NP - 1
Nurse Gail places a client in a four-point
1. The nurse In-charge in labor and delivery
unit administered a dose of terbutaline to a
client without checking the client’s pulse.
The standard that would be used to
determine if the nurse was negligent is:
A. The physician’s orders.
B. The action of a clinical nurse specialist
who is recognized expert in the field.
C. The statement in the drug literature
about administration of terbutaline.
D. The actions of a reasonably prudent
nurse with similar education and
experience.
2. Nurse Trish is caring for a female client
with a history of GI bleeding, sickle cell
disease, and a platelet count of 22,000/μl.
The female client is dehydrated and
receiving dextrose 5% in half-normal saline
solution at 150 ml/hr. The client complains
of severe bone pain and is scheduled to
receive a dose of morphine sulfate. In
administering the medication, Nurse Trish
should avoid which route?
A. I.V
B. I.M
C. Oral
D. S.C
3. Dr. Garcia writes the following order for
the client who has been recently admitted
“Digoxin .125 mg P.O. once daily.” To
prevent a dosage error, how should the nurse
document this order onto the medication
administration record?
A. “Digoxin .1250 mg P.O. once daily”
B. “Digoxin 0.1250 mg P.O. once daily”
C. “Digoxin 0.125 mg P.O. once daily”
D. “Digoxin .125 mg P.O. once daily”
4. A newly admitted female client was
diagnosed with deep vein thrombosis.
Which nursing diagnosis should receive the
highest priority?
A. Ineffective peripheral tissue perfusion
related to venous congestion.
B. Risk for injury related to edema.
C. Excess fluid volume related to
peripheral vascular disease.
D. Impaired gas exchange related to
increased blood flow.
5. Nurse Betty is assigned to the following
clients. The client that the nurse would see
first after endorsement?
A. A 34 year-old post operative
appendectomy client of five hours who
is complaining of pain.
B. A 44 year-old myocardial infarction
(MI) client who is complaining of
nausea.
C. A 26 year-old client admitted for
dehydration whose intravenous (IV) has
infiltrated.
D. A 63 year-old post operative’s
abdominal hysterectomy client of three
days whose incisional dressing is
saturated with serosanguinous fluid.
6.
restraint following orders from the
physician. The client care plan should
include:
A. Assess temperature frequently.
B. Provide diversional activities.
C. Check circulation every 15-30 minutes.
D. Socialize with other patients once a
shift.
7. A male client who has severe burns is
receiving H2 receptor antagonist therapy.
The nurse In-charge knows the purpose of
this therapy is to:
A. Prevent stress ulcer
B. Block prostaglandin synthesis
C. Facilitate protein synthesis.
D. Enhance gas exchange
8. The doctor orders hourly urine output
measurement for a postoperative male client.
The nurse Trish records the following
amounts of output for 2 consecutive hours: 8
a.m.: 50 ml; 9 a.m.: 60 ml. Based on these
amounts, which action should the nurse
take?
A. Increase the I.V. fluid infusion rate
B. Irrigate the indwelling urinary catheter
C. Notify the physician
D. Continue to monitor and record hourly
urine output
9. Tony, a basketball player twist his right
ankle while playing on the court and seeks
care for ankle pain and swelling. After the
nurse applies ice to the ankle for 30 minutes, C. Emphasize the use of group C. Wash the skin over regularly.
which statement by Tony suggests that ice collaboration. D. Apply lotion or oil to the radiated area
application has been effective? D. Concentrates on tasks and activities. when it is red or sore.

A. “My ankle looks less swollen now”. 13.Which type of medication order might 17.In assisting a female client for immediate
B. “My ankle feels warm”. read “Vitamin K 10 mg I.M. daily × 3 surgery, the nurse In-charge is aware that
C. “My ankle appears redder now”. days?” she should:
D. “I need something stronger for pain
relief” A. Single order A. Encourage the client to void following
B. Standard written order preoperative medication.
10.The physician prescribes a loop diuretic C. Standing order B. Explore the client’s fears and anxieties
for a client. When administering this drug, D. Stat order about the surgery.
the nurse anticipates that the client may C. Assist the client in removing dentures
develop which electrolyte imbalance? 14.A female client with a fecal impaction and nail polish.
frequently exhibits which clinical D. Encourage the client to drink water
A. Hypernatremia manifestation? prior to surgery.
B. Hyperkalemia
C. Hypokalemia A. Increased appetite 18. A male client is admitted and diagnosed
D. Hypervolemia B. Loss of urge to defecate with acute pancreatitis after a holiday
C. Hard, brown, formed stools celebration of excessive food and alcohol.
11.She finds out that some managers have D. Liquid or semi-liquid stools Which assessment finding reflects this
benevolent-authoritative style of diagnosis?
management. Which of the following 15.Nurse Linda prepares to perform an
behaviors will she exhibit most likely? otoscopic examination on a female client. A. Blood pressure above normal range.
For proper visualization, the nurse should B. Presence of crackles in both lung fields.
A. Have condescending trust and position the client’s ear by: C. Hyperactive bowel sounds
confidence in their subordinates. D. Sudden onset of continuous epigastric
B. Gives economic and ego awards. A. Pulling the lobule down and back and back pain.
C. Communicates downward to staffs. B. Pulling the helix up and forward
D. Allows decision making among C. Pulling the helix up and back 19. Which dietary guidelines are important
subordinates. D. Pulling the lobule down and forward for nurse Oliver to implement in caring for
the client with burns?
12. Nurse Amy is aware that the following is 16. Which instruction should nurse Tom
true about functional nursing give to a male client who is having external A. Provide high-fiber, high-fat diet
radiation therapy: B. Provide high-protein, high-
A. Provides continuous, coordinated and carbohydrate diet.
comprehensive nursing services. A. Protect the irritated skin from sunlight. C. Monitor intake to prevent weight gain.
B. One-to-one nurse patient ratio. B. Eat 3 to 4 hours before treatment. D. Provide ice chips or water intake.

20.Nurse Hazel will administer a unit of
whole blood, which priority information
should the nurse have about the client?
A. Blood pressure and pulse rate.
B. Height and weight.
C. Calcium and potassium levels
D. Hgb and Hct levels.
21. Nurse Michelle witnesses a female client
sustain a fall and suspects that the leg may
be broken. The nurse takes which priority
action?
A. Takes a set of vital signs.
B. Call the radiology department for X-
ray.
C. Reassure the client that everything will
be alright.
D. Immobilize the leg before moving the
client.
22.A male client is being transferred to the
nursing unit for admission after receiving a
radium implant for bladder cancer. The
nurse in-charge would take which priority
action in the care of this client?
A. Place client on reverse isolation.
B. Admit the client into a private room.
C. Encourage the client to take frequent
rest periods.
D. Encourage family and friends to visit.
23.A newly admitted female client was
diagnosed with agranulocytosis. The nurse
formulates which priority nursing diagnosis?
A. Constipation C. 1.5 cc
B. Diarrhea D. 2.5 cc
C. Risk for infection
D. Deficient knowledge 27.A child of 10 years old is to receive 400
cc of IV fluid in an 8 hour shift. The IV drip
24.A male client is receiving total parenteral factor is 60. The IV rate that will deliver this
nutrition suddenly demonstrates signs and amount is:
symptoms of an air embolism. What is the
priority action by the nurse? A. 50 cc/ hour
B. 55 cc/ hour
A. Notify the physician. C. 24 cc/ hour
B. Place the client on the left side in the D. 66 cc/ hour
Trendelenburg position.
C. Place the client in high-Fowlers 28.The nurse is aware that the most
position. important nursing action when a client
D. Stop the total parenteral nutrition. returns from surgery is:
25.Nurse May attends an educational A. Assess the IV for type of fluid and rate
conference on leadership styles. The nurse is of flow.
sitting with a nurse employed at a large B. Assess the client for presence of pain.
trauma center who states that the leadership C. Assess the Foley catheter for patency
style at the trauma center is task-oriented and urine output
and directive. The nurse determines that the D. Assess the dressing for drainage.
leadership style used at the trauma center is: 29. Which of the following vital sign
assessments that may indicate cardiogenic
A. Autocratic. shock after myocardial infarction?
B. Laissez-faire.
C. Democratic. A. BP – 80/60, Pulse – 110 irregular
D. Situational B. BP – 90/50, Pulse – 50 regular
C. BP – 130/80, Pulse – 100 regular
26.The physician orders DS 500 cc with KCl D. BP – 180/100, Pulse – 90 irregular
10 mEq/liter at 30 cc/hr. The nurse in-charge
is going to hang a 500 cc bag. KCl is 30.Which is the most appropriate nursing
supplied 20 mEq/10 cc. How many cc’s of action in obtaining a blood pressure
KCl will be added to the IV solution? measurement?
A. .5 cc A. Take the proper equipment, place the
B. 5 cc client in a comfortable position, and
 record the appropriate information in A. Trochanter roll extending from the crest 37.The physician prescribes meperidine
the client’s chart. of the ileum to the midthigh. (Demerol), 75 mg I.M. every 4 hours as
B. Measure the client’s arm, if you are not B. Pillows under the lower legs. needed, to control a client’s postoperative
sure of the size of cuff to use. C. Footboard pain. The package insert is “Meperidine, 100
C. Have the client recline or sit D. Hip-abductor pillow mg/ml.” How many milliliters of meperidine
comfortably in a chair with the forearm should the
at the level of the heart. 34.Which stage of pressure ulcer client receive?
D. Document the measurement, which development does the ulcer extend into the
extremity was used, and the position subcutaneous tissue? A. 0.75
that the client was in during the B. 0.6
measurement. A. Stage I C. 0.5
B. Stage II D. 0.25
31.Asking the questions to determine if the C. Stage III
person understands the health teaching D. Stage IV 38. A male client with diabetes mellitus is
provided by the nurse would be included receiving insulin. Which statement correctly
during which step of the nursing process? 35.When the method of wound healing is describes an insulin unit?
one in which wound edges are not surgically
A. Assessment approximated and integumentary continuity A. It’s a common measurement in the
B. Evaluation is restored by granulations, the wound metric system.
C. Implementation healing is termed B. It’s the basis for solids in the
D. Planning and goals avoirdupois system.
A. Second intention healing C. It’s the smallest measurement in the
32.Which of the following item is B. Primary intention healing apothecary system.
considered the single most important factor C. Third intention healing D. It’s a measure of effect, not a standard
in assisting the health professional in D. First intention healing measure of weight or quantity.
arriving at a diagnosis or determining the
person’s needs? 36.An 80-year-old male client is admitted to 39.Nurse Oliver measures a client’s
the hospital with a diagnosis of pneumonia. temperature at 102° F. What is the
A. Diagnostic test results Nurse Oliver learns that the client lives equivalent Centigrade temperature?
B. Biographical date alone and hasn’t been eating or drinking.
C. History of present illness When assessing him for dehydration, nurse A. 40.1 °C
D. Physical examination Oliver would expect to find: B. 38.9 °C
C. 48 °C
33.In preventing the development of an A. Hypothermia D. 38 °C
external rotation deformity of the hip in a B. Hypertension 40.The nurse is assessing a 48-year-old
client who must remain in bed for any C. Distended neck veins client who has come to the physician’s
period of time, the most appropriate nursing D. Tachycardia office for his annual physical exam. One of
action would be to use: the first physical signs of aging is:
 A. Accepting limitations while developing B. 32 drops/minute A. Summative
assets. C. 20 drops/minute B. Informative
B. Increasing loss of muscle tone. D. 18 drops/minute C. Formative
C. Failing eyesight, especially close D. Retrospective
vision. 44.If a central venous catheter becomes
D. Having more frequent aches and pains. disconnected accidentally, what should the 48.A 45 year old client, has no family
nurse in-charge do immediately? history of breast cancer or other risk factors
41.The physician inserts a chest tube into a for this disease. Nurse John should instruct
female client to treat a pneumothorax. The A. Clamp the catheter her to have mammogram how often?
tube is connected to water-seal drainage. B. Call another nurse
The nurse in-charge can prevent chest tube C. Call the physician A. Twice per year
air leaks by: D. Apply a dry sterile dressing to the site. B. Once per year
C. Every 2 years
A. Checking and taping all connections. 45.A female client was recently admitted. D. Once, to establish baseline
B. Checking patency of the chest tube. She has fever, weight loss, and watery
C. Keeping the head of the bed slightly diarrhea is being admitted to the facility. 49.A male client has the following arterial
elevated. While assessing the client, Nurse Hazel blood gas values: pH 7.30; Pao2 89 mmHg;
D. Keeping the chest drainage system inspects the client’s abdomen and notice that Paco2 50 mmHg; and HCO3 26mEq/L.
below the level of the chest. it is slightly concave. Additional assessment Based on these values, Nurse Patricia should
should proceed in which order: expect which condition?
42.Nurse Trish must verify the client’s
identity before administering medication. A. Palpation, auscultation, and percussion. A. Respiratory acidosis
She is aware that the safest way to verify B. Percussion, palpation, and auscultation. B. Respiratory alkalosis
identity is to: C. Palpation, percussion, and auscultation. C. Metabolic acidosis
D. Auscultation, percussion, and palpation. D. Metabolic alkalosis
A. Check the client’s identification band.
B. Ask the client to state his name. 46. Nurse Betty is assessing tactile fremitus 50.Nurse Len refers a female client with
C. State the client’s name out loud and in a client with pneumonia. For this terminal cancer to a local hospice. What is
wait a client to repeat it. examination, nurse Betty should use the: the goal of this referral?
D. Check the room number and the client’s
name on the bed. A. Fingertips A. To help the client find appropriate
B. Finger pads treatment options.
43.The physician orders dextrose 5 % in C. Dorsal surface of the hand B. To provide support for the client and
water, 1,000 ml to be infused over 8 hours. D. Ulnar surface of the hand family in coping with terminal illness.
The I.V. tubing delivers 15 drops/ml. Nurse C. To ensure that the client gets counseling
John should run the I.V. infusion at a rate of: 47. Which type of evaluation occurs regarding health care costs.
continuously throughout the teaching and D. To teach the client and family about
A. 30 drops/minute learning process? cancer and its treatment.
 54.Nurse Len is administering sublingual had been maintained if which of the
51.When caring for a male client with a 3- nitrglycerin (Nitrostat) to the newly admitted following data is observed?
cm stage I pressure ulcer on the coccyx, client. Immediately afterward, the client may
which of the following actions can the nurse experience: A. Urine output: 45 ml/hr
institute independently? B. Capillary refill: 5 seconds
A. Throbbing headache or dizziness C. Serum pH: 7.32
A. Massaging the area with an astringent B. Nervousness or paresthesia. D. Blood pressure: 90/48 mmHg
every 2 hours. C. Drowsiness or blurred vision.
B. Applying an antibiotic cream to the area D. Tinnitus or diplopia. 58. Nurse Amy has an order to obtain a
three times per day. urinalysis from a male client with an
C. Using normal saline solution to clean 55.Nurse Michelle hears the alarm sound on indwelling urinary catheter. The nurse
the ulcer and applying a protective the telemetry monitor. The nurse quickly avoids which of the following, which
dressing as necessary. looks at the monitor and notes that a client is contaminate the specimen?
D. Using a povidone-iodine wash on the in a ventricular tachycardia. The nurse
ulceration three times per day. rushes to the client’s room. Upon reaching A. Wiping the port with an alcohol swab
the client’s bedside, the nurse would take before inserting the syringe.
52.Nurse Oliver must apply an elastic which action first? B. Aspirating a sample from the port on
bandage to a client’s ankle and calf. He the drainage bag.
should apply the bandage beginning at the A. Prepare for cardioversion C. Clamping the tubing of the drainage
client’s: B. Prepare to defibrillate the client bag.
C. Call a code D. Obtaining the specimen from the
A. Knee D. Check the client’s level of urinary drainage bag.
B. Ankle consciousness
C. Lower thigh 59.Nurse Meredith is in the process of
D. Foot 56.Nurse Hazel is preparing to ambulate a giving a client a bed bath. In the middle of
female client. The best and the safest the procedure, the unit secretary calls the
53.A 10 year old child with type 1 diabetes position for the nurse in assisting the client nurse on the intercom to tell the nurse that
develops diabetic ketoacidosis and receives is to stand: there is an emergency phone call. The
a continuous insulin infusion. Which appropriate nursing action is to:
condition represents the greatest risk to this A. On the unaffected side of the client.
child? B. On the affected side of the client. A. Immediately walk out of the client’s
C. In front of the client. room and answer the phone call.
A. Hypernatremia D. Behind the client. B. Cover the client, place the call light
B. Hypokalemia 57.Nurse Janah is monitoring the ongoing within reach, and answer the phone call.
C. Hyperphosphatemia care given to the potential organ donor who C. Finish the bed bath before answering
D. Hypercalcemia has been diagnosed with brain death. The the phone call.
nurse determines that the standard of care
 D. Leave the client’s door open so the
client can be monitored and the nurse
can answer the phone call.
60. Nurse Janah is collecting a sputum
specimen for culture and sensitivity testing
from a client who has a productive cough.
Nurse Janah plans to implement which
intervention to obtain the specimen?
A. Ask the client to expectorate a small
amount of sputum into the emesis
basin.
B. Ask the client to obtain the specimen
after breakfast.
C. Use a sterile plastic container for
obtaining the specimen.
D. Provide tissues for expectoration and
obtaining the specimen.
61. Nurse Ron is observing a male client
using a walker. The nurse determines that
the client is using the walker correctly if the
client:
A. Puts all the four points of the walker
flat on the floor, puts weight on the
hand pieces, and then walks into it.
B. Puts weight on the hand pieces, moves
the walker forward, and then walks into
it.
C. Puts weight on the hand pieces, slides
the walker forward, and then walks into
it.
D. Walks into the walker, puts weight on
the hand pieces, and then puts all four
points of the walker flat on the floor.
62.Nurse Amy has documented an entry
regarding client care in the client’s medical
record. When checking the entry, the nurse
realizes that incorrect information was
documented. How does the nurse correct this
error?
A. Erases the error and writes in the
correct information.
B. Uses correction fluid to cover up the
incorrect information and writes in the
correct information.
C. Draws one line to cross out the
incorrect information and then initials
the change.
D. Covers up the incorrect information
completely using a black pen and writes
in the correct information
63.Nurse Ron is assisting with transferring a
client from the operating room table to a
stretcher. To provide safety to the client, the
nurse should:
A. Moves the client rapidly from the table
to the stretcher.
B. Uncovers the client completely before
transferring to the stretcher.
C. Secures the client safety belts after
transferring to the stretcher.
D. Instructs the client to move self from
the table to the stretcher.
64.Nurse Myrna is providing instructions to
a nursing assistant assigned to give a bed
bath to a client who is on contact
precautions. Nurse Myrna instructs the
nursing assistant to use which of the
following protective items when giving bed
bath?
A. Gown and goggles
B. Gown and gloves
C. Gloves and shoe protectors
D. Gloves and goggles
65. Nurse Oliver is caring for a client with
impaired mobility that occurred as a result of
a stroke. The client has right sided arm and
leg weakness. The nurse would suggest that
the client use which of the following
assistive devices that would provide the best
stability for ambulating?
A. Crutches
B. Single straight-legged cane
C. Quad cane
D. Walker
66.A male client with a right pleural
effusion noted on a chest X-ray is being
prepared for thoracentesis. The client
experiences severe dizziness when sitting
upright. To provide a safe environment, the
nurse assists the client to which position for
the procedure?
A. Prone with head turned toward the side
supported by a pillow.
B. Sims’ position with the head of the bed
flat.
C. Right side-lying with the head of the
bed elevated 45 degrees.
D. Left side-lying with the head of the bed
elevated 45 degrees.
67.Nurse John develops methods for data C. Use of laboratory data becomes the proof of the negligent act, the
gathering. Which of the following criteria of D. Observation presence of the injury is said to exemplify
a good instrument refers to the ability of the the principle of:
instrument to yield the same results upon its 71.Monica is aware that there are times
repeated administration? when only manipulation of study variables is A. Force majeure
possible and the elements of control or B. Respondeat superior
A. Validity randomization are not attendant. Which type C. Res ipsa loquitor
B. Specificity of research is referred to this? D. Holdover doctrine
C. Sensitivity
D. Reliability A. Field study 75.Nurse Myrna is aware that the Board of
B. Quasi-experiment Nursing has quasi-judicial power. An
68.Harry knows that he has to protect the C. Solomon-Four group design example of this power is:
rights of human research subjects. Which of D. Post-test only design
the following actions of Harry ensures A. The Board can issue rules and
anonymity? 72.Cherry notes down ideas that were regulations that will govern the practice
derived from the description of of nursing
A. Keep the identities of the subject secret an investigation written by the person who B. The Board can investigate violations of
B. Obtain informed consent conducted it. Which type of reference source the nursing law and code of ethics
C. Provide equal treatment to all the refers to this? C. The Board can visit a school applying
subjects of the study. for a permit in collaboration with
D. Release findings only to the participants A. Footnote CHED
of the study B. Bibliography D. The Board prepares the board
C. Primary source examinations
69.Patient’s refusal to divulge information is D. Endnotes
a limitation because it is beyond the control 76. When the license of nurse Krina is
of Tifanny”. What type of research is 73.When Nurse Trish is providing care to revoked, it means that she:
appropriate for this study? his patient, she must remember that her duty
is bound not to do doing any action that will A. Is no longer allowed to practice the
A. Descriptive- correlational cause the patient harm. This is the meaning profession for the rest of her life
B. Experiment of the bioethical principle: B. Will never have her/his license re-
C. Quasi-experiment issued since it has been revoked
D. Historical A. Non-maleficence C. May apply for re-issuance of his/her
B. Beneficence license based on certain conditions
70.Nurse Ronald is aware that the best tool C. Justice stipulated in RA 9173
for data gathering is? D. Solidarity D. Will remain unable to practice
professional nursing
A. Interview schedule 74.When a nurse in-charge causes an injury
B. Questionnaire to a female patient and the injury caused
77.Ronald plans to conduct a research on the D. Decides to get 20 samples from the 84.Ms. Garcia is responsible to the number
use of a new method of pain assessment admitted patients of personnel reporting to her. This principle
scale. Which of the following is the second refers to:
step in the conceptualizing phase of the 80. The nursing theorist who developed
research process? transcultural nursing theory is: A. Span of control
B. Unity of command
A. Formulating the research hypothesis A. Florence Nightingale C. Downward communication
B. Review related literature B. Madeleine Leininger D. Leader
C. Formulating and delimiting the research C. Albert Moore
problem D. Sr. Callista Roy 85.Ensuring that there is an informed
D. Design the theoretical and conceptual consent on the part of the patient before a
framework 81.Marion is aware that the sampling surgery is done, illustrates the bioethical
method that gives equal chance to all units principle of:
78. The leader of the study knows that in the population to get picked is:
certain patients who are in a specialized A. Beneficence
research setting tend to respond A. Random B. Autonomy
psychologically to the conditions of the B. Accidental C. Veracity
study. This referred to as : C. Quota D. Non-maleficence
D. Judgment
A. Cause and effect 86.Nurse Reese is teaching a female client
B. Hawthorne effect 82.John plans to use a Likert Scale to his with peripheral vascular disease about foot
C. Halo effect study to determine the: care; Nurse Reese should include which
D. Horns effect instruction?
A. Degree of agreement and disagreement
79.Mary finally decides to use judgment B. Compliance to expected standards A. Avoid wearing cotton socks.
sampling on her research. Which of the C. Level of satisfaction B. Avoid using a nail clipper to cut
following actions of is correct? D. Degree of acceptance toenails.
C. Avoid wearing canvas shoes.
A. Plans to include whoever is there during 83.Which of the following theory addresses D. Avoid using cornstarch on feet.
his study. the four modes of adaptation?
B. Determines the different nationality of 87.A client is admitted with multiple
patients frequently admitted and A. Madeleine Leininger pressure ulcers. When developing
decides to get representations samples B. Sr. Callista Roy the client’s diet plan, the nurse should
from each. C. Florence Nightingale include:
C. Assigns numbers for each of the D. Jean Watson
patients, place these in a fishbowl and A. Fresh orange slices
draw 10 from it. B. Steamed broccoli
C. Ice cream
 D. Ground beef patties redness or edema. The nurse’s actions reflect A. Give the feedings at room temperature.
which step of the nursing process? B. Decrease the rate of feedings and the
88.The nurse prepares to administer a concentration of the formula.
cleansing enema. What is the most common A. Assessment C. Place the client in semi-Fowler’s
client position used for this procedure? B. Diagnosis position while feeding.
C. Implementation D. Change the feeding container every 12
A. Lithotomy D. Evaluation hours.
B. Supine
C. Prone 92.Nursing care for a female client includes 95.Nurse Patricia is reconstituting a
D. Sims’ left lateral removing elastic stockings once per day. powdered medication in a vial. After adding
The Nurse Betty is aware that the rationale the solution to the powder, she nurse should:
89.Nurse Marian is preparing to administer a for this intervention?
blood transfusion. Which action should the A. Do nothing.
nurse take first? A. To increase blood flow to the heart B. Invert the vial and let it stand for 3 to 5
B. To observe the lower extremities minutes.
A. Arrange for typing and cross matching C. To allow the leg muscles to stretch and C. Shake the vial vigorously.
of the client’s blood. relax D. Roll the vial gently between the palms.
B. Compare the client’s identification D. To permit veins in the legs to fill with 96.Which intervention should the nurse
wristband with the tag on the unit of blood. Trish use when administering oxygen by
blood. face mask to a female client?
C. Start an I.V. infusion of normal saline 93.Which nursing intervention takes highest
solution. priority when caring for a newly admitted A. Secure the elastic band tightly around
D. Measure the client’s vital signs. client who’s receiving a blood transfusion? the client’s head.
B. Assist the client to the semi-Fowler
90.A 65 years old male client requests his A. Instructing the client to report any position if possible.
medication at 9 p.m. instead of 10 p.m. so itching, swelling, or dyspnea. C. Apply the face mask from the client’s
that he can go to sleep earlier. Which type of B. Informing the client that the transfusion chin up over the nose.
nursing intervention is required? usually take 1 ½ to 2 hours. D. Loosen the connectors between the
C. Documenting blood administration in oxygen equipment and humidifier.
A. Independent the client care record.
B. Dependent D. Assessing the client’s vital signs when 97.The maximum transfusion time for a unit
C. Interdependent the transfusion ends. of packed red blood cells (RBCs) is:
D. Intradependent
94.A male client complains of abdominal A. 6 hours
91.A female client is to be discharged from discomfort and nausea while receiving tube B. 4 hours
an acute care facility after treatment for right feedings. Which intervention is most C. 3 hours
leg thrombophlebitis. The Nurse Betty notes appropriate for this problem? D. 2 hours
that the client’s leg is pain-free, without
98.Nurse Monique is monitoring the
effectiveness of a client’s drug
therapy. When should the nurse Monique
obtain a blood sample to measure the trough
drug level?
A. 1 hour before administering the next
dose.
B. Immediately before administering the
next dose.
C. Immediately after administering the
next dose.
D. 30 minutes after administering the next
dose.
99.Nurse May is aware that the main
advantage of using a floor stock system is:
A. The nurse can implement medication
orders quickly.
B. The nurse receives input from the
pharmacist.
C. The system minimizes transcription
errors.
D. The system reinforces accurate
calculations.
100. Nurse Oliver is assessing a client’s
abdomen. Which finding should the nurse
report as abnormal?
A. Dullness over the liver.
B. Bowel sounds occurring every 10
seconds.
C. Shifting dullness over the abdomen.
D. Vascular sounds heard over the renal
arteries.
Answers and Rationales
1. Answer: (D) The actions of a
reasonably prudent nurse with
similar education and experience. The
standard of care is determined by the
average degree of skill, care, and
diligence by nurses in similar
circumstances.
2. Answer: (B) I.M. With a platelet count
of 22,000/μl, the clients tends to
bleed easily. Therefore, the nurse
should avoid using the I.M. route
because the area is a highly vascular
and can bleed readily when penetrated
by a needle. The bleeding can be
difficult to stop.
3. Answer: (C) “Digoxin 0.125 mg P.O.
once daily” The nurse should always
place a zero before a decimal point so
that no one misreads the figure, which
could result in a dosage error. The nurse
should never insert a zero at the end of
a dosage that includes a decimal point
because this could be misread, possibly
leading to a tenfold increase in the
dosage.
4. Answer: (A) Ineffective peripheral
tissue perfusion related to
venous congestion. Ineffective
peripheral tissue perfusion related to
venous congestion takes the highest
priority because venous inflammation
and clot formation  impede blood flow
in a client with deep vein thrombosis.
5. Answer: (B) A 44 year-old myocardial
infarction (MI) client who
is complaining of nausea. Nausea is a
symptom of impending myocardial
infarction (MI) and should be assessed
immediately so that treatment can be
instituted and further damage to the
heart is avoided.
6. Answer: (C) Check circulation every
15-30 minutes. Restraints encircle the
limbs, which place the client at risk
for circulation being restricted to the
distal areas of the extremities.
Checking the client’s circulation every
15-30 minutes will allow the nurse to
adjust the restraints before injury from
decreased blood flow occurs.
7. Answer: (A) Prevent stress
ulcer. Curling’s ulcer occurs as a
generalized stress response in
burn patients. This results in a
decreased production of mucus and
increased secretion of gastric acid. The
best treatment for this prophylactic use
of antacids and H2 receptor blockers.
