REVIEW CENTER FOR ALLIED PROFESSIONS

(RCAP)
PRE-BOARD EXAMINATION
NURSING PRACTICE III CARE OF CLLIENTS WITH PHYSIOLOGIC AND PHSYCHOSOCIAL ALTERATIONS (PART A)
GENERAL INSTRUCTIONS:
1. This test questionnaires contains 100 test items
2. Shade only one (1) box for each questions on your answer sheets. Two or more boxes shaded will validate your answer.
3. AVOID ERASURES.
4. Write the subject title NURSING PRACTICE on the box provided
SITUATIONAL
Situation 1 Nurse Lara is assigned in the Surgical Ward. She has admitted a patient with detected thyroid malignancy. She is in the
process of completing her health assessment.
1. Nurse Lara should assess the client for the presence of:
1. Nodules
2. Signs of Hoarseness
A. 2, 3, and 4

B. 1 and 2

3. Dysphagia
4. Palpitations
C. 1 only

D, 1, 2 and 3

2. A Client is scheduled for total thyroidectomy. Prior to surgery, saturated solution, Potassium Iodide (SSKI) is ordered. The purpose of
this solution is to:
A. Hypercalcemia
C. Decrease vascularity of the thyroid gland
B. Slow down cancer growth
D. Decrease consumption of the body of thyroid hormone
3. Which of the following risk factors should be watched and reported IMMEDIATELY by Nurses to the surgeon after operation.
A. Hypercalmia
C. Tetany
B. Decreased level of consciousness
D. Hypoxemia
4. The position to be consumed by the patient post-thyroidectomy is:
A. Semi-supine with back supported by pillows
C. Right lateral with back supported by pillows
B. Left lateral position with back supported by pillows
D. Semi-fowlers head elevated and and supported by pillows
5. The following expected outcomes would appropriate for a client who has undergone total thyroidectomy:
A. Limit intake of carbohydrate and energy foods.
B. Restrict activities at home
C. Value the importance of reporting severe pain and bleeding
D. Eat solid foods which are high in protein and fats
Situation 3 Quality documentation is an essential component of Nurses role in clinic setting. Nurse Mercy is assigned in the Medical
Ward and is taking care of patients with heart problems. The following questions apply.
6. What specific term should Nurse Mercy accurately document in the chart when a client is experiencing a change in angle between
nail bases greater than 180 digress due to Congestive heart disease?
A. Clubbing of the fingers
C. Peripheral Cyanosis
B. Inflammation of the fingertips
D. Peripheral Neuropathy
7. In diuretic therapy, the expected entry in the patients chart of Nurse Mercy should include the following, EXCEPT:
A. Time of drug administration which is at 8oclock in the evening.
B. Weight taken prior to drug administration
C. Intake and output taken every monitored once a day.
D. Serum electrolyte monitored once a day.
8. A patient is suffering from congestive Heart failure with pitting edema, which of the following is NOT relevant to be included in the
Nurses documentation?
A. Degree of edema
B. Depth of Edema
C. Duration of Indentation
D. degree of temperature
9. An elderly client signed a documentation outlining selected medical treatments when he loses his ability to decide. The document is
referred as:
A. Consent Form
B. Treatment Sheet
C. Nursing Care Plan
D. Advance Directive
10. Nurse Mercy was requested by the doctor on duty, to lend the patients chart to the relative. As a nurse, you informed the doctor that
she cannot comply with the request because charts are considered as __________.
A. Legal Document
B. Research Document
C. Medical Document
D. Evidence-Based Document

Situation 3 Rusty, 68 year old Executive came to the ER because of dizziness nausea and pain on the neck. He has not been
drinking medicines on time. Smokes liberally, especially when he is stressed. His BP is 150/100. He was found to be hypertensive.
11. The following are considered a non-modifiable risk factors in the development of HPN EXCEPT:
A. Family history of HPN
B. Gender
C. Sedentary life style

