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This are the common board questions as I promised.

Situation : The Department of Health launched in July 1976 the Expanded

Program on Immunization (EPI) in cooperation with the World Health
Organization (WHO) and the UNICEF.

1. Nurse knows that the type of immunity which is longest acting is

________.
A. Natural Immunity C. Artificial Immunity
B. Passive Immunity D. Active Immunity

2. The temperature in the refrigerator and freezer should be checked:

A. Twice a month C. once a day
B. twice a day D. once a week

3. Vaccines should NEVER be stored in which part of the refrigerator?

A. Lower right-hand corner C. Floor
B. Lower right-hand compartment D. Door

4. Among which vaccine should be stored in the freezer?

A. DPT C. BCG
B. Hepatitis B D. Varicella

5. Which ethical principle might be difficult for the community/public

health nurse to implement?
A. Nonmaleficence C. Justice
B. Beneficence D. Respect for Autonomy

6. A patient refuses to undergo surgery after a conference with her

doctor. Which of the following ethical principle applies when Nurse
Greg and doctor respect the decision of the patient in spite
encouragement and pieces of advice given?
A. Autonomy C. Veracity
B. Beneficence D. Self determination

7. The physician orders an antibiotic injection for a pediatric client.

The client's mother refuses to allow the nurse to administer the
medication, however, the nurse proceeds to administer the injection.
Legally, the nurse has committed:___________
A. assault  C. invasion of privacy
B. battery D. False imprisonment
Situation: Ms. Karen, a 30 year old client was transported by ambulance to
the emergency room after being rescued from her burning house. She was
asleep at night when a spark from the family fireplace started a fire,
leaving her trapped in her bedroom. By the time the fire rescue squad
arrived, she had suffered severe burns and excessive smoke inhalation.

8. In the emergency room, Ms. Karen is unconscious. She had second-

degree burn, covering her anterior trunk, anterior aspect of both
 upper extremities, and anterior aspect of both lower extremities. The
burned area appears red, has blisters, and is very painful. How should
this injury be categorized?
A. Superficial partial-thickness
B. Deep partial-thickness
C. Superficial full-thickness
D. Full thickness

9. Using the Rule of Nines, estimate the total percentage of body surface
area burned in Ms. Karen.
A. 60% C. 63%
B. 45% D. 40.5%

10. In assessing Ms. Karen, you will expect which of the following
findings, EXCEPT:
A. Collapsed neck veins
B. Decreased urine specific gravity
C. Elevated hematocrit
D. Weight loss

11. During the emergent phase of burn injury, Nurse Katrina should
assess Ms. Karen for:_________________
A. hypokalemia and hypernatremia
B. hypokalemia and hyponatremia
C. hyperkalemia and hypernatremia
D. hyperkalemia and hyponatremia

12. In reviewing Ms. Karen's laboratory report of white blood cell

count with differential, all the following results are listed. Which
laboratory finding indicates the possibility of sepsis?
A. The total white blood cell count is 9000/mm3.
B. The lymphocytes outnumber the basophils.
C. The “bands” outnumber the “segs.”
D. The monocyte count is 180/mm3.

Situation - Many Filipinos are suffering from malnutrition. Nurse Aga knows
that it is a result from poor diet or lack of food.
13. Micronutrient supplementation is included in what program of the
DOH?
A. Sentrong Sigla
B. Araw ng Sangkap Pinoy
C. Expanded program on immunization
D. Reproductive health Bill.

14. You assess for a child's nutritional status using the mid-upper
arm circumference (MUAC). Measurement reads 120cm which falls under
the orange color of a 4-colored tape. This indicate that the child
__________.
A. Well nourished
B. Is at risk for acute malnutrition
 C. Should be immediately referred for supplementation
D. Should be immediately referred for treatment
Rationale: Red – severe acute malnutrition ( refer immediately for
treatment)
Orange – Moderate acute malnutrition- refer immediately for supplementation
Yellow – at risk for acute malnutrition- counsel and follow up
Green – well nourished child

15. You compute for the ideal weight of Edward whose actual weight
is 135lbs and height is 5’10”. His ideal body weight is _________lbs.
A. 140 C. 150
B. 135 D. 170

16. Edwards degree of malnutrition is _________percent of ideal body

weight (IBW)
A. 108.15 C. 100
B. 96.43 D. 92.4

17. The indication for Edward's degree of malnutrition is__________

A. 3rd degree C. 2nd degree
B. Obese D. 1stdegree

Situation- The following situations are related to fluid and electrolyte

imbalances

18. A client was brought to the hospital following a near-drowning

experience in the Pacific Ocean. In providing care to this client, the
nurse plans to carefully monitor for which of the following? 
A. hypernatremia  C. hypocalcemia
B. hyponatremia  D. hypercalcemia

19. The nurse monitor the patient signs and symptoms of

complications. The nurse knows that one of the PRIMARY risk when
treating hypernatremia is __________.
A. Renal shutdown C. Cellular dehydration
B. Cerebral edema D. RBC destruction

20. The nurse understand that a patient with hypernatremia is at

high risk for seizure. Which of the following safety measure is MOST
appropriate? Use of______.
A. Pillows place at the head C. Padded restraints
B. Padded tongue blades D. Padded side rails
 21. A nurse is assigned to care for a group of clients. On review of
the clients' medical records, the nurse determines that which client
is at risk for fluid volume deficit?
A. A client with a colostomy
B. A client with liver cirrhosis
C. A client with congestive heart failure
D. A client with decreased kidney function

22. A nurse is assigned to care for a group of clients. On review of

the client's medical records, the nurse determines that which client
is at risk for a fluid volume excess?
A. The client with renal failure
B. The client with an ileostomy
C. The client taking diuretics
D. The client who requires gastrointestinal suctioning

Situation – Mrs. Geminy, 20 years old, visited the prenatal clinic with her
husband George. Nurse Connie noted that the fundus is at the level of the
umbilicus. Being her first pregnancy, the patient asks the clinic nurse
about pregnancy and childbearing.

