Nursing Board Practice Test Compilation: 188 Questions

Nursing Board Practice Test Compilation
FOUNDATION OF PROFESSIONAL NURSING PRACTICE 188
Contents
NURSING PRACTICE I: FOUNDATION OF NURSING
PRACTICE .......................................................................... 4
NURSING PRACTICE II ..................................................... 15
NURSING PRACTICE III .................................................... 26
NURSING PRACTICE IV.................................................... 36
NURSING PRACTICE V..................................................... 46
TEST I - Foundation of Professional Nursing Practice .... 56
Answers and Rationale – Foundation of Professional
Nursing Practice ......................................................... 66
TEST II - Community Health Nursing and Care of the
Mother and Child ........................................................... 74
Answers and Rationale – Community Health Nursing
and Care of the Mother and Child ............................. 84

ANSWER KEY - FOUNDATION OF PROFESSIONAL
NURSING PRACTICE.................................................. 199
COMMUNITY HEALTH NURSING AND CARE OF THE
MOTHER AND CHILD .................................................... 200
ANSWER KEY: COMMUNITY HEALTH NURSING AND
CARE OF THE MOTHER AND CHILD .......................... 211
Comprehensive Exam 1................................................ 213
CARE OF CLIENTS WITH PHYSIOLOGIC AND
PSYCHOSOCIAL ALTERATIONS...................................... 222
ANSWER KEY: CARE OF CLIENTS WITH PHYSIOLOGIC
AND PSYCHOSOCIAL ALTERATIONS ......................... 234
Nursing Practice Test V ................................................ 235
Nursing Practice Test V ................................................ 245
TEST I - Foundation of Professional Nursing Practice .. 255

TEST III - Care of Clients with Physiologic and
Psychosocial Alterations ................................................ 91

Answers and Rationale – Foundation of Professional
Nursing Practice ....................................................... 265

Answers and Rationale – Care of Clients with
Physiologic and Psychosocial Alterations ................ 102

TEST II - Community Health Nursing and Care of the
Mother and Child ......................................................... 273

TEST IV - Care of Clients with Physiologic and
Psychosocial Alterations .............................................. 111

Answers and Rationale – Community Health Nursing
and Care of the Mother and Child ........................... 283


TEST III - Care of Clients with Physiologic and

TEST V - Care of Clients with Physiologic and Psychosocial
Alterations.................................................................... 133



TEST IV - Care of Clients with Physiologic and

PART III PRACTICE TEST I FOUNDATION OF NURSING . 153


ANSWERS AND RATIONALE – FOUNDATION OF
NURSING .................................................................. 158
PRACTICE TEST II Maternal and Child Health ............... 162
ANSWERS AND RATIONALE – MATERNAL AND CHILD
HEALTH..................................................................... 167
MEDICAL SURGICAL NURSING ..................................... 173
ANSWERS AND RATIONALE – MEDICAL SURGICAL
NURSING .................................................................. 178
PSYCHIATRIC NURSING ................................................ 180
ANSWERS AND RATIONALE – PSYCHIATRIC NURSING
................................................................................. 185

TEST V - Care of Clients with Physiologic and Psychosocial
Alterations.................................................................... 332
PART III ......................................................................... 352
PRACTICE TEST I FOUNDATION OF NURSING .............. 352
ANSWERS AND RATIONALE – FOUNDATION OF
NURSING .................................................................. 357
PRACTICE TEST II Maternal and Child Health ............... 361

ANSWERS AND RATIONALE – MATERNAL AND CHILD
HEALTH..................................................................... 366
MEDICAL SURGICAL NURSING ..................................... 372

MEDICAL SURGICAL NURSING Part 1 ........................... 475
ANSWERS and RATIONALES for MEDICAL SURGICAL
NURSING Part 1 ........................................................ 479

ANSWERS AND RATIONALE – MEDICAL SURGICAL
NURSING .................................................................. 377


PSYCHIATRIC NURSING ................................................ 379

NURSING Part 2 ........................................................ 489

ANSWERS AND RATIONALE – PSYCHIATRIC NURSING
................................................................................. 384
FUNDAMENTALS OF NURSING PART 1 ........................ 387
ANSWERS and RATIONALES for FUNDAMENTALS OF
NURSING PART 2 ...................................................... 397
ANSWERS and RATIONALES for FUNDAMENTALS OF
NURSING PART 3 ...................................................... 405
MATERNITY NURSING Part 1 ........................................ 409
ANSWERS and RATIONALES for MATERNITY NURSING
Part 1 ........................................................................ 418

MEDICAL SURGICAL NURSING Part 2 ....................... 485

NURSING Part 3 ........................................................ 495
PSYCHIATRIC NURSING Part 1 ...................................... 497
ANSWERS and RATIONALES for PSYCHIATRIC NURSING
Part 1 ........................................................................ 502
Part 2 ........................................................................ 509

MATERNITY NURSING Part 2 ........................................ 428

Part 3 ........................................................................ 516

Answer for maternity part 2 .................................... 433

PROFESSIONAL ADJUSTMENT ...................................... 519

PEDIATRIC NURSING .................................................... 434

LEADERSHIP and MANAGEMENT ................................. 522

ANSWERS and RATIONALES for PEDIATRIC NURSING
................................................................................. 439

NURSING RESEARCH Part 1 .......................................... 532

COMMUNITY HEALTH NURSING Part 1........................ 444

Nursing Research Suggested Answer Key ................ 546

COMMUNITY HEALTH NURSING Part 2........................ 454

2

NURSING RESEARCH Part 2 .......................................... 542

5.
NURSING PRACTICE I: FOUNDATION OF NURSING
PRACTICE
SITUATION: Nursing is a profession. The nurse should
have a background on the theories and foundation of
nursing as it influenced what is nursing today.
1.

2.

3.

4.

4

Nursing is the protection, promotion and
optimization of health and abilities, prevention
of illness and injury, alleviation of suffering
through the diagnosis and treatment of human
response and advocacy in the care of the
individuals, families, communities and the
population. This is the most accepted definition
of nursing as defined by the:
a. PNA
b. ANA
c. Nightingale
d. Henderson
Advancement in Nursing leads to the
development of the Expanded Career Roles.
Which of the following is NOT an expanded
career role for nurses?
a. Nurse practitioner
b. Nurse Researcher
c. Clinical nurse specialist
d. Nurse anaesthesiologist
The Board of Nursing regulated the Nursing
profession in the Philippines and is responsible
for the maintenance of the quality of nursing in
the country. Powers and duties of the board of
nursing are the following, EXCEPT:
a. Issue, suspend, revoke certificates of
registration
b. Issue subpoena duces tecum, ad
testificandum
c. Open and close colleges of nursing
d. Supervise and regulate the practice of
nursing
A nursing student or a beginning staff nurse who
has not yet experienced enough real situations
to make judgments about them is in what stage
of Nursing Expertise?
a. Novice
b. Newbie
c. Advanced Beginner
d. Competent

Benner’s “Proficient” nurse level is different
from the other levels in nursing expertise in the
context of having:
a. the ability to organize and plan activities
b. having attained an advanced level of
education
c. a holistic understanding and perception
of the client
d. intuitive and analytic ability in new
situations

SITUATION: The nurse has been asked to administer an
injection via Z TRACK technique. Questions 6 to 10 refer
to this.
6.

The nurse prepares an IM injection for an adult
client using the Z track technique. 4 ml of
medication is to be administered to the client.
Which of the following site will you choose?
a. Deltoid
b. Rectus femoris
c. Ventrogluteal
d. Vastus lateralis

7.

In infants 1 year old and below, which of the
following is the site of choice for intramuscular
Injection?
a. Deltoid
b. Rectus femoris
c. Ventrogluteal
d. Vastus lateralis

8.

In order to decrease discomfort in Z track
administration, which of the following is
applicable?
a. Pierce the skin quickly and smoothly at
a 90 degree angle
b. Inject the medication steadily at around
10 minutes per millilitre
c. Pull back the plunger and aspirate for 1
minute to make sure that the needle did
not hit a blood vessel
d. Pierce the skin slowly and carefully at a
90 degree angle

9.

After injection using the Z track technique, the
nurse should know that she needs to wait for a
few seconds before withdrawing the needle and
this is to allow the medication to disperse into
the muscle tissue, thus decreasing the client’s
discomfort. How many seconds should the nurse
wait before withdrawing the needle?
a. 2 seconds

5
b. 5 seconds
c. 10 seconds
d. 15 seconds
10.

The rationale in using the Z track technique in an
intramuscular injection is:
a. It decreases the leakage of discolouring
and irritating medication into the
subcutaneous tissues
b. It will allow a faster absorption of the
medication
c. The Z track technique prevent irritation
of the muscle
d. It is much more convenient for the nurse

that the patient smokes and drinks coffee. When
taking the blood pressure of a client who
recently smoked or drank coffee, how long
should the nurse wait before taking the client’s
blood pressure for accurate reading?
a. 15 minutes
b. 30 minutes
c. 1 hour
d. 5 minutes
15.

While the client has pulse oximeter on his
fingertip, you notice that the sunlight is shining
on the area where the oximeter is. Your action
will be to:
a. Set and turn on the alarm of the
oximeter
b. Do nothing since there is no identified
problem
c. Cover the fingertip sensor with a towel
or bedsheet
d. Change the location of the sensor every
four hours

16.

The nurse finds it necessary to recheck the blood
pressure reading. In case of such re assessment,
the nurse should wait for a period of:
a. 15 seconds
b. 1 to 2 minutes
c. 30 minutes
d. 15 minutes

17.

If the arm is said to be elevated when taking the
blood pressure, it will create a:
a. False high reading
b. False low reading
c. True false reading
d. Indeterminate

18.

You are to assessed the temperature of the
client the next morning and found out that he
ate ice cream. How many minutes should you
wait before assessing the client’s oral
temperature?
a. 10 minutes
b. 20 minutes
c. 30 minutes
d. 15 minutes

19.

When auscultating the client’s blood pressure
the nurse hears the following: From 150 mmHg
to 130 mmHg: Silence, Then: a thumping sound
continuing down to 100 mmHg; muffled sound
continuing down to 80 mmHg and then silence.

SITUATION: A Client was rushed to the emergency room
and you are his attending nurse. You are performing a
vital sign assessment.
11.

12.

13.

14.

All of the following are correct methods in
assessment of the blood pressure EXCEPT:
a. Take the blood pressure reading on both
arms for comparison
b. Listen to and identify the phases of
Korotkoff’s sound
c. Pump the cuff to around 50 mmHg
above the point where the pulse is
obliterated
d. Observe procedures for infection control
You attached a pulse oximeter to the client. You
know that the purpose is to:
a. Determine if the client’s hemoglobin
level is low and if he needs blood
transfusion
b. Check level of client’s tissue perfusion
c. Measure the efficacy of the client’s antihypertensive medications
d. Detect oxygen saturation of arterial
blood before symptoms of hypoxemia
develops
After a few hours in the Emergency Room, The
client is admitted to the ward with an order of
hourly monitoring of blood pressure. The nurse
finds that the cuff is too narrow and this will
cause the blood pressure reading to be:
a. inconsistent
b. low systolic and high diastolic
c. higher than what the reading should be
d. lower than what the reading should be
Through the client’s health history, you gather

What is the client’s blood pressure?
a. 130/80
b. 150/100
c. 100/80
d. 150/100
20.

