Name:___________________________________________________________Date:________

I. Multiple choice. No ERASURES and SUPERIMPOSITIONS!

Situation: Nursing as an profession, continuously struggle for autonomy in

response to societal needs. Events in the past have greatly influenced our
nursing practice today.

1. Which of the ff is true about Florence Nightingale?

a. She is the mother of modern American nursing.
b. She nurses wounded soldiers during the civil war
c. She established the first nursing school in Germany
d. She is the first nursing theorist

2. She is considered as the patroness of nursing

a. Catherine of Sienna
b. Elizabeth Seaton
c. Elizabeth of Hungary
d. Florence Nightingale

3. The code of Hammurabi

a. Lists the functions of the nurse
b. Describes the qualities of a nurse
c. Lists the rights of the clients
d. Is a law that requires all Hebrews to undergo circumcision
4. She is considered as the “Florence Nightingale of Iloilo”
a. Loreto Tupas
b. Sor Ricarda Mendoza
c. Anastacia Tupas
d. Socorro Diaz

5. Which of the ff developments occurred during the apprentice period?

a. “spirit of nursing”
b. Informal education in nursing
c. Standardization of nursing curriculum
d. CHN as specialized field

Situation: A nursing theory is a system of ideas that explains a certain

phenomena in nursing. It may be utilized by a nurse in the practice of her
profession.

6. Which of the ff theories consider and utilize nature and environment in the
healing process?
a. Orlando
b. Nightingale
c. Rogers
d. King

7. Which of the ff is recognized for developing the concept of high level

wellness?
a. Erickson
b. Maslow
c. Peplau
d. Dunn

8. Who is the first nursing theorist?`

a. Abdellah
b. Nightingale
c. Orem
d. Maslow

9. Nursing theories should include descriptions of the four concepts such as:
a. Person, environment, health, nursing
b. Nursing, environment, health, illness
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 c. Person, society, illness, health
d. Society, nursing, health, illness

10. She conceptualized the framework for psychiatric nursing, wherein a nurse
must established a therapeutic relationship with the client.
a. Peplau
b. Leninger
c. Hall
d. Neuman

Situation: Nurses assume a number of roles when the provide care to the
individual, family or community.

11. Misconceptions, superstitious beliefs of a client can be best corrected if a

nurse will act as a:
a. Communicator
b. Teacher
c. Counselor
d. Leader

12. When a nurse assists the client in meeting his hygienic needs, the nurse
portrays what role?
a. Manager
b. Client advocate
c. Caregiver
d. Leader

13. Before Lira undergoes an operation, the nurse checked whether Lira
understood what is to be done to her. With this regard the nurse acts as a:
a. Client’s advocate
b. Manager
c. Caregiver
d. Teacher

14. You demonstrate a client advocate role to a client for operation when you:
a. Check her v/s and carries out pre-op orders.
b. Arrange services for clients
c. Check if the client knows what is to be done to her.
d. Question the order of the doctor

Situation: Health is changing, evolving concept that is basic to nursing.

There is knowledge on how to attain a certain level of health. But, health
itself cannot be measured.

15. The actions people take understand their health state, maintain their
health or prevent illness and injury are called:
a. Health status
b. Health beliefs
c. Health behaviors
d. Health values

16. The health illness continuum concept views health as:

a. Spectrum that ranges from extreme state if ill health to peak
wellness
b. Adjustment to changes of the external and internal body
environments
c. Health illness curve is subject to biorhythmic influences
d. Hierarchy based upon satisfying the needs at the lowest end of the
continuum first

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 17. A single mother of three school age children is concerned about
maintaining her present health status. Although she knows that she should
exercise regularly, her job and the classes she is taking at the local
community college require all her spare time. Where is the client at the
Dunn’s health grid?
a. High level wellness in a favorable environment
b. Emergent high level wellness in unfavorable environment
c. Protected poor health in a favorable environment
d. Poor health in an unfavorable environment

18. Mira was not able to attend to the taping of her movie because of
abdominal pain. Mira is said to be on what stage of illness behavior?
a. Symptom experience
b. Assumption of sick role
c. Medical care contact
d. Dependent client role

19. Which of the ff activities is considered a promotive nursing action?

a. Environmental sanitation to decrease the incidence of dengue
b. Adequate nutrition to attain normal growth
c. Finding cases of clients suffering from HIV
d. Administration of antibiotics as ordered so infection will not set in

20. Health beliefs are affected by certain internal and external variables. What
is the best definition of health belief?
a. Actions taken by an individual related to health
b. Concepts related health
c. Health practices as a person
d. Health habits

Situation: The nursing process is systemic, scientific method of providing

care. Its components follow a logical sequence.