23. Based from the assessment of the nurse, what would be the
estimated age of gestation, in WEEKS, if the fundus is at level of the
umbilicus?

A. 12 C. 16
B. 10 D. 20

24. When is the placenta, which is the course of estrogen and

progesterone, fully developed? It is on the _____ weeks of pregnancy.
A. 8 C. 6
B. 10 D. 12

25. Mrs. Geminy related that she oftentimes feel nauseated in the
afternoon. Which of the following should Nurse Connie advise her to
do?
A. Eat sky flakes and follow it up with water.
B. Drink iced carbonated drinks.
C. Drink hot chocolate or coffee.
D. Eat frequently but small amount of foods.

26. The patient complained that every morning, she becomes nauseated
and oftentimes, she will vomit excessively. “What could be the cause
of this,” she asked? The nurse’s answer is: “It is due to increase
level of ___________.”
A. heart burn C. heart rate
B. estrogen D. progesterone
 27. Which phase is a part of the normal uterine cycle?
A. Follicular C. Luteal
B. Proliferative D. Ovulation

28. What is the condition wherein menstrual interval is 45 – 50 days?

A. Metrorrhagia C. Dysmenorrhea
B. Menorrhagia D. Oligomenorrhea

29. A woman is being counseled concerning the calendar method type of

natural family planning. The woman states her cycle runs 33 days. The
nurse teaches the woman that ovulation will probably occur on
_________ day.
A. 14 C. 18
B. 16 D. 19
Situation – Miel, on her 35 weeks of gestation, is admitted because of
hypertension, BP of 185/110, severe headache and blurred vision. She was
placed in imposed bedrest without toilet privileges. The physician orders
MgSo4.
30. Which of the following would Nurse Erika anticipate in the
patient’s maternal history?
A. On and off vaginal spotting
B. Esophageal discomfort is experienced after a heavy meal.
C. Weight gain of 20 lbs. in the 1st and 2nd Trimester.
D. Fetus move very frequently.

31. When a patient is on an imposed bedrest, which of the following

can help the patient cope? These are the following EXCEPT
_______________.
A. Let the patient lie on her side to allow more blood to the
uterus.
B. Increase fluid intake to 8 glasses a day to prevent
constipation.
C. Discourage participation of family in patient care to prevent
further anxiety.
D. Use relaxation techniques to help cope with stress such as
music and books.

32. The nurse must be alert to MgSo4 toxicity. Which of the following
is NOT included?
A. Fetal bradycardia
B. Urine output of <30 ml per hour
C. Respiration of <12 per min
D. Increase in maternal pulse rate

33. Which of the following hospital environment will be MOST

conductive to Miel’s condition? A room that is / with __________.
A. Bright and well-ventilated
B. 2 or 3 other patients
C. Quiet and non-stimulating
D. A call button for watcher’s use
 34. The natural reservoir of Ebola virus is:_________.
A. Monkeys C. Bats
B. Camels D. Deer

35. Upon the presidents instruction, the department of health has

mobilized task force MERS-CoV to create heightened awareness among our
people on the middle east respiratory syndrome- corona virus and
prevent the spread of this communicable disease. When and where was
the FIRST case of MERS-CoV reported?
A. April 2012, Saudi Arabia
B. April 2013, Abu Dhabi
C. April 2014, Saudi Arabia
D. January 2014, Abu Dhabi

36. What risk factor can aggravate the condition of MERS-CoV.

A. Tuberculosis C. Respiratory Distress Syndrome
B. Pneumonia D. Cancer

37. The MOST likely source of the MERS-CoV to humans are:__________

A. Sheep C. Cow
B. Camels D. Birds 

38. A highway accident involves 25 vehicles; there are many victims.

At the scene of the accident a triage nurse is identifying and
labeling victims according to triage acuity principles. What color tag
should the nurse label a person who has a simple fracture of the right
humerus and several lacerations of the face?
A. Yellow C. Green
B. Red D. Black

39. The nurse is present at a disaster scene and is participating in

the triage of victims. Which color tag should be assigned to a victim
with evidence of open pneumothorax?
A. Green C. Black
B. Red D. Yellow

40. Four victims of an automobile crash are brought by ambulance to

the emergency department. The triage nurse determines that the victim
who has the highest priority for treatment is the one with_________
A. severe bleeding of facial and head lacerations.
B. an open femur fracture with profuse bleeding.
C. a sucking chest wound.
D. absence of peripheral pulses
Answer: C
Rationale: Most immediate deaths from trauma occur because of problems with
ventilation, so the patient with a sucking chest wound should be treated
first. Face and head fractures can obstruct the airway, but the patient
with facial injuries has lacerations only. The other two patients also need
rapid intervention but do not have airway or breathing problems
 41. Which type of hallucination MOST commonly occurs in clients
diagnosed with dementia?
A. Gustatory C. Visual
B. Olfactory D. Auditory
Answer: C
Rationale: A hallucination is an experience of something that is not really
there. They can occur for all the senses, but visual hallucinations is the
most common type experienced by people with dementia.
Auditory hallucinations are among the most common type of hallucination in
Psychiatric patients. This is the most common form of hallucination in
schizophrenics and refers to the perception of non-existent sounds. In
schizophrenia, patients often hear voices talking to them but the
hallucinations may also take the form of whistling or hissing, for example.
The voices may be saying complimentary, critical or neutral words to them.
The voices may also form a running commentary on the person’s actions.
Command hallucinations may also occur.

