1. Based on the paradigm of nursing, health refers to
Personal responsibility and sense of
the holistic level of wellness that the person
experiences. Sniper identifies the nursing domain in
a paradigm which includes:
ANSWER: Person, situation, environment, nursing
2. Primordial prevention focuses on preventing the
emergence of risk factors. Primary prevention aimed
at health promotion and includes:
ANSWER: Immunization is PRIMARY prevention.
Cancer screening is SECONDARY prevention.
Self-administration of steroid is an example of TERTIARY
prevention.
3. To check if a client has a possible Vitamin C
deficiency, or scurvy, the nurse must make sure
to examine the client’s:
ANSWER: Gingiva.
Scurvy is a disease characterized by soft, bleeding
gums (gingivitis); along with loose teeth, pinpoint
hemorrhages, muscle and joint pain and poor wound
healing.
4. Specific prevention focuses on removing or
reducing the levels of the risk factors. Mrs.
Assassin was scheduled for Cervista Test by
Nurse Sage. This action is an example of:
ANSWER: Cervista Test is an example
SECONDARY prevention.
It focuses on early identification of health problems
and prompts intervention to alleviate health problems. Its
goal is to identify individuals in an early stage of
disease process and to limit future disability.
5. According to Florence Nightingale, health is a
state of being well and using every power the
individual possesses to the fullest extent. Which
of the following individuals appear to have taken
on the sick role?
ANSWER: An employer who is ill and says “I won’t be
able go to the office today.”
6. The World Health Organization defines health as
the state of complete physical, mental, and
social well-being, and not merely the absence of
disease. During which stage of illness will we
expect Rogue to relinquish the dependence
role?
ANSWER: Recovery or Rehabilitation
During the Recovery and Rehabilitation stage, the client
is expected to relinquish the dependent role and resume
former roles and responsibilities.
7.
control are the key concepts for promotion
of health. As the nurse reviews the client’s
level of knowledge after several health-
teaching sessions, she determined that
the client still fails to follow the information
provided. The nurse must respond by:
ANSWER: Reevaluate the client’s readiness
to change
A client's readiness to change is often
influenced by his or her perception of
importance and confidence. Importance
refers to the personal value of change.
Confidence relates to the mastering of the
skills needed to achieve the behavior and the
situations in which behavior change will be
challenging to the client.
8. A nurse is giving a bed bath to a client
who is on strict bed rest. To increase
venous return, the nurse bathes the
client’s extremities by using:
ANSWER: Long, firm strokes from distal to
proximal areas
Long, firm strokes in the direction of venous
flow promote venous return when the
of extremities are bathed.
Circular strokes are used on the face.
Short, patting strokes and light strokes are
not as comfortable for the client and do not
promote venous return.
9. Andrea, a critically-ill patient, who has
been in deep coma for couple of days,
needs eye care. The nurse then organizes
the necessary equipment to be used.
Which of the following actions if made by
the nurse would warrant an immediate
intervention from the nurse supervisor?
ANSWER: Wiping the eye with saline and
cotton balls from the outer to the inner
canthus.
Proper wiping technique moves debris away
from the eye, prevent reinfection or
contamination of the eye, and protects the
tear ducts.
10. Andrea, a mother who delivered via the
normal delivery, with episiorraphy has
been complaining of mild discomfort. As
the nurse assigned to take care of her,
which of the following should you omit in
the plan of care?
ANSWER: Avoiding sitz bath
11. When performing oral care on a comatose
client the nurse should:
ANSWER: Place the client in a side-lying
position, with the head of the bed lowered
12. A registered nurse is teaching a nurse
orienteer in their unit about proper bed
making. Which of the following
interventions should not be part of her
teaching?
ANSWER: For occupied bed, the side rail on
the opposite side must be down to easily
make a mitered corner.
A side rail provides safety and allows the
client to assist. The side rail on your side
must be down when mitering corner for the
client’s safety.
13. Florence Nightingale defined nursing as
“the act of utilizing the environment of the
patient to assist him in his recovery.”
Thief, 14 years, wants to be a nurse
someday as she idolizes the nurse
assigned to care for her. She asked her
nurse, “What is nursing?” All of the
following are not inappropriate
responses to the query, except?
ANSWER: Diagnosing, treating, prescribing
medication and doing minor surgery
Nursing is defined as assisting clients in the
performance of activities contributing to
health, its recovery or peaceful death that
clients will perform unaided, of they had the
necessary will, strength or knowledge,
Assisting clients toward independence
(Virginia Henderson) Nursing is the diagnosis