21. What is the goal of the nursing process?

a. Help nurses in the delivery of care
b. Give a quality , comprehensive client care
c. Modify the client’s plan of care
d. Identify client’s problem

22. Which of the ff steps in the nursing process serve as framework in

identifying client’s problem?
a. Evaluation
b. Nursing diagnosis
c. Assessment
d. Planning

23. It is statement of the health response of a client to his/her pathological

condition. What is this statement called?
a. Nursing diagnosis
b. Medical diagnosis
c. Diagnosis
d. Collaborative diagnosis

24. What type of nursing diagnosis needs further gathering of evidences to

support the problem?
a. Actual diagnosis
b. Wellness diagnosis
c. Risk nursing diagnosis
d. Possible nursing diagnosis

25. What is the primary purpose of time-lapsed assessment?

a. To identify the client’s problem
b. To establish a data base
c. To compare client’s present from previous health status
d. To identify ongoing problems
26. When the nurse monitors the BP of a client after admission, the nurse is on
what stage of the nursing process?

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 a. Assessment
b. Implementation
c. Planning
d. Evaluation

27. During the implementation process, the nurse needs to possess various
skills. If she is going to suction a neonate, which of the ff skills will mostly
be utilized by the nurse?
a. Cognitive
b. Interpersonal
c. Psychomotor
d. Communication

28. 28. A client comes to the clinic for comprehensive health assessment.
Upon obtaining the client’s biographic data, which of the ff questions
would be best to begin history taking?
a. “What brings you to the clinic today?
b. ”Would you describe your health as good?”
c. “Are you healthy?”
d. “Describe your health, now and in the past”
29. In formulating learning goals, which of the ff does not illustrate an
important factor to be considered at this stage of the teaching process?
a. Involvement of clients and their families in the development of
goals
b. Inclusion of teaching methods appropriate to client’s learning styles
c. Consideration of the primary learning domains in which to focus
teaching
d. Use of behavioral objectives in formulating goals

30. Making judgments and conclusions about the meaning of the data you
have collected in your assessment of Alfred is:
a. Analysis of data
b. Verifying data
c. Organizing data
d. Interpretation of data

31. Which of the ff techniques can be most helpful in identifying the degree of
distress and discomfort of a newly admitted client?
a. Review of nurses notes
b. Performing physical examination
c. Active listening on what the clients says
d. Observation of client’s behavior

32. Your admission data will include social data about your client. These are
examples of social data EXCEPT:
a. Client’s lifestyle
b. Perception of illness
c. Religious practices
d. Family home situation

33. The nurse should take the initiative in setting priorities when
a. In an emergency situation
b. The client is illiterate
c. The client is uncooperative
d. There are differences in cultures

Situation: Amihan, 25y/o, was brought to the hospital because of

convulsion, high fever and diarrhea. Stat and PRN drug were administered.

34. What is the most appropriate method of temperature taking will the nurse
use?
a. Per Oral
b. Per Axilla
c. Per Rectal
d. None of the above

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 35. How many degrees centigrade is the normal body temperature If taken by
such method (refer to above question)?
a. 37
b. 37.5
c. 37.8
d. 36.5

36. If the fever of Amihan fluctuates from 38 to 40.5 degrees centigrade, she
is said to have what type of fever?
a. Intermittent
b. Remittent
c. Constant
d. Relapsing

37. Amihan’s BP is 140/80. 60 mmHg is known as:

a. Systolic
b. Diastolic
c. Pulse pressure
d. Pulse deficit

38. During TSB, fever goes down through the process of :

a. Convection
b. Conduction
c. Radiation
d. Evaporation

39. An important nursing measure that should be carried about 30 minutes

after completing TSB is to:
a. Give aspirin
b. Offer fluids rich in Vit. C
c. Obtain vital signs
d. Provide thick blanket

40. A few minutes after the nursing measures, Amihan’s fever goes down
gradually. This method of fever abatement is known as:
a. Crisis
b. Lysis
c. Acute
d. Chronic

SITUATION: All living things need oxygen. Alterations in the respiratory and
cardiovascular system will affect the individuals level of oxygenation.

