* NLE * NCLEX * HAAD * PROMETRICS * DHA * MIDWIFERY * LET * RAD TECH * CRIMINOLOGY * DENTISTRY *
PHARMACY * MED TECH
RECALL 3 EXAMINATION
Nursing Practice I
Situation 1: Ice, a community health nurse, is newly
assigned as the clinic manager at Brgy. Cagdara-O
Health Station (BHS). He is to provide nursing care to
the members of the community and to train the
barangay health workers in the provision of health
services. The Municipal Health Officer (MHO) supervises
his activities in the barangay.
1. A mother with her child comes in to the clinic. She
complains that her child, baby SC, an 18- month old
male, is coughing with no secretions for about two days.
She tells the nurse that “My child is coughing. This is
going on for two days. Can I ask for Cotrimoxazole?”
The nurse’s best response for this situation is:
a. “This is not permissible because I am not a doctor. I
advise that you go to the Rural Health Unit for the
medicine. They have a doctor there.”
b. “Please wait, mother. There might be a problem that
can be solved by IMCI.”
c. “Okay, mother. There is medicine here that you
need.”
d. “Mother, I need to check him first. There might be a
more appropriate treatment for baby.”
2. After assessing the child, as per the Integrated
Management for Childhood Illnesses (IMCI) in 2014, the
child only has coughs and colds. The nurse determines
that the child should be given a safe remedy. With the
nurse’s knowledge on herbal medicine, which plant
decoction should he give to the child?
a. Oregano leaves
b. Five-leaved Chaste tree leaves
c. Ginger
d. Young leaves of the Mango tree
3. After two days, the mother returns with the child
experiencing asthma. Upon assessment per IMCI, the
nurse needs to nebulize the child with inhaled albuterol.
The BHS does not have any stock right now, but there is
a botika ng barangay a few meters away that is selling
albuterol nebules. What is an appropriate response of
the nurse?
a. “Mother, here is a prescription for medicine. Please go
to the botika ng barangay right now. They are selling
albuterol there. Afterwards, please go back here so that
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I could administer the drug to the baby. You can leave
the baby here.”
b. “Mother, this is the prescription for the medicine and
the nebulizer. Please go to the pharmacy to buy the
nebule. Afterwards, please nebulize the baby.”
c. “Mother, here is a prescription for medicine. Please go
with the baby to the pharmacy right now. They are
selling albuterol there. Afterwards, please go back here
so that I could administer the drug to the baby.”
d. “Mother, let’s just cry because your baby might die.”
4. Ice wants to know the predominating health problems
in the community. As part of data collection, he
performs interviews with random members of the
community. During one of his interviews, a man named
Argie said that “Come and eat with us first in our
babang luksa” before we answer your question.” What
is an appropriate response of the nurse?
a. “I’ll go and eat with you for a bit, but we’ll have to
talk about it over the food.”
b. “I have to refuse. I’m not allowed.”
c. “I’ll just stay with you.”
d. “I have to refuse. If you force me, I will tell on the
barangay captain.”
5. Wednesdays, as declared by the Philippine
Department of Health, is the vaccination day for
children. Ice encounters baby GB, a 9-month old female.
The anti-measles vaccine is prepared, with you knowing
that it should be administered through:
a. Intramuscular route; lower inner quadrant of the
gluteal area
b. Intramuscular route; middle third of the vastus
lateralis
c. Subcutaneous route; 90° angle
d. Subcutaneous route; 45° angle
Situation 2: Ice decides to go back to the hospital
setting. You, a new registered nurse and a top notcher
in last board exams, gets accepted as the community
health nurse with the position of a Public Health Nurse II
(PHN II). You will provide nursing care to all the
members of the community, regardless of the age and
the place of conduct
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6. You make it to a point that the BHS is cleaned every
day because you know that this assists clients to a
better state of health. This notion is in accordance with
the theory of nursing proposed by:
a. M. Leininger
b. D. Orem
c. F. Nightingale
d. C. Roy
7. The previous nurse wanted to know the
predominating health problems in the community.
However, this was not finished during his years of
service. You, as the new nurse, is responsible for the
continuation of the process. Upon checking the records,
you noticed that the persons infected with the human
immunodeficiency virus (HIV) have exponentially
increased during the previous months. As a health care
professional, you need to protect yourself from being
infected with the virus. To avoid being infected, you
know that the precautions that you need to do when you
handle a client with HIV is:
a. Universal Precautions
b. Blood Precautions
c. Airborne Precautions
d. Contact Precautions
8. For you to conclude that there really is an increase in
the cases of people living with HIV (PLHIV), you must
know the ______ of PLHIV in Brgy. Cagdara-O.