D. Ethnicity

12. As a part of your initial assessment which one is NOT an acceptable practice in taking blood pressure measurement?
A. BP is taken both arms, subsequent measurement at highest resting period at heart level
B. BP is taken with client seated with arm bared and positioned at heart level
C. BP is taken with calibrated anaeroid manometer
D. BP is taken mercury sphygmomanometer
13. Which of the following Nursing Diagnosis accurately described the condition of the patient?
A. Non-Compliant to Medical Treatment R/T Lack of Family Support
B. Ineffective Coping R/T Knowledge Deficit
C. Non-Compliance to drug Therapy R/T Over Fatigue
D. Activity Intolerance R/T Change in Lifestyle
14. Clients BP is 150/100, at what stage of hypertension of you consider this reading?
A. Pre-Hypertension
B. Normal
C. Stage I - Hypertension

D. Stage II Hypertension

15. A relative of Rusty told the nurse, Rusty is a coffee drinker. What drink has the highest caffeine content? The best response to this is:
A. Diet Cola
B. Blended Coffee
C. Chocolate Milk
D. Decaf Espresso
Situation 4 Nursing Management of Resources has become a challenging concern in todays health care delivery system. Safe
environment is currently a growing concern for both the health care
16. Month of March has been declared as Fire Prevention Mont by the Local Government. In any fire disaster, the health care team
should put the highest PRIORITY to:
A. Locate the nearest fire department
C. Locate the fire exits
B. Protect self from flames
D. Identify source of fire
17. You and your family are shopping in the mall, you observed a man in a restroom. He is unable to speak his hands are on his neck and
tapping his chest. You were asked by your family to attend to the man. After assessing the man who was choking, your INITIAL
ACTION is:
A. Call the doctor of the mall
C. Let the man lie down on his back
B. Perform the Heimlich maneuver
D. Ask the client whether he is choking
18. What is your priority action for clients suffering from a Heat Stroke?
A. Cover the body with cold towel
C. Give ice chips periodically
B. Put the patient in a cooler place
D. Submerge the extremities in cold iced water
19. You and your friend were conducting home visit in the community. Accidentally, your friend was bitten by snake. Which of the following
is your PRIORITY action?
A. Assess the area bitten by the snake
C. Incise the bitten part and suck the blood out of it
B. Call for help
D. Place a loose construction band distal to the bitten area
20. The nurse observes the patient who received anti-venom for anaphylaxis. Which of the following drugs the nurse make available at
the bed side?
A. Atropine
B. Lidocaine
C. Epinephrine
D. Sodium Bicarbonate
21. When a client has Pulmonary Tuberculosis, the following assessment findings are present, EXCEPT:
A. Loss of appetite
C. high grade fever often during the day
B. Easy fatigability
D. weight loss
22. Mr. Sony had several diagnostic tests. He was found out to have a growing malignant on his left lung aside from PBT. He has advised
by his doctor to undergo lobectomy to which he and his family consented. Which type of anesthesia would most likely be admisnisted
to the patient?
A. Local
B. Spinal Anesthesia
C. Caudal
D. General Anesthesia
23. After labectomy on the left lung, Mr. Sony was transferred to Post-Anesthesia care Unit (PACU). You are the nurse on duty, what
priority nursing assessment should you perform on client upon admission?
A. Change in EKG tracings B. patency of airway
C. Change in Urinary Output
D. Level of consciousness
24. The first sensory stimulus that returns in a post-surgery unconscious patient is?
A. Eyesight
B. Touch
C. Taste
25. When recovering from the anesthesia, the BEST position to be assumed by Mr. Sony is:

