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bs nursing (Southwestern University PHINMA)

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Fundamentals in Nursing 9. Which of the following behaviors by Nurse Jane Robles
demonstrates that she understands well th elements of effecting
Fundamentals in Nursing Set A
charting?
A. She writes in the chart using a no. 2 pencil.
1. Jake is complaining of shortness of breath. The nurse assesses B. She noted: appetite is good this afternoon.
his respiratory rate to be 30 breaths per minute and documents that C. She signs on the medication sheet after
Jake is tachypneic. The nurse understands that tachypnea means: administering the medication.
A. Pulse rate greater than 100 beats per minute D. She signs her charting as follow: J.R
B. Blood pressure of 140/90
C. Respiratory rate greater than 20 breaths per 10. What is the disadvantage of computerized documentation of
minute the nursing process?
D. Frequent bowel sounds A. Accuracy
B. Legibility
2. The nurse listens to Mrs. Sullen’s lungs and notes a hissing C. Concern for privacy
sound or musical sound. The nurse documents this as: D. Rapid communication
A. Wheezes
B. Rhonchi 11. The theorist who believes that adaptation and manipulation of
C. Gurgles stressors are related to foster change is:
D. Vesicular A. Dorothea Orem
B. Sister Callista Roy
3. The nurse in charge measures a patient’s temperature at 101 C. Imogene King
degrees F. What is the equivalent centigrade temperature? D. Virginia Henderson
A. 36.3 degrees C
B. 37.95 degrees C 12. Formulating a nursing diagnosis is a joint function of:
C. 40.03 degrees C A. Patient and relatives
D. 38.01 degrees C B. Nurse and patient
C. Doctor and family
4. Which approach to problem solving tests any number of D. Nurse and doctor
solutions until one is found that works for that particular problem?
A. Intuition 13. Mrs. Caperlac has been diagnosed to have hypertension since
B. Routine 10 years ago. Since then, she had maintained low sodium, low fat
C. Scientific method diet, to control her blood pressure. This practice is viewed as:
D. Trial and error A. Cultural belief
B. Personal belief
5. What is the order of the nursing process? C. Health belief
A. Assessing, diagnosing, implementing, evaluating, D. Superstitious belief
planning
B. Diagnosing, assessing, planning, implementing, 14. Becky is on NPO since midnight as preparation for blood test.
evaluating Adreno-cortical response is activated. Which of the following is
C. Assessing, diagnosing, planning, implementing, an expected response?
evaluating A. Low blood pressure
D. Planning, evaluating, diagnosing, assessing, B. Warm, dry skin
implementing C. Decreased serum sodium levels
D. Decreased urine output
6. During the planning phase of the nursing process, which of the
following is the outcome? 15. What nursing action is appropriate when obtaining a sterile
A. Nursing history urine specimen from an indwelling catheter to prevent infection?
B. Nursing notes A. Use sterile gloves when obtaining urine.
C. Nursing care plan B. Open the drainage bag and pour out the urine.
D. Nursing diagnosis C. Disconnect the catheter from the tubing and get
urine.
7. What is an example of a subjective data? D. Aspirate urine from the tubing port using a sterile
A. Heart rate of 68 beats per minute syringe.
B. Yellowish sputum
C. Client verbalized, “I feel pain when urinating.” 16. A client is receiving 115 ml/hr of continuous IVF. The nurse
D. Noisy breathing notices that the venipuncture site is red and swollen. Which of the
following interventions would the nurse perform first?
8. Which expected outcome is correctly written? A. Stop the infusion
A. “The patient will feel less nauseated in 24 hours.” B. Call the attending physician
B. “The patient will eat the right amount of food C. Slow that infusion to 20 ml/hr
daily.” D. Place a clod towel on the site
C. “The patient will identify all the high-salt food
from a prepared list by discharge.”
D. “The patient will have enough sleep.”

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17. The nurse enters the room to give a prescribed medication but D. Incorporation of both nursing and medical
the patient is inside the bathroom. What should the nurse do? diagnoses in patient care
A. Leave the medication at the bedside and leave the
room. 24. Using Maslow’s hierarchy of basic human needs, which of the
B. After few minutes, return to that patient’s room following nursing diagnoses has the highest priority?
and do not leave until the patient takes the A. Ineffective breathing pattern related to pain, as
medication. evidenced by shortness of breath.
C. Instruct the patient to take the medication and B. Anxiety related to impending surgery, as
leave it at the bedside. evidenced by insomnia.
D. Wait for the patient to return to bed and just leave C. Risk of injury related to autoimmune dysfunction
the medication at the bedside. D. Impaired verbal communication related to
tracheostomy, as evidenced by inability to speak.
18. Which of the following is inappropriate nursing action when
administering NGT feeding? 25. When performing an abdominal examination, the patient
A. Place the feeding 20 inches above the pint if should be in a supine position with the head of the bed at what
insertion of NGT. position?
B. Introduce the feeding slowly. A. 30 degrees
C. Instill 60ml of water into the NGT after feeding. B. 90 degrees
D. Assist the patient in fowler’s position. C. 45 degrees
D. 0 degree
19. A female patient is being discharged after thyroidectomy.
After providing the medication teaching. The nurse asks the Answers and Rationales
patient to repeat the instructions. The nurse is performing which
1. 1. (C) Respiratory rate greater than 20 breaths per minute. A respiratory
professional role?
rate of greater than 20 breaths per minute is tachypnea. A blood
A. Manager pressure of 140/90 is considered hypertension. Pulse greater than 100
B. Caregiver beats per minute is tachycardia. Frequent bowel sounds refer to
C. Patient advocate hyper-active bowel sounds.
D. Educator 2. (A) Wheezes. Wheezes are indicated by continuous, lengthy, musical;
heard during inspiration or expiration. Rhonchi are usually coarse
20. Which data would be of greatest concern to the nurse when breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular
completing the nursing assessment of a 68-year-old woman breath sounds are low pitch, soft intensity on expiration.
3. (B) 37.95 degrees C. To convert °F to °C use this formula, ( °F – 32 )
hospitalized due to Pneumonia?
(0.55). While when converting °C to °F use this formula, ( °C x 1.8) +
A. Oriented to date, time and place 32. Note that 0.55 is 5/9 and 1.8 is 9/5.
B. Clear breath sounds 4. (D) Trial and error. The trial and error method of problem solving isn’t
C. Capillary refill greater than 3 seconds and buccal systematic (as in the scientific method of problem solving) routine, or
cyanosis based on inner prompting (as in the intuitive method of problem
D. Hemoglobin of 13 g/dl solving).
5. (C) Assessing, diagnosing, planning, implementing, evaluating. The
21. During a change-of-shift report, it would be important for the correct order of the nursing process is assessing, diagnosing, planning,
implementing, evaluating.
nurse relinquishing responsibility for care of the patient to
6. (C) Nursing care plan. The outcome, or the product of the planning
communicate. Which of the following facts to the nurse assuming phase of the nursing process is a Nursing care plan.
responsibility for care of the patient? 7. (C) Client verbalized, “I feel pain when urinating.”. Subjective data are
A. That the patient verbalized, “My headache is those that can be described only by the person experiencing it.
gone.” Therefore, only the patient can describe or verify whether he is
B. That the patient’s barium enema performed 3 days experiencing pain or not.
ago was negative 8. (C) “The patient will identify all the high-salt food from a prepared list
C. Patient’s NGT was removed 2 hours ago by discharge.”. Expected outcomes are specific, measurable, realistic
statements of goal attainment. The phrases “right amount”, “less
D. Patient’s family came for a visit this morning.
nauseated” and “enough sleep” are vague and not measurable.
9. (C) She signs on the medication sheet after administering the
22. Which statement is the most appropriate goal for a nursing medication.A nurse should record a nursing intervention (ex. Giving
diagnosis of diarrhea? medications) after performing the nursing intervention (not before).
A. “The patient will experience decreased frequency Recording should also be done using a pen, be complete, and signed
of bowel elimination.” with the nurse’s full name and title.
B. “The patient will take anti-diarrheal medication.” 10. (C) Concern for privacy. A patient’s privacy may be violated if security
C. “The patient will give a stool specimen for measures aren’t used properly or if policies and procedures aren’t in
place that determines what type of information can be retrieved, by
laboratory examinations.”
whom, and for what purpose.
D. “The patient will save urine for inspection by the 11. (B) Sister Callista Roy. Sister Roy’s theory is called the adaptation
nurse. theory and she viewed each person as a unified biophysical system in
constant interaction with a changing environment. Orem’s theory is
23. Which of the following is the most important purpose of called self-care deficit theory and is based on the belief that individual
planning care with this patient? has a need for self-care actions. King’s theory is the Goal attainment
A. Development of a standardized NCP. theory and described nursing as a helping profession that assists
B. Expansion of the current taxonomy of nursing individuals and groups in society to attain, maintain, and restore health.
Henderson introduced the nature of nursing model and identified the 14
diagnosis
basic needs.
C. Making of individualized patient care

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12. (B) Nurse and patient. Although diagnosing is basically the nurse’s 3. Jason, 3 years old vomited. His mom stated, “He vomited 6
responsibility, input from the patient is essential to formulate the ounces of his formula this morning.” This statement is an example
correct nursing diagnosis. of:
13. (C) Health belief. Health belief of an individual influences his/her
A. objective data from a secondary source
preventive health behavior.
14. (D) Decreased urine output. Adreno-cortical response involves release B. objective data from a primary source
of aldosterone that leads to retention of sodium and water. This results C. subjective data from a primary source
to decreased urine output. D. subjective data from a secondary source
15. (D) Aspirate urine from the tubing port using a sterile syringe. The
nurse should aspirate the urine from the port using a sterile syringe to 4. Which of the following is a nursing diagnosis?
obtain a urine specimen. Opening a closed drainage system increase the A. Hypethermia
risk of urinary tract infection. B. Diabetes Mellitus
16. (A) Stop the infusion. The sign and symptoms indicate extravasation so
C. Angina
the IVF should be stopped immediately and put warm not cold towel
on the affected site. D. Chronic Renal Failure
17. (B) After few minutes, return to that patient’s room and do not leave
until the patient takes the medication. This is to verify or to make sure 5. What is the characteristic of the nursing process?
that the medication was taken by the patient as directed. A. stagnant
18. (A) Place the feeding 20 inches above the pint if insertion of NGT. The B. inflexible
height of the feeding is above 12 inches above the point of insertion, C. asystematic
bot 20 inches. If the height of feeding is too high, this results to very D. goal-oriented
rapid introduction of feeding. This may trigger nausea and vomiting.
19. (D) Educator. When teaching a patient about medications before
discharge, the nurse is acting as an educator. A caregiver provides 6. A skin lesion which is fluid-filled, less than 1 cm in size is
direct care to the patient. The nurse acts as s patient advocate when called:
making the patient’s wishes known to the doctor. A. papule
20. (C) Capillary refill greater than 3 seconds and buccal B. vesicle
cyanosis. Capillary refill greater than 3 seconds and buccal cyanosis C. bulla
indicate decreased oxygen to the tissues which requires immediate D. Macule
attention/intervention. Oriented to date, time and place, hemoglobin of
13 g/dl are normal data.
7. During application of medication into the ear, which of the
21. (C) Patient’s NGT was removed 2 hours ago. The change-of-shift
report should indicate significant recent changes in the patient’s following is inappropriate nursing action?
condition that the nurse assuming responsibility for care of the patient A. In an adult, pull the pinna upward.
will need to monitor. The other options are not critical enough to B. Instill the medication directly into the tympanic
include in the report. membrane.
22. (A) “The patient will experience decreased frequency of bowel C. Warm the medication at room or body
elimination.” The goal is the opposite, healthy response of the problem temperature.
statement of the nursing diagnosis. In this situation, the problem D. Press the tragus of the ear a few times to assist
statement is diarrhea.
flow of medication into the ear canal.
23. (C) Making of individualized patient care. To be effective, the nursing
care plan developed in the planning phase of the nursing process must
reflect the individualized needs of the patient. 8. Which of the following is appropriate nursing intervention for a
24. (A) Ineffective breathing pattern related to pain, as evidenced by client who is grieving over the death of her child?
shortness of breath.. Physiologic needs (ex. Oxygen, fluids, nutrition) A. Tell her not to cry and it will be better.
must be met before lower needs (such as safety and security, love and B. Provide opportunity to the client to tell their story.
belongingness, self-esteem and self-actualization) can be met. C. Encourage her to accept or to replace the lost
Therefore, physiologic needs have the highest priority. person.
25. (D) 0 degree. The patient should be positioned with the head of the bed
D. Discourage the client in expressing her emotions.
completely flattened to perform an abdominal examination. If the head
of the bed is elevated, the abdominal muscles and organs can be
bunched up, altering the findings 9. It is the gradual decrease of the body’s temperature after death.
A. livor mortis
B. rigor mortis
Fundamentals in Nursing Set B C. algor mortis
D. none of the above
1. A patient is wearing a soft wrist-safety device. Which of the
following nursing assessment is considered abnormal? 10. When performing an admission assessment on a newly
admitted patient, the nurse percusses resonance. The nurse knows
A. Palpable radial pulse that resonance heard on percussion is most commonly heard over
B. Palpable ulnar pulse which organ?
C. Capillary refill within 3 seconds A. thigh
D. Bluish fingernails, cool and pale fingers B. liver
C. intestine
2. Pia’s serum sodium level is 150 mEq/L. Which of the following D. Lung
food items does the nurse instruct Pia to avoid?
11. The nurse is aware that Bell’s palsy affects which cranial
nerve?
A. broccoli A. 2nd CN (Optic)
B. sardines B. 3rd CN (Occulomotor)
C. cabbage C. 4th CN (Trochlear)
D. tomatoes D. 7th CN (Facial)
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12. Prolonged deficiency of Vitamin B9 leads to: 20. When providing a continuous enteral feeding, which of the
A. scurvy following action is essential for the nurse to do?
B. pellagra A. Place the client on the left side of the bed.
C. megaloblastic anemia B. Attach the feeding bag to the current tubing.
D. pernicious anemia C. Elevate the head of the bed.
D. Cold the formula before administering it.
13. Nurse Cherry is teaching a 72 year old patient about a newly
prescribed medication. What could cause a geriatric patient to 21. Kussmaul’s breathing is;
have difficulty retaining knowledge about the newly prescribed A. Shallow breaths interrupted by apnea.
medication? B. Prolonged gasping inspiration followed by a very
A. Absence of family support short, usually inefficient expiration.
B. Decreased sensory functions C. Marked rhythmic waxing and waning of
C. Patient has no interest on learning respirations from very deep to very shallow
D. Decreased plasma drug levels breathing and temporary apnea.
D. Increased rate and depth of respiration.
14. When assessing a patient’s level of consciousness, which type
of nursing intervention is the nurse performing? 22. Presty has terminal cancer and she refuses to believe that loss
A. Independent is happening ans she assumes artificial cheerfulness. What stage of
B. Dependent grieving is she in?
C. Collaborative A. depression
D. Professional B. bargaining
C. denial
15. Claire is admitted with a diagnosis of chronic shoulder pain. D. Acceptance
By definition, the nurse understands that the patient has had pain
for more than: 23. Immunization for healthy babies and preschool children is an
A. 3 months example of what level of preventive health care?
B. 6 months A. Primary
C. 9 months B. Secondary
D. 1 year C. Tertiary
D. Curative
16. Which of the following statements regarding the nursing
process is true? 24. Which is an example of a subjective data?
A. It is useful on outpatient settings. A. Temperature of 38 0C
B. It progresses in separate, unrelated steps. B. Vomiting for 3 days
C. It focuses on the patient, not the nurse. C. Productive cough
D. It provides the solution to all patient health D. Patient stated, “My arms still hurt.”
problems.
25. The nurse is assessing the endocrine system. Which organ is
17. Which of the following is considered significant enough to part of the endocrine system?
require immediate communication to another member of the A. Heart
health care team? B. Sinus
A. Weight loss of 3 lbs in a 120 lb female patient. C. Thyroid
B. Diminished breath sounds in patient with D. Thymus
previously normal breath sounds
C. Patient stated, “I feel less nauseated.” Answers and Rationales
D. Change of heart rate from 70 to 83 beats per
minute. 1. (D) Bluish fingernails, cool and pale fingers. A safety device on the
wrist may impair blood circulation. Therefore, the nurse should
18. To assess the adequacy of food intake, which of the following assess the patient for signs of impaired circulation such as bluish
assessment parameters is best used? fingernails, cool and pale fingers. Palpable radial and ulnar pulses,
capillary refill within 3 seconds are all normal findings.
A. food preferences 2. (B) sardines. The normal serum sodium level is 135 to 145 mEq/L,
B. regularity of meal times the client is having hypernatremia. Pia should avoid food high in
C. 3-day diet recall sodium like processed food. Broccoli, cabbage and tomatoes are
D. eating style and habits good source of Vitamin C.
3. (A) objective data from a secondary source. Jason is the primary
19. Van Fajardo is a 55 year old who was admitted to the hospital source; his mother is a secondary source. The data is objective
with newly diagnosed hepatitis. The nurse is doing a patient because it can be perceived by the senses, verified by another
teaching with Mr. Fajardo. What kind of role does the nurse person observing the same patient, and tested against accepted
standards or norms.
assume? 4. (A) Hypethermia. Hyperthermia is a NANDA-approved nursing
A. talker diagnosis. Diabetes Mellitus, Angina and Chronic Renal Failure are
B. teacher medical diagnoses.
C. thinker 5. (D) goal-oriented. The nursing process is goal-oriented. It is also
D. Doer systematic, patient-centered, and dynamic.
6. (B) vesicle. Vesicle is a circumscribed circulation containing serous
fluid or blood and less than 1 cm (ex. Blister, chicken pox).

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7. (B) Instill the medication directly into the tympanic Maternal and Child Health Nursing Exam 1
membrane. During the application of medication it is inappropriate
to instill the medication directly into the tympanic membrane. The 1. A client asks the nurse what a third degree laceration is. She
right thing to do is instill the medication along the lateral wall of the
was informed that she had one. The nurse explains that this is:
auditory canal.
8. (B) Provide opportunity to the client to tell their story. Providing a A. that extended their anal sphincter
grieving person an opportunity to tell their story allows the person B. through the skin and into the muscles
to express feelings. This is therapeutic in assisting the client resolve C. that involves anterior rectal wall
grief. D. that extends through the perineal muscle.
9. (C) algor mortis. Algor mortis is the decrease of the body’s
temperature after death. Livor mortis is the discoloration of the skin 2. Betina 30 weeks AOG discharged with a diagnosis of placenta
after death. Rigor mortis is the stiffening of the body that occurs previa. The nurse knows that the client understands her care at
about 2-4 hours after death.
home when she says:
10. (D) lung. Resonance is loud, low-pitched and long duration that’s
heard most commonly over an air-filled tissue such as a normal A. I am happy to note that we can have sex
lung. occasionally when I have no bleeding.
11. (D) 7th CN (Facial). Bells’ palsy is the paralysis of the motor B. I am afraid I might have an operation when my
component of the 7th caranial nerve, resulting in facial sag, inability due comes
to close the eyelid or the mouth, drooling, flat nasolabial fold and C. I will have to remain in bed until my due date
loss of taste on the affected side of the face. comes
12. (C) megaloblastic anemia. Prolonged Vitamin B9 deficiency will D. I may go back to work since I stay only at the
lead to megaloblastic anemia while pernicious anemia results in
office.
deficiency in Vitamin B12. Prolonged deficiency of Vitamin C
leads to scurvy and Pellagra results in deficiency in Vitamin B3.
13. (B) Decreased sensory functions. Decreased in sensory functions 3. The uterus has already risen out of the pelvis and is
could cause a geriatric patient to have difficulty retaining experiencing farther into the abdominal area at about the:
knowledge about the newly prescribed medications. Absence of A. 8th week of pregnancy
family support and no interest on learning may affect compliance, B. 10th week of pregnancy
not knowledge retention. Decreased plasma levels do not alter C. 12th week of pregnancy
patient’s knowledge about the drug. D. 18th week of pregnancy
14. (A) Independent. Independent nursing interventions involve actions
that nurses initiate based on their own knowledge and skills without
the direction or supervision of another member of the health care 4. Which of the following urinary symptoms does the pregnant
team. woman most frequently experience during the first trimester:
15. (B) 6 months. Chronic pain s usually defined as pain lasting longer A. frequency
than 6 months. B. dysuria
16. (C) It focuses on the patient, not the nurse. The nursing process is C. incontinence
patient-centered, not nurse-centered. It can be use in any setting, D. Burning
and the steps are related. The nursing process can’t solve all patient
health problems.
5. Mrs. Jimenez went to the health center for pre-natal check-up.
17. (B) Diminished breath sounds in patient with previously normal
breath sounds. Diminished breath sound is a life threatening the student nurse took her weight and revealed 142 lbs. She asked
problem therefore it is highly priority because they pose the greatest the student nurse how much should she gain weight in her
threat to the patient’s well-being. pregnancy.
18. (C) 3-day diet recall. 3-day diet recall is an example of dietary A. 20-30 lbs
history. This is used to indicate the adequacy of food intake of the B. 25-35 lbs
client. C. 30- 40 lbs
19. (B) teacher. The nurse will assume the role of a teacher in this D. 10-15 lbs
therapeutic relationship. The other roles are inappropriate in this
situation.
20. (C) Elevate the head of the bed. Elevating the head of the bed 6. The nurse is preparing Mrs. Jordan for cesarean delivery. Which
during an enteral feeding prevents aspiration. The patient may be of the following key concept should the nurse consider when
placed on the right side to prevent aspiration. Enteral feedings are implementing nursing care?
given at room temperature to lessen GI distress. The enteral tubing A. Explain the surgery, expected outcome and kind
should be changed every 24 hours to limit microbial growth. of anesthetics.
21. (D) Increased rate and depth of respiration. Kussmaul breathing is B. Modify preoperative teaching to meet the needs of
also called as hyperventilation. Seen in metabolic acidosis and renal either a planned or emergency cesarean birth.
failure. Option A refers to Biot’s breathing. Option B is apneustic
C. Arrange for a staff member of the anesthesia
breathing and option C is the Cheyne-stokes breathing.
22. (C) denial. The client is in denial stage because she is unready to department to explain what to expect
face the reality that loss is happening and she assumes artificial post-operatively.
cheerfulness. D. Instruct the mother’s support person to remain in
23. (A) Primary. The primary level focuses on health promotion. the family lounge until after the delivery.
Secondary level focuses on health maintenance. Tertiary focuses on
rehabilitation. There is n Curative level of preventive health care 7. Bettine Gonzales is hospitalized for the treatment of severe
problems. preecplampsia. Which of the following represents an unusual
24. (D) Patient stated, “My arms still hurt.”. Subjective data are
finding for this condition?
apparent only to the person affected and can or verified only by that
person. A. generalized edema
25. (C) Thyroid. The thyroid is part of the endocrine system. Heart, B. proteinuria 4+
sinus and thymus are not. C. blood pressure of 160/110
D. Convulsions

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8. Nurse Geli explains to the client who is 33 weeks pregnant and D. Neutropenia
is experiencing vaginal bleeding that coitus:
A. Need to be modified in any way by either partner 16. Which age group is with imaginative minds and creates
B. Is permitted if penile penetration is not deep. imaginary friends?
C. Should be restricted because it may stimulate A. Toddler
uterine activity. B. Preschool
D. Is safe as long as she is in side-lying position. C. School
D. Adolescence
9. Mrs. Precilla Abuel, a 32 year old mulripara is admitted to labor
and delivery. Her last 3 pregnancies in short stage one of labor. 17. Which of the following situations would alert you to a
The nurses decide to observe her closely. The physician potentially developmental problem with a child?
determines that Mrs. Abuel’s cervix is dilated to 6 cm. Mrs. Abuel A. Pointing to body parts at 15 months of age.
states that she is extremely uncomfortable. To lessen Mrs. Abuel’s B. Using gesture to communicate at 18 months.
discomfort, the nurse can advise her to: C. Cooing at 3 months.
A. lie face down D. Saying “mama” or “dada” for the first time at 18
B. not drink fluids months of age.
C. practice holding breaths between contractions
D. assume Sim’s position 18. Isabelle, a 2 year old girl loves to move around and oftentimes
manifests negativism and temper tantrums. What is the best way to
10. Which is true regarding the fontanels of the newborn? deal with her behavior?
A. The anterior is large in shape when compared to A. Tell her that she would not be loved by others is
the posterior fontanel. she behaves that way..
B. The anterior is triangular shaped; the posterior is B. Withholding giving her toys until she behaves
diamond shaped. properly.
C. The anterior is bulging; the posterior appears C. Ignore her behavior as long as she does not hurt
sunken. herself and others.
D. The posterior closes at 18 months; the anterior D. Ask her what she wants and give it to pacify her.
closes at 8 to 12 months.
19. Baby boy Villanueva, 4 months old, was seen at the pediatric
11. Mrs. Quijones gave birth by spontaneous delivery to a full clinic for his scheduled check-up. By this period, baby Villanueva
term baby boy. After a minute after birth, he is crying and moving has already increased his height by how many inches?
actively. His birth weight is 6.8 lbs. What do you expect baby A. 3 inches
Quijones to weigh at 6 months? B. 4 inches
A. 13 -14 lbs C. 5 inches
B. 16 -17 lbs D. 6 inches
C. 22 -23 lbs
D. 27 -28 lbs 20. Alice, 10 years old was brought to the ER because of Asthma.
She was immediately put under aerosol administration of
12. During the first hours following delivery, the post partum Terbutaline. After sometime, you observe that the child does not
client is given IVF with oxytocin added to them. The nurse show any relief from the treatment given. Upon assessment, you
understands the primary reason for this is: noticed that both the heart and respiratory rate are still elevated
A. To facilitate elimination and the child shows difficulty of exhaling. You suspect:
B. To promote uterine contraction A. Bronchiectasis
C. To promote analgesia B. Atelectasis
D. To prevent infection C. Epiglotitis
D. Status Asthmaticus
13. Nurse Luis is assessing the newborn’s heart rate. Which of the
following would be considered normal if the newborn is sleeping? 21. Nurse Jonas assesses a 2 year old boy with a tentative
A. 80 beats per minute diagnosis of nephroblastoma. Symptoms the nurse observes that
B. 100 beats per minute suggest this problem include:
C. 120 beats per minute A. Lymphedema and nerve palsy
D. 140 beats per minute B. Hearing loss and ataxia
C. Headaches and vomiting
14. The infant with Down Syndrome should go through which of D. Abdominal mass and weakness
the Erikson’s developmental stages first?
A. Initiative vs. Self doubt 22. Which of the following danger sings should be reported
B. Industry vs. Inferiority immediately during the antepartum period?
C. Autonomy vs. Shame and doubt A. blurred vision
D. Trust vs. Mistrust B. nasal stuffiness
C. breast tenderness
15. The child with phenylketonuria (PKU) must maintain a low D. Constipation
phenylalanine diet to prevent which of the following
complications?
A. Irreversible brain damage
B. Kidney failure
C. Blindness
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23. Nurse Jacob is assessing a 15 month old child with acute otitis 9. (D) assume Sim’s position. When the woman is in Sim’s position,
media. Which of the following symptoms would the nurse this puts the weight of the fetus on bed, not on the woman and
anticipate finding? allows good circulation in the lower extremities.
10. (A) The anterior is large in shape when compared to the posterior
A. periorbital edema, absent light reflex and
fontanel.. The anterior fontanel is larger in size than the posterior
translucent tympanic membrane fontanel. Additionally, the anterior fontanel, which is diamond
B. irritability, purulent drainage in middle ear, nasal shaped closes at 18 month, whereas the posterior fontanel, which is
congestion and cough triangular in shape closes at 8 to 12 weeks. Neither fontanel should
C. diarrhea, retracted tympanic membrane and appear bulging, which may indicate increases ICP or sunken, which
enlarged parotid gland may indicate hydration.
D. Vomiting, pulling at ears and pearly white 11. (A) 13 -14 lbs. The birth weight of an infant is doubled at 6 months
tympanic membrane and is tripled at 12 months.
12. (B) To promote uterine contraction. Oxytocin is a hormone
produced by the pituitary gland that produces intermittent uterine
24. Which of the following is the most appropriate intervention to contractions, helping to promote uterine involution.
reduce stress in a preterm infant at 33 weeks gestation? 13. (B) 100 beats per minute. The normal heart rate for a newborn that
A. Sensory stimulation including several senses at a is sleeping is approximately 100 beats per minute. If the newborn
time was awake, the normal heart rate would range from 120 to 160
B. tactile stimulation until signs of over stimulation beats per minute.
develop 14. (D) Trust vs. Mistrust. The child with Down syndrome will go
C. An attitude of extension when prone or side lying through the same first stage, trust vs. mistrust, only at a slow rate.
Therefore, the nurse should concentrate on developing on bond
D. Kangaroo care
between the primary caregiver and the child.
15. (A) Irreversible brain damage. The child with PKU must maintain a
25. The parent of a client with albinism would need to be taught strict low phenylalanine diet to prevent central nervous system
which preventive healthcare measure by the nurse: damage, seizures and eventual death.
A. Ulcerative colitis diet 16. (B) Preschool. During preschool, this is the time when children do
B. Use of a high-SPF sunblock imitative play, imaginative play—the occurrence of imaginative
C. Hair loss monitoring playmates, dramatic play where children like to act, dance and sing.
D. Monitor for growth retardation 17. (D) Saying “mama” or “dada” for the first time at 18 months of
age.. A child should say “mama” or “dada” during 10 to 12 months
of age. Options A, B and C are all normal assessments of language
development of a child.
18. (C) Ignore her behavior as long as she does not hurt herself and
Answers and Rationales others.. If a child is trying to get attention or trying to get something
through tantrums—ignore his/her behavior.
1. (A) that extended their anal sphincter. Third degree laceration 19. (B) 4 inches. From birth to 6 months, the infant grows 1 inch (2.5
involves all in the second degree laceration and the external cm) per month. From 6 to 12 months, the infant grows ½ inch (1.25
sphincter of the rectum. Options B, C and D are under the second cm) per month.
degree laceration. 20. (D) Status Asthmaticus. Status asthmaticus leads to respiratory
2. (C) I will have to remain in bed until my due date comes. Placenta distress and bronchospasm despite of treatment and interventions.
previa means that the placenta is the presenting part. On the first Mechanical ventilation maybe needed due to respiratory failure.
and second trimester there is spotting. On the third trimester there is 21. (D) Abdominal mass and weakness. Nephroblastoma or Wilm’s
bleeding that is sudden, profuse and painless. tumor is caused by chromosomal abnormalities, most common
3. (D) 18th week of pregnancy. On the 8th week of pregnancy, the kidney cancer among children characterized by abdominal mass,
uterus is still within the pelvic area. On the 10th week, the uterus is hematuria, hypertension and fever.
still within the pelvic area. On the 12th week, the uterus and 22. (A) blurred vision. Danger signs that require prompt reporting are
placenta have grown, expanding into the abdominal cavity. On the leaking of amniotic fluid, blurred vision, vaginal bleeding, rapid
18th week, the uterus has already risen out of the pelvis and is weight gain and elevated blood pressure. Nasal stuffiness, breast
expanding into the abdominal area. tenderness, and constipation are common discomforts associated
4. (A) frequency. Pressure and irritation of the bladder by the growing with pregnancy.
uterus during the first trimester is responsible for causing urinary 23. (B) irritability, purulent drainage in middle ear, nasal congestion
frequency. Dysuria, incontinence and burning are symptoms and cough. Irritability, purulent drainage in middle ear, nasal
associated with urinary tract infection. congestion and cough, fever, loss of appetite, vomiting and diarrhea
5. (B) 25-35 lbs. A weight gain of 11. 2 to 15.9 kg (25 to 35 lbs) is are clinical manifestations of otitis media. Acute otitis media is
currently recommended as an average weight gain in pregnancy. common in children 6 months to 3 years old and 8 years old and
This weight gain consists of the following: fetus- 7.5 lb; placenta- above. Breast fed infants have higher resistance due to protection of
1.5 lb; amniotic fluid- 2 lb; uterus- 2.5 lb; breasts- 1.5 to 3 lb; blood Eustachian tubes and middle ear from breast milk.
volume- 4 lb; body fat- 7 lb; body fluid- 7 lb. 24. (D) Kangaroo care. Kangaroo care is the use of skin-to-skin contact
6. (B) Modify preoperative teaching to meet the needs of either a to maintain body heat. This method of care not only supplies heat
planned or emergency cesarean birth. A key point to consider when but also encourages parent-child interaction.
preparing the client for a cesarean delivery is to modify the 25. (B) Use of a high-SPF sunblock. Without melanin production, the
preoperative teaching to meet the needs of either planned or child with albinism is at risk for severe sunburns. Maximum sun
emergency cesarean birth, the depth and breadth of instruction will protection should be taken, including use of hats, long sleeves,
depend on circumstances and time available. minimal time in the sun and high-SPF sunblock, to prevent any
7. (D) convulsions. Options A, B and C are findings of severe problems.
preeclampsia. Convulsions is a finding of eclampsia—an obstetrical
emergency.
8. (C) Should be restricted because it may stimulate uterine
activity.. Coitus is restricted when there is watery discharge, uterine
contraction and vaginal bleeding. Also those women with a history
of spontaneous miscarriage may be advised to avoid coitus during
the time of pregnancy when a previous miscarriage occurred.

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Maternal and Child Health Nursing 8. When a mother bleeds and the uterus is relaxed, soft and
non-tender, you can account the cause to:
Exam 2 A. Atony of the uterus
B. Presence of uterine scar
C. Laceration of the birth canal
1. Nurse Bella explains to a 28 year old pregnant woman
D. Presence of retained placenta fragments
undergoing a non-stress test that the test is a way of evaluating the
condition of the fetus by comparing the fetal heart rate with:
9. Mrs. Pichie Gonzales’s LMP began April 4, 2010. Her EDD
A. Fetal lie
should be which of the following:
B. Fetal movement
A. February 11, 2011
C. Maternal blood pressure
B. January 11, 20111
D. Maternal uterine contractions
C. December 12, 2010
D. Nowember 14, 2010
2. During a 2 hour childbirth focusing on labor and delivery
process for primigravida. The nurse describes the second
10. Which of the following prenatal laboratory test values would
maneuver that the fetus goes through during labor progress when
the nurse consider as significant?
the head is the presenting part as which of the following:
A. Hematocrit 33.5%
A. Flexion
B. WBC 8,000/mm3
B. Internal rotation
C. Rubella titer less than 1:8
C. Descent
D. One hour glucose challenge test 110 g/dL
D. External rotation
11. Aling Patricia is a patient with preeclampsia. You advise her
3. Mrs. Jovel Diaz went to the hospital to have her serum blood
about her condition, which would tell you that she has not really
test for alpha-fetoprotein. The nurse informed her about the result
understood your instructions?
of the elevation of serum AFP. The patient asked her what was the
A. “I will restrict my fat in my diet.”
test for:
B. “I will limit my activities and rest more frequently
A. Congenital Adrenal Hyperplasia
throughout the day.”
B. PKU
C. “I will avoid salty foods in my diet.”
C. Down Syndrome
D. “I will come more regularly for check-up.”
D. Neural tube defects
12. Mrs. Grace Evangelista is admitted with severe preeclampsia.
4. Fetal heart rate can be auscultated with a fetoscope as early as:
What type of room should the nurse select this patient?
A. 5 weeks of gestation
A. A room next to the elevator.
B. 10 weeks of gestation
B. The room farthest from the nursing station.
C. 15 weeks of gestation
C. The quietest room on the floor.
D. 20 weeks of gestation
D. The labor suite.
5. Mrs. Bendivin states that she is experiencing aching swollen,
13. During a prenatal check-up, the nurse explains to a client who
leg veins. The nurse would explain that this is most probably the
is Rh negative that RhoGAM will be given:
result of which of the following:
A. Weekly during the 8th month because this is her
A. Thrombophlebitis
third pregnancy.
B. PIH
B. During the second trimester, if amniocentesis
C. Pressure on blood vessels from the enlarging
indicates a problem.
uterus
C. To her infant immediately after delivery if the
D. The force of gravity pulling down on the uterus
Coomb’s test is positive.
D. Within 72 hours after delivery if infant is found to
6. Mrs. Ella Santoros is a 25 year old primigravida who has
be Rh positive.
Rheumatic heart disease lesion. Her pregnancy has just been
diagnosed. Her heart disease has not caused her to limit physical
14. A baby boy was born at 8:50pm. At 8:55pm, the heart rate was
activity in the past. Her cardiac disease and functional capacity
99 bpm. She has a weak cry, irregular respiration. She was moving
classification is:
all extremities and only her hands and feet were still slightly blue.
A. Class I
The nurse should enter the APGAR score as:
B. Class II
A. 5
C. Class III
B. 6
D. class IV
C. 7
D. 8
7. The client asks the nurse, “When will this soft spot at the top of
the head of my baby will close?” The nurse should instruct the
15. Billy is a 4 year old boy who has an IQ of 140 which means:
mother that the neonate’s anterior fontanel will normally close by
age:
A. average normal
B. very superior
A. 2-3 months
C. above average
B. 6-8 months
D. Genius
C. 10-12 months
D. 12-18 months

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16. A newborn is brought to the nursery. Upon assessment, the 23. A client is noted to have lymphedema, webbed neck and low
nurse finds that the child has short palpebral fissures, thinned posterior hairline. Which of the following diagnoses is most
upper lip. Based on this data, the nurse suspects that the newborn appropriate?
is MOST likely showing the effects of:
A. Chronic toxoplasmosis
A. Turner’s syndrome
B. Lead poisoning
B. Down’s syndrome
C. Congenital anomalies
C. Marfan’s syndrome
D. Fetal alcohol syndrome
D. Klinefelter’s syndrome
17. A priority nursing intervention for the infant with cleft lip is
24. A 4 year old boy most likely perceives death in which way:
which of the following:
A. An insignificant event unless taught otherwise
A. Monitoring for adequate nutritional intake
B. Punishment for something the individual did
B. Teaching high-risk newborn care
C. Something that just happens to older people
C. Assessing for respiratory distress
D. Temporary separation from the loved one.
D. Preventing injury
25. Catherine Diaz is a 14 year old patient on a hematology unit
18. Nurse Jacob is assessing a 12 year old who has hemophilia A.
who is being treated for sickle cell crisis. During a crisis such as
Which of the following assessment findings would the nurse
that seen in sickle cell anemia, aldosterone release is stimulated. In
anticipate?
what way might this influence Catherine’s fluid and electrolyte
A. an excess of RBC
balance?
B. an excess of WBC
A. sodium loss, water loss and potassium retention
C. a deficiency of clotting factor VIII
B. sodium loss, water los and potassium loss
D. a deficiency of clotting factor IX
C. sodium retention, water loss and potassium
retention
19. Celine, a mother of a 2 year old tells the nurse that her child
D. sodium retention, water retention and potassium
“cries and has a fit when I have to leave him with a sitter or
loss
someone else.” Which of the following statements would be the
nurse’s most accurate analysis of the mother’s comment?
Answers and Rationales
A. The child has not experienced limit-setting or
structure. 1. (B) Fetal movement. Non-stress test measures response of the FHR
B. The child is expressing a physical need, such as to the fetal movement. With fetal movement, FHR increase by 15
hunger. beats and remain for 15 seconds then decrease to average rate. No
C. The mother has nurtured overdependence in the increase means poor oxygenation perfusion to fetus.
child. 2. (A) Flexion. The 6 cardinal movements of labor are descent, flexion,
D. The mother is describing her child’s separation internal rotation, extension, external rotation and expulsion.
anxiety. 3. (D) Neural tube defects. Alpha-fetoprotein is a substance produces
by the fetal liver that is present in amniotic fluid and maternal
serum. The level is abnormally high in the maternal serum if the
20. Mylene Lopez, a 16 year old girl with scoliosis has recently fetus has an open spinal or abdominal defect because the open
received an invitation to a pool party. She asks the nurse how she defect allows more AFP to appear.
can disguise her impairment when dressed in a bathing suit. Which 4. (D) 20 weeks of gestation. The FHR can be auscultated with a
nursing diagnosis can be justified by Mylene’s statement? fetoscope at about 20 weeks of gestation. FHR is usually
A. Anxiety auscultated at the midline suprapubic region with Doppler
B. Body image disturbance ultrasound at 10 to 12 weeks of gestation. FHR cannot be heard any
C. Ineffective individual coping earlier than 10 weeks of gestation.
5. (C) Pressure on blood vessels from the enlarging uterus. Pressure of
D. Social isolation the growing fetus on blood vessels results in an increase risk for
venous stasis in the lower extremities. Subsequently, edema and
21. The foul-smelling, frothy characteristic of the stool in cystic varicose vein formation may occur.
fibrosis results from the presence of large amounts of which of the 6. (A) Class I. Clients under class I has no physical activity limitation.
following: There is a slight limitation of physical activity in class II, ordinary
activity causes fatigue, palpitation, dyspnea or angina. Class III is
moderate limitation of physical activity; less than ordinary activity
A. sodium and chloride causes fatigue. Unable to carry on any activity without experiencing
B. undigested fat discomfort is under class IV.
C. semi-digested carbohydrates 7. (D) 12-18 months. Anterior fontanel closes at 12-18 months while
D. lipase, trypsin and amylase posterior fontanel closes at birth until 2 months.
8. (A) Atony of the uterus. Uterine atony, or relaxation of the uterus is
22. Which of the following would be a disadvantage of breast the most frequent cause of postpartal hemorrhage. It is the inability
to maintain the uterus in contracted state.
feeding? 9. (B) January 11, 20111. Using the Nagel’s rule, he use this formula
( -3 calendar months + 7 days).
A. involution occurs rapidly 10. (C) Rubella titer less than 1:8. A rubella titer should be 1:8 or
B. the incidence of allergies increases due to greater. Thus, a finding of a titer less than 1:8 is significant,
indicating that the client may not possess immunity to rubella. A
maternal antibodies hematocrit of 33.5%, WBC of 8,000/mm3, and a 1 hour glucose
C. the father may resent the infant’s demands on the challenge test of 110 g/dL are within normal parameters.
mother’s body 11. (B) “I will limit my activities and rest more frequently throughout
D. there is a greater chance of error during the day.”Pregnant woman with preeclampsia should be in a
preparation complete bed rest. When body is in recumbent position, sodium

