1. Assessment of the thorax includes the palpation of the tracheal position. Mr.

Tiny has been

recently admitted to the unit because of chest trauma d/t a vehicular accident. Dyspnea, anxiety,
tachypnea and tachycardia suddenly developed. Hyperresonance of the right lung field is
observed. Tension pneumothorax of the right lung is suspected. Which of the following
assessment findings if found by Nurse Bradwarden would indeed confirm the suspicion of
tension pneumothorax?
Choose one answer.

a. tracheal deviation to the left
A tension pneumothorax may generate sufficient
pressure inside the chest to force the trachea
towards the unaffected side. In this case, the
right lung is affected by tension penumothorax
and the trachea is expected to deviate towards
the unaffected side, which is the left. Tracheal
position at midline in the suprasternal notch is a
normal finding. (p. 465, Health Assessment and
Physical Examination by Estes 3rd edition,
2006)

2.Mr. Weasley, a client with nasoenteric tube feeding suddenly developed coughing, dyspnea,
and cyanosis. Upon auscultation, there are crackles in the lungs. Nurse Potters immediate
response are all but one:

d. Prepare possible initiation of antibiotics
It is a part of delayed response
wherein there is already fever. All
the other options are immediate
responses on aspiration of stomach
contents in the respiratory tract.
Potter-Perry 2004
Correct

3. Caring is an aspect unique in nursing which involves a sense of harmony within the mind,
body and soul of a person. Nurse Boris is taking care of Patrick, a 65 year old man, who is
diagnosed as having terminal cancer of the bladder. Patrick is aware that he only has 2 weeks to
live so he tells Nurse Boris his wish to be visited by the hospital chaplain. He wants his religion
be changed from Protestant to Roman Catholic. Which aspects of caring will the nurse focus on
in this client?

b. Spiritual aspect of care
Just as everybody has a spiritual
dimension all clients have needs that
reflect their spirituality. These needs are
often accentuated by an illness or other
health crisis. The given situation is an
example of the need to take care of the
spiritual aspect of a person. The person
has the need to be certain there is a
God or Ultimate power in the universe.
(Kozier pp. 1042-1043)

4.To auscultate correctly, the nurse needs good hearing acuity, a good stethoscope, and
knowledge of how to use the stethoscope properly. The nurse uses a stethoscope to auscultate a
male patients chest. Which statement about a stethoscope with a bell and diaphragm is true?

a. The diaphragm detects high-pitched
sounds best
The diaphragm of a stethoscope detects high-
pitched sound best; the bell detects low
pitched sounds best. Palpation detects thrills
best.
Potter-Perry, 2004

5.Mrs. Luna Lovegood, 30 yrs. Old, suffers from abdominal gaseous distention. Nurse Potter
knows that the following may be prescribed:

b.Carminative Enema
They improve the ability to pass flatus. An
example is MGW solution, which contains 30 ml
of magnesium, 60 ml of glycerine, and 90 ml of
water.
Emollient enema or stool softeners are
detergents that lower surface tension of feces,
allowing water and fat to penetrate such as
Docusate sodium. Saline enema agents contain
salt preparation not absorbed by intestines.
Osmotic effect increases pressure in bowel to
act as stimulant for peristalsis such as Milk of
Magnesia, sodium phosphate/fleet enema.
Lubricants are agents that coat fecal contents,
allowing easier passage of stool such as Mineral
oil. Potter-Perry 2004

6.Before administering the evening dose of a prescribed medication, the nurse on the evening
shift finds an unlabeled, filled syringe in the patients medication drawer. What should the nurse
in charge do?

c. Discard the syringe to avoid a medication
error
As a safety precaution, the nurse should
discard an unlabeled syringe that
contains medication. The other options
are considered unsafe because they
promote error. Potter-Perry, 2004

7.Medication absorption is the process by which a drug passes from its site of administration into
the bloodstream. Which of the following are true in the absorption of medications?
i. Rich blood flow promotes faster absorption of medications
ii. Liquid medications are more rapidly absorbed than solid medications
iii. Exercise enhances absorption of oral medications
iv. High concentration of drugs promote rapid effect

b.i, ii, iv
Statements i,ii and iv are true statement in the absorption of
medication.Rich blood flow promotes faster absorption of medication
that is the reason why intramuscular injections promotes faster
absorption that subcutaneous injection. Liquid medications are more
rapidly absorbed than solid medications because it wont undergo
the process of disintegration. Drugs administered in high
concentration tend to be more rapidly absorbed than drugs
administered in low concentrations. Bolus dose (high concentration)
is given to obtain rapid effect of the drug. Number iii statement is
incorrect because exercise reduces blood supply to the stomach due
to sympathetic response; therefore it slows the absorption of oral
medication. (Karch, 2006)