D. Hearing

A. Prone Position

B. Semi-Fowlers Position

C. Semi-Lateral Position

D. dorsal-Recumbent Position

Situation 6 Anita was admitted in the hospital complaining of a firm mass in her right breast. She was scheduled for diagnostic
procedures
26. Which of the following findings of Anitas history would suggest cancer of the breast as opposed to fibro cystic disease?
A. History of early menarche
C. History of anovulatory cycles
B. Cyclic change in mass size
D. Increased vascularity of the breast
27. The doctor ordered mammography. Which of the following information is important for the nurse to give prior to the procedure?
A. Overnight fasting is needed for accurate findings
C. The procedure will give slight discomfort
B. Use of talcum powder and deodorant is allowable
D. The procedure is safe from radiation exposure
28. The husband of the client asked the importance of mammography. As a nurse, the best response is:
A. Evaluate implants and other existing abnormalities of the breast issues.
B. Determine lesion and secretion cystic or solid
C. Visualize the structure of the breast for early detection of abnormalities
29. The client was admitted for breast biopsy. The evening prior to the operation, the patient verbalized, I dont want any test anymore. I
dont care whether I have breast cancer or not. Which of the following is the best response of the nurse?
A. The biopsy is important, you are just anxious right?
B. I understand how difficult it is, but there is an urgent need for the procedure.
C. I will inform the physician regarding your decision.
D. The doctor will be more guided with your treatment course because of the biopsy result.
30. You are planning to discharge the patient. What nursing diagnosis should be the focus of your nursing care plan?
A. Improved mobility R/T diagnostic procedure
C. Risk for inquiry R/T body weakness
B. Non-compliance: Impaired ability to perform task
D. risk for infection R/T surgical procedure
Situation 7 Cynthia is a cardiovascular Nurse in the Heart Institute. Nurse Cynthia has 5 patients with different problems during her shift.
After making the morning assessment, Nurse Cynthia started to prioritize nursing actions for her patients. The following questions apply.
31. Mr. Yulo receiving Lanoxin 0.25 mg once a day. Nurse Cynthia is aware that she should monitor her patients for any untoward affects.
Which of the following is a sign of Lanoxin Toxicity.
A. Diarrhea and abdominal spasm
C. Bradycardia and cool clammy perspiration
B. Visual disturbance and premature beats of the heart
D. Nausea and vomiting
32. Mr. Alex has been diagnosed with Myocardial Infraction and has been taking Coumadin per orem once a day. While Nurse Cynthia is
giving the medicine, she notices during her assessment that Mr. Alex has bruises on his arm and bleeding from his gum. What
PRIORITY action should nurse Cynthia take?
A. Adminster Coumadin and report your findings to your unit manager
B. Call the doctor at once and relay your observation
C. Call the nursing attendant and provide oral care
33. Which of the following is INCORRECT when administering Digitalis?
A. Banana and orange juice can be given as potassium supplements.
B. Digitalis and Antacid can be given orally at the same time.
C. Drug can be given orally with or without food.
D. Pulse rate has to be 60 for full before administering the drug.
34. Nurse Cynthia received an order from a cardiologist that a thrombolytic agent is to be administer to the patient. The EXPECTED
outcome of this drug is to:
A. Prevent occurrence of another heart attack
C. Promote adequate oxygenation
B. Lyse the clot and decrease extend of cardiac damage
D. Prevent client to have congestive heart failure
35. Mr. Nio, 45 years old has an order of Furosemide 80 mg to be administered IV. Nurse Cynthia has been monitoring the effect of the
drug. Which of the following assessment findings should be reported immediately to the doctor?
A. Diminished breath sound
C. BP is 130/90
B. Presence of abdominal pain
D. urine output is only 40 cc after 4 hours.
Situation 8 In todays world professional health practice, members of the team is faced with legal issues, which can become liability
concerns to everyone. The following questions apply.
36. Nurse Leonor is a Diabetic Nurse specialist but has renewed her Philippines License. She only arrived from United States after
migrating with her parents 15 years ago. Today, she was called by a neighbor who requested her to administer insulin intramuscularly
for her diabetes. What is the PRIORITIZED ACTION of Nurse Leonor in this situation?
A. Administer injection as she is a diabetes nurse specialist
B. Apply Philippine License before she can perform the injection

