Situation
Of total blockage of endometrial tissues
Lovely is a newly hired nurse at the Neonatal Intensive Care
Unit (NICU). She received an endorsement that Baby Boy A
and Baby Girl B are ready for discharge. At 5:15 in the
afternoon she gave the babies to their mothers. Two days after,
the mother of “Baby Boy A” came back to complain that she got
the wrong baby because she got a baby girl instead of a boy.
1. Which of the following should Lovely, being professional
nurse, understand as the primary outcome should she be proven
guilty of gross incompetence?
a. That she can be delisted as member of the APO
b. That she can be terminated from work by her employer
c. That she can be charged in the civil court
d. That her license to practice nursing can be suspended or
revoked for a period of time by the PRC RA 9173 SEC. 23
2. Which among the statements are TRUE about health
promotion? It is the process of __________.
1. Enabling individuals and communities to increase their
abilities to control and improve their health
2. Enhancing the individuals physical, psychologic and
spiritual well-being
3. Engaging in correcting the people’s health behavior
4. Preventing disease from occurring and treating it when it
occurs
a. 1 only
b. 3 and 4
c. 2 only
d. 1 and 2
Situation
Mrs. Fabricon, 28 years old, has been married for 4 years. She
postponed pregnancy to pursue her career as a lawyer. One day,
she went to see an obstetrician because of vaginal spotting and
to find ways of getting her pregnant. After a series of diagnostic
examinations, she was found to have endometriosis.
(PROLIFERATION OF ENDOMETRIAL TISSUE OUTSIDE THE UTERUS)
3. The nurse performs an assessment on Mrs. Fabricon. Which
of the findings would be indicative of endometriosis? Select all
that apply.
1. Spotting after intercourse
2. Persistent dysmenorrhea
3. Dyspareunia
4. Menorrhagia HEAVY BLEEDING
a. 1, 4
b. 3, 4
c. 1, 2, 3
d. 2, 3, 4
4. The physician prescribes Danazol (Danocrine)
ANDROGENIC for Mrs. Fabricon. The nurse should tell her that
while taking this drug she will experience all these symptoms,
EXCEPT ____________.
a. Anovulation
b. Weight gain and edema
c. Diminished menstrual flow
d. Cessation of her menses
5. What is the rationale behind endometriosis interfering with
fertility? It is because ____________.
a. Of pressure on the pituitary that leads to decreased FHS
levels.
b.
c. The uterine cervix becomes inflamed and swollen
d. The ovaries stop producing adequate estrogen
Situation
The nursing director assigned Glenn in the orthopedic ward to
care for patients with mobility problems.
6. Glenn Mapalo is teaching a patient with crutches how to go
up the stairs. Which among the following should he instruct the
patient with?
a. When moving the affected leg up, the body weight should be
on the crutches.
b. The unaffected leg goes up the step after the affected leg.
c. Patient should keep his feet together at the bottom of the stairs
d. The crutches and the affected leg go up the step together.
7. Glenn is assisted by another staff nurse in lifting a patient.
Which among the following actions will prevent injury to
Glenn?
a. Keeping the feet wide apart and knees extended
b. Positioning himself close to the patient
c. Using the muscles of the back in lifting
d. Rotating at the waist in lifting
8. Nurse Glenn asks two more nurses to help him logroll a
patient. Where should Glenn place the patient’s arms prior to
logrolling?
a. Along the sides
b. Crossed on the chest
c. Overhead, extended
d. Behind the hips
9. In applying restraints, Glenn Mapalo should employ which
type of ie?
a. Half-bow
b. Surgical tie
c. Double knot
d. Two-throw knot
Situation
One of the legal responsibilities of nurses is to ensure proper
documentation of patient care.
10. Julius, a staff nurse in the medical unit, understands that
his charting must consist of the following information
excluding:
a. Patient medical diagnosis NURSING DIGNOSIS
b. Information about the patient's health status
c. Relevant health data
d. Procedures performed
11. Julius shares to a Dagupan Hospital staff nurse the
importance of proper documentation. This includes:
1. Reflects quality and timeliness of nursing care (+)
2. Evidence of care provided by doctors and nurses (+)
3. Facilitates interprofessional communications (+)
4. Utilized as a legal document in a court litigation(+)
5. Holds vital information about the patient(+)
a. All but 1, 2 & 3
b. All but 5
c. All but 4
d. All of the above
12. What should be the size/gauge of the needle Nurse Kevin
would use in administering IV infusions for trauma patients?
a. 18
b. 22
c. 20 prescribed the medication if which condition is documented in
d. 24 the client’s medical history?