and treatment of human response to actual or
potential health problems (ANA 1980)
14. The respiratory therapist is doing the
Allen’s test erroneously if he performs
which of the following?
ANSWER: Withdraws blood if the pinkness of
the hand returns within 9 seconds
15. Nurse Sarah is caring for a client with
renal failure. Blood gas results indicate a
pH of 7.30, a PCO2 of 32 mmHg, and a
bicarbonate concentration of 20mEq/L.
Which of the following laboratory values
would Nurse Sarah expect to note?
ANSWER: Potassium level of 5.2 mEq/L
Normal values:
Sodium 135-145 mEq/L
Magnesium 1.5-2.5 mEq/L
Potassium 3.5-5.0 mEq/L
Phosphorus 2.4 to 4.1 mg/dL
16. Nurse Sarah is caring for a client after a
bronchoscopy and biopsy. Which of the
following signs if noted in the client should
be reported immediately to the physician?
ANSWER: Bronchospasm
Bronchospasm and/or laryngospasm, an
irritation of the airways and/or vocal cords
may interfere with a bronchoscopy.
17. Nurse Sarah is caring for a female client.
Which of the following actions is the most
essential that nurse Sarah must ensure
prior to Chest x-ray?
ANSWER: Ask about the first day of the last
menstruation.
18. Which of the following actions is the most
essential that Nurse Sarah must ensure
prior to the pulmonary angiography of her
patient?
ANSWER: Assess for allergies to iodine,
seafood or other dyes.
19. Nurse Sarah is preparing to obtain a
sputum specimen from a client. Which of
the following nursing actions will facilitate
obtaining the specimen?
ANSWER: Having the client take three deep
breaths
20. Nurse Sarah is conducting preoperative
teaching with a client about the use of an
incentive spirometer in the postoperative
period. Nurse Sarah would include which
piece of information in discussion with the
client?
ANSWER: The best results are achieved
when the head of the bed is elevated 45 to
90 degrees
21. Nurse Sarah’s client is unable to use the
incentive spirometer device. In counseling
the client, the first advice of nurse Sarah
would be to:
ANSWER: Start slowly and gradually
increase volume over several sessions.
22. Nurse Sarah must include all of the
following proper instructions in deep
breathing and coughing exercises to post-
operative clients except:
ANSWER: The client should perform this
exercise at least twice every shift.
23. Sister Callista Roy proposed the
Adaptation Model. Who among the
following theorist consider and utilize
nature and environment in the healing
process?
ANSWER: Florence Nightingale
24. A nurse orienteer states imperfectly to
Nurse Sarah the proper way of doing
chest physiotherapy (CPT) during their
post-conference if she specifies:
ANSWER: “If the client is receiving a tube
feeding, finish the feeding and begin doing
the CPT in high fowlers’ position”.
25. Nurse Sarah has assisted a physician
with the insertion of a chest tube. Nurse
Sarah monitors the client and notes
fluctuation of the fluid level in the water
seal chamber after the tube is inserted.
Based on this assessment, which of the
following actions would be most
appropriate?
ANNSWER: Continue to monitor, for this is an
expected finding
The water-seal chamber is filled with sterile
water to the level specified by the
manufacturer. You should see fluctuation
(tidaling) of the fluid level in the water-seal
chamber; if you don't, the system may not be
patent or working properly, or the patient's
lung may have re-expanded.
26. Nurse Sarah is caring for a client with a
chest tube. Nurse Sarah turns the client to
the side, and the chest tube accidentally
disconnects. The initial nursing action is
to:
ANSWER: Place the tube in a bottle of sterile
water
Creating a temporary water seal until a new
drainage system is set up. A chest tube
should never be clamped, except on orders
from a physical or qualified practitioner.
27. Nurse Sarah is assisting a physician with
the removal of a chest tube. Nurse Sarah
will appropriately instruct the client to:
ANSWER:  Deep breathe, exhale, and bear
down
When the chest tube is removed, the client is
asked to perform the Valsalva maneuver
(take a deep breathe, exhale and bear down).
The tube is quickly withdrawn, and an airtight
dressing is taped in place. An alternative
instruction is to ask the client to take deep
breath and hold the breath while the tube is
removed.
28. Nurse Sarah has observed a client self-
administer a dose of Albuterol (Ventolin)
via MDI. Within a short period of time, the
client begins to wheeze loudly. Nurse
Sarah interprets that this is due to:
ANSWER: Paradoxical bronchospasm,
which must be reported to the physician
Get emergency medical help if you have any
of these signs of an allergic reaction to
albuterol: hives; difficult breathing; swelling of
your face, lips, tongue, or throat.
29. Nurse Sarah has an order to give a client
Albuterol (Ventolin) two puffs, and
Budesonide (Fulmicort), two puffs, by
MDI. Nurse Sarah administers the
medication by giving the:
ANSWER: Albuterol first and then the
Budesonide
Inhaled B2-adrenergic agonists are first line
therapies for rapid symptomatic improvement
of bronchoconstriction. These medication
relax smooth muscles and reduce local
congestion, reducing airway spasm,