In a client with a previous blood pressure of
130/80 4 hours ago, how long will it take to
release the blood pressure cuff to obtain an
accurate reading?
a. 10-20 seconds
b. 30-45 seconds
c. 1-1.5 minutes
d. 3-3.5 minutes

to lungs. This can be avoided by:
a. Cleaning teeth and mouth with cotton
swabs soaked with mouthwash to avoid
rinsing the buccal cavity
b. swabbing the inside of the cheeks and
lips, tongue and gums with dry cotton
swabs
c. use fingers wrapped with wet cotton
washcloth to rub inside the cheeks,
tongue, lips and ums
d. suctioning as needed while cleaning the
buccal cavity
25.

Situation: Oral care is an important part of hygienic
practices and promoting client comfort.
21.

22.

23.

24.

6

An elderly client, 84 years old, is unconscious.
Assessment of the mouth reveals excessive
dryness and presence of sores. Which of the
following is BEST to use for oral care?
a. lemon glycerine
b. Mineral oil
c. hydrogen peroxide
d. Normal saline solution
When performing oral care to an unconscious
client, which of the following is a special
consideration to prevent aspiration of fluids into
the lungs?
a. Put the client on a sidelying position
with head of bed lowered
b. Keep the client dry by placing towel
under the chin
c. Wash hands and observes appropriate
infection control
d. Clean mouth with oral swabs in a careful
and an orderly progression
The advantages of oral care for a client include
all of the following, EXCEPT:
a. decreases bacteria in the mouth and
teeth
b. reduces need to use commercial
mouthwash which irritate the buccal
mucosa
c. improves client’s appearance and selfconfidence
d. improves appetite and taste of food
A possible problem while providing oral care to
unconscious clients is the risk of fluid aspiration

Your client has difficulty of breathing and is
mouth breathing most of the time. This causes
dryness of the mouth with unpleasant odor. Oral
hygiene is recommended for the client and in
addition, you will keep the mouth moistened by
using:
a. salt solution
b. petroleum jelly
c. water
d. mentholated ointment

Situation – Ensuring safety before, during and after a
diagnostic procedure is an important responsibility of
the nurse.
26.

To help Fernan better tolerate the
bronchoscopy, you should instruct him to
practice which of the following prior to the
procedure?
a. Clenching his fist every 2 minutes
b. Breathing in and out through the nose
with his mouth open
c. Tensing the shoulder muscles while lying
on his back
d. Holding his breath periodically for 30
seconds

27.

Following a bronchoscopy, which of the
following complains to Fernan should be noted
as a possible complication:
a. Nausea and vomiting
b. Shortness of breath and laryngeal
stridor
c. Blood tinged sputum and coughing
d. Sore throat and hoarseness

28.

Immediately after bronchoscopy, you instructed
Fernan to:
a. Exercise the neck muscles
b. Refrain from coughing and talking

7
c. Breathe deeply
d. Clear his throat

d. Weber’s test
34.

29.

30.

Right after thoracentesis, which of the following
is most appropriate intervention?
a. Instruct the patient not to cough or deep
breathe for two hours
b. Observe for symptoms of tightness of
chest or bleeding
c. Place an ice pack to the puncture site
d. Remove the dressing to check for
bleeding

A nurse is reviewing the arterial blood gas values
of a client and notes that the ph is 7.31, Pco2 is
50 mmHg, and the bicarbonate is 27 mEq/L. The
nurse concludes that which acid base
disturbance is present in this client?
a. Respiratory acidosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Metabolic alkalosis

35.

Allen’s test checks the patency of the:
a. Ulnar artery
b. Carotid artery
c. Radial artery
d. Brachial artery

Thoracentesis may be performed for cytologic
study of pleural fluid. As a nurse your most
important function during the procedure is to:
a. Keep the sterile equipment from
contamination
b. Assist the physician
c. Open and close the three-way stopcock
d. Observe the patient’s vital signs

Situation: Knowledge of the acid-base disturbance and
the functions of the electrolytes is necessary to
determine appropriate intervention and nursing actions.
31.

A client with diabetes milletus has a blood
glucose level of 644 mg/dL. The nurse interprets
that this client is at most risk for the
development of which type of acid-base
imbalance?
b. Respiratory alkalosis
c. Metabolic acidosis

32.

In a client in the health care clinic, arterial blood
gas analysis gives the following results: pH 7.48,
PCO2 32 mmHg, PO2 94 mmHg, HCO3 24 mEq/L.
The nurse interprets that the client has which
acid base disturbance?
b. Metabolic acidosis
c. Respiratory alkalosis

33.

A client has an order for ABG analysis on radial
artery specimens. The nurse ensures that which
of the following has been performed or tested
before the ABG specimens are drawn?
a. Guthrie test
b. Romberg’s test
c. Allen’s test

Situation 6: Eileen, 45 years old is admitted to the
hospital with a diagnosis of renal calculi. She is
experiencing severe flank pain, nauseated and with a
temperature of 39 0C.
36.

Given the above assessment data, the most
immediate goal of the nurse would be which of
the following?
a. Prevent urinary complication
b. maintains fluid and electrolytes
c. Alleviate pain
d. Alleviating nausea

37.

After IVP a renal stone was confirmed, a left
nephrectomy was done. Her post-operative
order includes “daily urine specimen to be sent
to the laboratory”. Eileen has a foley catheter
attached to a urinary drainage system. How will
you collect the urine specimen?
a. remove urine from drainage tube with
sterile needle and syringe and empty
urine from the syringe into the
specimen container
b. empty a sample urine from the
collecting bag into the specimen
container
c. Disconnect the drainage tube from the
indwelling catheter and allow urine to
flow from catheter into the specimen
container.
d. Disconnect the drainage from the
collecting bag and allow the urine to
flow from the catheter into the
specimen container.

38.

Where would the nurse tape Eileen’s indwelling
catheter in order to reduce urethral irritation?
a. to the patient’s inner thigh
b. to the patient’ buttocks
c. to the patient’s lower thigh
d. to the patient lower abdomen

regulation is secreted in the:
a. Thyroid gland
b. Parathyroid gland
c. Hypothalamus
d. Anterior pituitary gland
45.

39.

40.

Which of the following menu is appropriate for
one with low sodium diet?
a. instant noodles, fresh fruits and ice tea
b. ham and cheese sandwich, fresh fruits
and vegetables
c. white chicken sandwich, vegetable
salad and tea
d. canned soup, potato salad, and diet soda
How will you prevent ascending infection to
Eileen who has an indwelling catheter?
a. see to it that the drainage tubing
touches the level of the urine
b. change he catheter every eight hours
c. see to it that the drainage tubing does
not touch the level of the urine
d. clean catheter may be used since
urethral meatus is not a sterile area

Situation: Hormones are secreted by the various glands
in the body. Basic knowledge of the endocrine system is
necessary.
41.

All of the following are secreted by the anterior
pituitary gland except:
a. Somatotropin/Growth hormone
b. Thyroid stimulating hormone
c. Follicle stimulating hormone
d. Gonadotropin hormone releasing
hormone

Situation: The staff nurse supervisor requests all the staff
nurses to “brainstorm” and learn ways to instruct
diabetic clients on self-administration of insulin. She
wants to ensure that there are nurses available daily to
do health education classes.
46.

The plan of the nurse supervisor is an example of
a. in service education process
b. efficient management of human
resources
c. increasing human resources
d. primary prevention

47.

When Mrs. Guevarra, a nurse, delegates aspects
of the clients care to the nurse-aide who is an
unlicensed staff, Mrs. Guevarra
a. makes the assignment to teach the staff
member
b. is assigning the responsibility to the
aide but not the accountability for
those tasks
c. does not have to supervise or evaluate
the aide
d. most know how to perform task
delegated

48.

Connie, the new nurse, appears tired and
sluggish and lacks the enthusiasm she had six
weeks ago when she started the job. The nurse
supervisor should
a. empathize with the nurse and listen to
her
b. tell her to take the day off
c. discuss how she is adjusting to her new
job
d. ask about her family life

49.

Process of formal negotiations of working
conditions between a group of registered nurses
and employer is

Somatocrinin or the Growth hormone releasing
hormone is secreted by the:
a. Hypothalamus
b. Posterior pituitary gland
c. Anterior pituitary gland
d. Thyroid gland

42.

43.

44.
8

All of the following hormones are hormones
secreted by the Posterior pituitary gland except:
a. Vasopressin
b. Anti-diuretic hormone
c. Oxytocin
d. Growth hormone
Calcitonin, a hormone necessary for calcium

While Parathormone, a hormone that negates
the effect of calcitonin is secreted by the:
a. Thyroid gland
b. Parathyroid gland
c. Hypothalamus
d. Anterior pituitary gland

9
a.
b.
c.
d.

grievance
arbitration
collective bargaining
strike

d. It should disclose previous diagnosis,
prognosis and alternative treatments
available for the client
55.

50.

You are attending a certification on
cardiopulmonary resuscitation (CPR) offered and
required by the hospital employing you. This is
a. professional course towards credits
b. in-service education
c. advance training
d. continuing education

Situation: As a nurse, you are aware that proper
documentation in the patient chart is your responsibility.
51.

52.

53.

54.

Which of the following is not a legally binding
document but nevertheless very important in
the care of all patients in any health care
setting?
a. Bill of rights as provided in the Philippine
constitution
b. Scope of nursing practice as defined by
RA 9173
c. Board of nursing resolution adopting the
code of ethics
d. Patient’s bill of rights
A nurse gives a wrong medication to the client.
Another nurse employed by the same hospital as
a risk manager will expect to receive which of
the following communication?
a. Incident report
b. Nursing kardex
c. Oral report
d. Complain report
Performing a procedure on a client in the
absence of an informed consent can lead to
which of the following charges?
a. Fraud
b. Harassment
c. Assault and battery
d. Breach of confidentiality
Which of the following is the essence of
informed consent?
a. It should have a durable power of
attorney
b. It should have coverage from an
insurance company
c. It should respect the client’s freedom
from coercion

Delegation is the process of assigning tasks that
can be performed by a subordinate. The RN
should always be accountable and should not
lose his accountability. Which of the following is
a role included in delegation?
a. The RN must supervise all delegated
tasks
b. After a task has been delegated, it is no
longer a responsibility of the RN
c. The RN is responsible and accountable
for the delegated task in adjunct with
the delegate
d. Follow up with a delegated task is
necessary only if the assistive personnel
is not trustworthy

Situation: When creating your lesson plan for
cerebrovascular disease or STROKE. It is important to
include the risk factors of stroke.
56.

The most important risk factor is:
a. Cigarette smoking
b. binge drinking
c. Hypertension
d. heredity

57.

Part of your lesson plan is to talk about etiology
or cause of stroke. The types of stroke based on
cause are the following EXCEPT:
a. Embolic stroke
b. diabetic stroke
c. Hemorrhagic stroke
d. thrombotic stroke

58.

Hemmorhagic stroke occurs suddenly usually
when the person is active. All are causes of
hemorrhage, EXCEPT:
a. phlebitis
b. damage to blood vessel
c. trauma
d. aneurysm

59.

The nurse emphasizes that intravenous drug
abuse carries a high risk of stroke. Which drug is
closely linked to this?
a. Amphetamines
b. shabu
c. Cocaine
d. Demerol

d. Iron 75 mg/100 ml
60.