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tends to be excreted at a faster rate. It is the best method of aiding significant and will not see that person again, it’s inaccurate to infer
increased excretion of sodium and encouraging diuresis. Rest death is insignificant, regardless of the child’s response.
should always be in a lateral recumbent position to avoid uterine 25. (D) sodium retention, water retention and potassium loss. Stress
pressure on the vena cava and prevent supine hypotension. stimulates the adrenal cortex to increase the release of aldosterone.
12. (C) The quietest room on the floor.A loud noise such as a crying Aldosterone promotes the resorption of sodium, the retention of
baby, or a dropped tray of equipment may be sufficient to trigger a water and the loss of potassium.
seizure initiating eclampsia, a woman with severe preeclampsia
should be admiotted to a private room so she can rest as
undisturbed as possible. Darken the room if possible because bright Maternal and Child Health Nursing
light can trigger seizures.
13. (D) Within 72 hours after delivery if infant is found to be Rh Exam 3
positive. RhoGAM is given to Rh-negative mothers within 72 hours
after birth of Rh-positive baby to prevent development of antibodies
in the maternal blood stream, which will be fata to succeeding 1. A pregnant woman who is at term is admitted to the birthing
Rh-positive offspring. unit in active labor. The client has only progressed from 2cm to 3
14. (B) 6. Heart rate of 99 bpm-1; weak cry-1; irregular respiration-1; cm in 8 hours. She is diagnosed with hypotonic dystocia and the
moving all extremities-2; extremities are slightly blue-1; with a physician ordered Oxytocin (Pitocin) to augment her contractions.
total score of 6. Which of the following is the most important aspect of nursing
15. (D) genius. IQ= mental age/chronological age x 100. Mental age
intervention at this time?
refers to the typical intelligence level found for people at a give
chronological age. OQ of 140 and above is considered genius. A. Timing and recording length of contractions.
16. (D) Fetal alcohol syndrome. The newborn with fetal alcohol B. Monitoring.
syndrome has a number of possible problems at birth. C. Preparing for an emergency cesarean birth.
Characteristics that mark the syndrome include pre and postnatal D. Checking the perineum for bulging.
growth retardation; CNS involvement such as cognitive challenge,
microcephally and cerebral palsy; and a distinctive facial feature of 2. A client who hallucinates is not in touch with reality. It is
a short palpebral fissure and thin upper lip. important for the nurse to:
17. (A) Monitoring for adequate nutritional intake. The infant with cleft
A. Isolate the client from other patients.
lip is unable to create an adequate seal for sucking. The child is at
risk for inadequate nutritional intake as well as aspiration. B. Maintain a safe environment.
18. (C) a deficiency of clotting factor VIII. Hemophillia A (classic C. Orient the client to time, place, and person.
hemophilia) is a deficiency in factor VIII (an alpha globulin that D. Establish a trusting relationship.
stabilizes fibrin clots).
19. (D) The mother is describing her child’s separation anxiety. Before 3. The nurse is caring to a child client who has had a tonsillectomy.
coming to any conclusion, the nurse should ask the mother focused The child complains of having dryness of the throat. Which of the
questions; however, based on initial information, the analysis of following would the nurse give to the child?
separation anxiety would be most valid. Separation anxiety is a A. Cola with ice
normal toddler response. When the child senses he is being sent
away from those who most provide him with love and security. B. Yellow noncitrus Jello
Crying is one way a child expresses a physical need; however, the C. Cool cherry Kool-Aid
nurse would be hasty in drawing this as first conclusion based on D. A glass of milk
what the mother has said. Nurturing overdependence or not
providing structure for the toddler are inaccurate conclusions based 4. The physician ordered Phenylephrine (Neo-Synephrine) nasal
on the information provided. spray to a 13-year-old client. The nurse caring to the client
20. (B) Body image disturbance. Mylene is experiencing uneasiness provides instructions that the nasal spray must be used exactly as
about the curvative of her spine, which will be more evident when directed to prevent the development of:
she wears a bathing suit. This data suggests a body image
disturbance. There is no evidence of anxiety or ineffective coping. A. Increased nasal congestion.
The fact that Mylene is planning to attend a pool party dispels a B. Nasal polyps.
diagnosis of social isolation. C. Bleeding tendencies.
21. (B) undigested fat. The client with cystic fibrosis absorbs fat poorly D. Tinnitus and diplopia.
because of the think secretions blocking the pancreatic duct. The
lack of natural pancreatic enzyme leads to poor absorption of 5. A client with tuberculosis is to be admitted in the hospital. The
predominantly fats in the duodenum. Foul-smelling, frothy stool is nurse who will be assigned to care for the client must institute
termed steatorrhea. appropriate precautions. The nurse should:
22. (C) the father may resent the infant’s demands on the mother’s
body. With breast feeding, the father’s body is not capable of A. Place the client in a private room.
providing the milk for the newborn, which may interfere with B. Wear an N 95 respirator when caring for the
feeding the newborn, providing fewer chances for bonding, or he client.
may be jealous of the infant’s demands on his wife time and body. C. Put on a gown every time when entering the room.
Breast feeding is advantageous because uterine involution occurs D. Don a surgical mask with a face shield when
more rapidly, thus minimizing blood loss. The presence of maternal
antibodies in breast milk helps decrease the incidence of allergies in
entering the room.
the newborn. A greater chance for error is associated with bottle
feeding. No preparation required for breast feeding. 6. Which of the following is the most frequent cause of
23. (A) Turner’s syndrome. Lymphedema, webbed neck and low noncompliance to the medical treatment of open-angle glaucoma?
posterior hairline, these are the 3 key assessment features in A. The frequent nausea and vomiting accompanying
Turner’s syndrome. If the child is diagnosed early in age, proper use of miotic drug.
treatment can be offered to the family. All newborns should be B. Loss of mobility due to severe driving restrictions.
screened for possible congenital defects. C. Decreased light and near-vision accommodation
24. (D) Temporary separation from the loved one. The predominant
perception of death by preschool age children is that death is
due to miotic effects of pilocarpine.
temporary separation. Because that child is losing someone D. The painful and insidious progression of this type
of glaucoma.

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7. In the morning shift, the nurse is making rounds in the nursing
care units. The nurse enters in a client’s room and notes that the 13. A newborn infant with Down syndrome is to be discharged
client’s tube has become disconnected from the Pleurovac. What today. The nurse is preparing to give the discharge teaching
would be the initial nursing action? regarding the proper care at home. The nurse would anticipate that
the mother is probably at the:
A. 40 years of age.
A. Apply pressure directly over the incision site.
B. 20 years of age.
B. Clamp the chest tube near the incision site.
C. 35 years of age.
C. Clamp the chest tube closer to the drainage
D. 20 years of age.
system.
D. Reconnect the chest tube to the Pleurovac.
14. The emergency department has shortage of staff. The nurse
manager informs the staff nurse in the critical care unit that she
8. Which of the following complications during a breech birth the
has to float to the emergency department. What should the staff
nurse needs to be alarmed?
nurse expect under these conditions?
A. Abruption placenta.
A. The float staff nurse will be informed of the
B. Caput succedaneum.
situation before the shift begins.
C. Pathological hyperbilirubinemia.
B. The staff nurse will be able to negotiate the
D. Umbilical cord prolapse.
assignments in the emergency department.
C. Cross training will be available for the staff nurse.
9. The nurse is caring to a client diagnosed with severe depression.
D. Client assignments will be equally divided among
Which of the following nursing approach is important in
the nurses.
depression?
A. Protect the client against harm to others.
15. The nurse is assigned to care for a child client admitted in the
B. Provide the client with motor outlets for
pediatrics unit. The client is receiving digoxin. Which of the
aggressive, hostile feelings.
following questions will be asked by the nurse to the parents of the
C. Reduce interpersonal contacts.
child in order to assess the client’s risk for digoxin toxicity?
D. Deemphasizing preoccupation with elimination,
A. “Has he been exposed to any childhood
nourishment, and sleep.
communicable diseases in the past 2-3 weeks?”
B. “Has he been taking diuretics at home?”
10. A 3-month-old client is in the pediatric unit. During
C. “Do any of his brothers and sisters have history of
assessment, the nurse is suspecting that the baby may have
cardiac problems?”
hypothyroidism when mother states that her baby does not:
D. “Has he been going to school regularly?”
A. Sit up.
B. Pick up and hold a rattle.
16. The nurse noticed that the signed consent form has an error.
C. Roll over.
The form states, “Amputation of the right leg” instead of the left
D. Hold the head up.
leg that is to be amputated. The nurse has administered already the
preoperative medications. What should the nurse do?
11. The physician calls the nursing unit to leave an order. The
A. Call the physician to reschedule the surgery.
senior nurse had conversation with the other staff. The newly hired
B. Call the nearest relative to come in to sign a new
nurse answers the phone so that the senior nurses may continue
form.
their conversation. The new nurse does not knowthe physician or
C. Cross out the error and initial the form.
the client to whom the order pertains. The nurse should:
D. Have the client sign another form.
A. Ask the physician to call back after the nurse has
read the hospital policy manual.
17. The nurse in the nursing care unit checks the fluctuation in the
B. Take the telephone order.
water-seal compartment of a closed chest drainage system. The
C. Refuse to take the telephone order.
fluctuation has stopped, the nurse would:
D. Ask the charge nurse or one of the other senior
A. Vigorously strip the tube to dislodge a clot.
staff nurses to take the telephone order.
B. Raise the apparatus above the chest to move fluid.
C. Increase wall suction above 20 cm H2O pressure.
12. The staff nurse on the labor and delivery unit is assigned to
D. Ask the client to cough and take a deep breath.
care to a primigravida in transition complicated by hypertension.
A new pregnant woman in active labor is admitted in the same
18. The pediatric nurse in the neonatal unit was informed that the
unit. The nurse manager assigned the same nurse to the second
baby that is brought to the mother in the hospital room is wrong.
client. The nurse feels that the client with hypertension requires
The nurse determines that two babies were placed in the wrong
one-to-one care. What would be the initial actionof the nurse?
cribs. The most appropriate nursing action would be to:
A. Determine who is responsible for the mistake and
A. Accept the new assignment and complete an terminate his or her employment.
incident report describing a shortage of nursing B. Record the event in an incident/variance report
staff. and notify the nursing supervisor.
B. Report the incident to the nursing supervisor and C. Reassure both mothers, report to the charge nurse,
request to be floated. and do not record.
C. Report the nursing assessment of the client in D. Record detailed notes of the event on the mother’s
transitional labor to the nurse manager and discuss medical record.
misgivings about the new assignment.
D. Accept the new assignment and provide the best
care.
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19. Before the administration of digoxin, the nurse completes an D. Primary goal is to understand why predicted
assessment to a toddler client for signs and symptoms of digoxin outcomes have not been met and the correction of
toxicity. Which of the following is the earliest and most significant identified problems.
sign of digoxin toxicity?
A. Tinnitus 25. The physician orders a dose of IV phenytoin to a child client.
B. Nausea and vomiting In preparing in the administration of the drug, which nursing
C. Vision problem action is not correct?
D. Slowing in the heart rate A. Infuse the phenytoin into a smaller vein to prevent
purple glove syndrome.
20. Which of the following treatment modality is appropriate for a B. Check the phenytoin solution to be sure it is clear
client with paranoid tendency? or light yellow in color, never cloudy.
A. Activity therapy. C. Plan to give phenytoin over 30-60 minutes, using
B. Individual therapy. an in-line filter.
C. Group therapy. D. Flush the IV tubing with normal saline before
D. Family therapy. starting phenytoin.

21. The client with rheumatoid arthritis is for discharge. In 26. The pregnant woman visits the clinic for check –up. Which
preparing the client for discharge on prednisone therapy, the nurse assessment findings will help the nurse determine that the client is
should advise the client to: in 8-week gestation?
A. Wear sunglasses if exposed to bright light for an A. Leopold maneuvers.
extended period of time. B. Fundal height.
B. Take oral preparations of prednisone before C. Positive radioimmunoassay test (RIA test).
meals. D. Auscultation of fetal heart tones.
C. Have periodic complete blood counts while on the
medication. 27. Which of the following nursing intervention is essential for the
D. Never stop or change the amount of the client who had pneumonectomy?
medication without medical advice. A. Medicate for pain only when needed.
B. Connect the chest tube to water-seal drainage.
22. A pregnant client tells the nurse that she is worried about C. Notify the physician if the chest drainage exceeds
having urinary frequency. What will be the most appropriate 100mL/hr.
nursing response? D. Encourage deep breathing and coughing.
A. “Try using Kegel (perineal) exercises and limiting
fluids before bedtime. If you have frequency 28. The nurse is providing a health teaching to a group of parents
associated with fever, pain on voiding, or blood in regarding Chlamydia trachomatis. The nurse is correct in the
the urine, call your doctor/nurse-midwife. statement, “Chlamydia trachomatis is not only an intracellular
B. “Placental progesterone causes irritability of the bacterium that causes neonatal conjunctivitis, but it also can cause:
bladder sphincter. Your symptoms will go away A. Discoloration of baby and adult teeth.
after the baby comes.” B. Pneumonia in the newborn.
C. “Pregnant women urinate frequently to get rid of C. Snuffles and rhagades in the newborn.
fetal wastes. Limit fluids to 1L/daily.” D. Central hearing defects in infancy.
D. “Frequency is due to bladder irritation from
concentrate urine and is normal in pregnancy. 29. The nurse is assigned to care to a 17-year-old male client with
Increase your daily fluid intake to 3L.” a history of substance abuse. The client asks the nurse, “Have you
ever tried or used drugs?” The most correct response of the nurse
23. Which of the following will help the nurse determine that the would be:
expression of hostility is useful? A. “Yes, once I tried grass.”
A. Expression of anger dissipates the energy. B. “No, I don’t think so.”
B. Energy from anger is used to accomplish what C. “Why do you want to know that?”
needs to be done. D. “How will my answer help you?”
C. Expression intimidates others.
D. Degree of hostility is less than the provocation. 30. Which of the following describes a health care team with the
principles of participative leadership?
24. The nurse is providing an orientation regarding case
management to the nursing students. Which characteristics should
A. Each member of the team can independently make
the nurse include in the discussion in understanding case
decisions regarding the client’s care without
management?
necessarily consulting the other members.
A. Main objective is a written plan that combines
B. The physician makes most of the decisions
discipline-specific processes used to measure
regarding the client’s care.
outcomes of care.
C. The team uses the expertise of its members to
B. Main purpose is to identify expected client, family
influence the decisions regarding the client’s care.
and staff performance against the timeline for
D. Nurses decide nursing care; physicians decide
clients with the same diagnosis.
medical and other treatment for the client.
C. Main focus is comprehensive coordination of
client care, avoid unnecessary duplication of
services, improve resource utilization and
decrease cost.
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31. A nurse is giving a health teaching to a woman who wants to 37. The nurse must instruct a client with glaucoma to avoid taking
breastfeed her newborn baby. Which hormone, normally secreted over-the-counter medications like:
during the postpartum period, influences both the milk ejection A. Antihistamines.
reflex and uterine involution? B. NSAIDs.
A. Oxytocin. C. Antacids.
B. Estrogen. D. Salicylates.
C. Progesterone.
D. Relaxin. 38. A male client is brought to the emergency department due to
motor vehicle accident. While monitoring the client, the nurse
32. One staff nurse is assigned to a group of 5 patients for the suspects increasing intracranial pressure when:
12-hour shift. The nurse is responsible for the overall planning, A. Client is oriented when aroused from sleep, and
giving and evaluating care during the entire shift. After the shift, goes back to sleep immediately.
same responsibility will be endorsed to the next nurse in charge. B. Blood pressure is decreased from 160/90 to
This describes nursing care delivered via the: 110/70.
A. Primary nursing method. C. Client refuses dinner because of anorexia.
B. Case method. D. Pulse is increased from 88-96 with occasional
C. Functional method. skipped beat.
D. Team method.
39. The nurse is conducting a lecture to a class of nursing students
33. The ambulance team calls the emergency department that they about advance directives to preoperative clients. Which of the
are going to bring a client who sustained burns in a house fire. following statement by the nurse js correct?
While waiting for the ambulance, the nurse will anticipate A. “The spouse, but not the rest of the family, may
emergency care to include assessment for: override the advance directive.”
A. Gas exchange impairment. B. “An advance directive is required for a “do not
B. Hypoglycemia. resuscitate” order.”
C. Hyperthermia. C. “A durable power of attorney, a form of advance
D. Fluid volume excess. directive, may only be held by a blood relative.”
D. “The advance directive may be enforced even in
34. Most couples are using “natural” family planning methods. the face of opposition by the spouse.”
Most accidental pregnancies in couples preferred to use this
method have been related to unprotected intercourse before 40. A client diagnosed with schizophrenia is shouting and banging
ovulation. Which of the following factor explains why pregnancy on the door leading to the outside, saying, “I need to go to an
may be achieved by unprotected intercourse during the appointment.” What is the appropriate nursing intervention?
preovulatory period? A. Tell the client that he cannot bang on the door.
A. Ovum viability. B. Ignore this behavior.
B. Tubal motility. C. Escort the client going back into the room.
C. Spermatozoal viability. D. Ask the client to move away from the door.
D. Secretory endometrium.
41. Which of the following action is an accurate tracheal
35. An older adult client wakes up at 2 o’clock in the morning and suctioning technique?
comes to the nurse’s station saying, “I am having difficulty in A. 25 seconds of continuous suction during catheter
sleeping.” What is the best nursing response to the client? insertion.
A. “I’ll give you a sleeping pill to help you get more B. 20 seconds of continuous suction during catheter
sleep now.” insertion.
B. “Perhaps you’d like to sit here at the nurse’s C. 10 seconds of intermittent suction during catheter
station for a while.” withdrawal.
C. “Would you like me to show you where the D. 15 seconds of intermittent suction during catheter
bathroom is?” withdrawal.
D. “What woke you up?”
42. The client’s jaw and cheekbone is sutured and wired. The
36. The nurse is taking care of a multipara who is at 42 weeks of nurse anticipates that the most important thing that must be ready
gestation and in active labor, her membranes ruptured at the bedside is:
spontaneously 2 hours ago. While auscultating for the point of A. Suture set.
maximum intensity of fetal heart tones before applying an external B. Tracheostomy set.
fetal monitor, the nurse counts 100 beats per minute. The C. Suction equipment.
immediate nursing action is to: D. Wire cutters.

43. A mother is in the third stage of labor. Which of the following

A. Start oxygen by mask to reduce fetal distress.
signs will help the nurse determine the signs of placental
B. Examine the woman for signs of a prolapsed cord.
separation?
C. Turn the woman on her left side to increase
A. The uterus becomes globular.
placental perfusion.
B. The umbilical cord is shortened.
D. Take the woman’s radial pulse while still
C. The fundus appears at the introitus.
auscultating the FHR.
D. Mucoid discharge is increased.

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44. After therapy with the thrombolytic alteplase (t-PA), what C. Erythema toxicum
observation will the nurse report to the physician? D. Milia
A. 3+ peripheral pulses.
B. Change in level of consciousness and headache. 52. The client is brought to the emergency department because of
C. Occasional dysrhythmias. serious vehicle accident. After an hour, the client has been
D. Heart rate of 100/bpm. declared brain dead. The nurse who has been with the client must
now talk to the family about organ donation. Which of the
45. A client who undergone left nephrectomy has a large flank following consideration is necessary?
incision. Which of the following nursing action will facilitate deep A. Include as many family members as possible.
breathing and coughing? B. Take the family to the chapel.
A. Push fluid administration to loosen respiratory C. Discuss life support systems.
secretions. D. Clarify the family’s understanding of brain death.
B. Have the client lie on the unaffected side.
C. Maintain the client in high Fowler’s position. 53. The nurse is teaching exercises that are good for pregnant
D. Coordinate breathing and coughing exercise with women increasing tone and fitness and decreasing lower backache.
administration of analgesics. Which of the following should the nurse exclude in the exercise
program?
46. The community nurse is teaching the group of mothers about A. Stand with legs apart and touch hands to floor
the cervical mucus method of natural family planning. Which three times per day.
characteristics are typical of the cervical mucus during the B. Ten minutes of walking per day with an emphasis
“fertile” period of the menstrual cycle? on good posture.
A. Absence of ferning. C. Ten minutes of swimming or leg kicking in pool
B. Thin, clear, good spinnbarkeit. per day.
C. Thick, cloudy. D. Pelvic rock exercise and squats three times a day.
D. Yellow and sticky.
54. A client with obsessive-compulsive behavior is admitted in the
47. A client with ruptured appendix had surgery an hour ago and is psychiatric unit. The nurse taking care of the client knows that the
transferred to the nursing care unit. The nurse placed the client in a primary treatment goal is to:
semi-Fowler’s position primarily to: A. Provide distraction.
A. Facilitate movement and reduce complications B. Support but limit the behavior.
from immobility. C. Prohibit the behavior.
B. Fully aerate the lungs. D. Point out the behavior.
C. Splint the wound.
D. Promote drainage and prevent subdiaphragmatic 55. After ileostomy, the nurse expects that the drainage appliance
abscesses. will be applied to the stoma:
A. When the client is able to begin self-care
48. Which of the following will best describe a management procedures.
function? B. 24 hours later, when the swelling subsided.
A. Writing a letter to the editor of a nursing journal. C. In the operating room after the ileostomy
B. Negotiating labor contracts. procedure.
C. Directing and evaluating nursing staff members. D. After the ileostomy begins to function.
D. Explaining medication side effects to a client.
56. A female client who has a 28-day menstrual cycle asks the
49. The parents of an infant client ask the nurse to teach them how community health nurse when she get pregnant during her cycle.
to administer Cortisporin eye drops. The nurse is correct in What will be the best nursing response?
advising the parents to place the drops: A. It is impossible to determine the fertile period
A. In the middle of the lower conjunctival sac of the reliably. So it is best to assume that a woman is
infant’s eye. always fertile.
B. Directly onto the infant’s sclera. B. In a 28-day cycle, ovulation occurs at or about day
C. In the outer canthus of the infant’s eye. 14. The egg lives for about 24 hours and the
D. In the inner canthus of the infant’s eye. sperm live for about 72 hours. The fertile period
would be approximately between day 11 and day
50. The nurse is assessing on the client who is admitted due to 15.
vehicle accident. Which of the following findings will help the C. In a 28- day cycle, ovulation occurs at or about
nurse that there is internal bleeding? day 14. The egg lives for about 72 hours and the
A. Frank blood on the clothing. sperm live for about 24 hours. The fertile period
B. Thirst and restlessness. would be approximately between day 13 and 17.
C. Abdominal pain. D. In a 28-day cycle, ovulation occurs 8 days before
D. Confusion and altered of consciousness. the next period or at about day 20. The fertile
period is between day 20 and the beginning of the
51. The nurse is completing an assessment to a newborn baby boy. next period.
The nurse observes that the skin of the newborn is dry and flaking
and there are several areas of an apparent macular rash. The nurse
charts this as:
A. Icterus neonatorum
B. Multiple hemangiomas
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57. Which of the following statement describes the role of a nurse 63. A couple seeks medical advice in the community health care
as a client advocate? unit. A couple has been unable to conceive; the man is being
A. A nurse may override clients’ wishes for their evaluated for possible problems. The physician ordered semen
own good. analysis. Which of the following instructions is correct regarding
B. A nurse has the moral obligation to prevent harm collection of a sperm specimen?
and do well for clients.
C. A nurse helps clients gain greater independence
A. Collect a specimen at the clinic, place in iced
and self-determination.
container, and give to laboratory personnel
D. A nurse measures the risk and benefits of various
immediately.
health situations while factoring in cost.
B. Collect specimen after 48-72 hours of abstinence
and bring to clinic within 2 hours.
58. A community health nurse is providing a health teaching to a
C. Collect specimen in the morning after 24 hours of
woman infected with herpes simplex 2. Which of the following
abstinence and bring to clinic immediately.
health teaching must the nurse include to reduce the chances of
D. Collect specimen at night, refrigerate, and bring to
transmission of herpes simplex 2?
clinic the next morning.
A. “Abstain from intercourse until lesions heal.”
B. “Therapy is curative.”
64. The physician ordered Betamethasone to a pregnant woman at
C. “Penicillin is the drug of choice for treatment.”
34 weeks of gestation with sign of preterm labor. The nurse
D. “The organism is associated with later
expects that the drug will:
development of hydatidiform mole.
A. Treat infection.
B. Suppress labor contraction.
59. The nurse in the psychiatric ward informed the male client that
C. Stimulate the production of surfactant.
he will be attending the 9:00 AM group therapy sessions. The
D. Reduce the risk of hypertension.
client tells the nurse that he must wash his hands from 9:00 to 9:30
AM each day and therefore he cannot attend. Which concept does
65. A tracheostomy cuff is to be deflated, which of the following
the nursing staff need to keep in mind in planning nursing
nursing intervention should be implemented before starting the
intervention for this client?
procedures?
A. Depression underlines ritualistic behavior.
A. Suction the trachea and mouth.
B. Fear and tensions are often expressed in disguised
B. Have the obdurator available.
form through symbolic processes.
C. Encourage deep breathing and coughing.
C. Ritualistic behavior makes others uncomfortable.
D. Do a pulse oximetry reading.
D. Unmet needs are discharged through ritualistic
behavior.
66. A client is diagnosed with Tuberculosis and respiratory
isolation is initiated. This means that:
60. The nurse assesses the health condition of the female client.
A. Gloves are worn when handling the client’s tissue,
The client tells the nurse that she discovered a lump in the breast
excretions, and linen.
last year and hesitated to seek medical advice. The nurse
B. Both client and attending nurse must wear masks
understands that, women who tend to delay seeking medical
at all times.
advice after discovering the disease are displaying what common
C. Nurse and visitors must wear masks until
defense mechanism?
chemotherapy is begun. Client is instructed in
A. Intellectualization.
cough and tissue techniques.
B. Suppression.
D. Full isolation; that is, caps and gowns are required
C. Repression.
during the period of contagion.
D. Denial.
67. A client with lung cancer is admitted in the nursing care unit.
61. Which of the following situations cannot be delegated by the
The husband wants to know the condition of his wife. How should
registered nurse to the nursing assistant?
the nurse respond to the husband?
A. A postoperative client who is stable needs to
ambulate.
B. Client in soft restraint who is very agitated and A. Find out what information he already has.
crying. B. Suggest that he discuss it with his wife.
C. A confused elderly woman who needs assistance C. Refer him to the doctor.
with eating. D. Refer him to the nurse in charge.
D. Routine temperature check that must be done for a
client at end of shift. 68. A hospitalized client cannot find his handkerchief and accuses
other cient in the room and the nurse of stealing them. Which is
62. In the admission care unit, which of the following client would the most therapeutic approach to this client?
the nurse give immediate attention?
A. A client who is 3 days postoperative with left calf A. Divert the client’s attention.
pain. B. Listen without reinforcing the client’s belief.
B. A client who is postoperative hip pinning who is C. Inject humor to defuse the intensity.
complaining of pain. D. Logically point out that the client is jumping to
C. New admitted client with chest pain. conclusions.
D. A client with diabetes who has a glucoscan
reading of 180.

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69. After a cystectomy and formation of an ileal conduit, the nurse 74. An infant is brought to the health care clinic for three
provides instruction regarding prevention of leakage of the pouch immunizations at the same time. The nurse knows that hepatitis B,
and backflow of the urine. The nurse is correct to include in the DPT, and Haemophilus influenzae type B immunizations should:
instruction to empty the urine pouch:
A. Be drawn in the same syringe and given in one
A. Every 3-4 hours. injection.
B. Every hour. B. Be mixed and inject in the same sites.
C. Twice a day. C. Not be mixed and the nurse must give three
D. Once before bedtime. injections in three sites.
D. Be mixed and the nurse must give the injection in
70. Which telephone call from a student’s mother should the three sites.
school nurse take care of at once?
75. A female client with cancer has radium implants. The nurse
wants to maintain the implants in the correct position. The nurse
A. A telephone call notifying the school nurse that
should position the client:
the child’ pediatrician has informed the mother
that the child will need cardiac repair surgery
within the next few weeks. A. Flat in bed.
B. A telephone call notifying the school nurse that B. On the side only.
the child’s pediatrician has informed the mother C. With the foot of the bed elevated.
that the child has head lice. D. With the head elevated 45-degrees
C. A telephone call notifying the school nurse that a (semi-Fowler’s).
child has a temperature of 102ºF and a rash
covering the trunk and upper extremities of the 76. The nurse wants to know if the mother of a toddler
body. understands the instructions regarding the administration of syrup
D. A telephone call notifying the school nurse that a of ipecac. Which of the following statement will help the nurse to
child underwent an emergency appendectomy know that the mother needs additional teaching?
during the previous night.
A. “I’ll give the medicine if my child gets into some
71. Which of the following signs and symptoms that require
toilet bowl cleaner.”
immediate attention and may indicate most serious complications
B. “I’ll give the medicine if my child gets into some
during pregnancy?
aspirin.”
A. Severe abdominal pain or fluid discharge from the
C. “I’ll give the medicine if my child gets into some
vagina.
plant bulbs.”
B. Excessive saliva, “bumps around the areolae, and
D. “I’ll give the medicine if my child gets into some
increased vaginal mucus.
vitamin pills.”
C. Fatigue, nausea, and urinary frequency at any time
during pregnancy.
77. To assess if the cranial nerve VII of the client was damaged,
D. Ankle edema, enlarging varicosities, and
which changes would not be expected?
heartburn.

72. The nurse is assessing the newborn boy. Apgar scores are 7 A. Drooling and drooping of the mouth.
and 9. The newborn becomes slightly cyanotic. What is the initial B. Inability to open eyelids on operative side.
nursing action? C. Sagging of the face on the operative side.
A. Elevate his head to promote gravity drainage of D. Inability to close eyelid on operative side.
secretions.
B. Wrap him in another blanket, to reduce heat loss. 78. The community health nurse makes a home visit to a family.
C. Stimulate him to cry,, to increase oxygenation. During the visit, the nurse observes that the mother is beating her
D. Aspirate his mouth and nose with bulb syringe. child. What is the priority nursing intervention in this situation?

73. The nurse is formulating a plan of care to a client with a A. Assess the child’s injuries.
somatoform disorder. The nurse needs to have knowledge of B. Report the incident to protective agencies.
which psychodynamic principle? C. Refer the family to appropriate support group.
A. The symptoms of a somatoform disorder are an D. Assist the family to identify stressors and use of
attempt to adjust to painful life situations or to other coping mechanisms to prevent further
cope with conflicting sexual, aggressive, or incidents.
dependent feelings.
B. The major fundamental mechanism is regression.
C. The client’s symptoms are imaginary and the
suffering is faked.
D. An extensive, prolonged study of the symptoms
will be reassuring to the client, who seeks
sympathy, attention and love.

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B. “Don’t worry, you won’t die. You are just here for
79. The nurse in the neonatal care unit is supervising the actions of some test.”
a certified nursing assistant in giving care to the newborns. The C. “Why are you afraid of dying?”
nursing assistant mistakenly gives a formula feeding to a newborn D. “Try to sleep. You need the rest before
that is on water feeding only. The nurse is responsible for the tomorrow’s test.”
mistake of the nursing assistant:
84. In the hospital lobby, the registered nurse overhears a two staff
members discussing about the health condition of her client. What
A. Always, as a representative of the institution.
would be the appropriate action for the registered nurse to take?
B. Always, because nurses who supervise
less-trained individuals are responsible for their
mistakes. A. Join in the conversation, giving her input about
C. If the nurse failed to determine whether the the case.
nursing assistant was competent to take care of the B. Ignore them, because they have the right to
client. discuss anything they want to.
D. Only if the nurse agreed that the newborn could C. Tell them it is not appropriate to discuss such
be fed formula. things.
D. Report this incident to the nursing supervisor.
80. The nurse is assigned to care for a client with urinary calculi.
Fluid intake of 2L/day is encouraged to the client. the primary 85. The client has had a right-sided cerebrovascular accident. In
reason for this is to: transferring the client from the wheelchair to bed, in what position
should a client be placed to facilitate safe transfer?
A. Reduce the size of existing stones.
B. Prevent crystalline irritation to the ureter. A. Weakened (L) side of the cient next to bed.
C. Reduce the size of existing stones B. Weakened (R) side of the client next to bed.
D. Increase the hydrostatic pressure in the urinary C. Weakened (L) side of the client away from bed.
tract. D. Weakened (R) side of the cient away from bed.

81. The nurse is counseling a couple in their mid 30’s who have 86. The child client has undergone hip surgery and is in a spica
been unable to conceive for about 6 months. They are concerned cast. Which of the following toy should be avoided to be in the
that one or both of them may be infertile. What is the best advice child’s bed?
the nurse could give to the couple?
A. A toy gun.
A. “it is no unusual to take 6-12 months to get B. A stuffed animal.
pregnant, especially when the partners are in their C. A ball.
mid-30s. Eat well, exercise, and avoid stress.” D. Legos.
B. “Start planning adoption. Many couples get
pregnant when they are trying to adopt.” 87. The LPN/LVN asks the registered nurse why oxytocin
C. “Consult a fertility specialist and start testing (Pitocin), 10 units (IV or IM) must be given to a client after birth
before you get any older.” fo the fetus. The nurse is correct to explain that oxytocin:
D. “Have sex as often as you can, especially around
the time of ovulation, to increase your chances of
A. Minimizes discomfort from “afterpains.”
pregnancy.”
B. Suppresses lactation.
C. Promotes lactation.
82. The nurse is caring for a cient who Is a retired nurse. A
D. Maintains uterine tone.
24-hour urine collection for Creatinine clearance is to be done.
The client tells the nurse, “I can’t remember what this test is for.”
88. The nurse in the nursing care unit is aware that one of the
The best response by the nurse is:
medical staff displays unlikely behaviors like confusion, agitation,
lethargy and unkempt appearance. This behavior has been reported
A. “It provides a way to see if you are passing any to the nurse manager several times, but no changes observed. The
protein in your urine.” nurse should:
B. “It tells how well the kidneys filter wastes from
the blood.”
A. Continue to report observations of unusual
C. “It tells if your renal insufficiency has affected
behavior until the problem is resolved.
your heart.”
B. Consider that the obligation to protect the patient
D. “The test measures the number of particles the
from harm has been met by the prior reports and
kidney filters.”
do nothing further.
C. Discuss the situation with friends who are also
83. The nurse observes the female client in the psychiatric ward
nurses to get ideas .
that she is having a hard time sleeping at night. The nurse asks the
D. Approach the partner of this medical staff member
client about it and the client says, “I can’t sleep at night because of
with these concerns.
fear of dying.” What is the best initial nursing response?

A. “It must be frightening for you to feel that way.

Tell me more about it.”
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89. The physician ordered tetracycline PO qid to a child client 95. A male client tells the nurse that there is a big bug in his bed.
who weights 20kg. The recommended PO tetracycline dose is The most therapeutic nursing response would be:
25-50 mg/kg/day. What is the maximum single dose that can be
safely administered to this child?
A. Silence.
B. “Where’s the bug? I’ll kill it for you.”
A. 1g C. “I don’t see a bug in your bed, but you seem
B. 500 mg afraid.”
C. 250 mg D. “You must be seeing things.”
D. 125 mg
96. A pregnant client in late pregnancy is complaining of groin
90. The nurse is completing an obstetric history of a woman in pain that seems worse on the right side. Which of the following is
labor. Which event in the obstetric history will help the nurse the most likely cause of it?
suspects dysfunctional labor in the current pregnancy?
A. Beginning of labor.
A. Total time of ruptured membranes was 24 hours B. Bladder infection.
with the second birth. C. Constipation.
B. First labor lasting 24 hours. D. Tension on the round ligament.
C. Uterine fibroid noted at time of cesarean delivery.
D. Second birth by cesarean for face presentation. 97. The nurse is conducting a lecture to a group of volunteer
nurses. The nurse is correct in imparting the idea that the Good
91. The nurse is planning to talk to the client with an antisocial Samaritan law protects the nurse from a suit for malpractice when:
personality disorder. What would be the most therapeutic
approach?
A. The nurse stops to render emergency aid and
leaves before the ambulance arrives.
A. Provide external controls. B. The nurse acts in an emergency at his or her place
B. Reinforce the client’s self-concept. of employment.
C. Give the client opportunities to test reality. C. The nurse refuses to stop for an emergency
D. Gratify the client’s inner needs. outside of the scope of employment.
D. The nurse is grossly negligent at the scene of an
92. The nurse is teaching a group of women about fertility emergency.
awareness, the nurse should emphasize that basal body
temperature: 98. A woman is hospitalized with mild preeclampsia. The nurse is
A. Can be done with a mercury thermometer but no a formulating a plan of care for this client, which nursing care is
digital one. least likely to be done?
B. The average temperature taken each morning.
C. Should be recorded each morning before any
A. Deep-tendon reflexes once per shift.
activity.
B. Vital signs and FHR and rhythm q4h while
D. Has a lower degree of accuracy in predicting
awake.
ovulation than the cervical mucus test.
C. Absolute bed rest.
D. Daily weight.
93. The nursing applicant has given the chance to ask questions
during a job interview at a local hospital. What should be the most
99. While feeding a newborn with an unrepaired cardiac defect,
important question to ask that can increase chances of securing a
the nurse keeps on assessing the condition of the client. The nurse
job offer?
notes that the newborn’s respiration is 72 breaths per minute.
A. Begin with questions about client care
What would be the initial nursing action?
assignments, advancement opportunities, and
continuing education.
B. Decline to ask questions, because that is the A. Burp the newborn.
responsibility of the interviewer. B. Stop the feeding.
C. Ask as many questions about the facility as C. Continue the feeding.
possible. D. Notify the physician.
D. Clarify information regarding salary, benefits, and
working hours first, because this will help in 100. A client who undergone appendectomy 3 days ago is
deciding whether or not to take the job. scheduled for discharge today. The nurse notes that the client is
restless, picking at bedclothes and saying, “I am late on my
94. The nurse advised the pregnant woman that smoking and appointment,” and calling the nurse by the wrong name. The nurse
alcohol should be avoided during pregnancy. The nurse takes into suspects:
account that the developing fetus is most vulnerable to
environment teratogens that cause malformation during: A. Panic reaction.
A. The entire pregnancy. B. Medication overdose.
B. The third trimester. C. Toxic reaction to an antibiotic.
C. The first trimester. D. Delirium tremens.
D. The second trimester.

