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Ibarra is assigned to the triage area and while on duty, he assesses the condition of
Mrs. Simon who came in with asthma. She has difficulty breathing and her respiratory rate is 40 per
minute. Mr. Ibarra is asked to inject the client epinephrine 0.3mg subcutaneously
a. Reduce anaphylaxis
b. Relieve hypersensitivity to allergen
c. Relieve respirator distress due to bronchial spasm
d. Restore client’s cardiac rhythm
2. When preparing the epinephrine injection from an ampule, the nurse initially:
a. Taps the ampule at the top to allow fluid to flow to the base of the ampule
b. Checks expiration date of the medication ampule
c. Removes needle cap of syringe and pulls plunger to expel air
d. Breaks the neck of the ampule with a gauze wrapped around it
3. Mrs. Simon is obese. When administering a subcutaneous injection to an obese patient, it is best for
the nurse to:
a Inject needle at a 15 degree angle' over the stretched skin of the client
b. Pinch skin at the Injection site and use airlock technique
c. Pull skin of patient down to administer the drug in a Z track
d. Spread skin or pinch at the injection site and inject needle at a 45-90 degree angle
4. When preparing for a subcutaneous injection, the proper size of syringe and needle would be:
5. The rationale for giving medications through the subcutaneous route is;
Situation 2 - The use of massage and meditation to help decrease stress and pain have been strongly
recommended based on documented testimonials.
6. Martha wants to do a study on, this topic. "Effects of massage and meditation on stress and pain."
The type of research that best suits this topic is:
a. applied research
b. qualitative research
c. basic research
d. quantitative research
7. The type of research design that does not manipulate independent variable is:
a. experimental design
b. quasi-experimental design
c. non-experimental design
d. quantitative design
8. This research topic has the potential to contribute to nursing because it seeks to:
10. Client’s rights should be protected when doing research using human subjects. Martha identifies
these rights as follows EXCEPT:
a. right of self-determination
b. right to compensation
c. right of privacy
d. right not to be harmed
Situation 3 - Richard has a nursing diagnosis of ineffective airway clearance related to excessive
secretions and is at risk for infection because of retained secretions. Part of Nurse Mario's nursing care
plan is to loosen and remove excessive secretions in the airway,
11. Mario listens to Richard's bilateral sounds and finds that congestion is in the upper lobes of the
lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when
Mario does percussion would be:
a. Client lying on his back then flat on his abdomen on Trendelenburg position
b. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back
and on his abdomen
c. Client lying flat on his back and then flat on his abdomen
d. Client lying on his right then left side on Trendelenburg position
12. When documenting outcome of Richard's treatment Mario should include the following in his
recording EXCEPT:
13. When assessing Richard for chest percussion or chest vibration and postural drainage Mario would
focus on the following EXCEPT:
a. Amount of food and fluid taken during the last meal before treatment
b. Respiratory rate, breath sounds and location of congestion
c. Teaching the client's relatives to perform 'the procedure
d. Doctor's order regarding position restriction and client's tolerance for lying flat
14. Mario prepares Richard for postural drainage and percussion. Which of the flowing is a special
consideration when doing the procedure?
15. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference
between the procedure is;
a. Percussion uses only one hand white vibration uses both hands
b. Percussion delivers cushioned blows to the chest with cupped palms while gently shakes secretion
loose on the exhalation cycle
c. In both percussion and vibration the hands are on top of each other and hand action is in tune with
client's breath rhythm
d. Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the
inhalation of air
Situation 4 - A 61 year old man, Mr. Regalado, is admitted to the private ward for observation; after
complaints of severe chest pain. You are assigned to take care of the client.
16. When doing an initial assessment, the best way for you to identify the client’s priority problem is
to:
17. Upon establishing Mr. Regalado's nursing needs, the next nursing approach would be to:
a. introduce the client to the ward staff to put the client and family at ease
b. Give client and relatives a brief tour of the physical set up the unit
c. Take his vital signs for a baseline assessment
d. Establish priority needs and implement appropriate interventions
18. Mr. Regalado says he has "trouble going to sleep". In order to plan your nursing intervention you
will.
