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ANSWER KEY

who missed the last scheduled visit with her obstetrician


FUNDAMENTALS OF NURSING PRACTICE (70 points) require?
A. Partially compensatory
1. The equivalent of 100.8 degrees Fahrenheit in Celsius is B. Supportive-educative
A. 38.2 C. 39.4 C. Universal intervention
B. 38.7 D. 40.1 D. Wholly compensatory

FORMULA: F – 32 (5/9) = C (A) is applicable for patients with limited mobility and can do
partial self-care while (D) is for immobile and unconscious
2. Dorothy underwent diagnostic test and the result of the patients who can needs total care from the nurse. (C) involves
blood examination are back. On reviewing the result, the needs that are needed by all individuals or patients.
nurse notices which of the following as abnormal finding?
A. Neutrophils - 60% 7. Guillermo is allergic to non-steroidal drugs (NSAID). Which
B. Creatinine – 0.9 mg/dL of the following would be the LEAST relevant practice to
C. Erythrocyte sedimentation rate - 25 mm/hr ensure that the nurse who is preparing the drugs for the
D. Blood urea nitrogen – 15 mg/dL patient in the medication room becomes aware of his
allergy?
NORMAL: 0-20 mm/hr. Any increase in ESR indicates an A. The medication administration record has a note on it
inflammatory process. that patient is allergic to NSAID
Neutrophil (60-70%), creatinine (<1 mg/dL) and BUN (10-20 B. Paste a note that patient is allergic to NSAID on the
mg/dl) are all normal. Elevated neutrophil indicates ACUTE chart cover
inflammation while BUN & creatinine indicate renal damage. C. Have the patient wear a red identification bracelet
Creatinine is more accurate than BUN since BUN is affected labeled 'With allergy'
by diet, fluid intake and muscular activity. D. Place a note in the patients medication box that he
has an allergy
3. When doing physical examination as part of the nursing
process, the nurse should have sufficient understanding of The question asks what the nurse IN THE medication room
basic nursing procedures and skills. While auscultating can be made aware of the patient’s allergy. The patient cannot
Mario's lung fields, the nurse compares the Lung sounds. be with the nurse in the medication room.
The nurse applies a systematic pattern by:
A. listening from anterior to posterior 8. Care of patients with intravenous fluids is one of the major
B. assessing from top to bottom responsibilities of a nurse. A nurse caring for a client with
C. comparing lung sounds side to side PICC line (peripherally inserted central line) knows that
D. comparing from interspace to interspace. the tip of the IV access is located in the
A. Basilic vein C. Right atrium
Chest auscultation involves listening to breath sounds from B. Cephalic vein D. Antecubital vein
side to side, comparing left and right lung fields as it goes from
top to bottom. A PICC line is inserted in a peripheral vein with its tip placed at
the right atrium. B, C, and D are the insertion sites.
4. Who pioneered the idea of the nurse-client relationship
and interactive process? 9. A frail elderly woman undergoes a timed up and go test
A. Faye Abdellah with a result of 18 seconds. This means that the client
B. Florence Nightingale A. moves normally like any other adult
C. Hildegard Peplau B. is a fall risk
D. Virginia Henderson C. is within normal limits for her age and physical
condition
Abdellah focused on 21 nursing problems, Nightingale on D. needs assistance when moving out of bed
environmental theory, and Henderson on 14 basic needs.
5. The physician ordered a small volume enema to a client This is a test of mobility which involves measuring the time a
with fecal impaction. The client needed further clarification person rises from a chair, walks three meters, turn around, and
when she asks the nurse how the solution will work once it walk back to the chair and sit down. Completion of the test in
is administered. The most appropriate explanation of the less than 10 seconds is normal mobility; however, for elderly
nurse is that the solution: adults and those with disability, this may take them 11-20
A. Causes distention of the bowel and stimulates the seconds which is normal for this group. When a patient takes
defecation reflex. 21-30 seconds to perform the test, he needs additional
B. Draws water from the colonic mucosa cause water assistance during ambulation. A 30-second or more result
retention in the lower-colon. . . signifies a patient is a fall risk.
C. Decreases surface tension of stool allowing water to
enter stool more readily. 10. Allen’s test is indicated for which of the following clients? A
D. Promotes bowel evacuation that provides and client
stimulates the defecation reflex. A. who needs an arterial line
B. with ulnar nerve damage
Small-volume enema uses hypertonic solution, thus attracts C. with peripheral neuropathy
water into the feces. A and D are for hypotonic and isotonic D. who is about to undergo glucose test
enemas, while C for oil retention enema.
This is a test to determine adequacy of peripheral
6. According to Orem’s Self-Care Theory, what type of CIRCULATION.
nursing activity would a G2P1 mother, 7 months pregnant,
11. A client is reported to have orthostatic hypotension.
Which of the following would you consider a sign?
A. Increase in pulse of 40 beats/minute and decrease in A. hypothalamus C. anterior pituitary gland
BP of 30 mm Hg from a sitting to a standing position B. posterior pituitary gland D. thyroid gland
B. A drop of 30 mm Hg in BP from a supine to a
standing position with a rise in pulse of 40 beats/ 18. A suppository is prescribed for the client. When
minute administering the drug, the nurse must place the client in
C. Decrease in pulse by 20 beats / minute and increase which position?
in BP by 20 mm Hg from supine to standing position A. Sim’s C. Lithotomy
D. A sudden drop in BP of 30 mm Hg systolic and 10 B. Dorsal recumbent D. Prone
mm Hg diastolic from lying to sitting or sitting to
standing position Left Sim’s position is the preferred position for any procedure
that involves administration of medication or tube into the
Orthostatic hypotension is measured while a person is lying rectum as the sigmoid colon is located in the left lower
down, sitting AND standing. A 20-30 drop in systolic BP and quadrant of the abdomen.
10-15 drop in diastolic BP when changing position is a positive
finding. B and C are wrong positions for the client. 19. A client is transferred to the medical unit after a
transurethral resection of the prostate. The nurse reviews
12. A post-operative client complains of numbness and the transfer orders. The surgeon's order reads: "Maintain
tingling around his mouth and shows prolonged QT traction on the indwelling triple lumen catheter" Which of
interval on the cardiac monitor. These are associated with the following is the MOST appropriate action of the nurse?
which electrolyte imbalance? A. Tape the catheter to the abdomen and keep client in
A. Hypocalcemia C. Hyperkalemia supine position.
B. Hypokalemia D. Hypercalcemia B. Pull the catheter taut and tape to the thigh alternately
every 6 hours.
The symptom is an early sign of tetany or hypocalcemia. C. Instruct the client to keep both legs together and
Prolonged QT interval reflects a low calcium level. extended all the time.
D. Pull the catheter taut, tape to one thigh and keep the
13. Prevention of infection is one of the essential measures to leg extended all the time.
reduce negative outcomes in health care. Catheter care
must be performed frequently to prevent urinary tract This position maintains traction of the catheter.
infections. How often should the nurse change a client’s
condom catheter? 20. Normal heart sounds originate from the SA node. How
A. Every 24 hours C. every 72 hours many times per minute does the SA node emit electric
B. Every 48 hours D. every 96 hours currents in an adult?
A. 60-100 C. 40-60
Changing the catheter every 24 hours reduces the risk for UTI. B. 50-100 D. 80-120

14. In the physical examination of a patient with abdominal The sinoatrial node is the pacemaker of the heart. It normally
pain, what is the recommended sequence of examination emits 60-100 electric currents per minute. The atrioventricular
techniques? node emits 40-60, while the Bundles of His, 20-40.
A. Inspection, auscultation, percussion, palpation
B. Inspection, percussion, palpation, auscultation 21. When the body responds to stress, epinephrine is
C. Inspection, percussion, auscultation, palpation released producing which physiological response?
D. Inspection, palpation, auscultation, percussion A. Decreased oxygenated blood to vital organs
B. Decreased heart rate
Inspection is always the first technique of physical C. Peripheral vascular dilatation
assessment. In abdominal assessment, auscultation is done D. A more forceful heart beat
first prior to percussion and palpation to prevent altering the
bowel sounds. ABC are the opposite effects of epinephrine.

15. The patient with an acoustic nerve injury may have a 22. The nurse is aware that proper documentation when
positive Romberg’s sign. Which of the following describes taking care of the client is important. The purposes of
a positive Romberg’s sign? client care documentation include the following:
A. Inability to hear a whisper 1. Standardizes plan of care
B. Inability to hear unless the listener is looking at the 2. Communicates vital information about client’s
speaker health status to other health care providers
C. Inability to maintain an upright position with eyes 3. Serves as resource for research and education
closed 4. Serves as a legal document
D. Inability to maintain an upright position with eyes A. 2, 3 and 4 C. 1, 2 and 4
open B. 1, 3 and 4 D. 1, 2 and 3

Romberg’s test is a test of balance and equilibrium. Inability to According to Kozier, 234 are the purposes of documentation.
maintain such indicates an abnormality in the cerebellum.
23. When assessing for the apical pulse, where should the
16. Various methods of documentation are practiced by nurse place the stethoscope?
nursing staff, one of which is the SOAP method. The A. 5th ICS, left midclavicular
SOAP method stands for B. 4th ICS, left midsternal
A. subjective data, objective data, assessment, process C. 5th ICS, right midsternal
B. subjective data, objective data, assessment, planning D. 4the ICS, right midclavicular
C. subject, objection, assessment, process
D. subjective data, objective data, analysis, planning The apical pulse, also known as the point of maximum impulse
is located in the 5th left intercostal space, left midclavicular line.
17. Somatotropin releasing hormone or the growth hormone
releasing hormone is secreted by the:
24. A client has difficulty walking and needs wheel chair to NPO must be done prior to ultrasound of the bladder in order
facilitate performance of daily activities. Anticipating the to concentrate the bile in the bladder.
needs of the client, the nurse should have the wheel chair
ready by placing it at 30. Cultural sensitivity enables nurses to be responsive to the
A. 60-degree angle to the bed needs of patients with varied cultural background. A client
B. 45-degree angle to the bed practices Islam and his diet must consider his religious
C. 90-degree angle to the bed practices and beliefs. The nurse is aware that this client
D. 30-degree angle to the bed would avoid which of the following?
1. Shrimps and crabs
25. How will a nurse assess the client for pulse deficits? 2. Wine and alcohol drinks
A. Ask a colleague to take the apical pulse together with 3. Fish with scales
her. 4. Pork products like bacon
B. Ask a colleague to take the radial pulse as she is 5. Caffeinated products like cola drinks
taking the apical pulse. A. 2, 4 and 5 C. 3,4, 5
C. Take the apical pulse & compare with the pulse B. 1, 4 and 5 D. 1, 2 and 4
pressure.
D. Take the radial pulse after taking the apical pulse. 31. What is the formula to obtain cardiac output?
A. Heart rate x Diastolic pressure
Assessment of pulse deficit can be done by either the 1-nurse B. Heart rate x Pulse pressure
method or 2-nurse method. The question states “a nurse”. C. Heart rate x Stroke volume
Option B uses the 2-nurse method. D. Heart rate x Systolic pressure

26. Which of the following best describes Cheyne-Stokes Cardiac output is the amount of blood ejected by the heart in
respiration? one minute. It is determined by the heart rate and stroke
A. Abnormally deep, regular, and increased rate volume or the amount of blood ejected by the heart PER
B. Abnormally shallow for 2-3 breaths followed by contraction which is about 70 mL. If a person’s heart rate is 80,
irregular period of apnea multiply it by 70, then the cardiac output is 5,600 mL.
C. Irregular rate & depth with alternating periods of
apnea & hyperventilation 32. A pulse oximetry measures oxygen saturation of the
D. Regular rate & depth with alternating periods of blood. The oxygen saturation reading that is assessed by
apnea & hyperventilation using a pulse oximeter is documented as
A. SaO2 c. PO2
Choice A describes Kussmaul’s respiration. B. SpO2 d. PaO2

27. The nurse implement standards of care to prevent Oxygen saturation is SaO2. When assessed by a pulse
complications related to immobility. A client on bed rest is oximeter, it as reflected as SpO2.
rolled to a lateral position by the nurse. The nurse is
negotiating the move correctly when he: 33. The nurse has a sterile field in front of her and needs to
A. Positions himself at the mid part of the bed and reach something on the other side of the sterile field. To
places both hands at the back of the client and roll maintain the sterile field, the nurse should:
client onto side A. Walk around with the back to the sterile field.
B. Places one hand on the client’s far hip and the other B. Reach across the sterile field.
on the client’s far shoulder rock backward and roll C. Walk around facing the sterile field.
onto side of the body facing him D. Move the sterile field away from her and reach the
C. Assumes a broad stance with the foot nearest the bed object.
placing his arm under the client’s thighs and shoulder
and roll client onto side ABD all violate the principles of aseptic technique.
D. Supports the back and buttocks of the client and
shifts his own weight from the forward to the 34. When obtaining a urine sample from a patient with an
backward foot and roll the client onto side indwelling urinary catheter, where should the urine be
collected?
Choice B is the most appropriate way to turn a patient to the A. From the balloon port of the catheter using a needle.
lateral position. (Kozier) B. From the collection bag.
C. From the collection port using a needle.
28. Which of the following represents ventricular relaxation? D. From the tube near the meatus using a needle.
A. P wave C. Q wave
B. R wave D. T wave Letter A will remove the fluid that anchors the catheter. Urine is
never collected from the collection bag.
P wave represent atrial depolarization/contraction. QRS waves 35. A nurse receives an order to obtain sputum sample for
reflect ventricular depolarization. culture from a client with pneumonia. What action should
be avoided when obtaining the specimen?
29. The nurse is preparing the client for an ultrasound of the A. Having the client brush teeth before expectoration.
gallbladder. Which of the following statements would be B. Instructing the client to take deep breaths before
the most important to prepare the client for the test? coughing.
A. "You will have food and fluids restricted for 4 to 8 C. Obtaining the specimen early in the morning.
hours prior to the test.“ D. Placing the lid of the culture container face down on
B. "Stool in the bowel may cause a reporting of the bedside table.
inaccurate findings.“
C. "There is no special preparation for this procedure. Oral care (A) may be done prior to sputum specimen collection
You may eat and drink as usual.“ as long as antiseptic mouthwash or saline gargles are not
D. "You will be asked to drink a solution of radionuclide 2 done. B facilitates sputum expectoration. C is the preferred
hours prior to the procedure." time to collect sputum. D contaminates the lid of the specimen
container.
42. A patient whose ventilation is inadequate should be
36. A nurse is preparing to suction a client through a observed for early symptoms of hypoxia, which include
tracheostomy tube. Which of the following protective items A. Restlessness C. Pallor
would the nurse wear to perform this procedure? B. Cyanosis D. Disorientation
A. Goggles, mask and sterile gloves
B. Mask. gown and cap TIP: Signs of hypoxia
C. Mask, sterile gloves and cap ALWAYS: Early sign of low oxygen is behavioral change since
D. Gown, mask and sterile gloves the brain is sensitive to changes in oxygen level. Cyanosis is a
LATE sign of hypoxia.
Gowns and caps are not required for tracheostomy suctioning.
43. Urinary tract infections remain to be the most common
37. When performing incentive spirometry after lobectomy, cause of hospital acquired infections. When considering
how should the nurse position the client? the safety needs of a client with a urinary catheter, which
A. Semi-Fowler’s C. Supine of the following should the nurse observe?
B. Trendelenburg D. Lithotomy A. Keep a closed sterile drainage system
B. Irrigate the catheter daily
Incentive spirometry facilitates lung expansion. Semi-Fowler’s C. Keep the bag lower than the bed
position helps achieve that purpose. D. Measure intake and output daily

38. While orienting a new nurse to the unit, the charge nurse Safety needs = prevention of infection. Maintain a closed
stresses the importance of accurate documentation, the system if a patient is on an indwelling catheter.
primary reason for a nurse to document care accurately is
A. Be in compliance with individual regulatory agencies 44. Lizbeth is reviewing her notes in preparation for her
B. Demonstrate responsibility and accountability upcoming exam. In concepts of health illness, who
C. Facilitate insurance reimbursement postulated that health is the ability to maintain the internal
D. Prevent any legal action against the healthcare facility milieu?
and its staff A. Walter Cannon C. Claude Bernard
B. Hans Selye D. Florence Nightingale
39. A 12-year old girl has a long leg cast applied to her left
leg. She is being instructed in crutch walking with no Claude Bernard – first to explain internal milieu
weight-bearing on her left leg. Which of the following Walter Cannon – first to give the name “homeostasis”
observations indicates that the girl needs further teaching? Hans Selye – first to explain the stress response
A. Her elbows are slightly flexed
B. She is supporting her weight on the axillary bars and 45. Nursing practice is governed by different theoretical
hand pieces of the crutches framework postulated by known theorists. The four
C. She is using the three-point gait concepts common to nursing conceptual models are:
D. She places the crutches approximately six to eight A. Person, environment, health and nursing
inches (15-20 cm.) in front of her with each step B. Person, environment, psychology and nursing
C. Person, health, nursing and support system
The weight must be borne by the hands on the hand bars, not D. Person, nursing, environment and medicine
by the axillae. This may cause neurovascular impairment.
These are also called the four metaparadigms in nursing.
40. An infant who weighs 11 lbs. (5 kg.) is to receive 750 mg
of antibiotic in a 24-hour period. The liquid antibiotic 46. Stress is the simple most important contributing factor to
comes in a concentration of 125 mg per 5 ml. If the illness. It is related to many of man’s illnesses and
antibiotic is to be given three times each day, how many interventions of these are based on the body’s reaction to
milliliters would the nurse administer with each dose? stress. Which of the following body systems is primarily
A. 10 B. 2 C. 5 D. 6.25 involved in GAS as a response to stress?
A. Central nervous system and cardiovascular system
750 mg per day / 3 doses per day = 250 mg/dose B. Neurological and endocrine system
250 mg per dose / 125 mg x 5 ml = 10 mL C. Endocrine system and respiratory system
D. Musculoskeletal and immunological system
41. The nurse performs tracheostomy care to a client with
acute respiratory distress syndrome. After thoroughly GAS = general adaptation syndrome
cleansing the lumen and the entire inner cannula in The nervous system, through the autonomic nervous system
hydrogen peroxide solution the nurse is now ready to releases epinephrine and the endocrine system, via the
return the cannula to the tracheostomy site. To ensure adrenal gland releases epinephrine and corticosteroids, which
that the cannula is in place the nurse should: are the stress hormones.
A. Replace the inner cannula following the curve of the
tube, lock by rotating the external ring clockwise until 47. Changing the wound dressing of a client requires utmost
it clicks into place care to prevent infection of the wound. When doing wound
B. Insert the flange of the tube and lock until it clicks into care, the most appropriate nursing action would be to
place A. Remove old dressings with sterile gloves
C. Secure the flange of the inner cannula to the outer B. Pour antiseptic solution out of the container
cannula C. Open the sterile dressings with sterile gloves
D. Return the inner cannula, lock by rotating the external D. Wear sterile gloves whenever in contact with the
ring counterclockwise until clicks into place. wound area

To lock a tracheostomy cannula = turn clockwise (lock, clock) Sterile dressings are opened by the clean bare hands by
To unlock a tracheostomy cannula = turn counterclockwise holding the edges of the package.