8.Methotrexate is a folic acid analog under the anti-metabolite family. These drugs are
structurally similar to nutrients like purine, pyrimidine and folic acid but when synthesizes by
cells, metabolic pathways are disrupted leading to slowed growth or death. Methothrexate
(Folex) PO is prescribed to Mrs. Lina, a cancer patient who is a postpartum mother. All of the
following are pertinent health teachings for the patient except for one:

a. Take the tablet with meals.
The drug must be taken 1 hour before or 2 hours
after a meal because food decreases absorption
of tablets and reduces peak blood level.
Methotrexate is teratogenic with a pregnancy
category X. Drug therapy usually lasts for 5 days
so contraception is necessary for 1 menstrual
cycle. Breastfeeding is also contraindicated as
the drug can be passed to the infant. Undue
fatigue may be due to decreased RBC related to
bone marrow suppression. Infection due to
decreased WBC can also develop which is also
related to bone marrow suppression. (pp. 561-
563, Pharmacology for Nurses by Adams,
Holland and Bostwick 2nd edition, 2007; pp.
731-735, Nursing Spectrum Drug Handbook by
Schull, 2010)

9.The goal of IV fluid administration is to correct or prevent fluid and electrolyte disturbances.
Nurse Potter is observing Mr. Weasley for signs and symptoms indicating fluid or electrolyte
imbalances that may be affected by IV fluid administration. These signs and symptoms may be
present except:

c. Regular pulse rhythm
Rate and rhythm change can occur with
changes in intravascular volume, as well as
changes in potassium, calcium, and/or
magnesium. Change in body weight of 1 kg
corresponds to 1 L of fluid retention or loss.
With fluid volume excess, the cardiovascular
system is unable to compensate for this
excess and fluids build up in the lungs,
creating abnormal lung sounds and distended
neck veins.
Potter-Perry, 2004

10.Mr. Charlie was dying from lymphoma. Orange-size tumors had invaded his neck, groin,
chest and abdomen, and his doctors had exhausted all available treatments. Dr. Duyongco
prescribed a radical approach in the management of Mr. Charlie. Nevertheless, Mr. Charlie is
confident and strongly believes that a new anticancer drug called Vemurafenib would cure him,
according to the latest report by pharmaceutical-research company Plexxikon and
Roche/Genentech. Mr. Charlie is bedridden and fights for each breath when he received his first
injection. But three days later he is cheerfully ambling around the unit, joking with the nurses.
Mr. Charlies tumors had shrunk by half, and after 10 more days of treatment he was discharged
from the hospital. And yet the other patients in the hospital who had received Vemurafenib
showed no improvement. These impressive results may best be attributed to:


a. Placebo Effect
The patients attitude about a drug has been
shown to have a real effect on how that drugs
works. A drug is more likely to be effective if the
patient thinks it will work than if the patient
believes it will not work. (Karch, A.M., 2003,
Focus on Nursing Pharmacology, 2nd ed., 23,
25). A placebo effect is a psychologic benefit
from a compound that may not have a chemical
structure of a drug effect. (Kee, J.L., 2006,
Pharmacology: A Nursing Approach. p.11) It is
one elicited by the administration of any drug,
whether it is pharmacologically active or inert.
The effects vary from a variety of factors,
including relationship of the client with those
providing treatment, belief in the ultimate success
of their therapy, and the client's cultural and
ethnic background, as well as many other factors.
An idiosyncratic effect is one that is unexpected
and may be individual to a client; the drug may
have a completely different effect from the normal
one or cause unpredictable and unexplainable
symptoms in a particular client. Tachyphylaxis is
drug tolerance to a frequently repeated
administration of a certain drug.First-pass effect
(hepatic first-pass effect) is the process in which
the drug passes to the liver first. (Broyles, B.,
2007, Pharmacological Aspects of Nursing Care,
7th ed., p.26.)




11.Nurse Potter knows that the correct length of insertion of the rectal tube for Mrs. Luna
Lovegood is:

d. 7.5-10 cms
Adult 7.5-10 cms(3-4 in)
Child 5-7.5cms (2-3 in)
Infant 2.5-3.75 cm (1-1.5 in)
Potter-Perry 2004

12.Mr. Clinx, along with his two grandchildren, which are also his primary caregivers, is also
present in the health teaching class. The 77-year old patient asks you about his problem, which is
related to hearing. I often have trouble hearing what my grandchildren are saying to me. Mary
and May often shouts in front of me, but I still have trouble understanding them. Is this normal
nurse? What should I do? Nurse Raigor responds incorrectly to the patient by saying:

a. Hard consonants like k, d and t and long
vowel sounds like ay, ee are most difficult to
understand, while sibilant sounds like s, th and f
are the easiest to hear for you.
Hard consonants (k, d and t) and long vowel
sounds (ay, ee) are the easiest to
understand, while sibilant sounds (s, th and
f) are the hardest to understand for elderly
patients with hearing problems. Sounds in
low frequencies are more easily understood
than higher-frequency sounds. Presbycusis
is a normal change that comes with aging,
and usually affects people over 65,
particularly males. Impacted earwax can
also contribute to hearing problem, so it
must be removed. Assistive devices can be
used if hearing is already diminished.
(p.415, Fundamentals of Nursing by Kozier
et.al. 8th edition, 2008)

