REFRESHER COURSE: PREBOARD EXAMINATION

Nursing Practice III: Care of Clients with Physiologic and

Psychosocial Alterations (Part A)
GENERAL INSTRUCTIONS:
1. This test questionnaire contains 100 test questions
2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalid your answer.
3. AVOID ERASURES.
4. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set.
5. Write the subject title “NURSING PRACTICE III” on the box provided.

Situation: Jasmine is working in the cardiac unit with a

Situation: Florenda, 52 years old, was transported to nurse floater. Together, they made their rounds while
the Operating Room for Total Abdominal Hysterectomy Kristine assessed the nurse’s knowledge on the
commonly used cardiac drugs.
1. The scrub nurse ensures that aseptic technique is
maintained throughout the procedure. When she serves the 6. Jasmine asked the floater why nitroglycerin is given to a
right gloves to the surgeon, which of the following is the client with angina. The correct response of the nurse is that
correct technique to be followed by the scrub nurse? nitroglycerine:
A. Keep thumbs away from the cuff A. increases preload
B. Pick up the gloves and place the palm towards you B. increases afterload
C. Maintain fingers of the gloves facing you C. dilates the veins
D. Slide the gloves by holding under the glove cuff and spread D. constricts the arteries
to create wide opening
7. Being new in the cardiac unit, Jasmine emphasized to the
2. The surgeon uses electrosurgical equipment to cauterize floater that the long standing hallmark in nursing intervention
blood vessels. Which of the following nursing activity should for clients taking Digoxin (Lanoxin) is:
have been done by the circulating nurse to ensure safety? A. Take the apical pulse for one full minute stethoscope
A. Correctly drape electro cautery cable and cord B. Monitor intake and output hourly
B. Electro cautery equipment is placed appropriately at the C. Check the blood pressure reading with the same BP
back of the surgeon apparatus
C. Grounding pad is connected to grounding cable properly D. Palpate the radial pulse for one full minute
placed under the patent’s buttocks
D. Electro cautery pencil is made easily available each time the 8. Jasmine tests the floater’s readiness for the assignment by
surgeon uses it asking this question “When you find a client in cardiac arrest,
which of the following drugs would you be ready to
3. The surgeon passed the specimen to the scrub nurse. Which administer?” The correct answer of the nurse floater is:
of the following is the correct action of the scrub nurse? A. Atropine sulfate
A. Place specimen in a basin moistened with saline solution B. Lidocaine 2% anti - arrhytmic
B. Wipe specimen with sponge C. Morphine sulfate
C. Wipe specimen with surgical sponge (OS) D. Epinephrine
D. Pass the specimen to the circulating nurse
9. One of the hypertensive clients assigned to the nurse floater
4. The surgeon asked a suture to close the peritoneum. Which is on Captopril (Capoten), an Angiotensin Converting Enzyme
of the following should have been done by the scrub nurse (ACE) Inhibitor. Which of the following nursing interventions
before suture is handed to the surgeon? should be included in the plan of care?
A. Specimen passed to the circulating nurse A. Monitor sugar level
B. Needle holder passed to the surgeon B. Observe complete bed rest
C. Needle mounted on the needle holder C. Measure intake and output carefully
D. “Surgical count” completed D. Monitor for bruising, petechiae, or bleeding

5. The surgeon tells the scrub nurse that the procedure done 10. The nurse floater is instructing one of her clients on
was total abdominal hysterectomy with bilateral sphingo- Clopidogrel bisulfate (Plavix). Which of the following indicates
oophorectomy. The scrub nurse understands that the that her client understands the effect of the drug?
specimen she received would consist of which of the following A. “I should slow down on my carbohydrate intake.”
organs? B. “I should take liberal amount of fluid while on this drug.”
A. Right and left ovaries, uterus, a fallopian tube C. “I should use caution in taking over the counter drugs that
B. Uterus, fallopian tube, ovary, and urinary bladder might cause bleeding.”
C. Uterus, right and left fallopian tubes, and ovaries D. “I may gain weight while on this drug.”
D. Uterus, urinary bladder, two ovaries, right and left fallopian
tubes Situation: Virgilio, 40 years old, was admitted for
check- up. He was diagnosed with essential

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hypertension a year ago. Upon admission, his blood C. Elevate the affected foot
pressure is 170/90, slightly dysneic, dizzy and with D. Apply bandage around the affected foot
blurred vision.
20. Colchicine is prescribed during the acute attack phase.
11. The admitting nurse understands that increased diastolic Nurse Karmela is aware that the action of the drug is to:
pressure indicates which of the following? systolic - at work A. Provide fast symptomatic relief
A. Generalized vasoldilation diastolic - at rest
B. Lower serum uric acid allupurinol
B. Loss of elasticity of the aorta and arteries C. Block the conduction of pain sensation
C. Increased peripheral resistance and increased workload of D. Interfere with the inflammation response of uric acid
the left ventricle crystals in the joints NSAID