48. A client is positive of neck vein distention if the nurse sees


a bulging neck vein when the client is in what position?
A. Supine C. high-Fowler’s B. Instruct the client to cough
B. Semi-Fowler’s D. Trendelenburg C. Give a client a sip of water through a straw
D. Inject 10 ml of water into the NG tube
The patient is initially placed on supine position for the nurse to
check the neck veins. Then the patient is put on a semi- TIP: Methods of checking for the placement of NGT
Fowler’s position. If a patient has a vein distention, it is visible  Immersion – dip the end of the NGT in a cup of water.
on that position. Bubbling indicates placement of tube in the lungs.
 Auscultation – inject 10 ml of air into the tube and
49. A client with severe flank pain has a suspected renal listen for gurgling or borborygmi sounds.
stones and is to undergo diagnostic procedures such as  Aspiration – presence of gastric aspirate confirms
intravenous pyelography. An important nursing placement. It is the most accurate among the three
intervention after an intravenous pyelography is to methods.
A. Determine response to the injected dye
B. Assess for allergy to iodine Abdominal x-ray, however, is the BEST method to determine
C. Push fluids placement of NGT.
D. Check the IV site
54. A female client confesses during admission assessment
Intravenous pyelography involves administration of a dye or that she has a lump in her breast. Which of the following is
contrast medium. Post-procedure, hydrate the patient to the appropriate action of the nurse?
facilitate excretion of the dye. A. Lift the client hand to palpate the breast where she
noted the lump.
50. Having finished with you Masters degree in Nursing, you B. Palpate both breasts simultaneously to compare.
were hired as a faculty member and were assigned to C. Assess the breast with the lump first.
teach the topic “History of Nursing”. Florence Nightingale D. Start assessment of the normal breast.
and her contemporary nurse learned nursing skills and
techniques as “trainees” during which period in the nursing During admission, the initial action is to start assessment of the
history? normal breast. The suspected abnormal breast is done next.
A. Apprenticeship period C. Primitive period
B. Intuitive period D. Educative period 55. Which of the following activities demonstrate secondary
level of prevention?
TIP: Periods in the history of nursing A. A mother going to her physician for her annual
1. Intuitive nursing (from pre-historic time to 1700s)– care was mammography
based on instincts B. Nurses attending a seminar of crisis management
2. Apprentice period (1700s-Nightingale era in 1800s) – strategies
nursing was based on “on-the job” training, focus on skills; no C. Monitoring the blood glucose level of a diabetic
formal education for nurses patient
3. Educated nursing (1800s-1940s) – Florence Nightingale D. A child receives his booster dose of varicella
initiated formal schooling and training for nurses immunization
4. Contemporary nursing (1940s – present) – nursing based on
scientific principles, research and influenced by advances in TIP: Levels of Prevention
science and technology  Primary prevention – health promotion and disease
prevention. Examples are dietary modification,
51. The nurse correctly performs endotracheal suctioning avoidance of alcohol and smoking, stress
when she does which of the following? management, immunization and exercise.
A. Administer 100% oxygen before the procedure.  Secondary prevention – early diagnosis and
B. Apply intermittent suction while gently inserting the treatment. Examples are screening, diagnostic tests,
suction catheter. medications, surgery.
C. Advance the suction catheter when a resistance is  Tertiary prevention – recovery and rehabilitation
felt. Examples are prevention of complications, assistance
D. Suction the client for a minimum of 10-15 seconds. with ADL, physical therapy

Always pre-oxygenate the patient before and after suctioning. 56. A patient with pneumonia has respiratory acidosis. In
Do not apply suction while inserting the suction catheter (B). compensating for acid-base imbalances, the first
Choice C may cause tissue trauma. TIP: Never force any mechanism that is usually activated is the
invasive equipment past any resistance. Suctioning is done for A. Retention of bicarbonates by the kidneys
a maximum of 15 seconds (D). B. Excretion of carbon dioxide by the lungs
C. Bicarbonate-carbonic acid chemical buffer system
52. A client is receiving an IV infusion of dextrose 5% in water D. Retention of oxygen by the lungs
and Ringer’s lactate solution at 125 ml/hour to treat a fluid
a volume deficit. Which of these signs indicates a need for TIP: Sequence of compensatory mechanisms for acid-
additional IV fluids? base imbalances
A. Dark amber urine 1. Chemical buffer system – the most common is the
B. Serum sodium level of 135 mEq/L bicarbonate (base/alkaline)-carbonic acid buffer system
C. Temperature of 37.5ºC 2. Respiratory system – the lungs excrete CO2 if the blood is
D. Neck vein distention acidotic and retains CO2 if it is alkalotic. CO2 becomes an acid
(carbonic acid) when mixed with water.
Dark amber urine is a sign of dehydration. The serum sodium 3. Renal system – the last and most effective means to correct
is normal (135-145 meq/L). An elevated level reflects imbalances. If the blood is acidotic, the kidneys retain
dehydration. Neck vein distention suggests fluid overload. bicarbonates (base) and excretes hydrogen ions (acid). If the
blood is alkalotic, they excrete bicarbonates and retain the
53. Before administering a medication through a nasogastric hydrogen ions.
(NG) tube, the nurse should do which of the following
first?
A. Inject 10 ml of air into the NG tube and aspirate
57. If a blood pressure cuff is too tight for a client, blood 4. Providing emotional support
pressure readings taken with such a cuff may do which of A. 2 and 3 C. 1 and 2
the following? B. 4 only D. 1, 2 and 4
A. Cause a sciatic nerve damage
B. Fail to show changes in blood pressure Hospice care, or care of the terminally ill, focuses on making
C. Produce a false-high measurement the patient feel comfortable by focusing on pain management
D. Produce a false-low measurement and alleviation of symptoms (palliative care).

When the BP cuff is too tight, it needs LESS air to inflate the 62. Control of infection is emphasized in the care of clients
cuff. The reading will be lower. and must not be compromised. An understanding of the
infectious process and appropriate methods to prevent
58. A patient with renal failure has elevated phosphorus level. transmission of infection is important. The nurse in the
Which of the following interventions is appropriate to health center is explaining “standard precautions” to the
restore eliminate excess phosphorus from the body? client. This involves which of the following actions?
A. Advise patient to drink more milk A. Use clean gloves when handling items like blood,
B. Tell patient to eat chocolates and nuts body fluids, and non-intact skin.
C. Take aluminum- based antacids like Amphojel B. Recap used needles with both hands before
D. Increase fluid intake discarding in puncture-resistant container.
C. Wash hands thoroughly using antimicrobial soap and
Aluminum binds with phosphorous and is eliminated via the hot water.
digestive system. Milk (A) and dairy products (B) have high D. Wear protective equipment when doing any nursing
phosphorus content. Although increasing fluids may help procedures.
eliminate phosphorous, medications are more effective.
B is unsafe practice; never recap needles. Use of antimicrobial
59. The intern-2nd assistant surgeon contaminated his gown soap (C) is only indicated if hands are contaminated; the
while the surgery is ongoing. He is expected to change his guidelines say the for routine handwashing, regular soap may
gown and gloves. Which of the following is the CORRECT be used. Not all routine procedures need PPE (D).
technique to be followed?
A. The intern removes his gown and gloves then puts on 63. Which of the following roles match the work-related
another sterile gown and gloves. activity of the nurse whereby she functions as clinician,
B. The intern removes his gloves, then his gown; does a educator, manager, consultant and researcher within a
3-minute hand scrub and don another sterile gown specific practice?
and gloves. A. Nurse practitioner
C. The intern unties his gown, removes his gowns and B. Nurse anesthetist
put on another gown and gloves. C. Clinical nurse specialist
D. The circulating nurse unties the gown. The intern D. Nurse-educator
removes his gown, then removes the gloves and puts
another sterile gown and gloves. A clinical nurse specialist performs the roles of a clinician,
educator, manager, consultant and researcher. A nurse
In ABC, the intern removes the gown on his own. He is not practitioner (A) is a generalist.
supposed to do that with contaminated gloves on. Only choice
D has another personnel removing the gown for him. 64. Maria will be preparing a patient for thoracentecis. She
should assist the patient to which of the following position
60. Mr. Tee is admitted to the hospital with vomiting, diarrhea, for the procedure?
fever and a 5 lb (2.3 kg) weight loss. The nursing A. Prone with the head turned to the side and supported
diagnosis reads fluid volume deficit related to vomiting and by a pillow
diarrhea. Which of the following laboratory values can the B. Lying in bed on the affected side with the head of the
nurse expect to find on Mr. Tee’s chart? bed elevated 45 degrees
A. Decreased urine specific gravity (USG) C. Sim’s position with the head of the bed flat
B. Elevated serum potassium level D. Lying in bed on the unaffected side with the head of
C. Increased hematocrit level (Hct) the bed elevated 45 degrees
D. Normal serum chloride level
The preferred position for thoracentesis is an upright position
Hematocrit (37%-47%) is the percentage of blood cells to with arms propped up to exposed the rib cage or intercostal
plasma, the liquid component of the blood. When one has fluid spaces. If a patient cannot tolerate this position, the choice D
volume deficit or dehydrated, the blood becomes more is the next preferred position.
concentrated, thus giving a higher hematocrit level.
65. As a nurse, what is one of the best way to reconcile
medications across the continuum of care?
A. Endorse the routine and “stat” medications every shift
TIP: Laboratory values B. Communicate a complete list of the patient’s
 High hematocrit = hemoconcentration; fluid deficit medication to the next provider of service
 Low hematocrit = hemodilution; fluid excess C. Endorse on a case to case basis
 High USG = urine is concentrated; fluid deficit D. Endorse in writing
 Low USG – urine is diluted; fluid excess
Medication reconciliation is a process whereby the nurse
61. The nurse is taking care of a client, Luisa, 62 years old, endorses the patient’s list of medication, in a written form, to
who received a diagnosis of uterine cancer and is in the the next level of care/provider. This practice aims to promote
terminal stage. The focus on care for the terminally ill patient safety and errors in medication.
client includes:
1. Meeting physiologic needs 66. A nurse is reviewing the electrolyte results of an assigned
2. Managing pain client and notes that the potassium level is 6.6 mEq/L.
3. Identifying and treating physical symptoms Which of the following would the nurse expect to note on
the ECG as a result of this laboratory value?
A. ST depression C. inverted T wave Total parenteral nutrition delivers a high calorie glucose,
B. prominent U wave D. tall peaked T waves protein and fat-rich solution intravenously. Hyperglycemia is a
common side-effect that needs to be monitored.
The potassium level is increased. NV = 3.5-5.5 meq/L
NURSING RESEARCH (20 points)
TIP: Potassium & ECG
High potassium = high, peak, or tall T wave 71. Which of the following is NOT a component of evidence-
Low potassium = low, depressed T wave; presence of U wave based practice?
A. Use of the best available research finding
67. A male client with a left lower leg prosthesis states that he B. Applying the research evidence using clinical
can feel his heart "skipping beats" when he walks up the expertise
stairs. He states his doctor has ordered an outpatient test C. Acceptability of the research finding by the patient
that will take many hours, and he wants to know what it is. D. Generalizability of the research finding to the general
Your response would be: population
A. "Your physician has ordered an echocardiogram,
which will utilize sound waves to project a picture of The fourth component of evidence-based practice (EBP) is the
your heart in motion.“ availability of resources to implement the evidence. The finding
B. "Your physician has ordered a Holter monitor test, is only applicable to a single patient or a group of patients with
which will record your cardiac rhythm and rate while similar problems. Generalizability is not needed in EBP.
you go about your normal activities.“
C. "Your physician has ordered a graded exercise 72. In most instances, Filipinos do not know their rights as
treadmill test (GXT), which will record your cardiac patients. To be a patient advocate, nurses must have a
activity as you exercise on a treadmill.“ good understanding of the “Patients’ Bill of Rights”. Which
D. "Your physician has ordered a 12-lead ECG, which of the following is an emerging role of the nurse in her
will record your resting heart rhythm and rate." mission to provide quality care in any setting regardless of
type of client and meet her goal to contribute new
Key words: “Skipped beats” refers to cardiac dysrthythmias knowledge and technology in nursing?
which are diagnosed by an ECG. “Out patient test” that takes A. Nurse executive D. Nurse manager
“many hours” are characteristics of a Holter monitor (B) . A 12- B. Nurse researcher C. Nurse educator
lead ECG (D) only takes a few minutes.
The main objective of nursing research is to contribute new
68. Which of the following nursing diagnoses contains the knowledge and technology to improve patient care.
proper components?
A. Risk for caregiver role strain related to unpredictable 73. A researcher would like to study two groups of students,
illness course particularly, the freshmen and the sophomore students
B. Risk for falls related to tendency to collapse when regarding their study habits before every periodical
having difficulty breathing examination. The survey will be made on a same time to
C. Decreased communication related to stroke determine if there is any difference as regards the two
D. Sleep deprivation secondary to fatigue and a noisy groups. This type of survey is called:
environment A. Cross-sectional survey C. Evaluation survey
B. Longitudinal survey D. Sample survey
TIP: The components of a nursing diagnosis: PES
P – patient’s problem 74. The researcher would like to determine the effectiveness
E- etiology or related factor of a new system of scheduling and staffing in a particular
S – signs and symptoms tertiary hospital to prevent sudden shortage in the ratio of
nurses to patients. The type of research method is called:
B – the problem (risk for fall) and etiology (tendency to A. Manipulative C. Descriptive
collapse) are the same B. Quasi-experimental D. Experimental
C – the etiology is a medical diagnosis
D – wrongly stated (secondary to); it should be “related to” Although the study determines the effectiveness of an
intervention, the situation does not specifically mention two
69. Following a bronchoscopy, which of the following groups of subjects, experimental and control groups, thus
complains should be noted as a possible complication? making it a quasi-experimental research.
A. nausea and vomiting
B. shortness of breath and laryngeal stridor 75. In the research study entitled “Effects of timing of initial
C. blood tinged sputum and coughing bath on the temperature of the newborn”, which of the
D. sore throat and hoarseness following is correct?
A. The presumed cause is the timing of initial bath
Stridor is a narrowing of the upper airway. It may indicate B. The presumed effects of the study is the timing of
laryngeal edema as a result of the bronchoscope irritating the initial bath
tissues. A blood-tinged sputum (C), sore throat and C. The variable to be manipulated is the temperature
hoarseness (D) may be common and expected after an D. The variable to be measured is the timing of initial
invasive procedure. Nausea and vomiting (A) may be an affect bath
of the anesthetic sprayed to suppress the gag reflex.
TIP: Independent vs. Dependent Variables
70. Promotion of adequate nutrition is a challenge to patients  Independent variable = the presumed cause,
with cancer. The nurse caring for a client on total treatment or manipulated variable (timing of bath)
parenteral nutrition should perform which of the following  Dependent variable = the presumed effect or
assessments regularly? measured variable (temperature)
A. Serum glucose level
B. Serum electrolytes 76. Which of these states the expected relationship between
C. Urine output the independent and dependent variable?
D. Level of consciousness A. Assumptions C. Hypothesis
B. Research design D. Research purpose
Hypothesis = educated guess, a prediction of the possible Experimental and quasi-experimental researches, which are
result of the study both quantitative designs, both involve manipulation of an
independent (treatment) variable.
77. A researcher embarked on an intensive study of health
problems affecting the residents of Brgy. San Carlos. She 83. In statistics, this expresses the variability of the data in
decided to study every third family representing the total reference to the mean. It provides us with a numerical
population in the said community. Types of sampling estimate of how far, on the average the separate
suited for the study is: observation are from the mean. What is this called?
A. Cluster sampling C. Incidental sampling A. Mode C. Standard deviation
B. Systematic sampling D. Stratified sampling B. Median D. Frequency