13.Which of the following is an incorrect way of breaking an ampule in preparation for drug
withdrawal?

c. Use a piece of sterile gauze
between your thumb and the ampule
neck and break off the top by bending
it away from you.
Use an ampule opener or place a piece of sterile
gauze or alcohol wipe between your thumb and
ampule neck or around the ampule neck, and
break it off the top by bending it toward you to
ensure the ampule is broken away from yourself
and away from others. The sterile gauze protects
the fingers from the broken glass, and any glass
fragments will spray away from the nurse. Place
antiseptic wipe packet over the top of the ampule
before breaking off the top. This method ensures
that all glass fragments fall into the packet and
reduces the risk of cuts. (Berman, A. (2008).
Fundamentals of Nursing New Jersey: Pearson)


14.The concepts of man forms the first foundational component of nursing. To be able to provide
individualized, holistic, humane, ethical and quality nursing care, it is primary consideration to
understand MAN. The theory on man as a Biopsychosocial and Spiritual Human being by Sister
Callista Roy conceptualizes the following except:

c. Man, is a spiritual being only when
he professes that he believes in
God.
According to the theory on Man as a
Biopsychosocial and Spiritual being, all men are
spiritual in nature. Man, as a biologic being is like all
other men because all men have the same basic
human needs. Man, as a psychologic being is like
no other man because man is a unique,
irreplaceable, one time being. Man, as a psychologic
being has the following characteristics: rational but
at times irrational, mature with core of immaturity,
with limited and unlimited nature, and a being who is
usually at the crossroads of indecisiveness. Man, as
a social being is like some other men because a
group of people have common attributes that make
them different from other groups. (Udan, 2009)

15.Mrs. Lich, an elder woman, asks Nurse Raigor about changes in the body with regards to
sexual function. Why is there pain when we have sex with my husband? Is there something
wrong with me or is it just normal? she asked. The nurses best answer is:

b. Painful intercourse in an elderly woman is usually
caused by changes in vaginal secretion production. I
recommend using lubricating jellies and if the pain is
still present, address it to me or to your
doctor.
Women experience different changes
related to intercourse. One of these
changes is related to vaginal secretions.
It takes longer for a woman to produce
vaginal secretions during intercourse
and also the production is decreased,
which can be the cause of painful
intercourse. Lubricating jellies can be
recommended. These changes are only
normal. Going to a gynecologist is
unnecessary since the problem can be
addressed by using artificial lubricants.
The husband has nothing to do with the
problem. (pp. 415-416, Fundamentals of
Nursing by Kozier et.al. 8th edition)

16.Airborne precaution are used for microorganisms transmitted by small-particle that can remain suspended
and widely disperesed by air currents. Nurse Ron enters the room of the client on airborne precautions due to
tuberculosis. Which of the following are appropriate actions by Nurse Ron?
i. He wears mask covering, covering the mouth and nose.
ii. He washes his hands before and after removing gloves, after suctioning the clients secretions.
iii. He removes gloves and mask before leaving the clients room.
iv. He discards contaminated suction catheter tip in a trash can found in the clients room

c. i, ii, iii and iv
The mask should cover the nose and mouth snugly. The hands
should be washed befcre and after removing the gloves . Gloves
and mask should be removed before leaving the clients room, to
contain the microorganisms within the clients unit. Contaminated
articles like suction catheter should be discarded in a trash found in
the clients room to prevent contamination of the outside
environment. (De Laune,2006)

17.A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse
asks the patient to repeat the instructions. The nurse is performing which professional role?

d.Educator
When teaching a patient about medications
before discharge, the nurse is acting as an
educator. The nurse acts as a manager when
performing such activities as scheduling and
making patient care assignments. The nurse
performs the care giving role when providing
direct care, including bathing patients and
administering medications and prescribed
treatments. The nurse acts as a patient
advocate when making the patients wishes
known to the doctor. Potter-Perry, 2004
Correct

18.A female patient with a terminal illness is in denial. Indicators of denial include:

d. Shock dismay
Shock and dismay are early signs of denial-the first
stage of grief. The other options are associated with
depressiona later stage of grief. Anger-resists the
loss, may strike out at everyone and
everything.Potter-Perry, 2004

19.Communication is essential in establishing the helping-healing relationship between the nurse and the
patient. Important aspects of health education are information, communication and education. Which of the
following statements is most likely to promote a clients compliance in performing post-operative deep
breathing, coughing and turning exercises?

