1.

Answer: B

a) Gastric lavage
Gastric lavage cannot be used as a general treatment for poisoning. It has limited
therapeutic effects and produces problems related with the procedure.

b) Activated charcoal
The administration of activated charcoal is the most effective in the management of
poisoning because it absorbs chemicals in the gastrointestinal tract, thus reducing its
toxicity.

c) Cathartic administration
The elimination of the poisonous substance could be aided by cathartic administration.
However, it is not the most effective intervention.

d) Milk dilution
Diluting the ingested poison with milk is not the most effective management for
ingested poison.

2.Answer: A

a) Botulism
Botulism is treated with antitoxins and induced vomiting or enema in the emergency
department. There is no vaccine available for the agent.

b) Smallpox
There is no exact treatment for smallpox, but antiviral medications and vaccines can
help improve the clients condition.

c) Anthrax
Antibiotics are the preferred treatment for anthrax.

d) Tularemia
The treatment for tularemia does not involve the introduction of antitoxins.

3.Answer: C
Rationale:

a) Let the client rest.

The client is already experiencing respiratory depression so the nurse must administer
naloxone (Narcan).

b) Administer oxygen.
It may be given but is not the priority at this time.

c) Administer naloxone (Narcan) per physicians order.

This is given to reverse respiratory depression.

d) Place epinephrine at the bedside.

This is unnecessary at the moment.

4.Answer: B

a) Temperature: 38.9C, BP 90/60, pulse 98 and thready.

This indicates dehydration.

b) Cool skin, respiratory crackles, pulse 84 and bounding.

Symptoms present in fluid volume overload are elevated blood pressure, bounding
pulse, edema, distended neck veins, headache, diarrhea, polyuria and hepatomegaly.

c) Abdominal pain, headache and lethargy.

This is not related to fluid volume overload.

d) CVP of 5, Urinary output: 700 cc/24 hours and nystagmus.

The CVP must be elevated (greater than 10 mm/H2O) and nystagmus is not present.

5.Answer: C

a) Stopping bleeding from open wounds

Circulatory needs or interventions can be done immediately after clients airway is
established and respirations has been stabilized.
b) Checking for neck fracture
Although this is also an important intervention this can be done after the priority
interventions were given to the client

c) Establishing an airway
This is the priority when caring for unconscious clients with multiple injuries. The nurse
should take note of ABC (airway, breathing and circulation) as a priority.

d) Replacing blood loss

Circulatory needs or interventions can be done immediately after clients airway is
established and respirations has been stabilized.

6.Answers: B, C, E and F

Rationale: Clients with stoma should be advised to regularly wash the stoma using
washcloth, apply thin layer of petroleum jelly into the skin surrounding the stoma to
avoid skin cracking and to keep water away from the stoma. Items such as soaps,
cotton swabs and tissues must not be used when caring for the stoma as these can
potentially enter the stoma and block the airway. Use of alcohol should not be practiced
as well as it can promote irritation and drying.

7.Answer: D

Rationale:
Fluid volume deficit is related to various conditions such as diarrhea, vomiting,
increased urinary output, heightened rates of respiration, inadequate fluid replacement,
ileostomy, draining fistulas and colostomy. Fluid volume excess on the other hand can
be observed in clients with liver cirrhosis, diminished kidney function and congestive
heart failure.

8.Answers: B, E and F

Rationale:
Fingertips should not be used to handle casts while it is still drying since it cause
indentations in the cast and can produce continuous pressure into the underlying skin.
Instead of using the fingertips, the palms of the hand should be used to lift the cast.
Sharp objects and small toys must be kept away from the cast, and padded objects
should not be placed inside the cast as it can increase the risk of altered skin integrity.
Heating pads should not be applied into the cast or fingers because the presence of cold
fingers may signify the development of neurovascular impairment and must be reported
to the doctor immediately. The affected side must also be elevated to prevent swelling.
And any signs of neurovascular impairment such as numbness and tingling in the
extremity should be reported right away to the health care provider.

9.Answer: B

Rationale:
a) Give a bottle if Ipecac to your child to induce vomiting.
Parents are advised to have Ipecac at home for each child. Doses range from 10 to 30
cc.

b) Induce vomiting if your child swallows lighter fluid.

Vomiting is contraindicated if hydrocarbons such as lighter fluid is ingested. This
increases the clients risk for aspiration.

c) Give your child water or milk to dilute the poison.

These fluids may dilute toxins.

d) Store harmful chemicals in hard to reach areas.

Store harmful chemicals so that children cannot gain access to it.

10.Answer: D

a) The graft is warm to touch

A skin graft that is warm to touch indicates good circulation.

b) Brisk capillary refill is noted

Brisk capillary refill also indicates good circulation and skin perfusion.

c) Sanguinous fluid at the surgical drain

Sanguinous fluid noted at the surgical drain is normal after the surgical procedure and
would gradually turn into serosanguinous fluid then into serous fluid.
d) Graft has a different color from patients skin
The skin graft should have the same color with the patients skin. Discoloration
indicates poor perfusion to the skin graft.

11.Answer: C

Rationale:
Regression is characterized by a return to earlier behavior (such as in childhood) to
reduce anxiety is the basic defense mechanism in undifferentiated schizophrenia.
Projection involves blaming others and is related to paranoid schizophrenia.
Rationalization involves justification of ones actions. Repression is the basic defense
mechanism in neuroses.

12.Answer: A

Rationale:
Echopraxia is the copying and imitating of anothers behaviours and is related to the
lost of ego boundaries. Ego-syntonicity are behaviours that correspond with the
persons sense of self. Modeling is the conscious copying or imitating of someones
behaviors. Ritualism refers to repetitive and compulsive behaviors.

13.Answer: D

a) A schizophrenic client hearing voices

ECT is not used in schizophrenia, tranquilizers are commonly prescribed.

b) Client with an Antisocial personality disorder with a history of brawling

ECT is not commonly used in treatment of personality disorders.

c) Client who exhibits 7 different personalities or persona

ECT is not the treatment of choice for clients with split personality.

d) Client with major depression who is in antidepressants for 2 months

ECT is commonly used for treatment of major depression in clients who have not
responded to antidepressants.

14.Answer: B
a) Serotonin
Benzodiazepines do not affect the regulation of serotonin in the body.

b) GABA
Benzodiazepines are able to attach the receptors of GABA. The drug potentiates the
ability of GABA in the body.

c) Dopamine
Benzodiazepine does not affect the regulation of dopamine in the body.

d) Acetylcholine
When Benzodiazepine is absorbed in the body it does not alter the levels of
acetylcholine.

15.Answer: B

a) Serotonin
Benzodiazepines do not affect the regulation of serotonin in the body.

b) GABA
Benzodiazepines are able to attach the receptors of GABA. The drug potentiates the
ability of GABA in the body.

c) Dopamine
Benzodiazepine does not affect the regulation of dopamine in the body.

d) Acetylcholine
When Benzodiazepine is absorbed in the body it does not alter the levels of
acetylcholine.

16.Answer: C

a) Patient is drowsy
Drowsiness and patient lethargy are therapeutic effects of drug. Excessive levels of
magnesium would cause muscle weakness and unresponsiveness.

b) Exaggerated deep tendon reflexes

Below normal or absent deep tendon reflex is a sign of magnesium toxicity.
c) Urinary output of 180 ml for 8 hours
Magnesium is exclusively excreted by the kidneys. Urine output of <30ml/hour
suggests accumulation of toxic magnesium levels in the body.

d) Respiratory rate of 16/min

Magnesium sulfate toxicity would cause respiratory depression (RR is <12/min).

17.Answer: D

a) Early onset breast milk jaundice is common in breastfed infants.

This occurs in the first week of life due to insufficient breastfeeding.

b) Dont worry, jaundice is normal after birth.

Yellowish discoloration of the eyes and the skin is not normal if it occurs within the first
24 hours after birth.

c) Your baby was delivered preterm that is why he has jaundice.

Preterm and low birth weight infants will have physiologic jaundice that appears on the
second or third day after birth.

d) Breastfeed your baby frequently while we further assess your babys condition.
The jaundice occurred twelve hours after birth, which needs further investigation and
management. Frequent breastfeeding will provide nutrient needs and enhances bilirubin
excretion.

