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Situation 1: Mr.

Martin, 71 years old was suddenly rushed to the hospital because of severe
chest pain. On admission, he was diagnosed to have acute myocardial infarction and was
placed in the ICU.
1. While in the ICU, he executes the document tat list the medical treatment he chooses to refuse in case
his condition becomes severe to a point that he will be unable to make decisions for himself. This
document is:
A. living will
C. last will and testament
B. informed consent
D. power of attorney
2. After one day, the patients condition worsened and feeling hopeless. He requested the nurse to remove
the oxygen. The nurse should:
A. follow the patient because it is his right to die gracefully
B. follow the patient as it is his right to determine the medical regimen he needs
C. refuse the patient and encourage him to verbalize hid feelings
D. refuse the patient since euthanasia is not accepted in the Philippines
3. Euthanasia is an ethical dilemma which confronts nurses in the ICU because:
A. the choices involved do not appear to be clearly right or wrong
B. a clients legal right co-exist with the nurses professional obligation
C. decisions has to be made based on societal norms.
D. decisions has to be mad quickly, often under stressful conditions
4. A nurse who supports a patient and familys need to make decisions that is right for them is practicing
which of the following ethical principles?
A. Autonomy
B. confidentiality
C. privacy
d. truthfulness
5. Mr. Martin felt better after 5 days but recognizing the severity of his illness, he executes a document
authorizing the wife to transact any form of business in his behalf in addition to all decisions relative to his
confinement his document is referred to as:
A. power f attorney
C. informed consent
B. living will
D. medical records
Situation 2: Miss Castro was recently appointed chief nurse of a 50-bed government hospital in
Valenzuela. On her first day of duty, she tried to remember the elements of administration she
learned from her basic nursing education.
6. One of the first things Ms. Castro did was to engage her until in objective writing, formulating goals and
philosophy of nursing service. Which activities are MOST appropriately described to which elements of
administration?
A. planning
B. controlling
C. directing
d. organizing
7. In recognizing the Department of Nursing, she comes up with the organizational structure defining the
role and function of the different nursing positions and line-up the position with qualified people. This is
included in which element of administration:
A. monitoring
B. evaluation
C. organizing
d. planning
8. After one month, she and her management committee assess the regulatory measures taken and
correct whatever discrepancies are found. This is part of which element of administration:
A. monitoring
B. organizing
C. evaluation
d. planning
9. Revaluation and administrative process is BEST described as:
A. a continuing process of seeing that performance meets goals and targets
B. obtaining commitment of members to do better
C. informing personnel how well and how much improvement has been made
D. follow-up of activities that have been studied
10. In all of the various administrative functions, which of the following management skill is demanded
efficiently and effectively of Ms. Castro?
1. Decision making skills
2. Forecasting skills
3. Auditing skills
4. Communications skills
A. 2 & 3

B. 1 & 4

C. 1 & 2

D. 2 & 4

Situation 3: Meldy. 40 years old. is waiting for her doctors appointment at the clinic where
you work.
11. You are to interview her as an initial nursing action so that you can.
A. Document important data in her client records for health team to read.
B. Gather data about her lifestyle, health needs, lifestyle, health needs and problems to develop
plan of care
C. provide solutions to her immediate health concern

D. identify the most appropriate nurse diagnosis for her heath problem
12. During the interview, Meldy experiences a sharp abdominal pain on the right side of her abdomen. She
further tells you that an hour ago, she ate fatty food and this had happened many times before. You will
record this as:
A. Client complains of intermittent abdominal pain an hour after eating fatty foods
B. After eating fatty food the client experienced severe abdominal pain
C. Client claims to have sharp abdominal pains after eating fatty food unrelieved by pain
medication
D. Client reported sharp abdominal pain on the right upper quadrant of abdomen an hour after
ingestion of fatty foods.
13. Melody tells you that she has been on a high protein / high fat / low carbohydrate diet order to lose
weight and that she has successfully lost 8 lbs during the past two weeks. In planning a healthy balanced
diet for her, you will:
A. Encourage her to eat well-balanced diet with a variety of food from the major food groups and
take plenty of fluids.
B. Ask her to shift to a macrobiotic diet rich in complex carbohydrates.
C. Encourage her to cleanse her body toxins by changing a vegetarian diet with regular exercise.
D. Encourage her to eat a high carbohydrate, low protein diet and low fat diet.
14. You learn that Meldy drinks 5-8 cups o coffee a day plus cola drinks. Because she is in her premenopausal years, the nurse instructs her to decrease consumption of coffee and cola preparation
because:
A. these products increase calcium loss from the bones
B. These products have stimulant effect n the body
C. these products encourage increase in sugar consumption
D. these products are addicting
15. Health education plan for Meldy stresses prevention of NCD or Non-communicable diseases that are
influenced by lifestyle. These include the following EXCEPT:
A. Cancer
B. DM
C. Osteoporosis
D. Cardiovascular diseases
Situation 4: Changes in technology, the nations economy and the increasing number of
population have brought about changes in the Health Care System.
16. At present, government hospitals are expected to offer comprehensive health services to include
illness prevention and health promotion. In which of the following unit of services are these services
integrated?
A. Wellness center
C. Rehabilitation Center
C. Intensive Care unit
D. newborn screening unit
17. Which of the following is the MOST recent government initiative to help subsidize the cost of health
services for both the employed and the unemployed?
A. National Health Insurance Act
C. Medicare Act
B. Workers Compensation Act
D. Magna Carta for Public Health Workers
18. The top ten morbidity cases in the Phil. Include TB, diarrhea among children to name a few. Many of
these conditions are preventable and have implications are preventable and have implications in the
development of which nursing competencies?
A. Execution of nsg. procedure and technique
B. Therapeutic use of self
C. Administration of treatment and medication
D. Health education
19. The cost of hospitalization is getting more expensive and unaffordable to many of our people. These
facts will MOST LIKELY bring about development in which of the following?
A. acute services
C. home care services
B. managed care services
D. advance practice nursing
20. Which of the following latest trend has expanded health services based on prepaid fees with emphasis
on health promotion and illness prevention?
A. Government Insurance Plan
C. Health Maintenance Organization
B. Preferred Provider Organization
D. Private Insurance Plan
Situation 5: It is Safety Awareness Week in the Community and the nurse checks on the
presence of hazards at home. The nurse plan is to have the residents themselves identify the
physical hazards in their own homes.
21. Which of the following is NOT a physical hazard in the home?
A. unstable and slippery stairway
B. large windows that allow good ventilation

C. obstacle people cam trip over like door mats, rugs, electric cords
D. inadequate lighting in and out of the house
22. Risk factors exist for each of the different developmental levels. From infancy to preschool age, the
most common cause of death is injury rather than disease. To protect children from harm, that parents
should be aware that MOST injuries for this age group are due to:
A. Accidents at home caused by the swallowed poisonous materials, small objects, exploring
electrical sockets
B. Accidents from self inflicted wounds
C. accidents from sports related activities at school or the neighborhood
D. accidents in the Playground Park, school and presence of strangers who may abduct of molest
the child.
23. To promote safety at home, the nurse identifies ways and means of child proofing the house. Which
of the following is NOT safe?
A. apply child proof caps and medicine bottles and chemicals
B. covering electrical outlets, tying up long and loose electrical and telephone cords, securing
cabinets or doors within reach the child
C. giving colorful grocery bags to play with or to store toys and materials
D. removing objects that the child could easily dismantle and swallow like small parts of a
mechanical
toy, buttons, materials inside, stuffed animals, liquid chemicals.
24. The nurse knows that a persons hygienic practices are influenced family customs and traditions.
Which of the following is NOT part of Basic Hygienic Practices?
A. bathing practices, frequency and time, care of eyes, ear and nose
B. oral hygiene practices such as brushing and flossing teeth, gum care
C. care of skin with lesions, cuts with infection
D. hair and skin such as washing hair and face, feet, hand and nail care
25. Falls are the common home accident among elderly and these are due to physical limitations imposed
by aging and some hazards in the home setting. The nurse reduces the risk of falling through the following
EXCEPT:
A. rearranging furniture frequently
B. having the bed or mattress close to the floor
C. providing a nonskid and well fitted shoes or slippers
D. having a call bell within the persons reach and answering call bells immediately
Situation 6: Eileen, 45 years old is admitted to the hospital with a diagnosis of renal calculi.
She is experiencing severe flank pain, nauseated and with a temperature of 39 0C.
26. Given the above assessment data, the most immediate goal of the nurse would be which of the
following?
A. Prevent urinary complication
C. Alleviate pain
B. maintains fluid and electrolytes
D. Alleviating nausea
27. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes
daily urine specimen to be sent to the laboratory . Eileen has a foley catheter attached to a urinary
drainage system. How will you collect the urine specimen?
A. remove urine from drainage tube with sterile needle and syringe and empty urine from the
syringe into the specimen container
B. empty a sample urine from the collecting bag into the specimen container
C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter
into the specimen container.
D. disconnect the drainage the from the collecting bag and allow the urine to flow from the
catheter into
the specimen container.
28. Where would the nurse tape Eileens indwelling catheter in order to reduce urethral irritation?
A. to the patients inner thigh
C. to the patient
B. to the patients lower thigh
D. to the patient lower abdomen
29. Which of the following menu is appropriate for one with low sodium diet?
A. instant noodles, fresh fruits and ice tea
B. ham and cheese sandwich, fresh fruits and vegetables
C. white chicken sandwich, vegetable salad and tea
D. canned soup, potato salad, and diet soda
30. Howe will you prevent ascending infection to Eileen who has an indwelling catheter?
A. see to it that the drainage tubing touches the level of the urine
B. change he catheter every eight hours

C. see to it that the drainage tubing does not touch the level of the urine
D. clean catheter may be used since urethral meatus is not a sterile area
Situation 7: Miss Tingson is assigned to Mang Carlos, a 60 year old newly diagnosed diabetic
patient. She is beginning to write objectives of her teaching plan.
31. Which of the following objectives is written in behavioral terms?
A. Mang Carlos will know about diabetes related to foot care and the techniques and equipments
necessary to
carry it out
B. Mang Carlos daughter should learn about DM within the week
C. Mang Carlos wife needs to understand the side effects of insulin
D. Mang Carlos sister will be able to determine in two days his insulin requirement based on
blood glucose levels obtained from glucometer
32. Which of the following is the BEST rationale for written objectives?
A. ensure communication among staff members
B. facilitate evaluation of the nurses performance
C. ensure learning on the part of the nurse
D. document the quality of care
33. Which of the following behavior BEST contribute to the learning of Mang Carlos regarding his disease
condition?
A. frequent use of technical terms for familiarization
B. drawing him into discussion about diabetes
C. detailed lengthy explanation about his condition
D. loosely structured teaching session
34. Miss Tingson should encourage exercise in the management of diabetes, because it:
A. decrease total triglyceride levels
C. lowers blood glucose
B. improves insulin utilization
D. accomplishes all of the above
35. The chief life-threatening hazard for surgical patient with uncontrolled diabetes is:
A. dehydration
B. hypertension
C. hypoglycemia
D. glucosuria
Situation 8: Caring for the perioperative patient.
36. An appendectomy during a hysterectomy would be classified as:
A. Major, emergency, diagnosis
C. Minor, elective, ablative
B. major, urgent, palliative
D. minor, urgent, reconstructive
37. An informed consent is required for:
A. closed reduction of a fracture
B. insertion of intravenous catheter

C. irrigation of the external ear canal


D. urethral catheterization

38. The circulating nurses responsibilities, in contrast to the scrub nurses responsibilities, include:
A. assisting the surgeon
C. setting up the sterile tables
B. monitoring aseptic practices
D. all of the above functions
39. The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function
and prevention of:
A. Laryngospasm
C. hypoxemia and hypercapnea
B. hyperventilation
D. pulmonary edema ad embolism
40. Unless contraindicated, any unconscious patient should be positioned:
A. flat on his of her back, without elevation of the head, to facilitate frequent turning and minimize
pulmonary complications
B. in semi-fowlers position, to promote respiratory function and reduce the incidence of orthostatic
hypotension when the patient can eventually stand.
c. in fowlers position, which most closely stimulates a sitting position, thus facilitating reparatory
as well as gastrointestinal functioning.
D. on his or her side without a pillow at the patients back and his or her chin extended to minimize
the danger of aspirations
Situation 9: To prevent further injury to patients with problems of immobility / mobility, the
nurse should observe certain principles of body mechanics for herself and her patients.
41. Which of the following are appropriate goals for client with positioning and mobility needs?
A. developing of contractures
C. sensory alterations
B. proper body alignment
D. decrease in activity tolerance
42. Which for the following would MOST likely cause injury to the nurse when moving the patient from bed
to the wheelchair?

A. bending at the knees


B. standing with feet together

C. using body weight to assist with the movement


D. standing with feet apart

43. Which of the following is the CORRECT guideline when positioning patients?
A. put pillows above a joint to immobilize it
B. position of the joint should be slightly extended
C. joints of patient to be supported with pillow
D. patients position should be changed at least three or four times a day
44. Which of the following can be used by clients with problem of immobility to enable them raise their
body from bed to wheelchair or perform some bed exercises?
A. sandbag
B. side-rail
C. trochanter roll
D. trapeze bar
45. The importance of forcing fluids with an immobilized patient is to:
A. prevent pneumonia
C. prevent skin breakdown
B. prevent urinary stasis
D. maintain peristalsis
46. Which of the following is the least nursing activity in performing assessment of the patient?
A. laboratory test
C. Health history
B. physical examination
D. systemic review
47. One of the responsibilities of Mr. Lata, RN, an industrial nurse, is to conduct physical head-to-toe
assessment of a newly hired factory worker. As part of the assessment, he took the vital signs. Which of
the four assessment techniques did he utilize?
1. auscultation
3. palpation
2. percussion
4. inspection
A. 1,2 & 3
B. 3 &4
C. 1 & 2
D. 1,3 & 4
48. Which of the following are the purpose of performing a physical assessment?
1. gather baseline data about the clients health
2. confirm and identify nursing diagnosis
3. evaluate physiological outcome of care
4. make clinical judgment of patients diagnosis
A. 1,2 & 4
B. 2, 3 & 4
C. 1, 3 & 4
D. 1,2 & 3
49. Which of the following should be given the HIGHEST PRIORITY before physical examination is done to a
patient?
A. preparation of the equipment
C. preparation of the environment
B. psychological preparation of the client
D. physical preparation of the client
50. During the assessment phase of the nursing process, the nurse is concerned with:
A. interpreting data
B. designing nursing strategies
C. establishing a data base
D. comparing client responses with the anticipated outcome
Situation 11: The nurse is responsible to accurately records and reports patients progress.
She is able to communicate to the other member of the team by documenting the nursing care
plan and the appropriate nursing intervention.
51. A main function of the patients records is to:
A. prepare the nurse for the shift worked
B. serve as a record of financial charges
C. serve as a vehicle for communication
D. ensure that the message is received
52. When the nurse writes in the chart and discovers an error has been made, which is the BEST approach?
A. erase the erroneous material
B. carefully ink out the erroneous material
C. place as asterisk next to the statement, then footnote it
D. draw a straight line through the error and initial it.
53. Which of the following persons cannot have the access to the patient record?
A. physical therapist
C. the patient
B. lawyer of the family
D. speech therapist
54. POMR charting is different from traditional method because of which of the following practices?
1. SOAP charting
3. narrative charting
2. use of flow sheet
4 . use of checklist
A. 3 & 4
B. 1 & 2
C. 1 & 3
D. 2 & 3

55. Which of the following qualities are relevant in documenting patients care?
1.
Accuracy and consciousness
2.
thoroughness and currentness
3.
systematic and orderly
4.
legibly, properly dated and signed
5.
use of locally accepted abbreviation
A. 1,3,4 & 5
B. 2,3,4 & 5
C. 1,2,3 & 5
D. 1,2,3 & 4
Situation 12: The practice of primary nurse in primary nursing is preferred by many nurses
because it supports professional autonomy and accountability of the nurses>
56. What is the function of the primary nurse in primary nursing?
A. acts as patient advocate and coordinate the health care team for specific group of patients
B. act as the charge nurse, organizing staff assignments and help in solving problem in the unit
C. plans and coordinate the patient care assigned to her from admission to discha
D. coordinates the care given to a group of patients by support staff