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Answers and Rationales supervisors in order to resolve the current problems and permit
the institution to prevent the problem from happening again.
1. A. The oxytocic effect of Pitocin increases the intensity 19. D. One of the earliest signs of digoxin toxicity is Bradycardia.
and durations of contractions; prolonged contractions will For a toddler, any heart rate that falls below the norm of about
jeopardize the safetyof the fetus and necessitate discontinuing 100-120 bpm would indicate Bradycardia and would necessitate
the drug. holding the medication and notifying the physician.
2. B. It is of paramount importance to prevent the client from 20. B. This option is least threatening.
hurting himself or herself or others. 21. D. In preparing the client for discharge that is receiving
3. B. After tonsillectomy, clear, cool liquids should be given. prednisone, the nurse should caution the client to (a) take oral
Citrus, carbonated, and hot or cold liquids should be avoided preparations after meals; (b) remember that routine checks of
because they may irritate the throat. Red liquids should be vital signs, weight, and lab studies are critical; (c) NEVER
avoided because they give the appearance of blood if the child STOP OR CHANGE THE AMOUNT OF MEDICATION
vomits. Milk and milk products including pudding are avoided WITHOUT MEDICAL ADVICE; (d) store the medication in a
because they coat the throat, cause the child to clear the throat, light-resistant container.
and increase the risk of bleeding. 22. A. Progesterone also reduces smooth muscle motility in the
4. A. Phenylephrine, with frequent and continued use, can cause urinary tract and predisposes the pregnant woman to urinary
rebound congestion of mucous membranes. tract infections. Women should contact their doctors if they
5. B. The N 95 respirator is a high-particulate filtration mask that exhibit signs of infection. Kegel exercise will help strengthen
meets the CDC performance criteria for a tuberculosis the perineal muscles; limiting fluids at bedtime reduces the
respirator. possibility of being awakened by the necessity of voiding.
6. C. The most frequent cause of noncompliance to the treatment 23. B. This is the proper use of anger.
of chronic, or open-angle glaucoma is the miotic effects of 24. C. There are several models of case management, but the
pilocarpine. Pupillary constriction impedes normal commonality is comprehensive coordination of care to better
accommodation, making night driving difficult and hazardous, predict needs of high-risk clients, decrease exacerbations and
reducing the client’s ability to read for extended periods and continually monitor progress overtime.
making participation in games with fast-moving objects 25. A. Phenytoin should be infused or injected into larger veins to
impossible. avoid the discoloration know as purple glove syndrome;
7. B. This stops the sucking of air through the tube and prevents infusing into a smaller vein is not appropriate.
the entry of contaminants. In addition, clamping near the chest 26. C. Serum radioimmunoassay (RIA) is accurate within 7days of
wall provides for some stability and may prevent the clamp from conception. This test is specific for HCG, and accuracy is not
pulling on the chest tube. compromised by confusion with LH.
8. D. Because umbilical cord’s insertion site is born before the 27. D. Surgery and anesthesia can increase mucus production. Deep
fetal head, the cord may be compressed by the after-coming breathing and coughing are essential to prevent atelectasis and
head in a breech birth. pneumonia in the client’s only remaining lung.
9. B. It is important to externalize the anger away from self. 28. B. Newborns can get pneumonia (tachypnea, mild hypoxia,
10. D. Development normally proceeds cephalocaudally; so the first cough, eosinophilia) and conjunctivitis from Chlamydia.
major developmental milestone that the infant achieves is the 29. D. The client may perceive this as avoidance, but it is more
ability to hold the head up within the first 8-12 weeks of life. In important to redirect back to the client, especially in light of the
hypothyroidism, the infant’s muscle tone would be poor and the manipulative behavior of drug abusers and adolescents.
infant would not be able to achieve this milestone. 30. C. It describes a democratic process in which all members have
11. D. Get a senior nurse who know s the policies, the client, and input in the client’s care.
the doctor. Generally speaking, a nurse should not accept 31. A. Contraction of the milk ducts and let-down reflex occur
telephone orders. However, if it is necessary to take one, follow under the stimulation of oxytocin released by the posterior
the hospital’s policy regarding telephone orders. Failure to pituitary gland.
followhospital policy could be considered negligence. In this 32. B. In case management, the nurse assumes total responsibility
case, the nurse was new and did not know the hospital’s policy for meeting the needs of the client during the entire time on
concerning telephone orders. The nurse was also unfamiliar with duty.
the doctor and the client. Therefore the nurse should not take the 33. A. Smoke inhalation affects gas exchange.
order unless a) no one else is available and b) it is an emergency 34. C. Sperm deposited during intercourse may remain viable for
situation. about 3 days. If ovulation occurs during this period, conception
12. C. The nurse is obligated to inform the nurse manager about may result.
changes in the condition of the client, which may change the 35. B. This option shows acceptance (key concept) of this
decision made by the nurse manager. age-typical sleep pattern (that of waking in the early morning).
13. A. Perinatal risk factors for the development of Down syndrome 36. D. Taking the mother’s pulse while listening to the FHR will
include advanced maternal age, especially with the first differentiate between the maternal and fetal heart rates and rule
pregnancy. out fetal Bradycardia.
14. B. Assignments should be based on scope of practice and 37. A. Antihistamines cause pupil dilation and should be avoided
expertise. with glaucoma.
15. B. The child who is concurrently taking digoxin and diuretics is 38. A. This suggests that the level of consciousness is decreasing.
at increased risk for digoxin toxicity due to the loss of potassium. 39. D. An advance directive is a form of informed consent, and only
The child and parents should be taught what foods are high in a competent adult or the holder of a durable power of attorney
potassium, and the child should be encouraged to eat a has the right to consent or refuse treatment. If the spouse does
high-potassium diet. In addition, the child’s serum potassium not hold the power of attorney, the decisions of the holder, even
level should be carefully monitored. if opposed by the spouse, are enforced.
16. A. The responsible for an accurate informed consent is the 40. C. Gentle but firm guidance and nonverbal direction is needed
physician. An exception to this answer would be a to intervene when a client with schizophrenic symptoms is being
life-threatening emergency, but there are no data to support disruptive.
another response. 41. C. Suctioning is only done for 10 seconds, intermittently, as the
17. D. Asking the client to cough and take a deep breath will help catheter is being withdrawn.
determine if the chest tube is kinked or if the lungs has 42. D. The priority for this client is being able to establish an
reexpanded. airway.
18. B. Every event that exposes a client to harm should be recorded 43. A. Signs of placental separation include a change in the shape of
in an incident report, as well as reported to the appropriate the uterus from ovoid to globular.

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44. B. This could indicate intracranial bleeding. Alteplase is a 65. A. Secretions may have pooled above the tracheostomy cuff. If
thrombolytic enzyme that lyses thrombi and emboli. Bleeding is these are not suctioned before deflation, the secretions may be
an adverse effect. Monitor clotting times and signs of any aspirated.
gastrointestinal or internal bleeding. 66. C. Proper handling of sputum is essential to allay droplet
45. D. Because flank incision in nephrectomy is directly below the transference of bacilli in the air. Clients need to be taught to
diaphragm, deep breathing is painful. Additionally, there is a cover their nose and mouth with tissues when sneezing or
greater incisional pull each time the person moves than there is coughing. Chemotherapy generally renders the client
with abdominal surgery. Incisional pain following nephrectomy noninfectious within days to a few weeks, usually before
generally requires analgesics administration every 3-4 hours for cultures for tubercle bacilli are negative. Until chemical
24-48 hours after surgery. Therefore, turning, coughing and isolation is established, many institutions require the client to
deep-breathing exercises should be planned to maximize the wear a mask when visitors are in the room or when the nurse is
analgesic effects. in attendance. Client should be in a well-ventilated room,
46. B. Under high estrogen levels, during the period surrounding without air recirculation, to prevent air contamination.
ovulation, the cervical mucus becomes thin, clear, and elastic 67. A. It is best to establish baseline information first.
(spinnbarkeit), facilitating sperm passage. 68. B. Listening is probably the most effective response of the four
47. D. After surgery for a ruptured appendix, the client should be choices.
placed in a semi-Fowler’s position to promote drainage and to 69. A. Urine flow is continuous. The pouch has an outlet valve for
prevent possible complications. easy drainage every 3-4 hours. (the pouch should be changed
48. C. Directing and evaluation of staff is a major responsibility of a every 3-5 days, or sooner if the adhesive is loose).
nursing manager. 70. C. A high fever accompanied by a body rash could indicate that
49. A. The recommended procedure for administering eyedrops to the child has a communicable disease and would have exposed
any client calls for the drops to be placed in the middle of the other students to the infection. The school nurse would want to
lower conjunctival sac. investigate this telephone call immediately so that plans could
50. B. Thirst and restlessness indicate hypovolemia and hypoxemia. be instituted to control the spread of such infection.
Internal bleeding is difficult to recognized and evaluate because 71. A. Severe abdominal pain may indicate complications of
it is not apparent. pregnancy such as abortion, ectopic pregnancy, or abruption
51. C. Erythema toxicum is the normal, nonpathological macular placenta; fluid discharge from the vagina may indicate
newborn rash. premature rupture of the membrane.
52. D. The family needs to understand what brain death is before 72. D. Gentle aspiration of mucus helps maintain a patent airway,
talking about organ donation. They need time to accept the required for effective gas exchange.
death of their family member. An environment conducive to 73. A. Somatoform disorders provide a way of coping with
discussing an emotional issue is needed. conflicts.
53. A. Bending from the waist in pregnancy tends to make backache 74. C. Immunization should never be mixed together in a syringe,
worse. thus necessitating three separate injections in three sites. Note:
54. B. Support and limit setting decrease anxiety and provide some manufacturers make a premixed combination of
external control. immunization that is safe and effective.
55. C. The stoma drainage bag is applied in the operating room. 75. A. Clients with radioactive implants should be positioned flat in
Drainage from the ileostomy contains secretions that are rich in bed to prevent dislodgement of the vaginal packing. The client
digestive enzymes and highly irritating to the skin. Protection of may roll to the side for meals but the upper body should not be
the skin from the effects of these enzymes is begun at once. Skin raised more than 20 degrees.
exposed to these enzymes even for a short time becomes 76. A. Syrup of ipecac is not administered when the ingested
reddened, painful and excoriated. substances is corrosive in nature. Toilet bowl cleaners, as a
56. B. It is the most accurate statement of physiological facts for a collective whole, are highly corrosive substances. If the ingested
28-day menstrual cycle: ovulation at day 14, egg life span 24 substance “burned” the esophagus going down, it will “burn”
hours, sperm life span of 72 hours. Fertilization could occur the esophagus coming back up when the child begins to vomit
from sperm deposited before ovulation. after administration of syrup of ipecac.
57. C. An advocate role encourage freedom of choice, includes 77. B. Inability to open eyelids on operative side is seen with cranial
speaking out for the client, and supports the client’s best nerve III damage.
interests. 78. A. Assessment of physical injuries (like bruises, lacerations,
58. A. Abstinence will eliminate any unnecessary pain during bleeding and fractures) is the first priority.
intercourse and will reduce the possibility of transmitting 79. C. The nurse who is supervising others has a legal obligation to
infection to one’s sexual partner. determine that they are competent to perform the assignment, as
59. B. Anxiety is generated by group therapy at 9:00 AM. The well as legal obligation to provide adequate supervision.
ritualistic behavioral defense of hand washing decreases anxiety 80. D. Increasing hydrostatic pressure in the urinary tract will
by avoiding group therapy. facilitate passage of the calculi.
60. D. Denial is a very strong defense mechanism used to allay the 81. A. Infertility is not diagnosed until atleast 12months of
emotional effects of discovering a potential threat. Although unprotected intercourse has failed to produce a pregnancy. Older
denial has been found to be an effective mechanism for survival couples will experience a longer time to get pregnant.
in some instances, such as during natural disasters, it may in 82. B. Determining how well the kidneys filter wastes states the
greater pathology in a woman with potential breast carcinoma. purpose of a Creatinine clearance test.
61. B. The registered nurse cannot delegate the responsibility for 83. A. Acknowledging a feeling tone is the most therapeutic
assessment and evaluation of clients. The status of the client in response and provides a broad opening for the client to elaborate
restraint requires further assessment to determine if there are feelings.
additional causes for the behavior. 84. C. The behavior should be stopped. The first is to remind the
62. C. The client with chest pain may be having a myocardial staff that confidentiality maybe violated.
infarction, and immediate assessment and intervention is a 85. C. With a right-sided cerebrovascular accident the client would
priority. have left-sided hemiplegia or weakness. The client’s good side
63. B. Is correct because semen analysis requires that a freshly should be closest to the bed to facilitate the transfer.
masturbated specimen be obtained after a rest (abstinence) 86. D. Legos are small plastic building blocks that could easily slip
period of 48-72 hours. under the child’s cast and lead to a break in skin integrity and
64. C. Betamethasone, a form of cortisone, acts on the fetal lungs to even infection. Pencils, backscratchers, and marbles are some
produce surfactant. other narrow or small items that could easily slip under the
child’s cast and lead to a break in skin integrity and infection.
87. D. Oxytocin (Pitocin) is used to maintain uterine tone.

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88. B. The submission of reports about incidents that expose clients
to harm does not remove the obligation to report ongoing
behavior as long as the risk to the client continues.
89. C. The recommended dosage of tetracycline is 25-50mg/kg/day.
If the child weighs 20kg and the maximum dose is 50mg/kg, this
would indicate a total daily dose of 1000mg of tetracycline. In
this case, the child is being given this medication four times a
day. Therefore the maximum single dose that can be given is
250mg (1000 mg of tetracycline divided by four doses.)
90. C. An abnormality in the uterine muscle could reduce the
effectiveness of uterine contractions and lengthen the duration
of subsequent labors.
91. A. Personality disorders stem from a weak superego, implying a
lack of adequate controls.
92. C. The basal body temperature is the lowest body temperature of
a healthy person that is taken immediately after waking and
before getting out of bed. The BBT usually varies from 36.2 ºC
to 36.3ºC during menses and for about 5-7 days afterward.
About the time of ovulation, a slight drop in temperature may be
seen, after ovulation in concert with the increasing progesterone
levels of the early luteal phase, the BBT rises 0.2-0.4 ºC. This
elevation remains until 2-3 days before menstruation, or if
pregnancy has occurred.
93. A. This choice implies concern for client care and
self-improvement.
94. C. The first trimester is the period of organogenesis, that is, cell
differentiation into the various organs, tissues, and structures.
95. C. This response does not contradict the client’s perception, is
honest, and shows empathy.
96. D. Tension on round ligament occurs because of the erect
human posture and pressure exerted by the growing fetus.
97. D. The Good Samaritan Law does not impose a duty to stop at
the scene of an emergency outside of the scope of employment,
therefore nurses who do not stop are not liable for suit.
98. C. Although reducing environment stimuli and activity is
necessary for a woman with mild preeclampsia, she will most
probably have bathroom privileges.
99. B. A normal respiratory rate for a newborn is 30-40 breaths per
minute.
100. D. The behavior described is likely to be symptoms of delirium
tremens, or alcohol withdrawal (often unsuspected on a surgical
unit.)

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7. You also told Mr. Rojas to hold the cane
A. 1 Inches in front of the foot.
Medical Surgical Nursing Exam 1 B. 3 Inches at the lateral side of the foot.
C. 6 Inches at the lateral side of the foot.
D. 12 Inches at the lateral side of the foot.

SITUATION : Arthur, A registered nurse, witnessed an old 8. Mr. Rojas was discharged and 6 months later, he came back to
woman hit by a motorcycle while crossing a train railway. The old the emergency room of the hospital because he suffered a mild
woman fell at the railway. Arthur rushed at the scene. stroke. The right side of the brain was affected. At the
rehabilitative phase of your nursing care, you observe Mr. Rojas
1. As a registered nurse, Arthur knew that the first thing that he use a cane and you intervene if you see him
will do at the scene is A. Moves the cane when the right leg is moved.
A. Stay with the person, Encourage her to remain B. Leans on the cane when the right leg swings
still and Immobilize the leg while While waiting through.
for the ambulance. C. keeps the cane 6 Inches out to the side of the right
B. Leave the person for a few moments to call for foot.
help. D. Holds the cane on the right side.
C. Reduce the fracture manually.
D. Move the person to a safer place. SITUATION: Alfred, a 40 year old construction worker developed
cough, night sweats and fever. He was brought to the nursing unit
2. Arthur suspects a hip fracture when he noticed that the old for diagnostic studies. He told the nurse he did not receive a BCG
woman’s leg is vaccine during childhood
A. A. Lengthened, Abducted and Internally Rotated.
B. Shortened, Abducted and Externally Rotated. 9. The nurse performs a Mantoux Test. The nurse knows that
C. Shortened, Adducted and Internally Rotated. Mantoux Test is also known as
D. Shortened, Adducted and Externally Rotated.
A. PPD
3. The old woman complains of pain. John noticed that the knee is B. PDP
reddened, warm to touch and swollen. John interprets that this C. PDD
signs and symptoms are likely related to D. DPP
A. Infection
B. Thrombophlebitis 10. The nurse would inject the solution in what route?
C. Inflammation A. IM
D. Degenerative disease B. IV
C. ID
4. The old woman told John that she has osteoporosis; Arthur D. SC
knew that all of the following factors would contribute to
osteoporosis except 11. The nurse notes that a positive result for Alfred is
A. Hypothyroidism A. 5 mm wheal
B. End stage renal disease B. 5 mm Induration
C. Cushing’s Disease C. 10 mm Wheal
D. Taking Furosemide and Phenytoin. D. 10 mm Induration

5. Martha, The old woman was now Immobilized and brought to 12. The nurse told Alfred to come back after
the emergency room. The X-ray shows a fractured femur and A. a week
pelvis. The ER Nurse would carefully monitor Martha for which B. 48 hours
of the following sign and symptoms? C. 1 day
A. Tachycardia and Hypotension D. 4 days
B. Fever and Bradycardia
C. Bradycardia and Hypertension 13. Mang Alfred returns after the Mantoux Test. The test result
D. Fever and Hypertension read POSITIVE. What should be the nurse’s next action?
A. Call the Physician
SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of B. Notify the radiology dept. for CXR evaluation
OLFU Lagro is admitted due to pain in his weight bearing joint. C. Isolate the patient
The diagnosis was Osteoarthritis. D. Order for a sputum exam

6. As a nurse, you instructed Mr. Rojas how to use a cane. Mr. 14. Why is Mantoux test not routinely done in the Philippines?
Rojas has a weakness on his right leg due to self immobilization A. It requires a highly skilled nurse to perform a
and guarding. You plan to teach Mr. Rojas to hold the cane Mantoux test
A. On his left hand, because his right side is weak. B. The sputum culture is the gold standard of PTB
B. On his left hand, because of reciprocal motion. Diagnosis and it will definitively determine the
C. On his right hand, to support the right leg. extent of the cavitary lesions
D. On his right hand, because only his right leg is C. Chest X Ray Can diagnose the specific
weak. microorganism responsible for the lesions
D. Almost all Filipinos will test positive for Mantoux
Test
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15. Mang Alfred is now a new TB patient with an active disease.
What is his category according to the DOH? 23. The nurse plans to teach Michiel about colostomy irrigation.
A. I As the nurse prepares the materials needed, which of the following
B. II item indicates that the nurse needs further instruction?
C. III
D. IV
A. Plain NSS / Normal Saline
B. K-Y Jelly
16. How long is the duration of the maintenance phase of his
C. Tap water
treatment?
D. Irrigation sleeve
A. 2 months
B. 3 months
24. The nurse should insert the colostomy tube for irrigation at
C. 4 months
approximately
D. 5 months
A. 1-2 inches
B. 3-4 inches
17. Which of the following drugs is UNLIKELY given to Mang
C. 6-8 inches
Alfred during the maintenance phase?
D. 12-18 inches
A. Rifampicin
B. Isoniazid
25. The maximum height of irrigation solution for colostomy is
C. Ethambutol
A. 5 inches
D. Pyridoxine
B. 12 inches
C. 18 inches
18. According to the DOH, the most hazardous period for
D. 24 inches
development of clinical disease is during the first
A. 6-12 months after
26. Which of the following behavior of the client indicates the best
B. 3-6 months after
initial step in learning to care for his colostomy?
C. 1-2 months after
A. Ask to defer colostomy care to another individual
D. 2-4 weeks after
B. Promises he will begin to listen the next day
C. Agrees to look at the colostomy
19. This is the name of the program of the DOH to control TB in
D. States that colostomy care is the function of the
the country
nurse while he is in the hospital
A. DOTS
B. National Tuberculosis Control Program
27. While irrigating the client’s colostomy, Michiel suddenly
C. Short Coursed Chemotherapy
complains of severe cramping. Initially, the nurse would
D. Expanded Program for Immunization
A. Stop the irrigation by clamping the tube
B. Slow down the irrigation
20. Susceptibility for the disease [ TB ] is increased markedly in
C. Tell the client that cramping will subside and is
those with the following condition except
normal
A. 23 Year old athlete with diabetes insipidus
D. Notify the physician
B. 23 Year old athlete taking long term Decadron
therapy and anabolic steroids
28. The next day, the nurse will assess Michiel’s stoma. The nurse
C. 23 Year old athlete taking illegal drugs and
noticed that a prolapsed stoma is evident if she sees which of the
abusing substances
following?
D. Undernourished and Underweight individual who
A. A sunken and hidden stoma
undergone gastrectomy
B. A dusky and bluish stoma
C. A narrow and flattened stoma
21. Direct sputum examination and Chest X ray of TB
D. Protruding stoma with swollen appearance
symptomatic is in what level of prevention?
29. Michiel asked the nurse, what foods will help lessen the odor
A. Primary of his colostomy. The nurse best response would be
B. Secondary A. Eat eggs
C. Tertiary B. Eat cucumbers
D. Quarterly C. Eat beet greens and parsley
D. Eat broccoli and spinach
SITUATION: Michiel, A male patient diagnosed with colon
cancer was newly put in colostomy. 30. The nurse will start to teach Michiel about the techniques for
colostomy irrigation. Which of the following should be included
22. Michiel shows the BEST adaptation with the new colostomy if in the nurse’s teaching plan?
he shows which of the following? A. Use 500 ml to 1,000 ml NSS
B. Suspend the irrigant 45 cm above the stoma
C. Insert the cone 4 cm in the stoma
A. Look at the ostomy site
D. If cramping occurs, slow the irrigation
B. Participate with the nurse in his daily ostomy care
C. Ask for leaflets and contact numbers of ostomy
support groups
D. Talk about his ostomy openly to the nurse and
friends
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31. The nurse knew that the normal color of Michiel’s stoma 38. Wilma knew that James have an adequate respiratory
should be condition if she notices that

A. Brick Red A. James’ respiratory rate is 18

B. Gray B. James’ Oxygen saturation is 91%
C. Blue C. There are frank blood suction from the tube
D. Pale Pink D. There are moderate amount of tracheobronchial
secretions
SITUATION: James, A 27 basketball player sustained inhalation
burn that required him to have tracheostomy due to massive upper 39. Wilma knew that the maximum time when suctioning James is
airway edema.
A. 10 seconds
32. Wilma, His sister and a nurse is suctioning the tracheostomy
B. 20 seconds
tube of James. Which of the following, if made by Wilma
C. 30 seconds
indicates that she is committing an error?
D. 45 seconds
A. Hyperventilating James with 100% oxygen before
and after suctioning
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal
B. Instilling 3 to 5 ml normal saline to loosen up
was diagnosed with Acute Close Angle Glaucoma. He is being
secretion
seen by Nurse Jet.
C. Applying suction during catheter withdrawal
D. Suction the client every hour
40. What specific manifestation would nurse Jet see in Acute close
angle glaucoma that she would not see in an open angle
33. What size of suction catheter would Wilma use for James, who
glaucoma?
is 6 feet 5 inches in height and weighing approximately 145 lbs?
A. Fr. 5
B. Fr. 10 A. Loss of peripheral vision
C. Fr. 12 B. Irreversible vision loss
D. Fr. 18 C. There is an increase in IOP
D. Pain
34. Wilma is using a portable suction unit at home, What is the E. \
amount of suction required by James using this unit? 41. Nurse jet knew that Acute close angle glaucoma is caused by
A. 2-5 mmHg
B. 5-10 mmHg A. Sudden blockage of the anterior angle by the base
C. 10-15 mmHg of the iris
D. 20-25 mmHg B. Obstruction in trabecular meshwork
C. Gradual increase of IOP
35. If a Wall unit is used, What should be the suctioning pressure D. An abrupt rise in IOP from 8 to 15 mmHg
required by James?
42. Nurse jet performed a TONOMETRY test to Mr. Batumbakal.
A. 50-95 mmHg What does this test measures
B. 95-110 mmHg
C. 100-120 mmHg A. It measures the peripheral vision remaining on the
D. 155-175 mmHg client
B. Measures the Intra Ocular Pressure
36. Wilma was shocked to see that the Tracheostomy was C. Measures the Client’s Visual Acuity
dislodged. Both the inner and outer cannulas was removed and left D. Determines the Tone of the eye in response to the
hanging on James’ neck. What are the 2 equipment’s at james’ sudden increase in IOP.
bedside that could help Wilma deal with this situation?
43. The Nurse notices that Mr. Batumbakal cannot anymore
A. New set of tracheostomy tubes and Oxygen tank determine RED from BLUE. The nurse knew that which part of
B. Theophylline and Epinephrine the eye is affected by this change?
C. Obturator and Kelly clamp
D. Sterile saline dressing A. IRIS
B. PUPIL
37. Which of the following method if used by Wilma will best C. RODS [RETINA]
assure that the tracheostomy ties are not too tightly placed? D. CONES [RETINA]

A. Wilma places 2 fingers between the tie and neck 44. Nurse Jet knows that Aqueous Humor is produce where?
B. The tracheotomy can be pulled slightly away from
the neck A. In the sub arachnoid space of the meninges
C. James’ neck veins are not engorged B. In the Lateral ventricles
D. Wilma measures the tie from the nose to the tip of C. In the Choroids
the earlobe and to the xiphoid process. D. In the Ciliary Body

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45. Nurse Jet knows that the normal IOP is 53. Ear drops are prescribed to an infant, The most appropriate
A. 8-21 mmHg method to administer the ear drops is
B. 2-7 mmHg
C. 31-35 mmHg
A. Pull the pinna up and back and direct the solution
D. 15-30 mmHg
towards the eardrum
B. Pull the pinna down and back and direct the
46. Nurse Jet wants to measure Mr. Batumbakal’s CN II Function.
solution onto the wall of the canal
What test would Nurse Jet implement to measure CN II’s Acuity?
C. Pull the pinna down and back and direct the
A. Slit lamp
solution towards the eardrum
B. Snellen’s Chart
D. Pull the pinna up and back and direct the solution
C. Wood’s light
onto the wall of the canal
D. Gonioscopy
54. Nurse Jenny is developing a plan of care for a patient with
47. The Doctor orders pilocarpine. Nurse jet knows that the action
Menieres disease. What is the priority nursing intervention in the
of this drug is to
plan of care for this particular patient?
A. Contract the Ciliary muscle
A. Air, Breathing, Circulation
B. Relax the Ciliary muscle
B. Love and Belongingness
C. Dilate the pupils
C. Food, Diet and Nutrition
D. Decrease production of Aqueous Humor
D. Safety
48. The doctor orders timolol [timoptic]. Nurse jet knows that the
55. After mastoidectomy, Nurse John should be aware that the
action of this drug is
cranial nerve that is usually damage after this procedure is
A. CN I
A. Reduce production of CSF B. CN II
B. Reduce production of Aquesous Humor C. CN VII
C. Constrict the pupil D. CN VI
D. Relaxes the Ciliary muscle
49. When caring for Mr. Batumbakal, Jet teaches the client to 56. The physician orders the following for the client with
avoid Menieres disease. Which of the following should the nurse
question?
A. Watching large screen TVs
B. Bending at the waist A. Dipenhydramine [Benadryl]
C. Reading books B. Atropine sulfate
D. Going out in the sun C. Out of bed activities and ambulation
50. Mr. Batumbakal has undergone eye angiography using an D. Diazepam [Valium]
Intravenous dye and fluoroscopy. What activity is contraindicated
immediately after procedure? 57. Nurse Anna is giving dietary instruction to a client with
Menieres disease. Which statement if made by the client indicates
that the teaching has been successful?
A. Reading newsprint
A. I will try to eat foods that are low in sodium and
B. Lying down
limit my fluid intake
C. Watching TV
B. I must drink atleast 3,000 ml of fluids per day
D. Listening to the music
C. I will try to follow a 50% carbohydrate, 30% fat
51. If Mr. Batumbakal is receiving pilocarpine, what drug should
and 20% protein diet
always be available in any case systemic toxicity occurs?
D. I will not eat turnips, red meat and raddish

A. Atropine Sulfate 58. Peachy was rushed by his father, Steven into the hospital
B. Pindolol [Visken] admission. Peachy is complaining of something buzzing into her
C. Naloxone Hydrochloride [Narcan] ears. Nurse Joemar assessed peachy and found out It was an insect.
D. Mesoridazine Besylate [Serentil] What should be the first thing that Nurse Joemar should try to
SITUATION : Wide knowledge about the human ear, it’s parts remove the insect out from peachy’s ear?
and it’s functions will help a nurse assess and analyze changes in A. Use a flashlight to coax the insect out of peachy’s
the adult client’s health. ear
B. Instill an antibiotic ear drops
52. Nurse Anna is doing a caloric testing to his patient, Aida, a 55 C. Irrigate the ear
year old university professor who recently went into coma after D. Pick out the insect using a sterile clean forceps
being mauled by her disgruntled 3rd year nursing students whom
she gave a failing mark. After instilling a warm water in the ear, 59. Following an ear surgery, which statement if heard by Nurse
Anna noticed a rotary nystagmus towards the irrigated ear. What Oca from the patient indicates a correct understanding of the post
does this means? operative instructions?
A. Indicates a CN VIII Dysfunction A. Activities are resumed within 5 days
B. Abnormal B. I will make sure that I will clean my hair and face
C. Normal to prevent infection
D. Inconclusive C. I will use straw for drinking
D. I should avoid air travel for a while
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60. Nurse Oca will do a caloric testing to a client who sustained a 65. Approximately how much fluid is lost in acute weight loss
blunt injury in the head. He instilled a cold water in the client’s of .5kg?
right ear and he noticed that nystagmus occurred towards the left
ear. What does this finding indicates?
A. 50 ml
B. 750 ml
A. Indicating a Cranial Nerve VIII Dysfunction C. 500 ml
B. The test should be repeated again because the D. 75 ml
result is vague
C. This is Grossly abnormal and should be reported 66. Postural Hypotension is
to the neurosurgeon
D. This indicates an intact and working vestibular
A. A drop in systolic pressure less than 10 mmHg
branch of CN VIII
when patient changes position from lying to
sitting.
61. A client with Cataract is about to undergo surgery. Nurse Oca
B. A drop in systolic pressure greater than 10 mmHg
is preparing plan of care. Which of the following nursing
when patient changes position from lying to
diagnosis is most appropriate to address the long term need of this
sitting
type of patient?
C. A drop in diastolic pressure less than 10 mmHg
when patient changes position from lying to
A. Anxiety R/T to the operation and its outcome sitting
B. Sensory perceptual alteration R/T Lens extraction D. A drop in diastolic pressure greater than 10
and replacement mmHg when patient changes position from lying
C. Knowledge deficit R/T the pre operative and post to sitting
operative self care
D. Body Image disturbance R/T the eye packing after 67. Which of the following measures will not help correct the
surgery patient’s condition

62. Nurse Joseph is performing a WEBERS TEST. He placed the

A. Offer large amount of oral fluid intake to replace
tuning fork in the patients forehead after tapping it onto his knee.
fluid lost
The client states that the fork is louder in the LEFT EAR. Which
B. Give enteral or parenteral fluid
of the following is a correct conclusion for nurse Josph to make?
C. Frequent oral care
D. Give small volumes of fluid at frequent interval
A. He might have a sensory hearing loss in the left
ear 68. After nursing intervention, you will expect the patient to have
B. Conductive hearing loss is possible in the right ear
C. He might have a sensory hearing loss in the right
1. Maintain body temperature at 36.5 C
hear, and/or a conductive hearing loss in the left
2. Exhibit return of BP and Pulse to normal
ear.
3. Manifest normal skin turgor of skin and tongue
D. He might have a conductive hearing loss in the
4. Drinks fluids as prescribed
right ear, and/or a sensory hearing loss in the left
A. 1,3
ear.
B. 2,4
C. 1,3,4
63. Aling myrna has Menieres disease. What typical dietary
D. 2,3,4
prescription would nurse Oca expect the doctor to prescribe?
SITUATION: A 65 year old woman was admitted for Parkinson’s
A. A low sodium , high fluid intake Disease. The charge nurse is going to make an initial assessment.
B. A high calorie, high protein dietary intake
C. low fat, low sodium and high calorie intake 69. Which of the following is a characteristic of a patient with
D. low sodium and restricted fluid intake advanced Parkinson’s disease?

SITUATION : [ From DEC 1991 NLE ] A 45 year old male

A. Disturbed vision
construction worker was admitted to a tertiary hospital for
B. Forgetfulness
incessant vomiting. Assessment disclosed: weak rapid pulse, acute
C. Mask like facial expression
weight loss of .5kg, furrows in his tongue, slow flattening of the
D. Muscle atrophy
skin was noted when the nurse released her pinch.
70. The onset of Parkinson’s disease is between 50-60 years old.
Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also
This disorder is caused by
complains for postural hypotension. There was no infection.

A. Injurious chemical substances

64. Which of the following is the appropriate nursing diagnosis? B. Hereditary factors
A. Fluid volume deficit R/T furrow tongue C. Death of brain cells due to old age
B. Fluid volume deficit R/T uncontrolled vomiting D. Impairment of dopamine producing cells in the
C. Dehydration R/T subnormal body temperature brain\
D. Dehydration R/T incessant vomiting

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71. The patient was prescribed with levodopa. What is the action SITUATION : Knowledge of the drug PROPANTHELINE
of this drug? BROMIDE [Probanthine] Is necessary in treatment of various
A. Increase dopamine availability disorders.
B. Activates dopaminergic receptors in the basal
ganglia 79. What is the action of this drug?
C. Decrease acetylcholine availability
D. Release dopamine and other catecholamine from
A. Increases glandular secretion for clients affected
neurological storage sites
with cystic fibrosis
B. Dissolve blockage of the urinary tract due to
72. You are discussing with the dietician what food to avoid with
obstruction of cystine stones
patients taking levodopa?
C. Reduces secretion of the glandular organ of the
A. Vitamin C rich food
body
B. Vitamin E rich food
D. Stimulate peristalsis for treatment of constipation
C. Thiamine rich food
and obstruction
D. Vitamin B6 rich food
80. What should the nurse caution the client when using this
73. One day, the patient complained of difficulty in walking. Your
medication
response would be

A. Avoid hazardous activities like driving, operating

A. You will need a cane for support
machineries etc.
B. Walk erect with eyes on horizon
B. Take the drug on empty stomach
C. I’ll get you a wheelchair
C. Take with a full glass of water in treatment of
D. Don’t force yourself to walk
Ulcerative colitis
D. I must take double dose if I missed the previous
SITUATION: Mr. Dela Isla, a client with early Dementia exhibits
dose
thought process disturbances.
81. Which of the following drugs are not compatible when taking
74. The nurse will assess a loss of ability in which of the following
Probanthine?
areas?
A. Caffeine
A. Balance
B. NSAID
B. Judgment
C. Acetaminophen
C. Speech
D. Alcohol
D. Endurance
82. What should the nurse tell clients when taking Probanthine?
75. Mr. Dela Isla said he cannot comprehend what the nurse was
A. Avoid hot weathers to prevent heat strokes
saying. He suffers from:
B. Never swim on a chlorinated pool
C. Make sure you limit your fluid intake to 1L a day
A. Insomnia D. Avoid cold weathers to prevent hypothermia
B. Aphraxia
C. Agnosia 83. Which of the following disease would Probanthine exert the
D. Aphasia much needed action for control or treatment of the disorder?
A. Urinary retention
76. The nurse is aware that in communicating with an elderly B. Peptic Ulcer Disease
client, the nurse will C. Ulcerative Colitis
A. Lean and shout at the ear of the client D. Glaucoma
B. Open mouth wide while talking to the client
C. Use a low-pitched voice SITUATION : Mr. Franco, 70 years old, suddenly could not lift
D. Use a medium-pitched voice his spoons nor speak at breakfast. He was rushed to the hospital
unconscious. His diagnosis was CVA.
77. As the nurse talks to the daughter of Mr. Dela Isla, which of
the following statement of the daughter will require the nurse to 84. Which of the following is the most important assessment
give further teaching? during the acute stage of an unconscious patient like Mr. Franco?
A. I know the hallucinations are parts of the disease A. Level of awareness and response to pain
B. I told her she is wrong and I explained to her what B. Papillary reflexes and response to sensory stimuli
is right C. Coherence and sense of hearing
C. I help her do some tasks he cannot do for himself D. Patency of airway and adequacy of respiration
D. Ill turn off the TV when we go to another room
85. Considering Mr. Franco’s conditions, which of the following
78. Which of the following is most important discharge teaching is most important to include in preparing Franco’s bedside
for Mr. Dela Isla equipment?
A. Hand bell and extra bed linen
A. Emergency Numbers B. Sandbag and trochanter rolls
B. Drug Compliance C. Footboard and splint
C. Relaxation technique D. Suction machine and gloves
D. Dietary prescription
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86. What is the rationale for giving Mr. Franco frequent mouth 93. Post op care for appendectomy include the following except
care?
A. Early ambulation
A. He will be thirsty considering that he is doesn’t B. Diet as tolerated after fully conscious
drink enough fluids C. Nasogastric tube connect to suction
B. To remove dried blood when tongue is bitten D. Deep breathing and leg exercise
during a seizure
C. The tactile stimulation during mouth care will 94. Peritonitis may occur in ruptured appendix and may cause
hasten return to consciousness serious problems which are
D. Mouth breathing is used by comatose patient and
it’ll cause oral mucosa dying and cracking.
1. Hypovolemia, electrolyte imbalance
2. Elevated temperature, weakness and diaphoresis
87. One of the complications of prolonged bed rest is decubitus
3. Nausea and vomiting, rigidity of the abdominal
ulcer. Which of the following can best prevent its occurrence?
wall
4. Pallor and eventually shock
A. Massage reddened areas with lotion or oils
B. Turn frequently every 2 hours A. 1 and 2
C. Use special water mattress B. 2 and 3
D. Keep skin clean and dry C. 1,2,3
D. All of the above
88. If Mr. Franco’s Right side is weak, What should be the most
accurate analysis by the nurse? 95. If after surgery the patient’s abdomen becomes distended and
no bowel sounds appreciated, what would be the most suspected
complication?
A. Expressive aphasia is prominent on clients with
right sided weakness
B. The affected lobe in the patient is the Right lobe A. Intussusception
C. The client will have problems in judging distance B. Paralytic Ileus
and proprioception C. Hemorrhage
D. Clients orientation to time and space will be much D. Ruptured colon
affected
96. NGT was connected to suction. In caring for the patient with
SITUATION : a 20 year old college student was rushed to the ER NGT, the nurse must
of PGH after he fainted during their ROTC drill. Complained of
severe right iliac pain. Upon palpation of his abdomen, Ernie
A. Irrigate the tube with saline as ordered
jerks even on slight pressure. Blood test was ordered. Diagnosis is
B. Use sterile technique in irrigating the tube
acute appendicitis.
C. advance the tube every hour to avoid kinks
D. Offer some ice chips to wet lips
89. Which result of the lab test will be significant to the diagnosis?
A. RBC : 4.5 TO 5 Million / cu. mm.
97. When do you think the NGT tube be removed?
B. Hgb : 13 to 14 gm/dl.
C. Platelets : 250,000 to 500,000 cu.mm.
D. WBC : 12,000 to 13,000/cu.mm A. When patient requests for it
B. Abdomen is soft and patient asks for water
90. Stat appendectomy was indicated. Pre op care would include C. Abdomen is soft and flatus has been expelled
all of the following except? D. B and C only
A. Consent signed by the father Situation: Amanda is suffering from chronic arteriosclerosis Brain
B. Enema STAT syndrome she fell while getting out of the bed one morning and
C. Skin prep of the area including the pubis was brought to the hospital, and she was diagnosed to have
D. Remove the jewelries cerebrovascular thrombosis thus transferred to a nursing home.