18.Answer: A

a) Effacement precedes dilatation

In a primipara, effacement usually occurs before dilatation begins.

b) Effacement and dilatation occur simultaneously

In a multipara, effacement and dilatation progress together.

c) Dilatation precedes effacement

Effacement precedes dilatation or it can happen simultaneously with dilatation.

d) Effacement is not necessary

Effacement is always necessary in the labor process of the client.
19.Answer: B

a) A large amount of bloody fluid

This can be a sign when the client is experiencing vaginal bleeding and is a danger sign
during pregnancy.

b) A moderate amount of clear to straw-colored fluid

With the fetus in a vertex LOA presentation and no other indicators of distress, amniotic
fluid should have a clear to straw-colored appearance.

c) A small amount of greenish fluid

This is noted when there is meconium passed before or during labor.

d) A small segment of the umbilical cord

This happens in a prolapsed umbilical cord.

20.Answer: A

a) Assess for presence of a full bladder.

Encourage the client in labor to void as necessary. Inform the client that a full bladder
can hinder efficient uterine contractions. An empty bladder allows more space for the
presenting part to pass through for delivery.

b) Suggest placement of an internal uterine pressure catheter to determine adequacy of

contractions.
This is a device placed into the amniotic space to measure the strength of uterine
contractions during labor. This is not a priority to use this time.

c) Encourage the woman to do deep breathing techniques.

Breathing techniques can help to handle discomforts during contractions but is not a
priority this time.

d) Suggest to physician that oxytocin augmentation be started to stimulate labor.

Induction of labor may be done when labor process is not progressing normally. For this
time, assessment for a full bladder is the priority.

21.Answer: B
a) Higher altitude changes the bodys absorption of essential nutrients.
Nutrition has nothing to do with the high number of RBC in higher altitudes.

b) Decrease in atmospheric oxygen stimulates erythropoiesis.

Clients residing at a higher altitude have less atmospheric oxygen available that is why
RBC production is stimulated and enhanced to cope up with the environment.

c) RBC sequestration of the spleen is impaired in higher altitudes.

The function of the spleen is not altered in high altitudes.

d) Limited production of leukocytes and platelets in higher altitudes makes the ratio of
RBC higher.
Platelet and leukocyte production are not altered in high altitudes.

22.Answer: B

a) Tremor
Tremor is clinically defined as the rhythmic and repetitive muscle movement.

b) Chorea
Chorea is clinically defined as brief and involuntary muscle twitching of the face or limbs
which hinders the clients mobility.

c) Athetosis
Athetosis is clinically defined as the presence of irregular and slow twisting motions.

d) Dystonia
Dystonia is similar to the definition of Athetosis but involves larger muscle areas.

23.Answer: C

a) Stand at arms length from the working area.

Standing close to the working area is a proper body mechanic to prevent muscle
fatigue.

b) Elevate adjustable beds to hip level.

The nurse should adjust the bed to waist level in order to prevent stretching and muscle
strain.
c) Swivel the body when moving the client.
Proper body mechanic includes turning the body as a whole unit when moving the client
to avoid twisting the back.

d) Move the client with wide base and straight knees.

The knees are bent to support the bodys center of gravity and maintain body balance.
Bending the knees will provide a wider base of support for effective leverage and use of
energy.

24.Answer: D

a) Move the left crutch and the right foot forward.

The two-point gait is applied when moving the left crutch and right foot at the same
time.

b) Move both crutches forward.

The swing-to or swing-through gait starts by placing both crutches forward.

c) Advance the affected leg and crutches together.

The three-point gait is applied when both crutches and the affected leg are moved
together.

d) Move the right crutch forward followed by the left foot

The four-point gait is applied by moving the right clutch forward followed by the left
foot. Then the left crutch will be moved forward followed by the right foot.

25.Answer: C

a) Osteoporosis
When too much calcium is dissolved from the bones, they lose density and are easily
fractured.

b) Arthritis
As we age, our joint tissues become less resilient to wear and tear and start to
degenerate manifesting swelling, pain, and oftentimes, loss of mobility of joints. This is
called arthritis.
c) Coccydynia
This is an Inflammation of the tailbone. Coccydynia is associated with pain and
tenderness at the tip of the tailbone between the buttocks. The condition is worsened
by sitting.

d) Muscular dystrophy
Muscular dystrophy is a group of inherited diseases in which the muscles that control
movement progressively weaken.

26.Answer: B

a) Monitor duration of stiffness and not the intensity to determine when to perform
ROM
This intervention is for arthritis.

b) When swallowing is difficult, give semi-solid foods instead of liquids to lessen the risk
of choking
This is a nursing intervention for Myasthenia Gravis due to difficulty swallowing.

c) Have the client sleep with a pillow between the trunk and arm to decrease tension on
the supraspinatus tendon and to prevent blood flow compromise in its watershed region
This is for a Rotator cuff tear condition. This is to provide comfort for the client.

d) Position the client in a semi-fowlers position to relieve dyspnea

This is for respiratory disorders such as Pneumonia. We place the client in this position
to relieve difficulty of breathing.

27.Answer: B

a) Surgery
As much as possible, surgery should be the last resort for musculoskeletal pain.

b) Opioids
When pain was not relieved by NSAIDs, opioids will be the next choice of treatment
most especially for moderate to severe pain rated 9/10.
c) Alternative NSAID
Since previous NSAID seems to be ineffective, there is no reason to prescribe another
brand. They have same content.

d) Chiropractic treatment
This treatment involves spinal adjustment, but since physical therapy did not produce
beneficial outcome, this is no longer advisable.

28.Answer: D

a) Albumin
Albumin is a protein made by the liver. A serum albumin test measures the amount of
this protein in the clear liquid portion of the blood.

b) CPK-MB
The CPK-MB test is a cardiac marker used to assist diagnoses of an acute myocardial
infarction.

c) RBS
Random glucose test or random blood glucose (RBG) is taken from a non-fasting
subject.

d) RH-factor
This is the correct answer. The rheumatoid factor (RF) test is primarily used to help
diagnose rheumatoid arthritis (RA) and to help distinguish RA from other forms of
arthritis or other conditions that cause similar symptoms.

29.Answer: C

a) Notify the physician immediately.

The nurse must check the peripheral pulses before notifying the physician.

b) Schedule the client for emergency surgery.

This is not a priority intervention for a client with arterial insufficiency.

c) Recheck pedal pulses with a Doppler.

For 15% of the normal population, the dorsalis pedis is not palpable. Also, the pulses
may disappear after exercise, so reassessing the peripheral pulse would be an
appropriate intervention.

d) Assess the apical and radial pulses for any irregularity.

The pulses to be assessed are the distal and peripheral pulse.

30.Answer: A

a) It is the constriction of the cutaneous vessels due to the vasospasm of the arterioles
and the arteries of the upper and lower extremities. Raynauds disease affects primarily
the fingers, toes, ears and cheeks due to the vasospasm of the arterioles and the
arteries of the upper and lower extremities. It therefore causes numbness, tingling,
sweating and coldness of the affected body part.

b) It is an occlusive disease of the median and small arteries and veins. This is a
description of Buergers disease.

c) It is the abnormal dilation of the arterial wall caused by localized weakness and
stretching in the wall of the artery. This is what happens in an aortic aneurysm.

d) It is a chronic disorder in which partial or total arterial occlusion deprives the lower
extremity of oxygen and nutrients. This is a description suitable for explaining
peripheral arterial disease.

31.Answer: C

a) First degree AV block

In this type of AV block, the interval between the PR node increases.

b) Second degree AV block

In this type of AV block, electrical conduction between the atria and ventricle is blocked.

c) Third degree AV block

In this type of AV block, there is no conduction of impulses through the AV node. It is
also known as complete heart block.

d) Fourth degree AV block

This type of AV block does not exist.
32.Answer: D

a) A complete health history with emphasis on preceding events.

It may provide vital information but is not the priority this time.

b) Chest exam with auscultation

It may also provide vital information but is not the priority this time.

c) An electrocardiogram
It may provide information about the electrical activity of the heart but is not the
priority this time.

d) Take clients vital signs.

This action provides a baseline wherein further interventions can be based.