57. Primary nursing is MOST advantageous and satisfying to the patient and nurse because of which of the
following principles?
A. autonomy and authority for planning care are best delegated to a nurse
B. accountability is clearest since our nurse is responsible for the overall plan and implementation
of care
C. the holistic approach provides fro a therapeutic relationship continuity of care and efficient
nursing care
D. continuity of patients care promotes efficient nursing care.
58. Which is the role of the associate nurse in primary nursing?
A. over-all manager of the unit
B. responsible for the over-all care of the patient during off days of primary nurse
C. patient advocate in the health care team
D. coordinator of comprehensive, holistic patient care
59. In primary nursing, the nurse is responsible for which of the following group of patient?
A. the whole ward
C. big group of patients like 10-15
B. small group of patient like 3-5 patients
patients
D. the whole unit
60. In primary nursing who among the following is needed to her leadership and quality control in the
ward?
A. the chief nurse
C. the nurse supervisor
B. the head nurse
D. the service director
Situation 13: Your nursing unit plans to conduct a study on the use of structured preoperative
preparation in lessening the demand for post-operative pain medications.
61. Which of the following research activities should you initially do?
A. find out from interview how many patients are willing to participate
B. get the permission from the hospital director
C. review literature on the topic
D. prepare the tool for collecting data
62. Which of the following statements do NOT contribute to the researchabilty of your proposed problem?
A. potential use of findings
C. well-defined problem statement
B. readability of findings
D. measurability of variables
63. A study /research table should NOT contain which of the following ?
A. categories of data collected
C. specific title of table
B. relevant rows and columns
D. names and sample of the selected
64. Which of the following actions will facilitate analysis of research data?
A. consult a physician
C. consult a complete expert
B. consult an adviser
D. categorize data collected
65. The research methodology that is appropriate for the above problem would be:
A. descriptive
B. normative
C. experimental
experimental

D. quasi

Situation 14: The nurse meets a new client, Mr. Principe, 50 years old. During the initial
interview, the nurse begins to feel irritated towards the client. Shortly after, he becomes

uncomfortable and politely leaves the room. The nurse realizes the behavior and mannerism of
Mr. Principe reminds him of his strict disciplinarian father who abused him physically.
66. The recognize that his feeling for the client is known as:
A. denial
B. counter transference
C. revenge
D. transference
67. Seeing that his negative feelings for Mr. Principe could affect his nursing care, the nurse applies the
concept of therapeutic use of self when:
A. the nurse talks about his personal feelings towards the client
B. the nurse suppresses his feelings and continue to take care of the client
C. the nurse uses his awareness and asks to be reassigned to another client
D. the nurse uses self-awareness to manage his feelings and thoughts towards the client
68. Mr. Principe is terminally ill and his family is coping with his impending death. The nurse has to deal
with his own thoughts and personal feelings about death and grieving in order to:
A. avoid sharing personal thought about their impending loss and feeling of grief since this is very
subjective
B. get self out of the way while he assists the client and his family express their feelings of
impending loss
C. prevent self from being affected by the familys grief and remain objective
D. help the family plan for the funeral arrangement and burial services
69. One morning when the nurse enters the clients room. Mr. Principe asks the nurse to leave me alone
and stop bothering me and I dont want your pity. The following response by the nurse would be MOST
appropriate?
A. You seem upset this morning and remains with the client
B. You are probably upset because you dont feel well
C. Why you are angry with me? What did I do anything to upset you?
D. I understand and will leave you for a while
70. The nurse understands that the nurse-client relationship is a therapeutic alliance when:
A. the nurse is a role model for a client
B. this is an essential part of the nursing process
C. the nurse has to be therapeutic at all times
D. how the nurse thinks and feels affects her actions and behavior towards her client and her work
Situation 15: Mr. Ong is for admission to the medical unit and you are his nurse.
71. The MOST important initial nursing approach when admitting client is to:
A. introduce the client to the ward staff
B. orient the client to the physical set up of the unit
C. identify the most immediate needs of the client and implement the necessary intervention
D. take V/S fro baseline assessment
72. When gathering baseline data, the BEST way for you to check if the client has pedal edema is to:
A. talk to the relatives
C. do auscultation
B. interview the client
D. do a physical assessment
73. You want to know the sleeping pattern of Mr. Ong You will:
A. interview the clients and relatives
B. take his BP before sleeping and upon waking up
C. observe his sleeping pattern over a period of time
D. perform physical assessment
74. Mr. Ong has severe pedal edema. Which accessory device would be appropriate for his condition?
A. footboard
B. cradle
C. bed board
D. rolled pillows
75. A student nurse is observed putting a standard size cuff on an obese client. The action would probably
result in BP reading that is:
A. false high
B. false low
C. normal
D. undetectable
Situation 16: Health is wealth specifically in this time of the century. The nurse is trained to
promote well being of the people.
76. How does a nurse promote ones well being?
A. periodic travels for rest and recreation
B. faithful and observance of healthy simple
lifestyle

C. run away from polluted, stressful


areas
D. avoid sleepless, over fatigue nights

77. The nurse can be involved with health promotion as a significant person in helping the family:
A. become a better family

B. prevent disease

C. control their symptoms

D. modify health promotive behaviors

78. The nurse should NOT leave medication at the bedside because:
a. the bedside table is not sterile
b. it is convenient for the nurse
c. the nurse will not be able to accurately document that the patient actually took the medication
d. the patient may forget to take it.
79. Non-pharmacologic pain management includes all the following EXCEPT:
a. relaxation techniques
c. use of herbal medicines
b. massage
d. body movement
80. When assessing a clients blood pressure, the nurse finds it necessary to recheck the reading. How
many seconds after deflating the cuff should the nurse wait before rechecking the pressure?
a. 10
b. 30
c. 45
d. 60
Situation 17: Safe nursing practice involves an understanding of the law.
81. In the Philippines, this law is :
a. The Philippine Nursing Act of 2002 or R.A. 9173
b. the Philippine Nursing Act of 1991 or R.A. 7164
c. IRR or Resolution 425 of 2003
d. Republic Act No. 8981
82. The Philippine Nursing Act delineates the scope of nursing. It specifies that independent practicing nurse
is responsible for:
a. health promotion and prevention of illness
b. administration of written prescription for treatment and therapies
c. rehabilitative aspect of care
d. Collaborating with other healthcare providers for health restoration and alleviation of suffering
83. Standards of care provide the legal basis for evaluation of nursing practice or malpractice. Its functions
include all EXCEPT:
a. used by nurse experts to define what appropriate nursing practice is in a given situation
b. used to measure or evaluate nursing conduct to determine if the nurse acted reasonably
as any prudent nurse would under similar circumstances
c. used to delineate the scope, function and role of the nurse
d. use to measure or evaluate the conduct of nurse specialists who are certified in their own
specialty fields
84. As a standard in ethics, this represents an understanding and agreement to respect another persons
right to decide a course his or her own destiny:
a. Autonomy
c. Beneficence
b. justice
d. nonmalifecence
85. The Code of Ethics refers to standards of behavior or ideals of conduct. The ability to answer for and
stand by ones action refers to:
a. accountability
c. advocacy
b. veracity
d. responsibility
Situation 18: An understanding of the factors influencing the health care delivery system will
enable nurses to adjust to change, create better ways of providing nursing care and develop
new nursing roles.
86. Wellness clinics and health education activities have been integrated in government hospitals to render
appropriate services. Which of the following purposes LEAST helps clients in cases of these health
promotion activities?
A. maintain maximum functions
C. promote health habits
B. reduce the costs of health care
D. identify disease symptoms
87. With regards to illness prevention activities as part of nursing care, which of the following will help
clients MOST?
A. maintain maximum function
C. promote habits related to health care
B. reduce risk factor
D. manage stress
88. By experience, which of the following nursing goals are MOST often overlooked by nurses and other
members of the hospital team in the care of their clients in the hospital?
A. illness prevention
C. diagnosis and treatment
B. health promotion
D. rehabilitation of patients

89. Which of the following health care agencies is usually family-centered, relatively recent in popularity
and oftentimes focuses on maintenance of comfort and satisfactory lifestyle of clients in the terminal
phase of illness?
A. non-government organization
C. community health center
B. hospice
D. support group
90. Which of the following is NOT a legally binding document but nonetheless very important in the care of
all patients in any setting?
A. Bill of rights as provided in the Philippine Constitution
B. Scope of nursing practice as defined in R.A. 9173
C. Patients Bill of Rights ( as adopted by American Nurses Association )
D. Board of Nursing resolution adopting the Code of Ethics
Situation 19: One of the professional competencies that nurse must always demonstrate is in
the area of communication:
91. Which communication technique would be MOST effective in eliciting detailed information from the
client?
A. open-ended questioning
C. active listening
B. verbalizing observations
D. summarizing clients views
92. Which of the following terms refer to the senders attitude towards the self, the message and the
listener?
A. verbal communication
C. non-verbal communication
B. double-bind communication
D. meta communication
93. In interacting with patients, the nurses should remember that a clients personal space is:
A. that which revolves around the client
B. highly mobile depending upon certain situation
C. clearly visible to others
D. the same as that of the nurse
94. In interpersonal communication is LEAST threatening during what type of relationship?
A. social
C. personal
B. intimate
D. professional
95. In demonstrating the method for deep breathing exercises, the nurse places the hands on the clients
abdomen to explain diaphragmatic movement. This technique involves the use of which element of
communication?
A. appropriateness
C. channel
B. feedback
D. message
Situation 20: Roy, an adolescent, was diagnosed to have pneumonia. He constantly complains
of chest pain and has a standing order of Morphine SO4.
96. Which of the following MOST appropriately describe pain sensation that has periods of remission and
exacerbation?
A. chronic
C. acute
B. intractable
D. Psychosomatic
97. Roy is constantly asking to be relieved from pain. Since morphine is an addicting drug, which of the
following is BEST for the patient?
A. administer morphine SO4 PRN
B. administer morphine on a routine schedule as ordered
C. give instructions on relaxation technique to reduce frequency of pain sensation
D. divert the attention by not limiting visitors
98. To get accurate information about the quality of pain the patient is experiencing, which of the following
statements would be MOST APPROPRIATE?
A. What cause you the pain?
C. Have you taken something to relieve the
pain?
B. Tell me what your pain feels like
D. Is it stubbing or radiating pain?
99. As the nurse assigned to Ray, which of the following can decrease his chest pain?
A. supporting his rib cage when he coughs
C. teaching him
B. advising him
D. encouraging him to breathe deeply
100. Which of the following is the nurses primary goal in caring for clients with chronic pain?
A. change the clients perception of pain
B. reduce the clients perception of pain
C. change the clients reaction to pain
D. enumerate the source of pain

JUNE 2007
Situation 1 Mr. Ibarra is assigned to the triage area and while on duty, he assesses the
condition of Mrs. Simon who came in with asthma. She has difficulty breathing and her
respiratory rate is 40 per minute. Mr. Ibarra is asked to inject the client epinephrine 0.3 mg
subcutaneously.
1. The indication for epinephrine injection for Mrs. Simon is to:
A. Reduce anaphylaxis
C. Relieve respiratory distress due to
B. Relieve hypersensitivity to allergen
bronchial spasm
D. Restore clients cardiac rhythm
2. When preparing the epinephrine injection from an ampule, the nurse initially:
A. Taps the ampule at the top to allow fluid to flow to the base of the ampule
B. Checks expiration date of the medication ampule
C. Removes needle cap of syringe and pulls plunger to expel air
D. Breaks the neck of the ampule with a gauze wrapped around it
3. Mrs. Simon is obese. When administering a subcutaneous injection to an obese patient, it is best for the
nurse to:
A. Inject needle at a 15 degree angle over the stretched skin of the client
B. Pinch skin at the injection site and use airlock technique
C. Pull skin of patient down to administer the drug in a Z track
D. Spread skin or pinch at the injection site and inject needle at a 45-90
degree angle
4. When preparing for a subcutaneous injection, the proper size of syringe and needle would be:
A. Syringe 3-5 ml and needle gauge 21 to 23
B. Tuberculin syringe 1 ml with needle gauge 26 or 27
C. Syringe 2 ml and needle gauge 22
D. Syringe 1-3 ml and needle gauge 25 to 27
5. The rationale for giving medications through the subcutaneous route is:
A. There are many alternative sites for subcutaneous injection
B. Absorption time of the medicine is slower
C. There are less pain receptors in this area
D. The medication can be injected while the client is in any position
Situation 2 The use of massage and meditation to help decrease stress and pain have
been strongly recommended based on documented testimonials.
6. Martha wants to do a study on this topic: Effects of massage and meditation on stress
and pain. The type of research that best suits this topic is:
A. Applied research
C. Basic research
B. Qualitative research
D. Quantitative research
7. The type of research design that does not manipulate independent variable is:
A. Experimental design
C. Non-experimental design
B. Quasi-experimental design
D. Quantitative design
8. This research topic has the potential to contribute to nursing because it seeks to
A. include new modalities of care
C. clarify an ambiguous modality of care
B. resolve a clinical problem
D. enhance client care
9. Martha does review of related literature for the purpose of
A. determine statistical treatment of data research
B. gathering data about what is already known or unknown about the problem
C. to identify if problem can be replicated
D. answering the research question
10. Clients rights should be protected when doing research using human subjects. Martha identifies these
rights as follows EXCEPT:
A. right of self-determination
C. right of privacy
B. right to compensation
D. right not to be harmed
Situation 3 Richard has a nursing diagnosis of ineffective airway clearance related to
excessive secretions and is at risk for infection because of retained secretions. Part of Nurse
Marios nursing care plan is to loosen and remove excessive secretions in the airway.

11. Mario listens to Richards bilateral sounds and finds that congestion is in the upper lobes of the lungs.
The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does
percussion would be:
A. Client lying on his back then flat on his abdomen on Trendelenburg position
B. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his
back and on his abdomen
C. Client lying flat on his back and then flat on his abdomen
D. Client lying on his right then left side on Trendelenburg position
12. When documenting outcome of Richards treatment Mario should include the following in his recording
EXCEPT:
A. Color, amount and consistency of sputum
B. Character of breath sounds and respiratory rate before and after procedure
C. Amount of fluid intake of client before and after the procedure
D. Significant changes in vital signs
13. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would
focus on the following EXCEPT:
A. Amount of food and fluid taken during the last meal before treatment
B. Respiratory rate, breath sounds and location of congestion
C. Teaching the clients relatives to perform the procedure
D. Doctors order regarding position restrictions and clients tolerance for lying flat
14. Mario prepares Richard for postural drainage and percussion. Which of the following is a special
consideration when doing the procedure?
A. Respiratory rate of 16 to 20 per minute
C. Client has no signs of infection
B. Client can tolerate sitting and lying positions
D. Time of last food and fluid intake of the client
15. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference
between the procedures is:
A. Percussion uses only one hand while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes
secretion loose on the exhalation cycle
C. In both percussion and vibration the hands are on top of each other and hand action is in tune with
clients breath rhythm
D. Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the
inhalation of air
Situation 4 A 61 year old man, Mr. Regalado, is admitted to the private ward for observation
after complaints of severe chest pain. You are assigned to take care of the client.
16. When doing an initial assessment, the best way for you to identify the clients priority
problem is to:
A. Interview the client for chief complaints and other symptoms
B. Talk to the relatives to gather data about history of illness
C. Do auscultation to check for chest congestion
D. Do a physical examination while asking the client relevant questions
17. Upon establishing Mr. Regalados nursing needs, the next nursing approach would be to:
A. Introduce the client to the ward staff to put the client and family at ease
B. Give client and relatives a brief tour of the physical set up the unit
C. Take his vital signs for a baseline assessment
D. Establish priority needs and implement appropriate interventions
18. Mr. Regalado says he has trouble going to sleep. In order to plan your nursing
intervention you will:
A. Observe his sleeping patterns in the next few days
B. Ask him what he means by this statement
C. Check his physical environment to decrease noise level
D. Take his blood pressure before sleeping and upon waking up
19. Mr. Regalados lower extremities are swollen and shiny. He has pitting pedal edema. When taking care
of Mr. Regalado, which of the following interventions would be the most appropriate immediate nursing
approach?
A. Moisturize lower extremities to prevent skin irritation
B. Measure fluid intake and output to decrease edema
C. Elevate lower extremities for postural drainage
D. Provide the client a list of food low in sodium
20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client
for discharge include all EXCEPT:

A. Making a final physical assessment before client leaves the hospital


B. Giving instructions about his medication regimen
C. Walking the client to the hospital exit to ensure his safety
D. Proper recording of pertinent data
Situation 5 Nancy, mother of 2 young kids, 36 years old, had a mammogram and was told
that she has breast cysts and that she may need surgery. This causes her anxiety as shown by
increase in her pulse and respiratory rate, sweating and feelings of tension.
21. Considering her level of anxiety, the nurse can best assist Nancy by:
A. Giving her activities to divert her attention
B. Giving detailed explanations about the treatments she will undergo
C. Preparing her and her family in case surgery is not successful
D. Giving her clear but brief information at the level of her understanding
22. Nancy blames God for her situation. She is easily provoked to tears and wants to be left alone, refusing
to eat or talk to her family. A religious person before, she now refuses to pray or go to church stating that
God has abandoned her. The nurse understands that Nancy is grieving for her self and is in the stage of:
A. bargaining
C. anger
B. denial
D. acceptance
23. The nurse visits Nancy and prods her to eat her food. Nancy replies whats the use? My time is
running out. The nurses best response would be:
A. The doctor ordered full diet for you so that you will be strong for surgery
B. I understand how you feel but you have to try for your childrens sake
C. Have you told your doctor how you feel? Are you changing your mind about your surgery?
D. You sound like you are giving up.
24. The nurse feels sad about Nancys illness and tells her head nurse during the end of
shift endorsement that its unfair for Nancy to have cancer when she is still so young and with two kids.
The best response of the head nurse would be:
A. Advise the nurse to be strong and learn to control her feelings
B. Assign the nurse to another client to avoid sympathy for the client
C. Reassure the nurse that the client has hope if she goes through all treatments prescribed for her
D. Ask the other nurses what they feel about the patient to find out if they share the same feelings
25. Realizing that she feels angry about Nancys condition, the nurse learns that being selfaware is a
conscious process that she should do in any situation like this because:
A. This is a necessary part of the nurse client relationship process
B. The nurse is a role model for the client and should be strong
C. How the nurse thinks and feels affect her actions towards her client and her work
D. The nurse has to be therapeutic at all times and should not be affected

