ANSWER KEY
who missed the last scheduled visit with her obstetrician
FUNDAMENTALS OF NURSING PRACTICE (70 points)
1. The equivalent of 100.8 degrees Fahrenheit in Celsius is
A. 38.2 C. 39.4
B. 38.7 D. 40.1
FORMULA: F – 32 (5/9) = C
2. 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. Creatinine – 0.9 mg/dL
C. Erythrocyte sedimentation rate - 25 mm/hr
D. Blood urea nitrogen – 15 mg/dL
NORMAL: 0-20 mm/hr. Any increase in ESR indicates an
inflammatory process.
Neutrophil (60-70%), creatinine (<1 mg/dL) and BUN (10-20
mg/dl) are all normal. Elevated neutrophil indicates ACUTE
inflammation while BUN & creatinine indicate renal damage.
Creatinine is more accurate than BUN since BUN is affected
by diet, fluid intake and muscular activity.
3. When doing physical examination as part of the nursing
process, the nurse should have sufficient understanding of
basic nursing procedures and skills. While auscultating
Mario's lung fields, the nurse compares the Lung sounds.
The nurse applies a systematic pattern by:
A. listening from anterior to posterior
B. assessing from top to bottom
C. comparing lung sounds side to side
D. comparing from interspace to interspace.
Chest auscultation involves listening to breath sounds from
side to side, comparing left and right lung fields as it goes from
top to bottom.
4. Who pioneered the idea of the nurse-client relationship
and interactive process?
A. Faye Abdellah
B. Florence Nightingale
C. Hildegard Peplau
D. Virginia Henderson
Abdellah focused on 21 nursing problems, Nightingale on
environmental theory, and Henderson on 14 basic needs.
5. The physician ordered a small volume enema to a client
with fecal impaction. The client needed further clarification
when she asks the nurse how the solution will work once it
is administered. The most appropriate explanation of the
nurse is that the solution:
A. Causes distention of the bowel and stimulates the
defecation reflex.
B. Draws water from the colonic mucosa cause water
retention in the lower-colon. . .
C. Decreases surface tension of stool allowing water to
enter stool more readily.
D. Promotes bowel evacuation that provides and
stimulates the defecation reflex.
Small-volume enema uses hypertonic solution, thus attracts
water into the feces. A and D are for hypotonic and isotonic
enemas, while C for oil retention enema.
6. According to Orem’s Self-Care Theory, what type of
nursing activity would a G2P1 mother, 7 months pregnant,
require?
A. Partially compensatory
B. Supportive-educative
C. Universal intervention
D. Wholly compensatory
(A) is applicable for patients with limited mobility and can do
partial self-care while (D) is for immobile and unconscious
patients who can needs total care from the nurse. (C) involves
needs that are needed by all individuals or patients.
7. Guillermo is allergic to non-steroidal drugs (NSAID). Which
of the following would be the LEAST relevant practice to
ensure that the nurse who is preparing the drugs for the
patient in the medication room becomes aware of his
allergy?
A. The medication administration record has a note on it
that patient is allergic to NSAID
B. Paste a note that patient is allergic to NSAID on the
chart cover
C. Have the patient wear a red identification bracelet
labeled 'With allergy'
D. Place a note in the patients medication box that he
has an allergy
The question asks what the nurse IN THE medication room
can be made aware of the patient’s allergy. The patient cannot
be with the nurse in the medication room.
8. Care of patients with intravenous fluids is one of the major
responsibilities of a nurse. A nurse caring for a client with
PICC line (peripherally inserted central line) knows that
the tip of the IV access is located in the
A. Basilic vein C. Right atrium
B. Cephalic vein D. Antecubital vein
A PICC line is inserted in a peripheral vein with its tip placed at
the right atrium. B, C, and D are the insertion sites.
9. A frail elderly woman undergoes a timed up and go test
with a result of 18 seconds. This means that the client
A. moves normally like any other adult
B. is a fall risk
C. is within normal limits for her age and physical
condition
D. needs assistance when moving out of bed
This is a test of mobility which involves measuring the time a
person rises from a chair, walks three meters, turn around, and
walk back to the chair and sit down. Completion of the test in
less than 10 seconds is normal mobility; however, for elderly
adults and those with disability, this may take them 11-20
seconds which is normal for this group. When a patient takes
21-30 seconds to perform the test, he needs additional
assistance during ambulation. A 30-second or more result
signifies a patient is a fall risk.
10. Allen’s test is indicated for which of the following clients? A
client
A. who needs an arterial line
B. with ulnar nerve damage
C. with peripheral neuropathy
D. who is about to undergo glucose test
This is a test to determine adequacy of peripheral
CIRCULATION.
11. A client is reported to have orthostatic hypotension.
Which of the following would you consider a sign?
 A. Increase in pulse of 40 beats/minute and decrease in
BP of 30 mm Hg from a sitting to a standing position
B. A drop of 30 mm Hg in BP from a supine to a
standing position with a rise in pulse of 40 beats/
minute
C. Decrease in pulse by 20 beats / minute and increase
in BP by 20 mm Hg from supine to standing position
D. A sudden drop in BP of 30 mm Hg systolic and 10
mm Hg diastolic from lying to sitting or sitting to
standing position
Orthostatic hypotension is measured while a person is lying
down, sitting AND standing. A 20-30 drop in systolic BP and
10-15 drop in diastolic BP when changing position is a positive
finding. B and C are wrong positions for the client.
12. A post-operative client complains of numbness and
tingling around his mouth and shows prolonged QT
interval on the cardiac monitor. These are associated with
which electrolyte imbalance?
A. Hypocalcemia C. Hyperkalemia
B. Hypokalemia D. Hypercalcemia
The symptom is an early sign of tetany or hypocalcemia.
Prolonged QT interval reflects a low calcium level.
13. Prevention of infection is one of the essential measures to
reduce negative outcomes in health care. Catheter care
must be performed frequently to prevent urinary tract
infections. How often should the nurse change a client’s
condom catheter?
A. Every 24 hours C. every 72 hours
B. Every 48 hours D. every 96 hours
Changing the catheter every 24 hours reduces the risk for UTI.
14. In the physical examination of a patient with abdominal
pain, what is the recommended sequence of examination
techniques?
A. Inspection, auscultation, percussion, palpation
B. Inspection, percussion, palpation, auscultation
C. Inspection, percussion, auscultation, palpation
D. Inspection, palpation, auscultation, percussion
Inspection is always the first technique of physical
assessment. In abdominal assessment, auscultation is done
first prior to percussion and palpation to prevent altering the
bowel sounds.
15. The patient with an acoustic nerve injury may have a
positive Romberg’s sign. Which of the following describes
a positive Romberg’s sign?
A. Inability to hear a whisper
B. Inability to hear unless the listener is looking at the
speaker
C. Inability to maintain an upright position with eyes
closed
D. Inability to maintain an upright position with eyes
open
Romberg’s test is a test of balance and equilibrium. Inability to
maintain such indicates an abnormality in the cerebellum.
16. Various methods of documentation are practiced by
nursing staff, one of which is the SOAP method. The
SOAP method stands for
A. subjective data, objective data, assessment, process
B. subjective data, objective data, assessment, planning
C. subject, objection, assessment, process
D. subjective data, objective data, analysis, planning
17. Somatotropin releasing hormone or the growth hormone
releasing hormone is secreted by the:
A. hypothalamus C. anterior pituitary gland
B. posterior pituitary gland D. thyroid gland
18. A suppository is prescribed for the client. When
administering the drug, the nurse must place the client in
which position?
A. Sim’s C. Lithotomy
B. Dorsal recumbent D. Prone
Left Sim’s position is the preferred position for any procedure
that involves administration of medication or tube into the
rectum as the sigmoid colon is located in the left lower
quadrant of the abdomen.
19. A client is transferred to the medical unit after a
transurethral resection of the prostate. The nurse reviews
the transfer orders. The surgeon's order reads: "Maintain
traction on the indwelling triple lumen catheter" Which of
the following is the MOST appropriate action of the nurse?
A. Tape the catheter to the abdomen and keep client in
supine position.
B. Pull the catheter taut and tape to the thigh alternately
every 6 hours.
C. Instruct the client to keep both legs together and
extended all the time.
D. Pull the catheter taut, tape to one thigh and keep the
leg extended all the time.
This position maintains traction of the catheter.
20. Normal heart sounds originate from the SA node. How
many times per minute does the SA node emit electric
currents in an adult?
A. 60-100 C. 40-60
B. 50-100 D. 80-120
The sinoatrial node is the pacemaker of the heart. It normally
emits 60-100 electric currents per minute. The atrioventricular
node emits 40-60, while the Bundles of His, 20-40.
21. When the body responds to stress, epinephrine is
released producing which physiological response?
A. Decreased oxygenated blood to vital organs
B. Decreased heart rate
C. Peripheral vascular dilatation
D. A more forceful heart beat
ABC are the opposite effects of epinephrine.
22. The nurse is aware that proper documentation when
taking care of the client is important. The purposes of
client care documentation include the following:
1. Standardizes plan of care
2. Communicates vital information about client’s
health status to other health care providers
3. Serves as resource for research and education
4. Serves as a legal document
A. 2, 3 and 4 C. 1, 2 and 4
B. 1, 3 and 4 D. 1, 2 and 3
According to Kozier, 234 are the purposes of documentation.
23. When assessing for the apical pulse, where should the
nurse place the stethoscope?
A. 5th ICS, left midclavicular
B. 4th ICS, left midsternal
C. 5th ICS, right midsternal
D. 4the ICS, right midclavicular
The apical pulse, also known as the point of maximum impulse
is located in the 5th left intercostal space, left midclavicular line.
24. A client has difficulty walking and needs wheel chair to
facilitate performance of daily activities. Anticipating the
needs of the client, the nurse should have the wheel chair
ready by placing it at
A. 60-degree angle to the bed
B. 45-degree angle to the bed
C. 90-degree angle to the bed
D. 30-degree angle to the bed
25. How will a nurse assess the client for pulse deficits?
A. Ask a colleague to take the apical pulse together with
her.
B. Ask a colleague to take the radial pulse as she is
taking the apical pulse.
C. Take the apical pulse & compare with the pulse
pressure.
D. Take the radial pulse after taking the apical pulse.
Assessment of pulse deficit can be done by either the 1-nurse
method or 2-nurse method. The question states “a nurse”.
Option B uses the 2-nurse method.
26. Which of the following best describes Cheyne-Stokes
respiration?
A. Abnormally deep, regular, and increased rate
B. Abnormally shallow for 2-3 breaths followed by
irregular period of apnea
C. Irregular rate & depth with alternating periods of
apnea & hyperventilation
D. Regular rate & depth with alternating periods of
apnea & hyperventilation
Choice A describes Kussmaul’s respiration.
27. The nurse implement standards of care to prevent
complications related to immobility. A client on bed rest is
rolled to a lateral position by the nurse. The nurse is
negotiating the move correctly when he:
A. Positions himself at the mid part of the bed and
places both hands at the back of the client and roll
client onto side
B. Places one hand on the client’s far hip and the other
on the client’s far shoulder rock backward and roll
onto side of the body facing him
C. Assumes a broad stance with the foot nearest the bed
placing his arm under the client’s thighs and shoulder
and roll client onto side
D. Supports the back and buttocks of the client and
shifts his own weight from the forward to the
backward foot and roll the client onto side
Choice B is the most appropriate way to turn a patient to the
lateral position. (Kozier)
28. Which of the following represents ventricular relaxation?
A. P wave C. Q wave
B. R wave D. T wave
P wave represent atrial depolarization/contraction. QRS waves
reflect ventricular depolarization.
29. The nurse is preparing the client for an ultrasound of the
gallbladder. Which of the following statements would be
the most important to prepare the client for the test?
A. "You will have food and fluids restricted for 4 to 8
hours prior to the test.“
B. "Stool in the bowel may cause a reporting of
inaccurate findings.“
C. "There is no special preparation for this procedure.
You may eat and drink as usual.“
D. "You will be asked to drink a solution of radionuclide 2
hours prior to the procedure."
NPO must be done prior to ultrasound of the bladder in order
to concentrate the bile in the bladder.
30. Cultural sensitivity enables nurses to be responsive to the
needs of patients with varied cultural background. A client
practices Islam and his diet must consider his religious
practices and beliefs. The nurse is aware that this client
would avoid which of the following?
1. Shrimps and crabs
2. Wine and alcohol drinks
3. Fish with scales
4. Pork products like bacon
5. Caffeinated products like cola drinks
A. 2, 4 and 5 C. 3,4, 5
B. 1, 4 and 5 D. 1, 2 and 4
31. What is the formula to obtain cardiac output?
A. Heart rate x Diastolic pressure
B. Heart rate x Pulse pressure
C. Heart rate x Stroke volume
D. Heart rate x Systolic pressure
Cardiac output is the amount of blood ejected by the heart in
one minute. It is determined by the heart rate and stroke
volume or the amount of blood ejected by the heart PER
contraction which is about 70 mL. If a person’s heart rate is 80,
multiply it by 70, then the cardiac output is 5,600 mL.
32. A pulse oximetry measures oxygen saturation of the
blood. The oxygen saturation reading that is assessed by
using a pulse oximeter is documented as
A. SaO2 c. PO2
B. SpO2 d. PaO2
Oxygen saturation is SaO2. When assessed by a pulse
oximeter, it as reflected as SpO2.
33. The nurse has a sterile field in front of her and needs to
reach something on the other side of the sterile field. To
maintain the sterile field, the nurse should:
A. Walk around with the back to the sterile field.
B. Reach across the sterile field.
C. Walk around facing the sterile field.
D. Move the sterile field away from her and reach the
object.
ABD all violate the principles of aseptic technique.
34. When obtaining a urine sample from a patient with an
indwelling urinary catheter, where should the urine be
collected?
A. From the balloon port of the catheter using a needle.
B. From the collection bag.
C. From the collection port using a needle.
D. From the tube near the meatus using a needle.
Letter A will remove the fluid that anchors the catheter. Urine is
never collected from the collection bag.
35. A nurse receives an order to obtain sputum sample for
culture from a client with pneumonia. What action should
be avoided when obtaining the specimen?
A. Having the client brush teeth before expectoration.
B. Instructing the client to take deep breaths before
coughing.
C. Obtaining the specimen early in the morning.
D. Placing the lid of the culture container face down on
the bedside table.
Oral care (A) may be done prior to sputum specimen collection
as long as antiseptic mouthwash or saline gargles are not
done. B facilitates sputum expectoration. C is the preferred
time to collect sputum. D contaminates the lid of the specimen
container.