D. Widening of the lumen of the arteries

Situation: Henry, 65 year old underwent Transurethral
12. Virgilio has been taking Atenolol (Tenormin) 50 mg. orally Prostatectomy (TURP). He was admitted to the Post
once daily. The nurse understands that the specific action is to Anesthesia Care Unit (PACU). The following questions
block: apply.
A. Beta receptor stimulation of the heart
B. Effects of the angiotensin II on receptors 21. The Operating Room (OR) nurse endorsed the ongoing
C. Calcium entry into the myocardium cells intravenous infusion of Dextrose 5% Ringer’s Lactate, 500ml,
D. Alpha receptors in vascular smooth muscle running at 40ml per hour at the level of 300ml. The nurse who
received the client in PACU at 1500H,would expect the present
13. Hydrochlorothiazide (Hytaz) 12.5mg 1 tablet orally once infusion to be consumed at:
daily has been prescribed for the client. The specific action of A. 2400H
this thiazide diuretic is to: B. 0100H
A. Promote excretion of sodium and chloride be decreasing C. 2200H
absorption in the distal tubule D. 0300H
B. Increase osmotic draw of the urine inhibiting water re-
absorption 22. The client has an indwelling triple catheter to continuous
C. Inhibit sodium and chloride re-absorption in the ascending bladder irrigation (CBI) with Normal Saline Solution (NSS)
loop of Henle infusing at 200ml per hour. After four hours, the nurse
D. Inhibit sodium- potassium exchange in the distal tubule emptied the drainage bag and obtained and output of 1,080
ml. Which of the following will the nurse record as the client’s
14. From the results of the laboratory test prescribed by the urinary output?
200 times 4 hours = 800 Normal saline solution
physician, which of the following will the nurse consider as an A. 180ml
indication of impaired renal function? Elevated levels of; B. 1,080 ml 1080-800= 280
A. Creatinine C. 800ml
B. Hematocrit D. 280ml
C. Potassium
D. Total Cholesterol 23. The surgeon’s order reads: “Maintain traction on the
indwelling triple lumen catheter.” Which of the following is the
15. “Risk for excess fluid volume” is a nursing diagnosis MOST appropriate action of the nurse?
identified by the nurse. The following are acceptable indicators A. Tape the catheter to the abdomen and keep client in supine
of excess fluid volume, EXCEPT: position
A. Intake and output record B. Pull the catheter taut and tape to the thigh alternately every
B. Compliance to sodium restriction 6 hours
C. Vital signs reading C. Instruct the client to keep both legs together and extended
D. Weight changes all the time
D. Pull the catheter taut, tape to one thigh and keep the leg
Situation: Conrado sought admission for acute gout of extended all the time
the right foot. Nurse Karmela was in-charge of the
client. 24. The nurse understands that Normal Saline Solution (NSS)
is used for CBI to prevent which of the following?
16. Nurse Karmela performs initial assessment. Which of the A. Later intoxication
following types of joint pain supports the physician’s diagnosis? B. Elevation of specific urine gravity
A. Bilateral C. Dehydration
B. Symmetrical D. Formation of stones
C. Polyarticular
D. Monoarticular 25. The nurse assigned to the client monitored and maintained
the CBI rate of NSS at 200 ml per hour. This intervention is
17. Which of the following examinations would the nurse critical because it:
expect to be ordered? A. Washes out remaining fragments of stones
A. Bone marrow aspiration B. Avoids postoperative infection
B. Knee-jerk examination C. Decreases bleeding and keep the bladder free from blood
C. Synovial fluid analysis clot
D. Bone density D. Maintains adequate hydration.