19. Mr. Regalado's lower extremities are swollen and shiny. He has pitting pedal edema. When taking
care of Mr. Regalado, which of the following intervention would be the most appropriate immediate
nursing approach.
20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a
client for discharge include all EXCEPT:
Situation 5 - Nancy, mother of 2 young kids. 36 years old, had a mammogram and was told that she has
breast cysts and that she may need surgery. This causes her anxiety as shown by increase in her pulse
and respiratory rate, sweating and feelings of tension.
21. Considering her level of anxiety, the nurse can best assist Nancy by:
22. Nancy blames God for her situation. She is easily provoked to tears and wants to be left alone,
refusing to eat or talk to her family. A religious person before, she now refuses to pray or go to church
stating that God has abandoned her. The nurse understands that Nancy is grieving for her self and is in
the stage of:
a. bargaining
b. denial
c. anger
d. acceptance
23. The nurse visits Nancy and prods her to eat her food. Nancy replies "what's the use? My time is
running out. The nurse's best response would be:
a. "The doctor ordered full diet for you so that you will be strong for surgery."
b. "I understand how you fee! but you have 1o try for your children's sake."
c. "Have you told your, doctor how you feel? Are you changing your mind) about surgery?"
d. "You sound like you are giving up."
24. The nurse feels sad about Nancy's illness and tells her head nurse during the end of shift
endorsement that "it's unfair for Nancy to have cancer when she is still so young and with two kinds.
The best response of the head nurse would be:
a. Advise the nurse to "be strong and learn to control her feelings"
b. Assign the nurse to another client to avoid sympathy for the client
c. Reassure the nurse that the client has hope if she goes through all statements prescribed for her
c. Ask the other nurses what they feel about the patient to find out if they share the same feelings
25. Realizing that she feels angry about Nancy's condition, the nurse Seams that being self-aware is a
conscious process that she should do in any situation like this because:
Situation 6 – Mrs. Seva, 32 years old, asks you about possible problems regarding her elimination now
that she is in the menopausal stage.
26. Instruction on health promotion regarding urinary elimination is important. Which would you
include?
a. Hold urine, as long as she can before emptying the bladder to strengthen her sphincters muscles
b. If burning sensation is experienced while voiding, drink pineapple-juice
c. After urination, wipe from anal area up towards the pubis
d. Jell client to empty the bladder at each voiding
27. Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical
changes predispose her to constipation?
28. The nurse understands that one of these factors contributes to constipation:
a. excessive exercise
b. high fiber diet
c. no regular tine for defecation daily
d. prolonged use of laxatives
29. Mrs. Seva talks about rear of being incontinent due to a prior experience of dribbling urine when
laughing or sneezing and when she has a full bladder. Your most appropriate .instruction would be to:
Situation 7 - Using Maslow's need theory, Airway, Breathing and Circulation are the physiological needs
vital to life. The nurse's knowledge and ability to identify and immediately intervene to meet these
needs is important to save lives.
31. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues:
32. You noted from the lab exams in the chart of Mr. Santos that he has reduced oxygen in the blood.
This condition is called:
a. Cyanosis
b. Hypoxia
c. Hypoxemia
d. Anemia
33. You will nasopharyngeal suctioning Mr. Abad. Your guide for the length of insertion of the tubing
for an adult would be:
34. While doing nasopharyngeal suctioning on .Mr. Abad, the nurse can avoid trauma to the area by:
a. Apply suction for at least 20-30 seconds each time to ensure that all secretions are removed
b. Using gloves to prevent introduction of pathogens to the respiratory system
c. Applying no suction while inserting the catheter
d. Rotating catheter as it is inserted with gentle suction
35. Myrna has difficulty breathing when on her back and must sit upright in bed to breath, effectively
and comfortably. The nurse documents this condition as:
a. Apnea
b. Orthopnea
c. Dyspnea
d. Tachypnea
Situation 8 - You are assigned to screen for hypertension: Your task is to take blood pressure readings
and you are informed about avoiding the common mistakes in BP taking that lead to 'false or inaccurate
blood pressure readings.