41. The nurse palpated the clients back to assess the lung sounds. Which of
the following will reveal a normal lung sounds?
a. presence of vesicular sounds
b. absence of vesicular sounds
c. presence of tactile fremitus
d. absence of tactile fremitus

42. Purse lip breathing exercises was advised. What is the effect of this action
to the clients respiratory system?
a. prevents air trapping
b. maintains a patent airway
c. liquefies secretions
d. promotes ciliary function

43. Immobilize clients should be turned to sides every 1 to 2 hours to:

1. clear the clients air passages of secretions
2. prevent stasis of lung secretions

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 3. promote lung expansion
4. liquefy secretions
a. 1,2
b. 1,4
c. 2,3
d. 3,4

2. The process by which gases are exchange from the lungs into the
atmosphere and vice versa is known as:
a. Diffusion
b. Perfusion
c. Ventilation
d. Osmosis

3. Which of the following term is defined as the ability of the lungs to

expand?
a. Lung atelectasis
b. Lung compliance
c. Inspiration
d. Ventilation

4. The most comfortable position for a client to assume during asthmatic

attack is:
a. sitting
b. fowlers
c. orthopnic
d. supine with 2 pillows

5. Danya’s respiratory pattern was described by the nurse Kussmaul. This

means that Danaya’s character of breathing is:
a. Rapid, shallow
b. Slow, shallow
c. Rapid, deep
d. Slow, deep

SITUATION: Utilizing the concept of Nutrition helps the nurse to become an

effective health educator.

6. The nurse discusses the need for a diet rich in calcium. Which of the
following foods are the best sources of calcium?
a. Meat, poultry
b. Orange, grapefruit
c. Potatoes, carrots
d. Cheddar cheese, sardines

7. Cooking vegetables quickly under low fire and with the least amount of
water possible in a covered container help avoid destroying what vitamin?
a. Vitamin C
b. Vitamin D
c. Vitamin A
d. Vitamin K

8. Alena tells the nurse that her 3 year-old son, Kalil does not like and will not
drink milk. Which of the following foods is an alternative source of
essential amino acids?
a. Beans
b. Gelatin
c. Fresh fruits
d. Fresh eggs

9. The nurse is correct when teaches that the vitamin is important for the
proper absorption and utilization of calcium in the body is:
a. Vitamin A

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 b. Vitamin B
c. Vitamin C
d. Vitamin D

10. Which of the following foods is considered food of high biological?

a. Beans
b. Carrots
c. Fish
d. Broccoli

11. Pirena asks the nurse if her 12 year-old son, with a height of 1.2 meters
and a weight of 50 kgs, has a normal height? Based on his BMI, in which of
the following categories does the child belongs?
a. Underweight
b. Overweight
c. Normal weight
d. Obese

SITUATION: Adequate elimination is one of the physiologic needs of man. A

nurse must always include patterns of bowel and bladder elimination in her
assessment when admitting a client.

12. What is the position of a client during abdominal palpation?

a. Lateral
b. Supine
c. Dorsal recumbent
d. Knee chest

13. During your assessment, you noticed that there is hypertympanism when
you percussed your clients abdomen. Your client should be suffering from
what bowel problem?
a. Constipation
b. Fecal impaction
c. Flatulence
d. Diarrhea

14. Which of the following fecal characteristics is considered normal?

a. It has bacteria and bile ligaments.
b. It contains fat and undigested food.
c. It is dry and hard.
d. It is clay colored and has pungent odor.

15. Which of the following sites is best used for bowel sound auscultation/
a. Right upper quadrant
b. Left upper quadrant
c. Right lower quadrant
d. Left lower quadrant

16. A mother told the nurse that her 13-year-old son strains everytime he
defecates. Which of the following actions is more appropriate to the child?
a. Decrease his level of activity
b. Serve food neither too hot nor too cold
c. Modify his lifestyle
d. Include dark green leafy vegetables in his diet

17. What is the minimum safe range for the hourly urinary output from the
indwelling catheter?
a. 20-30cc
b. 90-120cc
c. 60-90cc
d. 30-60cc

18. The mechanism that start the act of urination is:

a. feeling of voiding
b. volume of urine in the bladder

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 c. parasympathetic responses
d. relaxation of urinary sphincter

19. If Benedict’s test is used to determine presence of glucose in the urine,

how will you test if the solution is free from impurities?
a. Add 5-10gtts of urine and note for changes in color.
b. Heat the solution and note for color changes.
c. Add a few drops of alcohol and note for changes in color.
d. Heat the solution and note for cloudiness.

20. The best urine specimen for determining glucose in the urine is:
a. second voided urine
b. 24 hour urine collection
c. Early morning urine
d. Midstream urine

21. Which of the following urine specific gravity values will indicate that there
is dehydration?
a. 1.010
b. 1.005
c. 1.024
d. 1.035
SITUATION: Sleep is a state of conciousness but the persons awareness and
response to the environment is decreased.