36. A nurse is preparing to suction a client through a
tracheostomy tube. Which of the following protective items
would the nurse wear to perform this procedure?
A. Goggles, mask and sterile gloves
B. Mask. gown and cap
C. Mask, sterile gloves and cap
D. Gown, mask and sterile gloves
Gowns and caps are not required for tracheostomy suctioning.
37. When performing incentive spirometry after lobectomy,
how should the nurse position the client?
A. Semi-Fowler’s C. Supine
B. Trendelenburg D. Lithotomy
Incentive spirometry facilitates lung expansion. Semi-Fowler’s
position helps achieve that purpose.
38. While orienting a new nurse to the unit, the charge nurse
stresses the importance of accurate documentation, the
primary reason for a nurse to document care accurately is
A. Be in compliance with individual regulatory agencies
B. Demonstrate responsibility and accountability
C. Facilitate insurance reimbursement
D. Prevent any legal action against the healthcare facility
and its staff
39. A 12-year old girl has a long leg cast applied to her left
leg. She is being instructed in crutch walking with no
weight-bearing on her left leg. Which of the following
observations indicates that the girl needs further teaching?
A. Her elbows are slightly flexed
B. She is supporting her weight on the axillary bars and
hand pieces of the crutches
C. She is using the three-point gait
D. She places the crutches approximately six to eight
inches (15-20 cm.) in front of her with each step
The weight must be borne by the hands on the hand bars, not
by the axillae. This may cause neurovascular impairment.
40. An infant who weighs 11 lbs. (5 kg.) is to receive 750 mg
of antibiotic in a 24-hour period. The liquid antibiotic
comes in a concentration of 125 mg per 5 ml. If the
antibiotic is to be given three times each day, how many
milliliters would the nurse administer with each dose?
A. 10 B. 2 C. 5 D. 6.25
750 mg per day / 3 doses per day = 250 mg/dose
250 mg per dose / 125 mg x 5 ml = 10 mL
41. The nurse performs tracheostomy care to a client with
acute respiratory distress syndrome. After thoroughly
cleansing the lumen and the entire inner cannula in
hydrogen peroxide solution the nurse is now ready to
return the cannula to the tracheostomy site. To ensure
that the cannula is in place the nurse should:
A. Replace the inner cannula following the curve of the
tube, lock by rotating the external ring clockwise until
it clicks into place
B. Insert the flange of the tube and lock until it clicks into
place
C. Secure the flange of the inner cannula to the outer
cannula
D. Return the inner cannula, lock by rotating the external
ring counterclockwise until clicks into place.
To lock a tracheostomy cannula = turn clockwise (lock, clock)
To unlock a tracheostomy cannula = turn counterclockwise
42. A patient whose ventilation is inadequate should be
observed for early symptoms of hypoxia, which include
A. Restlessness C. Pallor
B. Cyanosis D. Disorientation
TIP: Signs of hypoxia
ALWAYS: Early sign of low oxygen is behavioral change since
the brain is sensitive to changes in oxygen level. Cyanosis is a
LATE sign of hypoxia.
43. Urinary tract infections remain to be the most common
cause of hospital acquired infections. When considering
the safety needs of a client with a urinary catheter, which
of the following should the nurse observe?
A. Keep a closed sterile drainage system
B. Irrigate the catheter daily
C. Keep the bag lower than the bed
D. Measure intake and output daily
Safety needs = prevention of infection. Maintain a closed
system if a patient is on an indwelling catheter.
44. Lizbeth is reviewing her notes in preparation for her
upcoming exam. In concepts of health illness, who
postulated that health is the ability to maintain the internal
milieu?
A. Walter Cannon C. Claude Bernard
B. Hans Selye D. Florence Nightingale
Claude Bernard – first to explain internal milieu
Walter Cannon – first to give the name “homeostasis”
Hans Selye – first to explain the stress response
45. Nursing practice is governed by different theoretical
framework postulated by known theorists. The four
concepts common to nursing conceptual models are:
A. Person, environment, health and nursing
B. Person, environment, psychology and nursing
C. Person, health, nursing and support system
D. Person, nursing, environment and medicine
These are also called the four metaparadigms in nursing.
46. Stress is the simple most important contributing factor to
illness. It is related to many of man’s illnesses and
interventions of these are based on the body’s reaction to
stress. Which of the following body systems is primarily
involved in GAS as a response to stress?
A. Central nervous system and cardiovascular system
B. Neurological and endocrine system
C. Endocrine system and respiratory system
D. Musculoskeletal and immunological system
GAS = general adaptation syndrome
The nervous system, through the autonomic nervous system
releases epinephrine and the endocrine system, via the
adrenal gland releases epinephrine and corticosteroids, which
are the stress hormones.
47. Changing the wound dressing of a client requires utmost
care to prevent infection of the wound. When doing wound
care, the most appropriate nursing action would be to
A. Remove old dressings with sterile gloves
B. Pour antiseptic solution out of the container
C. Open the sterile dressings with sterile gloves
D. Wear sterile gloves whenever in contact with the
wound area
Sterile dressings are opened by the clean bare hands by
holding the edges of the package.
48. A client is positive of neck vein distention if the nurse sees
a bulging neck vein when the client is in what position?
 A. Supine C. high-Fowler’s
B. Semi-Fowler’s D. Trendelenburg
The patient is initially placed on supine position for the nurse to
check the neck veins. Then the patient is put on a semi-
Fowler’s position. If a patient has a vein distention, it is visible
on that position.
49. A client with severe flank pain has a suspected renal
stones and is to undergo diagnostic procedures such as
intravenous pyelography. An important nursing
intervention after an intravenous pyelography is to
A. Determine response to the injected dye
B. Assess for allergy to iodine
C. Push fluids
D. Check the IV site
Intravenous pyelography involves administration of a dye or
contrast medium. Post-procedure, hydrate the patient to
facilitate excretion of the dye.
50. Having finished with you Masters degree in Nursing, you
were hired as a faculty member and were assigned to
teach the topic “History of Nursing”. Florence Nightingale
and her contemporary nurse learned nursing skills and
techniques as “trainees” during which period in the nursing
history?
A. Apprenticeship period C. Primitive period
B. Intuitive period D. Educative period
TIP: Periods in the history of nursing
1. Intuitive nursing (from pre-historic time to 1700s)– care was
based on instincts
2. Apprentice period (1700s-Nightingale era in 1800s) –
nursing was based on “on-the job” training, focus on skills; no
formal education for nurses
3. Educated nursing (1800s-1940s) – Florence Nightingale
initiated formal schooling and training for nurses
4. Contemporary nursing (1940s – present) – nursing based on
scientific principles, research and influenced by advances in
science and technology
51. The nurse correctly performs endotracheal suctioning
when she does which of the following?
A. Administer 100% oxygen before the procedure.
B. Apply intermittent suction while gently inserting the
suction catheter.
C. Advance the suction catheter when a resistance is
felt.
D. Suction the client for a minimum of 10-15 seconds.
Always pre-oxygenate the patient before and after suctioning.
Do not apply suction while inserting the suction catheter (B).
Choice C may cause tissue trauma. TIP: Never force any
invasive equipment past any resistance. Suctioning is done for
a maximum of 15 seconds (D).
52. A client is receiving an IV infusion of dextrose 5% in water
and Ringer’s lactate solution at 125 ml/hour to treat a fluid
a volume deficit. Which of these signs indicates a need for
additional IV fluids?
A. Dark amber urine
B. Serum sodium level of 135 mEq/L
C. Temperature of 37.5ºC
D. Neck vein distention
Dark amber urine is a sign of dehydration. The serum sodium
is normal (135-145 meq/L). An elevated level reflects
dehydration. Neck vein distention suggests fluid overload.
53. Before administering a medication through a nasogastric
(NG) tube, the nurse should do which of the following
first?
A. Inject 10 ml of air into the NG tube and aspirate
B. Instruct the client to cough
C. Give a client a sip of water through a straw
D. Inject 10 ml of water into the NG tube
TIP: Methods of checking for the placement of NGT
 Immersion – dip the end of the NGT in a cup of water.
Bubbling indicates placement of tube in the lungs.
 Auscultation – inject 10 ml of air into the tube and
listen for gurgling or borborygmi sounds.
 Aspiration – presence of gastric aspirate confirms
placement. It is the most accurate among the three
methods.
Abdominal x-ray, however, is the BEST method to determine
placement of NGT.
54. A female client confesses during admission assessment
that she has a lump in her breast. Which of the following is
the appropriate action of the nurse?
A. Lift the client hand to palpate the breast where she
noted the lump.
B. Palpate both breasts simultaneously to compare.
C. Assess the breast with the lump first.
D. Start assessment of the normal breast.
During admission, the initial action is to start assessment of the
normal breast. The suspected abnormal breast is done next.
55. Which of the following activities demonstrate secondary
level of prevention?
A. A mother going to her physician for her annual
mammography
B. Nurses attending a seminar of crisis management
strategies
C. Monitoring the blood glucose level of a diabetic
patient
D. A child receives his booster dose of varicella
immunization
TIP: Levels of Prevention
 Primary prevention – health promotion and disease
prevention. Examples are dietary modification,
avoidance of alcohol and smoking, stress
management, immunization and exercise.
 Secondary prevention – early diagnosis and
treatment. Examples are screening, diagnostic tests,
medications, surgery.
 Tertiary prevention – recovery and rehabilitation
Examples are prevention of complications, assistance
with ADL, physical therapy
56. A patient with pneumonia has respiratory acidosis. In
compensating for acid-base imbalances, the first
mechanism that is usually activated is the
A. Retention of bicarbonates by the kidneys
B. Excretion of carbon dioxide by the lungs
C. Bicarbonate-carbonic acid chemical buffer system
D. Retention of oxygen by the lungs
TIP: Sequence of compensatory mechanisms for acid-
base imbalances
1. Chemical buffer system – the most common is the
bicarbonate (base/alkaline)-carbonic acid buffer system
2. Respiratory system – the lungs excrete CO2 if the blood is
acidotic and retains CO2 if it is alkalotic. CO2 becomes an acid
(carbonic acid) when mixed with water.
3. Renal system – the last and most effective means to correct
imbalances. If the blood is acidotic, the kidneys retain
bicarbonates (base) and excretes hydrogen ions (acid). If the
blood is alkalotic, they excrete bicarbonates and retain the
hydrogen ions.
57. If a blood pressure cuff is too tight for a client, blood
pressure readings taken with such a cuff may do which of
the following?
A. Cause a sciatic nerve damage
B. Fail to show changes in blood pressure
C. Produce a false-high measurement
D. Produce a false-low measurement
When the BP cuff is too tight, it needs LESS air to inflate the
cuff. The reading will be lower.
58. A patient with renal failure has elevated phosphorus level.
Which of the following interventions is appropriate to
restore eliminate excess phosphorus from the body?
A. Advise patient to drink more milk
B. Tell patient to eat chocolates and nuts
C. Take aluminum- based antacids like Amphojel
D. Increase fluid intake
Aluminum binds with phosphorous and is eliminated via the
digestive system. Milk (A) and dairy products (B) have high
phosphorus content. Although increasing fluids may help
eliminate phosphorous, medications are more effective.
59. The intern-2nd assistant surgeon contaminated his gown
while the surgery is ongoing. He is expected to change his
gown and gloves. Which of the following is the CORRECT
technique to be followed?
A. The intern removes his gown and gloves then puts on
another sterile gown and gloves.
B. The intern removes his gloves, then his gown; does a
3-minute hand scrub and don another sterile gown
and gloves.
C. The intern unties his gown, removes his gowns and
put on another gown and gloves.
D. The circulating nurse unties the gown. The intern
removes his gown, then removes the gloves and puts
another sterile gown and gloves.
In ABC, the intern removes the gown on his own. He is not
supposed to do that with contaminated gloves on. Only choice
D has another personnel removing the gown for him.
60. Mr. Tee is admitted to the hospital with vomiting, diarrhea,
fever and a 5 lb (2.3 kg) weight loss. The nursing
diagnosis reads fluid volume deficit related to vomiting and
diarrhea. Which of the following laboratory values can the
nurse expect to find on Mr. Tee’s chart?
A. Decreased urine specific gravity (USG)
B. Elevated serum potassium level
C. Increased hematocrit level (Hct)
D. Normal serum chloride level
Hematocrit (37%-47%) is the percentage of blood cells to
plasma, the liquid component of the blood. When one has fluid
volume deficit or dehydrated, the blood becomes more
concentrated, thus giving a higher hematocrit level.
TIP: Laboratory values
 High hematocrit = hemoconcentration; fluid deficit
 Low hematocrit = hemodilution; fluid excess
 High USG = urine is concentrated; fluid deficit
 Low USG – urine is diluted; fluid excess
61. The nurse is taking care of a client, Luisa, 62 years old,
who received a diagnosis of uterine cancer and is in the
terminal stage. The focus on care for the terminally ill
client includes:
1. Meeting physiologic needs
2. Managing pain
3. Identifying and treating physical symptoms
4. Providing emotional support
A. 2 and 3 C. 1 and 2
B. 4 only D. 1, 2 and 4
Hospice care, or care of the terminally ill, focuses on making
the patient feel comfortable by focusing on pain management
and alleviation of symptoms (palliative care).
62. Control of infection is emphasized in the care of clients
and must not be compromised. An understanding of the
infectious process and appropriate methods to prevent
transmission of infection is important. The nurse in the
health center is explaining “standard precautions” to the
client. This involves which of the following actions?
A. Use clean gloves when handling items like blood,
body fluids, and non-intact skin.
B. Recap used needles with both hands before
discarding in puncture-resistant container.
C. Wash hands thoroughly using antimicrobial soap and
hot water.
D. Wear protective equipment when doing any nursing
procedures.
B is unsafe practice; never recap needles. Use of antimicrobial
soap (C) is only indicated if hands are contaminated; the
guidelines say the for routine handwashing, regular soap may
be used. Not all routine procedures need PPE (D).
63. Which of the following roles match the work-related
activity of the nurse whereby she functions as clinician,
educator, manager, consultant and researcher within a
specific practice?
A. Nurse practitioner
B. Nurse anesthetist
C. Clinical nurse specialist
D. Nurse-educator
A clinical nurse specialist performs the roles of a clinician,
educator, manager, consultant and researcher. A nurse
practitioner (A) is a generalist.
64. Maria will be preparing a patient for thoracentecis. She
should assist the patient to which of the following position
for the procedure?
A. Prone with the head turned to the side and supported
by a pillow
B. Lying in bed on the affected side with the head of the
bed elevated 45 degrees
C. Sim’s position with the head of the bed flat
D. Lying in bed on the unaffected side with the head of
the bed elevated 45 degrees
The preferred position for thoracentesis is an upright position
with arms propped up to exposed the rib cage or intercostal
spaces. If a patient cannot tolerate this position, the choice D
is the next preferred position.
65. As a nurse, what is one of the best way to reconcile
medications across the continuum of care?
A. Endorse the routine and “stat” medications every shift
B. Communicate a complete list of the patient’s
medication to the next provider of service
C. Endorse on a case to case basis
D. Endorse in writing
Medication reconciliation is a process whereby the nurse
endorses the patient’s list of medication, in a written form, to
the next level of care/provider. This practice aims to promote
patient safety and errors in medication.
66. A nurse is reviewing the electrolyte results of an assigned
client and notes that the potassium level is 6.6 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 C. inverted T wave
B. prominent U wave D. tall peaked T waves
The potassium level is increased. NV = 3.5-5.5 meq/L
TIP: Potassium & ECG
High potassium = high, peak, or tall T wave
Low potassium = low, depressed T wave; presence of U wave
67. A male client with a left lower leg prosthesis states that he
can feel his heart "skipping beats" when he walks up the
stairs. He states his doctor has ordered an outpatient test
that will take many hours, and he wants to know what it is.
Your response would be:
A. "Your physician has ordered an echocardiogram,
which will utilize sound waves to project a picture of
your heart in motion.“
B. "Your physician has ordered a Holter monitor test,
which will record your cardiac rhythm and rate while
you go about your normal activities.“
C. "Your physician has ordered a graded exercise
treadmill test (GXT), which will record your cardiac
activity as you exercise on a treadmill.“
D. "Your physician has ordered a 12-lead ECG, which
will record your resting heart rhythm and rate."
Key words: “Skipped beats” refers to cardiac dysrthythmias
which are diagnosed by an ECG. “Out patient test” that takes
“many hours” are characteristics of a Holter monitor (B) . A 12-
lead ECG (D) only takes a few minutes.
68. Which of the following nursing diagnoses contains the
proper components?
A. Risk for caregiver role strain related to unpredictable
illness course
B. Risk for falls related to tendency to collapse when
having difficulty breathing
C. Decreased communication related to stroke
D. Sleep deprivation secondary to fatigue and a noisy
environment
TIP: The components of a nursing diagnosis: PES
P – patient’s problem
E- etiology or related factor
S – signs and symptoms
B – the problem (risk for fall) and etiology (tendency to
collapse) are the same
C – the etiology is a medical diagnosis
D – wrongly stated (secondary to); it should be “related to”
69. Following a bronchoscopy, which of the following
complains 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
Stridor is a narrowing of the upper airway. It may indicate
laryngeal edema as a result of the bronchoscope irritating the
tissues. A blood-tinged sputum (C), sore throat and
hoarseness (D) may be common and expected after an
invasive procedure. Nausea and vomiting (A) may be an affect
of the anesthetic sprayed to suppress the gag reflex.
70. Promotion of adequate nutrition is a challenge to patients
with cancer. The nurse caring for a client on total
parenteral nutrition should perform which of the following
assessments regularly?
A. Serum glucose level
B. Serum electrolytes
C. Urine output
D. Level of consciousness
Total parenteral nutrition delivers a high calorie glucose,
protein and fat-rich solution intravenously. Hyperglycemia is a
common side-effect that needs to be monitored.
NURSING RESEARCH (20 points)
71. Which of the following is NOT a component of evidence-
based practice?
A. Use of the best available research finding
B. Applying the research evidence using clinical
expertise
C. Acceptability of the research finding by the patient
D. Generalizability of the research finding to the general
population
The fourth component of evidence-based practice (EBP) is the
availability of resources to implement the evidence. The finding
is only applicable to a single patient or a group of patients with
similar problems. Generalizability is not needed in EBP.
72. In most instances, Filipinos do not know their rights as
patients. To be a patient advocate, nurses must have a
good understanding of the “Patients’ Bill of Rights”. Which
of the following is an emerging role of the nurse in her
mission to provide quality care in any setting regardless of
type of client and meet her goal to contribute new
knowledge and technology in nursing?
A. Nurse executive D. Nurse manager
B. Nurse researcher C. Nurse educator
The main objective of nursing research is to contribute new
knowledge and technology to improve patient care.
73. A researcher would like to study two groups of students,
particularly, the freshmen and the sophomore students
regarding their study habits before every periodical
examination. The survey will be made on a same time to
determine if there is any difference as regards the two
groups. This type of survey is called:
A. Cross-sectional survey C. Evaluation survey
B. Longitudinal survey D. Sample survey
74. The researcher would like to determine the effectiveness
of a new system of scheduling and staffing in a particular
tertiary hospital to prevent sudden shortage in the ratio of
nurses to patients. The type of research method is called:
A. Manipulative C. Descriptive
B. Quasi-experimental D. Experimental
Although the study determines the effectiveness of an
intervention, the situation does not specifically mention two
groups of subjects, experimental and control groups, thus
making it a quasi-experimental research.
75. In the research study entitled “Effects of timing of initial
bath on the temperature of the newborn”, which of the
following is correct?
A. The presumed cause is the timing of initial bath
B. The presumed effects of the study is the timing of
initial bath
C. The variable to be manipulated is the temperature
D. The variable to be measured is the timing of initial
bath
TIP: Independent vs. Dependent Variables
 Independent variable = the presumed cause,
treatment or manipulated variable (timing of bath)
 Dependent variable = the presumed effect or
measured variable (temperature)
76. Which of these states the expected relationship between
the independent and dependent variable?
A. Assumptions C. Hypothesis
B. Research design D. Research purpose
Hypothesis = educated guess, a prediction of the possible
result of the study
77. A researcher embarked on an intensive study of health
problems affecting the residents of Brgy. San Carlos. She
decided to study every third family representing the total
population in the said community. Types of sampling
suited for the study is:
A. Cluster sampling C. Incidental sampling
B. Systematic sampling D. Stratified sampling
78. The plan for how a study will be conducted is called the:
A. Data-collection method C. Research design
B. Research process D. Hypothesis
79. Which statistical treatment is best used to answer the
research question, “The Level of Difficulty of the May
2014 Nurse Licensure Examination as Perceived by
the Examinees”?
A. Chi-square C. ANOVA
B. Mean D. T-test
The study simply requires frequency distribution and/or mean
determination.
TIP: Statistics
 Chi-square – to determine the relationship between
two variables that are on a nominal or ordinal scale
 ANOVA or analysis of variance – to determine
significant difference between three or more groups of
respondents
 T-test – to determine significant difference between
two groups of respondents and to determine
difference between pre-test and post-test scores
80. A competency-based assessment tool for nursing program
has been constructed. To assist the faculty in assessing
student attainment of competencies a measuring
instrument has to be developed. In developing the
research instrument, existing instruments that measured
similar variables were reviewed by the researcher. After
compiling and writing items, format was decided for each
variable to be assessed. Which of the following should the
researcher do to make sure that the instrument measures
the attainment of competencies?
1.Have colleagues review the items for logical validity
2.Revise items based on colleagues' feedback
3.Locate a group with experience appropriate to the
study
4.Try out the instrument with a group as similar as
possible to the study respondents.
A. 1,2 and 4 C. 1 and 2
B. 2 and 4 D. 1, 2, 3 and 4
The question refers on how to assess validity (accuracy) of a
research instrument. All of these items ensure validity.
81. The final step of the research process for the researcher is
to:
A. Analyze the data
B. Utilize the findings
C. Communicate the findings
D. Interpret the findings
Research utilization is the last phase of the research process.
82. The type of research design that does not manipulate
independent variable is:
A. non-experimental design
B. quantitative design
C. quasi- experimental design
D. experimental design
Experimental and quasi-experimental researches, which are
both quantitative designs, both involve manipulation of an
independent (treatment) variable.
83. In statistics, this expresses the variability of the data in
reference to the mean. It provides us with a numerical
estimate of how far, on the average the separate
observation are from the mean. What is this called?
A. Mode C. Standard deviation
B. Median D. Frequency
Key word: Variability = measures of variability includes range,
variance, standard deviation
84. The researcher implemented a medication regimen using
a new type of combination drugs to manic patients while
another group of manic patient receives the routine drugs.
The researcher however handpicked the experimental
group for they are the clients with multiple episodes of
bipolar disorder. The researcher utilized which research
design?
A. Quasi-experimental C Pure experimental
B. Phenomenological D. Longitudinal
TIP: Experimental vs. quasi-experimental research
If an experimental study DOES NOT involve random selection
of subjects (handpicked) and include two groups of subjects
(experimental and control groups), it is considered a quasi-
experimental study.
85. In the hypothesis “The utilization of technology in teaching
improves the retention and attention of the nursing
students.” Which is the manipulated variable in the study?
A. Utilization of technology
B. Improvement in the retention and attention
C. Nursing students
D. Teaching
Manipulated variable is also known as the independent,
treatment variable, or the presumed cause.
86. Nina, a staff nurse in the Oncology unit was asked to
participate as a member of the team in the Phase III
clinical trial of the effect of a new drug treatment for
cancer patients. The study has been approved by the
Institutional Review Board of the hospital where Nina is
employed. Nina was informed that a double blind
approach will be utilized. Which of the following is the
CORRECT description of approach?
A. Subjects who are randomly assigned to different
treatments are different people
