NLE COMPREHENSIVE EXAMS

1. A pregnant woman who is at term is admitted to the birthing unit in active labor. The client
has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with
hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her contractions.
Which of the following is the most important aspect of nursing intervention at this time?

A. Timing and recording length of contractions.

B. Monitoring.
C. Preparing for an emergency cesarean birth.
D. Checking the perineum for bulging.

2. A client who hallucinates is not in touch with reality. It is important for the nurse to:

A. Isolate the client from other patients.

B. Maintain a safe environment.
C. Orient the client to time, place, and person.
D. Establish a trusting relationship.

3. The nurse is caring to a child client who has had a tonsillectomy. The child complains of
having dryness of the throat. Which of the following would the nurse give to the child?

A. Cola with ice

B. Yellow noncitrus Jello
C. Cool cherry Kool-Aid
D. A glass of milk

4. The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-old client.

The nurse caring to the client provides instructions that the nasal spray must be used exactly
as directed to prevent the development of:

A. Increased nasal congestion.

B. Nasal polyps.
C. Bleeding tendencies.
D. Tinnitus and diplopia.
5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned
to care for the client must institute appropriate precautions. The nurse should:

A. Place the client in a private room.

B. Wear an N 95 respirator when caring for the client.
C. Put on a gown every time when entering the room.
D. Don a surgical mask with a face shield when entering the room.

6. Which of the following is the most frequent cause of noncompliance to the medical
treatment of open-angle glaucoma?

A. The frequent nausea and vomiting accompanying use of miotic drug.

B. Loss of mobility due to severe driving restrictions.
C. Decreased light and near-vision accommodation due to miotic effects of pilocarpine.
D. The painful and insidious progression of this type of glaucoma.

7. In the morning shift, the nurse is making rounds in the nursing care units. The nurse enters
in a client’s room and notes that the client’s tube has become disconnected from the
Pleurovac. What would be the initial nursing action?

A. Apply pressure directly over the incision site.

B. Clamp the chest tube near the incision site.
C. Clamp the chest tube closer to the drainage system.
D. Reconnect the chest tube to the Pleurovac.

8. Which of the following complications during a breech birth the nurse needs to be alarmed?

A. Abruption placenta.
B. Caput succedaneum.
C. Pathological hyperbilirubinemia.
D. Umbilical cord prolapse.

9. The nurse is caring to a client diagnosed with severe depression. Which of the following
nursing approach is important in depression?
A. Protect the client against harm to others.
B. Provide the client with motor outlets for aggressive, hostile feelings.
C. Reduce interpersonal contacts.
D. Deemphasizing preoccupation with elimination, nourishment, and sleep.

10. A 3-month-old client is in the pediatric unit. During assessment, the nurse is suspecting
that the baby may have hypothyroidism when mother states that her baby does not:

A. Sit up.
B. Pick up and hold a rattle.
C. Roll over.
D. Hold the head up.

11. The physician calls the nursing unit to leave an order. The senior nurse had conversation
with the other staff. The newly hired nurse answers the phone so that the senior nurses may
continue their conversation. The new nurse does not knowthe physician or the client to whom
the order pertains. The nurse should:

A. Ask the physician to call back after the nurse has read the hospital policy manual.
B. Take the telephone order.
C. Refuse to take the telephone order.
D. Ask the charge nurse or one of the other senior staff nurses to take the telephone order.

12. The staff nurse on the labor and delivery unit is assigned to care to a primigravida in
transition complicated by hypertension. A new pregnant woman in active labor is admitted in
the same unit. The nurse manager assigned the same nurse to the second client. The nurse
feels that the client with hypertension requires one-to-one care. What would be the initial
actionof the nurse?

A. Accept the new assignment and complete an incident report describing a shortage of
nursing staff.
B. Report the incident to the nursing supervisor and request to be floated.
C. Report the nursing assessment of the client in transitional labor to the nurse manager and
discuss misgivings about the new assignment.
D. Accept the new assignment and provide the best care.
13. A newborn infant with Down syndrome is to be discharged today. The nurse is preparing
to give the discharge teaching regarding the proper care at home. The nurse would anticipate
that the mother is probably at the:

A. 40 years of age.
B. 20 years of age.
C. 35 years of age.
D. 20 years of age.

14. The emergency department has shortage of staff. The nurse manager informs the staff
nurse in the critical care unit that she has to float to the emergency department. What should
the staff nurse expect under these conditions?

A. The float staff nurse will be informed of the situation before the shift begins.
B. The staff nurse will be able to negotiate the assignments in the emergency department.
C. Cross training will be available for the staff nurse.
D. Client assignments will be equally divided among the nurses.

15. The nurse is assigned to care for a child client admitted in the pediatrics unit. The client is
receiving digoxin. Which of the following questions will be asked by the nurse to the parents
of the child in order to assess the client’s risk for digoxin toxicity?

A. “Has he been exposed to any childhood communicable diseases in the past 2-3 weeks?”
B. “Has he been taking diuretics at home?”
C. “Do any of his brothers and sisters have history of cardiac problems?”
D. “Has he been going to school regularly?”

16. The nurse noticed that the signed consent form has an error. The form states, “Amputation
of the right leg” instead of the left leg that is to be amputated. The nurse has administered
already the preoperative medications. What should the nurse do?

A. Call the physician to reschedule the surgery.

B. Call the nearest relative to come in to sign a new form.
C. Cross out the error and initial the form.
D. Have the client sign another form.
17. The nurse in the nursing care unit checks the fluctuation in the water-seal compartment of
a closed chest drainage system. The fluctuation has stopped, the nurse would:

A. Vigorously strip the tube to dislodge a clot.

B. Raise the apparatus above the chest to move fluid.
C. Increase wall suction above 20 cm H2O pressure.
D. Ask the client to cough and take a deep breath.

18. The pediatric nurse in the neonatal unit was informed that the baby that is brought to the
mother in the hospital room is wrong. The nurse determines that two babies were placed in
the wrong cribs. The most appropriate nursing action would be to:

A. Determine who is responsible for the mistake and terminate his or her employment.
B. Record the event in an incident/variance report and notify the nursing supervisor.
C. Reassure both mothers, report to the charge nurse, and do not record.
D. Record detailed notes of the event on the mother’s medical record.

19. Before the administration of digoxin, the nurse completes an assessment to a toddler client
for signs and symptoms of digoxin toxicity. Which of the following is the earliest and most
significant sign of digoxin toxicity?

A. Tinnitus
B. Nausea and vomiting
C. Vision problem
D. Slowing in the heart rate

20. Which of the following treatment modality is appropriate for a client with paranoid
tendency?

A. Activity therapy.
B. Individual therapy.
C. Group therapy.
D. Family therapy.
21. The client with rheumatoid arthritis is for discharge. In preparing the client for discharge
on prednisone therapy, the nurse should advise the client to:

A. Wear sunglasses if exposed to bright light for an extended period of time.

B. Take oral preparations of prednisone before meals.
C. Have periodic complete blood counts while on the medication.
D. Never stop or change the amount of the medication without medical advice.

22. A pregnant client tells the nurse that she is worried about having urinary frequency. What
will be the most appropriate nursing response?

A. “Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have
frequency associated with fever, pain on voiding, or blood in the urine, call your
doctor/nurse-midwife.
B. “Placental progesterone causes irritability of the bladder sphincter. Your symptoms will go
away after the baby comes.”
C. “Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids to 1L/daily.”
D. “Frequency is due to bladder irritation from concentrate urine and is normal in pregnancy.
Increase your daily fluid intake to 3L.”

23. Which of the following will help the nurse determine that the expression of hostility is
useful?

A. Expression of anger dissipates the energy.

B. Energy from anger is used to accomplish what needs to be done.
C. Expression intimidates others.
D. Degree of hostility is less than the provocation.

24. The nurse is providing an orientation regarding case management to the nursing students.
Which characteristics should the nurse include in the discussion in understanding case
management?

A. Main objective is a written plan that combines discipline-specific processes used to

measure outcomes of care.
B. Main purpose is to identify expected client, family and staff performance against the
timeline for clients with the same diagnosis.
C. Main focus is comprehensive coordination of client care, avoid unnecessary duplication of
services, improve resource utilization and decrease cost.
D. Primary goal is to understand why predicted outcomes have not been met and the
correction of identified problems.

25. The physician orders a dose of IV phenytoin to a child client. In preparing in the
administration of the drug, which nursing action is not correct?

A. Infuse the phenytoin into a smaller vein to prevent purple glove syndrome.
B. Check the phenytoin solution to be sure it is clear or light yellow in color, never cloudy.
C. Plan to give phenytoin over 30-60 minutes, using an in-line filter.
D. Flush the IV tubing with normal saline before starting phenytoin.

26. The pregnant woman visits the clinic for check –up. Which assessment findings will help
the nurse determine that the client is in 8-week gestation?

A. Leopold maneuvers.
B. Fundal height.
C. Positive radioimmunoassay test (RIA test).
D. Auscultation of fetal heart tones.

27. Which of the following nursing intervention is essential for the client who had
pneumonectomy?

A. Medicate for pain only when needed.

B. Connect the chest tube to water-seal drainage.
C. Notify the physician if the chest drainage exceeds 100mL/hr.
D. Encourage deep breathing and coughing.

28. The nurse is providing a health teaching to a group of parents regarding Chlamydia
trachomatis. The nurse is correct in the statement, “Chlamydia trachomatis is not only an
intracellular bacterium that causes neonatal conjunctivitis, but it also can cause:
A. Discoloration of baby and adult teeth.
B. Pneumonia in the newborn.
C. Snuffles and rhagades in the newborn.
D. Central hearing defects in infancy.

29. The nurse is assigned to care to a 17-year-old male client with a history of substance
abuse. The client asks the nurse, “Have you ever tried or used drugs?” The most correct
response of the nurse would be:

A. “Yes, once I tried grass.”

B. “No, I don’t think so.”
C. “Why do you want to know that?”
D. “How will my answer help you?”

30. Which of the following describes a health care team with the principles of participative
leadership?

A. Each member of the team can independently make decisions regarding the client’s care
without necessarily consulting the other members.
B. The physician makes most of the decisions regarding the client’s care.
C. The team uses the expertise of its members to influence the decisions regarding the client’s
care.
D. Nurses decide nursing care; physicians decide medical and other treatment for the client.

31. A nurse is giving a health teaching to a woman who wants to breastfeed her newborn baby.
Which hormone, normally secreted during the postpartum period, influences both the milk
ejection reflex and uterine involution?

A. Oxytocin.
B. Estrogen.
C. Progesterone.
D. Relaxin.

32. One staff nurse is assigned to a group of 5 patients for the 12-hour shift. The nurse is
responsible for the overall planning, giving and evaluating care during the entire shift. After
the shift, same responsibility will be endorsed to the next nurse in charge. This describes
nursing care delivered via the:

A. Primary nursing method.

B. Case method.
C. Functional method.
D. Team method.

33. The ambulance team calls the emergency department that they are going to bring a client
who sustained burns in a house fire. While waiting for the ambulance, the nurse will
anticipate emergency care to include assessment for:

A. Gas exchange impairment.

B. Hypoglycemia.
C. Hyperthermia.
D. Fluid volume excess.

34. Most couples are using “natural” family planning methods. Most accidental pregnancies
in couples preferred to use this method have been related to unprotected intercourse before
ovulation. Which of the following factor explains why pregnancy may be achieved by
unprotected intercourse during the preovulatory period?

A. Ovum viability.
B. Tubal motility.
C. Spermatozoal viability.
D. Secretory endometrium.

35. An older adult client wakes up at 2 o’clock in the morning and comes to the nurse’s
station saying, “I am having difficulty in sleeping.” What is the best nursing response to the
client?

A. “I’ll give you a sleeping pill to help you get more sleep now.”
B. “Perhaps you’d like to sit here at the nurse’s station for a while.”
C. “Would you like me to show you where the bathroom is?”
D. “What woke you up?”
36. The nurse is taking care of a multipara who is at 42 weeks of gestation and in active labor,
her membranes ruptured spontaneously 2 hours ago. While auscultating for the point of
maximum intensity of fetal heart tones before applying an external fetal monitor, the nurse
counts 100 beats per minute. The immediate nursing action is to:

A. Start oxygen by mask to reduce fetal distress.

B. Examine the woman for signs of a prolapsed cord.
C. Turn the woman on her left side to increase placental perfusion.
D. Take the woman’s radial pulse while still auscultating the FHR.

37. The nurse must instruct a client with glaucoma to avoid taking over-the-counter
medications like:

A. Antihistamines.
B. NSAIDs.
C. Antacids.
D. Salicylates.

38. A male client is brought to the emergency department due to motor vehicle accident.
While monitoring the client, the nurse suspects increasing intracranial pressure when:

A. Client is oriented when aroused from sleep, and goes back to sleep immediately.
B. Blood pressure is decreased from 160/90 to 110/70.
C. Client refuses dinner because of anorexia.
D. Pulse is increased from 88-96 with occasional skipped beat.

39. The nurse is conducting a lecture to a class of nursing students about advance directives to
preoperative clients. Which of the following statement by the nurse js correct?

A. “The spouse, but not the rest of the family, may override the advance directive.”
B. “An advance directive is required for a “do not resuscitate” order.”
C. “A durable power of attorney, a form of advance directive, may only be held by a blood
relative.”
D. “The advance directive may be enforced even in the face of opposition by the spouse.”
40. A client diagnosed with schizophrenia is shouting and banging on the door leading to the
outside, saying, “I need to go to an appointment.” What is the appropriate nursing
intervention?

A. Tell the client that he cannot bang on the door.

B. Ignore this behavior.
C. Escort the client going back into the room.
D. Ask the client to move away from the door.

41. Which of the following action is an accurate tracheal suctioning technique?

A. 25 seconds of continuous suction during catheter insertion.

B. 20 seconds of continuous suction during catheter insertion.
C. 10 seconds of intermittent suction during catheter withdrawal.
D. 15 seconds of intermittent suction during catheter withdrawal.

42. The client’s jaw and cheekbone is sutured and wired. The nurse anticipates that the most
important thing that must be ready at the bedside is:

A. Suture set.
B. Tracheostomy set.
C. Suction equipment.
D. Wire cutters.

43. A mother is in the third stage of labor. Which of the following signs will help the nurse
determine the signs of placental separation?

A. The uterus becomes globular.

B. The umbilical cord is shortened.
C. The fundus appears at the introitus.
D. Mucoid discharge is increased.

44. After therapy with the thrombolytic alteplase (t-PA. , what observation will the nurse
report to the physician?
A. 3+ peripheral pulses.
B. Change in level of consciousness and headache.
C. Occasional dysrhythmias.
D. Heart rate of 100/bpm.

45. A client who undergone left nephrectomy has a large flank incision. Which of the
following nursing action will facilitate deep breathing and coughing?

A. Push fluid administration to loosen respiratory secretions.

B. Have the client lie on the unaffected side.
C. Maintain the client in high Fowler’s position.
D. Coordinate breathing and coughing exercise with administration of analgesics.

46. The community nurse is teaching the group of mothers about the cervical mucus method
of natural family planning. Which characteristics are typical of the cervical mucus during the
“fertile” period of the menstrual cycle?