33.Answer: C

a) Ventricular septal defect (VSD)

It is a defect in the ventricular septum, which is the wall dividing the left and right
ventricles of the heart. Infants having this kind of condition show signs of pansystolic
murmur along lower left of sternal border

b) Atrioventricular septal defect (AVSD)

It is characterized by an abnormal or inadequate fusion of the superior and inferior
endocardial cushion with the mid portion of the atrial septum and the muscular portion
of the ventricular septum. Upon cardiac auscultation, atypical murmur and loud heart
tones can be heard.

c) Tetralogy of Fallot (ToF)

Tetralogy of Fallot is one of the most common congenital heart disorders. Infants with
ToF disorder often display difficulty with feeding, failure to thrive, episodes of bluish
pale skin during crying or feeding and exertional dyspnea, usually worsening with age.

d) Ebsteins Anomaly
It is a rare heart defect thats present at birth (congenital). In Eibsteins anomaly, the
tricuspid valve doesnt work properly and blood leaks back through the valve. This
condition may also lead to enlargement of the heart or heart failure.
34.Answer: A

a) Creatinine kinase
Creatinine kinase levels are used primarily to aid in the diagnosis of acute MI or skeletal
muscle damage. However, vigorous exercise, a fall, or deep intramuscular injections can
cause significant increase in CK levels.

b) Amylase
Amylase is the enzyme produced by the pancreas that helps digest carbohydrates.
When the pancreas is inflamed, amylase is released into the blood. An increase in the
blood amylase levels may occur due to acute pancreatitis, cancer of the pancreas,
ovaries or lungs, cholecystitis or gastroenteritis.

c) Acid phosphatase
Acid phosphatase is an enzyme found in the kidneys, serum, semen and prostate gland.
An increase in this enzyme can cause prostate cancer or infarction, Pagets disease,
Gauchers disease, and multiple myeloma.

d) Alkaline phosphatase
Alkaline phosphatase is found primarily in the liver and bone. The importance of
measuring alkaline phosphatase is to check the possibility of bone disease or liver
disease. An increase in serum alkaline phosphatase may be due to liver congestion or
cholestasis and osteoblastic bone conditions.

35. Answer: B

a) Diaxozide
This drug is used in the treatment of hypoglycemia.

b) Nitroprusside
Sodium Nitroprusside is the drug of choice for hypertensive emergencies because it has
the most reliable antihypertensive activity. It takes effect immediately upon
administration.

c) Hydralazine
It was considered as the drug of choice for hypertensive emergencies but it is replaced
by Sodium Nitroprusside because of its unpredictable therapeutic profile.
d) Trimethaphen
It is a short-acting ganglionic blocking agent, used to produce controlled hypotension
during surgery.

1. Answer: A

The most critical part upon admission is the hydration status of the patient. While all
the answers were correct and important, the first objective is the hydration status of
the child.

2. Answer: B

Promoting venous return flow may prevent thrombophlebitis. A sign that a patient may
suffer from thrombophlebitis is called Homans sign. The other goals are not well
indicated in the assessment.

3. Answer: D

The proper way to irrigate the nasogastric tube is to use gentle pressure during the
instillation of the normal saline solution. Withdrawing the solution afterwards can end
the procedure. Gentle pressure is needed in order to preserve the integrity of the
stomach walls.

4. Answer: A

Open-ended questions can help the patient verbalize his feelings. It helps the nurse
explore the thoughts of the patient in order to provide a means of nursing care in terms
of psychological support and as an active listener.

5. Answer: D

As a client advocate, the nurse protects the interests of the client. She represents the
patient when the patient is not able to voice out his or her needs. She may also relay
information to the physician when the patient is not able to represent himself.

6. Answer: D.
Being a teacher in this situation means that you must allow the patient to learn proper
wound care on his own. As a teacher, the nurse helps the client to learn about their
health and health care procedures.

7. Answer: C

As a part of the healthcare team, nurses should be able to know that they have
responsibility on the situation above. In order to correct the behavior of the two nursing
aides, they must understand the reason to change the beddings. Giving them
information about the germ transmission is the appropriate approach.

8. Answer: B

Lactated Ringers Solution must be used within the first 24 hours. Colloids such as
D5Water and D5 NSS increase capillary permeability which may increase the risk of
pulmonary edema.

9. Answer: C

Assertion of automony is seen in 2 to 21/2-year-old toddlers as they begin their

language and social development. The stage of initiative vs. guilt (2) is more common
in the preschool-age child, 3 to 6 years. At 3 to 4 years of age, children have imaginary
playmates (1).

10. Answer: C

Stress does not always result in feelings of distress such as harmful or unpleasant
stress. The others options definitely describes stress.

11. Answer: A

A 1-year-old child normally learns to walk. Any interruption on this development such
as physical stress and hospitalization can affect the normal development. The child
should sit (4) by 6 months and should already be crawling (1) by 1 year of age.

12. Answer: B
A regular diet with moderate sodium is suggested for children who are in acute
glomerulonephritis. If the clients condition progresses to renal failure, sodium,
potassium, and protein are restricted

13. Answer: A

Clients who have been on anti-TB drug regimes for at least 2-3 weeks and have
absence of AFB in at least two successive sputum cultures, no longer need to be on
Respiratory Isolation. Taking medication alone, or the absence of adventitious breath
sounds such as rhonchi, rales, etc, or the absence of infiltrates on chest x-ray, usually
seen with Pneumonia would not be a reason to D/C Isolation, making choices (b), (c),
and (d) incorrect.

14. Answer: C

Rales are defined as abnormal lung sounds which is crackling in nature. Rhonchi is
characterized by dry coarse sounds which is present when the patient coughs. Wheezes
is common upon expiration and denotes narrowed passages.

15. Answer: A

The classic finding when an appendix ruptures is a sudden cessation of pain. Options b,
c and dare expected findings for a child of this age who is diagnosed with acute
appendicitis.

16. Answer: C.

Blood pressure elevation signals a frequent complication associated with Acute

Glomerulonephritis. The nurse should expect to assess blood pressure every 2 to 4
hours with vital signs. Options a, b and d are appropriate orders for a child with Acute
Glomerulonephritis

17. Answer: D

Patients with renal failure should have a diet that provides (high biologic value) proteins
rich foods such as eggs, dairy products and meats. These are necessary to maintain a
positive nitrogen balance. Foods high in calories are also necessary, and sodium intake
should be limited. Foods high in Potassium should be AVOIDED due to decreased ability
of the kidney(s) to filter and excrete Potassium

18. Answer: C

The HIV virus has been found and isolated in all of the above body fluids, as well as in
the stool and urine. However, the highest concentration is found in the blood of infected
individuals.

19. Answer: A

Although abstinence is still the best protection against spread of the HIV virus, the use
of a latex condom with a H20 soluble lubricant is the most effective means. Other
choices does not give assurance of preventing acquiring HIV virus.

20. Answer: C.

Using open-ended questions can allow the patient with depression to voice out his or
her problems or what is bothering him or her. Using silence at this time is not
appropriate as well as with the other options.

21. Answer: A

Being talkative indicates that the patient may be developing dementia.

22. Answer: D

Elderly patients, are at a higher risk for sustaining injuries, especially in unfamiliar
surroundings. While other choices are potential interventions that the nurse could
implement, choice (c.) would allow the patient to better visualize the surroundings,
delimiting possible accidents or falls. Orienting the patient, as well as checking the
patient, and keeping side rails up are also importan , each patient must be assessed
individually to determine which measure(s) should be employed

23. Answer: B
Percussion is first done in order to assess all the quadrants and the next is palpation
which involves direct pressure. This step can also elicit pain or dullness.

24.Answer: C

The cranial nerve I or olfactory nerve is responsible to take in the scents and send
signals to the brain.

25. Answer: D

Wheezes is continuous, lengthy, musical heard during inspiration or expiration. It is

common to those with asthma since there is an active narrowing of the bronchioles.

1. Rationale: C is the correct answer because it provides a moist environment for the
wound thus promotes healing as it reduces bacterial colonization. The other choices
though correct but they cannot explain clearly the importance of wound dressing. A is
wrong because it talks about avoiding to touch the wound. B is wrong because it is
more on assisting patients comfortable position. D is wrong because it is more on the
removal of the dressing and checking the condition of wound.

2. Rationale: A is the correct answer because the cause of thermal burns happens
usually in the house (e.g. kitchen) which makes a person more prone to hot liquids or
flames. B, C, and D are not considered as more frequent types though they may
happen at workplace.

3. Rationale: B is the correct answer because it uses age-dependent graphs which are
most preferred for children and neonates. A is incorrect because it is more applicable to
adults. Children have different body proportions compared to children. C is incorrect
because this scale is use to determine the color of the skin to determine the response
to the UV light.

4. Rationale: D is the correct answer because it correctly defines the type of burn
classification. Subdermal burn appears as white, brown, or deep red with no blisters.
Grafting is required and scarring will occur. A is wrong because it only involves
epidermis, dermis, and subcutaneous tissue; it appears as with or without blisters. B is
wrong because it only involves epidermis and extends into the papillary or superficial
layer of the dermis; there are small blisters. C is wrong because it involves only the
epidermis and no blisters.

