NP1 Nursing Board Exam November 2008

Answer Key 'Foundation of Professional

Nursing Practice'
100 Nursing Board Exam test questions of November 2008 Nurse
Licensure Examination (NLE)
Nursing Practice 1 – Foundation of Professional Nursing Practice
Fundamentals of Nursing

PART 1 Board Exam test questions 1 - 50

Situation 1: Nursing is a profession. The nurse should have a background on the theories and foundation
of nursing as it influenced what is nursing today.

1. Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and
injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in
the care of the individuals, families, communities and population. This is the most accepted definition of
nursing as defined by the:
A. PNA
B. ANA
C. Nightingale
D. Henderson

2. Advancement in Nursing leads to the development of the Expanded Career Roles. Which of the following
is NOT expanded career role for nurse?
A. Nurse practitioner
B. Clinical Nurse Specialist
C. Nurse Researcher
D. Nurse anaesthesiologist

3. The Board of Nursing regulated the Nursing profession in the Philippines and is responsible for the
maintenance of the quality of nursing in the country. Powers and duties of the board of nursing are the
following EXCEPT:
A. Issue, suspend revoke certificates of registration
B. Issue subpoena duces tecum, ad testificandum
C. Open and close colleges of nursing
D. Supervise and regulate the practice

4. A nursing student or a beginning staff nurse who has not yet experienced enough in a situation to make
judgments about them is in what stage of Nursing Expertise?
A. Novice
B. Newbie
C. Advanced Beginner
D. Competent

5. Benner’s “Proficient” nurse level is different from the other levels in nursing expertise in the context of
having:
A. The ability to organize and plan activities
B. Having attained an advanced level of education
C. A holistic understanding and perception of the client
D. Intuitive and analytic ability in new situations
Situation 2: The nurse has been asked to administer an injection via Z TRACK technique. Questions 6 to
10 refer this.

6. The nurse prepares an IM injection for an adult client using the Z track techniques, 4 ml of medication
is to be administered to the client. Which of the following site will you choose?
A. Deltoid
B. Rectus Femoris
C. Ventrogluteal
D. Vastus lateralis

7. In infants 1 year old and below, which of the following is the site of choice in intramuscular injection?
A. Deltoid
B. Rectus Femoris
C. Ventrogluteal
D. Vastus lateralis

8. In order to decrease discomfort in Z track administration, which of the

A. Pierce the skin quickly and smoothly at 90 degree angle
B. Inject the medication at around 10 minutes per millilitre
C. Pull back the plunger and aspirate for 1 minute t make sure that the needle did not hit a blood vessel
D. Pierce the skin slowly and carefully at a 90 degree angle

9. After injection using the Z track technique, the nurse should know that she needs to wait for few
second before withdrawing the needle and this is to allow the medication to disperse into the muscle
tissue thus decreasing the client’s discomfort. How many seconds should the nurse wait before
withdrawing the needle?
A. 2 second
B. 5 seconds
C. 10 seconds
D. 15 seconds

10. The rationale in using the Z track technique in an intramuscular injection is:
A. It decreases the leakage of discolouring and irritating medication into the subcutaneous
tissue.
B. It will allow a faster absorption of the medication
C. The Z track technique prevent irritation of the muscle
D. It is much more convenient for the nurse

Situation 3: A client was rushed to the emergency room and you are his attending nurse. You are
performing a vital sign assessment:

11. All of the following are correct methods in assessment of the blood pressure EXCEPT:
A. Take the blood pressure reading on both arms for comparison
B. Listen to and identify the phases of Korotkoff sound
C. Pump the cuff to around 50mmHg above the point where the pulse is obliterated
D. Observe procedures for infection control

12. You attached a pulse oximeter to the client. You know that the purpose id to:
A. Determine if the client’s hemoglobin level is low and if he needs blood transfusion
B. Check level of client’s tissue perfusion
C. Measure the efficacy of the client’s anti-hypertension medications
D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops

13. After a few hours in the Emergency Room, the client is admitted to the ward with an order of hourly
monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood
pressure reading to be:
A. Inconsistent
B. Low systolic and high diastolic
C. Higher than what the reading should be
D. Lower than what the reading should be
14. Through the client’s health history, you gather that the patient smokes and drinks coffee. When taking
the blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before
taking the client’s blood pressure for accurate reading?
A. 15 minutes
B. 30 minutes
C. 1 hour
D. 5 minutes

15. While the client has pulse oximeter on his fingertip, you notice that the sunlight is shining on the area
where the oximiter is. Your action will be to:
A. Set and turn on the alarm of the oximeter
B. Do nothing since there is no identified problem
C. Cover the fingertip sensor with a towel or bedsheet
D. Change the location of the sensor every four hours

16. The nurse finds it necessary to recheck the blood pressure reading. In case of such reassessment, the
nurse should wait for a period of:
A. 15 seconds
B. 1 to 2 minutes
C. 30 minutes
D. 15 minutes

17. If the arm is said to be elevated when taking the blood pressure. It will create a:
A. False high reading
B. False low reading
C. True False reading
D. Indeterminate

18. You are to assessed the temperature of the client the next morning and found out that he ate ice
cream. How many minutes should you wait before assessing the client’s oral temperature?
A. 10 minutes
B. 20 minutes
C. 30 minutes
D. 15 minutes
19. When auscultating the client’s blood pressure the nurse hears the following: From 150 mmHg to 130
mmHg: Silence, Then: a thumping sound continuing down to 100 mmHg: muffled sound continuing down
to 80 mmHg and then silence. What is the client’s pressure?
A. 130/80
B. 150/100
C. 100/80
D. 150/100

20. In a client with a previous blood pressure of 130/80 4 hours ago, how long will it take to release the
blood pressure cuff to obtain an accurate reading?
A. 10 – 20 seconds
B. 30 – 45 seconds
C. 1 - 1.5 minutes
D. 3 – 3.5 minutes

Situation 4 – Oral care is an important part of hygienic practices and promoting client
comfort.

21. 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

22. 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

23. 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

24. 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 mouthwash 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 ums
D. suctioning as needed while cleaning the buccal cavity

25. 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 5: Ensuring safety before, during and after a diagnostic procedure is an important responsibility
of the nurse.

26. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the
following prior to the procedure:
A. Clenching his fist every 2 minutes
B. Breathing in and out through the nose with his mouth open
C. Tensing the shoulder muscles while lying on his back
D. Holding his breath periodically for 30 seconds

27. Following a bronchoscopy, which of the following complains to Fernan should be noted as a possible
complication:
A. Nausea and vomiting
B. Shortness of breath and laryngeal stridor
C. Blood tinged sputum and coughing
D. Sore throat and hoarseness

28. Immediately after bronchoscopy, you instructed Fernan to:

A. Exercise the neck muscles
B. Breathe deeply
C. Refrain from coughing and talking
D. Clear his throat

29. Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important
function during the procedure is to:
A. Keep the sterile equipment from contamination
B. Assist the physician
C. Open and close the three-way stopcock
D. Observe the patient’s vital signs

30. Right after thoracentesis, which of the following is most appropriate intervention?
A. Instruct the patient not to cough or deep breathe for two hours
B. Observe for symptoms of tightness of chest or bleeding
C. Place an ice pack to the puncture site
D. Remove the dressing to check for bleeding
 Situation 6: Knowledge of the acid base disturbance and the functions of the electrolytes is necessary to
determine appropriate intervention and nursing actions.