Situation 6 Mrs. Seva, 52 years old, asks you about possible problems regarding her
elimination now that she is in the menopausal stage.
26. Instruction on health promotion regarding urinary elimination is important. Which would you include?
A. Hold urine as long as she can before emptying the bladder to strengthen her sphincter muscles
B. If burning sensation is experienced while voiding, drink pineapple juice
C. After urination, wipe from anal area up towards the pubis
D. Tell client to empty the bladder at each voiding
27. Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical
changes predispose her to constipation?
A. inhibition of the parasympathetic reflex
B. weakness of sphincter muscles of anus
C. loss of tone of the smooth muscles of the colon
D. decreased ability to absorb fluids in the lower intestines
28. The nurse understands that one of these factors contributes to constipation:
A. excessive exercise
C. no regular time for defecation daily
B. high fiber diet
D. prolonged use of laxatives
29. Mrs. Seva talks about fear of being incontinent due to a prior experience of dribbling
urine when laughing or sneezing and when she has a full bladder. Your most appropriate instruction would
be to:
A. tell client to drink less fluids to avoid accidents
B. instruct client to start wearing thin adult diapers

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


D. teach client pelvic exercise to strengthen perineal muscles
30. Mrs. Seva asked for instructions for skin care for her mother who has urinary incontinence and is
almost always in bed. Your instruction would focus on prevention of skin irritation and breakdown by:
A. Using thick diapers to absorb urine well
B. Drying the skin with baby powder to prevent or mask the smell of ammonia
C. Thorough washing, rising and drying of skin area that get wet with urine
D. Making sure that linen are smooth and dry at all times
Situation 7 Using Maslows need theory, Airway, Breathing and Circulation are the
physiological needs vital to life. The nurses knowledge and ability to identify and immediately
intervene to meet these needs is important to save lives.
31. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues:
A. Carol with tumor in the brain
C. Sonnyboy with a fracture in the femur
B. Theresa with anemia
D. Brigitte with diarrhea
32. You noted from the lab exams in the chart of M. Santos that he has reduced oxygen in the blood. This
condition is called:
A. Cyanosis
C. Hypoxemia
B. Hypoxia
D. Anemia
33. You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of insertion of the tubing
for an adult would be:
A. tip of the nose to the base of the neck
B. the distance from the tip of the nose to the middle of the neck
C. the distance from the tip of the nose to the tip of the ear lobe
D. eight to ten inches
34. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by:
A. Apply suction for at least 20-30 seconds each time to ensure that all secretions are removed
B. Using gloves to prevent introduction of pathogens to the respiratory system
C. Applying no suction while inserting the catheter
D. Rotating catheter as it is inserter with gentle suction
35. Myrna has difficulty breathing when on her back and must sit upright in bed to breath effectively and
comfortably. The nurse documents this condition as:
A. Apnea
C. Dyspnea
B. Orthopnea
D. Tachypnea
Situation 8 You are assigned to screen for hypertension. Your task is to take blood pressure
readings and you are informed about avoiding the common mistakes in BP taking that lead to
false or inaccurate blood pressure readings.
36. When taking blood pressure reading the cuff should be:
A. deflated fully then immediately start second reading for same client
B. deflated quickly after inflating up to 180 mmHg
C. large enough to wrap around upper arm of the adult client 1 cm above brachial artery
D. inflated to 30 mmHg above the estimated systolic BP based on palpation of radial or bronchial artery
37. Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of death worldwide and is
a preventable disease. The primary cause of COPD is
A. tobacco hack
C. asthma
B. bronchitis
D. cigarette smoking
38. In your health education class for clients with diabetes you teach them the areas for Control of
Diabetes which include all EXCEPT
A. regular physical activity
C. prevention nutrition
B. thorough knowledge of foot care
D. proper nutrition
39. You teach your clients the difference between, Type I (IDDM) and Type II (NDDM) diabetes. Which of the
following is true?
A. both types diabetes mellitus clients are all prone to developing ketosis
B. Type II (NIDDM) is more common and is also preventable compared to
Type I (IDDM) diabetes which is genetic in etiology
C. Type I (IIDM) is characterized by fasting hyperglycemia
D. Type II (NIDDM) is characterized by abnormal immune response
40. Lifestyle-related diseases in general share areas common risk factors. These are the following except:
A. physical activity
C. genetics
B. smoking
D. nutrition

Situation 9 Nurse Rivera witnesses a vehicular accident near the hospital where she works.
She decides to get involved and help the victims of the accident
41. Her priority nursing action would be to:
A. Assess damage to property
B. Assist in the police investigation since she is a witness
C. Report the incident immediately to the local police authorities
D. Assess the extent of injuries incurred by the victims of the accident
42. Priority attention should be given to which of these clients?
A. Linda who shows severe anxiety due to trauma of the accident
B. Ryan who has chest injury, is pale and with difficulty breathing
C. Noel who has lacerations on the arms with mild bleeding
D. Andy whose left ankle swelled and has some abrasions
43. In the emergency room, Nurse Rivera is assigned to attend to the client with lacerations on the arms.
While assessing the extent of the wound the nurse observes that the wound is now starting to bleed
profusely. The most immediate nursing action would be to:
A. Apply antiseptic to prevent infection
B. Clean the wound vigorously of contaminants
C. Control and reduce bleeding of the wound
D. Bandage the wound and elevate the arm
44. The nurse applies dressing on the bleeding site. This intervention is done to:
A. Reduce the need to change dressing frequently
C. Protect the wound from microorganisms in the
B. Allow the pus to surface faster
air
D. Promote hemostasis
45. After the treatment, the client is sent home and asked to come back for follow-up care. Your
responsibilities when the client is to be discharged include the following EXCEPT:
A. Encouraging the client to go to the outpatient clinic for follow up care
B. Accurate recording of treatment done and instructions given to client
C. Instructing the client to see you after discharge for further assistance
D. Providing instructions regarding wound care
Situation 10 While working in the clinic, a new client, Geline, 35 years old, arrives for her
doctors appointment. As the clinic nurse, you are to assist the client fill up forms, gather data
and make an assessment.
46. The purpose of your initial nursing interview is to:
A. Record pertinent information in the clients chart for health team to read
B. Assist the client find solutions to he her health concerns
C. Understand her lifestyle, health needs and possible problems to develop
a plan of care
D. Make nursing diagnoses for identified health problems
47. While interviewing Geline, she starts to moan and doubles up in pain. She tells you that this pain
occurs about an hour after taking black coffee without breakfast for three weeks now. You will record this
as follows:
A. Claims to have abdominal pains after intake of coffee unrelieved by analgesics
B. After drinking coffee, the client experienced severe abdominal pain
C. Client complained of intermittent abdominal pain an hour after drinking coffee
D. Client reported abdominal pain an hour after drinking black coffee for three weeks now.
48. Geline tells you that she drinks black coffee frequently within the day to have energy and be wide
awake and she eats nothing for breakfast and eats strictly vegetable salads for lunch and dinner to lose
weight. She has lost weight during the past two weeks. In planning a healthy balanced diet with Geline,
you will:
A. Start her off with a cleansing diet to free her body of toxins then change to a vegetarian diet and drink
plenty of fluids
B. Plan a high protein diet, low carbohydrate diet for her considering her favorite food.
C. Instruct her to attend classes in nutrition to find food rich in complex carbohydrates to maintain daily
high energy level.
D. Discuss with her the importance of eating a variety of food from major food groups with plenty of fluids.
49. Geline tells you that she drinks 4-5 cups of black coffee and diet cola drinks. She also smokes up to a
pack of cigarettes daily. She confesses that she is in her 2nd month of pregnancy but does not want to
become fat that is why she limits her food intake. You warn or caution her about which of the following?
A. Caffeine products affect the central nervous system and may cause the mother to have a nervous
breakdown
B. Malnutrition and its possible effects on growth and development problems in the unborn fetus

C. Caffeine causes a stimulant effect on both mother and the baby


D. Studies show conclusively that caffeine causes mental retardation
50. Your health education plan for Geline stresses proper diet for a pregnant woman and the prevention of
non-communicable diseases that are influenced by her lifestyle. These include the following EXCEPT:
A. Cardiovascular diseases
C. Diabetes Mellitus
B. Cancer
D. Osteoporosis
51. An example of a management function of a nurse is:
A. Teaching patient do breathing and coughing
C. Performing nursing procedures for clients
exercises
D. Directing and evaluating the staff nurses
B. Preparing for a surprise party for a client
52. Your head nurse in the unit believes that the staff nurses are not capable of decision making so she
makes the decisions for everyone without consulting anybody. This type of leadership is:
A. Laissez faire leadership
C. Autocratic leadership
B. Democratic leadership
D. Managerial leadership
53. When the head nurse in your ward plots and approves your work schedules and directs your work, she
is demonstrating:
A. Responsibility
C. Accountability
B. Delegation
D. Authority
54. The following tasks can be safely delegated by a nurse to a non-nurse health worker EXCEPT:
A. Transfer a client from bed to chair
C. Irrigation of a nasogastric tube
B. Change IV infusions
D. Take vital signs
55. You made a mistake in giving the medicine to the wrong client. You notify the clients doctor and write
an incident report. You are demonstrating:
A. Responsibility
D. Autocracy
B. Accountability
C. Authority

Situation 12 Mr. Dizon, 84 years old, brought to the Emergency Room for complaint of
hypertension, flushed face, severe headache, and nausea. You are doing the initial assessment
of vital signs.
56. You are to measure the clients initial blood pressure reading by doing all of the following EXCEPT:
A. Take the blood pressure reading on both arms for comparison
B. Listen to and identify the phases of Korotkoffs sound
C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated
D. Observe procedures for infection control
57. A pulse oximeter is attached to Mr. Dizons finger to:
A. Determine if the clients hemoglobin level is low and if he needs blood transfusion
B. Check level of clients tissue perfusion
C. Measure the efficacy of the clients anti-hypertensive medications
D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops
58. After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an order of hourly
monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood
pressure reading to be:
A. inconsistent
C. higher than what the reading should be
B. low systolic and high diastolic
D. lower than what the reading should be
59. Through the clients health history, you gather that Mr. Dizon smokes and drinks coffee. When taking
the blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before
taking the clients blood pressure for accurate reading?
A. 15 minutes
C. 1 hour
B. 30 minutes
D. 5 minutes
60. While the client has pulse oximeter on his fingertip, you notice that the sunlight is shining on the area
where the oximeter is. Your action will be to:
A. Set and turn on the alarm of the oximeter
D. Change the location of the sensor every four
B. Do nothing since there is no identified problem
hours
C. Cover the fingertip sensor with a towel or
bedsheet
Situation 13 The nurses understanding of ethico-legal responsibilities will guide his/her
nursing practice.

61. The principles that govern right and proper conduct of a person regarding life, biology and the health
professionals is referred to as:
A. Morality
C. Values
B. Religion
D. Bioethics
62. The purpose of having a nurses code of ethics is:
A. Delineate the scope and areas of nursing practice
B. Identify nursing action recommended for specific health care situations
C. To help the public understand professional conduct expected of nurses
D. To define the roles and functions of the health care givers, nurses, clients
63. The most important nursing responsibility where ethical situations emerge in patient care is to:
A. Act only when advised that the action is ethically sound
B. Not takes sides, remain neutral and fair
C. Assume that ethical questions are the responsibility of the health team
D. Be accountable for his or her own actions
64. You inform the patient about his rights which include the following EXCEPT:
A. Right to expect reasonable continuity of care
B. Right to consent to or decline to participate in research studies or experiments
C. Right to obtain information about another patient
D. Right to expect that the records about his care will be treated as confidential
65. This principle states that a person has unconditional worth and has the capacity to
determine his own destiny:
A. Bioethics
C. Fidelity
B. Justice
D. Autonomy
Situation 14 Your director of nursing wants to improve the quality of health care offered in
the hospital. As a staff nurse in that hospital you know that this entails quality assurance
programs.
66. The following mechanisms can be utilized as part of the quality assurance program of your hospital
EXCEPT:
A. Patient satisfaction surveys
B. Peer review to assess care provided
D. Use of Nursing Interventions Classification
C. Review of clinical records of care of client
67. The use of the Standards of Nursing Practice is important in the hospital. Which of the following
statements best describes what it is?
A. These are statements that describe the maximum or highest level of acceptable performance in nursing
practice
B. It refers to the scope of nursing practice as defined in Republic Act 9173
C. It is a license issued by the Professional Regulation Commission to protect the public from substandard
nursing practice
D. The Standards of Care includes the various steps of the nursing process and the standards of
professional performance
68. you are taking care of critically ill client and the doctor in charge calls to order a DNR (do not
resuscitate) for the client. Which of the following is the appropriate action when getting DNR order over the
phone?
A. Have the registered nurse, family spokesperson, nurse supervisor and doctor sign
B. Have 2 nurse validate the phone order, both nurses sign the order and the doctor should sign his order
within 24 hours
C. Have the registered nurse, family and doctor sign the order
D. Have 1 nurse take the order and sign it and have the doctor sign it within 24 hours
69. To ensure client safety before starting blood transfusions the following are needed before the
procedure can be done EXCEPT:
A. take baseline vital signs
B. blood should be warmed to room temperature for 30 minutes before blood transfusions is administered
C. have two nurses verify client identification, blood type, unit number and expiration date of blood
D. get consent signed for blood transfusion
70. Part of standards of care has to do with the use of restraints. Which of the following statements is NOT
true?
A. Doctors order for restraints should be signed within 24 hours
B. Remove and reapply restraints every 2 hours
C. Check clients pulse, blood pressure and circulation every 4 hours
D. Offer food and toileting every 2 hours

Situation 15 During the NUTRITION EDUCATION class discussion a 58 year old man, Mr. Bruno,
shows increased interest.
71. Mr. Bruno asks what the normal allowable salt intake is. Your best response to Mr. Bruno is:
A. 1 tsp of salt/day with iodine and sprinkle of MSG
B. 5 gms per day or 1 tsp of table salt/day
C. 1 tbsp of salt/day with some patis and toyo
D. 1 tsp of salt/day but no patis and toyo
72. Your instructions to reduce or limit salt intake include all the following EXCEPT:
A. eat natural food with little or no salt added
C. use herbs and spices
B. limit use of table salt and use condiments
D. limit intake of preserved or processed food
instead
73. Teaching strategies and approaches when giving nutrition education is influenced by age, sex and
immediate concerns of the group. Your presentation for a group of young mothers would be best if you
focus on:
A. diets limited in salt and fat
B. harmful effects of drugs and alcohol intake
C. commercial preparation of dishes
D. cooking demonstration and meal planning
74. Cancer cure is dependent on
A. use of alternative methods of healing
B. watching out for warning signs of cancer

C. proficiency in doing breast self-examination


D. early detection and prompt treatmen

75. The role of the health worker in health education is to


A. report incidence of non-communicable diseases to community health center
B. educate as many people about warning signs of non-communicable diseases
C. focus on smoking cessation projects
D. monitor clients with hypertension
Situation 16 You are assigned to take care of 10 patients during the morning shift. The
endorsement includes the IV infusion and medications for these clients.
76. Mr. Felipe, 36 years old is to be given 2700 ml of D5LR to infuse for 18 hours starting at 8 am. At what
rate should the IV fluid be flowing hourly?
A. 100 ml per hour
C. 150 ml per hour
B. 210 ml per hour
D. 190 ml per hour
77. Mr. Atienza is to receive 150 ml/hour of D% W IV infusion for 12 hours for a total of 1800ml. He is also
losing gastric fluid which must be replaced every two hours. Between 8 am and 10 am, Mr. Atienza has lost
250 ml of gastric fluid. How much fluid should he receive at 11 am?
A. 350 ml/hour
C. 400 ml/hour
B. 275 ml/hour
D. 200 ml/hour
78. You are to apply a transdermal patch of nitoglycerin to your client. The following are important
guidelines to observe EXCEPT:
A. Apply to hairless clean area of the skin not subject to much wrinkling
B. Patches may be applied to distal part of the extremities like forearm
C. Change application and site regularly to prevent irritation of the skin
D. Wear gloves to avoid any medication on your hand
79. You will be applying eye drops to Miss Romualdez. After checking all the necessary information and
cleaning the affected eyelid and eyelashes, you administer the ophthalmic drops by instilling the eye
drops:
A. directly onto the cornea
B. pressing the lacrimal duct
C. into the outer third of the lower conjunctival sac
D. from the inner canthus going towards the side of the eye
80. When applying eye ointment, the following guidelines apply EXCEPT:
A. squeeze about 2 cm of ointment and gently close but not squeeze the eye
B. apply the ointment from the inner canthus going outward of the affected eye
C. discard the first bead of the eye ointment before application because the
tube is likely to expel more than desired amount of ointment
D. hold the tube above the conjunctival sac, do not let tip touch the conjunctiva
Situation 17 The staff nurse supervisor requests all the staff nurses to brainstorm and
learn ways to instruct diabetic clients on self-administration of insulin. She wants to ensure
that there are nurses available daily to do health education classes.