5. Rationale: C is the correct answer because it correctly defines a stage 3 pressure

injury. A is wrong because it is a stage 4 pressure injury. B is wrong because it is a
stage 2 pressure injury. D is wrong because it is a stage 1 pressure injury. This stage
may be difficult to assess especially to individuals who have dark skin tones.

6. Rationale: D is the correct answer because it signifies that pain over the site is a
precursor to tissue breakdown. A, B, C, are wrong because they are secondarily check
during assessment of the skin and their presence may mean other skin condition.

7. Rationale: A is correct answer because massaging or rubbing any bony

prominences will only increase the chance of developing a pressure injury leading to
tissue damage. Pillows can be used to avoid pressure injury especially if the patient is
positioned properly. B is essential because it allows the body to repair itself. C is
essential because good skin hygiene preserves skin integrity. D explains the importance
of proper positioning in order to prevent shear and friction.

8. Rationale: C is correct answer because it is associated with a loss of protective

sensation (neuropathy) and/or the presence of ischemia with patients having diabetes.
A is wrong because it ranges from no pain to severe, constant pain. It is often worse
after standing for long periods. B is wrong because it is often accompanied by severe
cramping pain in the foot or calf muscle at rest when the legs are elevated.

9. Rationale: A is the correct answer because it is not true that nurses dont make
important decisions, rather they are. These decisions often include the total well-being
of their patients. B, C, and D are all options which clearly describe the importance of
using critical thinking by the nurses in the work field.

10. Rationale: B is the correct answer because it is in the evaluating stage where a
nurse collects the data in order to determine the outcomes. From the outcomes
gathered, a nurse compares and relates it to the goals set or the patient. If changes
need to be done, it is here where the nurse will continue, modify or terminate the
clients plan. A is wrong because it is the step where the nurse will analyze the data and
formulate diagnostic statements. C is wrong because it is a step where a nurse collects,
organize and validate the data. D is wrong because it is a step where a nurse
implements the interventions planned for the patient.

11. Rationale: D is the correct answer because it is the type of assessment use in
order to identify any life threatening problems and/or new or overlooked problems. A is
wrong because it is done during several months after initial assessment. B is wrong
because it is performed within specified time after admission to a health care facility. C
is wrong because it is performed during the ongoing process of nursing care.

12. Rationale: C is the correct answer because an objective data are the ones which
can be detected by someone else (observer) and can be measured using accepted
standard procedures; this is the reason why it is also termed as signs or overt data. A is
wrong because a subjective data is also referred as symptoms or covert data; these
type of data is the one that the patient feels. B is wrong because a constant data are
information which doesnt change over a period of time (e.g. blood type). D is
completely wrong because it is not included in the types of data that a nurse acquires.

13. Rationale: A is the correct answer because an actual diagnosis is made based on
the signs and symptoms present. B is wrong because it describes human responses to
levels of wellness in an individual, family, or community that have a readiness for
enhancement: (NANDA International, 2005, p.277). C is wrong because it is made
based on the presence of risk factors that suggest that a problem will likely occur if it is
left untreated and/or left unseen by the healthcare team. D is wrong because it is a
type of diagnosis which is related to a number of other diagnoses.

14. Rationale: C is the correct answer because Maslows hierarchy of needs is not self-
centered rather it is problem centered. A, B, and D are all characteristics of Maslows
hierarchy of needs.

15. Rationale: B is the correct answer because it is one of the needs that Kalish added
between the physiologic and safety and security needs of Maslow. A is wrong because
affection needs is under the love and belongingness needs of Maslow. C and D are
wrong because independence needs and recognition are under the self-esteem needs of
Maslow.
16. Rationale: D is correct because a Denver Developmental Screening Test is an
example of screening survey and/or procedures. A and C are wrong because they are
both primary level of prevention. B is wrong because it is an example of a tertiary level
of prevention.

17. Rationale: A is correct because it correctly defines the contemplation stage. B is

wrong because it is the preparation stage. C is wrong because it is the action stage. D
is wrong because it is the maintenance stage.

18. Rationale: D is correct because this model considers that sickness is the inability
to fulfill ones role. A is wrong because this model deals about how an individual adapts
with his environment towards to good health. Both B and C are wrong because they are
not included in the accepted models of health and illness.

19. Rationale: C is the correct answer because lack of body nutrients predisposes a
certain individual in acquiring a disease; other example include environmental factor or
stress factor. A and B are both wrong because climate and economic level are all
example of environment factor. D is wrong because family history is an example of host
factor; other example includes age and lifestyle habits.

20. Rationale: A is correct because it is not included in the four aspects; it is not true
that clients are held responsible for their condition. B, C, and D are all included in the
four aspects of sick role.

21. Rationale: B correctly describe the about growth and development. A is wrong
because the pace of growth and development is uneven; as such, growth is greater
during infancy compared to childhood. C is wrong because development becomes
increasingly differentiated, i.e. it starts in a generalized response to a skilled specific
response. D is wrong because development proceeds from single acts to integrated
acts.

22. Rationale: D is correct because this nursing intervention is very important in

toddlerhood stage. A is wrong because it is important during adolescence stage. B is
wrong because it is important during neonatal stage. C is wrong because it is important
in the preschool stage.
23. Rationale: B is correct because during this age that anal stage happens. A is
wrong because it happens during latency stage. C is wrong because it is just a diversion
to the choices. D is wrong because it happens during the phallic stage.

24. Rationale: A is correct because it is the right negative resolution during early
childhood; others include compulsive compliance and defiance. B and C are both wrong
because they happen during infancy stage. D is wrong because it happens during late
childhood stage.

25. Rationale: C is the correct term for the definition given above. A is wrong because
accommodation is defined as the process of change where cognitive processes mature
sufficiently to allow an individual to solve problems that were unsolvable before. Both B
and D are wrong because they mean the same thing; it is the ability to deal with the
demands in the environment.

26. Rationale: A is correct because a low stress level will result to a less risk of low
birth weight baby. B, C, and D are all maternal factors that contribute to the higher risk
of low birth weight babies.

27. Rationale: C is correct because tonic neck reflex is the other term for fencing
reflex; it is defined as the postural reflex which disappears after 4-6 months. A is wrong
because Babinski reflex is characterized as rising of the big toe and fanning out of other
toes when the sole of the foot is being stroked. B is wrong because it is also known as
the walking or dancing reflex which disappears at about 2 months. D is wrong because
a palmar reflex happens when a small object is placed against the palm of the hand
causing the fingers to curl on it.

28. Rationale: D is correct because according to Erikson the resolution of this stage
will determine how a person will handle to resolve the next stages to come. A, B, and C
are all diversion to the question.

29. Rationale: A is correct because the statement acknowledges the patient in a

nonjudgmental way. B is wrong because it uses a presenting reality technique. C is
wrong because it uses an offering self technique. D is wrong because it uses an open-
ended questions technique.
30. Rationale: C is correct because it describes how a nurse clearly applies the
humanistic theory towards his patient. D is wrong because the nurse applies the
cognitive theory. A and B are both wrong because they describe a nurse who uses the
behavioristic theory.

31. Rationale: A is correct because an adult will response to either new or same
situations based on the previous experiences that they encountered. B is wrong
because people will mature from dependence to independence. C is wrong because an
adults readiness is related to developmental task or social role. D is wrong because
adult is more oriented in learning when the materials are presented immediately and
not in the future.

32. Rationale: D is correct because it indicates that a patient may have a problem
with his health literacy level. A, B, and C are not client behaviors that will indicate a
health literacy problem to a patient.

33. Rationale: C is correct because a minimal leader activity level depicts a laissez-
faire style which is why it is considered as inefficient. A and B are both wrong because
they are both high in terms of leader activity level.

34. Rationale: B is correct because evaluation of care effectiveness should be done by

nurses; unlicensed assistive personnel are not required to create a nursing care plan. A,
C, and D are tasks which can be delegated to unlicensed assistive personnel.

35. Rationale: D is the answer because the limbs should not be far from the body but
rather close to it. A, B, and C are all nursing interventions that can be done to patients
with hypothermia.

1.) Answer: D

Dark green leafy vegetables are good sources of iron. Oranges are good sources of
vitamin C that enhances iron absorption in the small intestines.

2.) Answer: B
Individuals with G6PD may exhibit hemolytic anemia when exposed to infection, certain
medications or chemicals. Salicylates such as Aspirin damages plasma membranes of
erythrocytes, leading to hemolytic anemia.