78. The plan for how a study will be conducted is called the: Key word: Variability = measures of variability includes range,
A. Data-collection method C. Research design variance, standard deviation
B. Research process D. Hypothesis
84. The researcher implemented a medication regimen using
79. Which statistical treatment is best used to answer the a new type of combination drugs to manic patients while
research question, “The Level of Difficulty of the May another group of manic patient receives the routine drugs.
2014 Nurse Licensure Examination as Perceived by The researcher however handpicked the experimental
the Examinees”? group for they are the clients with multiple episodes of
A. Chi-square C. ANOVA bipolar disorder. The researcher utilized which research
B. Mean D. T-test design?
A. Quasi-experimental C Pure experimental
The study simply requires frequency distribution and/or mean B. Phenomenological D. Longitudinal
determination.
TIP: Experimental vs. quasi-experimental research
TIP: Statistics If an experimental study DOES NOT involve random selection
 Chi-square – to determine the relationship between of subjects (handpicked) and include two groups of subjects
two variables that are on a nominal or ordinal scale (experimental and control groups), it is considered a quasi-
 ANOVA or analysis of variance – to determine experimental study.
significant difference between three or more groups of
respondents 85. In the hypothesis “The utilization of technology in teaching
 T-test – to determine significant difference between improves the retention and attention of the nursing
two groups of respondents and to determine students.” Which is the manipulated variable in the study?
difference between pre-test and post-test scores A. Utilization of technology
B. Improvement in the retention and attention
80. A competency-based assessment tool for nursing program C. Nursing students
has been constructed. To assist the faculty in assessing D. Teaching
student attainment of competencies a measuring
instrument has to be developed. In developing the Manipulated variable is also known as the independent,
research instrument, existing instruments that measured treatment variable, or the presumed cause.
similar variables were reviewed by the researcher. After
compiling and writing items, format was decided for each 86. Nina, a staff nurse in the Oncology unit was asked to
variable to be assessed. Which of the following should the participate as a member of the team in the Phase III
researcher do to make sure that the instrument measures clinical trial of the effect of a new drug treatment for
the attainment of competencies? cancer patients. The study has been approved by the
1.Have colleagues review the items for logical validity Institutional Review Board of the hospital where Nina is
2.Revise items based on colleagues' feedback employed. Nina was informed that a double blind
3.Locate a group with experience appropriate to the approach will be utilized. Which of the following is the
study CORRECT description of approach?
4.Try out the instrument with a group as similar as A. Subjects who are randomly assigned to different
possible to the study respondents. treatments are different people
A. 1,2 and 4 C. 1 and 2 B. Neither the subject nor those who administer the
B. 2 and 4 D. 1, 2, 3 and 4 treatment know who is in the experimental and control
group.
The question refers on how to assess validity (accuracy) of a C. Pairing of subjects in one group with those in another
research instrument. All of these items ensure validity. group based on similarities
D. Control group receives the full treatment and deferred
temporarily.
81. The final step of the research process for the researcher is
to: A double blind approach increases the validity of the study. All
A. Analyze the data subjects receive a treatment but no one knows, even the one
B. Utilize the findings who administers the treatment, who belongs to the
C. Communicate the findings experimental or control group.
D. Interpret the findings
87. In a research, the hypothesis developed was: Gingko
Research utilization is the last phase of the research process. biloba improves memory and retention. This is an example
of what type of hypothesis?
82. The type of research design that does not manipulate A. Simple, directional hypothesis
independent variable is: B. Simple, non-directional hypothesis
A. non-experimental design C. Complex, directional hypothesis
B. quantitative design D. Complex, non-directional hypothesis
C. quasi- experimental design
D. experimental design TIP: Types of hypothesis
Simple – one independent and one dependent variable 3. Cooks and assistant cooks 6. Nurses
Complex – 2 or more independent and 2 or more dependent A. 1,2,3,4,5 and 6
variables B. 1,2,3 and 4
Directional – indicates a positive or negative effect C. 1,2 and 3 only
Non-directional – the effect cannot be determined D. 1,2,3,4 and 5

88. A student nurse is curious to find out whether Safeguard That is the definition of public health workers as defined in RA
or Dial is more effective in cleaning an infected wound. 7305.
The first step in locating for evidence in evidence-based
practice is to formulate the research question using the 94. PD 825 is law that pertains to:
PICO format. PICO stands for A. environmental sanitation
A. Problem, intervention, comparison, outcome B. compulsory immunization of children (PD 996)
B. Population, interest, control, outcome C. anti-smoking (RA 9211)
C. Presentation, intervention, comparison, organization D. registration of child births (PD 651)
D. Problem, implementation, control, output
95. The purpose of the first home visit is to
89. Which of the following levels of significance would yield A. Assess family situation through initial data base
the most accurate research finding? B. Develop a health care plan with the family
A. P = 0.01 C. P = 0.10 C. Make a personal account of the family’s health
B. P = 0.05 D. P = 1.00 situation
D. Promote health of the family
TIP: Level of significance
 0.01: 1% margin of error; 99% accuracy rate First home visit focuses on assessment of the family.
 0.05: 5% margin of error; 95% accuracy rate
96. To ensure that the nurse can perform nursing procedures
90. A questionnaire is being used to gather data on the study with ease and deftness, saving time and effort with the
sample. Identification numbers on the corner of the end in view of rendering effective nursing care, he must
questionnaires correspond to the researcher’s master list A. Apply the nursing process
of names and numbers. Respondents are assured that B. Develop a family care plan
this information will not be shared with anyone. The C. Perform bag technique
researcher is trying to provide: D. Prioritize family health nursing problems
A. Confidentiality C. Informed consent
B. Anonymity D. Data security 97. The primary goal of community health nursing is
A. Enhancing the health capabilities of the people
Assigning respondents to numbers or codes ensures towards self-reliance in health
anonymity. B. Health promotion and disease prevention
C. Upholding the worth and dignity of man
COMMUNITY HEALTH NURSING (40 points) D. Raising the level of health of the citizenry

91. The United Nations identified eight Millennium 98. The philosophy of CHN is
Development Goals to address the pressing issues in the A. Enhancing health capabilities of the people towards
entire world. The Philippine Department of Health adopted self-reliance in health
the Basic Emergency Management Obstetric Care in B. Health promotion and disease prevention
response to this calling. This reflects C. Raising the level of health of the citizenry
A. Millenium Development Goal #3 D. Upholding the worth and dignity of man
B. Millenium Development Goal #4
C. Millenium Development Goal #5 99. The theoretical bases of Community Health Nursing
D. Millenium Development Goal #6 practice are theories and principles of
A. Community Development
TIP: Millenium Development Goals B. Nursing
MDG #4 – infants and children C. Nursing & Public Health
MDG #5 – pregnant mothers and women D. Public Health

92. The community Health Nurse Conduct’s home visits to 100. People’s participation in health affairs is optimized through
families in the community. Planning for a home visit is an the establishments of
essential tool in achieving best results in healthcare. The A. Community-based health program
following BUT ONE are the principles B. People’s organization
A. Home visit should have a purpose C. NGO
B. Planning of continuing care must be developed by the D. Community health centers
nurse
C. Planning should be flexible and practical 101. A dynamic process the nurse employ to achieve optimum
D. Plans are based on available information including level of functioning of any level of clientele in CHN is the
those from other agencies that may have rendered A. Community organizing process
services to the family B. Epidemiologic process
C. Nursing process
Planning is collaboratively done by the nurse and the patient. D. Problem-solving process

93. To encourage more health workers to stay in government 102. The client/patient in community health nursing is the
service, Republic Act 7305 or Magna Carta of Public A. Family as a socialization unit and undergoing different
Health Workers was passed into law last 1991. “Public stages of development
health workers” include all persons working in the B. Group of people sharing common characteristics and
government health facilities such as the: interests in a particular area
1. Physicians 4. Cashier, clerical staff
2. Midwives 5. Janitor staff
C. Individual that is identified as a bio-psycho-social and 111. Communicable disease control program is one component
spiritual being of CHN services. The nurse utilizes her concepts of
D. Population aggregates that require specialized care disease prevention. The best strategy in the prevention of
communicable diseases is:
The client in CHN is the community. A. Correct diagnosis and treatment
B. Health education
103. The focus of care in CHN is the C. Immunization/chemoprophylaxis
A. Family C. Individual D. Screening
B. Population group D. Community
112. Nurses working under the RN Heals are enrolled in the
104. When reviewing the function of the rural health unit, the Philhealth iGroup Insurance. Which of the following are
community health nurse concurs that the RHU functions the benefits of the nurses who are under the RN Heals
as a: Project? Select all that apply.
A. Clinic for the municipality A. Premium of P1,200.00 per person per year
B. Community resource B. GSIS Group Accident Insurance premium of P 500.00
C. Health arm of the local government unit per person per year covering the following
D. Central health resource for the municipality C. Accidental Death/Dismemberment of P500,000.00
per person
105. Which of the following herbal medicines is effective for D. Medical Reimbursement of P50,000.00 per person
asthma, cough and dysentery? E. Bereavement Assistance of P10,000.00.
A. Yerba Buena C. Lagundi
B. Sambong D. Tsaang gubat 113. Primary level of prevention of ascariasis pertain to the
following EXCEPT:
106. The primary health care (PHC) approach is implemented A. Food sanitation
to ensure people’s health. Full participation of the people B. Handwashing
is made possible through the application of community C. Mebendazole as prophylaxis
organizing process in health. The ultimate end is to: D. Septic tank toilet
A. Develop community health programs
B. Improve availability and accessibility of health service Primary level of prevention focuses on disease prevention and
C. Promote people’s health health promotion. Choice C is secondary prevention.
D. Transfer health into the hands of the people
114. The original objective of the Expanded Program on
107. There is the need to phase out the community once the Immunization is
community-based health program is functional. The A. Correct epidermiological situation in the country
reason for is to: B. Eradicate communicable diseases among infants and
A. Indicate termination of community organizing process young children
B. Provide opportunity for the role to stand on their own C. Reduce morbidity and mortality among infants and
C. Start a new project in other depressed communities children caused six immunizable diseases
D. Test the new health program if already viable D. Reduce mortality and morbidity of pregnant women

108. The cornerstones or pillars of PHC are 115. The community health nurse collects data about 100% of
1-active community participation the population in a barangay. The nurse is conducting:
2-multi-sectoral approach A. Community assembly C. Community survey
3-use of appropriate technology B. Census taking D. Epidemiologic survey
4-support mechanisms made available
A. All of the above C. 1 and 3 116. BCG is given to school entrants at
B. 1,2 and 3 D. 1 and 2 A. 0.1 ml ID C. 0.05 ml ID
B. 0.5 ml ID D. 0.5 ml IM
109. In prioritizing family health nursing problems, which of
these criteria should not be used by the nurse? 117. The nurse conducts case findings for leprosy in the
A. Acceptability of the problem community. She recalls that for the tuberculoid type of
B. Preventive potential of the problem leprosy, the best treatment is
C. Modifiability of the problem A. PB 19 blister packs C. MB 18 blister packs
D. Nature of the problem B. MB 24 blister packs D. PB 6 blister packs

The fourth criterion is salience, how the family perceives the 118. The most serious side effect of DPT is
problem. A. convulsion C. fever
B. inflamed site D. infection
110. Vital statistics is one of the epidemiological tools that the
community health nurse uses in recording the impact of 119. Various programs have been designed and implemented
health programs in the community. What is the most by the Philippine government to assist new nurses in their
significant implication of a community’s infant mortality transition into the labor market. EntrepreNurse and RN
rate? HEALS are two of such recent programs. The
A. It determines the deaths among infants within a EntrepreNurse program is an initiative of the
specific period of time. A. Department of Health
B. It is the best indicator of the community’s health B. Department of Labor and Employment
status. C. PRC Board of Nursing
C. It shows the number of deaths among babies during D. Philippine Nurses Association
the first 28 days of life.
D. It reflects the effectiveness of the delivery of health 120. We are aware that Community Health Nursing (CHN) in
services. the Philippines encompasses health care provisions
affecting 4 clients: individual, families, population groups
and communities. In the course of our community health
work, traditional, non-traditional, alternative, or EO 119 – reorganization of the DOH
complimentary health care strategies are stabilized. Legal
basis for this action maybe derived from the: 127. A meeting of clients for home care (HC) is essential in
A. PhilHealth Act order to explain the role of the nurse and the advantages
B. Traditional and Alternative Healthcare Law of this alternative health provision. Among important
C. Philippine Nursing Act emphasis to be made is that home care
D. Philippine Medical Act A. Encourages a dependent relationship between the
nurse and the client
121. The following statements pertain to Community B. Provides a holistic view of the client that helps nurse
Organizing EXCEPT to establish appropriate goals and to plan appropriate
A. A never-ending process once started care
B. A process for increasing awareness, facilitating C. Allows the nurse to have primary control over the
organization and initiating responsible action environment where the client will recover
C. Can apply to all communities D. Saves the client money because the care is provided
D. Its goal is community development in a one-to-one situation

Each community is unique. The CO process depends on the Home care promotes patient independence (A) and control
individual community situation. (C). It may cost more as care is provided on 1-on-1 basis (D).

122. A public health nurse conducts a home visit and uses the 128. In implementing the IMCI guidelines, the nurse should
family nursing care plan. During her assessment, which of always make it an assessment standard in children to
the following is categorized as a health deficit? check in capillary refill especially when:
A. The father does not want to have a regular check-up A. The extremities of the child feels cold
at the rural health unit. B. If there is a fever for more than 7 days
B. The mother has a history of pre-eclampsia. C. The child’s extremities feel warm
C. The eldest child is malnourished. D. If the child has petechiae
D. The youngest will enter first grade when the school
starts. 129. The community health nurse as a supervisor in the
community functions by doing which of the following?
Choices A, B are health threats while D is a foreseeable crisis. A. Detects deviations from health
B. Ensures continuity of care to clients/patients
123. The community health nurse implements various health C. Participates in development and distribution of IEC
programs of the Department of Health. The Essential materials
Intrapartum and Newborn Care’s (EINC) Active D. Provides technical and administrative support to
Management of Third Stage of Labor (AMTSL) advocates midwives
the implementation of the following practices EXCEPT?
A. mobility and position of choice in labor
B. partograph use 130. Under Republic Act 9173 of 2002, AMENDED by
C. antenatal steroid administration in preterm labor Congressional Joint Resolution of 2009 sets the entry
D. application of fundal pressure level position for nurses at what salary grade?
A. Salary Grade 15 C. Salary Grade 24
124. An 8-month-old child is brought to the health facility for B. Salary Grade 20 D. Salary Grade 10
“fast breathing.” Using the Integrated Management of
Childhood Illnesses (IMCI) guidelines, correct COMMUNICABLE DISEASE NURSING (20 points)
interpretation of “fast breathing” in this situation MEANS:
A. 40 breaths per minute C. 45 breaths per minute 131. The nurse observes a patient with typhoid fever constantly
B. 38 breaths per minute D. 55 breaths per minute picking the linen while he is lying supine on the bed. The
nurse notes this as a sign called
TIP: Fast breathing in IMCI A. coma vigil C. asterixis
Less than 12 months of age = more than 50 per min B. subcultus tendinum D. rhisus sardonicus
More than 12 months of age = more than 40 per min
Subcultus tendinum – due to the contractions of the tendons of
125. The nurse utilizes the IMCI chart in assessing her the wrist
pediatric clients in the rural health unit. When checking the Coma vigil – state of unconsciousness due to typhoid fever
general danger signs in a 4 month old child, the following Asterixis – flapping tremors of the hands seen in hepatic
questions are asked EXCEPT: encephalopathy due to rising ammonia level
A. Did the child have convulsions? Rhisus sardonicus – also called sardonic grin; seen among
B. Is the child eating well during illness? patent with tetanus/lockjaw
C. Is the child able to breastfeed?
D. Has the child had diarrhea? 132. A patient is told he is positive of Taenia saginata on his
TIP: Danger signs stool exam for ova & parasites. The nurse explains to the
 Convulsion patient that this might have come from
 Lethargy or unconsciousness A. drinking contaminated water
 Inability to breastfeed or drink B. eating fresh fruits and vegetables
 Severe vomiting. C. swimming in flood water
D. ingesting improperly cooked beef
126. For purposes of accuracy and completion of documents
regarding childbirth in the community, the nurse working at Taeniasis is a parasitic infection caused by tapeworms for
the RHU is required that registration birth within 30 days improperly cooked food. T. saginata comes from beef.
from must be done. Which law requires this?
A. R.A. 3573 C. R.A. 3375 133. Schistosomiasis is an endemic disease. Endemic means
B. PD 651 D. EO 119 that the disease occurs
A. at one time during in a specific period of the year
RA 3573 – reporting of communicable diseases B. if there is a sudden increase in infections
C. continuously in a community throughout the year B. unequal pupils D. diarrhea
D. widespread in the country at a particular time
Meningococcemia causes disruption in the blood vessels,
B refers to epidemic and D pertains to pandemic. causing hemorrhage.

134. The nurse evaluates effectiveness of her health teachings 141. Syphilis is caused by:
on a group of mothers regarding ascariasis. An accurate A. Neisseria gonorrhea C. Treponema pallidum
statement made by a mother regarding prevention of B. Cytomegalovirus D. Herpes simplex virus
ascariasis is
A. “I will tell my kids to wash hands after meals.” 142. A sign of gonorrhea is
B. “I will discourage my child from playing on the soil.” A. generalized skin rash
C. “I will not let my children eat raw fruits.” B. yellowish genital discharge
D. “I will make sure not to buy expired canned goods.’ C. clear white genital discharge
D. cheesy substance on the genitalia
Ascaris lumbricoides thrives in the soil. Playing on the soil may
get the ova into the skin and nails which may eventually be Clear white discharge is common in syphilis. Cheesy white
ingested if proper handwashing is not observed. substance is seen in candidiasis.

135. Which of the following statements made by a patient 143. The modes of transmission of the human immune
suggests the presence of enterobiasis? deficiency virus are categorized as horizontal and vertical
A. “I feel nauseated every morning.” transmission. Which of these is an example of a vertical
B. “I feel itchiness in my anus at night.” mode of transmission?
C. “My abdomen is cramping frequently.” A. Sexual intercourse with an infected partner
D. “I didn’t’ have a bowel movement in 3 days.” B. Needlestick injury from an infected patient
C. Placental transfer from an infected mother
Pinworm infestation by Enterobius vermicularis causes D. Sharing among infected IV drug users
nocturnal perianal pruritus.
ABD are considered horizontal modes of transmission.
136. A patient presents to the emergency room with meningitis.
The patient is most likely to present with which chief 144. A confirmatory diagnostic test for HIV infection is
complaints? A. the Western blot test
A. headache and nuchal rigidity B. enzyme linked immunosorbent assay (ELISA) test
B. vomiting and blurred vision C. T4 cell count determination
C. dilated pupils and seizures D. differential CBC test
D. loss of consciousness and cyanosis
ABC are all used in HIV diagnosis. B is used as the initial
Early sign of meningeal irritation is stiffness of the neck. Other screening test. T4 cell count is used to monitor progression of
signs may include Brudzinsky sign and Kernig’s sign. the disease.