42. Which neurotransmitter has been implicated in the development of

Alzheimer’s disease?
A. Acetylcholine C. Epinephrine
B. Dopamine D. Serotonin
Answer: A
Rationale: Depletion of the neurotransmitter acetylcholine has been
implicated as a: critical factor in Alzheimer's disease. A relative
deficiency of acetylcholine is associated with this disorder. The drugs
used in the early stages of Alzheimer's disease will act to increase
available acetylcholine in the brain. The remaining neurotransmitters have
not been implicated in Alzheimer's disease.

43. In clients with a cognitive impairment disorder, the phenomenon

of increased confusion in the early evening hours is called________
A. Aphasia C. Sundowning
B. Agnosia D. Confabulation

Answer: C
Rationale: Sundown syndrome is a condition where older individuals are more
confused and combative later in the day, such as at bedtime. A condition in
which persons with cognitive impairment (people with Alzheimer's disease)
and older people tend to become confused or disoriented at the end of the
day, exhibiting such behaviors as wandering, combativeness, suspiciousness,
hallucinations, and delusions.
Confabulation is the act of filling in memory gaps. the false recollection
of episodic memory, filling in gaps. Confabulation is the making up of
stories or answers to maintain self-esteem when the person does not
remember.
Aphasia is a language disorder affecting ability to talk, ability to
understand the spoken word, reading & writing
Agnosia - "not knowing" impairments, types of agnosia includes visual,
auditory, somatosensory. agnosia
unable to identify an object based on sight despite being able to describe
texture color and shape.

44. While administering a medication to a psychiatric patient, the

nurse did enticing and seductive actions in order to encourage the
client to take his medications. Someone can file an administrative
case against the nurse to the Board of Nursing and the:__________
A. NBI C. Ombudsman
B. Supreme Court D. PRC
Answer: C
Rationale: administrative cases against erring professionals can be filed
to the Board of nursing under PRC and the office of the ombudsman.

45. The nurse committed a serious medication error and patient died.
Who is responsible to revoking the nurse’s license and certificate of
registration?
A. Professional Regulation Commission.
B. Professional Regulatory Board in Nursing.
C. Department of Health
D. National Bureau of Investigation
Answer: B
Rationale: The Board of Examiners for Nurses is vested with authority
conformably with the provisions of this Act, to issue, suspend, revoke, or
reissue certificates of registration for practice of nursing.

46. Ethical dilemmas often arise over a conflict of opinion. Once the
nurse has determined that the dilemma is ethical, a critical FIRST
step in negotiating the difference of opinion would be
to:_____________
A. Consult a professional ethicist to ensure that the steps of the
process occur in full
B. Gather all relevant information regarding the clinical, social,
and spiritual aspects of the dilemma
C. List the ethical principles that inform the dilemma so that
negotiations agree on the language of the discussion
D. Ensure that the attending physician has written an order for an
ethics consultation to support the ethics process
Answer: B
Rationale: B. Gather all relevant information regarding the clinical,
social, and spiritual aspects of the dilemma. Before proceeding with
discussion about any difficult situation, just as in the nursing process,
participants take time to gather all relevant information as insurance for
reliability and validity during the discussion

47. A health care issue often becomes an ethical dilemma

because:_____________
A. A clients legal rights coexist with a health professionals
obligation
B. Decisions must be made quickly, often under stressful conditions
C. Decisions must be made based on value system
D. The choices involved do not appear to be clearly right or wrong

Answer: D
Rationale: By definition, an ethical dilemma involves the need to choose
from among two or more morally acceptable options or between equally
unacceptable courses of action, when one choice prevents selection of the
other. Ethical dilemmas exists when two or more rights, values,
obligations, or responsibilities come in conflict. Conflict may arise
between the nurses personal values and those of another person or the
organization.

48. In MOST ethical dilemmas, the solution to the dilemma requires

negotiation among members of the health care team. The nurse's point
of view is valuable because:________________,
A. Nurses have a legal license that encourages their presence during
ethical discussions.
B. The principle of autonomy guides all participants to respect
their own self-worth
C. Nurses develop a relationship to the client that is unique among
all professional health care providers
D. The nurse's code of ethics recommends that a nurse be present at
any ethical discussion about client care
Answer: C
Rationale: Nurses develop a relationship to the patient that is unique
among all professional health care providers. When ethical dilemmas arise,
the nurses point of view unique and critical. The nurse usually interacts
with clients over longer time intervals than do other disciples.
49. Which of the following is an Ethical Dilemma ?
A. a rape victim ask the nurse not to inform her family /relatives
B. a 45-year-old patient signed to refuse all medication of her
cancer treatment.
C. a mother overhead a physician to isolate her son with meningitis
D. none of these
Answer: A
Rationale: Ethical dilemmas exists when two or more rights, values,
obligations, or responsibilities come in conflict. Conflict may arise
between the nurses personal values and those of another person or the
organization

50. When a client is confused, left alone with the side rails down,
and the bed in a high position, the client falls and breaks a hip.
What law has been broken?
A. Assault C. Negligence :
B. Battery D. Malpractice
Answer: C
Rationale: Knowing what to do to prevent injury is a part of the standards
of care for nurses to follow. Safety guidelines dictate raising the side
rails, staying with the client, lowering the bed, and observing the client
until the environment is safe. As a nurse, these activities are known as
basic safety measures that prevent injuries, and to not perform them is not
acting in a safe manner. Negligence is conduct that falls below the
standard of care that protects others against unreasonable risk of harm.

51. The nursing theorist who developed transcultural nursing theory

A. Dorothea Orem C. Betty Newman
B. Madeleine Leininger D. Sr. Callista Roy

Answer: B
Rationale: Florence Nightingale - Environment theory
Hildegard Peplau - Interpersonal theory
Virginia Henderson - Need Theory
Fay Abdella - Twenty One Nursing Problems
Ida Jean Orlando - Nursing Process theory
Dorothy Johnson - System model
Martha Rogers - Unitary Human beings
Dorothea Orem - Self-care theory
Imogene King - Goal Attainment theory
Betty Neuman - System model
Sister Calista Roy - Adaptation theory
Jean Watson - Philosophy and Caring Model
Madeleine Leininger - Transcultural nursing
Patricia Benner - From Novice to Expert
Lydia E. Hall - The Core, Care and Cure
Joyce Travelbee - Human-To-Human Relationship Model
Margaret Newman - Health As Expanding Consciousness
Katharine Kolcaba - Comfort Theory
Rosemarie Rizzo Parse - Human Becoming Theory

52. A confused client who fell out of bed because side rails were NOT
used is an example of which type of liability?
A. Malpractice C. Battery
B. Assault D. Negligence
Answer: D
Rationale:
Rationale: Negligence: conduct that falls below the standards of care.
Negligence is conduct that falls below the standard established by law for
the protection of others against unreasonable risk of harm. Malpractice is
a professional negligence.
53. A client who had a "Do Not Resuscitate" order passed away. After
verifying there is no pulse or respirations, the nurse should
NEXT:_______________
A. Have family members say goodbye to the deceased
B. Call the transplant team to retrieve vital organs
C. Remove all tubes and equipment (unless organ donation is to take
place), clean the body, and position appropriately.
D. Call the funeral director to come and get the body
Answer: C
The body of the deceased should be prepared before the family comes in to
view and say their goodbyes. This includes removing all equipment, tubes,
supplies, and dirty linens according to protocol, bathing the client,
applying clean sheets, and removing trash from the room.

54. The nurse puts a restraint jacket on a client without the

client's permission and without the physicians order. The nurse may be
guilty of:_____________
A. Assault C. Negligence
B. Battery D. Malpractice
Answer: B
Rationale: Using restraints without the order of the primary healthcare
provider may lead to battery and false imprisonment charges. Assault is a
threat or an attempt to do violence to another, and battery means touching
an individual in an offensive manner or actually injuring another person.
 55. The nurse is assigned to care for a client with systemic lupus
erythematosus (SLE). The nurse plans care knowing that this disorder
is:_________
A. A local rash that occurs as a result of allergy
B. A disease caused by overexposure to sunlight
C. An inflammatory disease of collagen contained in connective
tissue
D. A disease caused by the continuous release of histamine in the
body
Answer: C
Rationale: SLE is an inflammatory disease of collagen contained in
connective tissue. SLE is a chronic inflammatory immune disorder affecting
the skin and other body organs. Antibodies to DNA and RNA cause an
autoimmune inflammatory response, resulting in swelling and pain. It is
most common in young women, and has a strong genetic factor. The etiology
or cause is not known. SLE characterized by periods of remission and
exacerbation

56. A nurse is providing dietary instructions to a client with

systemic lupus erythematosus. Which of the following dietary items
would the nurse instruct the client to avoid?
A. Cauliflower C. Legumes
B. Fish D. Steaks
Answer: D
The client with systemic lupus erythematosus is at risk for cardiovascular
disorders such as coronary artery disease and hypertension. The client is
advised of lifestyle changes to reduce these risks, which include smoking
cessation and prevention of obesity and hyperlipidemia. The client is
advised to reduce salt, fat, and cholesterol intake.
The client with SLE is at risk for cardiovascular disorders. The client
should be instructed on nutritional lifestyle changes to prevent these
disorders. The client should be instructed to reduce fat (steak, bacon),
salt (bacon), and to quit smoking. The other food choices are part of a
healthy diet.

Additional info:
Did you know that sugar might trigger a lupus flare? Being high in fat, red
meat is not the best type of protein to eat, as it can lead to heart
disease. Switch from red meat to fatty fishes, like tuna, salmon, sardines
and mackerel.
57. A complete blood cell count is performed on a client with
systemic lupus erythematosus (SLE). In the client with SLE, a complete
blood count commonly shows pancytopenia which means:_____________
A. Increased red blood cell count
 B. Increased white blood cell count
C. Decrease of all cell types
D. Increased neutrophils

Answer: C
Rationale: In the client with SLE, a complete blood count commonly shows
pancytopenia, a decrease of all cell types, probably caused by a direct
attack of all blood cells or bone marrow by immune complexes. The other
options are incorrect.

58. The nurse monitors a patient to have Systemic Lupus

Erythematosus. Which of the following symptoms is characteristic of
this diagnosis?
A. Increased T-cell count
B. Scaly, inflamed rash on shoulders, neck, and face
C. Swelling of the extremities
D. Decreased erythrocyte sedimentation rate (ESR)
Answer: B
Rationale: Skin lesions or rash on the face across the bridge of the nose
and on the cheeks is an initial characteristic sign of systemic lupus
erythematosus (SLE).

59. The nurse has assessment findings of dusky appearance with bluish
mucus membranes and production of large amounts of mucus. The nurse
suspects which illness? 
A. asthma  C. chronic bronchitis 
B. emphysema  D. acute bronchitis
Answer: C
Rationale: an obstructive airway disease characterized by excessive mucus
production with chronic productive cough on most days for at least 3
consecutive months of the year for 2 consecutive years.
(Blue bloater= is the bronchitis the cyanosis and bloaters due to RHF.
from overworked right ventricle)
(Pink Puffer= is the emphysema the hyperventilation that works just enough
to keep the pink complexion. Puffer from the barrel chest)
60. Which assessment data would support that the client has
experienced a pulmonary embolism? 
A. calf pain with dorsiflexion of the foot 
B. sudden onset of chest pain with dyspnea 
C. left side chest pain and diaphoresis 
D. bilateral crackles and low grade fever
Answer: B
Rationale: Pulmonary Embolism can arise from a thromboembolism, tumor
emboli or from other sources such as amniotic fluid, air, fat, bone marrow,
and intravenous material. Symptoms of a Pulmonary embolism includes
Dyspnea, Respirophasic chest pain, cough, leg pain, hemoptysis,
palpitations, wheezing, anginal pain