36. When taking blood pressure reading the cuff should be:
a. deflated fully then immediately start second reading for same client
b deflated quickly after inflating up to 180 mmHg
c. large enough to wrap around upper arm of the adult client 1 cm above brachial artery
d. inflated to 30 mmHg above the estimated systolic BP based on palpation of radial or bronchial artery
37. Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of death worldwide
and is a preventable disease. The primary cause of COPD is:
a. tobacco hack
b. bronchitis
c. asthma
d. cigarette smoking
38. In your health education class for clients with diabetes you teach, them the areas, for control .
Diabetes which include all EXCEPT:
39. You teach your clients the difference between, Type I (IDDM) and Type II (NDDM) Diabetes. Which
of the following is true?
a. both types diabetes mellitus clients are all prone to developing ketosis
b. Type II (NIDDM) is more common and is also preventable compared to Type I (IDDM) diabetes which
is genetic in etiology
c. Type I (IDDM) is characterized by fasting hyperglycemia
d. Type II (IDDM) is characterized by abnormal immune response
40. Lifestyle-related diseases in general share areas common risk factors. These are the following
except
a. physical activity
b. smoking
c. genetics
d. nutrition
Situation 9 - Nurse Rivera witnesses a vehicular accident near the hospital where she works. She decides
to get involved and help the victims of the accident.
43. In the emergency room, Nurse Rivera is assigned to attend to the client with .lacerations on the
arms, while assessing the extent of the wound the nurse observes that the wound is now starting to
bleed profusely. The most immediate nursing action would be to:
44. The nurse applies pressure dressing on the bleeding site. This intervention is done to:
Situation 10 - While working in the clinic, a new client, Geline, 35 years old, arrives for her doctor's
appointment. As the clinic nurse, you are to assist the client fiil up forms, gather data and make an
assessment.
a. Record pertinent information in the client chart for health team to read
b Assist the client find solutions to her health concerns
c. Understand her lifestyle, health needs and possible problems to develop a plan of care
d. Make nursing diagnoses for identified health problems
47. While interviewing Geline, she starts to moan and doubles up in pain, She tells you that this pain
occurs about an hour after taking black coffee without breakfast for a few weeks now. You will record
this as follows:
48. Geline tells you that she drinks black coffee frequently within the day to "have energy and be wide
awake" and she eats nothing for breakfast and eats strictly vegetable salads for lunch and dinner to
lose weight. She has lost weight during the past two weeks, in planning a healthy balanced diet with
Geline, you will:
a. Start her off with a cleansing diet to free her body of toxins then change to a vegetarian, diet and
drink plenty of fluids
b. Plan a high protein, diet; low carbohydrate diet for her considering her favorite food
c. Instruct her to attend classes in nutrition to find food rich in complex carbohydrates to maintain daily
high energy level
d. Discuss with her the importance of eating a variety of food from the major food groups with plenty of
fluids
49. Geline tells you that she drinks 4-5 cups of black coffee and diet cola drinks. She also smokes up to
a pack of cigarettes daily. She confesses that she is in her 2nd month of pregnancy but she does not
want to become fat that is why she limits her food intake. You warn or caution her about which of the
following?
a. Caffeine products affect the central nervous system and may cause the mother to have a "nervous
breakdown"
b. Malnutrition and its possible effects on growth and development problems in the unborn fetus
c. Caffeine causes a stimulant effect on both the mother and the baby
d. Studies show conclusively that caffeine causes mental retardation
50. Your health education plan for Geline stresses proper diet for a pregnant woman and the
prevention of non-communicable diseases that are influenced by her lifestyle these include of the
following EXCEPT:
a. Cardiovascular diseases
b. Cancer
c. Diabetes Mellitus
d. Osteoporosis
Situation 11 - Management of nurse practitioners is done by qualified nursing leaders who have had
clinical experience and management experience.