3.) Answer: B

Lower GI fluids are alkaline in nature and can be lost via ileostomy. Thus, loss of HCO3,
results to metabolic acidosis.

4.) Answer: C

Initially, respiratory system will try to compensate metabolic acidosis. Patients with
metabolic acidosis have high respiratory rate.

5.) Answer: A

Normal phosphorus level is 2.5 4.5 mg/dL .The level reflects hyperphosphatemia
which is inversely proportional to calcium. Client should be assessed for tetany which is
a prominent symptom of hypocalcemia.

6.) Answer: C

Clinical manifestations of pyloric stenosis include projectile vomiting, irritability,

constipation, and signs of dehydration, including a decrease in urine output.

7.) Answer: A, E, F, C, B, D

In accordance with the new guidelines, remember AB-CABS. A-airway B-breathing

normally? C-chest compression A-airway open B-breathing for patient S-serious
bleeding, shock, spinal injury. The nurse should first assess consciousness of the
patient. Next, open patients airway to check for breathing. When there is no breathing,
immediately perform chest compression then give 2 breaths, do the cycle of care over.
Finally, check for serious bleeding, shock, and spinal injury.

8.) Answer: D
Continuous bubbling seen in water-seal bottle/ chamber indicates an air leak or loose
connection, and air is sucked continuously into the closed chest drainage system.

9.) Answer: C

Testicular cancer is most likely to affect males in late adolescence. Undescended testis
is also one major risk for testicular cancer.

10.) Answer: D

Hypocalcemia occurs when there is accidental removal or destruction of parathyroid

tissue during surgical removal of the thyroid gland. Laryngospasm is one of the clinical
manifestations of tetany, an indicator of hypocalcemia.

11.) Answer: A

Its normal for a toddler to have bowlegs and a protruding belly. The head still appears
somewhat large in proportion from the rest of the body.

12.) Answer: D

13.) Answer: B

There is 6-8 months activity restriction following a spinal fusion. Sitting, lying,
standing, normal stair climbing, walking, and gentle swimming is allowed. Bending and
twisting at the waist should be avoided, along with lifting more than 10 lbs.

14.) Answer: D

Z-track technique is used to administer drugs especially irritating to the subcutaneous

tissue. This method promotes absorption of the drug by preventing drug leakage into
the subcutaneous layer.

15.) Answer: B
Establishing rapport is a way to gain trust that will lead for a patient to relax. You can
get more insights and information from a patient when rapport is established.

16.) Answer: A

Low magnesium (hypomagnesemia) produces clinical manifestations like increased

reflexes, tremors, and seizures. Magnesium Sulfate is the drug of choice to prevent
seizures in pre-eclampsia and eclampsia.

17.) Answer: C

Ear canal of children ages 3years and above can be straightened by pulling the pinna up
then backwards. For children below 3 years of age, the ear canal can be straightened by
pulling the pinna down then backwards.

18.) Answer: A

Infants are nose breathers. A gastric tube may be inserted to facilitate lung expansion
and stomach decompression, but not a nasogastric tube as it can occlude the nare,
thus, making breathing difficult for the infant.

19.) Answer: B

20.) Answer: B

Blind finger sweeps are not recommended in all CPR cases especially for infants and
children because the foreign object may be pushed back into the airway.

21.) Answer: B

First step in cardiopulmonary resuscitation (CPR) is assessing responsiveness of the

patient.

22.) Answer: C
Priority nursing action is to administer oxygen to patients with chest pain. Chest pain is
caused by insufficient myocardial oxygenation.

23.) Answer: D

Pneumococcal Vaccine is a priority immunization for the elderly. Seniors, ages 65 years
old and above, have higher risk for serious pneumococcal infection and likely have low
immunity. This is administered every 5 years.

24.) Answer: A

Burns on the face and neck can cause swelling of the respiratory mucosa that can lead
to airway obstruction manifested by hoarseness of voice and difficulty in breathing.
Maintaining an airway patency is the main concern.

25.) Answer: C

An in-line filter is required for blood transfusions.

26.) Answer: D

Negative outcome: Hemodialysis decreases red blood cell count which worsens anemia,
because RBCs are lost in dialysis from anticoagulation during the procedure, and from
residual blood that is left in the dialyzer.

27.) Answer: D

Decrease in level of consciousness and headache are early signs of increase in

intracranial pressure (ICP). Altered level of consciousness is the most common
symptom that indicates a deficit in brain function.

28.) Answer: B

Recall the anatomy of the colon. The appropriate position is left lateral to facilitate flow
of enema by gravity into the colon.
29.) Answer: D

Recall the 12 Rights of administration. Checking the patients name is critical for client-
safety.

30.) Answer: A , D

Crohns disease is a chronic inflammation of the colon with symptoms of diarrhea,

abdominal pain, and weight loss. Corticosteroid is a treatment for Crohns disease.
Antidiarrheal can give relief to diarrheal episodes. Aspirin should be avoided as it can
worsen inflammation. Those with Crohns disease are mostly lactose intolerant, so
choice no. (2) is incorrect.

1. Answer: A

Rationale:

Angina pectoris is a substernal pain that radiates to the neck, jaw, back and arms and
is relieved by rest. Lower abdominal pain may indicate other gastrointestinal problems.

2. Answer: A

Rationale:

50 mL/hr is the normal urine output. A normal urine output indicates that there is a
good renal perfusion, and also connotes that the client is hemodynamically stable,
therefore, the repair is successful.

3. Answer: A

Rationale:

In cardiac catheterization or coronary angiogram, a catheter is inserted into the heart

via a vein to measure the ventricular function. A dye is used to provide further
assessment of the structure and motion of the heart. Thallium is a radioactive isotope
injected parenterally so that the scintillation camera can count the radioactive uptake.
This is observed when a physician requests for a Nuclear Cardiology test. When
performing a Transesophageal Echocardiogram (TEE), a probe with a transducer tip is
swallowed by the client to visualize for valvular abnormalities, possible thrombus,
bacterial endocarditis and any congenital heart defects. When performing an
Intracoronary Ultrasound, a tiny ultrasound probe is inserted into the coronary artery to
evaluate for plaque size and consistency, arterial walls and effectiveness of the
treatment.

4. Answer: D

Rationale:

The central venous pressure is within the superior vena cava. The Normal CVP is 2-6
mmHg. A decrease in the CVP indicates a decrease in the circulating blood volume,
which may be a result of hemorrhage or fluid imbalances. The right atrium is located at
the midaxillary line at the fourth intercostal space, and the zero point on the transducer
needs to be at the level of the right atrium. The client needs to be supine, with the
head of the bed elevated at 45 degrees to correctly assess the CVP.

5. Answer: D

Rationale:

In hypokalemia, the electrocardiogram may show flattening and inversion of the T

wave, the appearance of a U wave, and ST depression. Hypercalcemia can cause a
shortened ST and widened T wave. The electrocardiogram of a hyperkalemic client
shows tall peak T waves, widened QRS complexes, prolonged PR intervals or flat P
waves.

6. Answer: A, B, E

Rationale:

Loading of drug depends on the type of dry powder inhaler. Take note that some dry
powder inhalers do not require loading. Dry powder inhalers are kept dry always and
are place at room temperature. Never shake a dry powder inhaler. It is not a
pressurized container. There is no propellant, only the clients breath can pull the drug
in. Because the drug is a dry powder and there is no propellant, the client will not feel,
smell, or taste the drug during inhalation. The clients breath will moisten the powder
causing it to clump and not be delivered accurately. Immediately after inhalation of
drug, the inhaler must be removed from the clients mouth to prevent moisture.

7. Answer: C, D, E

Rationale:

Stripping is not allowed. Also when changing the drainage system or when checking air
leaks, clamp the chest tube for short periods only. Emptying of collection chamber or
changing the drainage system should be done before the drainage comes in contact
with the bottom of the tube. Avoid kinks and dependent loops to allow effective
drainage and prevent disrupting the system. Report excessive drainage that is cloudy or
red. Drainage will often increase with position changes or coughing.

Bubbling is expected and indicates air drainage from the client. Absence of bubbling
may mean that the chest tube is obstructed, the lungs have fully reexpanded and no
more air is leaking into the pleural space. Keep drainage system lower than the level of
the chest to allow effective drainage.

8. Answer: D

Rationale:

Sodium Bicarbonate should be slowly administered because fast infusion may result to
abrupt reduction of serum potassium level which can eventually lead to arrhythmias.
Diluting or mixing the drug with hypotonic solution (i.e. D5W) or isotonic solution (0.9%
NaCl) can be ordered but not with hypertonic solution (I.e D10W).