A. Absence of ferning.
B. Thin, clear, good spinnbarkeit.
C. Thick, cloudy.
D. Yellow and sticky.

47. A client with ruptured appendix had surgery an hour ago and is transferred to the nursing
care unit. The nurse placed the client in a semi-Fowler’s position primarily to:

A. Facilitate movement and reduce complications from immobility.

B. Fully aerate the lungs.
C. Splint the wound.
D. Promote drainage and prevent subdiaphragmatic abscesses.

48. Which of the following will best describe a management function?

A. Writing a letter to the editor of a nursing journal.

B. Negotiating labor contracts.
C. Directing and evaluating nursing staff members.
D. Explaining medication side effects to a client.

49. The parents of an infant client ask the nurse to teach them how to administer Cortisporin
eye drops. The nurse is correct in advising the parents to place the drops:

A. In the middle of the lower conjunctival sac of the infant’s eye.

B. Directly onto the infant’s sclera.
C. In the outer canthus of the infant’s eye.
D. In the inner canthus of the infant’s eye.

50. The nurse is assessing on the client who is admitted due to vehicle accident. Which of the
following findings will help the nurse that there is internal bleeding?

A. Frank blood on the clothing.

B. Thirst and restlessness.
C. Abdominal pain.
D. Confusion and altered of consciousness.

51. The nurse is completing an assessment to a newborn baby boy. The nurse observes that
the skin of the newborn is dry and flaking and there are several areas of an apparent macular
rash. The nurse charts this as:

A. Icterus neonatorum
B. Multiple hemangiomas
C. Erythema toxicum
D. Milia

52. The client is brought to the emergency department because of serious vehicle accident.
After an hour, the client has been declared brain dead. The nurse who has been with the client
must now talk to the family about organ donation. Which of the following consideration is
necessary?

A. Include as many family members as possible.

B. Take the family to the chapel.
C. Discuss life support systems.
D. Clarify the family’s understanding of brain death.

53. The nurse is teaching exercises that are good for pregnant women increasing tone and
fitness and decreasing lower backache. Which of the following should the nurse exclude in
the exercise program?

A. Stand with legs apart and touch hands to floor three times per day.
B. Ten minutes of walking per day with an emphasis on good posture.
C. Ten minutes of swimming or leg kicking in pool per day.
D. Pelvic rock exercise and squats three times a day.

54. A client with obsessive-compulsive behavior is admitted in the psychiatric unit. The nurse
taking care of the client knows that the primary treatment goal is to:

A. Provide distraction.
B. Support but limit the behavior.
C. Prohibit the behavior.
D. Point out the behavior.

55. After ileostomy, the nurse expects that the drainage appliance will be applied to the
stoma:

A. When the client is able to begin self-care procedures.

B. 24 hours later, when the swelling subsided.
C. In the operating room after the ileostomy procedure.
D. After the ileostomy begins to function.

56. A female client who has a 28-day menstrual cycle asks the community health nurse when
she get pregnant during her cycle. What will be the best nursing response?

A. It is impossible to determine the fertile period reliably. So it is best to assume that a

woman is always fertile.
B. In a 28-day cycle, ovulation occurs at or about day 14. The egg lives for about 24 hours
and the sperm live for about 72 hours. The fertile period would be approximately between day
11 and day 15.
C. In a 28- day cycle, ovulation occurs at or about day 14. The egg lives for about 72 hours
and the sperm live for about 24 hours. The fertile period would be approximately between day
13 and 17.
D. In a 28-day cycle, ovulation occurs 8 days before the next period or at about day 20. The
fertile period is between day 20 and the beginning of the next period.

57. Which of the following statement describes the role of a nurse as a client advocate?

A. A nurse may override clients’ wishes for their own good.

B. A nurse has the moral obligation to prevent harm and do well for clients.
C. A nurse helps clients gain greater independence and self-determination.
D. A nurse measures the risk and benefits of various health situations while factoring in cost.

58. A community health nurse is providing a health teaching to a woman infected with herpes
simplex 2. Which of the following health teaching must the nurse include to reduce the
chances of transmission of herpes simplex 2?

A. “Abstain from intercourse until lesions heal.”

B. “Therapy is curative.”
C. “Penicillin is the drug of choice for treatment.”
D. “The organism is associated with later development of hydatidiform mole.

59. The nurse in the psychiatric ward informed the male client that he will be attending the
9:00 AM group therapy sessions. The client tells the nurse that he must wash his hands from
9:00 to 9:30 AM each day and therefore he cannot attend. Which concept does the nursing
staff need to keep in mind in planning nursing intervention for this client?

A. Depression underlines ritualistic behavior.

B. Fear and tensions are often expressed in disguised form through symbolic processes.
C. Ritualistic behavior makes others uncomfortable.
D. Unmet needs are discharged through ritualistic behavior.

10. The nurse assesses the health condition of the female client. The client tells the nurse that
she discovered a lump in the breast last year and hesitated to seek medical advice. The nurse
understands that, women who tend to delay seeking medical advice after discovering the
disease are displaying what common defense mechanism?

A. Intellectualization.
B. Suppression.
C. Repression.
D. Denial.

61. Which of the following situations cannot be delegated by the registered nurse to the
nursing assistant?

A. A postoperative client who is stable needs to ambulate.

B. Client in soft restraint who is very agitated and crying.
C. A confused elderly woman who needs assistance with eating.
D. Routine temperature check that must be done for a client at end of shift.

62. In the admission care unit, which of the following client would the nurse give immediate
attention?

A. A client who is 3 days postoperative with left calf pain.

B. A client who is postoperative hip pinning who is complaining of pain.
C. New admitted client with chest pain.
D. A client with diabetes who has a glucoscan reading of 180.

63. A couple seeks medical advice in the community health care unit. A couple has been
unable to conceive; the man is being evaluated for possible problems. The physician ordered
semen analysis. Which of the following instructions is correct regarding collection of a sperm
specimen?

A. Collect a specimen at the clinic, place in iced container, and give to laboratory personnel
immediately.
B. Collect specimen after 48-72 hours of abstinence and bring to clinic within 2 hours.
C. Collect specimen in the morning after 24 hours of abstinence and bring to clinic
immediately.
D. Collect specimen at night, refrigerate, and bring to clinic the next morning.
64. The physician ordered Betamethasone to a pregnant woman at 34 weeks of gestation with
sign of preterm labor. The nurse expects that the drug will:

A. Treat infection.
B. Suppress labor contraction.
C. Stimulate the production of surfactant.
D. Reduce the risk of hypertension.

65. A tracheostomy cuff is to be deflated, which of the following nursing intervention should
be implemented before starting the procedures?

A. Suction the trachea and mouth.

B. Have the obdurator available.
C. Encourage deep breathing and coughing.
D. Do a pulse oximetry reading.

66. A client is diagnosed with Tuberculosis and respiratory isolation is initiated. This means
that:

A. Gloves are worn when handling the client’s tissue, excretions, and linen.
B. Both client and attending nurse must wear masks at all times.
C. Nurse and visitors must wear masks until chemotherapy is begun. Client is instructed in
cough and tissue techniques.
D. Full isolation; that is, caps and gowns are required during the period of contagion.

67. A client with lung cancer is admitted in the nursing care unit. The husband wants to know
the condition of his wife. How should the nurse respond to the husband?

A. Find out what information he already has.

B. Suggest that he discuss it with his wife.
C. Refer him to the doctor.
D. Refer him to the nurse in charge.

68. A hospitalized client cannot find his handkerchief and accuses other cient in the room and
the nurse of stealing them. Which is the most therapeutic approach to this client?
A. Divert the client’s attention.
B. Listen without reinforcing the client’s belief.
C. Inject humor to defuse the intensity.
D. Logically point out that the client is jumping to conclusions.

69. After a cystectomy and formation of an ileal conduit, the nurse provides instruction
regarding prevention of leakage of the pouch and backflow of the urine. The nurse is correct
to include in the instruction to empty the urine pouch:

A. Every 3-4 hours.

B. Every hour.
C. Twice a day.
D. Once before bedtime.

70. Which telephone call from a student’s mother should the school nurse take care of at
once?

A. A telephone call notifying the school nurse that the child’ pediatrician has informed the
mother that the child will need cardiac repair surgery within the next few weeks.
B. A telephone call notifying the school nurse that the child’s pediatrician has informed the
mother that the child has head lice.
C. A telephone call notifying the school nurse that a child has a temperature of 102ºF and a
rash covering the trunk and upper extremities of the body.
D. A telephone call notifying the school nurse that a child underwent an
emergency appendectomy during the previous night.

71. Which of the following signs and symptoms that require immediate attention and may
indicate most serious complications during pregnancy?

A. Severe abdominal pain or fluid discharge from the vagina.

B. Excessive saliva, “bumps around the areolae, and increased vaginal mucus.
C. Fatigue, nausea, and urinary frequency at any time during pregnancy.
D. Ankle edema, enlarging varicosities, and heartburn.
72. The nurse is assessing the newborn boy. Apgar scores are 7 and 9. The newborn becomes
slightly cyanotic. What is the initial nursing action?

A. Elevate his head to promote gravity drainage of secretions.

B. Wrap him in another blanket, to reduce heat loss.
C. Stimulate him to cry,, to increase oxygenation.
D. Aspirate his mouth and nose with bulb syringe.

73. The nurse is formulating a plan of care to a client with a somatoform disorder. The nurse
needs to have knowledge of which psychodynamic principle?
A. The symptoms of a somatoform disorder are an attempt to adjust to painful life situations
or to cope with conflicting sexual, aggressive, or dependent feelings.
B. The major fundamental mechanism is regression.
C. The client’s symptoms are imaginary and the suffering is faked.
D. An extensive, prolonged study of the symptoms will be reassuring to the client, who seeks
sympathy, attention and love.

74. An infant is brought to the health care clinic for three immunizations at the same time.
The nurse knows that hepatitis B, DPT, and Haemophilus influenzae type B immunizations
should:
A. Be drawn in the same syringe and given in one injection.
B. Be mixed and inject in the same sites.
C. Not be mixed and the nurse must give three injections in three sites.
D. Be mixed and the nurse must give the injection in three sites.

75. A female client with cancer has radium implants. The nurse wants to maintain the
implants in the correct position. The nurse should position the client:

A. Flat in bed.
B. On the side only.
C. With the foot of the bed elevated.
D. With the head elevated 45-degrees (semi-Fowler’s).
76. The nurse wants to know if the mother of a toddler understands the instructions regarding
the administration of syrup of ipecac. Which of the following statement will help the nurse to
know that the mother needs additional teaching?

A. “I’ll give the medicine if my child gets into some toilet bowl cleaner.”
B. “I’ll give the medicine if my child gets into some aspirin.”
C. “I’ll give the medicine if my child gets into some plant bulbs.”
D. “I’ll give the medicine if my child gets into some vitamin pills.”

77. To assess if the cranial nerve VII of the client was damaged, which changes would not be
expected?

A. Drooling and drooping of the mouth.

B. Inability to open eyelids on operative side.
C. Sagging of the face on the operative side.
D. Inability to close eyelid on operative side.

78. The community health nurse makes a home visit to a family. During the visit, the nurse
observes that the mother is beating her child. What is the priority nursing intervention in this
situation?

A. Assess the child’s injuries.

B. Report the incident to protective agencies.
C. Refer the family to appropriate support group.
D. Assist the family to identify stressors and use of other coping mechanisms to prevent
further incidents.

79. The nurse in the neonatal care unit is supervising the actions of a certified nursing
assistant in giving care to the newborns. The nursing assistant mistakenly gives a formula
feeding to a newborn that is on water feeding only. The nurse is responsible for the mistake of
the nursing assistant:

A. Always, as a representative of the institution.

B. Always, because nurses who supervise less-trained individuals are responsible for their
mistakes.
C. If the nurse failed to determine whether the nursing assistant was competent to take care of
the client.
D. Only if the nurse agreed that the newborn could be fed formula.

80. The nurse is assigned to care for a client with urinary calculi. Fluid intake of 2L/day is
encouraged to the client. the primary reason for this is to:

A. Reduce the size of existing stones.

B. Prevent crystalline irritation to the ureter.
C. Reduce the size of existing stones
D. Increase the hydrostatic pressure in the urinary tract.

81. The nurse is counseling a couple in their mid 30’s who have been unable to conceive for
about 6 months. They are concerned that one or both of them may be infertile. What is the
best advice the nurse could give to the couple?

A. “it is no unusual to take 6-12 months to get pregnant, especially when the partners are in
their mid-30s. Eat well, exercise, and avoid stress.”
B. “Start planning adoption. Many couples get pregnant when they are trying to adopt.”
C. “Consult a fertility specialist and start testing before you get any older.”
D. “Have sex as often as you can, especially around the time of ovulation, to increase your
chances of pregnancy.”

82. The nurse is caring for a cient who Is a retired nurse. A 24-hour urine collection for
Creatinine clearance is to be done. The client tells the nurse, “I can’t remember what this test
is for.” The best response by the nurse is:

A. “It provides a way to see if you are passing any protein in your urine.”
B. “It tells how well the kidneys filter wastes from the blood.”
C. “It tells if your renal insufficiency has affected your heart.”
D. “The test measures the number of particles the kidney filters.”

83. The nurse observes the female client in the psychiatric ward that she is having a hard time
sleeping at night. The nurse asks the client about it and the client says, “I can’t sleep at night
because of fear of dying.” What is the best initial nursing response?
A. “It must be frightening for you to feel that way. Tell me more about it.”
B. “Don’t worry, you won’t die. You are just here for some test.”
C. “Why are you afraid of dying?”
D. “Try to sleep. You need the rest before tomorrow’s test.”

84. In the hospital lobby, the registered nurse overhears a two staff members discussing about
the health condition of her client. What would be the appropriate action for the registered
nurse to take?

A. Join in the conversation, giving her input about the case.

B. Ignore them, because they have the right to discuss anything they want to.
C. Tell them it is not appropriate to discuss such things.
D. Report this incident to the nursing supervisor.

85. The client has had a right-sided cerebrovascular accident. In transferring the client from
the wheelchair to bed, in what position should a client be placed to facilitate safe transfer?

A. Weakened (L) side of the cient next to bed.

B. Weakened (R) side of the client next to bed.
C. Weakened (L) side of the client away from bed.
D. Weakened (R) side of the cient away from bed.

86. The child client has undergone hip surgery and is in a spica cast. Which of the following
toy should be avoided to be in the child’s bed?

A. A toy gun.
B. A stuffed animal.
C. A ball.
D. Legos.

87. The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10 units (IV or IM) must
be given to a client after birth fo the fetus. The nurse is correct to explain that oxytocin:

A. Minimizes discomfort from “afterpains.”

B. Suppresses lactation.
C. Promotes lactation.
D. Maintains uterine tone.

88. The nurse in the nursing care unit is aware that one of the medical staff displays unlikely
behaviors like confusion, agitation, lethargy and unkempt appearance. This behavior has been
reported to the nurse manager several times, but no changes observed. The nurse should:

A. Continue to report observations of unusual behavior until the problem is resolved.

B. Consider that the obligation to protect the patient from harm has been met by the prior
reports and do nothing further.
C. Discuss the situation with friends who are also nurses to get ideas .
D. Approach the partner of this medical staff member with these concerns.

89. The physician ordered tetracycline PO qid to a child client who weights 20kg. The
recommended PO tetracycline dose is 25-50 mg/kg/day. What is the maximum single dose
that can be safely administered to this child?