61. Which disease is an alveoli problem that causes loss of lung

elasticity and hyperinflation that results in dyspnea and increased
respiratory rate? 
A. chronic bronchitis  C. asthma
B. COPD D. emphysema
Answer: D
Rationale: Respiratory disease characterized by weakening and permanent
enlargement of the air spaces distal to the terminal bronchioles and by
destruction of alveolar walls. Pink puffer disease or a hyper inflated
lungs.
62. A 62 year old client has a history COPD, but present with edema
of the legs and feet, distended neck veins and enlarged palpable
liver. Considering these clients signs and symptoms the client is MOST
likely suffering from:______
A. Cor pulmonale C. Atelectasis
B. Pleurisy D. Pulmonary embolus

Answer: A
Rationale: Cor Pulmonale also known as right ventricular failure it is
Defined as an alteration in the structure (hypertrophy or dilatation) and/
or function of the right ventricle caused by a primary disorder of the
respiratory system. The MOST common cause is COPD.

63. Which assessment data would the nurse recognize to support the
diagnoses of abdominal aortic aneurysm (AAA)?
A. Dullness C. Crackles
B. Abdominal bruit  D. Bone Friction
Answer: B
An audible bruit associated with an abdominal aortic aneurysm may be heard
in the area to the left of the umbilicus. A bruit, a vascular sound
resembling heart murmur, suggests partial arterial occlusion. Crackles are
indicative of fluid in the lungs. Dullness is heard over solid organs, such
as the liver. Friction rubs indicate inflammation of the peritoneal
surface.
 64. Which of the following groups of symptoms indicated a ruptured
abdominal aneurysm?
A. Lower back pain, increased BP, decreased RBC, increased WBC
B. Severe lower back pain, decreased BP, decreased RBC, increased
WBC
C. Severe lower back pain, decreased BP, decreased RBC, decreased
WBC
D. Intermittent lower back pain, decreased BP, decreased RBC,
increased WBC
Answer: B.
Severe lower back pain indicates an aneurysm rupture, secondary to pressure
being applied within the abdominal cavity. When rupture occurs, the pain is
constant because it can't be alleviated until the aneurysm is repaired.
Blood pressure decreases due to the loss of blood. After the aneurysm
ruptures, the vasculature is interrupted and blood volume is lost, so blood
pressure wouldn't increase. For the same reason, the RBC count is decreased
- not increase. The WBC count increases as cells migrate to the site of
injury.

65. A 65-year-old patient arrived at the triage area with complaints

of diaphoresis, dizziness, and left-sided chest pain. This patient
should be prioritized into which category?
A. Non-urgent. C. Emergent.
B. Urgent D. High urgent.
Answer: C
Chest pain is considered an emergent priority, which is defined as
potentially life-threatening. Option B: Clients with urgent priority need
treatment within 2 hours of triage (e.g. kidney stones). Option A: Non-
urgent conditions can wait for hours or even days. Option D: High urgent is
not commonly used; however, in 5-tier triage systems, High urgent patients
fall between emergent and urgent in terms of the time elapsing prior to
treatment.
66. The client who is scheduled to have surgery cannot read or write.
The surgeon obtaining the consent wants to have the client's spouse
sign the consent instead. What is the nurse's BEST action?
A. Nothing; a signed informed consent statement does not need to be
obtained from this client.
B. Locate the spouse, because the informed consent statement must be
signed by the client's closest relative.
C. Inform the surgeon that the client may sign the informed consent
statement with an X in front of two witnesses.
D. Notify the administration because the court must appoint a legal
guardian to represent the client's best interests and give
consent for all surgical procedures.
Answer: C

The lack of ability to read or write does not constitute incapacity to

give legal consent. If the client meets all other legal and clinical
aspects of competence for self-determination, he or she has the right to
consent directly by using either his or her own signature or an X to
demonstrate consent if the act is witnessed by two people.

67.  A few minutes after you have given an intradermal injection of

an allergen to a patient who is undergoing skin testing for allergies,
the patient reports feeling anxious, short of breath, and dizzy. Which
action included in the emergency protocol should you take FIRST?
A. Start oxygen at 4 L/min using a nasal cannula.
B. Obtain IV access with a large-bore IV catheter.
C. Give epinephrine (Adrenalin) 0.3 mL intramuscularly.
D. Administer 3 mL of nebulized albuterol (Proventil) 0.083%.
Answer: C
Rationale: Epinephrine is the initial drug of choice for treatment of
anaphylaxis. Giving epinephrine rapidly at the onset of an anaphylactic
reaction may prevent or reverse cardiovascular collapse as well as airway
narrowing caused by bronchospasm and inflammation. Oxygen use is also
appropriate, but oxygen would be administered using a nonrebreather mask in
order to achieve a fraction of inspired oxygen closer to 100%. Albuterol
may also be administered to decrease airway narrowing but would not be the
first therapy used for anaphylaxis. IV access will take longer to establish
and should not be the first intervention.

68. While on the playground, a school child is stung by a bee,

resulting in redness and swelling. The school nurse is nearby when it
happens. What does the nurse do FIRST?
A. Applies an ice pack to the stinger
B. Gently scrapes out the stinger with a credit card
C. Injects the child with an epinephrine pen
D. Removes the bee and saves it for evidence of the sting
Answer: B
Gently scrape out the stinger with a credit card.The preferred method is to
remove the stinger by gently scraping or brushing it off with the edge of a
knife blade, credit card, or needle. However, it is important to realize
that the method used to remove the stinger is not as relevant as the speed
of removal. Applying an ice pack would be the second course of action that
should be taken; removal of the stinger is more important. An epinephrine
pen would be administered for known allergies or for a severe allergic
reaction, not for localized redness and swelling. Keeping the bee is not an
important element in the treatment of this emergency; bumble bees and wasps
can re-sting, but honey bees can sting only once and die after injecting
their victim with their stingers.
 69. A client diagnosed with bulimia nervosa has been attending a
mental health clinic for several months. Which factor should a nurse
identify as an appropriate indicator of a positive client behavioral
change?
A. The client gains 2 pounds in 1 week.
B. The client focuses conversations on nutritious food.
C. The client demonstrates healthy coping mechanisms that decrease
anxiety.
D. The client verbalizes an understanding of the etiology of the
disorder.

Answer: C
Rationale: The nurse should identify that when a client uses healthy coping
mechanisms that decrease anxiety, positive behavioral change is
demonstrated. Stress and anxiety can increase bingeing, which is followed
by inappropriate compensatory behaviors. 

70. Over the past year, a woman has cooked gourmet meals for her
family but eats only tiny servings. She wears layered, loose clothing
and now has amenorrhea. Her current weight is 95 pounds, a loss of 35
pounds. Which medical diagnosis is MOST likely?
A. Binge eating disorder C. Bulimia nervosa
B. Anorexia nervosa D. Pica
Answer: B
Overly controlled eating behaviors, extreme weight loss, amenorrhea,
preoccupation with food, and wearing several layers of loose clothing to
appear larger are part of the clinical picture of an individual with
anorexia nervosa. The individual with bulimia usually is near normal
weight. The binge eater is often overweight. Pica refers to eating nonfood
items.

71. What is the MOST common functional mental illness in the elderly?
A. Dementia C. Depression
B. Schizophrenia D. Alzheimer’s
Answer: C
Depression is the most common and most frequent mental illness among older
adults.
Depression in Later Life
- NOT a normal part of aging
- Persistent and interferes significantly with the ability to function 
- Low rates of diagnosis and treatment in later life
- Higher rates for women than men
- Higher rates among those in healthcare settings

72. A patient is prescribed theophylline, for what adverse effect

should the nurse monitor the patient?
A. Drowsiness C. Diarrhea
B. Constipation D. Hypoglycemia

Answer: C
increased heart rate nausea and vomiting increased CNS effects headache
seizure hematemesis increased glucose hypokalemia and DIARRHEA
73. What theory is responsible for a healthy Environment?
A. Goal Attainment Theory C. Environmental Theory
B. Caring Model D. Transcultural Nursing Model
Answer: C
RATIONALE: Nightingale's Environmental Theory includes the 4 metaparadigm
of nursing--person, environment, health, and nursing. The focus is
primarily on the patient and the environment, with the nurse manipulating
the environment to enhance patient recovery. Nightingale viewed the
physical environment as a critical component in health and disease. Nature
would bring healing.

74. The nursing diagnosis Hypothermia is an example of which of the

following?
A. Risk nursing diagnosis C. Potential nursing diagnosis
B. Actual nursing diagnosis D. Wellness nursing diagnosis

Answer: B
B - An actual nursing diagnosis describes a human response to health
conditions or life processes in an individual, family, or community. The
term readiness is present in a wellness nursing diagnosis. A potential
nursing diagnosis is a risk for diagnosis.

75. The rank of Prostate cancer in year 2010 among men is_______
A. First C. Third
B. Second D. Fourth
Answer: D
The 10 leading cancer sites among men in 2010 (lung, liver, colon/rectum,
prostate, stomach, leukemia, brain/nervous system, other pharynx, non-
Hodgkin lymphoma, kidney) comprise 71% of all new cases.

76. The affected part in acoustic neuroma is the:___________

A. Outer ear C. Middle ear
B. Tympanic membrane D. Inner ear
Answer: D
An acoustic neuroma (vestibular schwannoma) is a benign tumor that develops
on the balance (vestibular) and hearing, or auditory (cochlear) nerves
leading from your inner ear to the brain, as shown in the top image. The
pressure on the nerve from the tumor may cause hearing loss and imbalance.

77. The clinic nurse is preparing to test the visual acuity of a

client, using a Snellen chart. Which identifies the accurate procedure
for this visual acuity test?
A. The right eye is tested, followed by the left eye, and then both
eyes are tested.
B. Both eyes are assessed together, followed by an assessment of the
right eye and then the left eye.
C. The client is asked to stand at a distance of 40 feet from the
chart and is asked to read the largest line on the chart.
D. The client is asked to stand at a distance of 40 feet from the
chart and to read the line that can be read 200 feet away by an
individual with unimpaired vision
Answer: A
Visual acuity is assessed in one eye at a time, and then in both eyes
together with the client comfortably standing or sitting. The right eye is
tested with the left eye covered; then the left eye is tested with the
right eye covered. Both eyes then are tested together. Visual acuity is
measured with or without corrective lenses and the client stands at a
distance of 20ft. from the chart.

78. A client's vision is tested with a Snellen chart. The results of

the tests are documented as 20/60. How should the nurse interpret this
finding?
A. The client is legally blind.
B. The client's vision is normal.
C. The client can read at a distance of 60 feet what a client with
normal vision can read at 20 feet.
D. The client can read only at a distance of 20 feet what a client
with normal vision can read at 60 feet.
Answer: D
Vision that is 20/20 is normal, that is, the client is able to read from 20
feet what a person with normal vision can read from 20 feet. A client with
a visual acuity of 20/60 only can read at a distance of 20 feet of what a
person with normal vision can read at 60 feet.

79. Tonometry is performed on a client with a suspected diagnosis of

glaucoma. The nurse looks at the test results documented in the
client's chart, knowing that which is the range for normal intraocular
pressure?
A. 2 to 7 mm Hg C. 22 to 30 mm Hg
B. 10 to 21 mm Hg D. 31 to 35 mm Hg

Answer: B
Tonometry is the method of measuring intraocular fluid pressure using a
calibrated instrument that indents or flattens the corneal apex. Pressures
between 10 and 21 mmHg are considered within normal range.

80. A client receives CPR in the emergency room but it is

unsuccessful. The wife of the client indicates that the client is an
organ donor and that they want to donate the client's eyes. Which
should the nurse implement first to promote organ transplantation?
A. Confirm that the client is valid donor with an organ registry
B. Cover eyes with wet saline gauze pads and small ice packs
C. Place the client in a supine position with the head on one pillow
D. Ask the wife to produce the legal documents supporting the
donation
Answer: B
The nurse should preserve firs he eyes by covering the eyes and placing it
with a wet sterile saline gauze pads, preserved in an ice packs.

81. What is the affected part in acoustic neuropathy?

A. Tympanic membrane C. Cochlea
B. Brainstem D. Stapes
Answer: C
Auditory neuropathy is hearing loss caused by a disruption of nerve
impulses travelling from the inner ear to the brain. Auditory
Neuropathy (AN) is a hearing disorder in which the outer hair cells of
the cochlea are present and functional, but sound information is not
transmitted sufficiently by the auditory nerve to the brain. 
 82. A patient, injured at work, was seen by the factory occupational
nurse. The nurse treated the wound and instructed the patient to get a
tetanus antitoxin injection at the City Health Center. The patient
failed to follow instruction, developed tetanus, and subsequently
filed a suit against the nurse. What is the MOST likely result of
ensuing trial? The nurse is ________________________.
A. liable, because there was no follow-up to ensure that the
patient received the injection
B. not liable for damages, because the nurse has right to expect
that instructions will be followed
C. liable, because tetanus is a easily treatable after diagnosis
D. not liable, because tetanus is a reportable disease and the
health center is should have insisted the treatment.
Answer: B
Rationale: The court recognizes that the patient's own negligence could
contribute to adverse outcomes, as in this case. The patient has a right to
refuse or follow advice or instructions, but must bear the results of that
decision. When this occurs, the legal system applies the concept of
contributory or comparative negligence. While follow-up is common, the
patient still retains the right to follow or not follow instructions.
Unless the disease is one that is a danger to the general public if not
treated, the patient can refuse treatment at the health department as well.
Tetanus is not easily treatable, but the ease of treatment is not a factor
in this case.

83. Alexis is a registered nurse who is giving end-of-shift report on

her patient with hepatitis B, which he acquired through IV drug use.
She tells the on-coming nurse that the patient is nasty and
uncooperative and that she's not surprised he has hepatitis, given his
lifestyle. Alexis could be sued for which of the following?
A. Battery C. Slander
B. Libel D. Malpractice

Answer: C
Slander is a verbal form of defamation of character. The other responses
are incorrect because the nurse is not performing a procedure or otherwise
touching the patient, there is no evidence that the nurse is not
implementing a plan of care, and there has been no breach of duty.
Slander: An oral defamation of character with the intention to hurt
someone's reputation. Defamation is a false communication or a careless
disregard for the truth that causes damage to someone's reputation, either
in writing (Libel) or verbally (slander). Battery is the willful touching
of a person without permission like Performing a procedure without consent
is an example of battery. 
 84. A nurse working in a coronary care unit resuscitates a client who
had expressed wishes not to be resuscitated. Which tort has the nurse
committed?
A. Battery C. Malpractice
B. Negligence D. Assault
Answer: A
The nurse has committed a mistake and can be sued for battery because of
unlawfully carrying out a procedure that the client had refused. Battery is
an assault and includes negligent touching of another person's body or
clothes or anything attached to or held by that other person. Assault is
the threat of touching another person without his or her consent.
Negligence may be an act of omission or commission. Defamation of character
in spoken words is called slander. Libel is defamation of character in
written words.

85. A nurse is called to a deposition for a malpractice charge that

has resulted in the death of a client. As the chart is reviewed, the
prosecuting attorney questions the nurse about several defaming
comments written in the medical record about the client. What charges
can be filed against the nurse due to these comments? 
A. Malpractice C. libel
B. Negligence D. slander
Answer: C
Libel is damaging statements written and read by others. Since there were
defaming comments written in the chart, libel charges could be appropriate.
Malpractice, slander, and negligence are not charges in this scenario.
86. When a nurse causes an injury to the patient and the injury caused
becomes the proof of the negligent act, the presence of the injury is said
to exemplify the principle of: 
A.Force majeure 
B.Respondeat superior 
C.Res ipsa loquitur 
D.Holdover doctrine 

Answer: (C) Res ipsa loquitur 

Res ipsa loquitur literally means the thing speaks for itself. This means
in operational terms that the injury caused is the proof that there was a
negligent act.
87. Ensuring that there is an informed consent on the part of the patient
before a surgery is done, illustrates the bioethical principle of: 
A.Beneficence 
B.Autonomy 
C.Truth telling/veracity 
D.Non-maleficence 
Answer: (B) Autonomy 
Informed consent means that the patient fully understands what will be the
surgery to be done, the risks involved and the alternative solutions so
that when s/he give consent it is done with full knowledge and is given
freely. The action of allowing the patient to decide whether a surgery is
to be done or not exemplifies the bioethical principle of autonomy.
88. When a nurse is providing care to her/his patient, s/he must remember
that she is duty bound not to do doing any action that will cause the
patient harm. This is the meaning of the bioethical principle: 
A.Non-maleficence 
B.Beneficence 
C.Justice 
D.Solidarity 

Answer: (A) Non-maleficence 

Non-maleficence means do not cause harm or do any action that will cause
any harm to the patient/client. To do good is referred as beneficence.
89. When the patient is asked to testify in court, s/he must abide by the
ethical principle of: 
A.Privileged communication 
B.Informed consent 
C.Solidarity 
D.Autonomy 

Answer: (A) Privileged communication 

All confidential information that comes to the knowledge of the nurse in
the care of her/his patients is considered privileged communications.
Hence, s/he is not allowed to just reveal the confidential information
arbitrarily. S/he may only be allowed to break the seal of secrecy in
certain conditions. One such condition is when the court orders the nurse
to testify in a criminal or medico-legal case.
90. When the doctor orders “do not resuscitate”, this means that 
A.The nurse need not give due care to the patient since s/he is terminally
ill 
B.The patient need not be given food and water after all s/he is dying 
C.The nurses and the attending physician should not do any heroic or
extraordinary measures for the patient 
D.The patient need not be given ordinary care so that her/his dying process
is hastened 

Answer: (C) The nurses and the attending physician should not do any heroic
or extraordinary measures for the patient 
Do not resuscitate” is a medical order which is written on the chart after
the doctor has consulted the family and this means that the members of the
health team are not required to give extraordinary measures but cannot
withhold the basic needs like food, water, and air. It also means that the
nurse is still duty bound to give the basic nursing care to the terminally
ill patient and ensure that the spiritual needs of the patient is taken
cared of.

Situation : Harry a new research staff of the Research and Development

Department of a tertiary hospital is tasked to conduct a research study
about the increased incidence of nosocomial infection in the hospital.

90. Which of the following ethical issues should he consider in the conduct
of his study?

1. Confidentiality of information given to him by the subjects

2. Self-determination which includes the right to withdraw from the study
group
3. Privacy or the right not to be exposed publicly
4. Full disclosure about the study to be conducted 
A.1, 2, 3 
B.1, 3, 4 
C.2, 3, 4 
D.1, 2, 3, 4 

Answer: (D) 1, 2, 3, 4 
This includes all the options as these are the four basic rights of
subjects for research.
91. Which of the following is the best tool for data gathering? 
A.Interview schedule 
B.Questionnaire 
C.Use of laboratory data. 
D.Observation 

Answer: (C) Use of laboratory data. 

Incidence of nosocomial infection is best collected through the use of
biophysiologic measures, particularly in vitro measurements, hence
laboratory data is essential.
92. During data collection, Harry encounters a patient who refuses to talk
to him. Which of the following is a limitation of the study? 
A.Patient’s refusal to fully divulge information. 
B.Patients with history of fever and cough 
C.Patients admitted or who seeks consultation at the ER and doctors
offices 
D.Contacts of patients with history of fever and cough 

Answer: (A) Patient’s refusal to fully divulge information. 

Patient’s refusal to divulge information is a limitation because it is
beyond the control of Harry.
93. What type of research is appropriate for this study? 
A.Descriptive- correlational 
B.Experiment 
C.Quasi-experiment 
D.Historical 

Answer: (A) Descriptive- correlational 

Descriptive- correlational study is the most appropriate for this study
because it studies the variables that could be the antecedents of the
increased incidence of nosocomial infection.
94. In the statement, “Frequent hand washing of health workers decreases
the incidence of nosocomial infections among post-surgery patients”, the
dependent variable is 
A.incidence of nosocomial infections 
B.decreases 
C.frequent hand washing 
D.post-surgery patients 

Answer: (A) incidence of nosocomial infections 

The dependent variable is the incidence of nosocomial infection, which is
the outcome or effect of the independent variable, frequent hand washing.

95. Harry knows that he has to protect the rights of human research
subjects. Which of the following actions of Harry ensures anonymity? 
A.Keep the identities of the subject secret 
B.Obtain informed consent 
C.Provide equal treatment to all the subjects of the study. 
D.Release findings only to the participants of the study 

Answer: (A) Keep the identities of the subject secret 

Keeping the identities of the research subject secret will ensure anonymity
because this will hinder providing link between the information given to
whoever is its source.

Situation 10: Filariasis is endemic in some parts of the Philippines. The

disease often progresses to become chronic, debilitating and often
unfamiliar to health workers.

96. Effective methods that the government would likely to pursue to

eliminate filariasis in the country are all of the following EXCEPT:
a. Pursue annual mass drug administration using two drugs in all endemic
areas for at least five consecutive years
b. Vaccination of all susceptible in high risk areas and high risk
populations
c. Intensify health information and advocacy campaigns in its prevention,
control and elimination
d. Halt progression of disease through disability prevention
97. The vector for Filariasis is
a. Wuchereria bancrofti
b. Aedes poecillus
c. Anopheles
d. Aedes egypti

98. A long incubation period characterizes Filariasis that typically ranges

from:
a. 2-4 weeks c. 2-3 years
b. 4-6 weeks d. 8-16 months

99. A 36-year-old man is brought by his wife to a doctor's clinic to be

tested for filariasis. The most likely diagnostic test that he will undergo
is:
a. Immunochromatographic test (ICT)
b. Nocturnal Blood Examination
c. Stool examination
d. Urinalysis

100. A client in the acute stage of the disease will include which of the
following clinical findings?
a. Lymphangitis, lymphadenitis, epidydimitis
b. Hydrocele, lymphedema, elephantiasis
c. Orchitis, hydrocele, elephantiasis
d. Lymphadenitis, lympedema and orchitis

“Just when the caterpillar thought the world was ending, he turned into a
butterfly.”
“The starting point of all achievement is desire.” —Napoleon Hill