18. The client is for 24- hour urine collection for uric acid Situation: The nurse is assigned to admit a 27 year old
determination. To have a reliable result, the nurse anticipates female patient with protruding eyeballs and an
which diet prescription prior to the examination? enlarged neck. Physician’s diagnosis is Grave’s disease.
A. Low fat diet
B. Low protein diet 26. The nurse performs initial assessment and confers with the
C. Purine free diet medical resident. Which of the following will the nurse consider
D. Low purine diet as the correct description of Grave’s disease?
A. Antibodies bind to TSH receptors causing increased thyroid
19. During the acute attack, the pain of the affected foot can hormone
be so intense that even the weight of the linen can be B. Multiple thyroid nodules resulting in thyroid hyper function
unbearable. The MOST appropriate nursing intervention is to: C. Increased in thyroid secretion of T3 cause unknown
A. Apply splint on the affected D. Uncontrolled secretion of T3 and T4 form benign thyroid
B. Place a foot cradle on the bed tumor

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 for hyperthyroidism levothyroxin for hypothyroidism A. The classic triad of symptoms was observed in 9 out of 60
27. During the interview, nurse found out that the client takes sick children
Prophylthiouracil (Prophyl-Thracil) daily. Which of the following B. Approximately 15 sick children experienced the classic triad
is the specific action of this drug? of symptoms
A. Beta-adreneric blocking drug C. When seen initially, 30 sick children did not show any of the
B. Decreases blood flow to the thyroid gland symptoms
C. Destroys thyroid cells D. Among the 60 children, there were 25 who showed the
D. Blocks thyroid hormone production classic triad of symptoms

28. The nurse identified the nursing diagnosis “Disturbed Situation: The primary goal of nursing research is to
sensory perception related to exophthalmus.” Which of the develop a scientific knowledge base for nursing
following nursing interventions is intended to promote practice. Nursing research includes all students
decrease in periorbital fluid? concerning nursing practice, nursing education, and
A. Cover eyes nursing administration.
B. Administer artificial tears as prescribed
C. Elevate head at 45 degrees 36. Researcher Bea conducted a research of the effect of using
D. Use cool moist eye compress an agent in giving oral hygiene in the nursing care of the
acutely ill surgical patients. In this type of study, it necessary
Lugol’s solution
29. The client is scheduled for subtotal thyroidectomy. Strong to:
iodine solution is prescribed. The nurse prepares to administer A. conduct a pilot study
the medication knowing that therapeutic effect of the B. administer treatment
medication is to: C. conduct interview
A. increase thyroid hormone D. develop a questionnaire
B. replace the thyroid hormone
C. suppress thyroid hormone production 37. Of the following listed designs below, which one would
D. prevent oxidation of iodide allow the researcher to have the most confidence that the oral
care with agent is effective in helping acutely ill surgical client
30. Following thyroidectomy, the nurse notes the very weak attain health outcome?
and hoarse voice of the client. Which nursing intervention is A. One-shot case study
most appropriate at this time? B. Non-equivalent control group design
A. Caution the client not to force herself to talk C. Post-test only control group design
B. Notify the surgeon immediately Laryngeal nerve damage laryngeal edema D. One-group pre-test post-test group design
