Fundamentals of Nursing Exam 13: NLE Pre-Boards

(100 Items)
Question 1
CORRECT
The indication for epinephrine injection for Mrs Simon is to:

A Reduce anaphylaxis

B Relieve hypersensitivity to allergen

Relieve respiratory distress due to bronchospasm

D Restore clients cardiac rhythm

Question 2
CORRECT
When preparing the epinephrine injection from an ampule, the nurse initially:

A Taps the ampule at the top to allow fluid to flow to the base of the ampule

Checks expiration date of the medication ampule

C Removes needle cap of syringe and pulls plunger to expel air

D Breaks the neck of the ampule with a gauze wrapped around it
Question 3
CORRECT
Mrs. Simon is obese. When administering a subcutaneous injection to an obese patient, it is best for the nurse
to:

Inject needle at a 15 degree angle over the stretched skin of the client
A
B Pinch skin at the Injection site and use airlock technique

C Pull skin of patient down to administer the drug in a Z track

Spread skin or pinch at the injection site and inject needle at a 45-90 degree angle
Question 4
WRONG
When preparing for a subcutaneous injection, the proper size of syringe and needle would be:

A Syringe 3-5ml and needle gauge 21 to 23

Tuberculin syringe 1 ml with needle gauge 26 or 27

C Syringe 2ml and needle gauge 22

Syringe 1-3 ml and needle gauge 25 to 27
Question 5
CORRECT
The rationale for giving medications through the subcutaneous route is:

A There are many alternative sites for subcutaneous injection

Absorption time of the medicine is slower

C There are less pain receptors in this area

D The medication can be injected while the client is in any position
Question 6
CORRECT
Martha wants to do a study on, this topic. Effects of massage and meditation on stress and pain. The type of
research that best suits this topic is:

A applied research
 qualitative research

C basic research
D quantitative research
Question 7
CORRECT
The type of research design that does not manipulate independent variable is:

A experimental design

B quasi-experimental design

non-experimental design

D quantitative design
Question 8
CORRECT
This research topic has the potential to contribute to nursing because it seeks to:

A include new modalities of care

B resolve a clinical problem

C clarify an ambiguous modality of care

enhance client care
Question 9
CORRECT
Martha does review of related literature for the purpose of:

A determine statistical treatment of data research

 gathering data about what is already known or unknown

C to identify if problem can be replicated

D answering the research question
Question 10
CORRECT
Clients rights should be protected when doing research using human subjects. Martha identifies these rights as
follows EXCEPT:

A right of self-determination

right to compensation

C right of privacy
D right not to be harmed
Question 11
WRONG
SITUATION: Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions
and is at risk for infection because of retained secretions. Part of Nurse Marios nursing care plan is to loosen
and remove excessive secretions in the airway,Mario listens to Richards bilateral sounds and finds that
congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical
segments of the lungs when Mario does percussion would be:

Client lying on his back then flat on his abdomen on Trendelenburg position

Client seated upright in bed or on a chair then leaning forward in sitting position
then flat on his back and on his abdomen

C Client lying flat on his back and then flat on his abdomen
D Client lying on his right then left side on Trendelenburg position
Question 12
 CORRECT
When documenting outcome of Richards treatment Mario should include the following in his recording
EXCEPT:

A Color, amount and consistent of sputum

B Character of breath sounds and respiratory/rate before and after procedure

Amount of fluid intake of client before and after the procedure

D Significant changes in vital signs

Question 13
CORRECT
When assessing Richard for chest percussion or chest vibration and postural drainage Mario would focus on
the following EXCEPT:

A Amount of food and fluid taken during the last meal before treatment

B Respiratory rate, breath sounds and location of congestion

Teaching the clients relatives to perform the procedure

D Doctors order regarding position restriction and clients tolerance for lying flat
Question 14
WRONG
Mario prepares Richard for postural drainage and percussion. Which of the following is a special consideration
when doing the procedure?

A Respiratory rate of 16 to 20 per minute

Client can tolerate sitting and lying position

C Client has no signs of infection

Time of fast food and fluid intake of the client
Question 15
WRONG
The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the
procedure is:

Percussion uses only one hand white vibration uses both hands

Percussion delivers cushioned blows to the chest with cupped palms while gently
shakes secretion loose on the exhalation cycle

In both percussion and vibration the hands are on top of each other and hand action
C is in tune with clients breath rhythm
Percussion slaps the chest to loosen secretions while vibration shakes the secretions
D along with the inhalation of air
Question 16
CORRECT
SITUATION: A 61 year old man, Mr. Regalado, is admitted to the private ward for observation after
complaints of severe chest pain. You are assigned to take care of the client.When doing an initial assessment,
the best way for you to identify the clients priority problem is to:

Interview the client for chief complaints and other symptoms

B Talk to the relatives to gather data about history of illness

C Do auscultation to check for chest congestion

D Do a physical examination white asking the client relevant questions
Question 17
CORRECT
Upon establishing Mr. Regalados nursing needs, the next nursing approach would be to:

A introduce the client to the ward staff to put the client and family at ease

B Give client and relatives a brief tour of the physical set up the unit

Take his vital signs for a baseline assessment

D Establish priority needs and implement appropriate interventions
Question 18
WRONG
Mr. Regalado says he has trouble going to sleep. In order to plan your nursing intervention you will.

Observe his sleeping patterns in the next few days

Ask him what he means by this statement

C Check his physical environment to decrease noise level

D Take his blood pressure before sleeping and upon waking up
Question 19
WRONG
Mr. Regalados lower extremities are swollen and shiny. He has pitting pedal edema. When taking care of Mr.
Regalado, which of the following intervention would be the most appropriate immediate nursing approach.

Moisturize lower extremities to prevent skin irritation

B Measure fluid intake and output to decrease edema

C Elevate lower extremities for postural drainage

Provide the client a list of food low in sodium
Question 20
WRONG
Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client for
discharge include all EXCEPT:

Making a final physical assessment before client leaves the hospital

B Giving instructions about his medication regimen

Walking the client to the hospital exit to ensure his safety

D Proper recording of pertinent data
Question 21
CORRECT
SITUATION: Nancy, mother of 2 young kids. 36 years old, had a mammogram and was told that she has
breast cysts and that she may need surgery. This causes her anxiety as shown by increase in her pulse and
respiratory rate, sweating and feelings of tension.Considering her level of anxiety, the nurse can best assist
Nancy by:

A Giving her activities to divert her attention

B Giving detailed explanations about the treatments she will undergo

C Preparing her and her family in case surgery is not successful

Giving her clear but brief information at the level of her understanding
Question 22
CORRECT
Nancy blames God for her situation. She is easily provoked to tears and wants to be left alone, refusing to eat
or talk to her family. A religious person before, she now refuses to pray or go to church stating that God has
abandoned her. The nurse understands that Nancy is grieving for her self and is in the stage of:

A bargaining

B denial

anger

D acceptance
Question 23
CORRECT
The nurse visits Nancy and prods her to eat her food. Nancy replies whats the use? My time is running out.
The nurses best response would be:
 The doctor ordered full diet for you so that you will be strong for surgery.
A
I understand how you fee! but you have 1o try for your childrens sake.
B
Have you told your, doctor how you feel? Are you changing your mind) about
C surgery?
You sound like you are giving up.
Question 24
CORRECT
The nurse feels sad about Nancys illness and tells her head nurse during the end of shift endorsement that its
unfair for Nancy to have cancer when she is still so young and with two kinds. The best response of the head
nurse would be:

Advise the nurse to be strong and learn to control her feelings

A
B Assign the nurse to another client to avoid sympathy for the client

Reassure the nurse that the client has hope if she goes through all statements
C prescribed for her
Ask the other nurses what they feel about the patient to find out if they share the
same feelings
Question 25
WRONG
Realizing that she feels angry about Nancys condition, the nurse sees that being self-aware is a conscious
process that she should do in any situation like this because:

A This is a necessary part of the nurse -client relationship process

B The nurse is a role model for the client and should be strong

How the nurse thinks and feels affect her actions towards her client and her work

The nurse has to be therapeutic at all times and should not be affected
Question 26
CORRECT
SITUATION: Mrs. Seva, 32 years old, asks you about possible problems regarding her elimination now that
she is in the menopausal stage.Instruction on health promotion regarding urinary elimination is important.
Which would you include?