B. Neither the subject nor those who administer the
treatment know who is in the experimental and control
group.
C. Pairing of subjects in one group with those in another
group based on similarities
D. Control group receives the full treatment and deferred
temporarily.
A double blind approach increases the validity of the study. All
subjects receive a treatment but no one knows, even the one
who administers the treatment, who belongs to the
experimental or control group.
87. In a research, the hypothesis developed was: Gingko
biloba improves memory and retention. This is an example
of what type of hypothesis?
A. Simple, directional hypothesis
B. Simple, non-directional hypothesis
C. Complex, directional hypothesis
D. Complex, non-directional hypothesis
TIP: Types of hypothesis
Simple – one independent and one dependent variable
Complex – 2 or more independent and 2 or more dependent
variables
Directional – indicates a positive or negative effect
Non-directional – the effect cannot be determined
88. A student nurse is curious to find out whether Safeguard
or Dial is more effective in cleaning an infected wound.
The first step in locating for evidence in evidence-based
practice is to formulate the research question using the
PICO format. PICO stands for
A. Problem, intervention, comparison, outcome
B. Population, interest, control, outcome
C. Presentation, intervention, comparison, organization
D. Problem, implementation, control, output
89. Which of the following levels of significance would yield
the most accurate research finding?
A. P = 0.01 C. P = 0.10
B. P = 0.05 D. P = 1.00
TIP: Level of significance
 0.01: 1% margin of error; 99% accuracy rate
 0.05: 5% margin of error; 95% accuracy rate
90. A questionnaire is being used to gather data on the study
sample. Identification numbers on the corner of the
questionnaires correspond to the researcher’s master list
of names and numbers. Respondents are assured that
this information will not be shared with anyone. The
researcher is trying to provide:
A. Confidentiality C. Informed consent
B. Anonymity D. Data security
Assigning respondents to numbers or codes ensures
anonymity.
COMMUNITY HEALTH NURSING (40 points)
91. The United Nations identified eight Millennium
Development Goals to address the pressing issues in the
entire world. The Philippine Department of Health adopted
the Basic Emergency Management Obstetric Care in
response to this calling. This reflects
A. Millenium Development Goal #3
B. Millenium Development Goal #4
C. Millenium Development Goal #5
D. Millenium Development Goal #6
TIP: Millenium Development Goals
MDG #4 – infants and children
MDG #5 – pregnant mothers and women
92. The community Health Nurse Conduct’s home visits to
families in the community. Planning for a home visit is an
essential tool in achieving best results in healthcare. The
following BUT ONE are the principles
A. Home visit should have a purpose
B. Planning of continuing care must be developed by the
nurse
C. Planning should be flexible and practical
D. Plans are based on available information including
those from other agencies that may have rendered
services to the family
Planning is collaboratively done by the nurse and the patient.
93. To encourage more health workers to stay in government
service, Republic Act 7305 or Magna Carta of Public
Health Workers was passed into law last 1991. “Public
health workers” include all persons working in the
government health facilities such as the:
1. Physicians 4. Cashier, clerical staff
2. Midwives 5. Janitor staff
3. Cooks and assistant cooks 6. Nurses
A. 1,2,3,4,5 and 6
B. 1,2,3 and 4
C. 1,2 and 3 only
D. 1,2,3,4 and 5
That is the definition of public health workers as defined in RA
7305.
94. PD 825 is law that pertains to:
A. environmental sanitation
B. compulsory immunization of children (PD 996)
C. anti-smoking (RA 9211)
D. registration of child births (PD 651)
95. The purpose of the first home visit is to
A. Assess family situation through initial data base
B. Develop a health care plan with the family
C. Make a personal account of the family’s health
situation
D. Promote health of the family
First home visit focuses on assessment of the family.
96. To ensure that the nurse can perform nursing procedures
with ease and deftness, saving time and effort with the
end in view of rendering effective nursing care, he must
A. Apply the nursing process
B. Develop a family care plan
C. Perform bag technique
D. Prioritize family health nursing problems
97. The primary goal of community health nursing is
A. Enhancing the health capabilities of the people
towards self-reliance in health
B. Health promotion and disease prevention
C. Upholding the worth and dignity of man
D. Raising the level of health of the citizenry
98. The philosophy of CHN is
A. Enhancing health capabilities of the people towards
self-reliance in health
B. Health promotion and disease prevention
C. Raising the level of health of the citizenry
D. Upholding the worth and dignity of man
99. The theoretical bases of Community Health Nursing
practice are theories and principles of
A. Community Development
B. Nursing
C. Nursing & Public Health
D. Public Health
100. People’s participation in health affairs is optimized through
the establishments of
A. Community-based health program
B. People’s organization
C. NGO
D. Community health centers
101. A dynamic process the nurse employ to achieve optimum
level of functioning of any level of clientele in CHN is the
A. Community organizing process
B. Epidemiologic process
C. Nursing process
D. Problem-solving process
102. The client/patient in community health nursing is the
A. Family as a socialization unit and undergoing different
stages of development
B. Group of people sharing common characteristics and
interests in a particular area
 C. Individual that is identified as a bio-psycho-social and
spiritual being
D. Population aggregates that require specialized care
The client in CHN is the community.
103. The focus of care in CHN is the
A. Family C. Individual
B. Population group D. Community
104. When reviewing the function of the rural health unit, the
community health nurse concurs that the RHU functions
as a:
A. Clinic for the municipality
B. Community resource
C. Health arm of the local government unit
D. Central health resource for the municipality
105. Which of the following herbal medicines is effective for
asthma, cough and dysentery?
A. Yerba Buena C. Lagundi
B. Sambong D. Tsaang gubat
106. The primary health care (PHC) approach is implemented
to ensure people’s health. Full participation of the people
is made possible through the application of community
organizing process in health. The ultimate end is to:
A. Develop community health programs
B. Improve availability and accessibility of health service
C. Promote people’s health
D. Transfer health into the hands of the people
107. There is the need to phase out the community once the
community-based health program is functional. The
reason for is to:
A. Indicate termination of community organizing process
B. Provide opportunity for the role to stand on their own
C. Start a new project in other depressed communities
D. Test the new health program if already viable
108. The cornerstones or pillars of PHC are
1-active community participation
2-multi-sectoral approach
3-use of appropriate technology
4-support mechanisms made available
A. All of the above C. 1 and 3
B. 1,2 and 3 D. 1 and 2
109. In prioritizing family health nursing problems, which of
these criteria should not be used by the nurse?
A. Acceptability of the problem
B. Preventive potential of the problem
C. Modifiability of the problem
D. Nature of the problem
The fourth criterion is salience, how the family perceives the
problem.
110. Vital statistics is one of the epidemiological tools that the
community health nurse uses in recording the impact of
health programs in the community. What is the most
significant implication of a community’s infant mortality
rate?
A. It determines the deaths among infants within a
specific period of time.
B. It is the best indicator of the community’s health
status.
C. It shows the number of deaths among babies during
the first 28 days of life.
D. It reflects the effectiveness of the delivery of health
services.
111. Communicable disease control program is one component
of CHN services. The nurse utilizes her concepts of
disease prevention. The best strategy in the prevention of
communicable diseases is:
A. Correct diagnosis and treatment
B. Health education
C. Immunization/chemoprophylaxis
D. Screening
112. Nurses working under the RN Heals are enrolled in the
Philhealth iGroup Insurance. Which of the following are
the benefits of the nurses who are under the RN Heals
Project? Select all that apply.
A. Premium of P1,200.00 per person per year
B. GSIS Group Accident Insurance premium of P 500.00
per person per year covering the following
C. Accidental Death/Dismemberment of P500,000.00
per person
D. Medical Reimbursement of P50,000.00 per person
E. Bereavement Assistance of P10,000.00.
113. Primary level of prevention of ascariasis pertain to the
following EXCEPT:
A. Food sanitation
B. Handwashing
C. Mebendazole as prophylaxis
D. Septic tank toilet
Primary level of prevention focuses on disease prevention and
health promotion. Choice C is secondary prevention.
114. The original objective of the Expanded Program on
Immunization is
A. Correct epidermiological situation in the country
B. Eradicate communicable diseases among infants and
young children
C. Reduce morbidity and mortality among infants and
children caused six immunizable diseases
D. Reduce mortality and morbidity of pregnant women
115. The community health nurse collects data about 100% of
the population in a barangay. The nurse is conducting:
A. Community assembly C. Community survey
B. Census taking D. Epidemiologic survey
116. BCG is given to school entrants at
A. 0.1 ml ID C. 0.05 ml ID
B. 0.5 ml ID D. 0.5 ml IM
117. The nurse conducts case findings for leprosy in the
community. She recalls that for the tuberculoid type of
leprosy, the best treatment is
A. PB 19 blister packs C. MB 18 blister packs
B. MB 24 blister packs D. PB 6 blister packs
118. The most serious side effect of DPT is
A. convulsion C. fever
B. inflamed site D. infection
119. Various programs have been designed and implemented
by the Philippine government to assist new nurses in their
transition into the labor market. EntrepreNurse and RN
HEALS are two of such recent programs. The
EntrepreNurse program is an initiative of the
A. Department of Health
B. Department of Labor and Employment
C. PRC Board of Nursing
D. Philippine Nurses Association
120. We are aware that Community Health Nursing (CHN) in
the Philippines encompasses health care provisions
affecting 4 clients: individual, families, population groups
and communities. In the course of our community health
 work, traditional, non-traditional, alternative, or
complimentary health care strategies are stabilized. Legal
basis for this action maybe derived from the:
A. PhilHealth Act
B. Traditional and Alternative Healthcare Law
C. Philippine Nursing Act
D. Philippine Medical Act
121. The following statements pertain to Community
Organizing EXCEPT
A. A never-ending process once started
B. A process for increasing awareness, facilitating
organization and initiating responsible action
C. Can apply to all communities
D. Its goal is community development
Each community is unique. The CO process depends on the
individual community situation.
122. A public health nurse conducts a home visit and uses the
family nursing care plan. During her assessment, which of
the following is categorized as a health deficit?
A. The father does not want to have a regular check-up
at the rural health unit.
B. The mother has a history of pre-eclampsia.
C. The eldest child is malnourished.
D. The youngest will enter first grade when the school
starts.
Choices A, B are health threats while D is a foreseeable crisis.
123. The community health nurse implements various health
programs of the Department of Health. The Essential
Intrapartum and Newborn Care’s (EINC) Active
Management of Third Stage of Labor (AMTSL) advocates
the implementation of the following practices EXCEPT?
A. mobility and position of choice in labor
B. partograph use
C. antenatal steroid administration in preterm labor
D. application of fundal pressure
124. An 8-month-old child is brought to the health facility for
“fast breathing.” Using the Integrated Management of
Childhood Illnesses (IMCI) guidelines, correct
interpretation of “fast breathing” in this situation MEANS:
A. 40 breaths per minute C. 45 breaths per minute
B. 38 breaths per minute D. 55 breaths per minute
TIP: Fast breathing in IMCI
Less than 12 months of age = more than 50 per min
More than 12 months of age = more than 40 per min
125. The nurse utilizes the IMCI chart in assessing her
pediatric clients in the rural health unit. When checking the
general danger signs in a 4 month old child, the following
questions are asked EXCEPT:
A. Did the child have convulsions?
B. Is the child eating well during illness?
C. Is the child able to breastfeed?
D. Has the child had diarrhea?
TIP: Danger signs
 Convulsion
 Lethargy or unconsciousness
 Inability to breastfeed or drink
 Severe vomiting.
126. For purposes of accuracy and completion of documents
regarding childbirth in the community, the nurse working at
the RHU is required that registration birth within 30 days
from must be done. Which law requires this?
A. R.A. 3573 C. R.A. 3375
B. PD 651 D. EO 119
RA 3573 – reporting of communicable diseases
EO 119 – reorganization of the DOH
127. A meeting of clients for home care (HC) is essential in
order to explain the role of the nurse and the advantages
of this alternative health provision. Among important
emphasis to be made is that home care
A. Encourages a dependent relationship between the
nurse and the client
B. Provides a holistic view of the client that helps nurse
to establish appropriate goals and to plan appropriate
care
C. Allows the nurse to have primary control over the
environment where the client will recover
D. Saves the client money because the care is provided
in a one-to-one situation
Home care promotes patient independence (A) and control
(C). It may cost more as care is provided on 1-on-1 basis (D).
128. In implementing the IMCI guidelines, the nurse should
always make it an assessment standard in children to
check in capillary refill especially when:
A. The extremities of the child feels cold
B. If there is a fever for more than 7 days
C. The child’s extremities feel warm
D. If the child has petechiae
129. The community health nurse as a supervisor in the
community functions by doing which of the following?
A. Detects deviations from health
B. Ensures continuity of care to clients/patients
C. Participates in development and distribution of IEC
materials
D. Provides technical and administrative support to
midwives
130. Under Republic Act 9173 of 2002, AMENDED by
Congressional Joint Resolution of 2009 sets the entry
level position for nurses at what salary grade?
A. Salary Grade 15 C. Salary Grade 24
B. Salary Grade 20 D. Salary Grade 10
COMMUNICABLE DISEASE NURSING (20 points)
131. The nurse observes a patient with typhoid fever constantly
picking the linen while he is lying supine on the bed. The
nurse notes this as a sign called
A. coma vigil C. asterixis
B. subcultus tendinum D. rhisus sardonicus
Subcultus tendinum – due to the contractions of the tendons of
the wrist
Coma vigil – state of unconsciousness due to typhoid fever
Asterixis – flapping tremors of the hands seen in hepatic
encephalopathy due to rising ammonia level
Rhisus sardonicus – also called sardonic grin; seen among
patent with tetanus/lockjaw
132. A patient is told he is positive of Taenia saginata on his
stool exam for ova & parasites. The nurse explains to the
patient that this might have come from
A. drinking contaminated water
B. eating fresh fruits and vegetables
C. swimming in flood water
D. ingesting improperly cooked beef
Taeniasis is a parasitic infection caused by tapeworms for
improperly cooked food. T. saginata comes from beef.
133. Schistosomiasis is an endemic disease. Endemic means
that the disease occurs
A. at one time during in a specific period of the year
B. if there is a sudden increase in infections
 C. continuously in a community throughout the year
D. widespread in the country at a particular time
B refers to epidemic and D pertains to pandemic.
134. The nurse evaluates effectiveness of her health teachings
on a group of mothers regarding ascariasis. An accurate
statement made by a mother regarding prevention of
ascariasis is
A. “I will tell my kids to wash hands after meals.”
B. “I will discourage my child from playing on the soil.”
C. “I will not let my children eat raw fruits.”
D. “I will make sure not to buy expired canned goods.’
Ascaris lumbricoides thrives in the soil. Playing on the soil may
get the ova into the skin and nails which may eventually be
ingested if proper handwashing is not observed.
135. Which of the following statements made by a patient
suggests the presence of enterobiasis?
A. “I feel nauseated every morning.”
B. “I feel itchiness in my anus at night.”
C. “My abdomen is cramping frequently.”
D. “I didn’t’ have a bowel movement in 3 days.”
Pinworm infestation by Enterobius vermicularis causes
nocturnal perianal pruritus.
136. A patient presents to the emergency room with meningitis.
The patient is most likely to present with which chief
complaints?
A. headache and nuchal rigidity
B. vomiting and blurred vision
C. dilated pupils and seizures
D. loss of consciousness and cyanosis
Early sign of meningeal irritation is stiffness of the neck. Other
signs may include Brudzinsky sign and Kernig’s sign.
137. Which of the following laboratory results for CSF suggests
the presence of bacterial meningitis?
A. increased protein level
B. decreased white blood cells
C. reduced glucose level
D. increased red blood cells
Bacteria in the CSF consumes the glucose, reducing the
glucose level in the CSF.
138. The nurse assesses a patient with meningitis by asking
the patient to flex his knees towards his abdomen and
assessing his response. The nurse is performing an
assessment to elicit the
A. Babinski sign C. Brudzinsky’s sign
B. Kernig’s sign D. Cushing’s sign
Babinski sign – sign of neurological immaturity seen in infants
Brudzinsky sign – sign of meningitis elicited by flexing the neck
and observing for involuntary flexion of the knees and neck
pain
Cushing’s sign – late sign of increased intracranial pressure
characterized by high BP or widened pulse pressure,
bradycardia and bradypnea (slow RR)
139. To determine the presence of rabies in an animal, its brain
tissues can be examined for the presence of
A. necrotic tissues C. hematomas
B. Negri bodies D. antibodies
The presence of Negri bodies is pathognomomic of rabies.
140. The nurse notes meningococcemia in a patient if she
observes
A. stiffness of the neck C. petechiae on the skin
B. unequal pupils D. diarrhea
Meningococcemia causes disruption in the blood vessels,
causing hemorrhage.
141. Syphilis is caused by:
A. Neisseria gonorrhea C. Treponema pallidum
B. Cytomegalovirus D. Herpes simplex virus
142. A sign of gonorrhea is
A. generalized skin rash
B. yellowish genital discharge
C. clear white genital discharge
D. cheesy substance on the genitalia
Clear white discharge is common in syphilis. Cheesy white
substance is seen in candidiasis.
143. The modes of transmission of the human immune
deficiency virus are categorized as horizontal and vertical
transmission. Which of these is an example of a vertical
mode of transmission?
A. Sexual intercourse with an infected partner
B. Needlestick injury from an infected patient
C. Placental transfer from an infected mother
D. Sharing among infected IV drug users
ABD are considered horizontal modes of transmission.
144. A confirmatory diagnostic test for HIV infection is
A. the Western blot test
B. enzyme linked immunosorbent assay (ELISA) test
C. T4 cell count determination
D. differential CBC test
ABC are all used in HIV diagnosis. B is used as the initial
screening test. T4 cell count is used to monitor progression of
the disease.
145. A patient asks the nurse for early signs of HIV infection.
The nurse tells that early HIV infection is usually
manifested by the presence of
A. enlarged lymph nodes in multiple areas of the body
B. recurrent oral thrush
C. rapid weight loss and diarrhea
D. multiple infections
Persistent generalized lymphadenopathy or the enlargement of
1 or more lymph nodes for a long period of time without the
presence of any infection is an early sign of HIV infection.
146. Multiple drug therapy is given to a patient with AIDS.
Which of these is an example of an anti-viral drug for
AIDS?
A. Amphotericin B C. Zidovudine
B. Amantadine D. Azithromycin
Anti-retroviral therapy is used to inhibit the replication of the
HIV. (A) is an anti-fungal, (B) anti-flu, and (C) anti-bacterial.
147. A patient with HIV infection has whitish spots on the
mouth and throat. The nurse will most likely administer
A. Neomycin sulfate C. Nystatin solution
B. Glycerine oral swabs D. Amphotericin B
These indicate oral candiasis, a superficial (skin and mucous
membranes) infection caused by the fungus, Candida albicans.
C and D are both anti-fungal drugs but Amphotericin B is used
for severe systemic fungal infections.
148. A nurse teaches the public where malaria is endemic
about prevention and management of the infection. Which
statement about malaria is accurate? Malaria
A. affects the white blood cells
 B. is caused by a protozoan
C. is caused by the Anopheles mosquito
D. leads to internal hemorrhage
Malaria causes hemolysis of RBC (A), not hemorrhage (D). It
is caused by the protozoa of the Plasmodium species and is
transmitted, NOT caused, by a female Anopheles mosquito (C)
149. Which vital statistics relating to Tuberculosis (TB) in our
country is INACCURATE?
A. The Philippine is among the 22 highly burdened poor
countries in the world
B. TB is the 6th leading cause of illness among Filipinos
C. TB is the 6th leading cause of deaths among Filipinos
D. Most TB patients belong to the 0-15 age groups
150. When a nurse gets a hepatitis vaccine after exposure to a
body fluid of a patient with hepatitis B, the type of
immunity that develops is
A. a naturally acquired active immunity
B. a naturally acquired passive immunity
C. an artificially acquired passive immunity
D. an artificially acquired active immunity
Hepatitis B immunization involves administration of
immunoglobulins or antibodies for immediate protection.
TIP: Active vs. passive immunity
Active – the body produces its OWN antibody
Passive – the antibody comes from an OUTSIDE source
PHARMACOLOGY (30 points)
151. Felicito, 65 years old, post coronary artery bypass due to
acute myocardial infarction, sought consultation because
of worsening pedal edema. Upon admission, Morphine
sulfate was administered intravenously. Which of the
following is the purpose of administering the drug?
A. improve efficacy of breathing
B. relieve chest pain
C. reduce venous return
D. reduce anxiety
It is true that Morphine sulfate is an opioid analgesic and is
used to relieve chest pain in myocardial infarction. The
situation presents the development of pedal edema, which is a
sign of impending heart failure. In heart failure, morphine is
used to promote pulmonary circulation, thus, improves the
breathing of a patient.
152. The physician prescribes oral penicillin 500 mg every six
hours for seven days. On the fifth day before Cora
administer the first dose for the day she computed the
total amount in milligrams of the oral penicillin that has
been received by the client. Which is the correct amount?
A. 2,500 mg C. 10,000 mg
B. 15,000 mg D. 8,000 mg
The situation is asking the dose given on the previous four
days only (before the nurse gives the first dose on the 5th day).
153. Which of the following conditions would alert the nurse
that a patient receiving Chloramphenicol (Chloromycetin)
is developing severe toxic reactions?
A. Nausea, vomiting, diarrhea
B. Anemia, infections, bleeding
C. Jaundice, tinnitus, oliguria
D. Photosensitivity, rash, constipation
Chloramphenicol causes bone marrow depression, causing
reduced production of RBC, WBC, and platelets, leading to
anemia, infections, and bleeding, respectively.
154. A patient is in a Respiratory Isolation room and is taking
multi-drug therapy for tuberculosis. Which of the following
statements made by the patient suggests that he is
exhibiting adverse effect of Streptomycin?
A. “I am having numbness in my hands.”
B. “I have some trouble hearing.”
C. “I noticed my urine turned orange.”
D. “My hands seem to be more swollen today.”
TIP: Side-effects of anti-TB drugs (RIPES)
Rifampicin – orange discoloration of the urine
Isoniazid – peripheral neuropathy; hepatotoxicity
Pyrazinamide – hyperuricemia
Ethambutol – optic neuritis; hepatotoxicity
Streptomycin – otoxocicity, tinnitus
155. Mr. A is a 56-year old patient admitted at the ED with an
internal hemorrhage. He was given Epinephrine 1:1000
SQ. Which of the following sets of physiological responses
reflects the effects of Epinephrine?
A. bradycardia, vasoconstriction, miosis
B. bronchodilation, mydriasis, hyperglycemia
C. tachycardia, hypotension, tachypnea
D. vasodilation, hypoglycemia, bronchoconstriction
Effects of Epinephrine: tachycardia, vasoconstriction
(hypertension), mydriasis (pupil dilation), tachypnea,
hyperglycemia, bronchodilation.
156. Low molecular weight Heparin such as Enoxaparin
(Lovenox) was prescribed to be administered. Which of
the following should the nurse include in her nursing care
plan to ensure absence of injury?
A. Deltoid is the preferred site because it is less painful
B. Aspirate prior to injecting to ensure no blood vessel is
hit
C. Use gauge 25 and 1/4 inch long needle
D. Massage after the injection to promote fast absorption
The drug is administered subcutaneously on the abdomen only
(A) using a gauge 25-26, ¼-5/8 inch needle (C). Aspiration (B)
and massage (D) are not done before and after administering
the drug.
157. Mr. C is a 65 y/o patient with myasthenia gravis. Which of
the following medications is used to treat myasthenia
gravis?
A. Pyridostigmine (Mestinon)
B. Trihexyphenidyl HCl (Artane)
C. Bethanechol Cl (Urecholine)
D. Methyldopa (Aldomet)
Myasthenia is caused by low level of acetylcholine (Ach).
Treatment involves use of antic-cholinesterase medications to
prevent the breakdown of Ach by the enzyme, cholinesterase.
This will eventually increase Ach levels.
158. Mr. S is a 40-year old patient at the psychiatric unit and is
being treated with anti-psychotic drugs. The nurse
observes that Mr. S is exhibiting symptoms of Parkinson’s
disease. Which of the following anti-cholinergic drugs is
often used to reduce side effects of anti-psychotic
medications such as pseudo-parkinsonism?
A. Benztropine mesylate (Cogentin)
B. Pilocarpine (Pilocar)
C. Neostigmine bromide (Prostigmine)
D. Atenolol (Tenormin)
TIP: Anti-cholinergic meds to prevent pseudo-
parkinsonism or extra-pyramidal symptoms (EPS) caused
by antipsychotics
A – Akineton (Biperiden HCl)
A – Artane (Trihexiphenydyl HCl)
B – Benadryl (Diphenhydramine HCl)
C – Cogentin (Benztropine mesylate)

