1. Nurse Suzie is administering 12:00 PM medication in Ward 4.

Two patients have to receive

Lanoxin. What should
Nurse Suzie does when one of the clients does NOT have a readable identification band?
A. Ask the client if she is Mrs. Santos
B. Ask the client his name
C. Ask the room mate if the client is Mrs. Santos
D. Compare the ID band with the bed tag

2. Lizette, a head nurse in a surgical unit, hears one of the staff nurses say that she
does not touch any client assigned to her unless she performs nursing procedures or
conducts physical assessment. To guide staff nurse in the use of touch, which of the
following would be the BEST response of Lizette?
A. "Use touch when the situation calls for it".
B. Touch serves as a connection between the nurse and the patient."
C. "Use touch with discretion."
D. Touch is used in physical assessment."

3. You are asked to teach the client, Mr. Lapuz who has right sided weakness the use of
a cane. Which observation will indicate that Mr. Lapuz is using the cane correctly?
A. The cane and one foot or both feet are on the floor at all times
B. He advances the cane followed by the left leg
C. Client keeps the cane on the right side along the weak leg
D. Client leans to the left side which is stronger

4. George, a 43 year old executive, is scheduled for cardiac bypass surgery. While being
prepared for surgery, he says to the nurse "I am not going to have the surgery. I may die
because of the risk". Which response by the nurse is most appropriate?
A. "Without the surgery you will most likely die sooner."
B. There are always risks involved with surgery."
C. There is a client in the other room who had successful surgery and you can talk to
him".
D. "This must be very frightening for you. Tell me how you feel about the surgery."

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

6. Nurse Glenda gets a call from a neighbor who tells her that his 3 years old daughter
has been vomiting and has fever and asks for advice. Which of the following is the most
appropriate action of the nurse?
A. Observe the child for an hour if the child does not improve, refer to the physician in
the neighborhood
B. Recommend to bring the child immediately to the hospital
C. Assess the child, recommend observation and administer acetaminophen. If
symptoms continue, bring to the hospital
D. Tell the neighbor to observe the child and give plenty of fluids. If the child does not
improve, bring the child to the hospital

7. Wilfred, 30 years old male, was brought to the hospital due to injuries sustained from
a vehicular accident. While being transported to the X-ray department, the straps
accidentally broke and the client fell to the floor hitting his head. In this situation, the nurse
is:
A. Not responsible because of the doctrine of respondent superior
B. Free from any negligence that caused harm to the patient
C. Liable along with the employer for the use of a detective equipment that harms the
client
D. Totally responsible for the negligence

8. While going on evening round, Nurse Edna saw Mrs. Pascual meditating and
afterwards started singing prayerful hymns. What is the BEST response of Edna?
A. Ignore the incidence
B. Report the incidence to the head nurse
C. Respect the client's actions as this provides structure and support to the client
D. Call her attention so she can go to sleep

9. A client asks for advice on low cholesterol food. You advise the client to eat the
following:
A. Chicken liver, cow liver, eggs
B. Lean beef and pork, egg white, fish
C. Balut, salted eggs, duck and chicken egg
D. Pork liempo, cow brain, lungs and kidney

10. The code of ethics for nurses has an interpretive statement that provides:
A. Continuity of care for the improvement of the client
B. Guide for carrying out nursing responsibilities that provide quality care and for the
ethical obligation of the profession
C. Standards of care in carrying out nursing responsibilities
D. Identical care to all clients in any setting

11. Which of the following situations would possibly cause a nurse to be sued due to
negligence?
A. Nurse gave a client wrong medication and an hour later, client complained of
dyspnea
B. While preparing a medication, the nurse notices that instead of 1 tablet, she put two
tablets into the client's medicine cup
C. As the nurse was about to administer medication, the client questioned why the
medication is still given when in fact the physician discontinued it
D. Nurse administered 2 tablets of analgesic instead of 1 tablet as prescribed. Patient
noticed the error and complained.
12. Your nurse supervisor asks you who among the following clients is most susceptible
to getting infection if admitted to the hospital:
A. Diabetic client type 2
B. Client with chronic obstructive pulmonary disease (COPD)
C. Client with second degree burns
D. Client with psoriasis

13. Mr. Chris Martinez has been confined for three days. His wife helped take care of him
and he has observed her to be too involved in his care. He complained to the head nurse
about this. Which of the following would be the BEST response of the nurse?
A. "Dont worry. I will call the attention of your wife."
B. "Your wife is just trying to help because she is worried about you."
C. "What are your thoughts about your wife's involvement in your care?"
D. Your wife can assist you well in your care and recovery."

14. The nurse is in the hospital canteen and hears two staff nurses talking about the
client confined in Room 612. They mentioned his name and discussed details of his
condition. Which of the following actions should the nurse take?
A. Approach the two nurses and tell them that their actions are inappropriate especially
in a public place
B. Wait till the nurses finish the discussion and report the situation to the supervisor
C. Say nothing to avoid embarrassing the staff nurses
D. Remain quiet and ignore the discussion

15. The son of Mr. Rosario, a 76 year old man, reports to the nurse in the community
health center that his father has been getting out of bed at night and walks around the
house in the early hours of the morning causing him to fail and injure himself. Which
instruction would you give?
A. Apply restraints during the night hours only
B. Advise hospitalization to prevent future accidents
C. Keep a radio or TV for company and to orient the client
D. Have someone check on the client frequently at night

SITUATIONAL

Situation 1 - Preparation and administration of medications is a nursing function that cannot

be delegated. It is important that the nurse has a deep understanding of this responsibility
that is meant to save patients' lives

16. You are to administer an intramuscular injection to Dulce, 1 1/2 year old girl. The
most appropriate site to administer the drug is:
A. dorso gluteal region
B. ventrogluteal region
C. vastus lateralis
D. gluteal region
17. An infant is ordered to receive 500 ml of D5NSS for 24 hours. The Intravenous
infusion set is at 60 drops/ml. How many drops per minute should the flow rate be?
A. 60 drops per minute
B. 21 drops per minute
C. 30 drops per minute
D. 15 drops per minute

18. Following surgery, Henry is to receive 20 mEq (milliequivalent) of potassium chloride

to be added to 1000 ml of D5W to run for 8 hours. The intravenous infusion set is calibrated
at 20 drops per milliliter. How many drops per minute should the rate be to infuse 1 liter of
D5W for 8 hours?
A. 42 drops
B. 20 drops
C. 60 drops
D. 32 drops

19. Mr. Lagrito is to receive 1 liter of D5LR to run for 12 hours. The drop factor of the IV
infusion set is 10 drops per ml. Approximately how many drops per minutes should the IV be
regulated?
A. 13 14 drops
B. 17 18 drops
C. 10 12 drops
D. 15 16 drops

20. The Physician ordered Nembutal Na gr. XX. The bottle contains 100 mg/capsule. How
many capsules will be administered to the client?
A. 11 capsule
B. 12 capsules
C. 15 capsule
D. 10 capsule

Situation 2 - The nurse supervisor is observing the staff nurses in her hospital to see how
quality of care provided to clients can be improved.

21. The nurse supervisor is not satisfied with the bed bath that is provided by Nurse
Arthur. To improve the care provided to the patients in the unit by Nurse Arthur, the nurse
supervisor should:
A. tell the nurse how to give bed baths correctly
B. ask another staff nurse to do the bed baths instead
C. provide a manual to be read on giving bed baths
D. bring the staff nurse to a client's room and demonstrate a cleansing bath

22. The staff nurse discusses with the novice nurse the type of wound dressing that is
best to use for a client. Together, they observe how well the dressings absorb the drainage.
In what-step of the decision making process are they?
A. Testing options
B. Considering effects on results
C. Defining the problem
D. Making final decisions

23. To check if the nurses under her supervision use critical thinking, Mrs. David
observers if the nurses act responsibly when at work. Which of the following actions of a
nurse demonstrates the attitude of responsibility?
A. Thinking of alternative methods of nursing care
B. Sharing ideas regarding patient care
C. Following standards of practice
D. Planning other approaches for patient care

24. The nurse who makes clinical judgment can be depended upon to improve the quality
of care of clients. Nurse Julie uses such good clinical judgment when she gives priority care
to this client:
A. Roman, a client who is ambulatory and for surgery tomorrow
B. A post-operative client, Rey, who has a blood pressure of 90/50 mmHg
C. Mr. Abad, a client who needs instructions for home medications
D. Fred, a client who received pain medication 5 minutes ago

25. A good nursing care plan is dependent on a correctly written nursing diagnosis. It
defines a clients problem and its possible cause. The following is an example of a well
written nursing diagnosis:
A. Acute pain related to altered skin integrity secondary to hysterectomy
B. Electrolyte imbalance related to hypocalcemia
C. Altered nutrition related to high fat intake secondary to obesity
D. Knowledge deficit related to proctosigmoidoscopy

Situation 3 - You are taking care of Mrs. Bernas, 66 years old, who is terminally ill with
ovarian cancer stage IV.

26. When caring for a dying client you will perform which of the following activities?
A. Encourage the client to reach optimal health
B. Assist client perform activities of daily living
C. Assist the client towards a peaceful death
D. Motivate client to gain independence

27. The client prepares for her eventual death and discusses with the nurse and her
family how she would like her funeral to look like and what dress she will use. This client is in
the stage of:
A. acceptance
B. resolution
C. denial
D. bargaining
28. The nurse is to administer Demerol 50 mg and Vistaril 50 mg. IM to Mrs. Leyba.
Demerol is available in a mutidose vial labeled 100mg/ml while Vistaril comes in an ampule
labeled 50 mg/ml. You are to give both medications in one injection. You will:
A. withdraw the medication from the vial first then from the ampule
B. inject air into the vial, then into the ampule
C. Inject air into the ampule, aspirate desired dose, then into the vial
D. withdraw medication from the ampule then from the vial

29. When giving Demerol 50 mg from a multidose vial labeled 100 mg/ml and Vistaril 50
mg from an ampule labeled 50 mg/ml. What is the total volume that you will inject to the
client?
A. 2 ml
B. I ml
C. 1.5 ml
D. 1.75 ml

30. Mrs. Bernas is emaciated and is at risk for developing which problem in skin
integrity?
A. Blisters
B. Reddening of the skin
C. Pressure sores
D. Pustules

Situation 4 - You are assigned to work in an orthopedic ward where clients are expected to
have problems in mobility and immobility.

