NURSING PRACTICE III – SET A

NURSING PRACTICE III – Care of the Clients with Physiologic and

Psychologic Alterations (Part A)

GENERAL INSTRUCTIONS:
1. This test booklet contains 100 test questions
2. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheets
3. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded
will invalidate your answer.
4. AVOID ERASURES

NUTRITION

SITUATION - Muslims eat as a matter of faith and for good health. Overindulgence is discouraged.
Islamic dietary laws are called halal, which is also the term used to describe all permitted foods.
Haram are prohibited foods.
1. Which of the following is not allowed to be served for a patient observing Islamic practices?
1 - Pork sinigang
2 - Tuna sisig
3 - Milk products
4 - Beer
5 - Fruit cake
A. 2, 4 and 5
B. 1, 2 and 5
C. 1, 4 and 5
D. 1, 3 and 4

2. Meldy tells you that she has been on a high protein / high fat / low carbohydrate diet order to lose
weight and that she has successfully lost 8 lbs during the past two weeks. In planning a healthy
balanced diet for her, you will:
A. Encourage her to eat well-balanced diet with a variety of food from the major food groups and take
plenty of fluids.
B. Ask her to shift to a macrobiotic diet rich in complex carbohydrates.
C. Encourage her to cleanse her body toxins by changing a vegetarian diet with regular exercise.
D. Encourage her to eat a high carbohydrate, low protein diet and low fat diet.

3. You learn that Meldy drinks 5-8 cups o coffee a day plus cola drinks. Because she is in her pre-
menopausal years, the nurse instructs her to decrease consumption of coffee and cola preparation
because:
A. These products increase calcium loss from the bones
B. These products have stimulant effect n the body
C. These products encourage increase in sugar consumption
D. These products are addicting

4. Eating habits of the family has changed due to the existing fast food establishment in the area.
What health risk should you warn the family?
A. Food-borne infection
B. Increase weight
C. Indigestion
D. Hand washing
 NURSING PRACTICE III – SET A
5. Bonnie, 3 months pregnant, has reported for her first prenatal visit. The nurse should instruct her to
do which of the following?
A. eat more dairy products and green leafy vegetables to provide an additional 300 calories each day
B. increase her intake of carbohydrates-breads and sweets to prevent protein metabolism
C. eat whenever she feels hungry because her body will let her know when she needs nutrients and
extra calories
D. limit intake of amino acids to prevent development of diabetic ketoacidosis

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

7. Mr. Bruno asks what the “normal” allowable salt intake is. Your best response to Mr. Bruno is:
A. 1 tsp of salt/day with iodine and sprinkle of MSG
B. 5 gms per day or 1 tsp of table salt/day
C. 1 tbsp of salt/day with some patis and toyo
D. 1 tsp of salt/day but no patis and toyo

8. Your instructions to reduce or limit salt intake include all the following EXCEPT:
A. eat natural food with little or no salt added
B. limit use of table salt and use condiments instead
C. use herbs and spices
D. limit intake of preserved or processed food

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

10. Sheila eats a lot of ice chips and asks the nurse about going vegetarian. The nurse gives correct
nutritional information when she says:
1. Ice chips are considered non-nutritive substances and cannot be substitute for food
2. Strict vegetarian diets provide fiber but do not have enough calories to meet the needs of a
pregnant woman
3. Absence of animal products may lead to inadequate intake of calcium zinc vitamins and proteins
4. Raw vegetables are ideal sources of phytochemicals, boosts the immune system and provides
sufficient nutrients necessary for fetal growth and development
1, 3 and 4
2, 3 and 4
1, 2 and 4
1, 2 and 3

11. Which of the following are considered clear liquids?

A. Tea, milk and fruit juice
 NURSING PRACTICE III – SET A
B. ice cream, tea and pudding
C. cola, tea and gelatin
D. milk, tea and gelatin

12. The BEST strategies to address the nutrition problem of Filipinos related to non communicable
diseases are the following EXCEPT?
A. Consider food preferences of family
B. Choose food wisely
C. Build healthy nutrition related practices
D. Aim for ideal body weight

13. The Filipino Food Guide Pyramid strongly emphasizes the need for:
1.Ensuring variety of foods everyday.
2.Eating diet low in fats and sugar.
3.Maintaining specific daily serving of food groups.
4.Ensuring that bulk of our diets consists of water, grains, vegetables and fruits.
5.Avoiding poor eating habits.
A. 1 and 2 only.
B. 1,2,3,4, and 5.
C. 1,2,3,and 4.
D. 1,2 and 3.