wheezing, and mucus production.
30. Nurse Sarah is assigned to take care of
an asthmatic patient; she must administer
the medications containing a
bronchodilator and a corticosteroid
through nebulization. Nurse Sarah is
performing this procedure imperfectly if:
ANSWER: After nebulization, rinse the bottle
with tap water to remove all remaining
solution and allow to dry
31. An oxygen delivery system is prescribed
for a client with Chronic Obstructive
Pulmonary Disease (COPD) to deliver a
precise oxygen concentration. Which of
the following types of oxygen delivery
systems would Nurse Sarah anticipates to
be prescribed?
ANSWER: Venturi mask
This device uses different size adaptors to
deliver a fixed or predicted FiO2. The FiO2
delivered depends on the flow rate and/or
entrainment port size. It is used for patients
who have COPD when an accurate FiO2 is
essential and carbon dioxide buildup must be
kept to a minimum. Humidifiers usually are
not used with this device. ( 60% to 100%)
32. Nurse Sarah is caring for a client with
emphysema. The client is receiving
oxygen. Nurse Sarah assesses the
oxygen flow rate to ensure that it does not
exceed:
ANSWER: 2L/min
O2 therapy may be prescribed but must be
used cautiously. The goal of O2 therapy is to
maintain the PaO2 between 50 and 60
mmhg. The initial liter flow is usually
1-3L/min.
33. A group of nursing students is discussing
about the descriptions related to non-
rebreather mask. The student incorrectly
states the proper description of non-
rebreather mask to nurse Sarah if she
identified which of the following?
ANSWER: “The valves should open during
inhalation and close during exhalation”.
With Non-rebreather masks, make sure
valves are open during expiration and closed
during inhalation to prevent drastic decrease
in FIO2 (fraction of inspired oxygen)
34. Madeleine Leininger proposed that
nursing is learned humanistic and
scientific profession and discipline which
is focused on the human care phenomena
and activities in order to support, facilitate,
or enable individuals or groups to maintain
or regain their well-being (Transcultural
Nursing). Who among the following
theorists conceptualized the framework for
psychiatric nursing, wherein a nurse must
established a therapeutic relationship with
the client?
ANSWER: Hildegard Peplau
Hildegard Peplau is known for her theory on
Interpersonal Relations in Nursing.
Betty Neuman is known for the Health Care
Systems Model.
Imogene King is known for the Goal
Attainment Theory
Lydia Hall is known for the Care-Core-Cure
Model
35. Which nursing action by Nurse Sarah is
essential to prevent hypoxemia during
tracheal suctioning on her patient?
ANSWER: Administering 100% oxygen to
reduce the effects of airway obstruction
during suctioning.
Hyperoxygenation is performed bt increasing
the intake of oxygen immediately prior to
suctioning and when appropriate after
suctioning (Pedersen et al., 2008) and helps
reduce the occurrence of hypoxemia. Hyper
oxygenation (pre-oxygenation) before
suctioning offers some protection from a drop
in arterial blood oxygen.
36. A client requires tracheal suctioning
through the nose. Which nursing action by
Nurse Sarah would be incorrect?
ANSWER: Suctioning for 20 seconds
37. In verifying and ensuring the placement of
an endotracheal tube, Nurse Sarah must
know that the following are necessary
EXCEPT:
ANSWER: Use maximal occlusive pressure
when inflating the cuff in order to create a
seal
Verifying Tube Placement. Verify the distal tip
marking on endotracheal tube and
immediately after ET tube is inserted,
placement should be verified. The most
accurate ways to verify placement are by
checking end-tidal carbon dioxide levels and
by chest x-ray. Assess for breath sounds
bilaterally, sound over the gastric area,
symmetric chest movement, and air emerging
from ET tube. Auscultate over the trachea for
presence of air leak.
38. Nurse Sarah is caring for a client
immediately after removal of the
endotracheal tube following radical neck
dissection. Nurse Sarah reports which of
the following signs immediately if
experienced by the client?
ANSWER: Stridor
Auscultate breath sounds as needed. In the
immediate postoperative period, place
stethoscope over the trachea to assess for
Stridor. Abnormal breath sounds may indicate
ineffective ventilation, decreased perfusion,
and fluid accumulation. Stridor a harsh, high-
pitched sound primarily heard on inspiration
indicates airway obstruction.
39. Nurse Sarah is changing the tapes on a
tracheostomy tube. The client coughs and
the tube is dislodged. The initial nursing
action is to:
ANSWER: Grasp the retention sutures to
spread the opening
40. A nurse is taking care of a client with
Rheumatoid Arthritis and was ordered to
collect feces for occult blood exam. Which
of the following statements if made by the
client need for further instructions?
ANSWER: “I may continue taking my Arcoxia 72
hours prior to collection of the sample”.
41. The client being seen in a physician’s
office has just been scheduled for a
barium swallow the next day. The nurse
writes down which of the following
instructions for the client to follow before
the test?