C. Use her US license as practicing nurse in the Philippines

D. Not to administer insulin injection as she is not licensed in the Philippines.
37. Nurse Jinky has a pending application to Australia. She has a 3-year contract with the hospital, where she is currently employed and
will be finished in 6 months time. Her immigration application has just been approved, and she has to leave within one month. What
PRIORITY action should she undertake?
A. Complete her contract with the hospital and leave for Australia
B. Terminate her present contract and leave for Australia
C. Write a letter of request to the Australian immigration for an extension
D. Discuss the concern with her Chief Nurse for a workable solution
38. Ms. Sonia is a Quality Assurance Nurse who was assigned to conduct a research regarding Diabetes Ulcer and its impact to the selfesteem of female patients. Since she is currently overloaded with many task, she requested a friend to do the duty for her. In review of
literature, her friend did a cut and paste in the materials she submitted without citations of the authors. Nurse Sonia and her friend
can be charged of:
A. Dishonorable conduct
C. Plagiarism
B. Dishonesty
D. Violation of Intellectual property
39. The medical director of a university hospital has difficulty in implementing the policy regarding the purchase of medicines in the
hospital pharmacy by all patients, which protects them from fake drugs. In this situation, he has to implement what kind of leadership?
A. Expert Power
B. Authority Power
C. referent Power
D. Coercive Power
40. A hospital is about to close-down because of financial instability brought by the law which increases the salary of health care
personnel. When people are removed without right compensation, this situation can lead to:
A. Malpractice
B. Beneficence
C. Injustice
D. Tort
Situation 9 Eunice is a staff-nurse working in a tertiary hospital whose specialty is muscular and peripheral disorders. She has 6 patients
under her care, two of which were diagnosed with peripheral arterial disease.
41. Eunice is aware that the number one predisposing factor in the development of PAD is:
A. Sedentary life and obesity
C. Stress and over activity
B. Middle-age and familial tendency
D. Hyperlipdemia and cigarette smoking
42. Mr. John is suffering from burger Disease. He is waiting for surgery because occlusion was found on the tip of his right toe. Which of
the following information is INCORRECT about Buergers Disease?
A. Smoking is a major cause of Buerger disease
B. Small and medium-sized arteries and veins are commonly affected
C. There is a strong relationship between Diabetes and Buergers Disease
D. The incidence of Buergers Disease is high in men than women.
43. A patient who has Reynauds phenomena has been having recurrent vasospastic blood vessels. The priority nursing action to be
done by Nurse Eunice is to:
A. Allow him to drink coffee or chocolate
C. Turn-on the air-conditioning unit when under stress
B. Keep the lower extremities elevated
D. provide loose, thick and warm hospital gown
44. When developing a nurse care plan for Mr. John, which of the following nursing diagnosis is APPROPRIATE for this patient?
A. Nutritional Imbalance
C. High Risk for infection
B. Ineffective Airway Clearance
D. Provide loose, thick and warm hospital gown
45. The main objective in the treatment of Buergers Disease are the following EXCEPT:
A. Improve circulation of the extremities
C. Protect the extremities from trauma and infection
B. Prevent the progression of disease
D. none of the above
Situation 10 The primary purpose of Quality Assurance program in nursing is to improve the quality of nursing delivered in the agency.
46. Director of Nursing Services asked the Quality Assurance (QA) office the reason of the increasing incidence of bedsore in the
neurological ward. The rationale of this action is to:
A. Have a prompt resolution of the complaints
C. Design protocol for future complaints
B. Establish a trouble-free health service
D. Validate the comments feedback from the dissatisfied client
47. The model for Continuous Quality Improvement (CQI) is Plan-Do-Check-Act. Check portion of the model is:
1. Review the trail of the process
3. Determine learning points
2. Analyze the result
4. Evaluation of the outcome
A. 1, 2, and 3

B. 1 and 2

C. 1 only

D. 1, 2, 3 and 4

48. Chief Nurse reviews the patients records to examine and verify the performance of the staffs on established criteria, this is called:
A. Joint Audit
B. Health Audit
C. Nursing Audit
D. Clinical Audit