81. The plan of the nurse supervisor is an example of


A. in service education process
B. efficient management of human resources

C. increasing human resources


D. primary prevention

82. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an
unlicensed staff, Mrs. Guevarra
A. makes the assignment to teach the staff member
B. is assigning the responsibility to the aide but not the accountability forthose tasks
C. does not have to supervise or evaluate the aide
D. most know how to perform task delegated
83. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six weeks ago
when she started the job. The nurse supervisor should
A. empathize with the nurse and listen to her
C. discuss how she is adjusting to her new job
B. tell her to take the day off
D. ask about her family life
84. Process of formal negotiations of working conditions between a group of registered nurses and
employer is
A. grievance
C. collective bargaining
B. arbitration
D. strike
85. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and required by the
hospital employing you. This is
A. professional course towards credits
C. advance training
B. inservice education
D. continuing education
Situation 18 There are various developments in health education that the nurse should know about:
86. The provision of health information in the rural areas nationwide through television and radio programs
and video conferencing is referred to as:
A. Community health program
C. Wellness program
B. Telehealth program
D. Red Cross program
87. A nearby community provides blood pressure screening, height and weight measurement, smoking
cessation classes and aerobics class services. This type of program is referred to as
A. outreach program
C. barangay health program
B. hospital extension program
D. wellness program
88. Part of teaching client in health promotion is responsibility for ones health. When Danica states she
needs to improve her nutritional status this means:
A. Goals and interventions to be followed by client are based on nurses priorities
B. Goals and intervention developed by the nurse and client should be approved bythe doctor
C. Nurse will decide goals and interventions needed to meet client goals
D. Client will decide the goals and interventions required to meet her goals
89. Nurse Beatrice is providing tertiary prevention to Mrs. De Villa. An example of tertiary provision is
A. Marriage counseling
C. Identifying complication of diabetes
B. Self-examination for breast cancer
D. Poison Control
90. Mrs. Ostrea has a schedule for Pap Smear. She has a strong family history of cervical cancer. This is an
example of
A. tertiary prevention
C. health screening
B. secondary prevention
D. primary prevention
Situation 19 Ronnie was in a vehicular accident where he sustained injury to his left ankle. In
the Emergency Room, you notice how anxious he looks.
91. You establish rapport with him and to reduce his anxiety you initially:
A. Take him to the radiology section for X-ray of affected extremity
B. Identify yourself and state your purpose in being with the client
C. Talk to the physician for an order of Valium
D. Do inspection and palpation to check extent of his injuries
92. While doing your assessment, Ronnie asks you Do I have a fracture? I dont want to have a cast. The
most appropriate nursing response would be:
A. You have to have an x ray first to know if you have a fracture.
B. Why do you sound so scared? It is just a cast and its not painful.
C. You seem to be concerned about being in a cast.
D. Based on my assessment, there doesnt seem to be a fracture.
93. Ronnie is very anxious and is unaware of the extent of his injury. The nurse can best assist him by:
A. Asking the doctor to give an order for a sedative to call him down

A. Not
B.
Informing
be harmed
him that he is being treated by a very competent
C. Privacy
health team so he has nothing to worry
about
B.
Disclosure
D. Self-determination
C. Identifying his level of anxiety to determine how much information hecan understand
D. Allaying
97.
A nursehis
preceptor
anxietyobserves
by tellingthat
him many
that he
clients
only sustained
are being readmitted
a minor injury
in the ward for postoperative
infections. She suggests to the students that they do a research on this topic. What research activity is
94. After cleaning the abrasions and applying antiseptic, the nurse applies cold compress to the swollen
this?
ankle
A.
Sharing
as ordered
research
by results
the physician.
with colleagues
This statement shows that
C. Developing
the nurse guidelines
has correctfor
understanding
patient care of the
useIdentifying
B.
of cold compress:
clinical problem
D. Data collection
A. Cold compress reduces blood viscosity in the affected area
B. ItQuantitative
98.
is safer to apply
research
than involves
hot compress
numerical data. Which of the following is based on quantitative
C. Cold compress prevents edema and reduces pain
research?
D. A
A.
It study
eliminates
on the
toxic
effects
waste
of the
products
whitedue
uniform
to vasodilation
of hospital personnel on pediatricpatients
B. The effects of regular nurse visits to clients bedside on the number ofclients calls to the nurse
95.AAfter
C.
studyreceiving
on benefits
prescription
of pre-operative
for pain health
medication,
instructions
Ronnietoisclients
instructed
feeling
to continue
ofanxiety
applying 30 minute
cold
D.
A at
study
home
on and
the effects
start 30ofminute
touch on
hotthe
compress
clientsthe
feelings
next day.
of isolation
You
explain that the use of hot compress:
A. Produces
99.
Before the
anesthetic
nurse researcher
effect
starts her study, she analyzes how much time, money, materials and
B. Increases
people
she will
nutrition
need to
incomplete
the bloodthe
to promote
researchwound
project.
healing
This analysis prior to beginning the study is called:
C. Validity
A.
Increase oxygenation to the injured tissues for better healing
C. Reliability
D. Feasibility
B.
Induces vasoconstriction to prevent infection
D. Researchability
100. Data analysis
Situation
20 A nursing
is to be done
professor
and the
assigns
nurse researcher
a group of
wants
students
to include
to do
variability.
data gathering by
interviewing
These
include the
their
following
classmates
EXCEPT:
as subjects.
A. Variance
C. Standards of Deviation
96.Range
B.
She instructed the interviewees not to tell the interviewees
D. Mean
that the data gathered are for her own
research project for publication. This teacher has violated the students right to:
DECEMBER, 2007
MULTIPLE CHOICE
1. Nurse Suzie is administering 12:00 PM medication in Ward 4. Two patients have to receive Lanoxin. What
should Nurse Suzie do when one of the clients does NOT have a readable identification band?
A. Ask the client if she is Mrs. Santos
C. Ask the room mate if the client is Mrs. Santos
B. Ask the client his name
D. Compare the ID band with the bed tag
2. Lizette, a head nurse in a surgical unit, hears one of the staff nurses say that she does not touch any
client assigned to her unless she performs nursing procedures or conducts physical assessment. To guide
the staff nurse in the use of touch, which of the following would be BEST response of Lizette?
A. Use touch when the situation calls for it.
B. Touch serves as a connection between the nurse and the patient.
C. Use touch with discretion.
D. Touch is used in physical assessment.
3. You are asked to teach the client, Mr. Lapuz, who has right sided weakness the use of a cane. Which
observation will indicate that Mr. Lapuz is using the cane correctly?
A. The cane and one foot or both feet are on the floor at all times
B. He advances the cane followed by the left leg
C. Client keeps the cane on the right side along the weak leg
D. Client leans to the left side which is stronger
4. George, a 43 year old executive is scheduled for cardiac bypass surgery. While being
prepared for the surgery, he says to the nurse I am not going to have the surgery. I may die because of
the risk. Which response by the nurse is most appropriate?
A. Without the surgery you will most likely die sooner.
B. There are always risks involved with surgery.
C. There is a client in the other room who had successful surgery and you can talk to him.
D. This must be very frightening for you. Tel me how you feel about the surgery.
5. A client is ordered to take Lasix, a diuretic, to be taken orally daily. Which of the following is an
appropriate instruction by the nurse?
A. Report to the physician the effects of the medication on urination.
B. Take the medicine early in the morning
C. Take a full glass of water with the medicine
D. Measure frequency of urination in 24 hours
6. Nurse Glenda gets a call from the neighbor who tells her that his 3 years old daughter has been
vomiting and has fever and asks for advice. Which of the following is the most appropriate action of the
nurse?
A. Observe the child for an hour. If the child does not improve, refer to the physician in the neighborhood.
B. Recommend to bring the child immediately to the hospital

C. Assess the child, recommend observation and administer acetaminophen. If symptoms continue, bring
to the hospital.
D. Tell the neighbor to observe the child and give plenty of fluids. If the child does not improve, bring the
child to the hospital.
7. Wilfred, 30 years old male, was brought to the hospital due to injuries sustained from a vehicular
accident. While being transported to the X-ray department, the straps accidentally broke and the client fell
to the floor hitting to his head. In this situation, the nurse is:
A. not responsible because of the doctrine of respondent superior
B. free from any negligence that caused harm to the patient
C. liable along with the employer for the use of a defective equipment that harms the client
D. totally responsible for the negligence
8. While going on evening round, Nurse Edna saw Mrs. Pascual meditating and afterwards started singing
prayerful hymns. What is the BEST response of Edna?
A. Ignore the incidence
B. Report the incidence to the head nurse
C. Respect the clients actions as this provides structure and support to the client
D. Call her attention so she can go to sleep
9. A client asks for advice on low cholesterol food. You advise the client to eat the following:
A. Chicken liver, cow liver, eggs
C. Balut, salted eggs, duck and chicken egg
B. Lean beef and pork, egg ewhite, fish
D. Pork liempo, cow brain, lungs and kidney
10. The code of ethics for nurses has an interpretative statement that provides:
A. continuity of care for the improvement of the client
B. guide for carrying out nursing responsibilities that provide quality care and for the ethical obligation of
the profession
C. standards of care in carrying out nursing responsibilities
D. identical care to all clients in any setting
11. Which of the following situations would possibly cause a nurse to be sued due to negligence?
A. Nurse gave a client wrong medication, and an hour later, client complained of dyspnea
B. While preparing a medication, the nurse notices that instead of 1 tablet, she put two tablets into the
clients medicine cup
C. As the nurse was about to administer medication, the client questioned why the medication is still given
when in fact the physician discontinued it.
D. Nurse administered 2 tablets of analgesic instead of 1 tablet as prescribed. Patient noticed the error and
complained.
12. Your nurse supervisor asks you who among the following clients is most susceptible to getting infection
if admitted to the hospital?
A. Diabetic client type2
C. Client with second degree burns
B. Client with chronic obstructive pulmonary
D. Client with psoriasis
disease (COPD)
13. Mr. Chris Martinez has been confined for three days. His wife helped take care of him and he has
observed her to be too involved in his care. He complained to the head nurse about this. Which of the
following would be the BEST response of the nurse?
A. Dont worry. I will call the attention of your wife.
B. Your wife is just trying to help because she is worried about you.
C. What are your thoughts about your wifes involvement in your care?
D. Your wife can assist you well in your care and recovery.
14. The nurse is in the hospital canteen and hears two staff nurses talking about the client confined in
Room 612. They mentioned his name and discussed details of his condition. Which of the following actions
should the nurse take?
A. Approach the two nurses and tell them that their actions are inappropriate especially in a public place
B. Wait till the nurses finish the discussion and report the situation to the supervisor
C. Say nothing to avoid embarrassing the staff nurses
D. Remain quiet and ignore the discussion
15. The son of Mr. Rosario, a 76 year old man, reports to the nurse in the community health center that his
father has been getting out of bed at night and walks around the house in the early hours of the morning
causing him to fall and injure himself. Which instruction would you give?
A. Apply restraints during night hours only
B. Advise hospitalization to prevent future accidents
C. Keep a radio or TV for company and to orient the client
D. Have someone check on the client frequently at night

Situation 1 Preparation and administration of medications is a nursing function that cannot


be delegated. It is important that the nurse has a deep understanding of this responsibility
that is meant to save patients lives.
16. You are to administer an intramuscular injection to Dulce, 1 year old girl. The most
appropriate site to administer the drug is:
A. dorso gluteal region
C. vastus lateralis
B. ventral forearm
D. gluteal region
17. An infant is ordered to receive 500ml of D5NSS for 24 hours. The intravenous drip is running at 60
drops/minute. How many drops per minute should the flow rate be?
A. 60 drops per minute
C. 30 drops per minute
B. 21 drops per minute
D. 15 drops per minute
18. Following surgery, Henry is to receive 20 mEq (milliequivalent) of potassium chloride to be added to
1000 ml of D5W to run for 8 hours. The intravenous infusion set is calibrated at 20 drops per milliliter. How
many drops per minute should the rate be to infuse 1 liter of D5W for 8 hours?
A. 42 drops
C. 60 drops
B. 20 drops
D. 32 drops
19. Mr. Lagro is to receive 1 liter of D5LR to run for 12 hours. The drop factor of the IV infusion set is 10
drops per minute. Approximately how many drop per minutes should the IV be regulated?
A. 13-14 drops C. 10-12 drops
B. 17-18 drops D. 15-16 drops
20. The physician ordered Nembutal Na gr XX. The bottle contains 100mg/capsule. How many capsule will
be administered to the client?
A. 1 capsule
C. 2 capsule
B. 1 capsule
D. capsule
Situation 2 The nurse supervisor is observing the staff nurses in her hospital to see how
quality of care provided to clients can be improved.
21. The nurse supervisor is not satisfied with the bed bath that is provided by Nurse Arthur. To improve the
care provided to the patients in the unit by Nurse Arthur, the nurse supervisor should:
A. tell the nurse how to give bed baths correctly
B. ask another staff nurse to do bed baths instead
C. provide a manual to be read on giving bed baths
D. bring the staff nurse to a clients room and demonstrate
22. The staff nurse discusses with the novice nurse the type of wound dressing that is best to use for a
client. Together, they observe how well the dressings absorb the drainage. In what step of the decision
making process are they?
A. Testing options
C. Defining the problem
B. Considering effects on results
D. Making final decisions
23. To check if the nurses under her supervision use critical thinking, Mrs. David observes if the nurses act
responsibly when at work. Which of the following actions of the nurse demonstrates the attitude of
responsibility?
A. Thinking of alternative methods of nursing care
C. Following standards of practice
B. Sharing ideas regarding patient care
D. Planning other approaches for patient care
24. The nurse who makes clinical judgment can be depended upon to improve the quality of care of clients.
Nurse Julie uses such good clinical judgment when she gives priority care to this client:
A. Roman, a client who is ambulatory and for surgery tomorrow
B. A post operative client, Rey, who has a blood pressure of 90/50 mmHg
C. Mr. Abad, a client who needs instructions for home medications
D. Fred, a client who received pain medications 5 minutes ago
25. A good nursing care plan is dependent on a correctly written nursing diagnosis. It defines a clients
problem and its possible cause. The following is an example of a well written nursing diagnosis:
A. Acute pain related to altered skin integrity secondary to hysterectomy
B. Electrolyte imbalance related to hypocalcemia
C. Altered nutrition related to high fat intake secondary to obesity
D. Knowledge deficit related to proctosigmoidoscopy
Situation 3 You are taking care of Mrs. Leyba, 66 years old, who is terminally ill with ovarian
cancer stage IV.
26. When caring for a dying client, you will perform which of the following activities?
A. Encourage the client to reach optimal health
C. Assist the client towards a peaceful death
B. Assist client perform activities of daily living
D. Motivate client to gain independence

27. The client prepares for her eventual death and discusses with the nurse and her family how she would
like her funeral to look like and what dress she will use. This client is in the stage of:
A. acceptance
C. denial
B. resolution
D. bargaining
28. The nurse is to administer Demerol 50 mg IM to Mrs. Leyba. Demerol is available in a multidose vial
labelled 100 mg/ml and Vistaril comes in an ampule labelled 50 mg/ml. You are to give the both
medications in one injection. You will:
A. withdraw the medication from the vial first then from the ampule
B. inject air into the vial, then into the ampule
C. inject air into the ampule, aspirate the desired dose, then into the vial
D. withdraw medication from the ampule then from the vial
29. When giving Demerol 50 mg from a multidose vial labelled 100 mg/ml and Vistaril 50 mg/ml from an
ampule labelled 50 mg/ml, what is the total volume that you will inject to the client?
A. 2 ml
C. 1.5 ml
B. 1 ml
D. 1.75 ml
30. Mrs. Leyba is emaciated and is at risk for developing which problem in skin integrity?
A. Blisters
C. Pressure sores
B. Reddening of the skin
D. Pustules
Situation 4 You are assigned to work in an orthopedic ward where clients are expected to
have problems in mobility and immobility.
31. Ramils right leg is injured and Nurse Karen has to move him from the bed to wheel chair. Which of the
following is the appropriate nursing action of Nurse Karen?
A. Put the client on the edge of the bed and place the wheelchair at her back
B. Face the client and place the wheelchair on her left side
C. Put the client on the edge of the bed and place the wheelchair on the other side of the bed
D. Put the client on the edge of the bed and place the wheelchair on the clients left side
32. Carlo has to be maintained on a dorsal recumbent position. Which of the following should be
prevented?
A. adduction of the shoulder
C. Hyperextension of the knees
B. Lateral flexion of the sternocleidomastoid
D. Anterior flexion of the lumbar curvature
muscle
33. Joseph prefers to be in high fowlers position most of the time. The nurse should prevent which of the
following?
A. Posterior flexion of the lumbar curvature
C. External rotation of the hip
B. Internal rotation of the shoulder
D. Adduction of the shoulder
34. Anthony asks to be assisted to move up the bed. Which of the following should Nurse Diana do first?
A. Move the patient to the edge of the bed near
C. Lock the wheels of the bed
the nurse
D. Raise the bed rails opposite the nurse
B. Adjust the bed to flat position
35. Which of the following supportive devices can be used most effectively by Nurse Arnold to prevent
external rotation of the right leg?
A. Sandbags
C. Pillow
B. Firm mattress
D. High foot board
Situation 5 As you begin to work in the hospital where you are on probation, you are tasked
to take care of a few patients. The clients have varied needs and you are expected to provide
care for them.
36. An ambulatory client. Mr. Zosimo, is being prepared for bed. Which of the following nursing actions
promote safety for the client?
A. Turning off the lights to promote rest and sleep
C. Raising the side rails
B. Instructing the client about the use of call
D. Placing the bed in high position
system
37. Mikka, a 25 year old female client, is admitted with right lower quadrant abdominal pain. The physician
diagnosed the client with acute appendicitis and an emergency appendectomy was performed. Twelve
hours following surgery, the patient complained of pain. Which of the following is the most appropriate
nursing diagnosis?
A. Impaired mobility related to pain secondary to an abdominal incision
B. Impaired movements related to pain due to surgery
C. Impaired mobility related to surgery
D. Severe pain related to surgery