31. A client with diabetes milletus has glucose level of 644 mg/dL. The nurse interprets that this client is
at most risk for the involvement at which type of acid base imbalance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis

32. In a client in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48,
PCO2 32mmHg, PO2 94 mmHg, HCO3 24 mEq/L. The nurse interprets that the client has which acid base
disturbance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis

33. A client has an order for ABG analysis on radial artery specimens. The nurse ensures that which of the
following has been performed or tested before the ABG specimen are drawn?
A. Guthing test
B. Allen’s test
C. Romberg’s test
D. Weber’s test

34. A nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31, Pco2 is 500
mmHg, and the bicarbonate is 27 mEq/L. The nurse concludes that which acid base disturbance is present
in this client?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis

35. Allen’s test checks the patency of the:

A. Ulnar artery
B. Radial artery
C. Carotid artery
D. Brachial artery

37. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes
“daily urine specimen to be sent to the laboratory” . Eileen has a foley catheter attached to a urinary
drainage system. How will you collect the urine specimen?
A. remove urine from drainage tube with sterile needle and syringe and empty urine from the
syringe into the specimen container
B. empty a sample urine from the collecting bag into the specimen container
C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the
specimen container.
D. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into
the specimen container.

38. Where would the nurse tape Eileen’s indwelling catheter in order to reduce urethral irritation?
A. to the patient’s inner thigh
B. to the patient’s lower thigh
C. to the patient’s buttocks
D. to the patient lower abdomen

39. Which of the following menu is appropriate for one with low sodium diet?
A. instant noodles, fresh fruits and ice tea
B. ham and cheese sandwich, fresh fruits and vegetables
C. white chicken sandwich, vegetable salad and tea
D. canned soup, potato salad, and diet soda
40. Howe will you prevent ascending infection to Eileen who has an indwelling catheter?
A. see to it that the drainage tubing touches the level of the urine
B. change he catheter every eight hours
C. see to it that the drainage tubing does not touch the level of the urine
D. clean catheter may be used since urethral meatus is not a sterile area

Situation 7: Hormones are secreted by the various glands in the body. Basic knowledge of the endocrine
system is necessary.

41. Somatotropin or the Growth Hormone releasing hormone is secreted by the anterior pituitary gland:
A. Hypothalamus
B. Anterior pituitary gland
C. Posterior pituitary gland
D. Thyroid gland

42. All of the following are secreted by the anterior pituitary gland except:
A. Somatotropin/Growth hormone
B. Follicle stimulating hormone
C. Thyroid stimulating hormone
D. Gonadotropin hormone releasing hormone

43. All of the following hormones are hormones secreted by the Posterior pituitary gland except:
A. Vasopressin
B. Oxytocin
C. Anti-diuretic hormone
D. Growth hormone

44. Calcitonin, a hormone necessary for calcium regulation is secreted in the:

A. Thyroid gland
B. Hypothalamus
C. Parathyroid gland
D. Anterior pituitary gland

45. While Parathormone, a hormone that regulates the effect of calcitonin is secreted by the:
A. Thyroid gland
B. Hypothalamus
C. Parathyroid gland
D. Anterior pituitary gland

Situation 8 – The staff nurse supervisor requests all the staff nurses to “brainstorm” and
learn ways to instruct diabetic clients on self-administration of insulin. She wants to ensure
that there are nurses available daily to do health education classes.

46. The plan of the nurse supervisor is an example of

A. in service education process
B. efficient management of human resources
C. increasing human resources
D. primary prevention

47. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide
who is an unlicensed staff, Mrs. Guevarra
A. makes the assignment to teach the staff member
B. is assigning the responsibility to the aide but not the accountability for
those tasks
C. does not have to supervise or evaluate the aide
D. most know how to perform task delegated

48. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six
weeks ago when she started the job. The nurse supervisor should
A. empathize with the nurse and listen to her
B. tell her to take the day off
C. discuss how she is adjusting to her new job
D. ask about her family life

49. Process of formal negotiations of working conditions between a group of registered

nurses and employer is
A. grievance
B. arbitration
C. collective bargaining
D. strike

50. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and
required by the hospital employing you. This is
A. professional course towards credits
B. inservice education
C. advance training
D. continuing education

51. Which of the following is NOT a legally binding document but nonetheless very important in the care of

all patients in any setting?