52. Your head nurse in the unit believes that the staff nurses are not capable of decision making so
she makes the decisions for everyone without consulting anybody. This type of leadership is:
53. When the head nurse in your ward plots and approves your work schedules and directs your work,
she is demonstrating:
a. Responsibility
b. Delegation
c. Accountability
d. Authority
54. The following tasks can be safely delegated' by a nurse to a non-nurse health worker EXCEPT:
55. You made a mistake in giving the medicine to the wrong client You notify the client’s doctor and
write an incident report. You are demonstrating:
a. Responsibility
b. Accountability
c. Authority
d. Autocracy
Situation 12 – Mr. Dizon, 84 years old, is brought to the .Emergency Room for complaint of hypertension
flushed face, severe headache, and nausea. You are doing the initial assessment of vital signs.
56. You are to measure the client’s initial blood pressure reading by doing all of the following EXCEPT:
a. Determine if the client’s hemoglobin level is low and if he needs blood transfusion
b. Check level of client’s tissue perfusion
c. Measure the efficacy of the client’s anti hypertensive medications
d. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops
58. After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an order of
hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the
blood pressure reading to be:
a. Inconsistent
b. low systolic and high diastolic pressure
c. higher than what the reading should be
d. lower than what the reading should be
59. Through the client’s health history, you gather that Mr. Dizon smokes and drinks coffee. When
taking the blood pressure of a client who recently smoked or drank coffee, how long should be the
nurse wait before taking the client’s blood pressure for accurate reading?
a. 15 minutes
b. 30 minutes
c. 1 hour
d. 5 minutes
60. While the client has the pulse oximeter on his fingertip, you notice that the sunlight is shining on
.the area where the oximeter is. Your action will be to:
Situation 13 - The nurse's understanding of ethico-legal responsibilities will guide his/her nursing
practice.
61. The principles that .govern right and proper conducts of a person regarding life, biology and the
health professions is referred to as:
a. Morality
b. Religion
c. Values
d. Bioethics
63. The most important nursing responsibility where ethical situations emerge in patient care is to:
64. You inform the patient about his rights which include the following EXCEPT:
65. The principle states that a person has unconditional worth and has the capacity to determine his
own destiny.
a. Bioethics
b. Justice
c. Fidelity
d. Autonomy
Situation 14 – Your director of nursing wants to improve the quality of health care offered in the
hospital. As a staff nurse in that hospital you know that this entails quality assurance programs.
66. The following mechanisms can be utilized as part of the quality assessment program of your
hospital EXCEPT:
67. The nurse of the Standards of Nursing Practice is important in the hospital. Which of the following
statements best describes what it is?
a. These are statements that describe the maximum or highest level of acceptable performance in
nursing practice.
b. It refers to the scope of nursing as defined in Republic Act 9173
c. It is a license issued by the Professional Regulation Commission to protect the public from
substandard nursing practice.
d. The Standards of care includes the various steps of the nursing process and the standards of
professional performance.
68. You are taking care of critically ill client and the doctor in charge calls to order a DNR (do not
resuscitate) for the client. Which of the following is the appropriate action when getting DNR order
over the phone?
a. Have the registered nurse, family spokesperson, nurse supervisor and doctor sign
b. Have two nurses validate the phone order, both nurses sign the order and the doctor should sign his
order within 24 hours.
c. Have the registered nurse, family and doctor sign the order
d. Have 1 nurse take the order and sign it and have the doctor sign it within 24 hours
69. To ensure the client safety before starting blood transfusion the following are needed before the
procedure can be done EXCEPT:
70. Part of standards of care has to do with the use of restraints. Which of the following statements is
NOT true?
Situation 15 – During the NUTRITION EDUCATION class discussion a 58 year old man, Mr. Bruno shows
increased interest.