91. Pre-anesthetic med of Demerol and atrophine sulfate were 98. What do you call a STROKE that manifests a bizarre
ordered to : behavior?
A. Allay anxiety and apprehension
B. Reduce pain A. Inorganic Stroke
C. Prevent vomiting B. Inorganic Psychoses
D. Relax abdominal muscle C. Organic Stroke
D. Organic Psychoses
92. Common anesthesia for appendectomy is
99. The main difference between chronic and organic brain
A. Spinal syndrome is that the former
B. General A. Occurs suddenly and reversible
C. Caudal B. Is progressive and reversible
D. Hypnosis C. tends to be progressive and irreversible
D. Occurs suddenly and irreversible

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100. Which behavior results from organic psychoses? 62. C. He might have a sensory hearing loss in the right hear, and/or a
conductive hearing loss in the left ear.
63. D. low sodium and restricted fluid intake
A. Memory deficit 64. B. Fluid volume deficit R/T uncontrolled vomiting
B. Disorientation 65. C. 500 ml
C. Impaired Judgement 66. B. A drop in systolic pressure greater than 10 mmHg when patient
D. Inappropriate affect changes position from lying to sitting
Answers 67. A. Offer large amount of oral fluid intake to replace fluid lost
68. D. 2,3,4
69. C. Mask like facial expression
1. D. Move the person to a safer place.
70. D. Impairment of dopamine producing cells in the brain
2. D. Shortened, Adducted and Externally Rotated.
71. A. Increase dopamine availability
3. C. Inflammation
72. D. Vitamin B6 rich food
4. A. Hypothyroidism
73. A. You will need a cane for support
5. A. Tachycardia and Hypotension
74. B. Judgment
6. B. On his left hand, because of reciprocal motion.
75. D. Aphasia
7. c. 6 Inches at the lateral side of the foot.
76. D. Use a medium-pitched voice
8. A. Moves the cane when the right leg is moved.
77. B. I told her she is wrong and I explained to her what is right
9. A. PPD
78. B. Drug Compliance
10. C. ID
79. C. Reduces secretion of the glandular organ of the body
11. D. 10 mm Induration
80. A. Avoid hazardous activities like driving, operating machineries
12. B. 48 hours
etc.
13. A. Call the Physician
81. D. Alcohol
14. D. Almost all Filipinos will test positive for Mantoux Test
82. A. Avoid hot weathers to prevent heat strokes
15. A. I
83. B. Peptic Ulcer Disease
16. C. 4 months
84. D. Patency of airway and adequacy of respiration
17. C. Ethambutol
85. D. Suction machine and gloves
18. A. 6-12 months after
86. D. Mouth breathing is used by comatose patient and it’ll cause oral
19. B. National Tuberculosis Control Program
mucosa dying and cracking.
20. A. 23 Year old athlete with diabetes insipidus
87. B. Turn frequently every 2 hours
21. B. Secondary
88. A. Expressive aphasia is prominent on clients with right sided
22. B. Participate with the nurse in his daily ostomy care
weakness
23. A. Plain NSS / Normal Saline
89. D. WBC : 12,000 to 13,000/cu.mm
24. B. 3-4 inches
90. B. Enema STAT
25. C. 18 inches
91. A. Allay anxiety and apprehension
26. C. Agrees to look at the colostomy
92. A. Spinal
27. A. Stop the irrigation by clamping the tube
93. B. Diet as tolerated after fully conscious
28. D. Protruding stoma with swollen appearance
94. D. All of the above
29. C. Eat beet greens and parsley
95. B. Paralytic Ileus
30. B. Suspend the irrigant 45 cm above the stoma
96. A. Irrigate the tube with saline as ordered
31. A. Brick Red
97. C. Abdomen is soft and flatus has been expelled
32. D. Suction the client every hour
98. D. Organic Psychoses
33. D. Fr. 18
99. C. tends to be progressive and irreversible
34. C. 10-15 mmHg
100. B. Disorientation
35. C. 100-120 mmHg
36. C. Obturator and Kelly clamp
37. A. Wilma places 2 fingers between the tie and neck
38. A. James’ respiratory rate is 18
39. A. 10 seconds
Medical Surgical Nursing
40. D. Pain
41. A. Sudden blockage of the anterior angle by the base of the iris Exam 2
42. B. Measures the Intra Ocular Pressure
43. D. CONES [RETINA]
44. D. In the Ciliary Body 1. After a cerebrovascular accident, a 75 yr old client is admitted
45. A. 8-21 mmHg to the health care facility. The client has left-sided weakness and
46. B. Snellen’s Chart an absent gag reflex. He’s incontinent and has a tarry stool. His
47. A. Contract the Ciliary muscle blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g/dl.
48. B. Reduce production of Aquesous Humor Which of the following is a priority for this client?
49. B. Bending at the waist A. checking stools for occult blood
50. A. Reading newsprint B. performing range-of-motion exercises to the left
51. A. Atropine Sulfate
52. C. Normal
side
53. B. Pull the pinna down and back and direct the solution onto the C. keeping skin clean and dry
wall of the canal D. elevating the head of the bed to 30 degrees
54. D. Safety
55. C. CN VII 2. The nurse is caring for a client with a colostomy. The client tells
56. C. Out of bed activities and ambulation the nurse that he makes small pin holes in the drainage bag to help
57. A. I will try to eat foods that are low in sodium and limit my fluid relieve gas. The nurse should teach him that this action:
intake A. destroys the odor-proof seal
58. A. Use a flashlight to coax the insect out of peachy’s ear
59. D. I should avoid air travel for a while
B. wont affect the colostomy system
60. D. This indicates an intact and working vestibular branch of CN C. is appropriate for relieving the gas in a colostomy
VIII system
61. B. Sensory perceptual alteration R/T Lens extraction and D. destroys the moisture barrier seal
replacement
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3. When assessing the client with celiac disease, the nurse can A. onset to be at 2 p.m. and its peak at 3 p.m.
expect to find which of the following? B. onset to be at 2:15 p.m. and its peak at 3 p.m.
A. steatorrhea C. onset to be at 2:30 p.m. and its peak at 4 p.m.
B. jaundiced sclerae D. onset to be at 4 p.m. and its peak at 6 p.m.
C. clay-colored stools
D. widened pulse pressure 10. A client with a head injury is being monitored for increased
intracranial pressure (ICP). His blood pressure is 90/60 mmHG
4. A client is hospitalized with a diagnosis of chronic and the ICP is 18 mmHg; therefore his cerebral perfusion pressure
glomerulonephritis. The client mentions that she likes salty foods. (CPP) is:
The nurse should warn her to avoid foods containing sodium A. 52 mm Hg
because: B. 88 mm Hg
A. reducing sodium promotes urea nitrogen excretion C. 48 mm Hg
B. reducing sodium improves her glomerular D. 68 mm Hg
filtration rate
C. reducing sodium increases potassium absorption 11. A 52 yr-old female tells the nurse that she has found a painless
D. reducing sodium decreases edema lump in her right breast during her monthly self-examination.
Which assessment finding would strongly suggest that this client’s
5. The nurse is caring for a client with a cerebral injury that lump is cancerous?
impaired his speech and hearing. Most likely, the client has
experienced damage to the:
A. eversion of the right nipple and a mobile mass
A. frontal lobe
B. nonmobile mass with irregular edges
B. parietal lobe
C. mobile mass that is oft and easily delineated
C. occipital lobe
D. nonpalpable right axillary lymph nodes
D. temporal lobe
12. A Client is scheduled to have a descending colostomy. He’s
6. The nurse is assessing a postcraniotomy client and finds the
very anxious and has many questions regarding the surgical
urine output from a catheter is 1500 ml for the 1st hour and the
procedure, care of stoma, and lifestyle changes. It would be most
same for the 2nd hour. The nurse should suspect:
appropriate for the nurse to make a referral to which member of
A. Cushing’s syndrome
the health care team?
B. Diabetes mellitus
A. Social worker
C. Adrenal crisis
B. registered dietician
D. Diabetes insipidus
C. occupational therapist
D. enterostomal nurse therapist
7. The nurse is providing postprocedure care for a client who
underwent percutaneous lithotripsy. In this procedure, an
13. Ottorrhea and rhinorrhea are most commonly seen with which
ultrasonic probe inserted through a nephrostomy tube into the
type of skull fracture?
renal pelvis generates ultra-high-frequency sound waves to shatter
A. basilar
renal calculi. The nurse should instruct the client to:
B. temporal
A. limit oral fluid intake for 1 to 2 weeks
C. occipital
B. report the presence of fine, sandlike particles
D. Parietal
through the nephrostomy tube.
C. Notify the physician about cloudy or foul smelling
14. A male client should be taught about testicular examinations:
urine
D. Report bright pink urine within 24 hours after the A. when sexual activity starts
procedure B. after age 60
C. after age 40
8. A client with a serum glucose level of 618 mg/dl is admitted to D. before age 20
the facility. He’s awake and oriented, has hot dry skin, and has the
following vital signs: temperature of 100.6º F (38.1º C), heart rate 15. Before weaning a client from a ventilator, which assessment
of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based parameter is most important for the nurse to review?
on these assessment findings, which nursing diagnosis takes the A. fluid intake for the last 24 hours
highest priority? B. baseline arterial blood gas (ABG) levels
A. deficient fluid volume related to osmotic diuresis C. prior outcomes of weaning
B. decreased cardiac output related to elevated heart D. electrocardiogram (ECG) results
rate
C. imbalanced nutrition: Less than body 16. The nurse is speaking to a group of women about early
requirements related to insulin deficiency detection of breast cancer. The average age of the women in the
D. ineffective thermoregulation related to group is 47. Following the American Cancer Society (ACS)
dehydration guidelines, the nurse should recommend that the women:
A. perform breast self-examination annually
9. Capillary glucose monitoring is being performed every 4 hours B. have a mammogram annually
for a client diagnosed with diabetic ketoacidosis. Insulin is C. have a hormonal receptor assay annually
administered using a scale of regular insulin according to glucose D. have a physician conduct a clinical evaluation
results. At 2 p.m., the client has a capillary glucose level of 250 every 2 years
mg/dl for which he receives 8 U of regular insulin. The
nurse should expect the dose’s:
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17. When caring for a client with esophageal varices, the nurse 23. Which assessment finding indicates dehydration?
knows that bleeding in this disorder usually stems from:
A. Tenting of chest skin when pinched.
A. esophageal perforation B. Rapid filling of hand veins.
B. pulmonary hypertension C. A pulse that isn’t easily obliterated.
C. portal hypertension D. Neck vein distention
D. peptic ulcers
24. The nurse is teaching a client with a history of atherosclerosis.
18. A 49-yer-old client was admitted for surgical repair of a To decrease the risk of atherosclerosis, the nurse should encourage
Colles’ fracture. An external fixator was placed during surgery. the client to:
The surgeon explains that this method of repair:
A. Avoid focusing on his weight.
A. has very low complication rate B. Increase his activity level.
B. maintains reduction and overall hand function C. Follow a regular diet.
C. is less bothersome than a cast D. Continue leading a high-stress lifestyle.
D. is best for older people
25. For a client newly diagnosed with radiationinduced
19. A client is hospitalized with a diagnosis of chronic renal thrombocytopenia, the nurse should include which intervention in
failure. An arteriovenous fistula was created in his left arm for the plan of care?
hemodialysis. When preparing the client for discharge, the nurse
should reinforce which dietary instruction?
A. Administer aspirin if the temperature exceeds
A. “Be sure to eat meat at every meal.”
38.8º C.
B. “Monitor your fruit intake and eat plenty of
B. Inspect the skin for petechiae once every shift.
bananas.”
C. Provide for frequent periods of rest.
C. “Restrict your salt intake.”
D. Place the client in strict isolation.
D. “Drink plenty of fluids.”
26. A client is chronically short of breath and yet has normal lung
20. The nurse is caring for a client who has just had a modified
ventilation, clear lungs, and an arterial oxygen saturation (SaO2)
radical mastectomy with immediate reconstruction. She’s in her
96% or better. The client most likely has:
30s and has tow children. Although she’s worried about her future,
she seems to be adjusting well to her diagnosis. What should the
nurse do to support A. poor peripheral perfusion
her coping? B. a possible Hematologic problem
A. Tell the client’s spouse or partner to be supportive C. a psychosomatic disorder
while she recovers. D. left-sided heart failure
B. Encourage the client to proceed with the next 27. For a client in addisonian crisis, it would be very risky for a
phase of treatment. nurse to administer:
C. Recommend that the client remain cheerful for the
sake of her children. A. potassium chloride
D. Refer the client to the American Cancer Society’s B. normal saline solution
Reach for Recovery program or another support C. hydrocortisone
program. D. Fludrocortisone
21. A 21 year-old male has been seen in the clinic for a thickening 28. The nurse is reviewing the laboratory report of a client who
in his right testicle. The physician ordered a human chorionic underwent a bone marrow biopsy. The finding that would most
gonadotropin (HCG) level. The nurse’s explanation to the client strongly support a diagnosis of acute leukemia is the existence of a
should include the fact that: large number of immature:
A. The test will evaluate prostatic function. A. lymphocytes
B. The test was ordered to identify the site of a B. thrombocytes
possible infection. C. reticulocytes
C. The test was ordered because clients who have D. Leukocytes
testicular cancer has elevated levels of HCG.
D. The test was ordered to evaluate the testosterone 29. The nurse is performing wound care on a foot ulcer in a client
level. with type 1 diabetes mellitus. Which technique demonstrates
surgical asepsis?
22. A client is receiving captopril (Capoten) for heart failure. The A. Putting on sterile gloves then opening a container
nurse should notify the physician that the medication therapy is of sterile saline.
ineffective if an assessment reveals: B. Cleaning the wound with a circular motion,
A. A skin rash. moving from outer circles toward the center.
B. Peripheral edema. C. Changing the sterile field after sterile water is
C. A dry cough. spilled on it.
D. Postural hypotension. D. Placing a sterile dressing ½” (1.3 cm) from the
edge of the sterile field.

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30. A client with a forceful, pounding heartbeat is diagnosed with 36. A client comes to the emergency department with chest pain,
mitral valve prolapse. This client should avoid which of the dyspnea, and an irregular heartbeat. An electrocardiogram shows a
following? heart rate of 110 beats/minute (sinus tachycardia) with frequent
premature ventricular contractions. Shortly after admission, the
client has ventricular tachycardia and becomes unresponsive.
A. high volumes of fluid intake
After successful resuscitation, the client is taken to the intensive
B. aerobic exercise programs
care unit. Which nursing diagnosis is appropriate at this time?
C. caffeine-containing products
D. foods rich in protein
A. Deficient knowledge related to interventions used
31. A client with a history of hypertension is diagnosed with to treat acute illness
primary hyperaldosteronism. This diagnosis indicates that the B. Impaired physical mobility related to complete
client’s hypertension is caused by excessive hormone secretion bed rest
from which organ? C. Social isolation related to restricted visiting hours
A. adrenal cortex in the intensive care unit
B. pancreas D. Anxiety related to the threat of death
C. adrenal medulla
D. Parathyroid 37. A client is admitted to the health care facility with active
tuberculosis. The nurse should include which intervention in the
32. A client has a medical history of rheumatic fever, type 1 plan of care?
(insulin dependent) diabetes mellitus, hypertension, pernicious
anemia, and appendectomy. She’s admitted to the hospital and
A. Putting on a mask when entering the client’s
undergoes mitral valve replacement surgery. After discharge, the
room.
client is scheduled for a tooth extraction. Which history finding is
B. Instructing the client to wear a mask at all times
a major risk factor for infective endocarditis?
C. Wearing a gown and gloves when providing direct
A. appendectomy
care
B. pernicious anemia
D. Keeping the door to the client’s room open to
C. diabetes mellitus
observe the client
D. valve replacement
38. The nurse is caring for a client who underwent a subtotal
33. A 62 yr-old client diagnosed with pyelonephritis and possible
gastrectomy 24 hours earlier. The client has a nasogastric (NG)
septicemia has had five urinary tract infections over the past two
tube. The nurse should:
years. She’s fatigued from lack of sleep; urinates frequently, even
A. Apply suction to the NG tube every hour.
during the night; and has lost weight recently. Test reveal the
B. Clamp the NG tube if the client complains of
following: sodium level 152 mEq/L, osmolarity 340 mOsm/L,
nausea.
glucose level 125 mg/dl, and potassium level 3.8 mEq/L. which of
C. Irrigate the NG tube gently with normal saline
the following nursing diagnoses is most appropriate for this client?
solution.
A. Deficient fluid volume related to inability to D. Reposition the NG tube if pulled out.
conserve water
B. Imbalanced nutrition: less than body requirements 39. Which statement about fluid replacement is accurate for a
related to hypermetabolic state client with hyperosmolar hyperglycemic nonketotic syndrome
C. Deficient fluid volume related to osmotic diuresis (HHNS)?
induced by hypernatremia A. administer 2 to 3 L of IV fluid rapidly
D. Imbalanced nutrition: less than body requirements B. administer 6 L of IV fluid over the first 24 hours
related to catabolic effects of insulin deficiency C. administer a dextrose solution containing normal
saline solution
34. A 20 yr-old woman has just been diagnosed with Crohn’s D. administer IV fluid slowly to prevent circulatory
disease. She has lost 10 lb (4.5 kg) and has cramps and occasional overload and collapse
diarrhea. The nurse should include which of the following when
doing a nutritional assessment? 40. Which of the following is an adverse reaction to glipizide
A. Let the client eat as desired during the (Glucotrol)?
hospitalization. A. headache
B. Weight the client daily. B. constipation
C. Ask the client to list what she eats during a typical C. hypotension
day. D. Photosensitivity
D. Place the client on I & O status and draw blood
for electrolyte levels. 41. The nurse is caring for four clients on a stepdown intensive
care unit. The client at the highest risk for developing nosocomial
35. When instructions should be included in the discharge pneumonia is the one who:
teaching plan for a client after thyroidectomy for Grave’s disease?
A. Keep an accurate record of intake and output.
A. has a respiratory infection
B. Use nasal desmopressin acetate DDAVP).
B. is intubated and on a ventilator
C. Be sure to get regulate follow-up care.
C. has pleural chest tubes
D. Be sure to exercise to improve cardiovascular
D. is receiving feedings through a jejunostomy tube
fitness.

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42. The nurse is teaching a client with chronic bronchitis about 48. A visiting nurse is performing home assessment for a 59-yr old
breathing exercises. Which of the following should the nurse man recently discharged after hip replacement surgery. Which
include in the teaching? home assessment finding warrants health promotion teaching from
the nurse?
A. Make inhalation longer than exhalation.
B. Exhale through an open mouth. A. A bathroom with grab bars for the tub and toilet
C. Use diaphragmatic breathing. B. Items stored in the kitchen so that reaching up and
D. Use chest breathing. bending down aren’t necessary
C. Many small, unsecured area rugs
43. A client is admitted to the hospital with an exacerbation of her D. Sufficient stairwell lighting, with switches to the
chronic systemic lupus erythematosus (SLE). She gets angry when top and bottom of the stairs
her call bell isn’t answered immediately. The most appropriate
response to her would be: 49. A client with autoimmune thrombocytopenia and a platelet
count of 800/uL develops epistaxis and melena. Treatment with
corticosteroids and immunoglobulins has been unsuccessful, and
A. “You seem angry. Would you like to talk about
the physician recommends a splenectomy. The client states, “I
it?”
don’t need surgery—this will go away on its own.” In considering
B. “Calm down. You know that stress will make
her response to the client, the nurse must depend on the ethical
your symptoms worse.”
principle of:
C. “Would you like to talk about the problem with
the nursing supervisor?”
D. “I can see you’re angry. I’ll come back when A. beneficence
you’ve calmed down.” B. autonomy
C. advocacy
44. On a routine visit to the physician, a client with chronic D. Justice
arterial occlusive disease reports stopping smoking after 34 years.
To relive symptoms of intermittent claudication, a condition 50. Which of the following is t he most critical intervention
associated with chronic arterial occlusive disease, the nurse should needed for a client with myxedema coma?
recommend which additional measure?
A. Administering and oral dose of levothyroxine
A. Taking daily walks. (Synthroid)
B. Engaging in anaerobic exercise. B. Warming the client with a warming blanket
C. Reducing daily fat intake to less than 45% of total C. Measuring and recording accurate intake and
calories output
D. Avoiding foods that increase levels of highdensity D. Maintaining a patent airway
lipoproteins (HDLs)
51. Because diet and exercise have failed to control a 63 yr-old
45. A physician orders gastric decompression for a client with client’s blood glucose level, the client is prescribed glipizide
small bowel obstruction. The nurse should plan for the suction to (Glucotrol). After oral administration, the onset of action is:
be: A. 15 to 30 minutes
B. 30 to 60 minutes
C. 1 to 1 ½ hours
A. low pressure and intermittent
D. 2 to 3 hours
B. low pressure and continuous
C. high pressure and continuous
52. A client with pneumonia is receiving supplemental oxygen, 2
D. high pressure and intermitten
L/min via nasal cannula. The client’s history includes chronic
t
obstructive pulmonary disease (COPD) and coronary artery
46. Which nursing diagnosis is most appropriate for an elderly
disease. Because of these findings, the nurse closely monitors the
client with osteoarthritis?
oxygen flow and the client’s respiratory status. Which
complication may arise if the client receives a high oxygen
A. Risk for injury concentration?
B. Impaired urinary elimination A. Apnea
C. Ineffective breathing pattern B. Anginal pain
D. Imbalanced nutrition: less than body requirements C. Respiratory alkalosis
D. Metabolic acidosis
47. Parathyroid hormone (PTH) has which effects on the kidney?
53. A client with type 1 diabetes mellitus has been on a regimen of
A. Stimulation of calcium reabsorption and multiple daily injection therapy. He’s being converted to
phosphate excretion continuous subcutaneous insulin therapy. While teaching the client
B. Stimulation of phosphate reabsorption and bout continuous subcutaneous insulin therapy, the nurse would be
calcium excretion accurate in telling him the regimen includes the use of:
C. Increased absorption of vit D and excretion of vit A. intermediate and long-acting insulins
E B. short and long-acting insulins
D. Increased absorption of vit E and excretion of Vit C. short-acting only
D D. short and intermediate-acting insulins

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54. a client who recently had a cerebrovascular accident requires a 61. A client with a solar burn of the chest, back, face, and arms is
cane to ambulate. When teaching about cane use, the rationale for seen in urgent care. The nurse’s primary concern should be:
holding a cane on the uninvolved side is to:
A. fluid resuscitation
A. prevent leaning B. infection
B. distribute weight away from the involved side C. body image
C. maintain stride length D. pain management
D. prevent edema
62. Which statement is true about crackles?
55. A client with a history of an anterior wall myocardial
infarction is being transferred from the coronary care unit (CCU)
A. They’re grating sounds.
to the cardiac stepdown unit (CSU). While giving report to the
B. They’re high-pitched, musical squeaks.
CSU nurse, the CCU nurse says, “His pulmonary artery wedge
C. They’re low-pitched noises that sound like
pressures have been in the high normal range.” The CSU nurse
snoring.
should be especially observant for:
D. They may be fine, medium, or course.

A. hypertension 63. A woman whose husband was recently diagnosed with active
B. high urine output pulmonary tuberculosis (TB) is a tuberculin skin test converter.
C. dry mucous membranes Management of her care would include:
D. pulmonary crackles
A. scheduling her for annual tuberculin skin testing
56. The nurse is caring for a client with a fractures hip. The client
B. placing her in quarantine until sputum cultures are
is combative, confused, and trying to get out of bed. The nurse
negative
should:
C. gathering a list of persons with whom she has had
A. leave the client and get help
recent contact
B. obtain a physician’s order to restrain the client
D. advising her to begin prophylactic therapy with
C. read the facility’s policy on restraints
isoniazid (INH)
D. order soft restraints from the storeroom
64. The nurse is caring for a client who ahs had an above the knee
57. For the first 72 hours after thyroidectomy surgery, the nurse
amputation. The client refuses to look at the stump. When the
would assess the client for Chvostek’s sign and Trousseau’s sign
nurse attempts to speak with the client about his surgery, he tells
because they indicate which of the following?
the nurse that he doesn’t wish to discuss it. The client also refuses
A. hypocalcemia
to have his family visit. The nursing diagnosis that best describes
B. hypercalcemia
the client’s problem is:
C. hypokalemia
D. Hyperkalemia
A. Hopelessness
58. In a client with enteritis and frequent diarrhea, the nurse B. Powerlessness
should anticipate an acidbase imbalance of: C. Disturbed body image
A. respiratory acidosis D. Fear
B. respiratory alkalosis
C. metabolic acidosis 65. A client with three children who is still I the child bearing
D. metabolic alkalosis years is admitted for surgical repair of a prolapsed bladder. The
nurse would find that the client understood the surgeon’s
59. When caring for a client with the nursing diagnosis Impaired preoperative teaching when the client states:
swallowing related to neuromuscular impairment, the nurse
should: A. “If I should become pregnant again, the child
would be delivered by cesarean delivery.”
A. position the client in a supine position B. “If I have another child, the procedure may need
B. elevate the head of the bed 90 degrees during to be repeated.”
meals C. “This surgery may render me incapable of
C. encourage the client to remove dentures conceiving another child.”
D. encourage thin liquids for dietary intake D. “This procedure is accomplished in two separate
surgeries.”
60. A nurse is caring for a client who has a tracheostomy and
temperature of 39º C. which intervention will most likely lower 66. A client experiences problems in body temperature regulation
the client’s arterial blood oxygen saturation? associated with a skin impairment. Which gland is most likely
involved?
A. Endotracheal suctioning
B. Encouragement of coughing A. Eccrine
C. Use of cooling blanket B. Sebaceous
D. Incentive spirometry C. Apocrine
D. Endocrine

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67. A school cafeteria worker comes to the physician’s office 74. The nurse is providing home care instructions to a client who
complaining of severe scalp itching. On inspection, the nurse finds has recently had a skin graft. Which instruction is most important
nail marks on the scalp and small light-colored round specks for the client to remember?
attached to the hair shafts close to the scalp. These findings
suggest that the client suffers from:
A. Use cosmetic camouflage techniques.
B. Protect the graft from direct sunlight.
A. scabies C. Continue physical therapy.
B. head lice D. Apply lubricating lotion to the graft site.
C. tinea capitis
D. Impetigo 75. a 28 yr-old female nurse is seen in the employee health
department for mild itching and rash of both hands. Which of the
68. Following a small-bowel resection, a client develops fever and following could be causing this reaction?
anemia. The surface surrounding the surgical wound is warm to A. possible medication allergies
touch and necrotizing fasciitis is suspected. Another manifestation B. current life stressors she may be experiencing
that would most suggest necrotizing fasciitis is: C. chemicals she may be using and use of latex
A. erythema gloves
B. leukocytosis D. recent changes made in laundry detergent or bath
C. pressure-like pain soap.
D. Swelling
76. The nurse assesses a client with urticaria. The nurse
69. A 28 yr-old nurse has complaints of itching and a rash of both understands that urticaria is another name for:
hands. Contact dermatitis is initially suspected. The diagnosis is A. hives
confirmed if the rash appears: B. a toxin
A. erythematous with raised papules C. a tubercle
B. dry and scaly with flaking skin D. a virus
C. inflamed with weeping and crusting lesions
D. excoriated with multiple fissures 77. A client with psoriasis visits the dermatology clinic. When
inspecting the affected areas, the nurse expects to see which type
70. When assessing a client with partial thickness burns over 60% of secondary lesion?
of the body, which of the following should the nurse report A. scale
immediately? B. crust
A. Complaints of intense thirst C. ulcer
B. Moderate to severe pain D. Scar
C. Urine output of 70 ml the 1st hour
D. Hoarseness of the voice 78. The nurse is caring for a bedridden, elderly adult. To prevent
pressure ulcers, which intervention should the nurse include in the
71. A client is admitted to the hospital following a burn injury to plan of care?
the left hand and arm. The client’s burn is described as white and A. Turn and reposition the client a minimum of every
leathery with no blisters. Which degree of severity is this burn? 8 hours.
A. first-degree burn B. Vigorously massage lotion into bony
B. second-degree burn prominences.
C. third-degree burn C. Post a turning schedule at the client’s bedside.
D. fourth-degree burn D. Slide the client, rather than lifting when turning.

72. The nurse is caring for client with a new donor site that was 79. Following a full-thickeness (3rd degree) burn of his left arm, a
harvested to treat a new burn. The nurse position the client to: client is treated with artificial skin. The client understands
A. allow ventilation of the site postoperative care of the artificial skin when he states that during
B. make the site dependent the first 7 days after the procedure, he’ll restrict:
C. avoid pressure on the site A. range of motion
D. keep the site fully covered B. protein intake
C. going outdoors
73. a 45-yr-old auto mechanic comes to the physician’s office D. fluid ingestion
because an exacerbation of his psoriasis is making it difficult to
work. He tells the nurse that his finger joints are stiff and sore in 80. A client received burns to his entire back and left arm. Using
the morning. The nurse should respond by: the Rule of Nines, the nurse can calculate that he has sustained
A. Inquiring further about this problem because burns on what percentage of his body?
psoriatic arthritis can accompany psoriasis
vulgaris
A. 9%
B. Suggesting he take aspirin for relief because it’s
B. 18%
probably early rheumatoid arthritis
C. 27%
C. Validating his complaint but assuming it’s an
D. 36%
adverse effect of his vocation
D. Asking him if he has been diagnosed or treated for
carpal tunnel syndrome

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81. The nurse is providing care for a client who has a sacral 87.The nurse is caring for a client who is to undergo a lumbar
pressure ulcer with wet-to-dry dressing. Which guideline is puncture to assess for the presence of blood in the cerebrospinal
appropriate for a wet-to-dry dressing? fluid (CSF) and to measure CSF pressure. Which result would
indicate n abnormality?
A. The wound should remain moist form the
dressing. A. The presence of glucose in the CSF.
B. The wet-to-dry dressing should be tightly packed B. A pressure of 70 to 200 mm H2O
into the wound. C. The presence of red blood cells (RBCs) in the first
C. The dressing should be allowed to dry out before specimen tube
removal. D. A pressure of 00 to 250 mmH2O
D. A plastic sheet-type dressing should cover the wet
dressing. 88. The nurse is administering eyedrops to a client with glaucoma.
To achieve maximum absorption, the nurse should instill the
82. While in skilled nursing facility, a client contracted scabies, eyedrop into the:
which is diagnosed the day after discharge. The client is living at
her daughter’s home with six other persons. During her visit to
A. conjunctival sac
the clinic, she asks a staff nurse, “What should my family do?” the
B. pupil
most accurate response from the nurse is:
C. sclera
D. vitreous humor
A. “All family members will need to be treated.”
B. “If someone develops symptoms, tell him to see a 89. A 52 yr-old married man with two adolescent children is
physician right away.” beginning rehabilitation following a cerebrovascular accident. As
C. “Just be careful not to share linens and towels the nurse is planning the client’s care, the nurse should recognize
with family members.” that his condition will affect:
D. “After you’re treated, family members won’t be at
risk for contracting scabies.”
A. only himself
B. only his wife and children
83. In an industrial accident, client who weighs 155 lb (70.3 kg)
C. him and his entire family
sustained full-thickness burns over 40% of his body. He’s in the
D. no one, if he has complete recovery
burn unit receiving fluid resuscitation. Which observation shows
that the fluid resuscitation is benefiting the client?
90. Which action should take the highest priority when caring for
A. A urine output consistently above 100 ml/hour.
a client with hemiparesis caused by a cerebrovascular accident
B. A weight gain of 4 lb (1.8 kg) in 24 hours.
(CVA)?
C. Body temperature readings all within normal
limits
D. An electrocardiogram (ECG) showing no A. Perform passive range-of-motion (ROM)
arrhythmias. exercises.
B. Place the client on the affected side.
84. The nurse is reviewing the laboratory results of a client with C. Use hand rolls or pillows for support.
rheumatoid arthritis. Which of the following laboratory results D. Apply antiembolism stockings
should the nurse expect to find?
91. The nurse is formulating a teaching plan for a client who has
just experienced a transient ischemic attack (TIA). Which fact
A. Increased platelet count
should the nurse include in the teaching plan?
B. Elevated erythrocyte sedimentation rate (ESR)
C. Electrolyte imbalance
D. Altered blood urea nitrogen (BUN) and creatinine A. TIA symptoms may last 24 to 48 hours.
levels B. Most clients have residual effects after having a
TIA.
85. Which nursing diagnosis takes the highest priority for a client C. TIA may be a warning that the client may have
with Parkinson’s crisis? cerebrovascular accident (CVA)
A. Imbalanced nutrition: less than body requirements D. The most common symptom of TIA is the
B. Ineffective airway clearance inability to speak.
C. Impaired urinary elimination
D. Risk for injury 92. The nurse has just completed teaching about postoperative
activity to a client who is going to have a cataract surgery. The
86. A client with a spinal cord injury and subsequent urine nurse knows the teaching has been effective if the client:
retention receives intermittent catheterization every 4 hours. The
average catheterized urine volume has been 550 ml. The nurse A. coughs and deep breathes postoperatively
should plan to: B. ties his own shoes
A. Increase the frequency of the catheterizations. C. asks his wife to pick up his shirt from the floor
B. Insert an indwelling urinary catheter after he drops it.
C. Place the client on fluid restrictions D. States that he doesn’t need to wear an eyepatch or
D. Use a condom catheter instead of an invasive one. guard to bed