14. Lorelei was put on low calcium diet to decrease the total intake of calcium and prevent renal
calculi. You will instruct the client to avoid which foods?
A. Oats, potatoes, soybean.
B. Oranges, yogurt, spinach.
C. Rice, malunggay leaves, carrots.
D. Whole grain, leafy vegetables, milk.

15. The nurse is teaching a family to take food with high protein content. She discovers that the
family’s consideration is the high cost. Which of the following affordable high protein food should the
nurse recommended?
A. Peas and beans
B. Fried rice and dried fish
C. Beef steak and vegetables
D. Spaghetti and bread

PERI-OPERATIVE NURSING CARE

Situation 3 – Mariane, 42 years old was brought to the OR Suite for vaginal hysterectomy under spinal
anesthesia.
16. The circulating nurse welcomes the clients to the OR Suite. Which of the following is the
PRIORITY nursing intervention at this point?
A. Validates if the clients observed NPO appropriately.
B. Validates the OR schedule.
C. Checks the client for presence of denture, ring and nail polish.
D. Checks the ID bracelet and call the client by name.

17. Because of the complexity of the surgical environment each member of the surgical team has a
vital role to play. Who is the guardian of asepsis while Mariane is undergoing the procedure?
A. The scrub nurse.
B. The anaesthesiologist.
C. The circulating nurse.
 NURSING PRACTICE III – SET A
D. The surgeon.

18. Mariane will be assisted to assume the lithotomy position for the operation. This position can
damage the peripheral blood vessels, nerves and joints if not done properly. Which of the following
precautionary measures should be observed by the circulating nurse?
A. Both legs are placed simultaneously and adjusted to the stirrups.
B. Legs are raised one at a time slowly and simultaneously placed on padded stirrups.
C. Legs are placed slowly on well padded stirrups one at a time.
D. Both legs are raised slowly and placed simultaneously on well padded stirrups.

19. While the surgery is on-going, the circulating nurse has to monitor the needs of the scrub nurse
and the rest of the team. What is the safe distance from the sterile area for her to avoid contaminating
the sterile field?
A. Anywhere behind the scrub nurse.
B. Arm-length from the sterile area.
C. As long as you can see the operative field.
D. Within hearing distance from the surgical team.

20. Research studies have shown that client’s awareness during intraoperative period maybe greater
than once believed. For this reason the circulating nurse should consistently remind the surgical team
to keep the conversation during surgical procedure:
A. Tolerated.
B. Modulated.
C. Professional.
D. Limited.

Situation 4 – The operating room is one area where the team members can communicate their
therapeutic presence.
21. A client in the holding area communicates that she has not received instructions not to take her
usual anti-hypertensive drug. She states “I am so nervous about my surgery.” Which response of the
nurse is MOST appropriate?
A. “You need not worry, your surgeon has done a lot of this kind of surgery before.”
B. “You seem nervous about your impending surgery?”
C. “Stop worrying. It will do you no good but make you nervous all the more.”
D. “Relax, the whole surgical team is here to attend to your needs.”

22. Among the other interventions, the OR nurse called the ward nurse to verify if the preanesthetic
drug have been administered as prescribed. The nurse anticipates the following effects of the
preanesthetic drugs to be as follows EXCEPT:
A. Reduction of preoperative pain.
B. Potentiation of anesthetic effects.
C. Reduction of anxiety.
D. Facilitation of the induction of anesthesia.

23. The nurse welcomes a preoperative client as she enters the operating room suite. The nurse shall
interpret that the client appreciated her presence if the client:
A. Clasped the nurse’s hands.
B. Closed her eyes as though asleep.
C. Turned to the opposite direction from the nurse.
D. Put her blanket all the way to cover her face.

24. What positive indicator would the nurse look for in a client who is aware about his/her impending
surgery?
A. Asks if he/she will be awake during the surgery.
B. Expresses concern about postoperative pain.
C. Verbalizes his or her fears to the family and significant other.
D. Participates willingly in the preoperative preparation.
 NURSING PRACTICE III – SET A
25. Because clients who undergo anesthesia or moderate sedation experience temporary
sensory/perceptual alteration or loss, the nurse MOST critical role at this time is as:
A. Consultant.
B. Guardian.
C. Advocate.
D. Arbiter.