31. Ramils right leg is injured and Nurse Karen has to move him from the bed to a wheel
chair. Which of the following is the appropriate nursing action of Nurse Karen?
A. Put the client on the edge of the bed and place the wheelchair at her back
B. Face the client and place the wheelchair on her left side
C. Put the client on the edge of the bed and place the wheelchair on the other side of
the bed
D. Put the client on the edge of the bed and place the wheelchair on the client's left side

32. Carlo has to be maintained on a dorsal recumbent position. Which of the following
should be prevented?
A. Adduction of the shoulder
B. Lateral flexion of the sternocleidosmastoid muscle
C. Hyperextension of the knees
D. Anterior flexion of lumbar curvature

33. Joseph prefers to be in high fowler's position most of the time. The nurse should
prevent which of the following?
A. Posterior flexion of the lumbar curvature
B. Internal rotation of the shoulder
C. External rotation of the hip
D. Adduction of the shoulder
34. Anthony asks to be assisted to move up the bed. Which of the following should Nurse
Diana do first?
A. Move the patient to the edge of the bed near the nurse
B. Adjust the bed to a flat position
C. Lock the wheels of the bed
D. Raise the bed rails opposite the nurse

35. Which of the following supportive devices can be used most effectively by Nurse
Arnold to prevent external rotation of the right leg?
A. Sandbags
B. Firm mattress
C. Pillow
D. High foot board

Situation 5 - As you begin work in the hospital where you are on probation, you are tasked to
take care of a few patients. The clients have varied needs and you are expected to provide
care for them.

36. An ambulatory client, Mr. Zosimo, is being prepared for bed. Which of the following
nursing actions promote safety for the client?
A. Turning off the lights to promote sleep and rest
B. Instructing the client about the use of the call system
C. Raising the side rails
D. Placing the bed in high position

37. Mikka, a 25 year old female client, is admitted with right lower quadrant abdominal
pain. The physician diagnosed the client with acute appendicitis and an emergency
appendectomy was performed. Twelve hours following surgery, the patient complained of
pain. Which of the following is the most appropriate nursing diagnosis?
A. Impaired mobility related to pain secondary to an abdominal incision
B. Impaired movements related to pain due to surgery
C. Impaired mobility related to surgery
D. Severe pain related to surgery

38. You are preparing a plan of care for a client who is experiencing pain related to
incisional swelling following laminectomy. Which of the following should be included in the
nursing care plan?
A. Encourage the client to log roll when turning
B. Encourage the client to do self-care
C. Instruct the client to do deep breathing exercises
D. Ambulate the client in that ward premises every twenty minutes

39. Mr. Lozano, 50 year old executive, is recovering from severe myocardial infarction.
For the past 3 days, Mr. Lozano's hygiene and grooming needs have been met by the
nursing staff. Which of the following activities should be implemented to achieve the goal of
independence for Mr. Lozano?
A. Involving family members in meeting client's personal needs
B. Meeting his needs till he is ready to perform self-care
C. Preparing a day to day activity list to be followed by client
D. Involving Mr. Lozano in his care

40. Mr. Ernest Lopez is terminally ill and he chose to be at home with his family. What
nursing actions are best initiated to prepare the family of Mr. Lopez?
A. Talk with the family members about the advantage of staying in the hospital for
proper care
B. Provide support to the family members by teaching ways to care for their loved one
C. Convince the client to stay in the hospital for professional care
D. Tell the client to be with his family

Situation 6 - Myrna a researcher proposes a study on the relationship between health values
and the health promotion activities of staff nurses in a selected college of nursing.

41. In both quantitative and qualitative research, the use of a frame of reference is
required. Which of the following items serves as the purpose of a framework?
A. Incorporates theories into nursing's body of knowledge
B. Organizes the development of study and links the findings to nursing's body of
knowledge
C. Provides logical structure of the research findings
D. Identifies concepts and relationships between concepts

42. Myrna needs to review relevant literature and studies. The following processes are
undertaken in reviewing literature EXCEPT:
A. Locating and identifying resources
B. Reading and recording notes
C. Clarifying a research topic
D. Using the library

43. The primary purpose for reviewing literature is to :

A. organize materials related to the problem of interest
B. generate broad background and understanding of information related to the research
problem of interest
C. select topics related to the problem of interest
D. gather current knowledge of the problem of interest

44. In formulating the research hypotheses, researcher Myrna should state the research
question as:
A. What is the response of the staff nurses to the health values?
B. How is variable health value" perceived in a population?
C. Is there a significant relationship between health values and health promotion
activities of the staff nurses?
D. How do health values affect health promotion activities of the staff nurses?

45. The proposed study shows the relationship between the variables. Which of the
following is the independent variable?
A. Staff nurses in a selected college of nursing
B. Health values
C. Health promotion activities
D. Relationship between health values and health promotion activities

Situation 7 - White working in a tertiary hospital, you are assigned to the medical ward.

46. Your client, Mr. Diaz, is concerned that he can not pay his hospital bills and
professional fees. You refer him to a:
A. nurse supervisor
B. social worker
C. bookkeeping department
D. physician

47. Mr. Magno has lung cancer and is going through chemotherapy. He is referred by the
oncology nurse to a self-help group of clients with cancer to:
A. receive emotional support
B. to be part of a research study
C. provide financial assistance
D. assist with chemotherapy

48. A diabetic hypertensive client, Mrs. Linao, needs a change in diet to improve her
health status. She should be referred to a:
A. nutritionist
B. dietitian
C. physician
D. medical pathologist

49. When collaborating with other health team members, the best description of Nurse
Rita's role is:
A. encourages the client's involvement in his care
B. shares and implements orders of the health team to ensure quality care
C. she listens to the individual views of the team members
D. helps client set goals of care and discharge

50. Nurse Rita is successful in collaborating with health learn members about the care of
Mr. Linao. This is because she has the following competencies:
A. Communication, trust, and decision making
B. Conflict management, trust, negotiation
C. Negotiation, decision making
D. Mutual respect, negotiation, trust
Situation 8 - The practice of nursing goes with responsibilities and accountability whether
you work in a hospital or in the community setting your main objective is to provide safe
nursing to your clients?

51. To provide safe quality nursing care to various clients in any setting, the most
important tool of the nurse so is:
A. critical thinking to decide appropriate nursing actions
B. understanding of various nursing diagnoses
C. observation skills for data collection
D. possession of in scientific knowledge about client needs

52. You ensure the appropriateness and safety of your nursing interventions while caring
for various client groups by:
A. Creating plans of care for particular clientele
B. Identifying the correct nursing diagnoses for clients
C. Making a thorough assessment of client needs and problems
D. Using standards of nursing care as your criteria for evaluation

53. The effectiveness of your nursing care plan for your clients is determined by:
A. The number of nursing procedures performed to comfort the client
B. The amount of-medications administered to the client as ordered
C. The number of times the client calls the nurse
D. The outcome of nursing interventions based on plan of care

54. You are assigned to Mrs. Amado, age 49, who was admitted for possible surgery. She
complained of recurrent pain at the right upper quadrant of the abdomen 1-2 hours after
ingestion of fatty food. She also had frequent bouts of dizziness, blood pressure of 170/100
hot flashes. Which of the above symptoms would be an objective cue?
A. Blood pressure measurement of 170/100
B. Complaint of hot flashes
C. Report of pain after ingestion of fatty food
D. Complaint of frequent bouts of dizziness

55. While talking with Mrs. Amado, it is most important for the nurse to:
A. Schedule the laboratory exams ordered for her
B. Do an assessment of the client to determine priority needs
C. Tell the client that your shift ends after eight hours
D. Have the client sign an informed consent

Situation 9 - Oral care is an important part of hygienic practices and promoting client
comfort.

56. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals
excessive dryness and presence of sores. Which of the following is BEST to use for oral care?
A. Lemon glycerine
B. Hydrogen peroxide
C. Mineral oil
D. Normal saline solution

57. When performing oral care to an unconscious client, which of the following is a
special consideration to prevent aspiration of fluids into the lungs?
A. Put the client on a sidelying position with head of bed lowered
B. Keep the client dry by placing towel under the chin
C. Wash hands and observe appropriate infection control
D. Clean mouth with oral swabs in a careful and an orderly progression

58. The advantages of oral care for a client include all of the following, EXCEPT :
A. decreases bacteria in the mouth and teeth
B. reduces need to use commercial mouthwash which irritate the buccal mucosa
C. improves client's appearance and self-confidence
D. improves appetite and taste of food

59. A possible problem while providing oral care to unconscious clients is the risk of fluid
aspiration to lungs. This can be avoided by:
A. Cleaning teeth and mouth with cotton swabs soaked with mouth wash to avoid
rinsing the buccal cavity
B. Swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs
C. Use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips
and gums
D. Suctioning as needed while cleaning the buccal cavity

60. Your client has difficulty of breathing and is mouth breathing most of the time. This
causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the
client and in addition, you will keep the mouth moistened by using:
A. salt solution
B. water
C. petroleum jelly
D. mentholated ointment

Situation 10 - Errors while providing nursing care to patients must be avoided and minimized
at all times. Effective management of available resources enables the nurse to provide safe
quality patient care.

61. In the hospital where you work, increased incidence of medication error was
identified as the number one problem in the unit. During the brainstorming session of the
nursing service department, probable causes were identified. Which of the following is
process related?
A. Interruptions
B. Use of unofficial abbreviations
C. Lack of knowledge
D. Failure to identify client
62. Miscommunication of drug orders was identified as a probable cause of medication
error. Which of the following is a safe medication practice related to this?
A. Maintain medication in its unit dose package until point of actual administration
B. Note both generic and brand name of the medication in the Medication
Administration Record
C. Only officially approved abbreviations maybe used in the prescription orders
D. Encourage clients to ask question about their medications

63. The hospital has an ongoing quality assurance program. Which of the following
indicates implementation of process standards?
A. The nurses check client's identification band before giving medications
B. The nurse reports adverse reaction to drugs
C. Average waiting time for medication administration is measured
D. The unit has well ventilated medication room

64. Which of the following actions indicate that Nurse Jerome is performing outcome
evaluation of quality care?
A. Interviews nurses for comments regarding staffing
B. Measures waiting time for clients per nurse's call
C. Checks equipment for its calibration schedule
D. Determines how many clients post surgery have experienced infection

65. An order for a client was given and the nurse in charge of the client reports that she
has no experience of doing the procedure before. Which of the following is the most
appropriate action of the nurse supervisor?
A. Assign another nurse to perform the procedure
B. Ask the nurse to find a way to learn the procedure
C. Tell the nurse to read the procedure manual
D. Do the procedure with the nurse

Situation 11 - Mr. Jose's chart is the permanent legal recording of all information that relates
lo his health care management. As such, the entries in the chart must have accurate data.