137. Which of the following laboratory results for CSF suggests 145. A patient asks the nurse for early signs of HIV infection.
the presence of bacterial meningitis? The nurse tells that early HIV infection is usually
A. increased protein level manifested by the presence of
B. decreased white blood cells A. enlarged lymph nodes in multiple areas of the body
C. reduced glucose level B. recurrent oral thrush
D. increased red blood cells C. rapid weight loss and diarrhea
D. multiple infections
Bacteria in the CSF consumes the glucose, reducing the
glucose level in the CSF. Persistent generalized lymphadenopathy or the enlargement of
1 or more lymph nodes for a long period of time without the
138. The nurse assesses a patient with meningitis by asking presence of any infection is an early sign of HIV infection.
the patient to flex his knees towards his abdomen and
assessing his response. The nurse is performing an 146. Multiple drug therapy is given to a patient with AIDS.
assessment to elicit the Which of these is an example of an anti-viral drug for
A. Babinski sign C. Brudzinsky’s sign AIDS?
B. Kernig’s sign D. Cushing’s sign A. Amphotericin B C. Zidovudine
B. Amantadine D. Azithromycin
Babinski sign – sign of neurological immaturity seen in infants
Brudzinsky sign – sign of meningitis elicited by flexing the neck Anti-retroviral therapy is used to inhibit the replication of the
and observing for involuntary flexion of the knees and neck HIV. (A) is an anti-fungal, (B) anti-flu, and (C) anti-bacterial.
pain
Cushing’s sign – late sign of increased intracranial pressure 147. A patient with HIV infection has whitish spots on the
characterized by high BP or widened pulse pressure, mouth and throat. The nurse will most likely administer
bradycardia and bradypnea (slow RR) A. Neomycin sulfate C. Nystatin solution
B. Glycerine oral swabs D. Amphotericin B
139. To determine the presence of rabies in an animal, its brain
tissues can be examined for the presence of These indicate oral candiasis, a superficial (skin and mucous
A. necrotic tissues C. hematomas membranes) infection caused by the fungus, Candida albicans.
B. Negri bodies D. antibodies C and D are both anti-fungal drugs but Amphotericin B is used
for severe systemic fungal infections.
The presence of Negri bodies is pathognomomic of rabies.
148. A nurse teaches the public where malaria is endemic
140. The nurse notes meningococcemia in a patient if she about prevention and management of the infection. Which
observes statement about malaria is accurate? Malaria
A. stiffness of the neck C. petechiae on the skin A. affects the white blood cells
B. is caused by a protozoan statements made by the patient suggests that he is
C. is caused by the Anopheles mosquito exhibiting adverse effect of Streptomycin?
D. leads to internal hemorrhage A. “I am having numbness in my hands.”
B. “I have some trouble hearing.”
Malaria causes hemolysis of RBC (A), not hemorrhage (D). It C. “I noticed my urine turned orange.”
is caused by the protozoa of the Plasmodium species and is D. “My hands seem to be more swollen today.”
transmitted, NOT caused, by a female Anopheles mosquito (C)
TIP: Side-effects of anti-TB drugs (RIPES)
149. Which vital statistics relating to Tuberculosis (TB) in our Rifampicin – orange discoloration of the urine
country is INACCURATE? Isoniazid – peripheral neuropathy; hepatotoxicity
A. The Philippine is among the 22 highly burdened poor Pyrazinamide – hyperuricemia
countries in the world Ethambutol – optic neuritis; hepatotoxicity
B. TB is the 6th leading cause of illness among Filipinos Streptomycin – otoxocicity, tinnitus
C. TB is the 6th leading cause of deaths among Filipinos
D. Most TB patients belong to the 0-15 age groups 155. Mr. A is a 56-year old patient admitted at the ED with an
internal hemorrhage. He was given Epinephrine 1:1000
150. When a nurse gets a hepatitis vaccine after exposure to a SQ. Which of the following sets of physiological responses
body fluid of a patient with hepatitis B, the type of reflects the effects of Epinephrine?
immunity that develops is A. bradycardia, vasoconstriction, miosis
A. a naturally acquired active immunity B. bronchodilation, mydriasis, hyperglycemia
B. a naturally acquired passive immunity C. tachycardia, hypotension, tachypnea
C. an artificially acquired passive immunity D. vasodilation, hypoglycemia, bronchoconstriction
D. an artificially acquired active immunity
Effects of Epinephrine: tachycardia, vasoconstriction
Hepatitis B immunization involves administration of (hypertension), mydriasis (pupil dilation), tachypnea,
immunoglobulins or antibodies for immediate protection. hyperglycemia, bronchodilation.

TIP: Active vs. passive immunity 156. Low molecular weight Heparin such as Enoxaparin
Active – the body produces its OWN antibody (Lovenox) was prescribed to be administered. Which of
Passive – the antibody comes from an OUTSIDE source the following should the nurse include in her nursing care
plan to ensure absence of injury?
PHARMACOLOGY (30 points) A. Deltoid is the preferred site because it is less painful
B. Aspirate prior to injecting to ensure no blood vessel is
151. Felicito, 65 years old, post coronary artery bypass due to hit
acute myocardial infarction, sought consultation because C. Use gauge 25 and 1/4 inch long needle
of worsening pedal edema. Upon admission, Morphine D. Massage after the injection to promote fast absorption
sulfate was administered intravenously. Which of the
following is the purpose of administering the drug? The drug is administered subcutaneously on the abdomen only
A. improve efficacy of breathing (A) using a gauge 25-26, ¼-5/8 inch needle (C). Aspiration (B)
B. relieve chest pain and massage (D) are not done before and after administering
C. reduce venous return the drug.
D. reduce anxiety
157. Mr. C is a 65 y/o patient with myasthenia gravis. Which of
It is true that Morphine sulfate is an opioid analgesic and is the following medications is used to treat myasthenia
used to relieve chest pain in myocardial infarction. The gravis?
situation presents the development of pedal edema, which is a A. Pyridostigmine (Mestinon)
sign of impending heart failure. In heart failure, morphine is B. Trihexyphenidyl HCl (Artane)
used to promote pulmonary circulation, thus, improves the C. Bethanechol Cl (Urecholine)
breathing of a patient. D. Methyldopa (Aldomet)

152. The physician prescribes oral penicillin 500 mg every six Myasthenia is caused by low level of acetylcholine (Ach).
hours for seven days. On the fifth day before Cora Treatment involves use of antic-cholinesterase medications to
administer the first dose for the day she computed the prevent the breakdown of Ach by the enzyme, cholinesterase.
total amount in milligrams of the oral penicillin that has This will eventually increase Ach levels.
been received by the client. Which is the correct amount?
A. 2,500 mg C. 10,000 mg
B. 15,000 mg D. 8,000 mg 158. Mr. S is a 40-year old patient at the psychiatric unit and is
The situation is asking the dose given on the previous four being treated with anti-psychotic drugs. The nurse
days only (before the nurse gives the first dose on the 5th day). observes that Mr. S is exhibiting symptoms of Parkinson’s
disease. Which of the following anti-cholinergic drugs is
153. Which of the following conditions would alert the nurse often used to reduce side effects of anti-psychotic
that a patient receiving Chloramphenicol (Chloromycetin) medications such as pseudo-parkinsonism?
is developing severe toxic reactions? A. Benztropine mesylate (Cogentin)
A. Nausea, vomiting, diarrhea B. Pilocarpine (Pilocar)
B. Anemia, infections, bleeding C. Neostigmine bromide (Prostigmine)
C. Jaundice, tinnitus, oliguria D. Atenolol (Tenormin)
D. Photosensitivity, rash, constipation
TIP: Anti-cholinergic meds to prevent pseudo-
Chloramphenicol causes bone marrow depression, causing parkinsonism or extra-pyramidal symptoms (EPS) caused
reduced production of RBC, WBC, and platelets, leading to by antipsychotics
anemia, infections, and bleeding, respectively. A – Akineton (Biperiden HCl)
A – Artane (Trihexiphenydyl HCl)
154. A patient is in a Respiratory Isolation room and is taking B – Benadryl (Diphenhydramine HCl)
multi-drug therapy for tuberculosis. Which of the following C – Cogentin (Benztropine mesylate)
165. Gingival hyperplasia is a common side-effect of
159. A patient is admitted to the ED 12 hours after ingesting a A. Phenytoin (Dilantin)
half-bottle of Acetaminophen (Tylenol). To determine B. Valproic acid (Depakote)
organ damage due to the toxic effect of the drug, the C. Carbamazapine (Tegretol)
nurse should evaluate which of these laboratory results? D. Chlordiazepoxide (Librium)
A. Aspartate transaminase (AST) / alanine transaminase
(ALT) levels Gingival hyperplasia or enlargement of the gums is a common
B. White blood count (WBC) and uric acid levels side-effect of Phenytoin. Oral care helps prevent this condition.
C. Platelet count and urinalysis
D. Blood urea nitrogen (BUN) and creatinine levels 166. The appropriate information to a COPD patient on action
of Acetylcysteine (Mucomyst) is:
Hepatotoxicity is an effect of Acetaminophen. Elevated A. “This medication helps loosen the secretions in your
ALT/AST levels indicate liver damage. lungs.”
B. “This drug will make you breathe easier by dilating
160. Mr. P is a 76-year old patient with rheumatoid arthritis. He your airways.”
is currently taking Aspirin 325 po q4h prn for joint pains. C. “You will feel dizzy or sleepy after taking this
Which of the following nursing interventions is appropriate medication.”
for patients taking Aspirin? D. “This drug makes your mouth dry because it
A. Administer the medication before meals. decreases oral secretions.”
B. Monitor the apical pulse prior to giving the drug.
C. Give the medication with meals. Acetylcysteine is a mucolytic, used to loosen thick, tenacious
D. Do not give the medication if the patient has urinary secretions in the trachea-bronchial tree.
obstruction.
167. A mother is asking questions to her 3-year-old son’s nurse
Aspirin, a non-steroidal anti-inflammatory drug (NSAID), about the newly prescribed Cromolyn sodium (Intal) for
causes gastric irritation. her son’s asthma. Which of the following nurse’s
statements accurately addresses the mother’s concern?
161. A 6-year-old child has a low grade fever due to a viral A. “It is the drug of choice for asthma caused by severe
respiratory infection. The choice of medication to reduce acute anaphylaxis.”
the temperature is B. “It is a potent bronchodilator therefore easing
A. Acetylsalicylic acid (Aspirin) respirations.”
B. Acetaminophen (Tylenol) C. “It is effective as a preventive measure for future
C. Ibuprofen (Advil) asthmatic attacks.”
D. Mefenamic acid (Ponstan) D. “It increases the effects of histamine on the lungs.”

Acetaminophen is the drug of choice to reduce fever in Cromolyn sodium is a mast cell stabilizer. It prevents the
children with viral infection. Salicylates are not given (A) due to degranulation of mast cells, which can release histamine and
the risk of developing Reye’s syndrome. C&D are primarily other chemical mediators that triggers the symptoms of
used as analgesics, not routinely given as anti-pyretic drugs. asthma. It is used to prevent asthmatic attacks.

162. A patient with cerebral edema is taking Dexamethasone 168. A patient is on Digoxin (Lanoxin) 0.25 mg po daily. What is
(Decadron) 8 mg po q6h. Which of the following the physiologic action of Digoxin?
assessment findings suggests a common side-effect of A. Increases the rate of cardiac contraction
corticosteroids? B. Decreases the force of cardiac contraction
A. Hyperglycemia C. Diarrhea C. Increases the force of cardiac contraction
B. Hyponatremia D. Dehydration D. Decreases the stroke volume

Hyperglycemia, hypokalemia, sodium and water retention, and Digoxin is a cardiac glycoside used in the management of
risk for infection due to immunosuppression are side-effects of heart failure. It acts by increasing the force of cardiac
steroids. contraction (positive inotropic effect). It can reduce the heart
rate (negative chronotropic effect) so the nurse needs to count
163. A nurse is conducting an admission interview. As she is the apical pulse for 1 full minute prior to its administration. Do
taking the patient’s medication history, the nurse discovers not administer if the apical pulse is below 60 beats per minute.
that the patient has a history of using Valproic acid
(Depakote) and Carbamazapine (Tegretol) daily. Which of 169. A patient is newly admitted to the hospital and tells the
the following conditions from the patient’s medical history nurse during the assessment interview that she is
justifies the need to take these medications? currently taking a potassium-wasting diuretic for her
A. Multiple sclerosis C. Seizure disorder cardiac problem. The nurse reviews her medication orders
B. Parkinson’s disease D. Pituitary tumor and finds: “Digoxin (Lanoxin) 0.125 mg po daily”. The
nurse’s action is appropriate if she
These are anti-convulsant medication, used to treat and A. Administers the medication as ordered
prevent seizures. B. Requests an order to check serum potassium level
C. Advises the patient to take half of the diuretic
164. A client with myocardial infarction is receiving an l.V. D. Reviews the patient’s latest CBC result
infusion of heparin sodium at 1,500 units per hour. The
concentration in the bag is 25,000 units per 500 ml. How The patient is taking a potassium-wasting diuretic which makes
many ml should the nurse document as intake from the him prone to hypokalemia. This can increase risk for digitalis
infusion for an eight shift? toxicity. Potassium level must be monitored.
A. 300 ml B. 450 ml C. 400 ml D. 240 ml
170. Dilantin 5 mg/kg body weight is ordered to a client who
Desired dose = 12,000 units (1,500 x 8-hour shift) x 500 mL weighs 50 lbs. The drug is to be administered in 3 equal
Stock dose = 25,000 units doses. The label reads Dilantin suspension 125 mg/ml.
= 600,000/25,000 = 240 mL how much medication should be administered to the
client?
A.1.8 ml B. 1.5 ml C. 1.0 ml D. 0.5 ml 177. A patient in labor is receiving Pitocin drip. Her contractions
are becoming more severe and intense, and lasting 30
50 lbs. / 2.2 kg = 22.73 kg seconds to 2 minutes. What is the nurse’s best initial
Desired dose = 5 mg/kg x 22.7 kg x 1 ml = 0.91 or 1 mL action?
Stock dose = 125 mg A. Notify the physician.
B. Check the fetal heart tone.
171. A patient asks why insulin is not administered orally. The C. Discontinue the infusion.
nurse is correct if she states: D. Document the findings.
A. “Insulin is destroyed by the gastric juices. “
B. “Insulin given orally may cause nausea and vomiting. Pitocin (Oxytocin) promotes uterine contraction. Contractions
C. “Insulin may irritate the gastric mucosa.” more than 90 seconds compromise fetal circulation, due to a
D. “Insulin absorption in faster if given orally.” reduced utero-placental circulation. A 2-minute contraction can
cause fetal distress necessitating the drip to be stopped.
172. A patient is to take NPH insulin 32 U and Regular insulin 8
U daily. In preparing the medication, the nurse would 178. The nurse is in charge of a client on a long term
BEST use Nitroglycerine sublingual tablets for angina pectoris. What
A. Two separate syringes instruction of the nurse is APPROPRIATE for the client to
B. An insulin syringe, drawing regular insulin first maintain the efficacy of the drug?
C. An insulin syringe, drawing NPH insulin first A. Retain sublinguaI tablets in a plastic transparent
D. A 1-cc syringe, drawing regular insulin first container
B. Maintain a supply for a duration of one year
Two types of insulin can be mixed in one syringe. However, C. Replace sublingual tablets supply every three months
the question asks for the best way to administer two types of D. Keep sublingual tablets in amber glass bottle
insulin and gives an option of using two syringes.
Nitroglycerine is heat and light sensitive and must be stored in
173. For a patient with addisonian crisis, it would be dangerous a colored/amber bottle, not transparent (A). An open bottle
to administer must be discarded after 6 months as it loses potency.
A. Epinephrine hydrochloride
B. Fludrocortisone 179. A patient with significant psychiatric history is discharged
C. Potassium chloride with Haloperidol to take twice a day by mouth. Which
D. Hydrocortisone discharge instruction should the nurse provide?
A. Decrease the dose if symptoms disappear.
Addison’s disease causes reduced level of aldosterone, which B. Double the dose if experiencing severe stress.
can decrease sodium and water retention. As sodium C. Apply sunscreen before exposure to the sun.
decreases, potassium is retained, causing hyperkalemia. D. Wait for two weeks before experiencing the effects of
the drug.
174. DDAVP is used in the treatment of
A. Pheochromocytoma One of the main effects of antipsychotics are photosensitivity
B. Syndrome of inappropriate antidiuretic hormone and skin rash. Protection from exposure to ultraviolet rays of
C. Diabetes insipidus the sun is essential. Adjusting the dose of any drug is always a
D. Addison’s disease wrong answer (A,B).

Diabetes insipidus is caused a lack of anti-diuretic hormone 180. The physician ordered Epinephrine 1 mg SQ x 1 dose
(ADH). Management involves replacement of synthetic ADH. only. The stock is Epinephrine 1:1000. The nurse should
give
TIP: DDAVP A. 0.01 ml C. 0.1 ml
DDA – Desmopressin or Desmopressin acetate B. 0.05 ml D. 1 ml
V – Vasopressin
P – Pitressin 1:1000 = 1 g Epinephrine : 1,000 mL solvent
= 1,000 mg : 1,000 mL
175. A patient with reflux disorder is prescribed Aluminum = 1 mg : 1 mL
hydroxide (Amphojel), an antacid. A common side effect is Desired dose = 1 mg x 1 mL = 1 mL
A. Nausea and vomiting C. Diarrhea Stock dose = 1 mg
B. Constipation D. Flatulence
TIP: Side-effects of antacids NURSING LEADERSHIP & MANAGEMENT / NURSING
Aluminum-based – constipation JURISPRUDENCE & PROFESSIONAL ADJUSTMENT (20
Magnesium-based – diarrhea points)
Calcium-based – constipation
181. According to Benner’s Stages of Clinical Expertise, how
176. A patient with liver failure is showing signs of hepatic many months of clinical experience should a nurse
encephalopathy. The physician ordered Lactulose. The possess before she can be called a competent nurse?
nurse knows that Lactulose is effective if the A. 6-12 months C. 24-36 months
patient/patient’s B. 12-24 months D. 36-60 months
A. ammonia level remains high
B. passes soft or liquid stools TIP: Stages of clinical expertise by Benner (NACPE)
C. bowel sounds is hypoactive  Novice – no experience; learning skills
D. does not vomit  Advanced beginner – 1-2 years of experience; task-
oriented
Lactulose helps reduce ammonia level among patients with  Competent – 2-3 years of experience; focuses on
hepatic encephalopathy by increasing its excretion from the organization
digestive system. Diarrhea, 2-3 x a day, is an expected effect.  Proficient – holistic understanding of patient situation
Bowel movement more than 3x per day indicates  Expert – uses intuition in patient care
overmedication.
182. Which of the following does not govern nursing practice?
A. R.A. 7164 D. A surgeon who performs hysterectomy to a client who
B. R.A. 9173 signed consent for exploratory laparotomy.
C. B.O.N. Resolution for Code of Ethics
D. Board Resolution Scope of Nursing Practice Benevolent deception is an ethical principle whereby the truth
is withheld from the patient in an attempt to protect the patient
RA 7164 is the old nursing law, amended by RA 9173. from potential harm.