159. A patient is admitted to the ED 12 hours after ingesting a
half-bottle of Acetaminophen (Tylenol). To determine
organ damage due to the toxic effect of the drug, the
nurse should evaluate which of these laboratory results?
A. Aspartate transaminase (AST) / alanine transaminase
(ALT) levels
B. White blood count (WBC) and uric acid levels
C. Platelet count and urinalysis
D. Blood urea nitrogen (BUN) and creatinine levels
Hepatotoxicity is an effect of Acetaminophen. Elevated
ALT/AST levels indicate liver damage.
160. Mr. P is a 76-year old patient with rheumatoid arthritis. He
is currently taking Aspirin 325 po q4h prn for joint pains.
Which of the following nursing interventions is appropriate
for patients taking Aspirin?
A. Administer the medication before meals.
B. Monitor the apical pulse prior to giving the drug.
C. Give the medication with meals.
D. Do not give the medication if the patient has urinary
obstruction.
Aspirin, a non-steroidal anti-inflammatory drug (NSAID),
causes gastric irritation.
161. A 6-year-old child has a low grade fever due to a viral
respiratory infection. The choice of medication to reduce
the temperature is
A. Acetylsalicylic acid (Aspirin)
B. Acetaminophen (Tylenol)
C. Ibuprofen (Advil)
D. Mefenamic acid (Ponstan)
Acetaminophen is the drug of choice to reduce fever in
children with viral infection. Salicylates are not given (A) due to
the risk of developing Reye’s syndrome. C&D are primarily
used as analgesics, not routinely given as anti-pyretic drugs.
162. A patient with cerebral edema is taking Dexamethasone
(Decadron) 8 mg po q6h. Which of the following
assessment findings suggests a common side-effect of
corticosteroids?
A. Hyperglycemia C. Diarrhea
B. Hyponatremia D. Dehydration
Hyperglycemia, hypokalemia, sodium and water retention, and
risk for infection due to immunosuppression are side-effects of
steroids.
163. A nurse is conducting an admission interview. As she is
taking the patient’s medication history, the nurse discovers
that the patient has a history of using Valproic acid
(Depakote) and Carbamazapine (Tegretol) daily. Which of
the following conditions from the patient’s medical history
justifies the need to take these medications?
A. Multiple sclerosis C. Seizure disorder
B. Parkinson’s disease D. Pituitary tumor
These are anti-convulsant medication, used to treat and
prevent seizures.
164. A client with myocardial infarction is receiving an l.V.
infusion of heparin sodium at 1,500 units per hour. The
concentration in the bag is 25,000 units per 500 ml. How
many ml should the nurse document as intake from the
infusion for an eight shift?
A. 300 ml B. 450 ml C. 400 ml D. 240 ml
Desired dose = 12,000 units (1,500 x 8-hour shift) x 500 mL
Stock dose = 25,000 units
= 600,000/25,000 = 240 mL
165. Gingival hyperplasia is a common side-effect of
A. Phenytoin (Dilantin)
B. Valproic acid (Depakote)
C. Carbamazapine (Tegretol)
D. Chlordiazepoxide (Librium)
Gingival hyperplasia or enlargement of the gums is a common
side-effect of Phenytoin. Oral care helps prevent this condition.
166. The appropriate information to a COPD patient on action
of Acetylcysteine (Mucomyst) is:
A. “This medication helps loosen the secretions in your
lungs.”
B. “This drug will make you breathe easier by dilating
your airways.”
C. “You will feel dizzy or sleepy after taking this
medication.”
D. “This drug makes your mouth dry because it
decreases oral secretions.”
Acetylcysteine is a mucolytic, used to loosen thick, tenacious
secretions in the trachea-bronchial tree.
167. A mother is asking questions to her 3-year-old son’s nurse
about the newly prescribed Cromolyn sodium (Intal) for
her son’s asthma. Which of the following nurse’s
statements accurately addresses the mother’s concern?
A. “It is the drug of choice for asthma caused by severe
acute anaphylaxis.”
B. “It is a potent bronchodilator therefore easing
respirations.”
C. “It is effective as a preventive measure for future
asthmatic attacks.”
D. “It increases the effects of histamine on the lungs.”
Cromolyn sodium is a mast cell stabilizer. It prevents the
degranulation of mast cells, which can release histamine and
other chemical mediators that triggers the symptoms of
asthma. It is used to prevent asthmatic attacks.
168. A patient is on Digoxin (Lanoxin) 0.25 mg po daily. What is
the physiologic action of Digoxin?
A. Increases the rate of cardiac contraction
B. Decreases the force of cardiac contraction
C. Increases the force of cardiac contraction
D. Decreases the stroke volume
Digoxin is a cardiac glycoside used in the management of
heart failure. It acts by increasing the force of cardiac
contraction (positive inotropic effect). It can reduce the heart
rate (negative chronotropic effect) so the nurse needs to count
the apical pulse for 1 full minute prior to its administration. Do
not administer if the apical pulse is below 60 beats per minute.
169. A patient is newly admitted to the hospital and tells the
nurse during the assessment interview that she is
currently taking a potassium-wasting diuretic for her
cardiac problem. The nurse reviews her medication orders
and finds: “Digoxin (Lanoxin) 0.125 mg po daily”. The
nurse’s action is appropriate if she
A. Administers the medication as ordered
B. Requests an order to check serum potassium level
C. Advises the patient to take half of the diuretic
D. Reviews the patient’s latest CBC result
The patient is taking a potassium-wasting diuretic which makes
him prone to hypokalemia. This can increase risk for digitalis
toxicity. Potassium level must be monitored.
170. Dilantin 5 mg/kg body weight is ordered to a client who
weighs 50 lbs. The drug is to be administered in 3 equal
doses. The label reads Dilantin suspension 125 mg/ml.
how much medication should be administered to the
client?
 A.1.8 ml B. 1.5 ml C. 1.0 ml D. 0.5 ml
50 lbs. / 2.2 kg = 22.73 kg
Desired dose = 5 mg/kg x 22.7 kg x 1 ml = 0.91 or 1 mL
Stock dose = 125 mg
171. A patient asks why insulin is not administered orally. The
nurse is correct if she states:
A. “Insulin is destroyed by the gastric juices. “
B. “Insulin given orally may cause nausea and vomiting.
C. “Insulin may irritate the gastric mucosa.”
D. “Insulin absorption in faster if given orally.”
172. A patient is to take NPH insulin 32 U and Regular insulin 8
U daily. In preparing the medication, the nurse would
BEST use
A. Two separate syringes
B. An insulin syringe, drawing regular insulin first
C. An insulin syringe, drawing NPH insulin first
D. A 1-cc syringe, drawing regular insulin first
Two types of insulin can be mixed in one syringe. However,
the question asks for the best way to administer two types of
insulin and gives an option of using two syringes.
173. For a patient with addisonian crisis, it would be dangerous
to administer
A. Epinephrine hydrochloride
B. Fludrocortisone
C. Potassium chloride
D. Hydrocortisone
Addison’s disease causes reduced level of aldosterone, which
can decrease sodium and water retention. As sodium
decreases, potassium is retained, causing hyperkalemia.
174. DDAVP is used in the treatment of
A. Pheochromocytoma
B. Syndrome of inappropriate antidiuretic hormone
C. Diabetes insipidus
D. Addison’s disease
Diabetes insipidus is caused a lack of anti-diuretic hormone
(ADH). Management involves replacement of synthetic ADH.
TIP: DDAVP
DDA – Desmopressin or Desmopressin acetate
V – Vasopressin
P – Pitressin
175. A patient with reflux disorder is prescribed Aluminum
hydroxide (Amphojel), an antacid. A common side effect is
A. Nausea and vomiting C. Diarrhea
B. Constipation D. Flatulence
TIP: Side-effects of antacids
Aluminum-based – constipation
Magnesium-based – diarrhea
Calcium-based – constipation
176. A patient with liver failure is showing signs of hepatic
encephalopathy. The physician ordered Lactulose. The
nurse knows that Lactulose is effective if the
patient/patient’s
A. ammonia level remains high
B. passes soft or liquid stools
C. bowel sounds is hypoactive
D. does not vomit
Lactulose helps reduce ammonia level among patients with
hepatic encephalopathy by increasing its excretion from the
digestive system. Diarrhea, 2-3 x a day, is an expected effect.
Bowel movement more than 3x per day indicates
overmedication.
177. A patient in labor is receiving Pitocin drip. Her contractions
are becoming more severe and intense, and lasting 30
seconds to 2 minutes. What is the nurse’s best initial
action?
A. Notify the physician.
B. Check the fetal heart tone.
C. Discontinue the infusion.
D. Document the findings.
Pitocin (Oxytocin) promotes uterine contraction. Contractions
more than 90 seconds compromise fetal circulation, due to a
reduced utero-placental circulation. A 2-minute contraction can
cause fetal distress necessitating the drip to be stopped.
178. The nurse is in charge of a client on a long term
Nitroglycerine sublingual tablets for angina pectoris. What
instruction of the nurse is APPROPRIATE for the client to
maintain the efficacy of the drug?
A. Retain sublinguaI tablets in a plastic transparent
container
B. Maintain a supply for a duration of one year
C. Replace sublingual tablets supply every three months
D. Keep sublingual tablets in amber glass bottle
Nitroglycerine is heat and light sensitive and must be stored in
a colored/amber bottle, not transparent (A). An open bottle
must be discarded after 6 months as it loses potency.
179. A patient with significant psychiatric history is discharged
with Haloperidol to take twice a day by mouth. Which
discharge instruction should the nurse provide?
A. Decrease the dose if symptoms disappear.
B. Double the dose if experiencing severe stress.
C. Apply sunscreen before exposure to the sun.
D. Wait for two weeks before experiencing the effects of
the drug.
One of the main effects of antipsychotics are photosensitivity
and skin rash. Protection from exposure to ultraviolet rays of
the sun is essential. Adjusting the dose of any drug is always a
wrong answer (A,B).
180. The physician ordered Epinephrine 1 mg SQ x 1 dose
only. The stock is Epinephrine 1:1000. The nurse should
give
A. 0.01 ml C. 0.1 ml
B. 0.05 ml D. 1 ml
1:1000 = 1 g Epinephrine : 1,000 mL solvent
= 1,000 mg : 1,000 mL
= 1 mg : 1 mL
Desired dose = 1 mg x 1 mL = 1 mL
Stock dose = 1 mg
NURSING LEADERSHIP & MANAGEMENT / NURSING
JURISPRUDENCE & PROFESSIONAL ADJUSTMENT (20
points)
181. According to Benner’s Stages of Clinical Expertise, how
many months of clinical experience should a nurse
possess before she can be called a competent nurse?
A. 6-12 months C. 24-36 months
B. 12-24 months D. 36-60 months
TIP: Stages of clinical expertise by Benner (NACPE)
 Novice – no experience; learning skills
 Advanced beginner – 1-2 years of experience; task-
oriented
 Competent – 2-3 years of experience; focuses on
organization
 Proficient – holistic understanding of patient situation
 Expert – uses intuition in patient care
182. Which of the following does not govern nursing practice?
 A. R.A. 7164
B. R.A. 9173
C. B.O.N. Resolution for Code of Ethics
D. Board Resolution Scope of Nursing Practice
RA 7164 is the old nursing law, amended by RA 9173.
183. While doing the routine nursing rounds during the night
shift, the nurse found a patient on the floor with blood
oozing from the forehead. The nurse called for help and
assisted the patient back to bed. When the patient's
condition stabilized, the nurse documented the
assessment and interventions in the chart. The nurse also
completed an incident report because:
A. it is a requirement of the head nurse in case the
patient files a legal suit against the hospital
B. the incident may lead to serious complications and
this may trigger a malpractice suit.
C. reporting an incident in writing is a hospital protocol to
determine precautionary measure to avoid similar
incidents
D. the incident is critical and therefore requires
documentation for future reference
Incident reports are made to prevent similar incidents from
happening in the future. It must NOT be placed in the patient’s
chart.
184. To maximize utilization of human resources, the nurse
manager emphasizes to the nurses to use technology as a
means to make work processes more efficient. She
advocates the use of the nurse call system. When a newly
admitted client is shown to use the nurse call system,
which of the' statements about the nurse call system
below is NOT appropriate?
A. It should be used whenever the client needs help.
B. It should be used during an emergency only.
C. It must be pushed or pressed several times to alert
the nurse at the station.
D. It must be Within the reach of the client.
The call system can be used by the patient at anytime,
whenever assistance is needed.
185. Quality improvement (QI) requires that client care
activities be constantly evaluated and improved to meet
the needs of the clients. Of the following situations, which
one illustrates quality improvement?
A. The nurse supervisor plans a ward class for clients for
discharge along with family members for better home
management.
B. The hospital personnel and clients are constantly
reminded about handwashing especially during the
epidemics.
C. The hospital involves the multidisciplinary team in
client medication by having zero medication error.
D. A client asks from the nursing aide assigned to the
client to be repositioned in bed due to post-operative
discomfort.
Quality improvement is a process whereby problem areas are
identified and resolved. Only Choice C presents a problem
area that needs to improve.
186. Benevolent deception is an ethical concept that describes
which of these situations?
A. A family insists to avail of all possible alternatives to a
terminally ill patient even without the possibility of
cure.
B. A staff criticizes another staff who received
recognition as an outstanding nurse.
C. A doctor tells lies to a patient regarding his condition
in order to benefit the client.
D. A surgeon who performs hysterectomy to a client who
signed consent for exploratory laparotomy.
Benevolent deception is an ethical principle whereby the truth
is withheld from the patient in an attempt to protect the patient
from potential harm.
187. The nurse caring for an immobilized client turns the client
every 2 hours during her 12-hour shift. This action of the
nurse
A. Reflects the standard of care
B. Is under the scope of nursing practice
C. Is a provision of the Nurse Practice Act
D. Demonstrates respect for the patient’s Bill of Rights
Doing what is supposed to be done reflects standard of care.
Choices B & C are similar options.
188. Which of the following mandates delineates the roles and
functions as well as responsibilities of a nurse?
A. Nurse Practice Act
B. Code of Ethics for Nurses
C. Standards of Care
D. Magna Carta for Health Workers
A nurse practice act or nursing law identifies the scope of
nursing practice.
189. A former clinical instructor is preparing his resume as part
of his application portfolio for a position as clinical
educator in a university medical center. When making his
portfolio, which of the following should be the first major
part of his professional resume?
A. Personal data and address
B. Educational background
C. Work experience
D. Trainings and professional qualifications
TIP: Resume
New RN – educational attainment comes first
Experienced RN – work experiences come first
190. A medical-surgical nurse is asked by the nursing
supervisor to float to the understaffed Neonatal Ward for
the entire shift. The Neonatal Nurse Manager should
assign which patient to the “floater” nurse?
A. A 4-day old neonate with Tetralogy of Fallot
B. A 10-day old neonate with spina bifida
C. A 3-week-old neonate with heart failure
D. A 4-week old neonate with esophageal atresia
TIP: Floating
 Assign the floater to a patient which has a case
familiar to the RN’s work experience
 Assign the most stable patient to the floater
191. The nurse reviews several concepts related to total quality
management (TQM). Which of the following statements
refer to quality improvement?
A. It is concerned with performance development and is
on-going, preventing future mistakes.
B. It defines performance measurements and compares
actual processes and outcomes to clinical and
satisfaction indicators.
C. It refers to a work ethic involving everyone in the
organization.
D. It includes systematic methods of ensuring conformity
to a desired standard or norm.
192. Which of the following criteria should not be used by the
charge nurse in delegating care to her staff?
A. Educational background and training of the staff
B. Complexity of patient care needed for the shift
C. Adequacy of client’s family support system and
resources
 D. Clinical experience of the nursing staff
Staffing focuses on analyzing the human resources’ (nurses,
aides) education and experience, not the family.
193. A nurse who is responsible for the care of the client from
admission to discharge with the primary responsibility of
coordinating care is doing which modality of nursing care?
A. Primary nursing C. Team nursing
B. Functional nursing D. Case management
Case management involves coordinating patient care from
admission to discharge. Primary nursing (A) provides patient
care from admission to discharge while functional nursing (B)
deals with specific tasks to be performed by the staff. Team
nursing (D) involves a group of staff working together to
provide patient care.
194. The nursing education department of a hospital is offering
a program about evidence-based practice to prepare
nurses before its implementation in the hospital. Which of
the following refers to this type of program?
A. Seminar workshop in evidence-based practice
B. Continuing education in evidence-based practice
C. In-service Education Program
D. Scientific forum in evidence-based practice
When a continuing education program or activity is required by
the employing institution, it is called an in-service education.
195. A nurse works in a college of nursing as a faculty and
reeds further experience to possess clinical skills and
theoretical knowledge. Which of the following should this
nurse pursue to qualify for teaching current nursing
practice?
A. Pursue master's degree in other fields such as
business or educational management
B. Possess a graduate degree in nursing and pursue
doctorate in advanced degrees in nursing, education
and administration
C. Participate in continuing education program in
national and international conference
D. Keep license valid by updating professional education
with organized groups.
To qualify for teaching current nursing practice, the nursing law
requires not a doctorate degree (B) but a master’s degree in
nursing, not business or education (A). Continuing education is
needed but it does not have to be national or international
acitvities (C). Keeping the license valid by updating
professional education means that the nurse should complete
the required 20 continuing education hours per year for three
years, through various professional activities.
196. The doctor’s order is, “Garamycin 1 gm IV initially after a
negative skin test; then 500 mg IV push every 6 hours for
23 days.“ The order was countersigned by the head nurse.
When the doctor made his rounds the following day, he
found out that 1 gm Garamycin was given IV push every 6
hours. Who among the following may be held liable?
A. All the nurses who administered the drug every 6
hours
B. The head nurse and the nurse who gave the first
dose for having erroneously transcribed the order
C. Only the head nurse under the principle of command
responsibility
D. All nurses involved including the head nurse
It is the responsibility of every nurse to verify doctor’s orders
prior to preparing and administering a drug.
197. When a nurse makes a decision based on the reasoning
that “good consequences will outweigh bad
consequences” she is following which theory?
A. Formalist theory C. Moralist theory
B. Utilitarian theory D. Deontological theory
Formalist theory – critical analysis of a situation
Moralist – determines the rightness or wrongness of an act
Deontological theory – based on duty, rules, laws, obligations
198. During the nurse tour of duty, very often they are
confronted with ethical dilemma. In their decision making,
which of the following would illustrates medical futility?
A. A young father of three boys with advanced lung
cancer asks that all known regime be done to prolong
his life despite no improvement
B. A confused 70 year old lady needs restraints for
protection from fall even if this makes her more
agitated
C. A 3rd day post cholecystectomy client requests
narcotic injection every 4 hours
D. A young patient who has asked not to receive tube
feeding due to intense pain
Medical futility refers to interventions that are unlikely to
produce any significant benefit for the patient.
199. A client is confined in your unit. He says that he has
difficulty sleeping because of the “ambience” in the unit.
When evaluating the effect the setting has on the quality
of care provided to the client the evaluation being done is
called:
A. Quality assurance C. Structure evaluation
B. Quality improvement D. Outcome evaluation
TIP: Nursing audit
 Structure evaluation – involves setting, facilities,
equipment, qualifications and characteristics of
personnel
 Process evaluation – refers to the actions or tasks
performed in rendering patient care
 Outcome evaluation – pertains to results of nursing
interventions
200. While taking care of a client, a nurse was instructed by
her head nurse to file an incident report. The following
situations warrant an incident report EXCEPT:
A. Client and family attitude towards care
B. Medico-legal incident
C. Client’s complaints of illness
D. Medication errors including administration of
intravenous fluids
Incident reports are made when any untoward incidents
happen with the purpose of preventing same incidents from
happening in the future. Patient’s complaint of illness is never
a part of incide
MATERNAL AND NEWBORN NURSING (40 points)
1. A client, 7 months pregnant, is brought to the emergency
department with abdominal pain and bright red vaginal
bleeding. What should the nurse do first?
A. Place the client in left lateral position and initiate
oxygen therapy as ordered.
B. Administer ordered IV oxytocin to stimulate
contractions and prevent hemorrhage.
C. Ease the client’s anxiety by coaching her to perform
relaxation techniques.
D. Massage the client’s fundus to control the
hemorrhage.
Left lateral position prevents compression of the inferior vena
cava that might compromise utero-placental circulation.
Oxytocin (B) and uterine massage (D) are contraindicated as
this stimulates contraction of the uterus. Relaxation techniques
(C) may help but not the priority for a bleeding patient.
2. At 15 weeks’ gestation, a client is scheduled for an alpha-
fetoprotein (AFP) test. Which maternal history finding best
explains the need for this test?
A. Family history of Down syndrome on the father’s side.
B. Family history of spina bifida in a sister.
C. History of gestational diabetes during a previous
pregnancy.
D. History of spotting during the first month of the current
pregnancy.
An elevated AFP level may indicate neural tube defects, such
as spina bifida.
3. Ada, a 38-year-old, G1P2, 36 weeks AOG pregnant
mother with a history of precipitous labor and low birth
weight infant informs the nurse that she has been having
on and off contractions and she feels like “bearing down.”
Upon examination, the obstetrician’s findings show that
the client is “75% effaced and 6 cm dilated”. The most
appropriate disposition for this client would be to
A. Send her home since she is only 6 cm dilated and
contractions are mild
B. Request the obstetrician for Pitocin drip to induce
stronger contractions
C. Ask the client to return to the hospital when
contractions are 2-3 minutes apart and strong in
intensity
D. Have the client stay in the hospital for maternal and
fetal monitoring
These are signs of true labor and the patient needs to be
monitored in the hospital; this makes A & C wrong answers.
Pitocin drip (B) is inappropriate at this time since uterine
contractions, cervical dilation and effacement are in progress.
4. Prior to a cesarean section delivery, a 24-year-old woman
is treated for abruption placenta. You are caring for this
client during the postpartum period. Which of these
symptoms, if present, would be suggestive if disseminated
intravascular coagulation (DIC)?
A. The woman is nauseated, lethargic, and has vomited
3 times
B. The woman’s laboratory result are: Hgb 13g/dl, Hct
40%, WBC 7,000/mm3
C. There is oozing blood from venipuncture site and
abdominal incision
D. The woman’s vital signs are BP 90/50 mm hg,
temperature 38.3 oC, pulse 112/min, respiration
18/min
DIC is manifested by bleeding tendencies. The drug of choice
is Heparin sulfate.
5. A mother at 40 weeks’ age of gestation is assessed by the
nurse. The nurse finds the fundic height to be
A. 35 cm C. 40 cm
B. 38 cm D. 43 cm
6. The nurse’s most important assessment on a client who
received epidural anesthesia during labor is
A. Level of consciousness
B. Urinary output
C. Blood pressure
D. Return of sensation on the legs
A common side-effect of epidural anesthesia is hypotension.
7. During the fourth stage of labor, the client should be
assessed for
A. Complete cervical dilation C. Placental expulsion
B. Umbilical cord prolapse D. Uterine atony
TIP: Stages of labor
 First stage – true labor to full cervical dilatation
 Second stage – full cervical dilatation to expulsion of
the fetus
 Third stage – expulsion of the fetus to expulsion of
placenta
 Fourth stage – expulsion of placenta to uterine
contraction
8. A postpartum client is ready for discharge. During
discharge preparation, the nurse should instruct the client
to report which of the following to a health care provider?
A. A temperature of 99.2 for 24 hours or more
B. Episiotomy discomfort
C. Lochia alba at 2 weeks postpartum
D. Redness, warmth and pain in the breasts
Report a sign that indicates an abnormal condition. Choice D
are signs of mastitis. A low-grade fever (A) within the first 24
hours is common due to dehydration. Choices B & C are
common and expected normally during the postpartum period.
9. Which of the following assessment findings would the
nurse interpret as abnormal in a full term male neonate
born an hour ago?
A. Enlargement of the mammary glands
B. Slight yellowish hue to the skin
C. Blue hands and feet
D. Black and blue spots on the buttocks
Jaundice that appears within 24 hours after birth is considered
pathologic. Physiologic jaundice occurs 24 hours after birth,
usually 2nd-3rd day. Enlarged breasts (A) is due to maternal
hormones. Acrocyanosis (C) is common at this time.
Mongolian spots (D) are common during the first year of life.
10. A client who is 7 months pregnant reports severe leg
cramps at night. Which nursing action would be most
effective in helping the client cope with these cramps?
A. Suggesting that she walk for 1 hour twice per day.
 B. Advising her to take over-the-counter calcium
supplements twice a day.
C. Teaching her how to dorsiflex the foot during a cramp.
D. Instructing her to increase her milk and cheese
intake to 5-8 servings per day.
Leg cramps are usually caused by depletion of calcium due to
rapid fetal development. This can be relieved by dorsiflexion of
the foot.
11. Which of the following signs of pregnancy is properly
classified?
A. Enlarging uterus: probable sign
B. Elevation of basal body temperature: Presumptive
C. Fetal movements felt by examiner: positive
D. Chloasma and linea nigra: probable
TIP: Signs of pregnancy
Presumptive signs – subjective; felt by the mother
Probable signs – objective; observed by the examiner
Positive signs – confirms pregnancy
12. A multigravida is in the second stage of labor for 30
minutes. This can be considered as a
A. Precipitous labor
B. Precipitous delivery
C. Normal labor
D. Normal spontaneous delivery
13. A postpartum mother has a temperature of 99.8 F within
the first 24 hours after delivery. The most common cause
of temperature elevation during this period is
A. Puerperal infection C. Dehydration
B. Chorioamnionitis D. Mastitis
Fever that occurs during the first 24 hours after delivery is due
to dehydration that results from NPO prior to and fluid loss
during delivery.
14. While caring for a full term female neonate, the nurse
notices red stains on the diaper after the baby voids.
Which action should the nurse take next?
A. Call the physician to report the problem.
B. Encourage the mother to feed the baby to prevent
dehydration.
C. Do nothing because this is normal.
D. Check the baby’s urine for hematuria.
Pseudomenstruation is normal and is caused by maternal
hormones.
15. The nurse is assessing a neonate born a day ago from a
client who smoked during pregnancy. Which of the
following findings is expected of a neonate from a mother
who smoked during pregnancy?
A. Postterm birth
B. Small for gestational age
C. Large for gestational age
D. Appropriate for gestational age
Small for gestational age (SGA) is common among babies of
mothers who has a history of smoking during pregnancy.
Vasoconstrictive effects of nicotine reduce uteroplacental
circulation.
16. A client at 28 weeks’ gestation complains of uterine
contractions. After assessment, hydration and admission,
the physician orders Beclomethasone 12 mg IM. The
purpose of giving this medication is to
A. Slow down uterine contractions
B. Promote fetal lung maturity
C. Prevent infection
D. Promote fetal growth
Administration of steroids to premature babies facilitates
maturation of the lungs, reducing the risk for respiratory
distress.
17. A client is admitted in preterm labor. To halt labor
contractions, the nurse expects the physician to prescribe
A. Betamethasone (CElestone)
B. Ritodrine (Yutopar)
C. Dinoprostone (Prepidil)
D. Ergonovine (Ergotrate maleate)
Tocolytics such as Ritodrine and Terbutaline promote
relaxation of the uterus.
18. The nurse assessing a client with pregnancy-induced
hypertension (PIH) will most probably expect which signs
and symptoms?
A. Proteinuria, headache, vaginal bleeding
B. Headache, double vision, vaginal bleeding
C. Proteinuria, headache, double vision
D. Proteinuria, double vision, uterine contractions
TIP: Triad symptoms of PIH
 Proteinuria
 Edema
 Hypertension
19. A woman in her 34th week of pregnancy presents with
sudden onset of bright red vaginal bleeding. Her uterus is
soft and experiences no pain. Fetal heart rate is 120 bpm.
Based on the presenting data, the nurse knows that the
client might have developed
A. Threatened abortion C. Abruptio placentae
B. Placenta previa D. Preterm labor
TIP: Bleeding disorders of pregnancy
First trimester: abortion, ectopic pregnancy
Second trimester: H-mole, incompetent cervix
Third trimester: placenta previa, abruptio placenta
20. The nurse reviews the laboratory results of a client with
hydatidiform mole. Which finding strongly suggests the
presence of this disorder?
A. An elevated human placental lactogen (hPL) level
B. A reduced alpha-fetoprotein (AFP) level
C. An increased human chorionic gonadotropin (hCG)
level
D. An increased carcinoembryonic antigen (CEA) level
An abnormally large abdomen, passage of grape-like vesicles,
absence of positive signs of pregnancy and elevated HCG
level indicate the presence of an H-mole.
21. The recommended Essential Intrapartal and Newborn
Care (EINC) practices during the intrapartum period
include continuous maternal support by having which of
the following? Select all that apply.
A. a companion of choice during labor and delivery
B. freedom of movement during labor
C. monitoring progress of labor using the partograph
D. pain relief with mild analgesics before offering labor
anesthesia
 E. position of choice during labor and delivery C. Pregnancy-induced hypertension
F. spontaneous pushing in a semi-upright position D. Infection
G. routine episiotomy
H. active management of the third stage of labor Bleeding, the most common cause of death during the
postpartal period, is usually due to uterine atony as a result of
Based on WHO guidelines, these are the recommended multiparity, retained placental fragments and trauma from
practices during the intrapartal period and during the care of severe lacerations.
the newborn.
27. Which of the following psychological changes during the
22. At 5 minutes of age, a neonate is pink with blue hands and post-partal period illustrates that the mother is in the
feet, has his knees flexed and fists clenched, has a taking-in phase? The mother
whimpering cry, a heart rate of 128 per minute and A. Looks intently at her newborn
withdraws his foot when slapped on his sole. What 5- B. Asks the nurse how to breastfeed the baby
minute Apgar score should the nurse document for this C. Restricts visitation because she needs to rest
neonate? D. Wants the father of the baby to participate in bathing
A. 6 B. 7 C. 8 D. 9 the baby