A. 1 g
B. 500 mg
C. 250 mg
D. 125 mg

90. The nurse is completing an obstetric history of a woman in labor. Which event in
the obstetric history will help the nurse suspects dysfunctional labor in the current pregnancy?

A. Total time of ruptured membranes was 24 hours with the second birth.
B. First labor lasting 24 hours.
C. Uterine fibroid noted at time of cesarean delivery.
D. Second birth by cesarean for face presentation.

91. The nurse is planning to talk to the client with an antisocial personality disorder. What
would be the most therapeutic approach?

A. Provide external controls.

B. Reinforce the client’s self-concept.
C. Give the client opportunities to test reality.
D. Gratify the client’s inner needs.

92. The nurse is teaching a group of women about fertility awareness, the nurse should
emphasize that basal body temperature:

A. Can be done with a mercury thermometer but no a digital one.

B. The average temperature taken each morning.
C. Should be recorded each morning before any activity.
D. Has a lower degree of accuracy in predicting ovulation than the cervical mucus test.

93. The nursing applicant has given the chance to ask questions during a job interview at a
local hospital. What should be the most important question to ask that can increase chances of
securing a job offer?

A. Begin with questions about client care assignments, advancement opportunities, and
continuing education.
B. Decline to ask questions, because that is the responsibility of the interviewer.
C. Ask as many questions about the facility as possible.
D. Clarify information regarding salary, benefits, and working hours first, because this will
help in deciding whether or not to take the job.

94. The nurse advised the pregnant woman that smoking and alcohol should be avoided
during pregnancy. The nurse takes into account that the developing fetus is most vulnerable to
environment teratogens that cause malformation during:

A. The entire pregnancy.

B. The third trimester.
C. The first trimester.
D. The second trimester.

95. A male client tells the nurse that there is a big bug in his bed. The most therapeutic
nursing response would be:
A. Silence.
B. “Where’s the bug? I’ll kill it for you.”
C. “I don’t see a bug in your bed, but you seem afraid.”
D. “You must be seeing things.”

96. A pregnant client in late pregnancy is complaining of groin pain that seems worse on the
right side. Which of the following is the most likely cause of it?

A. Beginning of labor.
B. Bladder infection.
C. Constipation.
D. Tension on the round ligament.

97. The nurse is conducting a lecture to a group of volunteer nurses. The nurse is correct in
imparting the idea that the Good Samaritan law protects the nurse from a suit for malpractice
when:

A. The nurse stops to render emergency aid and leaves before the ambulance arrives.
B. The nurse acts in an emergency at his or her place of employment.
C. The nurse refuses to stop for an emergency outside of the scope of employment.
D. The nurse is grossly negligent at the scene of an emergency.

98. A woman is hospitalized with mild preeclampsia. The nurse is formulating a plan of care
for this client, which nursing care is least likely to be done?

A. Deep-tendon reflexes once per shift.

B. Vital signs and FHR and rhythm q4h while awake.
C. Absolute bed rest.
D. Daily weight.

99. While feeding a newborn with an unrepaired cardiac defect, the nurse keeps on assessing
the condition of the client. The nurse notes that the newborn’s respiration is 72 breaths per
minute. What would be the initial nursing action?
A. Burp the newborn.
B. Stop the feeding.
C. Continue the feeding.
D. Notify the physician.

100. A client who undergone appendectomy 3 days ago is scheduled for discharge today. The
nurse notes that the client is restless, picking at bedclothes and saying, “I am late on my
appointment,” and calling the nurse by the wrong name. The nurse suspects:

A. Panic reaction.
B. Medication overdose.
C. Toxic reaction to an antibiotic.
D. Delirium tremens.

[divider] Answers & Rationale

1. A. The oxytocic effect of Pitocin increases the intensity and durations of contractions;
prolonged contractions will jeopardize the safetyof the fetus and necessitate discontinuing the
drug.

2. B. It is of paramount importance to prevent the client from hurting himself or herself or

others.

3. B. After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and hot or
cold liquids should be avoided because they may irritate the throat. Red liquids should be
avoided because they give the appearance of blood if the child vomits. Milk and milk
products including pudding are avoided because they coat the throat, cause the child to clear
the throat, and increase the risk of bleeding.

4. A. Phenylephrine, with frequent and continued use, can cause rebound congestion of
mucous membranes.

5. B. The N 95 respirator is a high-particulate filtration mask that meets the CDC performance
criteria for a tuberculosis respirator.
6. C. The most frequent cause of noncompliance to the treatment of chronic, or open-angle
glaucoma is the miotic effects of pilocarpine. Pupillary constriction impedes normal
accommodation, making night driving difficult and hazardous, reducing the client’s ability to
read for extended periods and making participation in games with fast-moving objects
impossible.

7. B. This stops the sucking of air through the tube and prevents the entry of contaminants. In
addition, clamping near the chest wall provides for some stability and may prevent the clamp
from pulling on the chest tube.

8. D. Because umbilical cord’s insertion site is born before the fetal head, the cord may be
compressed by the after-coming head in a breech birth.

9. B. It is important to externalize the anger away from self.

10. D. Development normally proceeds cephalocaudally; so the first major developmental

milestone that the infant achieves is the ability to hold the head up within the first 8-12 weeks
of life. In hypothyroidism, the infant’s muscle tone would be poor and the infant would not be
able to achieve this milestone.

11. D. Get a senior nurse who know s the policies, the client, and the doctor. Generally
speaking, a nurse should not accept telephone orders. However, if it is necessary to take one,
follow the hospital’s policy regarding telephone orders. Failure to followhospital policy could
be considered negligence. In this case, the nurse was new and did not know the hospital’s
policy concerning telephone orders. The nurse was also unfamiliar with the doctor and the
client. Therefore the nurse should not take the order unless A. no one else is available and B.
it is an emergency situation.

12. C. The nurse is obligated to inform the nurse manager about changes in the condition of
the client, which may change the decision made by the nurse manager.

13. A. Perinatal risk factors for the development of Down syndrome include advanced
maternal age, especially with the first pregnancy.

14. B. Assignments should be based on scope of practice and expertise.

15. B. The child who is concurrently taking digoxin and diuretics is at increased risk
for digoxin toxicity due to the loss of potassium. The child and parents should be taught what
foods are high in potassium, and the child should be encouraged to eat a high-potassium diet.
In addition, the child’s serum potassium level should be carefully monitored.

16. A. The responsible for an accurate informed consent is the physician. An exception to this
answer would be a life-threatening emergency, but there are no data to support another
response.

17. D. Asking the client to cough and take a deep breath will help determine if the chest tube
is kinked or if the lungs has reexpanded.

18. B. Every event that exposes a client to harm should be recorded in an incident report, as
well as reported to the appropriate supervisors in order to resolve the current problems and
permit the institution to prevent the problem from happening again.

19. D. One of the earliest signs of digoxin toxicity is Bradycardia. For a toddler, any heart rate
that falls below the norm of about 100-120 bpm would indicate Bradycardia and would
necessitate holding the medication and notifying the physician.

20. B. This option is least threatening.

21. D. In preparing the client for discharge that is receiving prednisone, the nurse should
caution the client to (A. take oral preparations after meals; (B. remember that routine checks
of vital signs, weight, and lab studies are critical; (C. NEVER STOP OR CHANGE THE
AMOUNT OF MEDICATION WITHOUT MEDICAL ADVICE; (D. store the medication in
a light-resistant container.

22. A. Progesterone also reduces smooth muscle motility in the urinary tract and predisposes
the pregnant woman to urinary tract infections. Women should contact their doctors if they
exhibit signs of infection. Kegel exercise will help strengthen the perineal muscles; limiting
fluids at bedtime reduces the possibility of being awakened by the necessity of voiding.

23. B. This is the proper use of anger.

24. C. There are several models of case management, but the commonality is comprehensive
coordination of care to better predict needs of high-risk clients, decrease exacerbations and
continually monitor progress overtime.

25. A. Phenytoin should be infused or injected into larger veins to avoid the discoloration
know as purple glove syndrome; infusing into a smaller vein is not appropriate.

26. C. Serum radioimmunoassay (RIA. is accurate within 7days of conception. This test is
specific for HCG, and accuracy is not compromised by confusion with LH.

27. D. Surgery and anesthesia can increase mucus production. Deep breathing and coughing
are essential to prevent atelectasis and pneumonia in the client’s only remaining lung.

28. B. Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophiliA. and
conjunctivitis from Chlamydia.

29. D. The client may perceive this as avoidance, but it is more important to redirect back to
the client, especially in light of the manipulative behavior of drug abusers and adolescents.

30. C. It describes a democratic process in which all members have input in the client’s care.

31. A. Contraction of the milk ducts and let-down reflex occur under the stimulation of
oxytocin released by the posterior pituitary gland.

32. B. In case management, the nurse assumes total responsibility for meeting the needs of the
client during the entire time on duty.

33. A. Smoke inhalation affects gas exchange.

34. C. Sperm deposited during intercourse may remain viable for about 3 days. If ovulation
occurs during this period, conception may result.

35. B. This option shows acceptance (key concept) of this age-typical sleep pattern (that of
waking in the early morning).
36. D. Taking the mother’s pulse while listening to the FHR will differentiate between the
maternal and fetal heart rates and rule out fetal Bradycardia.

37. A. Antihistamines cause pupil dilation and should be avoided with glaucoma.

38. A. This suggests that the level of consciousness is decreasing.

39. D. An advance directive is a form of informed consent, and only a competent adult or the
holder of a durable power of attorney has the right to consent or refuse treatment. If the
spouse does not hold the power of attorney, the decisions of the holder, even if opposed by
the spouse, are enforced.

40. C. Gentle but firm guidance and nonverbal direction is needed to intervene when a client
with schizophrenic symptoms is being disruptive.

41. C. Suctioning is only done for 10 seconds, intermittently, as the catheter is being
withdrawn.

42. D. The priority for this client is being able to establish an airway.

43. A. Signs of placental separation include a change in the shape of the uterus from ovoid to
globular.

44. B. This could indicate intracranial bleeding. Alteplase is a thrombolytic enzyme that lyses
thrombi and emboli. Bleeding is an adverse effect. Monitor clotting times and signs of any
gastrointestinal or internal bleeding.

45. D. Because flank incision in nephrectomy is directly below the diaphragm, deep breathing
is painful. Additionally, there is a greater incisional pull each time the person moves than
there is with abdominal surgery. Incisional pain following nephrectomy generally requires
analgesics administration every 3-4 hours for 24-48 hours after surgery. Therefore, turning,
coughing and deep-breathing exercises should be planned to maximize the analgesic effects.

46. B. Under high estrogen levels, during the period surrounding ovulation, the cervical
mucus becomes thin, clear, and elastic (spinnbarkeit), facilitating sperm passage.
47. D. After surgery for a ruptured appendix, the client should be placed in a semi-Fowler’s
position to promote drainage and to prevent possible complications.

48. C. Directing and evaluation of staff is a major responsibility of a nursing manager.

49. A. The recommended procedure for administering eyedrops to any client calls for the
drops to be placed in the middle of the lower conjunctival sac.

50. B. Thirst and restlessness indicate hypovolemia and hypoxemia. Internal bleeding is
difficult to recognized and evaluate because it is not apparent.

51. C. Erythema toxicum is the normal, nonpathological macular newborn rash.

52. D. The family needs to understand what brain death is before talking about organ donation.
They need time to accept the death of their family member. An environment conducive to
discussing an emotional issue is needed.

53. A. Bending from the waist in pregnancy tends to make backache worse.

54. B. Support and limit setting decrease anxiety and provide external control.

55. C. The stoma drainage bag is applied in the operating room. Drainage from the ileostomy
contains secretions that are rich in digestive enzymes and highly irritating to the skin.
Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to
these enzymes even for a short time becomes reddened, painful and excoriated.

56. B. It is the most accurate statement of physiological facts for a 28-day menstrual cycle:
ovulation at day 14, egg life span 24 hours, sperm life span of 72 hours. Fertilization could
occur from sperm deposited before ovulation.

57. C. An advocate role encourage freedom of choice, includes speaking out for the client,
and supports the client’s best interests.

58. A. Abstinence will eliminate any unnecessary pain during intercourse and will reduce the
possibility of transmitting infection to one’s sexual partner.
59. B. Anxiety is generated by group therapy at 9:00 AM. The ritualistic behavioral defense
of hand washing decreases anxiety by avoiding group therapy.

60. D. Denial is a very strong defense mechanism used to allay the emotional effects of
discovering a potential threat. Although denial has been found to be an effective mechanism
for survival in some instances, such as during natural disasters, it may in greater pathology in
a woman with potential breast carcinoma.

61. B. The registered nurse cannot delegate the responsibility for assessment and evaluation
of clients. The status of the client in restraint requires further assessment to determine if there
are additional causes for the behavior.

62. C. The client with chest pain may be having a myocardial infarction, and immediate
assessment and intervention is a priority.

63. B. Is correct because semen analysis requires that a freshly masturbated specimen be
obtained after a rest (abstinence) period of 48-72 hours.

64. C. Betamethasone, a form of cortisone, acts on the fetal lungs to produce surfactant.

65. A. Secretions may have pooled above the tracheostomy cuff. If these are not suctioned
before deflation, the secretions may be aspirated.

66. C. Proper handling of sputum is essential to allay droplet transference of bacilli in the air.
Clients need to be taught to cover their nose and mouth with tissues when sneezing or
coughing. Chemotherapy generally renders the client noninfectious within days to a few
weeks, usually before cultures for tubercle bacilli are negative. Until chemical isolation is
established, many institutions require the client to wear a mask when visitors are in the room
or when the nurse is in attendance. Client should be in a well-ventilated room, without air
recirculation, to prevent air contamination.

67. A. It is best to establish baseline information first.

68. B. Listening is probably the most effective response of the four choices.
69. A. Urine flow is continuous. The pouch has an outlet valve for easy drainage every 3-4
hours. (the pouch should be changed every 3-5 days, or sooner if the adhesive is loose).

70. C. A high fever accompanied by a body rash could indicate that the child has a
communicable disease and would have exposed other students to the infection. The school
nurse would want to investigate this telephone call immediately so that plans could be
instituted to control the spread of such infection.

71. A. Severe abdominal pain may indicate complications of pregnancy such as

abortion, ectopic pregnancy, or abruption placenta; fluid discharge from the vagina may
indicate premature rupture of the membrane.

72. D. Gentle aspiration of mucus helps maintain a patent airway, required for effective gas
exchange.

73. A. Somatoform disorders provide a way of coping with conflicts.

74. C. Immunization should never be mixed together in a syringe, thus necessitating three
separate injections in three sites. Note: some manufacturers make a premixed combination of
immunization that is safe and effective.

75. A. Clients with radioactive implants should be positioned flat in bed to prevent
dislodgement of the vaginal packing. The client may roll to the side for meals but the upper
body should not be raised more than 20 degrees.

76. A. Syrup of ipecac is not administered when the ingested substances is corrosive in nature.
Toilet bowl cleaners, as a collective whole, are highly corrosive substances. If the ingested
substance “burned” the esophagus going down, it will “burn” the esophagus coming back up
when the child begins to vomit after administration of syrup of ipecac.