A. Bill of rights as provided in the Philippine Constitution

B. Scope of nursing practice as defined in R.A. 9173

C. Board of Nursing resolution adopting the Code of Ethics

D. Patient’s Bill of Rights

52. A nurse gives a wrong medication to the client. Another nurse employed by the same hospital as a risk

manager will expect to receive which of the following communication?

A. Incident Report

B. Oral report

C. Nursing kardex

D. Complain report

53. Performing a procedure on a client in the absence of an informed consent can lead to which of the

following charges?

A. Fraud

B. Assault and Battery

C. Harassment

D. Breach of confidentiality

54. Which of the following is the essence of informed consent?

A. It should have a durable power of attorney

B. It should have coverage from an insurance company

C. It should respect the client’s freedom from coercion

D. It should discloses previous diagnosis, prognosis and alternative treatments available for

the client.

55. Delegation is the process of assigning tasks that can be performed by a subordinate. The RN should

always be accountable and should not lose his accountability. Which of the following is a role included in

delegation?

A. The RN must supervise all delegated tasks

B. After a task has been delegated. It is no longer a responsibility of the RN.

C. The RN is responsible and accountable for the delegated task in a adjunct with the delegate.

D. Follow up with a delegated task necessary only if the assistive personnel is not trustworthy.

Situation 10 – When creating your lesson plan for cerebrovascular disease or STROKE. It is important to

include the risk factors of stroke.

56. The most important risk factor is:

A. Cigarette smoking

B. Hypertension

C. binge drinking

D. heredity

57. 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

58. Hemmorhagic 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
59. 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

60. 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 cell increases hemoglobin content.”

D. “High RBC count increases blood pressure.”

Situation 11: Recognition of normal values is vital in assessment of clients with various disorders.

61. A nurse is reviewing the laboratory test results for a client with a diagnosis of severe dehydration. The

nurse would expect the hematocrit level for this client to be which of the following?

A. 60%

B. 47%

C. 45%

D. 32%

62. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is

5.6 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory

value?

A. ST depression

B. Inverted t wave

C. Prominent U wave

D. Tall peaked T waves

63. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is

3.2 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory

value?

A. U waves

B. Absent P waves

C. Elevated T waves
D. Elevated ST segment

64. 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) 9000/mm

C. Erythrocyte sedimentation rate (ESR) is 39 mm/hr

D. Iron 75 mg/100 ml

65. Which of the following laboratory test result indicate presence of an infectious process?

A. Erythrocyte sedimentation rate (ESR) 12 mm/hr

B. White blood cells (WBC) 18,000/mm3

C. Iron 90 g/100ml

D. Neutrophils 67%

Situation 12: Pleural effusion is the accumulation of fluid in the pleural space. Question to 66 to 70 refer

to this?

66. Which of the following is a finding that the nurse will be able to assess in a client with pleural effusion?

A. Reduced or absent breath sound at the base of the lungs, dyspnea, tachypnea and shortness

of breath.

B. Hypoxemia

C. Noisy respiration, crackles, stridor and wheezing

D. Tracheal deviation towards the affected side, increased fremitus and loud breath sounds

67. Thoracentesis is performed to the client with effusion. The nurse knows that he removal of fluid should

be slow. Rapid removal of fluid in thoracentesis might cause:

A. Pneumothorax

B. Pleurisy or Pleuritis

C. Cardiovascular collapse

D. Hypertension

68. 3 Days after thoracentesis, the client again exhibited respiratory distress. The nurse will know that the

pleural effusion has reoccurred when she noticed a sharp stabbing pain during inspiration. The physician

ordered a closed tube thoracotomy for the client. The nurse knows that the primary function of the chest

tube is to:
A. Restore positive intrathoracic pressure

B. Restore negative intrathoracic pressure

C. To visualize the intrathoracic content

D. As a method of air administration

69. The chest tube is functioning properly if:

A. There is an oscillation

B. There is no bubbling in the drainage bottle

C. There is a continuous bubbling in the water seal.

D. The suction control bottle has a continuous bubbling

70. In a client with pleural effusion, the nurse is instructing a appropriate breathing technique. Which of

the following is included in the teaching?