8. Answer: (D) Continue to monitor and
record hourly urine output. Normal
urine output for an adult is
approximately 1 ml/minute (60
ml/hour). Therefore, this client’s output
is normal. Beyond
continued evaluation, no nursing action
is warranted.
9. Answer: (B) “My ankle feels
warm”. Ice application decreases pain
and swelling. Continued or
increased pain, redness, and increased
warmth are signs of inflammation that
shouldn’t occur after ice application
10. Answer: (B) Hyperkalemia. A loop
diuretic removes water and, along with
it, sodium and potassium. This may
 result in hypokalemia, hypovolemia,
and hyponatremia.
11. Answer:(A) Have condescending trust
and confidence in
their subordinates. Benevolent-
authoritative managers pretentiously
show their trust and confidence to their
followers.
12. Answer: (A) Provides continuous,
coordinated and comprehensive nursing
services. Functional nursing is focused
on tasks and activities and not on the
care of the patients.
13. Answer: (B) Standard written
order. This is a standard written order.
Prescribers write a single order for
medications given only once. A stat
order is written for medications given
immediately for an urgent client
problem. A standing order, also known
as a protocol, establishes guidelines for
treating a particular disease or set of
symptoms in special care areas such as
the coronary care unit. Facilities also
may institute medication protocols
that specifically designate drugs that a
nurse may not give.
14. Answer: (D) Liquid or semi-liquid
stools. Passage of liquid or semi-liquid
stools results from seepage of unformed
bowel contents around the impacted
stool in the rectum. Clients with fecal
impaction don’t pass hard, brown,
formed stools because the feces can’t
move past the impaction. These clients
typically report the urge to defecate
(although they can’t pass stool) and a
decreased appetite.
15. Answer: (C) Pulling the helix up and
back. To perform an otoscopic
examination on an adult, the
nurse grasps the helix of the ear and
pulls it up and back to straighten the
ear canal. For a child, the nurse grasps
the helix and pulls it down to straighten
the ear canal. Pulling the lobule in any
direction wouldn’t straighten the ear
canal for visualization.
16. Answer: (A) Protect the irritated skin
from sunlight. Irradiated skin is very
sensitive and must be protected with
clothing or sunblock. The priority
approach is the avoidance of strong
sunlight.
17. Answer: (C) Assist the client in
removing dentures and nail
polish. Dentures, hairpins, and combs
must be removed. Nail polish must be
removed so that cyanosis can be easily
monitored by observing the nail beds.
18. Answer: (D) Sudden onset of
continuous epigastric and back
pain. The autodigestion of tissue by the
pancreatic enzymes results in pain from
inflammation, edema, and possible
hemorrhage. Continuous, unrelieved
epigastric or back pain reflects the
inflammatory process in the pancreas.
19. Answer: (B) Provide high-protein,
high-carbohydrate diet. A positive
nitrogen balance is important for
meeting metabolic needs, tissue repair,
and resistance to infection. Caloric
goals may be as high as 5000 calories
per day.
20. Answer: (A) Blood pressure and pulse
rate. The baseline must be established
to recognize the signs of an
anaphylactic or hemolytic reaction to
the transfusion.
21. Answer: (D) Immobilize the leg before
moving the client. If the nurse suspects
a fracture, splinting the area before
moving the client is imperative. The
nurse should call for emergency help if
the client is not hospitalized and call for
a physician for the hospitalized client.
22. Answer: (B) Admit the client into a
private room. The client who has a
radiation implant is placed in a private
room and has a limited number of
visitors. This reduces the exposure of
others to the radiation.
23. Answer: (C) Risk for
infection. Agranulocytosis is
characterized by a reduced number of
leukocytes (leucopenia) and neutrophils
(neutropenia) in the blood. The client is
at high risk for infection because of the
decreased body defenses against
microorganisms. Deficient knowledge
related to the nature of the disorder may
be appropriate diagnosis but is not the
priority.
24. Answer: (B) Place the client on the left
side in the Trendelenburg
position. Lying on the left side may
prevent air from flowing into the
pulmonary veins. The Trendelenburg
position increases intrathoracic
pressure, which decreases the amount
of blood pulled into the vena cava
during aspiration.
25. Answer: (A) Autocratic. The autocratic
style of leadership is a task-oriented and
directive.
26. Answer: (D) 2.5 cc. 2.5 cc is to be
added, because only a 500 cc bag of
solution is being medicated instead of a
1 liter.
27. Answer: (A) 50 cc/ hour. A rate of 50
cc/hr. The child is to receive 400 cc
over a period of 8 hours = 50 cc/hr.
28. Answer: (B) Assess the client for
presence of pain. Assessing the client
for pain is a very important measure.
Postoperative pain is an indication of
complication. The nurse should also
assess the client for pain to provide for
the client’s comfort.
29. Answer: (A) BP – 80/60, Pulse – 110
irregular. The classic signs of
cardiogenic shock are low blood
pressure, rapid and weak irregular
pulse, cold, clammy skin, decreased
urinary output, and cerebral hypoxia.
30. Answer: (A) Take the proper
equipment, place the client in a
comfortable position, and record the
appropriate information in the client’s
chart. It is a general or comprehensive
statement about the correct procedure,
and it includes the basic ideas which are
found in the other options
31. Answer: (B) Evaluation. Evaluation
includes observing the person, asking
questions, and comparing the patient’s
behavioral responses with the expected
outcomes.
32. Answer: (C) History of present
illness. The history of present illness is
the single most important factor in
assisting the health professional in
arriving at a diagnosis or determining
the person’s needs.
33. Answer: (A) Trochanter roll extending
from the crest of the ileum to the mid-
thigh. A trochanter roll, properly
placed, provides resistance to the
external rotation of the hip.
34. Answer: (C) Stage III. Clinically, a
deep crater or without undermining of
adjacent tissue is noted.
35. Answer: (A) Second intention
healing. When wounds dehisce, they
will allowed to heal by secondary
intention
36. Answer: (D) Tachycardia. With an
extracellular fluid or plasma volume
deficit, compensatory mechanisms
stimulate the heart, causing an increase
in heart rate.
37. Answer: (A) 0.75. To determine the
number of milliliters the client should
receive, the nurse uses the fraction
method in the following equation.
 75 mg/X ml = 100 mg/1 ml
 To solve for X, cross-multiply:
 75 mg x 1 ml = X ml x 100
mg
 75 = 100X
 75/100 = X
 0.75 ml (or ¾ ml) = X
38. Answer: (D) It’s a measure of effect,
not a standard measure of weight or
quantity. An insulin unit is a measure of
effect, not a standard measure of weight
or quantity. Different drugs measured in
units may have no relationship to one
another in quality or quantity.
39. Answer: (B) 38.9 °C. To convert
Fahrenheit degreed to Centigrade, use
this formula
 °C = (°F – 32) ÷ 1.8
 °C = (102 – 32) ÷ 1.8
 °C = 70 ÷ 1.8
 °C = 38.9
40. Answer: (C) Failing eyesight,
especially close vision. Failing
eyesight, especially close vision, is one
of the first signs of aging in middle life
(ages 46 to 64). More frequent aches
and pains begin in the early late years
(ages 65 to 79). Increase in loss of
muscle tone occurs in later years (age
80 and older).
41. Answer: (A) Checking and taping all
connections. Air leaks commonly occur
if the system isn’t secure. Checking all
connections and taping them will
prevent air leaks. The chest drainage
system is kept lower to promote
drainage – not to prevent leaks.
42. Answer: (A) Check the client’s
identification band. Checking the
client’s identification band is the safest
way to verify a client’s identity because
the band is assigned on admission and
isn’t be removed at any time. (If it is
removed, it must be replaced). Asking
the client’s name or having the client
repeated his name would be appropriate
only for a client who’s alert, oriented,
and able to understand what is being
said, but isn’t the safe standard of
practice. Names on bed aren’t always
reliable
43. Answer: (B) 32 drops/minute. Giving
1,000 ml over 8 hours is the same as
giving 125 ml over 1 hour (60 minutes).
Find the number of milliliters per
minute as follows:
 125/60 minutes = X/1 minute
  60X = 125 = 2.1 ml/minute
 To find the number of drops per
minute:
 2.1 ml/X gtt = 1 ml/ 15 gtt
 X = 32 gtt/minute, or 32
drops/minute
44. Answer: (A) Clamp the catheter. If a
central venous catheter becomes
disconnected, the nurse should
immediately apply a catheter clamp, if
available. If a clamp isn’t available, the
nurse can place a sterile syringe or
catheter plug in the catheter hub. After
cleaning the hub with alcohol or
povidone-iodine solution, the nurse
must replace the I.V. extension and
restart the infusion.
45. Answer: (D) Auscultation, percussion,
and palpation.The correct order of
assessment for examining the abdomen
is inspection, auscultation, percussion,
and palpation. The reason for this
approach is that the less intrusive
techniques should be performed before
the more intrusive techniques.
Percussion and palpation can alter
natural findings during auscultation.
46. Answer: (D) Ulnar surface of the
hand. The nurse uses the ulnar surface,
or ball, of the hand to asses tactile
fremitus, thrills, and vocal vibrations
through the chest wall. The fingertips
and finger pads best distinguish texture
and shape. The dorsal surface best feels
warmth.
47. Answer: (C) Formative. Formative (or
concurrent) evaluation occurs
continuously throughout the teaching
and learning process. One benefit is that
the nurse can adjust teaching strategies
as necessary to enhance learning.
Summative, or retrospective, evaluation
occurs at the conclusion of the teaching
and learning session. Informative is not
a type of evaluation.
48. Answer: (B) Once per year. Yearly
mammograms should begin at age 40
and continue for as long as the woman
is in good health. If health risks, such as
family history, genetic tendency, or past
breast cancer, exist, more
frequent examinations may be
necessary.
49. Answer: (A) Respiratory acidosis. The
client has a below-normal (acidic)
blood pH value and an above-normal
partial pressure of arterial carbon
dioxide (Paco2) value, indicating
respiratory acidosis. In respiratory
alkalosis, the pH value is above normal
and in the Paco2 value is below normal.
In metabolic acidosis, the pH and
bicarbonate (Hco3) values are below
normal. In metabolic alkalosis, the pH
and Hco3 values are above normal.
50. Answer: (B) To provide support for the
client and family in coping with
terminal illness. Hospices provide
supportive care for terminally ill clients
and their families. Hospice care doesn’t
focus on counseling regarding health
care costs. Most client referred to
hospices have been treated for their
disease without success and will receive
only palliative care in the hospice.
51. Answer: (C) Using normal saline
solution to clean the ulcer and applying
a protective dressing as
necessary. Washing the area with
normal saline solution and applying a
protective dressing are within the
nurse’s realm of interventions and will
protect the area. Using a povidone-
iodine wash and an antibiotic cream
require a physician’s order. Massaging
with an astringent can further damage
the skin.
52. Answer: (D) Foot. An elastic bandage
should be applied form the distal area to
the proximal area. This method
promotes venous return. In this case,
the nurse should begin applying the
bandage at the client’s foot. Beginning
at the ankle, lower thigh, or knee does
not promote venous return.
53. Answer: (B) Hypokalemia. Insulin
administration causes glucose and
potassium to move into the cells,
causing hypokalemia.
54. Answer: (A) Throbbing headache or
dizziness. Headache and dizziness often
occur when nitroglycerin is taken at the
beginning of therapy. However, the
client usually develops tolerance
55. Answer: (D) Check the client’s level of
consciousness. Determining
unresponsiveness is the first step
assessment action to take. When a client
is in ventricular tachycardia, there is a
significant decrease in cardiac output.
However, checking the
unresponsiveness ensures whether the
client is affected by the decreased
cardiac output.
56. Answer: (B) On the affected side of the
client.When walking with clients, the
nurse should stand on the affected side
 and grasp the security belt in the
midspine area of the small of the back.
The nurse should position the free hand
at the shoulder area so that the client
can be pulled toward the nurse in the
event that there is a forward fall. The
client is instructed to look up and
outward rather than at his or her feet.
57. Answer: (A) Urine output: 45
ml/hr. Adequate perfusion must be
maintained to all vital organs in order
for the client to remain visible as an
organ donor. A urine output of 45 ml
per hour indicates adequate renal
perfusion. Low blood pressure and
delayed capillary refill time are
circulatory system indicators of
inadequate perfusion. A serum pH of
7.32 is acidotic, which adversely affects
all body tissues.
58. Answer: (D ) Obtaining the specimen
from the urinary drainage bag. A urine
specimen is not taken from the urinary
drainage bag. Urine undergoes chemical
changes while sitting in the bag and
does not necessarily reflect the current
client status. In addition, it may become
contaminated with bacteria from
opening the system.
59. Answer: (B) Cover the client, place the
call light within reach, and answer the
phone call. Because telephone call is an
emergency, the nurse may need to
answer it. The other appropriate action
is to ask another nurse to accept the
call. However, is not one of the options.
To maintain privacy and safety, the
nurse covers the client and places the
call light within the client’s reach.
Additionally, the client’s door should
be closed or the room curtains pulled
around the bathing area.
60. Answer: (C) Use a sterile plastic
container for obtaining the
specimen. Sputum specimens for
culture and sensitivity testing need to be
obtained using sterile techniques
because the test is done to determine the
presence of organisms. If the procedure
for obtaining the specimen is not sterile,
then the specimen is not sterile, then the
specimen would be contaminated and
the results of the test would be invalid.
61. Answer: (A) Puts all the four points of
the walker flat on the floor, puts weight
on the hand pieces, and then walks into
it. When the client uses a walker, the
nurse stands adjacent to the affected
side. The client is instructed to put all
four points of the walker 2 feet forward
flat on the floor before putting weight
on hand pieces. This will ensure client
safety and prevent stress cracks in the
walker. The client is then instructed to
move the walker forward and walk into
it.
62. Answer: (C) Draws one line to cross
out the incorrect information and then
initials the change. To correct an error
documented in a medical record, the
nurse draws one line through the
incorrect information and then initials
the error. An error is never erased and
correction fluid is never used in the
medical record.
63. Answer: (C) Secures the client safety
belts after transferring to the
stretcher. During the transfer of the
client after the surgical procedure is
complete, the nurse should avoid
exposure of the client because of the
risk for potential heat loss. Hurried
movements and rapid changes in the
position should be avoided because
these predispose the client to
hypotension. At the time of the transfer
from the surgery table to the stretcher,
the client is still affected by the effects
of the anesthesia; therefore, the client
should not move self. Safety belts can
prevent the client from falling off the
stretcher.
64. Answer: (B) Gown and gloves. Contact
precautions require the use of gloves
and a gown if direct client contact is
anticipated. Goggles are not necessary
unless the nurse anticipates the splashes
of blood, body fluids, secretions, or
excretions may occur. Shoe protectors
are not necessary.
65. Answer: (C) Quad cane. Crutches and a
walker can be difficult to maneuver for
a client with weakness on one side. A
cane is better suited for client with
weakness of the arm and leg on one
side. However, the quad cane would
provide the most stability because of
the structure of the cane and because a
quad cane has four legs.
66. Answer: (D) Left side-lying with the
head of the bed elevated 45 degrees. To
facilitate removal of fluid from the
chest wall, the client is positioned
sitting at the edge of the bed leaning
over the bedside table with the feet
supported on a stool. If the client is
unable to sit up, the client is positioned
 lying in bed on the unaffected side with
the head of the bed elevated 30 to 45
degrees.
67. Answer: (D) Reliability Reliability is
consistency of the research instrument.
It refers to the repeatability of the
instrument in extracting the same
responses upon its repeated
administration.
68. Answer: (A) Keep the identities of the
subject secret. Keeping the identities of
the research subject secret will ensure
anonymity because this will hinder
providing link between the information
given to whoever is its source.
69. Answer: (A) Descriptive-
correlational. Descriptive- correlational
study is the most appropriate for this
study because it studies the variables
that could be the antecedents of the
increased incidence of nosocomial
infection.
70. Answer: (C) Use of laboratory
data. Incidence of nosocomial infection
is best collected through the use of
biophysiologic measures, particularly in
vitro measurements, hence laboratory
data is essential.
71. Answer: (B) Quasi-experiment. Quasi-
experiment is done when randomization
and control of the variables are not
possible.
72. Answer: (C) Primary source. This refers
to a primary source which is a direct
account of the investigation done by the
investigator. In contrast to this is a
secondary source, which is written by
someone other than the original
researcher.
73. Answer: (A) Non-maleficence. Non-
maleficence means do not cause harm
or do any action that will cause any
harm to the patient/client. To do good is
referred as beneficence.
74. Answer: (C) Res ipsa loquitor. Res ipsa
loquitor literally means the thing speaks
for itself. This means in operational
terms that the injury caused is the proof
that there was a negligent act.
75. Answer: (B) The Board can investigate
violations of the nursing law and code
of ethics. Quasi-judicial power means
that the Board of Nursing has the
authority to investigate violations of the
nursing law and can issue summons,
subpoena or subpoena duces tecum as
needed.
76. Answer: (C) May apply for re-issuance
of his/her license based on certain
conditions stipulated in RA 9173. RA
9173 sec. 24 states that for equity and
justice, a revoked license maybe re-
issued provided that the following
conditions are met: a) the cause for
revocation of license has already been
corrected or removed; and, b) at least
four years has elapsed since the license
has been revoked.
77. Answer: (B) Review related
literature. After formulating and
delimiting the research problem, the
researcher conducts a review of related
literature to determine the extent of
what has been done on the study by
previous researchers.
78. Answer: (B) Hawthorne
effect. Hawthorne effect is based on the
study of Elton Mayo and company
about the effect of an intervention done
to improve the working conditions of
the workers on their productivity. It
resulted to an increased productivity but
not due to the intervention but due to
the psychological effects of being
observed. They performed differently
because they were under observation.
79. Answer: (B) Determines the different
nationality of patients frequently
admitted and decides to get
representations samples from
each. Judgment sampling involves
including samples according to the
knowledge of the investigator about the
participants in the study.
80. Answer: (B) Madeleine
Leininger. Madeleine Leininger
developed the theory on transcultural
theory based on her observations on the
behavior of selected people within a
culture.
81. Answer: (A) Random. Random
sampling gives equal chance for all the
elements in the population to be picked
as part of the sample.
82. Answer: (A) Degree of agreement and
disagreement. Likert scale is a 5-point
summated scale used to determine the
degree of agreement or disagreement of
the respondents to a statement in a
study
83. Answer: (B) Sr. Callista Roy. Sr.
Callista Roy developed the Adaptation
Model which involves the physiologic
mode, self-concept mode, role function
mode and dependence mode.
84. Answer: (A) Span of control. Span of
control refers to the number of workers
who report directly to a manager.
85. Answer: (B) Autonomy. Informed
consent means that the patient fully
understands about the surgery,
including the risks involved and the
alternative solutions. In giving consent
it is done with full knowledge and is
given freely. The action of allowing the
patient to decide whether a surgery is to
be done or not exemplifies the
bioethical principle of autonomy.
86. Answer: (C) Avoid wearing canvas
shoes. The client should be instructed to
avoid wearing canvas shoes. Canvas
shoes cause the feet to perspire, which
may, in turn, cause skin irritation and
breakdown. Both cotton and cornstarch
absorb perspiration. The client should
be instructed to cut toenails straight
across with nail clippers.
87. Answer: (D) Ground beef patties. Meat
is an excellent source of complete
protein, which this client needs to repair
the tissue breakdown caused by
pressure ulcers. Oranges and broccoli
supply vitamin C but not protein. Ice
cream supplies only some incomplete
protein, making it less helpful in tissue
repair.
88. Answer: (D) Sims’ left lateral. The
Sims’ left lateral position is the most
common position used to administer a
cleansing enema because it allows
gravity to aid the flow of fluid along the
curve of the sigmoid colon. If the client
can’t assume this position nor has poor
sphincter control, the dorsal recumbent
or right lateral position may be used.
The supine and prone positions are
inappropriate and uncomfortable for the
client.
89. Answer: (A) Arrange for typing and
cross matching of the client’s
blood. The nurse first arranges for
typing and cross matching of the
client’s blood to ensure compatibility
with donor blood. The other
options,although appropriate when
preparing to administer a blood
transfusion, come later.
90. Answer: (A) Independent. Nursing
interventions are classified as
independent, interdependent, or
dependent. Altering the drug schedule
to coincide with the client’s daily
routine represents an independent
intervention, whereas consulting with
the physician and pharmacist to change
a client’s medication because of adverse
reactions represents an interdependent
intervention. Administering an already-
prescribed drug on time is a dependent
intervention. An intradependent nursing
intervention doesn’t exist.
91. Answer: (D) Evaluation. The nursing
actions described constitute evaluation
of the expected outcomes. The findings
show that the expected outcomes have
been achieved. Assessment consists of
the client’s history, physical
examination, and laboratory studies.
Analysis consists of considering
assessment information to derive the
appropriate nursing diagnosis.
Implementation is the phase of the
nursing process where the nurse puts
the plan of care into action.
92. Answer: (B) To observe the lower
extremities. Elastic stockings are used
to promote venous return. The nurse
needs to remove them once per day to
observe the condition of the skin
underneath the stockings. Applying the
stockings increases blood flow to the
heart. When the stockings are in place,
the leg muscles can still stretch and
relax, and the veins can fill with blood.
93. Answer:(A) Instructing the client to
report any itching, swelling, or
dyspnea. Because administration of
blood or blood products may cause
serious adverse effects such as allergic
reactions, the nurse must monitor the
client for these effects. Signs and
symptoms of life-threatening allergic
reactions include itching, swelling, and
dyspnea. Although the nurse should
inform the client of the duration of the
transfusion and should document its
administration, these actions are less
critical to the client’s immediate health.
The nurse should assess vital signs at
least hourly during the transfusion.
94. Answer: (B) Decrease the rate of
feedings and the concentration of the
formula. Complaints of abdominal
discomfort and nausea are common in
clients receiving tube feedings.
Decreasing the rate of the feeding and
the concentration of the formula should
decrease the client’s discomfort.
Feedings are normally given at room
temperature to minimize abdominal
cramping. To prevent aspiration during
 feeding, the head of the client’s bed
should be elevated at least 30 degrees.
Also, to prevent bacterial growth,
feeding containers should be routinely
changed every 8 to 12 hours.
95. Answer: (D) Roll the vial gently
between the palms. Rolling the vial
gently between the palms produces
heat, which helps dissolve the
medication. Doing nothing or inverting
the vial wouldn’t help dissolve the
medication. Shaking the vial vigorously
could cause the medication to break
down, altering its action.
96. Answer: (B) Assist the client to the
semi-Fowler position if possible. By
assisting the client to the semi-Fowler
position, the nurse promotes easier
chest expansion, breathing, and oxygen
intake. The nurse should secure the
elastic band so that the face mask fits
comfortably and snugly rather than
tightly, which could lead to irritation.
The nurse should apply the face mask
from the client’s nose down to the chin
— not vice versa. The nurse should
check the connectors between the
oxygen equipment and humidifier to
ensure that they’re airtight; loosened
connectors can cause loss of oxygen.
97. Answer: (B) 4 hours. A unit of packed
RBCs may be given over a period of
between 1 and 4 hours. It shouldn’t
infuse for longer than 4 hours because
the risk of contamination and sepsis
increases after that time. Discard or
return to the blood bank any blood not
given within this time, according to
facility policy.
98. Answer: (B) Immediately before
administering the next dose. Measuring
the blood drug concentration helps
determine whether the dosing has
achieved the therapeutic goal. For
measurement of the trough, or lowest,
blood level of a drug, the nurse draws a
blood sample immediately before
administering the next dose. Depending
on the drug’s duration of action and
half-life, peak blood drug levels
typically are drawn after administering
the next dose.
99. Answer: (A) The nurse can implement
medication orders quickly. A floor
stock system enables the nurse to
implement medication orders quickly. It
doesn’t allow for pharmacist input, nor
does it minimize transcription errors or NP II – CHN and MCN
reinforce accurate calculations.
100. Answer: (C) Shifting dullness over 1. May arrives at the health care clinic and
the abdomen. Shifting dullness over the tells the nurse that her last menstrual period
abdomen indicates ascites, an abnormal was 9 weeks ago. She also tells the nurse
finding. The other options are normal that a home pregnancy test was positive but
abdominal findings. she began to have mild cramps and is now
having moderate vaginal bleeding. During
the physical examination of the client, the
nurse notes that May has a dilated cervix.
The nurse determines that May is
experiencing which type of abortion?
A. Inevitable
B. Incomplete
C. Threatened
D. Septic
2. Nurse Reese is reviewing the record of a
pregnant client for her first prenatal visit.
Which of the following data, if noted on the
client’s record, would alert the nurse that the
client is at risk for a spontaneous abortion?
 A. Age 36 years
B. History of syphilis
C. History of genital herpes
D. History of diabetes mellitus
3. Nurse Hazel is preparing to care for a
client who is newly admitted to the hospital
with a possible diagnosis of ectopic
pregnancy. Nurse Hazel develops a plan of
care for the client and determines that which
of the following nursing actions is the
priority?
A. Monitoring weight
B. Assessing for edema
C. Monitoring apical pulse
D. Monitoring temperature
4. Nurse Oliver is teaching a diabetic
pregnant client about nutrition and insulin
needs during pregnancy. The nurse
determines that the client understands
dietary and insulin needs if the client states
that the second half of pregnancy require:
A. Decreased caloric intake
B. Increased caloric intake
C. Decreased Insulin
D. Increase Insulin
5. Nurse Michelle is assessing a 24 year old
client with a diagnosis of hydatidiform mole.
She is aware that one of the following is
unassociated with this condition?
A. Excessive fetal activity.
B. Larger than normal uterus for
gestational age.
C. Vaginal bleeding
D. Elevated levels of human chorionic
gonadotropin.
6. A pregnant client is receiving magnesium
sulfate for severe pregnancy induced
hypertension (PIH). The clinical findings
that would warrant use of the antidote ,
calcium gluconate is:
A. Urinary output 90 cc in 2 hours.
B. Absent patellar reflexes.
C. Rapid respiratory rate above 40/min.
D. Rapid rise in blood pressure.
7. During vaginal examination of Janah who
is in labor, the presenting part is at station
plus two. Nurse, correctly interprets it as:
A. Presenting part is 2 cm above the plane
of the ischial spines.
B. Biparietal diameter is at the level of the
ischial spines.
C. Presenting part in 2 cm below the plane
of the ischial spines.
D. Biparietal diameter is 2 cm above the
ischial spines.
8. A pregnant client is receiving oxytocin
(Pitocin) for induction of labor. A condition
that warrant the nurse in-charge to
discontinue I.V. infusion of Pitocin is:
A. Contractions every 1 ½ minutes lasting
70-80 seconds.
B. Maternal temperature 101.2
C. Early decelerations in the fetal heart
rate.
D. Fetal heart rate baseline 140-160 bpm.
9. Calcium gluconate is being administered
to a client with pregnancy induced
hypertension (PIH). A nursing action that
must be initiated as the plan of care
throughout injection of the drug is:
A. Ventilator assistance
B. CVP readings
C. EKG tracings
D. Continuous CPR
10. A trial for vaginal delivery after an
earlier caesareans, would likely to be given
to a gravida, who had:
A. First low transverse cesarean was for
active herpes type 2 infections; vaginal
culture at 39 weeks pregnancy was
positive.
B. First and second caesareans were for
cephalopelvic disproportion.
C. First caesarean through a classic
incision as a result of severe fetal
distress.
D. First low transverse caesarean was for
breech position. Fetus in this pregnancy
is in a vertex presentation.
11.Nurse Ryan is aware that the best initial
approach when trying to take a crying
toddler’s temperature is:
A. Talk to the mother first and then to the
toddler.
B. Bring extra help so it can be done
quickly.
C. Encourage the mother to hold the child.
D. Ignore the crying and screaming.
12.Baby Tina a 3 month old infant just had a
cleft lip and palate repair. What should the
nurse do to prevent trauma to operative site?
A. Avoid touching the suture line, even
when cleaning.
B. Place the baby in prone position.
C. Give the baby a pacifier.
D. Place the infant’s arms in soft elbow
restraints.
13. Which action should nurse Marian
include in the care plan for a 2 month old
with heart failure?
A. Feed the infant when he cries.
B. Allow the infant to rest before feeding.
C. Bathe the infant and administer
medications before feeding.
D. Weigh and bathe the infant before
feeding.
14.Nurse Hazel is teaching a mother who
plans to discontinue breast feeding after 5
months. The nurse should advise her to
include which foods in her infant’s diet?
A. Skim milk and baby food.
B. Whole milk and baby food.
C. Iron-rich formula only.
D. Iron-rich formula and baby food.
15.Mommy Linda is playing with her infant,
who is sitting securely alone on the floor of
the clinic. The mother hides a toy behind her
back and the infant looks for it. The nurse is
aware that estimated age of the infant would
be:
A. 6 months
B. 4 months
C. 8 months
D. 10 months
16.Which of the following is the most
prominent feature of public health nursing?
A. It involves providing home care to sick
people who are not confined in the
hospital.
B. Services are provided free of charge to
people within the catchments area.
C. The public health nurse functions as
part of a team providing a public health
nursing services.
D. Public health nursing focuses on
preventive, not curative, services.