66. Mr. Jose's chart contains all information about his health care. The functions of
records include all following EXCEPT:
A. Means of communication that health team members use to communicate their
contributions to the client's health care
B. The client's record also shows a document of how much health care agencies will be
reimbursed for their services
C. Educational resource for student of nursing and medicine
D. Recording of actions in advance to save time

67. An advantage of automated or computerized client care system is:

A. the nursing diagnosis for a client's data can be accurately determined
B. cost of confinement will be reduced
C. information concerning the client can be easily updated
D. the number of people to take care of the client will be reduced
68. Information in the patient's chart is inadmissible in court as evidence when:
A. the client's family refuses to have it used
B. the client objects to its use
C. the handwriting is not legible
D. it has too many abbreviations that are "unofficial

69. Nursing audit aims to:

A. provide research data to hospital personnel
B. study client's illness and treatment regimen closely
C. compare actual nursing done to established standards
D. provide information to health-care providers

70. A telephone order is given for a client in your ward. What is your most appropriate
action?
A. Copy the order on to the chart and sign the physician's name as close to his original
signature as possible
B. Repeat the order back to the physician, copy onto the order sheet and indicate that it
is a telephone order
C. Write the order in the client's chart and have the head nurse co-sign it
D. Tell the physician that you can not take the order but you will call the nurse
supervisor

Situation 12 - Nurse Roque, a newly hired nurse, is asked to take over an absent nurse in
another unit. She will take care of clients with various conditions

71. Which of the following client conditions should be Miss Roque's priority in the
pediatric unit?
A. The baby whose fontanel is bulging and firm while asleep
B. The infant who is brought in for upper respiratory tract infection whose temperature
is slightly elevated
C. A baby who is wailing after being awakened by the banging of the door
D. A baby boy whose circumcision has yellowish exudate

72. When suctioning the endotracheal tube, the nurse should:

A. explain procedure to patient, insert catheter gently applying suction, withdrawn using
twisting motion
B. insert catheter until resistance is met then withdraw slightly, applying suction
intermittently as catheter is withdrawn
C. Hyperoxygenate client then insert catheter using back and forth motion
D. Insert suction catheter four inches into the tube, suction 30 seconds using twirling
motion as catheter is withdrawn

73. Nurse Roque is giving instructions to Doris, the daughter of a comatose patient, to
give a sponge bath. While Doris is doing the sponge bath, what action of Doris needs
correction?
A. Answering the phone while wearing gloves used for sponge bath
B. Rolling the patient like a log to do back rub
C. Lining the rubber mat with bed sheet as incontinence pad for the patient
D. Turning the patient on the left side with head slightly elevated

74. Dina sustained a fracture of the ulna and a cast will be applied. What nursing action
before cast application is most important for Nurse Roque to do?
A. Use baby powder to reduce irritation under the cast
B. Assess sensation of each arm
C. Evaluate skin temperature in the area
D. Check radial pulses bilaterally and comparev

75. To obtain specimen for sputum culture and sensitivity, which of the following
instruction is best?
A. Upon waking up, cough deeply and expectorate into container
B. Cough after pursed lip breathing
C. Save sputum for two days in covered container
D. After respiratory treatment, expectorate into a container

Situation 13 - Infections are quite commonly the reasons for a client's hospitalization.
Appropriate interpretation of diagnostic tests and measures for infection control are helpful
in the management of patient care.

76. Dorothy underwent diagnostic test and the result of the blood examination are back.
On reviewing the result the nurse notices which of the following as abnormal finding?
A. Neutrophils 60%
B. White blood cells (WBC) 90007mm
C. Erythrocyte sedimentation (ESR) is 39 mm/hr
D. Iron 75 mg/100 ml

77. Surgical sepsis is observed when:

A. inserting an intravenous catheter
B. disposing of syringes and needles in puncture proof containers
C. washing hands before changing wound dressing
D. placing dirty soiled linen in moisture resistant bags

78. A client with viral infection will most likely manifest which of the following during the
illness stage of the infection?
A. Client was exposed to the infection 2 days ago but without any symptoms
B. Oral temperature shows fever
C. Acute symptoms are no longer visible
D. Client "feels sick" but can do normal activities

79. Which of the following laboratory test results indicate presence of an infectious
process?
A. Erythrocyte sedimentation rate (ESR) 12 mm/hr
B. White blood cells (WBC) 18.000/mm3
C. Iron 90g/100ml
D. Neutrophils 67%

80. Among the clients you are assigned to take care of, who is most susceptible to
infection?
A. Diabetic client
B. Client with burns
C. Client with pulmonary emphysema
D. Client with myocardial infarction

Situation 14 - A significant milestone influencing the development of nursing concepts and

theories was the establishment of journal of nursing research. Several nursing theorist have
published the framework for practice according to their respective nursing theory.

81. Which of the following theorists consider and utilize nature and environment in the
healing process?
A. Julia Sotejo
B. Ida Jean Orlando
C. Florence Nightingale
D. Imogene King

82. In her theory, Imogene King defined nursing process as a dynamic interpersonal
process between nurse, client and health care system. In this theory, which of the following
nursing skills is most important to help client establish positive adaptation to environment?
A. Assessment skills
B. Communication skills
C. Environment management skills
D. Technical skills

83. Who among the following theorists has identified twenty one specific client needs or
problems in the area of comfort, hygiene, safety, physiologic balance, psychologic and social
factors and sociological and community factors?
A. Faye Abdellah
B. Dorothy Johnson
C. Sister Callista Roy
D. Virginia Henderson

84. Which of the following nurse theorists has stated that the goals of nursing is to
maintain and promote health, prevent illness and care for and rehabilitate ill and disabled
client through humanistic science and nursing.
A. Orem
B. Abdellah
C. Nightingale
D. Rogers
85. Nursing care becomes necessary when clients is unable to fulfill biological,
physiological development or social needs explains which of the following theories:
A. Adaptation theory
B. Self-care deficit theory
C. Theory of the Unity of Man
D. Transcultural care theory

Situation 15 - When creating your lesson plan for cerebrosvascular disease or STROKE, it is
important to include the risk factors of stroke.

86. The most important risk factor is:

A. cigarette smoking
B. hypertension
C. binge drinking
D. heredity

87. Part of your lesson plan is to talk about etiology or cause of stroke. The types of
stroke based on cause are the following EXCEPT:
A. embolic stroke
B. hemorrhagic stroke
C. diabetic stroke
D. thrombotic stroke

CORRECT ANSWER: C
RATIONALE: Strokes can be classified into two main categories, including the following:
ischemic strokes - strokes caused by blockage of an artery.
hemorrhagic strokes - strokes caused by bleeding.
An ischemic stroke occurs when a blood vessel that supplies the brain becomes blocked or
"clogged" and impairs blood flow to part of the brain. Ischemic strokes are further divided
into two groups, including the following:
thrombotic strokes - caused by a blood clot that develops in the blood vessels inside
the brain.
embolic strokes - caused by a blood clot that develops elsewhere in the body and
then travels to one of the blood vessels in the brain via the bloodstream.
Hemorrhagic strokes occur when a blood vessel that supplies the brain ruptures and bleeds.
Hemorrhagic strokes are divided into two main categories, including the following:
intracerebral hemorrhage - bleeding from the blood vessels within the brain.
subarachnoid hemorrhage - bleeding in the subarachnoid space (the space between
the brain and the membranes that cover the brain).
http://medicalcenter.osu.edu/patientcare/healthcare_services/stroke/types/

88. Hemorrhagic stroke occurs suddenly usually when the person is active. All are
causes of hemorrhage, EXCEPT:
A. phlebitis
B. trauma
C. damage to blood vessel
D. aneurysm

89. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke.
Which drug is closely linked to this?
A. Amphetamines
B. Cocaine
C. Shabu
D. Demerol

90. A participant in the STROKE class asks what is a risk factor of stroke. Your best
response Is:
A. "More red blood cells thicken blood and make clots more possible."
B. "Increased RBC count is linked to high cholesterol."
C. "More red blood cells increase hemoglobin content."
D. "High RBC count increases blood pressure."

Situation 16 - Accurate computation prior to drug administration is a basic skill all nurses
must have.

91. Ronald is diagnosed with amoebiasis and is to receive Metronidazole (Flagyl) tablets
1.5 gm daily in 3 divided doses for 7 consecutive days. Which of the following is the correct
dose of the drug that the client will receive per oral administration?
A. 1,000 mg tid
B. 500 mg tid
C. 1,500 mg tid
D. 250 mg tid

92. Riza, a 2 year old female was prescribed to receive 62.5 mg suspension three times a
day. The available dose is 125 mg/ml. Which of the following should Nurse Paulo prepare for
each oral dose?
A. 0.5 ml
B. 1.25 ml
C. 2.5 ml
D. 1.0 ml

93. The physician ordered Potassium Chloride (KCl) in D5W 1 liter to be infused In 24
hours for Mrs. Gomez. Since Potassium Chloride is a high risk drug. Nurse Robert used an
intravenous pump. Which of the following should Nurse Robert do to safely administer this
drug?
A. Check the pump setting every 2 hours
B. Teach the client how the infusion pump operates
C. Have another nurse check the infusion pump setting
D. Set the alarm of the pump loud enough to be heard
94. Baby Liza, 3 months old, with a congenital heart deformity, has an order from her
physician; "give 3.00 cc of Lanoxin today for 1 dose only". Which of the following is the most
appropriate action by the nurse?
A. Clarify order with the attending physician
B. Discuss the order with the pediatric heart specialist in the unit
C. Administer Lanoxin intravenously as it is the usual route of administration
D. Refer to the medication administration record for previous administration of Lanoxin

95. When Nurse Norma was about to administer the medications of client Lennie, the
relative of Lennie told the nurse that they buy her medicines and showed the container of
medications of the client. Which of the following is the most appropriate action by the
nursed?
A. Hold the administration of the client's medication and refer to the head nurse
B. Put aside the medications she prepared and instead administer the client's
medications
C. Tell the client that she will inform the physician about this
D. Bring the medications of the client to the nurse's station and prepare accordingly

Situation 17 - You are taking care of Mrs. Santillan, a 48 year old woman who is unconscious
after a cerebrovascular accident. You are aware that there are many physical complications
due to immobility.

96. You should be alert for the following complications she may experience EXCEPT:
A. Impaired mobility
B. Contractures and muscle atrophy
C. Hypostatic pneumonia
D. Pressure sores

97. Proper positioning of an immobilized unconsciousness client is important for the

following reasons EXCEPT:
A. Maintain skin integrity
B. Promotes optimal lung expansion
C. Prevent injuries and deformities of the musculoskeletal system
D. Facilitates rest and sleep

98. When positioning your client, you should observe good body mechanics for yourself
and the client. This means that the nurse:
A. Uses back muscles
B. Assumes correct body alignment and efficient use of muscles to avoid injury
C. Observes rhythmic movements when moving about
D. Uses large muscles only
99. You are going to move Mrs. Santillan, a 150 lbs. unconscious woman. Some principles
to use when moving the client include the following EXCEPT:
A. Prepare to move client by taking a deep breath and tightening abdominal and gluteal
muscles
B. Maintain wide base of support With feet and with knees flexed
C. Push and pull using arms and legs instead of lifting
D. Move close to the object to be moved leaning cm bending at the waist

100. After moving Mrs. Santillan to the desired position, which action will you avoid?
A. Avoid friction between bony prominences
B. Place pillows to position client's extremities
C. Apply restraints
D. Raise bed rails

TEST II

1. Registered nurses can be identified as a:

A. organization
B. culture
C. group
D. subculture

2. Among children candidates for organ transplant, when all selected children have
appropriate tissue matches for the same donated organ, the basis for the decision as to
which child gets the organ is that the organ is given to the child who:
A. will receive the most benefit from the new organ
B. is most likely to die without the transplant
C. is selected by the lottery system for available organs
D. is at the top of the list and has waited the longest time

3. The nurse uses what equipment to check for fluid between the parietal and visceral
layers of the tunica vaginalis, the outermost covering of the testes?
A. 30 cc syringe
B. Transilluminator
C. Fluid meter
D. Manometer