9. Answer: D

Rationale:
Loosening tight clothing, applying warm blanket to prevent heat loss, and administering
oxygen supply might help but is not the priority this time. Direct pressure over the
bleeding site is a priority to prevent shock but placing a tourniquet on the artery is done
by a surgeon. Because the client is showing signs of altered mental status, there is
likely less perfusion in the brain, which calls for fluid resuscitation. At least two IV
access allows administration of fluids crystalloid, blood or clotting factors as necessary
which is vital in correcting acidosis, hypothermia and coagulopathy, and to restore
perfusion rapidly.

10. Answer: A

Rationale:

Cushings syndrome is clinically defined as the presence of excessive corticosteroids.

Addisons disease is clinically defined as adrenocortical insufficiency. Hypothyroidism is
a condition wherein there is insufficient thyroid hormone produced by the thyroid glands
while SIADH is characterized by excessive release of anti-diuretic hormone.

11. Answer: C

Rationale:

Facial tremors will occur even without performing a specific maneuver. Exaggerated
reflexes such as hyperreflexia can be assessed by performing a different maneuver.
Gentle tapping of the area below the zygomatic bone just in front of the ear is used to
elicit Chvostek sign to assess the presence of hypocalcemia. Trousseau sign is
characterized by spasm of the muscles of the hand and forearm upon inflation of a BP
cuff on it.

12. Answer: A, B, C, D, E and F

Rationale:

The leaking of vesicant drugs into surrounding tissue causes local tissue damage like
delayed healing, tissue necrosis, disfigurement, loss of function and even amputation.
13. Answer: B, C, E

Rationale:

Manual stimulation is recommended to evacuate impacted stool. Having the client sit up
straight and raise his head so that he is looking ahead helps reduce the blood pressure
as it allows gravitational pooling of blood in the lower extremities. Constrictive clothing
may trigger an autonomic reaction that would cause the blood pressure to go up so this
must be removed. Manual compression or tapping the bladder to allow urine to flow
down the catheter should be avoided because this would trigger an increase in blood
pressure. Administration of prescribed vasodilators is done to reduce high blood
pressure.

14. Answer: D

Rationale:

Option A is ataxic breathing. Option B is apneustic breathing. Option C is central

neurogenic hyperventilation. Cheyne-stokes breathing respirations are a pattern of
breathing in which phases of hyperpnea regularly alternate with apnea in a crescendo-
decrescendo pattern.

15. Answer: D

Rationale:

The lowest possible score for any response is 1. If a client is unresponsive to painful
stimuli, the score is 1. A score lower than 8 indicates that the client is in a comatose
state. The highest score for the GCS is 15. A score of 15 indicates an alert and oriented
person. A score of 3-8 indicates severe head injury.

16. Answer: D

Rationale:
Helping the client maintain an exercise program is a therapeutic intervention to
maintain joint mobility and good body alignment. This will also prevent venous stasis
due to impaired mobility. Client encouragement will not only address the physical
aspect of the disease but the clients emotions and self-esteem as well. The safety of
the client with impaired physical mobility should always be considered. Continuous
physical activity is not recommended. There should be an alternate period of activity
and rest to prevent excessive fatigue.

17. Answer: B

Rationale:

Receptive Aphasia refers to the inability to understand spoken words but can freely
express and verbalize. Expressive Aphasia refers to the inability to speak and
communicate formulated thoughts and sentiments. Global aphasia affects both
expressive ability and auditory comprehension. Apraxia is characterized by loss of the
ability to perform activities that a person is physically able and willing to do.

18. Answer: B

Rationale:

Graphesthesia is the ability to identify the writing on the skin even with the eyes closed.
The client provides a verbal response, identifying the figure that was drawn. Option A is
a test for stereognosis. Option C is a test used to assess the Rombergs sign while
option D is a test for Kernigs sign.

19. Answer: D

Rationale:

Any deterioration of oxygen saturation may necessitate intubation. However, the priority
this time is to maintain a patent airway. Infusion of IV fluids and administration of
antibiotics are expected nursing actions but not the top priority this time. Completing
vaccination at this time will not suffice or treat the underlying respiratory problem. The
situation calls for a curative management and not preventive measures. Airway closure
is the top priority. Throat examination is avoided as this increases the risk of laryngeal
obstruction. Aggression or agitation can also compromise airway and breathing.

20. Answer: B

Rationale:

Absorption is the process when the drug is transferred from the site of origin into the
bloodstream. Distribution occurs when the drug in the blood is distributed to different
parts of the body and accumulates in specific tissues. Metabolism or biotransformation
is the process wherein the drug is broken down into its inactive form. Excretion is the
bodys response to eliminate all the inactive form of the drug.

21. Answer: D

Rationale:

The Ventrogluteal site is safe for most intramuscular injections because it only involves
the gluteus medius and gluteus minimus muscles. The Vastus lateralis muscle is also a
safe injection site for intramuscular medications because there are no adjacent large
blood vessels and nerves. The deltoid muscle is a smaller muscle and is safe for
administration of intramuscular medications less than 1 mL. The Dorsogluteal muscle is
not recommended for intramuscular medications because of the potential damage to
the sciatic nerve. Large blood vessels are also located near the dorsogluteal muscle and
should be avoided.

22. Answer: B

Rationale:

Prescribing or stopping medications is the responsibility of the physician, thus the nurse
must refer this first. Thiazide diuretics cause loss of blood potassium while conserving
blood calcium, thus, the electrolyte level must be evaluated first.

23. Answer: D
The brandt-andrew maneuver is the proper extraction of the umbilical cord and
placenta. McRoberts maneuver is performed in case of shoulder dystocia during
childbirth. The Schultz mechanism is used to describe placental delivery. The Ritgens
maneuver is performed by applying pressure over the perineum and counter-pressure
on the fetal head. The Ritgens maneuver controls the exit of the fetal head and
prevents severe damage to maternal tissues.

24. Answer: B

Rationale:

The uterine fundus should start to descend after 24 hours of delivery. The normal rate
of uterine descent is 1 cm/day.

25. Answer: B

Rationale:

In Somatoform Disorder, there is no real organ damage, but the client verbalizes
symptoms of a disease in an unconscious manner. In Malingering, verbalization of
symptoms of a disease is conscious and is used by the client to achieve a secondary
gain or benefit. Anxiety comes in many forms panic attacks, phobia, and social anxiety
and the distinction between a disorder and normal anxiety isnt always clear. Amnesia
refers to the loss of memories, such as facts, information and experiences.

26. Answer: D

Rationale:

Not all chemotherapeutic agents alter the molecular structure of DNA. Chemotherapy
should slow down cell division not hasten it. All cells are sensitive to drug toxins.
Chemotherapeutic agents act on all rapidly dividing cells most action of
chemotherapeutic agents is that it affects all rapidly dividing cells including the normal
and cancer cells.

27. Answer: C
Rationale:

Ketoacidosis is associated with high levels of ketone bodies in the body brought by
breakdown of fatty acids and is not related to vomiting. Metabolic acidosis happens
when the body produces excessive quantity of acid. Severe vomiting will result to loss
of HCL and acids coming from extracellular fluids which in turn lead to metabolic
alkalosis. Respiratory alkalosis occurs when there is an increased respiration which
elevates the blood pH beyond the normal range of 7.35-7.45.

28. Answer: D

Rationale:

2nd degree skin reactions are evident by scaly skin, an itchy feeling and dry
desquamation. Reddening of the skin is not seen in 2nd degree skin reaction.

29. Answer: B

Rationale:

Tremor is clinically defined as the rhythmic and repetitive muscle movement. Chorea is
clinically defined as brief and involuntary muscle twitching of the face or limbs which
hinders the clients mobility. Athetosis is clinically defined as the presence of irregular
and slow twisting motions. Dystonia is similar to the definition of Athetosis but involves
larger muscle areas.

30. Answer: C

Rationale:

Standing close to the working area is a proper body mechanic to prevent muscle
fatigue. The nurse should adjust the bed to waist level in order to prevent stretching
and muscle strain. Proper body mechanic includes turning the body as a whole unit
when moving the client to avoid twisting the back. The knees are bent to support the
bodys center of gravity and maintain body balance. Bending the knees will provide a
wider base of support for effective leverage and use of energy.
1.Answers: B and F

Rationale:

Post supratentorial craniotomy clients must be positioned in semi-fowlers to promote

venous drainage from the head. These clients should also be lying with the head in a
midline position to prevent extreme hip or neck flexion. Positioning these clients in the
operative side must never be done as well since it can cause displacement of cranial
contents.

