RECALLS EXAMINATION 7 C.

Darren is anxious as manifested by his

tossing in bed
NURSING PRACTICE I COMMUNITY
HEALTH NURSING and disarrayed beddings

NOVEMBER 2024 Philippine Nurse D. Patient states, “I wish to end my life”

Licensure Examination Review
2. When documenting the intake-output
GENERAL INSTRUCTIONS: of Darren, Nurse Tara should remember
that she must use precise measurements
1. This test questionnaire contains 100
to ensure accuracy. Which of the
test questions
following reflects accuracy?
2. Shade only one (1) box for each
1. Darren drank an adequate amount of
question on your answer sheets. Two or
fluid during the shift. 2. Darren’s intake
more boxes shaded will invalid your
during the shift is 360 ml.
answer. 3. AVOID ERASURES.
3. Darren’s wound is 3 cm in length.
4. Detach one (1) answer sheet from the
bottom of your Examinee ID/Answer 4. Darren’s wound is large and gaping.
Sheet Set.
A. 1and3 B. 2and3 C. 3and4 D. 1and4
5. Write the subject title “NURSING
3. Another guideline for good
PRACTICE I” on the box provided
documentation and reporting that Nurse
Situation: Quality documentation and Tara recalls is about completion. When
reporting are necessary to enhance Nurse Tara administers medications, the
efficient, individualization patient care. following should be included, EXCEPT:
Nurse Tara is assigned to Darren who is
A. Any preliminary observations
diagnosed with diabetes mellitus for 10
years and has not be compliant to his B. Preliminary observations
medications and diet.
C. Patient’s response
1. Nurse Tara is aware that a record
D. Nursing measure taken for negative
should contain descriptive, objective
response
observations about what the nurse sees,
hears, feels and smells. The following 4. Nurse Tara is making a discharge plan.
describes what a record ought to be: The items she needs to document and
report should include, EXCEPT:
A. Darren is uncooperative as manifested
by his refusal to take a bath A. Needs for referrals

B. Darren appears depressed. B. Nurses’ observations

C. Client’s involvement in the care plan D. consider the presence of a gynecological
Patient’s goals or expected outcomes problem is .

5. Nurse Tara is ethically obligated to A. Date of menarche

information about client’s illness and
B. Date of last menstrual period C. Her
treatment confidential. The person who
age and civil status
has the legitimate access to the patient’s
record is the . D. Occupation

A. Husband 9. An important added data that Nurse

Adam should ask
B. Primary nurse C. attending doctor D.
patient Esther,

Situation- Nurse Adam is assigned in the is

out-patient department. He admits
A.
Esther, 28 years old, who is complaining
of moderate to severe abdominal pain B. C. D.
over the right iliac region for the last 2
should we consider the existence of a
days. This is accompanied by frequent surgical problem
urination.
. Fever
D. Interview Esther
Vomiting constipation character of pain
7. An important added data that Nurse
Adam should have if he is thinking of a 10. There are two important laboratory
urinary problem is examinations that could validate Nurse
Adam’ presumptions on the case which
A. Presence of blood in the urine
are
B. Presence of pain on urination
A.
C. When the pain appears whether at the
start or end of B. C. D.

urination .

D. Frequency, amount and burning CBC and stool examination

sensation on Urinalysis and CBC
urination Stool and urine examinations Urinalysis
8. An important added data that nurse and vaginal examinations
Adam should ask Esther, should we
6. The FIRST STEP that nurse Adam D. Commission on Higher Education
should do is to A. Percuss the abdomen
13. What Nursing Republic Act should
B. Get the vital signs Nurse Leah refer too? A. RA 9371

C. Palpate the right iliac region B. RA7164 C. RA 7664

______. 1|Page

Situation - Nurse Leah has just passed

the Nursing Licensure Examination. She
D. RA 9173
needs to refresh herself regarding the law
that governs the practice of nursing in the 14. Since she needs to work in a hospital
Philippines. to get hospital experience, which part of
the Nursing Law should Leah focus for her
11. By virtue of section 16 of the
safe practice as a novice nurse?
Philippine Nursing Law, the first step she
needs to do after passing the Nursing A. Scope of Nursing Practice B. Nursing
Licensure Examination is to . Research

A. Take the oath of the profession before C. Nursing Education

the Professional Regulatory Board of
D. Nursing Personal System
Nursing
15. When Leah eventually gets employed
B. Apply for the Certificate of
in the hospital, she will initially be
Registration/Professional License
required to utilize which of the following in
C. Get an official copy of her board rating rendering care to her clients?
from the PRC office
A. Traditional and innovative approaches
D. Apply for a Professional Identification B. Therapeutic use of self
Card
C. Health teachings
12. Which government body has the
D. Nursing process
power to revoke or suspend Leah’s
certificate of registration/professional Situation- Ben, 15 years old, has been
license, should she commit complaining of sleep disturbance for the
unprofessional and unethical conduct in past 3 weeks. He related that he feels
the future? weak and has no vigor in doing his school
work. He is brought to hospital for
A. Professional Regulatory Board of
specialization.
Nursing B. Philippine Nurses Association

C. Professional Regulation Commission

16. As his attending nurse, what will be complain of feeling hot and finds difficulty
the best question to ask in order to find of adjusting to the climate two days after.
out Ben’s cause of sleep disturbance? What is the APPROPRIATE answer to
Nurse Celine?
A. “Could you tell me what you feel about
school work?” B. “Is there something or A. “Foreigners cannot adjust to hot
anyone who is bothering you temperatures”

in school?” B. “People from cold regions have less

brown
C. “Could you share with me any major
problems that adipocytes”

do is to A. C. “Those who lived in cold places have

lower metabolic
B. C.
rate than those who live in tropical region”
D.
D. “People from cold regions have more
.
brown
Avoid giving round the clock medications
adipocytes”
Refrain from clutter at the nurse’s station
26. Nurse Celine develops patient safety
Omit vital sign tasking during the sleeping goals. What nursing goal is APPROPRIATE
time of Alex for safety environment? Select all that
apply.
Tone down nurse’s voice
1. Reduce the risk for patient harm
23. Client Simon wishes to know his
resulting from falls 2. Create a clean,
present temperature in Farenheit. Nurse
orderly environment of patient
Celine’s answer is which of the following?
3. Prevent high concentration drug errors
A. 102.2F B. 101.3F C. 100.4F D. 99.5F
4. Develop clean and simple signage for
24. Client Simon complains of severe
directions
chilly sensation. What regulatory function
of the hypothalamus describes his A. 1,2&3 B. 1,2&4 C. 2,3&4 D. 3&4
reaction?
27. Nurse Celine should prevent or
A. heat production B. heat promotion C. reduce infectious agents PRIMARILY
heat adaptation D. heat conversation through the following practices. Select all
that apply.
25. After client Simon’s body temperature
stabilized to normal, he began to
1. Clean the room with antiseptic C. twice before and after all the
solutions procedures are done to all the clients

2. Proper garbage disposal D. apply alcohol before and after

performing procedures to all patients
3. Mandatory hand washing upon entry to
hospital 4. Improve safety administration Situation - Client Arvie, 33 years old, is
of medicines known for his asthma attacks. His asthma
attacks commonly occur at the change of
A. 1,2&3 B. 2,3&4 C. 1&3 D. 1&4
climate in his hometown. He was just
28. Nurse Celine must comply with the wearing a “sando” {sleeveless shirt} and
policies of health care facilities regarding short pants when he was admitted to the
isolation precautions. The BASIC hospital.
precaution in the hospital is
A. 1,3,5
_______________________.
B. 1, 5, 6
A. posting of signs of silence
C. 2,4,6
B. limited visitors who are within the
patient’s age C. private room placement D. 2,3,4 B.

D. strict utilization of personal things you have encountered in school?” D.

“What is bothering you in school?”
29. Nurse Celine includes air-borne
precautions in addition to Standard 17. The nursing diagnosis appropriate for
Precautions to be observed at all times. Ben is A. Insomnia
These include, EXCEPT _______.
_____.
A. positioning and draping of patients B.
B. Sleep deprivation related to problems
hand washing techniques
in school
C. wearing of masks and gloves
C. Disturbed sleep pattern related to
D. limited patient transport school problem D. Readiness for
enhanced sleep
30. To protect spreading infection from
one patient to another, Nurse Celine must 18. In order to help Ben go to sleep, what
not forget to wash her hands _________. simple and inexpensive nursing
intervention can the nurse provide
A. before and after making rounds and
considering the type of room Ben is
endorsement of all clients
confined in?
B. before and after performing procedures
A. Room should be well ventilated
and in between patient care
B. Light should be dimmed at specific 1. Monitor temperature regularly
time C. Putting on the air conditioning unit
2. Offer only cold drinking water
D. Putting on dark-colored curtains frequently

19. If Ben cannot sleep immediately, 3. Provide tepid sponge bath

which of the following can be provided by
4. Administer Paracetamol every 4 hours
the nurse?
5. Encourage wearing loose cotton
A. A glass of warm milk B. A bedside story
clothing
C. a sleeping pill
6. Cover with thick blankets to stimulate
D. a warm bed bath sweating

20. In terms of nursing care, the BEST help 31. What will be Nurse Chard’s PRIORITY
that the nurse can INTERVENTION?

Situation- Simon, 66 years old, a A. Put him near the electric fan to assist
foreigner, was admitted to the hospital him in
due to high fever for five days. His
breathing
temperature on admission was 37.5 ‘C
with flushed and warm to touch skin. Ask him what triggered his attack this
Nurse Celine, who is his attending nurse, time
gave him a cool sponge bath.
2|Page
21. Cool sponge bath is an independent
intervention of nurse Celine aimed at .
C. Place him in a comfortable
A. Alleviating discomforts of client Simon
environment
B. Generalizing full sponge bath care to
D. Put him near the nurse’s station so that
client Jimmy get
he could be
hospital admission policy
assessed often
C. Diverting the temperature of client
32. What particular important vital sign
Simon D. Normalizing the vital signs of
should Nurse Chard monitor and report to
client Simon
the physician?
22. The independent nursing intervention
A. Respiratory rate B. blood pressure C.
to reduce temperature of client Simon
Cardiac rate
include which of the following? Select all
that apply. D. Pulse rate
33. Client Arvie knows that he will be 43. The research design of the study is
given decongestant through inhalation. ____________
What will be the instruction of Nurse
A. quasi-experimental B. experimental
Chard? That he should breathe and that
the nozzle of the NEBULIZER should be C. qualitative
MAINLY near his _____________.
D. descriptive
A. Nose only
44. In the cause-and-effect relationship,
B. Face which is the independent variable?

C. Mouth only A. Population B. Effect

D. Nose and mouth C. Relationship D. Cause

34. Respiratory function is altered in 45. Which of the following is the

clients with asthmatic attack. Which of appropriate operational definition of
the following is the cause of this wellness? Wellness is the state of well-
alteration that Nurse Chard should being of the participants in Zumba on
understand in order for him to make a their ____________
good nursing care plan?
A. social stability B. spiritual growth C.
group of nurses decided to conduct a physical health D. mental balance
study entitled, “Effects of Zumba as a
SITUATION -Some teachers in an
form of exercise in promoting wellness
elementary school reported that a high
among the health providers in the
proportion of children’s packed lunches
hospital setting.”
contain hotdog or ‘tocino’, sweetened
41. Which of the following is the drinks and potato chips. School Nurse
independent variable in this study? Victoria plans to conduct health
education classes among parents on
A. Exercise
“How to make healthy lunches and why it
B. health care providers C. zumba is important”

D. wellness 46. For this activity, Nurse Victoria

considers using the behavior change
42. Which is the dependent variable? A.
approach to encourage parents to adopt
health provider
healthy behaviors that will lead to
B. wellness improve health. This approach is popular
because of the following reasons. Select
C. Exercise
all that apply. 1. Views health as property
D. effects of individuals
2. Sees people as having the capacity to D. to be careful always because constant
change their lifestyle 3. Assumes that if asthma attacks
people do not act on their health, they
can trigger complication and death
suffer the consequences
Situation - Aurora underwent mastectomy
4. Does not consider the social and
of her right breast. After surgery, she was
environmental factors in which people
instructed to have range of motion
live
exercises
A. 1,2,3 B. 2,3,4 C. 3and4 D. 1and2
36. What is the main purpose of this type
47. Nurse Victoria finally plans to conduct of exercise for Aurora? It is to
parent’s classes using the educational ________________.
approach. This approach is intended to
A. prevent pain on the site of operation
_____. Select all that apply.
B. prevent contracture deformity of the
A. B. C. D.
muscle of the
Narrowing of the upper air passages
right arm and chest
Increased airway resistance
C. improve general circulation D. improve
Inadequate surfactant reaction
breathing
Paradoxical movements of the chest wall
37. The isotonic exercise such as Range
35. An
of Motion exercises are those that are
before client Arvie’s discharge is ________. initiated by the ________.

important health teaching that Nurse A. patient

Chard must give
B. physician
A. To avoid “sando” and shorts, if the
C. nurse
weather is cold
D. relatives of the patient
B. to use attire he is presently wearing
only during 38. Aurora needs some physical activity
after operation MAINLY to improve healing
summer time
of which parts of the body? Select all that
C. to watch out for climate change and apply.
unnecessary
1. Skeletal
exposure to elements of the environment
2. Integumentary 3. Respiratory
that trigger
4. Muscular
his asthma attacks
A. 1 only B. 4 only C. 1and4 D. 2and3 active

39. A good example of isotonic exercise question to ask?

for Aurora’s arm are the following, EXCEPT
start the health education class and to get
___________
the parent’s participation, which of the
A. combing the hair following is the BEST

B. brushing teeth A. “Did you cook your child’s lunch

today?”
C. dressing up
B. “Who among you have kids who are
D. closing and opening hand
underweight?”
40. When doing a range of motion
C. “Can you explain the “Plate Method”?”
exercise, it is important for the nurse to
observe Aurora’s ________. D. “What food do you usually prepare to
your kids
A. Temperature
lunch?”
B. Color of the skin C. Blood pressure D.
Respiratory rate 49. The educational approach to health
education states that learning involves
Situation- One of the thrusts of
three aspects. Which of the following is
management is to encourage more
NOT included?
nurses to do research in order to
contribute to the improvement of the A. Cognitive
nursing practice in their work setting. A
B. Affective
A. B. C. D.
C. Psychomotor D. Behavioral
1. Provide information
3|Page
2. Develop the necessary skills

3. Provide change to a particular direction

50. Since your participants are adult
4. Help people make an impulsive choice
parents, which of the following are
1and2
appropriate strategies? Select all that
1,2,and3 apply.

2,3,and4 1. Role playing

2 and 3 2. Group sharing

48.To 3. Demonstration
4. Return demonstration B. implement emergency measures
during fires and disasters
A. 2and3
C. risk elements should not be modified
B. 2and4
D. use infection control practices that
C. 1,2,4
prevent or control
D. 1,2,3
transmission of the pathogens
SITUATION - Safety in any health agency is
SITUATION - Applying therapeutic
a must. Nurse Amy wants this to maintain
communication skills is vital in the nurse-
in her unit.
client relationship.
51. The nursing process facilitates an
55. Which of the following is the BEST
understanding of the scope of challenges
SEQUENCE of communication
inherent in nursing care of clients at risk
techniques to use during an assessment
for ___________ EXCEPT:
interview? Begin with ____________.
A. Infection B. Suicide C. Restraint D.
A. giving a broad opening and move to
Injury
asking focused questions
52. The clients at risk require re-
B. Giving information and move to asking
assessment of their status on
focused questions
____________.
C. Asking focused questions and close-
A. shift basis
ended questions
B. daily basis
D. providing information and proceed to
C. as necessary basis D. injury stating

53. When a patient is placed in a bed rest, observations

the nurse must watch which part of the
56. You are caring for Malou, sixteen years
body most?
old, suffering from acute leukemia. You
A. Liver B. Head C. Legs D. skin want to actively listen to her concerns
and understand her meanings. You know
54. The Nursing Practice Standards which
that active listening is used to _______.
Nurse Amy must let her staff follow
includes, EXCEPT ___________. A. Treat patient’s medical problems

A. use a multidisciplinary approval to B. Recognize the issue that is most

enhance client safety as indicated important to the

client
C. Help the patient become dependent to C. staff nurse
the nurse in
D. nursing aide
addressing his concerns
62. In as much as you have not been
D. Make conclusions regarding client’s trained in initiating Intravenous infusion,
perception who among the following cannot also do
it?
57. You ask your newly admitted patient,
“What can we do to help you?” You know A. charge nurse B. staff nurse C. nursing
that this open-ended question will aide D. physician
_____________.
63. Turning Mr. BC every two hours would
A. Humor should focus on the client’s be difficult if you do it alone. In order to
humanity B. Humor is used to build keep the patient safe, the most number of
rapport nurse who can team up with you will be
____________
C. Constant use of humor can be healing
A. Four B. One C. Two D. Three
D. Laughter increases neurotransmitters
64. If Mr. BC would be for dialysis and you
SITUATION -Mr. BC is confines in the ICU
need to bring him to the dialysis unit, who
in a provincial hospital for some
among the following, could be the best to
complications of his type II diabetes. He
help you wheel him to the area? A
is edematous and complained of severe
______________.
chest pain. His vital signs are: BP160/98,
temperature 37.2C; PR- 90 bpm; RR- 30 A. institutional worker B. member of the
bpm 60. The order of the physician is for family C. physician
immediate intubation. For the priority
D. nurse aide
equipment, supplies and material to be
used for the procedure, the nurse should SITUATION- Thea, 15 years old, and a
collaborate with the _________. high-school student, visited the clinic
because she suspects that she is
A. operating room
pregnant. Her pregnancy is confirmed by
B. central supply unit the school physician. Thea requested
nurse Zenaida not to tell her parents
C. anesthesia department D. emergency
about her being pregnant. She also
department
expressed desire to terminate her
61. Morning care had to be done by the pregnancy.
________ A. nursing student
65. Which of the following ethical
B. all the options concepts apply to patient Thea’s case?
A. Bioethics other close to the parents to be the one to
relay about her pregnancy Advise her that
B. Deontology C. Teleology D. Intuitionism
as a minor, her parents should be duly
66. Nurse Zenaida should be guided by informed about her pregnancy
the steps in helping Thea make an ethical
58. As
decision. Sequence the steps below.
that is __________.
1. Gather data
you listen to a patient, you need to
2. Make decision
provide feedback
3. Identify and clarify the ethical problem
A. behavior-focused and evaluative B.
4. Act and assess the outcomes of well-timed and general
decisions 5. Identify options or
C. general and content-focused
alternatives
D. well-timed and content-focused
A. 3,1,5,2&4 B. 1, 5, 2, 4 & 3 C. 1, 3, 5, 2 &
4 D. 2, 4, 1, 3 & 5 59. Which of the following statements is
TRUE in relation to the use of humor?
67. The INITIAL advice of nurse Zenaida to
patient Thea is 68. Thea analyzed the advice of Nurse
Zenaida and realized the value of life and
A. B. C. D.
family. This attitude of realization is
result in specific information from the termed as _____________
patient allow patient to elaborate on his
4|Page
response allow patient to briefly answer
question

put the patient at ease A. Justice

which of A. B. Ethics

B. C. C. Autonomy

D. D. Values clarification

the following? 69. Patient Thea’s decision regarding her

pregnancy is termed as _____________.
Thea will inform her teacher about her
condition and to request the teacher to A. Autonomy B. Justice
tell her parents.
C. Veracity D. Fidelity
Thea will request the doctor to inform the
E.
parents Thea will choose a significant
SITUATION - Emma, 65 years of age, has that the Nurse can advise Emma to
just been widowed a year ago. Her two resolve constipation?
children are now all living in the U.S. She
1. Encourage increased fiber in diet
used to love cooking but since she is now
living alone, she eats meal irregularly. 2. Encourage physical activity and regular
Most of the time, she just watches exercise 3. Regular time for elimination
television. Her chief complaint is
4. Laxative
constipation.
A. 1,2,&3 B. 3and4 C. 1,3&4 D. 2,3&4
70. When assessing Emma, Nurse Alma
should ask the following, EXCEPT: 74. Health education should include
which of the following?
A. Dietary and fluid intake B. Cultural
beliefs 1. Responding to the urge to defecate and
establishing a daily pattern
C. Lifestyle
2. Role of dietary fiber and fluid in
D. Bowel pattern
maintaining bowel function 3. Role of
71. When auscultating the bowel sound of exercise and activity in maintaining bowel
Emma, the nurse should be able to hear function
___________.
4. Safe and correct use of pharmaceutical
A. loud and gurgling sound B. increased agents
bowel sound C. decreased bowel sound
A. 2,3and4
D. absent sound
B. 1,2,3and4 C. 2and3
72. The MOST APPROPRIATE nursing
diagnosis for Emma’s case is D. 1,2and3
_________________. SITUATION - Obesity is an emerging
A. risk of constipation related to lifestyle concern for patients and nurses. The
nurses has an important role in assessing
B. perceived constipation related to
and evaluating patient’s physiological
eating habits
status in relation to wight control
C. dysfunctional gastrointestinal motility
75. Nurse Claire is assessing patients at
related to
the outpatient clinic. Which of the
lifestyle following patients is at risk for health
complications related to weight?
D. constipation related to inactivity
A. a thirty three year old who has a body
73. Which of the following are the most
mass index (BMI) of 24 kg/m
simple and cost effective interventions
B. A fifty six year old who is 6 ft (180 cm) C. encourage the patient to eat small
tall and weighs 150 lb (68 kg) amounts throughout the day

C. A seventy one year old who is 5 ft 4 D. asking the patient about situations that
inches (160 cm), weighs 120 lb (55 kg), tend to increase appetite
and carries most of the weight in the
78. When developing a weight-reduction
thighs
plan for an obese patient who is starting a
D. a twenty four year old female with a weight loss program, which question is
waist measurement of 30 inches (75 cm) MOST important for Nurse Claire to ask?
and a hip measurement of 34 inches (85
A. “What factors do you think led to your
cm)
obesity?” B. “Have you been on any
76. A patient who has been consistently previous diets?”
following a diet and exercise program and
C. “What kind of physical activities do you
successfully losing one pound weekly for
enjoy?” D. “How long have you been
several months is weighed at the clinic.
overweight?”
However, he has not lost any weight for
the last month. Nurse Claire should first 79. An obese patient asks Nurse Claire
_______________. about using Orlistat (Xenical) for weight
reduction. Nurse Claire advises the
A. ask the patient whether there have
patient that _________.
been any recent changes in exercise or
diet patterns A. drugs may be helpful in weight loss, but
weight gain is likely to recur unless
B. discuss the possibility that the patient
changes in diet and exercise are
has reached a temporary weight loss
maintained
plateau
B. the long-term effect of orlistat is not
C. Instruct the patient to weigh weekly
known, and the drug may cause serious
and record the weights.
side effects such as heart valve problems
D. review the diet and exercise guideline
C. this drug can cause serious depletion
with the patient 77. When working with an
of fat-soluble vitamins and should be
obese patient who is enrolled in a
used only several weeks
behavior modification program, which
nursing action is APPROPRIATE? D. weight-reduction drugs of any type are
used for only those who do not have the
A. Having the patient write down the
will power to reduce their intake of food
caloric intake of each meal

B. suggesting that the patient has a

reward after achieving a weight loss goal
SITUATION- Nurse Beth is working on the 83. The doctor ordered to give a one year
hospital’s pediatric unit. She is assigned old patient an intramuscular injection.
as a medication and treatment nurse The appropriate and preferred muscle to
select for this child is the
80. In preparing to give medications to a
_______________.
preschool-age child, which of the
following statements is an APPROPRIATE A. Dorsogluteal B. Deltoid
interaction by Nurse Beth?
C. Ventrogluteal D. Vastus lateralis
A. “Let me explain about the injection that
SITUATION - Patient Charlotte, three years
you will be getting”
old, was brought to the clinic by her
B. “Do you want to take your medication mother due to ear ache and low-grade
now?” fever. While performing her physical
assessment, Nurse Hazel found Patient
C. “Would you like the medication with
Charlotte’s right ear to be inflamed and
water or juice?” D. “If you don’t take the
warm to touch. The Pediatrician ordered
medication now, you will not
ear drops to be instilled to the affected
get better.” ear.

81. To determine proper drug dosages for 5|Page

children, calculations are MOST precisely
made on the basis of the child’s
__________. 84. Nurse Hazel performs further
physical assessment on Patient Charlotte
A. Weight
BEFORE drug administration, which
B. Height includes the following, EXCEPT
_______________.
C. body surface area D. age
A. Appearance of the pinna and meatus of
82. Nurse Beth administered the
the ear
intramuscular medication of Iron by the z-
tract method. This method is used to B. Presence of the interference during the
________________. drug

A. provide more even absorption of the administration

drug
C. Type of any ear discharge
B. provide faster absorption of the drug
D. Location and extent of inflammation of
C. prevent the drug from irritating the ear
sensitive tissue D. reduce discomfort
from the needle
85. The MOST APPROPRIATE nursing B. Perform hand hygiene
action before instilling ear drops to
C. Explain procedure and postpone
Charlotte is to ______.
D. Check identification band and proceed
A. Check the medication to be within
room temperature B. Refrigerate the 89. On the other hand, Nomar notices
medication for thirty minutes that the Chief Nurse Executive has
charismatic leadership style. Which of the
C. Fill up the dropper with no more than
following behaviors best describes this
one millimeter D. Clean the outer surface
style?
of the dropper
A. Possesses inspirational quality that
86. In installing any drug into the ears,
makes followers gets attracted of him and
Nurse Hazel performs in SEQUENCE.
regards him with reverence
Which of the following steps?
B. Acts as he does because he expects
1. Allow the drug to flow into the ears
that his behavior will yield positive results
slowly
C. Uses visioning as the core of his
2. Tilt the head away from the nurse
leadership
3. Put a small cotton loosely into the ear
D. Matches his leadership style to the
4. Wait for 15 minutes before instilling situation at hand.
drops on the other ear 5. Instill the ear
90. One leadership theory states that
drops into the affected ear
“leaders are born and not made,” which
A. 1,4,2,5,3 B. 2,5,1,3,4 C. 4,1,5,3,2 D. refers to which of the following theories?
3,1,4,5,2
A. Trait
87. After instilling medications to the right
B. Charismatic C. Great Man D.
ear, what is the MOST appropriate
Situational
instruction to the mother?
Situation: Nurses are expected to be
A. Remain in the position for 5 minutes
leaders making difference in the health
B. Pack a cotton pledge tightly to the ear care settings- hospitals, clinics,
communities and other organizations.
C. Have the patient remain in the position
for one hour D. Advice the mother not to 91. Why leadership plays a vital role in the
let Charlotte drink hot water nursing profession?

88. In administering otic medication, A. It is not really important for nurses.

Nurse Hazel A. Don the gloves
B. Nurses have expert knowledge and are expected to display effective conflict
interacting resolution skills. Which of the following is
true about conflict?
with and influencing the clients.
A. It seldom occurs as part of the change
C. Nurses should know how to direct
process in health care settings.
people towards
B. It highlights differences in values,
accomplishment of goals.
belief, or actions. C. t is automatically
D. Nurses should always strive for higher negative
positions in the
D. It discourages creativity and
organization. innovation.

92. Nomar understands that a Theory 95. Conflict that occurs between groups
which states that the Leadership style is or teams is called: A. Interpersonal
dependent on the situation. Which of the
B. Intrapersonal C. Organizational D.
following styles best fits a situation when
Dysfunctional
the followers are self-directed, highly
motivated, experts and matured Situation: Nurse Kat is the head nurse of
individuals? the male medical ward in a tertiary
specialized hospital handling multiple
A. Participative B. Directive
cases in her unit. It is imperative that she
C. Permissive D. Bureaucratic is equipped with the basic managerial
skills.
93. Nomar would like to be a
Transformational leader. Which of the 96. In this conflict resolution method, a
following statements best describes this person ignores his or her own feelings
type of leadership? about an issue in order to agree with the
other side.
A. Uses visioning as the essence of
leadership. A. Collaborating

B. Serves the followers rather than being B. Confronting

served.
C. Accommodating D. Withdrawing
C. Maintains full trust and confidence in
97. With this method of conflict
the subordinates D. Possesses innate
resolution, each side gives up something
charisma that makes others feel
as well as gets something:
94. Grace RN is a head nurse assigned at
A. Negotiating
the Intensive Care Unit of a Secondary
Level Hospital. As a manager, Grace is B. Competing
C. Avoiding B. They often say, “We’ve always done it
this way, so let
D. Compromising
us do it this way again.”
98. Nurse Kat feels uncomfortable
believing that she is the scapegoat of C. They tend to analyze the components
everything that goes wrong in her of a problem. D. They generally do not
department. Which of the following is the assume another person’s point of view.
best action that she must take?

A. Identify the source of the conflict and

understand the points of friction

B. Disregard what she feels and continue

to work independently

C. Seek help from the Director of Nursing

D. Quit her job and look for another

employment.

99. Which of the following is a

characteristic of decision-making?

A. it only involves logical, rational thought

B. it is often the result of many

incremental steps rather

than one large step.

C. It must always be done quickly in the

health care

setting.

D. they generally do not assume another

person’s point

of view.

100. Which of the following is true about

effective creative thinkers?

A. They seldom generate new ideas and

alternatives.
 RECALLS EXAMINATION 7 the wound thoroughly with soap and
water, consult a physician and receive
NURSING PRACTICE II
anti-rabies vaccination. Which among the
CARE OF HEALTHY / AT RISK MOTHER following vaccines can provide active
AND CHILD immunity?

NOVEMBER 2024 Philippine Nurse 1. Purified vero cell vaccine

Licensure Examination Review
2. Human rabies immunoglobulin 3.
GENERAL INSTRUCTIONS: Equine rabies immunoglobulin 4. Purified
duck embryo vaccine A. 1and4
1. This test questionnaire contains 100
test questions B. 2 only

2. Shade only one (1) box for each C. 3and4

question on your answer sheets. Two or
D. 1 only
more boxes shaded will invalid your
answer. 3. AVOID ERASURES. 3. The vendor acquired rabies, what will
PHN Cords do to protect those who took
4. Detach one (1) answer sheet from the
care of him? He should
bottom of your Examinee ID/Answer
administer____________.
Sheet Set.
A. Pre-exposure prophylactic treatment
5. Write the subject title “NURSING
only for the family of Bert
PRACTICE II” on the box provided
B. Post-exposure prophylactic treatment
Situation – The family of Roxas is fond of
only for the family of the vendor
dogs. A vendor who entered the gate
without notice is bitten by one of the pet C. Pre-exposure prophylactic treatment to
dogs named Bert. PHN Cords Attends to Bert and the vendor’s families
the vendor.
D. Post-exposure prophylactic treatment
1. Which of the part of body of the vendor to Bert and the vendor’s families
will be the MOST affected in terms of
4. PHN Cord’s intervention to protect all
rabies? It is the _________.
residents who own pets, especially dogs,
A. Buttocks B. Head should be done by_______.

C. feet A. Coordinating with city/ municipal

agriculturist for immunization of all pets
D. hand
B. Coordinating with city/municipal
2. To protect the vendor from the dangers
officials to make an ordinance on stray
of rabies, PHN Cords advises him to clean
dogs
C. Massive campaign to families not to C. reporting forms
own pets at home
D. target/client list
D. Massive campaign for responsible pet
7. The monthly field health service activity
ownership
report is a form used in which of the
Situation – The Field Health Services and components of the FHSIS?
Information System (FHSIS) is recording
A. Target/client list
and reporting system in public health care
in the Philippines B. Output report

5. The following are the objectives of the C. individual health record D. tally report
FHSIS, EXCEPT:
8. In using the tally sheet, the
A. Complete the picture of acute and recommended frequency in tallying
chronic disease activities and services is_______.

B. Ensure data recorded are useful and A. Weekly B. Quarterly C. Monthly D. Daily
accurate and
9. To monitor clients client registered in
disseminated in a timely, easy to use long-term regimen such as the Multi drug
fashion Therapy, which component of the
reporting system will be most useful?
C. Minimize recording and reporting
burden allowing A. Output report

more time for patient care and promotive B. Tally report

activities
C. target/client list
D. Provides standardized facility-level
D. individual health record
data base which
Situation – Nurse Omar takes care of the
can be used for more in-depth studies
Ramos extended family who resides in the
6. As a nurse, you should know the house owned by Nilda’s mother, Marta.
process of how these information are Nilda tends a variety store is married to
processed and consolidated. The Ramon, a government employee. They
fundamental have four children: Lester, 20 years old;
Gina, 18 years old; Alex, 15 years old; and
block of the FHSIS system is the
Celine, 12 years old. Lester is a working
______________ A. Family treatment
student of his second year in computer
record
technology course. Gina is a high school
B. Output record graduate; Alex is in third year high school
and Celine is in Grade six. There is one
year old baby girl who is a daughter of combat shame and guilt
Gina. Gina, however, could not pinpoint
B. Lay down the foundation of a future by
the one who sired her child in as much as
trusting
she had multiple sex partners. This
angered Ramon. human association and developing
mutual trust initially with the nurse, then
10. Though he recognizes the remorse of
the family, and eventually the whole
his daughter, Ramon still feels confused
community
regarding the situation. He said he tried
his best to support his family and had C. Focus on the factors that will help
always been considerate and kind. He protect Gina towards proximal stimuli for
and his wife would always give them healthy growth and development to
reminders and advice calmly and never in develop her resiliency in confronting
a nagging manner. But still they failed as current and future problem
parents. The possible nursing diagnosis of
D. Transform interactions among family
Nurse Omar of his family is_____________.
members, strengthen specific roles and
A. Interrupted family process B. Impaired functions to strengthen family system in
parenting order to eventually cope

C. Parental role conflict 12. In one home visit, Nurse Omar was
approached by the 15 year old Alex. He
D. Ineffective role performance
was asking about condom use. He said he
11. Nurse Omar ’s conversation with Gina has a girlfriend with whom he is madly in
revealed that the young woman still love with but does not want her to get
suffers from a syndrome of failure: failure pregnant. Nurse Omar ’s most practical
to complete one’s normal growth and and best advice would be__________.
development, failure to complete
A. Postpone sex and suggest other ways
education, failure to establish a vocation
to expressing love
and become independent and failure to
have a life. The nurse Omar ’s intervention B. Explain to him the difference between
to this problem is_____________. sex and love

A. Linear approach with regards to the C. Teach him by step-to-step correct,

individual in the continuous and

1|Page consistent condom use

D. Discourage him on having a girlfriend

and focus more
context of the family, community and
culture that will on his studies
13. Ramon complains to Nurse Omar C. Accept and express gratitude for the
some weird behaviour of Nilda. These trust accorded him by the family
past few months, she has decreased sex
D. Politely decline and explain that his
drive, night’s sweats and mood swings.
relationship with the family must not go
He also received weird text message from
beyond professional
her such as: “Do you really love me?”,
“What role do I play in your life?” “Do you Situation – Belinda, the PHN in the
still find me attractive?” The best advice Municipality of La Trinidad, learned from
of Nurse Omar to Ramon should the residents that children and some
be________. elderly had been suffering from
respiratory and skin ailments allegedly
A. Give her some money for make-over to
due to the bad smell curly dark smoke
increase her self-esteem and make her
emitting from the factory nearby. She was
look attractive to him
invited to the community assembly that
B. Accompany her to a psychiatric was initiated by the barangay council.

C. Ignore his wife or tell her she is too old 15. The barangay captain asked, “What
to act like a can you do to help solve the problem of
Nurse Belinda?” What would be the right
teen-ager
response of Nurse Belinda?
D. Give reassurance that she is the best
A. “Well, your problem is easy to solve. I
person who
have here some cough syrup, ointments
came to his life for the skin and some antibiotics. I will
distribute this after the meeting.”
14. Apparently, the nurse interventions
have improved family relationships. The B. “Who among you here have children
members are now communicating with who are suffering from respiratory and
one another and are excited in preparing skin diseases? How about the adults who
for a family affair, which is the baptism of are here? Are you also having the same
Beatrice. Nurse Omar was asked to be the problems?”
godfather of the child. His best response
C. “I suppose you gave a lot of thought
is_________.
about the problem and its possible
A. Accept and proudly say that Beatrice solution. However, treating your children
will be his 49th godchild and the elderly is not the first solution. We
have to go to the root cause of the
B. Refuse and make an alibi that he
problem.”
belongs to another religion
D. “May I ask you what solution have you
identified for the community problem?”
Situation – Nurse Lovely, a newly which is when the pregnant woman
promoted senior nurse in Obstetrics ward is________.
(OB) is attending a seminar on
A. Feels the need to seek professional
management and leadership in
assistance
preparation for her work.
B. Demonstrates self-reliance in caring for
16. Nurse Lovely learns the five principles
herself
of goal setting in
C. Understands the communication of
which the senior nurse must provide
Nurse Lovely
enough time for OB nurse to improve
performance. This is called__________ regarding the services offered D. Begins to
have feeling belonging
A. Challenge
19. Nurse Lovely took note that evaluating
B. Commitment C. feedback
the OB staff is an on-going function of
D. task complexity management. Some of the reasons for
conducting evaluation include, EXCEPT to
17. The nurse also learns that continuous
_____________.
training is a personal as well as an
organizational goal. Choose the A. Provide an indication of the costs of
statements that are true regarding poor quality services
continuous training
B. Justify the use of resources
1. Training employees is an excellent
C. Dissuade self-evaluation of OB staff
investment and a cost to an institution
D. Ensure that quality of care is provided
2. Continuous training is more of a
by the OB staff
personal responsibility than institutional
Situation- You are an OB nurse in an out-
3. Cross training and job rotation provide
patient department of a hospital. You
on-going part-time learning experience
encounter pregnant women with
4. Select the best people when hiring complication 20. A 35-year old woman,
employees and invest their retention on her 2nd trimester of pregnancy with
through continuous training insulin-dependent diabetes mellitus,
comes to you for some advice. What is
A. 3and4 B. 1and2 C. 1and4 D. 2and3
the PRIORITY message for her at this
18. Noting the importance of Nurse- time?
Patient-Relationship, Nurse Lovely
A. Infants of diabetic mothers are big
reviewed Hildegard Peplau’s Theory which
which can result in more difficult delivery
identified three phases, the FIRST of
B. Breastfeeding is highly recommended satisfactory. After a year though, she had
and insulin use is not contraindicated to renew her PRC registration and
identification (ID) card.
C. Achievement of optimal glycemic
control is of utmost importance in 22. What action must the nursing
preventing congenital anomalies administration do FIRST?

D. Her insulin requirements will likely A. Report the matter to the head of office
increase beginning 3rd trimester of who had the
pregnancy
discretion to appoint the nurse
21. A 30-year old G6P5 woman at 12
B. Verify with the Professional Regulation
weeks has just begun prenatal care. Her
Commission
initial laboratory reveals that she has
human immunodeficiency virus (HIV) regarding the status of Nurse Dana
infection. What would be a priority
2|Page
evidence-based nurse information for this
patient?

A. Breastfeeding is still recommended C. Confront Nurse Dana and terminate

due to the great benefits to the infant her

B. Pregnancy is known to accelerate the D. Write a letter to the Civil Service

course of HIV disease in the mother Commission for

C. Medication for HIV infection is safe and proper action to Nurse Dana
can greatly reduce transmission of HIV to
23. It was found out that Nurse Dana did
the infant
not pass the Nurse Licensure
D. Breastfeeding will potentiate the Examinations (NLE). What legal action
transmission of HIV from the mother to should be filled against her?
the child A. Dishonesty
Situation– Nurse Dana, a nursing staff B. Conduct unbecoming of professional
applicant, passed both written and oral
C. Malpractice
examinations. Because she knows the
head of office, she promised to submit all D. Misrepresentation
her credentials after she has “fix things 24. In case Dana have medication error
up.” She was appointed as Nurse I with a during her tour of duty, the head of office
temporary status until she submits all her can be liable because of the law called
credentials, including her PRC license. ____________.
Her evaluation performance was
A. Unethical conduct that entered the boy’s body.”

B. Respondeat superior C. Politicking D. “You have to be sure that all the evil
spirits have been
D. Res Ipsa Loquitur
driven out of the boy’s body.”
25. All Nurses must understand that after
graduation they should pass the NLE. To 27. After a few minutes, Nanay Isa took a
be registered in the roster, they should big bowl of soup and gave to the boy. The
take the Professional Oath with a BEST remark of the Nurse is
________, EXCEPT. _____________.

A. Member of Sangguniang Panlalawigan A. “I also drink a soup when I get sick.

How about you, Nanay Isa, do you do the
B. Governor of Philippine Nurse
same?”
Association
B. “The soup could have been better if you
C. Member of the Professional Regulatory
put lemon grass on it.”
Board of
C. “Come on, tell me why soup must be
Nursing
given to a child with fever
D. Provincial Governor
D. “That’s correct. Increasing fluid intake
Situation – PHN Elfa works in barangay 14 will help lower down temperature.”
and 15 in the Municipality of Agoho. One
28. Finally, Nanay Isa took out from her
day, a neighbor summons her to attend to
pocket a dried rose flower and place it on
a 7-year old boy with high grade fever.
the boy’s forehead. How will Nurse Elsa
26. Upon reaching the house, a local handle this action?
herbolaria, Nanay Isa was already
A. Tell her not to use the dried flower
attending to the boy. She said that the boy
again because it does not have any good
played near the river and the bad spirits
effect on the sick
entered his body. The MOST appropriate
remark the nurse make is B. Ask for an extra piece of fried rose
_________________. flower and promise to use it

A. “Go on. Do what you have to do, then I C. Ask the herboloria the rationale for the
will take over.” intervention

B. “Nanay Isa, your intervention is entirely D. Leave the intervention as is. Anyway
wrong.” the intervention

C. “It’s good you’re here. You can drive is neutral: not harmful nor beneficial
away the spirits
Situation – The local health board C. Grayish white as differentiated from
established a reproductive health clinic in mucoid white of chlamydia
the main health center. Two nurses,
D. Yellowish white as compared to
Hunter and Irene, were assigned to
trichomoniasis’ greenish-yellow
handle services to address problems
related to sexuality, reproductive health 31. Nurse Hunter was invited by a
and fertility problems. 29. Nurse Hunter women’s group to give a lecture on
classifies cases according to the major healthy sexuality. In the expectation
categories of reproductive tract check, he noted that there are previous
infections. Which of the following is NOT misconceptions expressed by the
part of such classification? participants. Which of the following
statements are correct?
A. Iatrogenic infections as aftermath of
invasive procedures like catheterization A. It is the obligation of the wife to give in
and intra-uterine device (IUD) insertion to sex every time he asks for it

B. Urinary tract infections among male B. Sexuality is fluid and may change
and female patients
C. Effeminate men are gays
C. Sexually-transmitted infections
D. Homosexuality, being gay or lesbian, is
D. Endogenous infections resulting from an
poor personal
abnormality
hygiene
32. One of the clients was positive to
30. Irene handles the screening for Gonorrhea. Nurse Irene explained that
gonorrhoea every two weeks among gonorrhoea and chlamydia, if left
female sex workers in the implementation untreated can lead to Pelvic Inflammatory
of PD Disease (PID). Such condition may cause
infertility due to ______.
856. In differential diagnosis of discharge
among infected clients, which of the A. Foul smelling odor discharge which
following colors discharge will Irene take can kill the ovum B. An unknown cause
note to identify gonorrhoea from other
C. Scarring which can lead to tubal
causes?
occlusion
A. Greenish yellow as differentiated from
D. Purulent discharge which can kill the
mucoid white of trichomoniasis
sperm
B. Mucoid white as compared to grayish-
33. Nurse Irene further explained that a
white discharge of vaginosis
test used to determine tubal patency
using a radiopaque material is the when she engages in unprotected
__________. sex______.

A. Post-coital infetitlity test B. Sims A. B. C. D.

Huhner test
Several days after ovulation
C. Friedman’s test
During ovulation
D. hysterosalpingography
Immediately after ovulation
Situation – Ela, 21 years old, is a law
Immediately before ovulation
graduate. She wants to review for the Bar
but thinks she is pregnant. She said she nurse proceeded to take the menstrual
has regular menses but does not know history of Ela
when ovulation usually occurs. This have
36. The
something to do her fertility period during
her last sexual intercourse with her to find out if she is likely to be pregnant.
husband. Which of the following determines the
date of onset of last menstrual period
34. As a nurse, what would you tell Ela
(LPM)? It is the ___________.
regarding ovulation? The ovulation usually
corresponds to the life of the corpus A. Duration and character of the LMP
luteum which occurs approximately B. Implantation bleeding
_______________.
C. Spotting after the LMP
A. 14 days after the first day of the
succeeding menstrual D. Bleeding before the last menstrual
period (LMP)
B. 7 days after the first day of the
succeeding menstrual C. 7 days before 37. The nurse also asked about Ela’s
the first day of the succeeding secondary amenorrhea that would most
likely indicate her pregnancy. Secondary
menstrual amenorrhea is cessation of menses for
D. 14 days before the first day of the more than_______ months, after regular
succeeding menstrual cycle has been established.

menstrual A. Five B. Three C. six

35. Ela insisted she might have been D. four

fertile during the time of sexual
38. The nurse also asked for presence of
intercourse. The nurse explains that
secondary dysmenorrhea. Which of the
absolute period of fertility is the span of
time that a woman is likely to be pregnant
following conditions is not INCLUDED 41. Alice an O.P.D nurse admitted Mrs.
under secondary dysmenorrhea? Felia to the antepartum unit with a
diagnosis of severe Hyperemesis
A. Intra-uterine device (IUD)
Gravidarum. When the nurse reviews the
3|Page laboratory tests, she would expect which
of these findings?

A. Increased hematocrit
B. Pelvic Inflammatory Disease (PID)
B. Decreased blood urea nitrogen C.
C. Malposition of the cervix
Increased potassium
D. Absence of any underlying anatomic
D. Low urine specific gravity
abnormality
42. Nurse Alice suspects presence of
39. Carla another patient in the clinic just
sexually transmitted infection to Mrs.
found out that she is pregnant. She asks
Felia specifically Syphilis to a pregnant
when would be her delivery date. What is
client. Which of the following tests will be
the expected date of confinement (EDC)
recommended to the client to confirm
of a pregnant woman whose
diagnosis?
menstruation was from April 10 to April
13? A. Complete blood count B. Urinalysis

A. January 17 B. January 20 C. July 17 C. Benedict’s test

D. July 20 D. VDRL

40. The nurse noted the Fundic height of 43. Mrs. Ilagan a 26 year old Primigravida
Anna is at the level of the umbilicus. In is being prepared for a nonstress test.
documenting the data using This is an assessment test based on what
Bartholomew’s rule, the most probable phenomenon?
age of gestation (AOG) in week is :
A. Braxton-Hicks contractions cause fetal
A. 12 weeks B. 16 weeks C. 20 weeks D. heart rate alterations.
32 weeks
B. Fetal heart rate slows in response to a
Situation: A pregnant woman is monitored uterine contraction.
continuously for a range of signs and
C. Fetal movement causes an increase in
symptoms that indicate potential
maternal heart rate.
complication. Nurse Carol attends to
different discomforts and problems of D. Fetal heart sounds increase in
pregnant women. connection with fetal movement.
44. After a non-stress test is completed, C. Late decelerations after one
Nurse Ilagan observes on a monitor of the contraction on a strip with three
fetal strip results that the fetal heart rate contractions within a 10-minute time
accelerated 15 BPM with each fetal frame.
movement. The acceleration lasted for 20
D. An increase in fetal heart rate after
seconds and occurred 3 times during the
three contractions within a 10-minute
20 minute test. The Nurse is correct in
time frame.
interpreting the test as a:
47. The client complains of feeling tired
A. Reactive test
and thirsty. The nurse evaluates that the
B. Non- reactive test mother understand the reason for taking
only small sips of water and ice chips
C. Positive test
during labor. Which of the following
D. Negative test statement expressed by the mother would
reflect she understands the situation?
45. Another client is also scheduled for
When:
Amniocentesis. Nurse Carol explains to
the client that one of the risks of A. the body normally has a sufficient store
amniocentesis is: of energy

A. Rupture of membranes B. Premature B. the digestive process is normally

labor slower during labor C. the intestinal tract
should be completely empty before
C. Fetal death
delivery in order to avoid infecting the
D. Malformation
baby
46. The nurse is assessing the fetal heart
D. Cesarian section is always a possibility
monitor strip of a client having a
even in normal
contraction stress test. Which of the
following, if noted by the nurse, would labor
indicate a negative test?
48. Kim, a 27 year old, multigravida client,
A. No late decelerations after any has been transferred to the delivery room
contractions on a strip with three after spontaneous rupture of membrane
contractions within a 10-minute time and crowning was noted by the nurse in
frame. charge. You know that your teaching has
been effective when the laboring client's
B. Late decelerations after at least 2
partner shouts, "She's crowning!" as:
contractions on a strip with three
contractions within a 10-minute time A. You first start to see a little of the
frame. baby's head.
B. The baby's head recedes upward delivery that could predispose the
between pushing mothers to potential complications such
as hemorrhage.
contractions.
51. The Nurse in the delivery room is
C. The perineum is thin and stretching
attending to Mrs. Cruz on labor to make
around the
sure that maternal injury will be prevented
occiput. during the postpartum period. Which of
the following instruction should the nurse
D. The mouth and nose are being
consider to prevent postpartum
suctioned.
hemorrhage?
49. To deliver her infant, a woman is ask
A. Massage the fundus regularly
to push with contractions to deliver.
Ensuring the standards of nursing B. Postpone breastfeeding of the baby-
practice, which of the following is the
C. Apply warm compress to her abdomen
most effective and safest pushing
technique to teach her? D. Have bed rest and avoid early
ambulation
A. Lying supine with legs in lithotomy
stirrups. 52. When the placenta has been
delivered, the first thing the nurse should
B. Squatting while holding her breath.
do in adherence with the standards of
C. Head elevated, grasping knees, nursing practice is to:
breathing out. D. Lying on side, arms
A. Inspect the placenta for completeness
grasped on abdomen.
of the cotyledons
50. The delivery room nurse based on the
B. Palpate the uterus to see if it is
standards of nursing practice, episiotomy
contracted
is usually indicated for which of the
following purposes? C. Administer oxytoxic agents as ordered

A. To prevents distention of the bladder. D. Estimate the blood loss to detect any
bleeding
B. To relieve pressure on the fetal head.
53. The delivery room nurse palpates the
C. To aid in contraction of the uterus
client’s fundus immediately after delivery
following delivery. D. Done primarily for
of the placenta and assess that it is
the physician’s benefit.
boggy. The nurse massages the patient’s
Situation: It is important for an Obstetric uterus until it is firm. Considering
Nurse to perform a comprehensive evidence-based nursing practice, which
physical assessment after labor and medication would the nurse anticipate
might need to be administered if the 56. Which of the following would be the
uterus becomes boggy again? physiologic basis for a Placenta Previa?

A. Oxytocin (Pitocin) A. A loose placental implantation. B. Low

placental implantation.
B. Ibuprofen
C. A placenta with multiple lobes. D. A
C. Rho (D) immnune globulin (RhoGAM)
uterus with a midseptum.
D. Magnesium sulfate
57. A patient diagnosed with Placenta
54. Mrs. Evita 28 years old gave birth
Previa should be given specific instruction
through Cesarian section. The Nurse
before discharge from the hospital. To
examines her and identify the presence of
ensure standards of nursing practice,
lochia serosa and feels the fundus 4
which among the following should be
fingerbreadths below the umbilicus. This
considered by the nurse as part of
indicated that the time elapsed is:
instruction to the client?
A. 1 to 3 days postpartum B. 4 to 5 days
A. Eat a low calorie diet
postpartum C. 6 to 7 days postpartum D.
8 to 9 days postpartum B. May resume with regular exercise if
minimal bleeding
4|Page
has been noted.

C. Avoid sexual intercourse. D. Avoid

55. In assessing a new mother’s response
intake of spicy foods
to her son’s birth on the first post partum
day, which behavior does the Nurse 58. Another pregnant mother wants to be
expect to find present? clarified on her laboratory studies which
reveals blood Type -A and she is Rh
A. Talkativeness and dependency
negative. Problems related to
B. Autonomy and Independence incompatibility may develop in her infant
if the infant is:
C. Disinterest in her own body function
A. Type O
D. Interest in learning to care for the baby
B. Rh positive
Situation: A Maternal-Child staff nurse is
attending to the pregnant mothers with C. Delivered preterm D. Type B, Rh
varied obstetric disorers. A negative
comprehensive assessment was
59. An Obstetric nurse is assessing a 39
conducted. One of the clients seeks
year old pregnant woman who is married
further question regarding Placenta
to an American citizen and Rh negative, is
Previa.
seen by the Physician during the first A. place a hand gently on the fetal head to
trimester of pregnancy. A test to detect guide delivery.
presence of antibodies was conducted to
B. ask her to push with the next
her. The nurse’s teaching is effective if the
contraction so delivery is rapid.
client understands that she will first
receive Rho (D) immunoglobulin (RhIg): C. assess blood pressure and pulse to
detect placental bleeding.
A. If the result of Indirect Coomb’s test is
positive B. If the result of Indirect D. attach a fetal monitor to determine
Coomb’s test is negative C. If the result of fetal status.
Direct Coomb’s test is positive D. If the
62. Nurse Jamie in a labor room is
result of Direct Coomb’s test is negative
preparing to care for a hypertonic uterine
60. During the prenatal visit the Nurse dysfunction. The nurse observed that the
explains further to a client who is Rh client is experiencing uncoordinated
negative that RhogGAM will be contractions and erratic in their
administered: frequency, duration and intensity. The
priority nursing intervention in caring for
A. Weekly during the ninth month,
the client is to:
because this is her third pregnancy
A. Monitor the oxytocin (Pitocin) infusion
B. Within 72 hours after delivery if infant is
closely B. Provide pain relief measures
found to be Rh positive
C. Prepare client for amniotomy
C. During the second trimester , if an
Amniocentesis indicates a problem D. Promote ambulation every 30 minutes

D. To her infant , immediately after 63. Mrs. Barbara 34 years old is being
delivery if the Coomb’s test is positive admitted in the hospital unit for severe
Preeclampsia. When deciding on where
Situation: The birth process affects the
to place her, which of the following areas
physiologic systems of the mother and
would be most appropriate?
the fetus. Staff nurse Jamie is assigned in
the Labor and Delivery Room Area. A. By the nursery so she can maintain
hope she will have a child.
61. A G7P 6 woman is in the hospital only
15 minutes when she begins to deliver B. Near the elevator so she can be
precipitously. The fetal head begins to transported quickly. C. Near the nurse’s
deliver as you walk into the labor room. station so she can be observed
The best action of Nurse Jamie would be
closely.
to:
D. In the back hallway where there is a B. talk to her at a special time each day.
quiet, private C. respond to her consistently.

room. D. keep her stimulated with many toys.

64. The Physician orders intravenous 67. Whenever the parents of a 10-month-
Magnesium Sulfate for Mrs. Barbara. old leave their hospitalized child for short
Which of the following medications would periods, he begins to cry and scream. The
the Nurse has readily available at the nurse explains that this behavior
client’s bedside? demonstrates that the child:

A. Diazepam (Valium ) A. Needs to remain with his parents at all

times. B. Is experiencing separation
B. Calcium Gluconate
anxiety.
C. Hydralzine (Apresoline ) D. Phynetoin (
C. Is experiencing discomfort.
Dilantin )
D. Is extremely spoiled.
65. Which of the following signs would
alert the Nurse that Mrs. Barbara’s whose 68. Dennis, a preschooler sees you pour
latest blood pressure 160/110, may be his liquid medicine from a tall, thin glass
about to experience a seizure? into a short, wide one, he will probably
reason that:
A. Decreased contraction intensity B.
Epigastric pain A. the amount of medicine is less (the
glass is not as full).
C. Decreases temperature
B. the amount of medicine did not
D. Hyporeflexia
change, only the appearance.
Situation: As a Pediatric Nurse you are
C. pouring medicine hurts it in some way
confronted with varied concerns
because it changes.
regarding growth and development from
parents, teachers, and children. The D. the glass changed shape to
nurse recognizes the need for health accommodate the medicine.
supervision and anticipatory guidance for
69. A school nurse prepares a lecture on
these groups. 66. The best way for an
Puberty changes for first year high school
infant’s father to help his child complete
girls. She asks the group, "What is the first
the developmental task of the first year is
sign of Puberty?" A student correctly
to:
replies :
A. expose her to many caregivers to help
A. "The appearance of breast buds."
her learn variability.
B. "An increase in energy and appetite." C. A. He states he is tired and wants to
"The occurrence of the first menarche." D. sleep. B. His respiratory rate is gradually
"Appearance of body odor." increasing. C. His cough is becoming
harsher.
70. When encouraging the hospitalized
physically challenged or chronically ill D. His nasal discharge is increasing.
adolescent to develop and maintain a
72. A child is scheduled for a
sense of identity, you would:
Myringotomy with placement of
A. provide the opportunity for individual Tympanostomy tube. What is the goal of
decision making. this procedure that Nurse Paterno will
discuss with the parents?
B. provide physical comfort to the
individual. A. To decrease infection in the ear

C. ask the parents what the adolescent is B. To irrigate the eustachian tube
capable of
C. To correct a malformation in the inner
doing. ear

D. provide care until the adolescent D. To equalize pressure in the tympanic

insists on being membrane

independent. 73. An 8 year old female child was

admitted in the hospital with medical
Situation: Nurse Paterno a Pediatric
diagnosis of Acute Rheumatic fever.
Nurse enjoys taking care of children in the
When obtaining a health history from the
ward even though it is so difficult and
child’s mother, the nurse should ask the
takes so much time to attend to their
questions to determine if the child was
needs.
recently ill with:
71. Elvis 8 months old was diagnosed
A. Mumps
with Acute Laryngotracheobronchitis
(LTB) and is managed inside a mist B. Measles

5|Page C. a viral flu

D. a sore throat

tent. As Nurse Paterno conducts 74. You would teach the mother of a boy
assessment, which of the following with Tetralogy of Fallot (TOF) that if he
observations would lead her to suspect suddenly becomes cyanotic and dyspneic
that airway occlusion is occurring?
C. All the pants have become tight around
the waist.
D. The child prefers some salty foods condoms.”
more than others.
D. “No, Once you stop using the
Situation: A newly married couple Berta contraceptive method,
and Bart wants to practice Family
you can have children again.”
Planning to prepare a good future for their
family. Nurse Bing a Family Planning 83. Bart the husband, further asked Nurse
Counselor is planning a lecture regarding Bing if contraceptive method will result to
the different methods of family planning. loss of sexual desire. Nurse Bing’s most
appropriate response would be:
81. Which of the following family planning
method which identifies the fertile and A. “No, but it will make you
infertile days of the menstrual cycle as uncomfortable with your sexual
determined through a combination of relationship.”
observations made on the cervical
B. “Yes, it causes lack of sexual desire of
mucus, basal body temp recording and
the male partner.”
other signs of ovulation?
C. “Yes, it causes lack of sexual desire of
A. Basal Body Temperature
the female partner.’
B. Standard Days Method
D. “No, it can actually enhance your
C. Sympto-thermal Method sexual relationship.” 84. In a CHN class, a
student asked Mr. Pablo, the Clinical
D. Lactational Amenorrhea Method
Instructor, if family planning methods can
82. During a family planning seminar cause abortion. As an instructor, Mr.
conducted in the Barangay Health Center, Pablo’s response should be:
Nurse Bing was asked by Berta, a married
A. “No, family planning prevents
woman who wants to try using
pregnancy, but it does not terminate
contraceptives, if it is true that
pregnancy."
contraceptives will render couples sterile.
Nurse Bing’s response should be: B. “No, family planning puts a pregnant
woman at risk for miscarriage, but not
A. “Yes, It’s true.”
abortion.”
B. “Yes, If you are already using it for more
C. “Yes, family planning can cause
than 3
abortion.”
months.”
D. “Yes, if the couple is using the artificial
C. “No, It will not cause sterility if you are methods of
also using
family planning.”
85. Mackle-More, a Public Health Nurse advantages for the mother. Exclusive
(PHN), is assigned in conducting breastfeeding during the first half-year of
seminars on Family Planning Program in life is an important factor that can
the different Barangays. She is aware that prevent:
the roles of PHNs on Family Planning
A. Infant and childhood morbidity and
Program are the following EXCEPT:
mortality B. Infant and childhood Mental
A. Provide counseling among the clients Disorders
to help increase family planning
C. Occurrence of Cancer
acceptors and avoid defaulters.
to:
B. Ensure availability of family planning
supplies and logistics for the PHNs and A.
other barangay health workers only.
B. C. D.
C. Provide packages of health services
place him in a semi-Fowler’s position in
among reproductive age group in all
an infant seat. lie him supine with the
health facilities.
head turned to one side.
D. Inform the clients about the
lie him prone, being sure he can breathe
importance and
easily.
benefits/advantages/disadvantages of
family planning. place him in a knee-chest position.

Situation: Nurse Maja continues to 75. Dyspnea, cough, weight gain,

expand her roles by actively participating weakness, and edema are classic signs
in the activities of the Health Center in and symptoms of which condition?
collaboration with the Department of A. Pericarditis
Health.
B. Hypertension
86. Which of the following is not included
in the Child Health Programs of the DOH? C. Myocardial infarction (MI) D. Heart
failure
A. Adolescent Screening
Situation: There are varied Pediatric
B. Expanded Program on Immunization C. disorders that require comprehensive
Dental Health
assessment and nursing interventions.
D. Micronutrient Supplementation The following scenarios refer to health
problems of children.
87. Breastfeeding is the most essential
feeding for infants that has nutritional , 76. A 5-week-old infant is brought to the
immunologic values and maternal pediatrician’s office with symptoms of
irritability, weight loss, and projectile A. Nausea and vomiting for the last 24
vomiting. On physical examination, the hours
infant appears dehydrated. From these
B. Streptococcal throat infection 2 weeks
symptoms, you know that the infant
prior to
probably has:
diagnosis
A. Hirschsprung’s disease
C. History of urinary tract infection for 5
B. Tracheoesophageal Fistula C. Pyloric
days D. Pruritus for 1 week prior to
stenosis
diagnosis
D. Intussusception
80. A newly admitted 5-year old child in
77. Pediatric Nurse admitted a post cleft the Pediatric ward is diagnosed with
palate repair child and immediately the Wilm’s Tumor. Upon initial interview, the
nurse should position the child: nurse would be most concerned about
which statement by the child’s mother?
A. Left side lying.
A. My child has lost 3 pounds in the last
B. Prone.
month.
C. Dorsal recumbent. D. Semi Fowler's.
B. Urinary output seemed to be less over
78. Another neonate is suspected of the past 2
having a tracheoesophageal fistula.
days.
Priority nursing care until the diagnosis is
confirmed includes: 6|Page

A. monitoring the neonate carefully during

and after feedings
D. Occurrence of Heart Disease
B. elevating the neonate’s head after
88. Rona, G1P1, is on her 2nd post
feedings
partum day. She asks Nurse Maja about
C. feeding only glucose the definition of exclusive breastfeeding.
Nurse Maja responds based on his
D. feeding nothing by mouth
knowledge that exclusive breastfeeding
79. Upon interviewing the parents of the means:
child with Acute Glomerulonephritis, the
A. giving the baby breast milk and water
nurse understands that which information
only.
collected is most often associated with
this condition? B. giving the baby breast milk and solid
food only.
C. giving the baby breast milk and drops B. “The extent of protection against polio
or syrups is increased the earlier the BCG is given.”

consisting of vitamins, mineral C. “BCG given at earliest possible age

supplements, or protects the possibility of TB meningitis
and other TB infections in which infants
medicines only.
are prone.”
D. giving the baby breast milk only. Drops
D. “An early start of BCG reduces the
or syrups
chance of being infected and becoming a
consisting of vitamins, mineral carrier. It prevents liver cirrhosis and liver
supplements, or medicines should not cancer.”
yet be given until the 6th month of life.
Situation: Barangay Dionisia is situated in
89. The following are the benefits of a remote area. The Public Health Nurse
breastfeeding to the infants EXCEPT: conducted several health training
programs regarding Herbal plants that
A. Provides a nutritional complete food
would be useful in the treatment of illness
for the young infant.
and health problems. The following can
B. Strengthens the infant’s immune be found in the small garden of the
system, preventing many infections. Barangay.
C. Safely dehydrates and provides 96. Tsaang Gubat is used to treat which of
essential nutrients to a sick child. the following? A. Diarrhea and
Stomachache
D. Increases IQ points.
B. Cough and Fever
90. During a Ward class in the Obstetric
Ward of a community hospital, a mother C. Colds and Pain
asked the Nurse regarding the benefits of
D. Hypertension 97. Niyug-niyogan is an:
breastfeeding to the mothers. The Nurse
best response would be: A. Analgesic

A. B. C. D. B. Anti-helminthic C. Anti-hypertensive D.
Anti-gout
purpose of the first BCG vaccination given
to her son. The nurse’s best response 98. Ulasimang Bato or Pansit-pansitan is
should be: used to: A. lower cholesterol levels

A. “An early start with BCG reduces the B. lower blood sugar levels
chance of severe pertussis.”
C. lower ammonia levels

D. lower uric acid levels

99. This refers to a drug outlet managed “It increases the risk of ovarian and breast
by a legitimate community organization, cancers and osteoporosis.”
non-government organization, and the
91. Nurse Dorothy is preparing to
local government unit with a trained
administer vaccinations to children. She
operator and a supervising pharmacist,
knows that the following are correct
and specifically licensed by the Bureau of
EXCEPT:
Food and Drugs to sell, distribute, offer for
sale, and or make available low-priced A. The vaccination schedule should not
generic home remedies, Over the Counter be restarted from the beginning even if the
(OTC) drugs, antibiotics, and medication interval between doses exceeded the
for chronic diseases. recommended interval by months or
years.
A. Mercury drugs
B. Giving doses of a vaccine at less than
B. Right Med
the recommended 4 weeks interval may
C. Generic Pharmacy D. Botika ng lessen the antibody response.
Barangay
C. Lengthening the interval between
100. One strategy to address the problem doses of vaccines leads to higher
in a poor Barangay aside from Herbal antibody levels.
Plants is food production. Which of the
D. Use one syringe one needle for all the
following is a priority?
children receiving the same vaccination.
A. A community managed poultry and
92. Rose, a mother of a 7-month-old baby,
piggery
is asking the nurse in the Health Center
B. Planting plenty of Malunggay regarding the 7 vaccine preventable
diseases. All of the following diseases are
C. Planting tomatoes and eggplants in
included EXCEPT:
containers
A. Diphtheria B. Measles
D. Engaging in a home –based food
processing business C. Poliomyelitis D. Dengue

“It increases the woman’s risk of 93. Kurt, 4 years old, has Measles. His
excessive blood loss after birth.” mother asks the nurse if there is a chance
that Kurt will contract the virus again. The
“It reduces the woman’s risk of excessive
nurse’s response should be based on her
blood loss after birth.”
knowledge that:
“It provides artificial methods of delaying
pregnancies.”
A. reactivation of old infection is common
with Measles. B. immunity from Measles
is lifelong after the first

attack.

C. no immunity is induced by the

infection.

D. immunity from Measles is just for 6

months after the

first attack.

94. When can you say that a child is

already a “Fully Immunized Child”?

A. If he received one dose of BCG, 3 doses

of OPV, 2 doses of DPT, 3 doses of HB and
one dose of measles before his/her first
birthday.

B. If he received two doses of BCG, 3

doses of OPV, 3 doses of DPT, 3 doses of
HB and one dose of measles before
his/her first birthday.

C. If he received one dose of BCG, 2

doses of OPV, 3 doses of DPT, 3 doses of
HB and one dose of measles before
his/her first birthday.

D. If he received one dose of BCG, 3

doses of OPV, 3 doses of DPT, 3 doses of
HB and one dose of measles before
his/her first birthday.

95. Annabelle, a new mother, asks the

nurse about the

7|Page
RECALLS EXAMINATION 7 B. Refuse the order of the nurse
supervisor and stay put in the medical
NURSING PRACTICE III
ward
CARE OF CLIENTS WITH PHYSIOLOGIC
C. Comply with the order of the nurse
AND PSYCHOSOCIAL ALTERATIONS
supervisor
(PART A)
D. Request the nurse supervisor to give
NOVEMBER 2024 Philippine Nurse
her brief
Licensure Examination Review
orientation before compliance
GENERAL INSTRUCTIONS:
2. To qualify as an operating room nurse in
1. This test questionnaire contains 100
the Philippines setting, Nurse Luna
test questions
should possess the minimum
2. Shade only one (1) box for each requirements of _____________.
question on your answer sheets. Two or
A. Master’s degree holder with valid and
more boxes shaded will invalid your
current license B. Worked in the surgical
answer. 3. AVOID ERASURES.
unit for 8 hours
4. Detach one (1) answer sheet from the
C. RN and has worked abroad
bottom of your Examinee ID/Answer
Sheet Set. D. RN with valid and current license and
Surgical Ward
5. Write the subject title “NURSING
PRACTICE III” on the box provided orientation

Situation – Nurse Luna is employed in 3. Nurse Luna is a graduate in the

hospital “X” and assigned in the Medical Philippines nursing school. As part her
Ward for a year now. The nurse supervisor professional and personal development,
ordered her to proceed immediately to she should attend which of the following
the Surgical Ward as a reliever to another program? EXCEPT___________
nurse who went on emergency sick leave.
A. Programs by the Philippine Nurses
She was not oriented in the Surgical Ward
Association
and the unit was very busy.
B. Continuing Professional Development
1. Which of the following is the MOST
programs by the
appropriate action of Nurse Luna
Professional Regulation Commission
A. Request the nurse supervisor to assign
a more experienced nurse reliever C. Symposium and forum offered by the
school D. Programs of international
nurses associations
4. The PRIORITY objective behind career 7. Mr Gilbert is for postural drainage. The
advancement of Nurse Luna is nurse should position the client’s head at
____________. ______________.

A. Increasing revenue of the service A. No greater than a 25 degree downward

providers angle B. A 30 degree lateral angle for 25
minutes
B. Renew old acquaintances and
establish camaraderie C. Increased C. 25 degree at lateral angle
number of networking activities
D. A 30 degree downward angle for 25
D. Updating one’s knowledge, skills, minutes
conduct and values
8. Nurse Beth is teaching Michel, an
in professional nursing asthmatic, on how to use the Spirometer.
She should instruct the client to have the
5. Nurse Luna has an expired license but
mouthpiece________________.
promises to renew her license in due
time. Which of the following violation can A. Place into the mouth and have regular
she be charged if she participated in breathing B. Place into the mouth and
home health care activity? have a fast deep breath C. Place into the
mouth and inhale slowly
A. Malpractice
D. Place into the mouth and exhale slowly
B. Grave coercion C. Felony
9. Nurse Beth is teaching a client on how
D. Negligence
to use metered dose inhaler to prevent
Situation– Health Education is an area of asthmatic attack while in the hospital.
nursing practice when the nurse can be She should instruct the client to do the
creative and independent in the work following __________________ EXCEPT.
setting. The following questions apply.
A. Keep the head of the bed at 15 degree
6. A nurse is developing a Teaching plan angle B. Do oral care after use of the
for Isabel 18 year old with Bronchial inhaler
Asthma. She has an order for discharge.
C. Use the inhaler before she take her
Which part of the teaching plan should be
meals
given PRIORITY?
D. Use the inhaler as ordered
A. Quick relief medicines as ordered B.
Avoid contact with fur-bearing pets C. 10. You are conducting health-teaching
Avoid going to malls sessions to clients with cardiovascular
disorders. Client Pedro asks you this
D. Wash bed sheets in warm water
question: “Tell me, Nurse, what I should
do with my Hypertension?” The best 12. When the sympathetic nervous
response of a Nurse is____________. system is stimulated in the case of
pheochromocytoma, you expect which of
A. “comply with your diet, lifestyle and
the following signs?
exercise”
1. Hypertension
B. “strictly follow your prescribed daily
exercise and 2. Headache

smoking cessation” 3. Hyperhidrosis

C. “comply with your diet, life style 4. Hypermetabolism A. 3and4

modification and
B. 1 only
prescribed medicines”
C. 1,2,3,and4
D. “include garlic in your meals with
1|Page
regulation of alcohol

consumption”
D. 2and3
Situation - As a staff nurse in a
government hospital, you have been 13. Which of the following drugs can
exposed to varied cases of clients with induce hypertensive crisis in
endocrine problems. Your nursing Pheochromocytoma?
responsibility starts from admission to
A. Tricyclic antidepressant B.
discharge which is a domain of your
Corticosteroid
competencies.
C. Respiratory stimulant D. Radio iodine
11. Which of the following questions
therapy
should you ask during an admission
interview for a client with a diagnosis of 14. In the presence of
pheochromocytoma? pheochromocytoma, the diagnostic test
which is expected to be elevated is
A. Do you always feel like you are
___________.
suffocating, you want to rest and sleep
A. Serum thyroid hormone levels
B. Do you suddenly feel warm and flushed
when you get out of bed B. Albumin globulin test

C. Do you notice an increase in your heart C. Urine cyclic adenosine mono

beat? phosphate

D. Do you have an increase in urination D. 24 hours urine collection for

lately? vanillylmandelic acid
(VMA) D. Forms signed by any close relative or
watcher
15. Palpation, as a modality for physical
examination is AVOIDED when diagnosed 17. The patient asks you, “What do you
with pheochromocytoma because this think of my surgeon?” You answered
action_______________. “hmmmmm... he is not really the best
one and he seems not to care for
A. Will cause sudden release of
patient...” As a result, the patient
norepinephrine and severe hypotension
switches to another surgeon. The latter
B. Will cause a sudden release of may have grounds to sue you for
cathecolamines and severe hypertension _____________.

C. Will displace the location of the tumor A. Slander

D. Will cause sudden release of B. Invasion of privacy C. Malpractice

epinephrine and severe
D. Libel
palpitation
18. One of your patient’s visitors whisper
Situation – Mr. Con is being prepared for a to you, “I hope you will not try to revive my
major surgery. Legal preparation for dear friend if her heart stops as she has
surgery consists of checking all the already suffered a lot.” The correct
required forms for the operation. Equally response is ___________.
important is to make sure that the patient
A. “That decision is up to the physician”
is physically, psychologically, and
emotionally ready for the procedure. B. “We are all trained in cardiopulmonary
resuscitation” C. “There is a ‘ Do not
16. Informed consent is a process that
resuscitate’ order in her chart”
gives the patient opportunity involved in
his or her care. As patient advocate, the D. “ I understand your concern, but I can’t
nurse ensures the following three discuss this
conditions are present to make consent
matter with you”
valid, EXCEPT:
19. According to the Joint Commission,
A. Adequate disclosure of the diagnosis
the most frequently cited factor in
by the physician B. Comprehension of
sentinel (unanticipated) events that leads
information by the patient before
to a patient’s serious physical or
the operation psychological injury is
______________________.
C. Patient voluntarily giving consent
A. Confusion within the health team
B. Miscommunication among health team B. A written document published by the
members investigator herself

C. Incompetence by a team member C. Any retrieval from website that will help
her search for the subject on investigation
D. Policy changes are not followed by
adequate and D. A description of the scientific study
from an information provided by a faculty
consistent staff education
member teaching research
Situation – Conducting Research is one of
22. Weight is taken as a baseline
the major roles of the nurses both in
measurement of obese female
hospital and community settings. To be
adolescents as study subjects for a
able to develop such competencies, the
weight reduction program. This is
nurse has to undergo an actual conduct
repeated to note any changes. This pre-
of the research process.
test is done to___________________.
20. Which of the following statements
A. Determine whether the instrument is
BEST described a researchable problem?
defective
A. Responses of parents toward having
B. Assess if research design is appropriate
children with congenital heart diseases.
to the
B. The relationship between relaxation
problem identified
technique and relief of pain of post CABG
patients in the surgical coronary care unit. C. Evaluate whether the instrument is
defective
C. Incidence of medication errors and
reporting practices D. Obtain preliminary data before a
treatment is
of Health Care Professional in a teaching
hospital conducted by the researcher

D. To what extent do pre-operative 23. A Nurse researcher is using ACCU-

teaching affect the CHEK a monitoring kit to test presence of
Diabetes Mellitus among her study
length of hospitalization of patients going
subject. How do you classify this type of
for surgery 21. Nurse Joan has to undergo
measurement?
literature search for her study. She can
avail of this from the following A. Microbial
EXCEPT_____________.
B. Cytological C. Physiological D.
A. A summary of research articles that are Chemical
relevant to the study
24. Nurse Joan, wanted to conduct a B. Explain and validate health knowledge
study using quasi-experimental design. and beliefs of Patient Kian with that of the
This design will need a __________. hospital

A. Retrospective evaluation C. Help Patient Kian identify ways to

relate more to the culture where they now
B. Field setting for the study
resides
C. Comparable group
D. Ask patient Kian to help Nurse Tessie in
D. Manipulation of the dependent variable knowing more the culture of his origin

Situation – Kian, 16 year old, a foreigner 27. The family of Patient Kian request
was admitted in the medical ward due to utilization of warm compress with banana
abdominal pain, nausea and vomiting by leaves to Patient Kian. Which of the
Nurse Tessie. following is the MOST appropriate
response of Nurse Tessie? Alternative
25. In initiating care for patient Kian,
therapies_________.
which of the following would be an
APPROPRIATE question to be asked by A. Cost less than traditional therapies
Nurse Tessie in her assessment?
B. Are use when traditional therapies are
A. Since this is doctor’s order, you have to not effective
drink ice water, instead of hot tea.
C. Utilized natural products while
B. Do you have any books I could read traditional therapies do
about people of your culture?
not
C. Do you need to set aside your cultural
D. Can be effective as traditional
practices, and comply with hospital rules
therapies for some
and regulations?
conditions
D. Is there anything I am doing that is not
acceptable to your culture? 28. Patient Kian’s family requests time for
spiritual healing process in the hospital.
26. Nurse Tessie respects cultural
This is allowed by Nurse Tessie and
practices integration in her nursing care
hospital because
plan. Which of the following nursing
it______________________.
action is MOST represented of the
culturally competent nurse? A. Gives fulfillment and meaning to the
patient and
A. Help patient Kian to learn and
understand the language 2|Page
family A. Give her biscuit to eat

B. Demonstrate people being responsible B. Do urine testing for sugar

for their life
C. Provide her warm blanket
patterns
D. Take blood pressure and put her on bed
C. Is non-denominated community rest
service D. Formalizes a religious dogma
31. Patient Julia has been classified to
29. Positive Practice Environment (PPE) have a type II Diabetes Mellitus. Which of
influences healing process. Which of the the following is NOT a typical
following ways can help Nurse Tessie manifestation of individuals with this
create a healing environment? condition?

A. Ensure that relatives and friends visit A. Frequency of urination

the patient
B. Increased craving for food C. Increased
B. Empower clients to make healthy thirst
decisions for
D. Weight loss
themselves
Situation – Mr Dencio, 58 years old is
C. Place television in each room of the admitted to the pay ward because of
hospital respiratory problem. The nurse initiated
oxygen treatment by mask but the client
D. Ensure that staff nurses does not
refuses despite the encouragement by
experience burnout
the wife. The client is aware of the
Situation –Julie, 28 years old, has been benefits of the treatment.
diagnosed with Diabetes Mellitus. She
32. Which of the following should be given
was advised by her family physician to be
priority?
admitted to undergo preservation for
insulin therapy. Her blood sugar ranges A. Ask the opinion of the wife
from 200 to 210 mg/dL. At 6 am, Nurse
B. Conduct consensus building
Cynthia administered her insulin
injection. After 2 hours, the patient C. Let the attending physician decide on
complained of cold clammy perspiration, the necessity of
chilly sensation and abdominal
the treatment
discomfort.
D. Respect the decision of the client
30. Which of the following PRIORITY
nursing actions should the nurse 33. You are taking care of Mr Dencio who
perform? is on the last cycle of radiation therapy for
his lung cancer. You should instruct Mr A. Degree of pitting edema B. Time of
Dencio to indention recovery C. Depth of edema

A. Brush teeth and gums vigorously after D. All of the options

meals
37. Mr. Gabby is with left sided heart
B. Wait one hour after treatment before failure. Ime’s documentation of her
eating assessment findings will include the
following, EXCEPT______________.
C. Use mouthwash containing alcohol
every 2 hours D. Avoid drinking hot fluids A. Dependent edema

Situation – Ime is the Nurse on duty in the B. Pulmonary crackles C. Difficulty of

medical ward and many of her patients breathing D. Cough
are suffering from problems of
38. A client is on a diuretic therapy.
oxygenation.
Expected entry in patient’s chart should
34. The following are relevant data to be include the following information,
documented when taking the health EXCEPT:
history of a client with anemia EXCEPT:
A. Serum electrolytes monitored
A. Alcohol intake
B. Intake and output recorded
B. Fatigue and weakness C. Dietary intake
C. Lasix administered at 8 o’clock in the
D. Episodes of bleeding evening D. Weight is taken before drug is
given
35. A client with congenital heart disease
is suffering from thickening of the skin Situation 10 – Maya, a 42 year old teacher
under his fingers due to chronic with cardiac ailment, nervously informs
hemoglobin desaturation. Which of the the doctor that her goiter is getting bigger
following specific term should Ime use to and distracts her while swallowing food.
accurately describe MOST the client’s The physician who examined her
condition in the chart? instructed the nurse to admit Maya and to
prepare her for surgery after medical
A. Peripheral cyanosis
clearance.
B. Pallor of the finger tips C. Peripheral
39. While interviewing Patient Maya, she
neuropathy D. Clubbing of the fingers
claims that she is anxious for the coming
36. When the Nurse is assessing a client surgery. You expect the following signs
with Congestive Heart failure with pitting and symptoms when one is under stress,
edema, the Nurse’s documentation will EXCEPT___________
include which of the following:
A. Blood loss and weakness B. Increases 43. In order for the nurse to recall the
respiration rate C. Decreased mobility location of pain, he has
to_______________.
D. Pain due to tissue damage
A. Asks for onset and duration
40. Based on your knowledge, Patient
Maya, who has a history of cardiac illness, B. Mark the painful area in a body diagram
should not be given an enema before
C. Asks for facial expression
surgery. Which of the following reasons
inhibits the order of enema for Patient D. Asks verbal description using pain
Maya? Enema____________ intensity scale

A. Paralyzes the peristalsis movement 44. As example of a drug therapy to relieve

and increases abdominal pain moderate pain is_____________.

B. Produces vagal stimulation that is A. Codeine

dangerous to cardiac patient
B. Demerol
C. Causes constipation and fecal
C. Methadone
impaction after the surgery
D. Morphine sulphate
D. Enema results to increased water
absorption in the bowels 45. When a client is on prolonged pain
therapy, the nurse should watch
Situation 11 – Mr. S came to the ER
for____________.
because of sharp troubling pain. After his
surgery, he claimed pain is felt even he is A. Tolerance to drug
asleep.
B. Allergic reaction to drug C. Drug
41. At what stage of pain mechanism do resistance
you classify this pain? D. Addiction to drug
A. Perception B. Modulation C. Situation: Donny a 46 year old patient
Transmission D. Transduction admitted to the coronary care unit (CCU)
42. When a client complains of pain less with an MI and frequent premature
than 6 months, it is called_____________. ventricular contractions (PVCs) has
doctor orders for continuous amiodarone
A. Chronic pain
infusion, IV nitroglycerin infusion, and
B. Persistent pain C. Acute pain morphine sulfate 2 mg IV every 10
minutes until there is relief of pain. She is
D. Intermittent pain
taken care by Leona a newly graduate
nurse.
3|Page C. Explore and discuss possible effect of
stress

D. Provide reassurance while focusing on

46. Because of Donny’s premature
pleasant topics
ventricular contraction, the nurse should
monitor its effects on which of the 50. The Physician scheduled for an
following parameters? exercise electrocardiogram (stress test).
What information should the nurse
A. Electrolyte levels
include when explaining the value of this
B. Apical radial heart rate C. Oxygen test? Exercise stress testing is a:
saturation
A. definitive method to diagnose the
D. Medications cause of chest pain B. diagnostic
modality of minimal value in planning
47. In analyzing a patient’s
electrocardiographic (ECG) rhythm strip, treatment of angina
Leona uses the knowledge that the time
C. noninvasive means of assessing
of the conduction of an impulse through
cardiovascular
the Purkinje fibers is represented by
conduction and function
A. PR interval B. QT interval C. QRS
complex D. P wave D. minimally invasive manner of
assessing a body’s
48. A considerable difference between
the apical and radial pulse rate of Donny reaction to increase in exercise
would indicate
SITUATION: You are a nurse tasked to care
A. Stronger left than right ventricular for patients with several different
muscles conditions. You utilize your knowledge of
nursing concepts to help these patients.
B. Numerous weak ineffectual cardiac
contractions C. Thickened myocardium 51. The patient admitted in the unit with a
and large heart chambers D. Increased urinary condition asked you, the nurse,
pressure in systemic arteries where in the kidney does urine get
formed. You answer them correctly by
49. As Donny is assessed he complains of
stating that urine is produced in the:
being nauseated and very weak. The
nurse should A. Glomerulus.

A. Perform nutritional assessment B. Proximal convoluted tubule. C. Loop of

Henle.
B. Alert staff for potential help
D. Nephron.
52. A client was assigned to your unit after live just around the corner and come over
their abdominal surgery. You asked the a few times a week to visit.
patient during your morning rounds about
C. The fast food place near my home has
the passage of flatus. The patient
really good food. I eat there most of the
answered, “Yes, flatus has passed earlier
time.
this morning”. In anticipation of
defecation, which of the following D. What is a laxative?
instructions are most important for you,
54. You are the nurse on duty in the
the nurse, to give to this client?
emergency room. A client came via
A. Please call the nurse if you need to go ambulance with shortness of breath for
to the bathroom. the past 3 days. After a few hours in the
ER, the client is admitted to the intensive
B. If you feel the urge to have a bowel
care unit with pulmonary edema that
movement, please call for assistance
requires intubation and ventilation. A
before getting up to the toilet. When
Foley catheter was placed in the client
having a bowel movement, be sure to
and he had a total of 25 mL urine output.
breathe out to prevent straining. Do not
The laboratory reveals: blood glucose of
hold your breath.
300, blood urea nitrogen of 100, and
C. To prevent the Valsalva maneuver, creatinine of 5.0. The client has a history
contract the stomach muscles while of CHF, CAD, diabetes, COPD, and
holding your breath and push. This will asthma. What's the client’s most likely
assist in the passage of the stool and will
cause of A.
decrease the amount of time required to
have a bowel movement. B. C.

D. Your bowels will be moving soon. low urine output?

Please report any abdominal pain.
Acute and chronic renal failure due to
53. You are the nurse on duty in the unit. A diabetes and a decreased blood flow to
client verbalized complaints of a recent the kidneys due to heart failure.
constipation. You took the patient’s
Renal failure due to decreased coronary
health history. Which of the following
output secondary to heart failure.
statements by the client suggests the
likely cause of their constipation? Decreased blood flow to the kidneys due
to congestive heart failure (CHF)
A. I walk with a group of friends every day
secondary to noncompliance with home
at the mall for an hour.
fluid restriction.
B. My spouse died 20 years ago, but my
Severe dehydration.
family is very loving and supportive. They
D. kidney failure and is a sign that the
client’s kidney function is becoming
55. A client came to the hospital
worse. I will notify the physician about the
complaining of nausea and occasional
confusion. There are a couple of
vomiting. You are the nurse reviewing the
treatment options to consider. The
client’s medical records when you note
physician will discuss the treatment
that this client has a 4 year history of renal
options with the client and you.
insufficiency. They had been on fluid
restriction and renal diet. Their laboratory 56. One of the elderly patients assigned to
shows a steady increase in BUN, you in the ward has been complaining of
creatinine, and potassium. The client’s increasing trips to the bathroom to
spouse accompanied the client to the urinate. Her estimated coffee intake is 3
appointment. She pulled you aside and cups every day. What is the best
stated that his husband has been having explanation you can provide to this
episodes of confusion each day. She told patient?
you that she is very concerned about her
A. The increased urine production is most
husband and she wants to know if he is
likely due to a urinary tract infection.
having small strokes. Based on the
information provided, what is your best B. Coffee is causing the increased
response to the spouse’s question? urination due to your increased fluid
intake. This is completely normal and
A. Confusion is a common sign of
nothing to be concerned about.
transient ischemic attacks. Thank you for
informing me of this. The client will need a C. Coffee is causing the increased
CAT scan of the head. urination. Coffee contains caffeine that
causes diuresis, or increased urine
B. The client’s kidneys are not working
formation. Simply decreasing the number
very well. However, confusion is not a
of cups of coffee you drink each day, and
common symptom. I will inform the
limiting the consumption of caffeinated
physician of the confusion and have her
beverages to the morning hours, should
assess the situation further with the
help decrease your trips to the bathroom.
client.
D. Drinking coffee increases the
C. The elevated potassium is causing the
circulating plasma in the body and this
confusion. The client will need some
increases the urine formation. Simply
medication to decrease the potassium
decreasing the number of cups of coffee
level.
you are drinking should help.
D. The client is experiencing worsening
57. You are beginning your shift for the
uremic syndrome. This is associated with
day. You start by assessing a client that
has a Foley catheter connected to a activities include ambulating, eating,
collection bag. Which of the following is dressing, bathing, brushing the teeth, and
the best routine catheter care actions to grooming.
take while caring for this client?
B. Activities that assist the client in
A. Encourage increased oral fluid intake recognizing and managing stress. These
and observe for any opacity in the urine activities include facilitating interpersonal
suggesting bacterial infection. B. relationships, allowing adequate time for
Carefully wash the perineal area with rest, and providing regular, nutritious
soap and water meals.

after each bowel movement. C. Activities that allow the client to be

independent in society. These activities
4|Page
include shopping, preparing meals,
paying bills, and taking medications
appropriately.
C. Avoid touching the tip of the spigot to
any surfaces when emptying the D. Activities that support the
collection bag. effectiveness of direct care interventions.
These activities include checking
D. Encourage the client to drink at least
equipment, directing the maintenance of
2000 mL each day and carefully wash the
the client’s room, and managing the
perineal area, with soap and water, at
supply of materials needed for client care.
least twice daily and with each bowel
movement. 59. One of your clients arrived in the
preoperative area for their knee surgery.
58. A client of yours read the term
You asked them to put an elastic stocking
activities of daily living. As a
on the non operative leg. The client asked
knowledgeable nurse, you know that
you, “What is the purpose of these
activities of daily living (ADLs) are the
stockings?”. Your best response to the
essential and routine tasks that most
client’s question is:
young, healthy individuals can perform
without assistance. These include the A. The stockings promote return of
basic activities that are performed in the venous blood to the heart and assist in
course of a normal day. You also know preventing the blood from clotting in the
about instrumental activities of daily legs.
living (IADL). Which of the following
B. The operating room is very cold. The
statements best describes IADL?
stockings assist in maintaining a healthy
A. Activities that are usually performed in core body temperature during the
the course of a normal day. These operation.
C. The stockings promote joint mobility. longer responds to cure-focused
treatment.
D. The stockings promote the return of
arterial blood to C. Aggressive cure-focused disease
treatment and
the heart and prevent blood from clotting
in the legs. management. D. Comfort care.

60. The relative of an immobile client in 62. Coby asked you what the goal of
your unit asked you, the nurse, about the palliative care is. You answer him
complications of immobility. You answer correctly by stating that which of the
her correctly by stating that which of the following are the goals of palliative care?
following are the complications of Select all that apply.
immobility? Select all that apply.
I. Preventing disease symptoms. II.
I. Primary osteoporosis. II. Foot drop. Relieving disease symptoms.

III. Urinary stasis. IV. Pressure ulcer. III. Curing a disease. IV. Treating a
disease.
A. I.
A. I
B. I, II, III, IV C. I, II, IV
B. II
D. II, III, IV
C. I, II D. III, IV
SITUATION: You are a nurse providing
palliative care to Coby, an elderly with 63. Coby is now under home health with
terminal illness. You use your knowledge palliative care services. He stated that he
on terminal illness and palliative care to has been experiencing nausea. Which of
provide the best care to this patient. the following actions will most likely
promote comfort in this client?
61. Coby approached you and asked
about palliative care since he has been A. Educate the patient and family in the
hearing it a lot lately after he was use of prescribed antiemetics; providing
diagnosed with his terminal illness. As a oral care every 2 to 4 hours; consuming a
knowledgeable nurse, you know which of diet of clear liquids and ice chips; and
the following is the best definition of avoiding liquids such as coffee, milk, and
palliative care? citrus juices.

A. Care for terminally ill clients. B. Administer additional pain medication.

B. Symptom management for a client C. Provide education to the patient and

when a disease no family regarding

oral care and antiemetic medication.

D. Take a detailed medical history to C. Coordinating a visiting schedule for the
determine the family.

cause of the nausea. D. Communicating news of the client’s

impending death
64. The granddaughter of Coby
approached you and asked regarding the to the family while they are together.
symptoms their grandfather might
SITUATION: You are a nurse tasked to care
experience. You answer her correctly by
for Alvida, a patient with peripheral
stating that which of the following are the
vascular disease. You use your knowledge
common symptoms of terminally ill
on PVD to help care for this patient
clients?
effectively.
A. Hunger, thirst, fatigue, and diarrhea.
66. You are planning care for patient
B. Dehydration, nausea, effective Alvida with a history of PVD with
breathing, and symptoms of claudication. The focus of
your nursing care should be directed in
adequate nutrition.
avoiding which of the following
C. Discomfort, nausea, ineffective scenarios?
breathing, and
A. Oxygen demand by the muscle
fatigue. exceeds the supply.

D. Urinary continence, thirst, dehydration, B. Oxygen demand and supply of the

and diarrhea. working muscle

65. Coby is being cared for at home by his are in balance.

family members. You conducted your
C. Oxygen supply exceeds the demand of
physical assessment on Coby and based
the working
on your findings, you are aware that
Coby’s death is imminent. What is your muscle.
most important role in the care of family
D. Oxygen is absent.
at this point in time?
67. You are reviewing the labs of Alvida.
A. Providing temporary relief of caregiving
You note which of the following common
duties to allow the family to rest.
abnormal laboratory results that are
B. Providing education regarding the associated with the development of
symptoms the client will likely peripheral vascular disease (PVD)?
experience.
A. High serum calcium level. B. High
serum lipid levels.
C. Low serum potassium level. D. Low C. Decreased pain.
serum lipid levels.
D. Increased blood viscosity
68. You are conducting your assessment
SITUATION: You are a nurse in the
on Alvida. You are checking her lower
cardiothoracic ward of Hospital Merry.
extremities expecting to find which of the
You are assigned to patients with
following clinical manifestations of
aneurysms. You will utilize your nursing
peripheral vascular disease?
knowledge on aneurysms to care for
A. Hairy legs. these patients.

B. Mottled skin. 71. You are developing a discharge

teaching plan for Morgan, a patient who
C. Pink, cool skin.
underwent a repair of abdominal aortic
D. Warm, moist skin. aneurysm a few days ago. You reviewed
Morgan’s chart for information about his
69. Your patient Alvida with PVD has
health history. Key findings you noted in
undergone a right femoral-popliteal
his chart are as follows:
bypass graft. You assess her blood
pressure noting a decrease from 124/80 1) Smokes 4 cigars a month.
to 94/62. Which of the following should
2) Vital signs: blood pressure, ranges from
you assess in Alvida first?
150/76 mm Hg to 170/98 mm Hg; heart
A. IV fluid solution. rate, 90 to 100 beats per minute;
respirations, 12–18 per minute;
B. Pedal pulses.
temperature, 99.9° F (37.8° C).
C. Nasal cannula flow rate. D. Capillary
3) +1 bilateral ankle edema.
refill.
Based on the data and expected
70. After further assessment on Alvida
outcomes, which of the following should
who was diagnosed with PVD, you found
you emphasize in the teaching plan for
out that she also has a history of heart
Morgan?
5|Page
A. Food intake.

B. Fluid volume.
failure. You will develop a plan of care for
C. Skin integrity.
Alvida based on the fact that she may
have low tolerance for exercise related to: D. Tissue perfusion.

A. Decreased blood flow. 72. Helmeppo, a client admitted to the

emergency department is complaining of
B. Increased blood flow.
severe abdominal pain. After several C. Pulmonary edema. D. Myocardial
tests, a radiograph of his revealed a large infarction.
abdominal aortic aneurysm. The primary
75. Hatchan is to be discharged after his
goal for Helmeppo at this time is to:
surgery of aortic aneurysm repair with
A. Maintain circulation. synthetic graft to replace part of his aorta.
As part of your discharge teaching, you
B. Manage pain.
instruct Hatchan to notify his physician
C. Prepare the client for emergency before doing which of the following
surgery. D. Teach postoperative breathing procedures?
exercises.
A. Blood drawn.
73. Yasopp, a 54 year old client was
B. An I.V. line inserted. C. Major dental
admitted in the emergency department.
work.
On assessment, it was revealed he has
severe back pain, Grey Turner’s sign, D. An X-ray examination.
nausea, BP of 90/40, HR of 128 bpm, and
SITUATION: You are tasked to care and
RR of 28 cpm. As Yasopp’s nurse, you
educate patients regarding oral care to
should first do which of the following
help their conditions. You utilize your
actions:
knowledge to assist these patients.
A. Assess the urine output. B. Place a
76. Buggy, a client admitted to your unit,
large bore I.V.
has stomatitis. As a knowledgeable
C. Position onto the left side. D. Insert a nurse, you know that which of the
nasogastric tube. following interventions is most
appropriate for Buggy at this time?
74. Arlong, one of the patients assigned to
you, complains of sudden, severe pain in A. Drinking hot tea at frequent intervals.
his back and chest, accompanied by B. Gargling with antiseptic mouthwash. C.
SOB. He describes the pain sensation as Using an electric toothbrush.
“as if something was tearing inside”. The
D. Eating a soft, bland diet.
physician suspects that he is
experiencing a dissecting aortic 77. You are doing your assessment on
aneurysm. The code cart is brought into patient Kuro, and when you check his
Arlong’s room because you know that one mouth, you note the absence of saliva.
of the complications of dissecting Further
aneurysm is:
assessment reveals he has pain in the
A. Cardiac tamponade. B. Stroke. area of his ear. Kuro has been NPO for
several days now because of an NGT
insertion. Based on your assessment, you B. “If you increase your self-control, I am
suspect that Kuro may be developing sure you will be able to avoid smoking.”
which of the following conditions of the
C. “Try taking a couple of days of vacation
mouth?
to relieve the stress of your job.”
A. Stomatitis.
D. “It is good that you can talk about your
B. Oral candidiasis. C. Parotitis. concerns. Try calling a friend when you
want to smoke.”
D. Gingivitis.
80. Kuro was rushed to the emergency
78. You are tasked by your manager to
department after a motor vehicle
conduct a presentation to the community
accident where he fractured his
regarding oral cancer. You conducted your
mandible. Surgery has been performed to
research, and you found out several risk
immobilize his injury. The surgeon has
factors for the disease. Which of the
wired Kuro’s jaw. In the immediate
following will you include in your
postoperative phase, you as the nurse
presentation as the primary risk factor for
should:
oral cancer?
A. Prevent nausea and vomiting.
A. Use of alcohol.
B. Maintain a patent airway.
B. Frequent use of mouthwash.
C. Provide frequent oral hygiene.
C. Lack of vitamin B12.
D. Establish a way for the client to
D. Lack of regular teeth cleaning by a
communicate.
dentist
SITUATION: You are a nurse caring for
79. Jango is one of your patients in the
Tashigi, a patient with a chronic condition
unit. He has entered a smoking cessation
of the respiratory system. You help her by
program to quit a 2 pack per day cigarette
utilizing your nursing knowledge and skills
habit of his. He tells you, “I have not
on the topic.
smoked a cigarette for 3 weeks, but I am
afraid I am going to slip up and smoke 81. You are visiting Tashigi who reports
because of the pressures of my current that her chronic bronchitis has recently
job”. As Jango’s nurse, what would be the worsened. Which of the following
most appropriate reply to make in instructions would you reinforce to Tashigi
response to his comments? to help with her condition?

A. “Don’t worry about it. Everybody has A. Increase amount of bedrest B. Increase
difficulty quitting smoking, and you fluid intake
should expect to as well.”
C. Decrease caloric intake
D. Reduce home oxygen use B. Notify the respiratory therapist to
increase the
82. You are completing an assessment on
Tashigi. Based on your knowledge and positive pressure settings
previous experience of working with
6|Page
patients who have chronic bronchitis,
which of the following findings would you
expect Tashigi to present?
C. Call the physician to suggest sedatives
A. Minimal sputum with cough B. Pink, and paralytics
frothy sputum
D. Prepare to administer intravenous
C. Barrel chest aminophylline

D. Stridor on expiration 85. You are doing your charts in the

nurses’ station when you suddenly hear
83. Tashigi has been learning more about
high pressure alarms in Tashigi’s room.
self care for her chronic condition at a
Which of the following is your next best
community health class. She asked you
action?
why the participants are being taught
about lip breathing. You respond correctly A. Wait and allow the client time to
to Tashigi by explaining that pursed lip regulate breathing in coordination with
breathing will help to: the ventilator

A. reduce upper airway inflammation. B. Check ventilator tubing and

connections
B. reduce anxiety through humor.
C. Silence the alarm and restart the
C. strengthen respiratory muscles.
ventilator
D. increase effectiveness of inhaled
D. Lower the tidal volumes being
medications
delivered to the client
84. Tashigi’s condition worsened lately
SITUATION: You are a nurse
and she now needs a positive pressure
knowledgeable about various ethical,
mechanical ventilation. She has been
legal, and safety issues in nursing as this
fighting the ventilator assisted breaths,
will guide you in establishing a safe
and her BP has been steadily decreasing.
nursing practice.
Which of the following would be your
most appropriate intervention? 86. Nojiko is a hospitalized client under
your care. She was diagnosed with end
A. Place the client in the prone position
stage cancer and has suddenly decided
to discontinue her treatment. She
requests no more additional treatment C. Beneficence
like antibiotics, tube feedings, and
D. Justice
mechanical ventilation. Acting as Nojiko’s
advocate, which of the following actions 88. Van, one of the patients in your unit,
should you take? has a sudden change in his condition. You
called the physician to report this
A. Respect the client’s wishes and
occurrence. He gave orders over the
indicate those wishes on the plan of care
telephone for ABGs to be drawn stat.
B. Encourage the client to share the Which of the following is the most
decision with the family and the client’s important safety consideration when
physician obtaining the physician’s order over the
phone?
C. Clarify other treatments that the client
wishes to withhold A. Writing the order down and reading it
back to the physician
D. Wait until additional treatment is
required and then decide what to do B. Calling the respiratory therapist stat to
based on the client’s condition draw the ABGs

87. A car-pedestrian accident occurred C. Giving the order stat to the health unit
nearby. The pedestrian client named coordinator to
Mohji was brought to the ER of the
place in the computer
hospital you are working on. Mohji is alert
and oriented but complains of difficulty D. Writing down the order for ABGs
breathing. His SpO2 levels vary from 88- immediately
90%. O2 was applied at 2L per nasal
89. Patient Cabaji is to be admitted to the
cannula with no improvement in SpO2.
surgical unit. He has multiple rings, a
Oxygen per mask is then initiated at 40%
bracelet, a watch, and PHP 3500 in cash.
with little improvement. After some tests,
Which of the following is the safest action
Mohji’s radiograph films reveal no obvious
for you to take regarding the patient’s
injuries or fractures. Suddenly, Mohji
valuables?
loses consciousness, has a respiratory
arrest, and subsequently dies. During his A. Allowing the client to keep the items so
resuscitation, it is determined that one of they will be safeguarded by the client
the nurses failed to open the valve to the B. Collecting the items and placing them
O2 tank and Mohji has not been receiving in the client’s room closet
oxygen. What is the key ethical principle
involved in this scenario? C. Giving the money to the client’s spouse
and allowing the client to keep the jewelry
A. Nonmaleficence B. Fidelity
D. Collecting the items according to C. History of recent antibiotic use D.
hospital policy for safekeeping Living in colder climates

90. You admit patient Kuroobi who is 92. Yosaku is a male patient diagnosed
complaining of nausea and vomiting to with cirrhosis. While caring for Yosaku,
the emergency department. Kuroobi is you add the nursing diagnosis Disturbed
alone in the ED without any relatives or body image related to physical
guardians. After you complete your manifestations of the illness when you
assessment on Kuroobi, you prepare to overheard Yosaku telling his brother:
leave the room. Which of the following
A. “I don’t think I can handle this disease.”
statements is your safest instruction for
Kuroobi? B. “I know the doctors say I have liver
failure, but I
A. “If you need to vomit, here is a basin for
you. I don’t want you to get up on your don’t really believe them.”
own.”
C. “I know I should rest more, but I’m just
B. “I will be in the room next door. I’ll not that type
check back in about 10 minutes.”
of person.”
C. “I will go update the doctor about you.
D. “I don’t like the fact that I seem to have
Do you need anything before I go?”
breasts now.”
D. “Here is the nurse call light. Press this
93. Patient Johnny was admitted in the ED
button if you need me.”
after complaints of upper right sided
SITUATION: You are a nurse assigned to abdominal pain. You suspect that the
take care of patients with various liver client may have liver cancer when which
conditions. You utilize your knowledge serum laboratory test result is noted to be
and skills on the diseases to effectively elevated?
plan and manage care for these patients.
A. Creatinine
91. Patient Bellmere was admitted to the
B. Serum α-fetoprotein (AFP) levels C.
hospital with a diagnosis of nonalcoholic
Serum phosphorus levels
fatty liver disease (NAFLD). You are
reviewing her chart for her health history. D. CA-125
Which of the following findings is
94. You are caring for patient Carol after
consistent with the NAFLD disease her liver biopsy with the assistance of
process?
student nurse Apis. You evaluate that Apis
A. 70 years old understands liver biopsy post procedure

B. Obese
care when she does which of the the touch. D. The client’s serum uric acid
following? level is elevated.

A. plans to monitor vital signs every hour. 97. After Vivi’s diagnosis of osteoporosis,
she asked you why smoking cigarettes
B. promotes ambulation 1 hour after the
causes her bones to become brittle. Your
procedure.
most appropriate response is:
C. positions the client on the right side.
A. “Smoking causes nutritional
D. encourages the client to cough and deficiencies, which contribute to
deep breathe osteoporosis.”

immediately following the procedure. B. “Tobacco causes an increase in blood

supply to the bones, causing
95. Pell is a patient hospitalized for
osteoporosis.”
conservative treatment of liver cirrhosis.
As part of the collaborative plan of care, C. “Smoking low-tar cigarettes will not
you would anticipate which of the cause your bones to become brittle.”
following?
D. “Nicotine impairs the absorption of
A. monitoring the client’s blood sugar. calcium, causing decreased bone
strength.”
B. maintaining NPO (nothing by mouth)
status. C. administering antibiotics. 98. When discussing osteoporosis with
Vivi, you are aware that which of the
D. encouraging frequent ambulation.
following is an example of a secondary
SITUATION: You are a nurse providing care nursing intervention?
for patient Vivi who came to the hospital
7|Page
for assessment. She is suspected to have
osteoporosis. You help her by utilizing
your knowledge on the topic.
A. Obtain a bone density evaluation test.
96. You reviewed Vivi’s chart after
B. Perform non–weight-bearing exercises
conducting her physical assessment. You
regularly. C. Increase the intake of dietary
correctly identify that which of the
calcium.
following signs/symptoms indicate that
Vivi has already developed osteoporosis? D. Refer clients to a smoking cessation
program.
A. The client has lost one (1) inch in
height. 99. Vivi is prescribed by her physician
Calcitonin by nasal spray. Which of the
B. The client has lost 12 pounds in the last
year. C. The client’s hands are painful to
following assessment findings indicate an
adverse effect of the medication?

A. The client complains of nausea and

vomiting.

B. The client is drinking two (2) glasses of

milk a day.

C. The client has a runny nose and nasal

itching.

D. The client has had numerous episodes

of nosebleeds.

100. Vivi is taking Tums to help prevent

the further development of her
osteoporosis. Which of the following
health teaching should you implement for
Vivi?

A. Encourage the client to take Tums with

at least eight (8) ounces of water.

B. Teach the client to take Tums with the

breakfast meal only.

C. Instruct the client to take Tums 30 to 60

minutes before a meal.

D. Discuss the need to get a monthly

serum calcium level.

8|Page
 RECALLS EXAMINATION 7 C. Idiopathic atrophy of the adrenal gland.

NURSING PRACTICE IV D. Oversecretion of the adrenal medulla.

CARE OF CLIENTS WITH PHYSIOLOGIC 2. Igaram is admitted to your unit. After

AND PSYCHOSOCIAL ALTERATIONS your assessment on him, you formulated
(PART B) the nursing diagnosis Deficient fluid
volume related to inadequate fluid intake
NOVEMBER 2024 Philippine Nurse
and to fluid loss secondary to inadequate
Licensure Examination Review
adrenal hormone secretion. As Igaram’s
GENERAL INSTRUCTIONS: oral intake increases, which of the
following fluids would be the most
1. This test questionnaire contains 100
appropriate for him?
test questions
A. Milk and diet soda.
2. Shade only one (1) box for each
question on your answer sheets. Two or B. Water and eggnog.
more boxes shaded will invalid your
C. Bouillon and juice.
answer. 3. AVOID ERASURES.
D. Coffee and milkshakes.
4. Detach one (1) answer sheet from the
bottom of your Examinee ID/Answer 3. You are instructing Igaram how to
Sheet Set. adjust the dose of the glucocorticoids he
is taking. As his nurse, you should explain
5. Write the subject title “NURSING
to him that he may need an increased
PRACTICE IV” on the box provided
dosage of glucocorticoids in which of the
SITUATION: You are caring for patient following scenarios?
Igaram, a patient with Addison’s disease.
A. Completing the spring semester of
You utilize your knowledge on this
school. B. Gaining 4 pounds.
concept to help care for the patient.
C. Becoming engaged.
1. Igaram was just recently diagnosed
with Addison’s disease. He still lacks D. Undergoing a root canal.
knowledge about his disease so he
4. Igaram is diagnosed with Addison’s
decided to ask you some questions.
disease. As a knowledgeable nurse, you
Igaram asked you, “How does the disease
know that this condition may lead to
happen?” You answer him correctly by
Addisonian crisis if not adequately
stating that this disease results from:
managed. Which of the following
A. Insufficient secretion of growth manifestations would be expected in
hormone (GH). B. Dysfunction of the Igaram if he develops this condition?
hypothalamic pituitary.
A. Fluid retention. vasopressin IV and conduct a fluid
deprivation test.
B. Pain.
7. You
C. Peripheral edema. D. Hunger.
of the following clinical manifestations
5. If Igaram develops Addisonian crisis,
you noted in Karoo’s chart should be
which of the following would be your
reported to his primary care physician?
priority as Igaram’s primary nurse?
are reviewing the chart of Karoo who has
A. Controlling hypertension.
SIADH. Which
B. Preventing irreversible shock. C.
A. Serum sodium of 112 mEq/L and a
Preventing infection.
headache.
D. Relieving anxiety.
B. Serum potassium of 5.0 mEq/L and a
SITUATION: You are a nurse tasked to care heightened
for patients with different pituitary
awareness.
disorders. You are to take care of Karoo
and Koza, both diagnosed with SIADH, C. Serum calcium of 10 mg/dL and tented
and Paula, who is diagnosed with tissue turgor. D. Serum magnesium of 1.2
diabetes insipidus. You utilize your mg/dL and large urinary
knowledge on this concept to help care
output.
for your patients safely.
8. Another patient in your unit, Koza, was
6. One of the clients in your unit, Karoo, is
diagnosed with SIADH secondary to
diagnosed to have a pituitary tumor.
cancer of the lung. He tells you that he
Karoo developed Syndrome of
wants to discontinue his fluid restriction
Inappropriate Antidiuretic Hormone
and that he does not care if he dies.
(SIADH). Which of the following
Which of the following actions by the
interventions should you implement as
nurse is an example of the ethical
Karoo’s primary nurse?
principle of autonomy?
A.
A. Discuss the information the client told
B. C. D. the nurse with the health-care provider
and significant other.
Assess for dehydration and monitor blood
glucose levels. B. Explain it is possible the client could
have a seizure if he drank fluid beyond the
Assess for nausea and vomiting and
restrictions.
weigh daily. Monitor potassium levels and
encourage fluid intake. Administer
C. Notify the health-care provider of the D. “If I develop a tightness in my chest, I
client’s wishes and give the client fluids will call my health-care provider.”
as desired.
SITUATION: You are a nurse caring for
D. Allow the client an extra drink of water patients with inflammatory bowel
and explain the nurse could get into disease.
trouble if the client tells the health-care
11. Pierre is a patient admitted to the
provider.
hospital with a diagnosis of ulcerative
9. Paula, another patient assigned to you colitis. You are currently reviewing his
in the unit, is recently diagnosed with history and physical assessment chart.
diabetes insipidus. Which of the following Based on Pierre’s diagnosis, which
interventions should you implement as
1|Page
Paula’s primary nurse?

A. Administer sliding-scale insulin as

ordered. of the following information should you
expect to see in Pierre’s medical records?
B. Restrict caffeinated beverages.
A. Abdominal pain and bloody diarrhea
C. Check urine ketones if blood glucose is
>250. D. Assess tissue turgor every four B. Weight gain and elevated blood
(4) hours glucose

10. Following Paula’s diagnosis of C. Abdominal distension and hypoactive

diabetes insipidus, she stayed in the bowel sounds D. Heartburn and
hospital for a few days. She is now about regurgitation
to be discharged and you are conducting
12. Pierre had a recent exacerbation of
your health teaching regarding her
ulcerative colitis. He is put on
condition. Which of the following
mesalamine (Asacol), which is to be
statements made by Paula warrants
administered rectally via an enema. Pierre
further intervention?
finds this procedure distasteful and he
A. “I will keep a list of my medications in asks you, “Why can't the medication just
my wallet and wear a Medic Alert be given orally?”. You answer Pierre
bracelet.” correctly by saying which of the following?

B. “I should take my medication in the A. “It can be given orally; I’ll contact the
morning and leave it refrigerated at doctor and see if the change can be
home.” made.”

C. “I should weigh myself every morning B. “Rectal administration delivers the

and record any weight gain.” medication directly to the affected area.”
C. “Oral administration will not be as C. Call the health-care practitioner and
effective for the disease condition.” ask for a sedative order.

D. “It can be given orally, I’ll make the D. Tell the client that gathering data about
change and we’ll tell the doctor in the his current condition will promote
morning.” effective timely treatment of his health
concerns.
13. You overhear a licensed practical
nurse (LPN) talking to one of your 15. You are caring for Conis, a patient
patients, Mousse, who is being prepared admitted in your unit who is diagnosed
for a total colectomy with creation of an with Crohn’s disease. She has undergone
ileoanal reservoir for her ulcerative colitis. a barium enema that demonstrated the
To decrease Mousse’s anxiety, you should presence of strictures in her ileum. Based
intervene to clarify the information given on this finding, you should monitor the
by the LPN when you hear the LPN saying: client closely for signs of:

A. “This surgery will prevent you from A. peritonitis.

developing colon cancer.”
B. obstruction.
B. “After this surgery you will no longer
C. malabsorption. D. fluid imbalance.
have ulcerative colitis.”
SITUATION: You are a new nurse assigned
C. “When you return from surgery you will
to take care of patients with various eye
not be able to eat solid food for several
disorders. You use your knowledge to help
days.”
these patients with their condition.
D. “You will have an ileostomy when you
16. One of the patients in your unit,
return from this surgery.”
Pagaya, is diagnosed with glaucoma.
14. Wyper, a 20 year old male client, is Which of the following symptoms should
admitted to your unit because of the you expect the client to report during your
exacerbation of their ulcerative colitis. initial assessment with him?
You go into Wyper’s room to complete an
A. Loss of peripheral vision.
initial assessment, and he yells, “Get
outta here! I am tired of you nurses and B. Floating spots in the vision.
doctors looking at my body all the time!”
C. A yellow haze around everything. D. A
Which of the following is your best action?
curtain coming across vision.
A. Leave the room and ask a male
17. Pagaya has now been prescribed a
colleague to complete the assessment.
miotic cholinergic medication for his
B. Verbally acknowledge the client’s glaucoma. Which of the following data
frustration and anger.
indicates that the medication has been C. Do not read any material for at least
effective on Pagaya? one (1) week.

A. No redness or irritation of the eyes B. A D. Teach the client how to instill

decrease in intraocular pressure corticosteroid

C. The pupil reacts briskly to light ophthalmic drops.

D. The client denies any type of floaters 20. Eneru, a 65 year old male client is
complaining of blurred vision, but denies
18. You are caring for Gan Fall, a
having any type of pain. He reports to you,
postoperative patient, after his retinal
“I feel like I need to clean my glasses all
detachment surgery. Gas tamponade was
the time”. Which of the following eye
used to
disorders should you suspect that Eneru
flatten the patient’s retina during the has?
procedure. Which of the following
A. Corneal dystrophy B. Conjunctivitis
interventions should you implement first?
C. Diabetic retinopathy D. Cataracts
A. Teach the signs of increased
intraocular pressure. SITUATION: You are a nurse studying the
different types of shock and its
B. Position the client as prescribed by the
appropriate nursing interventions. You
surgeon.
come across the following patients in
C. Assess the eye for signs/symptoms of your unit. You applied the concepts
complications. D. Explain the importance you’ve learned to your nursing practice.
of follow-up visits.
21. Foxy is a client admitted to the
19. You are caring for Conis, a patient with emergency department. Assessment
severe myopia. She is scheduled for a findings include diaphoresis, pale
laser assisted in situ keratomileusis clammy skin, and a blood pressure
(LASIK) surgery. Which of the following reading of 90/70. Which of the following
instructions should you discuss with interventions should you implement first?
Conis prior to her discharge from the
A. Start an IV with an 18-gauge catheter.
surgery?
B. Administer dopamine intravenous
A. Wear bilateral eye patches for three (3)
infusion. C. Obtain arterial blood gases
days.
(ABGs).
B. Wear corrective lenses until the follow-
D. Insert an indwelling urinary catheter.
up visit.
22. Porche is a patient diagnosed with
neurogenic shock. As a knowledgeable
nurse, you expect to note which of the C. Apply sequential compression devices
following signs and symptoms in this to the lower
client?
extremities.
A. B. C. D.
D. Administer an antipyretic medication
Cool, moist skin. every four (4)

Bradycardia. hours PRN.

Wheezing. 25. A patient named Chiqicheetah

presents themselves in the emergency
Decreased bowel sounds
department complaining of abdominal
of the patients in your unit, Hamburg, was pain, is pale and clammy, and has a pulse
diagnosed of 110 and a blood pressure reading of
92/60. Chiqicheetah has vertebral
23. One
fractures, and she reported she has been
with septicemia. The following are the self-medicating with Ibuprofen, a type of
orders given by Hamburg’s primary nonsteroidal anti-inflammatory drug
physician. Which of these orders will have (NSAID). Which of the following type of
the highest priority? shocks should you expect in patient
Chiqicheetah?
A. Provide a clear liquid diet.
A. Cardiogenic shock. B. Hypovolemic
B. Initiate IV antibiotic therapy.
shock. C. Neurogenic shock. D. Septic
C. Obtain a STAT chest x-ray. shock.
D. Perform hourly glucometer checks. SITUATION: You are caring for patients in
24. You wrote the nursing diagnosis of your unit with alterations in their fluid and
“alteration in comfort related to chills in electrolytes. As a knowledgeable nurse,
fever” in one of your patients who has you apply the concepts of fluid and
sepsis. Which of the following electrolytes in your nursing practice.
interventions would you include in this 2|Page
patient’s plan of care?

A. Ambulate the client in the hallway

26. As an experienced nurse, you know
every shift.
that client incidence of
B. Monitor urinalysis, creatinine level, and hypermagnesemia is rare in comparison
BUN level. with hypomagnesemia. A student nurse
approached you and asked how
hypermagnesemia develops. You answer
her correctly by saying that B. The client with hyperaldosteronism
hypermagnesemia generally occurs
C. The client with Cushing’s syndrome
secondary to:
D. The client who is taking corticosteroids
A. Cardiac contractility. B. Hypokalemia.
30. You are reviewing one of your patient’s
C. Liver failure.
progress notes. You read that the
D. Renal insufficiency. physician has documented “insensible
fluid loss of approximately 800mL daily”.
27. You are assigned to care for Ace, a
As a knowledgeable nurse, you make a
patient diagnosed to have hypokalemia.
notation that insensible fluid loss occurs
As a knowledgeable nurse, you know that
through which of the following types of
the electrolyte that must be corrected in
excretion?
this scenario is:
A. Urinary output
A. Calcium.
B. Wound drainage
B. Magnesium. C. Manganese. D. Zinc.
C. Integumentary output
28. You are caring for a group of patients
in the ward. While reviewing each of the D. The gastrointestinal tract
patient’s charts, you determine which of
SITUATION: You are a nurse assigned to
the following patients is most likely at risk
care for and educate patients in the
for fluid volume deficit?
cancer unit of the hospital you are
A. A client with an ileostomy working on. You apply the concepts
you’ve learned regarding cancer to ensure
B. A client with heart failure
a safe nursing practice.
C. A client on long-term corticosteroid
31. You are reviewing your notes on
therapy
cancer. After much reading, you know
D. A client receiving frequent wound that cancer prevalence is defined as?
irrigations
A. The likelihood cancer will occur in a
29. You are refreshing your knowledge on lifetime.
sodium imbalances. As a knowledgeable
B. The number of persons with cancer at a
nurse, you know that which of the
given point in
following patients in the ward is most
likely to develop a sodium level at 130 time.
mEq/L (130 mmol/L)?
C. The number of new cancers in a year.
A. The client who is taking diuretics D. All cancer cases more than 5 years old.
32. Gol is your patient diagnosed to have 34. You are caring for Cricket, a patient
testicular cancer. He expressed his with pain related to bone cancer. You
concerns regarding fertility since him and conducted an assessment on Cricket in
his partner desires to eventually have a relation to this. You know that which of
family. As Gol’s primary nurse, you the following is the most important
discuss the option of sperm banking. You component of a thorough pain
inform Gol and his partner that sperm assessment specific for patient Cricket?
banking needs to be performed when?
A. Intensity.
A. Before treatment is started.
B. Cause.
B. Once the client is tolerating the
C. Aggravating factors. D. Location.
treatment.
35. Noland is a cancer patient you are
C. Upon completion of treatment.
tasked to care for. He is receiving the
D. When tumor markers drop to normal medication vincristine (Oncovin). You
levels. plan your health teaching for Noland
regarding this medication. Which of the
33. You are working with Bellamy, a client
following should you include in your
with known risks for lung cancer. He asks
instructions to Nolan?
you why he is scheduled for a computed
tomography (CT) scan as part of his initial A. Use of loperamide (Imodium). B. Fluid
workup. You answer Bellamy correctly restriction.
when you respond by saying:
C. Low fiber, bland diet.
A. “CT is far superior to magnetic
D. Bowel regimen.
resonance imaging for evaluating lymph
node metastasis.” 36. Sarquiss is a 57 year old client
receiving chemotherapy that has the
B. “CT is noninvasive and readily
potential to cause pulmonary toxicity.
available.”
Which of the following symptoms would
C. “CT is useful for distinguishing small you note in Sarquiss that could indicate a
differences in toxic response to the chemotherapy?

tissue density and detecting nodal A. Decrease in appetite.

involvement.”
B. Drowsiness.
D. “CT can distinguish malignant
C. Spasms of the diaphragm.
adenopathy from
D. Cough and shortness of breath.
nonmalignant adenopathy.”
37. Hina is one of the patients you are A. Place the client on bed rest with the
tasked to care for her in the unit. She is head of the bed elevated to 60 degrees for
beginning external beam radiation therapy 2 hours.
to the right axilla after her lumpectomy for
B. Place the client on the left side with the
breast cancer. You plan to conduct a
head of the bed at 45 degrees for 15
health teaching. Which of the following
minutes.
would you include in your education to
Hina? C. Assist the client out of bed to sit
upright in a chair for 1 hour.
A. Use a heating pad under the right arm.
D. Ask the client to rest in bed with the
B. Immobilize the right arm.
head of the bed elevated to 30 degrees for
C. Place ice on the area after each 20 minutes.
treatment. D. Apply deodorant only under
40. Portgas is a cancer patient receiving
the left arm.
chemotherapy. He is experiencing a flare
38. Tony Tony is a patient receiving up of pruritus. You are planning to
radiation therapy for lung cancer. He develop a care plan for Portgas. In order
complains that he is having difficulty to develop the nursing care plan, you
sleeping. After hearing this statement should ask him if he has been:
from your patient, you should:
A. Wearing clothes made from 100%
A. Suggest the client stop watching cotton.
television before bed.
B. Sleeping in a cool, humidified room.
B. Assess the client’s usual sleep
C. Increasing fluid intake to at least 3,000
patterns, amount of sleep, and bedtime
mL/ day. D. Taking daily baths with a
rituals.
deodorant soap.
C. Tell the client sleeplessness is
SITUATION: You are a nurse caring for
expected with radiation therapy.
patients with cardiac complications. You
D. Suggest that the client stop drinking use your knowledge on cardiovascular
coffee until the therapy is completed. concepts to help these patients.

39. You are caring for Nico, a patient with 41. You are working on the unit with
cancer who requires a bolus tube feeding. patient Brogy. At 7:30 AM, you received a
You prepare to administer the bolus tube verbal order from his primary HCP for a
feeding and as a skilled nurse, which of cardiac catheterization to be completed
the following nursing interventions is on him by 2:00 PM. Which of the following
most appropriate to decrease the risk of actions should you initiate first in Brogy?
aspiration in this patient?
A. Initiate NPO (nothing per mouth) status A. inspecting the incision site dressing for
for the client. B. Teach the client about bleeding and the incision for
the procedure. approximation

C. Start an intravenous (IV) infusion of B. limiting the client’s right arm activity
0.9% NaCl. and preventing the client reaching above
shoulder level
D. Ask the client to sign a consent form.
C. assisting the client with getting out of
42. You are working with Dorry, a male
bed and ambulating with a walker
patient who experienced a myocardial
infarction a few days ago. You noted that D. ordering a stat chest x-ray following
patient Dorry seems unusually fatigued. return from the implant procedure
Upon your assessment, you find that
44. You are increasing activity for patient
patient Dorry is dyspneic with
Bon with an admitting diagnosis of acute
3|Page coronary syndrome. Which of the
following symptoms experienced by
patient Bon best supports the nursing
activity, has a heart rate of 110 bpm, and diagnosis of activity intolerance?
has generalized edema. Which of the
A. Pulse rate increased by 15 beats per
following actions would be most
minute during activity
appropriate for this patient?
B. Blood pressure (BP) 130/86 mm Hg
A. Administer high-flow oxygen
before activity; BP 108/66 mm Hg during
B. Encourage the client to rest more activity

C. Continue to monitor the client’s heart C. Increased dyspnea and diaphoresis

rhythm relieved when sitting in a chair
D. Compare the client’s admission weight D. A mean arterial pressure (MAP) of 80
with the following activity

client’s current weight 45. Cobra is a patient who suffered an

inferior septal wall myocardial infarction.
43. You are caring for patient Whitebeard
Which of the following complications
immediately following an insertion of a
would you suspect in Cobra when you
permanent pacemaker via his right
note on your assessment a jugular venous
subclavian vein. As a skilled nurse, you
distention and ascites?
know that the action that can best prevent
pacemaker lead dislodgement is: A. Left-sided heart failure
B. Pulmonic valve malfunction C. Right- A. Elevate the arm after administering
sided heart failure medication.

D. Ruptured septum B. Maintain sterile technique throughout

the code.
SITUATION: You are an emergency nurse
tasked to work with patients with medical C. Treat the client’s signs/symptoms; do
emergencies. You utilize your knowledge not treat the
to help these patients.
monitor.
46. A patient’s wife is allowed to be
D. Provide accurate documentation of
present during resuscitation efforts for a
what happened
patient in the ICU. Which of the following
statements made by you would be the during the code.
most correct and appropriate?
Situation - Ms. Hange is the charge nurse
49. You are working as a triage nurse in a of a medical unit. She is responsible for
large trauma center. The center has been the management and supervision of the
notified of an explosion in a nearby major unit.
chemical manufacturing plant. Which of
51. Ms. Hange observes that one of the
the following actions should you
female staff nurses is not performing her
implement first when the injured patients
duties very well. Which of the following
arrive at the emergency department?
strategies will she implement to assist the
A. B. C. staff nurse?

D. A. Discuss with the staff nurse her

performance and ways she can improve.
“You can hold your loved one’s hand;
sometimes a recovering person B. Allow the staff nurse to select own
remembers that touch.” assignment.

“Another staff member will be with you; I C. Assign the staff nurse several clients
will show you where you can stand near with various
your husband.” “Because the
illnesses.
resuscitation team needs to work quickly,
you need to stay out of their way and not \ D. Ask the staff nurse to work as an
interfere.” assistant charge

“If the resuscitation efforts fail, the nurse.

health-care provider will ask you if you 52. Ms. Hange notes one of the male staff
want to terminate resuscitation efforts.” nurse is frequently absent and his
absence has adversely affected the The nurse prepares a care plan for the
quality of care given to the clients unit. client. The overall goal for the client is
Which of the following would be the BEST ________.
approach?
55. The client will:
A. Talk with the staff nurse regarding the
A. Achieve control of pain and discomfort.
concern and remind him of the standards
of the agency. B. Receive adequate cerebral oxygenation
and perfusion. C. Be free from infection.
B. Write the staff nurse a memorandum
regarding his absence. D. Receive life sustaining food and
liquids.
C. Inform the staff nurse that his absence
will be a ground for termination. 56. The nurse is aware of the document
that expresses a client’s wish for life
D. Record the absence of the staff nurse
sustaining treatment in the event of
in a log book. 53. Ms. Hange assigns a
terminal illness or permanent
new staff nurse to administer the
unconsciousness. This document is the
medications of a client. Which detail of
______;
the client’s drug therapy is the staff nurse
legally responsible to document? The A. No-code order
________.
B. Durable power of attorney C. Living will
A. Peak concentration time of the drug. B.
D. Last will and testament
Safe ranges of the drug.
47. An
C. Client’s socio-economic status.
victims
D. Client’s reaction to the drug.
Five families of the injured patients
54. Ms. Hange decides what is best for a
arrived in the ED subsequently to inquire
recovering client and acts on the decision
about the health status of their family
without consulting the client. Ms. Hange
members. Which of the following is your
is applying a moral principle which is
best action?
______________.
apartment fire broke out near the
A. Paternalism B. Beneficence C. Fidelity
hospital. The injured are sent to the
D. Autonomy emergency department of the hospital.

Situation - The nurse cares for a female A. Take the families to the triage area so
client who is terminally ill and is they can be with their loved ones
experiencing pain.
B. Ask the families to wait in the waiting 50. You
area until information is available
you recall that which of the following
C. Ensure that there is a designated area interventions is the most important for
for family staffed by available social you to implement when participating in a
workers or clergy code?

D. Direct families to a lounge where a 4|Page

receptionist will be keeping families
informed
57. The client nears death and requests
48. Patient Aokiji is a male client that
that no medication be given that would
presented themself in the emergency
cause a loss of consciousness, including
department after vomiting a “large”
pain medication. The nurse would
amount of bright red blood. Which of the
promote the best end-of-life care for the
following actions should you implement
client by which of the following?
first?
A. Discuss the request of the dying client
A. Start an intravenous line with an 18-
with family members and respect their
gauge needle.
wishes.
B. Have the UAP take the client’s vital
B. Comfort is the highest priority in this
signs.
situation so give medications as ordered.
C. Ask the client to provide a stool
C. Respect the client’s wishes and
specimen for blood. D. Send the client to
withhold pain medications and other
radiology for an abdominal CT scan.
medications ordered.
A. B.
D. Be compassionate and give half of
C. D. dose of the medication ordered.

Triage the clients and send them to the 58. Which of the following statement is
appropriate areas. TRUE about terminally ill clients?

Thoroughly wash the clients with soap A. Terminally ill clients require minimum
and water and then rinse. physical care.

Remove the clients’ clothing and have B. Health care personnel do not
them shower. Assume the clients have understand their own feelings about
been decontaminated at the plant. death and dying therefore they avoid

are attending a seminar on codes. After caring for terminally clients.

the session,
C. Terminally ill clients have the right to B. Pupils are unequally dilated.
die with dignity. D. Terminally ill client’s
C. Respiratory rate is more than 30
experiences pain most of the
breaths per minute. D. Pulse is less than
time. 60 beats per minute

59. The dying client wishes to donate her 61. In the early stages of shock, the nurse
eyes after she dies. Which of the following expects the result of arterial blood gas
statements is NOT TRUE about organ (ABG) analysis to indicate which of the
donation? following conditions ____________:

A. Any individual, at least 15 years old of A. Respiratory alkalosis B. Respiratory

age and of a sound mind may donate a acidosis C. Metabolic alkalosis D.
part of his body to take the effect after Metabolic acidosis
transplantation needed by the recipient.
62. The physician orders intravenous
B. Sharing of human organs or tissues infusion of packed red blood cells and
shall be made only through exchange normal saline solutions. The nurse
programs duly approved by the assesses the client for which of the
Department of Health. following _____________:

C. The choice to donate an organ must be A. Hypovolemia

a written document.
B. Anaphylactic reaction
D. Laws do not require the consent of a
C. Altered level of consciousness D. Pain
family members to retrieve organs if the
donor has expressed his last wish to 63. The nurse understands that the best
donate. indication that fluid replacement for the
client in hypovolemic shock is adequate
Situation- The nurse in the emergency
is when the ___________:
department admits a 45 year old female
for vomiting blood. According to a family A. Systolic blood pressure is above 110
member who accompanied the client, the mmHg.
client had a gastric ulcer for several years.
B. Diastolic blood pressure is above 90
The nurse assesses that the client is in
mmHg.
shock.
C. Urine output of 20- 30 mL/Hour. – urine
60. Which of the following assessment
output of less
findings indicate hypovolemic shock?
than 30 mL/hour is a sign of hypovolemic
A. Systolic blood pressure is less than 90
shock
mmHg.
(Brunner &Suddarth, p.2043).
D. Urine output is greater than 30 66. The nurse analyzes the laboratory
mL/Hour. values and notes that the serum
phosphate level is elevated. This finding
64. The physician schedules the client for
indicates which of the following:
surgery within six hours. The nurse
minimize anxiety of the client by A. It confirms the diagnosis of prostate
answering the client’s questions regarding cancer.
the surgery in calm manner, keeps the
B. The progression or regression of
client warm, advise the client to be on
prostate cancer. C. The likelihood of
bed rest and dims the lights in the room.
metastasis to the bones.
The reason for these interventions is to
________: D. There are complications associated
with cancer.
A. Increase comfort of the client and her
family. B. Minimize oxygen consumption. 67. The nurse knows that hormone
therapy is the mode of treatment for a
C. Prevent infection.
client with prostate cancer. The goal of
D. Stabilize fluid and electrolyte balance. this form of treatment is to ______:

Situation - A 60 year old male is admitted A. Limit the amount of circulating

to the oncology unit. According to the androgens.
client, he felt a growth during a routine
B. Increase prostaglandin level.
digital prostate examination. He
complains of pain on urination and C. Increase the amount of circulating
frequent urination. androgens. D. Increase testosterone
level.
65. The nurse understands that the
function of the prostate gland is primarily 68. The nurse writes a nursing diagnosis
to ______; of Fear and Anxiety secondary to the
diagnosis of prostate cancer. Which of the
A. Regulate the acidity and alkalinity
following interventions would be BEST for
environment for proper sperm
the nurse?
development.
A. Encourage the client to keep his
B. Produce a secretion that aids the
feelings to himself so his family will not be
nourishment and passage of sperm.
affected.
C. Secrete a hormone that stimulates the
B. Establish a nurse patient therapeutic
production and maturation of sperm.
relationship.
D. Store undeveloped sperm before
C. Advise the client to have a positive
ejaculation.
outlook
relationship. 71. When titrating a drug for the client in
pain, which of the following actions is
D. Provide spiritual support to the client.
MOST appropriate?
Situation - Nurse Petra works in the
A. Ask the physician to include a
oncology unit. She takes care of cancer
medication order for breakthrough pain.
patients in pain. She is aware that cancer
pain management is one of her B. Follow the physician’s order for the first
responsibilities. 24 hours.

69. Nurse Petra plans care for a cancer C. Reassess the client every 8 hours for
client experiencing pain. She is aware that drug
an important principle of using
effectiveness.
medication to manage pain is to:
D. Seek a new order after 2 doses that do
A. Individualize the medication therapy to
not achieve a
the client.
tolerable level of pain relief.
B. Provide the medication as soon as the
client requests 72. One of the clients experiences severe,
intractable pain and complains that the
for it.
pain medication is not working for him.
C. Discontinue the medications Which of the following actions is MOST
periodically to discourage appropriate for Nurse Petra?

the development of drug tolerance. A. Suggest to the client to try deep

breathing to cope with the pain.
D. Avoid giving client addictive
medications. B. Explore the nature of the pain and
encourage the client to perceive it in a
70. Nurse Petra collaborates with the
different way.
physician in the development of a drug
regimen for the clients. Which of the C. Support the client emotionally and tell
following medications should be avoided him he will receive the next dose of
in the treatment of cancer pain? medication as soon as possible.

A. Morphine 5|Page

B. Acetaminophen (Tylenol) C. Meperidine

(Demerol)
D. Refer the client to the attending
D. Hydrocodone physician immediately and report that the
pain medication is not providing adequate
pain relief.
73. Nurse Petra assesses a client B. civil service file
complaining of acute pain. The MOST
C. master patient index file D. hospital
appropriate nursing assessment would
library record file
include which of the following?
76. Ms. Helen is aware that when a client
A. The nurses’ impression of clients’ pain.
is readmitted to a hospital, the client’s file
B. The clients’ pain rating. is retrieved from the__________.

C. Nonverbal cues from the client. A. Physician’s file

D. Pain relief after appropriate nursing B. Civil service file

interventions.
C. Master patient index file D. Hospital
Situation - Ms. Helen is a nurse supervisor library record file
of three departments in hospital X. She
77. Ms. Helen is aware that when a client
attends an orientation seminar on
is discharged or dies, the following details
hospital records management.
should be entered in the client’s record
74. Ms. Helen understands that good which is the_______________.
client care relies on good record keeping.
A. Final diagnosis
Which of the following is NOT a purpose
of hospital record keeping? B. Outcomes classification C.
Educational attainment D. Religion
A. Records provide evidence of a
hospital’s accountability. 78. The following statements are true
about patients and hospital records
B. Records are a key source of data for
EXCEPT:
medical research or statistical reports.
A. Confidential records must be
C. Records provide data on health
protected against loss, damage ,
information system.
unauthorized access, modification and
D. Records provide personal information disclosure
on the
B. Patients have the right to confidential
physicians and nurses caring for the treatment of information they provide to
clients. health professional

75. Ms. Helen is aware that when a client C. Health records are the property of
is readmitted to a hospital, the client’s file community where the patient is treated
is retrieved from the _______________.
D. Hospital records maybe released
A. physician’s file without the patient’s consent when
required in investigation for serious A. Assessment
criminal offenses
B. nursing diagnosis C. planning
Situation: Ms. Mika is a director of the
D. evaluation
critical care unit of hospital x. She utilizes
the nursing process to communicate care 82. Ms. Mika confers with the client’s
to the client. primary nurse the following morning.
Together they determine that the client is
79. She is called to the bedside of a client
ready for surgery. This step of the nursing
who is scheduled to have laparoscopic
process is:
cholecystectomy. The client’s pulse is
slightly irregular. Ms. Mika confers with A. evaluation
the primary nurse regarding the client’s
B. planning
condition, which step of the nursing
process is Ms. Mika applying? C. nursing diagnosis D. assessment

A. Implementation B. Evaluation 83. Ms. Mika applies the human relations

approach in this situation. She is aware
C. Planning
that the key to productivity is
D. Assessment _________________.

80. Ms. Mika calls for a conference with A. the degree of independence allowed
the staff members who are attending to
B. meeting the objectives of the critical
the client. They decide to obtain a 12-lead
care unit C. Firm control of the situation
ECG for a more definitive picture. They
conclude that the client has no serious D. the behavior of people under direction
cardiac or pulmonary problems. Which
Situation - A mother with the diagnosis of
step of the nursing process is in effect in AIDS states that she has been caring for
this situation? her baby even though she has not been
A. nursing diagnosis B. Assessment feeling well.

C. evaluation 84. What important information should

the nurse determine?
D. planning
A. is she has kissed the baby
81. Ms. Mika consults with the attending
physician and the anesthesiologist. She B. if the baby is breastfeeding
advises the primary nurse to proceed with
C. when the baby last received antibiotics
the preparations and to remain alert for
any adverse symptoms. Which step of the D. how long she has been caring for the
nursing process is this? baby
85. The nurse is planning to provide A. Avoid dairy products and red meat
discharge teaching to the family of a
B. Plan large nutritious meals
client with AIDS. Which statement should
the nurse include in the teaching plan? C. Add spices to food to enhance flavour
D. Serve foods while they are warm
A. “Wash the dishes in hot soap as you
usually do.” 88. The Physician orders a Paracentesis.
How should the nurse instruct the client
B. “Let the dishes soak in hot water
to prepare for the radiograph?
overnight before
A. void before the procedure
washing.”
B. a laxative the evening before the
C. “You should boil the client’s dishes for
procedure
30 minutes
C. nothing by mouth for 8 hours before the
after use.”
procedure D. a low soapsuds enema the
D. “have the client eat from paper plates morning of the procedure
so they can be
Situation- In a Medical ward there are
discharged.” clients with potential or actual disorders
of fluids and electrolytes disturbance and
86. During an AIDS education class a
homeostatic mechanisms.
client states, “Vaseline works great when I
use condoms.” Which conclusions about 89. The nurse is caring for a client with
the client’s knowledge of condom use can chronic kidney failure. The nurse
the nurse draw this statement? understands that ammonia is normally
exerted by the kidney to help maintain:
A. an understanding of safer sex
A. osmotic pressure of the blood
B. an ability to assume self-responsibility
B. acid-base balance of the body C. low
C. ignorance concerning correct condom
bacterial level in the urine D. normal red
use
blood cell production
D. ignorance concerning the transmission
90. Which finding best suggests that
of HIV
nursing interventions for a client with an
87. The client with AIDS is experiencing excess fluid volume have been effective?
nausea and vomiting. The Nurse would
A. clear breath sounds
make which of the following dietary
alterations for this client to enhance B. positive pedal pulses
nutritional intake?
C. normal potassium level
D. increased urine specific gravity following are common reactions to an
insect sting EXCEPT:
6|Page
A. Swelling

B. Redness
91. The nurse understands that a client
with albuminuria has edema because of: C. Appearance of lesions D. Pain

A. fall in tissue hydrostatic pressure Situation – Nurse Gab is a staff nurse in

the oncology unit of a tertiary hospital. An
B. rise in plasma hydrostatic pressure C.
activity in the unit for continuing
rise in tissue colloid osmotic pressure D.
professional development is to
fall in plasma colloid oncotic pressure
disseminate information among the
92. When the nurse uses the clamp on the personnel and staff in the unit regarding
administration set to manually adjust the trends and treatment for cancer. Nurse
flow of IV fluid into a client by gravity, what Gab read an article entitled
change in energy takes place? “Understanding Colorectal Cancer”
which was recently published in a
A. potential energy is converted to kinetic
national newspaper.
energy B. kinetic energy is converted to
potential energy C. chemical energy is 95. According to the Philippine Cancer
converted to kinetic energy D. potential Facts and Estimates for 2010, one of the
energy is converted to chemical energy most common cancer among men is
colorectal cancer. It ranks ______ among
93. The client with which condition has an
all the diseases:
increased risk for developing
Hyperkalemia? A. First

A. Crohn’s disease B. Fourth C. Second D. Third

B. Cushing’s syndrome Situation– A 21 year old male is admitted
to the burn unit of x hospital. He
C. Chronic heart failure
sustained burns on the chest, abdomen,
D. End-stage renal disease right arm and right leg.
Situation – The nurse assists in the care of 96. The nurse assigned to his care
a 15 year old female experiencing anticipates that the client would be
anaphylaxis due to insect bite by particularly susceptible to which of the
honeybees. following fluid and electrolyte imbalances
during the emergent phase of burn case.
94. Upon assessment, the nurse observes
the client reacting to the insect bites. The A. Metabolic acidosis
B. Hypernatremia imbalances D. Allow the gastrointestinal
tract to rest
C. Hypokalemia
A. Provide adequate nutrition
D. Metabolic alkalosis
7|Page
97. The nurse assesses the client for fluid
shifting. During the emergent phase of a
burn injury, shifts occur due to fluid
moving from the_______________.

A. Extracellular to intracellular space. B.

Intracellular to extracellular space. C.
Vascular to interstitial space.

D. Interstitial to vascular space

98. The nurse understands that the fluid

shift results from an increase in
the_____________.:

A. Total volume of intravascular plasma B.

Total volume of circulating whole blood C.
Permeability of capillary walls

D. Permeability of the kidney tubules

99. The client receives fluid resuscitation

therapy. The nurse adjusts the infusion
rate by evaluating the client’s __________:

A. Hourly urine output

B. Daily body weight

C. Hourly urine specific gravity D. Hourly

body temperature

100. The client receives total parenteral

nutrition (TPN). The nurse understands
this therapy will help the client__________.

B. Ensure adequate caloric and protein

intake C. Correct water and electrolyte
 RECALLS EXAMINATION 7 admitted to the hospital. Which of the
following priority questions should the
NURSING PRACTICE V
nurse ask the woman?
CARE OF CLIENTS WITH PHYSIOLOGIC
A. The client’s reaction to the event,
AND PSYCHOSOCIAL ALTERATIONS
including any suicidal thoughts.
(PART C)
B. The client’s perceptions of her current
NOVEMBER 2024 Philippine Nurse
skills for coping with the event.
Licensure Examination Review
C. The availability of the client’s personal
GENERAL INSTRUCTIONS:
support systems.
1. This test questionnaire contains 100
D. The effect of the event on other
test questions
aspects of the client’s life.
2. Shade only one (1) box for each
2. An anxious, sobbing 19 year old is
question on your answer sheets. Two or
brought to the crisis shelter for an
more boxes shaded will invalid your
interview. She says, “I think I am pregnant
answer. 3. AVOID ERASURES.
but I don’t know what to do!” Which of the
4. Detach one (1) answer sheet from the following nursing interventions is most
bottom of your Examinee ID/Answer appropriate for her situation at this time?
Sheet Set.
A. Ask the client about the type of things
5. Write the subject title “NURSING that she had thought of doing.
PRACTICE V” on the box provided
B. Give the client some ideas about what
SITUATION: You are a mental health to expect to happen next.
nurse dealing with patients currently
C. Recommend a pregnancy test after
experiencing a crisis. You use your
acknowledging the client’s distress.
knowledge on crisis management to help
these patients. The following questions D. Question the client about her feelings
apply. and possible parental reactions.

1. In the rape crisis center, a woman is 3. You’re the nurse on duty when you saw
being seen a few days after she was an anxious 41-year-old client say that she
raped. She reports that she has not had would “rather die than be pregnant.”
any appetite, she is experiencing anxiety Which of the following responses by the
and depression, and that she has been nurse is most helpful?
having nightmares. You as the nurse make
A. “Try not to worry until after the
an assessment on the woman to
pregnancy test.”
determine if it is appropriate for her to be
B. “You know, pregnancy is a normal A. The name and phone number of the
event.” client’s physician. B. Emergency
resources and when to use them.
C. “You’re only 40 years old and not too
old to have a C. The coping strategies they are using.

baby.” D. Long-term solutions they plan to tell

the client to use.
D. “I see you’re upset. Take some deep
breaths to relax SITUATION: You are a nurse tasked to
work with patients coping with their
a little.”
illnesses.
4. You were doing some charts when a
6. A client was diagnosed with an acute
client comes to the crisis center in a very
cardiac illness. The nurse should
distressed state. He tells you that he just
determine that the client lacks
cannot get over being fired from his job
understanding of her illness and her
last week. He says that he already asked
ability to make changes in her lifestyle
for help and talked to friends. He says,
when they verbalize which of the following
“I’ve tried everything to get through this,
statements?
but nothing is working. Please, help me!”
Which of the following should you, as the A. “I already have my airline ticket, so I
nurse, use as the initial crisis intervention won’t miss my meeting tomorrow.”
strategy?
B. “These relaxation tapes sound okay; I’ll
A. Referral for counseling. see if they help me.”

B. Support system assessment. C. C. “No more working 10 hours a day for

Emotion management. me unless it’s an emergency.”

D. Unemployment assistance. D. “I talked with my husband yesterday

about working on a new budget together.”
5. Getting the client’s significant others
involved in helping with the immediate 7. You just admitted a 19-year-old client
crisis as soon as possible is one of the who was recently diagnosed with
major roles in crisis intervention. You as leukemia. What is the most appropriate
the nurse determine that the short term goal for the nurse and the
client to establish?
support persons are prepared to help
when they verbalize which of the A. Accepting his death as imminent.
following?
B. Expressing his angry feelings to the
nurse.
C. Decreasing interaction with peers to C. Providing the client with support and
conserve energy. D. Gaining an realistic information on the colostomy.
intellectual understanding of the illness.
D. Convincing the client that he will not be
8. The client hospitalized for diagnosis disfigured and can lead a full life.
and treatment of atrial fibrillation states
10. One of your patients in the ward
to the nurse, “Please hand me the
directs profanities at you, the nurse, then
telephone. I need to check on my stocks
abruptly hangs his head and pleads to
and bonds.” Which of the following
you, “Please forgive me. Something came
responses by the nurse is most
over me. Ugh, why do I say those things?”
therapeutic?
As a knowledgeable nurse, you interpret
A. B. this as which of the following?

C. 1|Page

D.

“You will get more upset if you make that A. Neologism

call.”
B. Confabulation
“You have atrial fi brillations. Let’s talk
C. Flight of ideas
about what that means.”
D. Emotional lability
“You really don’t care about the fact that
you’re sick, do you?” SITUATION: You are a nurse tasked to care
for patients experiencing stress and
“Do you realize you have a life-threatening
anxiety. You are to apply the nursing
condition?”
concepts you’ve learned about this topic
9. The colostomy club made to effectively care for these patients.
arrangements to meet with a client who
11. You notice that Nami, a young adult
will undergo a bowel surgery. Which of the
about to undergo a surgery is
following is accomplished when a
experiencing moderate anxiety regarding
representative of the colostomy club
her upcoming procedure. As a competent
visits the client preoperatively?
nurse, you help to reduce the patient’s
A. Letting the client know that he has anxiety by:
resources in the community to help him.
A. Telling her to distract himself with
B. Providing support for the physician’s games and television
plan of therapy for the client.
B. Reassure her that she will come
through the surgery without incident
C. Explaining to her what happens before Which of the following is a crucial goal of
and after surgery therapeutic communication when helping
this client?
D. Asking the surgeon to refer her to a
psychiatrist who can work with her to A. Communicating empathy through
diminish her anxiety gentle touch

12. You are discussing the concept of B. Conveying client respect and
anxiety to the student nurses in your unit. acceptance even if not
You explain that anxiety occurs in
all of the client’s behaviors are tolerated
degrees, from a level that stimulates
productive problem solving to a level that C. Mutual sharing of information,
is severely debilitating. The students spontaneity, emotions,
respond correctly when you ask that at a
and intimacy
mild, productive level of anxiety, one will
expect to see which of the following D. Guaranteeing total confidentiality and
cognitive characteristics of mild anxiety? anonymity for

A. Slight muscle tension. the client

B. Occasional irritability. 15. You are doing a follow up visit to the

home of a client diagnosed with
C. Accurate perceptions.
Alzheimer’s disease. You are assessing
D. Loss of contact with reality the stress level of the patient’s spouse,
the primary caregiver. Which of the
13. You followed up a question to the
following questions is most appropriate
student nurses. They answered you
for assessing the spouse’s level of stress?
correctly when they stated that as a
client’s anxiety level increases to a A. “So, what is a typical day like for you?”
debilitating degree, they would expect
B. “What do you do to relieve stress for
which of the following psychomotor
yourself?”
behavior indicating the panic level of
anxiety: C. “May I arrange for some part-time help
for you?”
A. Suicide attempts or violence. B.
Desperation and rage. D. “Being a full-time caregiver must be
very stressful,
C. Disorganized reasoning.
isn’t it?”
D. Loss of contact with reality.
SITUATION: You are a nurse tasked to care
14. You admitted a patient dealing with
for patients with schizophrenia. You use
personal issues and painful feelings.
your knowledge on this concept to A. “These are not typical side effects for
effectively and safely care for your that drug.”
patients.
B. “Just ignore the symptoms. They will go
16. You are caring for a patient diagnosed away in just
with paranoid schizophrenia. The patient
a few days.”
reports hearing a voice saying “Do not
remove your cap or they will be able to C. “These symptoms are more likely a
read your mind.” Which of the following result of not
responses is the most therapeutic for this
drinking alcohol for 5 days.”
patient?
D. “It is possible, since this medication is
A. “Who are ‘they’?”
contraindicated
B. “Why would someone want to read
in those who abuse alcohol.”
your mind?”
18. A patient with a history of violent
C. “I do not believe that anyone can read
command hallucinations was observed to
another’s
be mumbling erratically while making
mind.” threatening gestures directed toward a
particular staff member. Which of the
D. “It must be very frightening to believe
following interventions is most
that someone
appropriate when caring for patients with
can read your mind.” violent command hallucinations?

17. A patient diagnosed with a history of A. Ask the client to explain the cause of
paranoid schizophrenia and chronic anger.
alcohol abuse was admitted to your unit.
B. Place the client in seclusion to help de-
The patient has been taking Olanzapine
escalate anger. C. Inform the client of
for 14 days and
pending restraint if behavior does
has not consumed alcohol in the last 5
not subside.
days. They report shaky hands and
trouble sleeping because of frequent D. Observe the client for signs of
nightmares. The patient verbalized their escalating agitation.
concern that olanzapine may be causing
19. A patient diagnosed with paranoid
these problems. Which of the following is
schizophrenia was admitted to your unit.
your most therapeutic response to this
You include the nursing diagnosis of
patient?
Disturbed thought processes secondary
to paranoia in the patient’s care plan.
Which of the following approaches is 21. Zoro is utilizing a defense mechanism
most appropriate for this patient? commonly used by patients with
obsessive compulsive disorder. Which of
A. Avoid laughing or whispering in front of
the following defense mechanisms is
the client.
this?
B. Begin to identify social support in the
A. Suppression. B. Repression. C.
community.
Undoing.
C. Encourage the client to interact with
D. Denial.
others on the
22. You start your assessment on Zoro.
unit.
Which behavioral symptom would you
D. Have the client sign a written release of expect to assess in this patient?
information
A. The client uses excessive hand
form. washing to relieve anxiety.

20. The mother of a client diagnosed with B. The client rates anxiety at 8/10.
paranoid schizophrenia visiting her son 2
C. The client uses breathing techniques to
days after his admission to the psychiatric
decrease
unit approaches a nurse and states, “He
is still talking about how the government anxiety.
is controlling his thoughts.” What is the
D. The client exhibits diaphoresis and
most accurate nursing appraisal of the
tachycardia.
mother’s statement?
23. Which cognitive symptom would you
A. The mother’s expectations of her son
expect to assess in Zoro who has
are realistic.
obsessive compulsive disorder?
B. The mother’s concern is reasonable.
A. Compulsive behaviors that occupy
C. The mother should request a more than 4 hours per day.
medication adjustment. D. The mother
B. Excessive worrying about germs and
requires further education regarding the
illness.
client’s diagnosis.
C. Comorbid abuse of alcohol to
SITUATION: You are tasked to care for decrease anxiety.
Zoro, a patient newly diagnosed with
D. Excessive sweating and an increase in
obsessive compulsive disorder. You use
blood pressure
your knowledge to effectively and safely
care for the patient. and pulse.
24. Zoro is leaving his home for the first D. The client will use one relaxation
time in a year. He arrived in the unit technique to decrease obsessive and/or
wearing a surgical mask and white gloves. compulsive behaviors.
He states, “The germs in here are going to
SITUATION: You apply your knowledge on
kill me”. Which correctly written nursing
concepts of psychosocial health to
diagnosis addresses Zoro’s problem?
patients assigned to you in the ward. 26.
A. Social isolation R/T fear of germs AEB You are attending a seminar regarding
continually refusing to leave the home. coping skills. You were asked about the
beneficial effects of humor. You respond
B. Fear of germs R/T obsessive-
to the question appropriately based on
compulsive disorder.
which of the following documented
2|Page beneficial effects of humor?

A. Lessened depression B. Increased

relaxation C. Reduced aggression D.
C. Ineffective coping AEB dysfunctional
Improved sleep
isolation R/T unrealistic fear of germs.
27. As a knowledgeable nurse, you know
D. Anxiety R/T the inability to leave home,
that body image is the subjective view an
resulting in dysfunctional fear of germs.
individual has about his or her physical
25. Zoro has been in your care in the appearance including body shape, size,
psychiatric unit for 4 days now for the weight, and proportions. Which of the
treatment of their OCD. Which outcome following conditions would put a patient
takes priority for the patient at this time? at risk for disturbed body image?
A. The client will use a thought-stopping A. Urinary tract infection B.
technique to eliminate obsessive and/or Hyperlipidemia
compulsive behaviors.
C. Rheumatoid arthritis D. High blood
B. The client will stop obsessive and/or pressure
compulsive
28. You are a preoperative nurse preparing
behaviors in order to focus on activities of a client for an upcoming surgery. While
daily living. you’re preparing this patient, you inform
them of what they can expect after
C. The client will seek assistance from the
surgery and how their pain will be
staff to
controlled postoperatively. Which of the
decrease obsessive and/or compulsive following stress management techniques
behaviors. is being utilized in this scenario?

A. Relaxation
B. Guided imagery B. Bruises and scrapes on the extremities
C. Constricted pupils and fatigue
C. Progressive muscle relaxation D.
Anticipatory guidance D. Anorexia and recent weight loss

29. An elderly patient you’re caring for is 33. One of the patients you’re caring for in
about to be discharged. Which of the the unit is in methamphetamine
following statements, if made by the withdrawal. When caring for this patient,
patient, would indicate that they lack a the most appropriate intervention by the
support system at home? nurse should be to?

A. “My sister and her husband are taking A. Administer sedatives routinely to
me home today.” prevent seizures.

B. “My church members have been B. Allow the client to sleep and eat as
sending cards and letters while I have desired.
been in the hospital.”
C. Administer antipsychotic medications
C. “I am not sure how I am going to get to to manage
the grocery store after I get home.”
hallucinations.
D. “My neighbor is retired. We visit and
D. Encourage involvement in the
have our meals together every day.”
treatment milieu.
30. You are to assess a newly admitted
34. You are assessing one of the patients
patient regarding their health care
in your unit who abuses
practices. As a culturally competent
methamphetamine. The patient appears
nurse, which of the following factors
not to be willing to give up the usage of
would you include in your assessment?
the drug, as evidenced by their statement,
C. Minimization. “I do not plan to quit meth. I can work for
days when I am high.” Which of the
D. Projection.
following is your best response to the
32. The mother of one of your patients patient’s statement?
who are newly admitted to the mental
A. “You’ll exhaust yourself doing that.”
health unit expresses her concern that his
son may be using methamphetamine. B. “You can’t see the real problem yet
Which physical examination findings are because you are
consistent with methamphetamine abuse
in denial.”
by the client?
C. “You think using drugs helps you?”
A. Hypotension and bradycardia
D. “Good point. You probably work long D. The test will be repeated at intervals
hours while you during a five (5)- to six (6)-hour period.

are on meth.” 37. Robin stated her frustration regarding

her recent diagnosis of MS. She states, “I
35. One of your patients regularly uses
do not understand how I got this disease.
projection to protect themselves against
Is it genetic?” On which statement should
the negative realities resulting from their
you base your response?
methamphetamine use. Which of the
following statements will the nurse most A. Genetics may play a role in
likely document when the patient uses susceptibility to MS, but the disease may
projection as a coping mechanism? be caused by a virus.

A. “My dad and I don’t get along because B. There is no evidence suggesting there is
he thinks that I’m a failure.” any chromosomal involvement in
developing MS.
B. “I can’t go back to work. I’d be so
embarrassed for anyone to find out I’ve C. Multiple sclerosis is caused by a
been in treatment.” recessive gene, so both parents had to
have the gene for the client to get MS.
C. “I’m not giving up alcohol, just the
methamphetamine. I never had a problem D. Multiple sclerosis is caused by an
with alcohol.” autosomal dominant gene on the Y
chromosome, so only fathers can pass it
D. “Everything will be all right again if I can
on.
just stop using drugs.”
38. Which of the following issues
SITUATION: You are caring for Robin, a
presented by Robin is of most importance
patient diagnosed with Multiple Sclerosis.
to you at this time as her primary nurse?
The following questions apply.
A. She refuses to have a gastrostomy
36. Robin is scheduled for a magnetic
feeding.
resonance imaging (MRI) scan of the
head. Which of the following information B. She wants to discuss if she should tell
should you relay to Robin about the test? her fiancé. C. She tells the nurse life is not
worth living anymore. D. She needs the flu
A. The client will have wires attached to
and pneumonia vaccines.
the scalp and lights will flash off and on.
I. II. III. IV.
B. The machine will be loud and the client
must not move the head during the test. A. I

C. The client will drink a contrast medium B. III

30 minutes to one (1) hour before the test.
C. I, II, IV D. Suggest the client research an
investigational therapy instead.
D. I, II, III, IV
40. You enter Robin’s room after her
SITUATION: You are caring for various
diagnosis of acute exacerbation of MS.
patients with substance abuse disorder of
You find her crying. Which of the following
methamphetamines. You utilize your
statements is the most therapeutic
knowledge to help care for these patients.
response you can make as her nurse?
31. You are assessing a patient diagnosed
A. “Why are you crying? The medication
with substance abuse disorder. They
will help the disease.”
stated, “My wife causes me to abuse
methamphetamines. She uses B. “You seem upset. I will sit down and we
methamphetamine and she also expects can talk for awhile.”
me to.” As a knowledgeable nurse, you
C. “Multiple sclerosis is a disease that
know that the patient is using which of the
has good times and bad times.”
following defense mechanisms?
D. “I will have the chaplain come and stay
A. Rationalization. B. Denial.
with you for a while.”
Health-seeking behaviors Responsibility
SITUATION: You are caring for patient
for health care
Luffy who has seizures. You apply your
Folklore practices Barriers to health care knowledge on concepts of seizures to
better assess, diagnose, plan, and
3|Page
evaluate their condition.

41. Luffy is sitting in the chair when

39. Robin stated that she has been suddenly, his entire body went rigid with
investigating alternative therapies to treat his arms and legs contracting and
her disease. Which of the following relaxing. He is not aware of what’s going
interventions is most appropriate? on and is making guttural sounds. Which
of the following actions should you
A. Encourage the therapy if it is not
implement first?
contraindicated by the medical regimen.
A. Push aside any furniture.
B. Tell the client only the health-care
provider should discuss this with him. B. Place the client on his side. C. Assess
the client’s vital signs. D. Ease the client
C. Ask how his significant other feels
to the floor.
about this deviation from the medical
regimen. 42. Luffy is scheduled for an
electroencephalogram (EEG) to help
diagnose a seizure disorder. Which of the B. “My menstrual cycle will not affect my
following preprocedure teaching should seizure
you implement?
disorder.”
A. Tell the client to take any routine
C. “I am going to take a class in stress
antiseizure medication prior to the EEG.
management.”
B. Tell the client not to eat anything for
D. “I should wear dark glasses when I am
eight (8) hours prior to the procedure.
out in the
C. Instruct the client to stay awake for 24
sun.”
hours prior to the EEG.
45. Luffy is prescribed the anticonvulsant
D. Explain to the client that there will be
phenytoin (Dilantin) for his seizure
some discomfort during the procedure.
disorder. Which statement indicates that
43. Luffy just had a 3 minute seizure. He Luffy understands the discharge teaching
has no apparent injuries, is oriented to regarding this medication?
name, place, and time but he is very
A. “I will brush my teeth after every meal.”
lethargic and just wants to sleep. Which
of the following interventions should you B. “I will check my Dilantin level daily.”
implement?
C. “My urine will turn orange while on
A. Perform a complete neurological Dilantin.”
assessment.
D. “I won’t have any seizures while on this
B. Awaken the client every 30 minutes. medication.”

C. Turn the client to the side and allow the SITUATION: You are a new nurse assigned
client to in the operating room. You will apply your
knowledge on perioperative nursing to
sleep.
effectively and safely handle patients in
D. Interview the client to find out what this area.
caused the
46. You are preparing your patient for an
seizure. upcoming surgery. Which of the following
interventions should you implement first?
44. Which statement by Luffy indicates
that he understands factors that may A. Check the permit for the spouse’s
precipitate his seizure activity? signature.

A. “It is all right for me to drink coffee for B. Take and document intake and output.
breakfast.” C. Administer the sedative.
D. Complete the preoperative checklist. B. The client will have a pulse oximetry
reading of 97%
47. You are conducting an interview with
the surgical patient in the holding area. on room air.
Which of the following information should
C. The client will have a urine output of 30
you report to the anesthesiologist? Select
mL per hour. D. The client will be able to
all that apply.
distinguish sharp from dull
I. The client has loose, decayed teeth. II.
sensations.
The client is experiencing anxiety.
50. Which of the following problems
III. The client smokes two (2) packs of
should you identify as the priority for a
cigarettes a day.
patient who one day postoperative?
IV. The client has had a chest x-ray which
A. Potential for hemorrhaging.
does not show infiltrates.
B. Potential for injury.
V. The client reports using herbs. I, II, III, IV
C. Potential for fluid volume excess. D.
II, III
Potential for infection.
I, III, V
51. Antibiotics have limited use in the
A. B. C. D. actual treatment of Mastoiditis
because________.
A. Surgical supplies were cleaned and
sterilized prior to the case. A. Tissue destruction is extensive

B. The circulating nurse is wearing a long B. It is a long-term treatment

sleeve sterile gown.
C. Antibiotics do not easily penetrate the
C. Masks covering the mouth and nose infected bony
are being worn by the surgical team.
structure of the mastoid
D. The scrub nurse setting up the sterile
D. Culture has to be done to identify
field is wearing artificial nails.
which antibiotic is
49. The following statements are not an
most effective for the treatment of
expected outcome for the postoperative
Mastoiditis
client who had a general anesthesia,
except? A. The client will be able to sit in Situation– You are a staff nurse in a
the chair for 30 government hospital being transferred to
the Psychiatric Unit. You were required to
minutes.
equip yourself by attending the
enhancement program on Crisis
Intervention. To assess your knowledge 55. Which of the following nursing
and skills on the subject you were given a interventions is the most appropriate for a
pre-test. client who is in the early state of crisis?

52. A crisis that is acute but temporary III, V

and due to an external source
48. The circulating nurse intervenes when
is__________.
she notices which of the following
A. Developmental B. Transitional violations of surgical asepsis?

C. Traumatic 4|Page

D. Dispositional

53. The MAIN objective of crisis A. Encourage client to express feeling and
intervention is to_____________ emotions related to crisis

A. Make the person realize his/her B. Require client to be actively involved in

mistakes establishing goals

B. Ensure patient’s safety C. Encourage client to begin the

development of insight
C. Return the person to the root of the
crisis to identify D. Ask client to evaluate the situation

the cause Situation: In the PGH Ear Unit, the staff

nurse is attending to several outpatient
D. Eliminate the stressor
clients seeking follow-up care.
54. Which of the following is NOT an
56. In administering ear drops, the nurse
assumption in the concept of crisis?
observes which of the following
A. Crisis is acute and resolved within a principles?
short period of time
A. In a child, pull pinna upward and
B. All individuals experience a crisis backward.

C. Crisis is a growth-retarding factor to B. Let the ear drops fall on the middle
the emotional space of the

development of a person canal.

D. Specific identifiable events precipitate C. Lie on the unaffected side to facilitate

a crisis absorption. D. Position unaffected ear
uppermost.
57. The nurse assists in an ear irrigation. D. Recognize that PRN orders for
Which of the following statements by the restraints are unacceptable
nurse is correct?
60. Which of the following is a
A. “Tilt the head towards the unaffected characteristic sign of acute otitis media in
ear.” children?

B. “Direct the stream of irrigate at the A. Jumping in pain

sides of the ear
B. Ear tugging
canal.”
C. Painless inflammation D. Difficulty
C. “After the procedure, lie on the awakening
unaffected side to
Situation: Addiction disorders are
allow the irrigate to soften any hardened unnecessarily common in the modern
mass.” lifestyle of Filipinos, especially with the
rise of establishments selling products
D. “This procedure is allowed for otitis
with caffeine. Because of the various
media to clean
“improvements” in performance, this
the canal.” industry is still unwavering.

58. What makes children more 61. Caffeine greatly affects which part of
predisposed to chronic otitis media? the heart, as reflected in an ECG?

A. Shorter Eustachian tube A. Atrium

B. Horizontal orientation of the ear canal B. Ventricles

C. Primary diaphragmatic breathing C. Purkinje fibers

D. Both A and B D. Interventricular septum

59. The Psychiatrist orders “Restraints 62. Which of the following do not have the
PRN” for a client who has a history of potential of addiction, if consumed
violent behavior. Nurse Poppy should: frequently and in large amounts?

A. Utilize the restraint order if the client A. Chocolate-flavored Cola

begins to act-out
B. Apple juice
B. Ask the psychiatrist to clarify the type
C. Green tea
of restraint order
D. Common cold preparations
C. Ensure that the entire staff is aware of
the restraint order
63. In the previous situation of the young normal eye sees at 20 feet. She
professional intoxicated with caffeine, he documents this finding as:
suddenly was unable to take any caffeine
A. 10/20 B. 20/10 C. 2/1 D. 1/2
source for 24 hours already. The nurse
expects to note the following findings, 67. A student was not able to read the
except? letters in the 20/20 level. How should the
nurse proceed with the visual
A. Headache
assessment?
B. Difficulty in stimulating C. Nausea and
A. Document this finding as visual
vomiting D. Muscle pain
impairment.
64. The nurse suspects caffeine
B. Allow the student to come nearer at a
intoxication in a young professional if he
distance of 10
notes which finding?
ft.
A. Decreased flow of thought and speech
B. Psychomotor agitation C. Ask the student to squint, and try
reading the level
C. Urinary retention
again.
D. Pale face
D. Remind the student to avoid guessing
65. The following are the reasons why
at letters to
many people abuse caffeine. Choose the
exception. have an accurate finding.

A. Relieve fatigue 68. A patient is due to undergo tonometry

for confirmation of the diagnosis of
B. Increase mental alertness C.
glaucoma. The nurse advises the patient
BothAandB
against which of the following, except:
D. Neither A nor B
A. Squinting
Situation: The student nurse is reviewing
B. Breathing through open glottis C.
for his admission exam for a prestigious
Coughing
hospital in Taguig City. He is answering
questions related to eye disorders. D. Bending at the hips

66. In the clinic, the school health nurse is 69. The nurse is caring for a client
conducting a vision screening to incoming following enucleation. The nurse notes
Grade 1 and Grade 4 students. One of the the presence of bright red drainage on the
students was able to read at 10 ft, what a dressing. Which nursing action is
appropriate?
A. Notify the physician. C. teach the limitations imposed by the
disease
B. Document the finding.
D. have one of the client’s relatives stay at
C. Continue to monitor the drainage.
the bedside
D. Mark the drainage on the dressing and
72. Which clinical indicator does Nurse
monitor for
Jeremy identify when assessing a client
any increase in bleeding. with hemiplegia?

70. The nurse is performing an admission A. paresis of both lower extremities

assessment on a client with a diagnosis of
B. paralysis of one side of the body
detached retina. Which of the following is
associated with this eye disorder? C. paralysis of both lower extremities

A. Total loss of vision D. paresis of upper and lower extremities

B. Pain in the affected eye 73. Which statement by a client with

Multiple Sclerosis indicates to Nurse
C. A yellow discoloration of the sclera
Jeremy that the client needs further
D. A sense of a curtain falling across the teaching?
field of vision
A. “I use a straw to drink liquids.”
Situation: The diverse Neurologic
B. “I will take a hot bath to help relax my
disorders present unique challenges of
muscles.”
nursing care. The Nurse must have a clear
understanding of the pathologic C. “I plan to use an incontinence pad
processes for appropriate nursing when I go out.”
management. Nurse Jeremy is attending
D. “I may be having a rough time now, but
to clients in the ward with Multiple
I hope
Sclerosis.
tomorrow will be better.”
71. A recently hospitalized client with
Multiple Sclerosis is concerned about 5|Page
generalized weakness and a fluctuating
physical status. What is the priority
nursing intervention for this client? 74. Mr. Dela Cruz a 48 year old client
carpenter admitted after a spinal cord
A. encourage bed rest
injury and the Physician indicates that a
B. space activities throughout the day client is a Paraplegic. The family asks
Nurse Jeremy what this means. What
explanation should the nurse give to the 76. The Nurse develops a nursing
family? diagnosis of self care deficit for an older
client with Dementia. Which of the
A. upper extremities are paralyzed
following is the most appropriate goal for
B. lower extremities are paralyzed this client?

C. one side of the body is paralyzed A. The client will be admitted to a long
care facility to have activities of daily
D. both lower and upper extremities are
living needs met
paralyzed
B. The client will function at the highest
75. Jeremy is excited to be assigned to a
level of independence possible
Neuro –Ward after his extensive training.
He is preparing to conduct a Neurologic C. The client will complete all activities of
examination. What nursing intervention is daily living independently within one (1 )
anticipated for a client in the plateau hour time frame
phase of Guillain-Barre syndrome?
D. The Nursing staff will attend to all the
A. providing a straw to stimulate the facial client’s activities of daily living needs
muscles during the hospitalization

B. inserting an indwelling catheter to 77. The nurse recognizes that Dementia of

monitor urinary the Alzheimer’s type is characterized by:

output A. aggressive acting-out behavior

C. encouraging aerobic exercises to avoid B. periodic remissions and exacerbations

muscle
C. hypoxia of selected areas of brain
atrophy tissue

D. administering antibiotic medication to D. areas of brain destruction called senile

prevent plaques

pneumonia 78. When attempting to understand the

behavior of an older adult diagnosed with
Situation: In the Psychiatric ward nurses
Vascular Dementia, the nurse recognizes
are discussing the other factors that
that the client is probably:
caused Alzheimer's disease (AD). And
they all agree that it is a degenerative A. not capable of using any defense
disease of the brain caused by gradual mechanisms
death and loss of brain cells resulting to
B. using one method of defense for every
progressive and irreversible Dementia.
situation
C. making exaggerated use of old, familiar C. focusing on the needs of the wife
mechanism D. attempting to develop new
D. establishing on the needs of the wife
defense mechanism to
Situation: The ICU nurse assigned to a 60-
meet the current situation.
year old acutely ill client with Parkinson’s
79. Which of the following nursing disease who was hospitalized frequently.
intervention is most helpful in meeting The initial confinement was due to
the needs of an older adult hospitalized electrolyte imbalance. The following
with the diagnosis of Dementia of the confinement was due to injury sustained
Alzheimer’s type? from fall, he

A. providing a nutritious diet high in became to have incontinent of stools that

carbohydrates and protein further lead to development of skin
irritation and breakdown. Currently he
B. simplifying the environment as much
was admitted due to respiratory infection.
as possible while eliminating the need for
choices 81. The review of literature does not only
include published research studies but
C. developing a consistent nursing plan
also theory. In this case which theory is
with fixed time schedules to provide for
least related to the study?
emotional needs
A. Neuman’s system model
D. providing an opportunity for many
alternative choices in the daily schedule B. Lazarus’ theory of stress and coping C.
to stimulate interest Nightingale’s environmental theory D.
Roy’s theory of adaptation
80. A 75-year-old man with the diagnosis
of Dementia has been cared for by his 82. Related literature included case
wife for 5 years. For the past 2 years he situations similar to the case of the client.
has not spoken and incontinent of urine The nurse is interested in gaining further
and feces. During the last month he has knowledge that can help the client at risk
changed from being placid and easygoing for fecal incontinence. The nurse should
to agitated and aggressive. He is admitted use which of the following methods to
to a Psychiatric hospital for treatment strengthen this report?
with Psychopharmacology. Which is the
A. Historical research method
priority nursing care while this client is in
the psychiatric facility? B. Qualitative research method C.
Experimental research method D.
A. managing his behavior
Quantitative research method
B. preventing further deterioration
83. The patient also reports multiple D. Interviewing and using of questionnaire
lumbar muscle strains, thus is also on client’s
looking at using alternative therapies to
responses to his situation
reduce the pain. The client seeks advice
from the nurse as to what type of 85. Which of the following can the nurse
alternative therapy would provide the best use in protecting the safety of the
pain relief. How should the nurse subjects undergoing the research study?
respond?
i. Code for Nurses
A. "I have seen many individuals with your
ii. Nightingale’s pledge
type of pain be relieved of pain through
the use of acupuncture." iii. Patient’s Bill of Rights

B. "These types of therapies are more iv. Human Rights Guidelines

than just therapies; they are really a mind
A. 1,2,3,4 B. 1,3
over matter type of event or game."
C. 1,2
C. "Some of my other clients swear by
magnet therapy to reduce pain as it is very D. 3 only
small and very easy to use." Situation: In a Nursing Practice you are
D. "You need to choose the alternative directly involved in conducting a
therapy that is right for you based on comprehensive physical assessment
research that supports the intervention." especially to older clients with sensory
limitations.
84. While the nurse was able to identify
the cases that were studied, it is 86. The client with head injury is having
important to understand the problems with several sensory functions.
phenomenological experience of the Nurse Ymir should understand that the
client. This approach includes the structure that acts as a relay center for
following except: sensory impulses is the:

A. Exploring the idea expressed by the A. thalamus

person B. cerebellum
B. Getting the whole picture of fecal C. hypothalamus
incontinence and its
D. medulla oblongata
associated factors
87. When formulating nursing care plans
C. Focusing interview on fecal for older adults, Nurse Ymir should
incontinence include special measures to
accommodate for age-related sensory Nervous System. When formulating a
losses such as: response the nurse should understand
which common misconception about the
A. difficulty in swallowing
Autonomic Nervous System?
B. increased sensitivity to heat
A. both sympathetic and parasympathetic
C. diminished sensation of pain D. impulses continually affect most visceral
heightened response to stimuli effectors

88. After a brain attack a client remains B. the autonomic nervous systems is
unresponsive to sensory stimulation. regulated by impulses from the
Nurse Ymir understands general hypothalamus and other parts of the
sensations such as heat, cold, pain, and brain
touch are registered in the:
C. sympathetic impulses stimulate while
A. frontal lobe parasympathetic impulses inhibit the
functioning of any visceral effector
6|Page
D. visceral effectors (e.g., cardiac muscle,
smooth muscle, glandular epithelial
B. parietal lobe C. occipital lobe D. tissue) receive impulses only via
temporal lobe autonomic neurons
89. Visual Acuity declines with age. Situation: Poppy a Psychiatric Nurse
Presbyopia is a progressive decline in: responds in a variety setting to different
clients with Personality disorders.
A. Distinguishing between blues and
greens and among pastel shades 91. The Psychiatrist orders “Restraints
PRN” for a client who has a history of
B. Ability to see in darkness
violent behavior. Nurse Poppy should:
C. The ability of the eyes to accommodate
A. Utilize the restraint order if the client
for close
begins to act-out
detailed work
B. Ask the psychiatrist to clarify the type
D. Adaptation to abrupt changes from of restraint order
dark areas to light
C. Ensure that the entire staff is aware of
areas the restraint order
90. The novice nurse who is administering D. Recognize that PRN orders for
a beta blocker asks the Senior Staff Nurse restraints are unacceptable
about its effect on the Autonomic
92. Strict toilet and too early training to a something to say?”
toddler child will cause problems in
95. A client on the Psychiatric unit asks
personality development because at this
Nurse Poppy about Psychiatric Advance
age a child is learning to:
Directives (PAD). The nurse explains that
A. Satisfy own needs these advances directives:

B. Identify own needs A. Make the appointment of a surrogate

decision maker unnecessary
C. Satisfy parents’ needs
B. Permit the client to dictate what
D. Live up to society’s expectations
treatments will be given during future
93. The nurse encourages a client to join a hospitalization
self-helping group after being discharged
C. Eliminate the need for involuntary
from a Mental health facility. The purpose
admissions when the client is a threat to
of having people work in a group is to
self or others
provide:
D. Allow the client, while having the
A. Support
capacity, to consent or refuse potential
B. Confrontation psychiatric treatments in the event of a
future incapacitating mental health crisis
C. C. Psychotherapy D. Self-awareness
Situation: The fundamental assumption
94. As Depression begins to lift, a client is
of theory of life cycle theories is that
asked to join a small discussion group
development occurs in successive
that meets every evening on the unit. The
stages. The different life cycle theories try
client is reluctant to join because, “I have
to explain personality development as
nothing to talk about.” What is the best
well as development of Psychiatric
response by the nurse?
disorders. The following questions refer to
A. “Maybe tomorrow you will feel more this situation.
like talking.”
96. The nurse understands that problems
B. “Could you start off by talking about with dependence versus independence
your family?” develop during the stage of growth and
development known as:
C. “A person like you has a great deal to
offer the A. Infancy
group.” B. School age
D. “You feel you will not be accepted C. Toddlerhood D. Preschool age
unless you have
97. When planning to teach about the B. Introjection C. Competition D.
stages of growth and development, what Independence
stage does the nurse indicate as basically
7|Page
concerned with role identification?

A. Oral stage

B. Genital stage C. Oedipal stage D.

Latency stage

98. The nurse understands that Freud’s

phallic stage of psychosexual
development, which compares with
Erikson’s psychosocial phase of initiative
versus guilt, is seen best at:

A. adolescent

B. 6 to 12 years C. 3 to 51/2 years D. birth

to 1 year

99. A 3 year old boy was brought to a

Pediatric clinic for indifferent behavior.
About a month after their toddler is
diagnosed as moderately retarded, the
parents discuss the toddler’s future,
reflecting specifically on plans for their
child’s independent functioning. The
nurse recognizes that the parents:

A. Are using denial

B. Accept the child’s diagnoses C. Are

using intellectualization D. Accept their
child’s limitation

100. The nurse utilizes play when

interacting with children based on the
understanding that play for the preschool-
age child is necessary for the emotional
development of:

A. Projection