183. While doing the routine nursing rounds during the night 187. The nurse caring for an immobilized client turns the client
shift, the nurse found a patient on the floor with blood every 2 hours during her 12-hour shift. This action of the
oozing from the forehead. The nurse called for help and nurse
assisted the patient back to bed. When the patient's A. Reflects the standard of care
condition stabilized, the nurse documented the B. Is under the scope of nursing practice
assessment and interventions in the chart. The nurse also C. Is a provision of the Nurse Practice Act
completed an incident report because: D. Demonstrates respect for the patient’s Bill of Rights
A. it is a requirement of the head nurse in case the
patient files a legal suit against the hospital Doing what is supposed to be done reflects standard of care.
B. the incident may lead to serious complications and Choices B & C are similar options.
this may trigger a malpractice suit.
C. reporting an incident in writing is a hospital protocol to 188. Which of the following mandates delineates the roles and
determine precautionary measure to avoid similar functions as well as responsibilities of a nurse?
incidents A. Nurse Practice Act
D. the incident is critical and therefore requires B. Code of Ethics for Nurses
documentation for future reference C. Standards of Care
D. Magna Carta for Health Workers
Incident reports are made to prevent similar incidents from
happening in the future. It must NOT be placed in the patient’s A nurse practice act or nursing law identifies the scope of
chart. nursing practice.

184. To maximize utilization of human resources, the nurse 189. A former clinical instructor is preparing his resume as part
manager emphasizes to the nurses to use technology as a of his application portfolio for a position as clinical
means to make work processes more efficient. She educator in a university medical center. When making his
advocates the use of the nurse call system. When a newly portfolio, which of the following should be the first major
admitted client is shown to use the nurse call system, part of his professional resume?
which of the' statements about the nurse call system A. Personal data and address
below is NOT appropriate? B. Educational background
A. It should be used whenever the client needs help. C. Work experience
B. It should be used during an emergency only. D. Trainings and professional qualifications
C. It must be pushed or pressed several times to alert
the nurse at the station. TIP: Resume
D. It must be Within the reach of the client. New RN – educational attainment comes first
Experienced RN – work experiences come first
The call system can be used by the patient at anytime,
whenever assistance is needed. 190. A medical-surgical nurse is asked by the nursing
supervisor to float to the understaffed Neonatal Ward for
185. Quality improvement (QI) requires that client care the entire shift. The Neonatal Nurse Manager should
activities be constantly evaluated and improved to meet assign which patient to the “floater” nurse?
the needs of the clients. Of the following situations, which A. A 4-day old neonate with Tetralogy of Fallot
one illustrates quality improvement? B. A 10-day old neonate with spina bifida
A. The nurse supervisor plans a ward class for clients for C. A 3-week-old neonate with heart failure
discharge along with family members for better home D. A 4-week old neonate with esophageal atresia
management.
B. The hospital personnel and clients are constantly TIP: Floating
reminded about handwashing especially during the  Assign the floater to a patient which has a case
epidemics. familiar to the RN’s work experience
C. The hospital involves the multidisciplinary team in  Assign the most stable patient to the floater
client medication by having zero medication error. 191. The nurse reviews several concepts related to total quality
D. A client asks from the nursing aide assigned to the management (TQM). Which of the following statements
client to be repositioned in bed due to post-operative refer to quality improvement?
discomfort. A. It is concerned with performance development and is
on-going, preventing future mistakes.
Quality improvement is a process whereby problem areas are B. It defines performance measurements and compares
identified and resolved. Only Choice C presents a problem actual processes and outcomes to clinical and
area that needs to improve. satisfaction indicators.
C. It refers to a work ethic involving everyone in the
186. Benevolent deception is an ethical concept that describes organization.
which of these situations? D. It includes systematic methods of ensuring conformity
A. A family insists to avail of all possible alternatives to a to a desired standard or norm.
terminally ill patient even without the possibility of
cure. 192. Which of the following criteria should not be used by the
B. A staff criticizes another staff who received charge nurse in delegating care to her staff?
recognition as an outstanding nurse. A. Educational background and training of the staff
C. A doctor tells lies to a patient regarding his condition B. Complexity of patient care needed for the shift
in order to benefit the client. C. Adequacy of client’s family support system and
resources
D. Clinical experience of the nursing staff A. Formalist theory C. Moralist theory
B. Utilitarian theory D. Deontological theory
Staffing focuses on analyzing the human resources’ (nurses,
aides) education and experience, not the family. Formalist theory – critical analysis of a situation
Moralist – determines the rightness or wrongness of an act
193. A nurse who is responsible for the care of the client from Deontological theory – based on duty, rules, laws, obligations
admission to discharge with the primary responsibility of
coordinating care is doing which modality of nursing care? 198. During the nurse tour of duty, very often they are
A. Primary nursing C. Team nursing confronted with ethical dilemma. In their decision making,
B. Functional nursing D. Case management which of the following would illustrates medical futility?
A. A young father of three boys with advanced lung
Case management involves coordinating patient care from cancer asks that all known regime be done to prolong
admission to discharge. Primary nursing (A) provides patient his life despite no improvement
care from admission to discharge while functional nursing (B) B. A confused 70 year old lady needs restraints for
deals with specific tasks to be performed by the staff. Team protection from fall even if this makes her more
nursing (D) involves a group of staff working together to agitated
provide patient care. C. A 3rd day post cholecystectomy client requests
narcotic injection every 4 hours
194. The nursing education department of a hospital is offering D. A young patient who has asked not to receive tube
a program about evidence-based practice to prepare feeding due to intense pain
nurses before its implementation in the hospital. Which of
the following refers to this type of program? Medical futility refers to interventions that are unlikely to
A. Seminar workshop in evidence-based practice produce any significant benefit for the patient.
B. Continuing education in evidence-based practice
C. In-service Education Program 199. A client is confined in your unit. He says that he has
D. Scientific forum in evidence-based practice difficulty sleeping because of the “ambience” in the unit.
When evaluating the effect the setting has on the quality
When a continuing education program or activity is required by of care provided to the client the evaluation being done is
the employing institution, it is called an in-service education. called:
A. Quality assurance C. Structure evaluation
195. A nurse works in a college of nursing as a faculty and B. Quality improvement D. Outcome evaluation
reeds further experience to possess clinical skills and
theoretical knowledge. Which of the following should this TIP: Nursing audit
nurse pursue to qualify for teaching current nursing  Structure evaluation – involves setting, facilities,
practice? equipment, qualifications and characteristics of
A. Pursue master's degree in other fields such as personnel
business or educational management  Process evaluation – refers to the actions or tasks
B. Possess a graduate degree in nursing and pursue performed in rendering patient care
doctorate in advanced degrees in nursing, education  Outcome evaluation – pertains to results of nursing
and administration interventions
C. Participate in continuing education program in
national and international conference 200. While taking care of a client, a nurse was instructed by
D. Keep license valid by updating professional education her head nurse to file an incident report. The following
with organized groups. situations warrant an incident report EXCEPT:
A. Client and family attitude towards care
To qualify for teaching current nursing practice, the nursing law B. Medico-legal incident
requires not a doctorate degree (B) but a master’s degree in C. Client’s complaints of illness
nursing, not business or education (A). Continuing education is D. Medication errors including administration of
needed but it does not have to be national or international intravenous fluids
acitvities (C). Keeping the license valid by updating
professional education means that the nurse should complete Incident reports are made when any untoward incidents
the required 20 continuing education hours per year for three happen with the purpose of preventing same incidents from
years, through various professional activities. happening in the future. Patient’s complaint of illness is never
a part of incide
196. The doctor’s order is, “Garamycin 1 gm IV initially after a
negative skin test; then 500 mg IV push every 6 hours for
23 days.“ The order was countersigned by the head nurse.
When the doctor made his rounds the following day, he
found out that 1 gm Garamycin was given IV push every 6
hours. Who among the following may be held liable?
A. All the nurses who administered the drug every 6
hours
B. The head nurse and the nurse who gave the first
dose for having erroneously transcribed the order
C. Only the head nurse under the principle of command
responsibility
D. All nurses involved including the head nurse

It is the responsibility of every nurse to verify doctor’s orders


prior to preparing and administering a drug.

197. When a nurse makes a decision based on the reasoning


that “good consequences will outweigh bad
consequences” she is following which theory?
MATERNAL AND NEWBORN NURSING (40 points) D. The woman’s vital signs are BP 90/50 mm hg,
temperature 38.3 oC, pulse 112/min, respiration
1. A client, 7 months pregnant, is brought to the emergency 18/min
department with abdominal pain and bright red vaginal
bleeding. What should the nurse do first? DIC is manifested by bleeding tendencies. The drug of choice
A. Place the client in left lateral position and initiate is Heparin sulfate.
oxygen therapy as ordered.
B. Administer ordered IV oxytocin to stimulate 5. A mother at 40 weeks’ age of gestation is assessed by the
contractions and prevent hemorrhage. nurse. The nurse finds the fundic height to be
C. Ease the client’s anxiety by coaching her to perform A. 35 cm C. 40 cm
relaxation techniques. B. 38 cm D. 43 cm
D. Massage the client’s fundus to control the
hemorrhage. 6. The nurse’s most important assessment on a client who
received epidural anesthesia during labor is
Left lateral position prevents compression of the inferior vena A. Level of consciousness
cava that might compromise utero-placental circulation. B. Urinary output
Oxytocin (B) and uterine massage (D) are contraindicated as C. Blood pressure
this stimulates contraction of the uterus. Relaxation techniques D. Return of sensation on the legs
(C) may help but not the priority for a bleeding patient.
A common side-effect of epidural anesthesia is hypotension.
2. At 15 weeks’ gestation, a client is scheduled for an alpha-
fetoprotein (AFP) test. Which maternal history finding best 7. During the fourth stage of labor, the client should be
explains the need for this test? assessed for
A. Family history of Down syndrome on the father’s side. A. Complete cervical dilation C. Placental expulsion
B. Family history of spina bifida in a sister. B. Umbilical cord prolapse D. Uterine atony
C. History of gestational diabetes during a previous
pregnancy. TIP: Stages of labor
D. History of spotting during the first month of the current  First stage – true labor to full cervical dilatation
pregnancy.  Second stage – full cervical dilatation to expulsion of
the fetus
An elevated AFP level may indicate neural tube defects, such  Third stage – expulsion of the fetus to expulsion of
as spina bifida. placenta
 Fourth stage – expulsion of placenta to uterine
3. Ada, a 38-year-old, G1P2, 36 weeks AOG pregnant contraction
mother with a history of precipitous labor and low birth
weight infant informs the nurse that she has been having 8. A postpartum client is ready for discharge. During
on and off contractions and she feels like “bearing down.” discharge preparation, the nurse should instruct the client
Upon examination, the obstetrician’s findings show that to report which of the following to a health care provider?
the client is “75% effaced and 6 cm dilated”. The most A. A temperature of 99.2 for 24 hours or more
appropriate disposition for this client would be to B. Episiotomy discomfort
A. Send her home since she is only 6 cm dilated and C. Lochia alba at 2 weeks postpartum
contractions are mild D. Redness, warmth and pain in the breasts
B. Request the obstetrician for Pitocin drip to induce
stronger contractions Report a sign that indicates an abnormal condition. Choice D
C. Ask the client to return to the hospital when are signs of mastitis. A low-grade fever (A) within the first 24
contractions are 2-3 minutes apart and strong in hours is common due to dehydration. Choices B & C are
intensity common and expected normally during the postpartum period.
D. Have the client stay in the hospital for maternal and
fetal monitoring 9. Which of the following assessment findings would the
nurse interpret as abnormal in a full term male neonate
These are signs of true labor and the patient needs to be born an hour ago?
monitored in the hospital; this makes A & C wrong answers. A. Enlargement of the mammary glands
Pitocin drip (B) is inappropriate at this time since uterine B. Slight yellowish hue to the skin
contractions, cervical dilation and effacement are in progress. C. Blue hands and feet
D. Black and blue spots on the buttocks
4. Prior to a cesarean section delivery, a 24-year-old woman
is treated for abruption placenta. You are caring for this Jaundice that appears within 24 hours after birth is considered
client during the postpartum period. Which of these pathologic. Physiologic jaundice occurs 24 hours after birth,
symptoms, if present, would be suggestive if disseminated usually 2nd-3rd day. Enlarged breasts (A) is due to maternal
intravascular coagulation (DIC)? hormones. Acrocyanosis (C) is common at this time.
A. The woman is nauseated, lethargic, and has vomited Mongolian spots (D) are common during the first year of life.
3 times
B. The woman’s laboratory result are: Hgb 13g/dl, Hct 10. A client who is 7 months pregnant reports severe leg
40%, WBC 7,000/mm3 cramps at night. Which nursing action would be most
C. There is oozing blood from venipuncture site and effective in helping the client cope with these cramps?
abdominal incision A. Suggesting that she walk for 1 hour twice per day.
B. Advising her to take over-the-counter calcium the physician orders Beclomethasone 12 mg IM. The
supplements twice a day. purpose of giving this medication is to
C. Teaching her how to dorsiflex the foot during a cramp. A. Slow down uterine contractions
D. Instructing her to increase her milk and cheese B. Promote fetal lung maturity
intake to 5-8 servings per day. C. Prevent infection
D. Promote fetal growth
Leg cramps are usually caused by depletion of calcium due to
rapid fetal development. This can be relieved by dorsiflexion of Administration of steroids to premature babies facilitates
the foot. maturation of the lungs, reducing the risk for respiratory
distress.
11. Which of the following signs of pregnancy is properly
classified? 17. A client is admitted in preterm labor. To halt labor
A. Enlarging uterus: probable sign contractions, the nurse expects the physician to prescribe
B. Elevation of basal body temperature: Presumptive A. Betamethasone (CElestone)
C. Fetal movements felt by examiner: positive B. Ritodrine (Yutopar)
D. Chloasma and linea nigra: probable C. Dinoprostone (Prepidil)
D. Ergonovine (Ergotrate maleate)
TIP: Signs of pregnancy
Presumptive signs – subjective; felt by the mother Tocolytics such as Ritodrine and Terbutaline promote
Probable signs – objective; observed by the examiner relaxation of the uterus.
Positive signs – confirms pregnancy
18. The nurse assessing a client with pregnancy-induced
12. A multigravida is in the second stage of labor for 30 hypertension (PIH) will most probably expect which signs
minutes. This can be considered as a and symptoms?
A. Precipitous labor A. Proteinuria, headache, vaginal bleeding
B. Precipitous delivery B. Headache, double vision, vaginal bleeding
C. Normal labor C. Proteinuria, headache, double vision
D. Normal spontaneous delivery D. Proteinuria, double vision, uterine contractions

13. A postpartum mother has a temperature of 99.8 F within TIP: Triad symptoms of PIH
the first 24 hours after delivery. The most common cause  Proteinuria
of temperature elevation during this period is  Edema
A. Puerperal infection C. Dehydration  Hypertension
B. Chorioamnionitis D. Mastitis
19. A woman in her 34th week of pregnancy presents with
Fever that occurs during the first 24 hours after delivery is due sudden onset of bright red vaginal bleeding. Her uterus is
to dehydration that results from NPO prior to and fluid loss soft and experiences no pain. Fetal heart rate is 120 bpm.
during delivery. Based on the presenting data, the nurse knows that the
client might have developed
14. While caring for a full term female neonate, the nurse A. Threatened abortion C. Abruptio placentae
notices red stains on the diaper after the baby voids. B. Placenta previa D. Preterm labor
Which action should the nurse take next?
A. Call the physician to report the problem. TIP: Bleeding disorders of pregnancy
B. Encourage the mother to feed the baby to prevent First trimester: abortion, ectopic pregnancy
dehydration. Second trimester: H-mole, incompetent cervix
C. Do nothing because this is normal. Third trimester: placenta previa, abruptio placenta
D. Check the baby’s urine for hematuria. 20. The nurse reviews the laboratory results of a client with
hydatidiform mole. Which finding strongly suggests the
Pseudomenstruation is normal and is caused by maternal presence of this disorder?
hormones. A. An elevated human placental lactogen (hPL) level
B. A reduced alpha-fetoprotein (AFP) level
15. The nurse is assessing a neonate born a day ago from a C. An increased human chorionic gonadotropin (hCG)
client who smoked during pregnancy. Which of the level
following findings is expected of a neonate from a mother D. An increased carcinoembryonic antigen (CEA) level
who smoked during pregnancy?
A. Postterm birth An abnormally large abdomen, passage of grape-like vesicles,
B. Small for gestational age absence of positive signs of pregnancy and elevated HCG
C. Large for gestational age level indicate the presence of an H-mole.
D. Appropriate for gestational age
21. The recommended Essential Intrapartal and Newborn
Small for gestational age (SGA) is common among babies of Care (EINC) practices during the intrapartum period
mothers who has a history of smoking during pregnancy. include continuous maternal support by having which of
Vasoconstrictive effects of nicotine reduce uteroplacental the following? Select all that apply.
circulation. A. a companion of choice during labor and delivery
B. freedom of movement during labor
16. A client at 28 weeks’ gestation complains of uterine C. monitoring progress of labor using the partograph
contractions. After assessment, hydration and admission, D. pain relief with mild analgesics before offering labor
anesthesia
E. position of choice during labor and delivery C. Pregnancy-induced hypertension
F. spontaneous pushing in a semi-upright position D. Infection
G. routine episiotomy
H. active management of the third stage of labor Bleeding, the most common cause of death during the
postpartal period, is usually due to uterine atony as a result of
Based on WHO guidelines, these are the recommended multiparity, retained placental fragments and trauma from
practices during the intrapartal period and during the care of severe lacerations.
the newborn.
27. Which of the following psychological changes during the
22. At 5 minutes of age, a neonate is pink with blue hands and post-partal period illustrates that the mother is in the
feet, has his knees flexed and fists clenched, has a taking-in phase? The mother
whimpering cry, a heart rate of 128 per minute and A. Looks intently at her newborn
withdraws his foot when slapped on his sole. What 5- B. Asks the nurse how to breastfeed the baby
minute Apgar score should the nurse document for this C. Restricts visitation because she needs to rest
neonate? D. Wants the father of the baby to participate in bathing
A. 6 B. 7 C. 8 D. 9 the baby

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


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

Posterior presentation usually causes low back pain. This can 31. A nurse orientee at the Labor & Delivery Unit reviews the
be relieved by application of gentle sacral pressure or pelvic partogram sheet and identifies the word “liquor” which
rock exercises. refers to
A. The amniotic fluid
26. According to the WHO, the most common cause of B. A meconium-stained amniotic fluid
mortality among women during the post-partum period is C. The bloody show
A. Cephalo-pelvic disproportion D. An amnioinfusion therapy
B. Hemorrhage
32. The appropriate order of steps in active management of D. “IV fluids help prevent spinal headaches.”
the third stage of labor (AMTSL) include:
A. Cord clamping and cutting, controlled cord traction, Epidural anesthesia causes hypotension. This can be
ergometrine administration, and inspection to be sure prevented by increasing the circulating blood volume through
that the placenta is intact. infusion of intravenous fluids.
B. Intravenous oxytocin, cord clamping and cutting, and
fundal massage 38. A client is scheduled for amniocentesis. When preparing
C. Intramuscular injection of oxytocin, controlled cord her for the procedure, the nurse should do which of the
traction with counter traction to the uterus, uterine following?
massage A. Allowing her to void.
D. Controlled cord traction, fundal massage and oxytocin B. Instruct her to drink 1 liter of fluid.
C. Prepare to insert an IV access.
These are the steps in the AMTSL as defined by the WHO. D. Position her on the left side.