38. You are preparing a plan of care for a client who is experiencing pain related to incisional swelling
following laminectomy. Which of the following should be included in the nursing care plan?
A. Encourage the client to log roll when turning
D. Ambulate the client in ward premises every
B. Encourage the client to do self-care
twenty minutes
C. Instruct the client to do deep breathing
exercises
39. Mr. Lozano, 50 year old executive, is recovering from severe myocardial infarction. For the past 3 days,
Mr. Lozanos hygiene and grooming needs have been met by the nursing staff. Which of the following
activities should be implemented to achieve the goal of independence for Mr. Lozano?
A. Involving family members in meeting clients
C. Preparing a day to day activity list to be
personal needs
followed by client
B. Meeting his needs till he is ready to perform
D. Involving Mr. Lozano in his care
self-care
40. Mr. Ernest Lopez is terminally ill and he choose to be at home with his family. What nursing action is
best initiated to prepare the family of Mr. Lopez?
A. Talk with the family members about the advantage of staying in the hospital for proper care
B. Provide support to the family members by teaching ways to care for their loved one
C. Convince the client to stay in the hospital for professional care
D. Tell the client to be with his family
Situation 6 Myrna, a researcher, proposes a study on the relationship between health values
and the health promotion activities of staff nurses in a selected college of nursing.
41. In both quantitative and qualitative research, the used of a frame of reference is required. Which of the
following items serves as the purpose of a framework?
A. Incorporates theories into nursings body of knowledge
B. Organizes the development of study and links the findings to nursings bodyof knowledge
C. Provides logical structure of the research findings
D. Identifies concepts and relationships between concepts
42. Myrna need to review relevant literature and studies. The following processes are undertaken in
reviewing literature EXCEPT:
A. locating and identifying resources
C. clarifying a research topic
B. reading and recording notes
D. using the library
43. The primary purpose for reviewing literature is to:
A. organize materials related to the problem of interest
B. generate broad background and understanding of information related to the research problem of
interest
C. select topics related to the problem of interest
D. gather current knowledge of the problem of interest
44. In formulating the research hypotheses, researcher Myrna should state the research question as:
A. What is the response of the staff nurses to the health values?
B. How is variable health value perceived in a population?
C. Is there a significant relationship between health values and health promotion activities of the staff
nurses?
D. How do health values affect health promotion activities of the staff nurses?
45. The proposed study shows the relationship between the variables. Which of the following is the
independent variable?
A. Staff nurses in a selected college of nursing
D. Relationship between health values and health
B. Health values
promotion activities
C. Health promotion activities
Situation 7 While working in a tertiary hospital, you are assigned to the medical ward.
46. Your client, Mr. Diaz, is concerned that he can not pay his hospital bills and professional fees. You refer
him to a:
A. Nurse supervisor
C. bookkeeping department
B. Social worker
D. physician
47. Mr. Magno has lung cancer and is going through chemotherapy. He is referred by the oncology nurse to
a self-help group of clients with cancer to:
A. receive emotional support
C. provide financial assistance
B. to be a part of a research study
D. assist with chemotherapy
48. A diabetic hypertensive client, Mrs. Linao, needs a change in diet to improve her health status. She
should be referred to a:
A. nutritionist
C. physician
B. dietitian
D. medical pathologist

49. When collaborating with other health team members, the best description of Nurse Ritas role is:
A. encourages the clients involvement in his care
B. shares and implements orders of the health team to ensure quality care
C. she listens to the individual views of the team members
D. helps client set goals of care and discharge
50. Nurse Rita is successful in collaborating with health team members about the care of Mr. Linao. This is
because she has the following competencies:
A. Communication, trust, and decision making
B. Conflict management, trust, negotiation
C. Negotiation, decision making
D. Mutual respect, negotiation and trust
Situation 8 The practice of nursing goes with responsibilities and accountability whether you
work in a hospital or in the community setting you main objective is to provide safe nursing to
your clients?
51. To provide safe, quality nursing care to various clients in any setting, the most important tool of the
nurse is:
A. critical thinking to decide appropriate nursing actions
B. understanding of various nursing diagnoses
C. observation skills for data collection
D. possession of in scientific knowledge about client needs
52. You ensure the appropriateness and safety of your nursing interventions while caring for various client
groups by:
A. creating plans of care for particular clientele
B. identifying the correct nursing diagnoses for clients
C. making a thorough assessment of client needs and problems
D. using standards of nursing care as your criteria for evaluation
53. The effectiveness of your nursing care plan for your clients is determined by
A. the number of nursing procedures performed to comfort the client
B. the amount of medications administered to the client as ordered
C. the number of times the client calls the nurse
D. the outcome of nursing interventions based on plan of care
54. You are assigned to Mrs. Amado, age 49, who was admitted for possible surgey. She complained of
recurrent pain at the right upper quadrant of the abdomen 1-2 hours after ingestion of fatty food. She also
had frequent bouts of dizziness, blood pressure of 170/100, hot flashes. Which of the above symptoms
would be an objective cue?
A. Blood pressure measurement of 170/100
C. Report of pain after ingestion of fatty food
B. Complaint of hot flashes
D. Complaint of frequent bouts of dizziness
55. While talking with Mrs. Amado, it is most important for the nurse to:
A. schedule the laboratory exams ordered for her
B. do an assessment of the client to determine priority needs
C. tell the client that your shift ends after eight hours
D. have the client sign an informed consent
Situation 9 Oral care is an important part of hygienic practices and promoting client comfort.
56. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and
presence of sores. Which of the following is BEST to use for oral care?
A. lemon glycerine
C. Mineral oil
B. hydrogen peroxide
D. Normal saline solution
57. When performing oral care to an unconscious client, which of the following is a special consideration to
prevent aspiration of fluids into the lungs?
A. Put the client on a sidelying position with head of bed lowered
B. Keep the client dry by placing towel under the chin
C. Wash hands and observe appropriate infection control
D. Clean mouth with oral swabs in a careful and an orderly progression
58. The advantages of oral care for a client include all of the following, EXCEPT:
A. decreases bacteria in the mouth and teeth
B. reduces need to use commercial mouthwash which irritate the buccal mucosa
C. improves clients appearance and self-confidence
D. improves appetite and taste of food
59. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to
lungs. This can be avoided by:

A. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity
B. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs
C. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and gums
D. suctioning as needed while cleaning the buccal cavity
60. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of
the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep
the mouth moistened by using:
A. salt solution
C. petroleum jelly
B. water
D. mentholated ointment
Situation 10 Errors while providing nursing care to patients must be avoided and minimized
at all time. Effective management of available resources enables the nurse to provide safe,
quality patient care.
61. In the hospital where you work, increased incidence of medication error was identified as the number
one problem in the unit. During the brainstorming session of the nursing service department, probable
causes were identified. Which of the following is process related?
A. interruptions
C. lack of knowledge
B. use of unofficial abbreviations
D. failure to identify client
62. Miscommunication of drug orders was identified as a probable cause of medication errors. Which of the
following is safe medication practice related to this?
A. Maintain medication in its unit dose package until point of actual administration
B. Note both generic and brand name of the medication in the Medication Administration Method
C. Only officially approved abbreviations maybe used in prescription orders
D. Encourage clients to ask question about their medications.
63. The hospital has an ongoing quality assurance program. Which of the following indicates
implementation of process standards?
A. The nurses check clients identification band before giving medications
B. The nurse reports adverse reaction to drugs
C. Average waiting time for medication administration is measured
D. The unit has well ventilated medication room
64. Which of the following actions indicate that Nurse Jerome is performing outcome evaluation of quality
care?
A. Interviews nurses for comments regarding staffing
B. Measures waiting time for clients per nurses call
C. Checks equipment for its calibration schedule
D. Determines whether nurses perform skin assessment every shift
65. An order for a client was given and the nurse in charge of the client reports that she has no experience
of doing the procedure before. Which of the following is the most appropriate action of the nurse
supervisor?
A. Assign another nurse to perform the procedure
C. Tell the nurse to read the procedure manual
B. Ask the nurse to find way to learn the
D. Do the procedure with the nurse
procedure
Situation 11 Mr. Joses chart is the permanent legal recording of all information that relates
to his health care management. As such, the entries in the chart must have accurate data.
66. Mr. Joses chart contains all information about his health care. The functions of records include all
except:
A. means of communication that health team members use to communicate their contributions to the
clients health care
B. the clients record also shows a document of how much health care agencies will be reimbursed for their
services
C. educational resource for student of nursing and medicine
D. recording of actions in advance to save time
67. An advantage of automated or computerized client care system is:
A. The nursing diagnoses for a clients data can be accurately determined
B. Cost of confinement will be reduced
C. Information concerning the client can b easily updated
D. The number of people to take care of the client will be reduced
68. Information in the patients chart is inadmissible in court as evidence when:
A. The clients family refuses to have it used
D. It has too many abbreviations that are
B. The client objects to its use
unofficial
C. The handwriting is not legible
69. Nursing audit aims to:

A. provide research data to hospital personnel


B. study clients illness and treatment regimen
closely

C. compare actual nursing done to established


standards
D. provide information to health-care providers

70. A telephone order is given for a client in your ward. What is your most appropriate action?
A. Copy the order on to the chart and sign the physicians name as close to his original signature as
possible
B. Repeat the order back to the physician, copy onto the order sheet and indicate that it is a telephone
order
C. Write the order in the clients chart and have the head nurse co-sign it
D. Tell the physician that you cannot take the order but you will call the nurse supervisor
Situation 12 Nurse Roque, a newly hired nurse, is asked to take over an absent nurse in
another unit. She will take care of clients with various conditions.
71. Which of the following client conditions should be Miss Roques priority in the pediatric unit?
A. The baby whose fantanelle is bulging and firm while asleep
B. The infant who is brought in for upper respiratory tract infection whose temperature is slightly elevated
C. A baby who is wailing after being awakened by the banging door
D. A baby boy whose circumcision has yellowish exudate
72. When suctioning the endotracheal tube, the nurse should:
A. Explain procedure to patient; insert catheter gently applying suction. Withdrawn using twisting motion
B. Insert catheter until resistance is met, then withdraw slightly, applying suction intermittently as catheter
is withdrawn
C. Hyperoxygenate client insert catheter using back and forth motion
D. Insert suction catheter four inches into the tube, suction 30 seconds using twirling motion as catheter is
withdrawn
73. Nurse Roque is giving instructions to Doris, the daughter of a comatose patient, to give a sponge bath.
While Doris is doing spone bath, what action of Doris needs correction?
A. Answering the phone while wearing gloves used for sponge bath
B. Rolling the patient like a log to do back rub
C. Lining the rubber mat with bed sheet as incontinence pad for the patient
D. Turning the patient on the left side with head slightly elevated
74. Dina sustained a fracture of the ulna and a cast will be applied. What nursing action before cast
application is most important for Nurse Roque to do?
A. Use baby powder to reduce irritation under the
C. Evaluate skin temperature in the area
cast
D. Check radial pulses bilaterally and compare
B. Assess sensation of each arm
75. To obtain specimen for sputum culture and sensitivity, which of the following instruction is best?
A. Upon waking up, cough deeply and expectorate into container
B. Cough after pursed lip breathing
C. Save sputum for two days in covered container
D. After respiratory treatment, expectorate into a container
Situation 13 Infections are quite commonly the reasons for a clients hospitalization.
Appropriate interpretation of diagnostic tests and measures for infection control are helpful in
the management of patient care.
76. Dorothy underwent diagnostic test and the result of the blood examination are back. On reviewing the
result the nurse notices which of the following as abnormal finding?
A. Neutrophils 60%
C. Erythrocyte sedimentation rate (ESR) is 39
B. White blood cells (WBC) 9000/mm
mm/hr
D. Iron 75 mg/100 ml
77. Surgical sepsis is observed when:
A. inserting an intravenous catheter
B. disposing of syringes and needles in puncture
proof containers

C. washing hands before changing wound


dressing
D. placing dirty soiled linen in moisture resistant
bags

78. A client with viral infection will most likely manifest which of the following during the illness stage of
the infection?
A. Client was exposed to the infection 2 days ago
C. Acute symptoms are no longer visible
but without any symptoms
D. Client feels sick but can do normal activitie
B. Oral temperature shows fever
79. Which of the following laboratory test result indicate presence of an infectious process?
A. Erythrocyte sedimentation rate (ESR) 12
B. White blood cells (WBC) 18,000/mm3
mm/hr
C. Iron 90 g/100ml

D. Neutrophils 67%
80. Among the clients you are assigned to take care of, who is the most susceptible to infection?
A. Diabetic client
C. client with pulmonary emphysema
B. Client with burns
D. client with myocardial infarction
Situation 14 You are a newly hired nurse in a tertiary hospital. You have finished your
orientation program recently and you are beginning to assimilate the culture of the
profession.
81. Using Benners stages of nursing expertise, you are a beginning nurse practitioner. You will rank
yourself as a/an:
A. competent nurse
C. proficient nurse
B. novice nurse
D. advanced beginner
82. Benners Proficient nurse level is different from the other levels in nursing expertise in the context of
having:
A. the ability to organize and plan activities
C. a holistic understanding and perception of the
B. having attained an advanced level of
client
education
D. intuitive and analytic ability in new situations
83. As you become socialized into the nursing culture you become a patient advocate. Advocacy is
explained by the following EXCEPT:
A. respecting a persons right to be autonomous
D. protecting and supporting another persons
B. demonstrating loyalty to the institutions rights
rights
C. shared respect, trust and collaboration in
meeting health needs
84. Modern day nursing has led to the led development of the expanded role of the nurse as seen in the
function of a:
A. Clinical nurse specialist
C. community health nurse
B. Critical care nurse
D. staff nurse
85. You join a continuing education program to help you:
A. Earn credits for license renewal
D. Update your knowledge and skills related to
B. Get in touch with colleagues in nursing
field of interest
C. Enhance your basic knowledge
Situation 15 When creating your lesson plan for cerebrovascular disease or STROKE. It is
important to include the risk factors of stroke.
86. The most important risk factor is:
A. Cigarette smoking
C. binge drinking
B. Hypertension
D. heredity
87. Part of your lesson plan is to talk about etiology or cause of stroke. The types of stroke based on cause
are the following EXCEPT:
A. Embolic stroke
C. diabetic stroke
B. Hemorrhagic stroke
D. thrombotic stroke
88. Hemmorhagic stroke occurs suddenly usually when the person is active. All are causes of hemorrhage,
EXCEPT:
A. phlebitis
C. damage to blood vessel
B. trauma
D. aneurysm
89. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug is closely
linked to this?
A. Amphetamines
C. shabu
B. Cocaine
D. Demerol
90. A participant in the STROKE class asks what is a risk factor of stroke. Your best response is:
A. More red blood cells thicken blood and make clots more possible.
B. Increased RBC count is linked to high cholesterol.
C. More red blood cell increases hemoglobin content.
D. High RBC count increases blood pressure.
Situation 16 Accurate computation prior to drug administration is a basic skill all nurses must
have.
91. Rudolf is diagnosed with amoebiasis and is to received Metronidazole (Flagyl) tablets 1.5 gm daily in 3
divided doses for 7 consecutive days. Which of the following is the correct dose of the drug that the client
will received per oral administration?
A. 1,000 mg tid
C. 1,500 mg tid
B. 500 mg tid
D. 50 mg tid