A. Incidence rate
B. Prevalence rate
C. Morbidity Rate
D. Gender
9. You finished your community diagnosis and planning
of programs targeted at reducing the rate of increase in
HIV cases. During the implementation, you admitted to
yourself that, while you are well-versed with the artificial
methods in family planning, you are not entirely familiar
with the natural methods. You wanted to cooperate with
an organization that is well known for promoting natural
family planning and has collaborated with the
Department of Health (DOH) for the advocacy. You
would call a representative from:
a. Victory Church
b. Catholic Bishops Conference of the Philippines
c. Couples for Christ
d. United Methodist Church
10. During your screening, a mother with a 4- month old
child admits that she is positive for HIV. The records she
showed you confirms that she indeed has contracted the
disease. The mother asks, “Nurse, I read that HIV can
be transmitted through breastfeeding. However, my
mother said that it’s just okay to continue it, despite my
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status. Which one is really the truth?” What is the
appropriate response of the nurse?
a. “Ma’am, that is correct. You can pass HIV through
breast milk because it was proven to contain HIV. In this
case, you can use bottle feeding for your child as stated
by your doctor.”
b. “Ma’am, you should go with breast milk. The chances
are low for breast milk to transmit HIV. The benefits of
breast feeding outweigh the risks.”
c. “Ma’am, just give him rice water. I became smart
because of that. Just boil it enough to be sterilized.” d.
“Ma’am, you should ask your doctor about that.”
Situation 3: A woman goes into the BHS to ask for a
check-up. She complains occasional syncope, pallor, and
vaginal bleeding, with blood saturating a napkin pad
every hour. The client has just undergone hysterectomy.
You, a topnotch nurse, is considering heavy bleeding
secondary to surgical complications. You filled up a
referral form and calmed the client until the rural health
unit’s ambulance came to take her into the hospital. The
day has passed, and the client’s husband returned the
referral form, blaming the nurse for the loss of his wife.
He sued you for negligence.
11. The court issues an order to summon the MHO and
bring all relevant and tangible documents for use in the
hearing. What order is this?
a. Subpoena ad testificandum
b. Subpoena duces tecum
c. Subpoena opera omnia
d. Subpoena bravus exvius
12. Upon investigation, the court found no charting of
the incident. Because there was no proof of your
interventions, you were found guilty of the charges. In
addition, the court charged the MHO because he was
the one supervising you. This liability imposed upon to
the MHO is termed as:
a. Assumption of risk
b. Res ipsa loquitur
c. Mea maxima culpa
d. Respondeat superior
13. Accurate documentation is the hallmark of nursing
accountability, as dictated by the PRCBON Resolution
No. 220, s. 2004. This is also known as:
a. Affirmation of the Board of Nursing as the Regulatory
Arm of the Professional Regulations Commission for the
Profession of Nursing
b. Code of Ethics for Nurses
c. Implementing Rules and Regulations of the Philippine
Nursing Act of 2002
d. Implementing Rules and Regulations of the
Comprehensive Nursing Law
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14. The nurse, while claiming to have done everything in
his scope to help the client, admitted that he indeed was
not able to chart the incident because he forgot about it.
This ethical principle exerted by the nurse is called:
a. Veracity
b. Non-maleficence
c. Beneficence
d. Respect for Autonomy
5. The law governing your practice of the profession as
nurse is called:
A. RA 9731
B. RA 9713
C. RA 9173
D. RA 9371
Situation 4: Four months after the incident, the family
forgives you and the court lifts your suspension. You
decide to apply in a nongovernmental organization
(NGO) as a community health nurse.
16. The Projects Director for Public Health of that NGO
becomes your interviewer. She asks you about the
concept of primary health care. You, the most stellar
nurse in your batch during your board exams, answers
this question with:
a. “To strengthen the health care system by increasing
opportunities and supporting conditions wherein people
will manage their own health care”
b. “Health for all Filipinos, and health in the hands of the
people by the year 2020”
c. “To partner with and empower the people towards
self-reliance in health care”
d. “Guarantee equitable, sustainable, quality health for
all Filipinos”
17. You have been assigned as a clinic manager to the
“Post-Haiyan Community-Based Communicable Disease
Prevention Program” of the said NGO. Upon your arrival
in Guiuan, Eastern Samar, a child was immediately
brought to your post. He was bitten by a dog. Using
your knowledge on rabies, you treat the child based on
this sequence for the prevention of rabies:
I. Wash with soap and water for 15 minutes
II. Vaccinate with ERIg or HRIg
III. Apply either 70% ethanol, tincture, or aqueous
solution of iodine
IV. Observe the dog for 10- 14 days
V. Lie down.
VI. Try not to cry.
VII. Cry a lot.
a. I, VII, V, II
b. IV, V, VI, III
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c. III, II, VI, I
d. I, III,II, IV
18. The next morning, a three-month pregnant mother
comes into the clinic. She verbalized, “My boyfriend said
that you have a vaccine here for pregnant mothers.