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93. The least serious form of brain trauma, characterized by a brief 99. Alzheimer’s disease is the secondary diagnosis of a client
loss of consciousness and period of confusion, is called: admitted with myocardial infarction. Which nursing intervention
should appear on this client’s plan of care?
A. contusion
B. concussion A. Perform activities of daily living for the client to
C. coup decease frustration.
D. Contrecoup B. Provide a stimulating environment.
C. Establish and maintain a routine.
94. When the nurse performs a neurologic assessment on Anne D. Try to reason with the client as much as possible.
Jones, her pupils are dilated and don’t respond to light.
100. For a client with a head injury whose neck has been stabilized,
the preferred bed position is:
A. glaucoma
B. damage to the third cranial nerve
C. damage to the lumbar spine A. Trendelenburg’s
D. Bell’s palsy B. 30-degree head elevation
C. flat
95. A 70 yr-old client with a diagnosis of leftsided cerebrovascular D. side-lying
accident is admitted to the facility. To prevent the development of
diffuse osteoporosis, which of the following objectives is most Answers and Rationales
appropriate?
1. ANS: D
Because the client’s gag reflex is absent, elevating the head of
A. Maintaining protein levels. the bed to 30 degrees helps minimize the client’s risk of
B. Maintaining vitamin levels. aspiration. Checking the stools, performing ROM exercises, and
C. Promoting weight-bearing exercises keeping the skin clean and dry are important, but preventing
D. Promoting range-of-motion (ROM) exercises aspiration through positioning is the priority.
2. ANS: A
96. A client is admitted with a diagnosis of meningitis caused by Any hole, no matter how small, will destroy the odor-proof seal
of a drainage bag. Removing the bag or unclamping it is the
Neisseria meningitides. The nurse should institute which type of only appropriate method for relieving gas.
isolation precautions? 3. ANS: A
because celiac disease destroys the absorbing surface of the
A. Contact precautions intestine, fat isn’t absorbed but is passed in the stool. Steatorrhea
is bulky, fatty stools that have a foul odor. Jaundiced sclerae
B. Droplet precautions result from elevated bilirubin levels. Clay-colored stools are
C. Airborne precautions seen with biliary disease when bile flow is blocked. Celiac
D. Standard precautions disease doesn’t cause a widened pulse pressure.
4. ANS: D
97. A young man was running along an ocean pier, tripped on an Reducing sodium intake reduces fluid retention. Fluid retention
elevated area of the decking, and struck his head on the pier railing. increases blood volume, which changes blood vessel
According to his friends, “He was unconscious briefly and then permeability and allows plasma to move into interstitial tissue,
became alert and behaved as though nothing had happened.” causing edema. Urea nitrogen excretion can be increased only
by improved renal function. Sodium intake doesn’t affect the
Shortly afterward, he began complaining of a headache and asked glomerular filtration rate. Potassium absorption is improved
to be taken to the emergency department. If the client’s only by increasing the glomerular filtration rate; it isn’t affected
intracranial pressure (ICP) is increasing, the nurse would expect to by sodium intake.
observe which of the following signs first? 5. ANS: D
The portion of the cerebrum that controls speech and hearing is
the temporal lobe. Injury to the frontal lobe causes personality
A. pupillary asymmetry changes, difficulty speaking, and disturbance in memory,
B. irregular breathing pattern reasoning, and concentration. Injury to the parietal lobe causes
C. involuntary posturing sensory alterations and problems with spatial relationships.
D. declining level of consciousness Damage to the occipital lobe causes vision disturbances.
6. ANS: D
98. Emergency medical technicians transport a 28 yr-old iron Diabetes insipidus is an abrupt onset of extreme polyuria that
worker to the emergency department. They tell the nurse, “He fell commonly occurs in clients after brain surgery. Cushing’s
syndrome is excessive glucocorticoid secretion resulting in
from a two-story building. He has a large contusion on his left sodium and water retention. Diabetes mellitus is a
chest and a hematoma in the left parietal area. He has compound hyperglycemic state marked by polyuria, polydipsia, and
fracture of his left femur and he’s comatose. We intubated him polyphagia. Adrenal crisis is undersecretion of glucocorticoids
and he’s maintaining an arterial oxygen saturation of 92% by resulting in profound hypoglycemia, hypovolemia, and
pulse oximeter with a manual-resuscitation bag.” Which hypotension.
intervention by the nurse has the highest priority? 7. ANS: C
The client should report the presence of foulsmelling or cloudy
urine. Unless contraindicated, the client should be instructed to
A. Assessing the left leg drink large quantities of fluid each day to flush the kidneys.
B. Assessing the pupils Sand-like debris is normal because of residual stone products.
C. Placing the client in Trendelenburg’s position Hematuria is common after lithotripsy.
D. Assessing the level of consciousness 8. ANS: A
A serum glucose level of 618 mg/dl indicates hyperglycemia,
which causes polyuria and deficient fluid volume. In this client,
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tachycardia is more likely to result from deficient fluid volume client. The incidence of complications, such as pin tract
than from decreased cardiac output because his blood pressure is infections and neuritis, is 20% to 60%. Clients must be taught
normal. Although the client’s serum glucose is elevated, food how to do pin care and assess for development of neurovascular
isn’t a priority because fluids and insulin should be administered complications.
to lower the serum glucose level. Therefore, a diagnosis of 19. ANS: C
Imbalanced Nutrition: Less then body requirements isn’t In a client with chronic renal failure, unrestricted intake of
appropriate. A temperature of 100.6º F isn’t life threatening, sodium, protein, potassium, and fluids may lead to a dangerous
eliminating ineffective thermoregulation as the top priority. accumulation of electrolytes and protein metabolic products,
9. ANS: C such as amino acids and ammonia. Therefore, the client must
Regular insulin, which is a short-acting insulin, has an onset of limit his intake of sodium, meat (high in Protein), bananas (high
15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse in potassium), and fluid because the kidneys can’t secrete
gave the insulin at 2 p.m., the expected onset would be from adequate urine.
2:15 to 2:30 p.m. and the peak from 4 p.m. to 6 p.m. 20. ANS: D
10. ANS: A The client isn’t withdrawn or showing other signs of anxiety or
CPP is derived by subtracting the ICP from the mean arterial depression. Therefore, the nurse can probably safely approach
pressure (MAP). For adequate cerebral perfusion to take place, her about talking with others who have had similar experiences,
the minimum goal is 70 mmHg. The MAP is derived using the either through Reach for Recovery or another formal support
following formula: group. The nurse may educate the client’s spouse or partner to
MAP = ((diastolic blood pressure x 2) + systolic blood pressure) listen to concerns, but the nurse shouldn’t tell the client’s spouse
/3 what to do. The client must consult with her physician and make
MAP = ((60 x2) + 90) / 3 her own decisions
MAP = 70 mmHg about further treatment. The client needs to express her sadness,
To find the CPP, subtract the client’s ICP from the MAP; in this frustration, and fear. She can’t be expected to be cheerful at all
case , 70 mmHg – 18 mmHg = 52 mmHg. times.
11. ANS: B 21. ANS: C
Breast cancer tumors are fixed, hard, and poorly delineated with HCG is one of the tumor markers for testicular cancer. The
irregular edges. Nipple retraction —not eversion—may be a HCG level won’t identify the site of an infection or evaluate
sign of cancer. A mobile mass that is soft and easily delineated prostatic function or testosterone level.
is most often a fluid-filled benigned cyst. Axillary lymph nodes 22. ANS: B
may or may not be palpable on initial detection of a cancerous Peripheral edema is a sign of fluid volume overload and
mass. worsening heart failure. A skin rash, dry cough, and postural
12. ANS: D hypotension are adverse reactions to captopril, but the don’t
An enterostomal nurse therapist is a registered nurse who has indicate that therapy isn’t effective.
received advance education in an accredited program to care for 23. ANS: A
clients with stomas. The enterostomal nurse therapist can assist Tenting of chest skin when pinched indicates decreased skin
with selection of an appropriate stoma site, teach about stoma elasticity due to dehydration. Hand veins fill slowly with
care, and provide emotional support. dehydration, not rapidly. A pulse that isn’t easily obliterated and
13. ANS: A neck vein distention indicate fluid overload, not dehydration.
Ottorrhea and rhinorrhea are classic signs of basilar skull 24. ANS: B
fracture. Injury to the dura commonly occurs with this fracture, The client should be encouraged to increase his activity level.
resulting in cerebrospinal fluid (CSF) leaking through the ears Maintaining an ideal weight; following a low-cholesterol,
and nose. Any fluid suspected of being CSF should be checked low-sodium diet; and avoiding stress are all important factors in
for glucose or have a halo test done. decreasing the risk of atherosclerosis.
14. ANS: D 25. ANS: B
Testicular cancer commonly occurs in men between ages 20 and Because thrombocytopenia impairs blood clotting, the nurse
30. A male client should be taught how to perform testicular should assess the client regularly for signs of bleeding, such as
self-examination before age 20, preferably when he enters his petechiae, purpura, epistaxis, and bleeding gums. The nurse
teens. should avoid administering aspirin because it can increase the
15. ANS: B risk of bleeding. Frequent rest periods are indicated for clients
Before weaning a client from mechanical ventilation, it’s most with anemia, not thrombocytopenia. Strict isolation is indicated
important to have a baseline ABG levels. During the weaning only for clients who have highly contagious or virulent
process, ABG levels will be checked to assess how the client is infections that are spread by air or physical contact.
tolerating the procedure. Other assessment parameters are less 26. ANS: B
critical. Measuring fluid volume intake and output is always SaO2 is the degree to which hemoglobin is saturated with
important when a client is being mechanically ventilated. Prior oxygen. It doesn’t indicate the client’s overall Hgb adequacy.
attempts at weaning and ECG results are documented on the Thus, an individual with a subnormal Hgb level could have
client’s record, and the nurse can refer to them before the normal SaO2 and still be short of breath. In this case, the nurse
weaning process begins. could assume that the client has a Hematologic problem. Poor
16. ANS: B peripheral perfusion would cause subnormal SaO2. There isn’t
According to the ACS guidelines, “Women older than age 40 enough data to assume that the client’s problem is
should perform breast selfexamination monthly (not annually).” psychosomatic. If the problem were
The hormonal receptor assay is done on a known breast tumor to left-sided heart failure, the client would exhibit pulmonary
determine whether the tumor is estrogen- or crackles.
progesterone-dependent. 27. ANS: A
17. ANS: C Addisonian crisis results in Hyperkalemia; therefore,
Increased pressure within the portal veins causes them to bulge, administering potassium chloride is contraindicated. Because
leading to rupture and bleeding into the lower esophagus. the client will be hyponatremic, normal saline solution is
Bleeding associated with esophageal varices doesn’t stem from indicated. Hydrocortisone and fludrocortisone are both useful in
esophageal perforation, pulmonary hypertension, or peptic replacing deficient adrenal cortex hormones.
ulcers. 28. ANS: D
18. ANS: B Leukemia is manifested by an abnormal overpopulation of
Complex intra-articular fractures are repaired with external immature leukocytes in the bone marrow.
fixators because they have a better long-term outcome than 29. ANS: C
those treated with casting. This is especially true in a young A sterile field is considered contaminated when it becomes wet.

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Moisture can act as a wick, allowing microorganisms to respiratory tract, the nurse should put on a mask when entering
contaminate the field. The outside of containers, such as sterile the client’s room. Having the client wear a mask at all the times
saline bottles, aren’t sterile. The containers should be opened would hinder sputum expectoration and make the mask moist
before sterile gloves are put on and the solution poured over the from respirations. If no contact with the client’s blood or body
sterile dressings placed in a sterile basin. Wounds should be fluids is anticipated, the nurse need not wear a gown or gloves
cleaned from the most contaminated area to the least when providing direct care. A client with tuberculosis should be
contaminated area—for example, from the center outward. The in a room with laminar air flow, and the door should be closed at
outer inch of a sterile field shouldn’t be considered sterile. all times.
30. ANS: C 38. ANS: C
Caffeine is a stimulant, which can exacerbate palpitations and The nurse can gently irrigate the tube but must take care not to
should be avoided by a client with symptomatic mitral valve reposition it. Repositioning can cause bleeding. Suction should
prolapse. High fluid intake helps maintain adequate preload and be applied continuously, not every hour. The NG tube shouldn’t
cardiac output. Aerobic exercise helps in increase cardiac output be clamped postoperatively because secretions and gas will
and decrease heart rate. Protein-rich foods aren’t restricted but accumulate, stressing the suture line.
high calorie foods are. 39. ANS: A
31. ANS: A Regardless of the client’s medical history, rapid fluid
Excessive of aldosterone in the adrenal cortex is responsible for resuscitation is critical for maintaining cardiovascular integrity.
the client’s hypertension. This hormone acts on the renal tubule, Profound intravascular depletion requires aggressive fluid
where it promotes reabsorption of sodium and excretion of replacement. A typical fluid resuscitation protocol is 6 L of fluid
potassium and hydrogen ions. The pancreas mainly secretes over the first 12 hours, with more fluid to follow over the next
hormones involved in fuel metabolism. The adrenal medulla 24 hours. Various fluids can be used, depending on the degree
secretes the cathecolamines—epinephrine and norepinephrine. of hypovolemia. Commonly prescribed fluids include dextran
The parathyroids secrete parathyroid hormone. (in case of hypovolemic shock), isotonic normal saline solution
32. ANS: D and, when the client is stabilized, hypotonic half-normal saline
A heart valve prosthesis, such as a mitral valve replacement, is a solution.
major risk factor for infective endocarditis. Other risk factors 40. ANS: D
include a history of heart disease (especially mitral valve Glipizide may cause adverse skin reactions, such as pruritus,
prolapse), chronic debilitating disease, IV drug abuse, and and photosensitivity. It doesn’t cause headache, constipation, or
immunosuppression. Although diabetes mellitus may predispose hypotension.
a person to cardiovascular disease, it isn’t a major risk factor for 41. ANS: B
infective endocarditis, nor is an appendectomy or pernicious When clients are on mechanical ventilation, the artificial airway
anemia. impairs the gag and cough reflexes that help keep organisms out
33. ANS: A of the lower respiratory tract. The artificial airway also prevents
The client has signs and symptoms of diabetes insipidus, the upper respiratory system from humidifying and heating air
probably caused by the failure of her renal tubules to respond to to enhance mucociliary clearance. Manipulations of the artificial
antidiuretic hormone as a consequence of pyelonephritis. The airway sometimes allow secretions into the lower airways. Whit
hypernatremia is secondary to her water loss. Imbalanced standard procedures the other choices wouldn’t be at high risk.
nutrition related to hypermetabolic state or catabolic effect of 42. ANS: C
insulin deficiency is an inappropriate nursing diagnosis for the In chronic bronchitis, the diaphragmatic is flat and weak.
client. Diaphragmatic breathing helps to strengthen the diaphragm and
34. ANS: C maximizes ventilation. Exhalation should longer than inhalation
When performing a nutritional assessment, one of the first to prevent collapse of the bronchioles. The client with chronic
things the nurse should do is to assess what the client typically bronchitis should exhale through pursed lips to prolong
eats. The client shouldn’t be permitted to eat as desired. exhalation, keep the bronchioles from collapsing, and prevent
Weighing the client daily, placing her on I & O status, and air trapping. Diaphragmatic breathing—not chest
drawing blood to determine electrolyte level aren’t part of a breathing—increases lung expansion.
nutritional assessment. 43. ANS: A
35. Ans. C Verbalizing the observed behavior is a therapeutic
Regular follow-up care for the client with Grave’s disease is communication technique in which the nurse acknowledges
critical because most cases eventually result in hypothyroidism. what the client is feeling. Offering to listen to the client express
Annual thyroid-stimulating hormone tests and the client’s ability her anger can help the nurse and the client understand its cause
to recognize signs and symptoms of thyroid dysfunction will and begin to deal with it. Although stress can exacerbate the
help detect thyroid abnormalities early. Intake and output is symptoms of SLE, telling the client to calm down doesn’t
important for clients with fluid and electrolyte imbalances but acknowledge her feelings. Offering to get the nursing supervisor
not thyroid disorders. DDAVP is used to treat diabetes insipidus. also doesn’t acknowledge the client’s feelings. Ignoring the
While exercise to improve cardiovascular fitness is important, client’s feelings suggest that the nurse has no interest in what
for this client the importance of regular follow-up is most the client has said.
critical. 44. ANS: A
36. ANS: D Daily walks relieve symptoms of intermittent claudication,
Anxiety related to the threat of death is an appropriate nursing although the exact mechanism is unclear. Anaerobic exercise
diagnosis because the client’s anxiety can adversely affect hear may exacerbate these symptoms. Clients with chronic arterial
rate and rhythm by stimulating the autonomic nervous system. occlusive disease must reduce daily fat intake to 30% or less of
Also, because the client required resuscitation, the threat of total calories. The client should limit dietary cholesterol because
death is a real and immediate concern. Unless anxiety is dealt hyperlipidemia is associated with atherosclerosis, a known cause
with first, the client’s emotional state will impede learning. of arterial occlusive disease. However, HDLs have the lowest
Client teaching should be limited to clear concise explanations cholesterol concentration,
that reduce anxiety and promote cooperation. An anxious client so this client should eat foods that raise HDL levels.
has difficulty learning, so the deficient knowledge would 45. ANS: A
continue despite attempts teaching. Impaired physical mobility Gastric decompression is typically low pressure and intermittent.
and social isolation are necessitated by the client’s critical High pressure and continuous gastric suctioning predisposes the
condition; therefore, they aren’t considered problems warranting gastric mucosa to injury and ulceration.
nursing diagnoses. 46. ANS: A
37. ANS: A In osteoarthritis, stiffness is common in large, weight bearing
Because tuberculosis is transmitted by droplet nuclei from the joints such as the hips. This joint stiffness alters functional

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ability and range of motion, placing the client at risk for falling inflated for few minutes). These signs aren’t present with
and injury. Therefore, client safety is in jeopardy. Osteoporosis hypercalcemia, hypokalemia, or Hyperkalemia.
doesn’t affect urinary elimination, breathing, or nutrition. 58. ANS: C
47. ANS: A Diarrhea causes a bicarbonate deficit. With loss of the relative
PTH stimulates the kidneys to reabsorb calcium and excrete alkalinity of the lower GI tract, the relative acidity of the upper
phosphate and converts vit D to its active form: 1 , 25 dihydroxy GI tract predominates leading to metabolic acidosis. Diarrhea
vitamin D. PTH doesn’t have a role in the metabolism of Vit E. doesn’t lead to respiratory acid-base imbalances, such as
48. ANS: C respiratory acidosis and respiratory alkalosis. Loss of acid,
The presence of unsecured area rugs poses a hazard in all homes, which occurs with severe vomiting, may lead to metabolic
particularly in one with a resident at high risk for falls. alkalosis.
49. ANS: B 59. ANS: B
Autonomy ascribes the right of the individual to make his own The head of the bed must be elevated while the client is eating.
decisions. In this case, the client is capable of making his own The client should be placed in a recumbent position—not a
decision and the nurse should support his autonomy. supine position— when lying down to reduce the risk of
Beneficence and justice aren’t the principles that directly relate aspiration. Encourage the client to wear properly fitted dentures
to the situation. Advocacy is the nurse’s role in supporting the to enhance his chewing ability. Thickened liquids, not thin
principle of autonomy. liquids, decrease aspiration risk.
50. ANS: D 60. ANS: A
Because respirations are depressed in myxedema coma, Endotracheal suctioning secretions as well as gases from the
maintaining a patent airway is the most critical nursing airway and lowers the arterial oxygen saturation (SaO2) level.
intervention. Ventilatory support is usually needed. Thyroid Coughing and incentive spirometry improve oxygenation and
replacement will be administered IV. Although myxedema coma should raise or maintain oxygen saturation. Because of
is associated with severe hypothermia, a warming blanket superficial vasoconstriction, using a cooling blanket can lower
shouldn’t be used because it may cause vasodilation and shock. peripheral oxygen saturation readings, but SaO2 levels wouldn’t
Gradual warming blankets would be appropriate. Intake and be affected.
output are very important but aren’t critical 61. ANS: D
interventions at this time. With a superficial partial thickness burn such as a solar burn
51. ANS: A (sunburn), the nurse’s main concern is pain management. Fluid
Glipizide begins to act in 15 to 30 minutes. The other options resuscitation and infection become concerns if the burn extends
are incorrect. to the dermal and subcutaneous skin layers. Body image
52. ANS: A disturbance is a concern that has a lower priority than pain
Hypoxia is the main breathing stimulus for a client with COPD. management.
Excessive oxygen administration may lead to apnea by 62. ANS: D
removing that stimulus. Anginal pain results from a reduced Crackles result from air moving through airways that contain
myocardial oxygen supply. A client with COPD may have fluid. Heard during inspiration and expiration, crackles are
anginal pain from generalized vasoconstriction secondary to discrete sounds that vary in pitch and intensity. They’re
hypoxia; however, administering oxygen at any concentration classified as fine, medium, or coarse. Pleural friction rubs have a
dilates blood vessels, easing anginal pain. Respiratory alkalosis distinctive grating sound. As the name indicates, these breath
results from alveolar hyperventilation, not excessive oxygen sounds result when inflamed pleurae rub together. Continuous,
administration. In a client with COPD, high oxygen highpitched, musical squeaks, called wheezes, result when air
concentrations decrease the ventilatory drive, leading to moves rapidly through airways narrowed by asthma or infection
respiratory acidosis, not alkalosis. High oxygen concentrations or when an airway is partially obstructed by a tumor or foreign
don’t cause metabolic acidosis. body. Wheezes, like gurgles, occur on expiration and sometimes
53. ANS: C on inspiration. Loud, coarse, low-pitched sounds resembling
Continuous subcutaneous insulin regimen uses a basal rate and snoring are called gurgles. These sounds develop when thick
boluses of short-acting insulin. Multiple daily injection therapy secretions partially obstruct airflow through the large upper
uses a combination of short-acting and intermediate or airways.
long-acting insulins. 63. Ans. D
54. ANS: B Individuals who are tuberculin skin test converters should begin
Holding a cane on the uninvolved side distributes weight away a 6-month regimen of an antitubercular drug such as INH, and
from the involved side. Holding the cane close to the body they should never have another skin test. After an individual has
prevents leaning. Use of a cane won’t maintain stride length or a positive tuberculin skin test, subsequent skin tests will cause
prevent edema. severe skin reactions but won’t provide new information about
55. ANS: D the client’s TB status. The client doesn’t have active TB, so
High pulmonary artery wedge pressures are diagnostic for can’t transmit, or spread, the bacteria. Therefore, she shouldn’t
left-sided heart failure. With leftsided heart failure, pulmonary be quarantined or asked for information about recent contacts.
edema can develop causing pulmonary crackles. In leftsided 64. ANS: C
heart failure, hypotension may result and urine output will Disturbed body image is a negative perception of the self that
decline. Dry mucous membranes aren’t directly associated with makes healthful functioning more difficult. The defining
elevated pulmonary artery wedge pressures. characteristics for this nursing diagnosis include undergoing a
56. ANS: B change in body structure or function, hiding or overexposing a
It’s mandatory in most settings to have a physician’s order body part, not looking at a body part, and responding verbally or
before restraining a client. A client should never be left alone nonverbally to the actual or perceived change in structure or
while the nurse summons assistance. All staff members require function. This client may have any of the other diagnoses, but
annual instruction on the use of restraints, and the nurse should the signs and symptoms described in he case most closely match
be familiar with the facility’s policy. the defining characteristics for disturbed body image.
57. ANS: A 65. ANS: B
The client who has undergone a thyroidectomy is t risk for Because the pregnant uterus exerts a lot of pressure on the
developing hypocalcemia from inadvertent removal or damage urinary bladder, the bladder repair may need to be repeated.
to the parathyroid gland. The client with hypocalcemia will These clients don’t necessarily have to have a cesarean delivery
exhibit a positive Chvostek’s sign (facial muscle contraction if they become pregnant, and this procedure doesn’t render them
when the facial nerve in front of the ear is tapped) and a positive sterile. This procedure is completed in one surgery.
Trousseau’s sign (carpal spasm when a blood pressure cuff is 66. ANS: A
Eccrine glands are associated with body temperature regulation.

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Sebaceous glands lubricate the skin and hairs, and apocrine Toxin is a poison. A tubercle is a tiny round nodule produced by
glands are involved in bacteria decomposition. Endocrine glands the tuberculosis bacillus. A virus is an infectious parasite.
secrete hormones responsible for the regulation of body 77. ANS: A
processes, such as metabolism and glucose regulation. A scale is the characteristic secondary lesion occurring in
67. ANS: B psoriasis. Although crusts, ulcers, and scars also are secondary
The light-colored spots attached to the hair shafts are nits, which lesions in skin disorders, they don’t accompany psoriasis.
are the eggs of head lice. They can’t be brushed off the hair 78. ANS: C
shaft like dandruff. Scabies is a contagious dermatitis caused by A turning schedule with a signing sheet will help ensure that the
the itch mite, Sacoptes scabiei, which lives just beneath the skin. client gets turned and thus, help prevent pressure ulcers. Turning
Tinea capitis, or ringworm, causes patchy hair loss and circular should occur every 1-2 hours—not every 8 hours—for clients
lesions with healing centers. Impetigo is an infection caused by who are in bed for prolonged periods. The nurse should apply
Staphylococcus or Sterptococcus, manifested by vesicles or lotion to keep the skin moist but should avoid vigorous massage,
pustules that form a thick, honey-colored crust. which could damage capillaries. When moving the client, the
68. ANS: C nurse should lift rather than slide the client to void shearing.
Severe pressure-like pain out of proportion to visible signs 79. ANS: A
distinguishes necrotizing fasciitis from cellulites. Erythema, To prevent disruption of the artificial skin’s adherence to the
leukocytosis, and swelling are present in both cellulites and wound bed, the client should restrict range of motion of the
necrotizing fasciitis. involved limb. Protein intake and fluid intake are important for
69. ANS: A healing and regeneration and shouldn’t be restricted. Going
Contact dermatitis is caused by exposure to a physical or outdoors is acceptable as long as the left arm is protected from
chemical allergen, such as cleaning products, skin care products, direct sunlight.
and latex gloves. Initial symptoms of itching, erythema, and 80. ANS: C
raised papules occur at the site of the exposure and can begin According to the Rule of Nines, the posterior and anterior trunk,
within 1 hour of exposure. Allergic reactions tend to be red and and legs each make up 18% of the total body surface. The head,
not scaly or flaky. Weeping, crusting lesions are also uncommon neck, and arms each make up 9% of total body durface, and the
unless the reaction is quite severe or has been present for a long perineum makes up 1%. In this case, the client received burns to
time. Excoriation is more common in skin disorders associated his back (18%) and one arm (9%), totaling 27%.
with a moist environment. 81. ANS: A
70. ANS: D A wet-to-dry saline dressing should always keep the wound
Hoarseness indicate injury to the respiratory system and could moist. Tight packing or dry packing can cause tissue damage
indicate the need for immediate intubation. Thirst following and pain. A dry gauze —not a plastic-sheet-type
burns is expected because of the massive fluid shifts and dressing—should cover the wet dressing.
resultant loss leading to dehydration. Pain, either severe or 82. ANS: A
moderate, is expected with a burn injury. The client’s output is When someone in a group of persons sharing a home contracts
adequate. scabies, each individual in the same home needs prompt
71. ANS: C treatment whether he’s symptomatic or not. Towels and linens
Third-degree burn may appear white, red, or black and are dry should be washed in hot water. Scabies can be transmitted from
and leathery with no blisters. There may be little pain because one person to another before symptoms develop
nerve endings have been destroyed. First-degree burns are 83. ANS: A
superficial and involve the epidermis only. There is local pain In a client with burns, the goal of fluid resuscitation is to
and redness but no blistering. Second-degree burn appear red maintain a mean arterial blood pressure that provides adequate
and moist with blister formation and are painful. Fourth-degree perfusion of vital structures. If the kidneys are adequately
burns involve underlying muscle and bone tissue. perfused, they will produce an acceptable urine output of at least
72. ANS: C 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb
A universal concern I the care of donor sites for burn care is to client is 35 ml/hour, and a urine output consistently above 100
keep the site away from sources of pressure. Ventilation of the ml/hour is more than adequate. Weight gain from fluid
site and keeping the site fully covered are practices in some resuscitation isn’t a goal. In fact, a 4 lb weight gain in 24 hours
institutions but aren’t hallmarks of donor site care. Placing the suggests third spacing. Body temperature readings and ECG
site in a position of dependence isn’t a justified aspect of donor interpretations may demonstrate secondary benefits of fluid
site care. resuscitation but aren’t primary indicators.
73. ANS: A 84. ANS: B
Anyone with psoriasis vulgaris who reports joint pain should be The ESR test is performed to detect inflammatory processes in
evaluated for psoriaic arthritis. Approximately 15% to 20% of the body. It’s a nonspecific test, so the health care professional
individuals with psoriasis will also develop psoriatic arthritis, must view results in conjunction with physical signs and
which can be painful and cause deformity. It would be incorrect symptoms. Platelet count, electrolytes, BUN, and creatinine
to assume that his pain is caused by early rheumatoid arthritis or levels aren’t usually affected by the inflammatory process.
his vocation without asking more questions or performing 85. ANS: B
diagnostic studies. Carpal tunnel syndrome causes sensory and In Parkinson’s crisis, dopamine-related symptoms are severely
motor changes in the fingers rather than localized pain in the exacerbated, virtually immobilizing the client. A client who is
joints. confined to bed during a crisis is at risk for aspiration and
74. ANS: B pneumonia. Also, excessive drooling increases the risk of
To avoid burning and sloughing, the client must protect the graft airway obstruction. Because of these concerns, ineffective
from sunlight. The other three interventions are all helpful to the airway clearance is the priority diagnosis for this client.
client and his recovery but are less important. Although imbalanced nutrition:less than body requirements,
75. ANS: C impaired urinary elimination and risk for injury also are
Because the itching and rash are localized, an environmental appropriate diagnoses for this client, they aren’t immediately
cause in the workplace should be suspected. With the advent of lifethreatening and thus are less urgent.
universal precautions, many nurses are experiencing allergies to 86. ANS: A
latex gloves. Allergies to medications, laundry detergents, or As a rule of practice, if intermittent catheterization for urine
bath soaps or a dermatologic reaction to stress usually elicit a retention typically yields 500 ml or more, the frequency of
more generalized or widespread rash. catheterization should be increased. Indwelling catheterization is
76. ANS: A less preferred because of the risk of urinary tract infection and
Hives and urticaria are two names for the same skin lesion. the loss of bladder tone. Fluid restrictions aren’t indicated for
this case; the problem isn’t overhydration, rather it’s urine

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retention. A condom catheter doesn’t help empty the bladder of 98. ANS: A
a client with urine retention. In the scenario, airway and breathing are established so the
87. ANS: D nurse’s next priority should be circulation. With a compound
The normal pressure is 70 to 200 mm H2O are considered fracture of the femur, there is a high risk of profuse bleeding;
abnormal. The presence of glucose is an expected finding in therefore, the nurse should assess the site. Neurologic
CSF, and RBCs typically occur in the first specimen tube from assessment is a secondary concern to airway, breathing and
the trauma caused by the procedure. circulation. The nurse doesn’t have enough data to warrant
88. ANS: A putting the client in Trendelenburg’s position.
The nurse should instill the eyedrop into the conjunctival sac 99. ANS: C
where absorption can best take place. The pupil permits light to Establishing and maintaining a routine is essential to decreasing
enter the eye. The sclera maintains the eye’s shape and size. The extraneous stimuli. The client should participate in daily care as
vitreous humor maintains the retina’s placement and the shape much as possible. Attempting to reason with such clients isn’t
of the eye. successful, because they can’t participate in abstract thinking.
89. ANS: C 100. ANS: B
According to family theory, any change in a family member, For clients with increased intracranial pressure (ICP), the head
such as illness, produces role changes in all family members and of the bed is elevated to promote venous outflow.
affects the entire family, even if the client eventually recovers Trendelenburg’s position is contraindicated because it can raise
completely. ICP. Flat or neutral positioning is indicated when elevating the
90. ANS: B head of the bed would increase the risk of neck injury or airway
To help prevent airway obstruction and reduce the risk of obstruction. Sidelying isn’t specifically a therapeutic treatment
aspiration, the nurse should position a client with hemiparesis on for increased ICP.
the affected side. Although performing ROM exercises,
providing pillows for support, and applying antiembolism
stockings can be appropriate for a client with CVA, the first

91.
concern is to maintain a patent airway.
ANS: C Medical Surgical Nursing
Exam 3
TIA may be a warning that the client will experience a CVA, or
stroke, in the near future. TIA aymptoms last no longer than 24
hours and clients usually have complete recovery after TIA. The
most common symptom of TIA is sudden, painless loss of
vision lasting up to 24 hours.
92. ANS: C
Bending to pick up something from the floor would increase
1. Lisa is newly diagnosed with asthma and is being discharged
intraocular pressure, as would bending to tie his shoes. The from the hospital after an episode of status asthmaticus. Discharge
client needs to wear eye protection to bed to prevent accidental teaching should include which of the following:
injury during sleep. A. Limitations in sports that will be imposed by the
93. ANS: B illness
Concussions are considered minor with no structural signs of B. Specific instructions on staying cal during an
injury. A contusion is bruising of the brain tissue with small attack
hemorrhages in the tissue. Coup and contrecoup are type of C. The relationship of symptoms and a specific
injuries in which the damaged area on the brain forms directly
below that site of impact (coup) or at the
trigger such as physical exercise
site opposite the injury (contrecoup) due to movement of the D. Incidence of status asthmaticus in children and
brain within the skull. teens
94. ANS: B
The third cranial nerve (oculomotor) is responsible for pupil 2. Which of the following symptoms is most characteristic of a
constriction. When there is damage to the nerve, the pupils client with a cancer of the lung?
remain dilated and don’t respond to light. Glaucoma, lumbar A. air hunger
spine injury, and Bell’s palsy won’t affect pupil constriction. B. exertional dyspnea
95. ANS: C
When the mechanical stressors of weight bearing are absent,
C. cough with night sweats
diffuse osteoporosis can occur. Therefore, if the client does D. persistent changing cough
weight-bearing exercises, disuse complications can be prevented.
Maintaining protein and vitamins levels is important, but neither 3. The client has ST segment depression on his 12-lead ECG. The
will prevent osteoporosis. ROM exercises will help prevent nurse determines that this would indicate the following:
muscle atrophy and contractures. A. necrosis
96. ANS: B B. injury
This client requires droplet precautions because the organism C. ischemia
can be transmitted through airborne droplets when the client
coughs, sneezes, or doesn’t cover his mouth. Airborne
D. nothing significant
precautions would be instituted for a client infected with
tuberculosis. Standard precautions would be instituted for a 4. Red has just returned from the postanesthesia care unit (PACU)
client when contact with body substances is likely. Contact from a hemorrhidectomy. His postoperative orders include sitz
precautions would be instituted for a client infected with an baths every morning. The nurse understands that sitz bath is use
organism that is transmitted through skin-to-skin for:
contact. A. promote healing
97. ANS: D B. relive tension
With a brain injury such as an epidural hematoma (a diagnosis
that is most likely based on this client’s symptoms), the initial
C. lower body temperature
sign of increasing ICP is a change in the level of consciousness. D. cause swelling
As neurologic deterioration progresses, manifestations involving
pupillary symmetry, breathing patterns, and posturing will
occur.

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5. Trousseau’s sign is associated with which electrolyte 12. Dianne Hizon is a 27 year old woman who has been admitted
imbalance? to the ER due to severe vomiting. Her ABG values are pH= 7.50,
PaCO2= 85, HCO3= 31, and SaO2= 93%. The nurse interpretation
of this ABG analysis is:
A. hyponatremia
B. hypocalcemia
C. hypernatremia A. respiratory acidosis
D. Hypercalcemia B. respiratory alkalosis
C. metabolic acidosis
6. A 36 year old female complains of headache and neck pain. The D. metabolic alkalosis
nurse’s assessments reveal painful flexion of the neck to the chest.
The nurse understands that nuchal rigidity is associated with: 13. Mr. Perkson has a parkinson’s disease and he finds the resting
tremor he is experiencing in his right hand very frustrating. The
nurse advises him to:
A. brain tumor
A. take a warm bath
B. CVA
B. hold an object
C. meningitis
C. practice deep breathing
D. subdural hematoma
D. take diazepam as needed
7. The nurse teaching the client about behavioral changes, which
14. A shuffling gait is typically associated with the patient who
can affect development of atherosclerosis, should discuss which of
has:
the following as a non-modifiable risk factor for atherosclerosis?
A. Parkinson’s disease
B. Multiple sclerosis
A. cigarette smoking C. Raynaud’s disease
B. hyperlipidemia D. Myasthenia gravis
C. female over 55 years of age
D. sedentary lifestyle 15. The priority in preparing the room for a client with a C7 spinal
cord injury is having:
8. A 76 year old man enters the ER with complaints of back pain A. the halo brace device
and feeling fatigued. Upon examination, his blood pressure is B. a catheterization tray
190/100, pulse is 118, and hematocrit and hemoglobin are both C. a ventilator on stand by
low. The nurse palpates the abdomen which is soft, non-tender and D. the spinal kinetic bed
auscultates an abdominal pulse. The most likely diagnosis is:
16. A 47 year old man with liver failure who has developed ascites.
A. Buerger’s disease The nurse understands that ascites is due to:
B. CHF A. dehydration
C. Secondary hypertension B. protein deficiency
D. Aneurysm C. bleeding disorders
D. vitamin deficiency
9. Nurse Fiona is caring a patient with Raynaud’s disease. Which
of the following outcomes concerning medication regimen is of 17. A client with rheumatoid arthritis may reveal which of the
highest priority? following assessment data:
A. Controlling the pain once vasospasm occur A. Heberden’s nodes
B. Relaxing smooth muscle to avoid vasospasms B. Morning stiffness no longer than 30 minutes
C. Preventing major disabilities that may occur C. Asymmetric joint swelling
D. Avoiding lesions on the feet D. Swan neck deformities

10. Mr. Roberto Robles complains of a severe headache and is 18. Elsa Santos is a 18 year old student admitted to the ward with
extremely anxious. The nurse checks his vital signs and finds him a diagnosis of epilepsy. She tells the nurse that she is experiencing
to have a heart rate of 57 bpm and a blood pressure of 230/110 a generalized tingling sensation and is “smelling roses”. The nurse
mmHg. The nurse should also assess for? understands that Esla is probably experiencing:
A. presence of bowel sounds A. an acute alcohol withdrawal
B. presence of babinski reflex B. an acute CVA
C. fecal incontinence C. an aura
D. urinary catheter patency D. an olfactory hallucination

11. A 40n year old male patient is complaining of chronic 19. Mr. Lucas, a 63 year old, went to the clinic complaining of
progressive and mental deterioration is admitted to the unit. The hoarseness of voice and a cough. His wife states that his voice has
nurse recognizes that these characteristics indicate a disease that changed in the last few months. The nurse interprets that Mr.
results in degeneration of the basal ganglia and cerebral cortex. Lucas’s symptoms are consistent with which of the following
The disease is called: disorders:
A. multiple sclerosis A. chronic sinusitis
B. myasthenia gravis B. laryngeal cancer
C. Huntington’s disease C. gastroesophageal reflux disease
D. Guillain-Barre syndrome D. coronary artery disease

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20. Sarah complains of a nursing sensation, cramping pain in the Answers and Rationales
top part of her abdomen that becomes worse in the afternoon and
sometimes awakes her at night. She reports that when she eats, it 1. C. The relationship of symptoms and a specific trigger such as
helps the pain go away but that pain is now becoming more physical exercise. COPD clients have low oxygen and high
intense. Which of the following is the best condition for the nurse carbon dioxide levels. Therefore, hypoxia is the main stimulus
for ventilation is persons with chronic hypercapnea. Increasing
to draw: the level of oxygen would decrease the stimulus to breathe.
2. D. persistent changing cough. The most common sign of lung
A. these symptoms are consistent with an ulcer cancer is a persistent cough that changes. Other signs are
B. The client probably has indigestion dyspnea, bloody sputum and long term pulmonary infection.
Option A is common with asthma, option B is common with
C. A snack before going to bed should be advised COPD and option C is common with TB.
D. The client probably developing cholelithiasis 3. C. ischemia. Depressed ST segment and inverted T-waves
represent myocardial ischemia. Injury has a ST segment
21. Nurse Cynthia is providing a discharge teaching to a client elevation.
with chronic cirrhosis. His wife asks her to explain why there is so 4. A. promote healing. Sitz bath provides moist heat to the perineal
much emphasis on bleeding precautions. Which of the following and anal area to clean, promote healing and drainage and reduce
provides the most appropriate response? soreness to the area. Sitz bath helps healing with cleaning action
and promotion of circulation, thereby reducing swelling. Sitz
bath usually has no therapeutic value in lowering body
A. “The low protein diet will result in reduced temperature. Although relief of tension can occur, this effect is
clotting.” secondary to the promotion of healing.
B. “The increased production of bile decreases 5. B. hypocalcemia. Trousseau’s sign is a carpal pedal spasm
clotting factors.” elicited when a blood pressure cuff is inflated on the arm of a
patient with hypocalcemia.
C. “The liver affected by cirrhosis is unable to 6. C. meningitis. A patient with meningitis will exhibit signs that
produce clotting factors.” include photophobia and nuchal rigidity, which is pain on the
D. “The required medications reduce clotting flexion of the chin to chest.
factors.” 7. C. female over 55 years of age. Lifestyle, cigarette smoking and
hyperlipidemia can be changed by changing behaviors.
22. Betty Lee is a 58 year old woman who is being admitted to the 8. D. Aneurysm. The symptoms exhibited by the client are typical
medical ward with trigeminal neuralgia. The nurse anticipates that of an abdominal aortic aneurysm. The most significant sign is
Mr. Lee will demonstrate which of the following major the audible pulse in the abdominal area. If hemorrhage were
present, the abdomen would be tender and firm.
complaints? 9. B. Relaxing smooth muscle to avoid vasospasms. The major
A. excruciating, intermittent, paroxysmal facial pain task of the health care team is to medicate the client drugs that
B. unilateral facial droop produce smooth muscle relaxation, which will decrease the
C. painless eye spasm vasospasm and increase the arterial flow to the affected part.
D. mildly painful unilateral eye twitching The drugs used are calcium antagonists.
10. D. urinary catheter patency. The patient is complaining of
23. A 38 year old woman returns from a subtotal thryroidectomy symptoms of autonomic dysreflexia, which consists of the triad
for the treatment of hyperthyroidism. Upon assessment, the of hypertension, bradycardia and a headache. Major causes of
autonomic dysreflexia include urinary bladder distention and
immediate priority that the nurse would include is: fecal impaction. Checking the patency of the urinary catheter
will check for bladder distention.
A. Assess for pain 11. C. Huntington’s disease. Huntington’s disease is a hereditary
B. Assess for neurological status disease in which degeneration of the basal ganglia and cerebral
cortex causes chronic progressive chorea (muscle twitching) and
C. Assess fluid volume status mental deterioration, ending in dementia. Huntington’s disease
D. Assess for respiratory distress usually strikes people ages 25 to 55.
12. D. metabolic alkalosis. Ms. Hizon’s pH is above 7.45, which
24. Nurse Shiela is teaching self-care to a client with psoriasis. makes it alkalatic, and her bicarbonate is high which is also
The nurse should encourage which of the following for his scaled makes it basic. Thus, the diagnosis is metabolic alkalosis.
lesion? 13. B. hold an object. The resting or non-intentional tremor may be
controlled with purposeful movement such as holding an object.
A warm bath, deep breathing and diazepam will promote
A. Importance of follow-up appointments relaxation but are not specific interventions for tremor.
B. Emollients and moisturizers to soften scales 14. A. Parkinson’s disease. A shuffling gait from the
C. Keep occlusive dressings on the lesions 24 hours a musculoskeletal rigidity of the patient with Parkinson’s disease
day is common. Patients experiencing a stroke usually exhibit loss of
D. Use of a clean razor blade each time he shaves voluntary control over motor movements associated with
generalized weakness; a shuffling gait is usually not observed in
stroke patient.
25. A 48 year old woman presents to the hospital complaining of 15. C. a ventilator on stand by. Although a ventilator is not required
chest pain, tachycardia and dyspnea. On exam, heart sounds are for injury below C3, the innervation of intercostal muscles is
muffled. Which of the following assessment findings would affected. Hemorrhage and cord swelling extends the level of
support a diagnosis of cardiac tamponade? injury making it likely that this client will need a ventilator.
16. B. protein deficiency. Protein deficiency allows fluid to leak out
of the vascular system and third space into the tissues and
A. A deviated trachea spaces in the body such as the peritoneal space. Bleeding
B. Absent breath sounds to the lower lobes tendencies, dehydration and vitamin deficiency can occur but
C. Pulse 40 with inspiration don’t cause ascites.
D. Blood pressure 140/80 17. D. Swan neck deformities. Swan neck deformities of the hand
are classic deformities associated with rheumatoid arthritis

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secondary to the presence of fibrous connective tissue within the 3. A client was involved in a motor vehicular accident in which
joint space. Clients with RA do experience morning stiffness, the seat belt was not worn. The client is exhibiting crepitus,
but it can last from 30 minutes up to several hours. RA is decrease breath sounds on the left, complains of shortness of
characterized by symmetrical joint movement, and heberden’s
breath, and has a respiratory rate of 34 breaths per minute. Which
nodes are characteristic of osteoarthritis.
18. C. an aura. An aura frequently precedes an epileptic seizure and of the following assessment findings would concern the nurse
may manifest as vague physic discomfort or specific aromas. most?
Patients experiencing auras aren’t having a CVA, substance
withdrawal or hallucination.
A. Temperature of 102 degrees F and productive
19. B. laryngeal cancer. These symptoms, along with dysphagia,
foul-smelling breath, and pain when drinking hot or acidic, are cough
common signs of laryngeal cancer. B. ABG with PaO2 of 92 and PaCO2 of 40 mmHg
20. A. these symptoms are consistent with an ulcer. The description C. Trachea deviating to the right
of pain is consistent with ulcer pain. The pain is epigastric and is D. Barrel-chested appearance
worse when the stomach is empty and is relived by food.
21. C. “The liver affected by cirrhosis is unable to produce clotting 4. The proper way to open an envelop-wrapped sterile package
factors.” When bile production is reduced, the body has reduced after removing the outer package or tape is to open the first
ability to absorb fat-soluble vitamins. Without adequate Vitamin
position of the wrapper:
K absorption, clotting factors II, VII, IX, and X are not
produced in sufficient amounts.
22. A. excruciating, intermittent, paroxysmal facial pain. Trigeminal A. away from the body
neuralgia is a syndrome of excruciating, intermittent, B. to the left of the body
paroxysmal facial pain. It manifests as intense, periodic pain in
C. to the right of the body
the lips, gums, teeth or chin. The other symptoms aren’t
characteristic of trigeminal neuralgia. D. toward the body
23. D. Assess for respiratory distress. Though fluid volume status,
neurological status and pain are all important assessment, the 5. Assessment of a client with possible thrombophlebitis to the left
immediate priority for postoperative is the airway management. leg and a deep vein thrombosis is done by pulling up on the toes
Respiratory distress may result from hemorrhage, edema, while gently holding down on the knee. The client complains of
laryngeal damage or tetany. extreme pain in the calf. This should be documented as:
24. B. Emollients and moisturizers to soften scales. Emollients will
ease dry skin that increases pruritus and causes psoriasis to be
worse. Washing and drying the skin with rough linens or A. positive tourniquet test
pressure may cause excoriation. Constant occlusion may B. positive homan’s sign
increase the effects of the medication and increase the risk of C. negative homan’s sign
infection. D. negative tourniquet test
25. C. Pulse 40 with inspiration. Paradoxical pulse is a hallmark
symptom of cardiac tamponade. As pressure is exerted on the
left ventricle from fluid, the natural increase in pressure from
6. Thomas Elison is a 79 year old man who is admitted with
the right ventricle during inspiration creates even more pressure, diagnosis of dementia. The doctor orders a series of laboratory
diminishing cardiac output. tests to determine whether Mr. Elison’s dementia is treatable. The
nurse understands that the most common cause of dementia in this
population is:

Medical Surgical Nursing Exam 4 A. AIDS

B. Alzheimer’s disease
1. A patient is admitted to the medical surgical unit following C. Brain tumors
surgery. Four days after surgery, the patient spikes a 38.9 degrees D. Vascular disease
C oral temperature and exhibits a wet, productive cough. The
nurse assesses the patient with understanding that an infection that 7. Which of the following nursing interventions is contraindicated
is acquired during hospitalization is known as: in the care of a client with acute osteomyelitis?