17.When the nurse determines whether
resources were maximized in implementing
Ligtas Tigdas, she is evaluating
A. Effectiveness
B. Efficiency
C. Adequacy
D. Appropriateness
18.Vangie is a new B.S.N. graduate. She 22.Nurse Tina is aware that the disease
wants to become a Public Health Nurse. declared through Presidential Proclamation
Where should she apply? No. 4 as a target for eradication in the
A. Department of Health Philippines is?
B. Provincial Health Office A. Poliomyelitis
C. Regional Health Office B. Measles
D. Rural Health Unit C. Rabies
19.Tony is aware the Chairman of the D. Neonatal tetanus
Municipal Health Board is: 23.May knows that the step in community
A. Mayor organizing that involves training of potential
B. Municipal Health Officer leaders in the community is:
C. Public Health Nurse A. Integration
D. Any qualified physician B. Community organization
20.Myra is the public health nurse in a C. Community study
municipality with a total population of about D. Core group formation
20,000. There are 3 rural health midwives 24.Beth a public health nurse takes an active
among the RHU personnel. How many more role in community participation. What is the
midwife items will the RHU need? primary goal of community organizing?
A. 1 A. To educate the people regarding
B. 2 community health problems
C. 3 B. To mobilize the people to resolve
D. The RHU does not need any more community health problems
midwife item. C. To maximize the community’s
21.According to Freeman and Heinrich, resources in dealing with health
community health nursing is a problems.
developmental service. Which of the D. To maximize the community’s
following best illustrates this statement? resources in dealing with health
A. The community health nurse problems.
continuously develops himself 25.Tertiary prevention is needed in which
personally and professionally. stage of the natural history of disease?
B. Health education and community A. Pre-pathogenesis
organizing are necessary in providing B. Pathogenesis
community health services. C. Prodromal
C. Community health nursing is intended D. Terminal
primarily for health promotion and 26.The nurse is caring for a primigravid
prevention and treatment of disease. client in the labor and delivery area. Which
D. The goal of community health nursing condition would place the client at risk for
is to provide nursing services to people disseminated intravascular coagulation
in their own places of residence. (DIC)?
 A. Intrauterine fetal death.
B. Placenta accreta.
C. Dysfunctional labor.
D. Premature rupture of the membranes.
27.A fullterm client is in labor. Nurse Betty
is aware that the fetal heart rate would be:
A. 80 to 100 beats/minute
B. 100 to 120 beats/minute
C. 120 to 160 beats/minute
D. 160 to 180 beats/minute
28.The skin in the diaper area of a 7 month
old infant is excoriated and red. Nurse Hazel
should instruct the mother to:
A. Change the diaper more often.
B. Apply talc powder with diaper changes.
C. Wash the area vigorously with each
diaper change.
D. Decrease the infant’s fluid intake to
decrease saturating diapers.
29.Nurse Carla knows that the common
cardiac anomalies in children with Down
Syndrome (tri-somy 21) is:
A. Atrial septal defect
B. Pulmonic stenosis
C. Ventricular septal defect
D. Endocardial cushion defect
30.Malou was diagnosed with severe
preeclampsia is now receiving I.V.
magnesium sulfate. The adverse effects
associated with magnesium sulfate is:
A. Anemia
B. Decreased urine output
C. Hyperreflexia
D. Increased respiratory rate
31.A 23 year old client is having her
menstrual period every 2 weeks that last for
1 week. This type of menstrual pattern is
bets defined by:
A. Menorrhagia
B. Metrorrhagia
C. Dyspareunia
D. Amenorrhea
32. Jannah is admitted to the labor and
delivery unit. The critical laboratory result
for this client would be:
A. Oxygen saturation
B. Iron binding capacity
C. Blood typing
D. Serum Calcium
33.Nurse Gina is aware that the most
common condition found during the second-
trimester of pregnancy is:
A. Metabolic alkalosis
B. Respiratory acidosis
C. Mastitis
D. Physiologic anemia
34.Nurse Lynette is working in the triage
area of an emergency department. She sees
that several pediatric clients arrive
simultaneously. The client who needs to be
treated first is:
A. A crying 5 year old child with a
laceration on his scalp.
B. A 4 year old child with a barking
coughs and flushed appearance.
C. A 3 year old child with Down
syndrome who is pale and asleep in his
mother’s arms.
D. A 2 year old infant with stridorous
breath sounds, sitting up in his mother’s
arms and drooling.
35.Maureen in her third trimester arrives at
the emergency room with painless vaginal
bleeding. Which of the following conditions
is suspected?
A. Placenta previa
B. Abruptio placentae
C. Premature labor
D. Sexually transmitted disease
36.A young child named Richard is
suspected of having pinworms. The
community nurse collects a stool specimen
to confirm the diagnosis. The nurse should
schedule the collection of this specimen for:
A. Just before bedtime
B. After the child has been bathe
C. Any time during the day
D. Early in the morning
37.In doing a child’s admission assessment,
Nurse Betty should be alert to note which
signs or symptoms of chronic lead
poisoning?
A. Irritability and seizures
B. Dehydration and diarrhea
C. Bradycardia and hypotension
D. Petechiae and hematuria
38.To evaluate a woman’s understanding
about the use of diaphragm for family
planning, Nurse Trish asks her to explain
how she will use the appliance. Which
response indicates a need for further health
teaching?
A. “I should check the diaphragm carefully
for holes every time I use it”
B. “I may need a different size of
diaphragm if I gain or lose weight more
than 20 pounds”
C. “The diaphragm must be left in place
for atleast 6 hours after intercourse”
D. “I really need to use the diaphragm and
jelly most during the middle of my
menstrual cycle”.
39.Hypoxia is a common complication of
laryngotracheobronchitis. Nurse Oliver
should frequently assess a child with
laryngotracheobronchitis for:
A. Drooling
 B. Muffled voice
C. Restlessness
D. Low-grade fever
40.How should Nurse Michelle guide a child
who is blind to walk to the playroom?
A. Without touching the child, talk
continuously as the child walks down
the hall.
B. Walk one step ahead, with the child’s
hand on the nurse’s elbow.
C. Walk slightly behind, gently guiding
the child forward.
D. Walk next to the child, holding the
child’s hand.
41.When assessing a newborn diagnosed
with ductus arteriosus, Nurse Olivia should
expect that the child most likely would have
an:
A. Loud, machinery-like murmur.
B. Bluish color to the lips.
C. Decreased BP reading in the upper
extremities
D. Increased BP reading in the upper
extremities.
42.The reason nurse May keeps the neonate
in a neutral thermal environment is that
when a newborn becomes too cool, the
neonate requires:
A. Less oxygen, and the newborn’s
metabolic rate increases.
B. More oxygen, and the newborn’s
metabolic rate decreases.
C. More oxygen, and the newborn’s
metabolic rate increases.
D. Less oxygen, and the newborn’s
metabolic rate decreases.
43.Before adding potassium to an infant’s
I.V. line, Nurse Ron must be sure to assess
whether this infant has:
A. Stable blood pressure
B. Patant fontanelles
C. Moro’s reflex
D. Voided
44.Nurse Carla should know that the most
common causative factor of dermatitis in
infants and younger children is:
A. Baby oil
B. Baby lotion
C. Laundry detergent
D. Powder with cornstarch
45.During tube feeding, how far above an
infant’s stomach should the nurse hold the
syringe with formula?
A. 6 inches
B. 12 inches
C. 18 inches
D. 24 inches
46. In a mothers’ class, Nurse Lhynnete
discussed childhood diseases such as
chicken pox. Which of the following
statements about chicken pox is correct?
A. The older one gets, the more susceptible
he becomes to the complications of
chicken pox.
B. A single attack of chicken pox will
prevent future episodes, including
conditions such as shingles.
C. To prevent an outbreak in the
community, quarantine may be imposed
by health authorities.
D. Chicken pox vaccine is best given when
there is an impending outbreak in the
community.
47.Barangay Pinoy had an outbreak of
German measles. To prevent congenital
rubella, what is the BEST advice that you
can give to women in the first trimester of
pregnancy in the barangay Pinoy?
A. Advice them on the signs of German
measles.
B. Avoid crowded places, such as markets
and movie houses.
C. Consult at the health center where
rubella vaccine may be given.
D. Consult a physician who may give them
rubella immunoglobulin.
48.Myrna a public health nurse knows that
to determine possible sources of sexually
transmitted infections, the BEST method
that may be undertaken is:
A. Contact tracing
B. Community survey
C. Mass screening tests
D. Interview of suspects
49.A 33-year old female client came for
consultation at the health center with the
chief complaint of fever for a week.
Accompanying symptoms were muscle
pains and body malaise. A week after the
start of fever, the client noted yellowish
discoloration of his sclera. History showed
that he waded in flood waters about 2 weeks
before the onset of symptoms. Based on her
history, which disease condition will you
suspect?
A. Hepatitis A
B. Hepatitis B
C. Tetanus
D. Leptospirosis
50.Mickey a 3-year old client was brought to
the health center with the chief complaint of
severe diarrhea and the passage of “rice
water” stools. The client is most probably
suffering from which condition?
A. Giardiasis
B. Cholera
C. Amebiasis
 D. Dysentery
51.The most prevalent form of meningitis
among children aged 2 months to 3 years is
caused by which microorganism?
A. Hemophilus influenzae
B. Morbillivirus
C. Steptococcus pneumoniae
D. Neisseria meningitidis
52.The student nurse is aware that the
pathognomonic sign of measles is Koplik’s
spot and you may see Koplik’s spot by
inspecting the:
A. Nasal mucosa
B. Buccal mucosa
C. Skin on the abdomen
D. Skin on neck
53.Angel was diagnosed as having Dengue
fever. You will say that there is slow
capillary refill when the color of the nailbed
that you pressed does not return within how
many seconds?
A. 3 seconds
B. 6 seconds
C. 9 seconds
D. 10 seconds
54.In Integrated Management of Childhood
Illness, the nurse is aware that the severe
conditions generally require urgent referral
to a hospital. Which of the following severe
conditions DOES NOT always require
urgent referral to a hospital?
A. Mastoiditis
B. Severe dehydration
C. Severe pneumonia
D. Severe febrile disease
55.Myrna a public health nurse will conduct
outreach immunization in a barangay Masay
with a population of about 1500. The
estimated number of infants in the barangay
would be:
A. 45 infants
B. 50 infants
C. 55 infants
D. 65 infants
56.The community nurse is aware that the
biological used in Expanded Program on
Immunization (EPI) should NOT be stored
in the freezer?
A. DPT
B. Oral polio vaccine
C. Measles vaccine
D. MMR
57.It is the most effective way of controlling
schistosomiasis in an endemic area?
A. Use of molluscicides
B. Building of foot bridges
C. Proper use of sanitary toilets
D. Use of protective footwear, such as
rubber boots
58.Several clients is newly admitted and
diagnosed with leprosy. Which of the
following clients should be classified as a
case of multibacillary leprosy?
A. 3 skin lesions, negative slit skin smear
B. 3 skin lesions, positive slit skin smear
C. 5 skin lesions, negative slit skin smear
D. 5 skin lesions, positive slit skin smear
59.Nurses are aware that diagnosis of
leprosy is highly dependent on recognition
of symptoms. Which of the following is an
early sign of leprosy?
A. Macular lesions
B. Inability to close eyelids
C. Thickened painful nerves
D. Sinking of the nosebridge
60.Marie brought her 10 month old infant
for consultation because of fever, started 4
days prior to consultation. In determining
malaria risk, what will you do?
A. Perform a tourniquet test.
B. Ask where the family resides.
C. Get a specimen for blood smear.
D. Ask if the fever is present everyday.
61.Susie brought her 4 years old daughter to
the RHU because of cough and colds.
Following the IMCI assessment guide,
which of the following is a danger sign that
indicates the need for urgent referral to a
hospital?
A. Inability to drink
B. High grade fever
C. Signs of severe dehydration
D. Cough for more than 30 days
62.Jimmy a 2-year old child revealed “baggy
pants”. As a nurse, using the IMCI
guidelines, how will you manage Jimmy?
A. Refer the child urgently to a hospital for
confinement.
B. Coordinate with the social worker to
enroll the child in a feeding program.
C. Make a teaching plan for the mother,
focusing on menu planning for her
child.
D. Assess and treat the child for health
problems like infections and intestinal
parasitism.
63.Gina is using Oresol in the management
of diarrhea of her 3-year old child. She
asked you what to do if her child vomits. As
a nurse you will tell her to:
A. Bring the child to the nearest hospital
for further assessment.
B. Bring the child to the health center for
intravenous fluid therapy.
C. Bring the child to the health center for
assessment by the physician.
 D. Let the child rest for 10 minutes then
continue giving Oresol more slowly.
64.Nikki a 5-month old infant was brought
by his mother to the health center because of
diarrhea for 4 to 5 times a day. Her skin goes
back slowly after a skin pinch and her eyes
are sunken. Using the IMCI guidelines, you
will classify this infant in which category?
A. No signs of dehydration
B. Some dehydration
C. Severe dehydration
D. The data is insufficient.
65.Chris a 4-month old infant was brought
by her mother to the health center because of
cough. His respiratory rate is 42/minute.
Using the Integrated Management of Child
Illness (IMCI) guidelines of assessment, his
breathing is considered as:
A. Fast
B. Slow
C. Normal
D. Insignificant
66.Maylene had just received her 4th dose of
tetanus toxoid. She is aware that her baby
will have protection against tetanus for
A. 1 year
B. 3 years
C. 5 years
D. Lifetime
67.Nurse Ron is aware that unused BCG
should be discarded after how many hours of
reconstitution?
A. 2 hours
B. 4 hours
C. 8 hours
D. At the end of the day
68.The nurse explains to a breastfeeding
mother that breast milk is sufficient for all of
the baby’s nutrient needs only up to:
A. 5 months
B. 6 months
C. 1 year
D. 2 years
69.Nurse Ron is aware that the gestational
age of a conceptus that is considered viable
(able to live outside the womb) is:
A. 8 weeks
B. 12 weeks
C. 24 weeks
D. 32 weeks
70.When teaching parents of a neonate the
proper position for the neonate’s sleep, the
nurse Patricia stresses the importance of
placing the neonate on his back to reduce the
risk of which of the following?
A. Aspiration
B. Sudden infant death syndrome (SIDS)
C. Suffocation
D. Gastroesophageal reflux (GER)
71.Which finding might be seen in baby
James a neonate suspected of having an
infection?
A. Flushed cheeks
B. Increased temperature
C. Decreased temperature
D. Increased activity level
72.Baby Jenny who is small-for-gestation is
at increased risk during the transitional
period for which complication?
A. Anemia probably due to chronic fetal
hyposia
B. Hyperthermia due to decreased
glycogen stores
C. Hyperglycemia due to decreased
glycogen stores
D. Polycythemia probably due to chronic
fetal hypoxia
73.Marjorie has just given birth at 42 weeks’
gestation. When the nurse assessing the
neonate, which physical finding is expected?
A. A sleepy, lethargic baby
B. Lanugo covering the body
C. Desquamation of the epidermis
D. Vernix caseosa covering the body
74.After reviewing the Myrna’s maternal
history of magnesium sulfate during labor,
which condition would nurse Richard
anticipate as a potential problem in the
neonate?
A. Hypoglycemia
B. Jitteriness
C. Respiratory depression
D. Tachycardia
75.Which symptom would indicate the Baby
Alexandra was adapting appropriately to
extra-uterine life without difficulty?
A. Nasal flaring
B. Light audible grunting
C. Respiratory rate 40 to 60
breaths/minute
D. Respiratory rate 60 to 80
breaths/minute
76. When teaching umbilical cord care for
Jennifer a new mother, the nurse Jenny
would include which information?
A. Apply peroxide to the cord with each
diaper change
B. Cover the cord with petroleum jelly
after bathing
C. Keep the cord dry and open to air
D. Wash the cord with soap and water each
day during a tub bath.
77.Nurse John is performing an assessment
on a neonate. Which of the following
findings is considered common in the
healthy neonate?
 A. Simian crease
B. Conjunctival hemorrhage
C. Cystic hygroma
D. Bulging fontanelle
78.Dr. Esteves decides to artificially rupture
the membranes of a mother who is on labor.
Following this procedure, the nurse Hazel
checks the fetal heart tones for which the
following reasons?
A. To determine fetal well-being.
B. To assess for prolapsed cord
C. To assess fetal position
D. To prepare for an imminent delivery.
79.Which of the following would be least
likely to indicate anticipated bonding
behaviors by new parents?
A. The parents’ willingness to touch and
hold the new born.
B. The parent’s expression of interest
about the size of the new born.
C. The parents’ indication that they want
to see the newborn.
D. The parents’ interactions with each
other.
80.Following a precipitous delivery,
examination of the client’s vagina reveals
a fourth-degree laceration. Which of the
following would be contraindicated when
caring for this client?
A. Applying cold to limit edema during the
first 12 to 24 hours.
B. Instructing the client to use two or more
peripads to cushion the area.
C. Instructing the client on the use of sitz
baths if ordered.
D. Instructing the client about the
importance of perineal (kegel)
exercises.
81. A pregnant woman accompanied by her
husband, seeks admission to the labor and
delivery area. She states that she’s in labor
and says she attended the facility clinic for
prenatal care. Which question should the
nurse Oliver ask her first?
A. “Do you have any chronic illnesses?”
B. “Do you have any allergies?”
C. “What is your expected due date?”
D. “Who will be with you during labor?”
82.A neonate begins to gag and turns a
dusky color. What should the nurse do first?
A. Calm the neonate.
B. Notify the physician.
C. Provide oxygen via face mask as
ordered
D. Aspirate the neonate’s nose and mouth
with a bulb syringe.
83. When a client states that her “water
broke,” which of the following actions
would be inappropriate for the nurse to do?
A. Observing the pooling of straw-colored
fluid.
B. Checking vaginal discharge with
nitrazine paper.
C. Conducting a bedside ultrasound for an
amniotic fluid index.
D. Observing for flakes of vernix in the
vaginal discharge.
84. A baby girl is born 8 weeks premature.
At birth, she has no spontaneous respirations
but is successfully resuscitated. Within
several hours she develops respiratory
grunting, cyanosis, tachypnea, nasal flaring,
and retractions. She’s diagnosed with
respiratory distress syndrome, intubated, and
placed on a ventilator. Which nursing action
should be included in the baby’s plan of care
to prevent retinopathy of prematurity?
A. Cover his eyes while receiving oxygen.
B. Keep her body temperature low.
C. Monitor partial pressure of oxygen
(Pao2) levels.
D. Humidify the oxygen.
85. Which of the following is normal
newborn calorie intake?
A. 110 to 130 calories per kg.
B. 30 to 40 calories per lb of body weight.
C. At least 2 ml per feeding
D. 90 to 100 calories per kg
86. Nurse John is knowledgeable that
usually individual twins will grow
appropriately and at the same rate as
singletons until how many weeks?
A. 16 to 18 weeks
B. 18 to 22 weeks
C. 30 to 32 weeks
D. 38 to 40 weeks
87. Which of the following classifications
applies to monozygotic twins for whom the
cleavage of the fertilized ovum occurs more
than 13 days after fertilization?
A. conjoined twins
B. diamniotic dichorionic twins
C. diamniotic monochorionic twin
D. monoamniotic monochorionic twins
88. Tyra experienced painless vaginal
bleeding has just been diagnosed as having a
placenta previa. Which of the following
procedures is usually performed to diagnose
placenta previa?
A. Amniocentesis
B. Digital or speculum examination
C. External fetal monitoring
D. Ultrasound
89. Nurse Arnold knows that the following
changes in respiratory functioning during
pregnancy is considered normal:
 A. Increased tidal volume
B. Increased expiratory volume
C. Decreased inspiratory capacity
D. Decreased oxygen consumption
90. Emily has gestational diabetes and it is
usually managed by which of the following
therapy?
A. Diet
B. Long-acting insulin
C. Oral hypoglycemic
D. Oral hypoglycemic drug and insulin
91. Magnesium sulfate is given to Jemma
with preeclampsia to prevent which of the
following condition?
A. Hemorrhage
B. Hypertension
C. Hypomagnesemia
D. Seizure
92. Cammile with sickle cell anemia has an
increased risk for having a sickle cell crisis
during pregnancy. Aggressive management
of a sickle cell crisis includes which of the
following measures?
A. Antihypertensive agents
B. Diuretic agents
C. I.V. fluids
D. Acetaminophen (Tylenol) for pain
93. Which of the following drugs is the
antidote for magnesium toxicity?
A. Calcium gluconate (Kalcinate)
B. Hydralazine (Apresoline)
C. Naloxone (Narcan)
D. Rho (D) immune globulin (RhoGAM)
94. Marlyn is screened for tuberculosis
during her first prenatal visit. An intradermal
injection of purified protein derivative
(PPD) of the tuberculin bacilli is given. She
is considered to have a positive test for
which of the following results?
A. An indurated wheal under 10 mm in
diameter appears in 6 to 12 hours.
B. An indurated wheal over 10 mm in
diameter appears in 48 to 72 hours.
C. A flat circumcised area under 10 mm in
diameter appears in 6 to 12 hours.
D. A flat circumcised area over 10 mm in
diameter appears in 48 to 72 hours.
95. Dianne, 24 year-old is 27 weeks’
pregnant arrives at her physician’s office
with complaints of fever, nausea, vomiting,
malaise, unilateral flank pain, and
costovertebral angle tenderness. Which of
the following diagnoses is most likely?
A. Asymptomatic bacteriuria
B. Bacterial vaginosis
C. Pyelonephritis
D. Urinary tract infection (UTI)
96. Rh isoimmunization in a pregnant client
develops during which of the following
conditions?
A. Rh-positive maternal blood crosses into
fetal blood, stimulating fetal antibodies.
B. Rh-positive fetal blood crosses into
maternal blood, stimulating maternal
antibodies.
C. Rh-negative fetal blood crosses into
maternal blood, stimulating maternal
antibodies.
D. Rh-negative maternal blood crosses into
fetal blood, stimulating fetal antibodies.
97. To promote comfort during labor, the
nurse John advises a client to assume certain
positions and avoid others. Which position
may cause maternal hypotension and fetal
hypoxia?
A. Lateral position
B. Squatting position
C. Supine position
D. Standing position
98. Celeste who used heroin during her
pregnancy delivers a neonate. When
assessing the neonate, the nurse Lhynnette
expects to find:
A. Lethargy 2 days after birth.
B. Irritability and poor sucking.
C. A flattened nose, small eyes, and thin
lips.
D. Congenital defects such as limb
anomalies.
99. The uterus returns to the pelvic cavity in
which of the following time frames?
A. 7th to 9th day postpartum.
B. 2 weeks postpartum.
C. End of 6th week postpartum.
D. When the lochia changes to alba.
100. Maureen, a primigravida client, age 20,
has just completed a difficult, forceps-
assisted delivery of twins. Her labor was
unusually long and required oxytocin
(Pitocin) augmentation. The nurse who’s
caring for her should stay alert for:
A. Uterine inversion
B. Uterine atony
C. Uterine involution
D. Uterine discomfort
Answers and Rationales
1. Answer: (A) Inevitable. An inevitable
abortion is termination of pregnancy
that cannot be prevented. Moderate to
severe bleeding with mild cramping
and cervical dilation would be noted in
this type of abortion.
2. Answer: (B) History of
syphilis. Maternal infections such as
syphilis, toxoplasmosis, and rubella are
causes of spontaneous abortion.
3. Answer: (C) Monitoring apical 2 cm below the plane of the ischial damage the operative site, such as
pulse. Nursing care for the client with a spines. objects as pacifiers, suction catheters,
possible ectopic pregnancy is focused 8. Answer: (A) Contractions every 1 ½ and small spoons shouldn’t be placed in
on preventing or identifying minutes lasting 70-80 a baby’s mouth after cleft repair. A
hypovolemic shock and seconds. Contractions every 1 ½ baby in a prone position may rub her
controlling pain. An elevated pulse rate minutes lasting 70-80 seconds, face on the sheets and traumatize the
is an indicator of shock. is indicative of hyperstimulation of the operative site. The suture line should be
4. Answer: (B) Increased caloric uterus, which could result in injury cleaned gently to prevent infection,
intake. Glucose crosses the placenta, to the mother and the fetus if Pitocin is which could interfere with healing and
but insulin does not. High not discontinued. damage the cosmetic appearance of the
fetal demands for glucose, combined 9. Answer: (C) EKG tracings. A potential repair.
with the insulin resistance caused side effect of calcium gluconate 13. Answer: (B) Allow the infant to rest
by hormonal changes in the last half of administration is cardiac arrest. before feeding. Because feeding
pregnancy can result in elevation Continuous monitoring of cardiac requires so much energy, an infant with
of maternal blood glucose levels. This activity (EKG) throught administration heart failure should rest before feeding.
increases the mother’s demand of calcium gluconate is an essential part 14. Answer: (C) Iron-rich formula
for insulin and is referred to as the of care. only. The infants at age 5 months
diabetogenic effect of pregnancy. 10. Answer: (D) First low transverse should receive iron-rich formula and
5. Answer: (A) Excessive fetal caesarean was for breech position. that they shouldn’t receive solid food,
activity. The most common signs and Fetus in this pregnancy is in a vertex even baby food until age 6 months.
symptoms of hydatidiform presentation. This type of client has no 15. Answer: (D) 10 months. A 10 month
mole includes elevated levels of human obstetrical indication for a caesarean old infant can sit alone and understands
chorionic gonadotropin, section as she did with her first object permanence, so he would look
vaginal bleeding, larger than normal caesarean delivery. for the hidden toy. At age 4 to 6
uterus for gestational age, failure to 11. Answer: (A) Talk to the mother first months, infants can’t sit securely alone.
detect fetal heart activity even with and then to the toddler. When dealing At age 8 months, infants can sit
sensitive instruments, excessive nausea with a crying toddler, the best approach securely alone but cannot understand
and vomiting, and early development of is to talk to the mother and ignore the the permanence of objects.
pregnancy-induced hypertension. Fetal toddler first. This approach helps the 16. Answer: (D) Public health nursing
activity would not be noted. toddler get used to the nurse before she focuses on preventive, not curative,
6. Answer: (B) Absent patellar attempts any procedures. It also gives services. The catchments area in PHN
reflexes. Absence of patellar reflexes is the toddler an opportunity to see that consists of a residential community,
an indicator of hypermagnesemia, the mother trusts the nurse. many of whom are well individuals
which requires administration of 12. Answer: (D) Place the infant’s arms in who have greater need for preventive
calcium gluconate. soft elbow restraints. Soft restraints rather than curative services.
7. Answer: (C) Presenting part in 2 cm from the upper arm to the wrist prevent 17. Answer: (B) Efficiency. Efficiency is
below the plane of the ischial the infant from touching her lip but determining whether the goals were
spines. Fetus at station plus two allow him to hold a favorite item such attained at the least possible cost.
indicates that the presenting part is as a blanket. Because they could
18. Answer: (D) Rural Health Unit. R.A.
7160 devolved basic health services to
local government units (LGU’s ). The
public health nurse is an employee of
the LGU.
19. Answer: (A) Mayor. The local
executive serves as the chairman of the
Municipal Health Board.
20. Answer: (A) 1. Each rural health
midwife is given a population
assignment of about 5,000.
21. Answer: (B) Health education and
community organizing are necessary in
providing community health
services. The community health nurse
develops the health capability of people
through health education and
community organizing activities.
22. Answer: (B) Measles. Presidential
Proclamation No. 4 is on the Ligtas
Tigdas Program.
23. Answer: (D) Core group formation. In
core group formation, the nurse is able
to transfer the technology of
community organizing to the potential
or informal community leaders through
a training program.
24. Answer: (D) To maximize the
community’s resources in dealing with
health problems. Community
organizing is a developmental service,
with the goal of developing the people’s
self-reliance in dealing with
community health problems. A, B and
C are objectives of contributory
objectives to this goal.
25. Answer: (D) Terminal. Tertiary
prevention involves rehabilitation,
prevention of permanent disability and
disability limitation appropriate for
convalescents, the disabled,
complicated cases and the terminally ill
(those in the terminal stage of a
disease).
26. Answer: (A) Intrauterine fetal
death. Intrauterine fetal death, abruptio
placentae, septic shock, and amniotic
fluid embolism may trigger normal
clotting mechanisms; if clotting factors
are depleted, DIC may occur. Placenta
accreta, dysfunctional labor, and
premature rupture of the membranes
aren’t associated with DIC.
27. Answer: (C) 120 to 160 beats/minute. A
rate of 120 to 160 beats/minute in the
fetal heart appropriate for filling the
heart with blood and pumping it out to
the system.
28. Answer: (A) Change the diaper more
often. Decreasing the amount of time
the skin comes contact with wet soiled
diapers will help heal the irritation.
29. Answer: (D) Endocardial cushion
defect. Endocardial cushion defects are
seen most in children with Down
syndrome, asplenia, or polysplenia.
30. Answer: (B) Decreased urine
output. Decreased urine output may
occur in clients receiving I.V.
magnesium and should be monitored
closely to keep urine output at greater
than 30 ml/hour, because magnesium is
excreted through the kidneys and can
easily accumulate to toxic levels.
31. Answer: (A) Menorrhagia. Menorrhagia
is an excessive menstrual period.
32. Answer: (C) Blood typing. Blood type
would be a critical value to have
because the risk of blood loss is always
a potential complication during the
labor and delivery process.
Approximately 40% of a woman’s
cardiac output is delivered to the uterus,
therefore, blood loss can occur quite
rapidly in the event of uncontrolled
bleeding.