Situation
An Obstetric Nurse is currently handling patients who are a. Hypotension
undergoing various pregnant clients for certain laboratory and b. Hypothyroidism
diagnostic tests. The following questions apply. c. Diabetes mellitus
d. Peripheral vascular disease
13. The nurse is providing instructions to a pregnant client who
is scheduled for an amniocentesis. What instruction should the 20. What resources should a nurse use in teaching her
nurse provide? ASPIRATE AMNIOTIC (INVASIVE PROCEDURE) postpartum client? Select all that apply.
1. Pamphlets
a. Strict bed rest is required after the procedure. 2. Audiotapes
b. Hospitalization is necessary for 24 hours after the procedure. 3. Nurse specialist
c. An informed consent needs to be signed before the 4. Videotapes
procedure.
d. A fever is expected after the procedure because of the trauma a. 1, 2, 3, 4
to the abdomen. b. 1 and 3
c. 1, 2, 4
14. The nurse asks about a pregnant client who is in the first d. 2 and 4
trimester calls the nurse at a health care clinic and reports that
she has noticed a thin, colorless vaginal drainage. The nurse 21. Dina is a pregnant mother living in Sta. Ana, Manila. She
should make which statement to the client? has given birth to a twin, one child, and had an abortion. Which
of the statements below CORRECTLY applies, given the
a. “Come to the clinic immediately.” obstetrical history of Dina?
b. “The vaginal discharge may be bothersome, but is a
normal occurrence.” a. Since there has been a twin, Jolina is G4P4
c. “Report to the emergency department at the maternity center b. Since there was an abortion, Jolina is G4P3
immediately.” c. Jolina is Gravida 3 Para 2 (G3P2)
d. “Use tampons if the discharge is bothersome, but to be sure to d. Jolina is Gravida 4 Para 2 (G4P2)
change the tampons every 2 hours.”
Situation
15. The nurse has performed a nonstress test on a pregnant client The medical nurse has been assigned as a floater nurse in the
and is reviewing the fetal monitor strip. The nurse interprets the pediatric hematology ward for a night shift.
test as reactive. How should the nurse document this finding?
22. Which of the following would the nurse identify as the
a. Normal priority nursing diagnosis during a toddler’s vaso-occlusive
b. Abnormal sickle cell crisis?
c. The need for further evaluation
d. That findings were difficult to interpret a. Ineffective coping related to the presence of a life-threatening
disease
Situation b. Decreased cardiac output related to abnormal hemoglobin
Karla is a nurse in the maternity unit. Here, she takes care of formation
gravidomorbid clients. It is essential to know the normal and c. Pain related to tissue anoxia
abnormal changes in pregnancy in order to deliver the best d. Excess fluid volume related to infection
nursing care. The following questions apply.
23. Which statements by the mother of a toddler would lead the
16. During the night shift, a woman is hospitalized for the nurse to suspect that the child has iron-deficiency anemia?
treatment of severe preeclampsia. Which of the following Select all that apply.
represents an unusual finding for this condition?
1. “He drinks over 3 cups of milk per day.”
a. Convulsions. 2. “I can’t keep enough apple juice in the house; he must drink
b. Blood pressure 160/100. over 10 ounces per day.”
c. Proteinuria 41. 3. “He refuses to eat more than 2 different kinds of vegetables.”
d. Generalized edema. 4. “He doesn’t like meat, but he will eat small amounts of it.”
5. “He sleeps 12 hours every night and take a 2-hour nap.”
17. As a nurse in the maternity unit, Charm knows that the
action of hormones during pregnancy affect the body by? a. 1
b. 2
a. Raising resistance to insulin. c. 1 and 2
b. Blocking the release of insulin from the pancreas. d. 3 and 4
c. Preventing the liver from metabolizing glycogen.
d. Enhancing the conversion of food to glucose. Situation
A nurse is caring for several patients in the LR/DR complex.
18. A 28-year-old woman has had diabetes mellitus since she The following questions apply:
was an adolescent. She is 8 weeks pregnant and is admitted
under the care of Nurse Charm. Hyperglycemia during her first 24. What is the primary presenting symptom in a client with
trimester will have what effect on the fetus? abruption placentae?

a. Hyperinsulinemia. a. Concealed hemorrhage

b. Excessive fetal size. b. Oliguria
c. Malformed organs. c. Abdominal pain
d. Abnormal positioning. d. Rupture of membranes

19. Methylergonovine (Methergine) is prescribed for a client 25. A pregnant mother, 32 weeks gestation, was admitted to the
with postpartum hemorrhage. Before Charm administers the OB ward for significant bleeding in different mucosal areas. The
medication, she contacts the health care provider who
physician found out that she has dead fetus syndrome. What
could be the reason for the bleeding?
a. HELLP syndrome
b. Placenta previa
c. Disseminated intravascular coagulation (DIC)
d. Idiopathic thrombocytopenic purpura (ITP) NO KNOWN CAUSE
26. The nurse in the labor room monitors a patient in her
transitional phase for interval of contractions. She measures this:
a. From the beginning of one to the beginning of the next
contraction.
b. From the start of a contraction to the end of the same
contraction.
c. From the end of a contraction to the beginning of the next
contraction.
d. From the beginning of one contraction to the end of the next
contraction.
27. In the labor room, a pregnant patient was being assessed for
cervical dilation and uterine contraction. Which of the following
findings tells the nurse that the patient is on the active phase?
a. 3cm dilated, contractions every 15-30 mins
b. 7cm dilated, contractions every 3-5 mins
c. 8cm dilated, contractions every 3-5 mins
d. 10cm dilated, contractions every 2-3 mins
28. When PROM occurs, which of the following provides
evidence of the nurse's understanding of the client's immediate
needs?
a. The chorion and amnion ruptures 4 hours before the onset of
the labor.
b. PROM removes the fetus most effective defense against
infection.
c. Nursing care is based on fetal viability and gestational age.
d. PROM is associated with malpresentation and possible
incompetent cervix.
29. Dina is now in her second stage of labor; Cervix 8cm. Nurse
R puts her in lithotomy position. One of the dangers of this
position that Nurse R should watch for in Dina is ___________.
a. Hyperventilation
b. Hypertension
c. Hypotension
d. Tachypnea
30. If Dina has a long second stage of labor and needs to be
placed in Lithotomy position for a long time, Nurse R should
implement the following safety measures, EXCEPT
___________.
a. Wrap legs with elastic bandages
b. Put 2 pillows under her head
c. Place a small pad under her sacral area
d. Put a rolled towel under Dina’s right hip
31. Nurse R understands that Dina needs more support and
encouragement during the PEAK and MOST painful phase of
uterine contractions, which is called ____________.
a. Decrescendo
b. Decrement
c. Increment
d. Acme
32. Before the INITIAL vaginal examination commonly
referred to as internal examination, what must Nurse R check
FIRST?
a. Blood pressure for hypotension or hypertension
b. Heart rate of Dina for chest compression.
c. Abdominal palpitation for signs of fetal distress.
d. Abdominal palpitation for fetal lie and position, and fetal
heart tone
Situation
Nurse Charie is assigned to several patients in the orthopedic
ward.
33. A computed tomography (CT) scan is one of the diagnostic
evaluations used for musculo-skeletal function. Which of the
following is NOT an indication of the procedure?
a. To measure the girth of an extremity.
b. To visualize and assess tumors.
c. To identify the location and extent of fractures in areas that
are difficult to evaluate.
d. To assess severe trauma to the chest.
34. Which of the following conditions is NOT a factor that will
aggravate or increase the blood pressure of a patient?
a. Having post-operative pain
b. Brisk walking in a treadmill
c. Suffering from acute renal colic
d. Asthmatic attack
35. Another patient of Nurse C is Mrs. D, a 45-year old store
owner, with a beginning thrombophlebitis. Which of the
following instructions is BEST to be given to a client with this
condition?
a. Massaging her legs when tired
b. Pillows be put behind the knees when lying on bed
c. Wearing support stockings one size larger
d. Apply heat in the affected area
36. In the assessment of peroneal nerve function in relation to
movement, instruct the patient to _______.
a. Dorsiflex the foot and extend the toes
b. Prick the skin midway between the thumb and second finger
c. Plantar flex toes and foot
d. Prick the skin midway between the great and second toe
Situation
Nurse Clotilde is a nursing supervisor in the medical ward.
Having the adequate knowledge in nursing management, the
following questions apply:
37. Nurse X knows that one of her staff is experiencing
burnout. Which of the following is the BEST thing for to do?
a. Remind her to show loyalty to the institutions.
b. Ignore her observations; it will be resolved even without
intervention.
c. Let her staff ventilate her feelings and ask how she can be
of help.
d. Advise her staff to go on vacation.
38. She knows that the performance appraisal consists of the
following activities, EXCEPT ___________.
a. Setting specific standards and activities for individual
performance.
b. Using agency standards as a guide
c. Focusing activity on the correction of identified behavior
d. Determine areas of strengths and weaknesses
Situation
Mr Bagumbaran came to the ER because of sharp troubling
pain. After his surgery, he claimed pain is felt even he is asleep.