A. a community acquired infection A. Apply heat compress to the affected area

B. an iatrogenic infection B. Immobilize the affected area
C. a nosocomial infection C. Administer narcotic analgesics for pain
D. an opportunistic infection D. Administer OTC analgesics for pain

2. A client with anemia has a hemoglobin of 6.5 g/dL. The client 8. A client with congestive heart failure has digoxin (Lanoxin)
is experiencing symptoms of cerebral tissue hypoxia. Which of the ordered everyday. Prior to giving the medication, the nurse checks
following nursing interventions would be most important in the digoxin level which is therapeutic and ausculates an apical
providing care? pulse. The apical pulse is 63 bpm for 1 full minute. The nurse
should:
A. Providing rest periods throughout the day
B. Instituting energy conservation techniques A. Hold the Lanoxin
C. Assisting in ambulation to the bathroom B. Give the half dose now, wait an hour and give the
D. Checking temperature of water prior to bathing other half
C. Call the physician
D. Give the Lanoxin as ordered

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9. Nurse Marian is caring for a client with haital hernia, which of 17. Mang Edison is on bed rest has developed an ulcer that is full
the following should be included in her teaching plan regarding thickness and is penetrating the subcutaneous tissue. The nurse
causes: documents that this ulcer is in which of the following stages?

A. To avoid heavy lifting A. Stage 1

B. A dietary plan based on soft foods B. Stage 2
C. Its prevalence in young adults C. Stage 3
D. Its prevalence in fair-skinned individuals D. Stage 4

10. Joseph has been diagnosed with hepatic encephalopathy. The 18. A 24 year old male patient comes to the clinic after contracting
nurse observes flapping tremors. The nurse understands that genital herpes. Which of the following intervention would be most
flapping tremors associated with hepatic encephalopathy are also appropriate?
known as:
A. Encourage him to maintain bed rest for several
A. aphasia days
B. ascites B. Monitor temperature every 4 hours
C. astacia C. Instruct him to avoid sexual contact during acute
D. Asterixis phases of illness
D. Encourage him to use antifungal agents regularly
11. Hyperkalemia can be treated with administration of 50%
dextrose and insulin. The 50% dextrose: 19. An 8 year old boy is brought to the trauma unit with a
chemical burn to the face. Priority assessment would include
which of the following?
A. causes potassium to be excreted
B. causes potassium to move into the cell
C. causes potassium to move into the serum A. Skin integrity
D. counteracts the effects of insulin B. BP and pulse
C. Patency of airway
12. Which of the following findings would strongly indicate the D. Amount of pain
possibility of cirrhosis?
A. dry skin 20. A client with anemia due to chemotherapy has a hemoglobin
B. hepatomegaly of 7.0 g/dL. Which of the following complaints would be
C. peripheral edema indicative of tissue hypoxia related to anemia?
D. Pruritus
A. dizziness
13. Aling Puring has just been diagnosed with close-angle
B. fatigue relieved by rest
(narrow-angle) glaucoma. The nurse assesses the client for which
C. skin that is warm and dry to the touch
of the following common presenting symptoms of the disorder?
D. Apathy
A. halo vision
B. dull eye pain
21. Hazel Murray, 32 years old complains of abrupt onset of chest
C. severe eye and face pain
and back pain and loss of radial pulses. The nurse suspects that
D. impaired night vision
Mrs. Murray may have:
14. Chvostek’s sign is associated with which electrolyte
impabalnce? A. Acute MI
A. hypoclacemia B. CVA
B. hypokalemia C. Dissecting abdominal aorta
C. hyponatremia D. Dissecting thoracic aneurysm
D. Hypophosphatenia
22. Nurse Alexandra is establishing a plan of care for a client
15. What laboratory test is a common measure of the renal newly admitted with SIADH. The priority diagnosis for this client
function? would be which of the following?
A. CBC
B. BUN/Crea A. Fluid volume deficit
C. Glucose B. Anxiety related to disease process
D. Alanine amino transferase (ALT) C. Fluid volume excess
D. Risk for injury
16. Nurse Edward is performing discharge teaching for a newly
diagnosed diabetic patient scheduled for a fasting blood glucose 23. Nursing management of the client with a UTI should include:
test. The nurse explains to the patient that hyperglycemia is
defined as a blood glucose level above:
A. 100 mg/dl A. Taking medication until feeling better
B. 120 mg/dl B. Restricting fluids
C. 130 mg/dl C. Decreasing caffeine drinks and alcohol
D. 150 mg/dl D. Douching daily

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24. Felicia Gomez is 1 day postoperative from coronary artery 10. D. asterixis. Flapping tremors associated with hepatic
bypass surgery. The nurse understands that a postoperative patient encephalophaty are asterixis. Aphasia is the inability to speak.
who’s maintained on bed rest is at high risk for developing: Ascites is an accumulation of fluid in the peritoneal cavity. Astacia
is the inability to stand or sit still.
11. D. counteracts the effects of insulin. The 50% dextrose is given to
A. angina counteract the effects of insulin. Insulin drives the potassium into
B. arterial bleeding the cell, thereby lowering the serum potassium levels. The dextrose
C. deep vein thrombosis (DVT) doesn’t directly cause potassium excretion or any movement of
potassium.
D. dehiscence of the wound
12. B. hepatomegaly. Although option D is correct, it is not a strong
indicator of cirrhosis. Pruritus can occur for many reasons. Options
25. Which of the following statement is true regarding the visual A and C are incorrect, fluid accumulations is usually in the form of
changes associated with cataracts? ascites in the abdomen. Hepatomegaly is an enlarged liver, which is
correct. The spleen may also be enlarged.
13. C. severe eye and face pain. Narrow-angle glaucoma develops
A. Both eyes typically cataracts at the same time abruptly and manifests with acute face and eye pain and is a medial
B. The loss of vision is experienced as a painless, emergency. Halo vision, dull eye pain and impaired night vision are
gradual blurring symptoms associated with open-angle glaucoma.
C. The patient is suddenly blind 14. A. hypoclacemia. Chvostek’s sign is a spasm of the facial muscles
D. The patient is typically experiences a painful, elicited by tapping the facial nerve and is associated with
sudden blurring of vision. hypocalcemia. Clinical signs of hypokalemia are muscle weakness,
leg cramps, fatigue, nausea and vomiting. Muscle cramps, anorexia,
nausea and vomiting are clinical signs of hyponatremia. Clinical
Answers and Rationales
manifestations associated with hypophosphatemia include muscle
pain, confusion, seizures and coma.
1. C. a nosocomial infection. Nosocomial, or hospital-acquired are 15. B. BUN/Crea. The BUN is primarily used as indicator of kidney
infections acquired during hospitalization for which the patient isn’t function because most renal diseases interfere with its excretion and
being primarily treated. Community acquired or opportunistic cause blood vessels to rise. Creatinine is produced in relatively
infections may not be acquired during hospitalization. An iatrogenic constant amounts, according to the amount of muscle mass and is
infection is caused by the doctor or by medical therapy. And an excreted entirely by the kidneys making it a good indicator of renal
opportunistic infection affects a compromised host. function.
2. C. Assisting in ambulation to the bathroom. Cerebral tissue hypoxia 16. B. 120 mg/dl. Hyperglycemia is defined as a blood glucose level
is commonly associated with dizziness. The greatest potential risk greater than 120 mg/dl. Blood glucose levels of 120 mg/dl, 130
to the client with dizziness is injury, especially with changes in mg/dl and 150 mg/dl are considered hyperglycemic. A blood
position. Planning for periods of rest and conserving energy are glucose of 100 mg/dl is normal.
important with someone with anemia because of his or her fatigue 17. C. Stage 3. A stage 3 ulcer is full thickness involving the
level but most important is safety. subcutaneous tissue. A stage 1 ulcer has a defined area of persistent
3. C. Trachea deviating to the right. A mediastinal shift is indicative of redness in lightly pigmented skin. A stage 2 ulcer involves partial
a tension pneumothorax along with the other symptoms in the thickness skin loss. Stage 4 ulcers extend through the skin and
question. Since the individual was involved in a MVA, assessment exhibit tissue necrosis and muscle or bone involvement.
would be targeted at acute traumatic injuries to the lungs, heart or 18. C. Instruct him to avoid sexual contact during acute phases of
chest wall rather than other conditions indicated in the other illness. Herpes is a virus and is spread through direct contact. An
answers. Option A is common with pneumonia; values in option B antifungal would not be useful; bed rest and temperature
are not alarming; and option D is typical of someone with COPD. measurement are usually not necessary.
4. A. away from the body. When opening an envelop-wrapped sterile 19. C. Patency of airway. A burn face, neck or chest may cause airway
package, reaching across the package and using the first motion to closure because of the edema that occurs within hours. Remember
open the top cover away from the body eliminates the need to later the ABC’s: airway, breathing and circulation. Airway always
reach across the steri9le field while opening the package. To comes first, even before pain. The nurse will also assess options B
remove equipment from the package, opening the first portion of and D, but these are not the highest priority assessments.
the package toward, to the left, or to the right of the body would 20. A. dizziness. Central tissue hypoxia is commonly associated with
require reaching across a sterile field. dizziness. Recognition of cerebral hypoxia is critical since the body
5. B. positive homan’s sign. Pain in the calf while pulling up on the will attempt to shunt oxygenated blood to vital organs.
toes is abnormal and indicates a positive test. If the client feels 21. D. Dissecting thoracic aneurysm. A dissecting thoracic aneurysm
nothing or just feels like the calf muscle is stretching, it is may cause loss of radical pulses and severe chest and back pain. An
considered negative. A tourniquet test is used to measure for MI typically doesn’t cause loss of radial pulses or severe back pain.
varicose veins. CVA and dissecting abdominal aneurysm are incorrect responses.
6. B. Alzheimer’s disease. Alzheimer’s disease is the most common 22. C. Fluid volume excess. SIADH results in fluid retention and
cause of dementia in the elderly population. AIDS, brain tumors hyponatremia. Correction is aimed at restoring fluid and electrolyte
and vascular disease are all less common causes of progressive loss balance. Anxiety and risk for injury should be addressed following
of mental function in elderly patients. fluid volume excess.
7. A. Apply heat compress to the affected area. Options B, C and D 23. C. Decreasing caffeine drinks and alcohol. Caffeine and alcohol can
are appropriate nursing interventions when caring for a client increase bladder spasms and mucosal irritation, thus increase the
diagnosed with osteomyelitis. The application of heat can increase signs and symptoms of UTI. All antibiotics should be taken
edema and pain in the affected area and spread bacteria through completely to prevent resistant strains of organisms.
vasodilation. 24. C. deep vein thrombosis (DVT). DVT, is the most probable
8. D. Give the Lanoxin as ordered. The Lanoxin should be held for a complication for postoperative patients on bed rest. Options A, B
pulse of 60 bpm. Nurses cannot arbitrarily give half of a dose and D aren’t likely complications of the post operative period.
without a physician’s order. Unless specific parameters are given 25. B. The loss of vision is experienced as a painless, gradual
concerning pulse rate, most resources identify 60 as the reference blurring. Typically, a patient with cataracts experiences painless,
pulse. gradual loss of vision. Although both eyes may develop at different
9. A. To avoid heavy lifting. Heavy lifting is one factor that leads to rates.
development of a hiatal hernia. Dietary factors involve limiting fat
intake, not restricting client to soft foods. It is more prevalent in
individuals who are middle-aged or older. Fair-skinned individuals
are not prone to this condition.
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8. As described by Erikson, the major psychosexual conflict of the
above situation is
Pediatric Nursing Exam A. Autonomy vs. Shame and doubt
B. Industry vs. Inferiority
C. Trust vs. mistrust
D. Initiation vs. Guilt
Situation 1: Raphael, a 6 year’s old prep pupil is seen at the
school clinic for growth and development monitoring 9. Which of the following is true about Mongolian Spots?
(Questions 1-5) A. Disappears in about a year
B. Are linked to pathologic conditions
1. Which of the following is characterized the rate of growth C. Are managed by tropical steroids
during this period? D. Are indicative of parental abuse

10. Signs of cold stress that the nurse must be alert when caring
A. most rapid period of growth for a Newborn is:
B. a decline in growth rate A. Hypothermia
C. growth spurt B. Decreased activity level
D. slow uniform growth rate C. Shaking
D. Increased RR
2. In assessing Raphael’s growth and development, the nurse is
guided by principles of growth and development. Which is not Situation 3 Nursing care after delivery has an important
included? aspect in every stages of delivery

A. All individuals follow cephalo-caudal and 11. After the baby is delivered, the cord was cut between two
proximo-distal clamps using a sterile scissors and blade, then the baby is placed at
B. Different parts of the body grows at different rate the:
C. All individual follow standard growth rate A. Mother’s breast
D. Rate and pattern of growth can be modified B. Mother’s side
C. Give it to the grandmother
3. What type of play will be ideal for Raphael at this period? D. Baby’s own mat or bed
A. Make believe
B. Hide and seek 12. The baby’s mother is RH(-). Which of the following
C. Peek-a-boo laboratory tests will probably be ordered for the newborn?
D. Building blocks A. Direct Coomb’s
B. Indirect Coomb’s
4. Which of the following information indicate that Raphael is C. Blood culture
normal for his age? D. Platelet count
A. Determine own sense self
B. Develop sense of whether he can trust the world 13. Hypothermia is common in newborn because of their inability
C. Has the ability to try new things to control heat. The following would be an appropriate nursing
D. Learn basic skills within his culture intervention to prevent heat loss except:
A. Place the crib beside the wall
5. Based on Kohlberg’s theory, what is the stage of moral B. Doing Kangaroo care
development of Raphael? C. By using mechanical pressure
A. Punishment-obedience D. Drying and wrapping the baby
B. “good boy-Nice girl”
C. naïve instrumental orientation 14. The following conditions are caused by cold stress except
D. social contact A. Hypoglycemia
B. Increase ICP
Situation 2 Baby boy Lacson delivered at 36 weeks gestation C. Metabolic acidosis
weighs 3,400 gm and height of 59 cm (6-10) D. Cerebral palsy

6. Baby boy Lacson’s height is 15. During the feto-placental circulation, the shunt between two
atria is called
A. Ductus venosous
A. Long B. Foramen Magnum
B. Short C. Ductus arteriosus
C. Average D. Foramen Ovale
D. Too short
16. What would cause the closure of the Foramen ovale after the
7. Growth and development in a child progresses in the following baby had been delivered?
ways EXCEPT A. Decreased blood flow
A. From cognitive to psychosexual B. Shifting of pressures from right side to the left
B. From trunk to the tip of the extremities side of the heart
C. From head to toe C. Increased PO2
D. From general to specific D. Increased in oxygen saturation
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17. Failure of the Foramen Ovale to close will cause what
Congenital Heart Disease? 25. When assessing the fluid and electrolyte balance in an infant,
which of the following would be important to remember?
A. Total anomalous Pulmunary Artery
B. Atrial Septal defect A. Infant can concentrate urine at an adult level
C. Transposition of great arteries B. The metabolic rate of an infant is slower than in
D. Pulmunary Stenosis adults
C. Infants have more intracellular water that adult do
Situation 4 Children are vulnerable to some minor health D. Infant have greater body surface area than adults
problems or injuries hence the nurse should be able to teach
mothers to give appropriate home care. 26. When assessing a child with aspirin overdose, which of the
following will be expected?
18. A mother brought her child to the clinic with nose bleeding.
The nurse showed the mother the most appropriate position for the A. Metabolic alkalosis
child which is: B. Respiratory alkalosis
A. Sitting up C. Metabolic acidosis
B. With low back rest D. Respiratory acidosis
C. With moderate back rest
D. Lying semi flat 27. Which of the following is not a possible systemic clinical
manifestation of severe burns?
19. A common problem in children is the inflammation of the
middle ear. This is related to the malfunctioning of the:
A. Tympanic membrane A. Growth retardation
B. Eustachian tube B. Hypermetabolism
C. Adenoid C. Sepsis
D. Nasopharynx D. Blisters and edema

20. For acute otitis media, the treatment is prompt antibiotic 28. When assessing a family for potential child abuse risks, the
therapy. Delayed treatment may result in complications of: nurse would observe for which of the following?
A. Tonsillitis
B. Eardrum Problems A. Periodic exposure to stress
C. Brain damage B. Low socio-economic status
D. Diabetes mellitus C. High level of self esteem
D. Problematic pregnancies
21. When assessing gross motor development in a 3 year old,
which of the following activities would the nurse expect to finds? 29. Which of the following is a possible indicator of Munchausen
syndrome by proxy type of child abuse?
A. Riding a tricycle
B. Hopping on one foot A. Bruises found at odd locations, with different
C. Catching a ball stages of healing
D. Skipping on alternate foot. B. STD’s and genital discharges
C. Unexplained symptoms of diarrhea, vomiting and
22. When assessing the weight of a 5-month old, which of the apnea with no organic basis
following indicates healthy growth? D. Constant hunger and poor hygiene
A. Doubling of birth weight
B. Tripling of birth weight 30. Which of the following is an inappropriate interventions when
C. Quadrupling of birth weight caring for a child with HIV?
D. Stabilizing of birth weight

23. An appropriate toy for a 4 year old child is: A. Teaching family about disease transmission
B. Offering large amount of fresh fruits and
vegetables
A. Push-pull toys C. Encouraging child to perform at optimal level
B. Card games D. Teach proper hand washing technique
C. Doctor and nurse kits
D. Books and Crafts Situation 5 Agata, 2 years old is rushed to the ER due to
cyanosis precipitated by crying. Her mother observed that
24. Which of the following statements would the nurse expects a after playing she gets tired. She was diagnosed with Tetralogy
5-year old boy to say whose pet gerbil just died
of Fallot.

A. “The boogieman got him” 31. The goal of nursing care fro Agata is to:
B. “He’s just a bit dead” A. Prevent infection
C. “Ill be good from now own so I wont die like my B. Promote normal growth and development
gerbil” C. Decrease hypoxic spells
D. “Did you hear the joke about…” D. Hydrate adequately
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Situation 6 Laura is assigned as the Team Leader during the
32. The immediate nursing intervention for cyanosis of Agata is: immunization day at the RHU

A. Call up the pediatrician 39. What program for the DOH is launched at 1976 in cooperation
B. Place her in knee chest position with WHO and UNICEF to reduce morbidity and mortality among
C. Administer oxygen inhalation infants caused by immunizable disease?
D. Transfer her to the PICU
A. Patak day
33. Agata was scheduled for a palliative surgery, which creates B. Immunization day on Wednesday
anastomosis of the subclavian artery to the pulmonary artery. This C. Expanded program on immunization
procedure is: D. Bakuna ng kabtaan

A. Waterston-Cooley 40. One important principle of the immunization program is based

B. Raskkind Procedure on?
C. Coronary artery bypass
D. Blalock-Taussig A. Statistical occurrence
B. Epidemiologic situation
34. Which of the following is not an indicator that Agata C. Cold chain management
experiences separation anxiety brought about her hospitalization? D. Surveillance study

A. Friendly with the nurse 41. The main element of immunization program is one of the
B. Prolonged loud crying, consoled only by mother following?
C. Occasional temper tantrums and always says NO
D. Repeatedly verbalizes desire to go home A. Information, education and communication
B. Assessment and evaluation of the program
35. When Agata was brought to the OR, her parents where crying. C. Research studies
What would be the most appropriate nursing diagnosis? D. Target setting

A. Infective family coping r/t situational crisis 42. What does herd immunity means?
B. Anxiety r/t powerlessness
C. Fear r/t uncertain prognosis A. Interruption of transmission
D. Anticipatory grieving r/t gravity of child’s B. All to be vaccinated
physical status C. Selected group for vaccination
D. Shorter incubation
36. Which of the following respiratory condition is always
considered a medical emergency? 43. Measles vaccine can be given simultaneously. What is the
combined vaccine to be given to children starting at 15 months?
A. Laryngeotracheobronchitis (LTB)
B. Epiglottitis A. MCG
C. Asthma B. MMR
D. Cystic Fibrosis C. BCG
D. BBR
37. Which of the following statements by the family of a child
with asthma indicates a need for additional teaching? Situation 7: Braguda brought her 5-month old daughter in the
nearest RHU because her baby sleeps most of the time, with
A. “We need to identify what things triggers his decreased appetite, has colds and fever for more than a week.
attacks” The physician diagnosed pneumonia.
B. “He is to use bronchodilator inhaler before steroid
inhaler” 44. Based on this data given by Braguda, you can classify
C. “We’ll make sure he avoids exercise to prevent Braguda’s daughter to have:
asthma attacks”
D. “he should increase his fluid intake regularly to A. Pneumonia: cough and colds
thin secretions” B. Severe pneumonia
C. Very severe pneumonia
38. Which of the following would require careful monitoring in D. Pneumonia moderate
the child with ADHD who is receiving Methylphenidate (Ritalin)?
45. For a 3-month old child to be classified to have Pneumonia
A. Dental health (not severe), you would expect to find RR of:
B. Mouth dryness
C. Height and weight A. 60 bpm
D. Excessive appetite B. 40 bpm
C. 70 bpm
D. 50 pbm
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46. You asked Braguda if her baby received all vaccines under 54. When teaching a group of parents about seat belt use, when
EPI. What legal basis is used in implementing the UN’s goal on would the nurse state that the child be safely restrained in a regular
Universal Child Immunization? automobile seatbelt?

A. PD no. 996 A. 30 lb and 30 in

B. PD no. 6 B. 35 lb and 3 y/o
C. PD no. 46 C. 40 lb and 40 in
D. RA 9173 D. 60 lb and 6 y/o

47. Braguda asks you about Vitamin A supplementation. You 55. When assessing a newborn with cleft lip, the nurse would be
responded that giving Vitamin A starts when the infant reaches 6 alert which of the following will most likely be compromised?
months and the first dose is”
A. Sucking ability
A. 200,000 “IU” B. Respiratory status
B. 100,000 “IU” C. Locomotion
C. 500,000 “IU” D. GI function
D. 10,000 “IU”
56. For a child with recurring nephritic syndrome, which of the
48. As part of CARI program, assessment of the child is your main following areas of potential disturbances should be a prime
responsibility. You could ask the following question to the mother consideration when planning ongoing nursing care?
except:
A. “How old is the child?”
A. Muscle coordination
B. “IS the child coughing? For how long?”
B. Sexual maturation
C. “Did the child have chest indrawing?”
C. Intellectual development
D. “Did the child have fever? For how long?”
D. Body image
49. A newborn’s failure to pass meconium within 24 hours after
57. An inborn error of metabolism that causes premature
birth may indicate which of the following?
destruction of RBC?
A. Aganglionic Mega colon
B. Celiac disease
C. Intussusception A. G6PD
D. Abdominal wall defect B. Hemocystinuria
C. Phenylketonuria
50. The nurse understands that a good snack for a 2 year old with a D. Celiac Disease
diagnosis of acute asthma would be:
A. Grapes 58. Which of the following would be a diagnostic test for
B. Apple slices Phenylketonuria which uses fresh urine mixed with ferric
C. A glass of milk chloride?
D. A glass of cola
A. Guthrie Test
51. Which of the following immunizations would the nurse expect B. Phenestix test
to administer to a child who is HIV (+) and severely C. Beutler’s test
immunocomromised? D. Coomb’s test
A. Varicella
B. Rotavirus 59. Dietary restriction in a child who has Hemocystenuria will
C. MMR include which of the following amino acid?
D. IPV

52. When assessing a newborn for developmental dysplasia of the A. Lysine

hip, the nurse would expect to assess which of the following? B. Methionine
A. Symmetrical gluteal folds C. Isolensine tryptophase
B. Trendelemburg sign D. Valine
C. Ortolani’s sign
D. Characteristic limp 60. A milk formula that you can suggest for a child with
Galactosemia:
53. While assessing a male neonate whose mother desires him to
be circumcised, the nurse observes that the neonate’s urinary A. Lofenalac
meatus appears to be located on the ventral surface of the penis. B. Lactum
The physician is notified because the nurse would suspect which C. Neutramigen
of the following? D. Sustagen
A. Phimosis
B. Hydrocele
C. Epispadias
D. Hypospadias

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or incubators and drying and wrapping the baby will help
conserve heat.
Answers and Rationales 14. B. Increase ICP. Hypoglycemia may occur due to increase
metabolic rate, and because of newborns are born slightly acidic,
1. B. a decline in growth rate. During the Preschooler stage and they catabolize brownfat which will produce ketones which
growth is very minimal. Weight gain is only 4.5lbs (2kgs) per is an acid will cause metabolic acidosis. Also a NB with severe
year and Height is 3.5in (6-8cm) per year. hypothermia is in high risk for kernicterus (too much bilirubin in
the brain) can lead to Cerebral palsy. There is no connection in
 Review:
the increase of ICP with hypothermia. (NOTE: pathognomonic
 Most rapid growth and development- Infancy sign of Kernicterus in adult- asterexis, or involuntary flapping of
 Slow growth- Toddler hood and Preschooler the hand.)
 Slower growth- School age 15. D. Foramen Ovale. Foramen ovale is opening between two atria,
 Rapid growth- Adolescence Ductus venosus is the shunt from liver to the inferior vena cava,
2. D. Rate and pattern of growth can be modified. Growth and and your Ductus Arteriosus is the shunt from the pulmonary
development occurs in cephalo-caudal meaning development artery to the aorta.
occurs through out the body’s axis. Example: the child must be 16. B. Shifting of pressures from right side to the left side of the
able to lift the head before he is able to lift his chest. heart. During feto-placental circulation, the pressure in the heart
Proximo-distal is development that progresses from center of the is much higher in the right side, but once breathing/crying is
body to the extremities. Example: a child first develops arm established, the pressure will shift from the R to the L side, and
movement before fine-finger movement. Different parts of the will facilitate the closure of Foramen Ovale. (Note: that is why
body grows at different range because some body tissue mature you should position the NB in R side lying position to increase
faster than the other such as the neurologic tissues peaks its pressure in the L side of the heart.)
growth during the first years of life while the genital tissue  Review:
doesn’t till puberty. Also G&D is predictable in the sequence  Increase PO2-> closure of ductus arteriosus
which a child normally precedes such as motor skills and  Decreased bloodflow -> closure of the ductus venosus
behavior. Lastly G&D can never be modified .
 Circulation in the lungs is initiated by -> lung expansion and
3. A. Make believe. Make believe is most appropriate because it
pulmonary ventilation
enhances the imitative play and imagination of the preschooler.
C and D are for infants while letter A is B is recommended for  What will sustain 1st breath-> decreased artery pressure
schoolers because it enhances competitive play.  What will complete circulation-> cutting of the cord
4. C. Has the ability to try new things. Erickson defines the 17. B. Atrial Septal defect. Foramen ovale is the opening between
developmental task of a preschool period is learning Initiative vs. two Atria so, if its will not close Atrial Septal defect can occur.
Guilt. Children can initiate motor activities of various sorts on 18. A. Sitting up. The correct position is making the child having an
their own and no longer responds to or imitate the actions of upright sitting position with the head slightly tilted forward.
other children or of their parents. This position will minimize the amount of blood pressure in
5. C. naïve instrumental orientation. According to Kohlber, a nasal vessels and keep blood moving forward not back into the
preschooler is under Pre-conventional where a child learns about nasopharynx, which will have the choking sensation and
instrumental purpose and exchange, that is they will something increase risk of aspiration. Choices b, c, d, are inappropriate
do for another if that that person does something with the child cause they can cause blood to enter the nasopharynx.
in return. Letter A is applicable for Toddlers and letter B is for a 19. B. Eustachian tube. This is because children has short,
School age child. horizontal Eustachian tubes. The dysfunction in the Eustachian
6. A. Long. The average length of full-term babies at birth is 20 in. tube enables bacterial invasion of the middle ear and obstructs
(51 cm), although the normal range is 46 cm (18 in.) to 56 cm drainage of secretions.
(22 in.). 20. C. Brain damage. One of the complication of recurring acute
7. A. From cognitive to psychosexual. Growth and development otitis media is risk for having Meningitis, thereby causing
occurs in cephalo-caudal (head to toe), proximo-distal (trunk to possible brain damage. That is why patient must follow a
tips of the extremities and general to specific, but it doesn’t complete treatment regimen and follow up care. A,B and D are
occurs in cognitive to psychosexual because they can develop at not complications of AOM.
the same time. 21. A. Riding a tricycle. Answer is A, riding a tricycle is appropriate
8. C. Trust vs. mistrust. According to Erikson, children 0-18 for a 3 y/o child. Hopping on one foot can be done by a 4 y/o
months are under the developmental task of Trust vs. Mistrust. child, as well as catching and throwing a ball over hand.
9. A. Disappears in about a year. Mongolian spots are stale grey or Skipping can be done by a 5 y/o.
bluish patches of discoloration commonly seen across the 22. A. Doubling of birth weight. During the first 6 months of life the
sacrum or buttocks due to accumulation of melanocytes and weight from birth will be doubled and as soon as the baby
they disappears in 1 year. They are not linked to steroid use and reaches 1 year, its birth weight is tripled.
pathologic conditions. 23. C. Doctor and nurse kits. Letter C is appropriate because it will
10. D. Increased RR. Hypothermia is inaccurate cause normally, enhance the creativity and imagination of a pre-school child.
temperature of a newborn drop, Also a child under cold stress Letter B and D are inappropriate because they are too complex
will kick and cry to increase the metabolic rate thereby for a 4 y/o. Push-pull toys are recommended for infants.
increasing heat so B isn’t a good choice. A newborn doesn’t 24. B. “He’s just a bit dead”. A 5 y/o views death in “degrees”, so
have the ability to shiver, so letter B and C is wrong. A newborn the child most likely will say that “he is just a bit dead”.
will increase its RR because the NB will need more oxygen Personification of death like boogeyman occurs in ages 7 to 9 as
because of too much activity. well as denying death can if they will be good. Denying death
11. A. Mother’s breast. Place it at the mother’s breast for latch-on. using jokes and attributing life qualities to death occurs during
(Note: for NSD breast feed ASAP while for CS delivery, breast age 3-5.
feed after 4 hours) 25. D. Infant have greater body surface area than adults. Infants
12. A. Direct Coomb’s. Coomb’s test is the test to determine if RH have greater body surface area than adult, increasing their risk to
antibodies are present. Indirect Coomb’s is done to the mother F&E imbalances. Also infants cant concentrate a urine at an
and Direct Coomb’s is the one don’t to the baby. Blood culture adult level and their metabolic rate, also called water turnover, is
and Platelet count doesn’t help detect RH antibodies. 2 to 3 times higher than adult. Plus more fluids of the infants are
13. A. Place the crib beside the wall. Placing the crib beside the wall at the ECF spaces not in the ICF spaces.
is inappropriate because it can provide heat loss by radiation. 26. C. Metabolic acidosis. Remember that Aspirin is acid
Doing Kangaroo care or hugging the baby, mechanical pressure (Acetylsalicylic ACID).

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27. D. Blisters and edema. The question was asking for a 37. C. “We’ll make sure he avoids exercise to prevent asthma
SYSTEMIC clinical manifestation, Letters A,B and C are attacks”. Asthmatic children don’t have to avoid exercise. They
systemic manifestations while Blisters and Edema weren’t. can participate on physical activities as tolerated. Using a
28. D. Problematic pregnancies. Typical factors that may be risk for bronchodilator before administering steroids is correct because
Child abuse are problematic pregnancies, chronic exposure to steroids are just anti-inflammatory and they don’t have effects
stress not periodic, low level of self esteem not high level. Also on the dilation of the bronchioles. OF course letters A and B are
child abuse can happen in all socio-economic status not just on obviously correct.
low socio-economic status. 38. C. Height and weight. Dental problems are more likely to occur
29. C. Unexplained symptoms of diarrhea, vomiting and apnea with in children under going TCA therapy. Mouth dryness is a
no organic basis. Munchausen syndrome by Proxy is the expected side effects of Ritalin since it activates the SNS. Also
fabrication or inducement of an illness by one person to another loss of appetite is more likely to happen, not increase in appetite.
person, usually mother to child. It is characterized by symptoms The correct answer is letter C, because Ritalin can affect the
such as apnea and siezures, which may be due to suffocation, child’s G&D. Intervention: medication “holidays or vacation”.
drugs or poisoning, vomiting which can be induced with poisons (This means during weekends or holidays or school vacations,
and diarrhea with the use of laxatives. Letter A can be seen in a where the child wont be in school, the drug can be withheld.)
Physical abuse, Letter B for sexual abuse and Letter C is for 39. C. Expanded program on immunization
Physical Neglect. 40. B. Epidemiologic situation. Letters A, C and D are not included
30. B. Offering large amount of fresh fruits and vegetables. A child in the principles of EPI.
with HIV is immunocompromised. Fresh fruits and vegetables, 41. D. Target setting
which may be contaminated with organisms and pesticides can 42. A. Interruption of transmission
be harmful, if not fatal to the child, therefore these items should 43. B. MMR. MMR or Measles, Mumps, Rubella is a vaccine
be avoided. furnished in one vial and is routinely given in one injection
31. C. Decrease hypoxic spells. The correct answer is letter C. (Sub-Q). It can be given at 15 months but can also be given as
Though letter B would be a good answer too, this goal is too early as 12th month.
vague and not specific. Nursing interventions will not solely 44. B. Severe pneumonia. For a child aging 2months up to 5 years
promote normal G&D unless he will undergo surgical repair. So old can be classified to have sever pneumonia when he have any
decreasing Hypoxic Spells is more SMART. Letter A and D are of the following danger signs:
inappropriate.  Not able to drink
32. B. Place her in knee chest position. The immediate intervention  Convulsions
would be to place her on knee-chest or “squatting” position
because it traps blood into the lower extremities. Though also
 Abnormally sleepy or difficult to wake
letter C would be a good choice but the question is asking for  Stridor in calm child or
“Immediate” so letter B is more appropriate. Letter A and D are  Severe under-nutrition
incorrect because its normal for a child who have ToF to have 45. D. 50 pbm. A child can be classified to have Pneumonia (not
hypoxic or “tets” spells so there is no need to transfer her to the severe) if:
NICU or to alert the Pediatrician.  the young infant is less than 2 months- 60 bpm or more
33. D. Blalock-Taussig. Blalock-Taussig procedure its just a  if the child is 2 months up to less than 12 months- 50 bpm or
temporary or palliative surgery which creates a shunt between more
the aorta and pulmonary artery so that the blood can leave the  if the child is 12 months to 4 y/o- 40 bpm or more
aorta and enter the pulmonary artery and thus oxygenating the 46. B. PD no. 6 Presidential Proclamation no. 6 (April 3, 1986) is
lungs and return to the left side of the heart, then to the aorta the “Implementing a United Nations goal on Universal Child
then to the body. This procedure also makes use of the Immunization by 1990”. PD 996 (September 16, 1976) is
subclavian vein so pulse is not palpable at the right arm. The full “providing for compulsory basic immunization for infants and
repair for ToF is called the Brock procedure. Raskkind is a children below 8 years of age. PD no. 46 (September 16, 1992)
palliative surgery for TOGA. is the “Reaffirming the commitment of the Philippines to the
34. A. Friendly with the nurse. Because toddlers views universal Child and Mother goal of the World Health Assembly.
hospitalization is abandonment, separation anxiety is common. RA 9173 is of course the “Nursing act of 2002”
Its has 3 phases: PDD (parang c puff daddy LOL) 1. Protest 2. 47. B. 100,000 “IU”. An infant aging 6-11 months will be given
despair 3. detachment (or denial). Choices B, C, D are usually Vitamin supplementation of 100, 000 IU and for Preschoolers
seen in a child with separation anxiety (usually in the protest ages 12-83 months 200,000 “IU” will be given.
stage). 48. C. “Did the child have chest indrawing?”. The CARI program of
 REVIEW: the DOH includes the “ASK” and “LOOK, LISTEN” as part of
 Separation anxiety begin at: 9 months the assessment of the child who has suspected Pneumonia.
 Peaks: 18 months Choices A, B and D are included in the “ASK” assessment
35. D. Anticipatory grieving r/t gravity of child’s physical status. In while Chest indrawings is included in the “LOOK, LISTEN”
this item letter A and be are inappropriate response so remove and should not be asked to the mother.
them. The possible answers are C and D. Fear defined as the 49. A. Aganglionic Mega colon. Failure to pass meconium of
perceived threat (real or imagined) that is consciously Newborn during the first 24 hours of life may indicate
recognized as danger (NANDA) is applicable in the situation Hirschsprung disease or Congenital Aganglionic Megacolon, an
but its defining characteristics are not applicable. Crying per se anomaly resulting in mechanical obstruction due to inadequate
can not be a subjective cue to signify fear, and most of the motility in an intestinal segment. B, C, and D are not associated
symptoms of fear in NANDA are physiological. Anticipatory in the failure to pass meconium of the newborn.
grieving on the other hand are intellectual and EMOTIONAL 50. B. Apple slices. Grapes is in appropriate because of its “balat”
responses based on a potential loss. And remember that that can cause choking. A glass of milk is not a good snack
procedures like this cannot assure total recovery. So letter D is a because it’s the most common cause of Iron-deficiency anemia
more appropriate Nursing diagnosis. in children (milk contains few iron), A glass of cola is also not
36. B. Epiglottitis. Acute and sever inflammation of the epiglottis appropriate cause it contains complex sugar. (walang kinalaman
can cause life threatening airway obstruction, that is why its ang asthma dahil ala naman itong diatery restricted foods na
always treated as a medical emergency. NSG intervention : nasa choices.)
Prepare tracheostomy set at bed side. LTB, can also cause 51. D. IPV. IPV or Inactivated polio vaccine does not contain live
airway obstruction but its not an emergency. Asthma is also not micro organisms which can be harmful to an
an emergency. CF is a chronic disease, so its not a medical immunocompromised child. Unlike OPV, IPV is administered
emergency. via IM route.