33. Answer: (D) Physiologic
anemia. Hemoglobin values and
hematocrit decrease during pregnancy
as the increase in plasma volume
exceeds the increase in red blood cell
production.
34. Answer: (D) A 2 year old infant with
stridorous breath sounds, sitting up in
his mother’s arms and drooling. The
infant with the airway emergency
should be treated first, because of the
risk of epiglottitis.
35. Answer: (A) Placenta previa. Placenta
previa with painless vaginal bleeding.
36. Answer: (D) Early in the
morning. Based on the nurse’s
knowledge of microbiology, the
specimen should be collected early in
the morning. The rationale for
this timing is that, because the female
worm lays eggs at night around the
perineal area, the first bowel movement
of the day will yield the best results.
The specific type of stool specimen
used in the diagnosis of pinworms is
called the tape test.
37. Answer: (A) Irritability and
seizures. Lead poisoning primarily
affects the CNS, causing increased
intracranial pressure. This condition
results in irritability and changes in
 level of consciousness, as well as
seizure disorders, hyperactivity, and
learning disabilities.
38. Answer: (D) “I really need to use the
diaphragm and jelly most during the
middle of my menstrual cycle”. The
woman must understand that, although
the “fertile” period is approximately
mid-cycle, hormonal variations do
occur and can result in early or late
ovulation. To be effective, the
diaphragm should be inserted before
every intercourse.
39. Answer: (C) Restlessness. In a child,
restlessness is the earliest sign of
hypoxia. Late signs of hypoxia in a
child are associated with a change in
color, such as pallor or cyanosis.
40. Answer: (B) Walk one step ahead, with
the child’s hand on the nurse’s
elbow. This procedure is generally
recommended to follow in guiding a
person who is blind.
41. Answer: (A) Loud, machinery-like
murmur. A loud, machinery-like
murmur is a characteristic finding
associated with patent ductus arteriosus.
42. Answer: (C) More oxygen, and the
newborn’s metabolic rate
increases. When cold, the infant
requires more oxygen and there is an
increase in metabolic rate. Non-
shievering thermogenesis is a complex
process that increases the metabolic rate
and rate of oxygen consumption,
therefore, the newborn increase heat
production.
43. Answer: (D) Voided. Before
administering potassium I.V. to any
client, the nurse must first check that
the client’s kidneys are functioning and
that the client is voiding. If the client is
not voiding, the nurse should withhold
the  potassium and notify the physician.
44. Answer: (C) Laundry
detergent. Eczema or dermatitis is an
allergic skin reaction caused by an
offending allergen. The topical allergen
that is the most common causative
factor is laundry detergent.
45. Answer: (A) 6 inches. This distance
allows for easy flow of the formula by
gravity, but the flow will be slow
enough not to overload the stomach too
rapidly.
46. Answer: (A) The older one gets, the
more susceptible he becomes to the
complications of chicken pox. Chicken
pox is usually more severe in adults
than in children. Complications, such as
pneumonia, are higher in incidence in
adults.
47. Answer: (D) Consult a physician who
may give them rubella
immunoglobulin. Rubella vaccine is
made up of attenuated German measles
viruses. This is contraindicated in
pregnancy. Immune globulin, a specific
prophylactic against German measles,
may be given to pregnant women.
48. Answer: (A) Contact tracing. Contact
tracing is the most practical and reliable
method of finding possible sources of
person-to-person transmitted infections,
such as sexually transmitted diseases.
49. Answer: (D)
Leptospirosis. Leptospirosis is
transmitted through contact with the
skin or mucous membrane with water
or moist soil contaminated with urine of
infected animals, like rats.
50. Answer: (B) Cholera. Passage of
profuse watery stools is the major
symptom of cholera. Both amebic and
bacillary dysentery are characterized by
the presence of blood and/or mucus in
the stools. Giardiasis is characterized by
fat malabsorption and, therefore,
steatorrhea.
51. Answer: (A) Hemophilus
influenzae. Hemophilus meningitis is
unusual over the age of 5 years. In
developing countries, the peak
incidence is in children less than 6
months of age. Morbillivirus is the
etiology of measles. Streptococcus
pneumoniae and Neisseria meningitidis
may cause meningitis, but age
distribution is not specific in young
children.
52. Answer: (B) Buccal mucosa. Koplik’s
spot may be seen on the mucosa of the
mouth or the throat.
53. Answer: (A) 3 seconds. Adequate blood
supply to the area allows the return of
the color of the nailbed within 3
seconds.
54. Answer: (B) Severe dehydration. The
order of priority in the management of
severe dehydration is as follows:
intravenous fluid therapy, referral to a
facility where IV fluids can be initiated
within 30 minutes, Oresol or
nasogastric tube. When the foregoing
measures are not possible or effective,
then urgent referral to the hospital is
done.
55. Answer: (A) 45 infants. To estimate the
number of infants, multiply total
population by 3%.
56. Answer: (A) DPT. DPT is sensitive to
freezing. The appropriate storage
temperature of DPT is 2 to 8° C only.
OPV and measles vaccine are
highly sensitive to heat and require
freezing. MMR is not an immunization
in the Expanded Program on
Immunization.
57. Answer: (C) Proper use of sanitary
toilets. The ova of the parasite get out
of the human body together with feces.
Cutting the cycle at this stage is the
most effective way of preventing the
spread of the disease to susceptible
hosts.
58. Answer: (D) 5 skin lesions, positive slit
skin smear. A multibacillary leprosy
case is one who has a positive slit skin
smear and at least 5 skin lesions.
59. Answer: (C) Thickened painful
nerves. The lesion of leprosy is not
macular. It is characterized by a change
in skin color (either reddish or whitish)
and loss of sensation, sweating and hair
growth over the lesion. Inability to
close the eyelids (lagophthalmos) and
sinking of the nosebridge are late
symptoms.
60. Answer: (B) Ask where the family
resides. Because malaria is endemic, the
first question to determine malaria risk
is where the client’s family resides. If
the area of residence is not a known
endemic area, ask if the child had
traveled within the past 6 months,
where she was brought and whether she
stayed overnight in that area.
61. Answer: (A) Inability to drink. A sick
child aged 2 months to 5 years must be
referred urgently to a hospital if he/she
has one or more of the following signs:
not able to feed or drink, vomits
everything, convulsions, abnormally
sleepy or difficult to awaken.
62. Answer: (A) Refer the child urgently to
a hospital for confinement. “Baggy
pants” is a sign of severe marasmus.
The best management is urgent referral
to a hospital.
63. Answer: (D) Let the child rest for 10
minutes then continue giving Oresol
more slowly. If the child vomits
persistently, that is, he vomits
everything that he takes in, he has to be
referred urgently to a hospital.
Otherwise, vomiting is managed by
letting the child rest for 10 minutes and
then continuing with Oresol
administration. Teach the mother to
give Oresol more slowly.
64. Answer: (B) Some dehydration. Using
the assessment guidelines of IMCI, a
child (2 months to 5 years old) with
diarrhea is classified as having SOME
DEHYDRATION if he shows 2 or
more of the following signs: restless or
irritable, sunken eyes, the skin goes
back slow after a skin pinch.
65. Answer: (C) Normal. In IMCI, a
respiratory rate of 50/minute or more is
fast breathing for an infant aged 2 to 12
months.
66. Answer: (A) 1 year. The baby will have
passive natural immunity by placental
transfer of antibodies. The mother will
have active artificial immunity lasting
for about 10 years. 5 doses will give the
mother lifetime protection.
67. Answer: (B) 4 hours. While the unused
portion of other biologicals in EPI may
be given until the end of the day, only
BCG is discarded 4 hours
after reconstitution. This is why BCG
immunization is scheduled only in the
morning.
68. Answer: (B) 6 months. After 6 months,
the baby’s nutrient needs, especially the
baby’s iron requirement, can no longer
be provided by mother’s milk alone.
69. Answer: (C) 24 weeks. At
approximately 23 to 24 weeks’
gestation, the lungs are developed
enough to sometimes maintain
extrauterine life. The lungs are the most
immature system during the gestation
period. Medical care for premature
labor begins much earlier (aggressively
at 21 weeks’ gestation)
70. Answer: (B) Sudden infant death
syndrome (SIDS). Supine positioning is
recommended to reduce the risk of
SIDS in infancy. The risk of aspiration
is slightly increased with the supine
position. Suffocation would be less
likely with an infant supine than prone
and the position for GER requires the
head of the bed to be elevated.
71. Answer: (C) Decreased
temperature. Temperature instability,
especially when it results in a low
temperature in the neonate, may be a
sign of infection. The neonate’s color
often changes with an infection process
 but generally becomes ashen or
mottled. The neonate with an infection
will usually show a decrease in activity
level or lethargy.
72. Answer: (D) Polycythemia probably
due to chronic fetal hypoxia. The small-
for-gestation neonate is at risk for
developing polycythemia during the
transitional period in an attempt to
decreasehypoxia. The neonates are also
at increased risk for developing
hypoglycemia and hypothermia due to
decreased glycogen stores.
73. Answer: (C) Desquamation of the
epidermis. Postdate fetuses lose the
vernix caseosa, and the epidermis may
become desquamated. These neonates
are usually very alert. Lanugo is
missing in the postdate neonate.
74. Answer: (C) Respiratory
depression. Magnesium sulfate crosses
the placenta and adverse neonatal
effects are respiratory depression,
hypotonia, and bradycardia. The serum
blood sugar isn’t affected by
magnesium sulfate. The neonate would
be floppy, not jittery.
75. Answer: (C) Respiratory rate 40 to 60
breaths/minute. A respiratory rate 40 to
60 breaths/minute is normal for a
neonate during the transitional period.
Nasal flaring, respiratory rate more than
60 breaths/minute, and audible grunting
are signs of respiratory distress.
76. Answer: (C) Keep the cord dry and
open to air. Keeping the cord dry and
open to air helps reduce infection and
hastens drying. Infants aren’t given tub
bath but are sponged off until the cord
falls off. Petroleum jelly prevents the
cord from drying and encourages
infection. Peroxide could be painful and
isn’t recommended.
77. Answer: (B) Conjunctival
hemorrhage. Conjunctival hemorrhages
are commonly seen in neonates
secondary to the cranial pressure
applied during the birth process.
Bulging fontanelles are a sign of
intracranial pressure. Simian creases are
present in 40% of the neonates with
trisomy 21. Cystic hygroma is a neck
mass that can affect the airway.
78. Answer: (B) To assess for prolapsed
cord. After a client has an amniotomy,
the nurse should assure that the cord
isn’t prolapsed and that the baby
tolerated the procedure well. The most
effective way to do this is to check the
fetal heart rate. Fetal well-being is
assessed via a nonstress test. Fetal
position is determined by vaginal
examination. Artificial rupture of
membranes doesn’t indicate an
imminent delivery.
79. Answer: (D) The parents’ interactions
with each other. Parental interaction
will provide the nurse with a good
assessment of the stability of the
family’s home life but it has no
indication for parental bonding.
Willingness to touch and hold the
newborn, expressing interest about the
newborn’s size, and indicating a desire
to see the newborn are behaviors
indicating parental bonding.
80. Answer: (B) Instructing the client to use
two or more peripads to cushion the
area. Using two or more peripads would
do little to reduce the pain or promote
perineal healing. Cold applications, sitz
baths, and Kegel exercises are
important measures when the client has
a fourth-degree laceration.
81. Answer: (C) “What is your expected
due date?” When obtaining the history
of a client who may be in labor, the
nurse’s highest priority is to determine
her current status, particularly her due
date, gravidity, and parity. Gravidity
and parity affect the duration of labor
and the potential for labor
complications. Later, the nurse should
ask about chronic illnesses, allergies,
and support persons.
82. Answer: (D) Aspirate the neonate’s
nose and mouth with a bulb
syringe. The nurse’s first action should
be to clear the neonate’s airway with a
bulb syringe. After the airway is clear
and the neonate’s color improves, the
nurse should comfort and calm the
neonate. If the problem recurs or the
neonate’s color doesn’t improve
readily, the nurse should notify the
physician. Administering oxygen when
the airway isn’t clear would be
ineffective.
83. Answer: (C) Conducting a bedside
ultrasound for an amniotic fluid
index. It isn’t within a nurse’s scope of
practice to perform and interpret a
bedside ultrasound under these
conditions and without specialized
training. Observing for pooling of
straw-colored fluid, checking vaginal
discharge with nitrazine paper, and
 observing for flakes of vernix are
appropriate assessments for determining
whether a client has ruptured
membranes.
84. Answer: (C) Monitor partial pressure of
oxygen (Pao2) levels. Monitoring PaO2
levels and reducing the oxygen
concentration to keep PaO2 within
normal limits reduces the risk of
retinopathy of prematurity in a
premature infant receiving oxygen.
Covering the infant’s eyes and
humidifying the oxygen don’t reduce
the risk of retinopathy of prematurity.
Because cooling increases the risk of
acidosis, the infant should be kept
warm so that his respiratory
distress isn’t aggravated.
85. Answer: (A) 110 to 130 calories per
kg. Calories per kg is the accepted way
of determined appropriate nutritional
intake for a newborn. The
recommended calorie requirement is
110 to 130 calories per kg of newborn
body weight. This level will maintain a
consistent blood glucose level and
provide enough calories for continued
growth and development.
86. Answer: (C) 30 to 32 weeks. Individual
twins usually grow at the same rate as
singletons until 30 to 32 weeks’
gestation, then twins don’t’ gain weight
as rapidly as singletons of the same
gestational age. The placenta can no
longer keep pace with the nutritional
requirements of both fetuses after 32
weeks, so there’s some growth
retardation in twins if they remain in
utero at 38 to 40 weeks.
87. Answer: (A) conjoined twins. The type
of placenta that develops in
monozygotic twins depends on the time
at which cleavage of the ovum occurs.
Cleavage in conjoined twins occurs
more than 13 days after fertilization.
Cleavage that occurs less than 3 day
after fertilization results in diamniotic
dicchorionic twins. Cleavage that
occurs between days 3 and 8 results in
diamniotic monochorionic twins.
Cleavage that occurs between days 8 to
13 result in monoamniotic
monochorionic twins.
88. Answer: (D) Ultrasound. Once the
mother and the fetus are stabilized,
ultrasound evaluation of the placenta
should be done to determine the cause
of the bleeding. Amniocentesis is
contraindicated in placenta previa. A
digital or speculum examination
shouldn’t be done as this may lead to
severe bleeding or hemorrhage.
External fetal monitoring won’t detect a
placenta previa, although it will detect
fetal distress, which may result from
blood loss or placenta separation.
89. Answer: (A) Increased tidal volume. A
pregnant client breathes deeper, which
increases the tidal volume of gas moved
in and out of the respiratory tract with
each breath. The expiratory volume and
residual volume decrease as the
pregnancy progresses. The inspiratory
capacity increases during pregnancy.
The increased oxygen consumption in
the pregnant client is 15% to 20%
greater than in the nonpregnant state.
90. Answer: (A) Diet. Clients with
gestational diabetes are usually
managed by diet alone to control their
glucose intolerance. Oral hypoglycemic
drugs are contraindicated in pregnancy.
Long-acting insulin usually isn’t needed
for blood glucose control in the client
with gestational diabetes.
91. Answer: (D) Seizure. The
anticonvulsant mechanism of
magnesium is believes to depress
seizure foci in the brain and peripheral
neuromuscular blockade.
Hypomagnesemia isn’t a complication
of preeclampsia. Antihypertensive drug
other than magnesium are preferred for
sustained hypertension. Magnesium
doesn’t help prevent hemorrhage in
preeclamptic clients.
92. Answer: (C) I.V. fluids. A sickle cell
crisis during pregnancy is usually
managed by exchange transfusion
oxygen, and L.V. Fluids. The client
usually needs a stronger analgesic than
acetaminophen to control the pain of a
crisis. Antihypertensive drugs usually
aren’t necessary. Diuretic wouldn’t be
used unless fluid overload resulted.
93. Answer: (A) Calcium gluconate
(Kalcinate). Calcium gluconate is the
antidote for magnesium toxicity. Ten
milliliters of 10% calcium gluconate is
given L.V. push over 3 to 5 minutes.
Hydralazine is given for sustained
elevated blood pressure in preeclamptic
clients. Rho (D) immune globulin is
given to women with Rh-negative
blood to prevent antibody formation
from RH-positive conceptions.
 Naloxone is used to correct narcotic
toxicity.
94. Answer: (B) An indurated wheal over
10 mm in diameter appears in 48 to 72
hours. A positive PPD result would be
an indurated wheal over 10 mm in
diameter that appears in 48 to 72 hours.
The area must be a raised wheal, not a
flat circumcised area to be considered
positive.
95. Answer: (C) Pyelonephritis. The
symptoms indicate acute pyelonephritis,
a serious condition in a pregnant client.
UTI symptoms include dysuria,
urgency, frequency, and suprapubic
tenderness. Asymptomatic bacteriuria
doesn’t cause symptoms. Bacterial
vaginosis causes milky white vaginal
discharge but no systemic symptoms.
96. Answer: (B) Rh-positive fetal blood
crosses into maternal blood, stimulating
maternal antibodies. Rh
isoimmunization occurs when Rh-
positive fetal blood cells cross into the
maternal circulation and stimulate
maternal antibody production. In
subsequent pregnancies with Rh-
positive fetuses, maternal antibodies
may cross back into the fetal circulation
and destroy the fetal blood cells.
97. Answer: (C) Supine position. The
supine position causes compression of
the client’s aorta and inferior vena cava
by the fetus. This, in turn, inhibits
maternal circulation, leading to
maternal hypotension and, ultimately,
fetal hypoxia. The other positions
promote comfort and aid labor progress.
For instance, the lateral, or side-lying,
position improves maternal and fetal
circulation, enhances comfort, increases
maternal relaxation, reduces muscle
tension, and eliminates pressure points.
The squatting position promotes
comfort by taking advantage of gravity.
The standing position also takes
advantage of gravity and aligns the
fetus with the pelvic angle.
98. Answer: (B) Irritability and poor
sucking. Neonates of heroin-addicted
mothers are physically dependent on the
drug and experience withdrawal when
the drug is no longer supplied. Signs of
heroin withdrawal include irritability,
poor sucking, and restlessness.
Lethargy isn’t associated with neonatal
heroin addiction. A flattened nose,
small eyes, and thin lips are seen in
infants with fetal alcohol syndrome.
Heroin use during pregnancy hasn’t
been linked to specific congenital
anomalies.
99. Answer: (A) 7th to 9th day
postpartum. The normal involutional
process returns the uterus to the pelvic
cavity in 7 to 9 days. A significant
involutional complication is the failure
of the uterus to return to the pelvic
cavity within the prescribed time
period. This is known as subinvolution.
100. Answer: (B) Uterine atony. Multiple
fetuses, extended labor stimulation with
oxytocin, and traumatic delivery
commonly are associated with uterine
atony, which may lead to postpartum
hemorrhage. Uterine inversion may
precede or follow delivery and
commonly results from apparent
excessive traction on the umbilical cord
and attempts to deliver the placenta
manually. Uterine involution and some
uterine discomfort are normal after
delivery.
NP III
1. Nurse Michelle should know that the
drainage is normal 4 days after a sigmoid
colostomy when the stool is:
A. Green liquid
B. Solid formed
C. Loose, bloody
D. Semiformed
2. Where would nurse Kristine place the call
light for a male client with a right-sided
brain attack and left homonymous
hemianopsia?
A. On the client’s right side
B. On the client’s left side
C. Directly in front of the client
D. Where the client like
3. A male client is admitted to the
emergency department following
an accident. What are the first nursing
actions of the nurse?
A. Check respiration, circulation,
neurological response.
B. Align the spine, check pupils, and
check for hemorrhage.
C. Check respirations, stabilize spine, and
check circulation.
D. Assess level of consciousness and
circulation.
4. In evaluating the effect of nitroglycerin,
Nurse Arthur should know that it reduces
preload and relieves angina by:
A. Increasing contractility and slowing
heart rate.
 B. Increasing AV conduction and heart
rate.
C. Decreasing contractility and oxygen
consumption.
D. Decreasing venous return through
vasodilation.
5. Nurse Patricia finds a female client who is
post-myocardial infarction (MI) slumped on
the side rails of the bed and unresponsive to
shaking or shouting. Which is the nurse next
action?
A. Call for help and note the time.
B. Clear the airway
C. Give two sharp thumps to the
precordium, and check the pulse.
D. Administer two quick blows.
6. Nurse Monett is caring for a client
recovering from gastro-intestinal bleeding.
The nurse should:
A. Plan care so the client can receive 8
hours of uninterrupted sleep each night.
B. Monitor vital signs every 2 hours.
C. Make sure that the client takes food and
medications at prescribed intervals.
D. Provide milk every 2 to 3 hours.
7. A male client was on warfarin
(Coumadin) before admission, and has been
receiving heparin I.V. for 2 days. The partial
thromboplastin time (PTT) is 68 seconds.
What should Nurse Carla do?
A. Stop the I.V. infusion of heparin and
notify the physician.
B. Continue treatment as ordered.
C. Expect the warfarin to increase the
PTT.
D. Increase the dosage, because the level is
lower than normal.
8. A client undergone ileostomy, when
should the drainage appliance be applied to
the stoma?
A. 24 hours later, when edema has
subsided.
B. In the operating room.
C. After the ileostomy begin to function.
D. When the client is able to begin self-
care procedures.
9. A client undergone spinal anesthetic, it
will be important that the nurse immediately
position the client in:
A. On the side, to prevent obstruction of
airway by tongue.
B. Flat on back.
C. On the back, with knees flexed 15
degrees.
D. Flat on the stomach, with the head
turned to the side.
10.While monitoring a male client several
hours after a motor vehicle accident, which
assessment data suggest increasing
intracranial pressure?
A. Blood pressure is decreased from
160/90 to 110/70.
B. Pulse is increased from 87 to 95, with
an occasional skipped beat.
C. The client is oriented when aroused
from sleep, and goes back to sleep
immediately.
D. The client refuses dinner because of
anorexia.
11.Mrs. Cruz, 80 years old is diagnosed with
pneumonia. Which of the following
symptoms may appear first?
A. Altered mental status and dehydration
B. Fever and chills
C. Hemoptysis and Dyspnea
D. Pleuritic chest pain and cough
12. A male client has active tuberculosis
(TB). Which of the following symptoms will
be exhibit?
A. Chest and lower back pain
B. Chills, fever, night sweats, and
hemoptysis
C. Fever of more than 104°F (40°C) and
nausea
D. Headache and photophobia
13. Mark, a 7-year-old client is brought to
the emergency department. He’s tachypneic
and afebrile and has a respiratory rate of 36
breaths/minute and has a nonproductive
cough. He recently had a cold. Form this
history; the client may have which of the
following conditions?
A. Acute asthma
B. Bronchial pneumonia
C. Chronic obstructive pulmonary disease
(COPD)
D. Emphysema
14. Marichu was given morphine sulfate for
pain. She is sleeping and her respiratory rate
is 4 breaths/minute. If action isn’t taken
quickly, she might have which of the
following reactions?
A. Asthma attack
B. Respiratory arrest
C. Seizure
D. Wake up on his own
15. A 77-year-old male client is admitted for
elective knee surgery. Physical examination
reveals shallow respirations but no sign of
respiratory distress. Which of the following
is a normal physiologic change related to
aging?
A. Increased elastic recoil of the lungs
B. Increased number of functional
capillaries in the alveoli
 C. Decreased residual volume
D. Decreased vital capacity
16. Nurse John is caring for a male client
receiving lidocaine I.V. Which factor is the
most relevant to administration of this
medication?
A. Decrease in arterial oxygen saturation
(SaO2) when measured with a pulse
oximeter.
B. Increase in systemic blood pressure.
C. Presence of premature ventricular
contractions (PVCs) on
cardiac monitor.
D. Increase in intracranial pressure (ICP).
17. Nurse Ron is caring for a male client
taking an anticoagulant. The nurse should
teach the client to:
A. Report incidents of diarrhea.
B. Avoid foods high in vitamin K
C. Use a straight razor when shaving.
D. Take aspirin to pain relief.
18. Nurse Lhynnette is preparing a site for
the insertion of an I.V. catheter. The nurse
should treat excess hair at the site by:
A. Leaving the hair intact
B. Shaving the area
C. Clipping the hair in the area
D. Removing the hair with a depilatory.
19. Nurse Michelle is caring for an elderly
female with osteoporosis. When teaching the
client, the nurse should include information
about which major complication:
A. Bone fracture
B. Loss of estrogen
C. Negative calcium balance
D. Dowager’s hump
20. Nurse Len is teaching a group of women
to perform BSE. The nurse should explain
that the purpose of performing the
examination is to discover:
A. Cancerous lumps
B. Areas of thickness or fullness
C. Changes from previous examinations.
D. Fibrocystic masses
21. When caring for a female client who is
being treated for hyperthyroidism, it
is important to:
A. Provide extra blankets and clothing to
keep the client warm.
a B. Monitor the client for signs of
restlessness, sweating, and
excessive weight loss during thyroid
replacement therapy.
C. Balance the client’s periods of activity
and rest.
D. Encourage the client to be active to
prevent constipation.
22. Nurse Kris is teaching a client with
history of atherosclerosis. To decrease the
risk of atherosclerosis, the nurse should
encourage the client to:
A. Avoid focusing on his weight.
B. Increase his activity level.
C. Follow a regular diet.
D. Continue leading a high-stress lifestyle.
23. Nurse Greta is working on a surgical
floor. Nurse Greta must logroll a
client following a:
A. Laminectomy
B. Thoracotomy
C. Hemorrhoidectomy
D. Cystectomy.
24. A 55-year old client underwent cataract
removal with intraocular lens implant. Nurse
Oliver is giving the client discharge
instructions. These instructions
should include which of the following?
A. Avoid lifting objects weighing more
than 5 lb (2.25 kg).
B. Lie on your abdomen when in bed
C. Keep rooms brightly lit.
D. Avoiding straining during bowel
movement or bending at the waist.
25. George should be taught about testicular
examinations during:
A. when sexual activity starts
B. After age 69
C. After age 40
D. Before age 20.
26. A male client undergone a colon
resection. While turning him,
wound dehiscence with evisceration occurs.
Nurse Trish first response is to:
A. Call the physician
B. Place a saline-soaked sterile dressing on
the wound.
C. Take a blood pressure and pulse.
D. Pull the dehiscence closed.
27. Nurse Audrey is caring for a client who
has suffered a severe cerebrovascular
accident. During routine assessment, the
nurse notices Cheyne- Strokes respirations.
Cheyne-strokes respirations are:
A. A progressively deeper breaths
followed by shallower breaths
with apneic periods.
B. Rapid, deep breathing with abrupt
pauses between each breath.
C. Rapid, deep breathing and irregular
breathing without pauses.
D. Shallow breathing with an increased
respiratory rate.
28. Nurse Bea is assessing a male client with
heart failure. The breath sounds commonly
auscultated in clients with heart failure are:
A. Tracheal
 B. Fine crackles
C. Coarse crackles
D. Friction rubs
29. The nurse is caring for Kenneth
experiencing an acute asthma attack.
The client stops wheezing and breath sounds
aren’t audible. The reason for this change is
that:
A. The attack is over.
B. The airways are so swollen that no air
cannot get through.
C. The swelling has decreased.
D. Crackles have replaced wheezes.
30. Mike with epilepsy is having a seizure.
During the active seizure phase, the nurse
should:
A. Place the client on his back remove
dangerous objects, and insert a bite
block.
B. Place the client on his side, remove
dangerous objects, and insert a bite
block.
C. Place the client o his back, remove
dangerous objects, and hold down his
arms.
D. Place the client on his side, remove
dangerous objects, and protect his head.
31. After insertion of a cheat tube for a
pneumothorax, a client becomes hypotensive
with neck vein distention, tracheal shift,
absent breath sounds, and diaphoresis. Nurse
Amanda suspects a tension pneumothorax
has occurred. What cause of tension
pneumothorax should the nurse check for?
A. Infection of the lung.
B. Kinked or obstructed chest tube
C. Excessive water in the water-seal
chamber
D. Excessive chest tube drainage
32. Nurse Maureen is talking to a male
client, the client begins choking on
his lunch. He’s coughing forcefully. The
nurse should:
A. Stand him up and perform the
abdominal thrust maneuver from
behind.
B. Lay him down, straddle him, and
perform the abdominal
thrust maneuver.
C. Leave him to get assistance
D. Stay with him but not intervene at this
time.
33. Nurse Ron is taking a health history of
an 84 year old client. Which information
will be most useful to the nurse for planning
care?
A. General health for the last 10 years.
B. Current health promotion activities.
C. Family history of diseases.
D. Marital status.
34. When performing oral care on a
comatose client, Nurse Krina should:
A. Apply lemon glycerin to the client’s
lips at least every 2 hours.
B. Brush the teeth with client lying supine.
C. Place the client in a side lying position,
with the head of the bed lowered.
D. Clean the client’s mouth with hydrogen
peroxide.
35. A 77-year-old male client is admitted
with a diagnosis of dehydration and change
in mental status. He’s being hydrated with
L.V. fluids. When the nurse takes his vital
signs, she notes he has a fever of 103°F
(39.4°C) a cough producing yellow sputum
and pleuritic chest pain. The nurse suspects
this client may have which of the following
conditions?