2.Answer: B

Rationale:

a. Nifedipine
This is a Calcium Antagonist that produces relaxation of coronary and vascular smooth
muscles and dilates coronary arteries which lowers blood pressure.
b. Dobutamine
Dobutamine is not included in the treatment because this is an inotropic agent which
increases heart rate and raises the blood pressure.
c. Terazosin
It is an alpha blocker used in the management of hypertension.
d. Nitroglycerine paste
This topical paste is very convenient and safe to use to decrease blood pressure. It can
be wiped off as the blood pressure begins to normalize.

3.Answer: B

Rationale:

a. Client is given pain medication as pain is initially common after surgery.

The client will not feel any significant pain because the size of the neck incision is so
small.
b. The client will receive fluid and nutrients through a small thin tube.
The thin tube which is an intravenous (IV) catheter will provide the client with the
necessary nutrients postoperatively.
c. The client may resume physical activities immediately after surgery.
The client usually can begin normal physical activities several weeks after the surgery.
d. The client may return home on the same day of the operation.
The client has to stay in the hospital for 1-2 days so that the physician can monitor the
clients progress.

4.Answer: C

Rationale:

a. Permanent change in voice.

Nerve injury produces hoarseness of the voice but this usually returns after a month.
b. Sleep apnea or nose breathing.
This is a possible complication of tonsillectomy, not nerve injury after carotid
endarterectomy.
c. Numbness in the face or tongue.
This is brought about by nerve damage to the neck.
d. Bleeding.
This is not expected after surgery because of the small neck incision.

5.Answers: A, C, E, F

Rationale:

a. Avoid stressful situations.

The client should try to avoid too much stress as this can trigger a seizure.
b. Take a bath instead of showers.
Taking a bath is dangerous due to a risk of drowning during a seizure. Taking a shower
is considered safer.
c. Wear a medical alert or ID bracelet.
Wearing identification card is important in case of emergency because it will help
bystanders know what to do.
d. Keep seizure medicines in your dressing table or within reach.
Seizure medicines should be kept in a safe place to prevent children from taking it.
e. Keep your bathroom and bedroom doors unlocked.
This enables the family members to access the room immediately in case the client has
seizure attacks.
f. Going to the gym is generally okay.
Activities like going to the gym, jogging, hiking, aerobics and bowling are safe activities
for clients with seizure.

6.Answers: B, D, E and F

Rationale:

Chronic bronchitis is a respiratory condition characterized by premature onset of cough,

copious purulent mucus production, mild weight loss and mild attacks of dyspnea
whereas, scarce mucus production and distinctive amount of weight loss are mainly
associated with pulmonary emphysema, along with other symptoms such as marked
dyspnea attacks and late onset of cough. Barrel chest can occur over time.

7.Answer: C

Rationale:

a. Increased amount of vasodilation in the lungs

RDS is characterized by poor gas exchange and ventilatory failure.
b. Small surface area of the premature lungs
Premature infants are born with numerous underdeveloped and many uninflatable
alveoli.
c. Decrease amount of surfactant in the infants lungs
RDS refers to a condition of surfactant deficiency and physiologic immaturity of the
thorax.
d. Increase in the amount of surfactant in the infants lungs
There is decreased amount of surfactant in the infants lungs.

8.Answer: A

Rationale:

a. Notify the physician and document initial findings.

The nurse must notify the attending physician and relay the findings. Documentation is
one of the essential responsibilities of a nurse that should not be missed. Baseline data
helps in making clinical decisions.
b. Facilitate chest X-ray.
The nurse cannot facilitate any diagnostic or laboratory test without the physicians
advise.
c. Start a thorough physical examination and history.
A physical examination and history taking has already been done. A much thorough
examination is unnecessary and time-wasting.
d. Recheck the client after five minutes and see if there are changes.
There is a significant finding that should be relayed to the physician as soon as possible,
so delayed care is avoided.

9.Answer: C

Rationale:

a. Peak flow meter

Peak Flow Meter measures how air flows from the lungs but does not determine tissue
perfusion rate or oxygen saturation. The most important determinant to initiate
intubation is the percentage of oxygen in the blood.
b. Partial Oxygen Saturation in Arterial Blood Gas
Although this is a more accurate reading of oxygen saturation, obtaining ABG before an
intubation is time-wasting and causes treatment delay. It is not an ideal measurement
tool in an emergency set-up.
c. Oxygen Saturation in Pulse Oximeter
Getting the oxygen saturation through a pulse oximeter is quick and easy. This is a non-
invasive test and is the ideal tool to determine episodes of failing respiratory function
requiring immediate intubation.
d. Lung Function test
This is a breathing test that measures how much air can be blown out of the lungs and
how quickly. This does not measure the amount of oxygen present in tissues/cells.

10.Answer: C

Rationale:
a. Mild Intermittent
Symptoms occur less than once a week, episodes are short, lasting only a few hours,
symptoms are present at night no more frequently than twice per month.
b. Mild Persistent
Symptoms occur more than once per week, symptoms are present at night more than
twice per month and episodes affect activity and sleep.
c. Moderate Persistent
Symptoms occur daily, episodes affect activity and sleep, and symptoms are present at
night more than one per week.
d. Severe Persistent
Symptoms occur daily, episodes are frequent, and symptoms are present at night
frequently.

11.Answer: C

Rationale:

a. Allergic reaction
Allergic reaction occurs after an initial exposure to an allergen. This manifests on people
who were previously exposed to the drug and has developed antibodies.
b. Cumulative effect
This reaction occurs when the body develops drug tolerance and needs increasing the
drug quantity to achieve a desired effect.
c. Idiosyncratic effect
Idiosyncratic effect is defined as the peculiar or abnormal response of the body to the
drug. There could be a heightened or decreased reaction. Other people will manifest
with a different response from the expected outcome.
d. Synergistic effect
Synergistic effect refers to the combination of drugs that produces a greater effect
compared to a single drug administration.

12.Answer B

Rationale:
Aminophylline preparation is 250mg/10 ml. Since the physician ordered 500 mg, divide
it with 250 mg to get 2 ampules: 500mg / 250 mg = 2 ampules.

13.Answer C

Rationale:

Given : Weight = 10 kg
Required dose = 100 mg/kg/day
Concentration = 40 mg/ml
Step 1 Calculate the drug in mg. 10 kg x 100 mg/kg/day = 1000 mg/day
Step 2 Divide the dose by the frequency. - 1000 mg/day 1 (day) = 1000 mg/dose
Step 3 Compute mg/dose to ml. 1000 mg/dose 40 mg/ml = 25ml

14.Answer: A

Rationale:

a. Client will develop a trusting relationship with the nurse

Agreement and the formation of trust in the helping relationship are made during the
orientation phase and not on the working phase.
b. Client will actively participate in the helping relationship
Active participation is a part of the working phase.
c. Client will participate in activities geared towards attaining the goal
In the working phase, the client and the nurse will work towards achieving acceptable
goals.
d. Client will express feelings and concerns to the nurse
Client expression of feelings and concern are important aspect of the working
relationship.

15.Answer: C

Rationale:

a. Cardiac output
Cardiac output is the medical term referring to the quantity of blood circulated every
minute.
b. Preload
Preload is the medical term referring to the blood volume in the ventricles at the end of
diastole.
c. Afterload
Afterload is medically defined as the force opposing ventricular ejection.
d. Vascular resistance
Vascular resistance is medically defined as the opposition of the vascular bed to the
volume of blood ejected.

16.Answer: B

Rationale:

a. Respiratory distress
Clients with acute respiratory distress are immediately intubated.
b. Prolonged mechanical ventilation
Clients who are expected to have longer mechanical ventilation need a tracheostomy
not an endotracheal tube.
c. High risk of aspiration
Endotracheal intubation is needed for clients who are at high risk of aspiration at the
ICU.
d. Ineffective clearance of secretions
ICU clients who are unable to effectively clear airways secretions need endotracheal
intubation.

17.Answer: A

Rationale:

a. Delirium
Delirium is an altered state of awareness manifesting symptoms of disorientation,
confusion, restlessness, hallucination, and agitation.
b. Dementia
Dementia is the state of awareness wherein the client has difficulty regarding memory,
orientation, and language.
c. Stupor
Stupor is a more severe alteration in the state of awareness wherein the client is mostly
unconscious but can be aroused with painful or repetitive stimuli.
d. Confusion
The client in the state of awareness has a reduced awareness or is easily distracted.