22. Sleep is important because of which of the follwing reason?

1. It provides relaxation
2. To conserve energy
3. For protein synthesis and cell division
4. For growth
a. 1,2,3
b. 1,2,4
c. 2,3,4
d. All

2. A theory which states that sleep occurs due to the interrelationship

between two cerebral mechanisms that controls sleep and wakefulness.
a. RAS
b. BSR
c. Active
d. Passive

3. Slow-wave sleep occurs during what phases of sleep?

1. Stage I
2. Stage II
3. Stage III
4. Stage IV
a. 1,2,3
b. 1,2,4
c. 2,3,4
d. All

2. In what stage of sleep does brain tissue and cognitive restoration occur?
a. NREM
b. Stage III
c. REM
d. Delta sleep

3. Which of the following manifestations occur when an individual is deprived

of sleep?
1. clumsiness
2. decrease alertness
3. irritable

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 4. pain sensitive
a. 1,2,3
b. 1,3,4
c. 2,3,4
d. All

2. Which of the following factors affect sleep?

1. lifestyle
2. age
3. drugs
4. caloric intake
a. 1,2,3
b. 1,3,4
c. 2,3,4
d. All

2. Which among the following age group needs 16-20 hours of sleep?
a. Infant
b. Toddler
c. Preschooler
d. Adolescent

SITUATION: You were assigned in a neurological unit. Your client, Mrs.

Imang, is unconscious and right-side paralysis. After five days, you noted
reddening of skin over her sacral area.

3. Which of the ff is the first subjective manifestation of decubitus ulcer?

a. Papular rash
b. Tenderness
c. Reddened skin
d. Skin abrasions

4. The best nursing measure to prevent bedsore formation is

a. Increase client’s intake of fluid
b. Turn client side to side every 1-2 hours
c. Keep client dry and comfortable
d. Provide adequate nutrition

5. Which of the ff techniques in moving the client will most likely cause
decibitus ulcer formation?
a. Sliding client on a sheet to move him up on bed
b. Moving client to a chair with support
c. Lifting client from bed to stretcher
d. Turning client to her side with a draw sheet

6. In transferring c client from the bed to a stretcher, what is the best

position of the stretcher to the bed of the client?
a. Perpendicular
b. Parallel
c. At 90 degrees
d. None of the above

7. In turning a client to her side using a logroll, which of the following actions
are correct?
1. Place a pillow between the legs
2. One nurse counts counts 1,2,3 then turn client to her side
3. Client’s arms are crossed over her chest
4. Pull the client to one side of the bed before turning her to side
a. 1,2,3
b. 1,3,4
c. 2,3,4
d. All
2. Which of the ff basic elements are involved in body movement?
a. Posture, balance and coordinated body movements
b. Range of action movement and exercise
c. Exercise, nutrition and posture
d. Activities of daily living and exercise

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 3. Body mechanics is of value to the nurse as it:
a. Decrease risk for injury
b. Promote active exercise
c. Reduce extra body fats
d. Increase energy conservation

Situation: Drug administration is one of the most common errors committed

by the nurse. Prudence, possession of adequate knowledge and sound
judgment are important when administering drug to a client.

4. The doctor ordered for MgSO4 5 gram to be injected on each buttock? How
may cc will you inject on each buttock if the stock dose is 250 mg/cc in a
10 cc ampule?
a. 10cc
b. 20cc
c. 50cc
d. 100cc

5. The best site for injecting a drug to a 6 month old child is the:
a. Dorsogluteal
b. Vastus lateralis
c. Ventrgluteal
d. Rectus femoris

6. The nurse is going to irrigate the left ear of a 2 year-old child. What should
be her position?
a. Left lateral
b. Right lateral
c. Sitting with head tilted to the left
d. Sitting with head tilted to the right

7. To straighten the ear canal of a 5 year-old-child, you must:

a. pull the external ear upward, backward
b. pull the external ear downward, backward
c. pull the external ear downward, forward
d. pull the external ear upward, forward

8. In inserting rectal suppositories, the adult client should be positioned in

left lateral and encouraged to:
a. bear down during insertion
b. hold breathe during insertion
c. insert the suppository 1-2 inches
d. retain the suppository for 30-45 minutes

9. The mother brought her child at the health center because of diarrhea. IVF
was inserted to rehydrate the client. The doctor ordered that the IVF
should be regulated at 30gtts/min for the first three hours and the
remaining solution should run for 8 hours. What will be the regulation of
the remaining solution?
a. 5-16gtts/min
b. 20-21gtts/min
c. 24-25gtts/min
d. 29-30gtts/min