4. Which of the following examples best defines the term role reversal?
A. A lazy person becomes very productive in the family
B. The good child takes on a bad child role
C. A person who has been a good provider quits his or her job
D. The child assumes a caregiver role toward the caregiver
5. When a nurse breaches the duty of confidentiality, he or she can be disciplined by
both the employer and the Board of Nursing. In addition to this discipline, he or she can:
A. be held responsible for any damages that result
B. be fined by the federal government
C. be sentenced for up to 1 year in jail
D. immediately lose his or her nursing license

6. A strategy for change that focuses on teaching workers new technology is:
A. normative-reeducative
B. training
C. providing information
D. power coercive

7. The nurse knows that the occurrence of shoulder dystocia during labor is most likely
related to:
A. polyhydramnios
B. maternal age
C. preterm birth
D. macrosomia

8. The nurse instructs the mother that when overstimulated the infant will:
A. show increased alertness and eye contact
B. respond with coordinated, synchronous body movement
C. look away to reduce the intensity of the interaction
D. drift off to deep sleep to shut out the interaction

9. Some strategies to maintain professional health are listed below. Which is NOT
necessarily correct?
A. Networking with others in the health care field
B. Join a professional organization
C. Goal setting
D. Read fiction and nonfiction materials

10. The nurse is assessing a 6 month old infant for head lag, pulling the infant by the
hands from a supine to a sitting position. The head does not stay in line with the body when
being putted forward. Which of the following statements best represents the significance of
this finding?
A. Head lag should not be tested until the child is over 1 year of age.
B. Significant head lag after the age of 6 months may indicate brain injury and needs
further investigations.
C. The nurse has not conducted the test correctly and must do it again using proper
technique.
D. This is a normal finding, as the infant's head will not stay in line until after 3 months
of age.

11. Which statement is correct regarding the use of the cervical cap?
A. It may affect Pap smear results
B. It does not need to be fitted by a physician
C. It does not require the use of a spermicide
D. It must be removed within 24 hours

12. The major components of the communication process are:

A. verbal, written, and nonverbal
B. speaker, listener and reply
C. facial expression, tone of voice, and gestures
D. message, sender, channel, receiver, and feedback

13. The extent of burns in children are normally assessed and expressed in terms of:
A. the amount of body surface that is unburned
B. percentages of total body surface area (TBSA)
C. how deep the deepest burns are
D. the severity of the burns on a 1 to 5 burn scale

14. The school nurse notices a child who is wearing old, dirty, poor fitting clothes; is
always hungry; has no lunch money; and is always tired. When the nurse asks the boy his
tiredness, he talks of playing outside until midnight. The nurse will suspect that this child is;
A. being raised by a parent of level intelligence quotient (IQ)
B. an orphan
C. a victim of child neglect
D. the victim of poverty

15. Which of the following indicates the type(s) of acute renal failure?
A. Four types: hemorrhagic with and without clotting, and nonhemorrhagic with and
without clotting
B. One type: acute
C. Three types: prerenal, intrarenal and postrenal
D. Two types: acute and subacute

16. A means of facilitating professional staff development is by building upon skills,

abilities, and experience of each practitioner is called:
A. The novice to expert model
B. Situational leadership model
C. Career enhancement
D. Clinical ladder

17. Which of the following questions by the nurse would best fit the philosophy of the
nursing mutual participation model of care (NMPMC)?
A. "Have you brushed your child's teeth today?"
B. "How does your child look to you today?"
C. "Where have you been all morning?"
D. "Do you think your child's color is worse?"

18. There are numerous definitions of the word "health". Which definition below is from
Florence Nightingale?
A. A state or a process of being and becoming an integrated and whole person
B. The state of being free from illness or injury
C. Being well and using every power the individual possesses to the fullest extent.
D. A state of complete physical, social, and mental well-being and not merely the
absence of disease or infirmity

19. Informal communication takes place when individuals talk and is best described by
saying the participants:
A. are involved in a preexisting informal relationship
B. talk with slang words
C. have no particular agenda or protocol
D. are relaxed

20. Tertiary care by the home health nurse is directed toward children with:
A. problems in mobility
B. short-term needs
C. minor problems
D. clinically apparent disease

21. The endometrium thickens during which phase of the menstrual cycle?
A. Secretory phase
B. Menstrual phase
C. Proliferative phase
D. Ischemic phase

22. A measurement tool to articulate the nursing workload for a specific patient or groups
of patients over a specific period of time is called:
A. Staffing pattern
B. Skill mix
C. Benchmarking
D. Patient classification

23. The mother of a 9-month-old infant is concerned that the head circumference of her
baby is greater than the chest circumference. The BEST response by the nurse is:
A. These circumferences normally are the same, but in some babies this just differs.
B. "Perhaps your baby was small for gestational ago or premature."
C. This is normal until the age of 1 year, when the chest will be greater."
D. "Let me ask you a few questions, and perhaps we can figure out the cause of this
difference."

24. Which of the following approaches would work best when the nurse is communicating
with an infant?
A. Use an adult voice just as you would for anyone
B. Communicate through the caregivers
C. Allow the child lime to warm up to the nurse
D. Respond only after the child cries for a little while

25. Evidence-based care started in medicine as a way to:

A. promote technological advances in medicine
B. incorporate collaboration within all health care disciplines
C. integrate individual experience with clinical research
D. teach medical students the art and science of medicine

26. The nurse assessing newborn babies and infants during their hospital stay after birth
will notice which of the following symptoms as a primary manifestation of Hirschsprung's
disease?
A. A fine rash over the trunk
B. Failure to pass meconium during the first 24 to 40 hours after birth
C. The skin turns yellow and then brown over the first 48 hours of life
D. High-grade fever

27. A client is 7 months pregnant and has just been diagnosed as having a partial
placenta previa. She is stable and has minimal spotting and is being sent home. Which of
these instructions to the client may indicate a need for further teaching?
A. Maintain bed rest with bathroom privileges
B. Avoid intercourse for three days
C. Call if contractions occur
D. Stay on left side as much as possible when lying down

28. Which of the following groups of people in the world disproportionately represents the
homeless population?
A. Hispanics
B. Asians
C. African Americans
D. Caucasians

29. The nurse notices that the infant is wearing a plastic-coated diaper. If a topical
medication were to be prescribed and it were to go on the stomach or buttocks, the nurse
would teach the caregivers to:
A. avoid covering the area of the topical medication with the diaper
B. avoid the use of clothing on top of the diaper
C. put the diaper on as usual
D. apply an icepack for 5 minutes to the outside of the diaper

30. The nurse assessing a child of adolescent with a diagnosis of dysrhythmic disorder
would find which of the following symptoms?
A. Labile mood and hyperactive thyroid with an increase in circulating thyroid hormones
and associated symptoms
B. Severe shaking of the hands when trying to hold a glass of water or other object
C. A depression that is deeper, more acute, and more likely to lead to suicide than major
depressive disorder
D. A depressed or irritable mood for most of the day, on most days, for 2 or more years
and low energy or fatigue

31. You were the nurse assigned to work with a child who has had whole brain radiation.
You have assessed the child to be sleeping up to 20 hours a day and is having some nausea,
malaise, fever, and dysphasia. Based on this assessment, you have to work with the parents
in which of the following areas?
A. Accepting a reoccurrence of the tumor
B. Dealing with the side effects of radiation therapy
C. Caring for the dying child
D. Accepting the imminent death of their child

32. The nurse is planning interventions for a child who has inflammatory bowel disease
(IBD) with a nursing diagnosis of "Nutrition: Less than body requirements". Which of the
following interventions will be most helpful in resolving this nursing problem?
A. Two large meals a day instead of several minimeals and snacks
B. Special IBD diet (diet that has been proven effective for treating IBD)
C. Salt-free diet high in potassium, vitamins, and minerals
D. Diet as tolerated with lactose, hydrolyzed milk instead of milk products, and omission
of highly seasoned foods, and reduction of fiber

33. Emotional intelligence consists of a number of competencies. Some of these are

listed below. Which is NOT a characteristic of emotional intelligence?
A. Self-esteem
B. Self-awareness
C. Empathy
D. Self-regulation

34. Data collection for driving and restraining forces, including costs, desirability, and
feasibility, is a:
A. people issue
B. structural issue
C. political issue
D. technology issue

35. One of four factors describing the experience of sexually abused children and the
effect it has on their growth and development is somatization that occurs when:
A. a child blames him-or herself for the sexual abuse and begins to withdraw and isolate
B. newspapers and the media don't keep sexual abuse private and accidentally or on
purpose reveal the name of the victim
C. the child has been blamed by the abuser for his or her sexual behaviors, saying that
the child asked to be touched or did not make the abuser stop
D. the child is shared by other members of the family or friends when the sexual abuse
becomes public knowledge

36. The painful phenomenon known as "back labor" occurs in a client whose fetus in
what position?
A. Brow Position
B. Right Occipito-Anterior Position
C. Breech Position
D. Left Occipito-Posterior Position

37. FOCUS methodology stands for:

A. Focus, Organize, Clarify, Understand, Solution
B. Focus, Opportunity, Continuous, Utilize, Substantiate
C. Focus, Organize, Clarify, Understand, Substantiate
D. Focus, Opportunity, Continuous(process), Understand Solution

38. While community health nurses focus on the individual or the family, which of the
following do they also have as their final objective?
A. The well-being of the chronically ill
B. The financial well being of the family
C. The well-being of the extended family
D. The well-being of the community
39. Which of the following is the best example of the ethical principle of fidelity?
A. Doing whatever the client or the client's physician asks of you
B. Keeping a promise to return to the client's room at a given time
C. Being a good friend to the client by sharing secrets
D. Saving the client time and money by not wasting supplies

40. Which of the following factors is most important in determining the success of
relationships used in delivering nursing care?
A. Type of illness of the client
B. Transference and counter transference
C. Effective communication
D. Personality of the participants

41. Which of the following statements best describes the term glove type burn?
A. The parent was wearing heavy gloves or stockings on his or her hands while
immersing the child in hot scalding water.
B. The parents have dipped the child into hot liquid while he or she was asleep.
C. The child was wearing a glove when immersed in hot liquid.
D. The bum has the look of a glove immersed in hot scalding water.