What is that vaccine?” This vaccine is:
a. Measles, Mumps, Rubella (MMR) vaccine
b. Tetanus Toxoid (TT)
c. Anti-Measles Vaccine (AMV)
d. Pentavalent Vaccine (PentaHib)
19. The mother shows her vaccination record. It was
indicated she was first vaccinated for TT on June 12,
2018. If today’s date is July 16, 2018, the next dose
should have been given on:
a. July 2, 2018
b. December 12, 2018
c. June 12, 2019
d. Today
20. If the pregnant mother’s vaccination record shows
that she was given 3 DPT doses during childhood, when
will be the next dose?
a. July 2, 2018
b. December 12, 2018
c. June 12, 2018
d. Today
Situation 5: After spending 5 years in the program, you
decided that you want to be a maternal and child nurse
(MCN) in Eurasia Vienna Regional Medical Center
(EVRMC). As an MCN, you are tasked to take care of
pregnant mothers and their newborns.
21. During your break on your first day, you decided to
go to the staff room. You found out that your head
nurse was injecting an unknown liquid in his arm. Your
priority nursing action is:
a. Stop the head nurse from injecting that liquid.
b. Report the incident to your charge nurse
c. Report the incident to the nurse supervisor
d. Ask the police to kill the head nurse because he is an
“adik” and deserves to die, as dictated by a certain high-
ranking politician
22. After responding to that event, you admitted a
laboring 37-week pregnant mother who was pregnant 4
times prior, with 3 babies reaching childhood. All prior
pregnancies reached term, but 1 child died 30 minutes
after birth. There were no preterm deliveries. What is
the mother’s obstetric score?
a. G 4 T 4 P 0 A 0 L 4 M 0
b. G 5 T 5 P 0 A 0 L 5 M 0
c. G 4 T 3 P 0 A 0 L 3 M 0
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d. G 5 T 4 P 0 A 0 L 4 M 0
23. You now have a total of 8 single-gestation pregnant
mothers under your care. How many are your clients?
a. 8
b. 16
c. 9
d. 18
24. Your current hospital is a facility that provides all
basic emergency maternal and neonatal care, with the
addition of blood transfusions and caesarian deliveries to
mothers. With your experience in the community, you
know that this is the highest level in the four-tier service
delivery model. Recalling, what is the first level in this
delivery model used in the Philippines?
a. Comprehensive Emergency Obstetric and Newborn
Care (CEmONC)
b. Basic Emergency Obstetric and Newborn Care
(BEmONC)
c. Basic Essential Obstetric and Newborn Care (BEONC)
d. Community-based Teams (CBTs)
25. In a CEmONC facility, which of the following is NOT
a part of the team?
a. Midwife
b. Nurse
c. Surgeon
d. None of the Above
Situation 6: While you are a stellar MCN and CHN, your
friend Dindin is an excellent pediatric nurse. She is
assigned in the pediatric surgical ward.
26. Dindin is caring for 2-year-old child named CP. CP is
diagnosed with Pyloric Stenosis. The child comes back
from the Post-Anesthesia Care Unit (PACU). Knowing the
surgical procedure needed to correct the problem,
Dindin is expecting that the child is status post- ?
a. Fredet-Ramstedt Procedure
b. Swenson Pullthrough
c. Exploratory Laparotomy, Total Abdominal
Hysterectomy and Bilateral Salpingooopherectomy (EL-
TAHBSO)
d. Lobotomy
27. The resident physician orders for CP’s urine output
to be monitored hourly. If CP weighs 12 kg, her regular
hourly output should be approximately:
a. 6 cc
b. 12 cc
c. 24 cc
d. 36 cc
28. During the first hour of the client after the surgery,
Dindin notices that the child is having slow respirations
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of about 18 cycles/minute (CPM). Dindin’s priority
nursing action is to:
a. Monitor the client and document findings.
b. Provide oxygen of about 2 liters/minute (LPM) via
face mask
c. Refer to physician
d. Start Cardio-Pulmonary Resuscitation (CPR)
29. CP has an abdominal wound that has never been
cleaned after the surgery. The surgical consultant orders
that the surgical wound be cleaned every 8 hours by the
nurse on duty. Dindin’s first nursing action is to:
a. Use povidone-iodine to clean the wound
b. Wash hands with soap and water
c. Ask the resident physician to clean the wound
d. Clarify the order with the consultant
30. CP’s father asks if the baby’s thumb-sucking is
normal. She explains to the father that the child is in the
“oral phase”, according to a psychoanalyst named Freud.
Dindin displays her knowledge on the psychosexual
stages if she states that: (SELECT ALL THAT APPLY by
encircling all possible letters of the correct answers)
a. An infant sucks for nourishment & pleasure
b. An infant does not find pleasure in sucking but does
find enjoyment from the perception of nourishment from
the thumb
c. An infant may have more pleasure in breastfeeding
than in bottle feeding because it expends more energy
d. An infant does not find pleasure on a pacifier
e. An infant explores the world through her mouth f. An
infant begins to explore the genital area to learn sexual
identity
Situation 7: The nursing staff of the pediatric neurology
ward is having a mid-year staff outing. Dindin was asked
to relieve in the area.
