SUCCEED REVIEW CENTER

COMPREHENSIVE ASSESSMENT EXAM 2013

Situation 1: 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.
1. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues:
a. Aya with tumor in the brain
b. Sarah with anemia
c. Peter with a fracture in the femur
d. Susan with diarrhea
2. You noted from the lab exams in the chart of Mr. Aslan that he has reduced oxygen in the blood. This condition is
called:
a. Cyanosis
c. Hypoxemia
b. Hypoxia
d. Anemia
3. You will do nasopharyngeal suctioning on Mr. Aslan. 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
4. While doing nasopharyngeal suctioning on Mr. Aslan, 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
5. Jessica 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 2. Nurses have both independent and dependent functions in the care of patients. The only
dependent functions involve administration of medication and treatment.
6. Which of the following gauge of the needle is most appropriate for skin testing?
a. gauge 23
c. gauge 21
b. gauge 26
d. gauge 18
7. Mrs. Aquino was to receive an antibiotic intramuscularly. Which of the following factors might influence the nurse's
decision on the route of administration?
a. Presence of kidney disorder
b. Client's age and level of alertness
c. Permeability of the skin surface
d. Condition of the muscle tissue
8. A 63 year old patient is to receive an insulin injection. Nurse Elaine knows that only small doses of medication
are usually injected via the subcutaneous route. She is correct when she instill:
a. 0.5 ml b. 5 m c. 0.1 ml d. 0.01 ml
9. A 10 year old patient is to be given penicillin injection IM. Before it is carried out, skin testing has to be done.
Which of the following is the direction of the needle during a skin testing?
a. 15 degree angle
b. 45 degree angle
c. Needle is almost parallel to the skin
d. 90 degree angle
10. Which of the following is the most preferred site in administering IM injection among infants and toddlers?
1. vastus lateralis 3. dorsogluteal
2. ventrogluteal 4. deltoid
a. 1 and 2 c. 1 and 4
b. 1 and 3 d. 2 and 4
Situation 3. When a person becomes ill, hygienic practices frequently becomes secondary to her functions.
People who are ill often lack the energy to attend to their hygienic needs and therefore require assistance
from the nurse in this aspect.

11. Which of the following hygienic care is most appropriate for the nurse to provide to her bedridden client during
afternoons?
a. Changing clients pajamas
b. Assisting with a bed bath
c. Straightening bed linens
d. Providing back rub
12. 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 side-lying 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
13. 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 peroxide
c . Mineral oil
d. Normal saline solution
14. 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
15. 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
Situation 4. Proper food and nutrition are important factors that contribute to fast recovery and
rehabilitation of clients. As such, meeting the nutritional needs of clients must be a major part of the
nursing care plan.
16. Kilua, 55 years old, is undergoing dialysis once a week. He has a chronic renal problem and is on low sodium
diet. Which of the following is most appropriate for him?
a. Arrozcaldo, melon, tea
b. Canned fish, fresh cucumber, diet coke
c. Ham and cheese sandwich, banana and coffee
d. Jollibee burger, papaya, ice tea
17. Gon, a hypertensive client in the OPD, is advised by the physician to have a low cholesterol diet. Which of the
following menus would you best recommend?
a. Chicken salad, omelet, milk
b. Ampalaya salad, broiled fish, tea
c. Fried chicken, French fries, coffee
d. Broiled shrimp, steamed okra, coke
18. Leorio, a 3-year old child, is admitted due to diarrhea for 2 days. For a clear liquid diet, which of the following is
best for the child?
a. Water c. Pedialyte
b. Orange juice d. Broth
19. Kurapika, a 10-month old baby, has had measles. He had loose bowel movement while in the hospital. Which of
the following would you advice the mother to continue hydration therapy at home?
a. Rice based solution or am
b. Diluted soup and tea
c. Orange juice or coke
d. Discontinue breast milk
20. Which of the following should be included in the teaching plan for a client with ulcerative colitis who is about to
be discharge?
1. High protein diet 3. High residue diet