42. The school nurse keeps a list of enrolled students who have medical or religious
objections lo immunizations and those who are likely to have decreased immunity The nurse
likely keeps this just to:
A. provide statistics for the Department of Health
B. reassure the family that the nurse will respect the family's wishes at all times
C. meet national government requirements
D. facilitate exclusion in case of an outbreak of a highly communicable disease in the
school

43. Preschoolers are able to see things from which of the following perspectives?
A. Their peers
B. Their own and their caregivers
C. Their own and their mother's
D. Only their own

44. In conflict management, the win-win approach occurs when:

A. there are two conflicts and the parties agree to each win one
B. each party gives in on 50% of the disagreements making up the conflict
C. both parties involved are committed to solving the conflict
D. the conflict is settled out of court so the legal system and the parties win
45. According to the social-interactional systemic perspective of child abuse and neglect,
four factors place the family members at risk for abuse. These risk factors are the family
itself, the caregiver the child, and
A. the presence of a family crisis
B. genetics
C. the national emphasis on sex
D. chronic poverty

46. When a person is discussing the strong influences that child-rearing methods have on
the development of the child, this person is most probably coming from which of the
following viewpoints or theories?
A. Naturalistic
B. Nature
C. Neoclassic
D. Nurture

47. In working with the caregivers of a child with an acute or chronic illness, the nurse
would:
A. teach care dairy and let the caregivers do a return demonstration just before
discharge
B. delegate care of the child to a nurse's aide and make certain he or she understands
the care delegated and completes it
C. teach care early and allow the caregivers to provide daily care for as many aspects of
the child's care as possible
D. take responsibility for the child's care until the day before discharge, and then give
caregivers instructions

48. Which of the following signs and symptoms would you most likely find when
assessing an infant with Arnold-Chiari malformation?
A. Weakness of the leg muscles, loss of sensation in the legs, and restlessness
B. Difficulty swallowing, diminished or absent gag reflex, and respiratory distress
C. Difficulty sleeping, hypervigilant, and an arching of the back
D. Paradoxical irritability, diarrhea, and vomiting.

49. A patient calls you and frantically reports that her child has gotten into her ferrous
sulfate pills and ingested a number of these pills. The child is now vomiting, has bloody
diarrhea, and is complaining of abdominal pain. You will tell the mother to:
A. call emergency medical services (EMS) and get the child to the emergency room
B. relax because these symptoms will pass and the child will be fine
C. administer syrup of ipecac
D. call the poison control center
50. A client says she heard from a friend that you stop having periods once you are on
the pill". The most appropriate response would be
A. "The pill prevents the uterus from making such endometrial lining; that is why
periods may often be scant or skipped occasionally."
B. "If your friend has missed her period, she should stop taking the pills and get a
pregnancy test as soon as possible."
C. "The pill should cause a normal menstrual period every month. It sounds like your
friend has not been taking the pills properly."
D. "Missed periods can be very dangerous and may lead to the formation of
precancerous cells."

51. You are the nurse assigned to work with a child with acute glomerulonephritis. Try
following the prescribed treatment regimen, the child experiences a remission. You are not
checking to make sure the child does not have a relapse. Which finding would most lead you
to the conclusion that a relapse is happening?
A. Elevated temperature, cough, sore throat, changing complete blood count (CBC) with
differential
B. A urine dipstick measurement of 2+ proteinuria or more for 3 days, or the child found
to have 3-4+ proteinuria plus edema
C. The mine dipstick showing glucose in the urine for 3 days. Extreme thirst, increase in
urine output and a moon face
D. A temperature of 37.8 degrees C(100 degrees F), flank pain, burning, frequency,
urgency on voiding, and cloudy urine

52. The nurse is working with an adolescent who complains of being lonely and having a
lack of fulfillment in her life. This adolescent shies away from intimate relationships at times,
yet at other times she appears promiscuous. The nurse will likely work with this adolescent
in which of the following areas?
A. Isolation
B. Loneliness
C. Lack of fulfillment
D. Identity

53. The use of interpersonal decision making, psychomotor skills, and application of
knowledge expected in the role of a licensed health care professional in the context of public
health welfare and safety is an example of:
A. Delegation
B. Supervision
C. Responsibility
D. Competence

54. A child suffers a head injury in a tumbling accident in gym class. The nurse's best
course of action is to:
A. get the child up walking and make sure he or she stays awake
B. leave the child and go get help
C. leave the child in the care of an older child and go get help
D. stay with the child, keep assessing, and have someone call the caregivers

55. The American Academy of Pediatrics suggests that caregivers do which of the
following things in regard to physical activities for preschoolers?
A. Push the child lo practice sports activities while they are more flexible
B. Encourage a variety of physical activities in a noncompetitive environment
C. Have the child engage in competitive sports to see where they excel
D. Keep physical activities to a minimum until the child is in grade school

56. Which of the following arrangements is generally considered to be best for the
parents of a hospitalized infant or young child?
A. Rooming-in
B. Separate caregiver sleeping room on the unit
C. Day visits and sleeping at home
D. Staying at a nearby hotel or motel

57. When one person allows the conflict to be reserved at his or her own expense, this is
referred to in conflict management as:
A. losing
B. winning while losing
C. the win-lose approach
D. the lose-win approach

58. Which of the following statements best describes acquaintance rape?

A. Sexual intercourse when one person engaging in the activity is unsure about wanting
to do so
B. When two people don't love each other and engage in sexual activities
C. When someone on a date tricks the other person into having sexual intercourse
D. Sexual intercourse committed with force or the threat of force without a person's
consent

59. The school nurse is teaching a health education and hygiene course to a group of
high schools males, which includes a number of young men who are on competitive sports
teams. Which of the following health practices would the nurse most stress in preventing the
transmission of human immunodeficiency virus (HIV) virus in case any team member has
HIV or acquired immunodeficiency syndrome (AIDS)?
A. No sharing of underarm deodorant or shower soap
B. No storing of razors or toothbrushes
C. Making certain towels have been washed in boiling water
D. Avoiding physical contact such as sports hugs or swats
60. At 17 weeks' gestation, a type 1 diabetic undergoes an ultrasound examination. What
information about the fetus at this time in pregnancy would the results of this examination
provide?
A. Placental maturity
B. Estimated fetal weight
C. Gestational age
D. Fetal lung maturity

61. Which of the following best describes a difference in communicating with school-age
children versus toddlers?
A. Toddlers require more empathy and more touching and holding
B. For toddlers, preparation for procedures is just before the procedure and much earlier
for school-aged children
C. Caregivers need less information when care involves a school-aged child
D. The number of words is more when communicating with a toddler than it is with a
school-aged children

62. Genetic testing should be performed on a child only if:

A. the parents both want it performed
B. it is in the best interests of the child
C. it is necessary for the child to survive
D. no one objects

63. Infant head control is judged by the:

A. ability to hold head without support
B. presence or absence of head lag
C. rigidity of the neck and head
D. amount of neck wrinkling

64. Which of the following roles BEST exemplifies the expanded role of the nurse?
A. Circulating nurse in surgery
B. Medication nurse
C. Obstetrical nurse
D. Pediatric nurse practitioner

65. The tone and pitch of the voice, volume, inflection, speed, grunts and other
vocalizations are referred to by which of the following terms?
A. Paraverbal clues
B. Ancillary speech
C. Third element
D. Enhancements
66. The plan-do-study-act cycle begins with:
A. Four stages
B. Five agendas
C. Three questions
D. Two concepts

67. During your shift, you noted one of your pregnant clients considered as waiting
case" manifests morning sickness and which later progressed. Which assessment finding
may indicate a possible developing complication?
A. Maternal pulse 90
B. Trace glucose in the urine
C. FHT 155
D. 1+ ketones in the urine

68. The nurse is working with a child who is going to have a bone marrow aspiration. The
physician orders TAC (tetracaine, adrenaline, and cocaine). Which of the following is the
route of administration?
A. Application to the skin, covered with a dressing prior to the procedure
B. Subcutaneous
C. IV using a very slow drip over approximately 4 hours prior to procedure
D. Nasal inhalation

69. According to DeRosa and Kochura's (2006) article entitled "Implement Culturally
Competent Health Care in your Workplace." cultures have different patterns of verbal and
nonverbal communication. Which difference does NOT necessarily belong?
A. Personal behavior
B. Eye contact
C. Subject matter
D. Conversational style

70. The nurse instructs the caregivers of a newborn to notch the diapers or fold them in
such a way as to expose the cord. The major purpose of exposing the cord is to:
A. remind the caregivers to do cord care
B. keep the diaper from rubbing the cord
C. provide air circulation for the cord
D. allow visualization at all times

71. The level of health of an individual, family, group, population, or community is called:
A. Health assets
B. Health status
C. Quality of life
D. Health needs
72. The nurse is teaching a group of expectant mothers about the prevention of diaper
dermatitis. The nurse explains that one of the preventive measures is the use of:
A. absorbent disposable diapers
B. baby powder or cornstarch
C. plastic panties over diapers
D. cloth diaper

73. The Code of Nurses

A. delineates all obligations and responsibilities of the nurse
B. is a binding oath, which tells nurses how to make, ethical decisions
C. assists the nurse in formulating a personal belief system
D. supports the concept of respect for all persons

74. The obligation to correctly perform one's assigned duties is:

A. delegation
B. assignment
C. responsibility
D. accountability

75. During a routine postpartum assessment following a normal vaginal delivery, the
nurse notes the fundus to be slightly boggy. Which action should the nurse take to decrease
the risk of uterine inversion during uterine massage?
A. Massage only until cramping begins
B. Place one hand on the abdomen above the symphysis pubis
C. Ask the client to ambulate to the bathroom to empty her bladder
D. Position the client in a slight Trendelenburg position

SITUATIONAL

Situation 1- Nurse Mercy is a staff nurse in the OB ward of Laoag Medical Center.

76. When the separation begins at the center and the placenta slides down the birth
canal like a folded umbrella, this is referred to as:
A. Duncan mechanism
B. Schultz mechanism
C. Brandt Andrews maneuver
D. Ritgens maneuver

77. In the immediate postpartum period, the action of methylergonovine is to:

A. Cause sustained uterine contraction
B. Cause intermittent uterine contractions
C. Relax the uterus
D. Induce sleep so the mother can rest after an exhausting labor

78. Gina, a newly delivered multipara complains of heavy and painful breasts
accompanied by fever. The nurse tells Gina that it is normal breast engorgement as the
fever is characterized by:
A. More than 38 degree centigrade
B. Does not last more than 24 hours
C. Caused by infection
D. Needs to be treated with antibiotics

79. Postpartum depression occurs during which time frame?

A. Within 6 weeks after delivery
B. Within 12 weeks
C. Within 16 weeks
D. Within 24 weeks

80. Martha, a 38 year old multipara is admitted with a tentative diagnosis of femoral
thrombophlebitis. The nurse assesses the patient with:
A. Burning of urination
B. Leg pain
C. Abdominal pain
D. Increased lochial flow

Situation 2 - To assure wellness and survival of children 0-59 months old, there are activities
that are performed by a community health nurse:

81. For immediate care of the newborn, what should the nurse do first?
A. Put baby in rooming-in
B. Clear airways
C. Breastfeeding the baby
D. Inject Vit. K

82. What is the standard tool to record vital information about the child and kept in the
home?
A. Growth Development Record
B. Growth Monitoring Promotion
C. Growth Monitoring Chart
D. Growth Monitoring Record

83. When is the immunization of a child completed?

A. 0-12 months
B. 3-4 years
C. 5-6 months
D. 12-24 months

84. Four hours after birth, which finding in a newborn requires further assessment?
A. Yellowish sclera
B. Bluish palms and soles
C. Moro reflex
D. Heart rate of 160

85. The Ligtas Buntis Campaign of the DOH aims to achieve the following goals except:
A. Universal Access to Family Planning
B. Maternal Care Formation
C. Services of Men
D. Services for aging Couples

Situation 3 - With the increasing documented cases of CANCER the best alternative to
treatment still remains to be PREVENTION. The following conditions apply.