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

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

TIP: Gross motor development


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

TIP: Theories of personality development 50. When planning care for hospitalized children, the nurse
Freud Erikson must consider that which age group considers illness as a
Psychosexual Psychosocial punishment for misdeeds?
A. Infancy C. Preschoolers
Infancy Oral Trust vs. mistrust B. Toddlers D. School age
Toddlerhood Anal Autonomy vs. shame/doubt
Pre-school Phallic Initiative vs. guilt Pre-schoolers are in the phallic stage of development where
School age Latency Industry vs. inferiority they become more aware of their bodies. Having developed
Adolescence Genital Identity vs. diffusion their superego from toddlerhood, they associate illness as a
Young adulthood Intimacy vs. isolation punishment for misdeeds.
Mid-adulthood Generativity vs. Stagnation
Late adult-hood Integrity vs. despair 51. The nurse places a neonate with hyperbilirubinemia under
a phototherapy lamp, covering the eyes and gonads for
45. Bedtime rituals such as tucking to bed and reading
protection. The nurse knows that the goal of phototherapy Anything with flour is avoided. Patients with celiac disease are
is to given gluten-free diet. Foods that come from wheat, barley and
A. Prevent hypothermia rye are contraindicated.
B. Promote respiratory stability
C. Reduce conjugated bilirubin level 56. A 4-year-old child with a recent history of nausea, vomiting
D. Reduce unconjugated bilirubin level and diarrhea is admitted to the pediatric ward for
gastroenteritis. During physical assessment, the nurse
Phototherapy is used to manage infants with jaundice. The aim observes tenting. This clinical manifestation supports the
is to promote conjugation of bilirubin (unconjugated  nursing diagnosis of
conjugated). A. Activity intolerance related to hypoxia
B. Deficient fluid volume related to dehydration
52. Which of the following statements, is made by any parent- C. Ineffective peripheral tissue perfusion related to
client to you indicates understanding about the causes of cyanosis
the newborn’s diagnosis cystic fibrosis (CF)? D. Risk for injury related to capillary fragility
A. “Both of us carry a recessive treat of a cystic fibrosis”
B. “The gene came from my wife’s side of the family” Gastroenteritis causes severe diarrhea and dehydration which
C. “The gene came from my husband’s side of the may be manifested by a poor skin turgor or tenting.
family”
D. “There is a 50% chance that our next child will have 57. The nurse prepares to administer an intramuscular
disease” injection to a 7-month old girl. The most appropriate site to
administer the drug is:
Cystic fibrosis is an autosomal recessive trait, not a sex-linked A. dorso-gluteal region C. ventral forearm
trait (B,C). When both parents carry the recessive gene, there B. vastus lateralis D. gluteal region
is a 25% chance of developing the disease (D).
The preferred IM injection site for infants is the vastus lateralis.
TIP: Punnett’s square: to determine predisposition to The dorso-gluteal region is the least preferred site for all age
genetic diseases groups due to the risk of hitting the sciatic nerve. The ventro-
D – abnormal trait DD – has the disease gluteal site is the preferred site of IM injection among older
d – normal trait Dd – has the trait (carrier) children and adults.
dd – not affected
58. When developing a post-operative plan of care to a child
Cyctic fibrosis: autosomal recessive (carrier) transmission from who has undergone cleft lip-repair, which of the following
both parents is the nurse’s priority goal of care?
Mother / Father -> D (trait) d A. Avoiding disturbing crusts along the suture line.
D (trait) DD (25%) Dd (25%) B. Comforting the child as quickly as possible.
d Dd (25%) Dd (25%) C. Maintaining the child in a prone position.
D. Restraining the child’s arm at all times, using soft
DD – 25% chance to develop the disease elbow restraints.
Dd – 50% chance to become carriers
dd – 25% chance to be unaffected Protecting the integrity of the sutures is the priority goal of
post-cheiloplasty. The nurse must prevent crying
53. A 2-month old baby is expected to have completed which whenever possible to avoid trauma to the surgical site.
immunizations?
A. MMR, DPT, measles, BCG 59. A 2-month-old is brought to the clinic by his mother. His
B. Hepatitis, measles, BCG, OPV abdomen is distended and he has been vomiting forcefully
C. OPV, DPT, BCG for the past 2 weeks. The nurse notes dehydration and a
D. Hepatitis, OPV, BCG, HIB palpable mass on the right of the umbilicus. Peristaltic
waves are present, moving from left to right. Based on
Measles is administered at 9 months (A, B). Hepatitis is not these clinical manifestations, the infant most probably has:
routinely given during infancy (B,D). A. Tracheoesophageal fistula C. Intussusceptions
B. Pyloric stenosis D. Volvulus
54. A child is brought to the emergency room due to acute
onset of abdominal pain, vomiting and stools that look like An olive-shaped mass on the right side of the abdomen and
red currant jelly. The nurse suspects that this may be due non-bilious (without bile) vomiting are signs suggestive of
to pyloric stenosis. Tracheo-esophageal fistula (A) is suspected if
A. Intussusceptions C. Appendicitis the child chokes after feeding, suggesting the entry of food into
B. Pyloric stenosis D. inflammatory bowel disease the lungs. Intussusception (C) is manifested by a sausage-
shaped mass on the abdomen, abdominal pain and red,
Red currant jelly-like stool is a characteristic of currant jelly stools. Volvulus or twisting of the abdomen is
intussusception, or the telescoping of the intestines. characterized by severe abdominal pain.

55. The nurse advises a 6-year-old child with celiac disease 60. A 7-year-old child is brought to the ER due to a dislocated
should not have which of these dietary choices? right shoulder and simple fracture of the right humerus.
A. Mango shake C. Fruit salad Which of the following behaviors of a child would lead the
B. Ice cream D. Spaghetti nurse that the patient is a victim of child abuse? The child
A. Does not answer the nurses’ questions.
B. Does not maintain eye contact.
C. Tries to move away from the nurse
D. Does not cry when moved 67. To prevent discoloration of the teeth of a 6-year-old child
with URTI, the physician should not prescribe
An abused child has a high pain tolerance. Physical injuries A. Tetracycline C. Streptomycin
may not elicit pain on these children. B. Isonicotinic hydrazide D. Chloramphenicol

61. A nurse performs cardiopulmonary resuscitation on an 11- Tetracycline should not be given to pregnant women due to its
month-old infant. The nurse should assess for the infant’s teratogenic effects and to children below 12 years old due to
pulse on the: its destructive effects on the tooth enamel.
A. carotid area C. temporal area
B. brachial area D. popliteal area 68. Recommended practices under the Essential Infant and
Newborn Care (EINC) protocol include the following
The brachial area is the recommended site for assessing pulse except:
when doing an infant CPR. The carotid area is used for adults. A. skin-to-skin contact
B. properly timed cord clamping
62. Hypospadias is a congenital defect of the male genitalia C. initiation of breastfeeding
where the urethral meatus is located at the D. drying the baby with oil
A. Tip of the penis
B. Ventral surface of the penis Current EINC protocol promotes drying the baby with a warm
C. Dorsal surface of the penis clean cloth, not oil.
D. Side of the penis
69. After the delivery of the baby, prevention of hypothermia
TIP: Hypospadias = ventral side or anterior can be achieved by:
Epispadias – dorsal side or posterior A. drying baby covering with clean dry cloth
B. applying small amounts of oil on the skin
63. The nurse admits a 10-year-old child with rheumatic fever. C. covering the baby with warm sterile cloth
Which of the following aspects in the child’s history the D. positioning the baby on the mother’s abdomen
nurse should ask for a history of:
A. Staphylococcal infection C. Strep throat This prevents heat loss after birth of the neonate.
B. Influenza D. Chicken pox
70. A newborn with fetal alcohol syndrome is NOT expected
The main risk factor of rheumatic fever is a streptococcal to manifest which of the following signs?
infection, which may commonly affect the respiratory system. A. Low birth weight
B. Facial anomalies
64. A 10-month-old infant with phenylketonuria (PKU) is being C. Muscular incoordination
weaned from breast-feeding. In providing education to the D. Cognitive impairment
parents, the nurse should emphasize the need to restrict
A. Vegetables and meat 71. A child with lead poisoning is expected to manifest signs
B. Grains and fruits related to
C. Meats and dairy products A. Neurologic deficits
D. Sugar and vegetables B. Cardiovascular involvement
C. Renal impairment
Phenylalanine is an essential amino acid (protein), which is not D. Hepatic damage
metabolized in a child with PKU. Protein foods are restricted.
Lead can lead to developmental delays and cognitive
65. A child is to undergo nephrectomy for a removal of Wilm’s impairment due to its neurotoxic effects.
tumor. Which intervention should NOT be included in the
plan of care? 72. Which of the following statements is not accurate
A. Provide pre-operative teaching to the child and regarding Tanner staging?
parents. A. It is a rating system for pubertal development
B. Palpate the abdomen to assess for tenderness. B. It is a biological marker of maturity
C. Assess vital signs and report hypertension. C. It is based on the progressive development of
D. Monitor urine for hematuria. genitalia, breast and pubic hair in females
D. It is based on the progressive development of the
Wilm’s tumor affects the kidneys. Abdominal palpation is genitalia and pubic hair in males.
contraindicated as this may cause pain and metastasis.
Tanner staging is used to determine sexual maturation among
adolescents. Among females, criteria include assessment of
66. A toddler is diagnosed with nephrotic syndrome. The the breast and pubic hair, NOT the genitals. Among males,
nurse monitors the patients I&O and checks the urine genitalia and pubic hair development are assessed.
regularly. The nurse should expect to see which of these
findings? 73. Which of the following developmental milestones or
A. Glycosuria C. Albuminuria behaviors is a characteristic of a toddler?
B. Ketonuria D. Polyuria A. Magical thinking
B. Assertion of independence
Nephrotic syndrome is a protein-wasting disease manifested C. Compliance to parental rules
by albuminuria/proteinuria, hypoalbuminemia and edema due D. Cooperative play with siblings
to decreased colloid oncotic pressure.
The main developmental task of a toddler is independence or D. “Should Steven have continues hair loss, I need to
autonomy. Magical thinking, compliance to parents, and call my doctor”
cooperative play are characteristics of a pre-schooler (ACD).
Nausea and vomiting are the most common side-effects of
TIP: Types of play among children chemotherapy. However, if they are persistent together with
Infants Solitary play diarrhea, the patient may get dehydrated, which may need
Toddlers Associative play or parallel play medical attention.
Preschoolers Cooperative play
School age Competitive play 78. Wilma and another staff are talking on some important
reminders on the care of pediatric patients diagnosed with
74. A child with hiatal hernia may exhibit which of the following glomerulonephritis. When planning nursing care for a 5-
clinical manifestations? year-old with acute glomerulonephritis (AGN), the nurse
A. Inguinal pain realizes that the child needs help in understanding the
B. Difficulty of breathing necessary restrictions, one of which is:
C. Abdominal pain A. Isolation from other children with infections
D. Intractable pain on the groin area B. Daily does of IM penicillin
C. A bland diet high in protein
Hiatal hernia is the protrusion of abdominal organs into the D. Bed rest for at least 4 weeks
thoracic cavity though a weakness in the diaphragm. This
causes an increased pressure within the thoracic cavity. ACD AGN is treated with steroids which may cause
are all characteristics of inguinal hernia, the protrusion of immunosuppression, increasing the risk to infections.
abdominal organs into the scrotum via a defect in the inguinal
ring. 79. The mother of a nine-month-old infant is concerned that
the head circumference of her baby is greater than the
75. The nurse is taking nursing history from a mother. The chest circumference. The BEST response by the nurse is
infant displays discomfort by crying constantly, fussy A. “ These circumferences normally are the same, but
behavior and pulling the left ear. Which of the following in some babies this just differs.”
information gathered by the nurse would support the B. “Perhaps your baby was small for gestational age or
admitting diagnosis of acute otitis media? premature.“
A. Sudden rise of temperature to 39 degrees C C. “This is normal until the age of 1 year, when the
B. Had colds and low grade fever for a number of days chest will be greater”
C. Irritable and unable to consume scheduled feedings D. “Let me ask you a few questions, and perhaps we
D. Pain and itchiness of the ear canal can figure out the cause of this difference.”

The question asks about history taking. Acute otitis media is An infant’s head circumference is normally greater than the
often preceded by a history of colds and low grade fever a few chest circumference until 1 year of age. After that, the chest
days before the onset of the infection. ACD are all physical circumference slowly becomes larger than the head.
assessment findings, not history, of acute otitis media.
80. The nurse reads on the chart that a 5-month-old child has
76. Three-year-old Benito has been admitted to the Pediatric pectus carinatum. She recalls that this condition is
Unit. His blood pressure 100/70 mmHg; pulse rate, 110 characterized by a chest that
beats per minute; temperature, 38 C, and weight, 18 kg. A. has equal antero-posterior (AP) and lateral (LAT)
Impression: Nephrotic Syndrome. During his previous diameters
check-up at 2 ½ years-old, his blood pressure was 95/60 B. has a larger lateral (LAT) diameter than the antero-
mmHg; PR was 100 beats per minute and weighed 15 kg. posterior (AP) diameter
Which assessment finding would support the impression C. has an antero-posterior diameter (AP) that is larger
of nephrotic syndrome? than the lateral (LAT) diameter
A. Weight C. Blood pressure D. has a depression in the sternum
B. Temperature D. Pulse rate
TIP: Less than 1 year: AP = LAT diameter
As a protein-wasting disease, nephrotic syndrome causes More than 1 year: LAT > AP diameter
hypoalbuminemia which reduces colloid oncotic pressure. This Pectus carinatum (pigeon chest) = AP>LAT diameter
promotes water to shift from the intravascular to the interstitial Pectus excavatum (funnel chest) = LAT>AP diameter
space causing generalized edema. Fluid retention is best
assessed by daily weight monitoring. Weight is the best
indicator of fluid balance.

77. Steven is diagnosed with acute lymphoid leukemia (ALL) MEDICAL-SURGICAL NURSING (70 points)
and is beginning chemotherapy. Steven is discharged
from the hospital following his chemotherapy treatments. 81. While you are obtaining an assessment and health history,
Which statements of Steven’s mother indicates that she which of the following statements will alert the nurse to a
understands when she should contact the physician? possible immunodeficiency disorder?
A. “I will call my doctor if Steven has persistent vomiting A. "I love walking several times a week with friends.'
and diarrhea” B. “I had my chest x-ray 6 months ago when I had
B. ”I should contact the physician if Steven has difficulty pneumonia.”
in sleeping” C. “I had my spleen removed many years ago after a car
C. “My physician should be called is Steven is irritable accident.”
and unhappy”
D. “I usually eat eggs or meat for at least 2 meals every
day.” TIP: Stages of peritoneal dialysis/per 1 cycle of dialysate
Infusion time 5-10 minutes
The spleen is a lymphoid tissue which produces WBC. Dwelling/equilibration time 20-30 minutes
Removal of the spleen increases risk for immune disorders. Draining time 10-20 minutes

82. The nurse’s action is appropriate if she does which of the Dialysis aims to promote excretion of retained fluids,
following to nursing interventions in a patient with electrolytes and waste products from the body. It is expected
hypothyroidism? that more output should come out during the draining time.
A. Offer a high-calorie diet. Turning the patient from side to side can help drain the fluid
B. Increase fluid intake. that might have been trapped in the abdominal cavity.
C. Offer extra sheets or blankets to the patient.
D. Encourage the patient to take a bath twice a day. 87. A patient received spinal anesthesia 4 hours ago during
surgery. The patient has been on the ward for 2 hours and
With decreased level of thyroid hormones, patients with now reports severe incisional pain. The patient's blood
hypothyroidism have reduced basal metabolic rate and pressure is 170/90 mm Hg, pulse is 108 beats/min,
reduced heat production. Cold intolerance is therefore temperature is 37.2°C, and respirations are 30
common. Providing warmth helps manage this symptom. breaths/min. The patient's skin is pale and the dressing is
dry and intact. The most appropriate nursing intervention
83. A client recovering from breast surgery asks you what is to:
type of food would fight “free radicals” to increase A. call the physician and report the findings
protection from cancer. Your best response would be: B. medicate the patient for pain
A. “Do you want reading materials in cancer fighting C. place the patient in a high Fowler position and
food?” administer oxygen
B. “Foods rich in beta – carotene, vitamins A, C, E seem D. place the patient in a reverse Trendelenburg position
to fight free radicals.” and open the IV line
C. “Eat foods that are in rich in antioxidants and
phytochemicals.” Post-spinal anesthesia, a patient is placed flat on bed for 6-8
D. “Have you tried the herbal products in the market?” hours (C,D). The vital signs reflect a patient in severe pain.
Since the question asks for a nursing intervention, Choice B
Antioxidants and phytochemicals are proven to be effective in would be wrong since medication required a doctor’s order.
fighting free radicals that are known to cause cancer. The nurse needs to notify the physician.