C. Reassure the client this is usually a temporary condition
D. Offer the client warm NSS gargle 38. A team of researchers conducted a study on the
relationship of the completed surgical cases and the extent of
Situation: Nurse Remy is assigned in the pediatric performance of standard competencies among level 3 nursing
ward. She was in charge of a 20 month-old child, students assigned in the Operating Room, in correlational
Jayson, diagnosed with intussusception study, the researcher examines the:
A. questionnaire used to collect data from large samples
31. Nurse Remy is reviewing the chart of Jayson. What will she B. difference between two correlated groups
expect to read as symptoms of her client? C. relationship between or among two or more variables
A. Foul-smelling, watery stool D. cause and effect relationship
B. Nausea and vomiting
C. Projectile vomiting 39. The statistical tool that is used in determining the
D. Crampy and intermittent severe abdominal pain magnitude and direction of the relationship between two
variables is: analyzing for
32. A nursing student was with Nurse Remy. She wants to fully A. Test of relationship two groups
understand the case and so she asks the nurse to describe the B. Analysis of variance 3 or more group
case. The appropriate definition of intussusception is the: C. Pearson r coefficient of correlation correlational
A. herniation of the small intestine into the abdominal opening D. Spearman rho coefficient of correlation ordinal scale
B. telescoping of bowel into the adjacent segment
C. Mechanical obstruction from the inadequate motility of the 40. A researcher conducted a study on assessment of the
small intestine psychosocial problems of cancer patients in Metro Manila.
D. protrusion of the bowel through an abdominal opening Which of the following instruments was used to collect data
from large samples?
33. Nurse Remy prepares for the insertion of nasogastric tube A. Descriptive statistics
(NGT). She understands that the primary indication of NGT in B. Inferential statistics
Jayson’s case is for: C. Questionnaire and interview
A. irrigation D. Controlled laboratory setting
B. feeding
C. medication administration Situation: Statistics from nursing research show that
D. decompression structured health teaching programs have resulted in
modified client behavior and improved health status.
34. While making her rounds, Jayson’s mother showed nurse
Remy the child’s brown stool. What is the appropriate action of 41. Nurses are aware that normal aging affects the changes in
the nurse? client’s cognition. Therefore, when teaching a 72 year old
A. bring the stool to the laboratory diabetic client how to administer insulin, the nurse should:
B. instruct the mother to dispose the stool properly A. demonstrate faster because the client tires easily
C. document the characteristics of the stool B. present all information at one time
D. reports the passage of stool to the physician C. demonstrate by using audio visual technology
D. frequently repeat information for reinforcement
35. Nurse Remy reviewed a certain literature where the
classical triad of pain, palpable sausage-shaped abdominal 42. Considering the sensory changes in the elderly, which of
mass and currant jelly-like stool occurred only in 15% of the following techniques would be most helpful to enhance
children when they are seen initially. Which of the following is client’s recall?
nurse Remy’s correct interpretation of this finding, if there are A. use of colors to emphasize data and dose
60 sick children as the population? B. use properly labeled individual containers
C. highlight date and dose