2. Low protein diet 4. Bland diet

a. 2 and 4 c. 2 and 3
b. 1 and 4 d. 1 and 3
Situation 5. Nurse Hinata is assigned to work in an orthopedic ward where clients are expected to have problems in
mobility and immobility.
21. Narutos right leg is injured and nurse Hinata has to move him from the bed to the wheel chair. Which of the
following is the appropriate nursing action of nurse Hinata?
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
22. Ino has to be maintained on a dorsal recumbent position. Which of the following should be prevented?
a. Adduction of the shoulder
b. Lateral flexion of the sternocleidomastoid muscle
c. Hyperextension of the knees
d. Anterior flexion of the lumbar curvature
23. Neji 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
b. Internal rotation of the shoulder
c. External rotation of the hip
d. Adduction of the shoulder
24. Gaara asks to be assisted to move up the bed. Which of the following should nurse Hinata do first?
a. Move the patient to the edge of the bed near the nurse
b. Adjust the bed to flat position
c. Lock the wheels of the bed
d. Raise the bed rails opposite the nurse
25. Which of the following supportive devices can be used most effectively by nurse Hinata to prevent external
rotation of the right leg?
a. Sandbags c. Pillow
b. Firm mattress d. High foot board
1. Answer: B
Rationale: A client with anemia (decrease in red blood cells) has problem in transporting oxygen from the lungs to
the tissue since hemoglobin, which is responsible in distributing oxygen to the different parts of the body, is located
inside an RBC. With decrease number of RBC, a decrease in the number of oxygen-carrying hemoglobins also
occurs.
2. Answer: C
Rationale: Hypoxemia refers to reduced oxygen in the blood. Cyanosis (option A) is the bluish discoloration of the
skin, nailbeds and mucous membranes due to reduced hemoglobin-oxygen saturation. Hypoxia (option B) is a
condition of insufficient oxygen anywhere in the body, from the inspired gas to the tissues. Anemia (option D) is a
decrease in red blood cells.
3. Answer: C
Rationale: In performing nasopharyngeal suctioning, the length of insertion of the tubing for an adult would be the
distance from the tip of the nose to the tip of the ear lobe.
4. Answer: C
Rationale: While doing nasopharyngeal suctioning, suction should only be applied while removing the catheter, not
while inserting it, in order to prevent trauma to the trachea.
5. Answer: B
Rationale: Orthopnea is the inability to breathe except in an upright or standing position. Apnea (option A) is the
cessation of breathing. Dyspnea (option C) is the difficulty or uncomfortable breathing. Tachypnea (option D) is an
abnormally rapid respiratory rate.
6. Answer: B
Rationale: A 25- to 27-gauge needle measuring a half-inch in length is commonly used when administering an
intradermal injection.
7. Answer: D
Rationale: The condition of the muscle tissue is an important factor that can influence the nurse's decision in
administering intramuscular medications. Muscles can take a larger volume of fluid without discomfort than
subcutaneous tissues can, although the amount varies among individuals, chiefly based on the muscle size and
condition and the site used.

8. Answer: A
Rationale: Among the many kinds of drugs administered subcutaneously (just beneath the skin) are vaccines,
insulin and heparin. Only small doses (0.5 to 1 ml) of medication are usually injected via the subcutaneous route.
9. Answer: A
Rationale: Intradermal injections are commonly used for diagnostic purposes such as skin testing. When giving an
intradermal injection, the nurse instills the medication shallowly at a 10- to 15-degree angle of entry. 45-degree
angle (option B) is used for subcutaneous injections. Option D is incorrect because 90-degree angle is used for
intramuscular injections. Option C is inappropriate.
10. Answer: A
Rationale: The ventrogluteal site uses the gluteus medius and gluteus minimus muscles in the hip for injection. This
site is safe for use in children. The vastus lateralis site uses the vastus lateralis muscle, one of the muscles in the
quadriceps group of the outer thigh. It is a particularly desirable site for administering injections to infants and small
children and clients who are thin or debilitated with poorly developed gluteal muscles. Dorsogluteal site is avoided in
clients younger than 3 years because their muscle is not sufficiently developed. Deltoid site is only used for adults.
11. Answer: D
Rationale: Nurses commonly use terms to describe types of hygienic care. Hour of sleep (HS) or Afternoon (PM)
care is provided to clients before they retire for the night. It usually involves providing for elimination needs, washing
face and hands, giving oral care and giving a back massage. Providing back rub or massage to bedridden clients
prevent the formation of pressure ulcers.
12. Answer: A
Rationale: To prevent aspiration of fluids into the lungs, the client is positioned on a side-lying position with head of
bed lowered. In this position, the saliva automatically runs out by gravity rather than being aspirated into the lungs
13. Answer: D Rationale: Mouth care for unconscious or debilitated people is important because their mouths tends
to become dry and consequently predisposed to tooth decay, mouth sores and infections. Normal saline is used if
clients cannot tolerate the use of a toothbrush. Option A is incorrect because lemon glycerin swabs are not
recommended as they irritate and dry the oral mucosa and can decalcify teeth. In option B, although hydrogen
peroxide is approved as a mouth rinse, which provide a cleaning action as well as an antimicrobial effect, it is still
diluted with a saline solution in order to decrease the burning sensation experienced by the client. Option C is
incorrect because mineral oil is contraindicated because aspiration of it can initiate an infection.
14. Answer: B Rationale: The advantages of oral care for a client includes: (option A) decreases bacteria in the
mouth and teeth; (option C) improves clients appearance and self-confidence; and (option D) improves appetite and
taste of food.
15. Answer: D
Rationale: The risk of fluid aspiration to the lungs can be avoided by suctioning as needed while cleaning the buccal
cavity because fluid remaining in the mouth may be aspirated by the client.
16. Answer: A
Rationale: Low sodium diet is prescribed to clients with chronic renal problems. Common food sources rich in
sodium are the following: table salt, soy sauce, canned foods (option B), processed foods and cheese (option C and
D), milk, butter, ketchup, tomato, mustard, bacon and snack food.
17. Answer: D
Rationale: Common food sources high in cholesterol includes: animal products (option C), egg yolks (option A and
B), whole milk,cooking oil, liver and organ meats. Fish (any fresh or frozen), canned crabs, lobster,salmon, tuna,
clams, oysters, scallop, shrimp and sardines are considered low in cholesterol.
18. Answer: C Rationale: Clients on clear liquid diet are allowed to ingest only liquids that keep the GI tract empty
(no residue). These foods are see-through foods, which includes water, tea, clear broth, jello, strained and clear
juices, ginger ale, hard candy, clear carbonated beverages and frozen ice pops. Clear liquid diets also provides
fluids and electrolytes to prevent dehydration. Options A and D, although considered clear liquid diets, option C
provides more electrolytes need by a client with diarrhea. In option B, some orange juices are strained with its pulp
while others are not.
19. Answer: A
Rationale: Home remedy to continue hydration therapy includes: rice based solution or am, tea, broth and breast
milk.
20. Answer: B
Rationale: Clients with ulcerative colitis are instructed to consume a low residue and high protein diet and to avoid
foods as whole wheat grains, nuts, raw fruits and vegetables. Gas-forming foods, milk products, caffeinated
beverages, alcohol and pepper are also avoided. Bland diets are recommended because it excludes foods that
may be chemically or mechanically stimulating or irritating to the GI tract.