10. The nurse teaches a client about insulin and how to inject it. The nurse
explains to the client techniques to prevent inflammation and damage to
tissue at the injection site. Which of the following techniques is best?
a. Injecting the needle at 45 degree angle
b. Administering the insulin in alternate sites
c. Avoiding massage at the injection site after giving insulin
d. Facing the bevel of the needle toward the patient when injecting
the needle
11. If a client is receiving iron pills, which of the following laboratory test
should be assessed?
a. Occult blood
b. Hematocrit

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 c. RBC
d. Hemoglobin

SITUATION: Nurses are also tasked to perform certain procedures as

ordered by the doctor. These procedures are essential to meet the client’s
needs.

12. When catheterizing a female client, all of the following are correct
procedures EXCEPT:
a. The client is positioned in horizontal recumbent
b. The vestibule is swab with antiseptic solution
c. The catheter is lubricated with a water soluble jelly
d. The catheter is inserted into the bladder

13. Which of the following techniques should be done when inserting a cathter
into an adult male penis?
1. lifting the penis at 45 degree angle to the clients body
2. insert the catheter 6-8 inches
3. sterile technique should be observed
4. use Fr. 12 catheter to avoid trauma to the urethral sphincter
a. 1,2
b. 1,2,3
c. 2,3,4
d. All

2. Why should the nurse should asks the client to hyperextend the neck
during the insertion of the NGT towards the nasopharynx?
a. Avoid insertion of the tube to the trachea
b. Lessen the nasopharyngeal curvature
c. Prevent aspiration
d. Close the glottis

3. Which of the following actions SHOULD NOT be done when giving NGT
feeding?
a. Place the client on fowler’s position
b. Assess tube placement
c. Allow the formula to flow by gravity
d. Assist the client comfortably in right Sims after the feeding

4. If a client makes the following comments after about half of the blood is
transfused, which one should cause the nurse to suspect that the client is
having a transfusion reaction?
a. “I am thirsty.”
b. “I feel so tired.”
c. “I feel cold.”
d. “I need to go to the toilet.”

5. A client appears to have a reaction to the blood being transfused. The

nurse’s first course of action should be to:
a. Administer oxygen at 2 LPM
b. Discontinue the transfusion
c. Clamp the tubing to stop the blood flow and open the clamp to
normal saline
d. See to it that the nurse-in-charge and the blood bank are notified
immediately

6. A 24 hour urine collection was ordered. You should:

a. add preservative to the urine when needed
b. measure the urine output for the previous 24 hours
c. take the weight of the client before starting the collection of urine
d. add the last urine voided just before the 24 hour period ends

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 7. The nurses notes that the clients prothrombin time is 30 seconds. What
will be the best action of the nurse?
a. Apply the support stockings before getting out of bed.
b. Allow for rest periods while providing care.
c. Encourage client to ambulate.
d. Observe for bleeding tendencies.

8. When dressing a contaminated wound, you must keep in mind the

following EXCEPT:
a. Use a non-irritating disinfectant solution
b. Isolate client from those with clean wounds
c. Disinfect all instruments used
d. Apply heat around the area after dressing

SITUATION: Stress is always a fabric of life and may cause major life crisis.

9. Adaptation refers to the:

a. preventive measures to avoid stress
b. adjustments done by the individual to maintain homeostasis
c. ability to succeed in all types of endeavor
d. situation that requires problem solving approach

10. A syndrome of psychosocial and physiological exhaustion, decrease

perception and personal accomplishments due to chronic stress is known
as:
a. adaptation
b. stressor
c. crisis intervention
d. burn out

11. Which of the following theories explain that stress is demonstrated by a

specific physiological reaction without consideration of cognitive
influences on the person?
a. Stimulus-based model
b. Adaptation model
c. Response-based model
d. Transaction-based model

12. Which of the following actions are most helpful to relieve Sam of his
stress?
a. Teach him about the different coping mechanisms which he can
utilize
b. Make an ongoing assessment of specific stressors, support given
and coping status
c. Respect his privacy by allowing him to be alone as much as
possible
d. Encourage his family and friends too encourage him to work out his
problems

13. Uma, 50 year-old and a cancer client, asked you to explain to him, his
illness. Which of the following will be your best response?
a. “Are you afraid to die?”
b. “Tell me how you feel about your illness?”
c. “What do you want to know?”
d. :Your doctor will explain to you more about your illness.”