Situation 5 – Charice, a 50 year old mother of three school aged children was diagnosed with
cholelithiasis and admitted for possible surgical removal of the gall bladder.
26. When performing initial history and physical examination, the admitting nurse would expect the
client to describe pain as:
A. Sudden onset, intense, boring in the mid-epigastrium, radiates to left upper quadrant.
B. Gnawing, burning in the epigastric region, sometimes radiating to the back.
C. Severe, episodic in the right upper quadrant , radiates to the right shoulder or scapula.
D. Cramping on the periumbilical area, increasing in intensify and shifts to the right lower quadrant.

27. To be able to determine associated symptoms with pain, which of the following is LEAST relevant
question, the nurse may ask the client?
A. “Do you have allergies to food? What are they? How do you react?”
B. “Do you have indigestion, fratulence? What causes this?”
C. “Are there foods you cannot tolerate?”
D. “What are your food likes and dislikes?”

28. The physician ordered the following diagnostic tests. Which of the following will the nurse consider
as the TEST intended to identify obstructed bile flow?
A. Serum amylase and lipase.
B. Lactate dehydrogenase (LDH)
C. Complete blood count.
D. Serum Bilirubin.

29. During the teaching session preoperatively, the client asked the nurse why she experiences pain
whenever she takes food rich in fat. Which of the following is the CORRECT response of the nurse?
A. “When digested, fats cause the gallbladder to contract to excrete bile; if obstructed with gall stones,
tissue spasm occur.”
B. “Gallbladder contracts when fats are absorbed; pain results from muscle contractions attempting to
move gallstones.”
C. “When gallstones obstruct bile flow in the gallbladder duct, pain is felt due to tissue spasms.”
D. “When fats get to the duodenum, gallbladder contracts, if bile duct is obstructed with gallstone, pain
is experienced.”

30. The patient was discharged the day after the surgery. Which of the following behaviors of the
client indicates that the nurse needs to RE-INSTRUCT?
A. Talks about reducing fat intake while keeping her weight stable.
B. Anxiously look forward to resuming daily work activities.
C. Appropriately care for her incisions.
D. Verbalized understanding of initial activity restrictions.

31. A nurse is reviewing a physician’s prescription sheet for a preoperative client that states that the
client must be NPO after midnight. The nurse would telephone the physician to clarify that which of the
following medications should be given to the client and not withheld?
A. Prednisone
B. Ferrous sulfate
C. Cycloberizaprine (Flexeril)
D. Conjugated estrogen (Premarin)

32. A client arrives at the surgical unit after nasal surgery. The client has nasal packing in place. The
nurse reviews the physicians prescriptions and anticipates that which of the following client positions
would be prescribed to reduce swelling?
 NURSING PRACTICE III – SET A
A. Sims
B. Prone
C. Supine
D. Semi-Fowler’s position

33. A nurse prepares to assist a postoperative client to progress from a lying position to a sitting
position to prepare for ambulation. Which nursing action is appropriate to maintain the safety of the
client?
A. Assist the client to move quickly from the lying position to the sitting position.
B. Assess the client for signs of dizziness and hypotension.
C. Elevate the head of the bed quickly to assist the client to a sitting position.
D. Allow the client to rise from the bed to a standing position unassisted.

34. The nurse is assessing a client who had abdominal surgery earlier in the day. Which of the
following preexisting medical conditions would place the client at most risk for postoperative
complications?
A. Pacemaker
B. Osteoporosis
C. Alcohol abuse
D. Peptic ulcer disease

35. A nurse is providing instructions to a client and the family regarding home care after right eye
cataract removal. Which statement by the client would indicate an understanding of the instructions?
A. “I should not sleep on my left side.”
B. “I should not sleep on my right side.”
C. “I should not sleep with my head elevated.’
D “I should not wear my glasses at any time.’

CARING FOR CLIENTS WITH HEMATOLOGIC DISORDERS

36. A nurse teaches a 55-year-old strict vegetarian that, to decrease the risk of developing
megaloblastic anemia, the client should:
A. undergo a Schilling test.
B. increase intake of foods high in iron.
C. supplement the diet with vitamin B12.
D. have a monthly hemoglobin level drawn.