21. Answer: D
Rationale: In transferring a client with a leg injury into a a wheelchair, instruct the client to move forward and sit on
the edge of the bed. This is to bring the client's center of gravity closer to the nurse's. Then place the wheelchair on
the clients stronger side. In this way, the client can use the stronger leg muscles to stand and power the movement.
22. Answer: C
Rationale: Clients on dorsal recumbent position are placed on a back-lying position with knees flexed and hips
externally rotated, small pillow is placed under the head, and the soles of the feet on the surface. Hyperextension of
the knees should be prevented since it is done in a supine position
23. Answer: A
Rationale: In a high fowlers position, the client's head and trunk are raised 90 degrees. Posterior flexion of the
lumbar curvature is avoided since it is done in an orthopneic position
24. Answer: B
Rationale: In assisting a client to move up the bed, the nurse should first adjust the bed to flat position, then lock the
wheels of the bed to prevent it from moving during moving, then raise the bed rails opposite the nurse to prevent
unnecessary fall, then move the patient to the edge of the bed near the nurse before moving the client up to bring
the client's center of gravity nearer to the nurse.
25. Answer: A
Rationale: Sandbags are used most effectively by the nurse to prevent external rotation of the injured leg.
Situation 6. Meg, a psychologist sought the help of Dr. Evangelista, a neurologist, because of headache.
History revealed that the headache started when she banged her right frontal area 2 months ago after the
bus she was riding on made a sudden stop.
26. For early detection of Meg's problem, Dr. Evangelista ordered EEG (electroencephalogram). This is:
a. Reading of the electrical activity of the grey matter of the brain
b. Reading of the electrical activity of the heart
c. Reading of the electrical muscle of the brain
d. Reading of the electrical activity of the dura matter of the brain
27. Nurse Naj should address to her that EEG is useful in assessing the following, EXCEPT:
a. Type of seizure disorder
b. Location of fraction
c. Infection such as meningitis
d. Extend of head injury
28. The nurse physical preparation for this diagnostic procedure to her client must include:
a. A clean body
b. An excellent bed bath
c. A good shampoo
d. A clean hair
29. Which of these must be avoided from 24 to 48 hours prior to EEG?
a. Stimulants and anti-convulsants
b. Stimulants and sedatives
c. Anti-pyretics and stimulants
d Anti-convulsants and analgesics
30. If desired, which of these foods may be allowed for Meg to take few hours before her EEG?
a. Tea c. Cola
b. Coffee d. Ice Cream
Situation 7. Senator Rann, a post exploratory laparotomy client, is transported to the surgical unit.
31. Nurse Leana's primary concern upon receiving Senator Rann in the unit is to:
a. Check proper positioning
b. Check for bleeding
c. Check the dressing
d. Check peripheral perfusion
32. The nurse saw blood on the big top dressing (BTD) about the size of a ten centavo coin, what step will Nurse
Leana do?
a. Encircle the edge of the bloody area with your pen
b. Reinforce the dressing
c. Change the dressing
d. Call the physician immediately