49. The Director of Nursing Services conducted a performance appraisal among nurses. This is primarily done to:
A. Compare the performance of the nursing managers with the staffs
B. Replace inefficient and retirable nursing managers
C. Improve performance of the individual nursing managers
D. Identify nursing managers with family problems
50. The director in nursing wants to improve the quality of health care in the hospital. The following activities are examples of quality
assurance measurements:
A. Asking clients to accomplish client satisfaction survey forms
B. Checking if emergency carts or medications are properly stock
C. Evaluating outcomes or end results of care provided to client
D. All of the above
Situation 11 Lani, 22 years old, came to OPD because of menstrual disturbance. She complains being tired every time she finished her
daily tasks as a clerk. She was diagnosed with hypothyroidism.
51. During her examination, the nurse expects the following signs EXCEPT:
A. Hair loss and husky voice
C. Feeling warm even in cold weather
B. Lack of facial expression
D. Dry skin with brittle nails
52. She complained of mercurial disturbance, the nurse should ask the following changes in menstrual history?
A. Metrorrhagia
B. Oligomenorrhea
C. Amenorrhea
D. Dysmenorrheal
53. Which of the following rug theraphy would you likely expect to be ordered to patients with hypothyroidism?
A. Iodine
B. Levothyroxine
C. Iron pills
D. Propranolol
54. Which of the following should be avoided when diagnosed with Hypothyroidism?
A. Assist with self-care activities
C. Protect from exposure to cold temperatures
B. Turn and reposition the client intervals
d. Provide stimulation thRough conversation
55. Which of the following expected outcomes would be appropriate for Lani who is diagnosed with hypothyroidism?
A. Report that she is taking foods-low in fiber
B. Report the use of external heat like warm blankets
C. Restrict light activities at home to prevent relapse
D. Verbalize the importance of continuing her prescribed medications even after symptoms improved
Situation 12 A 57 years old male client, post Bilroth II was admitted to the Post Anesthesia Care Unit (PACU) from the OR. The client is
still sedated but responsive to comments. He has a nasogastric tube (NGT) draining orange-yellow fluid to a drainage bottle.
56. The nurse who admitted the patient recognizes that Bilroth II procedure means:
A. Gastrojejunostomy
B. Esophagojejunostomy
C. Entarostomy

D. Gastroduodenostomy

57. After admitting the client to PACU, the FIRST action of the nurse should be:
A. Assess the clients pain
C. Assess patency of airway
B. Monitor vital signs
D. Change the top dressing
58. As the nurse monitors the client she notices a bright spot on the dressings which measures 4 cm in diameter. The nurse would initially
do which APPROPRIATE nursing intervention?
A. Assess for presence of drain
C. Continue to monitor the vital signs
B. Notify the clients surgeon of a potential hemorrhage
D. Change the top dressing
59. In assisting the client to do deep breathing, coughing and turning to the sides on the first postoperative day, which nursing action be
most helpful for the client?
A. Administer the prescribed analgesic round the clock as prescribed.
B. Apply abdominal splint (pillow) while coughing
C. Restate the importance of respiratory exercises
D. Give the client reassurance that he can cough, breathe deeply and turn to sides safely
60. The client complained of abdominal pain, nauseas and vomiting with abdominal distention. The nurse anticipates which of the
following priority management after referring to the surgeon?
A. Gastric decompression B. Possible surgery
C. Endoscopy
Rectal tube insertion
61. Which of the following situations is considered an ethical dilemma among the health care professionals?
A. Family members conflicting feelings whether their father 68 years old would undergo renal transplant
B. A breast cancer patient who signed consent to stop all medicines and life saving devices.
C. An HIV patient instructing the nurse not to accept his family members during his confinement
D. An elderly husband has to be isolated from his wife due to acute pneumonia