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52. C. Ortolani’s sign. Correct answer is Ortolani’s sign; it is the
abnormal clicking sound when the hips are abducted. The sound
is produced when the femoral head enters the acetabulum. Letter
A is wrong because its should be “asymmetrical gluteal fold”.
Letter B and C are not applicable for newborns because they are
seen in older children.
53. D. Hypospadias. Hypospadias is a c condition in which the
urethral opening is located below the glans penis or anywhere
along the ventral surface of the penile shaft. Epispadias, the
urethral meatus is located at the dorsal surface of the penile
shaft. (Para di ka malilto, I-alphabetesize mo Dorsal, (Above) eh
mauuna sa Ventral (Below) , Epis mauuna sa Hypo.)
54. C. 40 lb and 40 in. Basta tandaan ang rule of 4! 4 years old, 40
lbs and 40 in.
55. A. Sucking ability. Because of the defect, the child will be
unable to form the mouth adequately arounf the nipple thereby
requiring special devices to allow feeding and sucking
gratification. Respiratory status may be compromised when the
child is fed improperly or during post op period.
56. D. Body image. Because of edema, associated with nephroitic
syndrome, potential self concept and body image disturbance
related to changes in appearance and social isolation should be
considered.
57. A. G6PD. G6PD is the premature destruction of RBC when the
blood is exposed to antioxidants, ASA (ano un? Aspirin),
legumes and flava beans.
58. B. Phenestix test. Phenestix test is a diagnostic test which uses a
fresh urine sample (diapers) and mixed with ferric chloride. If
positive, there will be a presence of green spots at the diapers.
Guthrie test is another test for PKU and is the one that mostly
used. The specimen used is the blood and it tests if CHON is
converted to amino acid.
59. B. Methionine. Hemocystenuria is the elevated excretion of the
amino acid hemocystiene, and there is inability to convert the
amino acid methionine or cystiene. So dietary restriction of this
amino acids is advised. This disease can lead to mental
retardation.
60. C. Neutramigen. Neutramien is suggested for a child with
Galactosemia. Lofenalac is suggested for a child with PKU.

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Philippine Nursing Licensure 6. A 16-year-old primigravida arrives at the labor and birthing unit
in her 38th week of gestation and states that she is labor. To verify
Examination 100 Items that the client is in true labor nurse Trina should:

A. Obtain sides for a fern test

1. A 10 year old who has sustained a head injury is brought to the
B. Time any uterine contractions
emergency department by his mother. A diagnosis of a mild
C. Prepare her for a pelvic examination
concussion is made. At the time of discharge, nurse Ron should
D. Apply nitrazine paper to moist vaginal tissue
instruct the mother to:
7. As part of the diagnostic workup for pulmonic stenosis, a child
A. Withhold food and fluids for 24 hours. has cardiac catheterization. Nurse Julius is aware that children
B. Allow him to play outdoors with his friends. with pulmonic stenosis have increased pressure:
C. Arrange for a follow up visit with the child’s
primary care provider in one week.
A. In the pulmonary vein
D. Check for any change in responsiveness every two
B. In the pulmonary artery
hours until the follow-up visit.
C. On the left side of the heart
D. On the right side of the heart
2. A male client has suffered a motor accident and is now
suffering from hypovolemic shock. Nurse Helen should frequency
8. An obese client asks nurse Julius how to lose weight. Before
assess the client’s vital signs during the compensatory stage of
answering, the nurse should remember that long-term weight loss
shock, because:
occurs best when:

A. Arteriolar constriction occurs

A. Eating patterns are altered
B. The cardiac workload decreases
B. Fats are limited in the diet
C. Decreased contractility of the heart occurs
C. Carbohydrates are regulated
D. The parasympathetic nervous system is triggered
D. Exercise is a major component
3. A paranoid male client with schizophrenia is losing weight,
9. As a very anxious female client is talking to the nurse May, she
reluctant to eat, and voicing concerns about being poisoned. The
starts crying. She appears to be upset that she cannot control her
best intervention by nurse Dina would be to:
crying. The most appropriate response by the nurse would be:

A. Allow the client to open canned or pre-packaged

A. “Is talking about your problem upsetting you?”
food
B. “It is Ok to cry; I’ll just stay with you for now”
B. Restrict the client to his room until 2 lbs are
C. “You look upset; lets talk about why you are
gained
crying.”
C. Have a staff member personally taste all of the
D. “Sometimes it helps to get it out of your system.”
client’s food
D. Tell the client the food has been x-rayed by the
10. A patient has partial-thickness burns to both legs and portions
staff and is safe
of his trunk. Which of the following I.V. fluids is given first?
4. One day the mother of a young adult confides to nurse Frida
that she is very troubled by he child’s emotional illness. The A. Albumin
nurse’s most therapeutic initial response would be: B. D5W
C. Lactated Ringer’s solution
D. 0.9% sodium chloride solution with 2 mEq of
A. “You may be able to lessen your feelings of guilt
potassium per 100 ml
by seeking counseling”
B. “It would be helpful if you become involved in
11. During the first 48 hours after a severe burn of 40% of the
volunteer work at this time”
clients body surface, the nurse’s assessment should include
C. “I recognize it’s hard to deal with this, but try to
observations for water intoxication. Associated adaptations
remember that this too shall pass”
include:
D. “Joining a support group of parents who are
coping with this problem can be quite helpful.
A. Sooty-colored sputum
5. To check for wound hemorrhage after a client has had a surgery B. Frothy pink-tinged sputum
for the removal of a tumor in the neck, nurse grace should: C. Twitching and disorientation
D. Urine output below 30ml per hour
A. Loosen an edge of the dressing and lift it to see
12. After a muscle biopsy, nurse Willy should teach the client to:
the wound
B. Observe the dressing at the back of the neck for A. Change the dressing as needed
the presence of blood B. Resume the usual diet as soon as desired
C. Outline the blood as it appears on the dressing to C. Bathe or shower according to preference
observe any progression D. Expect a rise in body temperature for 48 hours
D. Press gently around the incision to express
accumulated blood from the wound
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13. Before a client whose left hand has been amputated can be
fitted for a prosthesis, nurse Joy is aware that: 20. A client with a head injury has a fixed, dilated right pupil;
responds only to painful stimuli; and exhibits decorticate posturing.
Nurse Kate should recognize that these are signs of:
A. Arm and shoulder muscles must be developed
A. Meningeal irritation
B. Shrinkage of the residual limb must be completed
B. Subdural hemorrhage
C. Dexterity in the other extremity must be achieved
C. Medullary compression
D. Full adjustment to the altered body image must
D. Cerebral cortex compression
have occurred
21. After a lateral crushing chest injury, obvious right-sided
14. Nurse Cathy applies a fetal monitor to the abdomen of a client
paradoxic motion of the client’s chest demonstrates multiple rib
in active labor. When the client has contractions, the nurse notes a
fraactures, resulting in a flail chest. The complication the nurse
15 beat per minute deceleration of the fetal heart rate below the
should carefully observe for would be:
baseline lasting 15 seconds. Nurse Cathy should:
A. Mediastinal shift
B. Tracheal laceration
A. Change the maternal position C. Open pneumothorax
B. Prepare for an immediate birth D. Pericardial tamponade
C. Call the physician immediately
D. Obtain the client’s blood pressure 22. When planning care for a client at 30-weeks gestation,
admitted to the hospital after vaginal bleeding secondary to
15. A male client receiving prolonged steroid therapy complains placenta previa, the nurse’s primary objective would be:
of always being thirsty and urinating frequently. The best initial A. Provide a calm, quiet environment
action by the nurse would be to: B. Prepare the client for an immediate cesarean birth
C. Prevent situations that may stimulate the cervix or
A. Perform a finger stick to test the client’s blood uterus
glucose level D. Ensure that the client has regular cervical
B. Have the physician assess the client for an examinations assess for labor
enlarged prostate
C. Obtain a urine specimen from the client for 23. When planning discharge teaching for a young female client
screening purposes who has had a pneumothorax, it is important that the nurse include
D. Assess the client’s lower extremities for the the signs and symptoms of a pneumothorax and teach the client to
presence of pitting edema seek medical assistance if she experiences:
A. Substernal chest pain
16. Nurse Bea recognizes that a pacemaker is indicated when a B. Episodes of palpitation
client is experiencing: C. Severe shortness of breath
A. Angina D. Dizziness when standing up
B. Chest pain
C. Heart block 24. After a laryngectomy, the most important equipment to place
D. Tachycardia at the client’s bedside would be:
A. Suction equipment
17. When administering pancrelipase (Pancreases capsules) to B. Humidified oxygen
child with cystic fibrosis, nurse Faith knows they should be given: C. A nonelectric call bell
A. With meals and snacks D. A cold-stream vaporizer
B. Every three hours while awake
C. On awakening, following meals, and at bedtime 25. Nurse Oliver interviews a young female client with anorexia
D. After each bowel movement and after postural nervosa to obtain information for the nursing history. The client’s
draianage history is likely to reveal a:
A. Strong desire to improve her body image
18. A preterm neonate is receiving oxygen by an overhead hood. B. Close, supportive mother-daughter relationship
During the time the infant is under the hood, it would be C. Satisfaction with and desire to maintain her
appropriate for nurse Gian to: present weight
A. Hydrate the infant q15 min D. Low level of achievement in school, with little
B. Put a hat on the infant’s head concerns for grades
C. Keep the oxygen concentration consistent
D. Remove the infant q15 min for stimulation 26. Nurse Bea should plan to assist a client with an
obsessive-compulsive disorder to control the use of ritualistic
19. A client’s sputum smears for acid fast bacilli (AFB) are behavior by:
positive, and transmission-based airborne precautions are ordered. A. Providing repetitive activities that require little
Nurse Kyle should instruct visitors to: thought
A. Limit contact with non-exposed family members B. Attempting to reduce or limit situations that
B. Avoid contact with any objects present in the increase anxiety
client’s room C. Getting the client involved with activities that will
C. Wear an Ultra-Filter mask when they are in the provide distraction
client’s room D. Suggesting that the client perform menial tasks to
D. Put on a gown and gloves before going into the expiate feelings of guilt
client’s room
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27. A 2 ½ year old child undergoes a ventriculoperitoneal shunt 34. Nurse Wilma recognizes that failure of a newborn to make the
revision. Before discharge, nurse John, knowing the expected appropriate adaptation to extrauterine life would be indicated by:
developmental behaviors for this age group, should tell the parents
to call the physician if the child:
A. flexed extremities
A. Tries to copy all the father’s mannerisms
B. Cyanotic lips and face
B. Talks incessantly regardless of the presence of
C. A heart rate of 130 beats per minute
others
D. A respiratory rate of 40 breath per minute
C. Becomes fussy when frustrated and displays a
shortened attention span
35. The laboratory calls to state that a client’s lithium level is 1.9
D. Frequently starts arguments with playmates by
mEq/L after 10 days of lithium therapy. Nurse Reese should:
claiming all toys are “mine”

28. A urinary tract infection is a potential danger with an A. Notify the physician of the findings because the
indwelling catheter. Nurse Gina can best plan to avoid this level is dangerously high
complication by: B. Monitor the client closely because the level of
A. Assessing urine specific gravity lithium in the blood is slightly elevated
B. Maintaining the ordered hydration C. Continue to administer the medication as ordered
C. Collecting a weekly urine specimen because the level is within the therapeutic range
D. Emptying the drainage bag frequently D. Report the findings to the physician so the dosage
can be increased because the level is below
29. A client has sustained a fractured right femur in a fall on stairs. therapeutic range
Nurse Troy with the emergency response team assess for signs of
circulatory impairment by: 36. A client has a regular 30-day menstrual cycles. When teaching
A. Turning the client to side lying position about the rhythm method, Which the client and her husband have
B. Asking the client to cough and deep breathe chosen to use for family planning, nurse Dianne should emphasize
C. Taking the client’s pedal pulse in the affected that the client’s most fertile days are:
limb
D. Instructing the client to wiggle the toes of the A. Days 9 to 11
right foot B. Days 12 to 14
C. Days 15 to 17
30. To assess orientation to place in a client suspected of having D. Days 18 to 20
dementia of the alzheimers type, nurse Chris should ask:
A. “Where are you?” 37. Before an amniocentesis, nurse Alexandra should:
B. “Who brought you here?”
C. “Do you know where you are?”
A. Initiate the intravenous therapy as ordered by the
D. “How long have you been there?”
physiscian
B. Inform the client that the procedure could
31. Nurse Mary assesses a postpartum client who had an abruption
precipitate an infection
placentae and suspects that disseminated intravascular coagulation
C. Assure that informed consent has been obtained
(DIC) is occurring when assessments demonstrate:
from the client
D. Perform a vaginal examination on the client to
A. A boggy uterus assess cervical dilation
B. Multiple vaginal clots
C. Hypotension and tachycardia 38. While a client is on intravenous magnesium sulfate therapy for
D. Bleeding from the venipuncture site preeclampsia, it is essential for nurse Amy to monitor the client’s
deep tendon reflexes to:
32. When a client on labor experiences the urge to push a 9cm
dilation, the breathing pattern that nurse Rhea should instruct the
A. Determine her level of consciousness
client to use is the:
B. Evaluate the mobility of the extremities
C. Determine her response to painful stimuli
A. Expulsion pattern D. Prevent development of respiratory distress
B. Slow paced pattern
C. Shallow chest pattern 39. A preschooler is admitted to the hospital with a diagnosis of
D. blowing pattern acute glomerulonephritis. The child’s history reveals a 5-pound
weight gain in one week and peritoneal edema. For the most
33. Nurse Ronald should explain that the most beneficial accurate information on the status of the child’s edema, nursing
between-meal snack for a client who is recovering from the intervention should include:
full-thickness burns would be a:
A. Obtaining the child’s daily weight
A. Cheeseburger and a malted B. Doing a visual inspection of the child
B. Piece of blueberry pie and milk C. Measuring the child’s intake and output
C. Bacon and tomato sandwich and tea D. Monitoring the child’s electrolyte values
D. Chicken salad sandwich and soft drink

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40. Nurse Mickey is administering dexamethasome (Decadron) for 47. When assessing a newborn suspected of having Down
the early management of a client’s cerebral edema. This treatment syndrome, nurse Rey would expect to observe:
is effective because:
A. long thin fingers
A. Acts as hyperosmotic diuretic B. Large, protruding ears
B. Increases tissue resistance to infection C. Hypertonic neck muscles
C. Reduces the inflammatory response of tissues D. Simian lines on the hands
D. Decreases the information of cerebrospinal fluid
48. A 10 year old girl is admitted to the pediatric unit for recurrent
41. During newborn nursing assessment, a positive Ortolani’s sign pain and swelling of her joints, particularly her knees and ankles.
would be indicated by: Her diagnosis is juvenile rheumatoid arthritis. Nurse Janah
recognizes that besides joint inflammation, a unique manifestation
of the rheumatoid process involves the:
A. A unilateral droop of hip
B. A broadening of the perineum
C. An apparent shortening of one leg A. Ears
D. An audible click on hip manipulation B. Eyes
C. Liver
42. When caring for a dying client who is in the denial stage of D. Brain
grief, the best nursing approach would be to:
49. A disturbed client is scheduled to begin group therapy. The
client refuses to attend. Nurse Lolit should:
A. Agree and encourage the client’s denial
B. Allow the denial but be available to discuss death
C. Reassure the client that everything will be OK A. Accept the client’s decision without discussion
D. Leave the client alone to confront the feelings of B. Have another client to ask the client to consider
impending loss C. Tell the client that attendance at the meeting is
required
43. To decrease the symptoms of gastroesophageal reflux disease D. Insist that the client join the group to help the
(GERD), the physician orders dietary and medication management. socialization process
Nurse Helen should teach the client that the meal alteration that
would be most appropriate would be: 50. Because a severely depressed client has not responded to any
of the antidepressant medications, the psychiatrist decides to try
electroconvulsive therapy (ECT). Before the treatment the nurse
A. Ingest foods while they are hot
should:
B. Divide food into four to six meals a day
C. Eat the last of three meals daily by 8pm
D. Suck a peppermint candy after each meal A. Have the client speak with other clients receiving
ECT
44. After a mastectomy or hysterectomy, clients may feel B. Give the client a detailed explanation of the entire
incomplete as women. The statement that should alert nurse Gina procedure
to this feeling would be: C. Limit the client’s intake to a light breakfast on the
days of the treatment
D. Provide a simple explanation of the procedure and
A. “I can’t wait to see all my friends again”
continue to reassure the client
B. “I feel washed out; there isn’t much left”
C. “I can’t wait to get home to see my grandchild”
51. Nurse Vicky is aware that teaching about colostomy care is
D. “My husband plans for me to recuperate at our
understood when the client states, “I will contact my physician and
daughter’s home”
report ____”:
45. A client with obstruction of the common bile duct may show a
prolonged bleeding and clotting time because: A. If I notice a loss of sensation to touch in the stoma
tissue”
B. When mucus is passed from the stoma between
A. Vitamin K is not absorbed
irrigations”
B. The ionized calcium levels falls
C. The expulsion of flatus while the irrigating fluid is
C. The extrinsic factor is not absorbed
running out”
D. Bilirubin accumulates in the plasma
D. If I have difficulty in inserting the irrigating tube
into the stoma”
46. Realizing that the hypokalemia is a side effect of steroid
therapy, nurse Monette should monitor a client taking steroid
52. The client’s history that alerts nurse Henry to assess closely
medication for:
for signs of postpartum infection would be:
A. Three spontaneous abortions
A. Hyperactive reflexes B. negative maternal blood type
B. An increased pulse rate C. Blood loss of 850 ml after a vaginal birth
C. Nausea, vomiting, and diarrhea D. Maternal temperature of 99.9° F 12 hours after
D. Leg weakness with muscle cramps delivery

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53. A client is experiencing stomatitis as a result of chemotherapy. 59. A breastfeeding mother asks the nurse what she can do to ease
An appropriate nursing intervention related to this condition the discomfort caused by a cracked nipple. Nurse Tina should
would be to: instruct the client to:

A. Provide frequent saline mouthwashes A. Manually express milk and feed it to the baby in a
B. Use karaya powder to decrease irritation bottle
C. Increase fluid intake to compensate for the B. Stop breastfeeding for two days to allow the
diarrhea nipple to heal
D. Provide meticulous skin care of the abdomen with C. Use a breast shield to keep the baby from direct
Betadine contact with the nipple
D. Feed the baby on the unaffected breast first until
54. During a group therapy session, one of the clients ask a male the affected breast heals
client with the diagnosis of antisocial personality disorder why he
is in the hospital. Considering this client’s type of personality 60. Nurse Sandy observes that there is blood coming from the
disorder, the nurse might expect him to respond: client’s ear after head injury. Nurse Sandy should:

A. “I need a lot of help with my troubles” A. Turn the client to the unaffected side
B. “Society makes people react in old ways” B. Cleanse the client’s ear with sterile gauze
C. “I decided that it’s time I own up to my problems” C. Test the drainage from the client’s ear with
D. “My life needs straightening out and this might Dextrostix
help” D. Place sterile cotton loosely in the external ear of
the client
55. A child visits the clinic for a 6-week checkup after a
tonsillectomy and adenoidectomy. In addition to assessing hearing, 61. Nurse Gio plans a long term care for parents of children with
the nurse should include an assessment of the child’s: sickle-cell anemia, which includes periodic group conferences.
Some of the discussions should be directed towards:
A. Taste and smell
B. Taste and speech A. Finding special school facilities for the child
C. Swallowing and smell B. Making plans for moving to a more therapeutic
D. Swallowing and speech climate
C. Choosing a means of birth control to avoid future
56. A client is diagnosed with cancer of the jaw. A course of pregnancies
radiation therapy is to be followed by surgery. The client is D. Airing their feelings regarding the transmission of
concerned about the side effects related to the radiation treaments. the disease to the child
Nurse Ria should explain that the major side effects that will
experienced is: 62. The central problem the nurse might face with a disturbed
schizophrenic client is the client’s:
A. Suspicious feelings
A. Fatigue
B. Continuous pacing
B. Alopecia
C. Relationship with the family
C. Vomiting
D. Concern about working with others
D. Leucopenia
63. When planning care with a client during the postoperative
57. Nurse Katrina prepares an older-adult client for sleep, actions
recovery period following an abdominal hysterectomy and
are taken to help reduce the likelihood of a fall during the night.
bilateral salpingo-oophorectomy, nurse Frida should include the
Targeting the most frequent cause of falls, the nurse should:
explanation that:
A. Surgical menopause will occur
A. Offer the client assistance to the bathroom B. Urinary retention is a common problem
B. Move the bedside table closer to the client’s bed C. Weight gain is expected, and dietary plan are
C. Encourage the client to take an available sedative needed
D. Assist the client to telephone the spouse to say D. Depression is normal and should be expected
“goodnight”
64. An adolescent client with anorexia nervosa refuses to eat,
58. When evaluating a growth and development of a 6 month old stating, “I’ll get too fat.” Nurse Andrea can best respond to this
infant, nurse Patty would expect the infant to be able to: behavior initially by:
A. Not talking about the fact that the client is not
A. Sit alone, display pincer grasp, wave bye bye eating
B. Pull self to a standing position, release a toy by B. Stopping all of the client’s priviledges until food
choice, play peek-a-boo is eaten
C. Crawl, transfer toy from one hand to the other, C. Telling the client that tube feeding will eventually
display of fear of strangers be necessary
D. Turn completely over, sit momentarily without D. Pointing out to the client that death can occur with
support, reach to be picked up malnutrition.

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65. A pain scale is used to assess the degree of pain. The client 71. According to C.E.Winslow, which of the following is the goal
rates the pain as an 8 on a scale of 10 before medication and a 7 on of Public Health?
a scale of 10 after being medicated. Nurse Glenda determines that
the:
A. For people to attain their birthrights of health and
longevity
A. Client has a low pain tolerance B. For promotion of health and prevention of disease
B. Medication is not adequately effective C. For people to have access to basic health services
C. Medication has sufficiently decreased the pain D. For people to be organized in their health efforts
level
D. Client needs more education about the use of the 72. What other statistic may be used to determine attainment of
pain scale longevity?

66. To enhance a neonate’s behavioral development, therapeutic

A. Age-specific mortality rate
nursing measures should include:
B. Proportionate mortality rate
C. Swaroop’s index
A. Keeping the baby awake for longer periods of D. Case fatality rate
time before each feeding
B. Assisting the parents to stimulate their baby 73. Which of the following is the most prominent feature of public
through touch, sound, and sight. health nursing?
C. Encouraging parental contact for at least one
15-minute period every four hours.
A. It involves providing home care to sick people
D. Touching and talking to the baby at least hourly,
who are not confined in the hospital
beginning within two to four hours after birth
B. Services are provided free of charge to people
within the catchment area.
67. Before formulating a plan of care for a 6 year old boy with
C. The public health nurse functions as part of a team
attention deficit hyperactivity disorder (ADHD), nurse Kyla is
providing a public health nursing services.
aware that the initial aim of therapy is to help the client to:
D. Public health nursing focuses on preventive, not
curative, services.
A. Develop language skills
B. Avoid his own regressive behavior 74. Which of the following is the mission of the Department of
C. Mainstream into a regular class in school Health?
D. Recognize himself as an independent person of
worth
A. Health for all Filipinos
B. Ensure the accessibility and quality of health care
68. Nurse Wally knows that the most important aspect of the
C. Improve the general health status of the
preoperative care for a child with Wilms’ tumor would be:
population
D. Health in the hands of the Filipino people by the
A. Checking the size of the child’s liver year 2020
B. Monitoring the child’s blood pressure
C. Maintaining the child in a prone position 75. Nurse Pauline determines whether resources were maximized
D. Collecting the child’s urine for culture and in implementing Ligtas Tigdas, she is evaluating:
sensitivity
A. Effectiveness
69. At 11:00 pm the count of hydrocodone (Vicodin) is incorrect.
B. Efficiency
After several minutes of searching the medication cart and
C. Adequacy
medication administration records, no explanation can be found.
D. Appropriateness
The primary nurse should notify the:
76. Lissa is a B.S.N. graduate. She want to become a Public
A. Nursing unit manager Health Nurse. Where will she apply?
B. Hospital administrator
C. Quality control manager
A. Department of Health
D. Physician ordering the medication
B. Provincial Health Office
C. Regional Health Office
70. When caring for the a client with a pneumothorax, who has a
D. Rural Health Unit
chest tube in place, nurse Kate should plan to:
A. Administer cough suppressants at appropriate 77. As an epidemiologist, Nurse Celeste is responsible for
intervals as ordered reporting cases of notifiable diseases. What law mandates
B. Empty and measure the drainage in the collection reporting of cases of notifiable diseases?
chamber each shift A. Act 3573
C. Apply clamps below the insertion site when ever B. R.A. 3753
getting the client out of bed C. R.A. 1054
D. Encourage coughing, deep breathing, and range of D. R.A. 1082
motion to the arm on the affected side

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78. Nurse Fay is aware that isolation of a child with measles
belongs to what level of prevention? 85. Nurse Tony stresses the need for all the employees to follow
orders and instructions from him and not from anyone else. Which
of the following principles does he refer to?
A. Primary
A. Scalar chain
B. Secondary
B. Discipline
C. Intermediate
C. Unity of command
D. Tertiary
D. Order
79. Nurse Gina is aware that the following is an advantage of a
86. Nurse Joey discusses the goal of the department. Which of the
home visit?
following statements is a goal?
A. Increase the patient satisfaction rate
A. It allows the nurse to provide nursing care to a B. Eliminate the incidence of delayed administration
greater number of people. of medications
B. It provides an opportunity to do first hand C. Establish rapport with patients
appraisal of the home situation. D. Reduce response time to two minutes
C. It allows sharing of experiences among people
with similar health problems. 87. Nurse Lou considers shifting to transformational leadership.
D. It develops the family’s initiative in providing for Which of the following statements best describes this type of
health needs of its members. leadership?
A. Uses visioning as the essence of leadership
80. The PHN bag is an important tool in providing nursing care B. Serves the followers rather than being served
during a home visit. The most important principle of bag C. Maintains full trust and confidence in the
technique states that it: subordinates
A. Should save time and effort. D. Possesses innate charisma that makes others feel
B. Should minimize if not totally prevent the spread good in his presence.
of infection.
C. Should not overshadow concern for the patient 88. Nurse Mae tells one of the staff, “I don’t have time to discuss
and his family. the matter with you now. See me in my office later” when the
D. May be done in a variety of ways depending on latter asks if they can talk about an issue. Which of the following
the home situation, etc. conflict resolution strategies did she use?
A. Smoothing
81. Nurse Willy reads about Path Goal theory. Which of the B. Compromise
following behaviors is manifested by the leader who uses this C. Avoidance
theory? D. Restriction
A. Recognizes staff for going beyond expectations by
giving them citations 89. Nurse Bea plans of assigning competent people to fill the roles
B. Challenges the staff to take individual designed in the hierarchy. Which process refers to this?
accountability for their own practice A. Staffing
C. Admonishes staff for being laggards B. Scheduling
D. Reminds staff about the sanctions for non C. Recruitment
performance D. Induction

82. Nurse Cathy learns that some leaders are transactional leaders. 90. Nurse Linda tries to design an organizational structure that
Which of the following does NOT characterize a transactional allows communication to flow in all directions and involve
leader? workers in decision making. Which form of organizational
A. Focuses on management tasks structure is this?
B. Is a caretaker A. Centralized
C. Uses trade-offs to meet goals B. Decentralized
D. Inspires others with vision C. Matrix
D. Informal
83. Functional nursing has some advantages, which one is an
EXCEPTION? 91. When documenting information in a client’s medical record,
A. Psychological and sociological needs are the nurse should:
emphasized. A. erase any errors.
B. Great control of work activities. B. use a #2 pencil.
C. Most economical way of delivering nursing C. leave one line blank before each new entry.
services. D. end each entry with the nurse’s signature and title.
D. Workers feel secure in dependent role
84. Which of the following is the best guarantee that the patient’s 92. Which of the following factors are major components of a
priority needs are met? client’s general background drug history?
A. Checking with the relative of the patient A. Allergies and socioeconomic status
B. Preparing a nursing care plan in collaboration B. Urine output and allergies
with the patient C. Gastric reflex and age
C. Consulting with the physician D. Bowel habits and allergies
D. Coordinating with other members of the team
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93. Which procedure or practice requires surgical asepsis? Answers and Rationales
A. Hand washing
B. Nasogastric tube irrigation 1. C. Check for any change in responsiveness every two hours
C. I.V. cannula insertion until the follow-up visit. Signs of an epidural hematoma in
D. Colostomy irrigation children usually do not appear for 24 hours or more hours; a
follow-up visit usually is arranged for one to two days after the
injury.
94. The nurse is performing wound care using surgical asepsis. 2. A. Arteriolar constriction occurs.The early compensation of
Which of the following practices violates surgical asepsis? shock is cardiovascular and is seen in changes in pulse, BP, and
A. Holding sterile objects above the waist pulse pressure; blood is shunted to vital centers, particularly
B. Pouring solution onto a sterile field cloth heart and brain.
C. Considering a 1″ (2.5-cm) edge around the sterile 3. A. Allow the client to open canned or pre-packaged food. The
field contaminated client’s comfort, safety, and nutritional status are the priorities;
D. Opening the outermost flap of a sterile package the client may feel comfortable to eat if the food has been sealed
before reaching the mental health facility.
away from the body 4. D. “Joining a support group of parents who are coping with this
problem can be quite helpful. Taking with others in similar
95. On admission, a client has the following arterial blood gas circumstances provides support and allows for sharing of
(ABG) values: PaO2, 50 mm Hg; PaCO2, 70 mm Hg; pH, 7.20; experiences.
HCO3–, 28 mEq/L. Based on these values, 5. B. Observe the dressing at the back of the neck for the presence
the nurse should formulate which nursing diagnosis for this client? of blood. Drainage flows by gravity.
A. Risk for deficient fluid volume 6. C. Prepare her for a pelvic examination. Pelvic examination
B. Deficient fluid volume would reveal dilation and effacement
7. D. On the right side of the heart. Pulmonic stenosis increases
C. Impaired gas exchange resistance to blood flow, causing right ventricular hyperthropy;
D. Metabolic acidosis with right ventricular failure there is an increase in pressure on
the right side of the heart.
96. The use of larvivorous fish in malaria control is the basis for 8. A. Eating patterns are altered. A new dietary regimen, with a
which strategy of malaria control? balance of foods from the food pyramid, must be established
A. Stream seeding and continued for weight reduction to occur and be maintained.
B. Stream clearing 9. B. “It is Ok to cry; I’ll just stay with you for now”. This portrays
C. Destruction of breeding places a nonjudgmental attitude that recognizes the client’s needs.
10. C. Lactated Ringer’s solution. Lactated Ringer’s solution
D. Zooprophylaxis replaces lost sodium and corrects metabolic acidosis, both of
which commonly occur following a burn. Albumin is used as
97. In Integrated Management of Childhood Illness, severe adjunct therapy, not primary fluid replacement. Dextrose isn’t
conditions generally require urgent referral to a hospital. Which of given to burn patients during the first 24 hours because it can
the following severe conditions DOES NOT always require urgent cause pseudodiabetes. The patient is hyperkalemic from the
referral to a hospital? potassium shift from the intracellular space to the plasma, so
A. Mastoiditis potassium would be detrimental.
B. Severe dehydration 11. C. Twitching and disorientation. Excess extracellular fluid
moves into cells (water intoxication); intracellular fluid excess
C. Severe pneumonia in sensitive brain cells causes altered mental status; other signs
D. Severe febrile disease include anorexia nervosa, nausea, vomiting, twitching,
sleepiness, and convulsions.
98. A mother brought her daughter, 4 years old, to the RHU 12. B. Resume the usual diet as soon as desired. As long as the
because of cough and colds. Following the IMCI assessment guide, client has no nausea or vomiting, there are no dietary restriction.
which of the following is a danger sign that indicates the need for 13. B. Shrinkage of the residual limb must be completed. Shrinkage
urgent referral to a hospital? of the residual limb, resulting from reduction of subcutaneous
A. Inability to drink fat and interstitial fluid, must occur for an adequate fit between
the limb and the prosthesis.
B. High grade fever 14. A. Change the maternal position. Stimulation of the sympathetic
C. Signs of severe dehydration nervous system is an initial response to mild hypoxia that
D. Cough for more than 30 days accompanies partial cord compression (umbilical vein) during
contractions; changing the maternal position can alleviate the
99. Food fortification is one of the strategies to prevent compression.
micronutrient deficiency conditions. R.A. 8976 mandates 15. A. Perform a finger stick to test the client’s blood glucose
fortification of certain food items. Which of the following is level. The client has signs of diabetes, which may result from
among these food items? steroid therapy, testing the blood glucose level is a method of
screening for diabetes, thus gathering more data.
A. Sugar 16. C. Heart block. This is the primary indication for a pacemaker
B. Bread because there is an interfere with the electrical conduction
C. Margarine system of the heart.
D. Filled milk 17. A. With meals and snacks. Pancreases capsules must be taken
with food and snacks because it acts on the nutrients and readies
100. The major sign of iron deficiency anemia is pallor. What part them for absorption.
is best examined for pallor? 18. B. Put a hat on the infant’s head. Oxygen has cooling effect, and
the baby should be kept warm so that metabolic activity and
oxygen demands are not increased.
A. Palms 19. C. Wear an Ultra-Filter mask when they are in the client’s
B. Nailbeds room. Tubercle bacilli are transmitted through air currents;
C. Around the lips therefore personal protective equipment such as an Ultra-Filter
D. Lower conjunctival sac mask is necessary.

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20. D. Cerebral cortex compression. Cerebral compression affects 43. B. Divide food into four to six meals a day. The volume of food
pyramidal tracts, resulting in decorticate rigidity and cranial in the stomach should be kept small to limit pressure on the
nerve injury, which cause pupil dilation. cardiac sphincter.
21. A.Mediastinal shift. Mediastinal structures move toward the 44. B. “I feel washed out; there isn’t much left”. The client’s
uninjured lung, reducing oxygenation and venous return. statement infers an emptiness with an associated loss.
22. C. Prevent situations that may stimulate the cervix or 45. A. Vitamin K is not absorbed. Vitamin K, a fat soluble vitamin,
uterus. Stimulation of the cervix or uterus may cause bleeding or is not absorbed from the GI tract in the absence of bile; bile
hemorrhage and should be avoided. enters the duodenum via the common bile duct.
23. C. Severe shortness of breath. This could indicate a recurrence 46. D. Leg weakness with muscle cramps. Impulse conduction of
of the pneumothorax as one side of the lung is inadequate to skeletal muscle is impaired with decreased potassium levels,
meet the oxygen demands of the body. muscular weakness and cramps may occur with hypokalemia.
24. A. Suction equipment. Respiratory complications can occur 47. D. Simian lines on the hands. This is characteristic finding in
because of edema of the glottis or injury to the recurrent newborns with Down syndrome.
laryngeal nerve. 48. B. Eyes. Rheumatoid arthritis can cause inflammation of the iris
25. A. Strong desire to improve her body image. Clients with and ciliary body of the eyes which may lead to blindness.
anorexia nervosa have a disturbed self image and always see 49. A. Accept the client’s decision without discussion. This is all the
themselves as fat and needing further reducing. nurse can do until trust is established; facing the client to attend
26. B. Attempting to reduce or limit situations that increase will disrupt the group.
anxiety. Persons with high anxiety levels develop various 50. D. Provide a simple explanation of the procedure and continue
behaviors to relieve their anxiety; by reducing anxiety, the need to reassure the client. The nurse should offer support and use
for these obsessive-compulsive action is reduced. clear, simple terms to allay client’s anxiety.
27. C. Becomes fussy when frustrated and displays a shortened 51. D. If I have difficulty in inserting the irrigating tube into the
attention span. Shortened attention span and fussy behavior may stoma”. This occurs with stenosis of the stoma; forcing insertion
indicate a change in intracranial pressure and/or shunt of the tube could cause injury.
malfunction. 52. C. Blood loss of 850 ml after a vaginal birth. Excessive blood
28. B. Maintaining the ordered hydration. Promoting hydration loss predisposes the client to an increased risk of infection
maintains urine production at a higher rate, which flushes the because of decreased maternal resistance; they expected blood
bladder and prevents urinary stasis and possible infection. loss is 350 to 500 ml.
29. C. Taking the client’s pedal pulse in the affected 53. A. Provide frequent saline mouthwashes. This is soothing to the
limb. Monitoring a pedal pulse will assess circulation to the oral mucosa and helps prevent infection.
foot. 54. B. “Society makes people react in old ways”. The client is
30. A. “Where are you?”. “Where are you?” is the best question to incapable of accepting responsibility for self-created problems
elicit information about the client’s orientation to place because and blames society for the behavior.
it encourages a response that can be assessed. 55. A. Taste and smell. Swelling can obstruct nasal breathing,
31. D. Bleeding from the venipuncture site. This indicates a interfering with the senses of taste and smell.
fibrinogenemia; massive clotting in the area of the separation 56. A. Fatigue. Fatigue is a major problem caused by an increase in
has resulted in a lowered circulating fibrinogen. waste products because of catabolic processes.
32. D. blowing pattern. Clients should use a blowing pattern to 57. A. Offer the client assistance to the bathroom. Statistics indicate
overcome the premature urge to push. that the most frequent cause of falls by hospitalized clients is
33. A. Cheeseburger and a malted. Of the selections offered, this is getting up or attempting to get up to the bathroom unassisted.
the highest in calories and protein, which are needed for 58. D. Turn completely over, sit momentarily without support, reach
increased basal metabolic rate and for tissue repair. to be picked up. These abilities are age-appropriate for the 6
34. B. Cyanotic lips and face. Central cyanosis (blue lips and face) month old child.
indicates lowered oxygenation of the blood, caused by either 59. D. Feed the baby on the unaffected breast first until the affected
decreased lung expansion or right to left shunting of blood. breast heals. The most vigorous sucking will occur during the
35. A. Notify the physician of the findings because the level is first few minutes of breastfeeding when the infant would be on
dangerously high. Levels close to 2 mEq/L are dangerously the unaffected breast; later suckling is less traumatic.
close to the toxic level; immediate action must be taken. 60. D. Place sterile cotton loosely in the external ear of the
36. C. Days 15 to 17. Ovulation occurs approximately 14 days client. This would absorb the drainage without causing further
before the next menses, about the 16th day in 30 day cycle; the trauma.
15th to 17th days would be the best time to avoid sexual 61. D. Airing their feelings regarding the transmission of the disease
intercourse. to the child. Discussion with parents who have children with
37. C. Assure that informed consent has been obtained from the similar problems helps to reduce some of their discomfort and
client. An invasive procedure such as amniocentesis requires guilt.
informed consent. 62. A. Suspicious feelings. The nurse must deal with these feelings
38. D. Prevent development of respiratory distress. Respiratory and establish basic trust to promote a therapeutic milieu.
distress or arrest may occur when the serum level of magnesium 63. A. Surgical menopause will occur. When a bilateral
sulfate reaches 12 to 15 mg/dl; deep tendon reflexes disappear oophorectomy is performed, both ovaries are excised,
when the serum level is 10 to 12 mg/dl; the drug is withheld in eliminating ovarian hormones and initiating response.
the absence of deep tendon reflexes; the therapeutic serum level 64. D. Pointing out to the client that death can occur with
is 5 to 8 mg/dl. malnutrition. The client expects the nurse to focus on eating, but
39. A. Obtaining the child’s daily weight. Weight monitoring is the the emphasis should be placed on feelings rather than actions.
most useful means of assessing fluid balance and changes in the 65. B. Medication is not adequately effective. The expected effect
edematous state; 1 liter of fluid weighs about 2.2 pounds. should be more than a one point decrease in the pain level.
40. C. Reduces the inflammatory response of 66. B. Assisting the parents to stimulate their baby through touch,
tissues. Corticosteroids act to decrease inflammation which sound, and sight. Stimuli are provided via all the senses; since
decreases edema. the infant’s behavioral development is enhanced through
41. D. An audible click on hip manipulation. With specific parent-infant interactions, these interactions should be
manipulation, an audible click may be heard of felt as he encouraged.
femoral head slips into the acetabulum. 67. D. Recognize himself as an independent person of
42. B. Allow the denial but be available to discuss death. This does worth. Academic deficits, an inability to function within
not remove client’s only way of coping, and it permits future constraints required of certain settings, and negative peer
movement through the grieving process when the client is ready. attitudes often lead to low self-esteem.