Hold urine, as long as she can before emptying the bladder to strengthen her
A sphincters muscles

B If burning sensation is experienced while voiding, drink pineapple-juice

C After urination, wipe from anal area up towards the pubis

Tell client to empty the bladder at each voiding
Question 27
CORRECT
Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical changes
predispose her to constipation?

A inhibition of the parasympathetic reflex

B weakness of sphincter muscles of the anus

loss of tone of the smooth muscles of the color

D decreased ability to absorb fluids in the lower intestines

Question 28
CORRECT
The nurse understands that one of these factors contributes to constipation:

A excessive exercise

B high fiber diet

C no regular time for defecation daily
prolonged use of laxatives
Question 29
CORRECT
Mrs. Seva talks about rear of being incontinent due to a prior experience of dribbling urine when laughing or
sneezing and when she has a full bladder. Your most appropriate .instruction would be to:

A tell client to drink less fluids to avoid accidents

B instruct client to start wearing thin adult diapers

C ask the client to bring change of underwear just in case

teach client pelvic exercise to strengthen perineal muscles
Question 30
WRONG
Mrs. Seva asked for instructions for skin care for her mother who has urinary incontinence and is almost
always in bed. Your instruction would focus on prevention of skin irritation and breakdown by

A Using thick diapers to absorb urine well

B Drying the skin with baby powder to prevent or mask the smell of ammonia

Thorough washing, rising and during of skin area that get wet with urine

Making sure that linen are smooth and dry at all times
Question 31
CORRECT
SITUATION: Using Maslows need theory, Airway, Breathing and Circulation are the physiological needs
vital to life. The nurses knowledge and ability to identify and immediately intervene to meet these needs is
important to save lives. Which of these clients has a problem with the transport of oxygen from the lungs to the
tissues:
A Carol with a tumor in the brain

Theresa with anemia

C Sonny Boy with a fracture in the femur

D Brigette with diarrhea
Question 32
CORRECT
You noted from the lab exams in the chart of Mr. Santos that he has reduced oxygen in the blood. This
condition is called:

A Cyanosis

B Hypoxia

Hypoxemia

D Anemia
Question 33
CORRECT
You will nasopharyngeal suctioning Mr. Abad. Your guide for the length of insertion of the tubing for an adult
would be:

A tip of the nose to the base of the neck

B the distance from the tip of the nose to the middle of the cheek

the distance from the tip of the nose to the tip of the ear lobe

D eight to ten inches

Question 34
 WRONG
While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by:

Apply suction for at least 20-30 seconds each time to ensure that all secretions are
removed

B Using gloves to prevent introduction of pathogens to the respiratory system

Applying no suction while inserting the catheter

D Rotating catheter as it is inserted with gentle suction

Question 35
CORRECT
Myrna has difficulty breathing when on her back and must sit upright in bed to breath, effectively and
comfortably. The nurse documents this condition as:

A Apnea

Orthopnea

C Dyspnea
D Tachypnea
Question 36
CORRECT
SITUATION: You are assigned to screen for hypertension: Your task is to take blood pressure readings and
you are informed about avoiding the common mistakes in BP taking that lead to false or inaccurate blood
pressure readings.When taking blood pressure reading the cuff should be:

A deflated fully then immediately start second reading for same client

B deflated quickly after inflating up to 180 mmHg

large enough to wrap around upper arm of the adult client 1 cm above brachial
C artery
 inflated to 30 mmHg above the estimated systolic BP based on palpation of radial
or bronchial artery
Question 37
CORRECT
Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of death worldwide and is a
preventable disease. The primary cause of COPD is:

A tobacco hack

B bronchitis

C asthma
cigarette smoking
Question 38
WRONG
In your health education class for clients with diabetes you teach, them the areas, for control . Diabetes which
include all EXCEPT:

A regular physical activity

thorough knowledge of foot care

prevention nutrition

D proper nutrition
Question 39
CORRECT
You teach your clients the difference between, Type I (IDDM) and Type II (NDDM) Diabetes. Which of the
following is true?

A both types diabetes mellitus clients are all prone to developing ketosis

Type II (NIDDM) is more common and is also preventable compared to Type I

(IDDM) diabetes which is genetic in etiology
C Type I (IDDM) is characterized by fasting hyperglycemia
D Type II (NIDDM) is characterized by abnormal immune response
Question 40
CORRECT
Lifestyle-related diseases in general share areas common risk factors. These are the following except

A physical activity

B smoking

genetics

D nutrition
Question 41
CORRECT
SITUATION: Nurse Rivera witnesses a vehicular accident near the hospital where she works. She decides to
get involved and help the victims of the accident.Her priority nursing action would be to:

A Assess damage to property

B Assist in the police investigation since she is a witness

C Report the incident immediately to the local police authorities

Assess the extent of injuries incurred by the victims, of the accident
Question 42
CORRECT
Priority attention should be given to which of these clients?

A Linda who shows severe anxiety due to trauma of the accident

 Ryan who has chest injury, is pate and with difficulty of breathing

C Noel who has lacerations on the arms with mild-bleeding

D Andy whose left ankle swelled and has some abrasions
Question 43
CORRECT
In the emergency room, Nurse Rivera is assigned to attend to the client with .lacerations on the arms, while
assessing the extent of the wound the nurse observes that the wound is now starting to bleed profusely. The
most immediate nursing action would be to:

A Apply antiseptic to prevent infection

B Clean the wound vigorously of contaminants

C Control and. reduce bleeding of the wound

Bandage the wound and elevate the arm
Question 44
CORRECT
The nurse applies pressure dressing on the bleeding site. This intervention is done to:

A Reduce the need to change dressing frequently

B Allow the pus to surface faster

C Protect the wound from micro organisms in the air

Promote hemostasis
Question 45
CORRECT
After the treatment, the client is sent home and asked to come back for follow-up care. Your responsibilities
when the client is to be discharged include the following EXCEPT:
A Encouraging the client to go to the, outpatient clinic for follow up care

B Accurate recording, of treatment done and instructions given to client

Instructing the client to see you after discharge for further assistance

D Providing instructions regarding wound care

Question 46
CORRECT
SITUATION: While working in the clinic, a new client, Geline, 35 years old, arrives for her doctors
appointment. As the clinic nurse, you are to assist the client fill up forms, gather data and make an
assessment.The nurse purpose of your initial nursing interview is to:

A Record pertinent information in the client chart for health team to read

B Assist the client find solutions to her health concerns

Understand her lifestyle, health needs and possible problems to develop a plan of
care

D Make nursing diagnoses for identified health problems

Question 47
WRONG
While interviewing Geline, she starts to moan and doubles up in pain, She tells you that this pain occurs about
an hour after taking black coffee without breakfast for a few weeks now. You will record this as follows:

A Claims to have abdominal pains after intake of coffee unrelieved by analgesics

B After drinking coffee, the client experienced severe abdominal pain

Client complained of intermittent abdominal pain an hour after drinking coffee

Client reported abdominal pain an hour after drinking black coffee for three weeks
now
Question 48
CORRECT
Geline tells you that she drinks black coffee frequently within the day to have energy and be wide awake and
she eats nothing for breakfast and eats strictly vegetable salads for lunch and dinner to lose weight. She has
lost weight during the past two weeks, in planning a healthy balanced diet with Geline, you will:

Start her off with a cleansing diet to free her body of toxins then change to a
A vegetarian, diet and drink plenty of fluids

B Plan a high protein, diet, low carbohydrate diet for her considering her favorite food

Instruct her to attend classes in nutrition to find food rich in complex carbohydrates
C to maintain daily high energy level
Discuss with her the importance of eating a variety of food from the major food
groups with plenty of fluids
Question 49
CORRECT
Geline tells you that she drinks 4-5 cups of black coffee and diet cola drinks. She also smokes up to a pack of
cigarettes daily. She confesses that she is in her 2nd month of pregnancy but she does not want to become fat
that is why she limits her food intake. You warn or caution her about which of the following?