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D. label all medications with number in bold ink C. Cover the remaining NSS bottle aseptically right away
D. Transfer the remaining NSS to smaller sterile container
43. When teaching a client drug self-administration, which of
the following behaviors reflect that the client is not ready to 50. Immediately before opening and presenting any sterile
learn? item to the sterile field, the circulating nurse should inspect for
A. Arranges the medication in the container provided for which of the following indicators?
B. Hears without reaction 1. Package integrity
C. Agrees to schedule of teaching 2. Date when manufactures
D. Notes medication, dose and time 3. Sterilization indicator
4. Expiration date
44. Modifying the teaching program because the learner has 5. Purchase price
difficulty in comprehending involves which appropriate nursing 6. Device specification
action? A. 1,2,3,5
A. postponing the teaching until client’s condition improves B. All of these
B. contacting family members to assist in the goal C. 1,3,4 only
development to learn D. 1,2,3,6
C. changing the terms in the teaching pamphlet so that the Situation: Zyra, a 32 year old woman was rushed to the
learner can understand it nearest community hospital after obtaining burns in
D. altering the content of the program the anterior chest, both upper extremities and half of
her face. Nurse Lulu was assigned to her.
45. Nursing actions that can be used to motivate clients learn
the health programs include all of the following except: 51. Nurse Lulu reads the chart and finds out that NGT
A. negative criticism is emphasized at once placement was ordered for her patient. Nurse Lulu performs
B. the establishment of realistic goals based on individual client the procedure correctly if she does the following except: (-)
needs A. Tilts the patient’s nose upward before inserting the tube.
C. creation of a conducive atmosphere for client’s privacy B. Asks the patient to swallow when the tube is in the
D. feedback when a client has been unsuccessful nasopharynx.
C. Prepare the patient NPO 6-8 hours prior to the insertion.
Situation: Integral to quality management in the D. Apply water soluble lubricant at the tip of the tube.
Operating Room is the observance of the basic
principles and practices to establish and maintain a 52. After the procedure, the nurse checks if the tube is
sterile field by the sterile team involved in the surgical properly placed. She is correct of she states that the most
intervention. accurate method of checking tube placement is:
A. pH measurement of the aspirate
46. Once a scrubbed personnel dons a sterile gown and B. Air auscultation
gloves, he/she is considered “sterile”. This connotes that C. Visual assessment of the aspirate
he/she can: D. X-ray visualization
A. assist in positioning the client for surgery
B. touch sterile instrument on the sterile field 53. Patient Zyra was about to take her lunch. Before the
C. hand suture as needed to the scrub administration of osteorized food, the tube must be irrigated.
D. “prep” the surgical site Nurse Lulu has an accurate understanding of the situation if
she uses this fluid in tube irrigation:
47. The assistant surgeon accidentally contaminated his gloves A. Bottled water AKA WATER “ PURIFIED WATER” = 30 min before and after
while adjusting the retractor. As a perioperative nurse you B. Tap water
know that there are two methods that the surgeon can choose C. Normal saline solution
from. What are these methods? D. D5LRs
1. Change the contaminated gloves by the closed glove
technique 54. Enteral feeding poses patients receiving it to various
2. Change the contaminated gloves using the open glove complications. Appropriate interventions must done for the
technique following except: NGT = Insertion , Position ( HIGH FOWLERS)
3. One member of the surgical sterile team is to glove the A. Diarrhea NGT = FEEDING 30 degrees , semi fowler for maintain 30 minutes
assistant surgeon B. Pasty, unformed stool
4. The circulating nurse the sterile gloves to the assistant C. Constipation
surgeon D. Hyperglycemia
A. 3 and 4
B. 1 and 2 55. Zyra who was in NGT was prescribed a timed-release
C. 1 and 3 tablet. What action of the nurse indicates the she had an
D. 2 and 3 accurate understanding of the situation upon giving the drug?
A. Powderized the tablet and dissolve in water.
48. The scrub nurse aids the assistant surgeon apply the sterile B. Give it as prescribed.
drape. The scrub nurse understands that once the drapes are C. Call the physician to change the medication
positioned over the prepped incision site, the drapes must not D. Consult the pharmacist for an alternative form of the drug.
be:
A. marked Situation: Mr. John Skarner, a 57 year-old lawyer was
B. folded confined after complaining persistent and productive
C. aligned cough accompanied by shortness of breath. History
D. moved was taken and it revealed that he started smoking at
the age of 15 and was able to consume 10 cigarettes in
49. You are circulating in an Exploratory Laparotomy for a a day.
ruptured appendicitis. The scrub nurse asks for “normal saline
solution (NSS) wash”. You immediately opened one liter of NSS 56. Based on the situation, how many pack years does Mr.
and began to pour to the sterile basin of the scrub nurse. Skarner have?
Before you can empty the NSS container, the scrub nurse A. 42 years 57- 15 - 42 years
signal you “enough”. What is your appropriate action with the B. 28years
remaining NSS? C. 21 years 10 Divide 20 times 42 = 21 years
A. Discard the remaining NSS D. 36 years
B. Pour the remaining NSS to another sterile basin in the back
table