A. Adult respiratory distress syndrome
(ARDS)
B. Myocardial infarction (MI)
C. Pneumonia
D. Tuberculosis
36. Nurse Oliver is working in a out patient
clinic. He has been alerted that there is an
outbreak of tuberculosis (TB). Which of the
following clients entering the clinic today
most likely to have TB?
A. A 16-year-old female high school
student
B. A 33-year-old day-care worker
C. A 43-yesr-old homeless man with a
history of alcoholism
D. A 54-year-old businessman
37. Virgie with a positive Mantoux test
result will be sent for a chest X-ray.
The nurse is aware that which of the
following reasons this is done?
A. To confirm the diagnosis
B. To determine if a repeat skin test is
needed
C. To determine the extent of lesions
D. To determine if this is a primary or
secondary infection
38. Kennedy with acute asthma showing
inspiratory and expiratory wheezes and a
decreased forced expiratory volume should
be treated with which of the following
classes of medication right away?
A. Beta-adrenergic blockers
B. Bronchodilators
C. Inhaled steroids
D. Oral steroids
39. Mr. Vasquez 56-year-old client with a
40-year history of smoking one to two packs
of cigarettes per day has a chronic cough
producing thick sputum, peripheral edema
and cyanotic nail beds. Based on this
information, he most likely has which of the
following conditions?
A. Adult respiratory distress syndrome
(ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema
Situation: Francis, age 46 is admitted to the
hospital with diagnosis of
Chronic Lymphocytic Leukemia.
40. The treatment for patients with leukemia
is bone marrow transplantation. Which
statement about bone marrow
transplantation is not correct?
A. The patient is under local anesthesia
during the procedure
B. The aspirated bone marrow is mixed
with heparin.
C. The aspiration site is the posterior or
anterior iliac crest.
D. The recipient receives
cyclophosphamide (Cytoxan) for 4
consecutive days before the procedure.
41. After several days of admission, Francis
becomes disoriented and complains of
frequent headaches. The nurse in-charge
first action would be:
A. Call the physician
B. Document the patient’s status in his
charts.
C. Prepare oxygen treatment
D. Raise the side rails
42. During routine care, Francis asks the
nurse, “How can I be anemic if this disease
causes increased my white blood cell
production?” The nurse in-charge best
response would be that the increased number
of white blood cells (WBC) is:
A. Crowd red blood cells
B. Are not responsible for the anemia.
C. Uses nutrients from other cells
D. Have an abnormally short life span of
cells.
43. Diagnostic assessment of Francis would
probably not reveal:
A. Predominance of lymhoblasts
B. Leukocytosis
C. Abnormal blast cells in the bone
marrow
D. Elevated thrombocyte counts
44. Robert, a 57-year-old client with acute
arterial occlusion of the left leg undergoes
an emergency embolectomy. Six hours later,
the nurse isn’t able to obtain pulses in his
left foot using Doppler ultrasound. The
nurse immediately notifies the physician,
and asks her to prepare the client for
surgery. As the nurse enters the client’s
room to prepare him, he states that he won’t
have any more surgery. Which of the
following is the best initial response by the
nurse?
A. Explain the risks of not having the
surgery
B. Notifying the physician immediately
C. Notifying the nursing supervisor
D. Recording the client’s refusal in the
nurses’ notes
45. During the endorsement, which of the
following clients should the on-duty nurse
assess first?
A. The 58-year-old client who was
admitted 2 days ago with heart
failure, blood pressure of 126/76 mm
Hg, and a respiratory rate of 22
breaths/minute.
B. The 89-year-old client with end-stage
right-sided heart failure, blood pressure
of 78/50 mm Hg, and a “do not
resuscitate” order
C. The 62-year-old client who was
admitted 1 day ago
with thrombophlebitis and is receiving
L.V. heparin
D. The 75-year-old client who was
admitted 1 hour ago with new-
onset atrial fibrillation and is receiving
L.V. dilitiazem (Cardizem)
46. Honey, a 23-year old client complains of
substernal chest pain and states that her heart
feels like “it’s racing out of the chest”. She
reports no history of cardiac disorders. The
nurse attaches her to a cardiac monitor and
notes sinus tachycardia with a rate of
136beats/minutes. Breath sounds are clear
and the respiratory rate is 26
breaths/minutes. Which of the following
drugs should the nurse question the client
about using?
A. Barbiturates
B. Opioids
C. Cocaine
D. Benzodiazepines
47. A 51-year-old female client tells the
nurse in-charge that she has found a painless
lump in her right breast during her monthly
self-examination. Which assessment finding
would strongly suggest that this client’s
lump is cancerous?
A. Eversion of the right nipple and mobile
mass
B. Nonmobile mass with irregular edges
C. Mobile mass that is soft and easily
delineated
D. Nonpalpable right axillary lymph nodes
48. A 35-year-old client with vaginal cancer
asks the nurse, “What is the usual treatment
for this type of cancer?” Which treatment
should the nurse name?
A. Surgery
B. Chemotherapy
C. Radiation
D. Immunotherapy
49. Cristina undergoes a biopsy of a
suspicious lesion. The biopsy
report classifies the lesion according to the
TNM staging system as follows: TIS, N0,
M0. What does this classification mean?
A. No evidence of primary tumor, no
abnormal regional lymph nodes, and no
evidence of distant metastasis
B. Carcinoma in situ, no abnormal
regional lymph nodes, and no evidence
of distant metastasis
C. Can’t assess tumor or regional lymph
nodes and no evidence of metastasis
D. Carcinoma in situ, no demonstrable
metastasis of the regional lymph nodes,
and ascending degrees of distant
metastasis
50. Lydia undergoes a laryngectomy to treat
laryngeal cancer. When teaching the client
how to care for the neck stoma, the nurse
should include which instruction?
A. “Keep the stoma uncovered.”
B. “Keep the stoma dry.”
C. “Have a family member perform stoma
care initially until you get used to the
procedure.”
D. “Keep the stoma moist.”
51. A 37-year-old client with uterine cancer
asks the nurse, “Which is the most common
type of cancer in women?” The nurse replies
that it’s breast cancer. Which type of cancer
causes the most deaths in women?
A. Breast cancer
B. Lung cancer
C. Brain cancer
D. Colon and rectal cancer
52. Antonio with lung cancer develops
Horner’s syndrome when the tumor invades
the ribs and affects the sympathetic nerve
ganglia. When assessing for signs and
symptoms of this syndrome, the nurse
should note:
A. miosis, partial eyelid ptosis, and
anhidrosis on the affected side of
the face.
B. chest pain, dyspnea, cough, weight loss,
and fever.
C. arm and shoulder pain and atrophy of
arm and hand muscles, both on the
affected side.
D. hoarseness and dysphagia.
53. Vic asks the nurse what PSA is. The
nurse should reply that it stands for:
A. prostate-specific antigen, which is used
to screen for prostate cancer.
B. protein serum antigen, which is used to
determine protein levels.
C. pneumococcal strep antigen, which is a
bacteria that causes pneumonia.
D. Papanicolaou-specific antigen, which is
used to screen for cervical cancer.
54. What is the most important postoperative
instruction that nurse Kate must give a client
who has just returned from the operating
room after receiving a subarachnoid block?
A. “Avoid drinking liquids until the gag
reflex returns.”
B. “Avoid eating milk products for 24
hours.”
C. “Notify a nurse if you experience blood
in your urine.”
D. “Remain supine for the time specified
by the physician.”
55. A male client suspected of having
colorectal cancer will require
which diagnostic study to confirm the
diagnosis?
A. Stool Hematest
B. Carcinoembryonic antigen (CEA)
C. Sigmoidoscopy
D. Abdominal computed tomography (CT)
scan
56. During a breast examination, which
finding most strongly suggests that the Luz
has breast cancer?
A. Slight asymmetry of the breasts.
B. A fixed nodular mass with dimpling of
the overlying skin
C. Bloody discharge from the nipple
D. Multiple firm, round, freely movable
masses that change with the menstrual
cycle
57. A female client with cancer is being
evaluated for possible metastasis. Which of
the following is one of the most common
metastasis sites for cancer cells?
A. Liver
B. Colon
C. Reproductive tract
D. White blood cells (WBCs)
58. Nurse Mandy is preparing a client for
magnetic resonance imaging (MRI)
to confirm or rule out a spinal cord lesion.
During the MRI scan, which of the
following would pose a threat to the client?
A. The client lies still.
B. The client asks questions.
C. The client hears thumping sounds.
 D. The client wears a watch and wedding
band.
59. Nurse Cecile is teaching a female client
about preventing osteoporosis. Which of the
following teaching points is correct?
A. Obtaining an X-ray of the bones every
3 years is recommended to detect bone
loss.
B. To avoid fractures, the client should
avoid strenuous exercise.
C. The recommended daily allowance of
calcium may be found in a wide variety
of foods.
D. Obtaining the recommended daily
allowance of calcium requires taking a
calcium supplement.
60. Before Jacob undergoes arthroscopy, the
nurse reviews the assessment findings for
contraindications for this procedure. Which
finding is a contraindication?
A. Joint pain
B. Joint deformity
C. Joint flexion of less than 50%
D. Joint stiffness
61. Mr. Rodriguez is admitted with severe
pain in the knees. Which form of arthritis is
characterized by urate deposits and joint
pain, usually in the feet and legs, and occurs
primarily in men over age 30?
A. Septic arthritis
B. Traumatic arthritis
C. Intermittent arthritis
D. Gouty arthritis
62. A heparin infusion at 1,500 unit/hour is
ordered for a 64-year-old client with stroke
in evolution. The infusion contains 25,000
units of heparin in 500 ml of saline solution.
How many milliliters per hour should be
given?
A. 15 ml/hour D. Osteoarthritis has dislocations and
B. 30 ml/hour subluxations, rheumatoid
C. 45 ml/hour arthritis doesn’t
D. 50 ml/hour 66. Mrs. Cruz uses a cane for assistance in
63. A 76-year-old male client had a walking. Which of the following statements
thromboembolic right stroke; his left arm is true about a cane or other assistive
is swollen. Which of the following devices?
conditions may cause swelling after a A. A walker is a better choice than a cane.
stroke? B. The cane should be used on the affected
A. Elbow contracture secondary to side
spasticity C. The cane should be used on the
B. Loss of muscle contraction decreasing unaffected side
venous return D. A client with osteoarthritis should be
C. Deep vein thrombosis (DVT) due to encouraged to ambulate without the
immobility of the ipsilateral side cane
D. Hypoalbuminemia due to protein 67. A male client with type 1 diabetes is
escaping from an inflamed glomerulus scheduled to receive 30 U of 70/30 insulin.
64. Heberden’s nodes are a common sign of There is no 70/30 insulin available. As a
osteoarthritis. Which of the substitution, the nurse may give the client:
following statement is correct about this A. 9 U regular insulin and 21 U neutral
deformity? protamine Hagedorn (NPH).
A. It appears only in men B. 21 U regular insulin and 9 U NPH.
B. It appears on the distal interphalangeal C. 10 U regular insulin and 20 U NPH.
joint D. 20 U regular insulin and 10 U NPH.
C. It appears on the proximal 68. Nurse Len should expect to administer
interphalangeal joint which medication to a client with gout?
D. It appears on the dorsolateral aspect of A. aspirin
the interphalangeal joint. B. furosemide (Lasix)
65. Which of the following statements C. colchicines
explains the main difference D. calcium gluconate (Kalcinate)
between rheumatoid arthritis and 69. Mr. Domingo with a history of
osteoarthritis? hypertension is diagnosed with
A. Osteoarthritis is gender-specific, primary hyperaldosteronism. This diagnosis
rheumatoid arthritis isn’t indicates that the client’s hypertension
B. Osteoarthritis is a localized disease is caused by excessive hormone secretion
rheumatoid arthritis is systemic from which of the following glands?
C. Osteoarthritis is a systemic disease, A. Adrenal cortex
rheumatoid arthritis is localized B. Pancreas
C. Adrenal medulla
 D. Parathyroid
70. For a diabetic male client with a foot
ulcer, the doctor orders bed rest, a wetto- dry
dressing change every shift, and blood
glucose monitoring before meals and
bedtime. Why are wet-to-dry dressings used
for this client?
A. They contain exudate and provide a
moist wound environment.
B. They protect the wound from
mechanical trauma and promote
healing.
C. They debride the wound and promote
healing by secondary intention.
D. They prevent the entrance of
microorganisms and minimize
wound discomfort.
71. Nurse Zeny is caring for a client in acute
addisonian crisis. Which laboratory data
would the nurse expect to find?
A. Hyperkalemia
B. Reduced blood urea nitrogen (BUN)
C. Hypernatremia
D. Hyperglycemia
72. A client is admitted for treatment of the
syndrome of inappropriate
antidiuretic hormone (SIADH). Which
nursing intervention is appropriate?
A. Infusing I.V. fluids rapidly as ordered
B. Encouraging increased oral intake
C. Restricting fluids
D. Administering glucose-containing I.V.
fluids as ordered
73. A female client tells nurse Nikki that she
has been working hard for the last 3 months
to control her type 2 diabetes mellitus with
diet and exercise. To determine the
effectiveness of the client’s efforts, the nurse
should check:
A. urine glucose level.
B. fasting blood glucose level.
C. serum fructosamine level.
D. glycosylated hemoglobin level.
74. Nurse Trinity administered neutral
protamine Hagedorn (NPH) insulin to
a diabetic client at 7 a.m. At what time
would the nurse expect the client to be
most at risk for a hypoglycemic reaction?
A. 10:00 am
B. Noon
C. 4:00 pm
D. 10:00 pm
75. The adrenal cortex is responsible for
producing which substances?
A. Glucocorticoids and androgens
B. Catecholamines and epinephrine
C. Mineralocorticoids and catecholamines
D. Norepinephrine and epinephrine
76. On the third day after a partial
thyroidectomy, Proserfina exhibits
muscle twitching and hyperirritability of the
nervous system. When questioned, the
client reports numbness and tingling of the
mouth and fingertips. Suspecting a
lifethreatening electrolyte disturbance, the
nurse notifies the surgeon
immediately. Which electrolyte disturbance
most commonly follows thyroid surgery?
A. Hypocalcemia
B. Hyponatremia
C. Hyperkalemia
D. Hypermagnesemia
77. Which laboratory test value is elevated
in clients who smoke and can’t be used as a
general indicator of cancer?
A. Acid phosphatase level
B. Serum calcitonin level
C. Alkaline phosphatase level
D. Carcinoembryonic antigen level
78. Francis with anemia has been admitted
to the medical-surgical unit.
Which assessment findings are characteristic
of iron-deficiency anemia?
A. Nights sweats, weight loss, and diarrhea
B. Dyspnea, tachycardia, and pallor
C. Nausea, vomiting, and anorexia
D. Itching, rash, and jaundice
79. In teaching a female client who is HIV-
positive about pregnancy, the nurse would
know more teaching is necessary when the
client says:
A. The baby can get the virus from my
placenta.”
B. “I’m planning on starting on birth
control pills.”
C. “Not everyone who has the virus gives
birth to a baby who has the virus.”
D. “I’ll need to have a C-section if I
become pregnant and have a baby.”
80. When preparing Judy with acquired
immunodeficiency syndrome (AIDS)
for discharge to the home, the nurse should
be sure to include which instruction?
A. “Put on disposable gloves before
bathing.”
B. “Sterilize all plates and utensils in
boiling water.”
C. “Avoid sharing such articles as
toothbrushes and razors.”
D. “Avoid eating foods from serving
dishes shared by other
family members.”
81. Nurse Marie is caring for a 32-year-old
client admitted with pernicious anemia.
Which set of findings should the nurse
expect when assessing the
client?
 A. Pallor, bradycardia, and reduced pulse
pressure
B. Pallor, tachycardia, and a sore tongue
C. Sore tongue, dyspnea, and weight gain
D. Angina, double vision, and anorexia
82. After receiving a dose of penicillin, a
client develops dyspnea and hypotension.
Nurse Celestina suspects the client is
experiencing anaphylactic shock. What
should the nurse do first?
A. Page an anesthesiologist immediately
and prepare to intubate the client.
B. Administer epinephrine, as prescribed,
and prepare to intubate the client if
necessary.
C. Administer the antidote for penicillin,
as prescribed, and continue to monitor
the client’s vital signs.
D. Insert an indwelling urinary catheter
and begin to infuse I.V. fluids
as ordered.
83. Mr. Marquez with rheumatoid arthritis is
about to begin aspirin therapy to reduce
inflammation. When teaching the client
about aspirin, the nurse discusses adverse
reactions to prolonged aspirin therapy.
These include:
A. weight gain.
B. fine motor tremors.
C. respiratory acidosis.
D. bilateral hearing loss.
84. A 23-year-old client is diagnosed with
human immunodeficiency virus (HIV). After
recovering from the initial shock of the
diagnosis, the client expresses a desire to
learn as much as possible about HIV and
acquired immunodeficiency syndrome
(AIDS). When teaching the client about the
immune system, the nurse states that
adaptive immunity is provided by which
type of white blood cell?
A. Neutrophil
B. Basophil
C. Monocyte
D. Lymphocyte
85. In an individual with Sjögren’s
syndrome, nursing care should focus on:
A. moisture replacement.
B. electrolyte balance.
C. nutritional supplementation.
D. arrhythmia management.
86. During chemotherapy for lymphocytic
leukemia, Mathew develops abdominal pain,
fever, and “horse barn” smelling diarrhea. It
would be most important for the nurse to
advise the physician to order:
A. enzyme-linked immunosuppressant
assay (ELISA) test.
B. electrolyte panel and hemogram.
C. stool for Clostridium difficile test.
D. flat plate X-ray of the abdomen.
87. A male client seeks medical evaluation
for fatigue, night sweats, and a 20-lb weight
loss in 6 weeks. To confirm that the client
has been infected with the human
immunodeficiency virus (HIV), the nurse
expects the physician to order:
A. E-rosette immunofluorescence.
B. quantification of T-lymphocytes.
C. enzyme-linked immunosorbent assay
(ELISA).
D. Western blot test with ELISA.
88. A complete blood count is commonly
performed before a Joe goes into surgery.
What does this test seek to identify?
A. Potential hepatic dysfunction indicated
by decreased blood urea nitrogen
(BUN) and creatinine levels
B. Low levels of urine constituents
normally excreted in the urine
C. Abnormally low hematocrit (HCT) and
hemoglobin (Hb) levels
D. Electrolyte imbalance that could affect
the blood’s ability to coagulate properly
89. While monitoring a client for the
development of disseminated
intravascular coagulation (DIC), the nurse
should take note of what assessment
parameters?
A. Platelet count, prothrombin time, and
partial thromboplastin time
B. Platelet count, blood glucose levels, and
white blood cell (WBC) count
C. Thrombin time, calcium levels, and
potassium levels
D. Fibrinogen level, WBC, and platelet
count
90. When taking a dietary history from a
newly admitted female client, Nurse
Len should remember that which of the
following foods is a common allergen?
A. Bread
B. Carrots
C. Orange
D. Strawberries
91. Nurse John is caring for clients in the
outpatient clinic. Which of the
following phone calls should the nurse
return first?
A. A client with hepatitis A who states,
“My arms and legs are itching.”
B. A client with cast on the right leg who
states, “I have a funny feeling in my
right leg.”
C. A client with osteomyelitis of the spine
who states, “I am so nauseous that I
can’t eat.”
 D. A client with rheumatoid arthritis who
states, “I am having trouble sleeping.”
92. Nurse Sarah is caring for clients on the
surgical floor and has just received report
from the previous shift. Which of the
following clients should the nurse see first?
A. A 35-year-old admitted three hours ago
with a gunshot wound; 1.5 cm area of
dark drainage noted on the dressing.
B. A 43-year-old who had a mastectomy
two days ago; 23 ml of serosanguinous
fluid noted in the Jackson-Pratt drain.
C. A 59-year-old with a collapsed lung due
to an accident; no drainage noted in the
previous eight hours.
D. A 62-year-old who had an abdominal-
perineal resection three days ago; client
complaints of chills.
93. Nurse Eve is caring for a client who had
a thyroidectomy 12 hours ago for treatment
of Grave’s disease. The nurse would be most
concerned if which of the following was
observed?
A. Blood pressure 138/82, respirations 16,
oral temperature 99 degrees Fahrenheit.
B. The client supports his head and neck
when turning his head to the right.
C. The client spontaneously flexes his
wrist when the blood pressure
is obtained.
D. The client is drowsy and complains of
sore throat.
94. Julius is admitted with complaints of
severe pain in the lower right quadrant of the
abdomen. To assist with pain relief, the
nurse should take which of the following
actions?
A. Encourage the client to change
positions frequently in bed.
B. Administer Demerol 50 mg IM q 4
hours and PRN.
C. Apply warmth to the abdomen with a
heating pad.
D. Use comfort measures and pillows to
position the client.
95. Nurse Tina prepares a client for
peritoneal dialysis. Which of the
following actions should the nurse take first?
A. Assess for a bruit and a thrill.
B. Warm the dialysate solution.
C. Position the client on the left side.
D. Insert a Foley catheter
96. Nurse Jannah teaches an elderly client
with right-sided weakness how to use cane.
Which of the following behaviors, if
demonstrated by the client to the
nurse, indicates that the teaching was
effective?
A. The client holds the cane with his right
hand, moves the can forward followed
by the right leg, and then moves the left
leg.
B. The client holds the cane with his right
hand, moves the cane forward followed
by his left leg, and then moves the right
leg.
C. The client holds the cane with his left
hand, moves the cane forward followed
by the right leg, and then moves the left
leg.
D. The client holds the cane with his left
hand, moves the cane forward followed
by his left leg, and then moves the right
leg.
97. An elderly client is admitted to the
nursing home setting. The client
is occasionally confused and her gait is often
unsteady. Which of the following actions, if
taken by the nurse, is most appropriate?
A. Ask the woman’s family to provide
personal items such as photos
or mementos.
B. Select a room with a bed by the door so
the woman can look down the hall.
C. Suggest the woman eat her meals in the
room with her roommate.
D. Encourage the woman to ambulate in
the halls twice a day.
98. Nurse Evangeline teaches an elderly
client how to use a standard
aluminum walker. Which of the following
behaviors, if demonstrated by the client,
indicates that the nurse’s teaching was
effective?
A. The client slowly pushes the walker
forward 12 inches, then takes small
steps forward while leaning on the
walker.
B. The client lifts the walker, moves it
forward 10 inches, and then
takes several small steps forward.
C. The client supports his weight on the
walker while advancing it forward, then
takes small steps while balancing on the
walker.
D. The client slides the walker 18 inches
forward, then takes small steps while
holding onto the walker for balance.
99. Nurse Deric is supervising a group of
elderly clients in a residential home setting.
The nurse knows that the elderly are at
greater risk of developing sensory
deprivation for what reason?
A. Increased sensitivity to the side effects
of medications.
 B. Decreased visual, auditory, and
gustatory abilities.
C. Isolation from their families and
familiar surroundings.
D. Decrease musculoskeletal function and
mobility.
100. A male client with emphysema
becomes restless and confused. What
step should nurse Jasmine take next?
A. Encourage the client to perform pursed
lip breathing.
B. Check the client’s temperature.
C. Assess the client’s potassium level.
D. Increase the client’s oxygen flow rate.
Answers and Rationales
1. Answer: (C) Loose, bloody. Normal
bowel function and soft-formed stool
usually do not occur until around the
seventh day following surgery. The
stool consistency is related to how
much water is being absorbed.
2. Answer: (A) On the client’s right
side. The client has left visual field
blindness. The client will see only from
the right side.
3. Answer: (C) Check respirations,
stabilize spine, and check
circulation. Checking the airway would
be priority, and a neck injury should be
suspected.
4. Answer: (D) Decreasing venous return
through vasodilation. The significant
effect of nitroglycerin is vasodilation
and decreased venous return, so the
heart does not have to work hard.
5. Answer: (A) Call for help and note the
time. Having established, by
stimulating the client, that the client
is unconscious rather than sleep, the
nurse should immediately call for
help. This may be done by dialing the
operator from the client’s phone
and giving the hospital code for cardiac
arrest and the client’s room number
to the operator, of if the phone is not
available, by pulling the emergency
call button. Noting the time is important
baseline information for cardiac
arrest procedure.
6. Answer: (C) Make sure that the client
takes food and medications
at prescribed intervals. Food and drug
therapy will prevent the accumulation
of hydrochloric acid, or will neutralize
and buffer the acid that
does accumulate.
7. Answer: (B) Continue treatment as
ordered. The effects of heparin are
monitored by the PTT is normally 30 to
45 seconds; the therapeutic level is 1.5
to 2 times the normal level.
8. Answer: (B) In the operating room. The
stoma drainage bag is applied in the
operating room. Drainage from the
ileostomy contains secretions that are
rich in digestive enzymes and highly
irritating to the skin. Protection of the
skin from the effects of these enzymes
is begun at once. Skin exposed to
these enzymes even for a short time
becomes reddened, painful,
and excoriated.
9. Answer: (B) Flat on back. To avoid the
complication of a painful spinal
headache that can last for several days,
the client is kept in flat in a supine
position for approximately 4 to 12
hours postoperatively. Headaches are
believed to be causes by the seepage of
cerebral spinal fluid from the puncture
site. By keeping the client flat, cerebral
spinal fluid pressures are
equalized, which avoids trauma to the
neurons.
10. Answer: (C) The client is oriented when
aroused from sleep, and goes back to
sleep immediately. This finding suggest
that the level of consciousness
is decreasing.
11. Answer: (A) Altered mental status and
dehydration. Fever, chills, hemortysis,
dyspnea, cough, and pleuritic chest pain
are the common symptoms of
pneumonia, but elderly clients may
first appear with only an altered lentil
status and dehydration due to a
blunted immune response.
12. Answer: (B) Chills, fever, night sweats,
and hemoptysis. Typical signs and
symptoms are chills, fever, night
sweats, and hemoptysis. Chest pain
may be present from coughing, but
isn’t usual. Clients with TB typically
have low-grade fevers, not higher
than 102°F (38.9°C). Nausea, headache,
and photophobia aren’t usual
TB symptoms.
13. Answer:(A) Acute asthma. Based on
the client’s history and symptoms, acute
asthma is the most likely diagnosis.
He’s unlikely to have bronchial
pneumonia without a productive cough
and fever and he’s too young to
have developed (COPD) and
emphysema.
14. Answer: (B) Respiratory
arrest. Narcotics can cause respiratory
arrest if given in large quantities. It’s
unlikely the client will have asthma
attack or a seizure or wake up on his
own.
15. Answer: (D) Decreased vital
capacity.  Reduction in vital capacity is
a normal physiologic changes include
decreased elastic recoil of the lungs,
fewer functional capillaries in the
alveoli, and an increased in residual
volume.
16. Answer: (C) Presence of premature
ventricular contractions (PVCs) on
a cardiac monitor. Lidocaine drips are
commonly used to treat clients
whose arrhythmias haven’t been
controlled with oral medication and
who are having PVCs that are visible on
the cardiac monitor. SaO2,
blood pressure, and ICP are important
factors but aren’t as significant as
PVCs in the situation.
17. Answer: (B) Avoid foods high in
vitamin K. The client should avoid
consuming large amounts of vitamin
K because vitamin K can interfere with
anticoagulation. The client may need to
report diarrhea, but isn’t effect of taking
an anticoagulant. An electric razor-not a
straight razor-should be used to prevent
cuts that cause bleeding. Aspirin may
increase the risk of bleeding;
acetaminophen should be used to pain
relief.
18. Answer: (C) Clipping the hair in the
area. Hair can be a source of infection
and should be removed by clipping.
Shaving the area can cause skin
abrasions and depilatories can irritate
the skin.
19. Answer: (A) Bone fracture. Bone
fracture is a major complication of
osteoporosis that results when loss of
calcium and phosphate increased the
fragility of bones. Estrogen deficiencies
result from menopause-not
osteoporosis. Calcium and vitamin D
supplements may be used to support
normal bone metabolism, But a
negative calcium balance isn’t a
complication of osteoporosis.
Dowager’s hump results from bone
fractures. It develops when repeated
vertebral fractures increase spinal
curvature.
20. Answer: (C) Changes from previous
examinations. Women are instructed to
examine themselves to
discover changes that have occurred in
the breast. Only a physician can
diagnose lumps that are cancerous,
areas of thickness or fullness that signal
the presence of a malignancy, or masses
that are fibrocystic as opposed
to malignant.
21. Answer: (C) Balance the client’s
periods of activity and rest. A client
with hyperthyroidism needs to be
encouraged to balance periods of
activity and rest. Many clients with
hyperthyroidism are hyperactive and
complain of feeling very warm.
22. Answer: (B) Increase his activity
level. The client should be encouraged
to increase his activity
level. Maintaining an ideal weight;
following a low-cholesterol, low
sodium diet; and avoiding stress are all
important factors in decreasing the risk
of atherosclerosis.
23. Answer: (A) Laminectomy. The client
who has had spinal surgery, such as
laminectomy, must be log rolled to
keep the spinal column straight when
turning. Thoracotomy and cystectomy
may turn themselves or may be
assisted into a comfortable position.
Under normal
circumstances, hemorrhoidectomy is an
outpatient procedure, and the client may
resume normal activities immediately
after surgery.