84. During hemodialysis, a patient with ESRD suddenly TIP: In answering medication questions, if the question asks
becomes confused, restless and verbally abusive. The for a nursing action, look for the phrase “as ordered” or “as
nurse interprets this a sign of prescribed”, to qualify that as a nursing action. Remember
A. helplessness giving a medication without an order is outside the scope of
B. disequilibrium syndrome nursing practice.
C. allergic reaction to the dialysate
D. increased cerebral tissue perfusion 88. Bone marrow depression is an adverse effect of
chemotherapy. Which of the following laboratory values
Rapid removal of fluid from the brain during hemodialysis can indicate that the patient has bone marrow depression?
lead to disequilibrium syndrome that can be manifested by A. hemoglobin - 15.1 mg/dl
behavioral changes during the procedure. B. white blood cell - 4,500 mg/cc
C. red blood cell - 4 million/ cc
85. The nurse should be alert for potential complications D. platelets - 90,000/cc
during the post-operative phase. Which of the following
manifestations possibly suggest a developing Chemotherapy reduces the production of RBC, WBC and
complication? platelets as a result of bone marrow suppression.
A. temperature of 37.9 C, chills and cold clammy skin
B. urine output of 120 cc for the past first four hours TIP: CBC normal values
after surgery RBC 3.5-5.5 million/cu. mm.
C. tachycardia and decreased blood pressure WBC 5,000-10,000/cu.mm.
D. shallow respirations and pulse oximeter reading of Platelets 150,000-450,000/cu.mm
95% Hemoglobin 12-16 mg/dL
Hematocrit 37%-47%
A reduced blood pressure and increased pulse rate may 89. A staff nurse is called to a client’s room. When the nurse
suggest bleeding post-operatively. ABD are all normal arrived in the room, she noted that the waste basket is on
assessments post-operatively. fire. However, the client has been moved out of the room.
Which of the following is the priority action of the nurse?
86. The nurse instilled 2,000 ml of dialysate on a patient for A. Activate the fire alarm C. Evacuate the unit
peritoneal dialysis. During the draining time, the nurse B. Extinguish the fire D. Confine the fire
observes a decreased output of only 550 ml. The next
best nursing action is to: TIP: RACE(E)
A. document the output in the flow sheet R – Rescue the patients
B. turn the patient from side to side A – Activate the alarm
C. report the output to the physician C – Confine/contain the fire
D. infuse another bottle of dialysate E – Extinguish the fire
E – Evacuate the premises 95. Which of these statements made by a mother during an
education session in the community tells the nurse that
90. In planning care for a patient with Parkinson’s disease, the her child is prone to Hepatitis A infection?
nurse decides that the patient may need the most help A. “I always prepare my child’s lunch for school.”
with B. “My child shares her lunch with her brother at recess.”
A. getting out of bed C. “My son sometimes buys food from the street
B. buttoning his shirt and pants vendor.”
C. taking his medications D. “I remember when my daughter had a blood
D. communicating with caregivers transfusion.”

Tremors, pill-rolling of the fingers, and rigidity are Hepatitis A is transmitted via fecal-oral route. Unsanitary food
characteristics of Parkinson’s disease. Buttoning may be a handling and preparation is a risk factor.
difficult task for this patient.
96. Early signs and/or symptoms of hepatitis include:
91. Understanding the risks of infection, who among the A. nausea, vomiting and abdominal pain
clients listed below should receive immediate attention B. fever, yellowish sclera and skin
and care? C. dark colored urine and diarrhea
A. Adult female with Vitamin B deficiency due to chronic D. ascites, difficulty breathing and swallowing
alcohol intake
B. Adult male with fresh second degree burns on arms While all of these may be seen in hepatic disorders, early signs
and chest of hepatitis are vague and non-specific.
C. A teenager who is bleeding due to a cut on the finger
D. An elderly male with diabetes mellitus and toe 97. For clients with diabetic ketoacidosis (DKA), their body
infection compensate for the acidosis in many ways. When caring
for these clients, which of the following manifestations will
An intact skin is the first line of defense against infection. you anticipate to observe?
Altered skin integrity breaks this defense, increasing the risk 1. Nausea and vomiting 3. Kussmaul breathing
for infections. 2. Oliguria 4. Polyuria
A. 1 and 2 C. 3 and 4
92. The most important nursing intervention in caring for a B. 1, 3 and 4 D. All of the above
patient with a newly-placed nephrostomy tube is to
A. clamp the tube every 4 hours In DKA, the body compensates to reduce the acidity of the
B. disinfect the surgical site every shift blood by attempting to excrete the ketone bodies
C. flush the tube with normal saline, as ordered  from the kidneys by promoting increased urine output.
D. monitor the surgical dressing for bleeding This can lead to polyuria.
 from the lungs giving the characteristic deep, rapid
A nephrostomy tube must be kept patient in order to prevent breathing (Kussmaul’s) and acetone odor of the
damage to the kidneys. This can be accomplished by regularly breath
flushing the tube with 5-10 mL of NSS q4h with a physician’s  from the digestive system through vomiting
order.
98. Which of the following laboratory results tell the nurse that
93. A patient with stroke is put on Mannitol intravenously. The a patient has acute liver failure?
nurse evaluates the effectiveness of the drug by noting A. increased serum blood urea nitrogen level
which observation? B. decreased bilirubin level
A. blood pressure increases C. increased aspartate transaminase level
B. level of consciousness improves D. decreased alanine transaminase level
C. urine output decreases
D. pupils are dilated and sluggishly reacting An increased liver enzymes (ALT, AST) indicates liver
damage.
Mannitol is an osmotic diuretic that is used to reduce an
increased intracranial pressure. As a diuretic, it promotes the 99. The most appropriate nursing action in the event of a
excretion of fluid from the kidneys. Reduced fluid volume can wound dehiscence is to
decrease edema in the brain, thereby, improving the level of A. wear sterile gloves then attempt to push the organs
consciousness. back into the abdominal cavity
B. cover the intestines with sterile dressing moistened
94. Extreme hyperglycemia of uncontrolled diabetes mellitus with normal saline solution
results in: C. apply an abdominal binder to prevent protrusion of
A. Metabolic alkalosis C. A state of dehydration abdominal organs
B. Oliguria D. Weight gain D. cover the organs with a dry sterile dressing then notify
the physician
Hyperglycemia attracts water from various fluid compartments
in an attempt to dilute the concentrated blood. This temporarily Wound dehiscence is the separation of surgical sutures post-
increases the circulating fluid volume. As the fluid passes operatively. ABD refer to wound evisceration, the protrusion of
through the kidneys, they are excreted into the urine, causing abdominal organs outside the abdominal cavity.
osmotic diuresis. This may lead to dehydration.
100. An assessment finding that is consistent with pancreatitis
is the presence of
A. severe right upper quadrant pain
B. foul smelling stools When the stomach is surgically attached to the jejunum, rapid
C. palpable abdominal mass entry of hyperosmolar food into the small intestines can lead to
D. blood in the urine dumping syndrome.

The pancreas is located in the left side of the abdomen (A). in 106. A patient undergoing chemotherapy has the following as
pancreatitis, reduced production of lipase reduces fat digestion his latest laboratory CBC results: RBC - 5 million/cc,
on the intestines. This causes malabsorption of fats causing it WBC-3,000/cc, and platelets-180,000/cc. Based on these
to be excreted to the stools, causing steatorrhea. results, the nurse should identify which nursing diagnosis?
A. Activity intolerance
101. The nurse assessing for risk factors for meningitis asks for B. Risk for infections
the presence of which medical history? C. Impaired tissue perfusion
A. diabetes mellitus and anemia D. Risk for injury
B. tuberculosis and otitis media
C. renal failure and urinary tract infection The CBC shows an abnormal WBC count, increasing the risk
D. hepatitis and pancreatitis for infections.

Meningitis is mostly caused by bacteria or virus. Choice B are 107. Which patient statement made prior to discharge after an
caused by bacteria. Diabetes, renal failure, and pancreatitis appendectomy needs further teaching?
not usually caused by infection. A. “I need to call the doctor if I develop fever.”
B. “My incision will be painful and sore for a few
102. Which of the following observations will make the nurse days.”
suspect of bleeding in a post-thyroidectomy patient? C. “I can resume my activities before surgery without
A. The patient’s blood pressure increases and pulse rate restrictions.”
decreases. D. “I should not see any drainage from the surgical
B. The surgical dressing has a scant amount of sero- wound.”
sanguineous drainage.
C. The patient is swallowing frequently. Activity restriction is recommended after abdominal surgeries.
D. The patient is drowsy and has slow shallow
respirations. 108. The priority nursing diagnosis of a patient with Addison’s
disease is
Bleeding can be assessed by monitoring for frequent A. Altered nutrition: less than body requirements
swallowing or checking the back of the neck for blood. B. Fluid volume deficit
C. Risk of blood glucose imbalance: hypoglycemia
103. During the post-operative period for thyroidectomy, the D. Altered body image
nurse observes muscle twitching on the patient’s arms as
the blood pressure is being taken. This may likely be an Addison’s disease is characterized by lack of aldosterone that
indication of: causes reduced sodium and water retention. This promotes
A. hypocalcemia caused by accidental removal of the increased excretion of urine, which may cause dehydration.
parathyroid glands
B. hypothermia due to the temperature inside the 109. A nurse is circulating in an exploratory laparatomy for a
recovery room ruptured appendicitis. The scrub nurse asks for "Normal
C. respiratory alkalosis due to inability to perform deep Saline Solution (NSS) wash". The circulating nurse
breathing exercises immediately opened one liter of NSS and began to pour to
D. seizures related to effects of general anesthesia and the sterile basin of the scrub nurse. Before she can empty
narcotics the NSS container, the scrub nurse signals "enough",
what is the appropriate action with the remaining NSS?
One of the common complications of thyroidectomy is tetany or A. Discard the remaining NSS.
hypocalcemia due to accidental removal of the parathyroid B. Pour the remaining NSS to another sterile basin in the
glands. This can be manifested by early signs such as back table.
numbness and tingling of the mouth. Characteristics of tetany C. Cover the remaining NSS bottle aseptically right
include Chvostek’s sign (facial muscle spasms) and away.
Trousseaus’s (spasms of the hand and feet). D. Transfer the remaining NSS to smaller sterile
container.
104. A surgical procedure that involves removing a portion of
the stomach and anastomosing the remaining part with Any sterile container is considered unsterile once it is opened.
the duodenum is called
A. total mastectomy C. bougeinage procedure 110. A patient is prepared for a fluid deprivation test. The nurse
B. Billroth I D. Billroth II knows that this is used in the diagnosis of
A. diabetes insipidus
TIP: Billroth I – gastroduodenostomy B. Cushing’s syndrome
Billroth II - gastrojejunostomy C. pheochromocytoma
D. syndrome of inappropriate anti-diuretic hormone
105. The nurse taking care of a patient who underwent
gastrectomy with Billroth II should watch out for Fluid deprivation test is a screening for diabetes insipidus (DI).
complications associated with If a patient is not given any fluids but still has an increased
A. electrolyte imbalances C. dumping syndrome urine output, it may indicate DI. This is due to the inability to
B. hypoglycemia D. wound dehiscence reabsorb water from the kidneys caused by lack of anti-diuretic
hormone.
 Bradycardia
111. The nurse encourages a patient with Addison’s disease to  Bradypnea
have an adequate intake of which types of diet?
A. high-sodium, high-calorie, low-potassium diet 116. The nurse should plan the diet of a patient with liver
B. low-sodium, high-calorie, high-potassium diet cirrhosis who has a normal ammonia level that is
C. high-sodium, low-calorie, high-potassium diet A. rich in calories C. high in fats
D. low-sodium, low-calorie, low-potassium diet B. low in proteins D. high in sodium

Patients with Addison’s disease have low aldosterone level. TIP: Diet in liver disorders
This reduces sodium reabsorption and potassium excretion  high calorie – liver has a high metabolic rate
from the kidneys. Patients develop hyponatremia and  low sodium – reduced albumin synthesis leads to
hyperkalemia. Diet management should be high in sodium and edema due to reduced colloid oncotic pressure
low in potassium.  low protein – ONLY if ammonia level is increased
 balanced diet – if ammonia level is normal
112. The nurse’s action is appropriate if she prepares which of
the following pain medications for a patient complaining of 117. The nurse notifies the physician regarding a patient’s
sharp abdominal pain due to cholelithiasis? serum potassium of 7.1 meq/l. The physician orders
A. Morphine sulfate (MS Contin) intravenous glucose and insulin. This is to
B. Meperidine hydrochloride (Demerol) A. enhance renal excretion of potassium
C. Mefenamic acid (Ponstan) B. promote cellular entry of potassium
D. Butorphanon hydrochloride(Stadol) C. cause exchange of potassium with hydrogen ion in
the intestines for excretion
The main problem of patients with cholelithiasis is acute D. treat hypoglycemia associated with the potassium
severe pain. The preferred analgesic is Meperidine HCl. imbalance
Morphine sulfate is contraindicated as it may cause contraction
of the sphincter of Oddi. TIP: Drugs for hyperkalemia
 Glucose with insulin – insulin promotes the entry of
113. An important nursing intervention for patients with liver glucose and potassium into the cell
cirrhosis is to  Kayexalate – ion exchange resin; facilitates the
A. provide diet that is low in calories and salt exchange between potassium and sodium ions in the
B. encourage the use of soft-bristled brush intestines
C. massage the skin with alcohol
D. administer Acetaminophen (Tylenol) for abdominal 118. The nurse monitors the vital signs of a patient at risk for
pain internal hemorrhage. Which set of vital signs reflects that
the patient is having hemorrhage?
Patients with liver disorders are prone to bleeding due to A. BP-150/90 mmHg, PR-110, RR-20, T-37.5 C
impaired synthesis of clotting factors. Use of soft-bristled brush B. BP-120/75 mmHg, PR-100, RR-16, T-36.9 C
prevents gum bleeding. They are given high-calorie diet (A) C. BP-90/50 mmHg, PR-55, RR-10, T-38.4
due to the high metabolic rate of the liver. Acetaminophen is D. BP-90/45 mmHg, PR-120, RR-24, T-36.1 C
hepatotoxic (D).
TIP: Signs of bleeding
114. Patients with diabetic ketoacidosis (DKA) will more likely  BP – initially increased due to compensatory
exhibit the following changes in their arterial blood gases vasoconstriction; eventually decreases as bleeding
(ABG): progresses
A. pH - 7.56, pCO2 - 60 mmHg, HCO3 - 15 meq/L  Pulse – increased as the heart compensates
B. pH - 7.40, pCO2 - 44 mmHg, HCO3 - 24 meq/L  Respiratory rate – increased as lungs attempt to
C. pH - 7.34, pCO2 - 50 mmHg, HCO3 - 29 meq/L provide more oxygen to tissues
D. pH - 7.25, pCO2 - 30 mmHg, HCO3 - 19 meq/L  Temperature – decreased due to reduced blood flow

TIP: ABG Interpretation 119. A patient is anxious about her upcoming upper
gastrointestinal series. The nurse attempts to allay the
Normal Value Increased Decreased patient’s anxiety by explaining that this procedure involves
pH 7.35-7.45 Alkalosis Acidosis A. insertion of a fiber optic tube to visualize the upper
PaCO2 35-45 mmHg Acidosis Alkalosis digestive organs
HCO3 22-26 meq/L Alkalosis Acidosis B. getting an x-ray of the upper abdomen after ingestion
PaO2 80-100 mmHg - Hypoxemia of barium
C. visualization of the abdomen through a CT scan
115. The nurse monitoring a patient in the acute care knows machine
that the intracranial pressure is increased by noting which D. thorough physical assessment of the upper
of these changes in vital signs? gastrointestinal system
A. T-40.1 C, BP-165/105 mmHg, RR-10 cpm, PR-58
B. T-38.2 C, BP-140/90 mmHg, RR-14 cpm, PR-95 Upper GI series is the other term for barium swallow. Choice A
C. T-37.4 C, BP-120/75 mmHg, RR-12 cpm, PR-75 refers to endoscopy; C is abdominal x-ray; and D is physical
D. T-36.2 C, BP-90/40 mmHg, RR-22 cpm, PR-115 assessment.

TIP: Cushing’s triad – late sign of increased ICP 120. A patient with epilepsy is to undergo electroencephalo-
 Hypertension or increased/widened pulse pressure graphy (EEG) after breakfast. The nurse enters the patient
 Hyperthermia
room, sees the meal tray and tells the patient not to take B. Normal speaking, breathing and swallowing are
the: restored
A. slice of pineapple C. glassful of water C. Unable to communicate with difficulty of swallowing
B. scrambled eggs D. cup of coffee and breathing
D. Permanent tracheostomy created; normal speech is
EEG measures electrical activity of the brain and is used to lost
diagnose seizure and epileptic disorders. Patients should avoid
any stimulants that may falsely increase brain wave activity. TIP: Changes after laryngectomy
 Partial laryngectomy – voice is preserved; airway
121. A patient who has been diabetic for 15 years develops normal
neuropathy. Which of the following home care instructions  Total laryngectomy – permanent loss of voice; upper
will best prevent injury? airway is bypassed with a permanent stoma
A. “Trim your toenails and in-growns every week to
prevent toe infections.” 126. After appendectomy, the client complained of abdominal
B. “Take hot shower on your own to promote self-care pain, nausea and vomiting with abdominal distention. The
and independence.” nurse anticipates which of the following priority
C. “Make sure to clean the floor regularly before walking management after referring to the surgeon?
barefoot.” A. Oropharyngeal suctioning
D. “Inspect inside your shoes before wearing them.” B. Possible surgery
C. Endoscopy
Peripheral neuropathy causes numbness that may increase D. Rectal tube insertion
the risk for injuries since patients have reduced ability to feel.
Foot care and trauma prevention is therefore essential. Avoid These signs indicate paralytic ileus, which is due to
trimming the in-growns (A), taking hot shower (B) and going accumulation of gas due to lack of intestinal peristalsis. This
barefoot (C). can be relieved by NGT attached to intermittent suction and/or
rectal tube insertion.
122. Which of the following ECG readings indicate that a
patient has a myocardial infarction? 127. Nurse Fely did her admission assessment on a patient
A. Suppressed ST segment C. Elevated T waves with acute pancreatitis. She understands that the
B. Absence of P waves D. Pathologic Q waves abdominal pain associated with this disorder is
characterized as
TIP: ECG in myocardial infarction A. Tenderness that is generalized in the upper epigastric
 Elevated ST segment area
 Inverted T wave B. Pain in the left upper quadrant radiating to the left
 Pathologic or abnormal Q wave shoulder
C. Tenderness and rigidity at the left hypogastric area
123. The nurse is monitoring the tracheostomy cuff pressure of radiating to the back
a patient of mechanical ventilation. To minimize the risk of D. Tenderness and rigidity at the upper right abdomen
tracheal tissue necrosis the nurse should maintain the radiating to the midsternal area
pressure to
A. 10-15 mmHg C. 30-35 mmHg Acute pancreatitis is felt as pain the left upper quadrant since
B. 20-25 mmHg D. 40-45 mmHg the pancreas is on the left upper quadrant of the abdomen.

