing change of a client’s abdominal dressing, a nurse notes an increase in
the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse.
The nurse would do which of the following in the initial care of this wound?
a. Leave the incision open to the air to dry the area
b. Apply a sterile dressing soaked in povidone-iodine (Betadine)
c. Irrigate the wound and apply sterile dressing
d. Apply a sterile dressing soaked with normal saline.

Situation 6 - Carlo, 16 years old, comes to the ER with acute asthmatic attack. RR is 46/min and he appears to be in
acute respiratory distress,

26. Which of the following nursing actions should be initiated first?

a. Promote emotional support
b. Administer oxygen at 6L/min
c. Suction the client every 30 min
d. Administer bronchodilator by nebulizer

27. Aminophylline was ordered for acute asthmatic attack. The mother asked the nurse, “what is its indication?”
the nurse will say:
a. Relax smooth muscles of the bronchial airway
b. Promote expectoration
c. Prevent thickening of secretions
d. Suppress cough

28. You will give health instructions to Carlo, a case of bronchial asthma. The health instruction will include
the following EXCEPT:
a. Avoid emotional stress and extreme temperature
b. Avoid pollution like smoking
c. Avoid pollens, dust seafood
d. Practice respiratory isolation

29. The asthmatic client asked you what breathing technique he can best practice when asthmatic attack starts.
What will be the best position?
a. Sit in high-Fowler's position with extended legs
b. Sit-up with shoulders back
c. Push on abdomen during exhalation
d. Lean forward 30-40 degrees with each exhalation
 30. As a nurse you are always alerted to monitor status asthmaticus who will likely and initially manifest symptoms of:
a.metabolic alkalosis
b.respiratory acidosis
c. respiratory alkalosis
d.metabolic acidosis

Situation 7 – P. Cruz, 65 years old, was admitted in the hospital because of signs and symptoms of acute MI. You are
expected to recognize ECG readings on the cardiac monitor.

31. Which of the following will appear abnormal in the ECG when ischemia and injury occur in the myocardium?
a. QRS interval
b. ST segment and T wave
c. P wave
d. PR interval

32. From an ECG reading, a QRS complex represents;

a.Ventricular depolarization
b.Ventricular repolarization
c. End of ventricular depolarization
d.Atrial depolarization

CORRECT ANSWER: A
RATIONALE: QRS complex represents ventricular muscle depolarization
OPTION B: T wave represents ventricular muscle repolarization
OPTION D:P wave represents atrial muscle depolarization
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 686

33. Which of the following represents ventricular repolarization?

a.T wave
b.ST segment
c. QRS complex
d.PR interval

33. It is important that the nurse measures interval of QRS complex. Which if the following represent the normal
interval of QRS complex?
a. Greater than .20 sec
b. .20 sec
c. .10 sec
d. .12 sec to .20 sec

35. Later in the acute phase of MI, which of the following typically appears as the first sign of tissue death?
a. ST segment suppression
b. Short T wave
c. Prolonged PR interval
d. Pathologic Q wave

Situation 8 - Mrs. Cruz was admitted in the Medical Floor due to pyrosis, dyspepsia and difficulty of swallowing.

36. Based from the symptoms presented, Nurse Yoshi might suspect:
a. Esophagitis
b. Hiatal hernia
c. GERD
d. Gastric Ulcer

37. What diagnostic test would confirm the type of problem Mrs. Cruz have?
a. Barium enema
b. Barium swallow
c. Colonoscopy
d. Lower GI series

38. Mrs. Cruz complained of pain and difficulty in swallowing. This term is referred as:
a.Odynophagia
b.Dysphagia
c. Pyrosis
d.Dyspepsia

39. To avoid acid reflux, Nurse Yoshi should advice Mrs. Cruz to avoid which type of diet?
a.Cola, coffee and tea
b.High fat, carbonated and caffeinated beverages
c. Beer and green tea
d.Lechon paksiw and bicol express

40. Mrs. Cruz’ body mass index (BMI) is 25. You can categorize her as:
a.Normal
 b.Overweight
c. Underweight
d.Obese

Situation 9 - Colostomy is a surgically created anus. It can be temporary or permanent, depending on the disease
condition.

41. 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 powder and rings around the stoma
c. Clean the area daily with soap and water before applying bag
d. Apply talcum powder twice a day

42. A nurse instructs the patient who had an ileostomy to avoid which of the following foods?
a.Potatoes
b.Beef
c. Popcorn
d.Yogurt

43. The patient who has had an ileostomy says to the nurse, “I will have to be isolated for the rest of my life
because no one will be able to stand this terrible odor.” Which of the following responses by the nurse
would most likely be reassuring?
a. “The odor will gradually become less noticeable.”
b. “I can understand your concern, but remaining in isolation does not reduce the odor.”
c. “There are techniques that can reduce the odor.”
d. “The odor is a normal part of your condition and will not offend people.”

44. 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. Hand the solution 18 inches above the stoma

45. The nurse is assessing the colostomy of a client who had an abdominal perineal resection for a bowel tumor.
Which of the following assessment findings indicate that the colostomy is beginning to function?
a. Blood drainage from the colostomy
b. Change the dressing as prescribed
c. Absent bowel sounds
d. The passage of flatus

Situation 10 - As a beginner in research, you are aware that sampling is an essential element of the research process.

46. What does a sample group represent?

a. Control group
b. Study participants
c. General population
d. Universe

47. This kind of research gathers data in detail about individual or groups and presented in narrative form, which is
a.Case study
b.Historical
c. Analytical
d.Experimental

48. Random sampling ensures that each subject has:

a. Been selected systematically
b. An equal change of selection
c. Been selected based on set criteria
d. Characteristics that match other samples

49. Which of the following sampling methods allows the use of any group of research subject?
a. Purposive
b. Convenience
c. Snow-bail
d. Quota

50. You decided to include 5 barangays in your municipality and chose a sampling method that would get
representative samples from each barangay. What should be the appropriate method for you to use in this care?
a. Cluster sampling
b. Random sampling
c. Stratified random sampling
d. Systematic sampling
Situation 11 - After an abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge and
Instrument count.

51. When is the first sponge/instrument count reported?

a. Before closing the subcutaneous layer
b. Before peritoneum is closed
c. Before initial incision
d. Before the fascia is sutured

52. What major supportive layer of the abdominal wall must be sutured with long tensile strength such as cotton
or nylon or silk suture?
a.Fascia
b.Muscle
c. Peritoneum
d.Skin

53. Like sutures, needles also vary in shape and uses. If you are the scrub nurse for a patient who is prone to
keloid formation and has a low threshold of pain, what needle would you prepare?
a. Round needle
b. Atraumatic needle
c. Reverse cutting needle
d. Tapered needle

54. Another alternative "suture" for skin closure is the use of

a. Staple
b. Therapeutic glue
c. Absorbent dressing
d. invisible suture

55. Like any nursing interventions, counts should be documented. To whom does the scrub nurse report any
discrepancy of counts so that immediate and appropriate action in instituted?
a. Anesthesiologist
b. Surgeon
c. OR nurse supervisor
d. Circulating nurse

Situation 12 - Knowledge of the drug propantheline bromide [Probanthine] is necessary in treatment of various disorders.

56. What is the action of this drug?

a. Increases glandular secretion for clients affected with cystic fibrosis
b. Dissolve blockage of the urinary tract due to obstruction of cystine stones
c. Reduces secretion of the glandular organ of the body
d. Stimulate peristalsis for treatment of constipation and obstruction

57. What should the nurse caution the client when using this medication?
a. Avoid hazardous activities like driving, operating machineries etc.
b. Take the drug on empty stomach
c. Take with a full glass of water in treatment of Ulcerative colitis
d. I must take double dose if I missed the previous dose

58. Which of the following drugs are not compatible when taking Probanthine?
a.Caffeine
b.NSAID
c. Acetaminophen
d.Alcohol

59. What should the nurse tell clients when taking Probanthine?
a.Avoid hot weathers to prevent heat strokes
b.Never swim on a chlorinated pool
c. Make sure you limit your fluid intake to 1L a day
d.Avoid cold weathers to prevent hypothermia

60. Which of the following disease would Probanthine exert the much needed action for control or treatment of
the disorder?
a.Urinary retention
b.Peptic Ulcer Disease
c. Ulcerative Colitis
d.Glaucoma

Situation 13 - Mrs. Gregorio, age 28, is admitted to the emergency department after a house fire. She has second and
third degree burns over approximately 30% of her body surface area (BSA).