31. Dindin is preparing a 4 year-old intersex client for
craniotomy. Which nursing action is appropriate for
preoperative teaching based on Erikson’s developmental
stages?
a. Allowing the child to make a project related to the
surgery
b. Having the child put a surgical mask on a doll
c. Asking the child how he feels about surgery
d. Allowing the child to listen to music without further
instructions
31. Dindin is preparing a 4 year-old intersex client for
craniotomy. Which nursing action is appropriate for
preoperative teaching based on Erikson’s developmental
stages?
a. Allowing the child to make a project related to the
surgery
b. Having the child put a surgical mask on a doll
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c. Asking the child how he feels about surgery
d. Allowing the child to listen to music without further
instructions
32. Dindin prepares the child’s medications. The mother
says, “My baby is afraid of strangers and afraid of
separating from me. My motherin-law is upset and
thinks I am causing it.” Which response by the nurse is
most appropriate?
a. “Give your baby to strangers while you are present,
so he gets used to strangers.”
b. “Your mother-in-law is correct; you need to include
her more in your baby’s needs.”
c. “Separation anxiety is an important component of a
parent-child attachment.”
d. “Just let your baby cry for a while; your baby will get
used to being separated from you.”
33. A 15 year-old transwoman client previously
diagnosed with a pituitary adenoma is about to be
discharged. The parents were taking care of the child’s
hospital clearance when Dindin approached the
adolescent. She told the nurse that, “I have something
to say to you, but I beg you, do not tell anyone about
this.” Dindin’s most appropriate action would be to:
a. Promise the client that the information will not be told
to anyone.
b. Tell the client that the information will be confidential
unless it is life threatening or harmful.
c. Tell the client that only the physician will be told;
otherwise the information will remain confidential. d. Ask
the client to tell a social worker who then can follow
through with the information if it is concerning.
34. Dindin is assessing an infant for attachment
behavior. Which observations are important in assessing
this relationship? (SELECT ALL THAT APPLY by encircling
all possible letters of the correct answers)
a. The kind of body contact between the parent and
infant
b. If the parent is holding and cuddling the infant
c. The kind of comfort techniques being used by the
parent
d. The comfort level of the parent while interacting with
the baby
e. Whether the infant is crying
35. A nursing care plan is being made by Dindin for a
child who is s/p removal of brain tumor. The child is
confused, disoriented, and restless. Which nursing
diagnosis should receive the highest priority?
a. Altered Sensory Perception r/t neurological surgery
b. Self-Care Deficit r/t confusion and disorientation
c. Impaired Verbal Communication r/t confusion
d. Risk for injury s/t disorientation and restlessness
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Situation 8: A strong earthquake has recently hit the
Province of Morgana. EVRMC was asked by the Local
Government Unit of Morgana and the DOH to send
health care providers. You, Dindin, and two other
colleagues named Vina, and Jousch were deployed. You
were to provide primary health care as supervised by
the Municipal Health Officer.
36. Dindin was assigned to provide reproductive health
(RH) services to the Manunubang. She helped a mother
to deliver the newborn. She was about to pull the
placenta. The cord was lengthening and there was a
sudden gush of blood. She is now only waiting for the
uterus to become firm and globular. This sign that
Dindin is waiting for is called:
a. Cullen’s Sign
b. Culkin’s Sign
c. Chadwick’s Sign
d. Candor’s Sign
37. A nursing supervisor from a known OB-Gyne hospital
in Manila told Dindin that what she did is termed as the
expectant management of the third stage of labor.
However, as per new evidence, the Philippines is moving
towards the active management of the third stage of
labor (AMTSL). The components of AMTSL includes the
following EXCEPT:
a. Giving a uterotonic drug to contract the uterus
(oxytocin)
b. Controlled Cord Traction
c. Delayed Cord Clamping
d. None of the Above
38. Vina and Jousch were assigned to provide primary
health care to adult clients. Jousch claimed that she was
told by the MHO that she is given permission to
diagnose and prescribe medicines to adult clients by
virtue of an interim primary health care guideline for
firstlevel health workers. Jousch was referring to:
a. International Guidelines on Medical Diagnoses for
Nurses
b. Nurse’s Primer for Advanced Primary Health Care
c. Integrated Management of Adult and Adolescent
Illnesses (IMAI)
d. Emergency Medical Training Guidelines for Allied
Health Professions
39. After the incident, Vina decided to go out with the
emergency response team and looked for people
needing help. She saw a man standing near a house.
Because Vina is knowledgeable about Psychological First
Aid (PFA), she approached him and introduced herself.
The man told her “I’m Tarib Yorimit. I’m scared! I was
about to come home from the farm when it started
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shaking! I don’t understand what is happening!” Vina’s
best response for Tarib is:
a. “You should have run away from your house. It could
be dangerous.”
b. “Yes, a 4.5 magnitude earthquake with the epicenter
at Fata, Morgana and a hypocenter at about 79 miles
deep into the earth’s crust happened.”
c. “Everything will be okay. You will have a new house.
The government will surely give you a job with a salary
of 10,000 pesos per month for a decent living. You just
have to work hard and not be lazy.”
d. “Yes, it was an earthquake and I can imagine it was
terrible for you. It’s not safe in this area for now, and
you might get hurt.”
40. Francois, an emergency room nurse, is assigned as a
triage nurse in the emergency center of the hospital.