37. A nurse should assess a client with hemolytic anemia for weakness, fatigue, malaise, skin and
mucous membrane pallor, and:
A. jaundice.
B. a smooth red tongue.
C. a craving for ice.
D. a poor intake of fresh vegetables.

38. A nurse obtains the following assessment data for a client diagnosed with acute myeloid
leukemia. For which finding should a nurse plan interventions first?
A. Pain from mucositis
B. Weakness and fatigue
C. T 99°, P100, R 20, and BP 132/64 mm Hg
D. Ecchymosis and petechiae noted on arms

39. Which nursing diagnosis should be the priority for a child hospitalized in sickle cell crisis?
A. Risk for deficient fluid volume related to inadequate fluid intake
B. Chronic pain related to chronic physical disability and clustering of sickled cells
C. Risk for infection related to ineffectively functioning spleen
 NURSING PRACTICE III – SET A
D. Ineffective tissue perfusion related to pulmonary infiltrates of abnormal blood cells

40. The parents of an 8-year-old African American child diagnosed with sickle cell anemia are being
taught pain control measures for their child. Which measure is most important to teach the parents to
prevent the onset of vaso-occlusive pain?
A. Apply ice packs to all joints as soon as the child awakens.
B. Encourage drinking large amounts of fluids daily.
C. Administer acetaminophen (Tylenol®) 650 mg orally daily.
D. Increase outdoor exercise and exposure to the fresh air and sunshine.

41. After 7 days of iron therapy, a child diagnosed with iron-deficiency anemia has serum laboratory
tests completed. Which finding indicates that the medication is beginning to correct the anemia?
A. Increased reticulocyte count
B. Increased granulocytes
C. Increased indirect bilirubin
D. Increased erythropoietin levels

CARING FOR CLIENTS WITH PERIPHERAL ARTERIAL DISEASE

42. A client is discovered to have a popliteal aneurysm. Because of the aneurysm, a nurse should
closely monitor the client for:
A. thoracic outlet syndrome.
B. ischemia in the lower limb.
C. pulmonary embolism.
D. Raynaud’s phenomenon.

43. A client with Raynaud’s disease is seen in a vascular clinic 6 weeks after nifedipine (Procardia®)
has been prescribed. A nurse evaluates that the medication has been effective when which findings
are noted?
A. The client’s blood pressure is 110/68 mm Hg.
B. The client states experiencing less pain and numbness.
C. The client states that tolerance to heat is improved.
D. The client walks without claudication.

44. A 31-year-old male client seeks care at a vascular clinic because of painful fingers and toes. He is
diagnose with Buerger’s disease (thromboangiitis obliterans). A nurse is teaching the client ways to
prevent progression of the disease. Which prevention measure should be the nurse’s initial focus
when teaching the client?
A. Avoiding exposure to cold
B. Maintaining meticulous hygiene practices
C. Abstaining from all tobacco products in all forms
D. Following a low-fat diet

45. An experienced nurse tells a new nurse that lymphedema is a complication that commonly occurs
after women have received surgery for breast cancer. Which statement to the new nurse regarding
lymphedema is correct?
A. Lymphedema is characterized by severe swelling in the arm and hand on the affected side.
B. Lymphedema usually resolves after the cancer treatment is completed when collateral lymph
circulation develops.
C. Lymphedema is mainly controlled by encouraging women to keep their arm elevated.
D. Lymphedema frequently signifies that there is a recurrence of the malignancy.

46. A nurse is assessing a client who is taking atorvastatin (Lipitor). For which manifestations should
the nurse specifically assess?
A. Constipation and hemorrhoids
B. Muscle pain and weakness
 NURSING PRACTICE III – SET A
C. Fatigue and dysrhythmias
D. Flushing and postural hypotension

CARING FOR CLIENTS WITH CARDIOVASCULAR DISORDERS

47. After an inferior-septal wall myocardial infarction, which complication should a nurse suspect when
noting jugular venous distention (JVD) and ascites?
A. Left-sided heart failure
B. Pulmonic valve malfunction
C. Right-sided heart failure
D. Ruptured septum