61. Which parenteral solution should Mrs. Gregorio receive during the fluid resuscitation phase of her treatment?
 a.Dextrose 5% in water
b.Lactated Ringer’s solution
c. Hypotonic Saline Solution
d.20 mEq of potassium chloride in half-normal saline solution

62. Which information is not used when the nurse calculates and maintains Mrs. Gregorio’s IV therapy for fluid
resuscitation?
a.depth and BSA percentage of burns
b.sex and past medical history
c. hematocrit and hemoglobin values
d.urine output and specific gravity

63. Which fluid and electrolyte imbalances are likely to occur in initial stage of Mrs. Gregorio’s burn injury?
a.Interstitial-to-plasma fluid shift and sodium excess
b.Plasma-to-interstitial fluid shift and potassium excess
c. Interstitial-to- extracellular fluid shift and sodium deficit
d.Intracellular-to-intravascular fluid shift and potassium deficit

64. Which laboratory value indicates that Mrs. Gregorio’s water intake should be restricted?
a.Elevated serum sodium level
b.Elevated potassium level
c. Decrease serum sodium level
d.Decrease serum magnesium level

65. Which treatment objective is not necessary to prevent or minimize further complications?
a.Preventing and controlling complications
b.Supplying nutritional needs, including replacement fluids and electrolytes
c. Encouraging the patient to attain her ideal body weight
d.Providing psychological support

Situation 14 - 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.

66. Your independent nursing care for hypothyroidism includes:

a. Administer sedative round the clock
b. Administer thyroid hormone replacement
c. Providing a warm, quiet, and comfortable environment
d. Encourage to drink 6-8 glasses of water

67. 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

68. 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 related to hypermetabolism
d. Deficient fluid volume related to diarrhea

69. 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

70. As a nurse, you know that the most common type of goiter is related to a deficiency in:
a. Thyroxine
b. Thyrotropin
c. Iron
d. Iodine

Situation 15 - Mrs. Pichay is admitted to your ward. The MD ordered "Prepared for thoracentesis this pm to remove
excess air from the pleural cavity."

71. Which of the following nursing responsibility is essential in Mrs. Pichay who will undergo thoracentesis?
a. Support, and reassure client during the procedure
b. Ensure that the client has been on NPO for 6 hours
c. Determine if client has allergic reaction to local anesthesia
 d. Ascertain if chest x-rays and other tests have been prescribed and completed

72. Mrs. Pichay who is for thoracentesis is assisted by the nurse to any of the following positions, EXCEPT:
a. Straddling a chair with arms and head resting on the back of the chair
b. Lying on the unaffected side with the bed elevated 30-40 degrees
c. Lying prone with the head of the bed lowered 15-30 degrees
d. Sitting on the edge of the bed with her feet supported and arms and head on a padded overhead
table

73. 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

74. To promote lung expansion and 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

75. Chest x-ray was ordered after thoracentesis. When your client asks what the reason for another chest x-ray
is, 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 16 - In the hospital, you are aware that we are helped by the use of a variety of equipment/devices to enhance
quality patient care delivery.

76. You are initiating an IV line to your patient, Kyle, 5, who is febrile. What IV administration set will you prepare?
a. Blood transfusion set
b. Macroset
c. Volumetric chamber
d. Microset

77. Kyle is diagnosed to have measles. Your protective personal attire includes?
a. Gown
b. Eyewear
c. Face mask
d. Gloves

78. The nurse making rounds discovers D5W infusing a 75 ml/hour. The order for the client states, “NS at 75 ml/hour.”
What is the best action for the nurse to take first?
a. Complete the infusion of D5W to avoid waste and then ensure the next bag is correct.
b. Slow the infusion and contact the physician for current orders
c. Immediately change the infusion to the ordered solution
d. Compare an unusual occurrence report and submit it to the supervisor.

79. Before bedtime, you went to ensure Kyle's safety in bed. You will do which of the following:
a. Put the lights on
b. Put the side rails up
c. Test the call system
d. Lock the doors

Situation 17 - Tony, 11 years old, has 'kissing tonsils' and is scheduled for tonsillectomy and adenoidectomy or T and A.

80. You are the nurse of Tony who will undergo T and A in the morning. His mother asked you if Tony will be
put to sleep. Your teaching will focus based on the understanding that T & A procedure is under what anesthesia:
a.Spinal anesthesia
b.Anesthesiologist's preference
c. Local anesthesia
d.General anesthesia

81. The nurse is caring for Tony who has just returned from surgery following a tonsillectomy and adenoidectomy.
Which action by the nurse is appropriate?
a. Offer ice cream every 2 hours
b. Place the child in a supine position
c. Allow the child to drink through a straw
d. Observe swallowing patterns
 82. The RR nurse should monitor for the most common postoperative complication of:
a. Hemorrhage
b. Endotracheal tube perforation
c. Esopharyngeal edema
d. Epiglottis

83. The PACU nurse will maintain postoperative T and A client in what position?
a.Supine with neck hyperextended and supported with pillow
b.Prone with the head on pillow and tuned to the side
c. Semi-Fowler's with neck flexed
d.Reverse trendelenburg with extended neck

84. After tonsillectomy, Tony begins to vomit bright red blood. The most appropriate
initial nursing action would be to:
a.Administer the prescribed antiemetic
b.Turn the child to the side
c. Notify the physician
d.Maintain an NPO status
Situation 18 - Rudy was diagnosed to have chronic renal failure. Hemodialysis is ordered that an A-V shunt was
surgically created.

85. Which of the following action would be of highest priority with regards to the external shunt?
a. Avoid taking BP or blood sample from the arm with shunt
b. Instruct the client not to exercise the arm with the shunt
c. Heparinize the shunt daily
d. Change dressing of the shunt daily

86. Diet therapy for Rudy, who has acute renal failure, is low-protein, low potassium and sodium. The nutrition
instruction should include:
a. Recommend protein of high biologic value like eggs, poultry and lean meat
b. Encourage client to include raw cucumbers, carrot, cabbage, and tomatoes
c. Allowing the client cheese, canned foods, and other processed food
d. Bananas, cantaloupe, orange and other fresh fruits can be included in the diet

87. Rudy undergoes hemodialysis for the first time and was scared of disequilibrium syndrome. He asked you
how this can be prevented. Your response is:
a. Maintain a conducive comfortable and cool environment
b. Maintain fluid and electrolyte balance
c. Initial hemodialysis shall be done for shorter periods only so as not to rapidly remove the waste
from the blood than from the brain
d. Maintain aseptic technique throughout the hemodialysis

88. You are assisted by a nursing aide with the care of the client with renal failure. Which of the following tasks can
be delegated to the nursing aide?
a. Measuring and recording I and O
b. Checking bowel movement
c. Health teachings
d. Making a nursing diagnosis

89. A renal failure patient was ordered for creatinine clearance. As the nurse you will collect
a. 48 hour urine specimen
b. First morning urine
c. 24 hour urine specimen
d. Random urine specimen

Situation 19 - Fe is experiencing left sharp pain and occasional hematuria. She was advised to undergo IVP by her
physician.

90. Fe was so anxious about the procedure and particularly expressed her low pain threshold. Nursing health
instruction will include:
a. Assure the client that the pain is associated with the warm sensation during the administration of
the dye
b. Assure the client that the procedure painless
c. Assure the client that contrast medium will be given orally
d. Assure the client that x-ray procedure like IVP is only done by experts

91. Before the test priority nursing action would be to:

a.Administer an oral preparation of radiopaque dye
b.Restrict fluids
c. Determine a history of allergies
d.Administer a sedative

92. What will the nurse monitor and instruct the client and significant others post IVP?
a. Monitor and report signs and symptoms for delayed allergic reactions
b. Observe NPO for 6 hours
 c. Limit fluid intake
d. Monitor intake and output

93. Post IVP, Fe should excrete the contrast medium. You instructed the family to include more vegetables in the
diet and
a. Increase fluid intake
b. Barium enema
c. Cleansing enema
d. Gastric lavage

94. The IVP reveals that Fe has small renal calculus that can be passed out spontaneously. To increase the
chance of passing the stones, you instructed her to force fluids and do which of the following?
a. Balanced diet
b. Ambulance more
c. Strain all urine
d. Bed rest

95. The presence of calculi in the urinary tract is called:

a.Cholelithiasis
b.Nephrolithiasis
c. Ureterolithiasis
d.Urolithiasis

Situation 20 - At the medical-surgical ward, the nurse must also be concerned about drug interactions.

96. You have a client with TPN. You know that in TPN, like blood transfusion, there should be no drug incorporation.
However, the MD's order read; incorporate insulin to present TPN. Will you follow the order?
a. No, because insulin will induce hyperglycemia in patients with TPN
b. Yes, because insulin is chemically stable with TPN and can enhance blood glucose level
c. No, because insulin is not compatible with TPN
d. Yes, because it was ordered by the MD

97. A patient is receiving Total Parenteral Nutrition secondary to acute pancreatitis. The nurse is about to administer
insulin when the patient states, “Why am I getting insulin? I’m not diabetic.” Which of the following responses
would be the most appropriate?
a.“The infection in your pancreas is causing too much insulin to be produced.”
b.“This type of infection stops the production of insulin.”
c. “The TPN solution contains high amount of glucose.”
d.“The TPN solution interferes with the production of insulin.”