ANSWER: Fast for 8 hours before the test
The patient should maintain NPO status after
midnight. Food and fluid in the stomach prevents
barium from accurately outlining the GI tract, and
the radiographic result may be misleading.
42. A nurse is taking care of client who has
just been scheduled for a barium swallow
the next day. The nurse must provide the
following instructions for the client after
the test except:
ANSWER: Expect that the bowel movement
not to occur within 2 days
The evening before the BE, administer
cathartics such as magnesium citrate
(laxative) or other cathartics designated by
institution policy. After the BE study, assess
the patient for excavation of the barium.
Retained barium may cause a hardened
impaction (increase OFI). Stool will be light
colored until all barium has expelled.
43. The client has undergone
esophagogastroduodenoscopy. The nurse
places highest priority on which of the
following items as part of the client’s care
plan?
ANSWER: Assessing for the return of the gag
reflex
The patient is usually given a preprocedure
intravenous (IV) sedative such as midazolam
(Versed). The patient pharynx is anesthetized
by spraying it with lidocaine hydrochloride
(Xylocaine). Therefore do not allow the
patient to eat or drink until gag reflex returns
(usually about 2 to 4 hours).
44. The nurse determines that the client
needs further information if the client
makes which of the following statements?
ANSWER: “I’m glad I don’t have to lie still for
this procedure”.
45. The science of Unitary Human Being and
Principles of Homeodynamics are
proposed by Martha Rogers. According to
Benner’s stages of nursing expertise, a
nurse with 2 to 3 years of experience
who can coordinate multiple complex
nursing care demands is at which stage?
ANSWER:  Competent
Novice - No experience, governed by rules,
limited and inflexible, task oriented.
Advance Beginner - Demonstrates
marginally acceptable performance
Competent - has 2-3 yrs. of experience,
consciously plans nursing care
Proficient - >3-5 yrs. of experience,
perceives the situation as a whole rather than
parts
Expert - Has intuitive grasp of nursing
situation.
46. The nurse has given post-procedure
instructions to a client who underwent
colonoscopy. The nurse determines that
the client needs further instructions if
the client stated that:
ANSWER: It is all right to drive once the client
has been home for an hour or so
47. The nurse is caring for a client who is
receiving total parenteral nutrition (TPN)
via a central line. Which nursing
intervention specifically would provide
assessment data related to the most
common complication related to TPN?
ANSWER: Monitoring the temperature –
infection
Infection is always a concern because the
high concentration of dextrose contained in
TPN provides excellent medium for bacterial
growth. Strict aseptic technique is important
while changing bottles containing the TPN
solution, tubing, filters, and dressings.
Because the catheter is in major blood
vessel, any infection would spread rapidly
throughout the body.
48. A nurse is preparing to change the TPN
solution bag and tubing. The client’s
central venous line is located in the right
subclavian vein. The nurse asks the client
to do who of the following most essential
items during the tubing change?
ANSWER: Take a deep breath, hold it, and
bear down.
The client should be asked to perform the
Valsalva maneuver during tubing changes.
This helps avoid air embolism during tubing
changes. The nurse asks the client to take a
deep breath, hold it, and bear down. If the IV
line is on the right, the client turns his or her
head to the left. This position will increase
intrathoracic pressure. Options A and C are
inappropriate and could cause the potential
for an air embolism during the tubing change.
49. A nurse is making initial rounds at the
beginning of the shift. The TPN bag of an
assigned client is empty. Which of the
following solutions readily available on the
nursing unit should the nurse hang until
 another TPN solution is mixed and
delivered to the nursing unit?
 ANSWER: 10% dextrose in water
50. A nurse is inserting a nasogastric tube in
an adult client. During the procedure, the
client begins to cough and has difficulty of
breathing. Which of the following is the
most appropriate nursing action?
ANSWER:  Pull back on the tube and wait
until the respiratory distress subsides
51. The nurse checks for residual before
administering a bolus tube feeding to a
client with nasogastric tube and obtains a
residual amount of 150 mL. What is the
appropriate action for the nurse to take?
ANSWER: Hold the feeding.
52. A nurse is preparing to administer
medication through a nasogastric tube
that is connected to suction. To administer
accurately, the nurse would:
ANSWER: Clamp the nasogastric tube for 30
minutes following administration of the
medication
53. A diabetes nurse educator is providing
health teaching regarding the proper
method of blood glucose determination
through skin puncture. The nurse needs
to reinforce the teaching if the client
identifies which of the following
statements?
ANSWER: “I should select the central tip of
