SITUATION: Mrs. Torres, a 63 year old client, is diagnosed with terminal illness.

You are assigned to take care of her.

1. Upon learning about her condition, Mrs. Torres became verbally hostile to her family and health team. Which of the
following is the nurses best approach?
A. Explain the situation C. Ignore the behavior
B. Encourage the client to verbalize feelings D. Quiet acceptance of her behavior

2. When the family learned of the clients condition, the family became indifferent. What is the best possible explanation of
their behavior?
A. Family members require more nursing care
B. Experience of powerlessness by family members
C. Inability to anticipate the medical crisis of the family
D. Husband and children are saddened upon knowing her condition

3. The nurse is aware that the characteristic behavior of the clients like Mrs. Torres in the initial stage of coping with impending
death includes:
A. Refusing to talk to everybody
B. Crying most of the time
C. Staying quiet and uncooperative with the health team members
D. Seeking their opinion to disprove the inevitable

4. Mrs. Torres has reached the point of being able to accept death. In the stage of acceptance, the client will mostly likely
manifest which behavior?
A. Angry and depressed
B. Crying uncontrollably
C. Decreased anxiety and detachment from environment
D. Unmindful of her environment

5. Lately, the client appears happy but demonstrates lack of interest in what is going on around her. How should the nurse deal
with the client?
A. Recognize and accept the clients behavior
B. Allow the client to express her feelings
C. Explain the reality of the situation
D. Point out the importance of the acceptance of the situation

SITUATION: Nurse Lydia is taking care of an elderly female client in the Geriatric Unit. The client is taking concurrently several
drugs. In taking care of this client, it is important to understand special considerations for medication use.
6. The elderly client is receiving aspirin, a non-steroidal anti-inflammatory drug (NSAID), for pain due to osteoarthritis. In
administering the drug the nurse should take into consideration which of the following?
A. Administer the drug regularly to maintain a constant blood level in older adults
B. Use analgesic carefully
C. Assess the symptom of pain carefully for its underlying cause
D. Note signs of salicylate toxicity

7. Since elderly clients are sensitive to the effects of aspirin the nurse should be cautious in monitoring which of the following
side effects?
A. Delayed clotting time C. Hypoglycemic reaction
B. Liver damage D. Gastrointestinal bleeding

8. Mrs. Domingo, an elderly client is currently receiving an anti-hypertensive medication, Micardis Plus 40mg, daily. For clients
taking antihypertensive drugs which of the following guidelines should be INITIALLY considered by the nurse?
A. Monitor client closely when therapy is initiated
B. Be alert to drug interactions
C. Assess blood pressure carefully in lying, sitting and standing positions
D. Monitor client for side effects

9. Atorvastatin calcium (Lipitor), 40mg daily is prescribed to Mrs. Domingo who has elevated levels of low-density lipoprotein
(LDL) cholesterol. When the client asked the nurse why the drug was prescribed, the nurse should state that the drug:
A. Reduces cardiovascular moratality in older adults
B. Raises the high density lipoprotein
C. Inhibits the absorption of cholesterol in the intestines
D. Blocks the cholesterol in the liver

10. General guidelines for elderly clients taking cholesterol lowering drugs include the following EXCEPT:
A. Liver function and other necessary test as ordered
B. Monitor for drug interaction
C. Dietary and lifestyle modification
D. Presence of muscle pain
SITUATION: Educating the client and his family has been a professional responsibility of nurses. It is imperative that nurses carry-out
their roles competently and confidently.
11. Rica, a community health nurse, is conducting a classs on the the risk factors for cancer. Which of the following is NOT to be
included in the teaching?
A. Unexplained weight gain C. Hoarseness of voice
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 B. Difficulty swallowing D. Change in bowel habits

12. Mr. Simon, 50 years old, had undergone laryngectomy and is ready for discharge. Which of the following instructions is the
MOST appropriate for the nurse to give?
A. Limit fluid and food intake C. May take shower as needed
B. May pursue outdoor activities D. Keep stoma open

13. A school nurse is teaching self testicular examination to male college students. What relative information should be included
in the teaching plan?
A. Concern of adolescents in self testicular examination
B. Frequency of testicular examination
C. Hygiene regarading reproductive system
D. Anatomy and physiology of the testis

14. Raechelle, 40 year old, is being discharged following a right simple mastectomy. Which of the following statements of
Raechelle indicates understanding of the discharge teaching?
A. I will make sure that my right arm should be spared when taking my blood pressure
B. I should not have sexual relation with my husband for a couple of months
C. I will not raise my arm for one month
D. I should move my right arm only when necessary

15. In another group of students, Rica was teaching a class in the preventon of skin cancer. Which information should be
included regarding the reduction of the risk of skin cancer?
A. Applying body lotion and hand creams
B. Taking shower following outdoor activities
C. Avoid exposure to ultra violet rays
D. Taking shower after exposure to sun

SITUATION: A clients record contains a variety of information describing a detailed account of the quality of care delivered to
clients.
16. The nurse and doctor affix their signature after an entry in the clients chart. Which of the following statements is TRUE
regarding the signature after an entry in a record?
A. The signature designates accountability for the contents of that entry
B. In conveys direct care intervention
C. It means he/she has accomplished the procedures and treatment
D. The signature protects the nurse from any legal litigation

17. Computerized documentation system is developed in standardized format. For which of the following is it done?
A. Easy access to clients information data
B. Capturing useful information from individual and groups
C. Quality recording
D. Continuity of care

18. Nurse Sylvia is monitoring and recording the progress of a clients problem. She uses SOAP structure notes. SOAP means
subjective data and:
A. Objective data, assessment, process
B. Observation, action, process
C. Observe, assess, process
D. Objective data, assessment, plan

19. Nurses are legally and ethically obligated to maintain confidentiality of the patients record. For those who are not directly
involved in the care of the client but have legitimate reason to use record for research, they should:
A. Secure permission from the attending physician
B. Ask the clients permission
C. Secure authorization according to hospital policy
D. Talk with the head nurse of the unit for permission to have access of the chart

20. The initial step of the nurse in providing a complete nursing record is to:
A. Provide a clear and concise record of the nursing process
B. Determine the effectiveness of nursing care and all other actions and therapies
C. Determine what information to include in the charting
D. Record patients needs

SITUATION: Collaboration and teamwork among health professionals is expected to provide support in improving the health of the
clients.
21. Nurse Bea has to take of several clients in the ward. She delegates the task of performing morning care of a client to a
nursing aide. Which of the following conditions suggests responsibility of the nurse?
A. Nurse should check that the task is performed correctly
B. Nursing aide may ask for assistance if needed
C. Nurse is responsible for the actions of the nursing aide
D. Nurse should stay with the nursing aide during the entire time

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 22. Nurse Bea is also supervising a student perform tracheostomy care for Mr. Garcia, a 57 year old male. Nurse Bea intervenes
when the student nurse:
A. Changes the tracheostomy ties and secure the tube in place
B. Suctions the tracheostomy tube before starting to perform tracheostomy care
C. Removes old dressing and encrustations and cleans off excess secretions
D. Performs standard handwashing procedure before removing and cleaning the inner cannula

23. Mr. Robles has Chronic Obstructive Pulmonary Disease (COPD) requiring effective airway management. Nurse Bea decides
that she can seek the assistance of the nursing aide for which of the following tasks?
A. Assist client to sit up on the side of the bed
B. Give instructions on effective coughing exercises
C. Auscultate for breath sounds every four hours
D. Teach the client to use incentive spirometry

24. The charge nurse is making assignments for the next shift and she asks nurse Beas suggestion as to who among the patients
may be assigned to a newly hired nurse. Considering that the nurse has only 4 months work experience, the client that nurse
Bea would recommend would be:
A. Mr. Jose who needs to use an incentive spirometry
B. Mr. Robles with COPD who is in mechanical ventilator
C. Mr. Garcia with tracheostomy tube
D. Mang Tomas who is suspected to have a pulmonary embolus