62. A 62 years old widower resides in an early care facility. He has an adult daughter who regularly visits him twice a week. One day, he
was found unconscious because of an overdose of sleeping pills and Amithrophylline. He has handwritten note stating for him not to
undergo resuscitation but daughter requests that everything be done to save her father. What is the right ethical decision in this case?
A. Respect the request of the daughter to save her father
C. Bring the patient to a hospital for an emergency care
B. Respect the patients decision to save a peaceful death
D. refer to the hospital chaplain
63. In clinical practice, nurses encounter Do not resuscitate (DNR) order from the physician. This order is brought by which of the
following ethical decision?
A. To forego any intervention to sustain life
B. Design a mutually acceptable treatment plan for a particular patient
C. Principle-based approach supporting the nurses role as a patients advocate
D. A balance between a patients belief and duty to promote course of treatment
64. A patient admitted in the CCU due to Acute MI, with unstable blood pressure and severe nausea. Medical management includes IV
Dopamine and intubation. However, the patient does not want to be incubated despite the willingness of the family. He is conscious
but hardly talks. Who should make the final decision for the intubation?
A. Patient
B. family Member
C. Physician
D. Nurse
65. The attending physician, Dr. Ronald Gomez, ordered Morphine SO4 100 mg to a patient who is suffering from chronic pain. Nurse
Betty questioned the order of the doctor as she finds the dose too strong for the advanced age and chronic condition. The nurse is
guided by the principle of:
A. Non-Malaficence
B. Maleficence
C. Autonomy
D. Justice
Situation 14 health Education is a major component of the caring process and health care porfessinals are responsible to patients under
their care. The following questions apply.
66. A group of health care professionals is conducting a session on Diabetes Care management. The team approach for this program is
primarily on:
A. Emphasis that health care professionals are source of information on Diabetes Care
B. Achieving a balance on nutrition, caring and teaching modalities and drug administration to clients
C. Putting up a nurse-led diabetic clinic
D. Nutrition therapy with drug regimen as effective tools to diabetic care
67. A group of newly hired nurses were doing their rounds with client with tracheotomy. The nurse on duty was demonstrating on how to
do safe and proper sanctioning procedures. This is done by:
A. Inserting catheter into the trachea and suction, at the same time with a rotating motion at 360 degrees.
B. Inserting catheter into the trachea and let the client take a deep breath and suction in a rotating motion.
C. Inserting catheter up to end of the tube, gently twirl as you withdraw suction catheter 360 degrees
D. Inserting the catheter into the trachea and let the client cough and then suction in a rotating motion.
68. The Department of health is planning to carry out an educational campaign on immunization against poliomyelitis in far flung areas of
Bohol. What strategy is BEST to be applied in this activity considering location and cost?
A. Send text messages to the people in the community.
B. Disseminate information through television.
C. Request the mayor to explain to the community about the campaign
D. Distribute information on immunization using comics.
69. The OR manager discussed in one of their conferences with the nurses and student nurses how to maintain the sterility of OR gown.
She should emphasize that the OR gown is sterile from:
A. Neck portion of the gown to table level
B. Chest to table level and sleeves 5 inches above elbow
C. Chest portion to table level and sleeves 4 inches above the elbow
D. Chest to table level and sleeves to 2 inches above the elbow
70. The nurse OR supervisor further emphasized with the group that the priority goal of the multi disciplinary team in the operating room
is to:
A. Achieve safe and quality patient care
C. Obtain the highest recognition for the surgeons expertise
B. Sustain team work among the OR personnel
D. Minimize fear of patient for surgery
Situation 15 As many as 50% of school gae children are obese by body mass index guidelines for ideal weight. Mike, an 8 year old,
grade two is one of them.
71. Children like Mike, have a tendency to be obese because of what kind of body built?
A. Mesomorphic
B. Endomorphic
C. Ectomorphic
72. Obesity is caused by several factors including the following. Choose all that apply:
1. Genetic
3. Peer Pressure
2. Family Influence
4. School Environment