33. The following can be life threatening postoperative complications, EXCEPT:

a. Wound dehiscence c. Infection
b. Hemorrhage d. Secondary pneumonia
34. The physician ordered a vasoconstrictor drug PRN. Which of these will the nurse give?
a. Levophed c. Xylocard
b. Isordil d. Verelan
35. Senator Rann's blood pressure now is 80/60. In order to promote increased venous return from the legs without
interfering cardiac output, nurse Leana will position him in what matter?
a. The lower extremities is elevated at a 45-degree angle from the hip, with the knees straight and the head slightly
higher than the chest
b. Fowler's position
c. The lower extremities is elevated at a 35-degree angle from the hip, with the knees straight and the head on a
level more higher than the chest
d. Lithotomy position
Situation 8. 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.
36. Lucy 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%
b. White blood cells (WBC) 9000/mm
c. Erythrocyte sedimentation rate (ESR) - 39 mm/hr
d. Iron - 75 mg/100 ml
37. Surgical asepsis 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
38. 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 but without any symptoms
b. Oral temperature shows fever
c. Acute symptoms are no longer visible
d. Client feels sick but can do normal activities
39. Which of the following laboratory test result indicate presence of an infectious process?
a. Erythrocyte sedimentation rate (ESR) - 12 mm/hr
b. White blood cells (WBC) 18,000/mm3
c. Iron - 90 g/100ml
d. Neutrophils 67%
40. Among the clients you are assigned to take care of, who is the most susceptible to infection?
a. Diabetic client
b. Client with burns
c. Client with pulmonary emphysema
d. Client with myocardial infarction
Situation 9. Nicole, a two-year-old girl, is brought to the emergency department of San Pedro Hospital
because of poisoning.
41. The first emergency action in poisoning is:
a. Give the antidote c. Induced vomiting
b. Lavage the patient d. Identify the poison
42. If the poison is corrosive, what is the best way to mange the poison?
a. Induced vomiting
b. Do gastric lavage
c. Give two parts burned toast
d. Administer syrup of Ipecac
43. Universal antidotes includes the following, EXCEPT:
a. One part milk of magnesia
b. One tablespoon Ipecac
c. Two parts burned toast
d. One part strong tea

44. The least priority in giving nursing interventions for Nicole is directed towards:
a. Providing supportive care
b. Correcting acid-base imbalance
c. Removing the poison from the child's body
d. Teaching parents safety measures to prevent future accidental poisoning
45. What is the rationale for using activated charcoal in poisoning?
a. Promotes acid-base balance
b. Absorbs or inactivates substance
c. Precipitates metals, alkaloids and glucosides
d. Neutralizes acids
Situation 10. Mrs. Puring, 84 years old, is admitted to Bataan Doctor's Hospital for evaluation health status.
Understanding the characteristics of elderly will enable the nurse to plan carefully.
46. Which of the following statements is not a common observation in assessment of elderly clients?
a. Increased dependence
b. Decline in sex function
c. Reduced functional capacity
d. Disease is unavoidable
47. Mrs. Puring will have most difficult in distinguishing what color?
a. Green and red c. Gold and blue
b. Blue and green d. Red and blue
48. What should be avoided when talking with Mrs. Padma who has a hearing problem?
a. Face the client when speaking
b. Accompany talk with sign language
c. Shout loudly and clearly
d. Speak nearest to her ear
49. Mrs. Padma is prone to infection because of:
a. Diminished physical activities
b. Decreased immune system functioning
c. Increased exposure to microorganisms
d. inadequate nutrition due to poor appetite
50. The nurse knows that elders often have difficulty reading because of an age-related decrease in tear production
called dry eye. The most appropriate intervention for dry eye is to:
a. Encourage use of eye drops
b. Encourage reading indoors only
c. Empathize with them
d. Encourage them to get new eyeware
26. Answer: D
Rationale: EEG (electroencephalogram) is the reading of the electrical activity of the dura matter of the brain. The
electrodes transmit electric energy from the cerebral cortex to pens that record the brain waves on a graphic paper.
27. Answer: C
Rationale: EEG is useful in assessing the focus or foci of seizure activity, location of fraction, the extend of head
injury and to quantitatively evaluate level of brain function.
28. Answer: D
Rationale: The physical preparation for a client that will undergo EEG is a clean hair. Clients are instructed to
shampoo the hair the evening before the procedure to facilitate the attachment of the electrodes
29. Answer: B
Rationale: Clients undergoing EEG are instructed to withhold sedatives, tranquilizers and stimulants for 2 to 3 days
before the procedure. (
30. Answer: D
Rationale: When a client is scheduled for EEG, instruct the client to withhold coffee, tea and cola beverages for 8
hours before the procedure.
31 Answer: C Rationale: The nurse systematically checks the following during initial postoperative assessment: level
of consciousness, vital signs, effectiveness of respirations, presence or need for supplementary oxygen, condition of
the wound and dressing, location of drains and drainage characteristics, location, type and rate of IV fluid, level of
pain and need for analgesia and lastly the presence of a urinary catheter and urine volume.
32. Answer: B