39. In order for the nurse to recall the location of pain, he has
to_______________.
a. Asks for onset and duration
b. Mark the painful area in a body diagram
c. Asks for facial expression
d. Asks verbal description using pain intensity scale
40. When a client is on prolonged pain therapy, the nurse should
watch for____________.
a. Tolerance to drug
b. Allergic reaction to drug
c. Drug resistance
d. Addiction to drug
Situation
Mariane Joy, a 42-year old teacher with cardiac ailment,
nervously informs the doctor that her goiter is getting bigger and
distracts her while swallowing food. The physician who
examined her instructed the nurse to admit Myreen and to
prepare her for surgery after medical clearance.
41. Based on your knowledge, Patient Mariane Joy, who has a
history of cardiac illness, should not be given an enema before
surgery. Which of the following reasons inhibits the order of
enema for Patient Mariane Joy? Enema ____________:
a. Paralyzes the peristalsis movement and increases abdominal
pain– enema increases peristalsis by distending the bowel or
irritating the intestinal mucosa
b. Produces vagal stimulation that is dangerous to cardiac
patient
c. Causes constipation and fecal impaction after the surgery – on
the contrary, enemas relieve constipation
d. Enema results to increased water absorption in the bowels
Situation
Mc Roldan, 16-year old, a foreigner was admitted in the medical
ward due to abdominal pain, nausea and vomiting by Nurse
Eclarin.
42. In initiating care for patient Mc Roldan, which of the
following would be an APPROPRIATE question to be asked by
Nurse Tessie in her assessment?
a. Since this is doctor’s order, you have to drink ice water,
instead of hot tea.
b. Do you have any books I could read about people of your
culture?
c. Do you need to set aside your cultural practices, and comply
with hospital rules and regulations?
d. Is there anything I am doing that is not acceptable to your
culture?
43. Nurse Eclarin respects cultural practices integration in her
nursing care plan. Which of the following nursing action is
MOST represented of the culturally competent nurse?
a. Help patient Kenneth to learn and understand the language
b. Explain and validate health knowledge and beliefs of Patient
Kenneth with that of the hospital
c. Help Patient Kenneth identify ways to relate more to the
culture where they now resides
d. Ask patient Kenneth to help Nurse Tessie in knowing
more the culture of his origin
44. Patient Mc Roldan’s family requests time for spiritual
healing process in the hospital. This is allowed by Nurse Eclarin
and hospital because it______________________.
a. Gives fulfillment and meaning to the patient and family
b. Demonstrate people being responsible for their life patterns
c. Is non-denominated community service
d. Formalizes a religious dogma
45. Positive Practice Environment (PPE) influences healing
process. Which of the following ways can help Nurse Eclarin
create a healing environment?
a. Ensure that relatives and friends visit the patient
b. Empower clients to make healthy decisions for themselves
c. Place television in each room of the hospital
d. Ensure that staff nurses does not experience burnout
Situation
Tisoy, 28 years old, has been diagnosed with Diabetes Mellitus.
She was advised by her family physician to be admitted to
undergo preservation for insulin therapy. Her blood sugar ranges
from 200 to 210 mg/dL. At 6 am, Nurse Gellie administered her
insulin injection. After 2 hours, the patient complained of cold
clammy perspiration, chilly sensation and abdominal
discomfort.
46. Which of the following PRIORITY nursing actions should
the nurse perform?
a. Give her biscuit to eat
b. Do urine testing for sugar
c. Provide her warm blanket
d. Take blood pressure and put her on bed rest
47. Patient Tisoy has been classified to have a type II Diabetes
Mellitus. Which of the following is NOT a typical
manifestation of individuals with this condition?
a. Frequency of urination
b. Increased craving for food
c. Increased thirst
d. Weight loss WEIGHT GAIN
Situation
Mr Franky, 58 years old is admitted to the pay ward because of
respiratory problem. The nurse initiated oxygen treatment by
mask but the client refuses despite the encouragement by the
wife. The client is aware of the benefits of the treatment.
48. Which of the following should be given priority?
a. Ask the opinion of the wife
b. Conduct consensus building
c. Let the attending physician decide on the necessity of the
treatment
d. Respect the decision of the client
49. You are taking care of Mr. Mr Franky who is on the last
cycle of radiation therapy for his lung cancer. You should
instruct Mr. Franky to
a. Brush teeth and gums vigorously after meals
b. Wait one hour after treatment before eating
c. Use mouthwash containing alcohol every 2 hours
d. Avoid drinking hot fluids
Situation
A nurse is caring for several patients in a pediatric unit. The
following questions apply:
50. What is the appropriate response to a mother who is anxious
to have her child undergo herniotomy?
a. You cannot do anything about it.
b. The case is an emergency. If he does not undergo surgery he
will die.
c. What can are your concerns about the procedure?
d. Why do you feel that way? Please tell me.