D. Esomorphic

A. 1, 2 and 3

B. 2, 3 and 4

C. 1,2, 3 and 4

D. 1, 2 and 4

73. The major psychological effort of obesity on children like Mike, includes the following EXCEPT:
A. Bullying
B. Self-destruction
C. Depression

D. Poor self-image

74. An immediate physical complication with Mike will NOT manifest includes which of the following?
A. Type 2 Diabetes
B. Elevated total cholesterol level C. Hypertension

D. Atherosclerosis

75. What is the BEST short term intervention that the nurse can propose to Mike and his family ?
A. An outright decrease in food portion sizes
C. A weight reduction program
B. Limiting time spent for video games and internet
D. Total ban on soft drinks and sweets
Situation 16 Leadership and management is one of the expected competencies in the role of the professional nurse. To become a
leader, one has to be abreast with the advancement in one discipline and become a lifelong learner. The following questions apply.
76. Nena is the Head Nurse in the OPD for almost 8 years. Every time there is a new program, she will plan and make her own decisions.
This style of leaders of leadership is known as:
A. Democratic
B. Autocratic
C. Participative
D. Laissez fare
77. The management-employee relationship is an important tool for success in an organization. Which of the following is the MOST
significant factor in building this relationship?
A. Cooperation
B. Empowerment
C. Communication
D. Collaboration
78. You are assigned to supervise two newly hired nurses in your unit. As a part of enhancing their competencies. What BEST style of
teaching should you adopt?
A. Problem-solving
B. Delegating
C. Coaching
D. Directing
79. Personal and professional growth is an essential component of Human Resources development. Intrinsic records can be given by
the organization as a form of motivation. Which of the following is a form of intrinsic reward for personnel?
A. Promotion
B. Positive Feedback
C. Scholarship Grant
D. Free books and travel
80. Nurse Jean received a 3-month scholarship to Japan from their administration and at the same time, an invitation from her sister to
join her in a trip to Australia. Which problem solving principle should she apply?
A. Identify solutions
C. Come up with Evaluation
B. Identify the problem
C. Generate alternatives
81. You made your routine patients rounds before endorsement to the night duty. You found a post operative thyroidectomy client wihout
any order of fluids to follow. Which of the following would be your MOST appropriate action?
A. Order one lietr of dextrose 5% in Lactated Ringers from the pharmacy
B. Regulate the ongoing IV solution to keep the vein open
C. Assess and refer to the resident on duty accordingly
D. Endorse to the incoming shift as is
82. You were requested by Clarise, a patient for discharge the following day, to contact her parents to pick her up. Since it is medication
time, you decided that it is proper to endorse the request to the:
A. Charge Nurse
B. Ward Clerk
C. Nursing Student
D. Nursing Attendant
83. You are scheduled first batch for lunch for today. While you prepare to go to lunch, your patient, David from PACU was being
wheeled in accompanied by the PACU nurse. Your BEST appropriate action at the point would be to:
A. Inform your head nurse that you cant go for lunch as scheduled
B. Request another nurse to receive David, your client from PACU
C. Go far lunch as scheduled
D. Forgo lunch for today
84. Edward, your patient for right lobectomy the following day, has an order to prepare 4 liters of fresh whole compatible blood to start
four hours prior to sending him to the Operating room. Which of the following members of the team would you inform FIRST?
A. Client
C. Anethesiologist
B. Blood bank personnel
D. OR personnel in charge of schedule
85. You supervised a nursing student in administering a premedication for survey. It is imperative for you to intervene if the nursing
student:
A. Removes the dentures prior to administering the premedication
B. Changes the patients gown prior to administering the premedication
C. Allows the patient to use the comfort room after the injection
D. Administers the premedication when the patient had been transferred to the stretcher