Caffeine products affect the central nervous system and may cause the mother to
A have a nervous breakdown

Malnutrition and its possible effects on growth and development problems in the
unborn fetus

C Caffeine causes a stimulant effect on both the mother and the baby
D Studies show conclusively that caffeine causes mental retardation
Question 50
CORRECT
Your health education plan for Geline stresses proper diet for a pregnant woman and the prevention of
noncommunicable diseases that are influenced by her lifestyle these include of the following EXCEPT:

A Cardiovascular diseases
B Cancer

C Diabetes Mellitus
Osteoporosis
Question 51
CORRECT
SITUATION: Management of nurse practitioners is done by qualified nursing leaders who have had clinical
experience and management experience.An example of a management function of a nurse is:

A Teaching patient do breathing and coughing exercises

B Preparing for a surprise party for a client

C Performing nursing procedures for clients

Directing and evaluating the staff nurses
Question 52
CORRECT
Your head nurse in the unit believes that the staff nurses are not capable of decision making so she makes the
decisions for everyone without consulting anybody. This type of leadership is:

A Laissez faire leadership

B Democratic leadership

Autocratic leadership

D Managerial leadership
Question 53
CORRECT
When the head nurse in your ward plots and approves your work schedules and directs your work, she is
demonstrating:
A Responsibility

B Delegation

C Accountability
Authority
Question 54
CORRECT
The following tasks can be safely delegated by a nurse to a non-nurse health worker EXCEPT:

A Transfer a client from bed to chair

Change IV infusions

C Irrigation of a nasogastric tube

D Take vital signs
Question 55
CORRECT
You made a mistake in giving the medicine to the wrong client You notify the clients doctor and write an
incident report. You are demonstrating:

A Responsibility

Accountability

C Authority
D Autocracy
Question 56
WRONG
SITUATION: Mr. Dizon, 84 years old, is brought to the Emergency Room for complaint of hypertension
flushed face, severe headache, and nausea. You are doing the initial assessment of vital signs.You are to
measure the clients initial blood pressure reading by doing all of the following EXCEPT:

Take the blood pressure reading on both arms for comparison

Listen to and identify the phases of Korotkoffs sounds

B
Pump the cuff up to around 50 mmHg above the point where the pulse is obliterated

D Observe procedures for infection control

Question 57
CORRECT
A pulse oximeter is attached to Mr. Dizons finger to:

Determine if the clients hemoglobin level is low and if he needs blood transfusion
A
Check level of clients tissue perfusion
B
C Measure the efficacy of the clients antihypertensive medications
Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops
Question 58
CORRECT
After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an order of hourly
monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure
reading to be:

A Inconsistent

B low systolic and high diastolic pressure

higher than what the reading should be

D lower than what the reading should be

Question 59
CORRECT
Through the clients health history, you gather that Mr. Dizon smokes and drinks coffee. When taking the
blood pressure of a client who recently smoked or drank coffee, how long should be the nurse wait before
taking the clients blood pressure for accurate reading?

A 15 minutes

30 minutes

C 1 hour
D 5 minutes
Question 60
CORRECT
While the client has the pulse oximeter on his fingertip, you notice that the sunlight is shining on the area
where the oximeter is. Your action will be to:

A Set and turn on the alarm of the oximeter

B Do nothing since there is no identified problem

Cover the fingertip sensor with a towel or bedsheet

D Change the location of the sensor every four hours

Question 61
CORRECT
SITUATION: The nurses understanding of ethico-legal responsibilities will guide his/her nursing practice.The
principles that .govern right and proper conducts of a person regarding life, biology and the health professions
is referred to as:

A Morality
B Religion

C Values
Bioethics
Question 62
WRONG
The purpose of having nurses code of ethics is:

Delineate the scope and areas of nursing practice

B Identify nursing action recommended for specific health care situations

To help the public understand professional conduct, expected of nurses

D To define the roles and functions of the health caregiver, nurses, clients
Question 63
CORRECT
The most important nursing responsibility where ethical situations emerge in patient care is to:

A Act only when advised that the action is ethically sound

B Not take sides remain neutral and fair

C Assume that ethical questions are the responsibility: of the health team
Be accountable for his or her own actions
Question 64
CORRECT
You inform the patient about his rights which include the following EXCEPT:

A Right to expect reasonable continuity of care

B Right to consent to or decline to participate in research studies or experiments

Right to obtain information about another patient

D Right to expect that the records about his care will be treated as confidential
Question 65
CORRECT
The principle states that a person has unconditional worth and has the capacity to determine his own destiny.

A Bioethics

B Justice

C Fidelity
Autonomy
Question 66
CORRECT
SITUATION: Your director of nursing wants to improve the quality of health care offered in the hospital. As a
staff nurse in that hospital you know that this entails quality assurance programs.The following mechanisms
can be utilized as part of the quality assessment program of your hospital EXCEPT:

A Patient satisfaction surveys provided

B Peer review clinical records of care of client

C Review of the Nursing Intervention Classification

Use of Nursing Interventions Classification
Question 67
WRONG
The nurse of the Standards of Nursing Practice is important in the hospital. Which of the following statements
best describes what it is?
 These are statements that describe the maximum or highest level of acceptable
performance in nursing practice.

B It refers to the scope of nursing as defined in Republic Act 9173

It is a license issued by the Professional Regulation Commission to protect the

C public from substandard nursing practice.
The Standards of care includes the various steps of the nursing process and the
standards of professional performance.
Question 68
WRONG
You are taking care of critically ill client and the doctor in charge calls to order a DNR (do not resuscitate) for
the client. Which of the following is the appropriate action when getting DNR order over the phone?

A Have the registered nurse, family spokesperson, nurse supervisor and doctor sign

Have two nurses validate the phone order, both nurses sign the order and the doctor
should sign his order within 24 hours.

C Have the registered nurse, family and doctor sign the order
Have 1 nurse take the order and sign it and have the doctor sign it within 24 hours
Question 69
CORRECT
To ensure the client safety before starting blood transfusion the following are needed before the procedure can
be done EXCEPT:

A take baseline vital signs

blood should be warmed to room temperature for 30 minutes before blood

B transfusion is administered

have two nurses verify client identification, blood type, unit number and expiration
C date of blood
get a consent signed for blood transfusion
Question 70
 WRONG
Part of standards of care has to do with the use of restraints. Which of the following statements is NOT true?