Rationale: The size of the blood on the big top dressing is not life-threatening to call the physician immediately.
Changing dressings is not a responsibility of a nurse.
33. Answer: D
Rationale: Hemorrhage, Infection and Wound dehiscence are life threatening postoperative complications.
34. Answer: A
Rationale: Norepinephrine (Levophed) is a potent vasoconstrictor that improves cardiac contractility and cardiac
output.
35. Answer: A
36. Answer: C
37. Answer: A
38. Answer: B
39. Answer: B
40. Answer: B
41. Answer: D
42. Answer: B
43. Answer: B
44. Answer: B
45. Answer: B
46. Answer: D
47. Answer: D
48. Answer: C
49. Answer: B
50. Answer: A
Rationale: The primary symptom and discomfort of dry eye is dryness. Eye drops with saline restore and lubricate
the eye and reduce itchiness. Option B is incorrect because although dry eye commonly results in photosensitivity,
elders can still read outside if they protect their eyes with lubrication and use amber or yellow lenses. Option C is
incorrect because although empathy is a supportive approach, most elders are able to continue reading with the use
of lubrication. Option D is incorrect because the condition has already been diagnosed and new glasses will not
improve vision
Situation 11. In your professional caring role, it is essential to establish a meaningful nurse-patient
relationship.
51. A helping nurse-patient relationship is a process characterized by which of the following:
a. Recovery promoting c. Mutual interaction
b. Growth facilities d. Health enhancing
52. Demonstrating a helping relationship enables the nurse to establish in the patient:
a. Compliance to treatment
b. Positive response to illness
c. Gratitude for the nurse's service
d. Some sense of trust in the nurse
53. Therapeutic communication begins with:
a. Giving initial care
b. Knowing the patient
c. Interacting with the patient
d. Showing empathy
54. Which of the following approaches would most likely encourage the patient to accept the help given by the
nurse?
a. Attending to all his needs
b. Calling him by his first name

c. Demonstrating a relaxed attending attitude

d. Asking personal questions for health information
55. In an effective nurse-patient relationship, this is not a desirable nurse caring attitude:
a. Respect c. Empathy
b. Genuineness d. Firmness
Collaboration and Team Work
Situation 12. Clients need consistency and continuity of care to achieve goals. Therefore, the nurse shares
the plan of care with the members of the health care team.
56. It is considered as a physiologic complication requiring both nurse- and physician-prescribed interventions. They
represent an interdependent domain of nursing practice.
a. Nursing diagnosis c. Short-term goals
b. Collaborative diagnosis d. Long-term goals
57. Nurse Tanya works with other members of the health care team to achieve a common goal. The nurse is
practicing what basic role?
a. Delegator c. Collaborator
b. Educators d. Caregiver
58. A 2-year-old is admitted to the emergency department with a high fever of unknown origin. Which of the
following is the nurse correct to delegate to a nursing assistant?
a. Administer an aspirin suppository to reduce the child's fever
b. Give the toddler a Popsicle or other fluid every 30 minutes
c. Call the laboratory for the results of diagnostic tests
d. Listen to the child's lungs for sounds of congestion
59. According to most nurse practice acts, if a charge nurse assigns a licensed practical nurse (LPN) to admit a new
client, the LPN's primary role is to:
a. Create an initial nursing care plan
b. Gather basic information from the client
c. Develop a list of the client's nursing diagnoses
d. Report assessment data to the client's physician
60. At a team conference, staff members discuss a client's nursing diagnoses. A nursing assistant questions which
nursing diagnosis is of highest priority. From the list that follows, the licensed practical nurse is most accurate in
identifying
a. Ineffective Airway Clearance
b. Ineffective Coping
c. Deficient Diversional Activity
d. interrupted Family Processes
Health Education
Situation 13. Mrs. Rhusha is discharged from Brokenshire Hospital. During her hospital confinement, nurse
Catherine noted that Mrs. Rhusha lacks knowledge about her illness. The nurse made a discharge teaching
plan.
61. The choice of discharge teaching will depend on:
a. Continuing needs of the patient
b. Patient diagnosis
c. Instruction as ordered by the physician
d. Treatment regimen
62. Nurse Catherine can say that Mrs. Rhusha has learned when:
a. She say she understood
b. Promises to follow advise
c. Ask further questions
d. Takes the desired action
63. When giving counsel to Mrs. Rhusha, she is most likely to heed your advise when you:
a. Assure her of the benefits
b. Let her make the decisions
c. Threat her for non-compliance
d. Give her time to reflect on
64. Nurse Catherine can best model her teacher's role through:
a. Instructing patients after care
b. Giving incidental teaching