98. A nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which of the
following actions, if performed by the client, indicate a need for further teaching?
a.Injects air into NPH insulin vial first
b.Injects an amount of air equal to the desired dose of insulin into the vial
c. Withdraws the NPH insulin first
d.Withdraws the regular insulin first

99. A pregnant client takes an-over-the-counter (OTC) iron preparation, drug data lists the drug is Pregnancy
Category A. the nurse teaches the client which of the following pieces of information?
a.To stop the medication during pregnancy
b.To immediately report to the physician that she has taken the drug while pregnant
c. That his medication is classified as safe to use during pregnancy
d.There may be staining of the baby’s first teeth from this medication

100. In insulin administration, it should be understood that our body normally releases insulin according to our
blood glucose level. When is insulin and glucose level highest?
a. After excitement
b. After a good night's rest
c. After an exercise
d. After ingestion of food
Situation 1 - Because of the serious consequences of severe burns management requires a multi disciplinary approach.
You have important responsibilities as a nurse.

1.While Sergio was lighting a barbecue grill with a lighter fluid, his shirt burst into flames. The most effective way
to extinguish the flames with as little further damage as possible is to:
a. log roll on the grass/ground
b. slap the flames with his hands
c. remove the burning clothes
d. pour cold liquid over the flames

2. Once the flames are extinguished, it is most important to:

a. cover Sergio with a warm blanket
b. give him sips of water
c. calculate the extent of his burns
d. assess Sergio's breathing

3. Sergio is brought to the Emergency Room after the barbecue grill accident. Based on the assessment of the
physician, Sergio sustained superficial partial thickness bums on his trunk, right upper extremities ad right
lower extremities. His wife asks what that means. Your most accurate response would be:
a. Structures beneath the skin are damaged
b. Dermis is partially damaged
c. Epidermis and dermis are both damaged
d. Epidermis is damaged

4. During the first 24 hours after thermal injury, you should assess Sergio for
a. hypokalemia and hypernatremia
b. hypokalemia and hyponatremia
c. hyperkalemia and hyponatremia
d. hyperkalemia and Hypernatremia

5. Teddy, who sustained deep partial thickness and full thickness burns of the face, whole anterior chest and both
upper extremities two days ago, begins to exhibit extreme restlessness. You recognize that this most likely
indicates that Teddy is developing:
a. Cerebral hypoxia
b. Hypervolemia
c. Metabolic acidosis
d. Renal failure .

Situation 2 - You are now working as a staff nurse in a general hospital. You have to be prepared to handle situations
with ethico-legal and moral implications.

6. You are on night duty in the surgical ward. One of our patients Martin is prisoner who sustained an
abdominal gunshot wound. He is being guarded by policemen from the local police unit. During your rounds
you heard a commotion. You saw the policeman trying to hit Martin. You asked why he was trying to hurt Martin.
He denied the matter. Which among the following activities will you do first?
a. Write an incident report
b. Call security officer and report the incident
c. Call your nurse supervisor and report the incident:
d. Call the physician on duty

7. The nurse gives an inaccurate dose of a medication to a client. Following assessment of the client, the
nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls
the physician to report the occurrence. The nurse who administered the inaccurate medication dose
understands that the:
a. error will result in suspension
b. incident report is a method of promoting quality care and risk management
 c. incident will be reported to the board of nursing
d. incident will be documented in the personnel file.

8. The nurse hears a client call for help. The nurse hurries down the hallway to the client’s room and finds the client
lying on the floor. The nurse performs a thorough assessment and assists the client back to bed. The nurse
notifies the physician of the incident and completes an incident report. Which of the following would the nurse
document on the incident report?
a. the client was found lying on the floor
b. the client climbed over the side rails
c. the client fell out of bed
d. the client became restless and tired to get out of bed

9. You are on duty in the medical ward. The mother of your patient who is also a nurse came running to the
nurse station and informed you that Fiolo went into cardiopulmonary arrest. Which among the following will you do
first?
a. Start basic life support measures
b. Call for the Code
c. Bring the crash cart to the room
d. Go to see Fiolo and assess for airway patency and breathing problems
10. A client is brought to the emergency medical services after being hit by a car. The name of the client is
not known. The client has sustained a severe head injury, multiple fractures, and is unconscious. An emergency
craniotomy is required. Regarding informed consent for the surgical procedure, which of the following is the best
action?
a. call the police to identify the client and locate the family
b. obtain a court order for the surgical procedure.
c. ask the emergency medical services team to sign the informed consent
d. transport the victim to the operating room for surgery

Situation 3 - Colorectal cancer can affect old and younger people. Surgical procedures and other modes of treatment are
done to ensure quality of life. You are assigned in the Cancer institute to care of patients with this type of cancer.

11. Larry, 55 years old, who is suspected of having colorectal cancer, is admitted to the CI. After taking the history
and vital signs the physician does which test as a screening test for colorectal cancer.
a. Barium enema
b. Carcinoembryonic antigen
c. Annual digital rectal examination
d. Proctosigmoidoscopy

12. To confirm his impression of colorectal cancer, Larry will require which diagnostic study?
a. carcinoembryonic antigen
b. incisional biopsy of the colon
c. stool hematologic test
d. abdominal computed tomography (CT) test

13. The following are risk factors for colorectal cancer, EXCEPT:
a. inflammatory bowels
b. low fat, high fiber diet
c. smoking
d. genetic factors-familial adenomatous polyposis

14. Symptoms associated with cancer of the colon include:

a. constipation, ascites and mucus in the stool
b. diarrhea, heartburn and eructation
c. blood in the stools, anemia, and pencil-shaped, stools
d. anorexia, hematemesis, and increased peristalsis

15. Several days prior to bowel surgery, Larry may be given sulfasuxidine and neomycin primarily to:
a. promote rest of the bowel by minimizing peristalsis
b. reduce the bacterial content of the colon
c. empty the bowel of solid waste
d. soften the stool by retaining water in the colon

Situation 4 - ENTEROSTOMAL THERAPY is now considered especially in nursing. You are participating in the OSTOMY
CARE CLASS.

16. You plan to teach Fermin how to irrigate the colostomy when:
a. The perineal wound heals and Fermin can sit comfortably on the commode
b. Fermin can lie on the side comfortably, about the 3rd postoperative day
c. The abdominal incision is close and contamination is no longer a danger
d. The stool starts to become formed, around the 7th postoperative day

17. When preparing to teach Fermin how to irrigate his colostomy, you should plan to do the procedure:
a. When Fermin would have normal bowel movement
b. At least 2 hours before visiting hours
c. After breakfast
 d. After Fermin accepts alteration in body image

18. When observing a rectum demonstration of colostomy irrigation, you know that more teaching is
required if Fermin:
a. Lubricates the tip of the catheter prior to inserting into the stoma
b. Hands the irrigating bag on the bathroom door doth hook during fluid insertion
c. Discontinues the insertion of fluid after only 500 ml of fluid had been insertion
d. Clamps off the flow of fluid when feeling uncomfortable

19. You are aware that teaching about colostomy care is understood when Fermin states, "I will contact my
physician and report:
a. If I have any difficulty inserting the irrigating tube into the stoma."
b. If I notice a loss of sensation to touch in the stoma tissue."
c. The expulsion of flatus while the irrigating fluid is running out."
d. When mucus is passed from the stoma between irrigation."

20. You would know after teaching. Fermin that dietary instruction for him is effective when he states, "It is
important that I eat:
a. Soft foods that are easily digested and absorbed by my large intestine."
b. Bland food so that my intestines do not become irritated."
c. Food low in fiber so that there is less stool."
d. Everything that I ate before the operation, while avoiding foods that cause gas."

Situation 5 - Ensuring safety is one of your most important responsibilities. You will need to provide instructions and
information to your clients to prevent complications.

21. 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

22. Fanny came in from PACK 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

23. To prevent recurrent attacks on Terry who has acute glomerulonephritis, 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

24. Herbert has 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

25. When caring for Larry after an exploratory chest surgery and pneumonectomy, your priority would be to maintain:
a. supplementary oxygen
b. ventilation exchange
c. chest tube drainage
d. blood replacement

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

26. Honrad, who has been complaining of anorexia and feeling tired, develops jaundice. After a workup he
is diagnosed of having Hepatitis A. His wife asks you about gamma globulin for herself and her household
help. Your most appropriate response would be:
a. "Don't worry your husband's type of hepatitis is no longer communicable"
b. "Gamma globulin provides passive immunity for Hepatitis B"
c. "You should contact your physician immediately about getting gamma globulin."
d. "A vaccine has been developed for this type of hepatitis"

27. Voltaire develops a nosocomial respiratory tract infection. He asks you what that means.
a. "You acquired the infection after you have been admitted to the hospital."
b. "This is a highly contagious infection requiring complete isolation."
 c. "The infection you had prior to hospitalization flared up."
d. "As a result of medical treatment, you have acquired a secondary infection."