A. Breath normally

B. Hold the breath after each inspiration for 1 full minute

C. Practice abdominal breathing

D. Inhale slowly and hold the breath for 3-5 seconds after each inhalation.

Situation 13: Health care delivery system affects the health status of every Filipino. As a Nurse,

Knowledge of this system is expected to ensure quality of life.

71. When should rehabilitation commence?

A. The day before discharge

B. When the patient desires

C. Upon admission

D. 24hours after discharge

72. What exemplified the preventive and promotive programs in the hospital?

A. Hospitals as a center to prevent and control infection

B. Program for smokers

C. Program for alcoholics and drug addicts

D. Wellness Center

73. Which makes nursing dynamic?

A. Every patient is a unique physical, emotional, social and spiritual being

B. The patient participate in the over all nursing care plan

C. Nursing practice is expanding in the light of modern development that takes place

D. The health status of the patient is constantly changing and the nurse must be cognizant and

responsive to these changes.

74. Prevention is an important responsibility of the nurse in:

A. Hospitals

B. Community

C. Workplace

D. All of the above

75. This form of Health Insurance provides comprehensive prepaid health services to enrollees for a

periodic payment.

A. Health Maintenance Organization

B. Medicare

C. Philippine Health Insurance Act

D. Hospital Maintenance Organization

91. Health care reports have different purposes. The availability of patients record to all health ream

members demonstrates which of the following purposes:

A. Legal documentation

B. Education

C. Research

D. Vehicle for communication

92. When a nurse commits medication error she should accurately document client’s response and her

corresponding action. This is very important for which of the following purposes:

A. Research

B. Nursing Audit

C. Legal documentation

D. Vehicle for communication

93. POMR has been widely used in many teaching hospitals. One of its unique features is SOAPIE charting.

The P in SOAPIE charting should include:

A. Prescription of the doctor to the patient’s illness

B. Plan of care for patient

C. Patient’s perception of one’s illness

D. Nursing Problem and Nursing Diagnosis

94. The medical records that are organized into separate section from doctors or nurses has more

disadvantages than advantages. This is classified as what type of recording?

A. POMR

B. SOAPIE

C. Modified POMR

D. SOMR

95. Which of the following is the advantage of SOMR or Traditional Recording?

A. Increase efficiency of Data gathering

B. Reinforces the use of the nursing process

C. The caregiver can easily locate proper section for making charting entries

D. Enhances effective communication among health care team members

Situation 17: June is 24 year old client with symptoms of dyspnea, absent breath sounds on the right lung

and chest X-ray revealed pleural effusion. The physician will perform thoracentesis

96. Thoracentesis is useful in treating which of the following pulmonary disorders except:

A. Hemothorax

B. Tuberculosis

C. Hydrothorax

D. Empyema

97. Which of the following psychological preparation is not relevant for him?

A. Telling him that the gauge of the needle and anesthesia to be used

B. Telling him to keep still during the procedure to facilitate the insertion of the needle in the correct

place.

C. Allow June to express his feeling and concerns

D. Physician’s explanation on the purpose of the procedure and how it will be done.

98. Before thoracentesis, the legal consideration you must check is:

A. Consent is signed by the client

B. Medicine preparation is correct

C. Position of the client is correct

D. Consent is signed by relative and physician

99. As a nurse, you know that the position for June before thoracentesis is:

A. Orthopneic

B. Knee-chest

C. Low fowlers

D. Sidelying position on the affected side

100. Which of the following anesthetic drug is used for thoracentecis?

A. Procaine 2 %

B. Valium 250 mg

C. Demerol 75 mg

D. Phenobarbital