the finger which has more dense blood
supply”.
54. What is the most important intervention
the nurse can perform to prevent
nosocomial infections associated with
enteral nutrition?
ANSWER: Wearing clean gloves when
handling the feeding system
55. The nurse is assessing a stoma prolapse
in a client with colostomy. The nurse
would observe which of the following if the
stoma prolapsed occurred?
ANSWER: Protruding stoma
A prolapsed stoma is one which the bowel
protruded through the stoma.
A stoma retraction is characterized by
sinking of the stoma.
Ischemia of the stoma would be associated
with dusky or bluish color
. A stoma with a narrowed opening at the
level of the skin or fascia is said to be
stenosed.
56. Goal Attainment Theory is proposed by
Imogene King. A student nurse asked her
clinical instructor about Benner’s
“Proficient” nurse level. The C.I. did not
incorrectly answer the question when
she stated that the nurses under this level:
ANSWER: Perceives situation as a whole
rather than in terms of parts
57. The client with a new colostomy is
concerned about the odor from stool in the
ostomy drainage bag. The nurse teaches
the client to include which of the following
foods in the diet to reduce odor?
ANSWER: Yogurt
The client should be taught to include
deodorizing foods in the diet, such a beet
greens, parsley, buttermilk, and yogurt.
Spinach also reduces odor but is a gas
forming food as well.
Broccoli, cucumbers, and eggs are gas
forming foods.
58. The nurse instructs the ileostomy client to
do which of the following as part of
essential care of the stoma?
ANSWER: Cleanse the peristomal skin
meticulously
The peristomal skin must receive meticulous
cleansing because the ileostomy drainage
has more enzymes and is more caustic to the
skin than colostomy drainage.
Foods such as nuts and those with seeds will
pass through the ileostomy. The client should
be taught that these foods will remain
undigested.
 The area below the ileostomy may be
massaged if needed if the ileostomy becomes
blocked by high fiber foods.
Fluid intake should be maintained to at least
six to eight glasses of water per day to
prevent dehydration.
59. The client has just had surgery to create
an ileostomy. The nurse assesses the
client in the immediate post-operative
period for which of the following most
frequent complication of this type of
surgery?
ANSWER: Fluid and electrolyte imbalance
60. A client has an order for “enemas until
clear” before major bowel surgery. After
preparing the equipment and solution, the
nurse assists the client into which of the
following positions to administer the
enema?
ANSWER:  Left-lateral Sim’s position
Ask the client to lie on the side (preferably the
Left-lateral Sim’s position). The colon’s
position within the body makes this position
the most effective.
61. You are to perform a complete physical
assessment to Mr. Mogul Khan, 48 years
old, diagnosed with a certain chronic
obstructive pulmonary disease. You
expect to hear which of the following
sounds during percussion of his lung
fields?
ANSWER: Hyper resonance
Flat Sound- Extremely dull (Elicited
Muscles and bones)
Dull Sound- Muffled (elicited in liver, spleen
and heart)
Resonant- Hallow (elicited in a normal lung);
Hyperresonant- Booming (elicited in lungs
with COPD)
Tympany - Drum-like (elicited in Stomach)
62. You were assigned to care for a patient
who has suffered from second-degree
burns all over his upper extremities just
last night. During examination, you noted
circumscribed, oval masses, filled with
serous fluids that are more than 1 cm.
You properly document this as:
ANSWER: Bullae
Pustule- Circumscribed elevation of skin filled
with serous fluid and pus
Bullae- thin walled blister greater than .5 cm with
serous fluid
Vesicle- translucent circumscribed filled with
serous fluid or blood lesser than .5 cm
Wheal- collection of edema fluid
63. Nurse Gyrocopter was assigned to assist
a patient who was admitted due to a
certain central nervous system disorder.
While he’s reviewing his patient’s chart,
he reads: “Right pupil – 7 mm in diameter,
left pupil – 4 mm in diameter.
ANSWER: The patient has anisocoria
Anisocoria is a condition where the pupil of
one eye differs in size from the pupil of the
other.
Normal size of pupil is 3-7mm
64. After Nurse Tinker has performed visual
assessment, using a Snellen chart, to her
patient Drow Ranger, she documented
that this patient’s visual acuity is 20/40.
She understands that:
ANSWER: The patient can read at distance of 20
feet away from the Snellen chart, that an
in
individual with normal vision can read from 40
feet distance.
A normal eye has a vision of 20/20.
The definition of legal blindness is 20/200.
The numerator is the distance of the patient from
the Snellen chart while the denominator is the
distance of an individual with a normal vision.
65. Windrunner, 27, is admitted after a
massive car accident. Nurse Necrolyte, is
to assess this patient’s pupil reactions and
accommodation. Which of the following
indicates an abnormal response?
ANSWER: Windrunner’s pupil constricts when ANSWER: Soft-intensity, low-pitched sounds
looking at the far object. heard at the base of the lungs.