14. Nurse Say is going to admit Mr. JB who is suffering from abdominal pain.
Which of the following objectives is more appropriate if Nurse Say will
utilize Adaptation Model of Stress?
a. Relief of pain
b. Relief of anxiety
c. Promote comfort
d. Prevent injury

15. After surgery (gastric resection) you will expect the drainage from the
nasogastric tube to be bloody for at least:
a. 6-12 hours

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 b. 12-24 hours
c. 24-32 hours
d. 32-72 hours

16. Why is a cleansing enema ordered in preparation for IV Pyelography?

a. to permit maximum filling of the bladder with radiopaque dye
b. to minimize discomfort during the procedure
c. to facilitate passage of cystoscope into urethra
d. to promote better visualization of his kidneys, ureters and bladder

17. Immediately after the physician told Mr. Panero that he is to have a
colostomy, what should the nurse do to support the patient?
a. give silent support to Mr. Panero’s feeling that the colostomy is
temporary
b. allow Mr. Panero to substitute the nurses strength for his weakness
c. explain to patient what procedures will be carried out before the
operation
d. let Mr. Panero take the lead to be angry, to deny or to retreat

18. In history-taking, which of the following considerations is most important if

the patient is elderly?
a. the usual routine information is adequate
b. start with mental status examination to validate reliability of
informant
c. avoid long interviews, obtain needed information as quickly as
possible
d. adjust method and pace of information gathering due to clients
sensory deficits

19. What principle is used in giving tepid sponge bath to lower elevated body
temperature by assisting the skin in its thermoregulatory function?
a. dissipation
b. conduction
c. convection
d. radiation

20. As part of the diagnostic work-up, Mr. Andrade is scheduled for a

bronchoscopy and a biopsy. Atropine, 1/150 grain, is ordered before the
procedure. The nurse should explain that this medication is helpful
because it:
a. reduces bronchial secretions and relaxes the bronchi
b. will induce sleep and prevent vomiting
c. strengthens the heart rate and reduces bronchial secretions

21. Mr. Nebres has been started on sitz bath and will have to contribute them
at home. Instructions should include directions to be sure to take them:
a. after exercise
b. after bowel movement
c. before exercise
d. upon arising and at bedtime

22. Mr. De Luna asks you what to expect after his upper gastro intestinal
series (UGIS). Your most appropriate response will be:
a. you will be able to move your bowels easily
b. you will be given an enema or a cathartic to expel the contrast
media
c. your dietary regimen will be changed
d. you will notice that your stool is dark in color

SITUATION: Accidents are the leading cause of death in persons younger

than 45 years resulting in injuries, deaths and sufferings that cannot be
measured in pesos. The role of the nurse in its prevention and management
require that she has to be knowledgeable of the basics of emergency care.

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 23. Because falls accounts for the highest cause of home accidents, what
home safety measures do NOT apply?
a. hand rails in bathrooms/ showers
b. risers in stairs marked with contrasting color plus good lighting
c. residential fire hazards
d. avoidance of slippery floor

24. Safety measures to prevent falls of hospital patients include bed side rails,
which group of patients do not need side rails?
a. weak but desiring to be independent
b. unconscious
c. those for executive/ general check-up
d. confused

25. Data collection in the treatment of emergencies is important before

instituting nursing interventions. What is the ABC of emergency
assessment?
a. Assist, Beware, Care
b. Airway, Breathing, Circulation
c. None of these
d. Analysis, Bleeding, Consciousness

26. What is the papillary response in unconscious patients caused by CVA or

intracranial hemorrhage?
a. Equal maybe dilated or constricted
b. Equal usually dilated
c. Fixed, no response to light
d. Usually unequal

27. What specific emergency care problem is suggested by shallow

respiration?
a. shock
b. central nervous system problem
c. airway obstruction
d. acidosis

28. When an accident victim gasps for air or make efforts to overcome
decreasing oxygenation. What is the proper term used?
a. laryngospasm
b. airway obstruction
c. carbon monoxide poisoning
d. asphyxia

29. In the first step for cardio-pulmonary resuscitation, level of consciousness

is assessed. If patient does not respond to shaking by answering you, what
is the safest position to place the patient in?
a. Support patient in standing position for the Heimlich abdominal
thrust maneuver
b. Hyperextended neck using jaw thrust maneuver
c. Prone, using Head-tilt, chin lift maneuver
d. Supine, on firm surface

30. A nurse doing cardiopulmonary resuscitation (CPR) must be aware of the

most common complication despite correct CPR technique. Identify from
list below:
a. fracture of ribs
b. lung contusion
c. laceration of liver
d. fractured sternum

31. Patients with cardiac arrests, are usually injected with atropine sulfate.
What is its principal action in this case?
a. causes vasoconstriction

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 b. accelerates heart rate
c. return serum PH to normal level
d. suppresses ventricular fibrillation

32. When there is ventricular fibrillation in cardiac arrest, Epinephrine HCL is

ordered. What is its expected effect?
a. shortens refractory period
b. increases cardiac output
c. suppresses ventricular fibrillation
d. improves force of contraction and regularity of heart beats

SITUATION: Aling Coring, 64 year old housewife is admitted to the hospital

with diagnosis of hypertension. Her husband is a casual employee and they
have 6 children.