18.Answer: C

Rationale:

a. Dull
A dull tone is normally noted over the liver and diaphragm.
b. Flat
A flat tone is usually noted over the sternum and thighs.
c. Tympanic
Tympanic is the characteristic tone of the abdomen on percussion. Tympany is an
expected finding since the client is on the first operative day and the clients
gastrointestinal tract is filled with air postoperatively.
d. Resonant
Resonance is a tone particularly noted over the normal lung.

19.Answer: D

Rationale:

a. 20/20 vision
A 20/20 vision is considered perfect vision.
b. Eye usually blinks 20 per minute
This is a normal assessment.
c. There are 5-35 bowel sounds
This is normal for a bowel sound.
d. There is negative knee jerk
There should be a positive knee jerk.

20.Answer: C
Rationale:

a. High pitch sound

Wheezes are usually the type of breathing with high pitch sound.
b. Unpredictable
Biots respiration is an abnormal pattern of breathing characterized by groups of quick,
shallow inspirations followed by regular or irregular periods of apnea.
c. Intermittent on inspiration
Rales may happen during inspiration and is characterized by crackles which may be due
to fluid in the lungs.
d. Constriction
Wheezing is caused by constriction or narrowing of airways.

21.Answer: B

Rationale:

a. Right upper quadrant

Liver and gallbladder are located here.
b. Right lower quadrant
The appendix and Ileocecal valve can be found here.
c. Left upper quadrant
Spleen and pancreas are present in this quadrant.
d. Left lower quadrant
The colon can be found here.

22.Answer: D

Rationale:

a. Whisper test
The whisper test does not use a tuning fork during the procedure.
b. Rinne test
Rinne test is performed by placing the tuning fork over the mastoid process and not on
the clients head.
c. Audiometer
An audiometer is a diagnostic tool and is different from a tuning fork.
d. Weber test
Weber test is performed by activating the tuning fork and placing it on top of the
clients head.

23.Answer: D

Rationale:

a. 2nd ICS, Right sternal border

This is the landmark for the aortic area.
b. 2nd ICS, Left sternal border
This is the landmark for the pulmonic area.
c. 5th ICS, Left sternal border
This is the landmark for the tricuspid area.
d. 5th ICS, Medial to the midclavicular line
The mitral area is located at the 5th ICS which is medial to the midclavicular line.

24.Answer: C

Rationale:

a. Check clients temperature.

The task is not communicated in a clear and complete manner.
b. Attend to the client who buzzed the emergency button.
The task should be communicated with clear directions and a set of parameter to
resolve confusion.
c. Turn the client every 2 hours following this schedule for tonight and report any skin
changes.
The nurse should communicate the task in a clear, correct, complete, and concise
manner. The nurse should also communicate the parameters expected. After
communicating the task, the nurse should clarify and ask for the delegates input.
d. Provide mouth care to intubated clients in the ward for the morning shift.
The parameter in this statement is unclear and incomplete.

25.Answer: A
Rationale:

a. Hypoactive bowel sounds

Normal serum calcium level ranges from 8.5 10 mg/dL. The condition of the client is
called hypocalcemia. Hyperactive bowel sounds are expected not hypoactive.
b. Muscle cramping
This is a sign of hypocalcemia.
c. Numbness in hands and feet
This is a sign of hypocalcemia.
d. Positive Chvosteks sign
This refers to the sustained twitching of facial muscles after tapping the cheekbone.
This is a hallmark of hypocalcemia.

26.Answer: B

Rationale:

a. Elevate the head of the bed 90 degrees.

The head of the bed must be elevated 30 to 45 degrees to avoid strain on the eyes.
b. Suggest client to sleep on the non-operative side.
This decreases the pain and swelling that the client may experience.
c. Assist the client in a sitting position to promote blood circulation every 15 minutes.
The client must be instructed to avoid bending, coughing and sitting, as it will cause an
increase in the intraocular pressure, which may further strain the eyes of the client.
d. Educate the client about the importance of aerobic and weight lifting exercises for a
more rapid recovery.
The client should be instructed to avoid any strenuous exercises like weight lifting to
avoid an increase in the intraocular pressure.

27.Answer: A

Rationale:

Option A: This describes how TURP is performed.

Option B: This refers to how Cystocopy is performed.
Option C: This refers to how Prostatectomy is performed.
Option D: This refers to how Cryosurgery for prostate cancer is performed.

28.Answer: A

Rationale:

Option A: In THR, general anesthesia is used to sedate the client. The client will be
unable to bear weight on the operated hip right away hence a Foley catheter will be in
place for urination and a tube for drainage. To prevent rotation of the hip or crossing of
legs, a firm pillow will be placed in between the legs.
Option B: The implant will remain in the hip joint for a lifetime and will only be replaced
when it gets infected and causes complication.
Option C: Laparoscopic surgery for THR has a minimally invasive approach to reduce
bleeding and trauma on soft tissues and muscles. Hence, blood transfusion is not
expected unless medically necessary.
Option D: Full recovery for THR may take years. Most individuals can return to usual
ambulation for 12 weeks.

29.Answer: A

Rationale:

a. Place a trochanter roll outside the thigh.

This stabilizes hip in a neutral position.
b. Perform resistive range of motion of the affected leg.
This does not prevent external leg rotation.
c. Adduct and internally rotate the left leg.
This does not change external rotation.
d. Maintain the left leg in a neutral position.
To maintain the neutral position, a trochanter roll is necessary.

30.Answer: B

Rationale:
a. Instruct client to avoid washing with water.
Washing with water only is advisable during treatment to avoid irritation.
b. Instruct client to avoid powder and creams to the area.
Creams and powders may further irritate the skin which is already sensitive due to
radiation therapy.
c. Instruct client to apply heating pad to the site.
Heating the area is not recommended since sensitive skin is more prone to burn and
irritation.
d. Instruct client to cover the area with an air-tight dressing.
The treated area should be left open to allow air to circulate through it.

31.Answer: C

Rationale:

a. Using an electronic razor.

Electric razor is preferable to prevent risk of cutting and bleeding.
b. Eating a high-protein diet.
High-protein diet is preferable to aid tissue growth and healing.
c. Taking children to crowded places.
People undergoing radiation therapy should avoid crowds because of the increased risk
for infection.
d. Eating dry crackers.
Eating dry crackers helps reduce the occurrence of nausea and vomiting resulting from
radiation therapy.

32.Answer: B

Rationale:

a. Encourage intake of three meals in a day.

Small frequent meals enhance client cooperation and are better tolerated by clients
rather than large meals.
b. Present the food in a more pleasing manner.
Clients develop anorexia as a side effect of the treatment; this may be accompanied by
mucositis and taste alterations which limits the clients food choices. Food presented in
a more pleasing manner or environment will increase clients desire with eating and
drinking.
c. Encourage low-protein diet.
Small frequent intake of high-protein and high-caloric diet is better tolerated.
d. Allow liquid diet if tolerated.
A liquid diet is not recommended for anorexic clients because it has limited nutritional
content.

33.Answer: A

Rationale:

a. Local infection and irritation

Infection is a concern regarding antineoplastic medications administered through the IV
route. However, infection and irritation are not classic signs of IV extravasation.
b. Tissue breakdown
Extravasation of chemotherapeutic drugs can present with tissue breakdown and
necrosis.
c. Redness and heat on the site
Heat (calor) and redness (rubor) on the IV site are part of the classic signs of
extravasation.
d. Pain on the IV site
Pain (dolor) is the cardinal sign of IV extravasation.

34.Answer: D

Rationale:

a. The first day of every month

Menopausal clients are advised to perform BSE on the first day of every month to keep
them reminded of the monthly screening procedure.
b. The first day of menstruation
Inaccurate results are taken when BSE is performed during the first day of
menstruation.
c. Before menstruation
The breasts are swollen a week before menstruation. There may be lump formation due
to normal physiologic processes. Performing BSE before menstruation will yield
inaccurate results.
d. After menstruation
There are less breast changes occurring after menstruation and is the best time to
perform BSE.

35.Answer: D

Rationale:

a. Irregular pattern of constipation and diarrhea

A sudden change in the bowel and bladder habits of a person is a warning sign of
cancer.
b. Blood in the stools
The presence of unusual bleeding or discharges from any body orifice is a warning sign.
c. Difficulty in swallowing
Indigestion or difficulty in swallowing is a warning sign of cancer.
d. Frequent vomiting
This is a generalized symptom and is not a warning sign of cancer.