86. Which among the following is the primary focus of prevention of cancer?
A. Elimination of conditions causing cancer
B. Diagnosis and treatment
C. Treatment of early stage
D. Early Detection

87. In the prevention and control of cancer which of the following activities is the most
important function of the community health nurse?
A. Conduct of community assemblies
B. Referral to cancer specialist those clients with symptoms of cancer
C. Use the nine warning signs of cancer as parameters in our process of detection,
control, and treatment modalities
D. Teach women about proper/correct nutrition

88. Who among the following are recipients of the secondary level of care for cancer
cases?
A. Those under early case detection
B. Those under post case treatment
C. Those scheduled for surgery
D. Those undergoing treatment

89. Who among the following are recipients of the tertiary level of care for cancer cases?
A. Those under early treatment
B. Those under supportive care
C. Those under early detection
D. Those scheduled for surgery

90. In Community Health nursing, despite the availability and use of many equipment
and devices to facilitate the job of the community health nurse, the best tool any nurse
should well be prepared to apply is a scientific approach. This approach ensures quality of
care even at the community setting. This in nursing parlance is nothing less than the:
A. nursing diagnosis
B. nursing protocol
C. nursing research
D. nursing process

Situation 4 - Dengue hemorrhagic fever is a common health concern in Philippine society. It

does not only pose a threat to health but more so to the lives of both young and old and well
as rich and marginalized sectors of society. The following conditions apply

91. An important rote of the community health nurse in the prevention and control of
Dengue H-fever includes:
A. Advising the elimination of vectors by keeping water containers covered
B. Conducting strong health education drives/campaign directed towards proper
garbage disposal .
C. Explaining to the individuals, families, groups and community the nature of the
disease and its causation
D. Practicing residual spraying with insecticides

92. Community health nurses should be alert in observing a Dengue suspect. The
following is NOT an indicator for hospitalization of H-fever suspects.
A. Marked anorexia, abdominal pain and vomiting
B. Increasing hematocrit count
C. Fever for more than 2 days
D. Persistent headache

93. The community health nurses' primary concern in the immediate control of
hemorrhage among patients with dengue is:
A. advising low fiber and non-fat diet
B. providing warmth through light weight covers
C. observing closely the patient for vital signs leading to shock
D. keeping the patient at rest

CORRECT ANSWER: D

94. Which of these signs may NOT be REGARDED as a truly positive signs indicative of
Dengue H-Fever?
A. Prolonged bleeding time
B. Appearance of at least 5 petechiae
C. Steadily increasing hematocrit count
D. Fall in the platelet count

95. Which of the following is the most important treatment of patients with Dengue H-
fever?
A. Give aspirin for fever
B. Replacement of body fluids
C. Avoid unnecessary movement of patient
D. Ice cap over the abdomen in case of melena

Situation 5 - Two children were brought to you. One with chest in-drawing and the other had
diarrhea. The following questions apply.

96. Using the Integrated Management & Childhood Illness (IMCI) approach, how would
you classify the 1st child?
A. Bronchopneumonia
B. No pneumonia: cough or cold
C. Severe pneumonia
D. Pneumonia

97. The 1st child who is 13 months has fast breathing using IMCI parameters he has:
A. 40 breaths per minute or more
B. 50 breaths per minute
C. 30 breaths per minute or more
D. 60 breaths per minute

98. Nina, the 2nd child has diarrhea for 5 days. There is no blood in the stool. She is
irritable, and her eyes are sunken. The nurse offered fluids and the child drinks eagerly. How
would you classify Nina's illness?
A. Some dehydration
B. Dysentery
C. Severe dehydration
D. No dehydration

99. Nina's treatment should include the following EXCEPT.

A. Reassess the child and classify him for dehydration
B. For infants under 6 months old who are not breastfed, give 100-200 ml clean water
as well during this period
C. Give in the health center the recommended amount of ORS for 4 hours
D. Do-not give any other foods to the child for home treatment

100. While on treatment, Nina, 18 months old weighed 10kg and her temperature
registered at 37 C. Her mother says she developed cough 3 days ago. Nina has no general
danger signs. She has 45 breaths/minute, no chest indrawing, no stridor. How would you
classify Nina's manifestation?
A. No pneumonia
B. Severe pneumonia
C. Pneumonia
D. Bronchopneumonia

Situation 1 - The PRC regulates the practice of 42 professions in the Philippines.

1. What is the basic requirement of the state for a nurse to practice her profession?
A. Willingness to practice the profession
B. A BSN degree
C. A nursing license
D. An NCLEX and CGFNS passer

2. The Code of Good Governance for the professions in the Philippines shall be adapted
by:
A. all registered professionals
B. all Filipino professionals
C. all professionals
D. all registered nurses

3. The standardized guidelines and procedures for the implementation of Continuing

Professional Education (CPE) for all professional. Resolution Number 2004-179 provides that
the total CPE credit units for registered professionals with baccalaureate degree should be:
A. 20 credit units per year
B. 30 credit units for 3 years
C. 60 credit units for 3 years
D. 10 Credit units required

4. The Board of Nursing is vested with power to issue, suspend, or revoke for cause, the:
A. certificate of Good Moral Character
B. certificate of Practice
C. certificate of Registration
D. certificate of Employment

5. RA 7193 stipulates the removal examination of the nurse licensure examination shall
be taken:
A. Within 3 years after the last failed examination
B. Anytime the examinee wants to take the examination
C. Within 2 years after the last failed examination
D. Within the same year after the last failed examination
Situation 2 Mr. Garzon, 35 years old, an accountant of one of the banks in Iloilo went to the
clinic complaining of headache and difficulty sleeping at night.

6. Nurse Anne is assessing the blood pressure (BP) of Mr. Garzon. She explains to him
that the basis for the diagnosis of hypertension should be established by:
A. Five readings one month apart
B. At least 3 readings with average blood pressure of 140/90
C. One reading of blood pressure greater than 140/90
D. Three blood pressure readings taken on the same day in different positions

7. Mr. Garzon is beginning medication therapy with furosemide (Lasix) once daily. Nurse
Anne should instruct him to take the medication at which of the following optimal times?
A. 8:00 A.M.
B. 12 noon
C. 6:00 P.M.
D. At bedtime

8. During the discharge teaching, Mr. Garzon mentions that he will stop taking her
antihypertensive medications as soon as his blood pressure is under control. Which of the
following should be included in your instructions?
A. "In order to maintain control of your blood pressure, the medication must be
continued indefinitely."
B. "Only the physician can answer this question."
C. "The medication will probably be stopped after your blood pressure is normal
D. "The medication will be decreased in time."

Situation 3 - Pain is always associated to surgery:

9. As a surgical nurse, which of the following nursing intervention will allay anxiety and
pain among surgical patients?
A. Assess the client for concerns especially those that can potentially cause pain
B. Verify that the operative permit is signed
C. Discourage the client from discussing the details of the surgical procedure
D. Ensure safety of client while in surgery

10. Rhizotomy is a condition surgical procedure to manage those that can potentially
cause pain. What is the crucial in determining a good candidate for rhizotomy?
A. Pain which is resistant to non-pharmacologic protocol for 6 month
B. Pain which is resistant to pharmacologic protocol for 12 months
C. Local pain with no radiating pain or signs of nervous compression
D. Deep pain with obvious signs of peripheral nerve damage
11. Which of the following would be the nurse's appropriate response to a crying female
client scheduled for emergency surgery who is verbalizing fear of pain but afraid to go to
sleep?
A. Let her cry and tell significant other to stand by
B. Squeeze her hand and assure her that there will be no pain at ail because she will be
given anesthesia
C. Stand by her side and quietly ask her to describe her feelings
D. Check her name tag and request anesthesiologist to sedate client

12. Which of the following client's statement indicates that he understands the nurse's
instruction about postoperative wound pain?
A. "I shall call the nurse when my wound itches and smells".
B. "I shall expect slight pain and discomfort from the surgical incision".
C. "I should call my doctor if my wound has no drainage, and intact".
D. "I should not touch my surgical wound".

13. What do you think is an important responsibility related to pain that is subjective in
nature?
A. Divert attention of client in pain
B. Leave the patient alone while in pain
C. Believe what the patient says about the pain
D. Assume responsibility to eliminate pain as described by the client

Situation 4 Nurse Bryan is taking care of the client who was diagnosed with osteomyelitis.

14. Nurse Bryan is knowledgeable that the primary organism responsible for
osteomyelitis is:
A. Staphylococcus aureus
B. Escherichia coli
C. Streptococcus
D. Pseudomonas

15. Which of the following nursing interventions is contraindicated in the care of a client
with acute osteomyelitis?
A. Apply heat compresses to the affected area
B. Immobilize the affected area
C. Administer narcotic analgesics for pain
D. Administer OTC analgesics for pain

Situation 5 - Nurses' attitudes toward pain influence the way they perceive and interact with
clients in pain.
16. Nurses should be aware that older adults are at risk of underrated pain. Nursing
assessment and management of pain should address the following beliefs EXCEPT:
A. Older patients seldom tend to report pain than the younger ones
B. Pain is a sign of weakness
C. Older patients do not believe in analgesics; they are tolerant
D. Complaining of pain will lead to being labeled a "bad patient

17. Nurses should understand that when a client responds favorably to a placebo, it is
known as the placebo effect. Placebos do not indicate whether or not a client has:
A. conscience
B. real pain
C. disease
D. drug tolerance

18. You are the nurse in the pain clinic where you have a client who has difficulty
specifying the location of pain. How can you assist such client?
A. The pain is vague
B. By charting-it hurts all over
C. Identify the absence and presence of pain
D. Ask the client to point to the painful area by just one finger

19. What symptom, more distressing than pain, should the nurse monitor when giving
opioids especially among elderly clients who are in pain?
A. Forgetfulness
B. Constipation
C. Drowsiness
D. Allergic reactions like pruritus

20. Physical dependence occurs in anyone who takes opioids over a period of time. What
do you tell a mother of a dependent when asked for advice?
A. Start another drug and slowly lessen the opioid dosage
B. Indulge in recreational outdoor activities
C. Isolate opioid dependent to a restful resort
D. Instruct slow tapering of the drug dosage and alleviate physical withdrawal
symptoms

Situation 6 - As a perioperative nurse, you are aware of the correct processing methods for
preparing instruments and other devices for patient use to prevent infection.