She receives four admissions. Prioritize the order in
which Francois will assess the clients.
I. A 40 year-old client who is diaphoretic and is feeling
chest pressure
II. An 18 year-old client who thinks he might have a
broken ankle
III. A 35 year-old client who cut her hand with a knife
preparing for food
IV. A 60 year-old client who is dyspneic and has swollen
lips after being stung by a bee
a. IV, I, III, II
b. IV, I, II, III
c. IV, III, II, I
d. IV, III, I, II
Situation 9: As a care specialist, a nurse should be
knowledgeable on socio-political aspects of health care.
41. The Philippine Health Agenda, a national health
development plan created during the period of the DOH
Secretary Paulyn Ubial, aims to attain the health-related
Sustainable Development Goal (SDG) Targets. With its
development, goals were defined by formulating its so-
called “Guarantees”. Which of the following statements
are NOT included in the Guarantees?
a. Services for Both Well and Sick
b. Functional Network of Health Facilities
c. Financial Freedom When Accessing Health Services
d. Advance Quality, Health Promotion, and Primary Care
42. The SDG in which the PHA is patterned from is the:
a. SDG 1
b. SDG 2
c. SDG 3
d. SDG 4
43. PHA’s Guarantee 1 ensures that all life stages and
the triple burden of disease is addressed. This includes
attention to Non-Communicable Disease (NCD) and
Malnutrition. In the Philippines, what is the protocol
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used to screen, diagnose and manage NCDs in the
primary health care level?
a. PFA
b. PhilPEN
c. OSHS
d. mhGAP
44. Communicable diseases are a problem that
continues to threaten child health. To combat the rise in
morbidity, the Philippines is implementing what is known
as the National Immunization Program. This program is
mandated by:
a. RA 10152
b. PD 996
c. RA 7305
d. PD 856
45. The current administration has appointed a new
DOH secretary. He wants to use a strategic approach
that will “enable the health department and the public to
monitor how the health sector is working to achieve
better timeliness, better responsiveness, better quality,
and better outcomes for patients”. This strategic
approach is thereby dubbed as: a. Duterte Health
Agenda (DHA)
b. Fourmula One for Health (F1)
c. F1 Plus
d. DHA Plus
Situation 10: As a nurse well-versed in the holism of
care, you provide care to people in various places and
situations.
46. You are walking to the Rural Health Unit when a
jeepney hit two persons walking on the pedestrian lane.
Client A, an adult, was bleeding from the abdomen, and
is visibly having a difficulty in breathing. As the first
responder, you identified yourself as a health care
professional and proceeded to the scene. What is the
first nursing action that you should do as you approach
the client?
a. Assess the client for cervical injuries
b. Stop the client’s bleeding
c. Check if the scene is safe
d. Insert a 23G IV cannula for PNSS to replace blood lost
47. As you assess client A, you noticed that the client is
unable to move his upper and lower limbs and the
airway is not open. You are suspecting a cervical spine
injury. Which of the following methods should you use
to open the airway?
a. Head-tilt/chin-lift technique
b. Modified jaw-thrust maneuver
c. Ritgen’s Maneuver
d. Crede’s Maneuver
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48. You noticed that there is a glass shard stuck in the
client’s abdomen. What is the nurse’s priority action with
regard to the glass shard?
a. Remove the glass shard
b. Stabilize and secure the impaling object in place
c. Push it deeper to prevent bleeding
d. Let the surgeon handle it
49. After 15 minutes, the client is still bleeding out,
despite nursing interventions. The EMT has still not
arrived in the scene. You noticed that the client is having
respirations of 30 CPM, PR of 120 BPM, and BP of 70/50.
You are now suspecting that the client is in:
a. Cardiogenic Shock
b. Anaphylactic Shock
c. Hypovolemic shock
d. Electric Shock
50. If a person is already in shock and has no head
and/or abdominal injuries, what is the most appropriate
position for the client?
a. Supine with legs elevated
b. Trendelenberg
c. Dorsal Recumbent
d. Lithotomy
Situation 11: Research is essential to the nursing
practice. It enables a nurse to have continuing
professional development and to provide quality, safe,
and up-to-date care for clients.
51. You, a very successful and intelligent nurse, decides
to research on the effects of music therapy in pain relief
on children during phlebotomy. Which of the following is
the dependent variable?
a. Amount of music therapy
b. Pain relief during phlebotomy
c. Children
d. Indiscernible from the given data
52. Which of the following is the independent variable?
a. Amount of music therapy
b. Pain relief during phlebotomy
c. Children
d. Indiscernible from the given data
53. If the study is quantitative and the standard
deviation is known, which of the following statistical
tests should the nurse use in the research? a. One-
Sample Z-Test b. One-Sample T-Test c. Chi-Square Test
of Association d. ANOVA 54. The responses that the
nurse will analyze comes directly from the perceptions of
the children in the study. These responses are research
data that are taken from a:
a. Primary Data Source
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b. Secondary Data Source
c. Tertiary Data Source
d. Quaternary Data Source
55. You wanted to use a measure of central tendency to
summarize information about the distribution of data.