24. Answer: (D) Avoiding straining during
bowel movement or bending at
the waist. The client should avoid
straining, lifting heavy objects,
and coughing harshly because these
activities increase intraocular
pressure. Typically, the client is
instructed to avoid lifting objects
weighing more than 15 lb (7kg) – not
5lb. instruct the client when lying in
bed to lie on either the side or back. The
client should avoid bright light by
wearing sunglasses.
25. Answer: (D) Before age 20. Testicular
cancer commonly occurs in men
between ages 20 and 30. A male client
should be taught how to perform
testicular selfexamination before age
20, preferably when he enters his teens.
26. Answer: (B) Place a saline-soaked
sterile dressing on the wound. The
nurse should first place saline-soaked
sterile dressings on the open wound to
 prevent tissue drying and possible
infection. Then the nurse should call the
physician and take the client’s vital
signs. The dehiscence needs to be
surgically closed, so the nurse should
never try to close it.
27. Answer: (A) A progressively deeper
breaths followed by shallower breaths
with apneic periods. Cheyne-Strokes
respirations are breaths that
become progressively deeper fallowed
by shallower respirations with
apneas periods. Biot’s respirations are
rapid, deep breathing with abrupt
pauses between each breath, and equal
depth between each breath.
Kussmaul’s respirations are rapid, deep
breathing without pauses. Tachypnea
is shallow breathing with increased
respiratory rate.
28. Answer: (B) Fine crackles. Fine
crackles are caused by fluid in the
alveoli and commonly occur in clients
with heart failure. Tracheal breath
sounds are auscultated over the trachea.
Coarse crackles are caused by secretion
accumulation in the airways. Friction
rubs occur with pleural inflammation.
29. Answer: (B) The airways are so swollen
that no air cannot get through. During
an acute attack, wheezing may stop and
breath sounds become inaudible
because the airways are so swollen that
air can’t get through. If the attack is
over and swelling has decreased, there
would be no more wheezing and less
emergent concern. Crackles do not
replace wheezes during an acute asthma
attack.
30. Answer: (D) Place the client on his not as significant for addressing the
side, remove dangerous objects, immediate medical problem.
and protect his head. During the active 34. Answer: (C) Place the client in a side
seizure phase, initiate precautions by lying position, with the head of the bed
placing the client on his side, removing lowered.  The client should be
dangerous objects, and protecting positioned in a side-lying position with
his head from injury. A bite block the head of the bed lowered to prevent
should never be inserted during the aspiration. A small amount
active seizure phase. Insertion can of toothpaste should be used and the
break the teeth and lead to aspiration. mouth swabbed or suctioned to remove
31. Answer: (B) Kinked or obstructed chest pooled secretions. Lemon glycerin can
tube. Kinking and blockage of the chest be drying if used for extended periods.
tube is a common cause of a tension Brushing the teeth with the client lying
pneumothorax. Infection and excessive supine may lead to aspiration.
drainage won’t cause a tension Hydrogen peroxide is caustic to tissues
pneumothorax. Excessive water won’t and should not be used.
affect the chest tube drainage. 35. Answer: (C) Pneumonia. Fever
32. Answer: (D) Stay with him but not productive cough and pleuritic chest
intervene at this time. If the client is pain are common signs and symptoms
coughing, he should be able to dislodge of pneumonia. The client with ARDS
the object or cause a complete has dyspnea and hypoxia with
obstruction. If complete obstruction worsening hypoxia over time, if not
occurs, the nurse should perform the treated aggressively. Pleuritic chest pain
abdominal thrust maneuver with the varies with respiration, unlike the
client standing. If the client is constant chest pain during an MI; so
unconscious, she should lay him down. this client most likely isn’t having an
A nurse should never leave a choking MI. the client with TB typically has a
client alone. cough producing blood-tinged sputum.
33. Answer: (B) Current health promotion A sputum culture should be obtained to
activities. Recognizing an individual’s confirm the nurse’s suspicions.
positive health measures is very useful. 36. Answer: (C) A 43-yesr-old homeless
General health in the previous 10 years man with a history of
is important, however, the current alcoholism. Clients who are
activities of an 84 year old client are economically disadvantaged,
most significant in planning care. malnourished, and have reduced
Family history of disease for a client in immunity, such as a client with a
later years is of minor significance. history of alcoholism,  are at extremely
Marital status information may be high risk for developing TB. A high
important for discharge planning but is school student, daycare worker, and
 businessman probably have a much low
risk of contracting TB.
37. Answer: (C ) To determine the extent of
lesions. If the lesions are large enough,
the chest X-ray will show their presence
in the lungs. Sputum culture confirms
the diagnosis. There can be false-
positive and false-negative skin test
results. A chest X-ray can’t determine if
this is a primary or secondary infection.
38. Answer: (B)
Bronchodilators. Bronchodilators are
the first line of treatment for
asthma because broncho-constriction is
the cause of reduced airflow. Beta
adrenergic blockers aren’t used to treat
asthma and can cause
bronchoconstriction. Inhaled oral
steroids may be given to reduce the
inflammation but aren’t used for
emergency relief.
39. Answer: (C) Chronic obstructive
bronchitis. Because of this extensive
smoking history and symptoms
the client most likely has chronic
obstructive bronchitis. Client with
ARDS have acute symptoms of hypoxia
and typically need large amounts
of oxygen. Clients with asthma and
emphysema tend not to have
chronic cough or peripheral edema.
40. Answer: (A) The patient is under local
anesthesia during the procedure. Before
the procedure, the patient is
administered with drugs that would
help to prevent infection and rejection
of the transplanted cells such as
antibiotics, cytotoxic, and
corticosteroids. During the
transplant, the patient is placed under 58- year-old client admitted 2 days ago
general anesthesia. with heart failure (his signs
41. Answer: (D) Raise the side rails. A and symptoms are resolving and don’t
patient who is disoriented is at risk of require immediate attention).
falling out of bed. The initial action of The lowest priority is the 89-year-old
the nurse should be raising the side rails with end stage right-sided heart
to ensure patients safety. failure, who requires time-consuming
42. Answer: (A) Crowd red blood supportive measures.
cells. The excessive production of white 46. Answer: (C) Cocaine. Because of the
blood cells crowd out red blood cells client’s age and negative medical
production which causes anemia to history, the nurse should question her
occur. about cocaine use. Cocaine
43. Answer: (B) Leukocytosis. Chronic increases myocardial oxygen
Lymphocytic leukemia (CLL) is consumption and can cause coronary
characterized by increased production artery spasm, leading to tachycardia,
of leukocytes and lymphocytes ventricular fibrillation, myocardial
resulting in leukocytosis, and ischemia, and myocardial infarction.
proliferation of these cells within the Barbiturate overdose may trigger
bone marrow, spleen and liver. respiratory depression and slow pulse.
44. Answer: (A) Explain the risks of not Opioids can cause marked
having the surgery. The best initial respiratory depression, while
response is to explain the risks of not benzodiazepines can cause drowsiness
having the surgery. If the client and confusion.
understands the risks but still refuses 47. Answer: (B) Nonmobile mass with
the nurse should notify the physician irregular edges. Breast cancer tumors
and the nurse supervisor and then are fixed, hard, and poorly
record the client’s refusal in the nurses’ delineated with irregular edges. A
notes. mobile mass that is soft and easily
45. Answer: (D) The 75-year-old client delineated is most often a fluid-filled
who was admitted 1 hour ago with new- benign cyst. Axillary lymph nodes may
onset atrial fibrillation and is receiving or may not be palpable on initial
L.V. dilitiazem (Cardizem). The client detection of a cancerous mass. Nipple
with atrial fibrillation has the greatest retraction — not eversion — may be a
potential to become unstable and is on sign of cancer.
L.V. medication that requires close 48. Answer: (C) Radiation. The usual
monitoring. After assessing this client, treatment for vaginal cancer is external
the nurse should assess the client or intravaginal radiation therapy. Less
with thrombophlebitis who is receiving often, surgery is
a heparin infusion, and then the performed. Chemotherapy typically is
 prescribed only if vaginal cancer is
diagnosed in an early stage, which is
rare. Immunotherapy isn’t used to treat
vaginal cancer.
49. Answer: (B) Carcinoma in situ, no
abnormal regional lymph nodes, and no
evidence of distant metastasis. TIS, N0,
M0 denotes carcinoma in situ, no
abnormal regional lymph nodes, and no
evidence of distant metastasis. No
evidence of primary tumor, no
abnormal regional lymph nodes, and no
evidence of distant metastasis is
classified as T0, N0, M0. If the tumor
and regional lymph nodes can’t be
assessed and no evidence of metastasis
exists, the lesion is classified as TX,
NX, M0. A progressive increase in
tumor size, no demonstrable metastasis
of the regional lymph nodes, and
ascending degrees of distant metastasis
is classified as T1, T2, T3, or T4; N0;
and M1, M2, or M3.
50. Answer: (D) “Keep the stoma
moist.” The nurse should instruct the
client to keep the stoma moist, such as
by applying a thin layer of petroleum
jelly around the edges, because a dry
stoma may become irritated. The nurse
should recommend placing a stoma bib
over the stoma to filter and warm air
before it enters the stoma. The client
should begin performing stoma care
without assistance as soon as possible
to gain independence in self-
care activities.
51. Answer: (B) Lung cancer.  Lung cancer
is the most deadly type of cancer in
both women and men. Breast cancer
ranks second in women, followed (in
descending order) by colon and rectal
cancer, pancreatic cancer, ovarian
cancer, uterine cancer, lymphoma,
leukemia, liver cancer, brain cancer,
stomach cancer, and multiple myeloma.
52. Answer: (A) miosis, partial eyelid
ptosis, and anhidrosis on the
affected side of the face. Horner’s
syndrome, which occurs when a lung
tumor invades the ribs and affects the
sympathetic nerve ganglia, is
characterized by miosis, partial eyelid
ptosis, and anhidrosis on the affected
side of the face. Chest pain, dyspnea,
cough, weight loss, and fever are
associated with pleural tumors. Arm
and shoulder pain and atrophy of the
arm and hand muscles on the affected
side suggest Pancoast’s tumor, a
lung tumor involving the first thoracic
and eighth cervical nerves within
the brachial plexus. Hoarseness in a
client with lung cancer suggests that
the tumor has extended to the recurrent
laryngeal nerve; dysphagia
suggests that the lung tumor is
compressing the esophagus.
53. Answer: (A) prostate-specific antigen,
which is used to screen for
prostate cancer. PSA stands for
prostate-specific antigen, which is used
to screen for prostate cancer. The other
answers are incorrect.
54. Answer: (D) “Remain supine for the
time specified by the physician.” The
nurse should instruct the client to
remain supine for the time specified by
the physician. Local anesthetics used in
a subarachnoid block don’t alter the gag
reflex. No interactions between local
anesthetics and food occur. Local
anesthetics don’t cause hematuria.
55. Answer: (C) Sigmoidoscopy. Used to
visualize the lower GI tract,
sigmoidoscopy and proctoscopy aid in
the detection of two-thirds of all
colorectal cancers. Stool Hematest
detects blood, which is a sign of
colorectal cancer; however, the test
doesn’t confirm the diagnosis. CEA
may be elevated in colorectal cancer but
isn’t considered a confirming test. An
abdominal CT scan is used to stage the
presence of colorectal cancer.
56. Answer: (B) A fixed nodular mass with
dimpling of the overlying skin. A fixed
nodular mass with dimpling of the
overlying skin is common during late
stages of breast cancer. Many women
have slightly asymmetrical breasts.
Bloody nipple discharge is a sign of
intraductal papilloma, a benign
condition. Multiple firm, round, freely
movable masses that change with the
menstrual cycle indicate fibrocystic
breasts, a benign condition.
57. Answer: (A) Liver. The liver is one of
the five most common cancer
metastasis sites. The others are the
lymph nodes, lung, bone, and brain.
The colon, reproductive tract, and
WBCs are occasional metastasis sites.
58. Answer: (D) The client wears a watch
and wedding band. During an MRI, the
client should wear no metal objects,
such as jewelry, because the strong
magnetic field can pull on them,
 causing injury to the client and (if they
fly off) to others. The client must lie
still during the MRI but can talk to
those performing the test by way of
the microphone inside the scanner
tunnel. The client should hear
thumping sounds, which are caused by
the sound waves thumping on the
magnetic field.
59. Answer: (C) The recommended daily
allowance of calcium may be found in a
wide variety of foods. Premenopausal
women require 1,000 mg of calcium per
day. Postmenopausal women require
1,500 mg per day. It’s often, though
not always, possible to get the
recommended daily requirement in the
foods we eat. Supplements are available
but not always necessary. Osteoporosis
doesn’t show up on ordinary X-rays
until 30% of the bone loss has occurred.
Bone densitometry can detect bone loss
of 3% or less. This test is sometimes
recommended routinely for women
over 35 who are at risk. Strenuous
exercise won’t cause fractures.
60. Answer: (C) Joint flexion of less than
50%. Arthroscopy is contraindicated in
clients with joint flexion of less than
50% because of technical problems in
inserting the instrument into the joint to
see it clearly. Other contraindications
for this procedure include skin and
wound infections. Joint pain may be an
indication, not a contraindication, for
arthroscopy. Joint deformity and joint
stiffness aren’t contraindications for
this procedure.
61. Answer: (D) Gouty arthritis. Gouty
arthritis, a metabolic disease, is
characterized by urate deposits and pain
in the joints, especially those in the feet
and legs. Urate deposits don’t occur in
septic or traumatic arthritis. Septic
arthritis results from bacterial invasion
of a joint and leads to inflammation of
the synovial lining. Traumatic arthritis
results from blunt trauma to a joint or
ligament. Intermittent arthritis is a rare,
benign condition marked by
regular, recurrent joint effusions,
especially in the knees.
62. Answer: (B) 30 ml/hour. An infusion
prepared with 25,000 units of heparin in
500 ml of saline solution yields 50 units
of heparin per milliliter of solution.
The equation is set up as 50 units times
X (the unknown quantity) equals
1,500 units/hour, X equals 30 ml/hour.
63. Answer: (B) Loss of muscle contraction
decreasing venous return. In clients
with hemiplegia or hemiparesis loss of
muscle contraction decreases venous
return and may cause swelling of
the affected extremity. Contractures, or
bony calcifications may occur with
a stroke, but don’t appear with swelling.
DVT may develop in clients with
a stroke but is more likely to occur in
the lower extremities. A stroke
isn’t linked to protein loss.
64. Answer: (B) It appears on the distal
interphalangeal joint. Heberden’s nodes
appear on the distal interphalageal joint
on both men and women. Bouchard’s
node appears on the dorsolateral aspect
of the proximal interphalangeal joint.
65. Answer: (B) Osteoarthritis is a localized
disease rheumatoid arthritis
is systemic.  Osteoarthritis is a localized
disease, rheumatoid arthritis
is systemic. Osteoarthritis isn’t gender-
specific, but rheumatoid arthritis
is. Clients have dislocations and
subluxations in both disorders.
66. Answer: (C) The cane should be used
on the unaffected side. A cane should
be used on the unaffected side. A client
with osteoarthritis should be
encouraged to ambulate with a cane,
walker, or other assistive device as
needed; their use takes weight and
stress off joints.
67. Answer: (A) 9 U regular insulin and 21
U neutral protamine
Hagedorn (NPH).  A 70/30 insulin
preparation is 70% NPH and 30%
regular insulin. Therefore, a correct
substitution requires mixing 21 U of
NPH and 9 U of regular insulin. The
other choices are incorrect dosages for
the prescribed insulin.
68. Answer: (C) colchicines. A disease
characterized by joint inflammation
(especially in the great toe), gout is
caused by urate crystal deposits in the
joints. The physician prescribes
colchicine to reduce these deposits and
thus ease joint inflammation. Although
aspirin is used to reduce joint
inflammation and pain in clients with
osteoarthritis and rheumatoid arthritis,
it isn’t indicated for gout because it has
no effect on urate crystal
formation. Furosemide, a diuretic,
doesn’t relieve gout. Calcium gluconate
 is used to reverse a negative calcium aldosterone secretion. Reduced cortisol androgens. The medulla produces
balance and relieve muscle cramps, not secretion leads to impaired catecholamines — epinephrine and
to treat gout. glyconeogenesis and a reduction of norepinephrine.
69. Answer: (A) Adrenal cortex. Excessive glycogen in the liver and muscle, 76. Answer: (A)
secretion of aldosterone in the adrenal causing hypoglycemia. Hypocalcemia. Hypocalcemia may
cortex is responsible for the client’s 72. Answer: (C) Restricting fluids. To follow thyroid surgery if the
hypertension. This hormone acts on the reduce water retention in a client with parathyroid glands were removed
renal tubule, where it promotes the SIADH, the nurse should restrict accidentally. Signs and symptoms of
reabsorption of sodium and excretion fluids. Administering fluids by any hypocalcemia may be delayed for up to
of potassium and hydrogen ions. The route would further increase the client’s 7 days after surgery. Thyroid surgery
pancreas mainly secretes already heightened fluid load. doesn’t directly cause serum sodium,
hormones involved in fuel metabolism. 73. Answer: (D) glycosylated hemoglobin potassium, or magnesium
The adrenal medulla secretes level. Because some of the glucose in abnormalities. Hyponatremia may occur
the catecholamines — epinephrine and the bloodstream attaches to some of the if the client inadvertently received too
norepinephrine. The hemoglobin and stays attached during much fluid; however, this can happen to
parathyroids secrete parathyroid the 120-day life span of red blood cells, any surgical client receiving I.V. fluid
hormone. glycosylated hemoglobin levels provide therapy, not just one recovering from
70. Answer: (C) They debride the wound information about blood glucose levels thyroid surgery. Hyperkalemia
and promote healing by during the previous 3 months. Fasting and hypermagnesemia usually are
secondary intention. For this client, blood glucose and urine glucose levels associated with reduced renal excretion
wet-to-dry dressings are most only give information about of potassium and magnesium, not
appropriate because they clean the foot glucose levels at the point in time when thyroid surgery.
ulcer by debriding exudate and they were obtained. Serum 77. Answer: (D) Carcinoembryonic antigen
necrotic tissue, thus promoting healing fructosamine levels provide information level. In clients who smoke, the level of
by secondary intention. Moist, about blood glucose control over the carcinoembryonic antigen is elevated.
transparent dressings contain exudate past 2 to 3 weeks. Therefore, it can’t be used as a general
and provide a moist wound 74. Answer: (C) 4:00 pm. NPH is an indicator of cancer. However, it is
environment. Hydrocolloid dressings intermediate-acting insulin that peaks 8 helpful in monitoring cancer treatment
prevent the entrance of microorganisms to 12 hours after administration. because the level usually falls to normal
and minimize wound discomfort. Dry Because the nurse administered NPH within 1 month if treatment is
sterile dressings protect the wound insulin at 7 a.m., the client is at greatest successful. An elevated acid
from mechanical trauma and promote risk for hypoglycemia from 3 p.m. to 7 phosphatase level may indicate prostate
healing. p.m. cancer. An elevated alkaline
71. Answer: (A) Hyperkalemia. In adrenal 75. Answer: (A) Glucocorticoids and phosphatase level may reflect bone
insufficiency, the client has androgens. The adrenal glands have two metastasis. An elevated serum
hyperkalemia due to reduced divisions, the cortex and medulla. The calcitonin level usually signals thyroid
aldosterone secretion. BUN increases as cortex produces three types of cancer.
the glomerular filtration rate is reduced. hormones: 78. Answer: (B) Dyspnea, tachycardia, and
Hyponatremia is caused by reduced glucocorticoids, mineralocorticoids, and pallor. Signs of iron-deficiency anemia
 include dyspnea, tachycardia, and pallor
as well as fatigue, listlessness,
irritability, and headache. Night sweats,
weight loss, and diarrhea may signal
acquired immunodeficiency syndrome
(AIDS). Nausea, vomiting, and
anorexia may be signs of hepatitis B.
Itching, rash, and jaundice may result
from an allergic or hemolytic reaction.
79. Answer: (D) “I’ll need to have a C-
section if I become pregnant and have a
baby.” The human immunodeficiency
virus (HIV) is transmitted from mother
to child via the transplacental route, but
a Cesarean section delivery isn’t
necessary when the mother is HIV-
positive. The use of birth control will
prevent the conception of a child who
might have HIV. It’s true that a mother
who’s HIV positive can give birth to a
baby who’s HIV negative.
80. Answer: (C) “Avoid sharing such
articles as toothbrushes and
razors.” The human immunodeficiency
virus (HIV), which causes AIDS, is
most concentrated in the blood. For this
reason, the client shouldn’t share
personal articles that may be blood-
contaminated, such as toothbrushes and
razors, with other family members. HIV
isn’t transmitted by bathing or by eating
from plates, utensils, or serving dishes
used by a person with AIDS.
81. Answer: (B) Pallor, tachycardia, and a
sore tongue. Pallor, tachycardia, and a
sore tongue are all
characteristic findings in pernicious
anemia. Other clinical manifestations
include anorexia; weight loss; a smooth,
beefy red tongue; a wide pulse 84. Answer:
pressure; palpitations; angina;
weakness; fatigue; and paresthesia of
the hands and feet. Bradycardia,
reduced pulse pressure, weight gain,
and double vision aren’t characteristic
findings in pernicious anemia.
82. Answer: (B) Administer epinephrine, as
prescribed, and prepare to intubate the
client if necessary. To reverse
anaphylactic shock, the nurse first
should administer epinephrine, a potent
bronchodilator as prescribed.
The physician is likely to order 85. Answer:
additional medications, such as
antihistamines and corticosteroids; if
these medications don’t relieve the
respiratory compromise associated with
anaphylaxis, the nurse should prepare
to intubate the client. No antidote for
penicillin exists; however, the
nurse should continue to monitor the
client’s vital signs. A client who
remains hypotensive may need fluid
resuscitation and fluid intake and
output monitoring; however,
administering epinephrine is the first 86. Answer: (C) stool for Clostridium
priority.
83. Answer: (D) bilateral hearing
loss. Prolonged use of aspirin and other
salicylates sometimes causes bilateral
hearing loss of 30 to 40 decibels.
Usually, this adverse effect resolves
within 2 weeks after the therapy is
discontinued. Aspirin doesn’t lead to
weight gain or fine motor tremors.
Large or toxic salicylate doses may
cause respiratory alkalosis, not
respiratory acidosis.
(D) Lymphocyte. The
lymphocyte provides adaptive
immunity — recognition of a foreign
antigen and formation of memory cells
against the antigen. Adaptive immunity
is mediated by B and T lymphocytes
and can be acquired actively or
passively. The neutrophil is crucial to
phagocytosis. The basophil plays an
important role in the release of
inflammatory mediators. The monocyte
functions in phagocytosis and
monokine production.
(A) moisture
replacement. Sjogren’s syndrome is an
autoimmune disorder leading
to progressive loss of lubrication of the
skin, GI tract, ears, nose, and
vagina. Moisture replacement is the
mainstay of therapy. Though
malnutrition and electrolyte imbalance
may occur as a result of Sjogren’s
syndrome’s effect on the GI tract, it
isn’t the predominant problem.
Arrhythmias aren’t a problem
associated with Sjogren’s syndrome.
difficile test. Immunosuppressed clients
— for example, clients
receiving chemotherapy, — are at risk
for infection with C. difficile, which
causes “horse barn” smelling diarrhea.
Successful treatment begins with
an accurate diagnosis, which includes a
stool test. The ELISA test is diagnostic
for human immunodeficiency virus
(HIV) and isn’t indicated in this case.
An electrolyte panel and hemogram
may be useful in the overall evaluation
 of a client but aren’t diagnostic for
specific causes of diarrhea. A flat plate
of the abdomen may provide useful
information about bowel function but
isn’t indicated in the case of “horse
barn” smelling diarrhea.
87. Answer: (D) Western blot test with
ELISA. HIV infection is detected by
analyzing blood for antibodies to HIV,
which form approximately 2 to 12
weeks after exposure to HIV and denote
infection. The Western blot test —
electrophoresis of antibody proteins —
is more than 98% accurate in detecting
HIV antibodies when used in
conjunction with the ELISA. It isn’t
specific when used alone.
Erosette immunofluorescence is used to
detect viruses in general; it
doesn’t confirm HIV infection.
Quantification of T-lymphocytes is a
useful monitoring test but isn’t
diagnostic for HIV. The ELISA test
detects HIV antibody particles but may
yield inaccurate results; a positive
ELISA result must be confirmed by the
Western blot test.
88. Answer: (C) Abnormally low
hematocrit (HCT) and hemoglobin
(Hb) levels. Low preoperative HCT and
Hb levels indicate the client
may require a blood transfusion before
surgery. If the HCT and Hb
levels decrease during surgery because
of blood loss, the potential need for
a transfusion increases. Possible renal
failure is indicated by elevated BUN or
creatinine levels. Urine constituents
aren’t found in the blood. Coagulation
is determined by the presence of
appropriate clotting factors, not
electrolytes.
89. Answer: (A) Platelet count,
prothrombin time, and partial
thromboplastin time. The diagnosis of
DIC is based on the results of
laboratory studies of prothrombin time,
platelet count, thrombin time,
partial thromboplastin time, and
fibrinogen level as well as client history
and other assessment factors. Blood
glucose levels, WBC count, calcium
levels, and potassium levels aren’t used
to confirm a diagnosis of DIC.
90. Answer: (D) Strawberries. Common
food allergens include berries, peanuts,
Brazil nuts, cashews, shellfish, and
eggs. Bread, carrots, and oranges rarely
cause allergic reactions.
91. Answer: (B) A client with cast on the
right leg who states, “I have a
funny feeling in my right leg.” It may
indicate neurovascular compromise,
requires immediate assessment.
92. Answer: (D) A 62-year-old who had an
abdominal-perineal resection three days
ago; client complaints of chills. The
client is at risk for peritonitis; should be
assessed for further symptoms and
infection.
93. Answer: (C) The client spontaneously
flexes his wrist when the blood pressure
is obtained. Carpal spasms indicate
hypocalcemia.
94. Answer: (D) Use comfort measures and
pillows to position the client.Using
comfort measures and pillows to
position the client is a non-
pharmacological methods of pain relief.
95. Answer: (B) Warm the dialysate
solution. Cold dialysate increases
discomfort. The solution should
be warmed to body temperature in
warmer or heating pad; don’t
use microwave oven.
96. Answer: (C) The client holds the cane
with his left hand, moves the
cane forward followed by the right leg,
and then moves the left leg. The cane
acts as a support and aids in weight
bearing for the weaker right leg.
97. Answer: (A) Ask the woman’s family
to provide personal items such
as photos or mementos.Photos and
mementos provide visual stimulation to
reduce sensory deprivation.
98. Answer: (B) The client lifts the walker,
moves it forward 10 inches, and then
takes several small steps forward. A
walker needs to be picked up, placed
down on all legs.
99. Answer: (C) Isolation from their
families and familiar
surroundings. Gradual loss of sight,
hearing, and taste interferes with
normal functioning.
100. Answer: (A) Encourage the client to
perform pursed lip breathing. Purse lip
breathing prevents the collapse of lung
unit and helps client control rate and
depth of breathing.
NP IV
NP V
1. Marco approached Nurse Trish
asking for advice on how to deal
with his alcohol addiction. Nurse
Trish should tell the client that the
only effective treatment for
alcoholism is:
A. Psychotherapy
B. Alcoholics anonymous (A.A.)
C. Total abstinence
D. Aversion Therapy
2. Nurse Hazel is caring for a male
client who experience false
sensory perceptions with no basis
in reality. This perception is known
as:
A. Hallucinations
B. Delusions
C. Loose associations
D. Neologisms
3. Nurse Monet is caring for a
female client who has suicidal
tendency. When accompanying the
client to the restroom, Nurse Monet
should…
A. Give her privacy
B. Allow her to urinate
C. Open the window and allow her
to get some fresh air
D. Observe her
4. Nurse Maureen is developing a
plan of care for a female client
with anorexia nervosa. Which action
should the nurse include in the
plan?
A. Provide privacy during meals
B. Set-up a strict eating plan for
the client
C. Encourage client to exercise to
reduce anxiety
D. Restrict visits with the family
5. A client is experiencing anxiety
attack. The most appropriate
nursing intervention should include?
A. Turning on the television
B. Leaving the client alone
C. Staying with the client and
speaking in short sentences
D. Ask the client to play with other
clients
6. A female client is admitted with a
diagnosis of delusions of
GRANDEUR. This diagnosis reflects
a belief that one is:
A. Being Killed
B. Highly famous and important
C. Responsible for evil world
D. Connected to client unrelated to
oneself
7. A 20 year old client was
diagnosed with dependent
personality disorder. Which
behavior is not likely to be evidence
of ineffective individual coping?
A. Recurrent self-destructive
behavior
B. Avoiding relationship
C. Showing interest in solitary
activities
D. Inability to make choices and
decision without advise
8. A male client is diagnosed with
schizotypal personality disorder.
Which signs would this client
exhibit during social situation?
A. Paranoid thoughts
B. Emotional affect
C. Independence need
D. Aggressive behavior
9. Nurse Claire is caring for a client
diagnosed with bulimia. The
most appropriate initial goal for a
client diagnosed with bulimia is?
A. Encourage to avoid foods
B. Identify anxiety causing
situations
C. Eat only three meals a day
D. Avoid shopping plenty of
groceries
10. Nurse Tony was caring for a 41
year old female client. Which
behavior by the client indicates
adult cognitive development?