28. As a nurse you know that one of the complications that you have to watch out for when caring for Omar
who is receiving total parenteral nutrition is:
a. stomatitis
b. hepatitis
c. dysrhythmia
d. infection

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

a. Dakin's solution
b. Half-strength hydrogen peroxide
c. Acetic acid
d. Betadine

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

a. Culture and sensitivity
b. Purulent drainage from a wound
c. WBC count of 20,000/pL
d. Gram stain testing

Situation 7 - As a nurse you need to anticipate the occurrence of complications of stroke so that life threatening situations
can be prevented.

31. 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 and an I.V. infusion was started. As a nurse assigned
to Wendy what will he your priority goal?
a. Prevent skin breakdown
b. Preserve muscle function
c. Promote urinary elimination
d. Maintain a patent airway

32. Knowing that for a comatose patient hearing is the best 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

33. Which among the following interventions should you consider as the highest priority when caring for June
who has hemiparersis secondary to stroke?
a. Place June on an upright lateral position
b. Perform range of motion exercises
c. Apply antiembolic stocking
d. Use hand rolls or pillows for support

34. 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 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

35. When performing a neurological 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 8 - 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.

36. 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 surface area
c. Decreased anterior-posterior chest diameter
d. Hyperventilation

37. The older patient is at higher risk for in incontinence because of:
a. dilated urethra
 b. increased glomerular filtration rate
c. diuretic use
d. decreased bladder capacity

38. 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

39. 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

40. The nurse is providing medication instructions to an older adult who is taking digoxin (Lanoxin) daily.
The nurse bears in mind that which age-related body changes could place the client at risk for digoxin toxicity?
a. decreased cough efficiency and decreased vital capacity
b. decreased lean body mass and decreased glomerular filtration rate
c. decreased salivation and decreased gastrointestinal motility
d. decreased muscle strength and loss of bone density

Situation 9 - 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
program and activities for all four emergency phases (mitigation, preparedness, response, and recovery), for all type of
emergencies and disasters (natural, man-made, and attack) and for all levels of government and the private sector.

41. Which of the four phases of emergency management is defined as "sustained action that reduces or eliminates
long-term risk to people and properly from natural hazards and the effect"?
a. Recovery
b. Mitigation
c. Response
d. Preparedness

42. 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

43. 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 will 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

44. 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

45. Which of the following terms refer to a process by which the individual receives education about recognition
of stress reactions and management strategies for handling stress which may be instituted after a disaster?
a. Critical incident stress management
b. Follow-up
c. Debriefing
d. Defusion

Situation 10 - 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,

46. While eating his meal, Matthew accidentally dislodges his IV line 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
 47. The nurse manager has implemented a change in the method of the nursing delivery system from functional team
nursing. A nursing assistant is resistant to the change and is not taking an active part in facilitating the process of
change. Which of the following would be the best approach in dealing with the nursing assistant?
a. ignore the resistance
b. exert coercion with the nursing assistant.
c. provide a positive reward system for the nursing assistant
d. confront the nursing assistant to encourage verbalization of feelings regarding the change.

48. Part of your responsibility as a member of the diabetes core group is to get referrals 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

49. The nurse is working in a long-term care facility and is administering medications to assigned clients. A client
refuses to take the prescribed medication, and the nurse threatens the client and tells the client that if the
medication is not taken orally, then restraints will be applied and the medication will be given by injection.
This statement by the nurse constitutes which legal tort?
a. invasion of privacy
b. negligence
c. assault
d.battery

50. The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which
of the following would indicate the need for further action and analysis?
a. a client’s family attending a diabetic teaching session
b. canceling physical therapy sessions on the weekend
c. normal vital signs and absence of wound infection in a postoperative client
d. a client demonstrating accurate medication administration following teaching

Situation 11 - One of the realities that we are confronted with is 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.

51. Nurse Fay is assigned to client Irma. Irma is terminally ill she speaks to Nurse Fay in confidence. Nurse Fay now
feels that Irma's family could be helpful if they knew what Irma has told her. What should Nurse Fay do first?
a. Tell the physician who in turn could tell the family
b. Obtain Irma's permission to share the information with 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

52. Nurse Nathalie Angie is assigned to client Ruby. Ruby who has been told she has terminal cancer turns away
and refuses to respond to Nurse Nathalie Angie. Nurse Nathalie Angie 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

53. Eddy 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 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

54. Which of the following statements would best indicate that Chun Lee; who is dying has accepted this
impending death?
a. "I'm ready to die."
b. "I have resigned myself to dying"
c. "What's the use"?
d: "I'm giving up"

55. Piola, 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 sedation
c. Denial with planning for continued life
d. Awareness that death will soon occur

Situation 12 - Brain tumor, whether malignant or benign, has serious management implications nurse, you should be able
to understand the consequences of the disease and the treatment.

56. Nurse Farrah Faye is caring for Conrad who has a brain tumor and Increased Intracranial Pressure (ICP).
 Which intervention should Nurse Farrah Faye include in her 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

57. Nurse Glaiza Mae helps in positioning patient Conrad. Keeping Conrad's head and neck in alignment results in:
a. increased intrathoracic pressure
b. increased venous outflow
c. decreased venous outflow
d. increased intra abdominal pressure

58. 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. Valsava's maneuver

59. After Nurse Ma. Erma assessed Conrad, she suspected increased ICP.Her most appropriate respiratory
goal is to:
a. maintain partial pressure of arterial 02 (Pa02) above 80 mmHg
b. lower arterial pH
c. prevent respiratory alkalosis
d. promote C02 elimination

60. 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

61. Which of the following instructions should Nurse Julie Lorraine provide to a patient who has
diabetes and hypertrophic lipodystrophy?
a. Rotate insulin injection sites
b. Inject insulin at the edge of the affected area
c. Withhold injection of insulin until the area heals
d. Use a longer needle to administer the insulin

62. The registered nurse’s signature as a witness on an informed consent indicates that the patient
a. has been informed regarding the procedure.
b. was medicated for pain before the consent was signed.
c. can describe how the procedure will be done.
d. voluntarily agreed to having the procedure performed.

63. Nurse Aileen is assessing a patient with hypovolemic shock, which of the following manifestations would
Nurse Aileen most likely see first?
a. Nervousness and apprehension
b. Decreased urinary output
c. Systolic blood pressure below 90 mmHg
d. Hypoventilation and tachycardia

64. Staff nurses, Allen and Mary Jane, learn that a patient they have been caring for during the last few weeks
Has just been diagnosed with tuberculosis. When the nurses express concern about contracting tuberculosis
themselves, the charge nurse’s response should be based on which of the following statements?
a. Tuberculosis is not highly infectious when standard precautions are followed.
b. The Mantoux test is used to confirm diagnosis of tuberculosis.
c. Tuberculosis is easily treated with a short course of antibiotics.
d. Vaccination with Bacillus Calmette Guerin (BCG) will be used to immunize the nurses against infection.

65. To which of the following nursing diagnosis would a nurse manager give priority when an impaired nurse returns
to work?
a.Ineffective individual coping
b.Situational low self-esteem
c. Growth and development; altered
d.Ineffective family coping; compromised

66. A woman who is dependent on alcohol is admitted to the detoxification unit. The answer to which of the following
question is essential for the nurse to obtain from the patient immediately?
a. How does her husband react to her problem?
b. When did she have her last drink?
c. How old she was when she began to drink?
d. What did she eat in the past four hours?
 67. A patient seems unconcerned about the sudden loss of vision in both eyes. Physical examination fails to reveal a
physical cause for this problem. Which of the following terms should the nurse use to describe this phenomenon
when charting the behavior?
a.La belle indifference
b.Malingering
c. Hypochondria
d.Confabulation

68. Nurse May is assigned to patient with PTSD. Which of the following observations would be most definitive when
Nurse May is assessing a patient with posttraumatic stress disorder?
a. Substance abuse
b. Aggression
c. Flashbacks
d. Depression

69. Disulfiram (Antabuse) is prescribed for a patient. Which of the following comments, if made by the patient, would
indicate correct understanding of the action of this medication?
a. “ I’ll drink fruit juice at social gatherings”
b. “ I’ll take my pulse four times a day”
c. “ I’ll lie down for half an hour after I take the pill”
d. “ I’ll take an antacid before my antabuse”
70. Which of the following arterial blood gas levels would nurse expect to observe when monitoring a patient who has
metabolic alkalosis?
a.pH, 7.50; pCO2, 38 mmHg; HC03, 30mEq
b.pH, 7.30; pCO2, 56 mmHg; HCO3, 24 mEq
c. pH, 7.38; pCO2, 42 mmHg; HCO3, 25 mEq
d.pH, 7.26; pCO2, 37 mmHg; HCO3, 18 mEq