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57. The patient was diagnosed of Chronic Bronchitis has a 64. Another patient was also admitted in the same ward and
correct understanding of the situation if she states that Chronic diagnosed of stage 3 lung cancer. He was advised to undergo
bronchitis is the presence of cough and sputum production for chemotherapy. The following statements indicate that the
how long? patient has an accurate understanding regarding the effects of
A. at least 2 months in each 3 consecutive years chemotherapy except: (-)
B. at least 3 months in each 2 consecutive years A. I will use soft-bristled toothbrush for my oral care.
C. more or less 3 months in each 3 consecutive year B. Imgonna eat nutritious foods like fresh fruits and
D. more than 3 months in a year vegetables.
C. I prefer artificial rather than fresh flowers in my room.
58. One night, the patient prompted the nurse because of D. I should avoid engaging in contact sports.
difficulty in breathing. The patient requested the nurse to raise
the oxygen level from what is being prescribed. The nurse has 65. The patient started to worry why his hair had started to fall
an accurate understanding of the situation if she does what off. You came off with a diagnosis of body image disturbance.
action? COPD, KNOWLEDGE DEFICIT The patient asked if his hair would grow back. The nurse has a
A. Follow the client’s wish to facilitate breathing. correct understanding of the situation if she stated that:
B. Discontinue the oxygen therapy because the patient is no A. “Hair loss is temporary and it will grow back right after the
longer responsive to it. treatment.”
C. Give the client expectorant immediately to expel retained B. “Your hair will never grow back and wearing of wigs is
secretions. recommended for life.”
D. Maintain the regulation and assess for other potential C. “Your hair will grow back some time after the therapy but it
problems. is not the same as before.”
D. “Worrying is the cause of hair loss and not the treatment so
59. Mr. Skarner was ordered for a postural drainage. The stop worrying.”
patient asked the nurse when it will be done. The nurse is
correct if she stated that CPT is best performed: Situation: Diabetes Mellitus is one of the leading
A. Early in the morning before breakfast. debilitating diseases in the world. It is related to
B. In the morning after eating merienda. sedentary lifestyle, improper diet and genetics.
C. In the afternoon before dinner.
D. Thirty minutes after the patient took his lunch. 66. Nurse Annie was assigned in the Diabetes enter. She is
NEVER AFTER MEALS, RISK FOR ASPIRATION, VOMITING aware that insulin is mainly responsible for controlling the
60. You noticed that the patient still have productive cough. levels of glucose in the blood. Insulin is produced by what cell?
Which method is best used for assessing breath sounds? A. Alpha-cells
A. Palpation B. Beta-cells
B. Auscultation C. Delta-cells
C. Percussion D. Goblet cells
D. Inspection
67. A type I DM client experiences Diabetic Ketoacidosis. Based
Situation: Cancer is one of the leading causes of on your knowledge, the acid-base balance most likely seen in
disability and death worldwide. Various treatments and the patient is:
medical regimen have been discovered to halt or A. Metabolic acidosis
minimize the progression of the said disease. B. Respiratory alkalosis
C. Metabolic alkalosis
61. A patient who was admitted in the oncology ward had his D. Respiratory acidosis
chart placed in the station. As the nurse browses the chart, HYPERGYLCEMIS - BREAKDOWN FATS - ( KETONES cause kausmall respiration)
she notices TIS, N0, and M0 written on the patient’s diagnosis. 68. A type II DM client is asking the nurse what is the best
She correctly interprets the data if she states that TIS, N0, M0 time to buy shoes. The nurse is correct if she replied:
means : A. Morning
A. No evidence of primary tumor, Regional lymph node can’t B. Anytime of the day will do
be assessed and distant metastasis C. Time is not a relevant factor
B. Primary Tumor can’t be assessed, No regional lymph node D. Late in the afternoon
metastasis and distant metastasis can’t be assessed
C. Carcinoma in situ, No regional lymph node metastasis and 69. The nurse is instructing a diabetic client about foot care.
no distant metastasis The patient needs no further instruction if he states the
D. Tumor less than 2 cm, One regional node involvement and following except:
distant metastasis can’t be assessed A. “I will walk barefooted in the house to promote circulation”.
B. “ I’m gonna avoid soaking my feet in the water for long
62. Tristana, a 38 year old woman was also admitted in the time”.
ward. She was diagnosed of having stage 2 cervical cancer and C. “I will cut my toe nails straight”.
was scheduled a radiation therapy specifically cervical D. “I will eat nutritious food recommended by my dietician”.
implants. Which of the following room locations is best for DM PATIENTS ARE RISK FOR PERIPHERAL NEUROPATHY
patient Tristana? BRACHYTHERAPY - INTERNAL 70. A client is taking Glyburide (Micronase) for her type II DM.
A. Near the nurses’ station TELETHERARNAL ; FREE FROM RADIATION Which statement from the patient would alert the nurse?
B. Away from the hallway A. The client stays up late when he overtimes at work.
C. Somewhere near the ward exit B. I limit my alcohol intake up to 2 glasses everytime we have
D. In front of the ward’s common rest room a night out. increase risk for hyperglycemia
C. I do not recommend this drug to my pregnant diabetic
63. As you make your rounds, you noticed that there are friends.
implants in the patient’s bed. Initially, what should the nurse D. I usually experience headache after taking this medication.
do? 3 radiation safety principles DISTANCE - MAX 1 - 2 meters
A. Pick up the implants using a gloved hand and place it in the Situation: In the OR, there are safety protocols that
trash bin. Time - 30 mins within 8 hr shift should be followed. The OR nurse should be well
B. Call the attention of the maintenance and let him dispose of versed with all these to safeguard the safety and
the implants. SHIELD - LEAD APRONS quality of patient delivery outcome.
C. Pick up the implants using long forceps and place it in a
lead container. 71. Which of the following should be given highest priority
D. Have the patient pick the implants and insert it back. when receiving patient in the OR?
A. Assess level of consciousness
B. Verify patient identification and informed consent