c. Deep breathing, coughing and turning
exercises will promote good breathing , body
circulation. This will prevent complications.
Giving information is a therapeutic technique of
communication,like giving explanation on the
benifits that a client will experience from deep
breathing,coughing and turning exercises
during post-operative period. Mentioning that
the exercises will cause pain would not promote
compliance. Enumerating the possible
complications and benifits using medical terms
would not promote compliance because the
patient may not understand the meaning of the
terms. The nurse should not give a vague
explanation and give the patient false
reassurance.(De Laune, 2006)



20.Inspection of the uvula is done by making the patient Ah. During the assessment, Nurse Lich notices that
the uvula is positioned at the midline of the soft palate and did not rise when the patient says Ah. Which of the
following actions should the nurse most appropriately do?

b.document the findings and report to the
physician
The uvula is normally found at the midline of the
soft palate. The soft palate and uvula should rise
symmetrically when the patient says Ah, which
indicates an intact CN X. An immobile uvula or a
uvula that does not rise may indicate damage to
the CN X and impairment of gag reflex. Having
the patient eat and drink might be dangerous.
This finding must be documented and reported
to the physician. (p. 604, Fundamentals of
Nursing by Kozier et. al. 8th edition, 2008; p.
405, Health Assessment and Physical
Examination by Estes 3rd edition, 2006)

21.Laxatives stimulate peristalsis and promote defecation. It is administered as ordered because overuse of
laxatives inhibits natural defecation reflexes,rebound constipation occurs. You are taking care of a patient who
is to undergo Barium enema. In preparation for this, he was ordered to take Castor oil. You know that castor oil
is what type of laxative?

b. a. Chemical stimulant
Castor oil provides chemical stimulation to the
intestinal mucosa, to increase peristalsis and
promote defecation. It is classified as a
chemical stimulant together with Bisacodyl
(Dulcolax) and Senna (Senekot). It may be
misleading to consider it as an oil for one might
classify it as a lubricant. Lubricants lubricates
the intestinal contents, example of it is mineral
oil.Stool softeners attract water into the
intestinal contents, example of it is Decosate
(colace). Bulk- forming laxative attracts water
into the lumen. Example of it are Lactulose,
Psyllium (Metamucil) and Milk of magnesia
(Karch, 2006)

22.Atelectasis is defined as the lack of gas exchange within alveoli, due to alveolar collapse or fluid
consolidation. Banehollow, a 4-year old child, was rushed to the ER after swallowing several pieces of clay.
After undergoing x-ray, the child is diagnosed with atelectasis of the right lung d/t to complete obstruction in the
right bronchus. Stat surgery is to be done. Which of the following assessment findings would Nurse
Bradwarden most likely find?

c. tracheal shift to the right, breath sounds absent
in the right lung, present in the left, dull
percussion on the right lung
In atelectasis, fewer aerating alveoli are
present and therefore have a lower
pressure. Therefore, the trachea is slightly
pushed by the healthy lung to the affected
side, which contains less air and lesser
pressure. Breath sounds are absent in the
right lung because alveoli are not
ventilated because air does not reach
them. Breath sounds are present in the
left lung because the alveoli are still
ventilated as the bronchus is
unobstructed. Dull percussion is elicited
because the alveoli are collapsed and air
is not present in the affected lung. (p. 473,
Health Assessment and Physical
Examination by Estes 3rd edition, 2006)

23.. In caring for a client receiving oxygen via nasal cannula which step takes precedence?

b. Attach the flow meter to the wall
outlet or tank.
Attach the flow meter to the wall outlet or tank.
Attach the humidifier bottle to the base of the flow
meter. Attach the prescribed oxygen tubing and
delivery device to the humidifier. Put the cannula
over the clients face, with the outlet prongs fitting
into the nares and the elastic band around the
head. (Berman, A. (2008). Fundamentals of
Nursing, (8th ed., p.1377) New Jersey: Pearson.)

24.Mrs. Rylai asked the nurse regarding urinary incontinence. She mentioned that she had been experiencing
incontinence for about a week now. She complains that she sometimes wets her underwear without her
noticing it. Is incontinence a part of getting old? What should I do about it? she asked. All of the following are
suitable responses to Mrs. Rylai except for one:

d. Incontinence is a typical part of aging so you
need not be so anxious about it.
It should be explained by the nurse that
Urinary incontinence (UI) is not a normal
change related to aging. The nurse must
promptly investigate UI, particularly of
new onset, because of its ill effects on
the patient, like social isolation, falls and
skin breakdown. Pelvic muscle exercises
and avoiding bladder irritants such as
chocolates, oranges, lemons, and
tomatoes help prevent or control UI.
(p.415, Fundamentals of Nursing by
Kozier et.al. 8th edition)

25.Cyclophosphamide (Cytoxan) is an alkylating agent which binds to the DNA and disrupts replication of cells.
Mrs. Mirana has been prescribed with cyclophosphamide (Cytoxan) PO for her cancer and has been taking the
drug for about a week. Which of the following assessment findings should immediately prompt Nurse Pudge to
report to the physician?