Doctors order for restraints should be signed within 24 hours

A
B Remove and reapply restraints every two hours

Check clients pulse, blood pressure and circulation every four hours

Offer food and toileting every two hours

Question 71
CORRECT
SITUATION: During the NUTRITION EDUCATION class discussion a 58 year old man, Mr. Bruno shows
increased interest.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

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 not patis or toyo
Question 72
CORRECT
Your instructions to reduce or limit salt intake include all the following EXCEPT:

A eat natural food with little or no salt added

limit use of table salt and use condiments instead

C use herbs and spices

D limit intake of preserved or processed food
Question 73
WRONG
Teaching strategies and approaches when giving nutrition education is influenced by age, sex and immediate
concerns of the group. Your presentation for a group of young mothers would be best if you focus on:

A diets limited in salt and fat

harmful effect on drugs and alcohol intake

C commercial preparation of dishes

cooking demonstration and meal planning
Question 74
CORRECT
Cancer cure is dependent on

A use of alternative methods of healing

B watching out for warning signs of cancer

C proficiency in doing breast self-examination

early detection and prompt treatment
Question 75
CORRECT
The role of the health worker in health education is to:

A report incidence of non-communicable disease to community health center

educate as many people about warning signs of non-communicable diseases

C focus on smoking cessation projects

D monitor clients with hypertension
Question 76
CORRECT
SITUATION: You are assigned to take care of 10 patients during the morning shift. The endorsement includes
the IV infusion and medications for these clients. Mr. Felipe, 36 years old is to be given 2700 ml of D5RL to
infuse for 18 hours starting at 8am. At what rate should the IV fluid be flowing hourly?

A 100 ml/hour

B 210 ml/hour

150 ml/hour

D 90 ml/hour
Question 77
WRONG
Mr. Atienza is to receive 150 mg/hour of D5W IV infusion for 12 hours for a total of 1800 ml. He is also
losing gastric fluid which must be replaced every two hours. Between 8am to 10am. Mr. Atienza has lost 250
ml of gastric fluid. How much fluid should he receive at 11am?

A 350 ml/hour

275 ml/hour

400 ml/hour

D 200 ml/hour
Question 78
WRONG
You are to apply a transdermal patch of nitroglycerin to your client. The following important guidelines to
observe EXCEPT:

A Apply to hairlines clean are of the skin not subject to much wrinkling

Patches may be applied to distal part of the extremities like forearm

C Change application and site regularly to prevent irritation of the skin
Wear gloves to avoid any medication of your hand
Question 79
CORRECT
You will be applying eye drops to Miss Romualdez. After checking all the necessary information and cleaning
the affected eyelid and eyelashes you administer the ophthalmic drops by instilling the eye drops.

A directly onto the cornea

pressing on the lacrimal duct

C into the outer third of the lower conjunctival sac

D from the inner canthus going towards the side of the eye
Question 80
WRONG
When applying eye ointment, the following guidelines apply EXCEPT:

squeeze about 2 cm of ointment and gently close but not squeeze eye

B apply ointment from the inner canthus going outward of the affected eye

discard the first bead of the eye ointment before application because the tube likely
to expel more than desired amount of ointment

D hold the tube above the conjunctival sac do not let tip touch the conjunctiva
Question 81
WRONG
SITUATION: The staff nurse supervisor request all the staff nurses to brainstorm and learn ways to instruct
diabetic clients on self-administration of insulin. She wants to ensure that there are nurses available daily to do
health education classes. The plan of the nurse supervisor is an example of

in service education process

B efficient management of human resources

increasing human resources

D primary prevention
Question 82
CORRECT
When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an unlicensed staff,
Mrs. Guevarra.

A makes the assignment to teach the staff member

is assigning the responsibility to the aide but not the accountability for those tasks

C does not have to supervise or evaluate the aide

D most know how to perform task delegated
Question 83
CORRECT
Connie, the-new nurse, appears tired and sluggish and lacks the enthusiasms she give six weeks ago when she
started the job. The nurse supervisor should:

A empathize with the nurse and listen to her

B tell her to take the day off

discuss how she is adjusting to her new job

D ask about her family life

Question 84
CORRECT
Process of formal negotiations of working conditions between a group of registered nurses and employer is:
A grievance

B arbitration

collective bargaining

D strike
Question 85
CORRECT
You are attending a certification program on cardiopulmonary resuscitation (CPR) offered and required by the
hospital employing you. This is:

A professional course towards credits

in-service education

C advance training
D continuing education
Question 86
CORRECT
SITUATION: There are various developments in health education that the nurse should know about. The
provision of health information in the rural areas nationwide through television and radio programs and video
conferencing is referred to as:

A Community health program

Telehealth program

C Wellness program
D Red cross program
Question 87
WRONG
A nearby community provides blood pressure screening, height and weight measurement smoking cessation
classes and aerobics class services. This type of program is referred to as:

outreach program

B hospital extension program

C barangay health center

wellness center
Question 88
CORRECT
Part of teaching client in health promotion is responsibility for ones health. When Danica states she need to
improve her nutritional status this means:

Goals and interventions to be followed by client are based on nurses priorities

A
Goals and intervention developed by nurse and client should be approved by the
B doctor

C Nurse will decide goals and, interventions needed to meet client goals
Client will decide the goals and interventions required to meet her goals
Question 89
CORRECT
Nurse Beatrice is providing tertiary prevention to Mrs. De Villa. An example of tertiary prevention is:

A Marriage counseling

B Self-examination for breast cancer

Identifying complication of diabetes

D Poison, control
Question 90
CORRECT
Mrs. Ostrea has a schedule for Pap Smear. She has a strong family history of cervical cancer. This is an
example of:

A tertiary prevention

secondary prevention

C health screening
D primary prevention
Question 91
CORRECT
SITUATION: Ronnie has a vehicular accident where he sustained injury to his left ankle. In the Emergency
Room, you notice how anxious he looks. You establish rapport with him and to reduce his anxiety you initially

A Take him to the radiology, section for X-ray of affected extremity

Identify yourself and state your purpose in being with the client

C Talk to the physician for an order of Valium

D Do inspection and palpation to check extent of his injuries
Question 92
CORRECT
While doing your assessment, Ronnie asks you Do I have a fracture? I dont want to have a cast. The most
appropriate nursing response would be:

You have to have an X-ray first to know if you have a fracture.

A
 Why do you sound so scared? It is just a cast and its not painful
B
You seem to be concerned about being in a cast.

D Based on my assessment, there doesnt seem to be a fracture.

Question 93
CORRECT
A technique in physical examination that is use to assess the movement of air through the tracheobronchial
tree:

A Palpation

Auscultation

C Inspection
D Percussion
Question 94
CORRECT
An instrument used for auscultation is:

A Percussion-hammer

B Audiometer

Stethoscope

D Sphygmomanometer
Question 95
WRONG
Resonance is best describe as:

Sounds created by air filled lungs

B Short, high pitch and thudding

C Moderately loud with musical quality

Drum-like
Question 96
CORRECT
The best position for examining the rectum is:

A Prone

Sims
B
Knee-chest

D Lithotomy
Question 97
CORRECT
It refers to the manner of walking

Gait

B Range of motion

C Flexion and extension

Dv
Question 98
CORRECT
The nurse asked the client to read the Snellen chart. Which of the following is tested:

Optic
B Olfactory

C Oculomotor
D Trochlear
Question 99
CORRECT
Another name for knee-chest position is:

A Genu-dorsal

Genu-pectoral

C Lithotomy
D Sims
Question 100
CORRECT
The nurse prepares an IM injection that is irritating to the subcutaneous tissue. Which of the following is the
best action in order to prevent tracking of the medication