A. Generates new levels of
awareness
B. Assumes responsibility for her
actions
C. Has maximum ability to solve
problems and learn new skills
D. Her perception are based on
reality
11.A neuromuscular blocking agent
is administered to a client before
ECT therapy. The Nurse should
carefully observe the client for?
A. Respiratory difficulties
B. Nausea and vomiting
C. Dizziness
D. Seizures
12.A 75 year old client is admitted
to the hospital with the diagnosis
of dementia of the Alzheimer’s type
and depression. The symptom that
is unrelated to depression would
be?
A. Apathetic response to the
environment
B. “I don’t know” answer to
questions
C. Shallow of labile effect
D. Neglect of personal hygiene
13.Nurse Trish is working in a
mental health facility; the nurse
priority nursing intervention for a
newly admitted client with bulimia
nervosa would be to?
A. Teach client to measure I & O
B. Involve client in planning daily
meal
C. Observe client during meals
D. Monitor client continuously
14.Nurse Patricia is aware that the
major health complication
associated with intractable
anorexia nervosa would be?
A. Cardiac dysrhythmias resulting
to cardiac arrest
B. Glucose intolerance resulting in
protracted hypoglycemia
C. Endocrine imbalance causing
cold amenorrhea
D. Decreased metabolism causing
cold intolerance
15.Nurse Anna can minimize
agitation in a disturbed client by?
A. Increasing stimulation
B. limiting unnecessary interaction
C. increasing appropriate sensory
perception
D. ensuring constant client and
staff contact
16.A 39 year old mother with
obsessive-compulsive disorder has
become immobilized by her
elaborate hand washing and
walking rituals. Nurse Trish
recognizes that the basis of O.C.
disorder is often:
A. Problems with being too
conscientious
 B. Problems with anger and
remorse
C. Feelings of guilt and inadequacy
D. Feeling of unworthiness and
hopelessness
17.Mario is complaining to other
clients about not being allowed by
staff to keep food in his room.
Which of the following interventions
would be most appropriate?
A. Allowing a snack to be kept in
his room
B. Reprimanding the client
C. Ignoring the clients behavior
D. Setting limits on the behavior
18.Conney with borderline
personality disorder who is to be
discharge soon threatens to “do
something” to herself if discharged.
Which of the following actions by
the nurse would be most important?
A. Ask a family member to stay
with the client at home
temporarily
B. Discuss the meaning of the
client’s statement with her
C. Request an immediate
extension for the client
D. Ignore the clients statement
because it’s a sign of
manipulation
19.Joey a client with antisocial
personality disorder belches loudly.
A staff member asks Joey, “Do you
know why people find you
repulsive?” this statement most
likely would elicit which of the
following client reaction?
A. Depensiveness
B. Embarrassment
C. Shame
D. Remorsefulness
20.Which of the following
approaches would be most
appropriate to use with a client
suffering from narcissistic
personality disorder when
discrepancies exist between what
the client states and what actually
exist?
A. Rationalization
B. Supportive confrontation
C. Limit setting
D. Consistency
21.Cely is experiencing alcohol
withdrawal exhibits tremors,
diaphoresis and hyperactivity. Blood
pressure is 190/87 mmhg and pulse
is 92 bpm. Which of the
medications would the nurse expect
to administer?
A. Naloxone (Narcan)
B. Benzlropine (Cogentin)
C. Lorazepam (Ativan)
D. Haloperidol (Haldol)
22.Which of the following foods
would the nurse Trish eliminate
from the diet of a client in alcohol
withdrawal?
A. Milk
B. Orange Juice
C. Soda
D. Regular Coffee
23.Which of the following would
Nurse Hazel expect to assess for a
client who is exhibiting late signs of
heroin withdrawal?
A. Yawning & diaphoresis
B. Restlessness & Irritability
C. Constipation & steatorrhea
D. Vomiting and Diarrhea
24.To establish open and trusting
relationship with a female client
who has been hospitalized with
severe anxiety, the nurse in charge
should?
A. Encourage the staff to have
frequent interaction with the
client
B. Share an activity with the client
C. Give client feedback about
behavior
D. Respect client’s need for
personal space
25. Nurse Monette recognizes that
the focus of environmental
(MILIEU) therapy is to:
A. Manipulate the environment to
bring about positive changes
in behavior
B. Allow the client’s freedom to
determine whether or not they
will be involved in activities
C. Role play life events to meet
individual needs
D. Use natural remedies rather
than drugs to control behavior
26.Nurse Trish would expect a child
with a diagnosis of reactive
attachment disorder to:
A. Have more positive relation with
the father than the mother
B. Cling to mother & cry on
separation
C. Be able to develop only
superficial relation with the
others
D. Have been physically abuse
27.When teaching parents about
childhood depression Nurse Trina
should say?
A. It may appear acting out
behavior
B. Does not respond to
conventional treatment
C. Is short in duration & resolves
easily
D. Looks almost identical to adult
depression
28.Nurse Perry is aware that
language development in autistic
child resembles:
A. Scanning speech
B. Speech lag
C. Shuttering
D. Echolalia
29.A 60 year old female client who
lives alone tells the nurse at
the community health center “I
really don’t need anyone to talk to”.
The TV is my best friend. The nurse
recognizes that the client is using
the defense mechanism known as?
A. Displacement
B. Projection
C. Sublimation
D. Denial
30.When working with a male client
suffering phobia about black cats,
Nurse Trish should anticipate that a
problem for this client would be?
A. Anxiety when discussing phobia
B. Anger toward the feared object
C. Denying that the phobia exist
D. Distortion of reality when
completing daily routines
31.Linda is pacing the floor and
appears extremely anxious. The
duty nurse approaches in an
attempt to alleviate Linda’s anxiety.
The most therapeutic question by
the nurse would be?
A. Would you like to watch TV?
B. Would you like me to talk with
you?
 C. Are you feeling upset now?
D. Ignore the client
32.Nurse Penny is aware that the
symptoms that distinguish post
traumatic stress disorder from
other anxiety disorder would be:
A. Avoidance of situation & certain
activities that resemble the
stress
B. Depression and a blunted affect
when discussing the
traumatic situation
C. Lack of interest in family &
others
D. Re-experiencing the trauma in
dreams or flashback
33.Nurse Benjie is communicating
with a male client with substance-
induced persisting dementia; the
client cannot remember facts and
fills in the gaps with imaginary
information. Nurse Benjie is aware
that this is typical of?
A. Flight of ideas
B. Associative looseness
C. Confabulation
D. Concretism
34.Nurse Joey is aware that the
signs & symptoms that would be
most specific for diagnosis
anorexia are?
A. Excessive weight loss,
amenorrhea & abdominal
distension
B. Slow pulse, 10% weight loss &
alopecia
C. Compulsive behavior, excessive
fears & nausea
D. Excessive activity, memory
lapses & an increased pulse
35.A characteristic that would
suggest to Nurse Anne that an
adolescent may have bulimia would
be:
A. Frequent regurgitation & re-
swallowing of food
B. Previous history of gastritis
C. Badly stained teeth
D. Positive body image
36.Nurse Monette is aware that
extremely depressed clients seem
to do best in settings where they
have:
A. Multiple stimuli
B. Routine Activities
C. Minimal decision making
D. Varied Activities
37.To further assess a client’s
suicidal potential. Nurse Katrina
should be especially alert to the
client expression of:
A. Frustration & fear of death
B. Anger & resentment
C. Anxiety & loneliness
D. Helplessness & hopelessness
38.A nursing care plan for a male
client with bipolar I disorder should
include:
A. Providing a structured
environment
B. Designing activities that will
require the client to maintain
contact with reality
C. Engaging the client in
conversing about current affairs
D. Touching the client provide
assurance
39.When planning care for a female
client using ritualistic behavior,
Nurse Gina must recognize that the
ritual:
 A. Helps the client focus on the
inability to deal with reality
B. Helps the client control the
anxiety
C. Is under the client’s conscious
control
D. Is used by the client primarily
for secondary gains
40.A 32 year old male graduate
student, who has become
increasingly withdrawn and
neglectful of his work and personal
hygiene, is brought to the
psychiatric hospital by his parents.
After detailed assessment,
a diagnosis of schizophrenia is
made. It is unlikely that the client
will demonstrate:
A. Low self esteem
B. Concrete thinking
C. Effective self boundaries
D. Weak ego
41.A 23 year old client has been
admitted with a diagnosis of
schizophrenia says to the nurse
“Yes, its march, March is little
woman”. That’s literal you know”.
These statement illustrate:
A. Neologisms
B. Echolalia
C. Flight of ideas
D. Loosening of association
42.A long term goal for a paranoid
male client who has unjustifiably
accused his wife of having many
extramarital affairs would be to help
the client develop:
A. Insight into his behavior
B. Better self control
C. Feeling of self worth
D. Faith in his wife
43.A male client who is
experiencing disordered thinking
about food being poisoned is
admitted to the mental health unit.
The nurse uses
which communication technique to
encourage the client to eat dinner?
A. Focusing on self-disclosure of
own food preference
B. Using open ended question and
silence
C. Offering opinion about the need
to eat
D. Verbalizing reasons that the
client may not choose to eat
44.Nurse Nina is assigned to care
for a client diagnosed with
Catatonic Stupor. When Nurse Nina
enters the client’s room, the client is
found lying on the bed with a body
pulled into a fetal position. Nurse
Nina should?
A. Ask the client direct questions
to encourage talking
B. Rake the client into the dayroom
to be with other clients
C. Sit beside the client in silence
and occasionally ask open-
ended question
D. Leave the client alone and
continue with providing care to
the other clients
45.Nurse Tina is caring for a client
with delirium and states that “look
at the spiders on the wall”. What
should the nurse respond to the
client?
A. “You’re having hallucination,
there are no spiders in this
room at all”
B. “I can see the spiders on the
wall, but they are not going to
hurt you”
 C. “Would you like me to kill the
spiders”
D. “I know you are frightened, but I
do not see spiders on the wall”
46.Nurse Jonel is providing
information to a community group
about violence in the family. Which
statement by a group member
would indicate a need to provide
additional information?
A. “Abuse occurs more in low-
income families”
B. “Abuser Are often jealous or
self-centered”
C. “Abuser use fear and
intimidation”
D. “Abuser usually have poor self-
esteem”
47.During electroconvulsive therapy
(ECT) the client receives oxygen
by mask via positive pressure
ventilation. The nurse assisting with
this procedure knows that positive
pressure ventilation is necessary
because?
A. Anesthesia is administered
during the procedure
B. Decrease oxygen to the brain
increases confusion
and disorientation
C. Grand mal seizure activity
depresses respirations
D. Muscle relaxations given to
prevent injury during seizure
activity depress respirations.
48.When planning the discharge of
a client with chronic anxiety, Nurse
Chris evaluates achievement of the
discharge maintenance goals.
Which goal would be most
appropriately having been included
in the plan of care requiring
evaluation?
A. The client eliminates all anxiety
from daily situations
B. The client ignores feelings of
anxiety
C. The client identifies anxiety
producing situations
D. The client maintains contact
with a crisis counselor
49.Nurse Tina is caring for a client
with depression who has not
responded to antidepressant
medication. The nurse anticipates
that what treatment procedure may
be prescribed.
A. Neuroleptic medication
B. Short term seclusion
C. Psychosurgery
D. Electroconvulsive therapy
50.Mario is admitted to the
emergency room with drug-included
anxiety related to over ingestion of
prescribed antipsychotic
medication. The most important
piece of information the nurse in
charge should obtain initially is the:
A. Length of time on the med.
B. Name of the ingested
medication & the amount
ingested
C. Reason for the suicide attempt
D. Name of the nearest relative &
their phone number
Answers and Rationales
1. C . Total abstinence is the only
effective treatment for
alcoholism
2. A . Hallucinations are visual,
auditory, gustatory, tactile or
olfactory perceptions that have
no basis in reality.
3. D . The Nurse has a
responsibility to observe
continuously the acutely
suicidal client. The Nurse
should watch for clues, such as
communicating
suicidal thoughts, and
messages; hoarding
medications and talking about
death.
4. B . Establishing a consistent
eating plan and monitoring
client’s weight are important to
this disorder.
5. C . Appropriate nursing
interventions for an anxiety
attack include using
short sentences, staying with
the client, decreasing stimuli,
remaining calm and medicating
as needed.
6. B . Delusion of grandeur is a
false belief that one is highly
famous and important.
7. D . Individual with dependent
personality disorder typically
shows indecisiveness
submissiveness and clinging
behavior so that others
will make decisions with them.
8. A . Clients with schizotypal
personality disorder experience
excessive social anxiety that
can lead to paranoid thoughts
9. B . Bulimia disorder generally is
a maladaptive coping response
to stress and underlying issues.
The client should identify
anxiety causing situation
that stimulate the bulimic
behavior and then learn new
ways of coping with the anxiety.
10. A . An adult age 31 to 45
generates new level of
awareness.
11. A . Neuromuscular Blocker,
such as SUCCINYLCHOLINE
(Anectine) produces respiratory
depression because it inhibits
contractions of
respiratory muscles.
12. C . With depression, there is
little or no emotional
involvement therefore
little alteration in affect.
13. D . These clients often hide
food or force vomiting;
therefore they must be carefully
monitored.
14. A . These clients have
severely depleted levels of
sodium and potassium because
of their starvation diet and
energy expenditure, these
electrolytes are necessary for
cardiac functioning.
15. B . Limiting unnecessary
interaction will decrease
stimulation and agitation.
16. C . Ritualistic behavior seen in
this disorder is aimed at
controlling guilt and inadequacy
by maintaining an absolute set
pattern of behavior.
17. D . The nurse needs to set
limits in the client’s
manipulative behavior to
help the client control
dysfunctional behavior. A
consistent approach by the
staff is necessary to decrease
manipulation.
18. B . Any suicidal statement
must be assessed by the nurse.
The nurse should discuss the
client’s statement with her to
determine its meaning in terms
of suicide.
19. A . When the staff member
ask the client if he wonders why
others find him repulsive, the
client is likely to feel defensive
because the question
is belittling. The natural
tendency is to counterattack the
threat to self image.
20. B . The nurse would
specifically use supportive
confrontation with the client
to point out discrepancies
between what the client states
and what actually exists to
increase responsibility for self.
21. C . The nurse would most
likely administer
benzodiazepine, such as
lorazepan (ativan) to the client
who is experiencing symptom:
The client’s
experiences symptoms of
withdrawal because of the
rebound phenomenon when
the sedation of the CNS from
alcohol begins to decrease.
22. D . Regular coffee contains
caffeine which acts as
psychomotor stimulants and
leads to feelings of anxiety and
agitation. Serving coffee top the
client may add to tremors or
wakefulness.
23. D . Vomiting and diarrhea are
usually the late signs of heroin
withdrawal, along with muscle
spasm, fever, nausea, repetitive,
abdominal cramps
and backache.
24. D . Moving to a client’s
personal space increases the
feeling of threat,
which increases anxiety.
25. A . Environmental (MILIEU)
therapy aims at having
everything in the
client’s surrounding area toward
helping the client.
26. C . Children who have
experienced attachment
difficulties with
primary caregiver are not able to
trust others and therefore relate
superficially
27. A . Children have difficulty
verbally expressing their
feelings, acting out behavior,
such as temper tantrums, may
indicate underlying depression.
28. D . The autistic child repeat
sounds or words spoken by
others.
29. D . The client statement is an
example of the use of denial, a
defense that blocks problem by
unconscious refusing to admit
they exist
30. A . Discussion of the feared
object triggers an emotional
response to the object.
31. B . The nurse presence may
provide the client with support &
feeling of control.
32. D . Experiencing the actual
trauma in dreams or flashback
is the major symptom that
distinguishes post traumatic
stress disorder from other
anxiety disorder.
33. C . Confabulation or the filling
in of memory gaps with
imaginary facts is a defense
mechanism used by people
experiencing memory deficits.
34. A . These are the major signs
of anorexia nervosa. Weight
loss is excessive (15% of
expected weight)
35. C . Dental enamel erosion
occurs from repeated self-
induced vomiting.
36. B . Depression usually is both
emotional & physical. A simple
daily routine is the best, least
stressful and least anxiety
producing.
37. D . The expression of these
feeling may indicate that this
client is unable to continue the
struggle of life.
38. A . Structure tends to
decrease agitation and anxiety
and to increase the client’s
feeling of security.
39. B . The rituals used by a client
with obsessive compulsive
disorder help control the anxiety
level by maintaining a set
pattern of action.
40. C . A person with this disorder
would not have adequate self-
boundaries
41. D . Loose associations are
thoughts that are presented
without the logical connections
usually necessary for the
listening to interpret the
message.
42. C . Helping the client to
develop feeling of self worth
would reduce the client’s need
to use pathologic defenses.
43. B . Open ended questions and
silence are strategies used to
encourage clients to discuss
their problem in descriptive
manner.
44. C . Clients who are withdrawn
may be immobile and mute, and
require consistent, repeated
interventions. Communication
with withdrawn clients requires
much patience from the nurse.
The nurse facilitates
communication with the client
by sitting in silence, asking
open-ended question and
pausing to provide
opportunities for the client to
respond.
45. D . When hallucination is
present, the nurse should
reinforce reality with the client.
46. A . Personal characteristics
of abuser include low self-
esteem,
immaturity, dependence,
insecurity and jealousy.
47. D . A short acting skeletal
muscle relaxant such as
succinylcholine (Anectine) is
administered during this
procedure to prevent injuries
during seizure.
48. C . Recognizing situations
that produce anxiety allows the
client to prepare to cope with
anxiety or avoid specific
stimulus.
49. D . Electroconvulsive therapy
is an effective treatment for
depression that has not
responded to medication
50. B . In an emergency, lives
saving facts are obtained first.
The name and the amount of
medication ingested are of
outmost important in treating
this potentially life threatening
situation.
NP 1
1. The four major concepts in
nursing theory are the
A. Person, Environment, Nurse,
Health
 B. Nurse, Person, Environment, A. Henderson 7. Caring is the essence and central
Cure B. Orem unifying, a dominant domain that
C. Promotive, Preventive, Curative, C. Swanson distinguishes nursing from other
Rehabilitative D. Neuman health disciplines. Care is an
D. Person, Environment, Nursing, 5. Nursing is a unique profession, essential human need.
Health Concerned with all the variables
2. The act of utilizing the affecting an individual’s response to A. Benner
environment of the patient to assist stressors, which are intra, inter and B. Watson
him in his recovery is theorized by extra personal in nature. C. Leininger
D. Swanson
A. Nightingale A. Neuman 8. Caring involves 5 processes,
B. Benner B. Johnson KNOWING, BEING WITH, DOING
C. Swanson C. Watson FOR, ENABLING and MAINTAINING
D. King D. Parse BELIEF.
3. For her, Nursing is a theoretical 6. The unique function of the nurse
system of knowledge that is to assist the individual, sick or A. Benner
prescribes a process of analysis well, in the performance of those B. Watson
and action related to care of the ill activities contributing to health that C. Leininger
person he would perform unaided if he has D. Swanson
the necessary strength, will and 9. Caring is healing, it is
A. King knowledge, and do this in such a communicated through the
B. Henderson way as to help him gain consciousness of the nurse to the
C. Roy independence as rapidly as individual being cared for. It allows
D. Leininger possible. access to higher human spirit.
4. According to her, Nursing is a
helping or assistive profession to A. Henderson A. Benner
persons who are wholly or partly B. Abdellah B. Watson
dependent or when those who are C. Levin C. Leininger
supposedly caring for them are no D. Peplau D. Swanson
longer able to give care.
10. Caring means that person,
events, projects and things matter
to people. It reveals stress and
coping options. Caring creates
responsibility. It is an inherent
feature of nursing practice. It helps
the nurse assist clients to recover in
the face of the illness.
A. Benner
B. Watson
C. Leininger
D. Swanson
11. Which of the following is NOT
TRUE about profession according
to Marie Jahoda?
A. A profession is an organization
of an occupational group based
on the application of special
knowledge
B. It serves specific interest of a
group
C. It is altruistic
D. Quality of work is of greater
importance than the rewards
12. Which of the following is NOT
an attribute of a professional?
A. Concerned with quantity
B. Self directed A. Initiate modification on client’s
C. Committed to spirit of inquiry lifestyle
D. Independent B. Protect client’s right
13. The most unique characteristic C. Coordinates the activities of
of nursing as a profession is other members of the health
team in managing patient care
A. Education D. Provide in service education
B. Theory programs, Use accurate nursing
C. Caring audit, formulate philosophy and
D. Autonomy vision of the institution
14. This is the distinctive individual 17. What best describes nurses as
qualities that differentiate a person a care provider?
to another
A. Determine client’s need
A. Philosophy B. Provide direct nursing care
B. Personality C. Help client recognize and cope
C. Charm with stressful psychological
D. Character situation
15. Refers to the moral values and D. Works in combined effort with
beliefs that are used as guides to all those involved in patient’s
personal behavior and actions care
18. The nurse questions a doctors
A. Philosophy order of Morphine sulfate 50 mg, IM
B. Personality for a client with pancreatitis. Which
C. Charm role best fit that statement?
D. Character
16. As a nurse manager, which of A. Change agent
the following best describes this B. Client advocate
function? C. Case manager
D. Collaborator
19. These are nursing intervention B. Team nursing B. Leininger
that requires knowledge, skills and C. Primary nursing C. Orlando
expertise of multiple health D. Total patient care D. Parse
professionals. 23. RN assumes 24 hour 27. Proposed the HEALTH CARE
responsibility for the client to SYSTEM MODEL.
A. Dependent maintain continuity of care across
B. Independent shifts, days or visits. A. Henderson
C. Interdependent B. Orem
D. Intradependent A. Functional nursing C. Parse
20. What type of patient care model B. Team nursing D. Neuman
is the most common for student C. Primary nursing 28. Conceptualized the
nurses and private duty nurses? D. Total patient care BEHAVIORAL SYSTEM MODEL
24. Who developed the first theory
A. Total patient care of nursing? A. Orem
B. Team nursing B. Johnson
C. Primary Nursing A. Hammurabi C. Henderson
D. Case management B. Alexander D. Parse
21. This is the best patient care C. Fabiola 29. Developed the CLINICAL
model when there are many nurses D. Nightingale NURSING – A HELPING ART
but few patients. 25. She introduces the NATURE OF MODEL
NURSING MODEL.
A. Functional nursing A. Swanson
B. Team nursing A. Henderson B. Hall
C. Primary nursing B. Nightingale C. Weidenbach
D. Total patient care C. Parse D. Zderad
22. This patient care model works D. Orlando 30. Developed the ROLE MODELING
best when there are plenty of 26. She described the four and MODELING theory
patient but few nurses conservation principle.
A. Erickson,Tomlin,Swain
A. Functional nursing A. Levin B. Neuman
 C. Newman 35. Freud postulated that child B. Westerhoff
D. Benner and Wrubel adopts parental standards and C. Fowler
31. Proposed the GRAND THEORY traits through D. Freud
OF NURSING AS CARING A. Imitation 39. Established in 1906 by the
A. Erickson, Tomlin, Swain B. Introjection Baptist foreign mission society of
B. Peterson,Zderad C. Identification America. Miss rose nicolet, was it’s
C. Bnner,Wrubel D. Regression first superintendent.
D. Boykin,Schoenhofer 36. According to them, Morality is A. St. Paul Hospital School of
32. Postulated the measured of how people treat nursing
INTERPERSONAL ASPECT OF human being and that a moral child B. Iloilo Mission Hospital School of
NURSING strives to be kind and just nursing
A. Travelbee A. Zderad and Peterson C. Philippine General Hospital
B. Swanson B. Benner and Wrubel School of nursing
C. Zderad C. Fowler and Westerhoff D. St. Luke’s Hospital School of
D. Peplau D. Schulman and Mekler nursing
33. He proposed the theory of 37. Postulated that FAITH is the 40. Anastacia Giron-Tupas was the
morality that is based on MUTUAL way of behaving. He developed four first Filipino nurse to occupy the
TRUST theories of faith and development position of chief nurse in this
A. Freud based on his experience. hospital.
B. Erikson A. Giligan A. St. Paul Hospital
C. Kohlberg B. Westerhoff B. Iloilo Mission Hospital
D. Peters C. Fowler C. Philippine General Hospital
34. He proposed the theory of D. Freud D. St. Luke’s Hospital
morality based on PRINCIPLES 38. He described the development 41. She was the daughter of
A. Freud of faith. He suggested that faith is a Hungarian kings, who feed 300-900
B. Erikson spiritual dimension that gives people everyday in their gate, builds
C. Kohlberg meaning to a persons life. Faith hospitals, and care of the poor and
D. Peters according to him, is a relational sick herself.
phenomenon. A. Elizabeth
A. Giligan B. Catherine
 C. Nightingale A. Dark period D. Educative period
D. Sairey Gamp B. Intuitive period 51. According to the
42. She dies of yellow fever in her C. Contemporary period Biopsychosocial and spiritual theory
search for truth to prove that yellow D. Educative period of Sister Callista Roy, Man, As a
fever is carried by a mosquitoes. 47. This period ended when Pastor SOCIAL being is
A. Clara louise Maas Fliedner, build Kaiserwerth institute A. Like all other men
B. Pearl Tucker for the training of Deaconesses B. Like some other men
C. Isabel Hampton Robb A. Apprentice period C. Like no other men
D. Caroline Hampton Robb B. Dark period D. Like men
43. He was called the father of C. Contemporary period 52. She conceptualized that man, as
sanitation. D. Educative period an Open system is in constant
A. Abraham 48. Period of nursing where interaction and transaction with a
B. Hippocrates religious Christian orders emerged changing environment.
C. Moses to take care of the sick A. Roy
D. Willam Halstead A. Apprentice period B. Levin
44. The country where B. Dark period C. Neuman
SHUSHURUTU originated C. Contemporary period D. Newman
A. China D. Educative period 53. In a CLOSED system, which of
B. Egypt 49. Founded the second order of St. the following is true?
C. India Francis of Assisi A. Affected by matter
D. Babylonia A. St. Catherine B. A sole island in vast ocean
45. They put girls clothes on male B. St. Anne C. Allows input
infants to drive evil forces away C. St. Clare D. Constantly affected by matter,
A. Chinese D. St. Elizabeth energy, information
B. Egyptian 50. This period marked the religious 54. Who postulated the WHOLISTIC
C. Indian upheaval of Luther, Who questions concept that the totality is greater
D. Babylonian the Christian faith. than sum of its parts?
46. In what period of nursing does A. Apprentice period A. Roy
people believe in TREPHINING to B. Dark period B. Rogers
drive evil forces away? C. Contemporary period C. Henderson
 D. Johnson
55. She theorized that man is
composed of sub and supra
systems. Subsystems are cells,
tissues, organs and systems while
the suprasystems are family,
society and community.
A. Roy
B. Rogers
C. Henderson
D. Johnson
56. Which of the following is not
true about the human needs?
A. Certain needs are common to
all people
B. Needs should be followed
exactly in accordance with their
hierarchy
C. Needs are stimulated by internal
factors
D. Needs are stimulated by
external factors
57. Which of the following is TRUE
about the human needs?
A. May not be deferred
B. Are not interrelated
C. Met in exact and rigid way
D. Priorities are alterable
58. According to Maslow, which of
the following is NOT TRUE about a
self actualized person?
A. Understands poetry, music,
philosophy, science etc.
B. Desires privacy, autonomous
C. Follows the decision of the
majority, uphold justice and
truth
D. Problem centered
59. According to Maslow, which of
the following is TRUE about a self
actualized person?
A. Makes decision contrary to
public opinion
B. Do not predict events
C. Self centered
D. Maximum degree of self
conflict
60. This is the essence of mental
health
A. Self awareness
B. Self actualization
C. Self esteem
D. Self worth
61. Florence nightingale is born in
A. Germany
B. Britain
C. France
D. Italy
62. Which is unlikely of Florence
Nightingale?
A. Born May 12, 1840
B. Built St. Thomas school of
nursing when she was 40 years
old
C. Notes in nursing
D. Notes in hospital
63. What country did Florence
Nightingale train in nursing?
A. Belgium
B. US
C. Germany
D. England
64. Which of the following is
recognized for developing the
concept of HIGH LEVEL
WELLNESS?
A. Erikson
B. Madaw
C. Peplau
D. Dunn
65. One of the expectations is for
nurses to join professional
association primarily because of
A. Promotes advancement and
professional growth among its
members
B. Works for raising funds for
nurse’s benefit
 C. Facilitate and establishes
acquaintances
D. Assist them and securing jobs
abroad
66. Founder of the PNA
A. Julita Sotejo
B. Anastacia Giron Tupas
C. Eufemia Octaviano
D. Anesia Dionisio
67. Which of the following provides
that nurses must be a member of a
national nurse organization?
A. R.A 877
B. 1981 Code of ethics approved
by the house of delegates and
the PNA
C. Board resolution No. 1955
Promulgated by the BON
D. RA 7164
68. Which of the following best
describes the action of a nurse who
documents her nursing diagnosis?
A. She documents it and charts it
whenever necessary
B. She can be accused of
malpractice
C. She does it regularly as an
important responsibility
D. She charts it only when the
patient is acutely ill
69. Which of the following does not failure to maintain internal
govern nursing practice? environment.