d. hematuria
Hematuria is a sign of hemorrhagic cyctitis,
which is an adverse effect of the drug. Several
metabolites of cyclophosphamide may cause
hemorrhagic cystitis if urine becomes
concentrated; therefore a high-fluid intake is
maintained during the course of
chemotherapy. Alopecia, N&V, as well as
thrompocytopenia are expected. Alopecia is
expected to subside and hair growth to return
once chemotherapy is over. Severe N&V
however, is an adverse reaction which
requires referral to physician. Platelet counts
as well as other blood cell counts are
expected to decrease, reaching a nadir at 6-
10 days, but eventually rises back to normal.
A persistent low platelet count beyond the
expected nadir however is abnormal. (pp.
558-559, Pharmacology for Nurses by Adams,
Holland and Bostwick 2nd edition, 2007; pp.
291-293, Nursing Spectrum Drug Handbook
by Schull, 2010)


26.Tactile or vocal fremitus is the palpable vibration of the chest wall that is produced by spoken words. Which
of the following assessment findings would be most likely found when Nurse Bradwarden assesses a health
individuals fremitus?

b. the fremitus created by the voices of
male patients are more readily palpated
than female voices
The low-pitched voices of males generate more
vibration and therefore are more readily palpated
than the high-pitched voices of females. The
fremitus are normally more pronounced in the
apex, over the trachea and major bronchi than in
the periphery and base of the lungs. There
should be bilateral symmetry of the fremitus. A
decreased or increased fremitus in either the left
or right indicates a disease or abnormality. (p.
615, Fundamentals of Nursing by Kozier et. al.
8th edition, 2008; pp. 463-464, Health
Assessment and Physical Examination by Estes
3rd edition, 2006)

27.Tamoxifen (Nolvadex) is an antiestrogen drug which exerts its therapeutic effect by blocking estrogen
receptors in breast cancer cells and activates estrogen receptors in other parts of the body. Nurse Pudge is
caring for 4 patients with breast cancer who are all taking tamoxifen. Who among the four patients would Nurse
Pudge report to the physician immediately?

c. Patient Drow, who complains of
swelling and tenderness in the leg
Tamoxifen is associated with an increased risk of
endometrial cancer and thromboembolic disease.
Calf pain or tenderness indicates DVT, which is a
form of thromboembolic disease. Tumor flare or an
idiosyncratic increase in tumor size, is an expected
therapeutic event in the initial stage of tamoxifen use.
Nausea and vomiting are expected of the drug.
Tamoxifen can also be used as a prophylaxis for
patients who are high-risk candidates for developing
breast cancers (older than 35 and have at least
1.67% chance of developing breast cancer in the
next 5 years. (pp. 569, Pharmacology for Nurses by
Adams, Holland and Bostwick 2nd edition, 2007; pp.
1122-1123, Nursing Spectrum Drug Handbook by
Schull, 2010)

28.The overall goal of bladder retraining is to restore a normal pattern of voiding. Nurse Snape tells the
incontinent client the different measures to gain control over urination which are all but one of the following:

c. None of the above
All are part of the restorative and rehabilitative
care. Other measures are: initiating a toileting
schedule on awakening, at least every 2 hrs
during the day and evening, before getting into
bed, and every 4 hrs at night.
Using methods to relax and aid complete
bladder emptying (reading and deep
breathing)
Minimizing tea, coffee, other caffeine drinks,
and alcohol
Taking prescribed diuretic medication or fluids
that increase diuresis early in the morning
Sampselle 2003s

29.Air rushing through the respiratory tract during inspiration and expiration generates different breath sounds.
Considering that he is a healthy male adult, when Nurse Bradwarden auscultates the area above his own
trachea, all but one of the following statements correctly describes the expected assessment finding?
Choose one answer.

a. vesicular breath sounds are
expected
Bronchial or tubular breath sounds is expected
over the trachea. Vesicular breath sounds are
heard over the peripheral or bases of the lungs.
All other options correctly describe bronchial or
tubular breath sounds. It has a high pitch with a
loud, harsh quality. It is heard longer during
expiration than inspiration (1:2). (p. 613,
Fundamentals of Nursing by Kozier et. al. 8th
edition, 2008; pp. 469-470, Health Assessment
and Physical Examination by Estes 3rd edition,
2006)

30. Off-label drug use occurs when a drug is approved by the FDA; the therapeutic indications for which the
drug approved are stated. Once a drug becomes available, it is sometimes used for indications that are not part
of the approved indications. Which of the following best shows the risks of off-label use of drugs?
Choose one answer.