c. Providing health posters

d. Practicing healthy habits
65. One of the nurse's most important nursing activity in promoting health is:
a. Case finding
b. Conducting patient instruction
c. Assisting in immunization
d. Giving anticipatory guidance
Situation 14. Nurse's teaching role is most essential if the people accept to keep healthy and well.
66. Maslow's needs theory is ranked according to:
a. Priority needs of man
b. Physician's needs
c. Identified problems in health assessment
d. Practical needs for survival
67. When teaching an elderly, which is the most important ability the nurse would assess?
a. Sensory alterations
b. level of developmental tasks
c. Able to express feelings
d. level of health knowledge
68. Nurses' teaching will be more effective if they start:
a. With a problem area of concern to the patient
b. When the doctor has discharge orders
c. When the patient is ready to learn
d. As early as the first nurse-patient contact
69. What is the first thing that a nurse would do when planning a teaching session?
a. Set teaching objectives
b. Interview target audience to get their interest
c. Identify learning needs
d. Identify learning resources
70. Giving health information by itself is unlikely to result to better health of a patient unless:
a. Patient take health actions
b. Patient shows willingness to comply
c. The nurse's message is clear
d. Information has been shared with other patients
Legal Responsibilities
Situation 15. There are some related laws affecting the practice of nursing. Nurses should be
knowledgeable on this.
71. This law transfers responsibility for delivery of basic services and facilities of the national government to local
government units. This involves devolution of powers, functions and responsibilities to the local government both
provincial and municipal.
a. R.A. 7432 c. R.A. 7600
b. R.A. 7160 d. R.A. 7305
72. An Act requiring compulsory immunization against Hepatitis B for infants and children below 8 years old.
a. R.A. 2382 c. R.A. 7846
b. R.A. 4073 d. R.A. 9288
73. This liberalized the treatment of leprosy
a. R.A. 3573 c. R.A. 4073
b. R.A. 6425 d. R.A. 8749
74. The Clean Air Act approved in the year 2000.
a. R.A. 3573 c. R.A. 4073
b. R.A. 6425 d. R.A. 8749
75. Created the Philippines Institute of Traditional and Alternative Care.
a. R.A. 8423 c. R.A. 6675
b. R.A. 6713 d. R.A. 8172

51. Answer: C
52. Answer: D
53. Answer: D
54. Answer: C
55. Answer: D
56. Answer: B
Rationale: Collaborative problems are physiologic complications requiring both nurse- and physician-prescribed
interventions. They represent an interdependent domain of nursing practice. Since it requires the nurse to use
diagnostic processes, some nursing leaders are proposing the use of the term Collaborative diagnosis instead.
57. Answer: C
Rationale: To meet client needs, nurses perform four basic roles: caregiver, educator, collaborator and delegator.
The nurse acts as a collaborator when the nurse works with other members of the health care team to achieve a
common goal.
58. Answer: B
Rationale: Giving the toddler a Popsicle or other fluid every 30 minutes is an appropriate task that can be delegated
to a nursing assistant. Nurse have the responsibility of performing assessment (option D), intervention (option A)
and evaluation (option C).
59. Answer: B
Rationale: Licensed Practical Nurses (LPNs) usually provide basic direct technical care to clients. The Registered
nurse (RN), who has the knowledge and skill to make more sophisticated nursing judgments, is responsible for
assessing the client's condition, planning care and evaluating the effect of the care provided
60. Answer: A
Rationale: Ineffective Airway Clearance is the highest priority because loss of respiratory functioning is a lifethreatening problem.
61. Answer: A
62. Answer: D
63. Answer: B
64. Answer: A
65. Answer: C
66. Answer: A
67. Answer: A
69. Answer: C
70. Answer: A
71. Answer: B
Rationale: Republic Act 7160 is the Local Government Code which transfers responsibility for delivery of basic
services and facilities of the national government to local government units. Option A is the Senior Citizen's Act (R.A.
7432). Option C is the Rooming-in and breastfeeding Act of 1992 (R.A. 7600). Option D is the Magna Carta for
Public Health Workers (R.A. 7305).
72. Answer: C
Rationale: Republic Act 7846 is an act requiring compulsory immunization against Hepatitis B for infants and
children below 8 years old. Option A is the Philippine Medical Act (R.A. 2382). Option B is the Leprosy Act (R.A.
4073). Option D is the Newborn Screening Act of 2004 (R.A. 9288).
73. Answer: C Rationale: Republic Act 4073 liberalizes the treatment of leprosy. Except when the disease requires
institutional treatment, no person afflicted with leprosy shall be confined in a leprosarium. Patients shall be treated in
a government skin clinic, rural health unit or by a duly licensed physician. Option A is the Communicable Disease
Act of 1929 (R.A. 3573). Option B is the Dangerous Drug Act of 1972 (R.A. 6425). Option D is the Clean Air Act.
(R.A. 8749).
74. Answer: D Rationale: Republic Act 8749 is the Clean Air Act of 1999. Option A is the Communicable Disease Act