TIP: APGAR Score TIP: Psychological responses during post-partum period

0 1 2  Taking-in – focuses on the self (mother)
Activity (muscle tone) flaccid poor strong  Taking hold – focuses on the neonate
Pulse rate 0 <100 >100  Letting go – acceptance of new role as a parent
Grimace (cry) absent weak strong
Appearance (color) all blue acrocyanosis pink 28. A mother is in the fourth stage of labor and the nurses
Reflex absent weak strong assesses for signs of placental separation. The earliest
sign that can be observed is
23. Based on the Essential Intrapartal and Newborn Care’s A. Sudden gush of blood from the vagina
new protocol, which of the following traditional beliefs and B. Lengthening of the umbilical cord
practices have been eliminated? Select all that apply. C. Rising of the uterus above the umbilicus
A. routine suctioning D. Onset of mild dull abdominal pain
B. foot printing
C. early bathing TIP: Signs of placental separation
D. routine separation  Sudden gush of blood from the vagina
E. continuance of artificial feeding  Lengthening of the umbilical cord
 Rising of the uterus above the umbilicus
WHO updated guidelines has eliminated these practices which
were traditionally done for newborn care. 29. A woman had her last menstrual period last September 8,
2013. The expected date of delivery is on
24. The neonatal nurse is preparing Vitamin K injection for the A. June 15, 2014 C. November 15, 2013
newborn. Why does the neonate need Vitamin K? B. May 1, 2014 D. July 15, 2014
A. Due to sterile gastrointestinal tract, there is no
bacteria to produce vitamin K Nagale’s rule: - 3 months, + 7 days of the following year
B. Vitamin K helps in producing clotting factors in the 9 8 2013
liver -3 +7 + 1_____
C. Platelets need Vitamin K for their production and 6 15 2014
maturation
D. Vitamin K is needed by the intestinal bacteria to 30. A mother is pregnant for the fifth time. Her firstborns were
produce clotting factors twins. Her second child was born prematurely and her
third pregnancy ended in intrauterine growth retardation.
The absence of bacteria in the intestines makes the neonate She delivered her fourth pregnancy normally. Her obstetric
unable to produce Vitamin K, making them at risk for bleeding. history is:
Bacterial growth starts when the neonate ingests fluid/milk. A. G5 T2 P1 A0 L4 C. G4 T3 P2 A1 L3
B. G5 T3 P2 A0 L4 D. G4 T2 P1 A0 L4
25. Which of the following maternal discomfort is most likely to
be expected if the fetus is in a Right Occiput Posterior TIP: Obstetric history
position? Gravida – pregnancy
A. Urinary frequency Term pregnancy – delivery of a full term neonate
B. Low back pain Prematurity – premature births
C. Leg cramps Abortion
D. Varicosities Living – currently surviving children

Posterior presentation usually causes low back pain. This can 31. A nurse orientee at the Labor & Delivery Unit reviews the
be relieved by application of gentle sacral pressure or pelvic partogram sheet and identifies the word “liquor” which
rock exercises. refers to
A. The amniotic fluid
26. According to the WHO, the most common cause of B. A meconium-stained amniotic fluid
mortality among women during the post-partum period is C. The bloody show
A. Cephalo-pelvic disproportion D. An amnioinfusion therapy
B. Hemorrhage
32. The appropriate order of steps in active management of
the third stage of labor (AMTSL) include:
A. Cord clamping and cutting, controlled cord traction,
ergometrine administration, and inspection to be sure
that the placenta is intact.
B. Intravenous oxytocin, cord clamping and cutting, and
fundal massage
C. Intramuscular injection of oxytocin, controlled cord
traction with counter traction to the uterus, uterine
massage
D. Controlled cord traction, fundal massage and oxytocin
These are the steps in the AMTSL as defined by the WHO.
33. The nurse explains to the post-partum mother who is for
discharge that the expected characteristic of her lochia 6
days after delivery is
A. reddish and moderate in amount
B. scant and pinkish drainage
C. whitish and moderate
D. bright red and scant in amount
TIP: Lochial discharge
 Lochia rubra – reddish to pink; day 1-3 postpartum
 Lochia serosa – brownish; day 3-6 postpartum
 Lochia alba – whitish; 1-2 weeks postpartum
34. Which of the following should the nurse tell a mother
during the intrapartal period to best help relieve pain?
A. “Find the most comfortable position for you especially
during the first stage of labor.”
B. “Ambulate as much as you can to relieve the
abdominal discomfort.”
C. “I can administer an opioid analgesic if you cannot
tolerate the pain any longer.”
D. “Do rapid deep breaths every time you feel a
contraction.”
Based on current WHO guidelines, the best position to relieve
pain is whatever the patient finds most comfortable for her.
35. A post-partum client develops disseminated intravascular
coagulation (DIC). The drug of choice for this condition is
A. Vitamin K C. Protamine zinc
B. Heparin sulfate D. Aspirin
Heparin is the drug of choice to treat DIC. As an anticoagulant,
Heparin releases the platelets from clumping, thereby making
them available in the circulation.
36. To confirm pregnancy, the doctor will most likely perform
which of these actions to a pregnant woman who is on her
first prenatal visit?
A. palpate for fetal parts and movement
B. order an ultrasound examination
C. instruct the client to do a home type pregnancy test
D. do an internal examination
Ultrasound is used to confirm pregnancy and to determine age
of gestation.
37. The nurse is preparing a woman for epidural anesthesia.
The woman asks, “Why is my IV running so fast? It feels
so cold!” What reply by the nurse is BEST?
A. “IV hydration helps prevent the blood pressure from
dropping so low.”
B. “Don’t worry, this is a routine procedure in preparation
for an epidural.”
C. “I’ll slow the IV down so you won’t feel cold.”
D. “IV fluids help prevent spinal headaches.”
Epidural anesthesia causes hypotension. This can be
prevented by increasing the circulating blood volume through
infusion of intravenous fluids.
38. A client is scheduled for amniocentesis. When preparing
her for the procedure, the nurse should do which of the
following?
A. Allowing her to void.
B. Instruct her to drink 1 liter of fluid.
C. Prepare to insert an IV access.
D. Position her on the left side.
Voiding prior to amniocentesis prevents trauma to the bladder.
39. Bonus
40. Malou is aware that in accordance with R.A. 7600 of 1992,
the purpose of the “rooming-in” national policy are two-
fold:
1 Encourage, protect and support the practice of
breastfeeding
2 Save on costs for utilities and personnel for a
newborn nursery
3 Create an environment where basic physical,
emotional, and psychological needs of mothers
and infants are fulfilled
4 Teach the mother to take responsibility for
caring for her newborn right after her delivery
A. 2 and 3 are correct C. 1 and 2 are correct
B. 3 and 4 are correct D. 1 and 3 are correct
PEDIATRIC NURSING (40 points)
41. Which of the following findings during newborn
assessment warrants alerting the pediatrician for a
potential problem? The neonate/neonate’s
A. Arms and feet are bluish
B. Skin color is yellowish
C. Head is larger than the chest
D. Has red stains on the diaper during voiding
Pathologic jaundice (abnormal) manifests during the first 24
hours after birth while physiologic jaundice (normal) appears
starting on the second day after birth. Acrocyanosis is normal
at this time (A). A newborn has a larger head circumference
(C) than the chest circumference until about 1 year of age.
Pseudomenstruation is normal due to effects of maternal
hormones (D).
42. The best indication that the breastfeed baby is digesting
the breast milk properly is when:
A. The baby passes soft, green, pasty stools
B. The baby passes soft, golden-yellow stools
C. The baby sleeps for several hours after each feeding
D. The baby does not experience colic
Breast-fed babies pass soft, golden-yellow stools while bottle-
fed babies pass hard, pasty and smelly stools.
82. The nurse noted the following behaviors in a 6-hour old,
full-term newborn: occasional tremors of extremities,
straightens arms and hands outward and flexes knees
when disturbed, toes fan out when heel is stroked, and
tries to walk when held upright. These findings indicate
A. Expected neurologic development
B. Signs of drug withdrawal
 C. Abnormal uncoordinated movements bedtime stories are particularly important to which of the
D. Asymmetric muscle tone following age groups:
A. Infants C. School-age
These are normal characteristics of a newborn, showing the B. Toddler D. Pre-schooler
normal reflexes (moro/startle, Babinski, walking).
46. An 8-year–old child is diagnosed with iron deficiency
83. While assessing another newborn, you noted that his anemia (IDA). When assessing the child’s fingernails, the
areola is flat with less than 0.5 cm of breast tissue. This nurse instructed the mother to look for:
finding indicates: A. spoon nails C. pale nail beds
A. Intrauterine growth retardation B. clubbing D. presence of Beau’s lines
B. Maternal hormonal depletion
C. Pre-term gestational age Koilonychia or spoon-shaped nails are seen in IDA. Clubbing
D. That the infant is male (B) indicates chronic hypoxia and Beau’s lines (D) suggests
trauma. Pale nail beds (C) are not specific to IDA, but common
Term infants have a raised areola and more than 0.5 mm of in all types of anemia.
breast
tissue. 47. Encouraging fantasy play and participation by children in
their own care is a useful developmental approach among
which pediatric age group?
N A. Preschoolers C. school age
B. Adolescence D. toddlers
Normal
Fantasy play and magical thinking are characteristics of pre-
IK school children. Being in the phallic stage of development, they
become more aware of their bodies and this enables them to
be more active in participating in their own care.
43. The mother is feeding her 20-month-old child. The child is
trying to eat with a spoon and is muddling the food on the 48. When assessing a neonate born at 30 weeks gestation,
tray. Which of the following approach of the nurse is the the nurse notes bounding femoral pulses, a palpable thrill
MOST appropriate? over the suprasternal notch, tachycardia, tachypnea and
A. Assist the mother in feeding the child. crackles. The nurse suspects for
B. Instruct the mother to give finger foods until the child A. Tetralogy of Fallot
is older. B. Patent ductus arteriosus
C. Praise and encourage the child as she eats. C. Ventricular septal defect
D. Get the spoon and do the feeding. D. Coarctation of the aorta

Toddlers’ main developmental task is autonomy or
independence. Allowing them to explore their environment and
to try out new skills are ways to establish their independence.
44. When developing plan of care for a child, the nurse
recognizes that which Eriksonian stage of development
corresponds to Freudian stage of phallic development?
A. Initiative versus guilt
B. Trust versus mistrust
C. Autonomy versus doubt
D. Industry versus inferiority
A neonate born at 30 weeks’ gestation is premature. Fetal
cardiac structures are left open, such as the ductus arteriosus,
which may be felt as a palpable thrill over the suprasternal
notch as blood passes through the pulmonary artery. Crackles
indicate pulmonary edema as blood flows back into the lungs.
Femoral pulses are absent in coarctation of the aorta (D).
49. The nurse expects an infant to sit without support at what
age?
A. 2 months C. 6 months
B. 4 months D. 8 months

TIP: Gross motor development

 2 months – social smile
 4 months – head control
 6 months – sits with support
 8 months – sits without support