A pressure of less than 20 mmHg may cause dislodgement of 128. The client is scheduled to undergo appendectomy.
the tube and increase risk of aspiration while higher than 25 Preparation for appendectomy does not include which of
mmHg can increase pressure on the tracheal mucosa, causing the following?
damage and necrosis. 1. Intravenous infusion A. 2,3,4
2. Laxative B. 1,3,5
124. A patient with fracture of the femur is on balanced 3. Pubic area shaving C. 2,3,5
suspension traction. The nurse considers the following 4. Enema D. 2,4,6
statements when taking care of a client with traction 5. Shower
EXCEPT 6. Pain medication
A. Steady pull from both directions to keep the fractured Laxatives and enema are contraindicated in appendicitis as
bone in place. this may cause rupture of the appendix. Pain medications are
B. Weights should be kept resting on the floor. generally not given as this may mask the pain that may falsely
C. Clients on traction need adequate skin care and indicate a ruptured appendix.
proper positioning.
D. Traction can be used to correct or prevent 129. For a client complaining of mild musculoskeletal pain, the
deformities. nurse will anticipate that the treatment for this client’s level
of discomfort will include which of the following?
ABD are all appropriate when caring for patient with traction. A. Ibuprofen C. Meperidine HCl
The weights should be continuous and not disrupted. B. Acetaminophen D. Fentanyl

125. A client with cancer of the larynx undergoes total TIP: WHO Analgesic Ladder – specific pain management
laryngectomy. Post-laryngectomy, which of the following depends on level or severity of pain
will the nurse expect?  Mild pain – non-opioids (Acetaminophen,
A. No risk of aspiration during swallowing; speech is lost. Paracetamol)
 Moderate pain – NSAIDs (Aspirin, Ibuprofen, A. RBC, WBC and platelets
Mefenamic acid) B. WBC, platelet and cholesterol
 Severe pain – opioids (Morphine, Meperidine HCl) C. Bilirubin, RBC, and platelet
D. BP, WBC, and hematocrit
130. Albert came to the hospital with chest pain and fever.
After a thorough assessment by the doctor he was Polycythemia vera is characterized by abnormal proliferation of
admitted for pericarditis management. The nurse RBC, with accompanying increase in WBC and platelet.
positions the client to reduce pain and discomfort.
Describe this position. 135. From the following data obtained from the chart, which is
A. Semi-Fowler’s position with one pillow to support the NOT a risk factor which could have predisposed the
head. patient to breast cancer?
B. Put two pillows to elevate the head and one pillow A. Age – 55 years
under the knees. B. Height – 5’2”; weight – 160 lbs.
C. Sit the client upright and lean forward C. Menarche at age 13
D. Supine lying on either left or right side with one pillow D. Mother died of colon cancer
to elevate the head
TIP: Risk factors of breast cancer
Upright position, with the patient leaning forward, is the  Age – increasing age (>40 years old)
position of choice to relieve chest pain in pericarditis.  Obesity
131. The nurse is aware that acromegaly is a condition when
Height Male Female
growth hormone occurs in excess. The following are the
First 5 feet 106 lbs 100 lbs
typical features of the disorder EXCEPT
For every 6 lbs 5 lbs
A. The soft tissues continue to grow
inch
B. Hands and feet are enlarged
C. The client grows taller Example: 106+8(6)=154 100+8(5)=140
D. Broad and bulbous nose 5’8”

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


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

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

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

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

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

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

With or without crisis intervention, crisis resolves usually within


4-6 weeks.

164. The following statements are true about anxiety except:


159. What is the priority assessment during the initial phase of A. Anxiety is a response to a specific negative stimulus.
crisis intervention? B. Mild anxiety is useful in bringing about better
A. Client’s support system performance.
B. Individual and the problem C. Persons use defense mechanisms to cope with their
C. Plan coping with the crisis anxiety.
D. Type of crisis the client is experiencing D. Persons who are anxious resort to flight or fight
mechanism.
TIP: Crisis assessment
 Perception of the problem – most important
The cause of anxiety is unknown, not specific. The patient
feels uneasy without an apparent cause. 170. Since admission 3 days ago, a female client has refused
to take a shower, stating, “There are poisonous spiders
165. Four days after admission, Mr. Lee says to the nurse, “I hidden in the shower head. I will get bitten by them and
want to go home. I’m alright.” Which of the following is the get killed if I take a shower!” How should the nurse
most therapeutic response of the nurse? respond?
A. “Alright you may go home if you want to.” A. Accept the fear and allow the client to take a sponge
B. “I know it must be difficult for you to stay in the bath instead.
hospital.” B. Ask a security guard to assist in giving the client a
C. “Why do you want to go home?” bath.
D. “You are not yet ready to go home, Mr. Lirio” C. Dismantle the shower head and show the client that
there is nothing in it.
Acknowledging patient’s feelings shows a nurse’s acceptance D. Tell her that the other clients complain about her body
of the patient. The use of “WHY” is non-therapeutic (C). odor, so she must take a shower.

166. When should the rehabilitation of a newly admitted The nurse should accept that phobia is real for the client.
schizophrenic patient start?
A. Before discharge 171. The characteristic traits of schizophrenia include the
B. During the recovery stage following except:
C. In the acute stage of his illness A. Blunting of affect
D. Upon admission B. Existence of two feeling tones
C. Loose association
Rehabilitation of patients starts during admission. D. Rapid change of mood

167. A client with major depression is to be discharged. Which TIP: 5 As of schizophrenia


of the following areas would be most important for the  Apathy – lack of affect
nurse to review with the client?  Ambivalence – 2 feelings at the same time
A. Conflict with another client  Associative looseness – jumps into different topics
B. Medication management  Autism – magical or dereistic thinking
C. Plans of returning to work  Auditory hallucination – most common type
D. Results of psychological testing
172. In taking care of schizophrenic patients, which of the
Antidepressant medications take an average of three weeks following nursing interventions should the nurse consider?
before therapeutic effects can be felt. This must be A. Always agree with the patient’s ideas.
emphasized to patients who are about to be discharged in B. Make use of short phases and specific words.
order to ensure compliance to the treatment. C. Use carefully detailed explanation.
D. Use sign language to be understood clearly.
168. Which of the following disorders may be seen concurrently
in a client with generalized anxiety disorder? Schizophrenia is a disorder of thought process. Use of simple
A. Bipolar disorder sentences makes it easier for patient to comprehend.
B. Gender identity disorder
C. Panic disorder 173. One morning, Paul says, “I hear Jose Rizal’s voice.”
D. Schizoaffective disorder Which of the following statements is the most therapeutic?
A. “I don’t hear the voice, but I know you hear what
TIP: Levels of anxiety sounds like a voice.”
 Mild – increases perception B. “No need to worry about the voice. It doesn’t belong
 Moderate – presence of physical symptoms to anybody alive.”
 Severe – difficulty of concentration C. “That could not be true. Jose Rizal has been dead
 Panic – inability to concentrate; personality for so many years.”
disintegration D. “You should ignore that voice. It would not help you
get well.”
169. A female victim of sexual assault went to the crisis center
for her third visit. She was raped 3 months ago and states Auditory hallucination is real for the client. Present reality by
that she feels as if the rape just happened yesterday. not acknowledging or focusing on the hallucination. Do not
What would be the best response of the nurse? argue with the patient or ignore the content of the hallucination.
A. “In time, our goal will help you move on from these
strong feelings about your rape.” 174. Which of the following drugs should the nurse expect to be
B. “It’s been over for 2 months now. Be realistic.” prescribed in order to reverse Parkinson-type symptoms in
C. “Tell me more about what happened during the rape a client receiving anti-psychotic medication?
that causes you now to feel like the rape just A. Benztropine mesylate (Cogentin)
occurred.” B. Chlordiazepoxide (Librium)
D. “What can you do to alleviate some of your fears C. Haloperidol (Haldol)
without being assaulted again?” D. Propanolol (Inderal)

Allowing the patient to verbalize the situation helps in TIP: Anti-cholinergic meds to prevent pseudo-
discovering emotional components associated with the event. parkinsonism or extra-pyramidal symptoms (EPS) caused
Therapy is then directed towards addressing the identified by antipsychotics
emotion. A – Akineton (Biperiden HCl)
A – Artane (Trihexiphenydyl HCl) She also manipulates the group with attention-seeking
B – Benadryl (Diphenhydramine HCl) behaviors, such as sexual comments and angry outbursts.
C – Cogentin (Benztropine mesylate) The nurse realizes that these behaviors are typical of:
A. Narcissistic personality disorder.
175. Which of the following is the most appropriate nursing B. Avoidant personality disorder.
diagnosis for a client reporting thoughts of being followed C. Histrionic personality disorder.
by CIA agents? D. Borderline personality disorder.
A. Disturbed sensory perception related to increased
anxiety Attention-seeking behavior is characteristic of a histrionic
B. Disturbed thought processes related to increased personality. Narcissistic behavior focuses on the self. Avoidant
anxiety personality withdraws from social relationships. Borderline
C. Impaired verbal communication related to disordered personality has inability to form relationships and has self-
thinking mutilating tendencies.
D. Altered thought content related to mistrust
180. A client is admitted to a psychiatric facility with a diagnosis
The client is experiencing delusion of persecution. Delusion is of chronic schizophrenia. The history indicates that the
a disorder of though process, not though content. client has been taking neuroleptic medication for many
 Alteration in thought content - delusion years. Assessment reveals unusual movements of the
 Alteration in thought process – hallucination, illusion tongue, neck, and arms. Which condition should the nurse
suspect?
176. A client with paranoid schizophrenia repeatedly uses A. Tardive dyskinesia
profanity during an activity therapy session. Which B. Dystonia
response by the nurse would be most appropriate? C. Neuroleptic malignant syndrome
A. “Your behavior won’t be tolerated. Go to your room D. Akathisia
immediately.”
B. “You’re just doing this to get back at me for making Tardive dyskinesia is an irreversible side-effect of anti-
you come to therapy.” psychotic drugs that involve rhythmic movement of the tongue.
C. “Your cursing is interrupting the activity. Take time Dystonia involves the muscles of the neck, arms and face.
out in your room for 10 minutes.” Neuroleptic malignant syndrome causes high fever, tremors.
D. “I’m disappointed in you. You can’t control yourself Akathisia involves restlessness and inability to keep still.
even for a few minutes.”
181. The nurse is caring for a client who is suicidal. When
Inappropriate behavior is addressed with a matter-of-fact accompanying the client to the bathroom, the nurse
approach. Limit setting exerts external control on the patient. should:
A. Give him privacy in the bathroom.
177. The nurse is assigned to a client with catatonic B. Allow him to shave.
schizophrenia. Which intervention should the nurse C. Open the window and allow him to get some fresh
include in the client’s plan of care? air.
A. Meeting all of the client’s physical needs D. Observe him.
B. Giving the client an opportunity to express concerns
C. Administering lithium carbonate (Lithonate) as A patient who is suicidal is placed on suicidal precautions.
prescribed Constant 24-hour surveillance must be done.
D. Providing a quiet environment where the client can be
alone 182. The nurse is developing a care plan for a client with
anorexia nervosa. Which action should the nurse include
Catatonic patients remain motionless for a period of time and in the plan?
may neglect their physical needs (e.g. nutrition, elimination). A. Restrict visits with the family until the client begins to
eat.
178. A client, age 36, with paranoid schizophrenia believes the B. Provide privacy during meals.
room is bugged by the Central Intelligence Agency and C. Set up a strict eating plan for the client.
that his roommate is a foreign spy. The client has never D. Encourage the client to exercise, which will reduce
had a romantic relationship, has no contact with family her anxiety.
members, and hasn’t been employed in the last 14 years.
Based on Erikson’s theories, the nurse should recognize Providing external control enables a patient with anorexia
that this client is in which stage of psychosocial nervosa to eat. The patient should be observed during meal
development? times to ensure that she ingests the food that is served.
A. Autonomy versus shame and doubt 183. A client whose husband recently left her is admitted to the
B. Generativity versus stagnation hospital with severe depression. The nurse suspects that
C. Integrity versus despair the client is at risk for suicide. Which of the following
D. Trust versus mistrust questions would be most appropriate and helpful for the
nurse to ask during an assessment for suicide risk?
Although the client is 36-years-old, his behaviors reflect an A. “Are you sure you want to kill yourself?”
inability to establish relationship and patterns of paranoia. B. “I know if my husband left me, I’d want to kill myself.
These are characteristics of not being able to establish trust. Is that what you think?”
C. “How do you think you would kill yourself?”
179. During a group therapy session in the psychiatric unit, a D. “Why don’t you just look at the positives in your life?”
client constantly interrupts with impulsive behavior and
exaggerated stories that cast her as a hero or princess.
A direct, confrontation approach is recommended and
therapeutic in assessing suicide risk. Amphetamines are CNS stimulants. BP and pulse may
increase (B,C). Diarrhea is more common. (D)
184. The nurse is caring for a client experiencing an anxiety
attack. Appropriate nursing interventions include: 190. During a shift report, the nurse learns that she’ll be
A. Turning on the lights and opening the windows so that providing care for a client who is vulnerable to panic
the client doesn’t feel crowded. attack. Treatment for panic attacks includes behavioral
B. Leaving the client alone. therapy, supportive psychotherapy, and medication such
C. Staying with the client and speaking in short as:
sentences. A. barbiturates. C. depressants.
D. Turning on stereo music. B. antianxiety drugs. D. amphetamines.

During an anxiety attack, the patient should be kept calm. As Panic is the highest level of anxiety. Anti-anxiety drugs are
cognitive function or perception may be affected, speaking in indicated in this situation. (e.g. Diazepam (Valium), Lorazepam
short sentences may be beneficial and therapeutic. (Ativan), Chlordiazepoxide (Librium)).

185. The nurse is teaching a new group of mental health aides. 191. A client has been receiving chlorpromazine (Thorazine),
The nurse should teach the aides that setting limits is an antipsychotic, to treat his psychosis. Which finding
most important for: should alert the nurse that the client is experiencing
A. A depressed client. C. A suicidal client. pseudoparkinsonism?
B. A manic client. D. An anxious client. A. Restlessness, difficulty sitting still, pacing
B. Involuntary rolling of the eyes
TIP: Attitude therapy C. Tremors, shuffling gait, mask like face
 Active friendliness – withdrawn, isolated patients D. Extremity and neck spasms, facial grimacing, jerky
 Passive friendliness – paranoid patients movements
 Kind firmness – depressed patients
 Matter-of-fact (limit setting) – for any inappropriate Pseudoparkinsonism or Parkinson’s-like symptoms are due to
behavior a reduction of dopamine level as an effect of taking anti-
 No demand – for aggressive and violent patients psychotic drugs. (A) refers to akathisia; (B) to oculogyric crisis
and (D) dystonia.
186. The nurse is caring for a client, a Vietnam veteran, who
exhibits signs and symptoms of posttraumatic stress 192. A 54-year-old female was found unconscious on the floor
disorder (PTSD). Signs and symptoms of posttraumatic of her bathroom with self-inflicted wrist lacerations. An
stress disorder include: ambulance was called and the client was taken to the
A. Hyper alertness and sleep disturbances. emergency department. When she was stable, the client
B. Memory loss of traumatic event and somatic distress. was transferred to the inpatient psychiatric unit for
C. Feelings of hostility and violent behavior. observation and treatment with antidepressants. Now that
D. Sudden behavioral changes and anorexia. the client is feeling better, which nursing intervention is
most appropriate?
Flashback, nightmares, and sleep disturbances are A. Observing for extrapyramidal symptoms
characteristics of PTSD. B. Beginning a therapeutic relationship
C. Canceling any no-suicide contracts
187. A client is admitted for detoxification after a cocaine D. Continuing suicide precautions
overdose. The client tells the nurse that he frequently uses
cocaine but that he can control his use if he chooses. When patients are treated with depression, a sudden
Which coping mechanism is he using? improvement in their mood or a sign of improvement is a major
A. Withdrawal C. Repression concern since it may signal an impending suicide. Suicidal
B. Logical thinking D. Denial tendencies are at its highest when the depression starts to lift.

TIP: Substance abuse


 Defense mechanism – denial
 Nursing diagnosis – Ineffective individual coping

193. A 26-year-old male reports losing his sight in both eyes.


188. A client with bipolar disorder is being treated with lithium He’s diagnosed as having a conversion disorder and is
for the first time. The nurse should observe the client for admitted to the psychiatric unit. Which nursing intervention
which common adverse effect of lithium? would be most appropriate for this client?
A. Sexual dysfunction C. Polyuria A. Not focusing on his blindness
B. Constipation D. Seizures B. Providing self-care for him
C. Telling him that his blindness isn’t real
Adverse effects of lithium include polyuria, diarrhea, tremors. D. Teaching eye exercises to strengthen his eyes

189. A client is admitted for an overdose of amphetamines. Conversion disorder is an anxiety disorder characterized by
When assessing this client, the nurse should expect to loss of function of a body part without on organic or pathologic
see: cause. It may be a symbolic representation of an unresolved
A. Tension and irritability. C. Hypotension conflict or anxiety. Nurses should not focus on the sign or
B. Slow pulse. D. Constipation. symptom so as to prevent reinforcing the anxiety.
A & B refer to the roles of the nurse as a clinician while C
194. A client is being admitted to the substance abuse unit for pertains to a patient advocate role.
alcohol detoxification. As part of the intake interview, the
nurse asks him when he had his last alcoholic drink. He 199. The objectives and activities that the nurse plans depend
says that he had his last drink 6 hours before admission. on the various stages of a therapeutic relationship. Which
Based on this response, the nurse should expect early is the following is the most appropriate during the
withdrawal symptoms to: orientation phase?
A. Not occur at all because the time period for their A. patients perception on the reason of her
occurrence has passed. hospitalization
B. Begin anytime within the next 1 to 2 days. B. identification of more effective ways of coping
C. Begin within 2 to 7 days. C. exploration of inadequate coping skills
D. Begin after 7 days. D. establishment of regular meeting of schedules

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

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

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


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

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

Encouraging verbalization of feelings provide a therapeutic


way to assess the patient’s underlying emotional concern.

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


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