77. B. Inability to open eyelids on operative side is seen with cranial nerve III damage.

78. A. Assessment of physical injuries (like bruises, lacerations, bleeding and fractures) is the
first priority.
79. C. The nurse who is supervising others has a legal obligation to determine that they are
competent to perform the assignment, as well as legal obligation to provide adequate
supervision.

80. D. Increasing hydrostatic pressure in the urinary tract will facilitate passage of the calculi.

81. A. Infertility is not diagnosed until atleast 12months of unprotected intercourse has failed
to produce a pregnancy. Older couples will experience a longer time to get pregnant.

82. B. Determining how well the kidneys filter wastes states the purpose of a Creatinine
clearance test.

83. A. Acknowledging a feeling tone is the most therapeutic response and provides a broad
opening for the client to elaborate feelings.

84. C. The behavior should be stopped. The first is to remind the staff that confidentiality
maybe violated.

85. C. With a right-sided cerebrovascular accident the client would have left-sided hemiplegia
or weakness. The client’s good side should be closest to the bed to facilitate the transfer.

86. D. Legos are small plastic building blocks that could easily slip under the child’s cast and
lead to a break in skin integrity and even infection. Pencils, backscratchers, and marbles are
some other narrow or small items that could easily slip under the child’s cast and lead to a
break in skin integrity and infection.

87. D. Oxytocin (Pitocin) is used to maintain uterine tone.

88. B. The submission of reports about incidents that expose clients to harm does not remove
the obligation to report ongoing behavior as long as the risk to the client continues.

89. C. The recommended dosage of tetracycline is 25-50mg/kg/day. If the child weighs 20kg
and the maximum dose is 50mg/kg, this would indicate a total daily dose of 1000mg of
tetracycline. In this case, the child is being given this medication four times a day. Therefore
the maximum single dose that can be given is 250mg (1000 mg of tetracycline divided by
four doses.)

90. C. An abnormality in the uterine muscle could reduce the effectiveness of uterine
contractions and lengthen the duration of subsequent labors.

91. A. Personality disorders stem from a weak superego, implying a lack of adequate controls.

92. C. The basal body temperature is the lowest body temperature of a healthy person that is
taken immediately after waking and before getting out of bed. The BBT usually varies from
36.2 ºC to 36.3ºC during menses and for about 5-7 days afterward. About the time of
ovulation, a slight drop in temperature may be seen, after ovulation in concert with the
increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 ºC. This
elevation remains until 2-3 days before menstruation, or if pregnancy has occurred.

93. A. This choice implies concern for client care and self-improvement.

94. C. The first trimester is the period of organogenesis, that is, cell differentiation into the
various organs, tissues, and structures.

95. C. This response does not contradict the client’s perception, is honest, and shows
empathy.

96. D. Tension on round ligament occurs because of the erect human posture and pressure
exerted by the growing fetus.

97. D. The Good Samaritan Law does not impose a duty to stop at the scene of an emergency
outside of the scope of employment, therefore nurses who do not stop are not liable for suit.

98. C. Although reducing environment stimuli and activity is necessary for a woman with
mild preeclampsia, she will most probably have bathroom privileges.

99. B. A normal respiratory rate for a newborn is 30-40 breaths per minute.
100. D. The behavior described is likely to be symptoms of delirium tremens, or alcohol
withdrawal (often unsuspected on a surgical unit.)

1. A 10 year old who has sustained a head injury is brought to the emergency department by
his mother. A diagnosis of a mild concussion is made. At the time of discharge, nurse Ron
should instruct the mother to:

A. Withhold food and fluids for 24 hours.

B. Allow him to play outdoors with his friends.
C. Arrange for a follow up visit with the child’s primary care provider in one week.
C. Check for any change in responsiveness every two hours until the follow-up visit.

2. A male client has suffered a motor accident and is now suffering from hypovolemic shock.
Nurse Helen should frequency assess the client’s vital signs during the compensatory stage of
shock, because:

A. Arteriolar constriction occurs

B. The cardiac workload decreases
C. Decreased contractility of the heart occurs
D. The parasympathetic nervous system is triggered

3. A paranoid male client with schizophrenia is losing weight, reluctant to eat, and voicing
concerns about being poisoned. The best intervention by nurse Dina would be to:

A. Allow the client to open canned or pre-packaged food

B. Restrict the client to his room until 2 lbs are gained
C. Have a staff member personally taste all of the client’s food
D. Tell the client the food has been x-rayed by the staff and is safe

4. One day the mother of a young adult confides to nurse Frida that she is very troubled by he
child’s emotional illness. The nurse’s most therapeutic initial response would be:
A. “You may be able to lessen your feelings of guilt by seeking counseling”
B. “It would be helpful if you become involved in volunteer work at this time”
C. “I recognize it’s hard to deal with this, but try to remember that this too shall pass”
D. “Joining a support group of parents who are coping with this problem can be quite helpful.

5. To check for wound hemorrhage after a client has had a surgery for the removal of a tumor
in the neck, nurse grace should:

A. Loosen an edge of the dressing and lift it to see the wound

B. Observe the dressing at the back of the neck for the presence of blood
C. Outline the blood as it appears on the dressing to observe any progression
D. Press gently around the incision to express accumulated blood from the wound

6. A 16-year-old primigravida arrives at the labor and birthing unit in her 38th week of
gestation and states that she is labor. To verify that the client is in true labor nurse Trina
should:

A. Obtain sides for a fern test

B. Time any uterine contractions
C. Prepare her for a pelvic examination
D. Apply nitrazine paper to moist vaginal tissue

7. As part of the diagnostic workup for pulmonic stenosis, a child has cardiac catheterization.
Nurse Julius is aware that children with pulmonic stenosis have increased pressure:

A. In the pulmonary vein

B. In the pulmonary artery
C. On the left side of the heart
D. On the right side of the heart

8. An obese client asks nurse Julius how to lose weight. Before answering, the nurse should
remember that long-term weight loss occurs best when:

A. Eating patterns are altered

B. Fats are limited in the diet
C. Carbohydrates are regulated
D. Exercise is a major component

9. As a very anxious female client is talking to the nurse May, she starts crying. She appears
to be upset that she cannot control her crying. The most appropriate response by the nurse
would be:

A. “Is talking about your problem upsetting you?”

B. “It is Ok to cry; I’ll just stay with you for now”
C. “You look upset; lets talk about why you are crying.”
D. “Sometimes it helps to get it out of your system.”

10. A patient has partial-thickness burns to both legs and portions of his trunk. Which of the
following I.V. fluids is given first?

A. Albumin
B. D5W
C. Lactated Ringer’s solution
D. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml

11. During the first 48 hours after a severe burn of 40% of the clients body surface, the
nurse’s assessment should include observations for water intoxication. Associated adaptations
include:

A. Sooty-colored sputum
B. Frothy pink-tinged sputum
C. Twitching and disorientation
D. Urine output below 30ml per hour

12. After a muscle biopsy, nurse Willy should teach the client to:

A. Change the dressing as needed

B. Resume the usual diet as soon as desired
C. Bathe or shower according to preference
D. Expect a rise in body temperature for 48 hours
13. Before a client whose left hand has been amputated can be fitted for a prosthesis, nurse
Joy is aware that:

A. Arm and shoulder muscles must be developed

B. Shrinkage of the residual limb must be completed
C. Dexterity in the other extremity must be achieved
D. Full adjustment to the altered body image must have occurred

14. Nurse Cathy applies a fetal monitor to the abdomen of a client in active labor. When the
client has contractions, the nurse notes a 15 beat per minute deceleration of the fetal heart
rate below the baseline lasting 15 seconds. Nurse Cathy should:

A. Change the maternal position

B. Prepare for an immediate birth
C. Call the physician immediately
D. Obtain the client’s blood pressure

15. A male client receiving prolonged steroid therapy complains of always being thirsty and
urinating frequently. The best initial action by the nurse would be to:

A. Perform a finger stick to test the client’s blood glucose level

B. Have the physician assess the client for an enlarged prostate
C. Obtain a urine specimen from the client for screening purposes
D. Assess the client’s lower extremities for the presence of pitting edema

16. Nurse Bea recognizes that a pacemaker is indicated when a client is experiencing:

A. Angina
B. Chest pain
C. Heart block
D. Tachycardia

17. When administering pancrelipase (Pancreases capsules) to child with cystic fibrosis, nurse
Faith knows they should be given:
A. With meals and snacks
B. Every three hours while awake
C. On awakening, following meals, and at bedtime
C. After each bowel movement and after postural draianage

18. A preterm neonate is receiving oxygen by an overhead hood. During the time the infant is
under the hood, it would be appropriate for nurse Gian to:

A. Hydrate the infant q15 min

B. Put a hat on the infant’s head
C. Keep the oxygen concentration consistent
D. Remove the infant q15 min for stimulation

19. A client’s sputum smears for acid fast bacilli (AFB) are positive, and transmission-based
airborne precautions are ordered. Nurse Kyle should instruct visitors to:

A.Limit contact with non-exposed family members

B. Avoid contact with any objects present in the client’s room
C. Wear an Ultra-Filter mask when they are in the client’s room
D. Put on a gown and gloves before going into the client’s room

20. A client with a head injury has a fixed, dilated right pupil; responds only to painful stimuli;
and exhibits decorticate posturing. Nurse Kate should recognize that these are signs of:

A. Meningeal irritation
B. Subdural hemorrhage
C. Medullary compression
D. Cerebral cortex compression

21. After a lateral crushing chest injury, obvious right-sided paradoxic motion of the client’s
chest demonstrates multiple rib fraactures, resulting in a flail chest. The complication the
nurse should carefully observe for would be:

A. Mediastinal shift
B. Tracheal laceration
C. Open pneumothorax
D. Pericardial tamponade

22. When planning care for a client at 30-weeks gestation, admitted to the hospital after
vaginal bleeding secondary to placenta previa, the nurse’s primary objective would be:

A. Provide a calm, quiet environment

B. Prepare the client for an immediate cesarean birth
C. Prevent situations that may stimulate the cervix or uterus
D. Ensure that the client has regular cervical examinations assess for labor

23. When planning discharge teaching for a young female client who has had a pneumothorax,
it is important that the nurse include the signs and symptoms of a pneumothorax and teach the
client to seek medical assistance if she experiences:

A. Substernal chest pain

B. Episodes of palpitation
C. Severe shortness of breath
D. Dizziness when standing up

24. After a laryngectomy, the most important equipment to place at the client’s bedside would
be:

A. Suction equipment
B. Humidified oxygen
C. A nonelectric call bell
D. A cold-stream vaporizer

25. Nurse Oliver interviews a young female client with anorexia nervosa to obtain
information for the nursing history. The client’s history is likely to reveal a:

A. Strong desire to improve her body image

B. Close, supportive mother-daughter relationship
C. Satisfaction with and desire to maintain her present weight
D. Low level of achievement in school, with little concerns for grades
26. Nurse Bea should plan to assist a client with an obsessive-compulsive disorder to control
the use of ritualistic behavior by:

A. Providing repetitive activities that require little thought

B. Attempting to reduce or limit situations that increase anxiety
C. Getting the client involved with activities that will provide distraction
D. Suggesting that the client perform menial tasks to expiate feelings of guilt

27. A 2 ½ year old child undergoes a ventriculoperitoneal shunt revision. Before discharge,
nurse John, knowing the expected developmental behaviors for this age group, should tell the
parents to call the physician if the child:

A. Tries to copy all the father’s mannerisms

B. Talks incessantly regardless of the presence of others
C. Becomes fussy when frustrated and displays a shortened attention span
D. Frequently starts arguments with playmates by claiming all toys are “mine”

28. A urinary tract infection is a potential danger with an indwelling catheter. Nurse Gina can
best plan to avoid this complication by:

A. Assessing urine specific gravity

B. Maintaining the ordered hydration
C. Collecting a weekly urine specimen
D. Emptying the drainage bag frequently

29. A client has sustained a fractured right femur in a fall on stairs. Nurse Troy with the
emergency response team assess for signs of circulatory impairment by:

A. Turning the client to side lying position

B. Asking the client to cough and deep breathe
C. Taking the client’s pedal pulse in the affected limb
D. Instructing the client to wiggle the toes of the right foot

30. To assess orientation to place in a client suspected of having dementia of the alzheimers
type, nurse Chris should ask:
A. “Where are you?”
B. “Who brought you here?”
C. “Do you know where you are?”
D. “How long have you been there?”

31. Nurse Mary assesses a postpartum client who had an abruption placentae and suspects
that disseminated intravascular coagulation (DIC) is occurring when assessments
demonstrate:

A. A boggy uterus
B. Multiple vaginal clots
C. Hypotension and tachycardia
D. Bleeding from the venipuncture site

32. When a client on labor experiences the urge to push a 9cm dilation, the breathing
pattern that nurse Rhea should instruct the client to use is the:

A. Expulsion pattern
B. Slow paced pattern
C. Shallow chest pattern
D. blowing pattern

33. Nurse Ronald should explain that the most beneficial between-meal snack for a client who
is recovering from the full-thickness burns would be a:

A. Cheeseburger and a malted

B. Piece of blueberry pie and milk
C. Bacon and tomato sandwich and tea
D. Chicken salad sandwich and soft drink

34. Nurse Wilma recognizes that failure of a newborn to make the appropriate adaptation to
extrauterine life would be indicated by:

A. flexed extremities
B. Cyanotic lips and face
C. A heart rate of 130 beats per minute
D. A respiratory rate of 40 breath per minute

35. The laboratory calls to state that a client’s lithium level is 1.9 mEq/L after 10 days of
lithium therapy. Nurse Reese should:

A. Notify the physician of the findings because the level is dangerously high
B. Monitor the client closely because the level of lithium in the blood is slightly elevated
C. Continue to administer the medication as ordered because the level is within the
therapeutic range
D. Report the findings to the physician so the dosage can be increased because the level is
below therapeutic range

36. A client has a regular 30-day menstrual cycles. When teaching about the rhythm method,
Which the client and her husband have chosen to use for family planning, nurse Dianne
should emphasize that the client’s most fertile days are:

A. Days 9 to 11
B. Days 12 to 14
C. Days 15 to 17
D. Days 18 to 20

37. Before an amniocentesis, nurse Alexandra should:

A. Initiate the intravenous therapy as ordered by the physiscian

B. Inform the client that the procedure could precipitate an infection
C. Assure that informed consent has been obtained from the client
D. Perform a vaginal examination on the client to assess cervical dilation

38. While a client is on intravenous magnesium sulfate therapy for preeclampsia, it is

essential for nurse Amy to monitor the client’s deep tendon reflexes to:

A. Determine her level of consciousness

B. Evaluate the mobility of the extremities
C. Determine her response to painful stimuli
D. Prevent development of respiratory distress

39. A preschooler is admitted to the hospital with a diagnosis of acute glomerulonephritis.

The child’s history reveals a 5-pound weight gain in one week and peritoneal edema. For the
most accurate information on the status of the child’s edema, nursing intervention should
include:

A. Obtaining the child’s daily weight

B. Doing a visual inspection of the child
C. Measuring the child’s intake and output
D. Monitoring the child’s electrolyte values

40. Nurse Mickey is administering dexamethasome (Decadron) for the early management of a
client’s cerebral edema. This treatment is effective because:

A. Acts as hyperosmotic diuretic

B. Increases tissue resistance to infection
C. Reduces the inflammatory response of tissues
D. Decreases the information of cerebrospinal fluid