a. Glutathione IV injection for purposes of
skin whitening
Glutathione IV, according to MIMS Philippines, is
prescribed for Adjunct treatment to minimize the
occurrence of toxicity associated w/ cisplatin
chemotherapy. The Department of Health issued
DOH-FDA Advisory No. 2011-004 dwelling on
safety issues of the off-label use of glutathione
solution for injection, namely: (1) Stevens
Johnsons Syndrome/TENS; (2) Derangements in
the thyroid function; (3) Suspected kidney
dysfunction potentially resulting in kidney failure;
(4) Severe abdominal pain in a patient receiving
twice-weekly; (5) sepsis; (6) air embolus; (7)
transmission of Hepa B and HIV; (8) use of non-
sterile preparation, leading to serious infections.
Clinical trials have shown that Gabapentin, which
is oft-marketed as an anti-seizure medication,
works effectively in the treatment of phantom
limb pain. Tricyclic Antidepresant are approved
and labeled to be used for clinical depression.
Today these drugs are seldom used for
depression because safer drugs are now
available to treat it. But doctors have found that
the tricyclics often work very well in treating
certain types of pain. Misoprostol is actually
labeled as being used for Termination of
pregnancy (?49 days of duration). Hence, this is
not an off-label use.

31.Inspection of the tonsils requires taking note of the color, discharge and size. Nurse Lich documents kissing
tonsils after inspecting Mr. Purists oral cavity. The best description for this would be:

b. Grade 4 or +4 one or both tonsils
extend to the midline of the oropharynx

Kissing tonsils means that the tonsils are already
touching each other, meaning that they are
already Grade 4 or +4. This indicates that both
tonsils have already extended up to the midline of
the oropharynx. Grade 1 is when the tonsils are
behind the tonsillar pillars. Grade 2 is when the
tonsils are between the pillars and uvula, Grade 3
is when the tonsils touches the uvula. Grades 3
4 already indicate tonsillitis while normal tonsillar
size is Grade 1 and 2. (p. 604, Fundamentals of
Nursing by Kozier et. al. 8th edition, 2008; p. 406,
Health Assessment and Physical Examination by
Estes 3rd edition, 2006)

32.Doxorubicin is an antitumor antibiotic which attaches to DNA, distorting its double helical structure and
preventing normal DNA and RNA synthesis. It is used for a variety of solid tumors. Mr. Gondar, a patient with
lung cancer, has been prescribed with doxorubicin (Adriamycin). During drug preparation and administration,
which of the following should Nurse Pudge not follow?

d. back pain, chest tightness and flushing
are expected but stay alert for
erythematous streaking along vein next to
injection site, which may indicate too-rapid
infusion
Back pains, chest tightness, flushing, as well as
erythematous streaking along the vein next to
the injection site are all acute infusion-related
reactions due to rapid administrations. These
are not expected effects of the drug. The drug is
easily absorbed in the skin and by inhalation so
protective equipment is worn during preparation.
Administer the drug using a large vein slowly for
3-5 minutes into tubing of free-flowing IV
infusion of either NSS or D5W. Extravasation
from an injection site can cause severe pain and
extensive tissue damage. The most serious
adverse effect is cadiotoxicity. Acute effects
include arrhythmias, and delayed effects include
irreversible heart failure, that is why cardiac
monitoring is essential. (pp. 563-565,
Pharmacology for Nurses by Adams, Holland
and Bostwick 2nd edition, 2007; pp. 378-381,
Nursing Spectrum Drug Handbook by Schull,
2010)

33.Mr. Balanar, another patient in his late 50s also asked questions regarding sexuality and aging. My older
friends here in the nursing home told me that by the time I reach 60 or 70 I would lose my libido and my ability
to produce sperm cells, and it would take longer for me to become sexually aroused and achieve ejaculation.
Are these all true? he asked. All but one of the following responses made by Nurse Raigor are correct:
Choose one answer.

a. Yes, interest in sex-related activities is
lost by the time you reach 60 or 70.
Interest in sex or libido is not lost with aging.
The elder mans libido may decrease, but it
should not disappear. Sperm cell production
still continues well into old age, but it gradually
decreases with aging. Sexual arousal as well
as ejaculation may take longer than when the
patient was still younger. (pp. 415-416,
Fundamentals of Nursing by Kozier et.al. 8th
edition)

34. Mrs. Villavicencio had been paralyzed for six months. Due to immobility she has acquired Stage IV
pressure ulcer at her scapula. After cleaning her wound, a hydrocolloid dressing will be applied. Which of the
following is not an advantage of using hydrocolloid dressing?

b. They are occlusive, are opaque,
and obscure wound visibility.
Hydrocolloid dressings are waterproof adhesive
wafers, pastes, or powders. The inner adhesive
layer has particles that absorb exudates and form a
hydrated gel over the wound; the outer film
provides an occlusive seal. Its purpose is to absorb
exudates; to produce a moist environment that
facilitates healing but does not cause maceration of
surrounding skin; to protect the wound form
bacterial contamination, foreign debris, and urine or
feces; and to prevent shearing. (Berman, A. (2008).
Fundamentals of Nursing New Jersey: Pearson.)

35.Nurse Snape is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to
have difficulty retaining knowledge about prescribed medications?

d. Sensory deficits
Sensory deficits could cause a geriatric patient to
have difficulty retaining knowledge about
prescribed medications. Decreased plasma drug
levels do not alter the patients knowledge about
the drug. A lack of family support may affect
compliance, not knowledge retention. Toilette
syndrome is unrelated to knowledge
retention.Potter and Perry, 2004



36.Physiologic aging can be considered as a phenomenon, because no two individuals age in the
same way. That is why a number of theories have been created in order to explain such
phenomenon. Nurse Raigor most accurately refers to the free-radical theory when he states that:
Choose one answer.

a. Organic materials like proteins and
carbohydrates which undergo oxidation in our
body produce unstable groups of atoms, which in
turn cause changes in the cells in our body, and
the cells cannot regenerate themselves.
Our immune system becomes less
effective with age, resulting in reduced
resistance to infectious disease and
viruses and an increase in autoimmune
responses, causing the body to attack
itself. refers to immunological theory, Our
bodies become run down with time, like
cars. Our cells become worn out through
exposure to internal and external
stressors. refers to wear-and-tear theory,
and Our hypothalamus and pituitary
glands which chiefly regulate hormone
production are responsible for changes in
hormone production that result in the
decline of our body. refers to endocrine
theory. Other theories which explains
physiologic aging includes genetic and
cross-linking theories. (p.411,
Fundamentals of Nursing by Kozier et.al.
8th edition)

37.An enema is the instillation of a solution into the rectum and sigmoid colon. The physician
ordered a cleansing enema for Mr. Weasley, 45 yrs. Old scheduled for colonoscopy. Nurse Potter
shows competence in administering the enema if he does all but one of the following:
Choose one answer.

a. Prepares a rectal tube French size
12
Appropriate sizes:
Adult 22-30 Fr
Child 12-18 Fr
Assessment determines the factors indicating
need for enema and the type of enema use.
Applying gloves reduces transmission of
microorganism. Assisting the client into a left side-
lying position allows enema solution to flow
downward by gravity along natural curve of
sigmoid colon and rectum, thus improving
retention of solution.
Potter-Perry 2004




38.A medication error should be documented at the:

b. medication administration record
To prevent other caregivers from giving the
client additional doses of similar drugs or
doses of drugs that may be contraindicated it
should be documented on the medication
administration record or at the nurses notes.
Lois White. Documentation & the Nursing
Process pp. 102-103

39.To improve quality of care and prevent legal accountability, Nurse Czar plans to implement a
standard protocol on documenting nursing care. Which of the following should not be included
in the protocol?

c. Accurate, factual, time-sequenced, non-
descriptive notations
Documenting nursing care should be
accurate, factual, time-sequenced and
DESCRIPTIVE. All other options are correc..
Lois White. Documentation & the Nursing
Process p.80

40.Enteral Nutrition refers to nutrients given via the GI tract. It is the preferred method if the
clients GI tract is functioning. All of these are indications for enteral nutrition except:

c. Paralytic Ileus
Enteral nutrition is only used if there
is a functional GI Tract. In the case
of Paralytic Ileus, Parenteral Nutritin
may be used.
Potter-Perry 2004

41.Drug prescription should be written clearly and legibly. A prescription was given by the physician. The part
where the drug name, strength and dose are written is called:

b.Superscription
Inscription contains the drug name,
strength and dose. Superscription includes
the clients name, address and age.
Subscription contains directions about the
number of tablets or amount to be
dispersed that is given to the pharmacist.
(De Laune, 2006)






42.Administering medications to pediatric patients should be given extra caution as they are more prone to
toxicity and over or under dose. You are caring for an 11-month old infant who has a PRN order of Paracetamol
if temperature exceeds 380C. Your paracetamol at hand has a stock dose of 500mg/15ml. You know that the
average adult dose of paracetamol is 1000 mg. Using the appropriate formula in calculating pediatric dosage,
you would administer the correct pediatric dose of paracetamol to the infant which is?
Choose one answer.

a. 2.2 ml
Frieds rule applies to a child younger than 1 year of
age. The rule assumes that an adult dose would be
appropriate for a child who is 150 months old.
Childs dose= infants age in months x average adult
dose
e. 150 months

b. = 11 months x 1000mg
a. 150 months

c. = 73.33 mg

Desired dose x diluent
Stock dose
= 73.33 mg x 15 ml
500 mg
=2.2 ml

43.Vincristine is a vinca alkaloid antineplastic which kills cancer cells by preventing their ability to complete
mitosis. It is a cell-cycle specific drug, which specifically targets the M-phase. Pugna, a patient with leukemia
has been prescribed with vincristine (Oncovin). Nurse Pudge is correct when he follows which of the following
guidelines with the use of vincristine:

d. regularly monitor neurologic and
mental status, as well as feelings of
despair, verbalized suicide plan or
suicidal attempt
The most serious adverse effect of vincristine is
related to nervous system toxicity. Numbness
and tingling of the limbs and muscular weakness
should be assessed, as well as difficulty in
walking and talking. Visual disturbances can
also occur. Convulsions and feelings of despair
or suicidal plan or attempt can also happen.
Intrathecal administration is fatal. Bone marrow
suppression is minimal with vincristine. Severe
constipation is common, as well as reversible
alopecia. (pp. 566-567, Pharmacology for
Nurses by Adams, Holland and Bostwick 2nd
edition, 2007; pp. 1232-1234, Nursing Spectrum
Drug Handbook by Schull, 2010)