48. A client with heart failure is scheduled to be discharged to home with digoxin (Lanoxin) and
furosemide (Lasix) as daily prescribed medications. The nurse tells the client to report which of the
following as an indication that the medications are not having the intended effect?
A. Cough accompanied by other signs of respiratory infection
B. Sudden increase in appetite
C. Weight gain of 2 to 3 lb in a few days
D. Increased urine output during the day

49. During assessment of a client newly diagnosed with hypertension, the nurse recognizes that it is
common for the client to do which of the following?
A. Have frequent nosebleeds
B. Be asymptomatic
C. Have visual disturbances
D. Be short of breath

50. A female client who has had a myocardial infarction asks the nurse why she should not bear down
or strain to ensure having a bowel movement. The nurse’s response incorporates the information that
bearing down or straining would trigger:
A. Vagus nerve stimulation, causing a decrease in heart rate and cardiac contractility
B. Vagus nerve stimulation, causing an increase in heart rate and cardiac contractility
C. Sympathetic nerve stimulation, causing an increase in heart rate and cardiac contractility
D. Sympathetic nerve stimulation, causing a decrease in heart rate and cardiac contractility

51. A nurse is caring for a client who has been hospitalized with a diagnosis of angina pectoris. The
client is receiving oxygen via nasal cannula at 2 L/min. The client asks why the oxygen is necessary.
The nurse accurately explains that:
A. Oxygen has a calming effect.
B. Oxygen will prevent the development of any thrombus.
C. Oxygen dilates the blood vessels so they can supply more nutrients to the heart muscle.
D. The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells.

52. A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to
the nursing unit after the procedure, and the nurse provides instructions to the client regarding home
care measures. Which of the following statements, if made by the client, indicates an understanding of
the instructions?
A. “I am so relieved that I can eat anything that I want to now.”
B. “I need to cut down on cigarette smoking.”
C. “I am so relieved that my heart is repaired.”
D. “I need to adhere to my dietary restrictions.’
 NURSING PRACTICE III – SET A
53. A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going
up two flights of stairs or after walking four blocks. The nurse determines that the client is
experiencing which of the following types of angina?
A. Stable
B. Unstable
C. Variant
D. Intractable

54. A client is admitted to the hospital for an acute episode of angina pectoris. Which of the following
parameters is the priority for the nurse to monitor?
A. Temperature and chest pain
B. Right upper quadrant pain and fatigue
C. Food tolerance and urinary output
D. Pulse and blood pressure

CARING FOR CLIENTS WITH RESPIRATORY TRACT DISORDERS

55. 12. When performing suctioning of a tracheostomy, the nurse would know
that the suction pressure should not exceed:
A. 120mmHg
B. 145mmHg
C. 160mmHg
D. 185mmHg

56. A client with a laryngectomy returns from surgery with a nasogastric tube
in place. The primary reason for placement of the nasogastric tube is to:
A. Prevent swelling and dysphagia
B. Decompress the stomach
C. Prevent contamination of the suture line
D. Promote healing of the oral mucosa

57. A client with a right lobectomy is being transported from the intensive care unit to a medical unit.
The nurse understands that the client’s chest drainage system:
A. Can be disconnected from suction if the chest tube is clamped
B. Can be disconnected from suction, but the chest tube should remain unclamped
C. Must remain connected by means of a portable suction
D. Must be kept even with the client’s shoulders during the transport

58. An adolescent with cystic fibrosis has an order for pancreatic enzyme replacement. The nurse
knows that the medication should be given:
A. At bedtime
B. With meals and snacks
C. Twice daily
D. Daily in the morning

59. The nurse is caring for clients on a respiratory unit. Upon receiving the
following client reports, which client should be seen first?
A. Client with emphysema expecting discharge
B. Bronchitis client receiving IV antibiotics
C. Bronchitis client with edema and neck vein distention
D. COPD client with PO2 of 85

60. The nurse has given instructions on pursed-lip breathing to a client with COPD. Which statement
by the client would indicate effective teaching?
A. “I should inhale through my mouth.”
B. “I should tighten my abdominal muscles with inhalation.”
C. “I should contract my abdominal muscles with exhalation.”
 NURSING PRACTICE III – SET A
D. “I should make inhalation twice as long as exhalation.”