71. While Jayvee, a burn patient is being transferred by Nurse Vicky from the burn unit to the operating room, the IV
bottle fell on Jayvee’s head. He sustained a laceration on his forehead. Nurse Vicky was proven guilty of
negligence. Which of the following did nurse Vicky fail to do?
a. Hold the IV bottle
b. Check the IV stand
c. Place the IV stand on the foot part of the stretcher
d. Restrain Jayvee

72. Nurse Krystel is caring for client Olga. Olga is receiving D5W 1 liter regulated at 30 drops/min to be consumed in
8 hrs. It was started at 8am. At 10 am her relative informed Nurse Krystel that the bottle is empty. Which of the
following will Nurse Krystel do first?
a.Refer to nurse manager
b.Assess Olga and check level of fluid left in the bottle
c. Discontinue IV and assess Olga
d.Replace the IV fluid with prescribed follow-up

73. When Nurse Lynchen Jeanne volunteers to work in a hospital setting and she commits a mistake, who is legally
responsible?
a. Volunteer nurse, hospital and the nurse in charge
b. The professional organization which the volunteer nurse represents
c. Hospital
d. Volunteer nurse because there is no employer employee relationship

74. Nurse Mark Lawrence is reviewing the laboratory results of Clare who has rheumatoid arthritis. Which laboratory
result should the nurse expect to find?
a. Increased platelet count
b. Altered blood urea nitrogen (BUN) and creatinine levels
c. Electrolyte imbalance
d. Elevated erythrocyte sedimentation rate (ESR)

75. Nurse Joseph T. accidentally administer 40 mg of Propanolol (Inderal) to a client instead of 10 mg. Although the
client exhibits no adverse reactions to the larger dose, Nurse Joseph T should:
a. Complete an incident report
b. Call the hospital attorney
c. Inform the clients family
d. Do nothing because the clients condition is stable

Situation 13 – Nurses Denice and Cynthia are going to participate in a Cancer Consciousness Week. They are assigned
to take charge of the women to make them aware of cancer, most especially cervical cancer. They reviewed their
manifestations and management.

76. The following are risk factors for cervical Cancer EXCEPT:
a. immunosuppressive therapy
b. sex at an early age, multiple partners, exposure to socially transmitted diseases, male partner's sexual
habits
c. viral agents like the Human Papilloma Virus
 d. smoking

77. Late signs and symptoms of cervical cancer include the following EXCEPT:
a. urinary/bowel changes
b. pain in pelvis, leg of flank
c. uterine bleeding
d. lymph edema of lower extremities

78. When a total hysterectomy is performed due to cancer of the cervix, which of the following organs are removed?
a. the uterus, cervix, fallopian tubes and one ovary
b. the uterus, cervix, and two-thirds of the vagina
c. the uterus, cervix, tubes and ovaries
d. the uterus and cervix

79. A client with cervical cancer is being treated with a radioactive cervical implant. The client's husband asks
the nurse if he can spend the night with his wife. The nurse should explain that:
a. Overnight stays by family members is against hospital policy.

b. There is no need for him to stay because staffing is adequate.

c. His wife will rest much better knowing that he is at home.

d. Visitation is limited to 30 minutes when the implant is in place.

80. A client with bladder cancer is being treated with iridium seed implants. The nurse's discharge teaching should
include telling the client to:

a.Strain his urine

b.Increase his fluid intake

c. Report urinary frequency

d.Avoid prolonged sitting

Situation 14 - Mr. Muscle, age 63, is admitted to the hospital with a diagnosis of Congestive Heart Failure (CHF). The
physician’s orders include 500 mg of chlorothiazide (Diuril) P.O. twice daily and 0.25 mg of Digoxin (Lanoxin) P.O. daily.

81. Assessment of Mr. Muscle would most likely reveal:

a. Crushing chest pain unrelieved by rest or nitroglycerin ( Nitro-Bid)
b. Diaphoresis with cool, clammy skin
c. Distended neck veins and dependent pitting edema
d. Fever and elevated white blood cell count.

81. Mr. Muscle is in the acute phase of left ventricular heart failure. To alleviate his symptoms, the nurse should
place him in:
a. The dorsal recumbent position with elevated feet to reduce edema.
b. An upright position to promote chest expansion.
c. The low-fowlers position with elevated knees to slow the return of blood to the heart.
d. The left lateral sims position to promote emptying to ride side of the heart.

83. Nurse Charm administers chlorothiazide. This drug should alleviate Mr. Muscle’s symptoms by:
a. Reducing circulatory volume through dieresis
b. Strengthening the force of ventricular contractions
c. Reducing the rate of metabolism and the body’s need for oxygen
d. Slowing the rate of heart contractions.

84. Mr. Muscle is placed on a strict low-sodium, high potassium diet. Which lunch menu is most appropriate for him?
a. Bologna sandwich on low-sodium bread, carrot sticks, orange, and skim milk.
b. Tuna fish, noodle and vegetable casserole, banana and coffee.
c. Boiled egg sandwich on low-sodium toast; lettuce, tomato, onion salad; banana; skim milk.
d. Chicken sandwich on low sodium bread, celery sticks, apple, and tea with lemon.

85. When assessing Mr. Muscle for sign and symptoms of digoxin toxicity, the nurse should watch for all
of the following except:
a. Bradycardia, tachycardia, begimeny, ectopic beats, and pulse deficits.
b. Anorexia, nausea and vomiting, diarrhea, and abdominal pain.
c. Headache, double or blurred vision, drowsiness, confusion, restlessness, and muscle weakness.
d. Abdominal distention, weakness, paralysis, apathy, depression and hallucinations

Situation 15 - Mr.Pakyaw has had a persistent cough for about 4 months. One week ago, he noted blood in his sputum.
He is admitted in the hospital for diagnostic testing. The physician orders a bronchoscopy.

86. Immediately after the bronchoscopy, the nurse should withhold food and fluid until Mr. Pakyaw’s
 gag reflex returns, to prevent:
a. Aspiration
b. Abdominal distention
c. Dyspnea
d. Dyspepsia

87. Mr Pakyaw is diagnosed with lung cancer. The physician orders various pulmonary function tests,
including measurements of forced vital capacity and forced expiratory volume. The test results are used
before surgery to:
a. Evaluate the spread of the disease
b. Estimate the amount of anesthesia needed for surgery
c. Determine the amount of lung tissue to be removed
d. Calculate whether the contemplated surgery will leave enough functioning lung tissue

88. After lobectomy, Mr. Pakyaw is returned to the unit with chest tubes in place. The nurse assigns a
nursing diagnosis of Impaired gas exchange related to lung alterations after surgery. With this diagnosis,
the expected outcome is that the patient will:
a. Report less chest pain
b. Assume a semi-fowlers position
c. Request pain medication frequently
d. Exhibit a respiratory rate of less than 20 breaths / minute without dyspnea

89. Mr. Pakyaw will undergo radiation therapy on an outpatient basis to treat the lung cancer. When teaching
Mr. Pakyaw about skin care, the nurse should encourage him to:
a. Use skin lotions and powders on the irradiated area
b. Avoid washing off the marks placed on his skin to guide radiation therapy
c. Wear constrictive clothing
d. Massage the irradiated area to increase circulation

90. Mr. Pakyaw’s wife, Chenny, is concerned about his poor appetite and weight loss. Nurse Erika explains
to her that radiation treatment, anxiety, and the disease itself can cause anorexia in cancer patients.
Nurse Erika should encourage Mr. Pakyaw to:
a. Limit activity before and after meals
b. Force fluids
c. Eat high calorie foods
d. Eat hot meat dishes with special sauces

Situation 16 - Mrs.Dyangga, age 53, has been experiencing bone pain, recurrent infections and abdominal pain for the
past 5 years. After ordering a battery of tests, including x-ray studies, the physician diagnoses Multiple Myeloma.

91. The physician orders administration of melphalan (Alkeran) for Mrs. Dyangga because this drug
causes pancytopenia, the nurse should assess the patient for:
a. Alopecia
b. Skin pigmentation changes
c. Thrombophlebitis
d. Decreased WBC count

92. Nursing care for Mrs. Dyangga should include:

a. Giving 2,000 ml of fluids daily
b. Giving more than 3,000 ml of fluid daily
c. Restricting fluid intake to equal the patient’s insensible fluid loss
d. Encouraging increased intake of fluids, particularly milk

Situation 17 - Nurse Lucille is caring for Madame L, age 59, in the hospital with tentative diagnosis of stage III B
Hodgkins disease.