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C. Assess vital signs B. Autoclaving
D. Check for jewelry, gown, manicure and dentures C. Flash sterilizer
D. Alcohol immersion
72. Surgeries like I and D (Incision and Drainage) and
debridement are relatively short procedures but considered Situation: Nurses hold a variety of roles when
“dirty cases.” When are these procedures best scheduled? providing care to a peri-operative patient.
A. Last case
B. In between cases 81. Which of the following role would be the responsibility of
C. According to the availability of the anesthesiologist the scrub nurse?
D. According to the surgeon’s preference A. Assess the readiness of the client prior to the surgery
B. Ensure that the airway is adequate
73. Katarina, an active cheerleader complains flashes of lights C. Account for the number of sponges, needles, supplies used
appearing and a shadow covering the upper vision of her left during the surgical procedure
eye. You suspect that Katarina sustained a: D. Evaluate the type of anesthesia appropriate for the surgical
Text
A. Retinal Detachment client
Text
B. Glaucoma LOSS OF VISION ; TUNNEL VISION
C. Cataract CLOUDY OR BLURRING VISION 82. As a peri-operative nurse, how can you best meet the
D. Macular degeneration LOSS OF CENTRAL VISION safety need of the client after administering pre-operative
narcotic?
74. Based on the situation, you plan to position the client on: A. Put side rails up and ask the client not to get out of bed
A. Side-lying on the affected eye B. Send the client to OR with the family
B. Lateral on the affected eye C. Assist client to get up to go to the comfort room
C. Dependent position on the area affected D. Obtain consent form
D. Independent position on the side affected
83. It is the responsibility of the pre-op nurse to do skin prep
75. As you prepare the patient for surgery, you noticed that for patients undergoing surgery. If hair at the operative site is
the patient is fidgeting, going in and out of his bed and not shaved, what should be done to make suturing easy and
frequently asks about the procedure. These behaviors of the lessen the chance of incision infection?
patient most likely suggest? A. Draped
A. The patient does not have enough sleep last night. B. Pulled
B. Client is pressed between financial burden and family C. Clipped
responsibilities. D. Shampooed
C. She drank too much coffee during breakfast
D. She is anxious about the surgery. 84. It is also the nurse’s function to determine when infection
has developed in the surgical incision. The perioperative nurse
Situation: Sterilization is the process of removing all should observe for what signs of impending infection?
living microorganisms. To be free of all living A. Localized heat and redness
microorganisms is sterility. B. Serosanguinous exudates and skin blanching
C. Separation of the incision
76. There are three general types of sterilization used in the D. Blood clots and scar tissue are visible
hospital. Which is not included? ( CALOR , RUBOR, TUMOR , DOLOR AND FUNCTIO LASSE)
A. Steam sterilization 85. Which of the following nursing interventions is done when
B. Chemical sterilization examining the incision wound and changing dressing?
cC Dry heat sterilization A. Observe the dressing, and type and odor of drainage if any
D. Sterilization by boiling B. Get patient’s consent
C. Wash hands
77. Autoclave on steam under pressure is the most common D. Request the client to expose the incision wound
method of sterilization in the hospital. The nurse knows that
the temperature and time is set to the optimum level to Situation: Enrolling as nursing students taught you
destroy not only the microorganism, but also the spores. what the nursing profession has in store for you and to
Which of the following is the ideal setting of the autoclave recognize that each one came from different environs,
machine? different influences, different past and present. As you
A. 10,0000C for 1 hour journey through nursing, you saw yourselves transform
B. 5,0000C for 30 minutes “from the person you were” to the “aspiring nurse” you
C. 370C for 15 minutes have become. Now that you have graduated and now
D. 1210C for 15 minutes taking your Nurse Licensure Examination (NLE) there is
only the “YOU, who is the nurse.”
78. It is important that before a nurse prepares the material to
be sterilized a chemical indicator strip, preferably a Muslin 86. As an aspirant, a beginning nurse practitioner after your
Sheet, should be placed above the package. What is the color basic nursing education, the “YOU, who is a professional
of the stripe produced after autoclaving? nurse” means:
A. Black A. I have simply fine tuned myself, my needs, my wants,
B. Blue my idiosyncrasies, to fit in the profession of nursing.
C. Gray B. The I in me and the nurse in me are two distinct
D. Purple identities that even my patients have to learn to
respect.
79. Chemical indicators communicate that: C. I have simply retained my former self but acquired
A. The items are sterile. the knowledge, skills, attitudes, and values expected
B. The items have undergone sterilization process but not of a nurse.
necessarily sterile. D. The person I am and the professional nurse I aspire
C. The items are disinfected. to be have now developed into one Filipino Nurse. We
D. The items have undergone disinfection process but not are one and the same identity.
necessarily disinfected
87. As you progress in developing your nursing competencies,
80. If a nurse will sterilize a heat and moisture label you have to thread a career-path according to the culture and
instruments, it is according to AORN recommendation to use design of Philippine Nursing. This means:
which of the methods of sterilization?
A. Ethylene oxide gas