66. Nurse Slayer was tasked to perform a Soft intensity, low pitched sounds heard at
cephalocaudal assessment to her patient the base of the lungs is called Vesicular
on the EENT ward. After the examination, sounds which are a normal finding.
she documented the findings accordingly.
Upon reading the chart, one entry reads: Option B is Crackles
“Weber negative”. This can be
Option C is Wheezes
interpreted as:
Option D is Ronchi. These are all abnormal
ANSWER:  A normal finding
sounds.
67. According to the American Nurses
70. You are to perform abdominal
Association, nursing is the diagnosis and
assessment to your patient who has been
treatment of human responses to actual
complaining of pain on the left upper
or potential health problems. The World
quadrant. You know that to properly
Health Organization (WHO) defines health
execute the procedure, you should:
as:
ANSWER: Palpate the left upper quadrant
 ANSWER: A state of complete physical, mental,
last
and social well-being
71. A patient was rushed into the Emergency
The World Health Organization (WHO) takes a
Department who was complaining of
more holistic view of health. Its constitution
abdominal pain. Based on initial
define health as "a state of complete physical,
assessment, appendicitis is suspected.
mental and social well-being and not merely the
The nurse expects that the patient will be
absence of disease or infirmity"
pointing pain on which of the following
68. Mr. Lifestealer, 57 years old, has been abdominal regions?
suffering from emphysema for five years.
ANSWER: Right inguinal
He was admitted in the hospital due to
exacerbation of his disease. Upon 72. The nurse is preparing a Snellen chart for
assessment his chest, you expect to find? the physical examination. This is used to
assess which of the following cranial
ANSWER: Barrel chest
nerve/s?
Pectus Carinatum is expected in patients with
ANSWER: Cranial nerve II
Vitamin D. Deficiency (condition: Rickets)
Cranial Nerve Number II is responsible for the
Pectus Excavatum is congenital and is
sense of sight, using the Snellen Chart is the
expected to have a depressed sternum
most appropriate test for visual acquity
Barrel Chest is expected in COPD which is
CN III, IV and VI are for extraoccular
an effect of the Carbon Dioxide accumulation
movement
in the lungs leading to the increasing of its AP
diameter. VII is for Facial expressions 2/3 anterior 73.
portion of the tongue (taste).
AP diameter is greater than or equal to
Transverse Diameter. 73. Mr. Grand Magus was admitted to the
hospital after falling from the stairs. Upon
examination, Nurse Neruvian called the
69. You are to examine your patient’s breath patient’s name and that’s the only time he
sounds admitted for general check-up. opened his eyes. The patient raised his
Which of the following sounds will be legs and hands when asked to do so. The
considered normal?
 patient was also oriented to time, place,
and person. The patient’s GCS score is:
ANSWER: M: 6, V: 5, E: 3
Eye( 4- spontaneous,3- to verbal command,
2- to pain, 1- no response)
Verbal(5- Oriented and Conversant, 4-
disoriented and conversant, 3-Inapprpriate
words, 2- Incomprehensible, sound 1- No
response)
Motor(6- to verbal command, 5-to localized
pain, 4-flexes and withdraws, 3- Decorticate,
2- decerebrate, 1- No response)
74. Mrs. Naga Siren, who is suspected to
have developed a sensory ataxia, had a
positive Romberg’s test. The positive
result means that:
ANSWER: The patient cannot maintain
balance while standing with eyes closed
Romberg’s test is a test of imbalance. The
patient is instructed to stand on both feet and
be instructed to close the eyes. A heavy sway
or misbalance would mean a positive
Romberg’s test.
75. When asked about the place where he
lives during a mini-mental status exam,
Mr. Warlock said, “It’s been a while since I
went home. When I’m home, I can do so
many things. I can paint, I can sing,
dance, and watch movies. I want to go
home now.” After what he has said, he
was not able to provide the information
requested. The client apparently has:
ANSWER: Tangentiality
76. You will receive this injection in a clinic or
hospital setting as part of a medical test.
Edrophonium (Tensilon) is used for the
diagnosis of myasthenia gravis because
this drug will cause a temporary increase
in:
ANSWER: Muscle strength
Tensilon, an anticholinesterase drug, causes
temporary relief of symptoms of myasthenia
gravis in clients who have the disease and is
therefore an effective diagnostic aid.
77. During the previous few months, a 55 year
old woman felt brief twinges of chest pain
while working in her garden and has had
frequent episodes of indigestion. She
comes to the hospital after experiencing
severe anterior chest pain while raking
leaves. Her evaluation confirms a
diagnosis of stable angina pectoris.
Evaluation of the effectiveness of
nitroglycerin SL is based on:
ANSWER:  Improved cardiac output
78. As per R.A. 9173, promotion of health and
prevention of illness are the primary
responsibilities of nurses as independent
practitioners. As a member of health
team, nurses shall collaborate with other
health care providers for the curative,
preventive, and rehabilitative aspects of
care, restoration of health, alleviation of
suffering, and when recovery is not
possible, towards a peaceful death. Nurse
Monk is conducting a series of promotive
and preventive programs for a group of
clients. All of the following activities are
not considered promotive nursing
actions, except?
ANSWER: Implementation of PD 491
PD 996 is the Expanded Program on
Immunization
RA 9288 is the Newborn Screening Act, both
are preventive nursing actions
Only PD 491 is a promotive nursing action
which is the Nutrition Program.
79. A client with heart failure is receiving
digoxin (Lanoxin) and will continue taking
the drug after discharge. Before giving the
medication, the nurse should assess the
patient’s:
ANSWER: Apical heart rate
Because digoxin slows the heart rate, the
apical pulse should be counted for 1 minute
before administration. If the apical rate is
below 60, digoxin should be withheld because
its administration could further depress the
heart rate.
80. A client is receiving heparin sodium and
warfarin sodium (Coumadin) concurrently
for a partial occlusion of the left common
carotid artery. The client expresses
concern about why both heparin and
Coumadin are needed. The nurse’s
explanation is based on the knowledge
that the plan:
ANSWER: Provides anticoagulant