A Use a small gauge needle

B Apply ice on the injection site

C Administer at a 45 angle
Use the Z-track technique
You have
 Fundamentals of Nursing Exam 13: NLE Pre-Boards
(100 Items)
Question 1
CORRECT
The indication for epinephrine injection for Mrs Simon is to:

A Reduce anaphylaxis

B Relieve hypersensitivity to allergen

Relieve respiratory distress due to bronchospasm

D Restore clients cardiac rhythm

Question 2
CORRECT
When preparing the epinephrine injection from an ampule, the nurse initially:

A Taps the ampule at the top to allow fluid to flow to the base of the ampule

Checks expiration date of the medication ampule

C Removes needle cap of syringe and pulls plunger to expel air

D Breaks the neck of the ampule with a gauze wrapped around it
Question 3
CORRECT
Mrs. Simon is obese. When administering a subcutaneous injection to an obese patient, it is best for the nurse
to:

Inject needle at a 15 degree angle over the stretched skin of the client
A
B Pinch skin at the Injection site and use airlock technique
C Pull skin of patient down to administer the drug in a Z track
Spread skin or pinch at the injection site and inject needle at a 45-90 degree angle
Question 4
WRONG
When preparing for a subcutaneous injection, the proper size of syringe and needle would be:

A Syringe 3-5ml and needle gauge 21 to 23

Tuberculin syringe 1 ml with needle gauge 26 or 27

C Syringe 2ml and needle gauge 22

Syringe 1-3 ml and needle gauge 25 to 27
Question 5
CORRECT
The rationale for giving medications through the subcutaneous route is:

A There are many alternative sites for subcutaneous injection

Absorption time of the medicine is slower

C There are less pain receptors in this area

D The medication can be injected while the client is in any position
Question 6
CORRECT
Martha wants to do a study on, this topic. Effects of massage and meditation on stress and pain. The type of
research that best suits this topic is:

A applied research

qualitative research
C basic research
D quantitative research
Question 7
CORRECT
The type of research design that does not manipulate independent variable is:

A experimental design

B quasi-experimental design

non-experimental design

D quantitative design
Question 8
CORRECT
This research topic has the potential to contribute to nursing because it seeks to:

A include new modalities of care

B resolve a clinical problem

C clarify an ambiguous modality of care

enhance client care
Question 9
CORRECT
Martha does review of related literature for the purpose of:

A determine statistical treatment of data research

gathering data about what is already known or unknown

C to identify if problem can be replicated
D answering the research question
Question 10
CORRECT
Clients rights should be protected when doing research using human subjects. Martha identifies these rights as
follows EXCEPT:

A right of self-determination

right to compensation

C right of privacy
D right not to be harmed
Question 11
WRONG
SITUATION: Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions
and is at risk for infection because of retained secretions. Part of Nurse Marios nursing care plan is to loosen
and remove excessive secretions in the airway,Mario listens to Richards bilateral sounds and finds that
congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical
segments of the lungs when Mario does percussion would be:

Client lying on his back then flat on his abdomen on Trendelenburg position

Client seated upright in bed or on a chair then leaning forward in sitting position
then flat on his back and on his abdomen

C Client lying flat on his back and then flat on his abdomen
D Client lying on his right then left side on Trendelenburg position
Question 12
CORRECT
When documenting outcome of Richards treatment Mario should include the following in his recording
EXCEPT:

A Color, amount and consistent of sputum

B Character of breath sounds and respiratory/rate before and after procedure

Amount of fluid intake of client before and after the procedure

D Significant changes in vital signs

Question 13
CORRECT
When assessing Richard for chest percussion or chest vibration and postural drainage Mario would focus on
the following EXCEPT:

A Amount of food and fluid taken during the last meal before treatment

B Respiratory rate, breath sounds and location of congestion

Teaching the clients relatives to perform the procedure

D Doctors order regarding position restriction and clients tolerance for lying flat
Question 14
WRONG
Mario prepares Richard for postural drainage and percussion. Which of the following is a special consideration
when doing the procedure?

A Respiratory rate of 16 to 20 per minute

Client can tolerate sitting and lying position

C Client has no signs of infection

Time of fast food and fluid intake of the client
Question 15
WRONG
The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the
procedure is:

Percussion uses only one hand white vibration uses both hands

Percussion delivers cushioned blows to the chest with cupped palms while gently
shakes secretion loose on the exhalation cycle

In both percussion and vibration the hands are on top of each other and hand action
C is in tune with clients breath rhythm
Percussion slaps the chest to loosen secretions while vibration shakes the secretions
D along with the inhalation of air
Question 16
CORRECT
SITUATION: A 61 year old man, Mr. Regalado, is admitted to the private ward for observation after
complaints of severe chest pain. You are assigned to take care of the client.When doing an initial assessment,
the best way for you to identify the clients priority problem is to:

Interview the client for chief complaints and other symptoms

B Talk to the relatives to gather data about history of illness

C Do auscultation to check for chest congestion

D Do a physical examination white asking the client relevant questions
Question 17
CORRECT
Upon establishing Mr. Regalados nursing needs, the next nursing approach would be to:

A introduce the client to the ward staff to put the client and family at ease

B Give client and relatives a brief tour of the physical set up the unit

Take his vital signs for a baseline assessment

D Establish priority needs and implement appropriate interventions
Question 18
WRONG
Mr. Regalado says he has trouble going to sleep. In order to plan your nursing intervention you will.

Observe his sleeping patterns in the next few days

Ask him what he means by this statement

C Check his physical environment to decrease noise level

D Take his blood pressure before sleeping and upon waking up
Question 19
WRONG
Mr. Regalados lower extremities are swollen and shiny. He has pitting pedal edema. When taking care of Mr.
Regalado, which of the following intervention would be the most appropriate immediate nursing approach.

Moisturize lower extremities to prevent skin irritation

B Measure fluid intake and output to decrease edema

C Elevate lower extremities for postural drainage

Provide the client a list of food low in sodium
Question 20
WRONG
Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client for
discharge include all EXCEPT:

Making a final physical assessment before client leaves the hospital

B Giving instructions about his medication regimen

Walking the client to the hospital exit to ensure his safety

D Proper recording of pertinent data
Question 21
CORRECT
SITUATION: Nancy, mother of 2 young kids. 36 years old, had a mammogram and was told that she has
breast cysts and that she may need surgery. This causes her anxiety as shown by increase in her pulse and
respiratory rate, sweating and feelings of tension.Considering her level of anxiety, the nurse can best assist
Nancy by:

A Giving her activities to divert her attention

B Giving detailed explanations about the treatments she will undergo

C Preparing her and her family in case surgery is not successful

Giving her clear but brief information at the level of her understanding
Question 22
CORRECT
Nancy blames God for her situation. She is easily provoked to tears and wants to be left alone, refusing to eat
or talk to her family. A religious person before, she now refuses to pray or go to church stating that God has
abandoned her. The nurse understands that Nancy is grieving for her self and is in the stage of:

A bargaining

B denial

anger

D acceptance
Question 23
CORRECT
The nurse visits Nancy and prods her to eat her food. Nancy replies whats the use? My time is running out.
The nurses best response would be:
 The doctor ordered full diet for you so that you will be strong for surgery.
A
I understand how you fee! but you have 1o try for your childrens sake.
B
Have you told your, doctor how you feel? Are you changing your mind) about
C surgery?
You sound like you are giving up.
Question 24
CORRECT
The nurse feels sad about Nancys illness and tells her head nurse during the end of shift endorsement that its
unfair for Nancy to have cancer when she is still so young and with two kinds. The best response of the head
nurse would be:

Advise the nurse to be strong and learn to control her feelings

A
B Assign the nurse to another client to avoid sympathy for the client

Reassure the nurse that the client has hope if she goes through all statements
C prescribed for her
Ask the other nurses what they feel about the patient to find out if they share the
same feelings
Question 25
WRONG
Realizing that she feels angry about Nancys condition, the nurse sees that being self-aware is a conscious
process that she should do in any situation like this because:

A This is a necessary part of the nurse -client relationship process

B The nurse is a role model for the client and should be strong

How the nurse thinks and feels affect her actions towards her client and her work

The nurse has to be therapeutic at all times and should not be affected
Question 26
CORRECT
SITUATION: Mrs. Seva, 32 years old, asks you about possible problems regarding her elimination now that
she is in the menopausal stage.Instruction on health promotion regarding urinary elimination is important.
Which would you include?