61. The nurse is assessing the arterial blood gases (ABG) of a chest trauma client with the results of
pH 7.35, PO2 85, PCO2 55, and HCO3 27. These
ABG values indicate that the client is in:
A. Uncompensated respiratory acidosis
B. Uncompensated metabolic acidosis
C. Compensated respiratory acidosis
D. Compensated metabolic acidosis

62. A pneumonectomy is performed on a client with lung cancer. Which of the following would
probably be omitted from the client’s plan of care?
A. Closed chest drainage
B. Pain-control measures
C. Supplemental oxygen
D. Coughing and deep-breathing exercises

63. The nurse is discussing cigarette smoking with an emphysema client. The client states, “I don’t
know why I should worry about cancer.” The nurse’s response is based on the fact that the most
important reason for a client with emphysema to avoid smoking is that it:
A. Affects peripheral blood vessels
B. Causes vasoconstriction
C. Destroys the lung parenchyma
D. Paralyzes ciliary activity

64. The nurse is caring for a COPD client who is discharged on p.o. Theophylline.Which of the
following statements by the client would indicate a correct understanding of discharge instructions?
A. “A slow, regular pulse could be a side effect.”
B. “Take the pill with antacid or milk and crackers.”
C. “The doctor might order it intravenously if symptoms worsen.”
D. “Hold the drug if symptoms decrease.”

65. The RN is planning client assignments. Which is the least appropriate task for the nursing
assistant?
A. Assisting a COPD client admitted 2 days ago to get up in the chair
B. Feeding a client with bronchitis who is paralyzed on the right side
C. Accompanying a discharged emphysema client to the transportation area
D. Assessing an emphysema client complaining of difficulty Breathing

PERIOPERATIVE NURSING CARE

66. During a surgical procedure in a specific OR, which member of the surgical team primarily employs
the use of the nursing process?
A. Scrub Nurse
B. Circulating Nurse
C. Surgical Technologist
D. Operating Room Supervisor

67. Which of the following is not a circulating nurse’s task?

A. position kick buckets
B. pass additional sterile supplies to scrub nurse as needed
C. prepare specimen for laboratory
D. pass instruments to the surgeon

68. Which of the following is not considered a PPE?

A. gloves
B. eye mask
C. cover gown
 NURSING PRACTICE III – SET A
D. lead apron

69. The following are ideal characteristics of surgical attire except:

A. does not hinder mobility
B. allows air circulation
C. bright-colored to prevent glare and eye strain
D. easy to wear

70. You are to assist in orthopedic surgeries involving radiation. Ideally, which of the following PPE are
used?
A. double gloving and lead apron
B. double mask and lead apron
C. double gloving and fluid proof apron
D. double mask and laser eyewear

71. What occurs when moisture soaks through drapes, whether sterile or unsterile?
A. capillary reaction
B. strike-through
C. vacuum effect
D. cross contamination

72. Which of the following is not a sterile instrument/device?

A. Metzenbaum scissors
B. Mayo curved scissors
C. speculum
D. IV catheter

73. Which of the following materials are indicated for wound closure?
1. staples
2. tapes
3. nylon
4. extractor
5. adhesive
6. hemostat
A. 1, 2, 5, and 6
B. 1, 2, 3, and 4
C. 2, 4, and 5
D. 1, 2, 3, and 5

74. Wound dehiscence usually occurs 5 to 8 days after surgery. As a nurse, you are aware that this
timely occurrence is attributed to the fact that:
A. the suture begins to weaken at this time.
B. the patient becomes vigorously active at this time.
C. the patient experiences the peak stress of the surgical experience at this time.
D. the suture begins to be exposed to infectious agent at this time.

75. Ms. Tan, a post-abdominal surgery patient, reports to the nurse that he felt something “popped” in
his surgical wound while coughing. The nurse’s initial action would be to:
A. Place the patient in a low fowler’s position with knees slightly bent.
B. Instruct the patient to splint the incision with a throw pillow.
C. Provide comfort measures since this is an expected minor discomfort associated with abdominal
surgery.
D. Ask what he meant by “pop”.

76. One of the major goals for the postoperative patient includes optimal respiratory function. The
nurse institutes postoperative pulmonary toilet. Which of the following is true regarding the plan of the
nurse?
A. It should begin as soon as the patient arrives on the clinical unit.
 NURSING PRACTICE III – SET A
B. The patient must be fully awake from anesthesia, to allow them to take several deep breaths.
C. Teach the patient to cough who have undergone intracranial surgery.
D. Use incentive spirometer every shift and encourage frequent turnings.