41. During newborn nursing assessment, a positive Ortolani’s sign would be indicated by:

A. A unilateral droop of hip

B. A broadening of the perineum
C. An apparent shortening of one leg
D. An audible click on hip manipulation

42. When caring for a dying client who is in the denial stage of grief, the best nursing
approach would be to:

A. Agree and encourage the client’s denial

B. Allow the denial but be available to discuss death
C. Reassure the client that everything will be OK
D. Leave the client alone to confront the feelings of impending loss
43. To decrease the symptoms of gastroesophageal reflux disease (GERD), the physician
orders dietary and medication management. Nurse Helen should teach the client that the meal
alteration that would be most appropriate would be:

A. Ingest foods while they are hot

B. Divide food into four to six meals a day
C.Eat the last of three meals daily by 8pm
D. Suck a peppermint candy after each meal

44. After a mastectomy or hysterectomy, clients may feel incomplete as women. The
statement that should alert nurse Gina to this feeling would be:

A. “I can’t wait to see all my friends again”

B. “I feel washed out; there isn’t much left”
C. “I can’t wait to get home to see my grandchild”
D. “My husband plans for me to recuperate at our daughter’s home”

45. A client with obstruction of the common bile duct may show a prolonged bleeding and
clotting time because:

A. Vitamin K is not absorbed

B. The ionized calcium levels falls
C. The extrinsic factor is not absorbed
D. Bilirubin accumulates in the plasma

46. Realizing that the hypokalemia is a side effect of steroid therapy, nurse Monette should
monitor a client taking steroid medication for:

A. Hyperactive reflexes
B. An increased pulse rate
C. Nausea, vomiting, and diarrhea
D. Leg weakness with muscle cramps

47. When assessing a newborn suspected of having Down syndrome, nurse Rey would expect
to observe:
A. long thin fingers
B. Large, protruding ears
C. Hypertonic neck muscles
D. Simian lines on the hands

48. A 10 year old girl is admitted to the pediatric unit for recurrent pain and swelling of her
joints, particularly her knees and ankles. Her diagnosis is juvenile rheumatoid arthritis. Nurse
Janah recognizes that besides joint inflammation, a unique manifestation of the rheumatoid
process involves the:

A. Ears
B. Eyes
C. Liver
D. Brain

49. A disturbed client is scheduled to begin group therapy. The client refuses to attend. Nurse
Lolit should:

A. Accept the client’s decision without discussion

B. Have another client to ask the client to consider
C. Tell the client that attendance at the meeting is required
D. Insist that the client join the group to help the socialization process

50. Because a severely depressed client has not responded to any of the antidepressant
medications, the psychiatrist decides to try electroconvulsive therapy (ECT). Before the
treatment the nurse should:

A. Have the client speak with other clients receiving ECT

B. Give the client a detailed explanation of the entire procedure
C. Limit the client’s intake to a light breakfast on the days of the treatment
D. Provide a simple explanation of the procedure and continue to reassure the client

51. Nurse Vicky is aware that teaching about colostomy care is understood when the client
states, “I will contact my physician and report ____”:
A. If I notice a loss of sensation to touch in the stoma tissue”
B. When mucus is passed from the stoma between irrigations”
C. The expulsion of flatus while the irrigating fluid is running out”
D. If I have difficulty in inserting the irrigating tube into the stoma”

52. The client’s history that alerts nurse Henry to assess closely for signs
of postpartuminfection would be:

A. Three spontaneous abortions

B. negative maternal blood type
C. Blood loss of 850 ml after a vaginal birth
D. Maternal temperature of 99.9° F 12 hours after delivery

53. A client is experiencing stomatitis as a result of chemotherapy. An appropriate nursing

intervention related to this condition would be to:

A. Provide frequent saline mouthwashes

B. Use karaya powder to decrease irritation
C. Increase fluid intake to compensate for the diarrhea
D. Provide meticulous skin care of the abdomen with Betadine

54. During a group therapy session, one of the clients ask a male client with the diagnosis of
antisocial personality disorder why he is in the hospital. Considering this client’s type
of personality disorder, the nurse might expect him to respond:

A. “I need a lot of help with my troubles”

B. “Society makes people react in old ways”
C. “I decided that it’s time I own up to my problems”
D. “My life needs straightening out and this might help”

55. A child visits the clinic for a 6-week checkup after a tonsillectomy and adenoidectomy. In
addition to assessing hearing, the nurse should include an assessment of the child’s:

A. Taste and smell

B. Taste and speech
C. Swallowing and smell
D. Swallowing and speech

56. A client is diagnosed with cancer of the jaw. A course of radiation therapy is to be
followed by surgery. The client is concerned about the side effects related to the radiation
treaments. Nurse Ria should explain that the major side effects that will experienced is:

A. Fatigue
B. Alopecia
C. Vomiting
D. Leucopenia

57. Nurse Katrina prepares an older-adult client for sleep, actions are taken to help reduce the
likelihood of a fall during the night. Targeting the most frequent cause of falls, the nurse
should:

A. Offer the client assistance to the bathroom

B. Move the bedside table closer to the client’s bed
C. Encourage the client to take an available sedative
D. Assist the client to telephone the spouse to say “goodnight”

58. When evaluating a growth and development of a 6 month old infant, nurse Patty would
expect the infant to be able to:

A. Sit alone, display pincer grasp, wave bye bye

B. Pull self to a standing position, release a toy by choice, play peek-a-boo
C. Crawl, transfer toy from one hand to the other, display of fear of strangers
D. Turn completely over, sit momentarily without support, reach to be picked up

59. A breastfeeding mother asks the nurse what she can do to ease the discomfort caused by a
cracked nipple. Nurse Tina should instruct the client to:

A. Manually express milk and feed it to the baby in a bottle

B. Stop breastfeeding for two days to allow the nipple to heal
C. Use a breast shield to keep the baby from direct contact with the nipple
D. Feed the baby on the unaffected breast first until the affected breast heals

60. Nurse Sandy observes that there is blood coming from the client’s ear after head injury.
Nurse Sandy should:

A. Turn the client to the unaffected side

B. Cleanse the client’s ear with sterile gauze
C. Test the drainage from the client’s ear with Dextrostix
D. Place sterile cotton loosely in the external ear of the client

61. Nurse Gio plans a long term care for parents of children with sickle-cell anemia, which
includes periodic group conferences. Some of the discussions should be directed towards:

A. Finding special school facilities for the child

B. Making plans for moving to a more therapeutic climate
C. Choosing a means of birth control to avoid future pregnancies
D. Airing their feelings regarding the transmission of the disease to the child

62. The central problem the nurse might face with a disturbed schizophrenic client is the
client’s:

A. Suspicious feelings
B. Continuous pacing
C. Relationship with the family
D. Concern about working with others

63. When planning care with a client during the postoperative recovery period following an
abdominal hysterectomy and bilateral salpingo-oophorectomy, nurse Frida should include the
explanation that:

A. Surgical menopause will occur

B. Urinary retention is a common problem
C. Weight gain is expected, and dietary plan are needed
D. Depression is normal and should be expected
64. An adolescent client with anorexia nervosa refuses to eat, stating, “I’ll get too fat.” Nurse
Andrea can best respond to this behavior initially by:

A. Not talking about the fact that the client is not eating
B. Stopping all of the client’s privileges until food is eaten
C. Telling the client that tube feeding will eventually be necessary
D. Pointing out to the client that death can occur with malnutrition.

65. A pain scale is used to assess the degree of pain. The client rates the pain as an 8 on a
scale of 10 before medication and a 7 on a scale of 10 after being medicated. Nurse Glenda
determines that the:

A. Client has a low pain tolerance

B. Medication is not adequately effective
C. Medication has sufficiently decreased the pain level
D. Client needs more education about the use of the pain scale

66. To enhance a neonate’s behavioral development, therapeutic nursing measures should

include:

A. Keeping the baby awake for longer periods of time before each feeding
B. Assisting the parents to stimulate their baby through touch, sound, and sight.
C. Encouraging parental contact for at least one 15-minute period every four hours.
D. Touching and talking to the baby at least hourly, beginning within two to four hours after
birth

67. Before formulating a plan of care for a 6 year old boy with attention deficit hyperactivity
disorder (ADHD), nurse Kyla is aware that the initial aim of therapy is to help the client to:

A. Develop language skills

B. Avoid his own regressive behavior
C. Mainstream into a regular class in school
D. Recognize himself as an independent person of worth
68. Nurse Wally knows that the most important aspect of the preoperative care for a child
with Wilms’ tumor would be:

A. Checking the size of the child’s liver

B. Monitoring the child’s blood pressure
C. Maintaining the child in a prone position
D. Collecting the child’s urine for culture and sensitivity

69. At 11:00 pm the count of hydrocodone (Vicodin) is incorrect. After several minutes of
searching the medication cart and medication administration records, no explanation can be
found. The primary nurse should notify the:

A. Nursing unit manager

B. Hospital administrator
C. Quality control manager
D. Physician ordering the medication

70. When caring for the a client with a pneumothorax, who has a chest tube in place, nurse
Kate should plan to:

A. Administer cough suppressants at appropriate intervals as ordered

B. Empty and measure the drainage in the collection chamber each shift
C. Apply clamps below the insertion site when ever getting the client out of bed
D. Encourage coughing, deep breathing, and range of motion to the arm on the affected side

71. According to C.E.Winslow, which of the following is the goal of Public Health?

A. For people to attain their birthrights of health and longevity

B. For promotion of health and prevention of disease
C. For people to have access to basic health services
D. For people to be organized in their health efforts

72. What other statistic may be used to determine attainment of longevity?

A. Age-specific mortality rate
B. Proportionate mortality rate
C. Swaroop’s index
D. Case fatality rate

73. Which of the following is the most prominent feature of public health nursing?

A. It involves providing home care to sick people who are not confined in the hospital
B. Services are provided free of charge to people within the catchment area.
C. The public health nurse functions as part of a team providing a public health nursing
services.
D. Public health nursing focuses on preventive, not curative, services.

74. Which of the following is the mission of the Department of Health?

A. Health for all Filipinos

B. Ensure the accessibility and quality of health care
C. Improve the general health status of the population
D. Health in the hands of the Filipino people by the year 2020

75. Nurse Pauline determines whether resources were maximized in implementing Ligtas
Tigdas, she is evaluating:

A. Effectiveness
B. Efficiency
C. Adequacy
D. Appropriateness

76. Lissa is a B.S.N. graduate. She want to become a Public Health Nurse. Where will she
apply?

A. Department of Health
B. Provincial Health Office
C. Regional Health Office
D. Rural Health Unit
77. As an epidemiologist, Nurse Celeste is responsible for reporting cases of notifiable
diseases. What law mandates reporting of cases of notifiable diseases?

A. Act 3573
B. R.A. 3753
C. R.A. 1054
D. R.A. 1082

78. Nurse Fay is aware that isolation of a child with measles belongs to what level of
prevention?

A. Primary
B. Secondary
C. Intermediate
D. Tertiary

79. Nurse Gina is aware that the following is an advantage of a home visit?

A. It allows the nurse to provide nursing care to a greater number of people.

B. It provides an opportunity to do first hand appraisal of the home situation.
C. It allows sharing of experiences among people with similar health problems.
D. It develops the family’s initiative in providing for health needs of its members.

80. The PHN bag is an important tool in providing nursing care during a home visit. The most
important principle of bag technique states that it:

A. Should save time and effort.

B. Should minimize if not totally prevent the spread of infection.
C. Should not overshadow concern for the patient and his family.
D. May be done in a variety of ways depending on the home situation, etc.

81. Nurse Willy reads about Path Goal theory. Which of the following behaviors is
manifested by the leader who uses this theory?
A. Recognizes staff for going beyond expectations by giving them citations
B. Challenges the staff to take individual accountability for their own practice
C. Admonishes staff for being laggards
D. Reminds staff about the sanctions for non performance

82. Nurse Cathy learns that some leaders are transactional leaders. Which of the following
does NOT characterize a transactional leader?

A. Focuses on management tasks

B. Is a caretaker
C. Uses trade-offs to meet goals
D. Inspires others with vision

83. Functional nursing has some advantages, which one is an EXCEPTION?

A. Psychological and sociological needs are emphasized.

B. Great control of work activities.
C. Most economical way of delivering nursing services.
D. Workers feel secure in dependent role

84. Which of the following is the best guarantee that the patient’s priority needs are met?

A. Checking with the relative of the patient

B. Preparing a nursing care plan in collaboration with the patient
C. Consulting with the physician
D. Coordinating with other members of the team

85. Nurse Tony stresses the need for all the employees to follow orders and instructions from
him and not from anyone else. Which of the following principles does he refer to?

A. Scalar chain
B. Discipline
C. Unity of command
D. Order
86. Nurse Joey discusses the goal of the department. Which of the following statements is a
goal?

A. Increase the patient satisfaction rate

B. Eliminate the incidence of delayed administration of medications
C. Establish rapport with patients
D. Reduce response time to two minutes

87. Nurse Lou considers shifting to transformational leadership. Which of the following
statements best describes this type of leadership?

A. Uses visioning as the essence of leadership

B. Serves the followers rather than being served
C. Maintains full trust and confidence in the subordinates
D. Possesses innate charisma that makes others feel good in his presence.

88. Nurse Mae tells one of the staff, “I don’t have time to discuss the matter with you now.
See me in my office later” when the latter asks if they can talk about an issue. Which of the
following conflict resolution strategies did she use?

A. Smoothing
B. Compromise
C. Avoidance
D. Restriction

89. Nurse Bea plans of assigning competent people to fill the roles designed in the hierarchy.
Which process refers to this?

A. Staffing
B. Scheduling
C. Recruitment
D. Induction
90. Nurse Linda tries to design an organizational structure that allows communication to flow
in all directions and involve workers in decision making. Which form of organizational
structure is this?

A. Centralized
B. Decentralized
C. Matrix
D. Informal

91. When documenting information in a client’s medical record, the nurse should:

A. erase any errors.

B. use a #2 pencil.
C. leave one line blank before each new entry.
D. end each entry with the nurse’s signature and title.

92. Which of the following factors are major components of a client’s general background
drug history?

A. Allergies and socioeconomic status

B. Urine output and allergies
C. Gastric reflex and age
D. Bowel habits and allergies

93. Which procedure or practice requires surgical asepsis?

A. Hand washing
B. Nasogastric tube irrigation
C. I.V. cannula insertion
D. Colostomy irrigation

94. The nurse is performing wound care using surgical asepsis. Which of the following
practices violates surgical asepsis?
A. Holding sterile objects above the waist
B. Pouring solution onto a sterile field cloth
C. Considering a 1″ (2.5-cm) edge around the sterile field contaminated
D. Opening the outermost flap of a sterile package away from the body

95. On admission, a client has the following arterial blood gas (ABG) values: PaO2, 50 mm
Hg; PaCO2, 70 mm Hg; pH, 7.20; HCO3–, 28 mEq/L. Based on these values,
the nurse should formulate which nursing diagnosis for this client?

A. Risk for deficient fluid volume

B. Deficient fluid volume
C. Impaired gas exchange
D. Metabolic acidosis

96. The use of larvivorous fish in malaria control is the basis for which strategy
of malariacontrol?

A. Stream seeding
B. Stream clearing
C. Destruction of breeding places
D. Zooprophylaxis

97. In Integrated Management of Childhood Illness, severe conditions generally require

urgent referral to a hospital. Which of the following severe conditions DOES NOT always
require urgent referral to a hospital?