A participant in the STROKE class asks what is a
risk factor of stroke. Your best response is:
a. “More red blood cells thicken blood
and make clots more possible.”
b. “Increased RBC count is linked to high
cholesterol.”
c. “More red blood cell increases
hemoglobin content.”
d. “High RBC count increases blood
pressure.”

Situation: Recognition of normal values is vital in
assessment of clients with various disorders.
61.

A nurse is reviewing the electrolyte results of an
assigned client and notes that the potassium
level is 5.6 mEq/L. Which of the following would
the nurse expect to note on the ECG as a result
of this laboratory value?
a. ST depression
b. Prominent U wave
c. Inverted T wave
d. Tall peaked T waves

63.

64.

10

A nurse is reviewing the electrolyte results of an
assigned client and notes that the potassium
the nurse expect to note on the ECG as a result
of this laboratory value?
a. U waves
b. Elevated T waves
c. Absent P waves
d. Elevated ST Segment
Dorothy underwent diagnostic test and the
result of the blood examination are back. On
reviewing the result the nurse notices which of
the following as abnormal finding?
a. Neutrophils 60%
b. White blood cells (WBC) 9000/mm
c. Erythrocyte sedimentation rate (ESR) is
39 mm/hr

Which of the following laboratory test result
indicate presence of an infectious process?
a. Erythrocyte sedimentation rate (ESR) 12
mm/hr
b. White blood cells (WBC) 18,000/mm3
c. Iron 90 g/100ml
d. Neutrophils 67%

Situation: Pleural effusion is the accumulation of fluid in
the pleural space. Questions 66 to 70 refer to this.
66.

Which of the following is a finding that the nurse
will be able to assess in a client with Pleural
effusion?
a. Reduced or absent breath sound at the
base of the lungs, dyspnea, tachpynea
and shortness of breath
b. Hypoxemia, hypercapnea and
respiratory acidosis
c. Noisy respiration, crackles, stridor and
wheezing
d. Tracheal deviation towards the affected
side, increased fremitus and loud breath
sounds

67.

Thoracentesis is performed to the client with
effusion. The nurse knows that the removal of
fluid should be slow. Rapid removal of fluid in
thoracentesis might cause:
a. Pneumothorax
b. Cardiovascular collapse
c. Pleurisy or Pleuritis
d. Hypertension

68.

3 Days after thoracentesis, the client again
exhibited respiratory distress. The nurse will
know that pleural effusion has reoccurred when
she noticed a sharp stabbing pain during
inspiration. The physician ordered a closed tube
thoracotomy for the client. The nurse knows
that the primary function of the chest tube is to:
a. Restore positive intrathoracic pressure
b. Restore negative intrathoracic pressure
c. To visualize the intrathoracic content
d. As a method of air administration via
ventilator

69.

The chest tube is functioning properly if:
a. There is an oscillation
b. There is no bubbling in the drainage
bottle

A nurse is reviewing the laboratory test results
for a client with a diagnosis of severe
dehydration. The nurse would expect the
hematocrit level for this client to be which of the
following?
a. 60%
b. 47%
c. 45%
d. 32%

62.

65.

11
c. There is a continuous bubbling in the
waterseal
d. The suction control bottle has a
continuous bubbling
70.

In a client with pleural effusion, the nurse is
instructing appropriate breathing technique.
Which of the following is included in the
teaching?
a. Breath normally
b. Hold the breath after each inspiration
for 1 full minute
c. Practice abdominal breathing
d. Inhale slowly and hold the breath for 3
to 5 seconds after each inhalation

75.

This form of Health Insurance provides
comprehensive prepaid health services to
enrollees for a fixed periodic payment.
a. Health Maintenance Organization
b. Medicare
c. Philippine Health Insurance Act
d. Hospital Maintenance Organization

Situation: Nursing ethics is an important part of the
nursing profession. As the ethical situation arises, so is
the need to have an accurate and ethical decision
making.
76.

The purpose of having a nurses’ code of ethics is:
a. Delineate the scope and areas of nursing
practice
b. identify nursing action recommended for
specific health care situations
c. To help the public understand
professional conduct expected of
nurses
d. To define the roles and functions of the
health care givers, nurses, clients

77.

The principles that govern right and proper
conduct of a person regarding life, biology and
the health professionals is referred to as:
a. Morality
b. Religion
c. Values
d. Bioethics

78.

A subjective feeling about what is right or wrong
is said to be:
a. Morality
b. Religion
c. Values
d. Bioethics

79.

Values are said to be the enduring believe about
a worth of a person, ideas and belief. If Values
are going to be a part of a research, this is
categorized under:
a. Qualitative
b. Experimental
c. Quantitative
d. Non Experimental

80.

The most important nursing responsibility where
ethical situations emerge in patient care is to:
a. Act only when advised that the action is
ethically sound

SITUATION: Health care delivery system affects the
health status of every filipino. As a Nurse, Knowledge of
this system is expected to ensure quality of life.
71.

When should rehabilitation commence?
a. The day before discharge
b. When the patient desires
c. Upon admission
d. 24 hours after discharge

72.

What exemplified the preventive and promotive
programs in the hospital?
a. Hospital as a center to prevent and
control infection
b. Program for smokers
c. Program for alcoholics and drug addicts
d. Hospital Wellness Center

73.

Which makes nursing dynamic?
a. Every patient is a unique physical,
emotional, social and spiritual being
b. The patient participate in the overall
nursing care plan
c. Nursing practice is expanding in the light
of modern developments that takes
place
d. The health status of the patient is
constantly changing and the nurse must
be cognizant and responsive to these
changes

74.

Prevention is an important responsibility of the
nurse in:
a. Hospitals
b. Community
c. Workplace
d. All of the above

b. Not takes sides, remain neutral and fair
c. Assume that ethical questions are the
responsibility of the health team
d. Be accountable for his or her own
actions
81.

82.

83.

84.

12

Why is there an ethical dilemma?
a. the choices involved do not appear to be
clearly right or wrong
b. a client’s legal right co-exist with the
nurse’s professional obligation
c. decisions has to be made based on
societal norms.
d. decisions has to be mad quickly, often
under stressful conditions
According to the code of ethics, which of the
following is the primary responsibility of the
nurse?
a. Assist towards peaceful death
b. Health is a fundamental right
c. Promotion of health, prevention of
illness, alleviation of suffering and
restoration of health
d. Preservation of health at all cost
Which of the following is TRUE about the Code
of Ethics of Filipino Nurses, except:
a. The Philippine Nurses Association for
being the accredited professional
organization was given the privilege to
formulate a Code of Ethics for Nurses
which the Board of Nursing
promulgated
b. Code for Nurses was first formulated in
1982 published in the Proceedings of the
Third Annual Convention of the PNA
House of Delegates
c. The present code utilized the Code of
Good Governance for the Professions in
the Philippines
d. Certificates of Registration of registered
nurses may be revoked or suspended for
violations of any provisions of the Code
of Ethics.
Violation of the code of ethics might equate to
the revocation of the nursing license. Who
revokes the license?
a. PRC
b. PNA
c. DOH
d. BON

85.

Based on the Code of Ethics for Filipino Nurses,
what is regarded as the hallmark of nursing
responsibility and accountability?
a. Human rights of clients, regardless of
creed and gender
b. The privilege of being a registered
professional nurse
c. Health, being a fundamental right of
every individual
d. Accurate documentation of actions and
outcomes

Situation: As a profession, nursing is dynamic and its
practice is directed by various theoretical models. To
demonstrate caring behaviour, the nurse applies various
nursing models in providing quality nursing care.
86.

When you clean the bedside unit and regularly
attend to the personal hygiene of the patient as
well as in washing your hands before and after a
procedure and in between patients, you indent
to facilitate the body’s reparative processes.
Which of the following nursing theory are you
applying in the above nursing action?
a. Hildegard Peplau
b. Dorothea Orem
c. Virginia Henderson
d. Florence Nightingale

87.

A communication skill is one of the important
competencies expected of a nurse. Interpersonal
process is viewed as human to human
relationship. This statement is an application of
whose nursing model?
a. Joyce Travelbee
b. Martha Rogers
c. Callista Roy
d. Imogene King

88.

The statement “the health status of an individual
is constantly changing and the nurse must be
cognizant and responsive to these changes” best
explains which of the following facts about
nursing?
a. Dynamic
b. Client centred
c. Holistic
d. Art

89.

Virginia Henderson professes that the goal of
nursing is to work interdependently with other
health care working in assisting the patient to

13
gain independence as quickly as possible. Which
of the following nursing actions best
demonstrates this theory in taking care of a 94
year old client with dementia who is totally
immobile?
a. Feeds the patient, brushes his teeth,
gives the sponge bath
b. Supervise the watcher in rendering
patient his morning care
c. Put the patient in semi fowler’s position,
set the over bed table so the patient can
eat by himself, brush his teeth and
sponge himself
d. Assist the patient to turn to his sides and
allow him to brush and feed himself only
when he feels ready

include:
a. Prescription of the doctor to the
patient’s illness
b. Plan of care for patient
c. Patient’s perception of one’s illness
d. Nursing problem and Nursing diagnosis
The medical records that are organized into
separate section from doctors or nurses has
more disadvantages than advantages. This is
classified as what type of recording?
a. POMR
b. Modified POMR
c. SOAPIE
d. SOMR

95.
90.

94.

Which of the following is the advantage of SOMR
or Traditional recording?
a. Increases efficiency in data gathering
b. Reinforces the use of the nursing
process
c. The caregiver can easily locate proper
section for making charting entries
d. Enhances effective communication
among health care team members

In the self-care deficit theory by Dorothea Orem,
nursing care becomes necessary when a patient
is unable to fulfil his physiological, psychological
and social needs. A pregnant client needing
prenatal check-up is classified as:
a. Wholly compensatory
b. Supportive Educative
c. Partially compensatory
d. Non compensatory

Situation: Documentation and reporting are just as
important as providing patient care, As such, the nurse
must be factual and accurate to ensure quality
documentation and reporting.

Situation: June is a 24 year old client with symptoms of
dyspnea, absent breath sounds on the right lung and
chest x ray revealed pleural effusion. The physician will
perform thoracentesis.
96.

91.

Health care reports have different purposes. The
availability of patients’ record to all health team
members demonstrates which of the following
purposes:
a. Legal documentation
b. Research
c. Education
d. Vehicle for communication

92.

POMR has been widely used in many teaching
hospitals. One of its unique features is SOAPIE
charting. The P in SOAPIE charting should

97.

Which of the following psychological preparation
is not relevant for him?
a. Telling him that the gauge of the needle
and anesthesia to be used
b. Telling him to keep still during the
procedure to facilitate the insertion of
the needle in the correct place
c. Allow June to express his feelings and
concerns
d. Physician’s explanation on the purpose
of the procedure and how it will be done

98.

Before thoracentesis, the legal consideration you
must check is:
a. Consent is signed by the client

When a nurse commits medication error, she
should accurately document client’s response
and her corresponding action. This is very
important for which of the following purposes:
a. Research
b. Legal documentation
c. Nursing Audit
d. Vehicle for communication

93.