CARING FOR CLIENTS WITH GASTRO-INTESTINAL TRACT DISORDERS

SITUATION: Mrs. Lee, 54 years old was diagnosed with acute hemorrhagic pancreatitis.

77. Mrs. Lee described the pain she is feeling because of her condition. Which of the following
assessment questions would most specifically elicit information regarding the pain that is associated
with acute pancreatitis?
1. “Does the pain in your lower abdomen radiate to your groin?”
2. “Does the pain in your stomach radiate to the back?”
3. “Does the pain in your stomach radiate to your lower middle abdomen?”
4. “Does the pain in your lower abdomen radiate to the hip?”

78. The nurse will direct the assessment to look for which of the following as a hallmark sign of acute
pancreatitis?
1. Severe abdominal pain relieved by vomiting
2. Severe abdominal pain that is unrelieved by vomiting
3. Hypothermia
4. Epigastric pain radiating to the neck area

79. The client with acute pancreatitis is experiencing severe pain from the disorder. The nurse would
teach the client to
avoid which of the following positions that could aggravate the pain?
1. Sitting up
2. Lying flat
3. Leaning forward
4. Flexing the left leg

80. The nurse plans care knowing that production of which of the following substances will be elevated
in the blood studies of Mrs. Lee?
1. Amylase
2. Pepsin
3. Enterokiriase
4. Lactase

81. Mrs. Lee and her relatives need information on dietary modification to manage her health problem.
The nurse teaches them to limit which item in the diet?
1. Lentil soup
2. Bagel
3. Chili
4. Watermelon

SITUATION: Mang Inggo, age 21, has a history of ulcerative colitis. Although his condition had been
stable for the past year, he now presents to the hospital with an acute exacerbation of the disease.

82. There are many differences between ulcerative colitis and crohn’s disease. Which of the following
statements is true?
a. Crohn’s disease involves the mucosal area only
b. Crohn’s disease commonly occurs in the proctosigmoid area
c. Ulcerative colitis affects the right ileum
d. Ulcerative colitis can cause rectal bleeding

83. Which of these nursing diagnoses should be given priority when caring for Mang Inggo?
a. Fluid volume deficit
b. Activity intolerance
 NURSING PRACTICE III – SET A
c. Risk for impaired skin integrity
d. Knowledge deficit

84. Because conservative treatment is no longer effective, Mang Inggo is scheduled for a total
colectomy with ileostomy. Which information is important for the nurse to include in her teaching plan?
a. The nurse should explain that the procedure isn’t permanent
b. The nurse should tell the patient that continence can be controlled
c. The nurse should instruct the patient that he’ll need to wear an appliance at all times
d. The nurse should tell the patient that’s he’ll have normal bowel movements

85. Before the surgery, enema must be administered until the return is clear. Mang Inggo complains of
abdominal cramping during enema administration. The nurse should respond by:
a. Giving the enema at fast rate
b. Continuing to administer the enema telling him the cramps will cease
c. Stopping the enema for 30 seconds, then restart the flow at a slower rate
d. Hang the solution container 36cm above the rectum.

86. The nurse is assessing the stoma of Mang Inggo’s ileostomy. What should the nurse observe if
stoma prolapse occurs?
1. Protruding stoma
2. Sunken and hidden stoma
3. Narrowed and flattened stoma
4. Dark- and bluish-colored stoma

CARING FOR CLIENTS WITH ENDOCRINE DISORDERS

Situation: Diabetes Mellitus ranks 3th as a national killer among the non-communicable diseases
prevalent in the Philippines affecting more than 5 million Filipinos. You are caring for Carlito, an 8 year
old child diagnosed with DM type 1

86. Carlito with his mother comes to the health care clinic for a routine examination. The nurse
evaluates the data collected during this visit to determine if the child has been euglycemic since the
last visit. Which information is the most significant indicator of euglycemia?
A. Daily glucose monitor log
B. Fasting blood glucose performed on the day of the clinic visit
C. Glycosylated hemoglobin
D. Dietary history for the previous week

87. The nurse is teaching Carlito’s mother on how to administer the child’s insulin injection. The child
will be receiving 2 units of regular insulin and 12 units of normal protamine Hagedorn (NPH) insulin
every morning. The nurse teaches his mother to:
A. Draw the insulin into separate syringes.
B. Draw the regular insulin first and then the NPH insulin into the same syringe.
C. Draw the NPH insulin first and then the regular insulin into the same syringe.
D. Check a blood glucose first, and if the result is between 80 and 120 mg/dL, withhold the insulin
injection.