A. RA 7164 A. Cannon
B. RA 9173 B. Bernard
C. BON Res. Code Of Ethics C. Leddy and Pepper
D. BON Res. Scope of Nursing D. Roy
Practice 74. Postulated that health is a state
70. A nurse who is maintaining a and process of being and becoming
private clinic in the community an integrated and whole person.
renders service on maternal and A. Cannon
child health among the B. Bernard
neighborhood for a fee is: C. Dunn
A. Primary care nurse D. Roy
B. Independent nurse practitioner 75. What regulates HOMEOSTASIS
C. Nurse-Midwife according to the theory of Walter
D. Nurse specialist Cannon?
71. When was the PNA founded? A. Positive feedback
A. September 22, 1922 B. Negative feedback
B. September 02, 1920 C. Buffer system
C. October 21, 1922 D. Various mechanisms
D. September 02, 1922 76. Stated that health is WELLNESS.
72. Who was the first president of A termed define by the culture or an
the PNA ? individual.
A. Anastacia Giron-Tupas A. Roy
B. Loreto Tupas B. Henderson
C. Rosario Montenegro C. Rogers
D. Ricarda Mendoza D. King
73. Defines health as the ability to 77. Defined health as a dynamic
maintain internal milieu. Illness state in the life cycle, and Illness as
according to him/her/them is the interference in the life cycle.
 A. Roy 81. According to them, Well being is 85. According to DUNN,
B. Henderson a subjective perception of Overcrowding is what type of illness
C. Rogers BALANCE, HARMONY and VITALITY precursor?
D. King A. Leavell and Clark A. Heredity
78. She defined health as the B. Peterson and Zderad B. Social
soundness and wholness of C. Benner and Wruber C. Behavioral
developed human structure and D. Leddy and Pepper D. Environmental
bodily mental functioning. 82. He describes the WELLNESS- 86. Health belief model was
A. Orem ILLNESS Continuum as interaction formulated in 1975 by who?
B. Henderson of the environment with well being A. Becker
C. Neuman and illness. B. Smith
D. Clark A. Cannon C. Dunn
79. According to her, Wellness is a B. Bernard D. Leavell and Clark
condition in which all parts and C. Dunn 87. In health belief model, Individual
subparts of an individual are in D. Clark perception matters. Which of the
harmony with the whole system. 83. An integrated method of following is highly UNLIKELY to
A. Orem functioning that is oriented towards influence preventive behavior?
B. Henderson maximizing one’s potential within A. Perceived susceptibility to an
C. Neuman the limitation of the environment. illness
D. Johnson A. Well being B. Perceived seriousness of an
80. Postulated that health is B. Health illness
reflected by the organization, C. Low level Wellness C. Perceived threat of an illness
interaction, interdependence and D. High level Wellness D. Perceived curability of an illness
integration of the subsystem of the 84. What kind of illness precursor, 88. Which of the following is not a
behavioral system. according to DUNN is cigarette PERCEIVED BARRIER in preventive
A. Orem smoking? action?
B. Henderson A. Heredity A. Difficulty adhering to the
C. Neuman B. Social lifestyle
D. Johnson C. Behavioral B. Economic factors
D. Environmental
 C. Accessibility of health care
facilities
D. Increase adherence to medical
therapies
89. Conceptualizes that health is a
condition of actualization or
realization of person’s potential.
Avers that the highest aspiration of
people is fulfillment and complete
development actualization.
A. Clinical Model
B. Role performance Model
C. Adaptive Model
D. Eudaemonistic Model
90. Views people as physiologic
system and Absence of sign and
symptoms equates health.
A. Clinical Model
B. Role performance Model
C. Adaptive Model
D. Eudaemonistic Model
91. Knowledge about the disease
and prior contact with it is what
type of VARIABLE according to the
health belief model?
A. Demographic
B. Sociopsychologic
C. Structural
D. Cues to action
92. It includes internal and external describes the nature of persons as
factors that leads the individual to they interact within the environment
seek help to pursue health
A. Demographic A. Ecologic Model
B. Sociopsychologic B. Health Belief Model
C. Structural C. Health Promotion Model
D. Cues to action D. Health Prevention Model
93. Influence from peers and social 97. Defined by Pender as all
pressure is included in what activities directed toward
variable of HBM? increasing the level of well being
A. Demographic and self actualization.
B. Sociopsychologic A. Health prevention
C. Structural B. Health promotion
D. Cues to action C. Health teaching
94. Age, Sex, Race etc. is included D. Self actualization
in what variable of HBM? 98. Defined as an alteration in
A. Demographic normal function resulting in
B. Sociopsychologic reduction of capacities and
C. Structural shortening of life span.
D. Cues to action A. Illness
95. According to Leavell and Clark’s B. Disease
ecologic model, All of this are C. Health
factors that affects health and D. Wellness
illness except 99. Personal state in which a
A. Reservoir person feels unhealthy
B. Agent A. Illness
C. Environment B. Disease
D. Host C. Health
96. Is a multi dimensional model D. Wellness
developed by PENDER that
100. According to her, Caring is
defined as a nurturant way of
responding to a valued client
towards whom the nurse feels a
sense of commitment and
responsibility.
A. Benner
B. Watson
C. Leininger
D. Swanson
Answers and Rationales
1. D. Person, Environment, Nursing,
Health. This is an actual board
exam question and is a
common board question.
Theorist always describes The
nursing profession by first
defining what is NURSING,
followed by the PERSON,
ENVIRONMENT and HEALTH
CONCEPT. The most popular
theory was perhaps
Nightingale’s. She defined
nursing as the utilization of the
persons environment to assist
him towards recovery. She
defined the person as
somebody who has a reparative
capabilities mediated and
enhanced by factors in his
environment. She describes the
environment as something that
would facilitate the person’s
reparative process and
identified different factors like
sanitation, noise, etc. that
affects a person’s reparative
state.
2.  A. Nightingale. Florence
nightingale do not believe in the
germ theory, and perhaps this
was her biggest mistake. Yet,
her theory was the first in
nursing. She believed that
manipulation of environment
that includes appropriate noise,
nutrition, hygiene, light, comfort,
sanitation etc. could provide the
client’s body the nurturance it
needs for repair and recovery.
3.  C. Roy. Remember the word “
THEOROYTICAL “ For Callista
Roy, Nursing is a theoretical
body of knowledge that
prescribes analysis and action
to care for an ill person. She
introduced the ADAPTATION
MODEL and viewed person as a
BIOSPSYCHOSOCIAL BEING.
She believed that by adaptation,
Man can maintain homeostasis.
4. B. Orem. In self care deficit
theory, Nursing is defined as A
helping or assistive profession
to person who are wholly or
partly dependent or when
people who are to give care to
them are no longer available.
Self care, are the activities that
a person do for himself to
maintain health, life and well
being.
5. A. Neuman. Neuman divided
stressors as either intra, inter
and extra personal in nature.
She said that NURSING is
concerned with eliminating
these stressors to obtain a
maximum level of wellness. The
nurse helps the client through
PRIMARY, SECONDARY AND
TERTIARY prevention modes.
Please do not confuse this with
LEAVELL and CLARK’S level of
prevention.
6. A. Henderson. This was an actual
board question. Remember this
definition and associate it with
Virginia Henderson. Henderson
 also describes the NATURE OF
NURSING theory. She identified
14 basic needs of the client.
She describes nursing roles as
SUBSTITUTIVE : Doing
everything for the client,
SUPPLEMENTARY : Helping the
client and COMPLEMENTARY :
Working with the client.
Breathing normally, Eliminating
waste, Eating and drinking
adquately, Worship and Play are
some of the basic needs
according to her.
7. C. Leininger. There are many
theorist that describes nursing
as CARE. The most popular was
JEAN WATSON’S Human Caring
Model. But this question
pertains to Leininger’s definition
of caring. CUD I LIE IN GER?
[ Could I Lie In There ] Is the
Mnemonics I am using not to
get confused. C stands for
CENTRAL , U stands for
UNIFYING, D stands for
DOMINANT DOMAIN. I
emphasize on this matter due to
feedback on the last June 2006
batch about a question about
CARING.
8. D. Swanson . Caring according to
Swanson involves 5 processes.
Knowing means understanding
the client. Being with
emphasizes the Physical
presence of the nurse for the
patient. Doing for means doing
things for the patient when he is
incapable of doing it for himself.
Enabling means helping client
transcend maturational and
developmental stressors in life
while Maintaining belief is the
ability of the Nurse to inculcate
meaning to these events.
9. B. Watson. The deepest and
spiritual definition of Caring
came from Jean watson. For
her, Caring expands the limits of
openess and allows access to
higher human spirit.
10. A. Benner.  I think of CARE
BEAR to facilitate retainment of
BENNER. As in, Care Benner.
For her, Caring means being
CONNECTED or making things
matter to people. Caring
according to Benner give
meaning to illness and re
establish connection.
11. B. It serves specific interest of a
group.Believe it or not, you
should know the definition of
profession according to Jahoda
because it is asked in the Local
boards. A profession should
serve the WHOLE COMMUNITY
and not just a specific intrest of
a group. Everything else, are
correct.
12. A. Concerned with quantity. A
professional is concerned with
QUALITY and not QUANTITY. In
nursing, We have methods of
quality assurance and control to
evaluate the effectiveness of
nursing care. Nurses, are never
concerned with QUANTITY of
care provided.
13. C. Caring. Caring and caring
alone, is the most unique quality
of the Nursing Profession. It is
the one the delineate Nursing
from other professions.
14. B. Personality. Personality are
qualities that make us different
from each other. These are
impressions that we made, or
 the footprints that we leave
behind. This is the result of the
integration of one’s talents,
behavior, appearance, mood,
character, morals and impulses
into one harmonious whole.
Philosophy is the basic truth
that fuel our soul and give our
life a purpose, it shapes the
facets of a person’s character.
Charm is to attract other people
to be a change agent. Character
is our moral values and belief
that guides our actions in life.
15. D. Character.Rationale: Refer to
number 14
16. D. Provide in service education
programs, Use accurate nursing
audit, formulate philosophy and
vision of the institution .  A refers
to being a change agent. B is a
role of a patient advocate. C is a
case manager while D basically
summarized functions of a
nurse manager. If you haven’t
read Lydia Venzon’s Book :
NURSING MANAGEMENT
TOWARDS QUALITY CARE, I
suggest reading it in advance
for your management subjects
in the graduate school.
Formulating philosophy and
vision is in PLANNING. Nursing
Audit is in CONTROLLING, In
service education programs are
included in DIRECTING. These
are the processes of Nursing
Management, I just forgot to
add ORGANIZING which
includes formulating an
organizational structure and
plans, Staffing and developing
qualifications and job
descriptions.
17. A. Determine client’s need.You
can never provide nursing care
if you don’t know what are the
needs of the client. How can
you provide an effective
postural drainage if you do not
know where is the bulk of the
client’s secretion. Therefore, the
best description of a care
provider is the accurate and
prompt determination of the
client’s need to be able to
render an appropriate nursing
care.
18. B. Client advocate. As a client’s
advocate, Nurses are to protect
the client’s right and promotes
what is best for the client.
Knowing that Morphine causes
spasm of the sphincter of Oddi
and will lead to further increase
in the client’s pain, The nurse
knew that the best treatment
option for the client was not
provided and intervene to
provide the best possible care.
19. C. Interdependent. Interdepend
ent functions are those that
needs expertise and skills of
multiple health professionals.
Example is when A child was
diagnosed with nephrotic
syndrome and the doctor
ordered a high protein diet,
Budek then work together with
the dietician about the age
appropriate high protein foods
that can be given to the child,
Including the preparation to
entice the child into eating the
food. NOTE : It is still debated if
the diet in NS is low, moderate
or high protein, In the U.S,
Protein is never restricted and
can be taken in moderate
amount. As far as the local
 examination is concerned,
answer LOW PROTEIN HIGH
CALORIC DIET.
20. A. Total patient care. This is
also known as case nursing. It
is a method of nursing care
wherein, one nurse is assigned
to one patient for the delivery of
total care. These are the
method use by Nursing
students, Private duty nurses
and those in critical or isolation
units.
21. D. Total patient care .Total
patient care works best if there
are many nurses but few
patients.
22. A. Functional
nursing. Functional nursing is
task oriented, One nurse is
assigned on a particular task
leading to task expertise and
efficiency. The nurse will work
fast because the procedures are
repetitive leading to task
mastery. This care is not
recommended as this leads
fragmented nursing care.
23. C. Primary nursing. Your
keyword in Primary nursing is
the 24 hours. This does not
necessarily means the nurse is
awake for 24 hours, She can
have a SECONDARY NURSES
that will take care of the patient
in shifts where she is not
arround.
24. D. Nightingale .  Refer to
question # 2. Hammurabi is the
king of babylon that introduces
the LEX TALIONES law, If you
kill me, you should be killed… If
you rob me, You should be
robbed, An eye for an eye and a
tooth for a tooth. Alexander the
great was the son of King Philip
II and is from macedonia but he
ruled Greece including Persia
and Egypt. He is known to use a
hammer to pierce a dying
soldier’s medulla towards
speedy death when he thinks
that the soldier will die anyway,
just to relieve their suffering.
Fabiola was a beautiful roman
matron who converted her
house into a hospital.
25. A. Henderson. Refer to
question # 6.
26. A. Levin. Myra Levin
described the 4 Conservation
principles which are concerned
with the Unity and Integrity of an
individual. These are ENERGY :
Our output to facilitate meeting
of our needs. STRUCTURAL
INTEGRITY : We mus maintain
the integrity of our organs,
tissues and systems to be able
to function and prevent harmful
agents entering our body.
PERSONAL INTEGRITY : These
refers to our self esteem, self
worth, self concept, identify and
personality. SOCIAL
INTEGRITY : Reflects our
societal roles to our society,
community, family, friends and
fellow individuals.
27. D. Neuman . Betty Neuman
asserted that nursing is a
unique profession and is
concerned with all the variables
affecting the individual’s
response to stressors. These
are INTRA or within ourselves,
EXTRA or outside the individual,
INTER means between two or
more people. She proposed the
 HEALTH CARE SYSTEM MODEL
which states that by PRIMARY,
SECONDARY and TERTIARY
prevention, The nurse can help
the client maintain stability
against these stressors.
28. B. Johnson. According to
Dorothy Johnson, Each person
is a behavioral system that is
composed of 7 subsystems.
Man adjust or adapt to
stressors by a using a LEARNED
PATTERN OF RESPONSE. Man
uses his behavior to meet the
demands of the environment,
and is able to modified his
behavior to support these
demands.
29. C. Weidenbach.Just remember
ERNESTINE
WEIDENBACHLINICAL.
30. A. Erickson,Tomlin,Swain
31. D. Boykin,Schoenhofer . This
theory was called GRAND
THEORY because boykin and
schoenofer thinks that ALL
MAN ARE CARING, And that
nursing is a response to this
unique call. According to them,
CARING IS A MORAL
IMPERATIVE, meaning, ALL
PEOPLE will tend to help a man
who fell down the stairs even if
he is not trained to do so.
32. A. Travelbee. Travelbee’s
theory was referred to as
INTERPERSONAL theory
because she postulated that
NURSING is to assist the
individual and all people that
affects this individual to cope
with illness, recover and FIND
MEANING to this experience.
For her, Nursing is a HUMAN TO
HUMAN relationship that is
formed during illness. To her, an
individual is a UNIQUE and
irreplaceable being in
continuous process of
becoming, evolving and
changing. PLEASE do
remember, that it is PARSE who
postulated the theory of
HUMAN BECOMING and not
TRAVELBEE, for I read books
that say it was TRAVELBEE and
not PARSE.
33. C. Kohlberg. Kohlber states
that relationships are based on
mutual trust. He postulated the
levels of morality development.
At the first stage called the
PREMORAL or preconventional,
A child do things and label them
as BAD or GOOD depending on
the PUNISHMENT or REWARD
they get. They have no concept
of justice, fairness and equity,
for them, If I punch this kid and
mom gets mad, thats WRONG.
But if I dance and sing, mama
smiles and give me a new toy,
then I am doing something
good. In the Conventional level,
The individual actuates his act
based on the response of the
people around him. He will
follow the rules, regulations,
laws and morality the society
upholds. If the law states that I
should not resuscitate this man
with a DNR order, then I would
not. However, in the Post
conventional level or the
AUTONOMOUS level, the
individual still follows the rules
but can make a rule or bend part
of these rules according to his
own MORALITY. He can change
the rules if he thinks that it is
 needed to be changed. Example
is that, A nurse still continue
resuscitating the client even if
the client has a DNR order
because he believes that the
client can still recover and his
mission is to save lives, not
watch patients die.
34. D. Peters . Remember PETERS
for PRINCIPLES. P is to P. He
believes that morality has 3
components : EMOTION or how
one feels, JUDGEMENT or how
one reason and BEHAVIOR or
how one actuates his EMOTION
and JUDGEMENT. He believes
that MORALITY evolves with the
development of PRINCPLES or
the person’s vitrue and traits.
He also believes in
AUTOMATICITY of virtues or he
calls HABIT, like kindness,
charity, honesty, sincerity and
thirft which are innate to a
person and therfore, will be
performed automatically.
35. C. Identification. A child,
according to Freud adopts
parental standards, traits, habits
and norms through identication.
A good example is the corned
beef commercial ” WALK LIKE A
MAN, TALK LIKE A MAN ”
Where the child identifies with
his father by wearing the same
clothes and doing the same
thing.
36. D. Schulman and
Mekler . According to Schulman
and Mekler, there are 2
components that makes an
action MORAL : The intention
should be good and the Act
must be just. A good example is
ROBIN HOOD, His intention is
GOOD but the act is UNJUST,
which makes his action
IMMORAL.
37. B. Westerhoff. There are only 2
theorist of FAITH that might be
asked in the board
examinations. Fowler and
Westerhoff. What differs them
is that, FAITH of fowler is
defined abstractly, Fowler
defines faith as a FORCE that
gives a meaning to a person’s
life while Westerhoff defines
faith as a behavior that
continuously develops through
time.
38. C. Fowler. Rationale: Refer to #
37
39. B. Iloilo Mission Hospital
School of nursing
40. C. Philippine General Hospital
41. A. Elizabeth.Saint Elizabeth of
Hungary was a daughter of a
King and is the patron saint of
nurses. She build hospitals and
feed hungry people everyday
using the kingdom’s money.
She is a princess, but devoted
her life in feeding the hungry
and serving the sick.
42. A. Clara louise Maas. Clara
Louise Maas sacrificed her life
in research of YELLOW FEVER.
People during her time do not
believe that yellow fever was
brought by mosquitoes. To
prove that they are wrong, She
allowed herself to be bitten by
the vector and after days, She
died.
43. C. Moses
44. C. India
45. A. Chinese. Chinese believes
that male newborns are demon
 magnets. To fool those
demons, they put female
clothes to their male newborn.
46. B. Intuitive period.Egyptians
believe that a sick person is
someone with an evil force or
demon that is inside their
heads. To release these evil
spirits, They would tend to drill
holes on the patient’s skull and
it is called TREPHINING.
47. A. Apprentice period.What
dilineates apprentice period
among others is that, it ENDED
when formal schools were
established. During the
apprentice period, There is no
formal educational institution
for nurses. Most of them
receive training inside the
convent or church. Some of
them are trained just for the
purpose of nursing the wounded
soldiers. But almost all of them
are influenced by the christian
faith to serve and nurse the
sick. When Fliedner build the
first formal school for nurses, It
marked the end of the
APPRENTICESHIP period.
48. A. Apprentice
period. Apprentice period is
marked by the emergence of
religious orders the are devoted
to religious life and the practice
of nursing.
49. C. St. Clare. The poor clares, is
the second order of St. Francis
of assisi. The first order was
founded by St. Francis himself.
St. Catherine of Siena was the
first lady with the lamp. St. Anne
is the mother of mama mary. St.
Elizabeth is the patron saint of
Nursing.
50. B. Dark period. Protestantism
emerged with Martin Luther
questions the Pope and
Christianity. This started the
Dark period of nursing when the
christian faith was smeared by
controversies. These leads to
closure of some hospital and
schools run by the church.
Nursing became the work of
prostitutes, slaves, mother and
least desirable of women.
51. B. Like some other
men.According to ROY, Man as a
social being is like some other
man. As a spiritual being and
Biologic being, Man are all alike.
As a psychologic being, No man
thinks alike. This basically
summarized her
BIOPSYHOSOCIAL theory which
is included in our licensure
exam coverage.
52. A. Roy. OPEN system theory
is ROY. As an open system, man
continuously allows input from
the environment. Example is
when you tell me Im good
looking, I will be happy the
entire day, Because I am an
open system and continuously
interact and transact with my
environment. A close system is
best exemplified by a CANDLE.
When you cover the candle with
a glass, it will die because it will
eventually use all the oxygen it
needs inside the glass for
combustion. A closed system
do not allow inputs and output
in its environment.
53. B. A sole island in vast ocean
54. B. Rogers. The wholistic
theory by Martha Rogers states
that MAN is greater than the
 sum of all its parts and that his
dignity and worth will not be
lessen even if one of this part is
missing. A good example is
ANNE BOLEYN, The mother of
Queen Elizabeth and the wife of
King Henry VIII. She was
beheaded because Henry wants
to mary another wife and that
his divorce was not approved by
the pope. Outraged, He insisted
on the separation of the Church
and State and divorce Anne
himself by making everyone
believe that Anne is having an
affair to another man. Anne was
beheaded while her lips is still
saying a prayer. Even without
her head, People still gave
respect to her diseased body
and a separate head. She was
still remembered as Anne
boleyn, Mother of Elizabeth who
lead england to their GOLDEN
AGE.
55. B. Rogers. According to
Martha Rogers, Man is
composed of 2 systems : SUB
which includes cells, tissues,
organs and system and SUPRA
which includes our famly,
community and society. She
stated that when any of these
systems are affected, it will
affect the entire individual.
56. B. Needs should be followed
exactly in accordance with their
hierarchy.Needs can be deferred.
I can urinate later as not to miss
the part of the movie’s climax. I
can save my money that are
supposedly for my lunch to
watch my idols in concert. The
physiologic needs can be meet
later for some other needs and
need not be strictly followed
according to their hierarchy.
57. D. Priorities are alterable. Refer
to question # 56.
58. C. Follows the decision of the
majority, uphold justice and
truth. A,B and D are all qualities
of a self actualized person. A
self actualized person do not
follow the decision of majority
but is self directed and can
make decisions contrary to a
popular opinion.
59. A. Makes decision contrary to
public opinion. Refer to question
# 58.
60. B. Self actualization. The peak
of maslow’s hierarchy is the
essence of mental health.
61. D. Italy. Florence Nightingale
was born in Florence, Italy, May
12, 1820. Studied in Germany
and Practiced in England.
62. A. Born May 12, 1840
63. C. Germany
64. D. Dunn. According to Dunn,
High level wellness is the ability
of an individual to maximize his
full potential with the limitations
imposed by his environment.
According to him, An individual
can be healthy or ill in both
favorable and unfavorable
environment.
65. A. Promotes advancement and
professional growth among its
members
66. B. Anastacia Giron Tupas
67. C. Board resolution No. 1955
Promulgated by the BON.  This is
an old board resolution. The
new Board resolution is No. 220
series of 2004 also known as
 the Nursing Code Of ethics
which states that [ SECTION 17,
A ] A nurse should be a member
of an accredited professional
organization which is the PNA.
68. C. She does it regularly as an
important responsibility
69. A. RA 7164. 7164 is an old
law. This is the 1991 Nursing
Law which was repealed by the
newer 9173.
70. B. Independent nurse practitioner
71. D. September 02,
1922.  According to the official
PNA website, they are founded
September 02, 1922.
72. C. Rosario
Montenegro. Anastacia Giron
Tupas founded the FNA, the
former name of the PNA but the
first President was Rosario
Montenegro.
73. B. Bernard. According to
Bernard, Health is the ability to
maintain and Internal Milieu and
Illness is the failure to maintain
the internal environment.
74. D. Roy. According to ROY,
Health is a state and process of
becoming a WHOLE AND
INTEGRATED Person.
75. B. Negative feedback. The
theory of Health as the ability to
maintain homeostasis was
postulated by Walter Cannon.
According to him, There are
certain FEEDBACK Mechanism
that regulates our Homeostasis.
A good example is that when
we overuse our arm, it will
produce pain. PAIN is a
negative feedback that signals
us that our arm needs a rest.
76. C. Rogers. Martha Rogers
states that HEALTH is
synonymous with WELLNESS
and that HEALTH and
WELLNESS is subjective
depending on the definition of
one’s culture.
77. D. King .Emogene King states
that health is a state in the life
cycle and Illness is any
interference on this cycle. I
enjoyed the Movie LION KING
and like what Mufasa said that
they are all part of the CIRCLE
OF LIFE, or the Life cycle.
78. A. Orem. Orem defined health
as the SOUNDNESS and
WHOLENESS of developed
human structure and of bodily
and mental functioning.
79. C. Neuman. Neuman believe
that man is composed of
subparts and when this
subparts are in harmony with
the whole system, Wellness
results. Please do not confuse
this with the SUB and SUPRA
systems of martha rogers.
80. D. Johnson . Once you see the
phrase BEHAVIORAL SYSTEM,
answer Dorothy Johnson.
81. D. Leddy and
Pepper .According to Leddy and
Pepper, Wellness is subjective
and depends on an individuals
perception of balance, harmony
and vitality. Leavell and Clark
postulared the ecologic model
of health and illness or the
AGENT-HOST-ENVIRONMENT
model. Peterson and Zderad
developed the HUMANISTIC
NURSING PRACTICE theory
while Benner and Wruber
 postulate the PRIMACY OF
CARING MODEL.
82. C. Dunn
83. D. High level Wellness
84. C. Behavioral. Behavioral
precursors includes smoking,
alcoholism, high fat intake and
other lifestyle choices.
Environmental factors involved
poor sanitation and over
crowding. Heridity includes
congenital and diseases
acquired through the genes.
There are no social precursors
according to DUNN.
85. D. Environmental
86. A. Becker. According to
Becker, The belief of an
individual greatly affects his
behavior. If a man believes that
he is susceptible to an illness,
He will alter his behavior in
order to prevent its occurence.
For example, If a man thinks
that diabetes is acquired
through high intake of sugar
and simple carbohydrates, then
he will limit the intake of foods
rich in these components.
87. D. Perceived curability of an
illness . If a man think he is
susceptibe to a certain disease,
thinks that the disease is
serious and it is a threat to his
life and functions, he will use
preventive behaviors to avoid
the occurence of this threat.
88. A. Difficulty adhering to the
lifestyle and B. Economic
factors. Perceived barriers are
those factors that affects the
individual’s health preventive
actions. Both A and B can affect
the individual’s ability to prevent
the occurence of diseases. C
and D are called Preventive
Health Behaviors which
enhances the individual’s
preventive capabilities.
89. D. Eudaemonistic Model . Smith
formulated 5 models of health.
Clinical model simply states
that when people experience
sign and symptoms, they would
think that they are unhealthy
therefore, Health is the absence
of clinical sign and symptoms
of a disease. Role performance
model states that when a
person does his role and
activities without deficits, he is
healthy and the inability to
perform usual roles means that
the person is ill. Adaptive Model
states that if a person adapts
well with his environment, he is
healthy and maladaptation
equates illness. Eudaemonistic
Model of health according to
smith is the actualization of a
person’s fullest potential. If a
person functions optimally and
develop self actualization, then,
no doubt that person is healthy.
90. A. Clinical
Model. Rationale: Refer to
question # 89.
91. C. Structural. Modifying
variables in Becker’s health
belief model includes
DEMOGRAPHIC : Age, sex, race
etc. SOCIOPSYCHOLOGIC :
Social and Peer influence.
STRUCTURAL : Knowledge
about the disease and prior
contact with it and CUES TO
ACTION : Which are the sign
and symptoms of the disease or
advice from friends, mass
 media and others that forces or
makes the individual seek help.
92. D. Cues to action . Refer to
question # 91.
93. B. Sociopsychologic. Refer to
question # 91.
94. A. Demographic. Refer to
question # 91.
95. A. Reservoir. According to
L&C’s Ecologic model, there are
3 factors that affect health and
illness. These are the AGENT or
the factor the leads to illness,
either a bacteria or an event in
life. HOST are persons that may
or may not be affected by these
agents. ENVIRONMENT are
factors external to the host that
may or may not predispose him
to the AGENT.
96. C. Health Promotion
Model. Pender developed the
concept of HEALTH
PROMOTION MODEL which
postulated that an individual
engages in health promotion
activities to increase well being
and attain self actualization.
These includes exercise,
immunization, healthy lifestyle,
good food, self responsibility responsibility created by Caring
and all other factors that in nursing. She was also
minimize if not totally eradicate responsible for the PRIMACY
risks and threats of health. OF CARING MODEL. Leininger
97. B. Health promotion. Refer to defind the 4 conservation
question # 96. principle while Swanson
98. B. Disease. Disease are introduced the 5 processes of
alteration in body functions caring.
resulting in reduction of
capabilities or shortening of life
span.
99. A. Illness. Illness is something
PERSONAL. Unlike disease,
Illness are personal state in
which person feels unhealthy.
An old person might think he is
ILL but in fact, he is not due, to
diminishing functions and
capabilities, people might think
they are ILL. Disease however,
is something with tangible basis
like lab results, X ray films or
clinical sign and symptoms.
100. B. Watson. This is Jean
Watson’s definition of Nursing
as caring. This was asked word
per word last June 06′ NLE.
Benner defines caring as
something that matters to
people. She postulated the