Thoracentesis is useful in treating all of the
following pulmonary disorders except:
a. Hemothorax
b. Hydrothorax
c. Tuberculosis
d. Empyema

b. Medicine preparation is correct
c. Position of the client is correct
d. Consent is signed by relative and
physician
99.

As a nurse, you know that the position for June
before thoracentesis is:
a. Orthopneic
b. Low fowlers
c. Knee-chest
d. Sidelying position on the affected side

100.

Which of the following anaesthetics drug is used
for thoracentesis?
a. Procaine 2%
b. Demerol 75 mg
c. Valium 250 mg
d. Phenobartbital 50 mg

14

15
D. Follicle stimulating hormone
NURSING PRACTICE II
Situation: Mariah is a 31 year old lawyer who has been
married for 6 months. She consults you for guidance in
relation with her menstrual cycle and her desire to get
pregnant.
1. She wants to know the length of her menstrual
cycle. Her previous menstrual period is October
22 to 26. Her LMB is November 21. Which of the
following number of days will be your correct
response?
A. 29
B. 28
C. 30
D. 31
2. You advised her to observe and record the signs
of Ovulation. Which of the following signs will
she likely note down?
1.
A 1 degree Fahrenheit rise in basal body
temperature
2.
Cervical mucus becomes copious and
clear
3.
One pound increase in weight
4.
Mittelschmerz
A. 1, 2, 4
B. 1, 2, 3
C. 2, 3, 4
D. 1, 3, 4
3. You instruct Mariah to keep record of her basal
temperature every day, which of the following
instructions is incorrect?
A. If coitus has occurred; this should be
reflected in the chart
B. It is best to have coitus on the evening
following a drop in BBT to become
pregnant
C. Temperature should be taken
immediately after waking and before
getting out of bed
D. BBT is lowest during the secretory
phase
4. She reports an increase in BBT on December 16.
Which hormone brings about this change in her
BBT?
A. Estrogen
B. Gonadotropine
C. Progesterone

5. The following month, Mariah suspects she is
pregnant. Her urine is positive for Human
chorionic gonadotrophin. Which structure
produces Hcg?
A. Pituitary gland
B. Trophoblastic cells of the embryo
C. Uterine deciduas
D. Ovarian follicles
Situation: Mariah came back and she is now pregnant.
6. At 5 month gestation, which of the following
fetal development would probably be achieve?
A. Fetal movement are felt by Mariah
B. Vernix caseosa covers the entire body
C. Viable if delivered within this period
D. Braxton hicks contractions are observed
7. The nurse palpates the abdomen of Mariah.
Now At 5 month gestation, What level of the
abdomen can the fundic height be palpated?
A. Symphysis pubis
B. Midpoint between the umbilicus and the
xiphoid process
C. Midpoint between the symphysis pubis
and the umbilicus
D. Umbilicus
8. She worries about her small breasts, thinking
that she probably will not be able to breastfeed
her baby. Which of the following responses of
the nurse is correct?
A. “The size of your breast will not affect
your lactation”
B. “You can switch to bottle feeding”
C. “You can try to have exercise to increase
the size of your breast”
D. “Manual expression of milk is possible”
9. She tells the nurse that she does not take milk
regularly. She claims that she does not want to
gain too much weight during her pregnancy.
Which of the following nursing diagnosis is a
priority?
A. Potential self-esteem disturbance
related to physiologic changes in
pregnancy
B. Ineffective individual coping related to
physiologic changes in pregnancy
C. Fear related to the effects of pregnancy
D. Knowledge deficit regarding nutritional

requirements of pregnancies related to
lack of information sources
10. Which of the following interventions will likely
ensure compliance of Mariah?
A. Incorporate her food preferences that
are adequately nutritious in her meal
plan
B. Consistently counsel toward optimum
nutritional intake
C. Respect her right to reject dietary
information if she chooses
D. Inform her of the adverse effects of
inadequate nutrition to her fetus
Situation: Susan is a patient in the clinic where you work.
She is inquiring about pregnancy.
11. Susan tells you she is worried because she
develops breasts later than most of her friends.
Breast development is termed as:
A. Adrenarche
B. Thelarche
C. Mamarche
D. Menarche
12. Kevin, Susan’s husband tells you that he is
considering vasectomy After the birth of their
new child. Vasectomy involves the incision of
which organ?
A. The testes
B. The epididymis
C. The vas deferens
D. The scrotum
13. On examination, Susan has been found of having
a cystocele. A cystocele is:
A. A sebaceous cyst arising from the vulvar
fold
B. Protrusion of intestines into the vagina
C. Prolapse of the uterus into the vagina
D. Herniation of the bladder into the
vaginal wall
14. Susan typically has menstrual cycle of 34 days.
She told you she had coitus on days 8, 10, 15 and
20 of her menstrual cycle. Which is the day on
which she is most likely to conceive?
A. 8th day
B. Day 15
C. 10th day
D. Day 20

16

15. While talking with Susan, 2 new patients arrived
and they are covered with large towels and the
nurse noticed that there are many cameraman
and news people outside of the OPD. Upon
assessment the nurse noticed that both of them
are still nude and the male client’s penis is still
inside the female client’s vagina and the male
client said that “I can’t pull it”. Vaginismus was
your first impression. You know that The
psychological cause of Vaginismus is related to:
A. The male client inserted the penis too
deeply that it stimulates vaginal closure
B. The penis was too large that is why the
vagina triggered its defense to attempt
to close it
C. The vagina does not want to be
penetrated
D. It is due to learning patterns of the
female client where she views sex as
bad or sinful
Situation: Overpopulation is one problem in the
Philippines that causes economic drain. Most Filipinos
are against in legalizing abortion. As a nurse, Mastery of
contraception is needed to contribute to the society and
economic growth.
16. Supposed that Dana, 17 years old, tells you she
wants to use fertility awareness method of
contraception. How will she determine her
fertile days?
A. She will notice that she feels hot, as if
she has an elevated temperature.
B. She should assess whether her cervical
mucus is thin, copious, clear and
watery.
C. She should monitor her emotions for
sudden anger or crying
D. She should assess whether her breasts
feel sensitive to cool air
17. Dana chooses to use COC as her family planning
method. What is the danger sign of COC you
would ask her to report?
A. A stuffy or runny nose
B. Slight weight gain
C. Arthritis like symptoms
D. Migraine headache
18. Dana asks about subcutaneous implants and she
asks, how long will these implants be effective.
Your best answer is:
A. One month

17
B. Five years
C. Twelve months
D. 10 years
19. Dana asks about female condoms. Which of the
following is true with regards to female
condoms?
A. The hormone the condom releases
might cause mild weight gain
B. She should insert the condom before
any penile penetration
C. She should coat the condom with
spermicide before use
D. Female condoms, unlike male condoms,
are reusable
20. Dana has asked about GIFT procedure. What
makes her a good candidate for GIFT?
A. She has patent fallopian tubes, so
fertilized ova can be implanted on them
B. She is RH negative, a necessary
stipulation to rule out RH incompatibility
C. She has normal uterus, so the sperm can
be injected through the cervix into it
D. Her husband is taking sildenafil, so all
sperms will be motile
Situation: Nurse Lorena is a Family Planning and
Infertility Nurse Specialist and currently attends to
FAMILY PLANNING CLIENTS AND INFERTILE COUPLES.
The following conditions pertain to meeting the nursing
needs of this particular population group.
21. Dina, 17 years old, asks you how a tubal ligation
prevents pregnancy. Which would be the best
answer?
A. Prostaglandins released from the cut
fallopian tubes can kill sperm
B. Sperm cannot enter the uterus because
the cervical entrance is blocked.
C. Sperm can no longer reach the ova,
because the fallopian tubes are blocked
D. The ovary no longer releases ova as
there is nowhere for them to go.
22. The Dators are a couple undergoing testing for
infertility. Infertility is said to exist when:
A. A woman has no uterus
B. A woman has no children
C. A couple has been trying to conceive for
1 year
D. A couple has wanted a child for 6
months

23. Another client named Lilia is diagnosed as having
endometriosis. This condition interferes with
fertility because:
A. Endometrial implants can block the
fallopian tubes
B. The uterine cervix becomes inflamed
and swollen
C. The ovaries stop producing adequate
estrogen
D. Pressure on the pituitary leads to
decreased FSH levels
24. Lilia is scheduled to have a
hysterosalphingogram. Which of the following
instructions would you give her regarding this
procedure?
A. She will not be able to conceive for 3
months after the procedure
B. The sonogram of the uterus will reveal
any tumors present
C. Many women experience mild bleeding
as an after effect
D. She may feel some cramping when the
dye is inserted
25. Lilia’s cousin on the other hand, knowing nurse
Lorena’s specialization asks what artificial
insemination by donor entails. Which would be
your best answer if you were Nurse Lorena?
A. Donor sperm are introduced vaginally
into the uterus or cervix
B. Donor sperm are injected intraabdominally into each ovary
C. Artificial sperm are injected vaginally to
test tubal patency
D. The husband’s sperm is administered
intravenously weekly
Situation: You are assigned to take care of a group of
patients across the lifespan.
26. Pain in the elder persons requires careful
assessment because they:
A. experienced reduce sensory perception
B. have increased sensory perception
C. are expected to experience chronic pain
D. have a decreased pain threshold
27. Administration of analgesics to the older persons
requires careful patient assessment because
older people:
A. are more sensitive to drugs

B. have increased hepatic, renal and
gastrointestinal function
C. have increased sensory perception
D. mobilize drugs more rapidly
28. The elderly patient is at higher risk for urinary
incontinence because of:
A. increased glomerular filtration
B. decreased bladder capacity
C. diuretic use
D. dilated urethra
29. Which of the following is the MOST COMMON
sign of infection among the elderly?
A. decreased breath sounds with crackles
B. pain
C. fever
D. change in mental status
30. Priorities when caring for the elderly trauma
patient:
A. circulation, airway, breathing
B. airway, breathing, disability (neurologic)
C. disability (neurologic), airway, breathing
D. airway, breathing, circulation
31. Preschoolers are able to see things from which
of the following perspectives?
A. Their peers
B. Their own and their mother’s
C. Their own and their caregivers’
D. Only their own
32. In conflict management, the win-win approach
occurs when:
A. There are two conflicts and the parties
agree to each one
B. Each party gives in on 50% of the
disagreements making up the conflict
C. Both parties involved are committed to
solving the conflict
D. The conflict is settled out of court so the
legal system and the parties win
33. According to the social-interactional perspective
of child abuse and neglect, four factors place the
family members at risk for abuse. These risk
factors are the family members at risk for abuse.
These risk factors are the family itself, the
caregiver, the child, and
A. The presence of a family crisis
B. The national emphasis on sex
C. Genetics
18