71. Mr. Bruno asks what the "normal" allowable salt intake is. Your best response to Mr. Bruno is:
72. Your instructions to reduce or limit salt intake include all the following EXCEPT:
a. eat natural food with little or no salt added
b. limit use of table salt and use condiments instead
c. use herbs and spices
d. limit intake of preserved or processed food
73. Teaching strategies and approaches when giving nutrition education is influenced by age, sex and
immediate concerns of the group. Your presentation for a group of young mothers would be best if
you focus on:
Situation 16 – You are assigned to take care of 10 patients during the morning shift. The endorsement
includes the IV infusion and medications for these clients.
76. Mr. Felipe, 36 years old is to be given 2700ml of D5RL to infuse for 18 hours starting at 8am. At
what rate should the IV fluid be flowing hourly?
a. 100 ml/hour
b. 210 ml/hour
c. 150 ml/hour
d. 90 ml/hour
77. Mr. Atienza is to receive 150mg/hour of D5W IV infusion for 12 hours for a total of 1800ml. He is
also losing gastric fluid which must be replaced every two hours. Between 8am to 10am. Mr. Atienza
has lost 250ml of gastric fluid. How much fluid should he receive at 11am?
a. 350 ml/hour
b. 275 ml/hour
c. 400 ml/hour
d. 200 ml/hour
78. You are to apply a transdermal patch of nitroglycerin to your client. The following important
guidelines to observe EXCEPT:
a. Apply to hairlines clean are of the skin not subject to much wrinkling
b. Patches may be applied to distal part of the extremities like forearm
c. Change application and site regularly to prevent irritation of the skin
d. Wear gloves to avoid any medication of your hand
79. You will be applying eye drops to Miss Romualdez. After checking all the necessary information
and cleaning the affected eyelid and eyelashes you administer the ophthalmic drops by instilling the
eye drops.
80. When applying eye ointment, the following guidelines apply EXCEPT:
a. squeeze about 2 cm of ointment and gently close but not squeeze eye
b. apply ointment from the inner canthus going outward of the affected eye
c. discard the first bead of the eye ointment before application because the tube likely to expel more
than desired amount of ointment
d. hold the tube above the conjunctival sac do not let tip touch the conjuctiva
Situation 17 – The staff nurse supervisor request all the staff nurses to “brainstorm” and learn ways to
instruct diabetic clients on self-administration of insulin. She wants to ensure that there are nurses
available daily to do health education classess.
82. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an
unlicensed staff, Mrs. Guevarra.
84. Process of formal negotiations of working conditions between a group of registered nurses and
employer is:
a. grievance
b. arbitration
c. collective bargaining
d. strike
85. You are attending a certification program on cardiopulmonary resuscitation (CPR) offered and
required by the hospital employing you. This is;
Situation 18 - There are various developments in health education that the nurse should know about.
86. The provision of health information in the rural areas nationwide through television and radio
programs and video conferencing is referred to as:
87. A nearby community provides blood pressure screening, height and weight measurement smoking
cessation classes and aerobics class services. This type of program is referred to as:
a. outreach program
b. hospital extension program
c. barangay health center
d. wellness center
88. Part of teaching client in health promotion is responsibility for one’s health. When Danica states
she need to improve her nutritional status this means:
89. Nurse Beatrice is providing tertiary prevention to Mrs. De Villa. An example of tertiary provestion
is:
a. Marriage counseling
b. Self-examination for breast cancer
c. Identifying complication of diabetes
d. Poison, control
90. Mrs. Ostrea has a schedule for Pap Smear. She has a strong family history of cervical cancer. This is
an example of:
a. tertiary prevention
b. secondary prevention
c. health screening
d. primary prevention
Situation: 19 - Ronnie has a vehicular accident where he sustained injury to his left ankle. In the
Emergency Room, you notice how anxious he looks.
91. You establish rapport with him and to reduce his anxiety you initially
92. While doing your assessment, Ronnie asks you "Do I have a fracture? I don't want to have a cast.”
The most appropriate nursing response would be: