INSTRUCTIONS: Please encircle the BEST ANSWER among the choices, and shade the corresponding box in

the answer sheet provided. You are allowed to write anything in the test question paper; but you can only
write the subject title set, and shading in the answer sheet.

1. Nursing theorist add to the basic knowledge of nursing by:

a. Defining better how the person nursed is to be viewed
b. Writing specific procedures such as how to count the pulse rate
c. Limiting the role of nurses to improving sanitary conditions
d. Writing standards to improve the appearance of nurses

2. She defined nursing as the “act of utilizing the environment of the patient to assist him in his recovery” and
was considered the first nurse theorist
a. Virginia Henderson b.Florence Nigntingale c. Hildergard Peplan d. Dorothea Orem

3. She believes the practice of caring is central to nursing: it is unifying focus of practice:
a. Jean Watson b. Faye Abdellah c. Josephine Paterson and Zredad d. Lydia Hall

4. Sister Callista Roy’s theory views the client as an adaptive system. According to her, the goal of nursing is to
help the person adapt to changes in physiological needs, self-concept, role functions and interdependent
relationship during health and illness. The theory is:
a. Science of Unitary Human Being
b. Adaptation Theory
c. Self-care Deficit Theory
d. Goal Attainment Theory

5. According to this model by Peplan, the client is an individual with a felt need, and nursing is an
interpersonal and therapeutic process.
a. Interpersonal Relations Model
b. Human Caring Model
c. Human Becoming Theory
d. Behavioral Systems Model

6. Data can be subjective or objective. Usually, who is in the best position to provide accurate, reliable, and
valid information about subjective data?
a. Client b. Caregivers c. Support people d. Friends

7. A nursing diagnosis has three major components. The cluster of sign and symptoms that indicate the
presence of a particular diagnostic label is the:
a. Etiology b. Problem statement c. Defining characteristics d. Qualifiers

8. Mr. Rham is a 60 years old with chronic obstructive pulmonary disease. He is admitted to the hospital for
pneumonia with a chief complaint of shortness of breath and congestion. Using Maslow’s Heirarchy of Needs,
the most basic need of Mr. Rham at this point in time would be:
a. Safety b. Air c. Self-esteem d. Food

9. An important problem at this point in Mr. Rham’s care would be:

a. Altered nutritional status related to inability to swallow
b. Potential for depression related to chronic illness
c. Inadequate oxygenated related to chronic lung disease
d. Impaired circulation related to congestive heart failure

10. His wife reports that he usually sleeps on two or three pillows at home. Which of the following nursing
interventions is most appropriate based on this information?
a. Have him assume the semi-fowler’s position for sleep
b. Allow him to sit in a chair to sleep
c. Ambulate three times a day with breathing exercise
d. Aoole oxygen as needed for dyspnea

11. Body temperature reflects the balance between heat produced and heat lost from the body. During a hot
weather, the increase in body temperature causes:
a. Vasoconstriction
b. Vasodilation
c. No effect in blood vessels
d. Atherosclerosis

12. In recording a blood pressure of 120/80 mmHg, the 120 represents the:
a. Pulse rate b. Diastolic pressure c. Systolic pressure d. Pulse deficit

13. Nursing interventions such as applying cool cloths to the axilla act to decrease body temperature by:
a. Conduction b. Convection c. Evaporation d. Radiation

14. A nurse receives a telephone call from the postanesthesia care unit (PACU) stating that a client is bing
transfered to the surgical unit. The nurse olans to do which of the following first upon arrival of the client?
a. Assess the patency of the airway
b. Assess the vital signs (VS) to compare with preoperative measurements
c. Check the dressing to assess for bleeding
d. Check tubes of drains for patency

15. Which of the following interventions should the nurse include in the plan of care for a client taking in ACE
inhibitor?
a. Monitor BP closely for 2 hrs after the first dose
b. Begin with a high dose and gradually decrease the dose
c. Administer potassium supplement to the client
d. Begin with a daily dosing followed by dosing every other day

16. When checking for temperature via the rectal route, the nurse will position the patient in the:
a. Dorsal recumbent position
b. Side-lying position
c. Left-sims’ position
d. Prone position

17. When assessing for peripheral visual fields of the eye, the nurse will ask the client to sit directly facing the
nurse at a distance of:
a. 1 foot b. 2-3 feet c. 3-4 feet d. 20 feet

18. The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When
describing a healthy stoma, which of the statement should the nurse be sure to include?
a. The stoma should appear dark and have a bluish hue
b. At first, the stoma may bleed slightly when touched
c. The stoma should remain swollen distal to the abdomen
d. A burning sensation under the stoma faceplate is normal
19. The nurse correctly identifies which of the following as belonging to the dorsal cavity?
a. Mediastinum b. Mouth c. Vertebral canal d. Reproductive organs

20. A nurse inspects a client’s pupil size and determines that it’s 2 mm in the left eye and 3mm in the right
eye . unequal pupils are known as:
a. Anisocoria b. Ataxia c. Cataract d. Diplopia

21. The client’s vision is tested with a Snellen’s chart. The results of the test are documented as 20/60. The
nurse interprets this as:
a. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet
b. The client is legally blind
c. The client’s vision is normal
d. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet

22. Which technique enhances breath sound auscultation?

a. Warming the stethoscope
b. Wetting the stethoscope
c. Listening with the diaphragm
d. Listening with the bell

23. Assessment of the thorax includes the chest wall, the lungs, the heart and the great vessels. The nurse
begins the assessment of the chest and lungs with the client undressed from waist up and assumes this
position initially:
a. Lying supine
b. Slightly leaning forward
c. Semi-fowler’s position while on his bed
d. Sitting up on the examining table

24. During an auscultation for normal heart sounds, a dull, low-pitched sound was heard. This sound or phrase
is
A. S2 b. S2 c. Systole d. Diastole

25. Nurse Bing is performing primary assessment on a child found lying on the floor. To assess for the presence
of pulse, Nurse Bing is most likely to palpitate for
a. Brachial pulse b. Carotid pulse c. Femoral pulse d. Radial pulse

26. In palpating the client’s breast, which of the following position is neessary for the patient to assume before
the start of the procedure?
a. Supine b. Dorsal recumbent c. Sitting d. Lithotomy

27. Nurse Lorie is performing one-handed palpation after bimanual palpation of the left breast. The following
techniques are correct, except:
a. Place the client in supine position
b. Palpate the breast tissue along the hands of the clock, moving from the areola to the periphery
c. Use the fingertips of one hand
d. Instruct the client to abduct the arm, and place her hand behind her head

28. Nurse Bers knows that the sequence in examining the quadrants of the abdomen is:
a. RUQ, RLQ, LUQ, LLO b. RLQ, RUQ, LLQ, LUQ c. RUQ, RLQ, LLQ, LUQ d. RLQ, RUQ, LUQ, LLQ

29. Assessment of the abdomen involves all four methods of examination. Before the procedure, nurse Jones
should assist the client in this position:
a. Position of comfort
b. Supine with arms comfortably at the sides
c. Sitting upright on the examining table
d. Semi-fowler’s with arms comfortably on the sides

30. When teaching Client Echo how to perform testicular sef-examination, all are orrect instructions, except:
a. Examine the testicles every other month, one at a time
b. Use the fingerprint to probe the surface gently, like examining an egg for imperfections
c. Roll the testicles between the thumb and fingers
d. Use the thumb, index, and middle fingers for examination

31. When assessing an elderly client, the nurse knows that changes in the female genitourinary system usually
take place. Included are normal findings except:
a. Loss of pubic hair and a flattening of the labia occur
b. The vaginal wall becomes thinner and less vascular
c. The vulva hypertrophies
d. The vaginal environment becomes drier and more alkaline

32. To evaluate a client’s cerebellar function, the nurse should ask:

a. “Do you have any problems with balance?”
b. “Do you have any difficulty speaking?”
c. “Do you have any trouble swallowing foods or fluids?”
d. “Have you noticed any changes in a muscle strength?”

33. A client admitted with hypoparathyroidismis being monitored for hypocalcemia. Which of the following
signs is used to check for hypocalcemia?
a. Battle’s sign b. Brudziinski’s sign c. Chevostek’s sign d. Homan’s sign

34. Nurse Herbert then starter assessing the monitor function of an unconscious client? He would plan to use
which of the following to test the client’s peripheral response to pain?
a. Sternal rub
b. Pressure on the orbital rim
c. Squeezing the sternocleidomastoid muscle
d. Nail bed pressure
35. Balance depends on the interrelationships of the center of gravity, base of support, and the line of gravity.
Which of the following statements is correct with regards to balance?
a. The closer the line of gravity is to center of the base of support, the greater the person’s stability
b. The closer the line of gravity is to the line of gravity to the edge of the base of support. The greater the
person’s stability
c. If the line of gravity falls outside the base of support, the person has more stable balance.
d. The broader the base of support, the more unstable is the person

36. A nurse is caring for client with history of Gl bleeding. He has sickle cell disease and a platelet count of 22,
000. the client is dehydrated and is receiving dextrose 5% in half normal saline solution at 150 ml/hour. He
reports severe bone pain and is scheduled to receive a dose of morphine SO4. In administering the
medication, the nurse should avoid which route?
a. Oral b. Intravenous c. Intramuscular d. Subcutaneous

37. A nurse is delivering a client’s 10 a.m. medications. The client is away from his room for a diagnostic study.
Which action is the most appropriate for the nurse to take?
a. Leave the medications on the client’s bed side table
b. Ask the client’s roommate to keep the medications for the client until he return
c. Lock the medications in the medicine preparation area until the client returns
d. Have the client skip that dose of medication

38. Which o the following actions by nurse Jones is correct with regards to mixing medications using one
syringe from two vials:
a. Draws up a volume of air equal to the volume of medications to be withdrawn from vial A
b. Injects a volume of air equal to the volume of medication to be withdrawn into vial A and aspirates the
medication, then injects air into vial B
c. Injects air into vial A without touching the solution, withdraws the needle, and injects the remaining air vial
B before withdrawing the desired amount of medication
d. Using the same needle, withdraw the required amount of medication from vial A after withdrawing solution
from vial B

39. The medication order reads: “Meperidine, 50 mg IM stat.” the pre-filled cartridge is available with a label
reading 50 mg/1 mL. The cartridge contains 1.2 mL of hesperidins. You should:
a. Give all the medication in the cartridge because it expanded when it was mixed
b. Call the pharmacy and request the proper dose
c. Refuse to give the medication
d. Dispose of 0.2 mL correctly before administering the drug

40. Dr. Dumaguing order reads Phenytoin (Dilantin) 0.2 PO bid. The medication label states 100mg capsules
Nurse Carlos prepares how many capsule(s) to administer one dose?
a. One capsule b. Two capsules c. Three capsules d. Four capsules

41. A nurse is using the health belief model to assess a patient. Using this model, teh nurse should begin to
understand:
a. Which clinical and financial resources the patient requires to improve his lifestyle
b. What motivates the patient to learn new behaviors
c. The effects of the healt delivery system has on the patient’s health patterns
d. Whether the patient is willing to take actions to support health

42. In this Health and Wellness model, people are viewed as physiologic systems with related functions, and
health is identified by absence of signs and symptoms of disease or injury.
a. Role Performance Model b. Clinical Model c. Adaptive Model d. Eudemonistic Model

43. In the Health Belief Model, individual perceptions include the following, except:
a. Perceived sustainability b. Perceived curability c. Perceived seriousness d. Perceived threat

44. Eudemonistic model incorporates a comprehensive view of health. According to this model, the apex of
the fully developed personality is:
a. Self-fulfillment b. Self-esteem c. Self-actualization d. Self-happiness

45. It is also known as HEALTH MAINTENANCE prevention.

a. Primary b. Secondary c.Tertiary d. None of the above
46. A client has been placed on contract precautions. The appropriate nursing intervention to prevent the
spread of infection is to:
a. Perform meticulous hand washing frequently
b. Wear a mask and gown for all client contacts
c. Restrict all visitors
d. Wear sterile gloves for all contacts with the client

47. A nurse in implementing measures to prevent the spread of infection to other clients. The nurse
understands that which measure is the best way to prevent the spread of infection?
a. Read the policy and procedure manual on performing treatments
b. Use proper hand washing techniques
c. Perform sterile technique on all procedures
d. Never stop in the middle of a performing a procedure

48. While donning sterile gloves (open method), the cuff of the first glove rolls under itself about 1/4 inches.
The best action for the nurse is to
a. Remove the glove and start over with a new pair
b. Wait until the second glove is in place and then unroll the cuff with the other sterile hand
c. Ask colleague to assist by unrolling the cuff
d. Leave the cuff rolled under

49. In caring for a client with a draining infected foot ulcer, correct technique includes:
a. Wearing mask during dressing changes
b. Providing disposable meal trays and silverware
c. Following standard precautions in all interactions with the client
d. Using surgical aseptic technique for all direct contact with the client

50. You are working with a student nurse who is assigned to care for an HIV-positive client with severe
esophagitis caused by Candida Albicans. Which action by the student indicates that you need to intervene
most quickly?
a. Puts on mask and gown before entering the client room
b. Gives the client a glass of water after oral nystatin suspension
c. Offers the client a choice of chicken soup or chili con carne for lunch
d. Places a “no visitor” sign on the door of the client