D. Chronic poverty
34. Which of the following signs and symptoms
would you most likely find when assessing and
infant with Arnold-Chiari malformation?
A. Weakness of the leg muscles, loss of
sensation in the legs, and restlessness
B. Difficulty swallowing, diminished or
absent gag reflex, and respiratory
distress
C. Difficulty sleeping, hypervigilant, and an
arching of the back
D. Paradoxical irritability, diarrhea, and
vomiting.
35. A parent calls you and frantically reports that her
child has gotten into her famous ferrous sulfate
pills and ingested a number of these pills. Her
child is now vomiting, has bloody diarrhea, and is
complaining of abdominal pain. You will tell the
mother to:
A. Call emergency medical services (EMS)
and get the child to the emergency room
B. Relax because these symptoms will pass
and the child will be fine
C. Administer syrup of ipecac
D. Call the poison control center
36. A client says she heard from a friend that you
stop having periods once you are on the “pill”.
The most appropriate response would be:
A. “The pill prevents the uterus from
making such endometrial lining, that is
why periods may often be scant or
skipped occasionally.”
B. “If your friend has missed her period,
she should stop taking the pills and get a
pregnancy test as soon as possible.”
C. “The pill should cause a normal
menstrual period every month. It
sounds like your friend has not been
taking the pills properly.”
D. “Missed period can be very dangerous
and may lead to the formation of
precancerous cells.”
37. The nurse assessing newborn babies and infants
during their hospital stay after birth will notice
which of the following symptoms as a primary
manifestation of Hirschsprung’s disease?
A. A fine rash over the trunk
B. Failure to pass meconium during the
first 24 to 48 hours after birth

19
C. The skin turns yellow and then brown
over the first 48 hours of life
D. High-grade fever
38. A client is 7 months pregnant and has just been
diagnosed as having a partial placenta previa.
She is stable and has minimal spotting and is
being sent home. Which of these instructions to
the client may indicate a need for further
teaching?
A. Maintain bed rest with bathroom
privileges
B. Avoid intercourse for three days.
C. Call if contractions occur.
D. Stay on left side as much as possible
when lying down.
39. A woman has been rushed to the hospital with
ruptured membrane. Which of the following
should the nurse check first?
A. Check for the presence of infection
B. Assess for Prolapse of the umbilical
cord
C. Check the maternal heart rate
D. Assess the color of the amniotic fluid
40. The nurse notes that the infant is wearing a
plastic-coated diaper. If a topical medication
were to be prescribed and it were to go on the
stomachs or buttocks, the nurse would teach the
caregivers to:
A. avoid covering the area of the topical
medication with the diaper
B. avoid the use of clothing on top of the
diaper
C. put the diaper on as usual
D. apply an icepack for 5 minutes to the
outside of the diaper
41. Which of the following factors is most important
in determining the success of relationships used
in delivering nursing care?
A. Type of illness of the client
B. Transference and counter transference
C. Effective communication
D. Personality of the participants
42. Grace sustained a laceration on her leg from
automobile accident. Why are lacerations of
lower extremities potentially more serious
among pregnant women than other?
A. lacerations can provoke allergic
responses due to gonadotropic hormone

release
B. a woman is less able to keep the
laceration clean because of her fatigue
C. healing is limited during pregnancy so
these will not heal until after birth
D. increased bleeding can occur from
uterine pressure on leg veins
43. In working with the caregivers of a client with an
acute or chronic illness, the nurse would:
A. Teach care daily and let the caregivers
do a return demonstration just before
discharge
B. Difficulty swallowing, diminished or
absent gag reflex, and respiratory
distress.
C. Difficulty sleeping, hypervigilant, and an
arching of the back
D. Paradoxical irritability, diarrhea, and
vomiting
44. Which of the following roles BEST exemplifies
the expanded role of the nurse?
A. Circulating nurse in surgery
B. Medication nurse
C. Obstetrical nurse
D. Pediatric nurse practitioner
45. According to DeRosa and Kochura’s (2006)
article entitled “Implement Culturally Competent
Health Care in your work place,” cultures have
different patterns of verbal and nonverbal
communication. Which difference does?
A. NOT necessarily belong?
B. Personal behavior
C. Subject matter
D. Eye contact
E. Conversational style
46. You are the nurse assigned to work with a child
with acute glomerulonephritis. By following the
prescribed treatment regimen, the child
experiences a remission. You are now checking
to make sure the child does not have a relapse.
Which finding would most lead you to the
conclusion that a relapse is happening?
A. Elevated temperature, cough, sore
throat, changing complete blood count
(CBC) with diiferential
B. A urine dipstick measurement of 2+
proteinuria or more for 3 days, or the
child found to have 3-4+ proteinutria
plus edema.

C. The urine dipstick showing glucose in the
urine for 3 days, extreme thirst, increase
in urine output, and a moon face.
D. A temperature of 37.8 degrees (100
degrees F), flank pain, burning
frequency, urgency on voiding, and
cloudy urine.
47. The nurse is working with an adolescent who
complains of being lonely and having a lack of
fulfillment in her life. This adolescent shies away
from intimate relationships at times yet at other
times she appears promiscuous. The nurse will
likely work with this adolescent in which of the
following areas?
A. Isolation
B. Lack of fulfillment
C. Loneliness
D. Identity
48. The use of interpersonal decision making,
psychomotor skills, and application of
knowledge expected in the role of a licensed
health care professional in the context of public
health welfare and safety is an example of:
A. Delegation
B. Responsibility
C. Supervision
D. Competence
49. The painful phenomenon known as “back labor”
occurs in a client whose fetus in what position?
A. Brow position
B. Breech position
C. Right Occipito-Anterior Position
D. Left Occipito-Posterior Position
50. FOCUS methodology stands for:
A. Focus, Organize, Clarify, Understand
and Solution
B. Focus, Opportunity, Continuous, Utilize,
Substantiate
C. Focus, Organize, Clarify, Understand,
Substantiate
D. Focus, Opportunity, Continuous
(process), Understand, Solution
SITUATION: The infant and child mortality rate in the low
to middle income countries is ten times higher than
industrialized countries. In response to this, the WHO
and UNICEF launched the protocol Integrated
Management of Childhood Illnesses to reduce the
morbidity and mortality against childhood illnesses.
20

51. If a child with diarrhea registers two signs in the
yellow row in the IMCI chart, we can classify the
patient as:
A. Moderate dehydration
B. Severe dehydration
C. Some dehydration
D. No dehydration
52. Celeste has had diarrhea for 8 days. There is no
blood in the stool, he is irritable, his eyes are
sunken, the nurse offers fluid to Celeste and he
drinks eagerly. When the nurse pinched the
abdomen it goes back slowly. How will you
classify Celeste’s illness?
A. Moderate dehydration
C. Some dehydration
D. No dehydration
53. A child who is 7 weeks has had diarrhea for 14
days but has no sign of dehydration is classified
as:
A. Persistent diarrhea
B. Dysentery
C. Severe dysentery
D. Severe persistent diarrhea
54. The child with no dehydration needs home
treatment. Which of the following is not
included in the rules for home treatment in this
case?
A. Forced fluids
B. When to return
C. Give vitamin A supplement
D. Feeding more
55. Fever as used in IMCI includes:
A. Axillary temperature of 37.5 or higher
B. Rectal temperature of 38 or higher
C. Feeling hot to touch
D. All of the above
E. A and C only
Situation: Prevention of Dengue is an important nursing
responsibility and controlling it’s spread is a priority once
outbreak has been observed.
56. An important role of the community health
nurse in the prevention and control of Dengue
H-fever includes:
A. Advising the elimination of vectors by
keeping water containers covered

21
B. Conducting strong health education
drives/campaign directed towards
proper garbage disposal
C. Explaining to the individuals, families,
groups and community the nature of
the disease and its causation
D. Practicing residual spraying with
insecticides
57. Community health nurses should be alert in
observing a Dengue suspect. The following is
NOT an indicator for hospitalization of H-fever
suspects?
A. Marked anorexia, abdominal pain and
vomiting
B. Increasing hematocrit count
C. Cough of 30 days
D. Persistent headache
58. The community health nurses’ primary concern
in the immediate control of hemorrhage among
patients with dengue is:
A. Advising low fiber and non-fat diet
B. Providing warmth through light weight
covers
C. Observing closely the patient for vital
signs leading to shock
D. Keeping the patient at rest
59. Which of these signs may NOT be REGARDED as
a truly positive signs indicative of Dengue Hfever?
A. Prolonged bleeding time
B. Appearance of at least 20 petechiae
within 1cm square
C. Steadily increasing hematocrit count
D. Fall in the platelet count
60. Which of the following is the most important
treatment of patients with Dengue H-fever?
A. Give aspirin for fever
B. Replacement of body fluids
C. Avoid unnecessary movement of patient
D. Ice cap over the abdomen in case of
melena
Situation: Health education and Health promotion is an
important part of nursing responsibility in the
community. Immunization is a form of health promotion
that aims at preventing the common childhood illnesses.
61. In correcting misconceptions and myths about
certain diseases and their management, the

health worker should first:
A. Identify the myths and misconceptions
prevailing in the community
B. Identify the source of these myths and
misconceptions
C. Explain how and why these myths came
about
D. Select the appropriate IEC strategies to
correct them
62. How many percent of measles are prevented by
immunization at 9 months of age?
A. 80%
B. 99%
C. 90%
D. 95%
63. After TT3 vaccination a mother is said to be
protected to tetanus by around:
A. 80%
B. 99%
C. 85%
D. 90%
64. If ever convulsions occur after administering
DPT, what should the nurse best suggest to the
mother?
A. Do not continue DPT vaccination
anymore
B. Advise mother to comeback after 1 week
C. Give DT instead of DPT
D. Give pertussis of the DPT and remove DT
65. These vaccines are given 3 doses at one month
intervals:
A. DPT, BCG, TT
B. OPV, HEP. B, DPT
C. DPT, TT, OPV
D. Measles, OPV, DPT
Situation – With the increasing documented cases of
CANCER the best alternative to treatment still remains to
be PREVENTION. The following conditions apply.
66. Which among the following is the primary focus
of prevention of cancer?
A. Elimination of conditions causing cancer
B. Diagnosis and treatment
C. Treatment at early stage
D. Early detection
67. In the prevention and control of cancer, which of
the following activities is the most important

function of the community health nurse?
A. Conduct community assemblies.
B. Referral to cancer specialist those clients
with symptoms of cancer.
C. Use the nine warning signs of cancer as
parameters in our process of detection,
control and treatment modalities.
D. Teach woman about proper/correct
nutrition.
68. Who among the following are recipients of the
secondary level of care for cancer cases?
A. Those under early case detection
B. Those under post case treatment
C. Those scheduled for surgery
D. Those undergoing treatment
69. Who among the following are recipients of the
tertiary level of care for cancer cases?
A. Those under early treatment
B. Those under early detection
C. Those under supportive care
D. Those scheduled for surgery
70. In Community Health Nursing, despite the
availability and use of many equipment and
devices to facilitate the job of the community
health nurse, the best tool any nurse should be
wel be prepared to apply is a scientific approach.
This approach ensures quality of care even at the
community setting. This is nursing parlance is
nothing less than the:
A. nursing diagnosis
B. nursing research
C. nursing protocol
D. nursing process
Situation – Two children were brought to you. One with
chest indrawing and the other had diarrhea. The
following questions apply:
71. Using Integrated Management and Childhood
Illness (IMCI) approach, how would you classify
the 1st child?
A. Bronchopneumonia
B. Severe pneumonia
C. No pneumonia : cough or cold
D. Pneumonia
72. The 1st child who is 13 months has fast
breathing using IMCI parameters he has:
A. 40 breaths per minute or more
B. 50 breaths per minute
22