A. Mastoiditis
B. Severe dehydration
C. Severe pneumonia
D. Severe febrile disease

98. A mother brought her daughter, 4 years old, to the RHU because of cough and colds.
Following the IMCI assessment guide, which of the following is a danger sign that indicates
the need for urgent referral to a hospital?
A. Inability to drink
B. High grade fever
C. Signs of severe dehydration
D. Cough for more than 30 days

99. Food fortification is one of the strategies to prevent micronutrient deficiency conditions.
R.A. 8976 mandates fortification of certain food items. Which of the following is among
these food items?

A. Sugar
B. Bread
C. Margarine
D. Filled milk

100. The major sign of iron deficiency anemia is pallor. What part is best examined for
pallor?

A. Palms
B. Nailbeds
C. Around the lips
D. Lower conjunctival sac

[divider] Answers & Rationale

1. C. Check for any change in responsiveness every two hours until the follow-up visit
Signs of an epidural hematoma in children usually do not appear for 24 hours or more hours;
a follow-up visit usually is arranged for one to two days after the injury.

2. A. Arteriolar constriction occurs

The early compensation of shock is cardiovascular and is seen in changes in pulse, BP, and
pulse pressure; blood is shunted to vital centers, particularly heart and brain.

3. A. Allow the client to open canned or pre-packaged food

The client’s comfort, safety, and nutritional status are the priorities; the client may feel
comfortable to eat if the food has been sealed before reaching the mental health facility.
4. D. “Joining a support group of parents who are coping with this problem can be quite
helpful.
Taking with others in similar circumstances provides support and allows for sharing of
experiences.

5. B. Observe the dressing at the back of the neck for the presence of blood
Drainage flows by gravity.

6. C. Prepare her for a pelvic examination

Pelvic examination would reveal dilation and effacement

7. D. On the right side of the heart

Pulmonic stenosis increases resistance to blood flow, causing right ventricular hypertrophy;
with right ventricular failure there is an increase in pressure on the right side of the heart.

8. A. Eating patterns are altered

A new dietary regimen, with a balance of foods from the food pyramid, must be established
and continued for weight reduction to occur and be maintained.

9. B. “It is ok to cry; I’ll just stay with you for now”

This portrays a nonjudgmental attitude that recognizes the client’s needs.

10. C. Lactated Ringer’s solution

Lactated Ringer’s solution replaces lost sodium and corrects metabolic acidosis, both of
which commonly occur following a burn. Albumin is used as adjunct therapy, not primary
fluid replacement. Dextrose isn’t given to burn patients during the first 24 hours because it
can cause pseudodiabetes. The patient is hyperkalemic from the potassium shift from the
intracellular space to the plasma, so potassium would be detrimental.

11. C. Twitching and disorientation

Excess extracellular fluid moves into cells (water intoxication); intracellular fluid excess in
sensitive brain cells causes altered mental status; other signs include anorexia nervosa, nausea,
vomiting, twitching, sleepiness, and convulsions.
12. B. Resume the usual diet as soon as desired
As long as the client has no nausea or vomiting, there are no dietary restriction.

13. B. Shrinkage of the residual limb must be completed

Shrinkage of the residual limb, resulting from reduction of subcutaneous fat and interstitial
fluid, must occur for an adequate fit between the limb and the prosthesis.

14. A. Change the maternal position

Stimulation of the sympathetic nervous system is an initial response to mild hypoxia that
accompanies partial cord compression (umbilical vein) during contractions; changing the
maternal position can alleviate the compression.

15. A. Perform a finger stick to test the client’s blood glucose level
The client has signs of diabetes, which may result from steroid therapy, testing the blood
glucose level is a method of screening for diabetes, thus gathering more data.

16. C. Heart block

This is the primary indication for a pacemaker because there is an interfere with the electrical
conduction system of the heart.

17. A. With meals and snacks

Pancreases capsules must be taken with food and snacks because it acts on the nutrients and
readies them for absorption.

18. B. Put a hat on the infant’s head

Oxygen has cooling effect, and the baby should be kept warm so that metabolic activity and
oxygen demands are not increased.

19. C. Wear an Ultra-Filter mask when they are in the client’s room
Tubercle bacilli are transmitted through air currents; therefore personal protective equipment
such as an Ultra-Filter mask is necessary.

20. D. Cerebral cortex compression

Cerebral compression affects pyramidal tracts, resulting in decorticate rigidity and cranial
nerve injury, which cause pupil dilation.
21. A. Mediastinal shift
Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous
return.

22. C. Prevent situations that may stimulate the cervix or uterus

Stimulation of the cervix or uterus may cause bleeding or hemorrhage and should be avoided.

23. C. Severe shortness of breath

This could indicate a recurrence of the pneumothorax as one side of the lung is inadequate to
meet the oxygen demands of the body.

24. A. Suction equipment

Respiratory complications can occur because of edema of the glottis or injury to the recurrent
laryngeal nerve.

25. A. Strong desire to improve her body image

Clients with anorexia nervosa have a disturbed self image and always see themselves as fat
and needing further reducing.

26. B. Attempting to reduce or limit situations that increase anxiety

Persons with high anxiety levels develop various behaviors to relieve their anxiety; by
reducing anxiety, the need for these obsessive-compulsive action is reduced.

27. C. Becomes fussy when frustrated and displays a shortened attention span
Shortened attention span and fussy behavior may indicate a change in intracranial pressure
and/or shunt malfunction.

28. B. Maintaining the ordered hydration

Promoting hydration maintains urine production at a higher rate, which flushes the bladder
and prevents urinary stasis and possible infection.

29. C. Taking the client’s pedal pulse in the affected limb

Monitoring a pedal pulse will assess circulation to the foot.
30. A. “Where are you?”
“Where are you?” is the best question to elicit information about the client’s orientation to
place because it encourages a response that can be assessed.

31. D. Bleeding from the venipuncture site

This indicates a fibrinogenemia; massive clotting in the area of the separation has resulted in a
lowered circulating fibrinogen.

32. D. blowing pattern

Clients should use a blowing pattern to overcome the premature urge to push.

33. A. Cheeseburger and a malted

Of the selections offered, this is the highest in calories and protein, which are needed for
increased basal metabolic rate and for tissue repair.

34. B. Cyanotic lips and face

Central cyanosis (blue lips and face) indicates lowered oxygenation of the blood, caused by
either decreased lung expansion or right to left shunting of blood.

35. A. Notify the physician of the findings because the level is dangerously high
Levels close to 2 mEq/L are dangerously close to the toxic level; immediate action must be
taken.

36. C. Days 15 to 17
Ovulation occurs approximately 14 days before the next menses, about the 16th day in 30 day
cycle; the 15th to 17th days would be the best time to avoid sexual intercourse.

37. C. Assure that informed consent has been obtained from the client
An invasive procedure such as amniocentesis requires informed consent.

38. D. Prevent development of respiratory distress

Respiratory distress or arrest may occur when the serum level of magnesium sulfate reaches
12 to 15 mg/dl; deep tendon reflexes disappear when the serum level is 10 to 12 mg/dl; the
drug is withheld in the absence of deep tendon reflexes; the therapeutic serum level is 5 to 8
mg/dl.
39. A. Obtaining the child’s daily weight
Weight monitoring is the most useful means of assessing fluid balance and changes in the
edematous state; 1 liter of fluid weighs about 2.2 pounds.

40. C. Reduces the inflammatory response of tissues

Corticosteroids act to decrease inflammation which decreases edema.

41. D. An audible click on hip manipulation

With specific manipulation, an audible click may be heard of felt as he femoral head slips into
the acetabulum.

42. B. Allow the denial but be available to discuss death

This does not remove client’s only way of coping, and it permits future movement through
the grieving process when the client is ready.

43. B. Divide food into four to six meals a day

The volume of food in the stomach should be kept small to limit pressure on the cardiac
sphincter.

44. B. “I feel washed out; there isn’t much left”

The client’s statement infers an emptiness with an associated loss.

45. A. Vitamin K is not absorbed

Vitamin K, a fat soluble vitamin, is not absorbed from the GI tract in the absence of bile; bile
enters the duodenum via the common bile duct.

46. D. Leg weakness with muscle cramps

Impulse conduction of skeletal muscle is impaired with decreased potassium levels, muscular
weakness and cramps may occur with hypokalemia.

47. D. Simian lines on the hands

This is characteristic finding in newborns with Down syndrome.
48. B. Eyes
Rheumatoid arthritis can cause inflammation of the iris and ciliary body of the eyes which
may lead to blindness.

49. A. Accept the client’s decision without discussion

This is all the nurse can do until trust is established; facing the client to attend will disrupt the
group.

50. D. Provide a simple explanation of the procedure and continue to reassure the client
The nurse should offer support and use clear, simple terms to allay client’s anxiety.

51. D. If I have difficulty in inserting the irrigating tube into the stoma”
This occurs with stenosis of the stoma; forcing insertion of the tube could cause injury.

52. C. Blood loss of 850 ml after a vaginal birth

Excessive blood loss predisposes the client to an increased risk of infection because of
decreased maternal resistance; they expected blood loss is 350 to 500 ml.

53. A. Provide frequent saline mouthwashes

This is soothing to the oral mucosa and helps prevent infection.

54. B. “Society makes people react in old ways”

The client is incapable of accepting responsibility for self-created problems and blames
society for the behavior.

55. A. Taste and smell

Swelling can obstruct nasal breathing, interfering with the senses of taste and smell.

56. A. Fatigue
Fatigue is a major problem caused by an increase in waste products because of catabolic
processes.

57. A. Offer the client assistance to the bathroom

Statistics indicate that the most frequent cause of falls by hospitalized clients is getting up or
attempting to get up to the bathroom unassisted.
58. D. Turn completely over, sit momentarily without support, reach to be picked up
These abilities are age-appropriate for the 6 month old child.

59. D. Feed the baby on the unaffected breast first until the affected breast heals
The most vigorous sucking will occur during the first few minutes of breastfeeding when the
infant would be on the unaffected breast; later suckling is less traumatic.

60. D. Place sterile cotton loosely in the external ear of the client
This would absorb the drainage without causing further trauma.

61. D. Airing their feelings regarding the transmission of the disease to the child
Discussion with parents who have children with similar problems helps to reduce some of
their discomfort and guilt.

62. A. Suspicious feelings

The nurse must deal with these feelings and establish basic trust to promote a therapeutic
milieu.

63. A. Surgical menopause will occur

When a bilateral oophorectomy is performed, both ovaries are excised, eliminating ovarian
hormones and initiating response.

64. D. Pointing out to the client that death can occur with malnutrition.
The client expects the nurse to focus on eating, but the emphasis should be placed on feelings
rather than actions.

65. B. Medication is not adequately effective

The expected effect should be more than a one point decrease in the pain level.

66. B. Assisting the parents to stimulate their baby through touch, sound, and sight.
Stimuli are provided via all the senses; since the infant’s behavioral development is enhanced
through parent-infant interactions, these interactions should be encouraged.
67. D. Recognize himself as an independent person of worth
Academic deficits, an inability to function within constraints required of certain settings, and
negative peer attitudes often lead to low self-esteem.

68. B. Monitoring the child’s blood pressure

Because the tumor is of renal origin, the rennin angiotensin mechanism can be involved,
and blood pressure monitoring is important.

69. A. Nursing unit manager

Controlled substance issues for a particular nursing unit are the responsibility of that unit’s
nurse manager.

70. D. Encourage coughing, deep breathing, and range of motion to the arm on the
affected side
All these interventions promote aeration of the re-expanding lung and maintenance of
function in the arm and shoulder on the affected side.

71. A. For people to attain their birthrights of health and longevity

According to Winslow, all public health efforts are for people to realize their birthrights of
health and longevity.

72. C. Swaroop’s index

Swaroop’s index is the percentage of the deaths aged 50 years or older. Its inverse represents
the percentage of untimely deaths (those who died younger than 50 years).

73. D. Public health nursing focuses on preventive, not curative, services.

The catchment area in PHN consists of a residential community, many of whom are well
individuals who have greater need for preventive rather than curative services.

74. B. Ensure the accessibility and quality of health care

Ensuring the accessibility and quality of health care is the primary mission of DOH.

75. B. Efficiency
Efficiency is determining whether the goals were attained at the least possible cost.
76. D. Rural Health Unit
R.A. 7160 devolved basic health services to local government units (LGU’s ). The public
health nurse is an employee of the LGU.

77. A. Act 3573

Act 3573, the Law on Reporting of Communicable Diseases, enacted in 1929, mandated the
reporting of diseases listed in the law to the nearest health station.

78. A. Primary
The purpose of isolating a client with a communicable disease is to protect those who are not
sick (specific disease prevention).

79. B. It provides an opportunity to do first hand appraisal of the home situation.

Choice A is not correct since a home visit requires that the nurse spend so much time with the
family. Choice C is an advantage of a group conference, while choice D is true of a clinic
consultation.

80. B. Should minimize if not totally prevent the spread of infection.

Bag technique is performed before and after handling a client in the home to prevent
transmission of infection to and from the client.

81. A. Bag technique is performed before and after handling a client in the home to
prevent transmission of infection to and from the client.
Path Goal theory according to House and associates rewards good performance so that others
would do the same.

82. D. Inspires others with vision

Inspires others with a vision is characteristic of a transformational leader. He is focused more
on the day-to-day operations of the department/unit.

83. A. Psychological and sociological needs are emphasized.

When the functional method is used, the psychological and sociological needs of the patients
are neglected; the patients are regarded as ‘tasks to be done”
84. B. Preparing a nursing care plan in collaboration with the patient
The best source of information about the priority needs of the patient is the patient himself.
Hence using a nursing care plan based on his expressed priority needs would ensure meeting
his needs effectively.

85. C. Unity of command

The principle of unity of command means that employees should receive orders coming from
only one manager and not from two managers. This averts the possibility of
sowing confusion among the members of the organization.

86. A. Increase the patient satisfaction rate

Goal is a desired result towards which efforts are directed. Options AB, C and D are all
objectives which are aimed at specific end.

87. A. Uses visioning as the essence of leadership

Transformational leadership relies heavily on visioning as the core of leadership.

88. C. Avoidance
This strategy shuns discussing the issue head-on and prefers to postpone it to a later time. In
effect the problem remains unsolved and both parties are in a lose-lose situation.

89. A. Staffing
Staffing is a management function involving putting the best people to accomplish tasks and
activities to attain the goals of the organization.

90. B. Decentralized
Decentralized structures allow the staff to make decisions on matters pertaining to their
practice and communicate in downward, upward, lateral and diagonal flow.

91. D. end each entry with the nurse’s signature and title.
The end of each entry should include the nurse’s signature and title; the signature holds the
nurse accountable for the recorded information. Erasing errors in documentation on a legal
document such as a client’s chart isn’t permitted by law. Because a client’s medical record is
considered a legal document, the nurse should make all entries in ink. The nurse is
accountable for the information recorded and therefore shouldn’t leave any blank lines in
which another health care worker could make additions.