93. Which assessment finding strongly indicates Hodgkin’s disease?

a. Night sweats
b. Enlarged lymph nodes
c. Reed-Sternberg cells
d. Hepatomegaly

94. The usual drug therapy for the patient with stage III B Hodgkin’s disease is called MOPP. The “O” in MOPP
stands for:
a. Prednisone (Orasone)
b. Vincristine (Oncovin)
c. Oxacillin (Bactocill)
d. Oxamniquine (Vansil)

95. Which nursing intervention is most effective in relieving nausea and vomiting associated with MOPP therapy?
a. Administering an antiemetic simultaneously with the drug
b. Encouraging the patient to drink hot liquids, such as coffee or tea
c. Giving an antiemetic 1 to 3 hours before MOPP administration
d. Provide frequent oral hygiene
 96. A patient who has sustained a fracture of femur is at risk for which of the following complications in the
immediate post-fracture period?
a. Electrolyte imbalance
b. Fat embolus
c. Fluid Volume deficit
d. Disuse Syndrome

97. A patient who has a long leg cast says to Nurse Hazel, “My thigh is itching under the cast.” To provide relief,
Nurse Hazel should?
a. teach patient guided imagery techniques.
b. apply heat to the cast at the site of the itching.
c. elevate the patients affected leg on pillows
d. encourage the patient to move his/her toes.

98. Nurse Cherry is caring for a patient who is receiving litium carbonate (Eskalith). Prior to administration of
the next dose, Nurse Cherry finds that the patient’s lithiumblood level is 1.6 mEq /dL. Which of the
following actions should Nurse Cherry take first?
a. Call the patient’s physician
b. Withhold the dose
c. Take the patients Vital signs
d. Repeat the blood lithium level

99. Which of the following goals would be given priority in the care plan of a two year old child who
has acute gastroenteritis?
a. Promote hydration.
b. Reduce lethargy
c. Preserve skin integrity
d. Maintain comfort

100. A priority nursing intervention for the care of a terminally ill patient diagnosed with metastatic cancer is
a. Maintaining bowel function
b. Alleviating and relieving pain
c. Preventing respiratory arrest
d. managing chemotherapy.
Situation 1 - Jimmy developed his goal for hospitalization. "To get a handle on my nervousness." The nurse is going to
collaborate with him to reach his goal. Jimmy was admitted to the hospital because he called his therapist that he planned
to asphyxiate himself with exhaust from his car but frightened instead. He realized he needed help.

1. The nurse recognized that Jimmy had conceptualized his problem and the next priority goal in the care plan is:
a. help the client find meaning in his experience
b. help the client to plan alternatives
c. help the client cope with present problem
d. help the client to communicate

2. The nurse iq guided that Jimmy is aware of his concerns nf the "here and now" when he crossed out which item
from his "list of what to know"
a. anxiety laden uncmnscious conflicts
b. subjective idea of the range of mild to severe anxiety
c. early signs of anxiety
d. physiological indices of anxiety

3. While Jimmy was discussing the signs and symptoms of anxiety with his nurse, he recognized that complete
disruption of the ability to perceive occurs in:
a. panic state of anxiety
b. severe anxiety
c. moderate anxiety
d. mild anxiety

4. Jimmy initiates independence and takes an active part in his se£f care with the following EXCMPT:
a. agreeing to contact the staff when he is anxious
b. becoming aware of the conscious feeling
c. assessing need for medication and medicating himself
d. writing out a list of behaviors that he identifies as anxious

5.! The nurse notes effectiveness of Intervéntions in using subjective and objective data in the:
a. initial plans or order
b. database
c. problem list
d. progress notes

Situation 2 - A research study was undertaken in order to identify and analyze a disabled boy's coping reaction pattern
during stress.

6. This study which is a depth study of one boy is a:

a. case study
b. longitudinal study
c. cross-sectional study
 d. evaluative study

7. The process recording was the principal tool for data collection. Which of the following is NOT a part of a process
recording?
a. Non verbal narrative account
b. Audio and interpretation
c. Audio-visual recording
d. Verbal narrative account

8. Which of these does NOT happen in a descriptive study?

a. Describing relationship among variables
b. Exploration of relationships between two or more phenomena
c. Manipulation of phenomenon in real life context
d. Manipulation of a variable

9. The investigator also provided the nursing care of the subject. The investigator is referred to as a/an.
a. Participant-observer
b. Observer researcher
c. Caregiver
d. Advocate

10. To ensure reliability of the study, the investigator analysis and interpretations were:
a. subjected to statistical treatment
b. correlated with a list coping behaviors
c. subjected to an inter-observe agreement
d. scored and compared standard criteria

Situation 3 - During the morning endorsement, the outgoing nurse informed the nursing staff that Regina, 5 years old,
was given Flurazepam (Dalmane) 15 mg at 10:00pm because she had trouble going to sleep. Before approaching
Regina, the nurse read the observation of the night nurse.

11. Which of the following approaches of the nurse validates the data gathered?
a. "I learned that you were up till ten last night, tell me what happened before you were finally able to sleep
and how was your sleep?"
b. "Hmm...You look like you had a very sound sleep. That pill you were given last night is effective isn't
it?"
c. "Regina, did you sleep well?"
d. "Regina, how are you?"

12. Regina is a high school teacher. Which of these information LEAST communicate attention and care for her
needs for information about her medicine?
a. Guided by a medication teaching plan go over with her the purpose, indications and special instructions,
about the medication and provides her a checklist
b. Provide a drug literature and explain its contents
c. Have an informal conversation about the medication and its effects
d. Ask her what time she would like to watch the informative video about the medication

13. The nurse engages Regina in the process of mutual inquiry to provide an opportunity for Regina to
a. face emerging problems realistically
b. conceptualize her problem
c. cope with her present problem
d. perceive her participation in an experience

14. Which of these responses indicate that Regina needs further discussion regarding special instructions?
a. "I have to take this medicine judiciously."
b. "I know I will stop taking the medicine when there is an advice form the doctor for me to discontinue."
c. "I will inform you and the doctor any untoward reactions I have."
d. "I like taking this sleeping pill. It solves my problem of insomnia. I wish I can take it for life."

15. Regina commits to herself that she understood and will observe all the medicine precautions by;
a. affixing her signature to the teaching plan that she has understood the nurse
b. committing what she learned to her memory
c. verbally agreeing with the nurse
d. relying on her husband to remember the precautions

Situation 4 - The nurse-patient relationship is a modality through which the nurse meets the client's needs.

16. The nurse's most unique tool in working with the emotionally ill client is his/her:
a. theoretical knowledge
b. personality make up
c. emotional reactions
d. communication skills

17. The premise that an individual’s behavior and affect are largely determined by the attitudes and assumptions one
has developed about the world underlies:
 a. modeling
b. milieu therapy
c. cognitive therapy
d. psychoanalytic psychotherapy

18. One way to increase objectivity in dealing with one's fears and anxieties is through the process of:
a. observation
b. intervention
c. validation
d. collaboration

19. All of the following response are non therapeutic. Which is the MOST direct violation of the concept, congruence
of behavior?
a. Responding in a punitive manner to the client
b. Rejecting the client as a unique human being
c. Tolerating all behavior in the client
d. Communicating ambivalent messages to the client

20. The mentally ill person demonstrating a child-like behavior responds positively to the nurse who is warm and
caring. This demonstration of the nurse's role as:
a. counselor
b. parent surrogate
c. therapist
d. socializing agent

Situation 5 - The nurse engages the client in a nurse-patient interaction.

21. The best time to inform the client about terminating the nurse-patient relationship is
a. when the client asks, how long one relationship would be
b. during the working phase
c. towards the end of the relationship
d. at the start of the relationship

22. The client says, "I want to tell you something but can you promise that you will keep this, a secret?" A therapeutic
response of the nurse is:
a. "Yes, our interaction is confidential provided the information you tell me is not detrimental to your safety."
b. "Of course yes, this is just between you and me. Promise!"
c. "Yes, it is my principle to uphold my client's rights."
d. "Yes, you have the right to invoke confidentiality of our interaction."

23. When the nurse respects the client's self-disclosure, this is a gauge for the nurse's:
a. trustworthiness
b. loyalty
c. integrity
d. professionalism

24. Building trust is important in:

a. orientation phase of the relationship
b. the problem identification subphase of the relationship
c. all phases of the relationship
d. the exploitation phase

25. The client has not been visited by relatives for months. He gives a, telephone number and requests the nurse
to call. An appropriate action of the nurse would be:
a. Inform the attending psychiatric about the request of the client
b. Assist the client to bring his concern to the attention of the social worker
c. "Here (gives her mobile phone). You may call this number now."
d. Ask the client what is the purpose of contacting his relatives

Situation 6 - Camila, 25 years old, was reported to be gradually withdrawing and isolating herself from friends and family
members. She became neglectful of her personal hygiene. She was observed to be talking irrelevantly and incoherently.
She was diagnosed as schizophrenia

26. The past history of Camila would most probably reveal that her premorbid personality is:
a. schizoid
b. extrovert
c. ambivert
d. cycloid

27. Which of the following are considered the negative sign of schizophrenia?
a. Anhedonia, Restricted range of feelings, Catatonia
b. Delusions, hallucinations, disordered thinking
c. Ambivalence, Associative looseness, hallucinations
d. Alogia, Echopraxia, Ideas of reference
 28. Which of the following disturbances in interpersonal relationships MOST often predispose, to the development of
schizophrenia?
a. Lack of participation in peer groups
b. Faulty family atmosphere and interaction
c. Extreme rebellion towards authority figures
d. Solo parenting

29. Schizophrenia is best described as a disorder characterized by:

a. Disturbed relationship related to an inability to communicate and think clearly
b. Severe mood swings and periods of low to high activity
c. Multiple personalities, one of which is more destructive than the others
d. Auditory and visual hallucinations

30. Schizophrenia is a/an:

a. anxiety disorder
b. neurosis
c. psychosis
d. personality disorder

Situation 7 - Salome, 80 year old widow, has been observed to be irritable, demanding and speaking louder than usual.
She would prefer to be alone and take her meals by herself, minimized receiving visitors at home and no longer bothers to
answer telephone calls because of deterioration of her hearing. She was brought by her daughter to, the Geriatric clinic
for assessment and treatment.