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68. B. Monitoring the child’s blood pressure. Because the tumor is 89. A. Staffing. Staffing is a management function involving putting
of renal origin, the rennin angiotensin mechanism can be the best people to accomplish tasks and activities to attain the
involved, and blood pressure monitoring is important. goals of the organization.
69. A. Nursing unit manager. Controlled substance issues for a 90. B. Decentralized. Decentralized structures allow the staff to
particular nursing unit are the responsibility of that unit’s nurse make decisions on matters pertaining to their practice and
manager. communicate in downward, upward, lateral and diagonal flow.
70. D. Encourage coughing, deep breathing, and range of motion to 91. D. end each entry with the nurse’s signature and title. The end of
the arm on the affected side. All these interventions promote each entry should include the nurse’s signature and title; the
aeration of the re-expanding lung and maintenance of function signature holds the nurse accountable for the recorded
in the arm and shoulder on the affected side. information. Erasing errors in documentation on a legal
71. A. For people to attain their birthrights of health and document such as a client’s chart isn’t permitted by law.
longevity. According to Winslow, all public health efforts are Because a client’s medical record is considered a legal
for people to realize their birthrights of health and longevity. document, the nurse should make all entries in ink. The nurse is
72. C. Swaroop’s index. Swaroop’s index is the percentage of the accountable for the information recorded and therefore
deaths aged 50 years or older. Its inverse represents the shouldn’t leave any blank lines in which another health care
percentage of untimely deaths (those who died younger than 50 worker could make additions.
years). 92. A. Allergies and socioeconomic status. General background data
73. D. Public health nursing focuses on preventive, not curative, consist of such components as allergies, medical history, habits,
services.. The catchment area in PHN consists of a residential socioeconomic status, lifestyle, beliefs, and sensory deficits.
community, many of whom are well individuals who have Urine output, gastric reflex, and bowel habits are significant
greater need for preventive rather than curative services. only if a disease affecting these functions is present.
74. B. Ensure the accessibility and quality of health care. Ensuring 93. C. I.V. cannula insertion. Caregivers must use surgical asepsis
the accessibility and quality of health care is the primary when performing wound care or any procedure in which a sterile
mission of DOH. body cavity is entered or skin integrity is broken. To achieve
75. B. Efficiency. Efficiency is determining whether the goals were surgical asepsis, objects must be rendered or kept free of all
attained at the least possible cost. pathogens. Inserting an I.V. cannula requires surgical asepsis
76. D. Rural Health Unit. R.A. 7160 devolved basic health services because it disrupts skin integrity and involves entry into a sterile
to local government units (LGU’s ). The public health nurse is cavity (a vein). The other options are used to ensure medical
an employee of the LGU. asepsis or clean technique to prevent the spread of infection.
77. A. Act 3573. Act 3573, the Law on Reporting of Communicable The GI tract isn’t sterile; therefore, irrigating a nasogastric tube
Diseases, enacted in 1929, mandated the reporting of diseases or a colostomy requires only clean technique.
listed in the law to the nearest health station. 94. B. Pouring solution onto a sterile field cloth. Pouring solution
78. A. Primary. The purpose of isolating a client with a onto a sterile field cloth violates surgical asepsis because
communicable disease is to protect those who are not sick moisture penetrating the cloth can carry microorganisms to the
(specific disease prevention). sterile field via capillary action. The other options are practices
79. B. It provides an opportunity to do first hand appraisal of the that help ensure surgical asepsis.
home situation. Choice A is not correct since a home visit 95. C. Impaired gas exchange. The client has a below-normal value
requires that the nurse spend so much time with the family. for the partial pressure of arterial oxygen (PaO2) and an
Choice C is an advantage of a group conference, while choice D above-normal value for the partial pressure of arterial carbon
is true of a clinic consultation. dioxide (PaCO2), supporting the nursing diagnosis of Impaired
80. B. Should minimize if not totally prevent the spread of gas exchange. ABG values can’t indicate a diagnosis of Fluid
infection. Bag technique is performed before and after handling volume deficit (or excess) or Risk for deficient fluid volume.
a client in the home to prevent transmission of infection to and Metabolic acidosis is a medical, not nursing, diagnosis; in any
from the client. event, these ABG values indicate respiratory, not metabolic,
81. A. Recognizes staff for going beyond expectations by giving acidosis.
them citations. Path Goal theory according to House and 96. A. Stream seeding. Stream seeding is done by putting tilapia fry
associates rewards good performance so that others would do in streams or other bodies of water identified as breeding places
the same. of the Anopheles mosquito.
82. D. Inspires others with vision. Inspires others with a vision is 97. B. Severe dehydration. The order of priority in the management
characteristic of a transformational leader. He is focused more of severe dehydration is as follows: intravenous fluid therapy,
on the day-to-day operations of the department/unit. referral to a facility where IV fluids can be initiated within 30
83. A. Psychological and sociological needs are emphasized. When minutes, Oresol/nasogastric tube, Oresol/orem. When the
the functional method is used, the psychological and foregoing measures are not possible or effective, tehn urgent
sociological needs of the patients are neglected; the patients are referral to the hospital is done.
regarded as ‘tasks to be done” 98. A. Inability to drink. A sick child aged 2 months to 5 years must
84. B. Preparing a nursing care plan in collaboration with the be referred urgently to a hospital if he/she has one or more of
patient. The best source of information about the priority needs the following signs: not able to feed or drink, vomits everything,
of the patient is the patient himself. Hence using a nursing care convulsions, abnormally sleepy or difficult to awaken.
plan based on his expressed priority needs would ensure 99. A. Sugar. R.A. 8976 mandates fortification of rice, wheat flour,
meeting his needs effectively. sugar and cooking oil with Vitamin A, iron and/or iodine.
85. C. Unity of command. The principle of unity of command 100. A. Palms. The anatomic characteristics of the palms allow a
means that employees should receive orders coming from only reliable and convenient basis for examination for pallor.
one manager and not from two managers. This averts the
possibility of sowing confusion among the members of the
organization.
86. A. Increase the patient satisfaction rate. Goal is a desired result
towards which efforts are directed. Options AB, C and D are all
objectives which are aimed at specific end.
87. A. Uses visioning as the essence of leadership. Transformational
leadership relies heavily on visioning as the core of leadership.
88. C. Avoidance. This strategy shuns discussing the issue head-on
and prefers to postpone it to a later time. In effect the problem
remains unsolved and both parties are in a lose-lose situation.

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Philippine Nursing Licensure 8. Clarissa is 7 weeks pregnant. Further examination revealed that
she is susceptible to rubella. When would be the most appropriate
Examination for her to receive rubella immunization?

A. At once
B. During 2nd trimester
1. A woman in a child bearing age receives a rubella vaccination.
C. During 3rd trimester
Nurse Joy would give her which of the following instructions?
D. After the delivery of the baby

A. Refrain from eating eggs or egg products for 24 9. A female child with rubella should be isolated from a:
hours
B. Avoid having sexual intercourse
A. 21 year old male cousin living in the same house
C. Don’t get pregnant at least 3 months
B. 18 year old sister who recently got married
D. Avoid exposure to sun
C. 11 year old sister who had rubeola during
childhood
2. Jonas who is diagnosed with encephalitis is under the treatment
D. 4 year old girl who lives next door
of Mannitol. Which of the following patient outcomes indicate to
Nurse Ronald that the treatment of Mannitol has been effective for
10. What is the primary prevention of leprosy?
a patient that has increased intracranial pressure?
A. Nutrition
B. Vitamins
A. Increased urinary output C. BCG vaccination
B. Decreased RR D. DPT vaccination
C. Slowed papillary response
D. Decreased level of consciousness 11. A bacteria which causes diphtheria is also known as?
A. Amoeba
3. Mary asked Nurse Maureen about the incubation period of B. Cholera
rabies. Which statement by the Nurse Maureen is appropriate? C. Klebs-loeffler bacillus
D. Spirochete
A. Incubation period is 6 months
B. Incubation period is 1 week 12. Nurse Ron performed mantoux skin test today (Monday) to a
C. Incubation period is 1 month male adult client. Which statement by the client indicates that he
D. Incubation period varies depending on the site of understood the instruction well?
the bite A. I will come back later
4. Which of the following should Nurse Cherry do first in taking B. I will come back next month
care of a male client with rabies? C. I will come back on Friday
D. I will come back on Wednesday, same time, to
read the result
A. Encourage the patient to take a bath
B. Cover IV bottle with brown paper bag 13. A male client had undergone Mantoux skin test. Nurse Ronald
C. Place the patient near the comfort room notes an 8mm area of indurations at the site of the skin test. The
D. Place the patient near the door nurse interprets the result as:
A. Negative
5. Which of the following is the screening test for dengue B. Uncertain and needs to be repeated
hemorrhagic fever? C. Positive
A. Complete blood count D. Inconclusive
B. ELISA
C. Rumpel-leede test 14. Tony will start a 6 month therapy with Isoniazid (INH). Nurse
D. Sedimentation rate Trish plans to teach the client to:
A. Use alcohol moderately
6. Mr. Dela Rosa is suspected to have malaria after a business trip B. Avoid vitamin supplements while o therapy
in Palawan. The most important diagnostic test in malaria is: C. Incomplete intake of dairy products
A. WBC count D. May be discontinued if symptoms subsides
B. Urinalysis
C. ELISA 15. Which is the primary characteristic lesion of syphilis?
D. Peripheral blood smear A. Sore eyes
B. Sore throat
7. The Nurse supervisor is planning for patient’s assignment for C. Chancroid
the AM shift. The nurse supervisor avoids assigning which of the D. Chancre
following staff members to a client with herpes zoster?
A. Nurse who never had chicken pox 16. What is the fast breathing of Jana who is 3 weeks old?
B. Nurse who never had roseola A. 60 breaths per minute
C. Nurse who never had german measles B. 40 breaths per minute
D. Nurse who never had mumps C. 10 breaths per minute
D. 20 breaths per minute

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17. Which of the following signs and symptoms indicate some 27. Time table showing planned work days and shifts of nursing
dehydration? personnel is:

A. Drinks eagerly A. Staffing

B. Restless and irritable B. Schedule
C. Unconscious C. Scheduling
D. A and B D. Planning
18. What is the first line for dysentery?
28. A force within an individual that influences the strength of
behavior?
A. Amoxicillin
B. Tetracycline
C. Cefalexin A. Motivation
D. Cotrimoxazole B. Envy
C. Reward
19. In home made oresol, what is the ratio of salt and sugar if you D. Self-esteem
want to prepare with 1 liter of water?
A. 1 tbsp. salt and 8 tbsp. sugar 29. “To be the leading hospital in the Philippines” is best illustrate
B. 1 tbsp. salt and 8 tsp. sugar in:
C. 1 tsp. salt and 8 tsp. sugar A. Mission
D. 8 tsp. salt and 8 tsp. Sugar B. Philosophy
C. Vision
20. Gentian Violet is used for: D. Objective
A. Wound
B. Umbilical infections 30. It is the professionally desired norms against which a staff
C. Ear infections performance will be compared?
D. Burn A. Job descriptions
B. Survey
21. Which of the following is a live attenuated bacterial vaccine? C. Flow chart
A. BCG D. Standards
B. OPV
C. Measles 31. Reprimanding a staff nurse for work that is done incorrectly is
D. None of the above an example of what type of reinforcement?
A. Feedback
22. EPI is based on? B. Positive reinforcement
A. Basic health services C. Performance appraisal
B. Scope of community affected D. Negative reinforcement
C. Epidemiological situation
D. Research studies 32. Questions that are answerable only by choosing an option from
a set of given alternatives are known as?
23. TT? provides how many percentage of protection against A. Survey
tetanus? B. Close ended
A. 100 C. Questionnaire
B. 99 D. Demographic
C. 80
D. 90 33. A researcher that makes a generalization based on
observations of an individuals behavior is said to be which type of
24. Temperature of refrigerator to maintain potency of measles reasoning:
and OPV vaccine is: A. Inductive
A. -3c to -8c B. Logical
B. -15c to -25c C. Illogical
C. +15c to +25c D. Deductive
D. +3c to +8c
34. The balance of a research’s benefit vs. its risks to the subject
25. Diptheria is a: is:
A. Bacterial toxin A. Analysis
B. Killed bacteria B. Risk-benefit ratio
C. Live attenuated C. Percentile
D. Plasma derivatives D. Maximum risk

26. Budgeting is under in which part of management process? 35. An individual/object that belongs to a general population is
A. Directing a/an:
B. Controlling A. Element
C. Organizing B. Subject
D. Planning C. Respondent
D. Author
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36. An illustration that shows how the members of an organization 46. The degree of patients abdominal distension may be
are connected: determined by:
A. Flowchart A. Auscultation
B. Bar graph B. Palpation
C. Organizational chart C. Inspection
D. Line graph D. Percussion

37. The first college of nursing that was established in the 47. A male client is addicted with hallucinogen. Which
Philippines is: physiologic effect should the nurse expect?
A. Fatima University A. Bradyprea
B. Far Eastern University B. Bradycardia
C. University of the East C. Constricted pupils
D. University of Sto. Tomas D. Dilated pupils

38. Florence nightingale is born on: 48. Tristan a 4 year old boy has suffered from full thickness burns
A. France of the face, chest and neck. What will be the priority nursing
B. Britain diagnosis?
C. U.S A. Ineffective airway clearance related to edema
D. Italy B. Impaired mobility related to pain
C. Impaired urinary elimination related to fluid loss
39. Objective data is also called: D. Risk for infection related to epidermal disruption
A. Covert
B. Overt 49. In assessing a client’s incision 1 day after the surgery, Nurse
C. Inference Betty expect to see which of the following as signs of a local
D. Evaluation inflammatory response?
A. Greenish discharge
40. An example of subjective data is: B. Brown exudates at incision edges
A. Size of wounds C. Pallor around sutures
B. VS D. Redness and warmth
C. Lethargy
D. The statement of patient “My hand is painful” 50. Nurse Ronald is aware that the amiotic fluid in the third
trimester weighs approximately:
41. What is the best position in palpating the breast? A. 2 kilograms
A. Trendelenburg B. 1 kilograms
B. Side lying C. 100 grams
C. Supine D. 1.5 kilograms
D. Lithotomy
51. After delivery of a baby girl. Nurse Gina examines the
42. When is the best time in performing breast self examination? umbilical cord and expects to find a cord to:
A. 7 days after menstrual period A. Two arteries and two veins
B. 7 days before menstrual period B. One artery and one vein
C. 5 days after menstrual period C. Two arteries and one vein
D. 5 days before menstrual period D. One artery and two veins
52. Myrna a pregnant client reports that her last menstrual cycle is
43. Which of the following should be given the highest priority July 11, her expected date of birth is
before performing physical examination to a patient? A. November 4
A. Preparation of the room B. November 11
B. Preparation of the patient C. April 4
C. Preparation of the nurse D. April 18
D. Preparation of environment
53. Which of the following is not a good source of iron?
44. It is a flip over card usually kept in portable file at nursing A. Butter
station. B. Pechay
A. Nursing care plan C. Grains
B. Medicine and treatment record D. Beef
C. Kardex
D. TPR sheet 54. Maureen is admitted with a diagnosis of ectopic pregnancy.
Which of the following would you anticipate?
45. Jose has undergone thoracentesis. The nurse in charge is aware A. NPO
that the best position for Jose is: B. Bed rest
A. Semi fowlers C. Immediate surgery
B. Low fowlers D. Enema
C. Side lying, unaffected side
D. Side lying, affected side

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55. Gina a postpartum client is diagnosed with endometritis. 63. On 2nd postpartum day, which height would you expect to find
Which position would you expect to place her based on this the fundus in a woman who has had a caesarian birth?
diagnosis? A. 1 finger above umbilicus
B. 2 fingers above umbilicus
C. 2 fingers below umbilicus
A. Supine
D. 1 finger below umbilicus
B. Left side lying
C. Trendelinburg
64. Which of the following criteria allows Nurse Kris to perform
D. Semi-fowlers
home deliveries?
56. Nurse Hazel knows that Myrna understands her condition well
when she remarks that urinary frequency is caused by: A. Normal findings during assessment
B. Previous CS
C. Diabetes history
A. Pressure caused by the ascending uterus
D. Hypertensive history
B. Water intake of 3L a day
C. Effect of cold weather
65. Nurse Carla is aware that one of the following vaccines is done
D. Increase intake of fruits and vegetables
by intramuscular (IM) injection?
57. How many ml of blood is loss during the first 24 hours post
delivery of Myrna? A. Measles
B. OPV
C. BCG
A. 100
D. Tetanus toxoid
B. 500
C. 200
66. Asin law is on which legal basis:
D. 400

58. Which of the following hormones stimulates the secretion of A. RA 8860

milk? B. RA 2777
C. RI 8172
D. RR 6610
A. Progesterone
B. Prolactin
67. Nurse John is aware that the herbal medicine appropriate for
C. Oxytocin
urolithiasis is:
D. Estrogen

59. Nurse Carla is aware that Myla’s second stage of labor is A. Akapulco
beginning when the following assessment is noted: B. Sambong
C. Tsaang gubat
D. Bayabas
A. Bay of water is broken
B. Contractions are regular
68. Community/Public health bag is defined as:
C. Cervix is completely dilated
D. Presence of bloody show
A. An essential and indispensable equipment of the
60. The leaking fluid is tested with nitrazine paper. Nurse Kelly community health nurse during home visit
confirms that the client’s membrane have ruptures when the paper B. It contains drugs and equipment used by the
turns into a: community health nurse
A. Pink C. Is a requirement in the health center and for home
B. Violet visit
C. Green D. It is a tool used by the community health nurse in
D. Blue rendering effective procedures during home visit

61. After amniotomy, the priority nursing action is: 69. TT4 provides how many percentage of protection against
A. Document the color and consistency of amniotic tetanus?
fluid
B. Listen the fetal heart tone
A. 70
C. Position the mother in her left side
B. 80
D. Let the mother rest
C. 90
D. 99
62. Which is the most frequent reason for postpartum
hemorrhage?
70. Third postpartum visit must be done by public health nurse:
A. Perineal lacerations
A. Within 24 hours after delivery
B. Frequent internal examination (IE)
B. After 2-4 weeks
C. CS
C. Within 1 week
D. Uterine atomy
D. After 2 months

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71. Nurse Candy is aware that the family planning method that 80. Nurse Christine provides health teaching for the parents of a
may give 98% protection to another pregnancy to women child diagnosed with celiac disease. Nurse Christine teaches the
parents to include which of the following food items in the child’s
diet:
A. Pills
B. Tubal ligation
C. Lactational Amenorrhea method (LAM) A. Rye toast
D. IUD B. Oatmeal
C. White bread
72. Which of the following is not a part of IMCI case management D. Rice
process
A. Counsel the mother 81. Nurse Randy is planning to administer oral medication to a 3
B. Identify the illness year old child. Nurse Randy is aware that the best way to proceed
C. Assess the child is by:
D. Treat the child
A. “Would you like to drink your medicine?”
73. If a young child has pneumonia when should the mother bring
B. “If you take your medicine now, I’ll give you
him back for follow up?
lollipop”
A. After 2 days
C. “See the other boy took his medicine? Now it’s
B. In the afternoon
your turn.”
C. After 4 days
D. “Here’s your medicine. Would you like a mango
D. After 5 days
or orange juice?”
74. It is the certification recognition program that develop and
82. At what age a child can brush her teeth without help?
promotes standard for health facilities:
A. 6 years
A. Formula
B. 7 years
B. Tutok gamutan
C. 5 years
C. Sentrong program movement
D. 8 years
D. Sentrong sigla movement
83. Ribivarin (Virazole) is prescribed for a female hospitalized
75. Baby Marie was born May 23, 1984. Nurse John will expect
child with RSV. Nurse Judy prepare this medication via which
finger thumb opposition on:
route?
A. April 1985
A. Intra venous
B. February 1985
B. Oral
C. March 1985
C. Oxygen tent
D. June 1985
D. Subcutaneous
76. Baby Reese is a 12 month old child. Nurse Oliver would
84. The present chairman of the Board of Nursing in the
anticipate how many teeth?
Philippines is:
A. 9
A. Maria Joanna Cervantes
B. 7
B. Carmencita Abaquin
C. 8
C. Leonor Rosero
D. 6
D. Primitiva Paquic
77. Which of the following is the primary antidote for Tylenol
85. The obligation to maintain efficient ethical standards in the
poisoning?
practice of nursing belong to this body:
A. Narcan
A. BON
B. Digoxin
B. ANSAP
C. Acetylcysteine
C. PNA
D. Flumazenil
D. RN
78. A male child has an intelligence quotient of approximately 40.
86. A male nurse was found guilty of negligence. His license was
Which kind of environment and interdisciplinary program most
revoked. Re-issuance of revoked certificates is after how many
likely to benefit this child would be best described as:
years?
A. Habit training
A. 1 year
B. Sheltered workshop
B. 2 years
C. Custodial
C. 3 years
D. Educational
D. 4 years
79. Nurse Judy is aware that following condition would reflect
87. Which of the following information cannot be seen in the PRC
presence of congenital G.I anomaly?
identification card?
A. Cord prolapse
A. Registration Date
B. Polyhydramios
B. License Number
C. Placenta previa
C. Date of Application
D. Oligohydramios
D. Signature of PRC chairperson

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88. Breastfeeding is being enforced by milk code or: 97. When Nurse Clarence respects the client’s self-disclosure, this
is a gauge for the nurses’
A. EO 51
B. R.A. 7600 A. Respectfulness
C. R.A. 6700 B. Loyalty
D. P.D. 996 C. Trustworthiness
D. Professionalism
89. Self governance, ability to choose or carry out decision
without undue pressure or coercion from anyone: 98. The Nurse is aware that the following tasks can be safely
delegated by the nurse to a non-nurse health worker except:
A. Veracity
B. Autonomy A. Taking vital signs
C. Fidelity B. Change IV infusions
D. Beneficence C. Transferring the client from bed to chair
D. Irrigation of NGT
90. A male patient complained because his scheduled surgery was
cancelled because of earthquake. The hospital personnel may be 99. During the evening round Nurse Tina saw Mr. Toralba
excused because of: meditating and afterwards started singing prayerful hymns. What
would be the best response of Nurse Tina?
A. Call the attention of the client and encourage to
A. Governance
sleep
B. Respondent superior
B. Report the incidence to head nurse
C. Force majeure
C. Respect the client’s action
D. Res ipsa loquitor
D. Document the situation
91. Being on time, meeting deadlines and completing all
100. In caring for a dying client, you should perform which of the
scheduled duties is what virtue?
following activities
A. Fidelity
A. Do not resuscitate
B. Autonomy
B. Assist client to perform ADL
C. Veracity
C. Encourage to exercise
D. Confidentiality
D. Assist client towards a peaceful death
92. This quality is being demonstrated by Nurse Ron who raises
101. The Nurse is aware that the ability to enter into the life of
the side rails of a confused and disoriented patient?
another person and perceive his current feelings and their meaning
A. Responsibility
is known:
B. Resourcefulness
A. Belongingness
C. Autonomy
B. Genuineness
D. Prudence
C. Empathy
D. Respect
93. Which of the following is formal continuing education?
A. Conference
102. The termination phase of the NPR is best described one of the
B. Enrollment in graduate school
following:
C. Refresher course
D. Seminar
A. Review progress of therapy and attainment of
94. The BSN curriculum prepares the graduates to become? goals
A. Nurse generalist B. Exploring the client’s thoughts, feelings and
B. Nurse specialist concerns
C. Primary health nurse C. Identifying and solving patients problem
D. Clinical instructor D. Establishing rapport

95. Disposal of medical records in government 103. During the process of cocaine withdrawal, the physician
hospital/institutions must be done in close coordination with what orders which of the following:
agency? A. Haloperidol (Haldol)
A. Department of Health B. Imipramine (Tofranil)
B. Records Management Archives Office C. Benztropine (Cogentin)
C. Metro Manila Development Authority D. Diazepam (Valium)
D. Bureau of Internal Revenue
104. The nurse is aware that cocaine is classified as:
96. Nurse Jolina must see to it that the written consent of mentally
ill patients must be taken from:
A. Hallucinogen
A. Nurse
B. Psycho stimulant
B. Priest
C. Anxiolytic
C. Family lawyer
D. Narcotic
D. Parents/legal guardians

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105. In community health nursing, it is the most important risk 114. The priority of care for a client with Alzheimer’s disease is
factor in the development of mental illness? A. Help client develop coping mechanism
A. Separation of parents B. Encourage to learn new hobbies and interest
B. Political problems C. Provide him stimulating environment
C. Poverty D. Simplify the environment to eliminate the need to
D. Sexual abuse make chores

106. All of the following are characteristics of crisis except 115. Autism is diagnosed at:
A. The client may become resistive and active in A. Infancy
stopping the crisis B. 3 years old
B. It is self-limiting for 4-6 weeks C. 5 years old
C. It is unique in every individual D. School age
D. It may also affect the family of the client
116. The common characteristic of autism child is:
107. Freud states that temper tantrums is observed in which of the A. Impulsitivity
following: B. Self destructiveness
A. Oral C. Hostility
B. Anal D. Withdrawal
C. Phallic
D. Latency 117. The nurse is aware that the most common indication in using
ECT is:
108. The nurse is aware that ego development begins during: A. Schizophrenia
A. Toddler period B. Bipolar
B. Preschool age C. Anorexia Nervosa
C. School age D. Depression
D. Infancy
118. A therapy that focuses on here and now principle to promote
109. Situation: A 19 year old nursing student has lost 36 lbs for 4 self-acceptance?
weeks. Her parents brought her to the hospital for medical A. Gestalt therapy
evaluation. The diagnosis was ANOREXIA NERVOSA. The B. Cognitive therapy
Primary gain of a client with anorexia nervosa is: C. Behavior therapy
A. Weight loss D. Personality therapy
B. Weight gain
C. Reduce anxiety 119. A client has many irrational thoughts. The goal of therapy is
D. Attractive appearance to change her:
E. A. Personality
110. The nurse is aware that the primary nursing diagnosis for the B. Communication
client is: C. Behavior
A. Altered nutrition : less than body requirement D. Cognition
B. Altered nutrition : more than body requirement
C. Impaired tissue integrity 120. The appropriate nutrition for Bipolar I disorder, in manic
D. Risk for malnutrition phase is:

111. After 14 days in the hospital, which finding indicates that her
A. Low fat, low sodium
condition in improving?
B. Low calorie, high fat
A. She tells the nurse that she had no idea that she is
C. Finger foods, high in calorie
thin
D. Small frequent feedings
B. She arrives earlier than scheduled time of group
therapy
121. Which of the following activity would be best for a depressed
C. She tells the nurse that she eat 3 times or more in
client?
a day
D. She gained 4 lbs in two weeks
A. Chess
112. The nurse is aware that ataractics or psychic energizers are B. Basketball
also known as: C. Swimming
A. Anti manic D. Finger painting
B. Anti depressants
C. Antipsychotics 122. The nurse is aware that clients with severe depression,
D. Anti anxiety possess which defense mechanism:

113. Known as mood elevators: A. Introjection

A. Anti depressants B. Suppression
B. Antipsychotics C. Repression
C. Anti manic D. Projection
D. Anti anxiety

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123. Nurse John is aware that self mutilation among Bipolar 132. Information in the patients chart is inadmissible in court as
disorder patients is a means of: evidence when:
A. Overcoming fear of failure
B. Overcoming feeling of insecurity
A. The client objects to its use
C. Relieving depression
B. Handwriting is not legible
D. Relieving anxiety
C. It has too many unofficial abbreviations
D. The clients parents refuses to use it
124. Which of the following may cause an increase in the cystitis
symptoms?
133. Nurse Karen is revising a client plan of care. During which
A. Water
step of the nursing process does such revision take place?
B. Orange juice
A. Planning
C. Coffee
B. Implementation
D. Mango juice
C. Diagnosing
D. Evaluation
125. In caring for clients with renal calculi, which is the priority
nursing intervention?
134. When examining a client with abdominal pain, Nurse Hazel
A. Record vital signs
should assess:
B. Strain urine
A. Symptomatic quadrant either second or first
C. Limit fluids
B. The symptomatic quadrant last
D. Administer analgesics as prescribed
C. The symptomatic quadrant first
D. Any quadrant
126. In patient with renal failure, the diet should be:
A. Low protein, low sodium, low potassium
135. How long will nurse John obtain an accurate reading of
B. Low protein, high potassium
temperature via oral route?
C. High carbohydrate, low protein
A. 3 minutes
D. High calcium, high protein
B. 1 minute
C. 8 minutes
127. Which of the following cannot be corrected by dialysis?
D. 15 minutes
A. Hypernatremia
B. Hyperkalemia
136. The one filing the criminal care against an accused party is
C. Elevated creatinine
said to be the?
D. Decreased hemoglobin
A. Guilty
B. Accused
128. Tony with infection is receiving antibiotic therapy. Later the
C. Plaintiff
client complaints of ringing in the ears. This ototoxicity is damage
D. Witness
to:
A. 4th CN
137. A male client has a standing DNR order. He then suddenly
B. 8th CN
stopped breathing and you are at his bedside. You would:
C. 7th CN
A. Call the physician
D. 9th CN
B. Stay with the client and do nothing
C. Call another nurse
129. Nurse Emma provides teaching to a patient with recurrent
D. Call the family
urinary tract infection includes the following:
A. Increase intake of tea, coffee and colas
138. The ANA recognized nursing informatics heralding its
B. Void every 6 hours per day
establishment as a new field in nursing during what year?
C. Void immediately after intercourse
A. 1994
D. Take tub bath everyday
B. 1992
C. 2000
130. Which assessment finding indicates circulatory constriction
D. 2001
in a male client with a newly applied long leg cast?
A. Blanching or cyanosis of legs
139. When is the first certification of nursing informatics given?
B. Complaints of pressure or tightness
A. 1990-1993
C. Inability to move toes
B. 2001-2002
D. Numbness of toes
C. 1994-1996
D. 2005-2008
131. During acute gout attack, the nurse administer which of the
following drug:
140. The nurse is assessing a female client with possible diagnosis
of osteoarthritis. The most significant risk factor for osteoarthritis
A. Prednisone (Deltasone) is:
B. Colchicines
C. Aspirin
A. Obesity
D. Allopurinol (Zyloprim)
B. Race
C. Job
D. Age

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141. A male client complains of vertigo. Nurse Bea anticipates 149. An infant is ordered to recive 500 ml of D5NSS for 24 hours.
that the client may have a problem with which portion of the ear? The Intravenous drip is running at 60 gtts/min. How many drops
per minute should the flow rate be?
A. Tymphanic membranes
B. Inner ear A. 60 gtts/min.
C. Auricle B. 21 gtts/min
D. External ear C. 30 gtts/min
D. 15 gtts/min
142. When performing Weber’s test, Nurse Rosean expects that
this client will hear 150. Mr. Gutierrez is to receive 1 liter of D5RL to run for 12 hours.
The drop factor of the IV infusion set is 10 drops per minute.
Approximately how many drops per minutes should the IV be
A. On unaffected side
regulated?
B. Longer through bone than air conduction
C. On affected side by bone conduction
D. By neither bone or air conduction A. 13-14 drops
B. 17-18 drops
143. Toy with a tentative diagnosis of myasthenia gravis is C. 10-12 drops
admitted for diagnostic make up. Myasthenia gravis can confirmed D. 15-16 drops
by:
A. Kernigs sign
B. Brudzinski’s sign Answers
C. A positive sweat chloride test
D. A positive edrophonium (Tensilon) test 1. C. Don’t get pregnant at least 3 months
2. A. Increased urinary output
144. A male client is hospitalized with Guillain-Barre Syndrome. 3. D. Incubation period varies depending on the site
Which assessment finding is the most significant? of the bite
A. Even, unlabored respirations 4. B. Cover IV bottle with brown paper bag
B. Soft, non distended abdomen 5. C. Rumpel-leede test
C. Urine output of 50 ml/hr 6. D. Peripheral blood smear
D. Warm skin 7. A. Nurse who never had chicken pox
8. D. After the delivery of the baby
145. For a female client with suspected intracranial pressure (ICP), 9. B. 18 year old sister who recently got married
a most appropriate respiratory goal is: 10. C. BCG vaccination
A. Maintain partial pressure of arterial oxygen (Pa 11. C. Klebs-loeffler bacillus
O2) above 80mmHg 12. D. I will come back on Wednesday, same time, to
B. Promote elimination of carbon dioxide read the result
C. Lower the PH 13. C. Positive
D. Prevent respiratory alkalosis 14. B. Avoid vitamin supplements while o therapy
15. D. Chancre
146. Which nursing assessment would identify the earliest sign of 16. A. 60 breaths per minute
ICP? 17. D. A and B
18. D. Cotrimoxazole
19. C. 1 tsp. salt and 8 tsp. sugar
A. Change in level of consciousness
20. B. Umbilical infections
B. Temperature of over 103°F
21. A. BCG
C. Widening pulse pressure
22. C. Epidemiological situation
D. Unequal pupils
23. D. 90
24. B. -15c to -25c
147. The greatest danger of an uncorrected atrial fibrillation for a
25. A. Bacterial toxin
male patient will be which of the following:
26. D. Planning
27. B. Schedule
A. Pulmonary embolism 28. A. Motivation
B. Cardiac arrest 29. C. Vision
C. Thrombus formation 30. D. Standards
D. Myocardial infarction 31. D. Negative reinforcement
32. B. Close ended
148. Linda, A 30 year old post hysterectomy client has visited the 33. A. Inductive
health center. She inquired about BSE and asked the nurse when 34. B. Risk-benefit ratio
BSE should be performed. You answered that the BSE is best 35. A. Element
performed: 36. C. Organizational chart
A. 7 days after menstruation 37. D. University of Sto. Tomas
B. At the same day each month 38. D. Italy
C. During menstruation 39. B. Overt
D. Before menstruation 40. D. The statement of patient “My hand is painful”
41. C. Supine

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42. A. 7 days after menstrual period 105. C. Poverty
43. B. Preparation of the patient 106. A. The client may become resistive and active in
44. C. Kardex stopping the crisis
45. C. Side lying, unaffected side 107. B. Anal
46. D. Percussion 108. D. Infancy
47. D. Dilated pupils 109. C. Reduce anxiety
48. A. Ineffective airway clearance related to edema 110. A. Altered nutrition : less than body requirement
49. D. Redness and warmth 111. D. She gained 4 lbs in two weeks
50. B. 1 kilograms 112. C. Antipsychotics
51. C. Two arteries and one vein 113. A. Anti depressants
52. D. April 18 114. D. Simplify the environment to eliminate the need
53. A. Butter to make chores
54. C. Immediate surgery 115. B. 3 years old
55. D. Semi-fowlers 116. D. Withdrawal
56. A. Pressure caused by the ascending uterus 117. D. Depression
57. B. 500 118. A. Gestalt therapy
58. D. Estrogen 119. D. Cognition
59. C. Cervix is completely dilated 120. C. Finger foods, high in calorie
60. D. Blue 121. D. Finger painting
61. B. Listen the fetal heart tone 122. A. Introjection
62. D. Uterine atomy 123. B. Overcoming feeling of insecurity
63. C. 2 fingers below umbilicus 124. C. Coffee
64. A. Normal findings during assessment 125. D. Administer analgesics as prescribed
65. D. Tetanus toxoid 126. A. Low protein, low sodium, low potassium
66. C. RI 8172 127. D. Decreased hemoglobin
67. B. Sambong 128. B. 8th CN
68. A. An essential and indispensable equipment of 129. C. Void immediately after intercourse
the community health nurse during home visit 130. A. Blanching or cyanosis of legs
69. D. 99 131. B. Colchicines
70. B. After 2-4 weeks 132. A. The client objects to its use
71. C. Lactational Amenorrhea method (LAM) 133. D. Evaluation
72. B. Identify the illness 134. B. The symptomatic quadrant last
73. A. After 2 days 135. A. 3 minutes
74. D. Sentrong sigla movement 136. C. Plaintiff
75. B. February 1985 137. B. Stay with the client and do nothing
76. D. 6 138. A. 1994
77. C. Acetylcysteine 139. B. 2001-2002
78. A. Habit training 140. D. Age
79. B. Polyhydramios 141. B. Inner ear
80. D. Rice 142. C. On affected side by bone conduction
81. D. “Here’s your medicine. Would you like a 143. D. A positive edrophonium (Tensilon) test
mango or orange juice?” 144. A. Even, unlabored respirations
82. A. 6 years 145. B. Promote elimination of carbon dioxide
83. C. Oxygen tent 146. A. Change in level of consciousness
84. B. Carmencita Abaquin 147. C. Thrombus formation
85. A. BON 148. B. At the same day each month
86. D. 4 years 149. B. 21 gtts/min
87. C. Date of Application 150. A. 13-14 drops
88. A. EO 51
89. B. Autonomy
90. C. Force majeure
91. A. Fidelity
92. D. Prudence
93. B. Enrollment in graduate school
94. C. Primary health nurse
95. A. Department of Health
96. D. Parents/legal guardians
97. C. Trustworthiness
98. B. Change IV infusions
99. C. Respect the client’s action
100. D. Assist client towards a peaceful death
101. C. Empathy
102. A. Review progress of therapy and attainment of
goals
103. D. Diazepam (Valium)
104. B. Psycho stimulant
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