51. At 4 months, what health teaching must be communicated to
parents to promote optimum safety?
a. Raise side rails high.
b. Remove small objects from floor.
c. Remove poisonous substances from low areas.
d. Provide head gear for temper tantrums.
52. A 3-year old client is prescribed with digoxin therapy. His
resting heart rate is 60 bpm and has vomited twice. After taking
prescribed doses of digoxin, which of the following would show
toxicity?
a. Bradycardia
b. Vomiting
c. Lethargy
d. Increased appetite
53. The parents are planning to give their child ginger candy for
cough. How will the nurse respond best?
a. Let him have some and let’s see what will happen.
b. I will get a prescription for that.
c. It is not prescribed by the physician.
d. It is better to give child natural ginger rather than the candy
form
54. A child is admitted to the hospital with a diagnosis of Wilms
tumor, stage II. Which of the following statements most
accurately describes this stage?
a. The tumor is less than 3 cm. in size and requires no
chemotherapy.
b. The tumor did not extend beyond the kidney and was
completely resected.
c. The tumor extended beyond the kidney but was
completely resected.
d. The tumor has spread into the abdominal cavity and cannot be
resected.
55. An 11-year-old boy is admitted to the pediatric unit in
traction with a fractured femur sustained in a motorcycle
accident. His uncle, who was driving the cycle when the
accident occurred, received only minor injuries. The child tells
the nurse that his uncle was not to blame for the accident. He is
“the best motorcycle rider in the
world.” The nurse interprets this to mean that the child is
exhibiting which defense mechanism?
a. Denial
b. Repression
c. Hero worship
d. Fantasy
56. The most common technique of male masturbation
involves:
a. Grasping and stroking the shaft of the penis.
b. Inserting the penis into objects.
c. Rubbing the legs together.
d. Running a stream of warm water over the genital region.
Situation
Conducting Research is one of the major roles of the nurses both
in hospital and community settings. To be able to develop such
competencies, the nurse has to undergo an actual conduct of the
research process.
57. Which of the following statements BEST described a
researchable problem?
a. Responses of parents toward having children with congenital
heart diseases.
b. What is the relationship between relaxation technique and
relief of pain of post CABG patients in the surgical coronary
care unit.
c. Incidence of medication errors and reporting practices of
Health Care Professional in a teaching hospital
d. To what extent do pre-operative teaching affect the length of
hospitalization of patients going for surgery
58. Weight is taken as a baseline measurement of obese female
adolescents as study subjects for a weight reduction program.
This is repeated to note any changes. This pre-test is done
to___________________.
a. Determine whether the instrument is defective
b. Assess if research design is appropriate to the problem
identified
c. Evaluate whether the instrument is defective
d. Obtain preliminary data before a treatment is conducted
by the researcher
59. A Nurse researcher is using ACCU-CHEK a monitoring kit
to test presence of Diabetes Mellitus among her study subject.
How do you classify this type of measurement?
a. Microbial
b. Cytological
c. Physiological
d. Chemical
60. Nurse Joan, wanted to conduct a study using quasi-
experimental design. This design will need a __________.
a. Retrospective evaluation
b. Field setting for the study
c. Comparable group
d. Manipulation of the independent variable
Situation
Mr See is being prepared for a major surgery. Legal preparation
for surgery consists of checking all the required forms for the
operation. Equally important is to make sure that the patient is
physically, psychologically, and emotionally ready for the
procedure.
61. Informed consent is a process that gives the patient
opportunity involved in his or her care. As patient advocate, the
nurse ensures the following three conditions are present to make
consent valid, EXCEPT:
a. Adequate disclosure of the diagnosis by the physician
b. Comprehension of information by the patient before the
operation
c. Patient voluntarily giving consent
d. Forms signed by any close relative or watcher
62. The patient asks you, “What do you think of my surgeon?”
You answered “hmmmmm… he is not really the best one and he
seems not to care for patient...” As a result, the patient switches
to another surgeon. The latter may have grounds to sue you for
_____________.
a. Slander PRIVATE
b. Invasion of privacy
c. Malpractice
d. Libel PUBLIC
63. One of your patient’s visitors whisper to you, “I hope you
will not try to revive my dear friend if her heart stops as she has
already suffered a lot.” The correct response is ___________.
a. “That decision is up to the physician”
b. “We are all trained in cardiopulmonary resuscitation”
c. “There is a ‘ Do not resuscitate’ order in her chart”
d. “ I understand your concern, but I can’t discuss this
matter with you”
63. According to the Joint Commission, the most frequently
cited factor in sentinel (unanticipated) events that leads to a
patient’s serious physical or psychological injury is
______________________.
a. Confusion within the health team
b. Miscommunication among health team members
c. Incompetence by a team member
d. Policy changes are not followed by adequate and consistent
staff education
Situation
Nurse Honelette is employed in hospital “X” and assigned in the
Medical Ward for a year now. The nurse supervisor ordered her
to proceed immediately to the Surgical Ward as a reliever to
another nurse who went on emergency sick leave. She was not
oriented in the Surgical Ward and the unit was very busy.