Hold urine, as long as she can before emptying the bladder to strengthen her
A sphincters muscles

B If burning sensation is experienced while voiding, drink pineapple-juice

C After urination, wipe from anal area up towards the pubis

Tell client to empty the bladder at each voiding
Question 27
CORRECT
Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical changes
predispose her to constipation?

A inhibition of the parasympathetic reflex

B weakness of sphincter muscles of the anus

loss of tone of the smooth muscles of the color

D decreased ability to absorb fluids in the lower intestines

Question 28
CORRECT
The nurse understands that one of these factors contributes to constipation:

A excessive exercise

B high fiber diet

C no regular time for defecation daily
prolonged use of laxatives
Question 29
CORRECT
Mrs. Seva talks about rear of being incontinent due to a prior experience of dribbling urine when laughing or
sneezing and when she has a full bladder. Your most appropriate .instruction would be to:

A tell client to drink less fluids to avoid accidents

B instruct client to start wearing thin adult diapers

C ask the client to bring change of underwear just in case

teach client pelvic exercise to strengthen perineal muscles
Question 30
WRONG
Mrs. Seva asked for instructions for skin care for her mother who has urinary incontinence and is almost
always in bed. Your instruction would focus on prevention of skin irritation and breakdown by

A Using thick diapers to absorb urine well

B Drying the skin with baby powder to prevent or mask the smell of ammonia

Thorough washing, rising and during of skin area that get wet with urine

Making sure that linen are smooth and dry at all times
Question 31
CORRECT
SITUATION: Using Maslows need theory, Airway, Breathing and Circulation are the physiological needs
vital to life. The nurses knowledge and ability to identify and immediately intervene to meet these needs is
important to save lives. Which of these clients has a problem with the transport of oxygen from the lungs to the
tissues:
A Carol with a tumor in the brain

Theresa with anemia

C Sonny Boy with a fracture in the femur

D Brigette with diarrhea
Question 32
CORRECT
You noted from the lab exams in the chart of Mr. Santos that he has reduced oxygen in the blood. This
condition is called:

A Cyanosis

B Hypoxia

Hypoxemia

D Anemia
Question 33
CORRECT
You will nasopharyngeal suctioning Mr. Abad. Your guide for the length of insertion of the tubing for an adult
would be:

A tip of the nose to the base of the neck

B the distance from the tip of the nose to the middle of the cheek

the distance from the tip of the nose to the tip of the ear lobe

D eight to ten inches

Question 34
 WRONG
While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by:

Apply suction for at least 20-30 seconds each time to ensure that all secretions are
removed

B Using gloves to prevent introduction of pathogens to the respiratory system

Applying no suction while inserting the catheter

D Rotating catheter as it is inserted with gentle suction

Question 35
CORRECT
Myrna has difficulty breathing when on her back and must sit upright in bed to breath, effectively and
comfortably. The nurse documents this condition as:

A Apnea

Orthopnea

C Dyspnea
D Tachypnea
Question 36
CORRECT
SITUATION: You are assigned to screen for hypertension: Your task is to take blood pressure readings and
you are informed about avoiding the common mistakes in BP taking that lead to false or inaccurate blood
pressure readings.When taking blood pressure reading the cuff should be:

A deflated fully then immediately start second reading for same client

B deflated quickly after inflating up to 180 mmHg

large enough to wrap around upper arm of the adult client 1 cm above brachial
C artery
 inflated to 30 mmHg above the estimated systolic BP based on palpation of radial
or bronchial artery
Question 37
CORRECT
Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of death worldwide and is a
preventable disease. The primary cause of COPD is:

A tobacco hack

B bronchitis

C asthma
cigarette smoking
Question 38
WRONG
In your health education class for clients with diabetes you teach, them the areas, for control . Diabetes which
include all EXCEPT:

A regular physical activity

thorough knowledge of foot care

prevention nutrition

D proper nutrition
Question 39
CORRECT
You teach your clients the difference between, Type I (IDDM) and Type II (NDDM) Diabetes. Which of the
following is true?

A both types diabetes mellitus clients are all prone to developing ketosis

Type II (NIDDM) is more common and is also preventable compared to Type I

(IDDM) diabetes which is genetic in etiology
C Type I (IDDM) is characterized by fasting hyperglycemia
D Type II (NIDDM) is characterized by abnormal immune response
Question 40
CORRECT
Lifestyle-related diseases in general share areas common risk factors. These are the following except

A physical activity

B smoking

genetics

D nutrition
Question 41
CORRECT
SITUATION: Nurse Rivera witnesses a vehicular accident near the hospital where she works. She decides to
get involved and help the victims of the accident.Her priority nursing action would be to:

A Assess damage to property

B Assist in the police investigation since she is a witness

C Report the incident immediately to the local police authorities

Assess the extent of injuries incurred by the victims, of the accident
Question 42
CORRECT
Priority attention should be given to which of these clients?

A Linda who shows severe anxiety due to trauma of the accident

 Ryan who has chest injury, is pate and with difficulty of breathing

C Noel who has lacerations on the arms with mild-bleeding

D Andy whose left ankle swelled and has some abrasions
Question 43
CORRECT
In the emergency room, Nurse Rivera is assigned to attend to the client with .lacerations on the arms, while
assessing the extent of the wound the nurse observes that the wound is now starting to bleed profusely. The
most immediate nursing action would be to:

A Apply antiseptic to prevent infection

B Clean the wound vigorously of contaminants

C Control and. reduce bleeding of the wound

Bandage the wound and elevate the arm
Question 44
CORRECT
The nurse applies pressure dressing on the bleeding site. This intervention is done to:

A Reduce the need to change dressing frequently

B Allow the pus to surface faster

C Protect the wound from micro organisms in the air

Promote hemostasis
Question 45
CORRECT
After the treatment, the client is sent home and asked to come back for follow-up care. Your responsibilities
when the client is to be discharged include the following EXCEPT:
A Encouraging the client to go to the, outpatient clinic for follow up care

B Accurate recording, of treatment done and instructions given to client

Instructing the client to see you after discharge for further assistance

D Providing instructions regarding wound care

Question 46
CORRECT
SITUATION: While working in the clinic, a new client, Geline, 35 years old, arrives for her doctors
appointment. As the clinic nurse, you are to assist the client fill up forms, gather data and make an
assessment.The nurse purpose of your initial nursing interview is to:

A Record pertinent information in the client chart for health team to read

B Assist the client find solutions to her health concerns

Understand her lifestyle, health needs and possible problems to develop a plan of
care

D Make nursing diagnoses for identified health problems

Question 47
WRONG
While interviewing Geline, she starts to moan and doubles up in pain, She tells you that this pain occurs about
an hour after taking black coffee without breakfast for a few weeks now. You will record this as follows:

A Claims to have abdominal pains after intake of coffee unrelieved by analgesics

B After drinking coffee, the client experienced severe abdominal pain

Client complained of intermittent abdominal pain an hour after drinking coffee

Client reported abdominal pain an hour after drinking black coffee for three weeks
now
Question 48
CORRECT
Geline tells you that she drinks black coffee frequently within the day to have energy and be wide awake and
she eats nothing for breakfast and eats strictly vegetable salads for lunch and dinner to lose weight. She has
lost weight during the past two weeks, in planning a healthy balanced diet with Geline, you will:

Start her off with a cleansing diet to free her body of toxins then change to a
A vegetarian, diet and drink plenty of fluids

B Plan a high protein, diet, low carbohydrate diet for her considering her favorite food

Instruct her to attend classes in nutrition to find food rich in complex carbohydrates
C to maintain daily high energy level
Discuss with her the importance of eating a variety of food from the major food
groups with plenty of fluids
Question 49
CORRECT
Geline tells you that she drinks 4-5 cups of black coffee and diet cola drinks. She also smokes up to a pack of
cigarettes daily. She confesses that she is in her 2nd month of pregnancy but she does not want to become fat
that is why she limits her food intake. You warn or caution her about which of the following?