TIP: Theories of personality development 50. When planning care for hospitalized children, the nurse
Freud Erikson must consider that which age group considers illness as a
Psychosexual Psychosocial punishment for misdeeds?
A. Infancy C. Preschoolers
Infancy Oral Trust vs. mistrust B. Toddlers D. School age
Toddlerhood Anal Autonomy vs. shame/doubt
Pre-school Phallic Initiative vs. guilt Pre-schoolers are in the phallic stage of development where
School age Latency Industry vs. inferiority they become more aware of their bodies. Having developed
Adolescence Genital Identity vs. diffusion their superego from toddlerhood, they associate illness as a
Young adulthood Intimacy vs. isolation punishment for misdeeds.
Mid-adulthood Generativity vs. Stagnation
Late adult-hood Integrity vs. despair 51. The nurse places a neonate with hyperbilirubinemia under
a phototherapy lamp, covering the eyes and gonads for
45. Bedtime rituals such as tucking to bed and reading
 protection. The nurse knows that the goal of phototherapy
is to
A. Prevent hypothermia
B. Promote respiratory stability
C. Reduce conjugated bilirubin level
D. Reduce unconjugated bilirubin level
Phototherapy is used to manage infants with jaundice. The aim
is to promote conjugation of bilirubin (unconjugated 
conjugated).
52. Which of the following statements, is made by any parent-
client to you indicates understanding about the causes of
the newborn’s diagnosis cystic fibrosis (CF)?
A. “Both of us carry a recessive treat of a cystic fibrosis”
B. “The gene came from my wife’s side of the family”
C. “The gene came from my husband’s side of the
family”
D. “There is a 50% chance that our next child will have
disease”
Cystic fibrosis is an autosomal recessive trait, not a sex-linked
trait (B,C). When both parents carry the recessive gene, there
is a 25% chance of developing the disease (D).
TIP: Punnett’s square: to determine predisposition to
genetic diseases
D – abnormal trait DD – has the disease
d – normal trait Dd – has the trait (carrier)
dd – not affected
Cyctic fibrosis: autosomal recessive (carrier) transmission from
both parents
Mother / Father -> D (trait) d A. Avoiding disturbing crusts along the suture line.
D (trait) DD (25%) Dd (25%)
d Dd (25%) Dd (25%)
DD – 25% chance to develop the disease
Dd – 50% chance to become carriers
dd – 25% chance to be unaffected
53. A 2-month old baby is expected to have completed which
immunizations?
A. MMR, DPT, measles, BCG
B. Hepatitis, measles, BCG, OPV
C. OPV, DPT, BCG
D. Hepatitis, OPV, BCG, HIB
Measles is administered at 9 months (A, B). Hepatitis is not
routinely given during infancy (B,D).
54. A child is brought to the emergency room due to acute
onset of abdominal pain, vomiting and stools that look like
red currant jelly. The nurse suspects that this may be due
to
A. Intussusceptions C. Appendicitis
B. Pyloric stenosis D. inflammatory bowel disease
Red currant jelly-like stool is a characteristic of
intussusception, or the telescoping of the intestines.
55. The nurse advises a 6-year-old child with celiac disease
should not have which of these dietary choices?
A. Mango shake C. Fruit salad
B. Ice cream D. Spaghetti
Anything with flour is avoided. Patients with celiac disease are
given gluten-free diet. Foods that come from wheat, barley and
rye are contraindicated.
56. A 4-year-old child with a recent history of nausea, vomiting
and diarrhea is admitted to the pediatric ward for
gastroenteritis. During physical assessment, the nurse
observes tenting. This clinical manifestation supports the
nursing diagnosis of
A. Activity intolerance related to hypoxia
B. Deficient fluid volume related to dehydration
C. Ineffective peripheral tissue perfusion related to
cyanosis
D. Risk for injury related to capillary fragility
Gastroenteritis causes severe diarrhea and dehydration which
may be manifested by a poor skin turgor or tenting.
57. The nurse prepares to administer an intramuscular
injection to a 7-month old girl. The most appropriate site to
administer the drug is:
A. dorso-gluteal region C. ventral forearm
B. vastus lateralis D. gluteal region
The preferred IM injection site for infants is the vastus lateralis.
The dorso-gluteal region is the least preferred site for all age
groups due to the risk of hitting the sciatic nerve. The ventro-
gluteal site is the preferred site of IM injection among older
children and adults.
58. When developing a post-operative plan of care to a child
who has undergone cleft lip-repair, which of the following
is the nurse’s priority goal of care?
B. Comforting the child as quickly as possible.
C. Maintaining the child in a prone position.
D. Restraining the child’s arm at all times, using soft
elbow restraints.
Protecting the integrity of the sutures is the priority goal of
post-cheiloplasty. The nurse must prevent crying
whenever possible to avoid trauma to the surgical site.
59. A 2-month-old is brought to the clinic by his mother. His
abdomen is distended and he has been vomiting forcefully
for the past 2 weeks. The nurse notes dehydration and a
palpable mass on the right of the umbilicus. Peristaltic
waves are present, moving from left to right. Based on
these clinical manifestations, the infant most probably has:
A. Tracheoesophageal fistula C. Intussusceptions
B. Pyloric stenosis D. Volvulus
An olive-shaped mass on the right side of the abdomen and
non-bilious (without bile) vomiting are signs suggestive of
pyloric stenosis. Tracheo-esophageal fistula (A) is suspected if
the child chokes after feeding, suggesting the entry of food into
the lungs. Intussusception (C) is manifested by a sausage-
shaped mass on the abdomen, abdominal pain and red,
currant jelly stools. Volvulus or twisting of the abdomen is
characterized by severe abdominal pain.
60. A 7-year-old child is brought to the ER due to a dislocated
right shoulder and simple fracture of the right humerus.
Which of the following behaviors of a child would lead the
nurse that the patient is a victim of child abuse? The child
A. Does not answer the nurses’ questions.
B. Does not maintain eye contact.
C. Tries to move away from the nurse
 D. Does not cry when moved
An abused child has a high pain tolerance. Physical injuries
may not elicit pain on these children.
61. A nurse performs cardiopulmonary resuscitation on an 11-
month-old infant. The nurse should assess for the infant’s
pulse on the:
A. carotid area C. temporal area
B. brachial area D. popliteal area
The brachial area is the recommended site for assessing pulse
when doing an infant CPR. The carotid area is used for adults.
62. Hypospadias is a congenital defect of the male genitalia
where the urethral meatus is located at the
A. Tip of the penis
B. Ventral surface of the penis
C. Dorsal surface of the penis
D. Side of the penis
TIP: Hypospadias = ventral side or anterior
Epispadias – dorsal side or posterior
63. The nurse admits a 10-year-old child with rheumatic fever.
Which of the following aspects in the child’s history the
nurse should ask for a history of:
A. Staphylococcal infection C. Strep throat
B. Influenza D. Chicken pox
The main risk factor of rheumatic fever is a streptococcal
infection, which may commonly affect the respiratory system.
64. A 10-month-old infant with phenylketonuria (PKU) is being
weaned from breast-feeding. In providing education to the
parents, the nurse should emphasize the need to restrict
A. Vegetables and meat
B. Grains and fruits
C. Meats and dairy products
D. Sugar and vegetables
Phenylalanine is an essential amino acid (protein), which is not
metabolized in a child with PKU. Protein foods are restricted.
65. A child is to undergo nephrectomy for a removal of Wilm’s
tumor. Which intervention should NOT be included in the
plan of care?
A. Provide pre-operative teaching to the child and
parents.
B. Palpate the abdomen to assess for tenderness.
C. Assess vital signs and report hypertension.
D. Monitor urine for hematuria.
Wilm’s tumor affects the kidneys. Abdominal palpation is
contraindicated as this may cause pain and metastasis.
66. A toddler is diagnosed with nephrotic syndrome. The
nurse monitors the patients I&O and checks the urine
regularly. The nurse should expect to see which of these
findings?
A. Glycosuria C. Albuminuria
B. Ketonuria D. Polyuria
Nephrotic syndrome is a protein-wasting disease manifested
by albuminuria/proteinuria, hypoalbuminemia and edema due
to decreased colloid oncotic pressure.
67. To prevent discoloration of the teeth of a 6-year-old child
with URTI, the physician should not prescribe
A. Tetracycline C. Streptomycin
B. Isonicotinic hydrazide D. Chloramphenicol
Tetracycline should not be given to pregnant women due to its
teratogenic effects and to children below 12 years old due to
its destructive effects on the tooth enamel.
68. Recommended practices under the Essential Infant and
Newborn Care (EINC) protocol include the following
except:
A. skin-to-skin contact
B. properly timed cord clamping
C. initiation of breastfeeding
D. drying the baby with oil
Current EINC protocol promotes drying the baby with a warm
clean cloth, not oil.
69. After the delivery of the baby, prevention of hypothermia
can be achieved by:
A. drying baby covering with clean dry cloth
B. applying small amounts of oil on the skin
C. covering the baby with warm sterile cloth
D. positioning the baby on the mother’s abdomen
This prevents heat loss after birth of the neonate.
70. A newborn with fetal alcohol syndrome is NOT expected
to manifest which of the following signs?
A. Low birth weight
B. Facial anomalies
C. Muscular incoordination
D. Cognitive impairment
71. A child with lead poisoning is expected to manifest signs
related to
A. Neurologic deficits
B. Cardiovascular involvement
C. Renal impairment
D. Hepatic damage
Lead can lead to developmental delays and cognitive
impairment due to its neurotoxic effects.
72. Which of the following statements is not accurate
regarding Tanner staging?
A. It is a rating system for pubertal development
B. It is a biological marker of maturity
C. It is based on the progressive development of
genitalia, breast and pubic hair in females
D. It is based on the progressive development of the
genitalia and pubic hair in males.
Tanner staging is used to determine sexual maturation among
adolescents. Among females, criteria include assessment of
the breast and pubic hair, NOT the genitals. Among males,
genitalia and pubic hair development are assessed.
73. Which of the following developmental milestones or
behaviors is a characteristic of a toddler?
A. Magical thinking
B. Assertion of independence
C. Compliance to parental rules
D. Cooperative play with siblings
The main developmental task of a toddler is independence or
autonomy. Magical thinking, compliance to parents, and
cooperative play are characteristics of a pre-schooler (ACD).
TIP: Types of play among children
Infants Solitary play
Toddlers Associative play or parallel play
Preschoolers Cooperative play
School age Competitive play
74. A child with hiatal hernia may exhibit which of the following
clinical manifestations?
A. Inguinal pain
B. Difficulty of breathing
C. Abdominal pain
D. Intractable pain on the groin area
Hiatal hernia is the protrusion of abdominal organs into the
thoracic cavity though a weakness in the diaphragm. This
causes an increased pressure within the thoracic cavity. ACD
are all characteristics of inguinal hernia, the protrusion of
abdominal organs into the scrotum via a defect in the inguinal
ring.
75. The nurse is taking nursing history from a mother. The
infant displays discomfort by crying constantly, fussy
behavior and pulling the left ear. Which of the following
information gathered by the nurse would support the
admitting diagnosis of acute otitis media?
A. Sudden rise of temperature to 39 degrees C
B. Had colds and low grade fever for a number of days
C. Irritable and unable to consume scheduled feedings
D. Pain and itchiness of the ear canal
The question asks about history taking. Acute otitis media is
often preceded by a history of colds and low grade fever a few
days before the onset of the infection. ACD are all physical
assessment findings, not history, of acute otitis media.
76. Three-year-old Benito has been admitted to the Pediatric
Unit. His blood pressure 100/70 mmHg; pulse rate, 110
beats per minute; temperature, 38 C, and weight, 18 kg.
Impression: Nephrotic Syndrome. During his previous
check-up at 2 ½ years-old, his blood pressure was 95/60
mmHg; PR was 100 beats per minute and weighed 15 kg.
Which assessment finding would support the impression
of nephrotic syndrome?
A. Weight C. Blood pressure
B. Temperature D. Pulse rate
As a protein-wasting disease, nephrotic syndrome causes
hypoalbuminemia which reduces colloid oncotic pressure. This
promotes water to shift from the intravascular to the interstitial
space causing generalized edema. Fluid retention is best
assessed by daily weight monitoring. Weight is the best
indicator of fluid balance.
77. Steven is diagnosed with acute lymphoid leukemia (ALL)
and is beginning chemotherapy. Steven is discharged
from the hospital following his chemotherapy treatments.
Which statements of Steven’s mother indicates that she
understands when she should contact the physician?
A. “I will call my doctor if Steven has persistent vomiting
and diarrhea”
B. ”I should contact the physician if Steven has difficulty
in sleeping”
C. “My physician should be called is Steven is irritable
and unhappy”
D. “Should Steven have continues hair loss, I need to
call my doctor”
Nausea and vomiting are the most common side-effects of
chemotherapy. However, if they are persistent together with
diarrhea, the patient may get dehydrated, which may need
medical attention.
78. Wilma and another staff are talking on some important
reminders on the care of pediatric patients diagnosed with
glomerulonephritis. When planning nursing care for a 5-
year-old with acute glomerulonephritis (AGN), the nurse
realizes that the child needs help in understanding the
necessary restrictions, one of which is:
A. Isolation from other children with infections
B. Daily does of IM penicillin
C. A bland diet high in protein
D. Bed rest for at least 4 weeks
AGN is treated with steroids which may cause
immunosuppression, increasing the risk to infections.
79. The mother of a nine-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 age 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.”
An infant’s head circumference is normally greater than the
chest circumference until 1 year of age. After that, the chest
circumference slowly becomes larger than the head.
80. The nurse reads on the chart that a 5-month-old child has
pectus carinatum. She recalls that this condition is
characterized by a chest that
A. has equal antero-posterior (AP) and lateral (LAT)
diameters
B. has a larger lateral (LAT) diameter than the antero-
posterior (AP) diameter
C. has an antero-posterior diameter (AP) that is larger
than the lateral (LAT) diameter
D. has a depression in the sternum
TIP: Less than 1 year: AP = LAT diameter
More than 1 year: LAT > AP diameter
Pectus carinatum (pigeon chest) = AP>LAT diameter
Pectus excavatum (funnel chest) = LAT>AP diameter
MEDICAL-SURGICAL NURSING (70 points)
81. While you are obtaining an assessment and health history,
which of the following statements will alert the nurse to a
possible immunodeficiency disorder?
A. "I love walking several times a week with friends.'
B. “I had my chest x-ray 6 months ago when I had
pneumonia.”
C. “I had my spleen removed many years ago after a car
accident.”
 D. “I usually eat eggs or meat for at least 2 meals every
day.”
The spleen is a lymphoid tissue which produces WBC.
Removal of the spleen increases risk for immune disorders.
82. The nurse’s action is appropriate if she does which of the
following to nursing interventions in a patient with
hypothyroidism?
A. Offer a high-calorie diet.
B. Increase fluid intake.
C. Offer extra sheets or blankets to the patient.
D. Encourage the patient to take a bath twice a day.
With decreased level of thyroid hormones, patients with
hypothyroidism have reduced basal metabolic rate and
reduced heat production. Cold intolerance is therefore
common. Providing warmth helps manage this symptom.
83. A client recovering from breast surgery asks you what
type of food would fight “free radicals” to increase
protection from cancer. Your best response would be:
A. “Do you want reading materials in cancer fighting
food?”
B. “Foods rich in beta – carotene, vitamins A, C, E seem
to fight free radicals.”
C. “Eat foods that are in rich in antioxidants and
phytochemicals.”
D. “Have you tried the herbal products in the market?”
Antioxidants and phytochemicals are proven to be effective in
fighting free radicals that are known to cause cancer.
84. During hemodialysis, a patient with ESRD suddenly
becomes confused, restless and verbally abusive. The
nurse interprets this a sign of
A. helplessness
B. disequilibrium syndrome
C. allergic reaction to the dialysate
D. increased cerebral tissue perfusion
Rapid removal of fluid from the brain during hemodialysis can
lead to disequilibrium syndrome that can be manifested by
behavioral changes during the procedure.
85. The nurse should be alert for potential complications
during the post-operative phase. Which of the following
manifestations possibly suggest a developing
complication?
A. temperature of 37.9 C, chills and cold clammy skin
B. urine output of 120 cc for the past first four hours
after surgery
C. tachycardia and decreased blood pressure
D. shallow respirations and pulse oximeter reading of
95%
A reduced blood pressure and increased pulse rate may
suggest bleeding post-operatively. ABD are all normal
assessments post-operatively.
86. The nurse instilled 2,000 ml of dialysate on a patient for
peritoneal dialysis. During the draining time, the nurse
observes a decreased output of only 550 ml. The next
best nursing action is to:
A. document the output in the flow sheet
B. turn the patient from side to side
C. report the output to the physician
D. infuse another bottle of dialysate
TIP: Stages of peritoneal dialysis/per 1 cycle of dialysate
Infusion time 5-10 minutes
Dwelling/equilibration time 20-30 minutes
Draining time 10-20 minutes
Dialysis aims to promote excretion of retained fluids,
electrolytes and waste products from the body. It is expected
that more output should come out during the draining time.
Turning the patient from side to side can help drain the fluid
that might have been trapped in the abdominal cavity.
87. A patient received spinal anesthesia 4 hours ago during
surgery. The patient has been on the ward for 2 hours and
now reports severe incisional pain. The patient's blood
pressure is 170/90 mm Hg, pulse is 108 beats/min,
temperature is 37.2°C, and respirations are 30
breaths/min. The patient's skin is pale and the dressing is
dry and intact. The most appropriate nursing intervention
is to:
A. call the physician and report the findings
B. medicate the patient for pain
C. place the patient in a high Fowler position and
administer oxygen
D. place the patient in a reverse Trendelenburg position
and open the IV line
Post-spinal anesthesia, a patient is placed flat on bed for 6-8
hours (C,D). The vital signs reflect a patient in severe pain.
Since the question asks for a nursing intervention, Choice B
would be wrong since medication required a doctor’s order.
The nurse needs to notify the physician.
TIP: In answering medication questions, if the question asks
for a nursing action, look for the phrase “as ordered” or “as
prescribed”, to qualify that as a nursing action. Remember
giving a medication without an order is outside the scope of
nursing practice.
88. Bone marrow depression is an adverse effect of
chemotherapy. Which of the following laboratory values
indicate that the patient has bone marrow depression?
A. hemoglobin - 15.1 mg/dl
B. white blood cell - 4,500 mg/cc
C. red blood cell - 4 million/ cc
D. platelets - 90,000/cc
Chemotherapy reduces the production of RBC, WBC and
platelets as a result of bone marrow suppression.
TIP: CBC normal values
RBC 3.5-5.5 million/cu. mm.
WBC 5,000-10,000/cu.mm.
Platelets 150,000-450,000/cu.mm
Hemoglobin 12-16 mg/dL
Hematocrit 37%-47%
89. A staff nurse is called to a client’s room. When the nurse
arrived in the room, she noted that the waste basket is on
fire. However, the client has been moved out of the room.
Which of the following is the priority action of the nurse?
A. Activate the fire alarm C. Evacuate the unit
B. Extinguish the fire D. Confine the fire
TIP: RACE(E)
R – Rescue the patients
A – Activate the alarm
C – Confine/contain the fire
E – Extinguish the fire
 E – Evacuate the premises
90. In planning care for a patient with Parkinson’s disease, the
nurse decides that the patient may need the most help
with
A. getting out of bed
B. buttoning his shirt and pants
C. taking his medications
D. communicating with caregivers
Tremors, pill-rolling of the fingers, and rigidity are
characteristics of Parkinson’s disease. Buttoning may be a
difficult task for this patient.
91. Understanding the risks of infection, who among the
clients listed below should receive immediate attention
and care?
A. Adult female with Vitamin B deficiency due to chronic
alcohol intake
B. Adult male with fresh second degree burns on arms
and chest
C. A teenager who is bleeding due to a cut on the finger
D. An elderly male with diabetes mellitus and toe
infection
An intact skin is the first line of defense against infection.
Altered skin integrity breaks this defense, increasing the risk
for infections.
92. The most important nursing intervention in caring for a
patient with a newly-placed nephrostomy tube is to
A. clamp the tube every 4 hours
B. disinfect the surgical site every shift
C. flush the tube with normal saline, as ordered
D. monitor the surgical dressing for bleeding
A nephrostomy tube must be kept patient in order to prevent
damage to the kidneys. This can be accomplished by regularly
flushing the tube with 5-10 mL of NSS q4h with a physician’s
order.
93. A patient with stroke is put on Mannitol intravenously. The
nurse evaluates the effectiveness of the drug by noting
which observation?
A. blood pressure increases
B. level of consciousness improves
C. urine output decreases
D. pupils are dilated and sluggishly reacting
Mannitol is an osmotic diuretic that is used to reduce an
increased intracranial pressure. As a diuretic, it promotes the
excretion of fluid from the kidneys. Reduced fluid volume can
decrease edema in the brain, thereby, improving the level of
consciousness.
94. Extreme hyperglycemia of uncontrolled diabetes mellitus
results in:
A. Metabolic alkalosis C. A state of dehydration
B. Oliguria D. Weight gain
Hyperglycemia attracts water from various fluid compartments
in an attempt to dilute the concentrated blood. This temporarily
increases the circulating fluid volume. As the fluid passes
through the kidneys, they are excreted into the urine, causing
osmotic diuresis. This may lead to dehydration.
95. Which of these statements made by a mother during an
education session in the community tells the nurse that
her child is prone to Hepatitis A infection?
A. “I always prepare my child’s lunch for school.”
B. “My child shares her lunch with her brother at recess.”
C. “My son sometimes buys food from the street
vendor.”
D. “I remember when my daughter had a blood
transfusion.”
Hepatitis A is transmitted via fecal-oral route. Unsanitary food
handling and preparation is a risk factor.
96. Early signs and/or symptoms of hepatitis include:
A. nausea, vomiting and abdominal pain
B. fever, yellowish sclera and skin
C. dark colored urine and diarrhea
D. ascites, difficulty breathing and swallowing
While all of these may be seen in hepatic disorders, early signs
of hepatitis are vague and non-specific.
97. For clients with diabetic ketoacidosis (DKA), their body
compensate for the acidosis in many ways. When caring
for these clients, which of the following manifestations will
you anticipate to observe?
1. Nausea and vomiting 3. Kussmaul breathing
2. Oliguria 4. Polyuria
A. 1 and 2 C. 3 and 4
B. 1, 3 and 4 D. All of the above
In DKA, the body compensates to reduce the acidity of the
blood by attempting to excrete the ketone bodies
 from the kidneys by promoting increased urine output.
This can lead to polyuria.
 from the lungs giving the characteristic deep, rapid
breathing (Kussmaul’s) and acetone odor of the
breath
 from the digestive system through vomiting
98. Which of the following laboratory results tell the nurse that
a patient has acute liver failure?
A. increased serum blood urea nitrogen level
B. decreased bilirubin level
C. increased aspartate transaminase level
D. decreased alanine transaminase level
An increased liver enzymes (ALT, AST) indicates liver
damage.
99. The most appropriate nursing action in the event of a
wound dehiscence is to
A. wear sterile gloves then attempt to push the organs
back into the abdominal cavity
B. cover the intestines with sterile dressing moistened
with normal saline solution
C. apply an abdominal binder to prevent protrusion of
abdominal organs
D. cover the organs with a dry sterile dressing then notify
the physician
Wound dehiscence is the separation of surgical sutures post-
operatively. ABD refer to wound evisceration, the protrusion of
abdominal organs outside the abdominal cavity.
100. An assessment finding that is consistent with pancreatitis
is the presence of
A. severe right upper quadrant pain
 B. foul smelling stools
C. palpable abdominal mass
D. blood in the urine
The pancreas is located in the left side of the abdomen (A). in
pancreatitis, reduced production of lipase reduces fat digestion
on the intestines. This causes malabsorption of fats causing it
to be excreted to the stools, causing steatorrhea.
101. The nurse assessing for risk factors for meningitis asks for
the presence of which medical history?
A. diabetes mellitus and anemia
B. tuberculosis and otitis media
C. renal failure and urinary tract infection
D. hepatitis and pancreatitis
Meningitis is mostly caused by bacteria or virus. Choice B are
caused by bacteria. Diabetes, renal failure, and pancreatitis
not usually caused by infection.
102. Which of the following observations will make the nurse
suspect of bleeding in a post-thyroidectomy patient?
A. The patient’s blood pressure increases and pulse rate
decreases.
B. The surgical dressing has a scant amount of sero-
sanguineous drainage.
C. The patient is swallowing frequently.
D. The patient is drowsy and has slow shallow
respirations.
Bleeding can be assessed by monitoring for frequent
swallowing or checking the back of the neck for blood.
103. During the post-operative period for thyroidectomy, the
nurse observes muscle twitching on the patient’s arms as
the blood pressure is being taken. This may likely be an
indication of:
A. hypocalcemia caused by accidental removal of the
parathyroid glands
B. hypothermia due to the temperature inside the
recovery room
C. respiratory alkalosis due to inability to perform deep
breathing exercises
D. seizures related to effects of general anesthesia and
narcotics
One of the common complications of thyroidectomy is tetany or
hypocalcemia due to accidental removal of the parathyroid
glands. This can be manifested by early signs such as
numbness and tingling of the mouth. Characteristics of tetany
include Chvostek’s sign (facial muscle spasms) and
Trousseaus’s (spasms of the hand and feet).
104. A surgical procedure that involves removing a portion of
the stomach and anastomosing the remaining part with
the duodenum is called
A. total mastectomy C. bougeinage procedure
B. Billroth I D. Billroth II
TIP: Billroth I – gastroduodenostomy
Billroth II - gastrojejunostomy
105. The nurse taking care of a patient who underwent
gastrectomy with Billroth II should watch out for
complications associated with
A. electrolyte imbalances C. dumping syndrome
B. hypoglycemia D. wound dehiscence
When the stomach is surgically attached to the jejunum, rapid
entry of hyperosmolar food into the small intestines can lead to
dumping syndrome.
106. A patient undergoing chemotherapy has the following as
his latest laboratory CBC results: RBC - 5 million/cc,
WBC-3,000/cc, and platelets-180,000/cc. Based on these
results, the nurse should identify which nursing diagnosis?
A. Activity intolerance
B. Risk for infections
C. Impaired tissue perfusion
D. Risk for injury
The CBC shows an abnormal WBC count, increasing the risk
for infections.
107. Which patient statement made prior to discharge after an
appendectomy needs further teaching?
A. “I need to call the doctor if I develop fever.”
B. “My incision will be painful and sore for a few
days.”
C. “I can resume my activities before surgery without
restrictions.”
D. “I should not see any drainage from the surgical
wound.”
Activity restriction is recommended after abdominal surgeries.
108. The priority nursing diagnosis of a patient with Addison’s
disease is
A. Altered nutrition: less than body requirements
B. Fluid volume deficit
C. Risk of blood glucose imbalance: hypoglycemia
D. Altered body image
Addison’s disease is characterized by lack of aldosterone that
causes reduced sodium and water retention. This promotes
increased excretion of urine, which may cause dehydration.
109. A nurse is circulating in an exploratory laparatomy for a
ruptured appendicitis. The scrub nurse asks for "Normal
Saline Solution (NSS) wash". The circulating nurse
immediately opened one liter of NSS and began to pour to
the sterile basin of the scrub nurse. Before she can empty
the NSS container, the scrub nurse signals "enough",
what is the appropriate action with the remaining NSS?
A. Discard the remaining NSS.
B. Pour the remaining NSS to another sterile basin in the
back table.
C. Cover the remaining NSS bottle aseptically right
away.
D. Transfer the remaining NSS to smaller sterile
container.
Any sterile container is considered unsterile once it is opened.
110. A patient is prepared for a fluid deprivation test. The nurse
knows that this is used in the diagnosis of
A. diabetes insipidus
B. Cushing’s syndrome
C. pheochromocytoma
D. syndrome of inappropriate anti-diuretic hormone
Fluid deprivation test is a screening for diabetes insipidus (DI).
If a patient is not given any fluids but still has an increased
urine output, it may indicate DI. This is due to the inability to
reabsorb water from the kidneys caused by lack of anti-diuretic
hormone.