65. Which of the following is the MOST appropriate action of
Nurse Honelette
a. Request the nurse supervisor to assign a more experienced
nurse reliever
b. Refuse the order of the nurse supervisor and stay put in the
medical ward
c. Comply with the order of the nurse supervisor
d. Request the nurse supervisor to give her brief orientation
before compliance
66. Nurse Honelette has an expired license but promises to
renew her license in due time. Which of the following violation
can she be charged if she participated in home health care
activity?
a. Misdemeanor
b. Grave coercion
c. Felony VIOLENCE
d. Negligence NON PROF
Situation
Health Education is an area of nursing practice when the nurse
can be creative and independent in the work setting. The
following questions apply.
67. A nurse is developing a Teaching plan for Patricia 18 year
old with Bronchial Asthma. She has an order for discharge.
Which part of the teaching plan should be given PRIORITY?
a. Quick relief medicines as ordered
b. Avoid contact with fur-bearing pets
c. Avoid going to malls
d. Wash bed sheets in warm water
68. Nurse Karen is teaching Michel, an asthmatic, on how to use
the Spirometer. She should instruct the client to have the
mouthpiece________________.
a. Place into the mouth and have regular breathing
b. Place into the mouth and have a fast deep breath
c. Place into the mouth and inhale slowly
d. Place into the mouth and exhale slowly
69. Nurse Kim is teaching a client on how to use metered dose
inhaler to prevent asthmatic attack while in the hospital. She
should instruct the client to do the following
__________________ EXCEPT.
a. Keep the head of the bed at 15 degree angle
b. Do oral care after use of the inhaler
c. Use the inhaler before she take her meals
d. Use the inhaler as ordered
Situation
The TQM nurse reported to their director that there are a lot of
medication errors committed by nurses and doctors in the
hospital for the past 3 months. They made a decision to conduct
a review of all the cases with these errors. A clinical
enhancement on drug administration was strongly recommended
by going back to the basics. The following questions apply:
70. In order to prevent error in insulin injection which of the
following safety measure should you do?
a. Leave the drug in the client refrigerator and ask it when
needed.
b. Double check with your head nurse calculations and
consider high “alert” drugs.
c. Compute the drug, proceed to the patient, and administer the
drug.
d. Request the dietary department to keep the drug until needed.
Situation
Jayson is a 72 year old who is a smoker and a social drinker. He
consulted the OPD because of rectal bleeding. His tentative
diagnosis is colorectal cancer. He was advised by the doctor for
admission.
71. Which of the following would you likely expect as a specific
complaint of the client during your initial health history taking?
a. Projectile vomiting
b. Bouts of hematemesis
c. Change in bowel habits
d. Passing out white watery stools
72. Colonoscopy has been ordered. Which of the following is
not advisable for the client to do?
a. Has to drink the electrolyte laxatives day before the procedure
b. Can take PRN medications when taking electrolyte solution
c. Can have liquid diet before the procedure.
d. Chilled electrolyte solution is allowed.
Situation
Ms. Marjorie, 42 years old, has been manifesting thyroid
enlargement and bulging of the eyeballs. She has been
complaining of dryness of the cornea even it is not a hot a
season. She was advised by a friend-doctor who is practicing in
a nearby hospital to be admitted for further work-up.
73. You plan to conduct physical examination of the enlarged
thyroids gland. What is the MOST APPROPRIATE procedure
to be done to examine Ms. Marjorie?
a. Have her drink cold water and measure the size of the thyroid
gland
b. Request Ms Janice to sit on the chair and let her
hyperextend the neck during palpation
c. Inspect and percuss the thyroid gland for dullness
d. Conduct a deep palpation to evaluate thickness of the
enlarged thyroid gland
74. You have formulated a nursing diagnosis, "Risk for Corneal
Injury R/T Exophthalmos" for patient Marjorie. Which of the
following interventions in the MOST appropriate to prevent this
problem to happen?
a. Apply artificial tears if ordered
b. Have an intraocular exercise as tolerated
c. Put patient Janice in upright position
d. Include salt restriction in her diet
Situation
Ashryl, 35 years old, consulted the OPD because of pain and
abdominal distention. She also complained of frequent urination
in small amount. Doctor's impression is presence of kidney
stone.