21. Items that enter sterile tissue or vascular system are categorized as critical items and
should be:
A. Clean
B. Decontaminated
C. Sterilized
D. Disinfected

22. As an OR nurse, what are your foremost considerations for selecting chemical agents
for disinfection?
A. Material compatibility and efficiency
B. Odor and availability
C. Cost and duration of disinfection process
D. Duration of disinfection and efficiency

23. Before you use a disinfected instrument, it is essential that you:

A. Rinse with tap water followed by alcohol
B. Wrap the instrument with sterile towel
C. Dry the instrument thoroughly
D. Rinse with sterile water

24. You have a critical heat labile instrument to sterilize and you are considering to use a
high level disinfectant. What should you do?
A. Cover the soaking vessel to contain the vapor
B. Double the amount of high level disinfectant
C. test the potency of the high level disinfectant
D. Prolong the exposure time according to manufacturer's direction

25. As a nurse, you know that intact skin acts as an effective barrier to most
microorganisms. Therefore, items that come in contact with the intact skin should be:
A. Disinfected
B. Sterile
C. Clean
D. Alcoholized

Situation 7 - The OR is divided into three zones to control traffic flow and contamination.

26. What OR attires are worn in the restricted area?

A. Scrub suit, OR shoes, head cap
B. Head cap, scrub suit, mask, OR shoes
C. Mask, OR shoes, scrub suit
D. Cap, mask, gloves, shoes

27. Which of the following nursing interventions should be given the highest priority
when receiving a client in the OR?
A. Check for presence of dentures, jewelry, nail polish, and other accessories
B. Receive the client at the semi-restricted area and change his gown
C. Assess level of consciousness
D. Verify the identification and informed consent

28. Conversation while in the operation is ongoing is minimized because:

A. full concentration is demanded during the entire procedure
B. it annoys the surgeon
C. it is unethical to talk about the client
D. it enhances the spread of microorganism to the incision site

29. Spaulding categorized instruments according to use. Where do you classify

endoscopic instrument?
A. Decontaminated instruments
B. High level disinfected instruments
C. High technology instruments
D. Sterile instruments

CORRECT ANSWER: B
RATIONALE:

30. In the OR. "Surgical Conscience" means.

A. Observance of Operating Room Protocol at all times
B. Use of prescribed OR attire in all areas of the OR
C. Honest adherence to surgical aseptic techniques all the time
D. Strict implementation of "Standard Precaution"

Situation 8 - Nurses have the responsibility to assist diabetic clients with insulin
administration it is essential that both nurse and client learns how to measure insulin dosage
accurately.

31. Insulin concentration is labeled and measured in:

A. units/ml
B. gm/ml
C. grain
D. mg/ml

32. Each unit of insulin provides the client with the same effect regardless of its
concentration per 1 ml of solution. Is insulin of 500 "u" per ml more potent that insulin of
100 "u" per ml?
A. Moderate potency
B. Less potent
C. More potent
D. Same potency
33. Nursing intervention for a patient on low dose IV insulin therapy includes the
following, EXCEPT:
A. elevation of serum ketones to monitor ketosis
B. vital signs including BP
C. estimate serum potassium
D. elevation of blood glucose levels

34. The doctor ordered to incorporate 1000 u insulin to the remaining on going IV. The
strength is 500 u/ml. How much should you incorporate into the IV solution?
A. 10 ml
B. 2 ml
C. 0.5 ml
D. 5 ml

35. Multiple vial-dose-insulin when in use should be:

A. kept at room temperature
B. kept in the refrigerator
C. kept in the narcotic cabinet
D. stored in the freezer

Situation 9 - Collaborative planning is essential if nursing and health care are to be made
available to all people.

36. Perioperative examples of collaboration are the following EXCEPT:

A. Communicate with other members of the health profession to improve the integrity
B. Communicate with health officials the incidence of Hepatitis B among OR personnel
C. Collaboration with other OR personnel regarding the practices of surgeons collecting
exorbitant professional fees
D. Collaborate with DOM regarding disposal or specimens

37. The nurses collaborate with other members of the health profession to improve the
integrity of the hospital working environment through the following ways EXCEPT:
A. Joining barangay health club projects
B. Joining the Mayo Uno Labor Union
C. Joining labor day rally to increase wages of healthcare workers and improve
dilapidated health centers
D. Affiliating with The All Healthcare Alliance

38. An example of a collaborating effort on public service particularly during summer is:
A. Boto Mo. Ipatrol Mo
B. Operation Linis
C. Clean and Green
D. Operation Tuli
39. When does a nurse accept the interdependence of providers and patients in
achieving access to health care?
A. "Our hospital does not honor visiting doctors "
B. When the nurse replies to a client's relative "You have the best doctor in town".
C. When the nurse communicates to the attending physician the desire of the patient to
be seen by a urologist
D. The doctor is not on duty today."

40. Individual patients and society as a whole benefit from nursing participation in
decisions made about health care. This is exemplified in:
A. Supporting, political candidates that advance nursing health care issues
B. Bringing the NCLEX in the Philippines
C. Supporting the proliferation of colleges of nursing in the country
D. Following the decision of CGFNS to retake test III and V to validate the visa screen for
the U.S.

Situation 10 - Pain management is not limited to pharmacological means.

41. Ronald, one of your clients who is being worked out for AIDS, tells you that he has
been using acupuncture to help with his pain. You questioned his treatment because:
A. acupuncture uses needles to stimulate certain points on the body to treat pain
B. acupuncture uses a variety of herbs and oils from wild plants
C. acupuncture uses manipulation of the skeletal muscles to relieve stress and pain
D. acupuncture uses pressure from the fingers and hands to stimulate body responses

42. Your younger brother came home with a right black eye. He asked you for an eye
ointment to relive the pain and swelling. You should offer:
A. ice pack over the right eye
B. tetracycline ophthalmic ointment
C. hot compress over the right eye
D. ice cold drinks

43. Menstrual pain and discomfort account for absences in schools and offices. A non-
pharmacological remedy for menstrual pain is:
A. regular bowel movement
B. knee-chest exercises before menstruation and hot water bag application over lower
abdomen during onset
C. warm shower during onset of menstrual period
D. diet restriction on fatty foods and liberal fluid intake
44. Among burn clients, especially 1st and 2nd degree, one of the primary nursing
functions is to alleviate pain. The following are appropriate nursing interventions, EXCEPT :
A. using cold water for hydrotherapy
B. avoiding exposure to draft
C. administering morphine S04 as proscribed
D. using of bed cradle to relive pain

45. Nurses taking care of post skin graft patients know that the post-op pain is at the:
A. Buttocks
B. Donor site
C. Recipient site
D. Injection site

Situation 11 - One learns by doing especially when you practice the best methods

46. Which action by a new nurse signifies a need for further teaching in infection control?
A. The nurse places the side rails the time to an unconscious patient
B. The nurse elevates the head of the bed to check the BP
C. The nurse uses her bare hands to change the dressing
D. The nurse applies oxygen mask to the mouth

47. You are on PM shift and about 5 patients are for discharge. You noted that the orderly
was looking through the items of one of the patients. Which action should you pursue?
A. Call the attention of the orderly in private
B. Ignore the situation because you are busy
C. Report this behavior to the nurse in charge
D. Monitor the situation and note whether any other items are reported missing

48. What appropriate action should you do when you overhear the nursing attendant
speaking harshly to an elderly patient?
A. Try to explore the interaction with the nursing attendant concerned
B. Change the attendant's assignment
C. Initiate a group discussion with all other nursing attendants
D. Discuss the matter with the patient's family

49. You have been in the surgical ward for almost a year and have cared for a number of
clients with CVP. Which observation from a colleague would indicate a need for further
teaching, EXCEPT?
A. The colleague turns the stop-cock to the off position from the IV fluid to the patient
B. The nurse colleague notes the level at the top of the meniscus
C. The colleague instructs the client to perform the valsalva maneuver during the CVP
reading
D. The nurse colleague charting medication administration that she has not yet given
50. You saw one colleague charting medication administration that she has not yet
administered. After talking to her, you also report the incident to the charge nurse. The
charge nurse should:
A. require the staff to submit an incident report
B. terminate the nurse
C. charge the erring nurse with dishonest
D. report to the Board of Nursing

Situation 12 You are assigned at the PACU at 9:30 AM, post-op clients started to be
wheeled in from the OR.

51. Which nursing diagnosis has priority among client in the PACU?
A. Acute pain related to discomfort of wound and immobility
B. Body image disturbance because of wound dressing and drains
C. Ineffective airway clearance related to general anesthesia
D. Knowledge deficit related to lack of information because patients are all sedated

52. Which of the following clients at the PACU will demonstrate the effectiveness of
preoperative teaching?
A. The client demonstrates deep breathing, coughing, splinting chest and leg exercises
B. The client manifests normal temperature
C. The client sleeps well
D. The client has good balance I and O

53. Which of the following remark indicates that the client's relative understood the
discharge instruction for wound care?
A. "If the wound is painful, I will say it is normal."
B. "It is alright to use adhesive tape over the wound to keep it intact."
C. "It is ok for his pet to remain at his bedside to keep him company."
D. "I will report any redness or swelling of the wound.

54. You just transferred out a post-op client to her room. What would your instruction to
the family include to prevent accidents?
A. Report when the IV infusion is almost finished
B. Test the call system if functioning
C. Keep the room lights on for 24 hours
D. Make sure the side rails are up

55. One of your post-op patients has a temperature of 37.9C and was shivering. You
covered him with a blanket and later took his temperature again and it is now 38.9C. The
nursing student asked you to explain the absence of shivering even if the temperature was
higher.
A. The patient is no longer febrile thus he is no longer chilling
B. Shivering normally disappears as temperature becomes higher
C. The body has reached its new set point thus the absence of shivering
D. The patient is feeling better

Situation 13 - Patients with chest tubes can be very challenging to new nurses.

56. The chest tube drainage of Tirso has continuous bubbling in the water seal drainage.
Which of the following condition is the possible cause of the malfunctioning sealed drainage?
A. A suction being too high
B. An air leak
C. A tube being too small
D. A tension pneumothorax

57. While you were making your endorsement, you found out the chest tube of a client
was disconnected. What would be your appropriate action?
A. Assist the client back to his bed and place him on the affected side
B. Cover the end of the chest tube with sterile gauze
C. Reconnect the tube to the chest tube system
D. Put the end of the chest tube into a cup of sterile normal saline

58. Dr. Reyes asked you to assist him with the removal of Tirso's chest tube. You would
instruct the client to :
A. continuously breathe normally during the normal of the chest tube
B. take a deep breath, exhale, and bear down
C. exhale upon actual removal of the tube
D. hold breath until the chest tube is pulled out

59. Chest tube diameter is measured or expressed in :

A. french
B. gauge
C. millilitres
D. inches

60. When transporting clients with chest tube, the system should be:
A. disconnected
B. closed
C. placed lower than the patient's chest
D. placed between the legs of the client to prevent breakage

Situation 14 - The perioperative nurse collaborates with the client, significant others, and
healthcare providers

61. Patient outcome reflect the collaborative interdisciplinary effort and independent
nursing activities. Who is the primary partner of the nurse in health care?
A. The family
B. The doctor
C. The client
D. The significant other

62. To control environmental hazards in the OR, the nurse collaborates with the following
departments EXCEPT:
A. biomedical division
B. chaplaincy services
C. infection control committee
D. pathology department

63. Waste disposal poses a big problem for the hospital. Biological wastes (i.e. amputated
limbs) disposal should be coordinated with the following agencies EXCEPT:
A. Crematorium
B. DOH
C. MMDA
D. DILG

64. Tess, the PACU nurse, discovered that Malou, who weighs 110 lbs prior to surgery, is
in severe pain 3 hrs after cholecystectomy. Upon checking the chart, Malou found out that
she has an order of Demerol 100 mg I.M. prn for pain, Tess should verify the order with:
A. A Nurse supervisor
B. Anesthesiologist
C. Surgeon
D. Intern on duty

65. Rosie, 57 who is a diabetic is for debridement of incision wound. When the circulating
nurse checked the present IV fluid, she found out that there is no insulin incorporated as
ordered. What should the circulating nurse do?
A. Double check the doctor's order and call the attending MD
B. Communicate with the ward nurse to verify if insulin was incorporated or not
C. Communicate with the client to verify if insulin was incorporated.
D. Incorporate insulin as ordered.