92. Rhona, a 2 year old female was prescribed to receive 62.5 mg suspension three times a day. The
available dose is 125 mg/ml. which of the following should Nurse Paolo prepare for each oral dose?
A. 0.5 ml
C. 2.5 ml
B. 1.5 ml
D. 10 ml
93. The physician ordered Potassium Chloride (KCL) in D5W 1 liter to be infused in 24 hours for Mrs.
Gomez. Since Potassium Chloride is a high risk drug, Nurse Robert used an intravenous pump. Which of the
following should Nurse Robert do to safely administer this drug?
A. Check the pump setting every 2 hours
B. Teach the client how the infusion pump operates
C. Have another nurse check the infusion pump setting
D. Set the alarm of the pump loud enough to be heard
94. Baby Liza, 3 months old, with a congenital heart deformity, has an order from her physician: give 3.00
cc of Lanoxin today for 1 dose only. Which of the following is the most appropriate action by the nurse?
A. Clarify order with the attending physician
B. Discuss the order with the pediatric heart specialist in the unit
C. Administer Lanoxin intravenously as it is the usual route of administration
D. Refer to the medication administration record for previous administration of Lanoxin
95. When Nurse Norma was about to administer the medications of client Lennie, the relative of Lennie
told the nurse that they buy her medicines and showed the container of medications of the client. Which of
the following is the most appropriate action by the nurse?
A. Hold the nurse administration of the clients medication and refer to the head nurse
B. Put aside the medications she prepared and instead administer the clientsmedications
C. Tell the client that she will inform the physician about this
D. Bring the medications of the client to the nurses station and prepare accordingly
Situation 17 You are taking care of Mrs. Santillan a 48 year old woman who is unconscious
after a cerebrovascular accident. You are aware that there are many physical complications
due to immobility.
96. You should be alert for the following complications she may experience EXCEPT:
A. Impaired mobility
C. hypostatic pneumonia
B. Contractures and muscle atrophy
D. pressure sores
97. Proper positioning of an immobilized unconsciousness client is important for the following reasons
EXCEPT:
A. Maintain skin integrity
B. Promotes optimal lung expansion
C. Prevent injuries and deformities of the musculo-skeletal system
D. Facilitates rest and sleep
98. When positioning your client, you should observe good body mechanics for yourself and the client. This
means that the nurse:
A. Uses back muscles
B. Assumes correct body alignment and efficient use of muscles to avoid injury
C. Observes rhythmic movements when moving about
D. Uses large muscles only
99. You are going to move Mrs. Santillan, a 150 lbs unconscious woman. Some principles to use when
moving the client include the following EXCEPT:
A. prepare to move client by taking deep breath and tightening abdominal and gluteal muscles
B. maintain wide base of support with feet and with knees flexed
C. push and pull using arms and legs instead of lifting
D. move close to the object to be moved leaning or bending at the waist
100. After moving Mrs. Santillan to the desired position, which action will you avoid?
A. Avoid friction between bony prominences
C. Apply restraints
B. Place pillows to position clients extremeties
D. Raise bed rails
Situation Accurate computation prior to drug administration is a basic skill all nurses must
have.
1. Rudolf is diagnosed with amoebiasis and is to received Metronidazole (Flagyl) tablets 1.5 gm daily in 3
divided doses for 7 consecutive days. Which of the following is the correct dose of the drug that the client
will received per oral administration?
A. 1,000 mg tid
C. 1,500 mg tid
B. 500 mg tid
D. 50 mg tid

2. Rhona, a 2 year old female was prescribed to receive 62.5 mg suspension three times a day. The
available dose is 125 mg/ml. which of the following should Nurse Paolo prepare for each oral dose?
A. 0.5 ml
C. 2.5 ml
B. 1.5 ml
D. 10 ml
3. The physician ordered Potassium Chloride (KCL) in D5W 1 liter to be infused in 24 hours for Mrs. Gomez.
Since Potassium Chloride is a high risk drug, Nurse Robert used an intravenous pump. Which of the
following should Nurse Robert do to safely administer this drug?
A. Check the pump setting every 2 hours
B. Teach the client how the infusion pump operates
C. Have another nurse check the infusion pump setting
D. Set the alarm of the pump loud enough to be heard
4. Baby Liza, 3 months old, with a congenital heart deformity, has an order from her physician: give 3.00
cc of Lanoxin today for 1 dose only. Which of the following is the most appropriate action by the nurse?
A. Clarify order with the attending physician
B. Discuss the order with the pediatric heart specialist in the unit
C. Administer Lanoxin intravenously as it is the usual route of administration
D. Refer to the medication administration record for previous administration of Lanoxin
5. When Nurse Norma was about to administer the medications of client Lennie, the relative of Lennie told
the nurse that they buy her medicines and showed the container of medications of the client. Which of the
following is the most appropriate action by the nurse?
A. Hold the nurse administration of the clients medication and refer to the head nurse
B. Put aside the medications she prepared and instead administer the clientsmedications
C. Tell the client that she will inform the physician about this
D. Bring the medications of the client to the nurses station and prepare accordingly
Situation You are a newly hired nurse in a tertiary hospital. You have finished your
orientation program recently and you are beginning to assimilate the culture of the
profession.
6. Using Benners stages of nursing expertise, you are a beginning nurse practitioner. You will rank yourself
as a/an:
A. competent nurse
C. proficient nurse
B. novice nurse
D. advanced beginner
7. Benners Proficient nurse level is different from the other levels in nursing expertise in the context of
having:
A. the ability to organize and plan activities
C. a holistic understanding and perception of the
B. having attained an advanced level of
client
education
D. intuitive and analytic ability in new situations
8. As you become socialized into the nursing culture you become a patient advocate. Advocacy is
explained by the following EXCEPT:
A. respecting a persons right to be autonomous
B. demonstrating loyalty to the institutions rights
C. shared respect, trust and collaboration in meeting health needs
D. protecting and supporting another persons rights
9. Modern day nursing has led to the led development of the expanded role of the nurse as seen in the
function of a:
A. Clinical nurse specialist
C. community health nurse
B. Critical care nurse
D. staff nurse
10. You join a continuing education program to help you:
A. Earn credits for license renewal
D. Update your knowledge and skills related to
B. Get in touch with colleagues in nursing
field of interest
C. Enhance your basic knowledge
Situation Mr. Joses chart is the permanent legal recording of all information that relates to
his health care management. As such, the entries in the chart must have accurate data.
11. Mr. Joses chart contains all information about his health care. The functions of records include all
except:
A. means of communication that health team members use to communicate their contributions to the
clients health care
B. the clients record also shows a document of how much health care agencies will be reimbursed for their
services
C. educational resource for student of nursing and medicine
D. recording of actions in advance to save time
12. An advantage of automated or computerized client care system is:

A. The nursing diagnoses for a clients data can be accurately determined


B. Cost of confinement will be reduced
C. Information concerning the client can b easily updated
D. The number of people to take care of the client will be reduced
13. Information in the patients chart is inadmissible in court as evidence when:
A. The clients family refuses to have it used
D. It has too many abbreviations that are
B. The client objects to its use
unofficial
C. The handwriting is not legible
14. Nursing audit aims to:
A. provide research data to hospital personnel
B. study clients illness and treatment regimen
closely

C. compare actual nursing done to established


standards
D. provide information to health-care providers

15. A telephone order is given for a client in your ward. What is your most appropriate action?
A. Copy the order on to the chart and sign the physicians name as close to his original signature as
possible
B. Repeat the order back to the physician, copy onto the order sheet and indicate that it is a telephone
order
C. Write the order in the clients chart and have the head nurse co-sign it
D. Tell the physician that you cannot take the order but you will call the nurse supervisor
Situation Errors while providing nursing care to patients must be avoided and minimized at
all time. Effective management of available resources enables the nurse to provide safe,
quality patient care.
16. In the hospital where you work, increased incidence of medication error was identified as the number
one problem in the unit. During the brainstorming session of the nursing service department, probable
causes were identified. Which of the following is process related?
A. interruptions
C. lack of knowledge
B. use of unofficial abbreviations
D. failure to identify client
17. Miscommunication of drug orders was identified as a probable cause of medication errors. Which of the
following is safe medication practice related to this?
A. Maintain medication in its unit dose package until point of actual administration
B. Note both generic and brand name of the medication in the Medication Administration Method
C. Only officially approved abbreviations maybe used in prescription orders
D. Encourage clients to ask question about their medications.
18. The hospital has an ongoing quality assurance program. Which of the following indicates
implementation of process standards?
A. The nurses check clients identification band before giving medications
B. The nurse reports adverse reaction to drugs
C. Average waiting time for medication administration is measured
D. The unit has well ventilated medication room
19. Which of the following actions indicate that Nurse Jerome is performing outcome evaluation of quality
care?
A. Interviews nurses for comments regarding
C. Checks equipment for its calibration schedule
staffing
D. Determines whether nurses perform skin
B. Measures waiting time for clients per nurses
assessment every shift
call
20. An order for a client was given and the nurse in charge of the client reports that she has no experience
of doing the procedure before. Which of the following is the most appropriate action of the nurse
supervisor?
A. Assign another nurse to perform the procedure
C. Tell the nurse to read the procedure manual
B. Ask the nurse to find way to learn the
D. Do the procedure with the nurse
procedure
Situation Oral care is an important part of hygienic practices and promoting client comfort.
21. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and
presence of sores. Which of the following is BEST to use for oral care?
A. lemon glycerine
C. Mineral oil
B. hydrogen peroxide
D. Normal saline solution
22. When performing oral care to an unconscious client, which of the following is a special consideration to
prevent aspiration of fluids into the lungs?
A. Put the client on a sidelying position with head of bed lowered
B. Keep the client dry by placing towel under the chin
C. Wash hands and observe appropriate infection control

D. Clean mouth with oral swabs in a careful and an orderly progression


23. The advantages of oral care for a client include all of the following, EXCEPT:
A. decreases bacteria in the mouth and teeth
B. reduces need to use commercial mouthwash which irritate the buccal mucosa
C. improves clients appearance and self-confidence
D. improves appetite and taste of food
24. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to
lungs. This can be avoided by:
A. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity
B. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs
C. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and ums
D. suctioning as needed while cleaning the buccal cavity
25. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of
the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep
the mouth moistened by using:
A. salt solution
C. petroleum jelly
B. water
D. mentholated ointment
Situation - Mr. Martin, 71 years old was suddenly rushed to the hospital because of severe
chest pain. On admission, he was diagnosed to have acute myocardial infarction and was
placed in the ICU.
26. While in the ICU, he executes the document tat list the medical treatment he chooses to refuse in case
his condition becomes severe to a point that he will be unable to make decisions for himself. This
document is:
A. living will
C. last will and testament
B. informed consent
D. power of attorney
27. After one day, the patients condition worsened and feeling hopeless. He requested the nurse to
remove the oxygen. The nurse should:
A. follow the patient because it is his right to die
C. refuse the patient and encourage him to
gracefully
verbalize hid feelings
B. follow the patient as it is his right to determine
D. refuse the patient since euthanasia is not
the medical regimen he needs
accepted in the Philippines
28. Euthanasia is an ethical dilemma which confronts nurses in the ICU because:
A. the choices involved do not appear to be clearly right or wrong
B. a clients legal right co-exist with the nurses professional obligation
C. decisions has to be made based on societal norms.
D. decisions has to be mad quickly, often under stressful conditions
29. A nurse who supports a patient and familys need to make decisions that is right for them is practicing
which of the following ethical principles?
A. Autonomy
C. privacy
B. confidentiality
D. truthfulness
30. Mr. Martin felt better after 5 days but recognizing the severity of his illness, he executes a document
authorizing the wife to transact any form of business in his behalf in addition to all decisions relative to his
confinement his document is referred to as:
A. power f attorney
B. living will

C. informed consent
D. medical records

Situation - Miss Castro was recently appointed chief nurse of a 50-bed government hospital in
Valenzuela. On her first day of duty, she tried to remember the elements of administration she
learned from her basic nursing education.
31. One of the first things Ms. Castro did was to engage her until in objective writing, formulating goals
and philosophy of nursing service. Which activities are MOST appropriately described to which elements of
administration?
A. planning
B. controlling
C.
d. organizing
directing
32. In recognizing the Department of Nursing, she comes up with the organizational structure defining the
role and function of the different nursing positions and line-up the position with qualified people. This is
included in which element of administration:
A. monitoring
B. evaluation
C. organizing
D. planning

33. After one month, she and her management committee assess the regulatory measures taken and
correct whatever discrepancies are found. This is part of which element of administration:
A. monitoring
B. organizing
C. evaluation
D. planning
34. Revaluation and administrative process is BEST described as:
A. a continuing process of seeing that performance meets goals and targets
B. obtaining commitment of members to do better
C. informing personnel how well and how much improvement has been made
D. follow-up of activities that have been studied
35. In all of the various administrative functions, which of the following management skill is demanded
efficiently and effectively of Ms. Castro?
1. Decision making skills
2. Forecasting skills
3. Auditing skills
4. Communications skills
A. 2 & 3

B. 1 & 4

C. 1 & 2

D. 2 & 4

Situation - Health is wealth specifically in this time of the century. The nurse is trained to
promote well being of the people.
36. How does a nurse promote ones well being?
A. periodic travels for rest and recreation
B. faithful and observance of healthy simple lifestyle
C. run away from polluted, stressful areas
D. avoid sleepless, over fatigue nights
37. The nurse can be involved with health promotion as a significant person in helping the family:
A. become a better family B. prevent disease C. control their symptom D. modify health promotive
behaviors
38. The nurse should NOT leave medication at the bedside because:
a. the bedside table is not sterile
b. it is convenient for the nurse
c. the nurse will not be able to accurately document that the patient actually took the medication
d. the patient may forget to take it.
39. Non-pharmacologic pain management includes all the following EXCEPT:
a. relaxation techniques
b. massage
c. use of herbal medicine

d. body movement

40. When assessing a clients blood pressure, the nurse finds it necessary to recheck the reading. How many
seconds after deflating the cuff should the nurse wait before rechecking the pressure?
a. 10
b. 30
c. 45
d. 60
Situation The use of massage and meditation to help decrease stress and pain have been
strongly recommended based on documented testimonials.
41. Martha wants to do a study on this topic: Effects of massage and meditation on stress and pain. The
type of research that best suits this topic is:
A. Applied research
B. Qualitative research
C. Basic research
D.
Quantitative research
42. The type of research design that does not manipulate independent variable is:
A. Experimental design
C. Non-experimental design
B. Quasi-experimental design
D. Quantitative design
43. This research topic has the potential to contribute to nursing because it seeks to
A. include new modalities of care
C. clarify an ambiguous modality of care
B. resolve a clinical problem
D. enhance client care
44. Martha does review of related literature for the purpose of
A. determine statistical treatment of data research
B. gathering data about what is already known or unknown about the problem
C. to identify if problem can be replicated
D. answering the research question
45. Clients rights should be protected when doing research using human subjects. Martha identifies these
rights as follows EXCEPT:
A. right of self-determination
C. right of privacy
B. right to compensation
D. right not to be harmed

Situation Richard has a nursing diagnosis of ineffective airway clearance related to excessive
secretions and is at risk for infection because of retained secretions. Part of Nurse Marios
nursing care plan is to loosen and remove excessive secretions in the airway.
46. Mario listens to Richards bilateral sounds and finds that congestion is in the upper lobes of the lungs.
The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does
percussion would be:
A. Client lying on his back then flat on his abdomen on Trendelenburg position
B. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back
and on his abdomen
C. Client lying flat on his back and then flat on his abdomen
D. Client lying on his right then left side on Trendelenburg position
47. When documenting outcome of Richards treatment Mario should include the following in his recording
EXCEPT:
A. Color, amount and consistency of sputum
B. Character of breath sounds and respiratory rate before and after procedure
C. Amount of fluid intake of client before and after the procedure
D. Significant changes in vital signs
48. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would
focus on the following EXCEPT:
A. Amount of food and fluid taken during the last meal before treatment
B. Respiratory rate, breath sounds and location of congestion
C. Teaching the clients relatives to perform the procedure
D. Doctors order regarding position restrictions and clients tolerance for lying flat
49. Mario prepares Richard for postural drainage and percussion. Which of the following is a special
consideration when doing the procedure?
A. Respiratory rate of 16 to 20 per minute
C. Client has no signs of infection
B. Client can tolerate sitting and lying positions
D. Time of last food and fluid intake of the client
50. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference
between the procedures is:
A. Percussion uses only one hand while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes
secretion loose on the exhalation cycle
C. In both percussion and vibration the hands are on top of each other and hand action is in tune with
clients breath rhythm
D. Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the
inhalation of air.
Situation A 61 year old man, Mr. Regalado, is admitted to the private ward for observation
after complaints of severe chest pain. You are assigned to take care of the client.
51. When doing an initial assessment, the best way for you to identify the clients priority problem is to:
A. Interview the client for chief complaints and other symptoms
B. Talk to the relatives to gather data about history of illness
C. Do auscultation to check for chest congestion
D. Do a physical examination while asking the client relevant questions
52. Upon establishing Mr. Regalados nursing needs, the next nursing approach would be to:
A. Introduce the client to the ward staff to put the client and family at ease
B. Give client and relatives a brief tour of the physical set up the unit
C. Take his vital signs for a baseline assessment
D. Establish priority needs and implement appropriate interventions
53. Mr. Regalado says he has trouble going to sleep. In order to plan your nursing intervention you will:
A. Observe his sleeping patterns in the next few
C. Check his physical environment to decrease
days
noise level
B. Ask him what he means by this statement
D. Take his blood pressure before sleeping and
upon waking up
54. Mr. Regalados lower extremities are swollen and shiny. He has pitting pedal edema. When taking care
of Mr. Regalado, which of the following interventions would be the most appropriate immediate nursing
approach?
A. Moisturize lower extremities to prevent skin irritation
B. Measure fluid intake and output to decrease edema
C. Elevate lower extremities for postural drainage
D. Provide the client a list of food low in sodium
55. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client
for discharge include all EXCEPT:

A. Making a final physical assessment before client leaves the hospital


B. Giving instructions about his medication regimen
C. Walking the client to the hospital exit to ensure his safety
D. Proper recording of pertinent data
Situation Using Maslows need theory, Airway, Breathing and Circulation are the
physiological needs vital to life. The nurses knowledge and ability to identify and immediately
intervene to meet these needs is important to save lives.
56. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues:
A. Carol with tumor in the brain
C. Sonnyboy with a fracture in the femur
B. Theresa with anemia
D. Brigitte with diarrhea
57. You noted from the lab exams in the chart of M. Santos that he has reduced oxygen in the blood. This
condition is called:
A. Cyanosis
C. Hypoxemia
B. Hypoxia
D. Anemia
58. You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of insertion of the tubing
for an adult would be:
A. tip of the nose to the base of the neck
B. the distance from the tip of the nose to the middle of the neck
C. the distance from the tip of the nose to the tip of the ear lobe
D. eight to ten inches
59. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by:
A. Apply suction for at least 20-30 seconds each time to ensure that all secretions are removed
B. Using gloves to prevent introduction of pathogens to the respiratory system
C. Applying no suction while inserting the catheter
D. Rotating catheter as it is inserter with gentle suction
60. Nurse Suzie is administering 12:00 PM medication in Ward 4. Two patients have to receive Lanoxin.
What should Nurse Suzie do when one of the clients does NOT have a readable identification band?
A. Ask the client if she is Mrs. Santos
C. Ask the room mate if the client is Mrs. Santos
B. Ask the client his name
D. Compare the ID band with the bed tag
Situation During the NUTRITION EDUCATION class discussion a 58 year old man, Mr. Bruno,
shows increased interest.
61. Mr. Bruno asks what the normal allowable salt intake is. Your best response to Mr.
Bruno is:
A. 1 tsp of salt/day with iodine and sprinkle of
C. 1 tbsp of salt/day with some patis and toyo
MSG
D. 1 tsp of salt/day but no patis and toyo
B. 5 gms per day or 1 tsp of table salt/day
62. Your instructions to reduce or limit salt intake include all the following EXCEPT:
A. eat natural food with little or no salt added
C. use herbs and spices
B. limit use of table salt and use condiments
D. limit intake of preserved or processed food
instead
63. Teaching strategies and approaches when giving nutrition education is influenced by age, sex and
immediate concerns of the group. Your presentation for a group of young mothers would be best if you
focus on:
A. diets limited in salt and fat
C. commercial preparation of dishes
B. harmful effects of drugs and alcohol intake
D. cooking demonstration and meal planning
64. Cancer cure is dependent on
A. use of alternative methods of healing
B. watching out for warning signs of cancer

C. proficiency in doing breast self-examination


D. early detection and prompt treatment

65. The role of the health worker in health education is to


A. report incidence of non-communicable diseases to community health center
B. educate as many people about warning signs of non-communicable diseases
C. focus on smoking cessation projects
D. monitor clients with hypertension
Situation As you begin to work in the hospital where you are on probation, you are tasked to
take care of a few patients. The clients have varied needs and you are expected to provide
care for them.
66. An ambulatory client. Mr. Zosimo, is being prepared for bed. Which of the following nursing actions
promote safety for the client?

A. Turning off the lights to promote rest and sleep


B. Instructing the client about the use of call system
C. Raising the side rails
D. Placing the bed in high position
67. Mikka, a 25 year old female client, is admitted with right lower quadrant abdominal pain. The physician
diagnosed the client with acute appendicitis and an emergency appendectomy was performed. Twelve
hours following surgery, the patient complained of pain. Which of the following is the most appropriate
nursing diagnosis?
A. Impaired mobility related to pain secondary to an abdominal incision
B. Impaired movements related to pain due to surgery
C. Impaired mobility related to surgery
D. Severe pain related to surgery
68. You are preparing a plan of care for a client who is experiencing pain related to incisional swelling
following laminectomy. Which of the following should be included in the nursing care plan?
A. Encourage the client to log roll when turning
D. Ambulate the client in ward premises every
B. Encourage the client to do self-care
twenty minutes
C. Instruct the client to do deep breathing
exercises
69. Mr. Lozano, 50 year old executive, is recovering from severe myocardial infarction. For the past 3 days,
Mr. Lozanos hygiene and grooming needs have been met by the nursing staff. Which of the following
activities should be implemented to achieve the goal of independence for Mr. Lozano?
A. Involving family members in meeting clients personal needs
B. Meeting his needs till he is ready to perform self-care
C. Preparing a day to day activity list to be followed by client
D. Involving Mr. Lozano in his care
70. Mr. Ernest Lopez is terminally ill and he choose to be at home with his family. What nursing action are
best initiated to prepare the family of Mr. Lopez?
A. Talk with the family members about the advantage of staying in the hospital for proper care
B. Provide support to the family members by teaching ways to care for their loved one
C. Convince the client to stay in the hospital for professional care
D. Tell the client to be with his family
Situation Myrna, a researcher, proposes a study on the relationship between health values
and the health promotion activities of staff nurses in a selected college of nursing.
71. In both quantitative and qualitative research, the used of a frame of reference is required. Which of the
following items serves as the purpose of a framework?
A. Incorporates theories into nursings body of knowledge
B. Organizes the development of study and links the findings to nursings bodyof knowledge
C. Provides logical structure of the research findings
D. Identifies concepts and relationships between concepts
72. Myrna need to review relevant literature and studies. The following processes are undertaken in
reviewing literature EXCEPT:
A. locating and identifying resources
C. clarifying a research topic
B. reading and recording notes
D. using the library
73. The primary purpose for reviewing literature is to:
A. organize materials related to the problem of interest
B. generate broad background and understanding of information related to the research problem of
interest
C. select topics related to the problem of interest
D. gather current knowledge of the problem of interest
74. In formulating the research hypotheses, researcher Myrna should state the research question as:
A. What is the response of the staff nurses to the health values?
B. How is variable health value perceived in a population?
C. Is there a significant relationship between health values and health promotion activities of the staff
nurses?
D. How do health values affect health promotion activities of the staff nurses?
75. The proposed study shows the relationship between the variables. Which of the following is the
independent variable?
A. Staff nurses in a selected college of nursing
D. Relationship between health values and health
B. Health values
promotion activities
C. Health promotion activities
Situation While working in a tertiary hospital, you are assigned to the medical ward.

76. Your client, Mr. Diaz, is concerned that he cannot pay his hospital bills and professional fees. You refer
him to a:
A. Nurse supervisor
C. bookkeeping department
B. Social worker
D. physician
77. Mr. Magno has lung cancer and is going through chemotherapy. He is referred by the oncology nurse to
a self-help group of clients with cancer to:
A. receive emotional support
C. provide financial assistance
B. to be a part of a research study
D. assist with chemotherapy
78. A diabetic hypertensive client, Mrs. Linao, needs a change in diet to improve her health status. She
should be referred to a:
A. nutritionist
C. physician
B. dietitian
D. medical pathologist
79. When collaborating with other health team members, the best description of Nurse Ritas role is:
A. encourages the clients involvement in his care
B. shares and implements orders of the health team to ensure quality care
C. she listens to the individual views of the team members
D. helps client set goals of care and discharge
80. Nurse Rita is successful in collaborating with health team members about the care of Mr. Linao. This is
because she has the following competencies:
A. Communication, trust, and decision making
B. Conflict management, trust, negotiation
C. Negotiation, decision making
D. Mutual respect, negotiation and trust
Situation The practice of nursing goes with responsibilities and accountability whether you
work in a hospital or in the community setting you main objective is toprovide safe nursing to
your clients?
81. To provide safe, quality nursing care to various clients in any setting, the most important tool of the
nurse is:
A. critical thinking to decide appropriate nursing actions
B. understanding of various nursing diagnoses
C. observation skills for data collection
D. possession of in scientific knowledge about client needs
82. You ensure the appropriateness and safety of your nursing interventions while caring for various client
groups by:
A. creating plans of care for particular clientele
B. identifying the correct nursing diagnoses for clients
C. making a thorough assessment of client needs and problems
D. using standards of nursing care as your criteria for evaluation
83. The effectiveness of your nursing care plan for your clients is determined by
A. the number of nursing procedures performed to comfort the client
B. the amount of medications administered to the client as ordered
C. the number of times the client calls the nurse
D. the outcome of nursing interventions based on plan of care
84. You are assigned to Mrs. Amado, age 49, who was admitted for possible surgey. She complained of
recurrent pain at the right upper quadrant of the abdomen 1-2 hours after ingestion of fatty food. She also
had frequent bouts of dizziness, blood pressure of 170/100, hot flashes. Which of the above symptoms
would be an objective cue?
A. Blood pressure measurement of 170/100
C. Report of pain after ingestion of fatty food
B. Complaint of hot flashes
D. Complaint of frequent bouts of dizziness
85. While talking with Mrs. Amado, it is most important for the nurse to:
A. schedule the laboratory exams ordered for her
B. do an assessment of the client to determine priority needs
C. tell the client that your shift ends after eight hours
D. have the client sign an informed consent
Situation - Eileen, 45 years old is admitted to the hospital with a diagnosis of renal calculi. She
is experiencing severe flank pain, nauseated and with a temperature of 39 0C.
86. Given the above assessment data, the most immediate goal of the nurse would be which of the
following?
A. Prevent urinary complication
B. maintains fluid and electrolytes

C. Alleviate pain
D. Alleviating nausea

87. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes
daily urine specimen to be sent to the laboratory . Eileen has a foley catheter attached to a urinary
drainage system. How will you collect the urine specimen?
A. remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into
the specimen container
B. empty a sample urine from the collecting bag into the specimen container
C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter int the
specimen container.
D. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into
the specimen container.
88. Where would the nurse tape Eileens indwelling catheter in order to reduce urethral irritation?
A. to the patients inner
C. to the patient
thigh
D. to the patient lower abdomen
B. to the patients lower thigh
89. Which of the following menu is appropriate for one with low sodium diet?
A. instant noodles, fresh fruits and ice tea
C. white chicken sandwich, vegetable
B. ham and cheese sandwich, fresh fruits and
salad and tea
vegetables
D. canned soup, potato salad, and diet
soda
90. How will you prevent ascending infection to Eileen who has an indwelling catheter?
A. see to it that the drainage tubing touches the level of the urine
B. change he catheter every eight hours
C. see to it that the drainage tubing does not touch the level of the urine
D. clean catheter may be used since urethral meatus is not a sterile area
Situation You are assigned to take care of 10 patients during the morning shift. The
endorsement includes the IV infusion and medications for these clients.
91. Mr. Felipe, 36 years old is to be given 2700 ml of D5LR to infuse for 18 hours starting at 8 am. At what
rate should the IV fluid be flowing hourly?
A. 100 ml per hour B. 210 ml per hour C. 150 ml per hour D. 190 ml per hour
92. Mr. Atienza is to receive 150 ml/hour of D% W IV infusion for 12 hours for a total of
1800ml. He is also losing gastric fluid which must be replaced every two hours. Between 8 am and 10 am,
Mr. Atienza has lost 250 ml of gastric fluid. How much fluid should he
receive at 11 am?
A. 350 ml/hour
B. 275 ml/hour
C. 400 ml/hour
D. 200 ml/hour
93. You are to apply a transdermal patch of nitoglycerin to your client. The following are important
guidelines to observe EXCEPT:
A. Apply to hairless clean area of the skin not subject to much wrinkling
B. Patches may be applied to distal part of the extremities like forearm
C. Change application and site regularly to prevent irritation of the skin
D. Wear gloves to avoid any medication on your hand
94. You will be applying eye drops to Miss Romualdez. After checking all the necessary information and
cleaning the affected eyelid and eyelashes, you administer the ophthalmic drops by instilling the eye
drops:
A. directly onto the cornea
D. from the inner canthus going towards the side
B. pressing the lacrimal duct
of the eye
C. into the outer third of the lower conjunctival
sac
95. When applying eye ointment, the following guidelines apply EXCEPT:
A. squeeze about 2 cm of ointment and gently close but not squeeze the eye
B. apply the ointment from the inner canthus going outward of the affected eye
C. discard the first bead of the eye ointment before application because the tube is likely to expel more
than desired amount of ointment
D. hold the tube above the conjunctival sac, do not let tip touch the conjunctiva
Situation The staff nurse supervisor requests all the staff nurses to brainstorm and learn
ways to instruct diabetic clients on self-administration of insulin. She wants to ensure that
there are nurses available daily to do health education classes.
96. The plan of the nurse supervisor is an example of
A. in service education process
B. efficient management of human resources

C. increasing human resources


D. primary prevention

97. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide
who is an unlicensed staff, Mrs. Guevarra
A. makes the assignment to teach the staff
C. does not have to supervise or evaluate the
member
aide
B. is assigning the responsibility to the aide but
D. most know how to perform task delegated
not the accountability for those tasks
98. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six weeks ago
when she started the job. The nurse supervisor should
A. empathize with the nurse and listen to her
C. discuss how she is adjusting to her new job
B. tell her to take the day off
D. ask about her family life
99. Process of formal negotiations of working conditions between a group of registered
nurses and employer is
A. grievance B. arbitration C. collective bargaining
D. strike
100. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and required by the
hospital employing you. This is
A. professional course towards credits
B. inservice education
C. advance training
D. continuing education
NOVEMBER, 2008
Situation 1: Nursing is a profession. The nurse should have a background on the theories and
foundation of nursing as it influenced what is nursing today.
1. Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and
injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the
care of the individuals, families, communities and population. This is the most accepted definition of
nursing as defined by the:
A. PNA
B. ANA
C. Nightingale
D. Henderson
2. Advancement in Nursing leads to the development of the Expanded Career Roles. Which of the following
is NOT expanded career role for nurse?
A. Nurse practitioner B. Clinical Nurse Specialist
C. Nurse Researcher D. Nurse anaesthesiologist
3. The Board of Nursing regulated the Nursing profession in the Philippines and is responsible for the
maintenance of the quality of nursing in the country. Powers and duties of the board of nursing are the
following EXCEPT:
A. Issue, suspend revoke certificates of registration
B. Issue subpoena duces tecum, ad testificandum
C. Open and close colleges of nursing
D. Supervise and regulate the practice
4. A nursing student or a beginning staff nurse who has not yet experienced enough in a situation to make
judgments about them is in what stage of Nursing Expertise?
A. Novice
B. Newbie
C. Advanced Beginner
D. Competent
5. Benners Proficient nurse level is different from the other levels in nursing expertise in the context of
having:
A. The ability to organize and plan activities
B. Having attained an advanced level of education
C. A holistic understanding and perception of the client
D. Intuitive and analytic ability in new situations
Situation 2: The nurse has been asked to administer an injection via Z TRACK technique.
Questions 6 to 10 refer this.
6. The nurse prepares an IM injection for an adult client using the Z track techniques, 4 ml of medication is
to be administered to the client. Which of the following site will you choose?
A. Deltoid
B. Rectus Femoris
C. Ventrogluteal
D. Vastus lateralis
7. In infants 1 year old and below, which of the following is the site of choice in intramuscular injection?
A. Deltoid
B. Rectus Femoris
C. Ventrogluteal
D. Vastus lateralis
8. In order to decrease discomfort in Z track administration, which of the
A. Pierce the skin quickly and smoothly at 90 degree angle
B. Inject the medication at around 10 minutes per millilitre

C. Pull back the plunger and aspirate for 1 minute t make sure that the needle did not hit a blood vessel
D. Pierce the skin slowly and carefully at a 90 degree angle
9. After injection using the Z track technique, the nurse should know that she needs to wait for few second
before withdrawing the needle and this is to allow the medication to disperse into the muscle tissue thus
decreasing the clients discomfort. How many seconds should the nurse wait before withdrawing the
needle?
A. 2 second B. 5 seconds C. 10 seconds D. 15 seconds
10. The rationale in using the Z track technique in an intramuscular injection is:
A. It decreases the leakage of discolouring and
C. The Z track technique prevent irritation of the
irritating medication into the subcutaneous
muscle
tissue.
D. It is much more convenient for the nurse
B. It will allow a faster absorption of the
medication
Situation 3: A client was rushed to the emergency room and you are his attending nurse. You
are performing a vital sign assessment:
11. All of the following are correct methods in assessment of the blood pressure EXCEPT:
A. Take the blood pressure reading on both arms for comparison
B. Listen to and identify the phases of Korotkoff sound
C. Pump the cuff to around 50mmHg above the point where the pulse is obliterated
D. Observe procedures for infection control
12. You attached a pulse oximeter to the client. You know that the purpose id to:
A. Determine if the clients hemoglobin level is low and if he needs blood transfusion
B. Check level of clients tissue perfusion
C. Measure the efficacy of the clients anti-hypertension medications
D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops
13. After a few hours in the Emergency Room, the client is admitted to the ward with an order of hourly
monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood
pressure reading to be:
A. Inconsistent
C. Higher than what the reading should be
B. Low systolic and high diastolic
D. Lower than what the reading should be
14. Through the clients health history, you gather that the patient smokes and drinks coffee. When taking
the blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before
taking the clients blood pressure for accurate reading?
A. 15 minutesB.
30 minutes
C. 1 hour
D. 5 minutes
15. While the client has pulse oximeter on his fingertip, you notice that the sunlight is shining on the area
where the oximiter is. Your action will be to:
A. Set and turn on the alarm of the oximeter
D. Change the location of the sensor every four
B. Do nothing since there is no identified problem
hours
C. Cover the fingertip sensor with a towel or
bedsheet
16. The nurse finds it necessary to recheck the blood pressure reading. In case of such reassessment, the
nurse should wait for a period of:
A. 15 seconds
B. 1 to 2 minutes
C. 30 minute
D. 15 minutes
17. If the arm is said to be elevated when taking the blood pressure. It will create a:
A. False high reading
B. False low reading
C. True False reading

D. Indeterminate

18. You are to assessed the temperature of the client the next morning and found out that he ate ice
cream. How many minutes should you wait before assessing the clients oral temperature?
A. 10 minutes
B. 20 minutes
C. 30 minutes
D. 15 minutes
19. When auscultating the clients blood pressure the nurse hears the following: From 150 mmHg to 130
mmHg: Silence, Then: a thumping sound continuing down to 100 mmHg: muffled sound continuing down
to 80 mmHg and then silence. What is the clients pressure?
A. 130/80
B. 150/100
C. 100/80
D. 150/100
20. In a client with a previous blood pressure of 130/80 4 hours ago, how long will it take to release the
blood pressure cuff to obtain an accurate reading?
A. 10 20 seconds
B. 30 45 seconds
C. 1 - 1.5 minutes
D. 3 3.5 minutes
Situation 4 Oral care is an important part of hygienic practices and promoting client comfort.

21. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and
presence of sores. Which of the following is BEST to use for oral care?
A. lemon glycerine B. hydrogen peroxideC. Mineral oil D. Normal saline solution
22. When performing oral care to an unconscious client, which of the following is a special consideration to
prevent aspiration of fluids into the lungs?
A. Put the client on a sidelying position with head
C. Wash hands and observe appropriate infection
of bed lowered
control
B. Keep the client dry by placing towel under the
D. Clean mouth with oral swabs in a careful and
chin
an orderly progression
23. The advantages of oral care for a client include all of the following, EXCEPT:
A. decreases bacteria in the mouth and teeth
B. reduces need to use commercial mouthwash which irritate the buccal mucosa
C. improves clients appearance and self-confidence
D. improves appetite and taste of food
24. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to
lungs. This can be avoided by:
A. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity
B. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs
C. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and ums
D. suctioning as needed while cleaning the buccal cavity
25. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of
the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep
the mouth moistened by using:
A. salt solution
C. petroleum jelly
B. water
D. mentholated ointment

Situation 5: Ensuring safety before, during and after a diagnostic procedure is an important
responsibility of the nurse.
26. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the
following prior to the procedure:
A. Clenching his fist every 2 minutes
C. Tensing the shoulder muscles while lying on his
B. Breathing in and out through the nose with his
back
mouth open
D. Holding his breath periodically for 30 seconds
27. Following a bronchoscopy, which of the following complains to Fernan should be noted as a possible
complication:
A. Nausea and vomiting
C. Blood tinged sputum and coughing
B. Shortness of breath and laryngeal stridor
D. Sore throat and hoarseness
28. Immediately after bronchoscopy, you instructed Fernan to:
A. Exercise the neck muscles
C. Refrain from coughing and talking
B. Breathe deeply
D. Clear his throat
29. Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important
function during the procedure is to:
A. Keep the sterile equipment from contamination
C. Open and close the three-way stopcock
B. Assist the physician
D. Observe the patients vital signs
30. Right after thoracentesis, which of the following is most appropriate intervention?
A. Instruct the patient not to cough or deep breathe for two hours
B. Observe for symptoms of tightness of chest or bleeding
C. Place an ice pack to the puncture site
D. Remove the dressing to check for bleeding
Situation 6: Knowledge of the acid base disturbance and the functions of the electrolytes is
necessary to determine appropriate intervention and nursing actions.
31. A client with diabetes milletus has glucose level of 644 mg/dL. The nurse interprets that this client is at
most risk for the involvement at which type of acid base imbalance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D.
Metabolic alkalosis

32. In a client in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, PCO2
32mmHg, PO2 94 mmHg, HCO3 24 mEq/L. The nurse interprets that the client has which acid base
disturbance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D.
Metabolic alkalosis
33. A client has an order for ABG analysis on radial artery specimens. The nurse ensures that which of the
following has been performed or tested before the ABG specimen are drawn?
A. Guthing test
B. Allens test
C. Rombergs test
D. Webers test
34. A nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31, Pco2 is 500
mmHg, and the bicarbonate is 27 mEq/L. The nurse concludes that which acid base disturbance is present
in this client?
A. Respiratory acidosis
B.Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
35. Allens test checks the patency of the:
A. Ulnar artery
B. Radial artery

C. Carotid artery

D. Brachial artery

37. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes
daily urine specimen to be sent to the laboratory . Eileen has a foley catheter attached to a urinary
drainage system. How will you collect the urine specimen?
A. remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into
the specimen container
B. empty a sample urine from the collecting bag into the specimen container
C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the
specimen container.
D. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into
the specimen container.
38. Where would the nurse tape Eileens indwelling catheter in order to reduce urethral irritation?
A. to the patients inner thigh
C. to the patients buttocks
B. to the patients lower thigh
D. to the patient lower abdomen
39. Which of the following menu is appropriate for one with low sodium diet?
A. instant noodles, fresh fruits and ice tea
C. white chicken sandwich, vegetable salad and
B. ham and cheese sandwich, fresh fruits and
tea
vegetables
D. canned soup, potato salad, and diet soda
40. Howe will you prevent ascending infection to Eileen who has an indwelling catheter?
A. see to it that the drainage tubing touches the
C. see to it that the drainage tubing does not
level of the urine
touch the level of the urine
B. change he catheter every eight hours
D. clean catheter may be used since urethral
meatus is not a sterile area
Situation 7: Hormones are secreted by the various glands in the body. Basic knowledge of the
endocrine system is necessary.
41. Somatotropin or the Growth Hormone releasing hormone is secreted by the anterior pituitary gland:
A. Hypothalamus
C. Posterior pituitary gland
B. Anterior pituitary gland
D. Thyroid gland
42. All of the following are secreted by the anterior pituitary gland except:
A. Somatotropin/Growth hormone
C. Thyroid stimulating hormone
B. Follicle stimulating hormone
D. Gonadotropin hormone releasing hormone
43. All of the following hormones are hormones secreted by the Posterior pituitary gland except:
A. Vasopressin
B. Oxytocin
C. Anti-diuretic hormone
D. Growth hormone
44. Calcitonin, a hormone necessary for calcium regulation is secreted in the:
A. Thyroid gland
B. Hypothalamus
C. Parathyroid gland
gland

D. Anterior pituitary

45. While Parathormone, a hormone that regulates the effect of calcitonin is secreted by the:
A. Thyroid gland
B. Hypothalamus
C. Parathyroid gland
D. Anterior pituitary
gland
Situation 8 The staff nurse supervisor requests all the staff nurses to brainstorm and learn
ways to instruct diabetic clients on self-administration of insulin. She wants to ensure that
there are nurses available daily to do health education classes.
46. The plan of the nurse supervisor is an example of
A. in service education process

B. efficient management of human resources

C. increasing human resources

D. primary prevention

47. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an
unlicensed staff, Mrs. Guevarra
A. makes the assignment to teach the staff member
B. is assigning the responsibility to the aide but not the accountability for those tasks
C. does not have to supervise or evaluate the aide
D. most know how to perform task delegated
48. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six weeks ago
when she started the job. The nurse supervisor should
A. empathize with the nurse and listen to her
C. discuss how she is adjusting to her new job
B. tell her to take the day off
D. ask about her family life
49. Process of formal negotiations of working conditions between a group of registered nurses and
employer is
A. grievance
B. arbitration
C. collective bargaining
D. strike
50. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and required by the
hospital employing you. This is
A. professional course towards credits
C. advance training
B. inservice education
D. continuing education
Situation 9: As a nurse, you are aware that proper documentation in the patient chart is your
responsibility.
51. Which of the following is NOT a legally binding document but nonetheless very important in the care of
all patients in any setting?
A. Bill of rights as provided in the Philippine
C. Board of Nursing resolution adopting the Code
Constitution
of Ethics
B. Scope of nursing practice as defined in R.A.
D. Patients Bill of Rights
9173
52. A nurse gives a wrong medication to the client. Another nurse employed by the same hospital as a risk
manager will expect to receive which of the following communication?
A. Incident Report
B. Oral report
C. Nursing kardex
D. Complain report
53. Performing a procedure on a client in the absence of an informed consent can lead to which of the
following charges?
A. Fraud
B. Assault and Battery
C. Harassment
D. Breach of
confidentiality
54. Which of the following is the essence of informed consent?
A. It should have a durable power of attorney
D. It should discloses previous diagnosis,
B. It should have coverage from an insurance
prognosis and alternative treatments available for
company
the client.
C. It should respect the clients freedom from
coercion
55. Delegation is the process of assigning tasks that can be performed by a subordinate. The RN should
always be accountable and should not lose his accountability. Which of the following is a role included in
delegation?
A. The RN must supervise all delegated tasks
B. After a task has been delegated. It is no longer a responsibility of the RN.
C. The RN is responsible and accountable for the delegated task in a adjunct with the delegate.
D. Follow up with a delegated task necessary only if the assistive personnel is not trustworthy.
Situation 10 When creating your lesson plan for cerebrovascular disease or STROKE. It is
important to include the risk factors of stroke.
56. The most important risk factor is:
A. Cigarette smoking
B. Hypertension

C. binge drinking

D. heredity

57. Part of your lesson plan is to talk about etiology or cause of stroke. The types of stroke based on cause
are the following EXCEPT:
A. Embolic stroke
B. Hemorrhagic stroke
C. diabetic stroke
D. thrombotic
stroke
58. Hemmorhagic stroke occurs suddenly usually when the person is active. All are causes of hemorrhage,
EXCEPT:
A. phlebitis
B. trauma
C. damage to blood vessel
D. aneurysm

59. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug is closely
linked to this?
A. Amphetamines
B. Cocaine
C. shabu
D. Demerol
60. A participant in the STROKE class asks what is a risk factor of stroke. Your best response is:
A. More red blood cells thicken blood and make
C. More red blood cell increases hemoglobin
clots more possible.
content.
B. Increased RBC count is linked to high
D. High RBC count increases blood pressure.
cholesterol.
Situation 11: Recognition of normal values is vital in assessment of clients with various
disorders.
61. A nurse is reviewing the laboratory test results for a client with a diagnosis of severe dehydration. The
nurse would expect the hematocrit level for this client to be which of the following?
A. 60%
B. 47%
C. 45%
D. 32%
62. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is
5.6 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory
value?
A. ST depression
B. Inverted t wave
C. Prominent U wave
D. Tall peaked T
waves
63. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is
3.2 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory
value?
A. U waves
B. Absent P waves
C. Elevated T waves
D. Elevated ST segment
64. Dorothy underwent diagnostic test and the result of the blood examination are back. On reviewing the
result the nurse notices which of the following as abnormal finding?
A. Neutrophils 60%
C. Erythrocyte sedimentation rate (ESR) is 39
B. White blood cells (WBC) 9000/mm
mm/hr
D. Iron 75 mg/100 ml
65. Which of the following laboratory test result indicate presence of an infectious process?
A. Erythrocyte sedimentation rate (ESR) 12
C. Iron 90 g/100ml
mm/hr
D. Neutrophils 67%
B. White blood cells (WBC) 18,000/mm3
Situation 12: Pleural effusion is the accumulation of fluid in the pleural space. Question to 66
to 70 refer to this?
66. Which of the following is a finding that the nurse will be able to assess in a client with pleural effusion?
A. Reduced or absent breath sound at the base of the lungs, dyspnea, tachypnea and shortness of breath.
B. Hypoxemia
C. Noisy respiration, crackles, stridor and wheezing
D. Tracheal deviation towards the affected side, increased fremitus and loud breath sounds
67. Thoracentesis is performed to the client with effusion. The nurse knows that he removal of fluid should
be slow. Rapid removal of fluid in thoracentesis might cause:
A. Pneumothorax
B. Pleurisy or Pleuritis
C. Cardiovascular collapse
D.
Hypertension
68. 3 Days after thoracentesis, the client again exhibited respiratory distress. The nurse will know that the
pleural effusion has reoccurred when she noticed a sharp stabbing pain during inspiration. The physician
ordered a closed tube thoracotomy for the client. The nurse knows that the primary function of the chest
tube is to:
A. Restore positive intrathoracic pressure
C. To visualize the intrathoracic content
B. Restore negative intrathoracic pressure
D. As a method of air administration
69. The chest tube is functioning properly if:
A. There is an oscillation
B. There is no bubbling in the drainage bottle
C. There is a continuous bubbling in the water
seal.

D. The suction control bottle has a continuous


bubbling

70. In a client with pleural effusion, the nurse is instructing a appropriate breathing technique. Which of
the following is included in the teaching?
A. Breath normally
C. Practice abdominal breathing
B. Hold the breath after each inspiration for 1 full
D. Inhale slowly and hold the breath for 3-5
minute
seconds after each inhalation.

Situation 13: Health care delivery system affects the health status of every Filipino. As a
Nurse, Knowledge of this system is expected to ensure quality of life.
71. When should rehabilitation commence?
A. The day before discharge B. When the patient desires C. Upon admission

D. 24hours after discharge

72. What exemplified the preventive and promotive programs in the hospital?
A. Hospitals as a center to prevent and control
C. Program for alcoholics and drug addicts
infection
D. Wellness Center
B. Program for smokers
73. Which makes nursing dynamic?
A. Every patient is a unique physical, emotional, social and spiritual being
B. The patient participate in the over all nursing care plan
C. Nursing practice is expanding in the light of modern development that takes place
D. The health status of the patient is constantly changing and the nurse must be cognizant and responsive
to these changes.
74. Prevention is an important responsibility of the nurse in:
A. Hospitals
B. Community
C. Workplace

D. All of the above

75. This form of Health Insurance provides comprehensive prepaid health services to enrollees for a
periodic payment.
A. Health Maintenance Organization
C. Philippine Health Insurance Act
B. Medicare
D. Hospital Maintenance Organization
91. Health care reports have different purposes. The availability of patients record to all health ream
members demonstrates which of the following purposes:
A. Legal documentation
B. Education
C. Research
D. Vehicle for
communication
92. When a nurse commits medication error she should accurately document clients response and her
corresponding action. This is very important for which of the following purposes:
A. Research
B. Nursing Audit
C. Legal documentation
D. Vehicle for
communication
93. POMR has been widely used in many teaching hospitals. One of its unique features is SOAPIE charting.
The P in SOAPIE charting should include:
A. Prescription of the doctor to the patients
C. Patients perception of ones illness
illness
D. Nursing Problem and Nursing Diagnosis
B. Plan of care for patient
94. The medical records that are organized into separate section from doctors or nurses has more
disadvantages than advantages. This is classified as what type of recording?
A. POMR
B. SOAPIE
C. Modified POMR
D. SOMR
95. Which of the following is the advantage of SOMR or Traditional Recording?
A. Increase efficiency of Data gathering
B. Reinforces the use of the nursing process
C. The caregiver can easily locate proper section for making charting entries
D. Enhances effective communication among health care team members
Situation 17: June is 24 year old client with symptoms of dyspnea, absent breath sounds on
the right lung and chest X-ray revealed pleural effusion. The physician will perform
thoracentesis
96. Thoracentesis is useful in treating which of the following pulmonary disorders except:
A. Hemothorax
B. Tuberculosis
C. Hydrothorax
D. Empyema
97. Which of the following psychological preparation is not relevant for him?
A. Telling him that the gauge of the needle and anesthesia to be used
B. Telling him to keep still during the procedure to facilitate the insertion of the needle in the correct place.
C. Allow June to express his feeling and concerns
D. Physicians explanation on the purpose of the procedure and how it will be done.
98. Before thoracentesis, the legal consideration you must check is:
A. Consent is signed by the client
C. Position of the client is correct
B. Medicine preparation is correct
D. Consent is signed by relative and physician

99. As a nurse, you know that the position for June before thoracentesis is:
A. Orthopneic
B. Knee-chest
C. Low fowlers
D. Sidelying position on the
affected side
100. Which of the following anesthetic drug is used for thoracentecis?
A. Procaine 2 %
B. Valium 250 mg
C. Demerol 75 mg

D. Phenobarbital