75. The client is asked to describe the pain she is experiencing.
Which of the following should the Nurse expect?
1. Intense deep ache in the costo-vertebral region
2. Pain usually radiates anteriorly and towards the bladder
3. Wavelike pain that radiates down to the thigh and genitalia
4. Acute excruciating pain, colicky in nature that radiates to
genitalia
a. 1 and 2
b. 1 only
c. 2 and 3
d. 1,2,3 and 4
76. Lithotripsy was ordered for Ashryl. She asked the Nurse c. Honor Code
"What is this procedure all about? The nurse replied, " It __: d. Ten Commandments

a. Will break up the stones in the calyces of the kidney"
b. Is a procedure to extract renal stones"
c. Will create electrical discharge to break the stones in the
kidney"
d. Will visualize the stone and destroy it"
83. Getting the informed consent of research participants show
that the nurse honors the principle of autonomy. However, there
are instances where participants become incapable of giving
informed consent. These groups of participants exclude which
of the following:

77. Ashryl is preparing to go home. Which of the following is a. Jestoni, a 19 year-old male who is paraplegic
NOT an essential component of your health instruction? b. Karlyn, a 17 year-old college student
c. Ayesha, a 34 year-old mother who is diagnosed with
a. Engage in outside activity so she can sweat a lot Schizophrenia with active positive symptoms
b. Drink 8-10 glasses per day d. All of the options
c. Restrict intake of protein to 60 g/day
d. Take non steroid drugs for pain Situation
As a staff nurse in a government hospital, you have been
Situation exposed to varied cases of clients with endocrine problems.
Mr. Kerro, a 62-year old male, complains of shortness of breath, Your nursing responsibility starts from admission to discharge
dyspnea on exertion, palpitation, and expectorating frothy, which is a domain of your competencies.
blood-tinged sputum. He was brought to the emergency room of
Hospital C. During the interview, he also complained of easy 84. When the sympathetic nervous system is stimulated in the
fatigability and weakness. case of pheochromocytoma, you expect which of the following
signs?
78. Mr. Kerro has been diagnosed with heart failure. Nurse i. Hypertension
Joncel expects this patient to not exhibit the following signs and ii. Headache
symptoms EXCEPT: iii. Hyperhidrosis
iv. Hypermetabolism
a. Pulse rate of 48 bpm
b. Murmurs a. 3 and 4
c. Respiratory rate of 18 cpm b. 1 only
d. Strong, bounding pulse c. 1, 2, 3, and 4
d. 2 and 3
79. Nurse Joncel prepares to perform the following interventions
for the immediate management of Mr. Kerro excluding: 85. Which of the following drugs can induce hypertensive crisis
in Pheochromocytoma?
a. Establish an IV line and administer PNSS immediately
b. Monitor heart rate and dysrhythmia by using a cardiac a. Tricyclic antidepressant
monitor b. Corticosteroid
c. Continuously assess level of consciousness c. Respiratory stimulant
d. Provide reassurance and support to the patient d. Radio iodine therapy

Situation 86. In the presence of pheochromocytoma, the diagnostic test

Nurse Ayanah was invited to be a member of the ethics
committee of Hospital D, a training hospital. A prerequisite to
her formal induction into the committee was for her to complete
a research.
80. Before and during the conduct of her research, she is guided
by the following ethical principles excluding:
which is expected to be elevated is ___________.
a. Serum thyroid hormone levels
b. Albumin globulin test
c. Urine cyclic adenosine mono phosphate
d. 24 hours urine collection for vanillylmandelic acid (VMA)
BY PRODUCT OF METABOLISM OF NOR EPI

1. Protect the privacy of the subjects Situation

2. Get the informed consent of the subjects Janine is the Nurse on duty in the medical ward and many of her
3. Avoid injury or harm to the subjects patients are suffering from problems of oxygenation.
4. Treat the subjects fairly and justly
87. The following are relevant data to be documented when
a. 1 & 2 taking the health history of a client with anemia EXCEPT:
b. None of the options
c. All but 3 a. Alcohol intake (+)
d. All of the options b. Fatigue and weakness
c. Dietary intake
81. Another important ethical principle that guides nurse d. Episodes of bleeding
researchers is the principle of justice. Nurse Ayanah knows that
this principle connotes: 88. A client with congenital heart disease is suffering from
thickening of the skin under his fingers due to chronic
a. Fairness and confidentiality hemoglobin desaturation. Which of the following specific term
b. Fairness and equality should Ime use to accurately describe MOST the client’s
c. Fairness and equity condition in the chart?
d. Fairness and anonymity
a. Peripheral cyanosis
82. Apart from the aforementioned ethical guidelines and b. Pallor of the finger tips
principles, Nurse Ayanah is aware that which of the following c. Peripheral neuropathy
codes of conduct has endured through the ages? d. Clubbing of the fingers

a. Code of Ethics for Professionals 89. Mr. Gabby is with left sided heart failure. Janine’s
b. Phairpine Constitution documentation of her assessment findings will include the
following, EXCEPT______________.