31. The nurse counsels Salome's daughter that Salome's becoming very loud and tendency to become
aggressive is a/an:
a. beginning indifference to the world around her
b. attempt to maintain authoritative role
c. overcompensation for hearing loss
d. behavior indicative of unresolved repressed conflict of the part

32. A nursing diagnosis for Salome is:

a. sensory deprivation
b. social isolation
c. cognitive impairment
d. ego despair

33. The nurse will assist Salome and her daughter to plan a goal which is:
a. adjust to the loss of sensory and perceptual function
b. participate in conversation and other social situations
c. accept the steady loss of hearing that occurs with aging
d. increase her self-esteem to maintain her authoritative role

34. The daughter understood the following ways to assist Salome meet her needs and avoiding which of the following:
a. Using short simple sentences
b. Speaking distinctly and slowly
c. Speaking at eye level and having the client's attention
d. Allowing her to take her meals alone

35. Salome was fitted a hearing aid. She understood the proper use and wear of this device when she ways that the
battery should be functional, the device is turned on and adjusted to a:
a. therapeutic level
b. comfortable level
c. prescribed level
d. audible level

Situation 8 - For more than a month now, Cecilia is persistently feeling restless, worried and feeling as if something
dreadful is going to happen. She fears being alone in places and situations where she thinks that no one might come to
rescue her just in case something happens to her.

36. Cecilia is demonstrating:

a. acrophobia
b. claustrophobia
c. agoraphobia
d. xenophobia

37. Cecilia's problem is that she always sees and thinks negative hence she is always fearful. Phobia is a symptom
described as:
a. organic
b. psychosomatic
c. psychotic
d. neurotic

CORRECT ANSWER: D
 RATIONALE: pertaining to neurosis, a category of mental disorder in which the symptoms are distressing to the
person, reality testing is intact, behavior does not violate gross social norms and there is no apparent organic
cause. The person who is neurotic is said to be emotionally unstable
OPTION A- organic disease or condition is any disease associated with detectable or observable changes in one
or more body organs
OPTION B- expression of an emotional conflict through physical symptoms
OPTION C- not in contact with reality
SOURCE: Mosby, Mosby’s Pocket Dictionary,4th ed, pp 856, 900, 1049, 1050

38. Cecilia has a lot of irrational thoughts: The goal of therapy is to modify her:
a. communication
b. cognition
c. observation
d. perception

39. Cognitive therapy is indicated for Cecilia when she is already able to handle anxiety reactions. Which of the
following should the nurse implement?
a. assist her in recognizing irrational beliefs and thoughts
b. help find meaning in her behavior
c. provide positive reinforcement for acceptable behavior
d. administer anxiolytic drug

40. After discharge, which of these behaviors indicate a positive result of being able to overcome her phobia?
a. she read a book in the public library
b. she drives alone along the long expressway
c. she watches television with the family in the recreation room
d. she goes out with a friend

Situation 9 - it is the first day of clinical experience of nursing students at the Psychiatry Ward- During the orientation, the
nurse emphasizes that the team members including nursing students are legally responsible to safeguard patient's
records from loss or destruction or from people not authorized to read it.

41. It is unethical to tell one's friends and family member's data bout patients because doing so is violation of
patients' rights to:
a. Informed consent
b. Confidentiality
c. Least restrictive environment
d. Civil liberty

42. The ourse must see to it that the written consent of mentally ill patients must be taken from:
a. Doctor
b. Social worker
c. Parents or legal guardian
d. Law enforcement authorities

43. In an extreme situation and when no other resident or intern is available, should a nurse receive, telephone
orders, the order has to be correctly written and signed by the physician within.
a. 24 hours
b. 36 hours
c. 48 hours
d. 12 hours

44. The following are SOAP (Subjective - Objective - Analysis -Plan) statements on a problem: Anxiety about
diagnosis. What is the objective data?
a. Relate patient's feelings to physician initiate and encourage her to verbalize her fears give emotional support
by spending more time with patient, continue to make necessary explanations regarding diagnostic test.
b. Has periods of crying, frequently verbalizes fear of what diagnostic tests will reveal
c. Anxiety due to the unknown
d. "I'm so worried about what else they'll find wrong with me"

45. Nursing care plans provide very meaningful data for the patient profile and initial plan because the focus is on the:
a. Summary of chronological notations made by individual’s health team members
b. Identification of patient's responses to medical diagnosis and treatment
c. Patient's responses to health and illness as a total person in interaction with the environment
d. Step procedures for the management of common problems

Situation 10 - Marie is 5 years old and described by the mother as bedwetting at night.

46. Which of the following is NOT a common cause of night bedwetting?

a. deep sleep factors
b. abnormal bladder development or structure problems
c. infections familial and genetic factors
d. drinking plenty of water before sleep
 47. All of the following, EXCEPT one comprise the concepts of behavior therapy program:
a. reward and punishment
b. extinction
c. learning
d. placebo as a form treatment

48. To help Marie who bed wets at night practice acceptable and appropriate behavior, it is important for the parents
to be consistent with the following approaches EXCEPT:
a. discipline with a king attitude
b. matter of fact in handling the behavior
c. sympathize for the child
d. be lowing yet firm

49. Which of the following is used to treat enuresis?

a. Imipramine (Tofranil)
b. Methylphenidate (Ritalin)
c. Olanzapine (Zyprexa)
d. Resperidone (Risperdal)

50. During your conference, the parent inquires how to motivate Marie to be dry in the morning. Your response which
is an immediate intervention would be:
a. Give a star each time she wakes up dry and every set of five stars, give a prize
b. Tokens make her materialistic at an early age. Give praise and hugs occasionally
c. What does your child want that you can give every time he/she wakes up dry in the morning?
d. Promise him/her a long awaited vacation after school is over.

Situation 11 - The nurse is often met with the following situations when clients become angry and hostile.

51. 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 pocket
c. fold his/her arms across his/her chest
d. keep an "open" posture, e.g. Hands by sides but palms turned outwards

52. During the pre-interaction phase of the N-P relationship the nurse recognizes this normal 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 the other members of the team
d. To stay and fight or run away

53. 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."

54. 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?"

55. A patient grabs a chair 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 12 - Nursing care for the elderly.

56. 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

57. A healthy adaptation to aging is primarily related to an individual.

a. Number of accomplishments
b. Ability to avoid interpersonal conflict
c. Physical health throughout life
d. Personality development in his life span
 58. 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

59. An elderly confused client gets out of bed at night to go to the bathroom and tries to go to another bed when she
returns. The MOST appropriate action the nurse would take is to:
a. Assign client to a single room
b. Leave a light on all night
c. Remind client to call the nurse when she wants to get up
d. put side rails on the bed

60. An elderly who has lots of regrets, unhappy and miserable is experiencing:
a. Crisis
b. Despair
c. Loss
d. Ambivalence

Situation 13 – Graciela, 1 year old is admitted in the hospital from the emergency room with a fracture of the left femur
due to a fall down a flight of stairs. Graciela is placed oh Bryant's traction.

61. While on Bryant's traction, which of these observations of Graciela and her traction apparatus would indicate a
decrease in the effectiveness of her traction?
a. Graciela's buttocks are resting on the bed
b. The traction weights are hanging 10 inches above the floor
c. Graciela's legs are suspended at a 90 degree angle to her trunk
d. The traction ropes move freely through the pulley

62. The nurse notes that the fall might also cause a possible head injury- She will be observed for signs of increased
intracranial pressure which include:
a. Narrowing of the pulse pressure
b. Vomiting
c. Periorbital edema
d. A positive Kernig's sign

63. Graciela is assessed to have no head injury. The Bryant's traction is removed. A plaster of paris is applied to his
spica. Which of these finding as a concern of immediate attention that must be reported to the physician
immediately?
a. Graciela is scratching the cast over her abdomen
b. The toes of Graciela's left foot blanch when the nurse applies pressure on them
c. Graciela's cast is still damp
d. The nurse is unable to insert a finger under the edge of Graciela's cast on her left foot

64. Part of discharge plan is for the nurse to give instructions about the care of Graciela's cast to the mother.
Which of statement by the mother indicates a need for further instructions?
a. “The cast may feel warm as the cast dries.”
b. “If the cast becomes wet, a blow drier set on the cool setting may be used to dry cast.”
c. “A small amount of white shoe polish can touch up a soiled white cast.”
d. “I can use lotion or powder around the cast edges to relieve itching.”