Situation 15 Technology and patients education has dramatically improved the

management of the diabetic client.

66. The current insulin pumps available in the market have the following capability.
EXCEPT ;
A. prevent unexpected saving in blood glucose measurements
B. detect signs and symptoms of hypoglycemia and hyperglycemia
C. deliver a pre-meal bolus dose of insulin before each meal
D. deliver a continuous basal rate of insulin at 0.5 units to 2.0 units per hour

67. Discharge plan of diabetic clients include injection-site-rotation. You should

emphasize that the space between sites should be :
A. 6 cm
B. 5 cm
C. 2.5 cm
D. 4 cm

68. It is critical also that a diabetic client should be educated in the possible sites of
regular insulin injection. The fastest absorption rate happens at the tissue areas of:
A. gluteal area
B. deltoid area
C. anterior thigh
D. abdominal area

69. Sell-monitoring of blood glucose (SMBG) is recommended for patient's use. You will
recommend this technology in the following diabetic patients, EXCEPT :
A. client with proliferative retinopathy
B. unstable diabetes
C. hypoglycemia without warning
D. Abnormal renal glucose threshold

70. It is necessary for a diabetic client to exercise regularly. What is the effect of regular
exercise to a diabetic client?
A. It burns excess glucose
B. It improves insulin utilization and lowers blood glucose
C. It lowers glucose, improves insulin utilization, decrease total triglyceride levels
D. It will make you fit and energized

Situation 16 - RN's should always be conscious that the contents in charting are admissible
in court as evidence.

71. If there is any deviation from normal practice or procedure e.g. streptomycin was
given by IV not IM, this should documented in the:
A. progress notes
B. incident report
C. nurse's note
D. patient's chart

72. Documentation of all nursing activities performed is legally and professionally vital.
Which of the following should NOT be included in the patient's chart?
A. Presence of prosthetics, devices such as dentures, artificial limbs, hearing aid. etc.
B. Baseline physical, emotional, and psychosocial data
C. Arguments between nurses and residents regarding treatments
D. Observed untoward signs and symptoms and interventions including concomitant
intervening factors

73. During your morning rounds. Mr. Tipol, 60 year old widower, tried to sit up and
instead of holding to the side rail held the IV stand causing the IV bottle to fall and break.
You wrote an incident report to show:
A. document the incident
B. be a part of the patient's chart
C. present confidential report
D. evidence of the quality of care

74. Erasures, alterations, and additions in medical records and the nurse's notes can be
avoided. The following are some tips on how to do corrections EXCEPT:
A. Cross out blank spaces
B. Cross out wrong word or phrase with one or two lines making the crossed out word
discernible
C. Insert additions or corrections
D. State the reason for any deviation from normal procedure/practice

75. Kathy is one of your patient's: Her uncle, who is a doctor, wants to read her chart.
Your appropriate action would be to:
A. Instruct Kathy's uncle to present a written authorization signed by the patient
B. Refer to the hospital director
C. Instruct Kathys uncle to present a written request to the Medical Records Section of
the hospital
D. Refer to the attending physician

Situation 17 - During the month of July, you noticed that there is an incidence of upper
respiratory disorders.

76. One of your cases is with acute pharyngitis. Your nursing management includes the
following EXCEPT?
A. Suggest a soft or liquid diet during acute stage
B. Encourage liberal amount of color fruit juices
C. Encourage bed rest during febrile stage
D. Apply ice collar for symptomatic relief of severe sore throat

77. For a nurse to assess an upper respiratory tract infection, you should palpate the
following:
A. The ears. eyes, nose, and throat
B. Adenoids, tonsils and nose
C. Nose and throat only
D. The tracheal and nasal mucosa including the frontal sinuses

78. Among patients with upper airway infection, airway clearance can be facilitated by
the following, EXCEPT:
A. regularly administering prescribed vasoconstrictive medications
B. decreasing systemic hydration
C. positional drainage
D. humidifying inspired room air

79. A friend asked you some nursing measures of uncomplicated common colds. You will
include the following measures. EXCEPT:
A. instruct client about symptoms of secondary infections
B. administer prescribed antibiotics
C. teach that the causative virus is contagious even before symptoms appear
D. suggest adequate of fluids and rest

80. The following are your nursing suggestions for a patient with acute or chronic
sinusitis EXCEPT:
A. Local heat application to promote drainage
B. Consult an ENT surgeon
C. Increase humidity
D. Advice adequate fluid intake

Situation 18 -A specimen is a piece of tissue or body fluid taken from the disease body organ
or tissue to aid the health care team in diagnosis and effective treatment. Necessarily, the
nurse assumes responsibility in the care of the specimen.

81. Carmen is suspected to have left breast CA. She is scheduled in your room for frozen
section. How will you prepare the specimen for laboratory?
A. Refrigerate and send it along with the day's specimens
B. Send to pathology immediately without soaking solution
C. Soak it in NSS
D. Soak it in formalin

82. How will you label this specimen? What information is essential in the label?
A. Name of client, age, sex. hospital number
B. Name of client, age, sex
C. Name, age, site, type of specimen, hospital number, doctor
D. Name, doctor, type of specimen, hospital number
83. Foreign body extracted from the body like pins, needles, seeds or bullets are also
considered as specimen. You assisted in the multiple gun-shot wound exploration. During the
surgery 3 bullets were recovered. You should send the specimen to:
A. the department of pathology
B. the National Bureau of Investigation
C. the OR head nurse
D. client's family

84. A post dilation and curettage (D and C) client is for discharge. Follow-up of lab result
should be part of the discharge plan. You will instruct the client to follow up result at the:
A. Medical record
B. Laboratory
C. Doctor's clinic
D. Nurse's station

85. You are the circulating nurse in OR 2. You have 4 thyroidectomy cases for the day.
How do you prevent switching of specimens?
A. Send specimens to laboratory right away after the operation with the proper labels
B. Collect all specimens and send to laboratory at the end of the day
C. Label specimen at once
D. Prepare 4 specimen vials first thing in the morning

Situation 19 Nurse Paul is providing care for clients with rheumatoid arthritis admitted in
the unit.

86. A health history and physical assessment on a client with rheumatoid arthritis (RA)
may reveal which of the following assessment data?
A. Heberden's nodes
B. Morning stiffness no longer than 30 minutes
C. Asymmetric joint swelling
D. Swan neck deformities

87. Which of the following is a priority when providing health teaching to a client with
rheumatoid arthritis (RA)? Instruct the client:
A. On weight reduction.
B. To decrease activity to avoid joint pain.
C. To pace activities to decrease joint stress.
D. To contact the Arthritis Foundation for support services.

Situation 20 - During the surgical procedure, contamination should be confined and

contained within the immediate vicinity of the surgical field to prevent the spread of
pathogenic microorganisms.

88. The following technique illustrates the concept "confine and contain", EXCEPT:
A. contaminated items like sponges are handled using gloves
B. all blood, tissue, and body fluid specimens should be placed in leak-proof
C. surgeons conduct their patient's rounds in scrub suit
D. prompt cleanup of accidental spills of contaminated debris e.g. Blood, body fluids

89. The OR is a 'restricted area' where OR attire is worn. Temperature and humidity are
set for patient and personnel safety and reduce bacterial contamination. During surgery,
movement of personnel including the circulating nurse is :
A. kept to a minimum
B. eliminated when possible
C. restricted
D. monitored

90. Sterility is the condition of almost all items, devices or supplies used in the OR are
ready for any surgical procedure. Shelf-life of packaged sterile item is event related and
depends on the following. EXCEPT:
A. type of sterilizer used to "sterilize items
B. amount of handling
C. the quality of packaging material used
D. storage conditions

91. Precaution recommends that the use of standard personal protective equipment
(PPE) to prevent cross contamination. Which is NOT considered a piece of PPE?
A. Cover gown
B. Eyewear
C. Gloves
D. Sterile gauze

92. Traffic patterns in the OR suite should:

A. prevent unauthorized personnel from entering the OR
B. prevent transmission of pathogenic microorganisms
C. assure that personnel walk in the same direction
D. allow personnel to move freely between restricted and unrestricted areas

Situation 21 - Nokia is so powerful to "connect people" from continent to continent, all

through communication via the cellphone. Other ways of communication to relay information
or instructions exist even in the healthcare setting.

93. An anesthesiologist is preparing to do a spinal anesthesia to a 220 lb. 30 year old

athlete. She requests the circulating nurse to prepare a pink spinal set with another blue set
as stand by. What gauge spinal sets will you make available in the OR suite?
A. Gauge 16 and 22
B. Gauge 18 and 23
C. Gauge 16 and 20
D. Gauge 25 and 22
94. Medical gases are used a lot in the OR. Some gases are used to operate equipment
and some are used to administer general anesthesia through inhalation. What is the
identifying color of the tank which contains 'laughing gas'?
A. Yellow
B. Green
C. Black
D. Blue

95. On a traffic light, yellow means "proceed with caution". In the field of healthcare,
where do you discard your used tissue papers?
A. Yellow bin - infectious
B. Orange bin - radioactive waste
C. Green bin - biodegradable
D. Black bin - chemical waste

96. An instrument tray with black striped autoclave/steam chemical indicator tape
communicates that the instrument tray:
A. Is clean
B. is ready for use in surgery
C. Is sterile
D. Has undergone the sterilization process

97. In health care, when lead apron is required in any procedure like orthosurgery, there
is danger of exposure to:
A. Water and blood splashes
B. pseudomona
C. radiation
D. bone fragments

Situation 22 - Nurse Ervin is a newly registered nurse who works as a volunteer in the burn
unit.

98. A client is admitted to the burn unit with 50 percent burns to the chest and arms. The
skin is white, dry, and there is no pain. Nurse Ervin assesses the type of burn the client has
as which of the following?
A. Superficial thickness
B. Superficial partial thickness
C. Deep partial thickness
D. Full thickness

99. A young boy is brought to the unit with a chemical burn to the face. Priority
assessment would include which of the following?
A. Skin integrity
B. Blood pressure and pulse
C. Patency of airway
D. Amount of pain

100. A client who presents with a burn to the anterior chest and both arms anterior and
posterior is said to have burned what percentage of the body using the Rule of Nines?
A. 27 percent
B. 45 percent
C. 37 percent
D. 36 percent