intravenously until the oral drug reaches its
therapeutic level.
81. The drug that the nurse should expect the
physician to order if symptoms of warfarin
(Coumadin) overdose are observed would
be:
ANSWER: Vitamin K
Warfarin depresses prothrombin activity and
inhibits the formation of vitamin K dependent
clotting factors by the liver. Its antagonist is
vitamin K which is involved in prothrombin
formation.
82. Which statement should the nurse make
when teaching the client about taking oral
glucocorticoids?
ANSWER: “Take your medication with
meals.”
83. The nurse administers neomycin to a
client with hepatic cirrhosis to prevent the
formation of:
ANSWER: Ammonia
Neomycin destroy intestinal flora, which
breaks down protein and in the process gives
off ammonia. Ammonia at this time is poorly
detoxified by the liver and can build up to
toxic levels.
84. What is the rationale that supports
multidrug treatment for clients with
tuberculosis?
ANSWER: Multiple drugs reduce
development of resistant strains of the
bacteria
Use of a combination of anti-tuberculosis
drugs slows the rate at which the organism
develops drug resistance. Combination
therapy also appears to be more effective
than single-drug therapy. Regimens that use
only single drugs result in the rapid
development of resistance and treatment
failure.
85. Jose, a recent graduate of BS Nursing is
attending a review class for the November
2014 board exam. The topic of the lecture
is Pharmacokinetics. Jose likes to know
more about the concept of
Pharmacokinetics so he asks the lecturer
about the importance of knowing the
Pharmacokinetics of a particular drug. The
lecturer will mention the following
importance of Pharmacokinetics:
ANSWER: Pharmacokinetics will explain the
details of the chemical interaction between
the drug and the target cell, tissue or organ
Pharmacokinetics does not discuss the
mechanism of action of the drug to the body,
instead it describes how the drug moves in
the body, and therefore it can help in
determining the serum drug concentration
86. The following situations demonstrate an
application of a Nurses’ knowledge about
the Pharmacodynamics of a given drug,
EXCEPT:
ANSWER: The Nurse instructs a diabetic
patient to avoid rubbing the injection site after
SubQ injection of insulin
87. Nurse Kelly noticed that the dose of the
opioids given P.O. is higher than that of
the I.M. route. Nurse Kelly will be correct
in her interpretation by stating that:
ANSWER: If the drug is given by the oral
route is will be subjected to first pass
metabolism.
A higher dose of a drug is required if the drug
undergoes first pass effect because the drug
will be subjected first to metabolism in the
liver, therefore inactivating the drug before it
reach the systemic circulation
88. If a highly protein bound drugs like
Diazepam (98% protein bound),
Lorazepam (92% protein bound) or
Valproic Acid (92% protein bound) is
 given to a patient with a liver disease, you
will expect:
ANSWER: An increased amount of unbound
drugs in the blood, therefore more drugs are
released into the systemic circulation,
increasing its effect
89. Primary level of prevention includes
health promotion and illness
prevention. Clown Gypsy Group of
Companies establishes a physical
exercise area in the workplace and
encourages all employees to use it. This
is an example of which level of
prevention?
ANSWER: Primary prevention
90. A patient is taking a drug that is known to
be toxic to the liver. The patient is being
discharged to home. What teaching points
related to liver toxicity of the drug that the
nurse needs to teach the patient to report
to the physician:
ANSWER: Body malaise, change in the color
of the stool
91. Which of the following will NOT be
included in your health teachings when
dealing with the excretion of drugs?
ANSWER: An acid ash diet will increase the
excretion of weak acidic drugs
An acid ash diet will acidify the urine therefore
promoting the excretion of alkaline drugs like
atropine. An alkaline ash diet will alkalinize
the urine therefore promoting the excretion of
acidic drugs
92. Nurse Michelle is studying different
classes of anti-hypertensive, and notes
their respective mechanism of action.
Which of the following sets of drugs
produce an effect of enzyme inhibition to
exert their therapeutic action of
decreasing the blood pressure?
ANSWER: Captopril, Perindopril, Enalapril
Losartan, Valsartan and Telmisartan are
Angiotensin II receptor antagonist
Metoprolol, Atenolol and Propranolol are
beta receptor antagonist
Methyldopa and Clonidine are Alpha 2
receptor agonists, these drugs do not directly
affect enzymes, but reacts with receptors
causing or inhibiting a response
Captopril, Perindopril and Enalapril are
Angiotensin Converting Enzyme Inhibitors
that prevents the formation of Angiotensin II
that can cause vasoconstriction
93. Nurse Marilyn is taking care of end stage
cancer patient. She will be administering
Morphine Sulfate and Tramadol for pain.
She is aware that it can result to additive
interaction, causing greater pain control.
She is aware of the other potential
advantage of this type of interaction which
includes:
ANSWER: Lower doses of each drug can be
administered, which can decrease the
probability of adverse reactions
94. A client confided to you that she
experiences cramping abdominal pains
and diarrheic episodes upon ingestion of
milk and dairy products. She expressed
her curiosity regarding lactose intolerance
and requested information regarding this
condition. All of the following are
inappropriate health teaching, aside
from:
ANSWER: “It’s a condition associated with
insufficient lactase, a digestive enzyme.”
Lactose intolerance is a condition associated
with insufficient or absent lactase, a
disaccharidase needed to transform lactose
into galactose and glucose.
The lack of lactase means the intestines
cannot absorb lactose which results in the
typical symptoms of LI: diarrhea, abdominal
pain, distention, flatulence, nausea etc.
Milk with a lower fat content has a higher
concentration of lactose. It is not an allergic
reaction (milk allergy is a completely separate
condition).
95. You have noted that client with a history of
cardiovascular diseases was advised to
increase his intake of soluble fiber. This
dietary modification, in this case, is
necessary because:
ANSWER: Soluble fiber has been proven to substantially more saturated fat than
decrease serum cholesterol levels. unsaturated.