of 1929 (R.A. 3573). Option B is the Dangerous Drug Act of 1972 (R.A. 6425). Option C is the Leprosy Act (R.A.
4073)
75. Answer: A Rationale: Republic Act 8423 is the Traditional and Alternative Health Act of 1998. Option B is the
Code of Conduct and Ethical Standard of Public Officials and Employees (R.A. 6713). Option C is the Generic Act of
1988 (R.A. 6675). Option D is the ASIN (Act Strengthening Iodinization Nationwide) Law (R.A. 8172)
Personal and Professional Developmental
Situation 16. Miss Faye is being interviewed by Mrs. Tantoy, the chief nurse of the hospital, in relation to her
application in a tertiary hospital as a staff nurse.
76. When asked whether nursing is a profession or not, she quoted one authority who holds the view that a
profession is characterized by the following:
a. It is highly skilled and purely technical
b. It demands specialized preparation and training
c. It is determined by the compensation received by its members
d. It is a developing science
77. Mrs. Tantoy explained to Miss Faye that the philosophy of nursing in the tertiary hospital is consistent with the
generally accepted definition of nursing which is:
a. caring for the sick only because the well patients are taken cared of by primary hospitals
b. Putting the patient in the best condition for nature to act
c. Caring for the sick and well
d.Allowing the patient to determine the medical and nursing plan of action
78. Mrs. Tantoy further explained to Miss Faye that of the many functions of the nurse, the one that encompasses
both dependent and independent function is:
a. Application and execution of doctor's orders
b. Application and execution of nursing procedures and techniques
c. observation of signs and symptoms
d. Supervision of patient and those participating in the care
79. In one of the seminars on continuing professional education (CPE), one of the lecturer's emphasized the
following primary characteristics of a profession which is:
a. It can be used as a stepping stone to go abroad
b. Nursing action is best supported by natural instincts
c. It is governed by a code of ethics based on ethical principles
d. Emphasis of nursing responsibilities is on dependent rather than independent functions.
80. The objectives behind requiring nurses to attend CPE seminars and workshop are to:
a. Increasing revenue of the government and organization providing CPE
b. Update one's knowledge and skills relevant to nursing
c. Renew old acquaintances and establish camaraderie among nurses
d. Update list of professionals in the country
Record Management
Situation 17. Documentation and reporting are just as important as providing patient care. As such the
nurse must be factual and accurate to ensure quality documentation and reporting.
81. Health care reports have different purposes. The availability of patient records to all health team members
demonstrates which of the following purposes?
a. Legal documentation c. Research
b. Education d. Communication
82. Nurse Drosera commits medication error, she should accurately document client's response and her
corresponding action. This is very important for which of the following purposes?
a. Auditing c. Communication
b. Assessment d. Legal documentation
83. Problem-Oriented Medical Records (POMR) has been widely used in many teaching hospitals. One of its unique
features is SOAPIE charting. Using this as a guideline in charting for the 2nd P. Which of the following shall the
nurse include in her charting?
a. Prescription of the doctor to patient's illness
b. Plan of care for patient
c. Patient's perception of one's illness
d. Nursing problem or nursing diagnosis