C. 30 breaths per minute or more
D. 60 breaths per minute
73. Nina, the 2nd child has diarrhea for 5 days.
There is no blood in the stool. She is irritable,
and her eyes are sunken. The nurse offered
fluids and and the child drinks eagerly. How
would you classify Nina’s illness?
A. Some dehydration
C. Dysentery
D. No dehydration
74. Nina’s treatment should include the following
EXCEPT:
A. reassess the child and classify him for
dehydration
B. for infants under 6 months old who are
not breastfed, give 100-200 ml clean
water as well during this period
C. Give in the health center the
recommended amount of ORS for 4
hours.
D. Do not give any other foods to the child
for home treatment
75. While on treatment, Nina 18 months old
weighed 18 kgs. and her temperature registered
at 37 degrees C. Her mother says she developed
cough 3 days ago. Nina has no general danger
signs. She has 45 breaths/minute, no chest indrawing, no stridor. How would you classify
Nina’s manifestation?
A. No pneumonia
B. Pneumonia
C. Severe pneumonia
D. Bronchopneumonia
76. Carol is 15 months old and weighs 5.5 kgs and it
is her initial visit. Her mother says that Carol is
not eating well and unable to breastfeed, he has
no vomiting, has no convulsion and not
abnormally sleepy or difficult to awaken. Her
temperature is 38.9 deg C. Using the integrated
management of childhood illness or IMCI
strategy, if you were the nurse in charge of
Carol, how will you classify her illness?
A. a child at a general danger sign
B. severe pneumonia
C. very severe febrile disease
D. severe malnutrition
77. Why are small for gestational age newborns at

23
risk for difficulty maintaining body temperature?
A. their skin is more susceptible to
conduction of cold
B. they are preterm so are born relatively
small in size
C. they do not have as many fat stored as
other infants
D. they are more active than usual so they
throw off comes
78. Oxytocin is administered to Rita to augment
labor. What are the first symptoms of water
intoxication to observe for during this
procedure?
A. headache and vomiting
B. a high choking voice
C. a swollen tender tongue
D. abdominal bleeding and pain
79. Which of the following treatment should NOT be
considered if the child has severe dengue
hemorrhagic fever?
A. use plan C if there is bleeding from the
nose or gums
B. give ORS if there is skin Petechiae,
persistent vomiting, and positive
tourniquet test
C. give aspirin
D. prevent low blood sugar
80. In assessing the patient’s condition using the
Integrated Management of Childhood Illness
approach strategy, the first thing that a nurse
should do is to:
A. ask what are the child’s problem
B. check for the four main symptoms
C. check the patient’s level of
consciousness
D. check for the general danger signs
81. A child with diarrhea is observed for the
following EXCEPT:
A. how long the child has diarrhea
B. presence of blood in the stool
C. skin Petechiae
D. signs of dehydration
82. The child with no dehydration needs home
treatment. Which of the following is NOT
included in the care for home management at
this case?
A. give drugs every 4 hours

B. give the child more fluids
C. continue feeding the child
D. inform when to return to the health
center
83. Ms. Jordan, RN, believes that a patient should be
treated as individual. This ethical principle that
the patient referred to:
A. beneficence
B. respect for person
C. nonmaleficence
D. autonomy
84. When patients cannot make decisions for
themselves, the nurse advocate relies on the
ethical principle of:
A. justice and beneficence
B. beneficence and nonmaleficence
C. fidelity and nonmaleficence
D. fidelity and justice
85. Being a community health nurse, you have the
responsibility of participating in protecting the
health of people. Consider this situation:
Vendors selling bread with their bare hands.
They receive money with these hands. You do
not see them washing their hands. What should
you say/do?
A. “Miss, may I get the bread myself
because you have not washed your
hands”
B. All of these
C. “Miss, it is better to use a pick up
forceps/ bread tong”
D. “Miss, your hands are dirty. Wash your
hands first before getting the bread”
Situation: The following questions refer to common
clinical encounters experienced by an entry level nurse.
86. A female client asks the nurse about the use of a
cervical cap. Which statement is correct
regarding the use of the cervical cap?
A. It may affect Pap smear results.
B. It does not need to be fitted by the
physician.
C. It does not require the use of
spermicide.
D. It must be removed within 24 hours.
87. The major components of the communication
process are:
A. Verbal, written and nonverbal

B. Speaker, listener and reply
C. Facial expression, tone of voice and
gestures
D. Message, sender, channel, receiver and
feedback
88. The extent of burns in children are normally
assessed and expressed in terms of:
A. The amount of body surface that is
unburned
B. Percentages of total body surface area
(TBSA)
C. How deep the deepest burns are
D. The severity of the burns on a 1 to 5
burn scale.
89. The school nurse notices a child who is wearing
old, dirty, poor-fitting clothes; is always hungry;
has no lunch money; and is always tired. When
the nurse asks the boy his tiredness, he talks of
playing outside until midnight. The nurse will
suspect that this child is:
A. Being raised by a parent of low
intelligence quotient (IQ)
B. An orphan
C. A victim of child neglect
D. The victim of poverty
90. Which of the following indicates the type(s) of
acute renal failure?
A. Four types: hemorrhagic with and
without clotting, and nonhemorrhagic
with and without clottings
B. One type: acute
C. Three types: prerenal, intrarenal and
postrenal
D. Two types: acute and subacute
Situation: Mike 16 y/o has been diagnosed to have AIDS;
he worked as entertainer in a cruise ship;
91. Which method of transmission is common to
contract AIDS?
A. Syringe and needles
B. Sexual contact
C. Body fluids
D. Transfusion
92. Causative organism in AIDS is one of the
following;
A. Fungus
B. retrovirus
C. Bacteria
24

D. Parasites
93. You are assigned in a private room of Mike.
Which procedure should be of outmost
importance;
A. Alcohol wash
B. Washing Isolation
C. Universal precaution
D. Gloving technique
94. What primary health teaching would you give to
mike;
A. Daily exercise
B. reverse isolation
C. Prevent infection
D. Proper nutrition
95. Exercise precaution must be taken to protect
health worker dealing with the AIDS patients .
which among these must be done as priority:
A. Boil used syringe and needles
B. Use gloves when handling specimen
C. Label personal belonging
D. Avoid accidental wound
Situation: Michelle is a 6 year old preschooler. She was
reported by her sister to have measles but she is at
home because of fever, upper respiratory problem and
white sports in her mouth.
96. Rubeola is an Arabic term meaning Red, the rash
appears on the skin in invasive stage prior to
eruption behind the ears. As a nurse, your
physical examination must determine
complication especially:
A. Otitis media
B. Inflammatory conjunctiva
C. Bronchial pneumonia
D. Membranous laryngitis
97. To render comfort measure is one of the
priorities, Which includes care of the skin, eyes,
ears, mouth and nose. To clean the mouth, your
antiseptic solution is in some form of which one
below?
A. Water
B. Alkaline
C. Sulfur
D. Salt
98. As a public health nurse, you teach mother and
family members the prevention of complication
of measles. Which of the following should be

25
closely watched?
A. Temperature fails to drop
B. Inflammation of the nasophraynx
C. Inflammation of the conjunctiva
D. Ulcerative stomatitis
99. Source of infection of measles is secretion of
nose and throat of infection person. Filterable
virus of measles is transmitted by:
A. Water supply
B. Food ingestion
C. Droplet
D. Sexual contact
100.
Method of prevention is to avoid
exposure to an infection person. Nursing
responsibility for rehabilitation of patient
includes the provision of:
A. Terminal disinfection
B. Immunization
C. Injection of gamma globulin
D. Comfort measures

c. 50 days
d. 14 days

NURSING PRACTICE III
Situation: Leo lives in the squatter area. He goes to
nearby school. He helps his mother gather molasses
after school. One day, he was absent because of fever,
malaise, anorexia and abdominal discomfort.
1.

2.

3.

4.

5.

26

Upon assessment, Leo was diagnosed to have
hepatitis A. Which mode of transmission has the
infection agent taken?
a. Fecal-oral
b. Droplet
c. Airborne
d. Sexual contact
Which of the following is concurrent disinfection
in the case of Leo?
a. Investigation of contact
b. Sanitary disposal of faeces, urine and
blood
c. Quarantine of the sick individual
d. removing all detachable objects in the
room, cleaning lighting and air duct
surfaces in the ceiling, and cleaning
everything downward to the floor
Which of the following must be emphasized
during mother’s class to Leo’s mother?
a. Administration of Immunoglobulin to
families
b. Thorough hand washing before and
after eating and toileting
c. Use of attenuated vaccines
d. Boiling of food especially meat
Disaster control should be undertaken when
there are 3 or more hepatitis A cases. Which of
these measures is a priority?
a. Eliminate faecal contamination from
foods
b. Mass vaccination of uninfected
individuals
c. Health promotion and education to
families and communities about the
disease it’s cause and transmission
d. Mass administration of Immunoglobulin
What is the average incubation period of
Hepatitis A?
a. 30 days
b. 60 days

Situation: As a nurse researcher you must have a very
good understanding of the common terms of concept
used in research.
6.

The information that an investigator collects
from the subjects or participants in a research
study is usually called;
a. Hypothesis
b. Variable
c. Data
d. Concept

7.

Which of the following usually refers to the
independent variables in doing research
a. Result
b. output
c. Cause
d. Effect

8.

The recipients of experimental treatment is an
experimental design or the individuals to be
observed in a non experimental design are
called;
a. Setting
b. Treatment
c. Subjects
d. Sample

9.

The device or techniques an investigator
employs to collect data is called;
a. Sample
b. hypothesis
c. Instrument
d. Concept

10.

The use of another person’s ideas or wordings
without giving appropriate credit results from
inaccurate or incomplete attribution of materials
to its sources. Which of the following is referred
to when another person’s idea is inappropriate
credited as one’s own;
a. Plagiarism
b. assumption
c. Quotation
d. Paraphrase

Situation – Mrs. Pichay is admitted to your ward. The
MD ordered “Prepare for thoracentesis this pm to
remove excess air from the pleural cavity.”

27
11.

Which of the following nursing responsibilities is
essential in Mrs. Pichay who will undergo
thoracentesis?
a. Support and reassure client during the
procedure
b. Ensure that informed consent has been
signed
c. Determine if client has allergic reaction
to local anesthesia
d. Ascertain if chest x-rays and other tests
have been prescribed and completed

a. Ease the patient to the floor
b. Lift the patient and put him on the bed
c. Insert a padded tongue depressor
between his jaws
d. Restraint patient’s body movement

Mr Santos is placed on seizure precaution.
Which of the following would be
contraindicated?
a. Obtain his oral temperature
b. Encourage to perform his own personal
hygiene
c. Allow him to wear his own clothing
d. Encourage him to be out of bed
Usually, how does the patient behave after his
seizure has subsided?
a. Most comfortable walking and moving
about
b. Becomes restless and agitated
c. Sleeps for a period of time
d. Say he is thirsty and hungry

20.

During thoracentesis, which of the following
nursing intervention will be most crucial?
a. Place patient in a quiet and cool room
b. Maintain strict aseptic technique
c. Advice patient to sit perfectly still
during needle insertion until it has been
withdrawn from the chest
d. Apply pressure over the puncture site as
soon as the needle is withdrawn

18.

Before, during and after seizure. The nurse
knows that the patient is ALWAYS placed in what
position?
a. Low fowler’s
b. Side lying
c. Modified trendelenburg
d. Supine

Mrs. Pichay who is for thoracentesis is assigned
by the nurse to which of the following positions?
a. Trendelenburg position
b. Supine position
c. Dorsal Recumbent position
d. Orthopneic position

13.

Mr Santos is scheduled for CT SCAN for the next
day, noon time. Which of the following is the
correct preparation as instructed by the nurse?
a. Shampoo hair thoroughly to remove oil
and dirt
b. No special preparation is needed.
Instruct the patient to keep his head
still and stead
c. Give a cleansing enema and give fluids
until 8 AM
d. Shave scalp and securely attach
electrodes to it

19.

12.

17.

14.

To prevent leakage of fluid in the thoracic cavity,
how will you position the client after
thoracentesis?
a. Place flat in bed
b. Turn on the unaffected side
c. Turn on the affected side
d. On bed rest

15.

Chest x-ray was ordered after thoracentesis.
When your client asks what is the reason for
another chest x-ray, you will explain:
a. To rule out pneumothorax
b. To rule out any possible perforation
c. To decongest
d. To rule out any foreign body

Situation: A computer analyst, Mr. Ricardo J. Santos, 25
was brought to the hospital for diagnostic workup after
he had experienced seizure in his office.

Situation: Mrs. Damian an immediate post op
cholecystectomy and choledocholithotomy patient,
complained of severe pain at the wound site.
21.

16.

Just as the nurse was entering the room, the
patient who was sitting on his chair begins to
have a seizure. Which of the following must the
nurse do first?

Choledocholithotomy is:
a. The removal of the gallbladder
b. The removal of the stones in the
gallbladder
c. The removal of the stones in the

common bile duct
d. The removal of the stones in the kidney
22.

23.

The simplest pain relieving technique is:
a. Distraction
b. Deep breathing exercise
c. Taking aspirin
d. Positioning
Which of the following statement on pain is
TRUE?
a. Culture and pain are not associated
b. Pain accompanies acute illness
c. Patient’s reaction to pain Varies
d. Pain produces the same reaction such as
groaning and moaning

24.

When a client complains of pain, your initial
response is:
a. Record the description of pain
b. Verbally acknowledge the pain
c. Refer the complaint to the doctor
d. Change to a more comfortable position

28.

The client complained of abdominal distention
and pain. Your nursing intervention that can
alleviate pain is:
a. Instruct client to go to sleep and relax
b. Advice the client to close the lips and
avoid deep breathing and talking
c. Offer hot and clear soup
d. Turn to sides frequently and avoid too
much talking

29.

Surgical pain might be minimized by which
nursing action in the O.R.
a. Skill of surgical team and lesser
manipulation
b. Appropriate preparation for the
scheduled procedure
c. Use of modern technology in closing the
wound
d. Proper positioning and draping of clients

30.

Inadequate anesthesia is said to be one of the
common cause of pain both in intra and post op
patients. If General anesthesia is desired, it will
involve loss of consciousness. Which of the
following are the 2 general types of GA?
a. Epidural and Spinal
b. Subarachnoid block and Intravenous
c. Inhalation and Regional
d. Intravenous and Inhalation

In pain assessment, which of the following
condition is a more reliable indicator?
a. Pain rating scale of 1 to 10
b. Facial expression and gestures
c. Physiological responses
d. Patients description of the pain
sensation

25.

alleviate anxiety
c. Avoid overdosing to prevent
dependence/tolerance
d. Monitor VS, more importantly RR

Situation: You are assigned at the surgical ward and
clients have been complaining of post pain at varying
degrees. Pain as you know, is very subjective.
26.

27.

28

A one-day postoperative abdominal surgery
client has been complaining of severe throbbing
abdominal pain described as 9 in a 1-10 pain
rating. Your assessment reveals bowel sounds on
all quadrants and the dressing is dry and intact.
What nursing intervention would you take?
a. Medicate client as prescribed
b. Encourage client to do imagery
c. Encourage deep breathing and turning
d. Call surgeon stat
Pentoxidone 5 mg IV every 8 hours was
prescribed for post abdominal pain. Which will
be your priority nursing action?
a. Check abdominal dressing for possible
swelling
b. Explain the proper use of PCA to

Situation: Nurse’s attitudes toward the pain influence
the way they perceive and interact with clients in pain.
31.

Nurses should be aware that older adults are at
risk of underrated pain. Nursing assessment and
management of pain should address the
following beliefs EXCEPT:
a. Older patients seldom tend to report
pain than the younger ones
b. Pain is a sign of weakness
c. Older patients do not believe in
analgesics, they are tolerant
d. Complaining of pain will lead to being
labeled a ‘bad’ patient

32.

Nurses should understand that when a client
responds favorably to a placebo, it is known as
the ‘placebo effect’. Placebos do not indicate

29
whether or not a client has:
a. Conscience
b. Disease
c. Real pain
d. Drug tolerance
33.

34.

35.

You are the nurse in the pain clinic where you
have client who has difficulty specifying the
location of pain. How can you assist such client?
a. The pain is vague
b. By charting-it hurts all over
c. Identify the absence and presence of
pain
d. As the client to point to the painful are
by just one finger
What symptom, more distressing than pain,
should the nurse monitor when giving opioids
especially among elderly clients who are in pain?
a. Forgetfulness
b. Drowsiness
c. Constipation
d. Allergic reactions like pruritis
Physical dependence occurs in anyone who
takes opiods over a period of time. What do you
tell a mother of a ‘dependent’ when asked for
advice?
a. Start another drug and slowly lessen the
opioid dosage
b. Indulge in recreational outdoor activities
c. Isolate opioid dependent to a restful
resort
d. Instruct slow tapering of the drug
dosage and alleviate physical
withdrawal symptoms

Situation: The nurse is performing health education
activities for Janevi Segovia, a 30 year old Dentist with
Insulin dependent diabetes Miletus.
36.

Janevi is preparing a mixed dose of insulin. The
nurse is satisfied with her performance when
she:
a. Draw insulin from the vial of clear
insulin first
b. Draw insulin from the vial of the
intermediate acting insulin first
c. Fill both syringes with the prescribed
insulin dosage then shake the bottle
vigorously
d. Withdraw the intermediate acting
insulin first before withdrawing the short

acting insulin first
37.

Janevi complains of nausea, vomiting,
diaphoresis and headache. Which of the
following nursing intervention are you going to
carry out first?
a. Withhold the client’s next insulin
injection
b. Test the client’s blood glucose level
c. Administer Tylenol as ordered
d. Offer fruit juice, gelatine and chicken
bouillon

38.

Janevi administered regular insulin at 7 A.M and
the nurse should instruct Jane to avoid
exercising at around:
a. 9 to 11 A.M
b. Between 8 A.M to 9 A.M
c. After 8 hours
d. In the afternoon, after taking lunch

39.

Janevi was brought at the emergency room after
four month because she fainted in her clinic. The
nurse should monitor which of the following test
to evaluate the overall therapeutic compliance
of a diabetic patient?
a. Glycosylated hemoglobin
b. Ketone levels
c. Fasting blood glucose
d. Urine glucose level

40.

Upon the assessment of Hba1c of Mrs. Segovia,
The nurse has been informed of a 9% Hba1c
result. In this case, she will teach the patient to:
a. Avoid infection
b. Prevent and recognize hyperglycaemia
c. Take adequate food and nutrition
d. Prevent and recognize hypoglycaemia

41.

The nurse is teaching plan of care for Jane with
regards to proper foot care. Which of the
following should be included in the plan?
a. Soak feet in hot water
b. Avoid using mild soap on the feet
c. Apply a moisturizing lotion to dry feet
but not between the toes
d. Always have a podiatrist to cut your toe
nails; never cut them yourself

42.

Another patient was brought to the emergency
room in an unresponsive state and a diagnosis of
hyperglycaemic hyperosmolar nonketotic
syndrome is made. The nurse immediately

prepares to initiate which of the following
anticipated physician’s order?
a. Endotracheal intubation
b. 100 unites of NPH insulin
c. Intravenous infusion of normal saline
d. Intravenous infusion of sodium
bicarbonate
43.

44.

45.

Jane eventually developed DKA and is being
treated in the emergency room. Which finding
would the nurse expect to note as confirming
this diagnosis?
a. Comatose state
b. Decreased urine output
c. Increased respiration and an increase in
pH
d. Elevated blood glucose level and low
plasma bicarbonate level
The nurse teaches Jane to know the difference
between hypoglycaemia and ketoacidosis. Jane
demonstrates understanding of the teaching by
stating that glucose will be taken if which of the
following symptoms develops?
a. Polyuria
b. Shakiness
c. Blurred Vision
d. Fruity breath odour
Jane has been scheduled to have a FBS taken in
the morning. The nurse tells Jane not to eat or
drink after midnight. Prior to taking the blood
specimen, the nurse noticed that Jane is holding
a bottle of distilled water. The nurse asked Jane
if she drink any, and she said “yes.” Which of the
following is the best nursing action?
a. Administer syrup of ipecac to remove
the distilled water from the stomach
b. Suction the stomach content using NGT
prior to specimen collection
c. Advice to physician to reschedule to
diagnostic examination next day
d. Continue as usual and have the FBS
analysis performed and specimen be
taken

Situation: Elderly clients usually produce unusual signs
when it comes to different diseases. The ageing process
is a complicated process and the nurse should
understand that it is an inevitable fact and she must be
prepared to care for the growing elderly population.
46.
30

Hypoxia may occur in the older patients because

of which of the following physiologic changes
associated with aging.
a. Ineffective airway clearance
b. Decreased alveolar surfaced area
c. Decreased anterior-posterior chest
diameter
d. Hyperventilation
47.

The older patient is at higher risk for
incontinence because of:
a. Dilated urethra
b. Increased glomerular filtration rate
c. Diuretic use
d. Decreased bladder capacity

48.

Merle, age 86, is complaining of dizziness when
she stands up. This may indicate:
a. Dementia
b. Functional decline
c. A visual problem
d. Drug toxicity

49.

Cardiac ischemia in an older patient usually
produces:
a. ST-T wave changes
b. Chest pain radiating to the left arm
c. Very high creatinine kinase level
d. Acute confusion

50.

The most dependable sign of infection in the
older patient is:
a. Change in mental status
b. Fever
c. Pain
d. Decreased breath sounds with crackles

Situation – In the OR, there are safety protocols that
should be followed. The OR nurse should be well versed
with all these to safeguard the safety and quality of
patient delivery outcome.
51.

Which of the following should be given highest
priority when receiving patient in the OR?
a. Assess level of consciousness
b. Verify patient identification and
informed consent
c. Assess vital signs
d. Check for jewelry, gown, manicure, and
dentures

52.

Surgeries like I and D (incision and drainage) and
debridement are relatively short procedures but
considered ‘dirty cases’. When are these

31
procedures best scheduled?
a. Last case
b. In between cases
c. According to availability of
anaesthesiologist
d. According to the surgeon’s preference
53.

OR nurses should be aware that maintaining the
client’s safety is the overall goal of nursing care
during the intraoperative phase. As the
circulating nurse, you make certain that
throughout the procedure…
a. the surgeon greets his client before
induction of anesthesia
b. the surgeon and anesthesiologist are in
tandem
c. strap made of strong non-abrasive
materials are fastened securely around
the joints of the knees and ankles and
around the 2 hands around an arm
board.
d. Client is monitored throughout the
surgery by the assistant anesthesiologist

The nurse knows that the temperature and time
is set to the optimum level to destroy not only
the microorganism, but also the spores. Which
of the following is the ideal setting of the
autoclave machine?
a. 10,000 degree Celsius for 1 hour
b. 5,000 degree Celsius for 30 minutes
c. 37 degree Celsius for 15 minutes
d. 121 degree Celsius for 15 minutes

59.

Chemical indicators communicate that:
a. The items are sterile
b. That the items had undergone
sterilization process but not necessarily
sterile
c. The items are disinfected
d. That the items had undergone
disinfection process but not necessarily
disinfected
If a nurse will sterilize a heat and moisture labile
instruments, It is according to AORN
recommendation to use which of the following
method of sterilization?
a. Ethylene oxide gas
b. Autoclaving
c. Flash sterilizer
d. Alcohol immersion

Another nursing check that should not be missed
before the induction of general anesthesia is:
a. check for presence underwear
b. check for presence dentures
c. check patient’s ID
d. check baseline vital signs

55.

It is important that before a nurse prepares the
material to be sterilized, a chemical indicator
strip should be placed above the package,
preferably, Muslin sheet. What is the color of
the striped produced after autoclaving?
a. Black
b. Blue
c. Gray
d. Purple

60.

54.

58.

Some lifetime habits and hobbies affect
postoperative respiratory function. If your client
smokes 3 packs of cigarettes a day for the past
10 years, you will anticipate increased risk for:
a. perioperative anxiety and stress
b. delayed coagulation time
c. delayed wound healing
d. postoperative respiratory infection

Situation: Sterilization is the process of removing ALL
living microorganism. To be free of ALL living
microorganism is sterility.
56.

There are 3 general types of sterilization use in
the hospital, which one is not included?
a. Steam sterilization
b. Physical sterilization
c. Chemical sterilization
d. Sterilization by boiling

57.

Autoclave or steam under pressure is the most
common method of sterilization in the hospital.

Situation 5 – Nurses hold a variety of roles when
providing care to a perioperative patient.
61.

Which of the following role would be the
responsibility of the scrub nurse?
a. Assess the readiness of the client prior
to surgery
b. Ensure that the airway is adequate
c. Account for the number of sponges,
needles, supplies, used during the
surgical procedure.
d. Evaluate the type of anesthesia
appropriate for the surgical client

62.

As a perioperative nurse, how can you best meet
the safety need of the client after administering
preoperative narcotic?
a. Put side rails up and ask the client not
to get out of bed
b. Send the client to OR with the family
c. Allow client to get up to go to the
comfort room
d. Obtain consent form

63.

It is the responsibility of the pre-op nurse to do
skin prep for patients undergoing surgery. If hair
at the operative site is not shaved, what should
be done to make suturing easy and lessen
chance of incision infection?
a. Draped
b. Pulled
c. Clipped
d. Shampooed

64.

65.

It is also the nurse’s function to determine when
infection is developing in the surgical incision.
The perioperative nurse should observe for what
signs of impending infection?
a. Localized heat and redness
b. Serosanguinous exudates and skin
blanching
c. Separation of the incision
d. Blood clots and scar tissue are visible

68.

Tess, the PACU nurse, discovered that Malou,
who weighs 110 lbs prior to surgery, is in severe
pain 3 hrs after cholecystectomy. Upon checking
the chart, Malou found out that she has an order
of Demerol 100 mg I.M. prn for pain. Tess should
verify the order with:
a. Nurse Supervisor
b. Surgeon
c. Anesthesiologist
d. Intern on duty

69.

Rosie, 57, who is diabetic is for debridement if
incision wound. When the circulating nurse
checked the present IV fluid, she found out that
there is no insulin incorporated as ordered.
What should the circulating nurse do?
a. Double check the doctor’s order and
call the attending MD
b. Communicate with the ward nurse to
verify if insulin was incorporated or not
c. Communicate with the client to verify if
insulin was incorporated
d. Incorporate insulin as ordered.

70.

The documentation of all nursing activities
performed is legally and professionally vital.
Which of the following should NOT be included
in the patient’s chart?
a. Presence of prosthetoid devices such as
dentures, artificial limbs hearing aid, etc.
b. Baseline physical, emotional, and
psychosocial data
c. Arguments between nurses and
residents regarding treatments
d. Observed untoward signs and symptoms
and interventions including contaminant
intervening factors

Which of the following nursing interventions is
done when examining the incision wound and
changing the dressing?
a. Observe the dressing and type and odor
of drainage if any
b. Get patient’s consent
c. Wash hands
d. Request the client to expose the incision
wound

Situation – The preoperative nurse collaborates with the
client significant others, and healthcare providers.
66.

To control environmental hazards in the OR, the
nurse collaborates with the following
departments EXCEPT:
a. Biomedical division
b. Infection control committee
c. Chaplaincy services
d. Pathology department

67.

An air crash occurred near the hospital leading
to a surge of trauma patient. One of the last

32

patients will need surgical amputation but there
are no sterile surgical equipments. In this case,
which of the following will the nurse expect?
a. Equipments needed for surgery need not
be sterilized if this is an emergency
necessitating life saving measures
b. Forwarding the trauma client to the
nearest hospital that has available sterile
equipments is appropriate
c. The nurse will need to sterilize the item
before using it to the client using the
regular sterilization setting at 121
degree Celsius in 15 minutes
d. In such cases, flash sterlizer will be use
at 132 degree Celsius in 3 minutes

33

Situation – Team efforts is best demonstrated in the OR.
71.

72.

73.

74.

75.

If you are the nurse in charge for scheduling
surgical cases, what important information do
you need to ask the surgeon?
a. Who is your internist
b. Who is your assistant and
anaesthesiologist, and what is your
preferred time and type of surgery?
c. Who are your anaesthesiologist,
internist, and assistant
d. Who is your anaesthesiologist
In the OR, the nursing tandem for every surgery
is:
a. Instrument technician and circulating
nurse
b. Nurse anaesthetist, nurse assistant, and
instrument technician
c. Scrub nurse and nurse anaesthetist
d. Scrub and circulating nurses
While team effort is needed in the OR for
efficient and quality patient care delivery, we
should limit the number of people in the room
for infection control. Who comprise this team?
a. Surgeon, anaesthesiologist, scrub nurse,
radiologist, orderly
b. Surgeon, assistants, scrub nurse,
circulating nurse, anaesthesiologist
c. Surgeon, assistant surgeon,
anaesthesiologist, scrub nurse,
pathologist
d. Surgeon, assistant surgeon,
anaesthesiologist, intern, scrub nurse
Who usually act as an important part of the OR
personnel by getting the wheelchair or stretcher,
and pushing/pulling them towards the operating
room?
a. Orderly/clerk
b. Nurse Supervisor
c. Circulating Nurse
d. Anaesthesiologist
The breakdown in teamwork is often times a
failure in:
a. Electricity
b. Inadequate supply
c. Leg work
d. Communication

Situation: Basic knowledge on Intravenous solutions is
necessary for care of clients with problems with fluids
and electrolytes.
76.

A client involved in a motor vehicle crash
presents to the emergency department with
severe internal bleeding. The client is severely
hypotensive and unresponsive. The nurse
anticipates which of the following intravenous
solutions will most likely be prescribed to
increase intravascular volume, replace
immediate blood loss and increase blood
pressure?
a. 0.45% sodium chloride
b. 0.33% sodium chloride
c. Normal saline solution
d. Lactated ringer’s solution

77.

The physician orders the nurse to prepare an
isotonic solution. Which of the following IV
solution would the nurse expect the intern to
prescribe?
a. 5% dextrose in water
b. 0.45% sodium chloride
c. 10% dextrose in water
d. 5% dextrose in 0.9% sodium chloride

78.

The nurse is making initial rounds on the nursing
unit to assess the condition of assigned clients.
The nurse notes that the client’s IV Site is cool,
pale and swollen and the solution is not infusing.
The nurse concludes that which of the following
complications has been experienced by the
client?
a. Infection
b. Phlebitis
c. Infiltration
d. Thrombophelibitis

79.

A nurse reviews the client’s electrolyte
laboratory report and notes that the potassium
the nurse note on the electrocardiogram as a
result of the laboratory value?
a. U waves
b. Absend P waves
c. Elevated T waves
d. Elevated ST segment

80.

One patient had a ‘runaway’ IV of 50% dextrose.
To prevent temporary excess of insulin or
transient hyperinsulin reaction what solution
you prepare in anticipation of the doctor’s

order?
a.
b.
c.
d.

82.

83.

An informed consent is required for:
a. closed reduction of a fracture
b. irrigation of the external ear canal
c. insertion of intravenous catheter
d. urethral catheterization
Which of the following is not true with regards
to the informed consent?
a. It should describe different treatment
alternatives
b. It should contain a thorough and
detailed explanation of the procedure
to be done
c. It should describe the client’s diagnosis
d. It should give an explanation of the
client’s prognosis
You know that the hallmark of nursing
accountability is the:
a. accurate documentation and reporting
b. admitting your mistakes
c. filing an incidence report
d. reporting a medication error

84.

A nurse is assigned to care for a group of clients.
On review of the client’s medical records, the
nurse determines that which client is at risk for
deficient fluid volume?
a. A client with colostomy
b. A client with congestive heart failure
c. A client with decreased kidney function
d. A client receiving frequent wound
irrigation

As an OR nurse, what are your foremost
considerations for selecting chemical agents for
disinfection?
a. Material compatibility and efficiency
b. Odor and availability
c. Cost and duration of disinfection process
d. Duration of disinfection and efficiency

87.

Before you use a disinfected instrument it is
essential that you:
a. Rinse with tap water followed by alcohol
b. Wrap the instrument with sterile water
c. Dry the instrument thoroughly
d. Rinse with sterile water

88.

You have a critical heat labile instrument to
sterilize and are considering to use high level
disinfectant. What should you do?
a. Cover the soaking vessel to contain the
vapor
b. Double the amount of high level
disinfectant
c. Test the potency of the high level
disinfectant
d. Prolong the exposure time according to
manufacturer’s direction

89.

To achieve sterilization using disinfectants,
which of the following is used?
a. Low level disinfectants immersion in 24
hours
b. Intermediate level disinfectants
immersion in 12 hours
c. High level disinfectants immersion in 1
hour
d. High level disinfectant immersion in 10
hours
Bronchoscope, Thermometer, Endoscope, ET
tube, Cytoscope are all BEST sterilized using
which of the following?
a. Autoclaving at 121 degree Celsius in 15
minutes
b. Flash sterilizer at 132 degree Celsius in 3
minutes
c. Ethylene Oxide gas aeration for 20 hours
d. 2% Glutaraldehyde immersion for 10
hours

A nurse is assigned to care for a group of clients.
On review of the client’s medical records, the
nurse determines that which client is at risk for
excess fluid volume?
a. The client taking diuretics
b. The client with renal failure
c. The client with an ileostomy
d. The client who requires gastrointestinal
suctioning

85.

86.

90.

81.

Any IV solution available to KVO
Isotonic solution
Hypertonic solution
Hypotonic solution

Situation: As a perioperative nurse, you are aware of the
correct processing methods for preparing instruments
and other devices for patient use to prevent infection.
34

Situation: The OR is divided into three zones to control
traffic flow and contamination

Nursing Board Practice Test Compilation: 188 Questions

Nursing Board Practice Test Compilation: 188 Questions

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