33. Aling Coring has been found to be a non-compliant hypertensive patient.

Your conclusion was based on her:
a. partially used medications
b. age and lifestyle
c. lifestyle and diet
d. age and diet

34. Which of the following is correct using nursing diagnosis on Aling Coring’s
condition?
a. knowledge deficit regarding exercise
b. ineffective individual coping
c. knowledge deficit regarding home blood pressure recording
d. non-compliance due to lack of understanding about seriousness of
her illness

35. To enhance Aling Coring compliance, you should include in her care plan:
a. side effects of anti-hypertensive drugs
b. psychological characteristic of patient
c. active patient involvement
d. provide patient relationship

36. You explained the rationale for compliance which are:

a. fewer illness-related sexual problems and psychosocial pressures
b. higher quality life and enhanced family relations
c. fewer illness related to job problems and lower pressure readings
d. more knowledge regarding medication and side effects of
treatment regimen

SITUATION: The nurse is doing nursing intervention to pave the way for Jim to get
rehabilitated.

37. The nurse assesses Jim’s ability to use his left hand to replace his right-
hand functions. This nursing behavior directs nursing care toward
replacing deficit with other skills to help him to:
a. show to his family bright hopes towards full recovery
b. adapt to changed caused by the illness
c. cooperate with other health team members in his treatment
regimen
d. unload some activities of the health team

38. Jim is beginning to compensate the bad for the good arm’s functions. The
nurse should evaluate the effect of the lack of arm function on Jim as a
whole. Based on the findings, the nurse now modifies care to maintain not
just the musculoskeletal but to maintain the function:
a. in all subsystems
b. gradually in most of the systems
c. moderately on the unaffected
d. partially on the unaffected

39. Helping Jim to make use of his left side as much as possible so that he
returns to school and previous levels of functioning sooner. These nursing

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 behaviors clearly show that displacement from usual activities would
result in:
a. threat
b. deficit
c. problem
d. stress

40. The nurse arranges the overbed table so Jim can feed himself using his left
hand. The focus of nursing care is on Jim, in order to assess his ability to
complete self-care; may be wholly compensatory or care may be:
a. traditional
b. supportive-educational
c. comprehensive
d. occasional

41. The nurse considers a health program towards Jim’s full adaptation when
she includes all of the following, EXCEPT:
a. self-concept
b. interdependence
c. dependence
d. physiological factors

SITUATION: You followed-up Aling Elma, a 55 year old. She was discharged
from the hospital after a stroke. She has paralysis of the left side of the
body. You made an assessment.

42. You prepare a plan of care for Aling Elma. Which of the following would be
your priority objectives?
a. encourage a gradual increase in activity to provide relief
b. prevent or minimize the effects of immobilization in certain parts of
the body
c. teach a member of the family to check patient’s blood pressure
d. none of the above

43. One of the physicians instructions is to continue with patients passive

range of motion exercises. In your visit, you therefore:
a. Explained to Elma’s daughter that the patient extremities must be
exercised at least twice daily
b. Exercise the patients muscles by moving the extremities in a
prescribed manner
c. Encourage the patient as you watch her to move extremities in a
prescribed manner
d. Advised that the patient should exercise her extremities whenever
she feels like doing it

44. You further explained to Aling Elma’s daughter the need of properly
position the patient in order to prevent:
a. muscular dystrophy and osteoporosis
b. contractures and pressure sores
c. osteoporosis
d. muscular atrophy

45. During your home visits, you always advise Aling Elma or daughter to
remind Aling Elma to do which of the following in order to prevent
hypostatic pneumonia:
a. body massage
b. deep breathing and coughing
c. take regular meals and snacks to increase body resistant
d. active and passive exercises

46. Concerned of Aling Elma’s health, you taught her daughter to explain a
nourishing well-balanced diet. As you teach, you must know that protein is
catabolized to meet energy needs when the diet is lacking in:
a. carbohydrates
b. vitamins
c. fats

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 d. potassium

SITUATION: Mang Pantaleon, 35 years old, sustained multiple wound injury

in both his legs after a vehicular accident. After suturing his wounds,
Penicillin is prescribed.