84. The medical records that are organized into separate section, wherein each person or department makes
notations in a separate section or sections of the patient's chart, is classified into which type of record?
a. Problem-oriented record
b. Source-oriented record
c. Modified problem-oriented medical record
d. SOAPIE
85. Which one of the following is an advantage of the traditional client record as against the POMR record system?
a. Increases efficiency in data gathering
b. Reinforces the use of the nursing process
c. The care giver can easily locate proper section for making charting entries
d. Enhances effective communication among heath care team members
Management of Resources and Environment
Situation 18. Miss Castalia is a new head nurse in the newly opened ward. She wanted to initiate some
changes in the nursing care delivery system with the approval of the chief nurse.
86. For patient assignment, she explained to the staff that each one will be responsible to a certain number of
patients for the whole 24 hours and are expected to prepare a 24 hours nursing care plan for each assigned patient.
This method of nursing care delivery is termed which of the following?
a. Team approach c. Case management
b. Primary nursing d. Functional method
87. Even if individual patients are assigned to a particular nurse, the head nurse is still accountable for all the
nursing care services rendered in the ward. This belief is an application of which of the following management
principle?
a. Unity of command
b. Proper channel of communication
c. Scalar principle
d. command responsibility
88. For systematic and orderly management of care, the head nurse confers with the staff for 10-15 minutes to
organize the work for the day. Which of the following sequence of structuring tasks is CORRECT?
1. Assign tasks to the team
2. Present to the team the needs of the patients for the day
3. Match the task with the abilities of each staff members
4. Ask for suggestions from the staff
a. 4, 2, 3 and 1 c. 2, 4, 3 and 1
b. 3, 2, 1 and 4 d. 1, 2, 3 and 4
89. Per hospital, when a member of the staff commits an error, the head nurse prepares an incident report. In
making an incident report, which of the following information should be included?
1. Includes all pertinent facts regarding the incident
2. All names involved in the incident
3. Includes the head nurse's appraisal of the incident
4. Signatures of all parties involved
a. 1, 2 and 4 c. 1 and 2
b. 1 and 3 d. 1, 3 and 4
90. In the hospital where Miss Castalia is working, nurses are evaluated by the head nurse every six months. Which
of the following actions should the nurse take if she feels she is unfairly evaluated?
a. Share her feelings with the peer group
b. Submit a disclaimer to the chief nurse of the hospital
c. Accept the evaluation
d. Clarify from the head nurse the basis for her evaluation
Quality Improvement
Situation 19. Miss Hesper, a nurse supervisor, is observing the staff nurses in her hospital to see how
quality of care provided to clients can be improved.
91. Miss Hesper is not satisfied with the bed bath that is provided by nurse Arthur. To improve the care provided to
the patient in the unit, 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 the bed bath
92. 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
b. Considering effects on results
c. Defining the problem
d. Making final decisions
93. To check if the nurses under her supervision use critical thinking, Miss Hesper 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
b. Sharing ideas regarding patient care
c. Following standards of practice
d. Planning other approaches for patient care
94. The nurse who makes clinical judgment can be depended upon to improve the quality of care of clients. Nurse
Jenny uses such good clinical judgment when she gives priority care to this client:
a. Ulmus, a client who is ambulatory and for surgery tomorrow
b. A postoperative client, Elphas, who has a blood pressure of 90/50 mmHg
c. Mr. Asphalt, a client who needs instructions for home medications
d. Dracus, a client who received pain medications 5 minutes ago
95. 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
Research
Situation 20. Pronimo, 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.
96. 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 body of knowledge
c. Provides logical structure of the research findings
d. Identifies concepts and relationships between concepts
97. Pronimo need to review relevant literature and studies. The following processes are undertaken in reviewing
literature EXCEPT:
a. Locating and identifying resources
b. Reading and recording notes
c. Clarifying a research topic
d. Using the library
98. 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
99. In formulating the research hypotheses, researcher Pronimo 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 healthpromotion activities of the staff nurses?
d. How do health values affect health promotion activities of the staff nurses?
100. 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
b. Health values
c. Health promotion activities
d. Relationship between health values and health promotion activities

76. Answer: B
Rationale: According to William Shepard, one of the criteria of a profession is that it must demand the possession of
a body of specialized and systematized preparation and training.
77. Answer: C
78. Answer: A
79. Answer: C
80. Answer: B
Rationale: One of the objectives of CPE or Continuing Professional Education is to further enhance the skills of
nurses to provide quality patient care. The focus is to keep updated on new concepts, knowledge and techniques
that relate to nursing care.
81. Answer: D
Rationale: The records serves as the vehicle by which different health professionals who interact with a client
communicate with each other. This prevents fragmentation, repetition and delays in client care.
82. Answer: D
Rationale: The client's record is a legal document and is usually admissible in court as evidence. In case of
medication errors, the nurse should accurately document the client's response and her corresponding action to
serve as evidence.
83. Answer: B
Rationale: Problem-Oriented Medical Record (POMR) has four basic components: database, problem list, plan of
care and progress notes. The 2nd P is Plan of Care wherein the initial list of orders or plan of care is made with
reference to the active problems. Care plans are generated by the person who lists the problems.
84. Answer: B
Rationale: Source-Oriented Record or the traditional client record organizes its data into separate sections, wherein
each person or department makes notations in a separate section or sections of the patient's chart
85. Answer: C
Rationale: One of the advantages of Source-Oriented Record or the traditional client record is its convenience
because care providers from each discipline can easily locate the forms on which to record data and it is easy to
trace the information specific to one's discipline
86. Answer: B
87. Answer: A
88. Answer: C
89. Answer: A
90. Answer: D
91. Answer: D
92. Answer: A
93. Answer: C
94. Answer: B
95. Answer: C
96. Answer: B
97. Answer: C
98. Answer: D
99. Answer: C
100. Answer: B