a. Dependent edema
b. Pulmonary crackles
c. Difficulty of breathing
d. Cough
90. A client is on a diuretic therapy. Expected entry in patient’s
chart should include the following information, EXCEPT:
a. Serum electrolytes monitored
b. Intake and output recorded
c. Lasix administered at 8 o’clock in the evening
MORNING
d. Weight is taken before drug is given
Situation
The Registered Nurses in the practice of the profession are
expected to demonstrate an upright and ethical values inside and
outside of their work settings.
91. The primary purpose of the Nurses’ Code of Ethics includes
which of the following?
a. Provide guidelines for the care provided to patients.
b. Establish right attitude and behavior of nurses.
c. Serves as a guide in making morally upright decision
related to nursing practice.
d. Regulate the practice of the profession
92. The ethical principle which considers the persons
unconditional worth in determining his own destiny is ______
a. Self-determination
b. Fidelity
c. Autonomy
d. Justice
93. Nurses can improve ethical decisions by:
a. compliant to the Code of Ethics
b. attending conferences and symposis on Ethics
c. compliant to policies and laws
d. being a member of the ethics committee
94. What ethical principle is applied in clinical situation, when
respirator is available for two patients in shock?
a. stewardship
b. inviolability of life
c. justice
d. respect for person's dignity
Situation
Miss Ahya and Mister Aaron are province mates and graduated
from the same nursing school. After two years of staff nursing
experience they decided to go home to their province. Nurse
Ahya was employed as a school nurse while Mr. Aaron joined a
tertiary health facility an infection control nurse. One day, a
group of school children approached Nurse Ahya because of
fever, cough and fatigue.
95. What PRIORITY nursing actions should Nurse Ahya
implement?
a. Give cough syrup and antipyretic in the children
b. Teach the children to cover their mouth when coughing
c. Call parents and teach them hand washing technique
d. Check if the children have been immunized with BCG
96. One of the children was complaining of headache and
epistaxis. Which of the following nursing measures should
Nurse Ahya undertake first?
a. Put client on bed in supine position
b. Have the child sit upright with head tilted forward
c. Bring the child to the nearest hospital
d. Pinch the soft outer portion of the nose for 6 to 15 minutes
97. Nurse Ahya conducted a visit to the community where the
children live. She found out that the brother of one of the school
children was just newly discharged from the hospital because of
Hepatitis A. Which of the following precautionary measures
should she give HIGHEST PRIORITY to the family members?
a. Dispose properly syringe used by patient in covered
containers
b. Avoid droplet infection
c. Use mask when caring for the patient
d. Wash hands before and after handling excretory and
secretory materials of the patient
98. Nurse Aaron is working with the infection control area and
participated admitting patients affected with suspected Viral
Infection. Which of the following action proved to be effective
to prevent incidence of cross contamination in the work setting?
a. Health care professionals should observe standard
precautions
b. Come up with a policy providing immunization to the health
care
c. Provide dispenser for alcohol-based hand wash in and outside
profession of patients room
d. Post EBOLA health precautions in all areas of the hospital
99. A 30-year old G6P5 woman at 12 weeks has just begun
prenatal care. Her initial laboratory reveals that she has human
immunodeficiency virus (HIV) infection. What would be a
priority evidence-based nurse information for this patient?
a. Breastfeeding is not recommended due to the great risks to the
infant
b. Pregnancy is known to accelerate the course of HIV disease
in the mother
c. Medication for HIV infection is safe and can greatly
reduce transmission of HIV to the infant
d. Breastfeeding will potentiate the transmission of HIV from
the mother to the child
100. There is a senior student where Nurse Aaron is assigned.
Which of the following infection control activity is
APPROPRIATE to be delegated to the senior students?
a. Assessment of patients with chronic respiratory problems
b. Take care of patient with pneumonia in acute phase of his
illness
c. Demonstration of hand washing to patients and relatives.
d. Disinfection of BP cuff, thermometer while patients are in the
hospital