Caffeine products affect the central nervous system and may cause the mother to
A have a nervous breakdown

Malnutrition and its possible effects on growth and development problems in the
unborn fetus

C Caffeine causes a stimulant effect on both the mother and the baby
D Studies show conclusively that caffeine causes mental retardation
Question 50
CORRECT
Your health education plan for Geline stresses proper diet for a pregnant woman and the prevention of
noncommunicable diseases that are influenced by her lifestyle these include of the following EXCEPT:

A Cardiovascular diseases
B Cancer

C Diabetes Mellitus
Osteoporosis
Question 51
CORRECT
SITUATION: Management of nurse practitioners is done by qualified nursing leaders who have had clinical
experience and management experience.An example of a management function of a nurse is:

A Teaching patient do breathing and coughing exercises

B Preparing for a surprise party for a client

C Performing nursing procedures for clients

Directing and evaluating the staff nurses
Question 52
CORRECT
Your head nurse in the unit believes that the staff nurses are not capable of decision making so she makes the
decisions for everyone without consulting anybody. This type of leadership is:

A Laissez faire leadership

B Democratic leadership

Autocratic leadership

D Managerial leadership
Question 53
CORRECT
When the head nurse in your ward plots and approves your work schedules and directs your work, she is
demonstrating:
A Responsibility

B Delegation

C Accountability
Authority
Question 54
CORRECT
The following tasks can be safely delegated by a nurse to a non-nurse health worker EXCEPT:

A Transfer a client from bed to chair

Change IV infusions

C Irrigation of a nasogastric tube

D Take vital signs
Question 55
CORRECT
You made a mistake in giving the medicine to the wrong client You notify the clients doctor and write an
incident report. You are demonstrating:

A Responsibility

Accountability

C Authority
D Autocracy
Question 56
WRONG
SITUATION: Mr. Dizon, 84 years old, is brought to the Emergency Room for complaint of hypertension
flushed face, severe headache, and nausea. You are doing the initial assessment of vital signs.You are to
measure the clients initial blood pressure reading by doing all of the following EXCEPT:

Take the blood pressure reading on both arms for comparison

Listen to and identify the phases of Korotkoffs sounds

B
Pump the cuff up to around 50 mmHg above the point where the pulse is obliterated

D Observe procedures for infection control

Question 57
CORRECT
A pulse oximeter is attached to Mr. Dizons finger to:

Determine if the clients hemoglobin level is low and if he needs blood transfusion
A
Check level of clients tissue perfusion
B
C Measure the efficacy of the clients antihypertensive medications
Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops
Question 58
CORRECT
After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an order of hourly
monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure
reading to be:

A Inconsistent

B low systolic and high diastolic pressure

higher than what the reading should be

D lower than what the reading should be

Question 59
CORRECT
Through the clients health history, you gather that Mr. Dizon smokes and drinks coffee. When taking the
blood pressure of a client who recently smoked or drank coffee, how long should be the nurse wait before
taking the clients blood pressure for accurate reading?

A 15 minutes

30 minutes

C 1 hour
D 5 minutes
Question 60
CORRECT
While the client has the pulse oximeter on his fingertip, you notice that the sunlight is shining on the area
where the oximeter is. Your action will be to:

A Set and turn on the alarm of the oximeter

B Do nothing since there is no identified problem

Cover the fingertip sensor with a towel or bedsheet

D Change the location of the sensor every four hours

Question 61
CORRECT
SITUATION: The nurses understanding of ethico-legal responsibilities will guide his/her nursing practice.The
principles that .govern right and proper conducts of a person regarding life, biology and the health professions
is referred to as:

A Morality
B Religion

C Values
Bioethics
Question 62
WRONG
The purpose of having nurses code of ethics is:

Delineate the scope and areas of nursing practice

B Identify nursing action recommended for specific health care situations

To help the public understand professional conduct, expected of nurses

D To define the roles and functions of the health caregiver, nurses, clients
Question 63
CORRECT
The most important nursing responsibility where ethical situations emerge in patient care is to:

A Act only when advised that the action is ethically sound

B Not take sides remain neutral and fair

C Assume that ethical questions are the responsibility: of the health team
Be accountable for his or her own actions
Question 64
CORRECT
You inform the patient about his rights which include the following EXCEPT:

A Right to expect reasonable continuity of care

B Right to consent to or decline to participate in research studies or experiments

Right to obtain information about another patient

D Right to expect that the records about his care will be treated as confidential
Question 65
CORRECT
The principle states that a person has unconditional worth and has the capacity to determine his own destiny.

A Bioethics

B Justice

C Fidelity
Autonomy
Question 66
CORRECT
SITUATION: Your director of nursing wants to improve the quality of health care offered in the hospital. As a
staff nurse in that hospital you know that this entails quality assurance programs.The following mechanisms
can be utilized as part of the quality assessment program of your hospital EXCEPT:

A Patient satisfaction surveys provided

B Peer review clinical records of care of client

C Review of the Nursing Intervention Classification

Use of Nursing Interventions Classification
Question 67
WRONG
The nurse of the Standards of Nursing Practice is important in the hospital. Which of the following statements
best describes what it is?
 These are statements that describe the maximum or highest level of acceptable
performance in nursing practice.

B It refers to the scope of nursing as defined in Republic Act 9173

It is a license issued by the Professional Regulation Commission to protect the

C public from substandard nursing practice.
The Standards of care includes the various steps of the nursing process and the
standards of professional performance.
Question 68
WRONG
You are taking care of critically ill client and the doctor in charge calls to order a DNR (do not resuscitate) for
the client. Which of the following is the appropriate action when getting DNR order over the phone?

A Have the registered nurse, family spokesperson, nurse supervisor and doctor sign

Have two nurses validate the phone order, both nurses sign the order and the doctor
should sign his order within 24 hours.

C Have the registered nurse, family and doctor sign the order
Have 1 nurse take the order and sign it and have the doctor sign it within 24 hours
Question 69
CORRECT
To ensure the client safety before starting blood transfusion the following are needed before the procedure can
be done EXCEPT:

A take baseline vital signs

blood should be warmed to room temperature for 30 minutes before blood

B transfusion is administered

have two nurses verify client identification, blood type, unit number and expiration
C date of blood
get a consent signed for blood transfusion
Question 70
 WRONG
Part of standards of care has to do with the use of restraints. Which of the following statements is NOT true?