Which of the following measures of central tendency has
a tendency to be affected by data outliers?
a. Median
b. Mode
c. Mean
d. Standard deviation
Situation 12: As a health care professional, whether you
are working in the community or in the hospital, you are
tasked to provide nursing care when unforeseeable
crises occur.
56. A few minutes after you made a reservation for
massage, you heard something hard hit the pavement.
Immediately after he lied down, you saw him with what
appears as jerking movements from all over his body. As
per assessment, he has lost his consciousness. You
know that the client is experiencing:
a. Simple partial seizures
b. Complex partial seizures
c. Generalized seizures
d. All of the above
57. Which of the following nursing interventions are
inappropriate for the client during the attack?
a. Do not restrain the client
b. Loosen his clothing
c. Place a small, folded blanket under the head
d. Place a tongue guard in his mouth
58. What is the position of choice for the client during
the seizure attack?
a. Dorsal recumbent
b. Side-lying
c. Supine
d. Trendelenburg
59. The Emergency Medical Team has arrived at the
scene. You identified yourself as a registered nurse
explained the situation and gave a brief background on
the EMT. Assessment parameters were given and
recommendations to take the client to EVRMC were
reiterated. This type of referral communication most
commonly used in nursing is called:
a. ISBAR
b. CABC
c. AVPU
d. ABCDE
60. One of the EMT rescuers took the client’s blood
pressure. He records it at 200/120 mmHg. As per the
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8th Joint National Commission Guidelines, this is
classified as:
a. Hypotension
b. Normotension
c. Stage I Hypertension
d. Stage II Hypertension
Situation 13: You are a clinic nurse providing care to
clients with chronic and terminal illnesses.
61. You are teaching an 18-year-old diabetic client to
perform self-administration of insulin. The nurse notes
that each time the client makes even a small mistake,
the client constantly apologizes for getting it wrong. The
nurse observes that the client also profusely apologizes
when making a minimal mistake in other activities. The
nurse concludes that, according to Erikson’s
development stages, the adult may have an unresolved
development task of:
a. Infancy.
b. Early childhood.
c. School-age childhood.
d. Adolescence.
62. A client states, “If I could live until my grandson’s
wedding in 2 months, then I would be ready to die.”
Based on this statement, you should interpret that the
client is in which stage of grief?
a. Denial
b. Depression
c. Bargaining
d. Acceptance
63. You are caring for a middle-aged client who is
disabled due to a recent motor vehicle accident. The
client has few interests, spends most days watching TV,
and has become estranged from the family. Which of
Erikson’s developmental stages should the nurse
conclude that the client is NOT meeting?
a. Industry versus inferiority
b. Initiative versus guilt
c. Generativity versus stagnation
d. Intimacy versus isolation
64. 25-year-old client, who had a hysterectomy due to
uterine cancer tells you, “My husband will probably leave
me now because I won’t be able to have any more
children. I am so glad I have one child already.” Which
response by you is most appropriate?
a. “That probably won’t happen. He’ll likely be thankful
that you already have one child.”
b. “Are you afraid your husband will leave you because
he wants more children?”
c. “There are support groups you and your husband
could attend to help cope with your loss.”
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d. “Your husband should be thankful that you are alive
and didn’t bleed to death!”
65. A 60-year-old client, admitted to a hospital with
chest pain, has been functioning independently at home.
During the night, the client is found wandering in the
hallway and states, “I can’t find my kitchen. I need a
glass of milk.” Your best interpretation of the client’s
behavior is:
a. The client likely had a stroke.
b. The stress of being in unfamiliar surroundings has
caused the client’s confusion.
c. The decline in mental status, especially at night, is a
normal part of aging.
d. This is an insidious change and it likely means the
client has early dementia.
Situation 14: In the Philippines, there has been a rise in
mental health illnesses. About 1 in 3 Filipinos die every
year from suicide.
66. Which nursing diagnosis should a nurse give highest
priority when caring for a client with major depressive
disorder? a. Powerlessness
b. Compromised Human Dignity
c. Risk for Self and Other- Directed Violence
d. Disturbed Sleeping Patterns
67. A nurse is meeting with a client who is being
discharged after hospitalization for suicidal ideation.
Based on knowledge of expert consensus of warning
signs for suicide, the nurse should plan to advise the
client to seek help by contacting a mental health
professional or calling the national suicide prevention
hotline if experiencing: (SELECT ALL THAT APPLY by
encircling all possible letters of the correct answers).
a. Sadness.
b. Hopelessness.
c. Severe Anxiety and Agitation.
d. Feeling of Being Trapped.
e. Increasing Alcohol or Drug Use.
68. You are reviewing diet restrictions with a suicidal
client taking a monoamine oxidase inhibitor (MAOI).