111. The nurse encourages a patient with Addison’s disease to
have an adequate intake of which types of diet?
A. high-sodium, high-calorie, low-potassium diet
B. low-sodium, high-calorie, high-potassium diet
C. high-sodium, low-calorie, high-potassium diet
D. low-sodium, low-calorie, low-potassium diet
Patients with Addison’s disease have low aldosterone level.
This reduces sodium reabsorption and potassium excretion
from the kidneys. Patients develop hyponatremia and
hyperkalemia. Diet management should be high in sodium and
low in potassium.
112. The nurse’s action is appropriate if she prepares which of
the following pain medications for a patient complaining of
sharp abdominal pain due to cholelithiasis?
A. Morphine sulfate (MS Contin)
B. Meperidine hydrochloride (Demerol)
C. Mefenamic acid (Ponstan)
D. Butorphanon hydrochloride(Stadol)
The main problem of patients with cholelithiasis is acute
severe pain. The preferred analgesic is Meperidine HCl.
Morphine sulfate is contraindicated as it may cause contraction
of the sphincter of Oddi.
113. An important nursing intervention for patients with liver
cirrhosis is to
A. provide diet that is low in calories and salt
B. encourage the use of soft-bristled brush
C. massage the skin with alcohol
D. administer Acetaminophen (Tylenol) for abdominal
pain
Patients with liver disorders are prone to bleeding due to
impaired synthesis of clotting factors. Use of soft-bristled brush
prevents gum bleeding. They are given high-calorie diet (A)
due to the high metabolic rate of the liver. Acetaminophen is
hepatotoxic (D).
114. Patients with diabetic ketoacidosis (DKA) will more likely
exhibit the following changes in their arterial blood gases
(ABG):
A. pH - 7.56, pCO2 - 60 mmHg, HCO3 - 15 meq/L
B. pH - 7.40, pCO2 - 44 mmHg, HCO3 - 24 meq/L
C. pH - 7.34, pCO2 - 50 mmHg, HCO3 - 29 meq/L
D. pH - 7.25, pCO2 - 30 mmHg, HCO3 - 19 meq/L
TIP: ABG Interpretation
Normal Value Increased Decreased
pH 7.35-7.45 Alkalosis Acidosis
PaCO2 35-45 mmHg Acidosis Alkalosis
HCO3 22-26 meq/L Alkalosis Acidosis
PaO2 80-100 mmHg - Hypoxemia
115. The nurse monitoring a patient in the acute care knows
that the intracranial pressure is increased by noting which
of these changes in vital signs?
A. T-40.1 C, BP-165/105 mmHg, RR-10 cpm, PR-58
B. T-38.2 C, BP-140/90 mmHg, RR-14 cpm, PR-95
C. T-37.4 C, BP-120/75 mmHg, RR-12 cpm, PR-75
D. T-36.2 C, BP-90/40 mmHg, RR-22 cpm, PR-115
TIP: Cushing’s triad – late sign of increased ICP
 Hypertension or increased/widened pulse pressure
 Hyperthermia
 Bradycardia
 Bradypnea
116. The nurse should plan the diet of a patient with liver
cirrhosis who has a normal ammonia level that is
A. rich in calories C. high in fats
B. low in proteins D. high in sodium
TIP: Diet in liver disorders
 high calorie – liver has a high metabolic rate
 low sodium – reduced albumin synthesis leads to
edema due to reduced colloid oncotic pressure
 low protein – ONLY if ammonia level is increased
 balanced diet – if ammonia level is normal
117. The nurse notifies the physician regarding a patient’s
serum potassium of 7.1 meq/l. The physician orders
intravenous glucose and insulin. This is to
A. enhance renal excretion of potassium
B. promote cellular entry of potassium
C. cause exchange of potassium with hydrogen ion in
the intestines for excretion
D. treat hypoglycemia associated with the potassium
imbalance
TIP: Drugs for hyperkalemia
 Glucose with insulin – insulin promotes the entry of
glucose and potassium into the cell
 Kayexalate – ion exchange resin; facilitates the
exchange between potassium and sodium ions in the
intestines
118. The nurse monitors the vital signs of a patient at risk for
internal hemorrhage. Which set of vital signs reflects that
the patient is having hemorrhage?
A. BP-150/90 mmHg, PR-110, RR-20, T-37.5 C
B. BP-120/75 mmHg, PR-100, RR-16, T-36.9 C
C. BP-90/50 mmHg, PR-55, RR-10, T-38.4
D. BP-90/45 mmHg, PR-120, RR-24, T-36.1 C
TIP: Signs of bleeding
 BP – initially increased due to compensatory
vasoconstriction; eventually decreases as bleeding
progresses
 Pulse – increased as the heart compensates
 Respiratory rate – increased as lungs attempt to
provide more oxygen to tissues
 Temperature – decreased due to reduced blood flow
119. A patient is anxious about her upcoming upper
gastrointestinal series. The nurse attempts to allay the
patient’s anxiety by explaining that this procedure involves
A. insertion of a fiber optic tube to visualize the upper
digestive organs
B. getting an x-ray of the upper abdomen after ingestion
of barium
C. visualization of the abdomen through a CT scan
machine
D. thorough physical assessment of the upper
gastrointestinal system
Upper GI series is the other term for barium swallow. Choice A
refers to endoscopy; C is abdominal x-ray; and D is physical
assessment.
120. A patient with epilepsy is to undergo electroencephalo-
graphy (EEG) after breakfast. The nurse enters the patient
 room, sees the meal tray and tells the patient not to take
the:
A. slice of pineapple C. glassful of water
B. scrambled eggs D. cup of coffee
EEG measures electrical activity of the brain and is used to
diagnose seizure and epileptic disorders. Patients should avoid
any stimulants that may falsely increase brain wave activity.
121. A patient who has been diabetic for 15 years develops
neuropathy. Which of the following home care instructions
will best prevent injury?
A. “Trim your toenails and in-growns every week to
prevent toe infections.”
B. “Take hot shower on your own to promote self-care
and independence.”
C. “Make sure to clean the floor regularly before walking
barefoot.”
D. “Inspect inside your shoes before wearing them.”
Peripheral neuropathy causes numbness that may increase
the risk for injuries since patients have reduced ability to feel.
Foot care and trauma prevention is therefore essential. Avoid
trimming the in-growns (A), taking hot shower (B) and going
barefoot (C).
122. Which of the following ECG readings indicate that a
patient has a myocardial infarction?
A. Suppressed ST segment C. Elevated T waves
B. Absence of P waves D. Pathologic Q waves
TIP: ECG in myocardial infarction
 Elevated ST segment
 Inverted T wave
 Pathologic or abnormal Q wave
123. The nurse is monitoring the tracheostomy cuff pressure of
a patient of mechanical ventilation. To minimize the risk of
tracheal tissue necrosis the nurse should maintain the
pressure to
A. 10-15 mmHg C. 30-35 mmHg
B. 20-25 mmHg D. 40-45 mmHg
A pressure of less than 20 mmHg may cause dislodgement of
the tube and increase risk of aspiration while higher than 25
mmHg can increase pressure on the tracheal mucosa, causing
damage and necrosis.
124. A patient with fracture of the femur is on balanced
suspension traction. The nurse considers the following
statements when taking care of a client with traction
EXCEPT
A. Steady pull from both directions to keep the fractured
bone in place.
B. Weights should be kept resting on the floor.
C. Clients on traction need adequate skin care and
proper positioning.
D. Traction can be used to correct or prevent
deformities.
ABD are all appropriate when caring for patient with traction.
The weights should be continuous and not disrupted.
125. A client with cancer of the larynx undergoes total
laryngectomy. Post-laryngectomy, which of the following
will the nurse expect?
A. No risk of aspiration during swallowing; speech is lost.
B. Normal speaking, breathing and swallowing are
restored
C. Unable to communicate with difficulty of swallowing
and breathing
D. Permanent tracheostomy created; normal speech is
lost
TIP: Changes after laryngectomy
 Partial laryngectomy – voice is preserved; airway
normal
 Total laryngectomy – permanent loss of voice; upper
airway is bypassed with a permanent stoma
126. After appendectomy, the client complained of abdominal
pain, nausea and vomiting with abdominal distention. The
nurse anticipates which of the following priority
management after referring to the surgeon?
A. Oropharyngeal suctioning
B. Possible surgery
C. Endoscopy
D. Rectal tube insertion
These signs indicate paralytic ileus, which is due to
accumulation of gas due to lack of intestinal peristalsis. This
can be relieved by NGT attached to intermittent suction and/or
rectal tube insertion.
127. Nurse Fely did her admission assessment on a patient
with acute pancreatitis. She understands that the
abdominal pain associated with this disorder is
characterized as
A. Tenderness that is generalized in the upper epigastric
area
B. Pain in the left upper quadrant radiating to the left
shoulder
C. Tenderness and rigidity at the left hypogastric area
radiating to the back
D. Tenderness and rigidity at the upper right abdomen
radiating to the midsternal area
Acute pancreatitis is felt as pain the left upper quadrant since
the pancreas is on the left upper quadrant of the abdomen.
128. The client is scheduled to undergo appendectomy.
Preparation for appendectomy does not include which of
the following?
1. Intravenous infusion A. 2,3,4
2. Laxative B. 1,3,5
3. Pubic area shaving C. 2,3,5
4. Enema D. 2,4,6
5. Shower
6. Pain medication
Laxatives and enema are contraindicated in appendicitis as
this may cause rupture of the appendix. Pain medications are
generally not given as this may mask the pain that may falsely
indicate a ruptured appendix.
129. For a client complaining of mild musculoskeletal pain, the
nurse will anticipate that the treatment for this client’s level
of discomfort will include which of the following?
A. Ibuprofen C. Meperidine HCl
B. Acetaminophen D. Fentanyl
TIP: WHO Analgesic Ladder – specific pain management
depends on level or severity of pain
 Mild pain – non-opioids (Acetaminophen,
Paracetamol)
  Moderate pain – NSAIDs (Aspirin, Ibuprofen, A. RBC, WBC and platelets
Mefenamic acid) B. WBC, platelet and cholesterol
 Severe pain – opioids (Morphine, Meperidine HCl) C. Bilirubin, RBC, and platelet
D. BP, WBC, and hematocrit
130. Albert came to the hospital with chest pain and fever.
After a thorough assessment by the doctor he was Polycythemia vera is characterized by abnormal proliferation of
admitted for pericarditis management. The nurse RBC, with accompanying increase in WBC and platelet.
positions the client to reduce pain and discomfort.
Describe this position. 135. From the following data obtained from the chart, which is
A. Semi-Fowler’s position with one pillow to support the NOT a risk factor which could have predisposed the
head. patient to breast cancer?
B. Put two pillows to elevate the head and one pillow A. Age – 55 years
under the knees. B. Height – 5’2”; weight – 160 lbs.
C. Sit the client upright and lean forward C. Menarche at age 13
D. Supine lying on either left or right side with one pillow D. Mother died of colon cancer
to elevate the head
TIP: Risk factors of breast cancer
Upright position, with the patient leaning forward, is the  Age – increasing age (>40 years old)
position of choice to relieve chest pain in pericarditis.  Obesity
131. The nurse is aware that acromegaly is a condition when
Height Male Female
growth hormone occurs in excess. The following are the
First 5 feet 106 lbs 100 lbs
typical features of the disorder EXCEPT
For every 6 lbs 5 lbs
A. The soft tissues continue to grow
inch
B. Hands and feet are enlarged
C. The client grows taller Example: 106+8(6)=154 100+8(5)=140
D. Broad and bulbous nose 5’8”

TIP: Gigantism (children) – growth in bone length  Early menstruation (menarche)

Acromegaly (adults) – growth in bone width
132. A 30-year-old client had cholesterol blood test before
admission to the hospital. The nurse in charge would
teach the family and significant others that the client
should exercise to help keep the total cholesterol to a
normal level of
A. 150-200 mg/dl C. 250-300 mg/dl
B. 200-250 mg/dl D. 300-350 mg/dl
Normal cholesterol level is below 200 mg/mL.
133. A 34-year-old female client with Grave’s disease was
admitted for treatment. The physician prescribed
Propylthiouracil to treat the disorder. The client is to have
surgery in 10 days. Lugol’s solution 4 gtts po was
prescribed for 10 days. The client asked the nurse for the
purpose of the drug. Which response of the nurse is
correct?
A. It decreases the risk of bleeding.
B. It eliminates the needs to take hormone replacement.
C. It stabilizes your immune system to withstand
surgery.
D. It decreases the risk for thyroid crisis.
TIP: Medical management of Grave’s disease
 Iodine solutions – to reduce the size and vascularity
of the thyroid gland to reduce the risk of bleeding
o Lugol’s solution
o Potassium iodide saturated solution
 Anti-thyroid drugs – to reduce the production of
thyroid hormones
o Propylthiouracil (PTU)
o Methimazole (Tapazole)
 Radioactive iodine (RAI 131) – to destroy thyroid
tissues
 Late menopause
 Use of estrogen
 Family history of cancer
136. The nurse in the intensive care unit is closely watching a
client for signs of hypovolemic shock. Which of the
following should the nurse report as early signs of
hypovolemic shock?
1. Lethargy A. 2,3,4 and 5
2. Rapid pulse B. 1,2,3 and 5
3. Clammy skin C. 1,2,5 and 6
4. Cyanosis D. 1,3,4 and 6
5. Restlessness
6. Hematemesis
Early signs of decreased oxygenation include changes in the
level of consciousness (restlessness, lethargy) since brain
cells are sensitive to low oxygen level. The vital signs reflect
tachycardia and tachypnea. Cold clammy skin is due to
reduced peripheral circulation. Cyanosis (4) is a late sign.
137. The nurse is aware that in acute respiratory distress
syndrome (ARDS), the basic changes in the lungs result
from injury to the alveolar wall and capillary membrane
leading to the following pathological changes EXCEPT
A. Fluid and protein leaks into alveoli and interstitial
tissue
B. Elevated blood hydrostatic pressure
C. Reduced colloid oncotic pressure
D. Increased alveolar capillary permeability
ARDS involves the sudden onset (24-48 hours) of leakage of
fluids into the lungs (pulmonary edema) as a result to injury to
the lung tissues. Injured tissues release histamine that makes
capillaries more permeable to fluids.

134. The nursing student reviews the laboratory findings of a 138. The nurse admitted a client because of pulmonary
patient with polycythemia vera and finds which blood edema. He has a history of congestive heart failure, type 2
results are elevated? diabetes mellitus and hypertension. Based on the history,
 the nurse noted that the patient regularly took Losartan.
What is the specific action of this drug?
A. Improves myocardial contractility, decreases the heart
rate, and reduces oxygen consumption
B. Causes vasoconstriction, increased preload and
dilation of the ventricles
C. Reduces peripheral vascular resistance and afterload,
reducing myocardial workload
D. Interferes with the production of angiotensin II
resulting in improved cardiac output and reducing
pulmonary congestion
Drugs that end in “SARTAN” are angiotensin receptor
blockers, a type of anti-hypertensive agent. Angiotensin II
causes vasoconstriction and increased sodium and water
retention. Blocking angiotensin II causes vasodilation and
reduced sodium and water retention.
Choice A refers to cardiac glycosides (e.g. Digoxin) while C
describes vasodilators (e.g Apresoline, Catapress).
139. Due to hypothalamic dysfunction, a syndrome of
inappropriate antidiuretic hormone (SIADH) develops.
Which of the following manifestations should the nurse
watch closely?
A. Increased urine output, decreased serum sodium
B. Increased urine output, increased serum sodium
C. Decreased urine output, decreased serum sodium
D. Decreased urine output, increased serum sodium
SIADH is due to an increased level of anti-diuretic hormone.
This causes increased water reabsorption from the kidneys
leading to fluid overload. As water is reabsorbed into the
circulation, it dilutes the sodium causing dilutional
hyponatremia.
 Hypotonic solution 0.45% NaCl
 Isotonic solution 0.9% NaCl, D5W, LRS
 Hypertonic solution 3% NaCl
As a hypertonic solution, 3% NaCl, attracts water that can
increase the circulating blood volume. This may lead to fluid
excess causing pulmonary edema, which is manifested by
crackles upon auscultation.
143. Timothy, 56 years old, was admitted because of aortic
aneurysm, fusiform type. The nurse recognizes which of
the following as the correct description of the patient’s
diagnosis?
A. Tear in the intima of the aorta with hemorrhage into
the tunica media
B. Stretching of both sides of the aorta
C. One-sided protrusion of one distinct area of the aorta
D. Pulsating hematoma on three layers of the aorta
TIP: Types of aneurysm
 Saccular – dilation on one side of an artery
 Fusiform – dilation of both sides of an artery
 Dissecting – tear in the layer/s of an artery
 Pseudoaneurysm – false aneurysm
144. Of the following diagnostic tests prescribed by the
physician, which of the following will the nurse expect to
show precise measurement of a cholelithiasis?
A. Cholecystography
B. Chest x-ray
C. Abdominal ultrasonography
D. Cholangiography
Abdominal ultrasound provides 95% accuracy in providing
information about the location and measurement of gallstones.

140. Neutropenia often results from bone marrow depression
as an adverse effect of chemotherapy. As a nurse, you
should observe for the following symptoms that include
A. Headache, dizziness, blurred vision
B. Severe sore throat, bacteremia, hepatomegaly
C. Petechiae, ecchymosis, epistaxis
D. Weakness, easy fatigability, pallor
Neutropenia is reduced WBC. This increases risk for infection.
A & D are due to anemia while C is due to thrombocytopenia.
141. Joseph has been receiving diuretic therapy and is
admitted to the hospital with a serum potassium level of
3.1 meq/L. Of the following medications that he has been
taking at home, which will you be most concerned about?
A. Oral digoxin (Lanoxin) 0.25 mg daily
B. Lantus insulin 23 U subcutaneously every evening
C. Ibuprofen (Motrin) 400 mg every 6 hours
D. Metoprolol (Lopressor) 12.5 mg orally daily
Hypokalemia increases risk for digitalis toxicity.
145. A client was rushed to the emergency department after a
vehicular accident where he had a traumatic head injury
(TBI). To determine the client’s level of consciousness, the
Glasgow Coma Scale (GCS) is used. Which of the
following is a correct interpretation of the nurse of the
GCS score?
A. The higher the score, the higher is the probability of
permanent damage
B. The lower the score is, the lower is the probability of
delayed recovery
C. The higher the score, the greater is the impairment in
the brain
D. The lower the score, the more serious is the brain
injury
TIP: Glasgow Coma Scale
Highest score is GCS of 15
Lowest score is GCS of 3
The GCS is an assessment tool to evaluate level of
consciousness. It assesses eye opening, verbal response and
motor response.

142. The nurse administered 3% saline to a patient who has a Eye Opening Verbal Response Motor Response
serum sodium level of 124 meq/L. Which assessment 6 - - Follows commands
5 - Oriented to time Localizes pain
findings may develop as a result of the treatment? place & person
A. Her blood pressure decreased from 150/90 to 130/80 4 Opens Disoriented, confused Flexion withdrawal
mmHg spontaneously
B. There is sediment and blood in Wanda’s urine 3 Opens to light Inappropriate sounds Decorticate
C. Wanda’s radial pulse is 105 beats per minute stimulation positioning
2 Opens to painful Incomprehensible Decerebrate
D. There are crackles audible throughout her lung fields
stimulation sounds positioning
1 No response No response No response
TIP: Concentrations of intravenous fluids
 D. Type II (IDDM) is characterized by abnormal immune
146. An immediate objective for nursing care of an overweight response.
mildly hypertensive client with ureteral colic and hematuria
is to decrease TIP: Types of diabetes mellitus
A. hypertension C. hematuria
B. pain D. weight Type I Type II
Name Insulin-dependent Non-insulin
The pain problem of patients with renal stones is pain. Priority dependent
goal of care is pain management. Opioid analgesics are the IDDM NIDDM
preferred medication. Onset Early; before 40 y/o Late: after 40 y/o
Risk Autoimmune – virus Obesity, genetic
147. A client who had a craniotomy has an increased Ketosis Yes No
intracranial pressure. Which of the following interventions Treatment Insulin Oral hypoglycemic
can the nurse include in the plan of care to control drug
intracranial pressure (ICP)? More common
A. Maintain his head and neck in neutral alignment
B. Initiate measures to enhance valsalva maneuver
C. Administer O2 to maintain paCO2 >50 mmHg MENTAL HEALTH & PSYCHIATRIC NURSING (50 items)
D. Elevate head of the bed to 60-90 degrees
151. Mental health is defined as:
The head and neck should be in neutral position to promote A. The ability to distinguish what is real from what is not.
venous outflow from the brain. Flexing the neck reduces the B. A state of well-being where a person can realize his
flow of venous blood from the brain, increasing ICP. Valvalva own abilities, can cope with normal stresses of life
maneuver increases ICP (B). Oxygen below 80 mmHg and and work productively.
carbon dioxide above 45 mmHg causes dilation of blood C. Is the promotion of mental health, prevention
vessels in the brain, increasing blood volume and eventually of mental disorders, nursing care of patients during
increasing ICP (C). The preferred position to reduce ICP is illness and rehabilitation
head of bed elevated to 30-45 degrees (D). D. Absence of mental illness
148. The ER nurse is assessing a client who had a closed Choice A refers to reality-testing. Choice C is the focus of
chest injury. Which of the following will the nurse do to psychiatric nursing. Choice D is a very limited definition of
assess subcutaneous emphysema? mental health.
A. Observe for signs of unequal chest expansion.
B. Auscultate the lungs and observe for crackles. 152. Liza says, “Give me 10 minutes to recall the name of our
C. Palpate neck for air bubble-popping sensation college professor who failed many students in our
D. Percuss for a hyperresonant percussion tone anatomy class.” She is operating on her:
A. Subconscious C. Conscious
Subcutaneous emphysema or the presence of air in the B. Unconscious D. Ego
subcutaneous tissues causes a characteristic crackling or
popping sound upon palpation. Unequal chest expansion (A) TIP: Levels of consciousness
may be seen in pneumothorax, flail chest or atelectasis.  Consciousness – focuses on the here and now
Crackles (B) indicate the presence of fluids in the lungs such  Subconscious – requires effort to recall the past
as in pulmonary edema. Hyperresonance (D) is heard on  Unconscious – past experiences are cannot be
percussion when excessive air is in the thoracic cavity like in recalled easily
emphysema or pneumothorax.
153. Primary level of prevention in psychiatric nursing is
149. The nurse recognizes that adjuvant chemotherapy for exemplified by:
cancer management may include any of the following A. Helping the client resume self-care
EXCEPT B. Ensuring the safety of a suicidal client in the
A. Monoclonal antibody C. Antitumor antibiotics institution.
B. Proton inhibitors D. Hormonal preparations C. Teaching the client stress management techniques
D. Case finding and surveillance in the community
Chemotherapeutic agents include anti-tumor antibiotics,
hormones, anti-metabolites, alkylating agents, and plant TIP: Levels of prevention
alkaloids. Immunotherapy, such as the use of monoclonal  Primary – promotion of health & prevention of illness
antibodies, cytokines, vaccines, and colony-stimulating factors,  Secondary – early diagnosis & treatment
is used as an adjuvant (in addition) to chemotherapy.  Tertiary – recovery & rehabilitation
150. The nurse teaches a group of clients the difference
between Type I (IDDM) and Type II (NIDDM) diabetes. 154. The therapeutic approach in the care of an autistic child
Which of the following is true? include the following EXCEPT:
A. Both types diabetes mellitus clients are prone to A. Engage in diversionary activities when acting -out
developing ketosis. B. Provide an atmosphere of acceptance
B. Type II (NIDDM) is more common and is also C. Provide safety measures
preventable compared to Type I (IDDM) diabetes, D. Rearrange the environment to activate the child
which is genetic in etiology.
C. Type I (IDDM) is characterized by fasting Care of autistic children includes maintaining their routine.
hyperglycemia. Disruption of their familiar environment increases their anxiety.
  Presence of support system
155. A 10-year-old child has very limited vocabulary and  Previous use of coping mechanism
interaction skills. She has an I.Q. of 45. She is diagnosed
to have Mental retardation of this classification: 160. The nurse initiates the nurse-client relationship with Marta.
A. Profound C. Moderate Which of the following is the least appropriate topic during
B. Mild D. Severe the orientation phase?
A. Establishment of regular schedule for interaction
TIP: Levels of mental retardation (diagnosed before 18 y/o) B. Exploration of the client’s inadequate coping
mechanism
IQ Category C. Objectives of the nurse-patient interaction
50-70 Mild Educable, mental age of 6th grade D. Perception of the client of the reason for her
35-50 Moderate Trainable ; mental age of 2nd hospitalization
grade
20-35 Severe Close supervision ACD are activities during the orientation of the therapeutic
Below 20 Profound Custodial; total care relationship. B is done during the working phase.