Doctors order for restraints should be signed within 24 hours

A
B Remove and reapply restraints every two hours

Check clients pulse, blood pressure and circulation every four hours

Offer food and toileting every two hours

Question 71
CORRECT
SITUATION: During the NUTRITION EDUCATION class discussion a 58 year old man, Mr. Bruno shows
increased interest.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

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 not patis or toyo
Question 72
CORRECT
Your instructions to reduce or limit salt intake include all the following EXCEPT:

A eat natural food with little or no salt added

limit use of table salt and use condiments instead

C use herbs and spices

D limit intake of preserved or processed food
Question 73
WRONG
Teaching strategies and approaches when giving nutrition education is influenced by age, sex and immediate
concerns of the group. Your presentation for a group of young mothers would be best if you focus on:

A diets limited in salt and fat

harmful effect on drugs and alcohol intake

C commercial preparation of dishes

cooking demonstration and meal planning
Question 74
CORRECT
Cancer cure is dependent on

A use of alternative methods of healing

B watching out for warning signs of cancer

C proficiency in doing breast self-examination

early detection and prompt treatment
Question 75
CORRECT
The role of the health worker in health education is to:

A report incidence of non-communicable disease to community health center

educate as many people about warning signs of non-communicable diseases

C focus on smoking cessation projects

D monitor clients with hypertension
Question 76
CORRECT
SITUATION: You are assigned to take care of 10 patients during the morning shift. The endorsement includes
the IV infusion and medications for these clients. Mr. Felipe, 36 years old is to be given 2700 ml of D5RL to
infuse for 18 hours starting at 8am. At what rate should the IV fluid be flowing hourly?

A 100 ml/hour

B 210 ml/hour

150 ml/hour

D 90 ml/hour
Question 77
WRONG
Mr. Atienza is to receive 150 mg/hour of D5W IV infusion for 12 hours for a total of 1800 ml. He is also
losing gastric fluid which must be replaced every two hours. Between 8am to 10am. Mr. Atienza has lost 250
ml of gastric fluid. How much fluid should he receive at 11am?

A 350 ml/hour

275 ml/hour

400 ml/hour

D 200 ml/hour
Question 78
WRONG
You are to apply a transdermal patch of nitroglycerin to your client. The following important guidelines to
observe EXCEPT:

A Apply to hairlines clean are of the skin not subject to much wrinkling

Patches may be applied to distal part of the extremities like forearm

C Change application and site regularly to prevent irritation of the skin
Wear gloves to avoid any medication of your hand
Question 79
CORRECT
You will be applying eye drops to Miss Romualdez. After checking all the necessary information and cleaning
the affected eyelid and eyelashes you administer the ophthalmic drops by instilling the eye drops.

A directly onto the cornea

pressing on the lacrimal duct

C into the outer third of the lower conjunctival sac

D from the inner canthus going towards the side of the eye
Question 80
WRONG
When applying eye ointment, the following guidelines apply EXCEPT:

squeeze about 2 cm of ointment and gently close but not squeeze eye

B apply ointment from the inner canthus going outward of the affected eye

discard the first bead of the eye ointment before application because the tube likely
to expel more than desired amount of ointment

D hold the tube above the conjunctival sac do not let tip touch the conjunctiva
Question 81
WRONG
SITUATION: The staff nurse supervisor request all the staff nurses to brainstorm and learn ways to instruct
diabetic clients on self-administration of insulin. She wants to ensure that there are nurses available daily to do
health education classes. The plan of the nurse supervisor is an example of

in service education process

B efficient management of human resources

increasing human resources

D primary prevention
Question 82
CORRECT
When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an unlicensed staff,
Mrs. Guevarra.

A makes the assignment to teach the staff member

is assigning the responsibility to the aide but not the accountability for those tasks

C does not have to supervise or evaluate the aide

D most know how to perform task delegated
Question 83
CORRECT
Connie, the-new nurse, appears tired and sluggish and lacks the enthusiasms she give six weeks ago when she
started the job. The nurse supervisor should:

A empathize with the nurse and listen to her

B tell her to take the day off

discuss how she is adjusting to her new job

D ask about her family life

Question 84
CORRECT
Process of formal negotiations of working conditions between a group of registered nurses and employer is:
A grievance

B arbitration

collective bargaining

D strike
Question 85
CORRECT
You are attending a certification program on cardiopulmonary resuscitation (CPR) offered and required by the
hospital employing you. This is:

A professional course towards credits

in-service education

C advance training
D continuing education
Question 86
CORRECT
SITUATION: There are various developments in health education that the nurse should know about. The
provision of health information in the rural areas nationwide through television and radio programs and video
conferencing is referred to as:

A Community health program

Telehealth program

C Wellness program
D Red cross program
Question 87
WRONG
A nearby community provides blood pressure screening, height and weight measurement smoking cessation
classes and aerobics class services. This type of program is referred to as:

outreach program

B hospital extension program

C barangay health center

wellness center
Question 88
CORRECT
Part of teaching client in health promotion is responsibility for ones health. When Danica states she need to
improve her nutritional status this means:

Goals and interventions to be followed by client are based on nurses priorities

A
Goals and intervention developed by nurse and client should be approved by the
B doctor

C Nurse will decide goals and, interventions needed to meet client goals
Client will decide the goals and interventions required to meet her goals
Question 89
CORRECT
Nurse Beatrice is providing tertiary prevention to Mrs. De Villa. An example of tertiary prevention is:

A Marriage counseling

B Self-examination for breast cancer

Identifying complication of diabetes

D Poison, control
Question 90
CORRECT
Mrs. Ostrea has a schedule for Pap Smear. She has a strong family history of cervical cancer. This is an
example of:

A tertiary prevention

secondary prevention

C health screening
D primary prevention
Question 91
CORRECT
SITUATION: Ronnie has a vehicular accident where he sustained injury to his left ankle. In the Emergency
Room, you notice how anxious he looks. You establish rapport with him and to reduce his anxiety you initially

A Take him to the radiology, section for X-ray of affected extremity

Identify yourself and state your purpose in being with the client

C Talk to the physician for an order of Valium

D Do inspection and palpation to check extent of his injuries
Question 92
CORRECT
While doing your assessment, Ronnie asks you Do I have a fracture? I dont want to have a cast. The most
appropriate nursing response would be:

You have to have an X-ray first to know if you have a fracture.

A
 Why do you sound so scared? It is just a cast and its not painful
B
You seem to be concerned about being in a cast.

D Based on my assessment, there doesnt seem to be a fracture.

Question 93
CORRECT
A technique in physical examination that is use to assess the movement of air through the tracheobronchial
tree:

A Palpation

Auscultation

C Inspection
D Percussion
Question 94
CORRECT
An instrument used for auscultation is:

A Percussion-hammer

B Audiometer

Stethoscope

D Sphygmomanometer
Question 95
WRONG
Resonance is best describe as:

Sounds created by air filled lungs

B Short, high pitch and thudding

C Moderately loud with musical quality

Drum-like
Question 96
CORRECT
The best position for examining the rectum is:

A Prone

Sims
B
Knee-chest

D Lithotomy
Question 97
CORRECT
It refers to the manner of walking

Gait

B Range of motion

C Flexion and extension

Dv
Question 98
CORRECT
The nurse asked the client to read the Snellen chart. Which of the following is tested:

Optic
B Olfactory

C Oculomotor
D Trochlear
Question 99
CORRECT
Another name for knee-chest position is:

A Genu-dorsal

Genu-pectoral

C Lithotomy
D Sims
Question 100
CORRECT
The nurse prepares an IM injection that is irritating to the subcutaneous tissue. Which of the following is the
best action in order to prevent tracking of the medication

A Use a small gauge needle

B Apply ice on the injection site

C Administer at a 45 angle
Use the Z-track technique
You have