Which symptom could occur with non-adherence to diet
restrictions while taking a MAOI?
a. Agranulocytosis
b. Explosive Occipital Headache
c. Severe Hypotension d. Akathisia
69. An experienced nurse is teaching a new nurse about
establishing therapeutic relationships with clients on a
mental health unit. Which intervention should the nurse
suggest when attempting to establish a therapeutic
relationship with a client diagnosed with major
depressive disorder?
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a. Sit with the client in silence.
b. Ask the client to join others to watch a 2- hour movie.
c. Invite the client to attend an exercise class.
d. Ask the client how his or her day should be
scheduled.
70. A depressed client tells a nurse, “Nothing gives me
joy. Things seem hopeless.” Which actions should be
you take when caring for this client? Prioritize the
nurse’s actions order.
I. Demonstrate genuine empathy and caring in
discussing client’s feelings about suicide.
II. Evaluate the client’s risk for suicide by direct
questioning (asking about suicide intent and plan).
III. Initiate suicide precautions as needed, according to
policy and standards of care.
IV. Continue to support and monitor prescribed medical
and psychosocial treatment plans.
V. Assist client in maintaining nutritional needs, hygiene,
and grooming.
VI. Contact the client’s support system in collaboration
with case manager and/or social services.
a. II, III, V, I, IV, VI
b. III, II, I, V, IV, VI
c. II, III, I, V, IV, VI
d. III, II, V, I, IV, VI
Situation 15: You are a newly hired registered nurse
taking care of clients with mental illnesses.
71. You are assessing a recently admitted client who is
exhibiting agitation that appears to be related to acute
mania. Which action should a nurse plan to utilize when
caring for a client experiencing agitation related to acute
mania?
a. Apply restraints to prevent the client from harming
self or others
b. Involve the client in group activities to provide
structure
c. Leave the client alone
d. Maintain a low level of stimuli in the client’s
environment
72. You are assessing a client recently admitted to a
psychiatric unit who is experiencing acute mania. Which
nursing action should the nurse plan when caring for a
client with acute mania?
a. Sustain conversations to improve the client’s
concentration.
b. Provide finger foods that the client can carry while
moving around the unit.
c. Teach the client and family about available community
resources.
d. Help the family understand that anger directed at
them is likely to escalate unless they confront the client’s
behavior.
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73. You are caring for a client diagnosed with acute
mania. You observe coarse hand tremors and learns that
the client’s serum lithium level is 1.8 mEq/L. Which
action should be you take?
a. Continue to administer lithium as ordered.
b. Advise the client to limit fluids.
c. Withhold the medication and notify the physician.
d. Acknowledge that the side effects are unpleasant.
74. Which goals should be included in the plan of care
for a client with dementia? (SELECT ALL THAT APPLY by
encircling all possible letters of the correct answers).
a. The client will remain physically safe.
b. The client will receive emotional support.
c. The client will receive physical health care.
d. The client will show cognitive improvement.
e. The client will function at highest level of
independence.
f. The client will perform activities of daily living
independently.
75. A client diagnosed with delirium is restrained in
order to prevent the removal of a Foley catheter and an
intravenous fluid line. Which response should you expect
after the client is restrained?
a. The client rests better at night.
b. The client becomes visibly agitated.
c. The client requires less pain medication.
d. The client experiences a decrease in blood pressure.
Situation 16: In all fields, a nurse’s foundation is key to
providing adequate and safe care.
76. A nurse reviews the record of a client who has been
immobile because of a degenerative neurological
condition. The nurse reads that the client has bilateral
foot drop. Which finding during the nurse’s assessment
supports the presence of foot drop?
a. The great toe is dorsiflexed and the other toes are
fanned out.
b. The feet are unable to be maintained perpendicular to
the legs
c. The client is unable to move feet into a position of
plantar flexion.
d. The client is only able to dorsiflex the feet bilaterally.
77. A client reports pain at an intravenous infusion site
that has infiltrated. When a nurse applies a warm, moist
compress to the site, the client asks how the treatment
will help the condition. The nurse answers the client
based on the understanding that the application of moist
heat will:
a. Alter tissue sensitivity by producing numbness.
b. Decrease the metabolic needs of the involved tissues.
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c. Stop the local release of histamine in the tissues.
d. Increase blood flow and improve capillary
permeability.
78. A client is transferred to a medical center from a
local hospital and undergoes emergency treatment
related to acute coronary syndrome. The client has slept
little over the past 24 hours. Which assessment finding
is consistent with sleep deprivation?
a. Periods of apnea lasting greater than 5 seconds
b. Slowing of thought processes
c. Hyperventilation
d. Cool extremities
79. A nurse takes a client’s blood pressure with an
automatic blood pressure machine. The blood pressure
is 86/56 mm Hg with a pulse rate of 64 beats per
minute. Which action should the nurse do first?
a. Assess the client for dizziness and assess the skin on
the extremities for warmth
b. Obtain a manual blood pressure cuff and retake the
client’s blood pressure
c. Elevate the head of the client’s bed
d. Read the client’s medical record and determine the
client’s normal range of blood pressure
80. Which signs should indicate to a nurse that a client
is experiencing a surgical site infection? (SELECT ALL
THAT APPLY by encircling all possible letters of the
correct answers).
a. Temperature of 100.4°F (38°C)
b. Localized pain and tenderness
c. Well-approximated wound edges
d. Redness or warmth at the affected site
e. Purulent drainage at the incision site
f. Thick, white drainage in the Jackson-Pratt (JP) tubing
Situation 17: The Filipino registered nurse, believing in
the worth and dignity of each human being, recognizes
the primary responsibility to preserve health at all costs.