Situation 18 Mr. Lee, 72 yers old, is having a neuropathic pain for several months now. He stepped on a nail one day and developed
ulceration on the right foot. It became infected so the doctor admitted him to the hospital.
86. When taking his pain history, the appropriate question for you to ask Mr. Lee is:
A. Do you have any complaint of pain?
C. Where is the pain located?
B. Do you feel any discomfort?
D. Are you in pain?
87. Which of the following statement is NOT CORRECT?
A. The person who experiences pain is the authority on its existence.
B. The nurse as a Health Care Provider is the expert about clients pain
C. Even after minor surgery, clients can still experience intense pain
D. Pain is a subject experience and can vary among individuals
88. Which of the following is the safety alert you should observe as a nurse during the first 24 hours after opoid therapy
A. Brain
B. Respiratory
C. Circulatory
D. Renal
89. You teach client how to care for residual limb
A. Wash daily using warm water and bacteriostatic soap
B. Expose to air 2 hours after washing

C. use lotion and poweder

D. Rinse and rub the stump

90. As part of your instructions, which of the following is a priority that the client should avoid?
A. Wearing closed-toed shoes that fir well
C. Rub the skin with lotion over the top and bottom feet
B. Trimming toe nail across and flow contour of the foe D. using heating pad on the peripheral part
Situation 19 The Community Health Nurse plans to organize a Sanitation program to people in SitioRemdios.
91. What would be the initial step of the Nurse and her team to undertake?
A. Assess available resources in the community
B. Plan a strategic action to meet the desired goals for the program
C. Analyze with the people in the community the need for sanitation program
D. Consult local health care council for assistance
92. The goal of the Sanitation program as a health promoting activity is to:
A. Increase level of awareness on curative aspect of health
B. Minimize occurrences of risk factors
C. Increase level of awareness on rehabilitation
D. Increase level of wellness among the people
93. The community health nurse developmental task is to achieve a desirable outcome in terms of health care. A nursing judgment
related to the clients capability for Good Health is considered:
A. Health Deficit
B. Health Threats
C. Foreseeable Crisis
D. Wellness State
94. The team has observed that people in the community are NOT participative in the program implementation. Which of the following
activities have to be undertaken by the leader of the team to mobilize them?
A. Ask the mayor to call their attention
B. Just ignore them
C. Invite the people for a party
D. Involve residents with high level of motivation to become leader of the group
95. Which of the following is a Disease preventive activity of a Community Health Nurse?
A. Assisting diabetic clients prepare diet regimen
C. Teaching obese clients for weight reduction
B. Administering immunization to infants
D. Conducting daily exercise among Senior Citizens
Situation 20 Sandy, 35 years old, 5 2, 200 pounds, sought consultation at the OPD because of breathing problem especially when
climbing the stairs, she craves for sweets and cant eat meals without rice. She does not engage in any form of exercise.
96. In your nutritional assessment, which of the following questions inappropriate?
A. What factors contribute to your weight gain?
C. How much budget do you allow for food?
B. What does food mean to you?
D. Are there family members who are overweight too?
97. Which one of the following health risks is associated with obesity when metabolic system is impaired?
A. Hypothyroidism
C. Type 2 diabetes mellitus
B. Menstrual irregularities
D. infertility
98. Patient asks the nurse, How much time do I have to exercise as a beginner? based on the recommended weight loss strategy, the
best response of the nurse should be:
A. 1 hour in the morning 1 hour in the afternoon

B. Type 2 diabetes mellitus

C. 30 minutes in the morning and 30 minutes in the afternoon
D. 2 hours per day
99. A patient plans to undergo bariatric surgery. Which of the following is a selection criterion for bariatric surgery?
A. 18 years old and above
C. Has been obese for less than 5 years
B. Has BMI of greater than or equal to 40kg/m2 D. With history of hyperthyroidism
100.In order to maintain stable weight in obese clients, which one of the of the following diet management should be avoided?
A. High protein, low carbohydrate and fats
C. Meals should be taken in 6 small feedings
B. Intake of fluids limited to 100 ml/day
D. Fluid be ingested with meals

- GOOD BLESS -