156. A client with organic brain disorder is exhibiting changes in 161. Lalaine, a 29 year-old married woman believes that the
behavior. What behavior or action will alert the nurse that doorknobs are contaminated and she touches them only
the patient may be experiencing delirium? with tissue paper. Which of the following is the most
A. Daytime sleepiness and night time incontinence appropriate nursing diagnosis that the nurse should
B. The client becomes confused within 24 hours from identify?
admission. A. Anxiety, moderate
C. Depression alternating with periods of cheerfulness B. Impaired adjustment
D. Depression and inability to get out of bed to do C. Ineffective coping
activities of daily living D. Self-esteem disturbance

Delirium is a sudden change in level of consciousness brought
about my acute change in brain functioning, which may be due
to organic causes.
157. Which of the following situations describes the cognitive
theory as a model of psychiatric care?
A. The nurse enforces limit setting on the patient’s
inappropriate behavior.
B. The therapist delves into the past life of the client to
assess her childhood experiences.
C. The psychologist assesses and corrects the client’s
distorted and negative thinking.
D. The psychiatrist prescribes anti-anxiety medications
to a client with panic disorder.
TIP: Models of psychiatric care
 Psychodynamic or psychoanalytic model – focuses
on past life experiences
 Cognitive model- focuses on thought, perceptions or
beliefs
 Behavioral model – focuses on actions or
characteristics that are learned from the environment
 Biomedical – focuses on alterations in physiologic
processes
158. Crisis is self-limiting. How many weeks does it usually
last?
A. 4-6 B. 2-4 C. 6-8 D. 8-10
Obsessive-compulsive behavior or personality is anxiety-
related.
162. Which of the following is the rationale for allowing a client
with obsessive-compulsive personality to continue her
ritualistic behavior?
A. To prevent increasing her level of anxiety
B. To encourage independence
C. To protect her from physical harm
D. To increase her self-esteem and confidence
Rituals are attempts to displace anxiety. When rituals are
performed, the level of anxiety that the patient experiences will
decrease. On the other hand, the anxiety level increases once
they cannot perform their rituals.
163. Which of the following is the appropriate nursing
intervention to reduce anxiety and the need for ritualistic
behavior?
A. Encourage the client to examine own perceptions.
B. Encourage the client to use problem-solving skills.
C. Focus on the strengths and potential of the client.
D. Provide opportunities to express feeling.
Since ritualistic behaviors arise from anxiety, expression of
feelings helps reduce anxiety. A reduced anxiety level
eventually reduces performance of ritualistic behaviors.

With or without crisis intervention, crisis resolves usually within

4-6 weeks.

164. The following statements are true about anxiety except:

159. What is the priority assessment during the initial phase of A. Anxiety is a response to a specific negative stimulus.
crisis intervention? B. Mild anxiety is useful in bringing about better
A. Client’s support system performance.
B. Individual and the problem C. Persons use defense mechanisms to cope with their
C. Plan coping with the crisis anxiety.
D. Type of crisis the client is experiencing D. Persons who are anxious resort to flight or fight
mechanism.
TIP: Crisis assessment
 Perception of the problem – most important
The cause of anxiety is unknown, not specific. The patient
feels uneasy without an apparent cause.
165. Four days after admission, Mr. Lee says to the nurse, “I
want to go home. I’m alright.” Which of the following is the
most therapeutic response of the nurse?
A. “Alright you may go home if you want to.”
B. “I know it must be difficult for you to stay in the
hospital.”
C. “Why do you want to go home?”
D. “You are not yet ready to go home, Mr. Lirio”
Acknowledging patient’s feelings shows a nurse’s acceptance
of the patient. The use of “WHY” is non-therapeutic (C).
166. When should the rehabilitation of a newly admitted
schizophrenic patient start?
A. Before discharge
B. During the recovery stage
C. In the acute stage of his illness
D. Upon admission
Rehabilitation of patients starts during admission.
167. A client with major depression is to be discharged. Which
of the following areas would be most important for the
nurse to review with the client?
A. Conflict with another client
B. Medication management
C. Plans of returning to work
D. Results of psychological testing
Antidepressant medications take an average of three weeks
before therapeutic effects can be felt. This must be
emphasized to patients who are about to be discharged in
order to ensure compliance to the treatment.
168. Which of the following disorders may be seen concurrently
in a client with generalized anxiety disorder?
A. Bipolar disorder
B. Gender identity disorder
C. Panic disorder
D. Schizoaffective disorder
TIP: Levels of anxiety
 Mild – increases perception
 Moderate – presence of physical symptoms
 Severe – difficulty of concentration
 Panic – inability to concentrate; personality
disintegration
169. A female victim of sexual assault went to the crisis center
for her third visit. She was raped 3 months ago and states
that she feels as if the rape just happened yesterday.
What would be the best response of the nurse?
A. “In time, our goal will help you move on from these
strong feelings about your rape.”
B. “It’s been over for 2 months now. Be realistic.”
C. “Tell me more about what happened during the rape
that causes you now to feel like the rape just
occurred.”
D. “What can you do to alleviate some of your fears
without being assaulted again?”
Allowing the patient to verbalize the situation helps in
discovering emotional components associated with the event.
Therapy is then directed towards addressing the identified
emotion.
170. Since admission 3 days ago, a female client has refused
to take a shower, stating, “There are poisonous spiders
hidden in the shower head. I will get bitten by them and
get killed if I take a shower!” How should the nurse
respond?
A. Accept the fear and allow the client to take a sponge
bath instead.
B. Ask a security guard to assist in giving the client a
bath.
C. Dismantle the shower head and show the client that
there is nothing in it.
D. Tell her that the other clients complain about her body
odor, so she must take a shower.
The nurse should accept that phobia is real for the client.
171. The characteristic traits of schizophrenia include the
following except:
A. Blunting of affect
B. Existence of two feeling tones
C. Loose association
D. Rapid change of mood
TIP: 5 As of schizophrenia
 Apathy – lack of affect
 Ambivalence – 2 feelings at the same time
 Associative looseness – jumps into different topics
 Autism – magical or dereistic thinking
 Auditory hallucination – most common type
172. In taking care of schizophrenic patients, which of the
following nursing interventions should the nurse consider?
A. Always agree with the patient’s ideas.
B. Make use of short phases and specific words.
C. Use carefully detailed explanation.
D. Use sign language to be understood clearly.
Schizophrenia is a disorder of thought process. Use of simple
sentences makes it easier for patient to comprehend.
173. One morning, Paul says, “I hear Jose Rizal’s voice.”
Which of the following statements is the most therapeutic?
A. “I don’t hear the voice, but I know you hear what
sounds like a voice.”
B. “No need to worry about the voice. It doesn’t belong
to anybody alive.”
C. “That could not be true. Jose Rizal has been dead
for so many years.”
D. “You should ignore that voice. It would not help you
get well.”
Auditory hallucination is real for the client. Present reality by
not acknowledging or focusing on the hallucination. Do not
argue with the patient or ignore the content of the hallucination.
174. Which of the following drugs should the nurse expect to be
prescribed in order to reverse Parkinson-type symptoms in
a client receiving anti-psychotic medication?
A. Benztropine mesylate (Cogentin)
B. Chlordiazepoxide (Librium)
C. Haloperidol (Haldol)
D. Propanolol (Inderal)
TIP: Anti-cholinergic meds to prevent pseudo-
parkinsonism or extra-pyramidal symptoms (EPS) caused
by antipsychotics
A – Akineton (Biperiden HCl)
 A – Artane (Trihexiphenydyl HCl)
B – Benadryl (Diphenhydramine HCl)
C – Cogentin (Benztropine mesylate)
175. Which of the following is the most appropriate nursing
diagnosis for a client reporting thoughts of being followed
by CIA agents?
A. Disturbed sensory perception related to increased
anxiety
B. Disturbed thought processes related to increased
anxiety
C. Impaired verbal communication related to disordered
thinking
D. Altered thought content related to mistrust
The client is experiencing delusion of persecution. Delusion is
a disorder of though process, not though content.
 Alteration in thought content - delusion
 Alteration in thought process – hallucination, illusion
176. A client with paranoid schizophrenia repeatedly uses
profanity during an activity therapy session. Which
response by the nurse would be most appropriate?
A. “Your behavior won’t be tolerated. Go to your room
immediately.”
B. “You’re just doing this to get back at me for making
you come to therapy.”
C. “Your cursing is interrupting the activity. Take time
out in your room for 10 minutes.”
D. “I’m disappointed in you. You can’t control yourself
even for a few minutes.”
Inappropriate behavior is addressed with a matter-of-fact
approach. Limit setting exerts external control on the patient.
177. The nurse is assigned to a client with catatonic
schizophrenia. Which intervention should the nurse
include in the client’s plan of care?
A. Meeting all of the client’s physical needs
B. Giving the client an opportunity to express concerns
C. Administering lithium carbonate (Lithonate) as
prescribed
D. Providing a quiet environment where the client can be
alone
Catatonic patients remain motionless for a period of time and
may neglect their physical needs (e.g. nutrition, elimination).
178. A client, age 36, with paranoid schizophrenia believes the
room is bugged by the Central Intelligence Agency and
that his roommate is a foreign spy. The client has never
had a romantic relationship, has no contact with family
members, and hasn’t been employed in the last 14 years.
Based on Erikson’s theories, the nurse should recognize
that this client is in which stage of psychosocial
development?
A. Autonomy versus shame and doubt
B. Generativity versus stagnation
C. Integrity versus despair
D. Trust versus mistrust
Although the client is 36-years-old, his behaviors reflect an
inability to establish relationship and patterns of paranoia.
These are characteristics of not being able to establish trust.
179. During a group therapy session in the psychiatric unit, a
client constantly interrupts with impulsive behavior and
exaggerated stories that cast her as a hero or princess.
She also manipulates the group with attention-seeking
behaviors, such as sexual comments and angry outbursts.
The nurse realizes that these behaviors are typical of:
A. Narcissistic personality disorder.
B. Avoidant personality disorder.
C. Histrionic personality disorder.
D. Borderline personality disorder.
Attention-seeking behavior is characteristic of a histrionic
personality. Narcissistic behavior focuses on the self. Avoidant
personality withdraws from social relationships. Borderline
personality has inability to form relationships and has self-
mutilating tendencies.
180. A client is admitted to a psychiatric facility with a diagnosis
of chronic schizophrenia. The history indicates that the
client has been taking neuroleptic medication for many
years. Assessment reveals unusual movements of the
tongue, neck, and arms. Which condition should the nurse
suspect?
A. Tardive dyskinesia
B. Dystonia
C. Neuroleptic malignant syndrome
D. Akathisia
Tardive dyskinesia is an irreversible side-effect of anti-
psychotic drugs that involve rhythmic movement of the tongue.
Dystonia involves the muscles of the neck, arms and face.
Neuroleptic malignant syndrome causes high fever, tremors.
Akathisia involves restlessness and inability to keep still.
181. The nurse is caring for a client who is suicidal. When
accompanying the client to the bathroom, the nurse
should:
A. Give him privacy in the bathroom.
B. Allow him to shave.
C. Open the window and allow him to get some fresh
air.
D. Observe him.
A patient who is suicidal is placed on suicidal precautions.
Constant 24-hour surveillance must be done.
182. The nurse is developing a care plan for a client with
anorexia nervosa. Which action should the nurse include
in the plan?
A. Restrict visits with the family until the client begins to
eat.
B. Provide privacy during meals.
C. Set up a strict eating plan for the client.
D. Encourage the client to exercise, which will reduce
her anxiety.
Providing external control enables a patient with anorexia
nervosa to eat. The patient should be observed during meal
times to ensure that she ingests the food that is served.
183. A client whose husband recently left her is admitted to the
hospital with severe depression. The nurse suspects that
the client is at risk for suicide. Which of the following
questions would be most appropriate and helpful for the
nurse to ask during an assessment for suicide risk?
A. “Are you sure you want to kill yourself?”
B. “I know if my husband left me, I’d want to kill myself.
Is that what you think?”
C. “How do you think you would kill yourself?”
D. “Why don’t you just look at the positives in your life?”
A direct, confrontation approach is recommended and
therapeutic in assessing suicide risk.
184. The nurse is caring for a client experiencing an anxiety
attack. Appropriate nursing interventions include:
A. Turning on the lights and opening the windows so that
the client doesn’t feel crowded.
B. Leaving the client alone.
C. Staying with the client and speaking in short
sentences.
D. Turning on stereo music.
During an anxiety attack, the patient should be kept calm. As
cognitive function or perception may be affected, speaking in
short sentences may be beneficial and therapeutic.
185. The nurse is teaching a new group of mental health aides.
The nurse should teach the aides that setting limits is
most important for:
A. A depressed client. C. A suicidal client.
B. A manic client. D. An anxious client.
TIP: Attitude therapy
 Active friendliness – withdrawn, isolated patients
 Passive friendliness – paranoid patients
 Kind firmness – depressed patients
 Matter-of-fact (limit setting) – for any inappropriate
behavior
 No demand – for aggressive and violent patients
186. The nurse is caring for a client, a Vietnam veteran, who
exhibits signs and symptoms of posttraumatic stress
disorder (PTSD). Signs and symptoms of posttraumatic
stress disorder include:
A. Hyper alertness and sleep disturbances.
B. Memory loss of traumatic event and somatic distress.
C. Feelings of hostility and violent behavior.
D. Sudden behavioral changes and anorexia.
Flashback, nightmares, and sleep disturbances are
characteristics of PTSD.
187. A client is admitted for detoxification after a cocaine
overdose. The client tells the nurse that he frequently uses
cocaine but that he can control his use if he chooses.
Which coping mechanism is he using?
A. Withdrawal C. Repression
B. Logical thinking D. Denial
TIP: Substance abuse
 Defense mechanism – denial
 Nursing diagnosis – Ineffective individual coping
188. A client with bipolar disorder is being treated with lithium
for the first time. The nurse should observe the client for
which common adverse effect of lithium?
A. Sexual dysfunction C. Polyuria
B. Constipation D. Seizures
Adverse effects of lithium include polyuria, diarrhea, tremors.
189. A client is admitted for an overdose of amphetamines.
When assessing this client, the nurse should expect to
see:
A. Tension and irritability. C. Hypotension
B. Slow pulse. D. Constipation.
Amphetamines are CNS stimulants. BP and pulse may
increase (B,C). Diarrhea is more common. (D)
190. During a shift report, the nurse learns that she’ll be
providing care for a client who is vulnerable to panic
attack. Treatment for panic attacks includes behavioral
therapy, supportive psychotherapy, and medication such
as:
A. barbiturates. C. depressants.
B. antianxiety drugs. D. amphetamines.
Panic is the highest level of anxiety. Anti-anxiety drugs are
indicated in this situation. (e.g. Diazepam (Valium), Lorazepam
(Ativan), Chlordiazepoxide (Librium)).
191. A client has been receiving chlorpromazine (Thorazine),
an antipsychotic, to treat his psychosis. Which finding
should alert the nurse that the client is experiencing
pseudoparkinsonism?
A. Restlessness, difficulty sitting still, pacing
B. Involuntary rolling of the eyes
C. Tremors, shuffling gait, mask like face
D. Extremity and neck spasms, facial grimacing, jerky
movements
Pseudoparkinsonism or Parkinson’s-like symptoms are due to
a reduction of dopamine level as an effect of taking anti-
psychotic drugs. (A) refers to akathisia; (B) to oculogyric crisis
and (D) dystonia.
192. A 54-year-old female was found unconscious on the floor
of her bathroom with self-inflicted wrist lacerations. An
ambulance was called and the client was taken to the
emergency department. When she was stable, the client
was transferred to the inpatient psychiatric unit for
observation and treatment with antidepressants. Now that
the client is feeling better, which nursing intervention is
most appropriate?
A. Observing for extrapyramidal symptoms
B. Beginning a therapeutic relationship
C. Canceling any no-suicide contracts
D. Continuing suicide precautions
When patients are treated with depression, a sudden
improvement in their mood or a sign of improvement is a major
concern since it may signal an impending suicide. Suicidal
tendencies are at its highest when the depression starts to lift.
193. A 26-year-old male reports losing his sight in both eyes.
He’s diagnosed as having a conversion disorder and is
admitted to the psychiatric unit. Which nursing intervention
would be most appropriate for this client?
A. Not focusing on his blindness
B. Providing self-care for him
C. Telling him that his blindness isn’t real
D. Teaching eye exercises to strengthen his eyes
Conversion disorder is an anxiety disorder characterized by
loss of function of a body part without on organic or pathologic
cause. It may be a symbolic representation of an unresolved
conflict or anxiety. Nurses should not focus on the sign or
symptom so as to prevent reinforcing the anxiety.

194. A client is being admitted to the substance abuse unit for
alcohol detoxification. As part of the intake interview, the
nurse asks him when he had his last alcoholic drink. He
says that he had his last drink 6 hours before admission.
Based on this response, the nurse should expect early
withdrawal symptoms to:
A. Not occur at all because the time period for their
occurrence has passed.
B. Begin anytime within the next 1 to 2 days.
C. Begin within 2 to 7 days.
D. Begin after 7 days.
A & B refer to the roles of the nurse as a clinician while C
pertains to a patient advocate role.
199. The objectives and activities that the nurse plans depend
on the various stages of a therapeutic relationship. Which
is the following is the most appropriate during the
orientation phase?
A. patients perception on the reason of her
hospitalization
B. identification of more effective ways of coping
C. exploration of inadequate coping skills
D. establishment of regular meeting of schedules

Withdrawal symptoms form alcohol may continue to be ABC are activities during the working phase of a therapeutic
observed up to 3 days or 72 hours after the last alcohol intake. relationship.

195. The nurse is caring for an adolescent female who reports 200. Freud stresses out that the EGO
amenorrhea, weight loss, and depression. Which A. Distinguishes between things in the mind and things
additional assessment finding would suggest that the in the reality.
woman has an eating disorder? B. Moral arm of the personality that strives for perfection
A. Wearing tight-fitting clothing than pleasure.
B. Increased blood pressure C. Reservoir of instincts and drives
C. Oily skin D. Control the physical needs instincts.
D. Excessive and ritualized exercise
TIP: Components of personality according to Freud
These are signs of anorexia nervosa. Patients with this  Id – pleasure principle; seeks satisfaction
condition tend to do excessive ritualistic exercises to promote  Ego – reality principle; concerned with here and now;
weight loss. balances the demands of the id and superego
 Superego – moral principle; censoring portion of the
196. In teaching a client about Alcoholics Anonymous, the mind; seeks to delay gratification
nurse states that Alcoholics Anonymous has helped in the
rehabilitation of many alcoholics, probably because many
people find it easier to change their behavior when they:
A. Have the support of rehabilitated alcoholics.
B. Know that rehabilitated alcoholics will sympathize with
them.
C. Can depend on rehabilitated alcoholics to help them
identify personal problems related to alcoholism.
D. Realize that rehabilitated alcoholics will help them
develop defense mechanisms to cope with their
alcoholism.

Alcoholics Anonymous is a self-help group. Members of the

group have similar problems on alcoholism and they serve to
be the support system for each other.

197. A client walks into the mental health clinic and states to
the nurse, “I guess I can’t make it without my wife. I can’t
even sleep without her.” Which of the following responses
by the nurse would be most therapeutic?
A. “Things always look worse before they get better.”
B. “I’d say that you’re not giving yourself a fair chance.”
C. “I’ll ask the doctor for some sleeping pills for you.”
D. “Tell me more about what you mean when you say
you can’t make it without your wife.”

Encouraging verbalization of feelings provide a therapeutic

way to assess the patient’s underlying emotional concern.

198. The psychiatric nurse has a variety or roles in dealing

with patients with maladaptive disorders. As a manager,
the nurse should:
A. Initiates nursing action with co-workers.
B. Plans nursing care with the patient.
C. Speaks in behalf of the patient.
D. Works together with the team.