81. As an ethical and professional nurse, which of the
following is NOT a part of your primary responsibilities?
a. Promotion of Health
b. Prevention of Illness
c. Alleviation of Suffering
d. None of the above
82. In the community setting, which of the following
ensures the nurse’s success in the delivery of health
programs?
a. Appropriate collaboration with the local government
officials
b. Pakikisama and respect to values, customs and
spiritual beliefs
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c. Good communication skills
d. Professional working relationship with coworkers
83. Nurses, whether in the hospital or in the community,
are accountable for all nursing actions done on the
clients and their measured outcomes. Which of the
following serves as the hallmark of nursing
accountability?
a. Accurate Documentation
b. Patient Advocacy
c. Professionalism
d. Safeguarding the rights and privileges of all clients
84. It is the due responsibility of the nurse to the
profession to be a member of an accredited professional
organization (APO). In the Philippines, which of the
following is the APO for nurses?
a. Philippine Nurses’ Association (PNA)
b. Critical Care Nurses’ Association of the Philippines,
Inc. (CCNAPI)
c. Association of Nursing Service Administrators in the
Philippines (ANSAP)
d. Operating Room Nurses Association of the Philippines
(ORNAP)
85. Ethically, nurses should respect individual freedom of
any client to make a rational and unconstrained
decision. This ethical principle is thereby termed as:
a. Trust
b. Autonomy
c. Initiative
d. Industry
Situation 18: Nurses must be aware of the legal bases of
their roles and responsibilities in caring for clients.
86. A presidential decree was enacted that requires the
registration of births and deaths in the Philippines from
January 1, 1974 and thereafter. This is dubbed as:
a. PD 996
b. PD 651
c. PD 856
d. PD 825
87. A presidential decree was enacted providing penalty
for improper disposal of garbage. This is dubbed as:
a. PD 996
b. PD 651
c. PD 856
d. PD 825
88. A presidential decree was enacted recognizing the
importance of sanitation and its effects on public health
and welfare. This is dubbed as
a. PD 996
b. PD 651
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c. PD 856 d. None of the above
d. PD 825
95. This is an act restricting the excise tax on alcohol
89. A presidential decree was enacted to protect children and tobacco products. This is dubbed as: a. RA 10354 b.
against death, disease, and disability through an RA 10351 c. RA 10643 d. None of the above Situation
integrated and comprehensive basic immunization 20: Environmental health is the field of health studying
program. This is also the basis for the new law on the how the environment influences human health and
national immunization program. This is dubbed as: disease. Nurses must be knowledgeable about the
a. PD 996 existing laws concerning environmental health.
b. PD 651
c. PD 856 96. This is an act establishing a comprehensive air
d. PD 825 quality management policy and program in the
Philippines. This is dubbed as:
90. A law was enacted to establish a system and defines a. RA 9003
powers of the provincial, city, municipal, and barangay b. RA 8749
governments in the Philippine, including control over the c. RA 9275
health offices in areas of rule. This is dubbed as: d. RA 6969
a. RA 9173
b. RA 7600 97. This is an act declaring the policy of the state in
c. RA 7160 adopting a systematic, comprehensive, and ecological
d. EO 51 solid waste management program. This is dubbed as:
a. RA 9003
Situation 19: Moreover, there are laws existing in the b. RA 8749
Philippines guiding nurses in the promotion of health in c. RA 9275
the primary level. d. RA 6969
91. This is a law that adopts a national code of
marketing of breastmilk substitutes, supplements, and 98. This is an act controlling toxic substances and
related products. This is dubbed as: hazardous and nuclear wastes. This is dubbed as:
a. RA 9173 a. RA 9003
b. RA 7600 b. RA 8749
c. RA 7160 c. RA 9275
d. EO 51 d. RA 6969

92. This is an act that provides incentives to all 99. This is an act providing for a comprehensive water
government and private health institutions with quality management. This is dubbed as:
rooming-in and breastfeeding practices. This dubbed as: a. RA 9003
a. RA 9173 b. RA 8749
b. RA 7600 c. RA 9275
c. RA 7160 d. RA 6969
d. EO 51
100. The law governing your practice of the profession
93. This is an act that guarantees universal access to as nurse is called:
methods of contraception, fertility control, sexual a. RA 9731
education, and maternal care. This is dubbed as: b. RA 9713
a. RA 10354 c. RA 9173
b. RA 10351 d. RA 9371
c. RA 10643
d. None of the above

94. This is an act effectively instilling health

consciousness through graphic health warnings on
tobacco products. This is dubbed as:
a. RA 10354
b. RA 10351
c. RA 10643

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