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 a. Serving in other countries and learning new and B. “The removal of the gallbladder usually interferes with
modern ways of doing nursing and sharing these back in digestion but can be remedied by dietary
the Philippines. modifications.”
b. Progressing as nurse-generalist in a multitude of C. “The removal of the gallbladder would significantly
choice-practice settings to that of expert nurse- interfere only with the digestion of fatty food.”
practitioner also in choice-practice-settings D. “The removal of gallbladder does not usually interfere
c. Avoiding personal and professional stagnation by with digestion.”
updating and upgrading one’s self
d. Constantly upgrading one’s self through advanced 94. While reviewing the laboratory findings of the client, Nurse
technological means and strategies Jade found out that which findings are elevated?
1. white blood cell count
88. It is important to remember that while RNs value “job 2. total serum bilirubin
tenure” because the years in service spell variety of 3. alkaline phosphate
experiences in nursing practice, it is far more valuable to 4. red blood cell count
consider that tenure-years are nothing if these are not parallel 5. cholesterol
with one’s personal-professional growth and maturity. This 6. serum amylase
implies: A. 3,5,6
a. Simply earning years of job-related service until we B. 1,2,6
retire from service. C. 1,2,3
b. Extending assistance to our less-fortunate fellow D. 2,3,4
nurses.
c. Progressive upgrading of competencies in terms of 95. A T-tube was inserted and the doctor ordered: “Monitor
knowledge, skills, attitudes, and values as the amount, color, consistency and odor of drainage.” Which of
professional nurse. the following procedures can the nurse perform without the
d. Volunteering our services wherever needed. doctor’s order?
A. clamping
89. We often give our best in caring but despite all efforts, the B. emptying
reality of facing death is inevitable. Our brand and core values C. aspirating
of nursing will always extend beyond the ordinary levels of D. irrigating
promotive, preventive, curative, and rehabilitative care. This
culturally-bound, Filipino values of nursing likewise needs to be Situation: Alfonsus sought hospital confinement for
nurtured: pleuritic pain, fever, and cough. The attending
A. Psychological care physician had a chest x-ray taken STAT. Result
B. Emotional care revealed presence of lung infiltrates. The client was
C. Spiritual care assigned to Kianne the staff nurse.
D. Relational care
96. When Kikay performed chest auscultation, she observed
90. It is important to not only enrich one’s mind with short discreet bubbling sounds over the lower region of the
progressive technical upgrades but equip one’s self with right lung. Which of the following abnormal findings will Kikay
holistic personal and professional development believing that: consider?
A. we are also God’s angels of mercy on earth A. Friction rub
B. we may also find real holism in the service we render B. Murmur
C. we and the beneficiaries of our care are made up of C. Wheezes
body, soul, and spirit and each component do have D. Crackles
health needs intertwined
D. should we encounter terminal patients, we may 97. Kikay put her priority nursing diagnosis as “Ineffective
understand how to support them to their dying stage airway clearance related to increased secretions and ineffective
coughing.” Which nursing intervention would be considered to
Situation: Nurse Jade is in charge of a client who was facilitate coughing with the LEAST discomfort?
admitted for management of acute episodes of A. Splinting chest wall with pillow when coughing
cholecystitis. B. Putting the client in semi-Fowler’s position all the time
C. Taking cough med q4 hours round the clock
INFLAMMATION OF GALLBLADDER
91. Nurse Jade did her admission assessment. She D. Utilizing the purse-lip technique of breathing
INEFFECTIVE AIRWAY CLEARANCE , IMPAIRED GAS
understands that the pain is characterized as: EXHANGE AND IMPAIRED BREATHING PATTERN
A. Tenderness that is generalized in the upper 98. The physician prescribes oral penicillin 500 mg every six
epigastric area hours for seven days. On the fifth day, before Kikay
B. Tenderness and rigidity at the left epigastric area administers the first dose for the day, she computed for the
radiating to the back total amount in the milligrams of the oral penicillin that has
C. Tenderness and rigidity of the upper right abdomen been received by the client. Which of the following is the
radiating to the midsternal area correct amount?
D. Pain of the left upper quadrant radiating to the left A. 2,500 mg 500MG Q6 HRS FOR 7 DAYS
shoulder B. 15,000 mg
C. 10,000 mg 4 DOSES X 500MG = 2000MG IN A DAY
92. To confirm the diagnosis of cholecystitis, the attending D. 8,000 mg 2000MG TIMES 4 DAYS = 8000
physician ordered the procedure that can detect gallstones as
small as 1 to 2 cm and inflammation. Nurse Jade would 99. Standard precaution dictates that the nurse observes which
prepare the client for which specific diagnostic procedure? of the following when caring for a client with streptococcal
A. cholangiography pneumonia?
B. gall bladder series A. Use of face mask
C. oral cholecystogram B. Use of sterile gloves
D. ultrasonography C. Observe two-feet distance when giving care
D. Use clean gloves
93. The diagnosis was confirmed as cholecystitis with
gallstones. The doctor prepared the client for the removal of 100. Sputum cultures are to be obtained to establish the
his gallbladder. The client asks the nurse: “How will this client’s specific antibiotic treatment. Kikay would BEST collect
procedure affect my digestion?” The nurse’s most correct the specimen:
response would be: GALL BLADDER- STORES BILE FOR DIGESTION FAT A. Early in the morning CONCENTRATED YUN SECRETION
A. c. “Your body system will adjust in due time.” B. Early morning after an antiseptic gargle

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 C. After brushing the client’s teeth
D. Anytime of the day after a warm salt solution gargle

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