44.The ten rights of medication administration are: right medication, dose, client, route, time, documentation,
assessment, right to refuse, education and evaluation. A nurse is carrying out the doctors order. Which of the
following drugs should the nurse question if the doctor prescribed it to a client on Methotrexate therapy, who
has been observed with bleeding gums, blood in stools, urine and vomitus?

b. a. Naproxen
Methotrexate overdose can result to hematologic toxicity
(platelet levels are decreased). In order to prevent this
salicylates, NSAIDs, phenytoin, tetracycline and chlorampenicol
should be avoided. Examples of NSAIDs are aspirin,
indomethacin (Indocin), ibuprofen (Motrin), naproxen
(Naprosyn), piroxicam (Feldene), and nabumetone (Relafen).
The breakdown of methotrexate produces uric acid. Allopurinol
is used to decrease uric acid in Methotrexate therapy.
Leucovorin is given for Methotrexate overdose. Vincristine is an
anti-cancer drug used alone or with other antineoplastics (e.g.
Methotrexate) in treating cancer/leukemia.(Karch, 2006)

45.During an assessment, the nurse learns that the client has a history of liver disease. Which of the following
diagnostic tests is least indicated for this client.

b. Myoglobin
ALT is an enzyme that contributes to
protein and carbohydrate metabolism. An
increase in the enzyme indicates damage
to the liver. Alkaline Phosphatase is found
in the liver, bone, intestine, and placenta.
It is used as an index of liver and bone
disease when correlated with other
clinical findings. The liver contributes to
the metabolism which results in the
production of ammonia. If the liver is
damaged, the ammonia level will
increase. Myoglobin is a marker for
muscle damage. (Berman, A. (2008).
Fundamentals of Nursing (8th ed., p. 803
-804) New Jersey: Pearson)

46.When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse
effects. Which factor makes geriatric patients to adverse drug effects?

d. Aging-related physiological changes
Aging-related physiological changes account
for the increased frequency of adverse drug
reactions in geriatric patients. Renal and
hepatic changes cause drugs to clear more
slowly in these patients. With increasing age,
neurons are lost and blood flow to the GI
tract decreases.
Correct




47.Jo, a postoperative client has not been able to void. The physician has ordered the client to have a urinary
catheter inserted. After explaining the procedure to the client, the nurse can facilitate the insertion by asking the
client to:

b.Breathe deeply
When inserting a urinary catheter, facilitate insertion
by asking the client to breathe deeply. Doing this will
relax the urinary sphincter. Initiating a stream of
urine isnt recommended during catheter insertion.
Holding the penis or the labia wont ease insertion,
and doing so may contaminate the sterile field.

48.Nursing theory guides knowledge development and directs education, research and practice. Health is a
fundamental right of every human being. The theorist who advocates that health is the ability to maintain
dynamic equilibrium is:

c.Walter Cannon
Walter Canon advocates that health is the ability to
maintain dynamic equilibrium (homeostasis) It is
regulated by the negative feedback mechanism.
Bernard advocates that health is the ability to maintain
internal milieu and that illness is the result of failure to
maintain the internal environment. Hans Selye is the
father of modern stress theory. Betty neuman believes
that health is a condition in which all parts and
subparts of an individual are in harmony with the
whole system.(Udan, 2009)

49.To prevent documentation discrepancies, Nurse Czar plans to implement a standard protocol on
documenting nursing care. In planning the protocol, she should know that documentation of the nursing care
the client receives must:
Choose one answer.

a. never have an error
Error is not allowed in documentation as much as
possible. It should not have spaces between
entries. Entries should be signed every after
documenting it not at the end of the shift. Finally
documentation must reflect the nursing process.
Lois White. Documentation & the Nursing Process
p.80

50.Assessment of the eyes includes the performance of the corneal reflex test. Nurse Lich is about to perform
corneal reflex test as part of the physical assessment of Mr. Purist. Which of the following statements should he
least likely consider?

b. ask the patient to look towards the
right if right-handed, and look towards
the left if left-handed
The patient is asked to keep both eyes open and
to look straight away so that he/she will not see
the gauze while it approaches the outer canthus of
the eye. This avoids making the patient
unnecessarily blink before the gauze touches the
cornea. All other options are correct. (p. 589,
Fundamentals of Nursing by Kozier et. al. 8th
edition, 2008)