65. The nurse counsels Graciela's mother ways to safeguard safety while providing opportunities of Graciela to
develop a sense of:
a. Trust
b. Initiative
c. Industry
d. Autonomy

66. Jolina is out on antidepressant drugs. These drugs act on the brain chemistry, therefore they would be useful in
which type of depression?
a. exogenous depression
b. neurotic depression
c. endogenous depression
d. psychotic depression

67. This is a tricyclic antidepressant drug:

a. Venlafaxine (Effexor)
c. Setraline (Zoloft)
b. Flouxetine (Prozac)
d. Imipramine (Tofranil)

68. After one week of antidepressant medication, Jolina still manifests depression. The nurse evaluates this as;
a. Unusual because action of antidepressant drug is immediate
b. Unexpected because therapeutic effectiveness takes within a few days
 c. Expected because therapeutic effectiveness takes 2-4 weeks
d. Ineffective result because perhaps the drug's dosage is inadequate

69. Jolina continues to verbalize feeling sad and hopeless. She is not mixing well with other clients. One of the
nurse's important consideration for Jolina initially is to:
a. Formulate a structured schedule so she is able to channel her energies externally
b. Let her alone until she feels like mingling with others
c. Encourage her to join socialization hour so she will start to relate with others
d. Encourage her to join group therapy with other patients

70. During the predischarge conference, the nurse suggests vocational guidance because it should help Jolina to:
a. Find a good job
b. Make some decision about her future
c. Realistically assess her assets and limitations
d. to solve her own problems

Situation 15 - Group Approach in Nursing.

71. Membership drop out generally occurs in group therapy after a member:
a. Accomplishes his goal in joining the group
b. Discovers that his feelings are shared by the group members
c. Monopolizes the group
d. Discusses personal concerns with group members

72. Which of the following questions illustrates the group role of encourager?
a. What were you saying?
b. Who wants to respond next?
c. Where do you go from here?
d. Why haven't we heard from you?

73. The goal of remotivation therapy is to facilitate:

a. Insight
b. Productivity
c. Socialization
d. Intimacy

74. The treatment of the family as a unit is based on the belief that the family:
a.is a social system and all the members are interrelated components of that system
b.as a unit of society needs the opportunity to change its own destiny
c. who has therapy together will tend to remain together
d.is "contaminated" by the presence of deviant member and all members need treatment

75. The working phase in therapy group is usually characterized by which of the following?
a. Caution
b. Cohesiveness
c. Confusion
d. Competition

Situation 16 – It is the nurse’s primary responsibility to ensure a safe environment for the patients at the Psychiatry Ward.

76. All of the following concepts are true, EXCEPT:

a. Hostility is destructive
b. Frustration develops in response to unmeet needs, wants and desires
c. Anger is incompatible with love
d. Aggression can be expressed in a constructive as well as destructive manner

77. Carlo is acting out hostile and aggressive feelings such as yelling, agitated, threatening, clenched fist, threatening
gestures, hostility. 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 harmful objects from the room
d. restrain the patient and place him in the “Isolation Room”

78. Mrs. Dizon was visiting her son at the Psychiatry Ward. Which of the following items will the nurse not allow to be
brought inside the ward?
a. string rosary bracelet
b. box of cake
c. bottle of coke
d. rubber shoes

79. 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
 80. Which of the following must be considered while planning activities for the depressed patient?
a. activities which require exertion of energy
b. challenging activities to get him out of his depression
c. reading materials to divert his thoughts
d. variety of unstructured activities

Situation 17 - Nurse's in all practice areas are likely to come in contact with clients suffering from acute or chronic drug
abuse.

81. The psychodynamic therapy of substance abuse is based upon the premise that drug abuse is:
a. a common problem brought about by socioeconomic deprivation
b. caused by multiplicity of factors
c. predisposed by an inability to develop appropriate psychological resources to manage developmental stresses
d. due to biochemical factors

82. Being in contact with reality and the environment is a function of the:
a. conscience
b. ego
c. id
d. super ego

83. Substance abuse is different from substance dependence in the sense that substance dependence:
a. includes characteristics of adverse consequences and repeated use
b. requires long term treatment in a hospital based program
c. produces less severe symptoms than that of abuse
d. includes characteristics of tolerance and withdrawal

84. During the detoxification stage, it is a priority for the nurse to:
a. teach skills to recognize and respond to health threatening situations
b. increase the client's awareness of unsatisfactory protective behaviors
c. implement behavior modification
d. promote homeostasis and minimize the client's withdrawal symptoms
85. Commonly known as "shabu" is:
a. Cannabis Sativa
b. Lysergic add diethylamide
c. Methylenedioxy methamphetamine
d. Methamphetamine hydrochloride

Situation 18 - It is common that client ask the nurse personal questions.

86. Anticipation of personal questions is given adequate attention during which phase of the nurse patient
relationship?
a. Orientation phase
b. Working phase
c. Pre-interaction phase
d. Termination phase

87. The client asks for the nurse's telephone number, which of these responses is NOT appropriate?
a. "it is confidential I just don't give it to anyone."
b. "What would you do with my number if I give it to you?"
c. "If I say no to your request, what are your thoughts about it?"
d. "Are you asking for an official number of the hospital/clinic for your reference?"

88. When the client asks about the family of the nurse the MOST appropriate response is:
a. Avoid the situation and redirect the client's attention
b. Give a brief and simple response and focus on the client
c. "Why don't we talk about your family instead?"
d. Introduce another topic like the client's interests

89. When the nurse is asked a personal question, which of these reactions indicates a need for her to introspect?
a. The client is simply curious
b. His/her right to privacy is being intruded
c. The client knows no other way to begin a conversation
d. Some patients are like children in seeking recognition from the nurse

90. It is 10 o'clock of your watch. The client asks, "What time is it?" The nurse's appropriate response is:
a. "Are you bored?"
b. "It is 10 o'clock."
c. "Why do you ask?"
d. "Guess, what time is it?"

Situation 19 – Jim, age 25, recalled that his problem began around age 15 or 16. He would count pencils in a mug over
and over with the thought that stopping could result in something bad happening.
 91. There are many things Jim seems he has to do to keep him from getting:
a. confused
b. suspicious
c. excited
d. anxious

92. He has to change clothes 20 times before work, chew each bite he eats 24 times and go up and down the stairs
four to five times before it feels right. He is demonstrating:
a. ideas of reference
b. denial and projection
c. obsession and compulsion
d. rationalization and over reaction

93. The objective of nursing care for Jim is to develop or increase feelings of:
a. self-mastery
b. self actualization
c. self worth
d. self-determination

94. All of these are therapeutic interventions, EXCEPT:

a. impose limits every time the behaviour becomes repetitive
b. establish a routine for him
c. assign task that can be done repetitively
d. facilitate self-expression

95. Jim is aware of his behavior, yet realizes that it is very disturbing to him. This is a pattern of:
a. personality disorder
b. psychosis
c. neurosis
d. habitual disorder

Situation 20 - The abuse of dangerous drug is a serious public health concern that nurses need to address

96. The nurse should recognize that the unit primarily responsible for education and awareness of the members
of the family on the ill effects of dangerous drugs is the:
a. law enforcement agencies
b. school
c. church
d. family

97. A drug dependent utilizes these defense mechanisms, EXCEPT:

a. sublimation
b. rationalization
c. projection
d. denial

98. This drug produces mirthfulness, fantasies, flight of ideas, loss of train of thought, distortion of size, distance and
time, and "bloodshot eyes", due to dilated pupils.
a. Opiates
b. LSD
c. Marijuana
d. Heroin

99. The nurse evaluates that-.her health teaching to a group of high school boys is effective if these students
recognize which of the following dangers of inhalant abuse.
a. Sudden death from cardiac or respiratory depression
b. Danger of acquiring hepatitis or AIDS
c. Experience of "blackout"
d. Psychological dependence after prolonged use

100. The mother of a drug dependent would never consider referring her son to a drug rehabilitation agency
because she fears her son might just becomes worse while relating with other drugs users. The mother's
behavior can be described as:
a. Unhelpful
b. Codependent
c. Caretaking
d. Supportive

CORRECT ANSWER: A
RATIONALE: Mother displays unwillingness in providing assistance and support to her son in getting well
OPTION B- a situation in which a person such as the partner of an alcoholic or parent of a drug-addicted
child needs to feel needed by the other person
OPTION C- giving care or emotional support to another
OPTION D- being understanding, giving moral or emotional support
SOURCE: Encarta Dictionaries