47. Which of the following may developed when a patient is under penicillin
treatment?
a. hypersensitivity
b. drug tolerance
c. infection at injection site
d. ringing at the ear

48. For pain, the doctor ordered Demerol IM 75mg, stat. The available stock is
50mg per ml in a 10cc. How much will you inject?
a. 1/2ml
b. 1 1/2ml
c. 1ml
d. 1.75ml

49. When giving any medication, which of the following is of prime importance
to record?
a. the expected effect of the drug
b. the action of the drug
c. the route of administration
d. side effects of the drug

50. In penicillin intramuscular injection, which of the following is most

important?
a. ask name of patient before injecting
b. do a skin test for any allergy
c. explain the procedure to the patient
d. dilute the penicillin vial as ordered

SITUATION: Mrs. Gonzaga is admitted to the hospital with a diagnosis of

hypertension. Her vital signs are a temperature of 98.4oF (36.9oC), a
pulse rate of 80 beats/minute, a respiratory rate of 20 breaths/minute,
and a blood pressure of 190/110. She is placed on antihypertensive drug
therapy and a low sodium diet.

137. Which independent nursing intervention would be appropriate for Mrs.

Gonzaga?
a. Assess the patient’s blood pressure before administering
antihypertensive medication
b. Place the patient in the Trendelenburg postion
c. Assess the temperature, pulse, rate and respiratory rate every hour
d. Wear gloves when auscultating the blood pressure

138. The physician orders a platelet count to be performed on Mrs. Gonzaga after
breakfast. The nurse is responsible for:
a. Instructing the patient about the diagnostic test
b. Writing the order for this test
c. Giving the patient breakfast
d. All of the above

139. Give Mrs. Gonzaga breakfast at the scheduled time is a nursing intervention
belonging to which of the following categories?
a. referral
b. teaching
c. diagnosis
d. therapy

140. A diagnostic nursing intervention for Mrs. Gonzaga would be:

a. assess the patient’s blood pressure every four hours
b. maintain the patient on bed rest
c. administer Phenobarbital 30mg by mouth every four hours
d. ask the dietician to explain the 500mg low sodium diet to the patient

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 141. An interdependent therapeutic nursing intervention for Mrs. Gonzaga would
be:
a. administer 30mg of oral Phenobarbital every four hours
b. escort the patient to the laboratory for a platelet count
c. refer the patient to the dietician
d. assess vital signs every four hours

142. Mrs. Gonzaga continues to have an elevated blood pressure of 184/106, and
the physician orders bed rest. The nurse explains to the patient the primary
reason for bed rest is to:
a. decrease cardiac output
b. decrease metabolic activity
c. conserve energy
d. reduce oxygen use

143. Mrs. Gonzaga has been given a copy of her diet. The nurse discusses the
foods allowed on a 500mg low sodium diet. These include:
a. a ham and swiss cheese sandwich on whole wheat bread
b. mashed potatoes and broiled chicken
c. a tossed salad with oil and vinegar and olives
d. chicken bouillon

144. A patient with signs and symptoms of congestive heart failure and leg
edema has been placed on diuretic therapy. Which of the following data would best
gauge his progress?
a. fluid intake and output
b. vital signs
c. weight
d. urine specific gravity

145. The best way to observe whether a patient is complying with fluid restriction
is through:
a. weight
b. fluid intake and output records
c. urine pH
d. urine specific gravity

146. Postural drainage to relieve respiratory congestion should take place:

a. before meals
b. after meals
c. at the nurses convenience
d. at the patients convenience

147. Immobility impairs bladder elimination, resulting in such disorders as:

a. increased urine acidity and relaxation of the perineal muscles, causing
incontinence
b. urine retention, bladder distention, and infection
c. diuresis, natriuresis, and decreased urine specific gravity
d. decreased calcium and phosphate levels in the urine

148. Constipation is a common problem for immobilized patients because of:

a. decreased peristalsis and positional discomfort
b. an increased defecation reflex
c. decreased tightening of the anal sphincter
d. increased colon motility

149. Which of the following statements is incorrect about a patient with

dysphagia?
a. the patient will find pureed or soft foods, such as custards, easier to
swallow than water
b. Fowler’s or semi-Fowler’s position reduces the risk of aspiration during
swallowing
c. The patient should always feed himself
d. The nurse should perform oral hygiene before assisting with feeding

150. A healthy adult’s body compensates for decreased urine output by:

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 a. decreased sweating
b. increased sweating
c. thirst
d. bladder distention

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