Soluble fiber is known to decrease serum
LDL and cholesterol levels, helpful in clients
with CVDs.
Choices B and D are health benefits from
ingesting insoluble fiber, not soluble.
Choice C, although partly true, is not the top
priority as the situation did not state that the
client has a weight problem.
96. Nurse Arya is conducting a nutritional
assessment of Lito, a child who is an
inhabitant of a rural village which had
been hit with drought and famine. Which
of the following assessment findings
would most likely lead Nurse Arya to
suspect that the Lito has kwashiorkor?
ANSWER: Presence of a pot belly
Choice B is wrong because fish, especially
fatty fish, contain Omega-3 fatty acid, a type
of polyunsaturated fat that is helpful in
decreasing the chances for heart disease.
Choice D is also incorrect. Hydrogenation is
process that turns unsaturated fat into
saturated fat; hence hydrogenated margarine
is very high in saturated fat.
98. Mio is a 28-year old married woman who
wants to use topical retinoic acid (Avita) to
decrease the fine wrinkles on her face,
and asks you about what she should know
about this medication. Which of the
following would be a suitable answer?
ANSWER: “We have to ascertain first that
you are not pregnant.”

The main symptom of kwashiorkor is

extensive edema hence a child suffering from
this condition would have a puffy appearance
and abdominal edema (Choice B).

Choices A, C and D are all more commonly

associated with marasmus and not
kwashiorkor.

97. Mr. Snorlax is a 38-year old client who

wants to institute dietary and lifestyle
changes in order to decrease his chances
of having a cardiac-related event in the
future. All of the following must be
included in your health teaching, aside
from:

ANSWER: “A low HDL level means you are

reducing your chances of having heart
disease.”

While conducting a health class on the

benefits of eating food with unsaturated fat
instead of saturated, you would know that
further teaching is unnecessary if the client
states:

ANSWER: “I should stop using coconut oil

when cooking.”

Coconut oil, palm oil and chocolate, although

coming from plant sources, contain