92. A. Allergies and socioeconomic status

General background data consist of such components as allergies, medical history, habits,
socioeconomic status, lifestyle, beliefs, and sensory deficits. Urine output, gastric reflex, and
bowel habits are significant only if a disease affecting these functions is present.

93. C. I.V. cannula insertion

Caregivers must use surgical asepsis when performing wound care or any procedure in which
a sterile body cavity is entered or skin integrity is broken. To achieve surgical asepsis, objects
must be rendered or kept free of all pathogens. Inserting an I.V. cannula requires surgical
asepsis because it disrupts skin integrity and involves entry into a sterile cavity (a vein). The
other options are used to ensure medical asepsis or clean technique to prevent the spread of
infection. The GI tract isn’t sterile; therefore, irrigating a nasogastric tube or a colostomy
requires only clean technique.

94. B. Pouring solution onto a sterile field cloth

Pouring solution onto a sterile field cloth violates surgical asepsis because moisture
penetrating the cloth can carry microorganisms to the sterile field via capillary action. The
other options are practices that help ensure surgical asepsis.

95. C. Impaired gas exchange

The client has a below-normal value for the partial pressure of arterial oxygen (PaO2) and an
above-normal value for the partial pressure of arterial carbon dioxide (PaCO2), supporting the
nursing diagnosis of Impaired gas exchange. ABG values can’t indicate a diagnosis of Fluid
volume deficit (or excess) or Risk for deficient fluid volume. Metabolic acidosis is a medical,
not nursing, diagnosis; in any event, these ABG values indicate respiratory, not metabolic,
acidosis.

96. A. Stream seeding

Stream seeding is done by putting tilapia fry in streams or other bodies of water identified as
breeding places of the Anopheles mosquito.
97. B. Severe dehydration
The order of priority in the management of severe dehydration is as follows: intravenous fluid
therapy, referral to a facility where IV fluids can be initiated within 30 minutes,
Oresol/nasogastric tube, Oresol/orem. When the foregoing measures are not possible or
effective, tehn urgent referral to the hospital is done.

98. A. Inability to drink

A sick child aged 2 months to 5 years must be referred urgently to a hospital if he/she has one
or more of the following signs: not able to feed or drink, vomits everything, convulsions,
abnormally sleepy or difficult to awaken.

99. A. Sugar
R.A. 8976 mandates fortification of rice, wheat flour, sugar and cooking oil with Vitamin A,
iron and/or iodine.

100. A. Palms
The anatomic characteristics of the palms allow a reliable and convenient b1. A woman in a
child bearing age receives a rubella vaccination. Nurse Joy would give her which of the
following instructions?

a. Refrain from eating eggs or egg products for 24 hours

b. Avoid having sexual intercourse
c. Don’t get pregnant at least 3 months
d. Avoid exposure to sun

2. Jonas who is diagnosed with encephalitis is under the treatment of Mannitol. Which of the
following patient outcomes indicate to Nurse Ronald that the treatment of Mannitol has been
effective for a patient that has increased intracranial pressure?

a. Increased urinary output

b. Decreased RR
c. Slowed pupillary response
d. Decreased level of consciousness
3. Mary asked Nurse Maureen about the incubation period of rabies. Which statement by the
Nurse Maureen is appropriate?

a. Incubation period is 6 months

b. Incubation period is 1 week
c. Incubation period is 1 month
d. Incubation period varies depending on the site of the bite

4. Which of the following should Nurse Cherry do first in taking care of a male client with
rabies?

a. Encourage the patient to take a bath

b. Cover IV bottle with brown paper bag
c. Place the patient near the comfort room
d. Place the patient near the door

5. Which of the following is the screening test for dengue hemorrhagic fever?

a. Complete blood count

b. ELISA
c. Rumpel-leede test
d. Sedimentation rate

6. Mr. Dela Rosa is suspected to have malaria after a business trip in Palawan. The most
important diagnostic test in malaria is:

a. WBC count
b. Urinalysis
c. ELISA
d. Peripheral blood smear

7. The Nurse supervisor is planning for patient’s assignment for the AM shift. The nurse
supervisor avoids assigning which of the following staff members to a client with herpes
zoster?
a. Nurse who never had chicken pox
b. Nurse who never had roseola
c. Nurse who never had german measles
d. Nurse who never had mumps

8. Clarissa is 7 weeks pregnant. Further examination revealed that she is susceptible to rubella.
When would be the most appropriate for her to receive rubella immunization?

a. At once
b. During 2nd trimester
c. During 3rd trimester
d. After the delivery of the baby

9. A female child with rubella should be isolated from a:

a. 21 year old male cousin living in the same house

b. 18 year old sister who recently got married
c. 11 year old sister who had rubeola during childhood
d. 4 year old girl who lives next door

10. What is the primary prevention of leprosy?

a. Nutrition
b. Vitamins
c. BCG vaccination
d. DPT vaccination

11. A bacteria which causes diphtheria is also known as?

a. Amoeba
b. Cholera
c. Klebs-loeffler bacillus
d. Spirochete
12. Nurse Ron performed mantoux skin test today (Monday) to a male adult client. Which
statement by the client indicates that he understood the instruction well?

a. I will come back later

b. I will come back next month
c. I will come back on Friday
d. I will come back on Wednesday, same time, to read the result

13. A male client had undergone Mantoux skin test. Nurse Ronald notes an 8mm area of
indurations at the site of the skin test. The nurse interprets the result as:

a. Negative
b. Uncertain and needs to be repeated
c. Positive
d. Inconclusive

14. Tony will start a 6 month therapy with Isoniazid (INH). Nurse Trish plans to teach the
client to:

a. Use alcohol moderately

b. Avoid vitamin supplements while o therapy
c. Incomplete intake of dairy products
d. May be discontinued if symptoms subsides

15. Which is the primary characteristic lesion of syphilis?

a. Sore eyes
b. Sore throat
c. Chancroid
d. Chancre

16. What is the fast breathing of Jana who is 3 weeks old?

a. 60 breaths per minute

b. 40 breaths per minute
c. 10 breaths per minute
d. 20 breaths per minute

17. Which of the following signs and symptoms indicate some dehydration?

a. Drinks eagerly
b. Restless and irritable
c. Unconscious
d. A and B

18. What is the first line for dysentery?

a. Amoxicillin
b. Tetracycline
c. Cefalexin
d. Cotrimoxazole

19. In home made oresol, what is the ratio of salt and sugar if you want to prepare with 1 liter
of water?

a. 1 tbsp. salt and 8 tbsp. sugar

b. 1 tbsp. salt and 8 tsp. sugar
c. 1 tsp. salt and 8 tsp. sugar
d. 8 tsp. salt and 8 tsp. sugar

20. Gentian Violet is used for:

a. Wound
b. Umbilical infections
c. Ear infections
d. Burn

21. Which of the following is a live attenuated bacterial vaccine?

a. BCG
b. OPV
c. Measles
d. None of the above

22. EPI is based on?

a. Basic health services

b. Scope of community affected
c. Epidemiological situation
d. Research studies

23. TT2 provides how many percentage of protection against tetanus?

a. 100
b. 99
c. 80
d. 90

24. Temperature of refrigerator to maintain potency of measles and OPV vaccine is:

a. -3c to -8c
b. -15c to -25c
c. +15c to +25c
d. +3c to +8c

25. Diptheria is a:

a. Bacterial toxin
b. Killed bacteria
c. Live attenuated
d. Plasma derivatives

26. Budgeting is under in which part of management process?

a. Directing
b. Controlling
c. Organizing
d. Planning

27. Time table showing planned work days and shifts of nursing personnel is:

a. Staffing
b. Schedule
c. Scheduling
d. Planning

28. A force within an individual that influences the strength of behavior?

a. Motivation
b. Envy
c. Reward
d. Self-esteem

29. “To be the leading hospital in the Philippines” is best illustrate in:

a. Mission
b. Philosophy
c. Vision
d. Objective

30. It is the professionally desired norms against which a staff performance will be compared?

a. Job descriptions
b. Survey
c. Flow chart
d. Standards

31. Reprimanding a staff nurse for work that is done incorrectly is an example of what type of
reinforcement?
a. Feedback
b. Positive reinforcement
c. Performance appraisal
d. Negative reinforcement

32. Questions that are answerable only by choosing an option from a set of given alternatives
are known as?

a. Survey
b. Close ended
c. Questionnaire
d. Demographic

33. A researcher that makes a generalization based on observations of an individuals behavior

is said to be which type of reasoning:

a. Inductive
b. Logical
c. Illogical
d. Deductive

34. The balance of a research’s benefit vs. its risks to the subject is:

a. Analysis
b. Risk-benefit ratio
c. Percentile
d. Maximum risk

35. An individual/object that belongs to a general population is a/an:

a. Element
b. Subject
c. Respondent
d. Author
36. An illustration that shows how the members of an organization are connected:

a. Flowchart
b. Bar graph
c. Organizational chart
d. Line graph

37. The first college of nursing that was established in the Philippines is:

a. Fatima University
b. Far Eastern University
c. University of the East
d. University of Sto. Tomas

38. Florence nightingale is born on:

a. France
b. Britain
c. U.S
d. Italy

39. Objective data is also called:

a. Covert
b. Overt
c. Inference
d. Evaluation

40. An example of subjective data is:

a. Size of wounds
b. VS
c. Lethargy
d. The statement of patient “My hand is painful”
41. What is the best position in palpating the breast?

a. Trendelenburg
b. Side lying
c. Supine
d. Lithotomy

42. When is the best time in performing breast self examination?

a. 7 days after menstrual period

b. 7 days before menstrual period
c. 5 days after menstrual period
d. 5 days before menstrual period

43. Which of the following should be given the highest priority before performing physical
examination to a patient?

a. Preparation of the room

b. Preparation of the patient
c. Preparation of the nurse
d. Preparation of environment

44. It is a flip over card usually kept in portable file at nursing station.

a. Nursing care plan

b. Medicine and treatment record
c. Kardex
d. TPR sheet

45. Jose has undergone thoracentesis. The nurse in charge is aware that the best position for
Jose is:

a. Semi fowlers
b. Low fowlers
c. Side lying, unaffected side
d. Side lying, affected side

46. The degree of patients abdominal distension may be determined by:

a. Auscultation
b. Palpation
c. Inspection
d. Percussion

47. A male client is addicted with hallucinogen. Which physiologic effect should the nurse
expect?

a. Bradyprea
b. Bradycardia
c. Constricted pupils
d. Dilated pupils

48. Tristan a 4 year old boy has suffered from full thickness burns of the face, chest and neck.
What will be the priority nursing diagnosis?

a. Ineffective airway clearance related to edema

b. Impaired mobility related to pain
c. Impaired urinary elimination related to fluid loss
d. Risk for infection related to epidermal disruption

49. In assessing a client’s incision 1 day after the surgery, Nurse Betty expect to see which of
the following as signs of a local inflammatory response?

a. Greenish discharge
b. Brown exudates at incision edges
c. Pallor around sutures
d. Redness and warmth

50. Nurse Ronald is aware that the amniotic fluid in the third trimester weighs approximately:
a. 2 kilograms
b. 1 kilograms
c. 100 grams
d. 1.5 kilograms

51. After delivery of a baby girl. Nurse Gina examines the umbilical cord and expects to find
a cord to:

a. Two arteries and two veins

b. One artery and one vein
c. Two arteries and one vein
d. One artery and two veins

52. Myrna a pregnant client reports that her last menstrual cycle is July 11, her expected date
of birth is

a. November 4
b. November 11
c. April 4
d. April 18

53. Which of the following is not a good source of iron?

a. Butter
b. Pechay
c. Grains
d. Beef

54. Maureen is admitted with a diagnosis of ectopic pregnancy. Which of the following would
you anticipate?

a. NPO
b. Bed rest
c. Immediate surgery
d. Enema
55. Gina a postpartum client is diagnosed with endometritis. Which position would you
expect to place her based on this diagnosis?

a. Supine
b. Left side lying
c. Trendelinburg
d. Semi-fowlers

56. Nurse Hazel knows that Myrna understands her condition well when she remarks that
urinary frequency is caused by:

a. Pressure caused by the ascending uterus

b. Water intake of 3L a day
c. Effect of cold weather
d. Increase intake of fruits and vegetables

57. How many ml of blood is loss during the first 24 hours post delivery of Myrna?

a. 100
b. 500
c. 200
d. 400

58. Which of the following hormones stimulates the secretion of milk?

a. Progesterone
b. Prolactin
c. Oxytocin
d. Estrogen

59. Nurse Carla is aware that Myla’s second stage of labor is beginning when the following
assessment is noted:

a. Bay of water is broken

b. Contractions are regular
c. Cervix is completely dilated
d. Presence of bloody show

60. The leaking fluid is tested with nitrazine paper. Nurse Kelly confirms that the client’s
membrane have ruptures when the paper turns into a:

a. Pink
b. Violet
c. Green
d. Blue

61. After amniotomy, the priority nursing action is:

a. Document the color and consistency of amniotic fluid

b. Listen the fetal heart tone
c. Position the mother in her left side
d. Let the mother rest

62. Which is the most frequent reason for postpartum hemorrhage?

a. Perineal lacerations
b. Frequent internal examination (IE)
c. CS
d. Uterine atony

63. On 2nd postpartum day, which height would you expect to find the fundus in a woman
who has had a caesarian birth?

a. 1 finger above umbilicus

b. 2 fingers above umbilicus
c. 2 fingers below umbilicus
d. 1 finger below umbilicus

64. Which of the following criteria allows Nurse Kris to perform home deliveries?
a. Normal findings during assessment
b. Previous CS
c. Diabetes history
d. Hypertensive history

65. Nurse Carla is aware that one of the following vaccines is done by intramuscular (IM)
injection?

a. Measles
b. OPV
c. BCG
d. Tetanus toxoid

66. Asin law is on which legal basis:

a. RA 8860
b. RA 2777
c. RI 8172
d. RR 6610

67. Nurse John is aware that the herbal medicine appropriate for urolithiasis is:

a. Akapulko
b. Sambong
c. Tsaang gubat
d. Bayabas

68. Community/Public health bag is defined as:

a. An essential and indispensable equipment of the community health nurse during home visit
b. It contains drugs and equipment used by the community health nurse
c. Is a requirement in the health center and for home visit
d. It is a tool used by the community health nurse in rendering effective procedures during
home visit
69. TT4 provides how many percentage of protection against tetanus?

a. 70
b. 80
c. 90
d. 99

70. Third postpartum visit must be done by public health nurse:

a. Within 24 hours after delivery

b. After 2-4 weeks
c. Within 1 week
d. After 2 months

71. Nurse Candy is aware that the family planning method that may give 98% protection to
another pregnancy to women

a. Pills
b. Tubal ligation
c. Lactational Amenorrhea method (LAM)
d. IUD

72. Which of the following is not a part of IMCI case management process

a. Counsel the mother

b. Identify the illness
c. Assess the child
d. Treat the child

73. If a young child has pneumonia when should the mother bring him back for follow up?

a. After 2 days
b. In the afternoon
c. After 4 days
d. After 5 days
74. It is the certification recognition program that develop and promotes standard for health
facilities:

a. Formula
b. Tutok gamutan
c. Sentrong program movement
d. Sentrong sigla movement

75. Baby Marie was born May 23, 1984. Nurse John will expect finger thumb opposition on:

a. April 1985
b. February 1985
c. March 1985
d. June 1985

76. Baby Reese is a 12 month old child. Nurse Oliver would anticipate how many teeth?

a. 9
b. 7
c. 8
d. 6

77. Which of the following is the primary antidote for Tylenol poisoning?

a. Narcan
b. Digoxin
c. Acetylcysteine
d. Flumazenil

78. A male child has an intelligence quotient of approximately 40. Which kind of
environment and interdisciplinary program most likely to benefit this child would be best
described as:

a. Habit training
b. Sheltered workshop
c. Custodial
d. Educational

79. Nurse Judy is aware that following condition would reflect presence of congenital G.I
anomaly?

a. Cord prolapse
b. Polyhydramios
c. Placenta previa
d. Oligohydramnios

80. Nurse Christine provides health teaching for the parents of a child diagnosed with celiac
disease. Nurse Christine teaches the parents to include which of the following food items in
the child’s diet:

a. Rye toast
b. Oatmeal
c. White bread
d. Rice

81. Nurse Randy is planning to administer oral medication to a 3 year old child. Nurse Randy
is aware that the best way to proceed is by:

a. “Would you like to drink your medicine?”

b. “If you take your medicine now, I’ll give you lollipop”
c. “See the other boy took his medicine? Now it’s your turn.”
d. “Here’s your medicine. Would you like a mango or orange juice?”

82. At what age a child can brush her teeth without help?

a. 6 years
b. 7 years
c. 5 years
d. 8 years
83. Ribivarin (Virazole) is prescribed for a female hospitalized child with RSV. Nurse Judy
prepare this medication via which route?

a. Intravenous
b. Oral
c. Oxygen tent
d. Subcutaneous

84. The present chairman of the Board of Nursing in the Philippines is:

a. Maria Joanna Cervantes

b. Carmencita Abaquin
c. Leonor Rosero
d. Primitiva Paquic

85. The obligation to maintain efficient ethical standards in the practice of nursing belong to
this body:

a. BON
b. ANSAP
c. PNA
d. RN

86. A male nurse was found guilty of negligence. His license was revoked. Re-issuance of
revoked certificates is after how many years?

a. 1 year
b. 2 years
c. 3 years
d. 4 years

87. Which of the following information cannot be seen in the PRC identification card?

a. Registration Date
b. License Number
c. Date of Application
d. Signature of PRC chairperson

88. Breastfeeding is being enforced by milk code or:

a. EO 51
b. R.A. 7600
c. R.A. 6700
d. P.D. 996

89. Self governance, ability to choose or carry out decision without undue pressure or
coercion from anyone:

a. Veracity
b. Autonomy
c. Fidelity
d. Beneficence

90. A male patient complained because his scheduled surgery was cancelled because of
earthquake. The hospital personnel may be excused because of:

a. Governance
b. Respondeat superior
c. Force majeure
d. Res ipsa loquitur

91. Being on time, meeting deadlines and completing all scheduled duties is what virtue?

a. Fidelity
b. Autonomy
c. Veracity
d. Confidentiality

92. This quality is being demonstrated by Nurse Ron who raises the side rails of a confused
and disoriented patient?
a. Responsibility
b. Resourcefulness
c. Autonomy
d. Prudence

93. Which of the following is formal continuing education?

a. Conference
b. Enrollment in graduate school
c. Refresher course
d. Seminar

94. The BSN curriculum prepares the graduates to become?

a. Nurse generalist
b. Nurse specialist
c. Primary health nurse
d. Clinical instructor

95. Disposal of medical records in government hospital/institutions must be done in close

coordination with what agency?

a. Department of Health
b. Records Management Archives Office
c. Metro Manila Development Authority
d. Bureau of Internal Revenue

96. Nurse Jolina must see to it that the written consent of mentally ill patients must be taken
from:

a. Nurse
b. Priest
c. Family lawyer
d. Parents/legal guardians
97. When Nurse Clarence respects the client’s self-disclosure, this is a gauge for the nurses’:

a. Respectfulness
b. Loyalty
c. Trustworthiness
d. Professionalism

98. The Nurse is aware that the following tasks can be safely delegated by the nurse to a
non-nurse health worker except:

a. Taking vital signs

b. Change IV infusions
c. Transferring the client from bed to chair
d. Irrigation of NGT

99. During the evening round Nurse Tina saw Mr. Toralba meditating and afterwards started
singing prayerful hymns. What would be the best response of Nurse Tina?

a. Call the attention of the client and encourage to sleep

b. Report the incidence to head nurse
c. Respect the client’s action
d. Document the situation

100. In caring for a dying client, you should perform which of the following activities

a. Do not resuscitate
b. Assist client to perform ADL
c. Encourage to exercise
d. Assist client towards a peaceful death

101. The Nurse is aware that the ability to enter into the life of another person and perceive
his current feelings and their meaning is known:

a. Belongingness
b. Genuineness
c. Empathy
d. Respect

102. The termination phase of the NPR is best described one of the following:

a. Review progress of therapy and attainment of goals

b. Exploring the client’s thoughts, feelings and concerns
c. Identifying and solving patients problem
d. Establishing rapport

103. During the process of cocaine withdrawal, the physician orders which of the following:

a. Haloperidol (Haldol)
b. Imipramine (Tofranil)
c. Benztropine (Cogentin)
d. Diazepam (Valium)

104. The nurse is aware that cocaine is classified as:

a. Hallucinogen
b. Psycho stimulant
c. Anxiolytic
d. Narcotic

105. In community health nursing, it is the most important risk factor in the development of
mental illness?

a. Separation of parents
b. Political problems
c. Poverty
d. Sexual abuse

106. All of the following are characteristics of crisis except

a. The client may become resistive and active in stopping the crisis
b. It is self-limiting for 4-6 weeks
c. It is unique in every individual
d. It may also affect the family of the client

107. Freud states that temper tantrums is observed in which of the following:

a. Oral
b. Anal
c. Phallic
d. Latency

108. The nurse is aware that ego development begins during:

a. Toddler period
b. Preschool age
c. School age
d. Infancy

109. Situation: A 19 year old nursing student has lost 36 lbs for 4 weeks. Her parents brought
her to the hospital for medical evaluation. The diagnosis was ANOREXIA NERVOSA. The
Primary gain of a client with anorexia nervosa is:

a. Weight loss
b. Weight gain
c. Reduce anxiety
d. Attractive appearance

110. The nurse is aware that the primary nursing diagnosis for the client is:

a. Altered nutrition : less than body requirement

b. Altered nutrition : more than body requirement
c. Impaired tissue integrity
d. Risk for malnutrition
111. After 14 days in the hospital, which finding indicates that her condition in improving?

a. She tells the nurse that she had no idea that she is thin
b. She arrives earlier than scheduled time of group therapy
c. She tells the nurse that she eat 3 times or more in a day
d. She gained 4 lbs in two weeks

112. The nurse is aware that ataractics or psychic energizers are also known as:

a. Anti manic
b. Anti depressants
c. Antipsychotics
d. Anti anxiety

113. Known as mood elevators:

a. Anti depressants
b. Antipsychotics
c. Anti manic
d. Anti anxiety

114. The priority of care for a client with Alzheimer’s disease is

a. Help client develop coping mechanism

b. Encourage to learn new hobbies and interest
c. Provide him stimulating environment
d. Simplify the environment to eliminate the need to make chores

115. Autism is diagnosed at:

a. Infancy
b. 3 years old
c. 5 years old
d. School age
116. The common characteristic of autism child is:

a. Impulsivity
b. Self destructiveness
c. Hostility
d. Withdrawal

117. The nurse is aware that the most common indication in using ECT is:

a. Schizophrenia
b. Bipolar
c. Anorexia Nervosa
d. Depression

118. A therapy that focuses on here and now principle to promote self-acceptance?

a. Gestalt therapy
b. Cognitive therapy
c. Behavior therapy
d. Personality therapy

119. A client has many irrational thoughts. The goal of therapy is to change her:

a. Personality
b. Communication
c. Behavior
d. Cognition

120. The appropriate nutrition for Bipolar I disorder, in manic phase is:

a. Low fat, low sodium

b. Low calorie, high fat
c. Finger foods, high in calorie
d. Small frequent feedings
121. Which of the following activity would be best for a depressed client?

a. Chess
b. Basketball
c. Swimming
d. Finger painting

122. The nurse is aware that clients with severe depression, possess which defense
mechanism:

a. Introjection
b. Suppression
c. Repression
d. Projection

123. Nurse John is aware that self mutilation among Bipolar disorder patients is a means of:

a. Overcoming fear of failure

b. Overcoming feeling of insecurity
c. Relieving depression
d. Relieving anxiety

124. Which of the following may cause an increase in the cystitis symptoms?

a. Water
b. Orange juice
c. Coffee
d. Mango juice

125. In caring for clients with renal calculi, which is the priority nursing intervention?

a. Record vital signs

b. Strain urine
c. Limit fluids
d. Administer analgesics as prescribed
126. In patient with renal failure, the diet should be:

a. Low protein, low sodium, low potassium

b. Low protein, high potassium
c. High carbohydrate, low protein
d. High calcium, high protein

127. Which of the following cannot be corrected by dialysis?

a. Hypernatremia
b. Hyperkalemia
c. Elevated creatinine
d. Decreased hemoglobin

128. Tony with infection is receiving antibiotic therapy. Later the client complaints of ringing
in the ears. This ototoxicity is damage to:

a. 4th CN
b. 8th CN
c. 7th CN
d. 9th CN

129. Nurse Emma provides teaching to a patient with recurrent urinary tract infectionincludes
the following:

a. Increase intake of tea, coffee and colas

b. Void every 6 hours per day
c. Void immediately after intercourse
d. Take tub bath everyday

130. Which assessment finding indicates circulatory constriction in a male client with a newly
applied long leg cast?

a. Blanching or cyanosis of legs

b. Complaints of pressure or tightness
c. Inability to move toes
d. Numbness of toes

131. During acute gout attack, the nurse administer which of the following drug:

a. Prednisone (Deltasone)
b. Colchicines
c. Aspirin
d. Allopurinol (Zyloprim)

132. Information in the patients chart is inadmissible in court as evidence when:

a. The client objects to its use

b. Handwriting is not legible
c. It has too many unofficial abbreviations
d. The clients parents refuses to use it

133. Nurse Karen is revising a client plan of care. During which step of the nursing process
does such revision take place?

a. Planning
b. Implementation
c. Diagnosing
d. Evaluation

134. When examining a client with abdominal pain, Nurse Hazel should assess:

a. Symptomatic quadrant either second or first

b. The symptomatic quadrant last
c. The symptomatic quadrant first
d. Any quadrant

135. How long will nurse John obtain an accurate reading of temperature via oral route?
a. 3 minutes
b. 1 minute
c. 8 minutes
d. 15 minutes

136. The one filing the criminal care against an accused party is said to be the?

a. Guilty
b. Accused
c. Plaintiff
d. Witness

137. A male client has a standing DNR order. He then suddenly stopped breathing and you
are at his bedside. You would:

a. Call the physician

b. Stay with the client and do nothing
c. Call another nurse
d. Call the family

138. The ANA recognized nursing informatics heralding its establishment as a new field in
nursing during what year?

a. 1994
b. 1992
c. 2000
d. 2001

139. When is the first certification of nursing informatics given?

a. 1990-1993
b. 2001-2002
c. 1994-1996
d. 2005-2008
140. The nurse is assessing a female client with possible diagnosis of osteoarthritis. The most
significant risk factor for osteoarthritis is:

a. Obesity
b. Race
c. Job
d. Age

141. A male client complains of vertigo. Nurse Bea anticipates that the client may have a
problem with which portion of the ear?

a. Tymphanic membranes
b. Inner ear
c. Auricle
d. External ear

142. When performing Weber’s test, Nurse Rosean expects that this client will hear

a. On unaffected side
b. Longer through bone than air conduction
c. On affected side by bone conduction
d. By neither bone or air conduction

143. Toy with a tentative diagnosis of myasthenia gravis is admitted for diagnostic make up.
Myasthenia gravis can confirmed by:

a. Kernigs sign
b. Brudzinski’s sign
c. A positive sweat chloride test
d. A positive edrophonium (Tensilon) test

144. A male client is hospitalized with Guillain-Barre Syndrome. Which assessment finding
is the most significant?
a. Even, unlabored respirations
b. Soft, non distended abdomen
c. Urine output of 50 ml/hr
d. Warm skin

145. For a female client with suspected intracranial pressure (ICP), a most appropriate
respiratory goal is:

a. Maintain partial pressure of arterial oxygen (Pa O2) above 80mmHg

b. Promote elimination of carbon dioxide
c. Lower the PH
d. Prevent respiratory alkalosis

146. Which nursing assessment would identify the earliest sign of ICP?

a. Change in level of consciousness

b. Temperature of over 103°F
c. Widening pulse pressure
d. Unequal pupils

147. The greatest danger of an uncorrected atrial fibrillation for a male patient will be which
of the following:

a. Pulmonary embolism
b. Cardiac arrest
c. Thrombus formation
d. Myocardial infarction

148. Linda, A 30 year old post hysterectomy client has visited the health center. She inquired
about BSE and asked the nurse when BSE should be performed. You answered that the BSE
is best performed:

a. 7 days after menstruation

b. At the same day each month
c. During menstruation
d. Before menstruation

149. An infant is ordered to recive 500 ml of D5NSS for 24 hours. The Intravenous drip is
running at 60 gtts/min. How many drops per minute should the flow rate be?

a. 60 gtts/min.
b. 21 gtts/min
c. 30 gtts/min
d. 15 gtts/min

150. Mr. Gutierrez is to receive 1 liter of D5RL to run for 12 hours. The drop factor of the IV
infusion set is 10 drops per minute. Approximately how many drops per minutes should the
IV be regulated?

a. 13-14 drops
b. 17-18 drops
c. 10-12 drops
d. 15-16 drops

[divider] Answers
1c
2a
3d
4b
5c
6d
7a
8d
9b
10 c
11 c
12 d
13 c
14 b
15 d
16 a
17 d
18 d
19 c
20 b
21 a
22 c
23 d
24 b
25 a
26 d
27 b
28 a
29 c
30 d
31 d
32 b
33 a
34 b
35 a
36 c
37 d
38 d
39 b
40 d
41 c
42 a
43 b
44 c
45 c
46 d
47 d
48 a
49 d
50 b

51 c
52 d
53 a
54 c
55 d
56 a
57 b
58 d
59 c
60 d
61 b
62 d
63 c
64 a
65 d
66 c
67 b
68 a
69 d
70 b
71 c
72 b
73 a
74 d
75 b
76 d
77 c
78 a
79 b
80 d
81 d
82 a
83 c
84 b
85 a
86 d
87 c
88 a
89 b
90 c
91 a
92 d
93 b
94 c
95 a
96 d
97 c
98 b
99 c
100 d

101 c
102 a
103 d
104 b
105 c
106 a
107 b
108 d
109 c
110 a
111 d
112 c
113 a
114 d
115 b
116 d
117 d
118 a
119 d
120 c
121 d
122 a
123 b
124 c
125 d
126 a
127 d
128 b
129 c
130 a
131 b
132 a
133 d
134 b
135 a
136 c
137 b
138 a
139 b
140 d
141 b
142 c
143 d
144 a
145 b
146 a
147 c
148 b
149 b
150 a
asis for examination for pallor.