88. Carlito was suddenly admitted to the emergency department for treatment of diabetic ketoacidosis
after missing his dose of insulin. Which assessment findings should the nurse expect to note?
A. Sweating and tremors
B. Hunger and hypertension
C. Cold, clammy skin and irritability
D. Fruity breath odor and decreasing level of consciousness

89. Carlito’s mother states that the child has been complaining of abdominal pain. Diabetic
ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer:
A. Potassium IV infusion
 NURSING PRACTICE III – SET A
B. NPH insulin IV infusion
C. 5% dextrose IV infusion
D. Normal saline IV infusion

90. In the emergent phase of burn, Insulin is given because it facilitates

A. Potassium reuptake by the cells to prevent hypokalemia
B. Potassium reuptake by the cells to prevent hyperkalemia
C. Potassium excretion by the kidneys to prevent hypokalemia
D. Potassium excretion by the kidneys to prevent hyperkalemia

91. A nurse in the health care clinic is reviewing the record of a client with diabetes mellitus who was
just seen by the physician. The nurse notes that the physician has prescribed metformin
(Glucophage). Which of the following preexisting disorders, if noted in the client’s record, would
indicate a need to collaborate with the physician before instructing the client to take the medication?
A. Hypertension
B. Foot ulcers
C. Renal Insufficiency
D. Hypothyroidism

92. The client’s serum blood glucose level is 389 mg/dL. The nurse would expect to find which of the
following as an additional finding when assessing this client?
A. Unsteady gait
B. Slurred speech
C. Increased thirst
D. Cold, clammy skin

93. A nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The
priority nursing
diagnosis would be:
A. Deficient knowledge
B. Deficient fluid volume
C. Fluid Volume Excess
D. Imbalenced nutrition, less than body requirements

94. A client is brought to the emergency department in an unresponsive state, and a diagnosis of
hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to
initiate which of the following anticipated physician’s prescriptions?
A. Endotracheal intubation
B. 100 units of NPH insulin
C. Intravenous infusion of normal saline
D. Intravenous infusion of sodium bicarbonate

Situation: GMA, a prominent public figure was admitted at St. Luke’s medical center. She was
diagnosed with hypoparathyroidism.

95. The nurse reviews the laboratory results of blood tests for GMA and notes that the calcium level is
extremely low. The nurse would expect to note which of the following on assessment of the client?
A. Positive Trousseau’s sign
B. Negative Chvostek’s sign
C. Unresponsive pupils
D. Hyperactive bowel sounds

96. The nurse instructs GMA and her relatives to include which of the following items in her diet?
A. Vegetables
B. Meat and poultry
C. Fish
D. Cereals
 NURSING PRACTICE III – SET A
97. Following a post operative surgery of the parathyroid gland, GMA suddenly complains of tingling
sensation of lips. What should be the next action of the nurse?
A. Check the client’s serum calcium level
B. Check for episodes of dysphagia
C. Check for Trousseau and Chvostek's sign
D. Check for the presence of deep tendon reflexes

98. A nurse has developed a postoperative plan of care for a client who had a thyroidectomy and
formulates a nursing diagnosis of risk for Ineffective breathing pattern. Which of the following nursing
interventions will the nurse include in the plan of care?
A. Maintain a supine position.
B. Encourage deep breathing exercises and vigorous coughing exercises.
C. Monitor neck circumference every 4 hours.
D. Maintain a pressure dressing on the operative site.

99. A client with suspected primary hyperparathyroidism is undergoing diagnostic testing. The nurse
would assess for which of the following as a sign of this disorder?
A. Polyphagia
B. Weight gain
C. Diarrhea
D. Polyuria

100. Which of the following statements about the Pareto principle is true?
A. Effort is a priceless commodity
B. Unequal effort and outcome is consistent
C. Small efforts will lead to maximum results when done properly
D. Outcome and efforts are always equal

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