25. Dr. Ricardo ordered a placebo to be injected to a client assigned to nurse Bea who suffers from chronic pain. She is not
comfortable with the idea of giving a placebo to the client. Nurse Beas most APPROPRIATE action would be to:
A. Follow her intuitive feelings since intuition is a good guide
B. Consult her charge nurse for advice
C. Look for hospitals policy regarding giving the placebo
D. Prepare the medication and give it to the doctor

SITUATION: Nurse Tina is preparing an IV solution ordered by the physician to a 68 year old male elderly client, admitted to the
Emergency Department for bouts of nausea and vomiting.
26. The nurses responsibility prior to the initiation of IV therapy is to:
A. Obtain informed consent and document in the clients permanent record
B. Prepare the client for the procedure and document in the clients medical record
C. Review the physicians order and gather the necessary equipment
D. Ask assistance from another nurse following hospital protocol

27. In initiating IV therapy, nurse Tina assesses the potential site. Which of the following should nurse Tina take into
consideration when assessing the venipuncture site?
A. Check expiry date, amount of solution and clinical impairment
B. Size of the needle and type of solution and condition of the client
C. Age, body size, clinical status and skin condition
D. Size of the vein, suitable location and type of solution

28. Prior to the insertion of the needle to the IV site, nurse Tina observes precautionary measures to ensure that the IV solution is
not contaminated or out dated by:
A. Assuring that the solution has been stored in the area assigned by the institution
B. Determining the amount of the solution, presence of particulate matter and expiry date
C. Checking for clarity of the fluid and manufacture date
D. Inspecting the bag for leaks, tears or cracks and expiry date

29. Nurse Tina is priming the IV tubing. This is accomplished by:

A. Attaching the IV tubing to the venipuncture catheter to prevent entrance of air into the tube
B. Opening the roller clamp on the tubing to allow the fluid to enter the tube and expel the air
C. Closing the roller clamp and replacing cap protector to prevent air from reentering the tube
D. Opening the clamp and regulating the flow of the IV solution or setting the flow rate

30. Which assessment finding would lead nurse Tina to suspect that the client is inadvertently received too much IV fluid?
A. Temperature has risen to 38.5 degree centigrade
B. Bounding pulse and crackles and wheezes in the lungs
C. Blood pressure is 160/70
D. Imbalances in arterial blood gases

SITUATION: The following situations are opportunities for the nurse to give health teachings to clients and their family members.
31. A client who had a cerebrovascular accident resulted in right sided weakness of extremities and mild slurring of speech. The
nurse is assisting the client to ambulate. To prevent the client from falling, the nurse should stand at the:
A. Left side with one arm of the around the clients waist
B. Right side and holding the clients arm
C. Right side with one arm around the clients waist
D. Left side and holding the clients arm
32. The use of principles of body mechanics is important when taking care of clients. To prevent injury to self and others, the
nurse teaches the family members to do which of the following?
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 A. Move about a foot away from the client if possible
B. Form a broad base of support, flex the knees and keep the feet wide apart
C. Use back and arm muscles to support lifting or moving activities
D. Bend from the waist with knees straight and feet wide apart
33. The clinic nurse in a large factory teaches some exercises to some office workers. Which of the following statements is the
most appropriate?
A. Exercises can easily burn and expend daily caloric intake
B. The best cardiovascular activity is walking on a threadmill
C. Less intense activity or not very tiring exercises should be done frequently and to be of value
D. Continuous activity for a long period is useful as an exercise
34. An elderly client has been taught how to use crutches in going up and down the stairway. You observe that clients use of
crutches is appropriate when he:
A. Uses the crutch next of the affected leg when going up or down the stairs
B. Advances the crutches first to go up the stairs then the affected leg
C. Uses the stair banister for support while going up or down the stairs
D. Advances the crutches to go down the stairs then move the affected leg afterwards

35. A mother calls the Emergency Unit to ask for advice after she found her child seated on the bathroom floor with cleanser
around her mouth and tongue. The appropriate advice given to the mother would be to:
A. Check if the child is breathing and if the airway is open
B. Give the child ipecac syrup to induce vomiting
C. Call the poison control of a general hospital
D. Remove the cleanser from the mouth and tongue
SITUATION: While working in a female medical ward, you are assigned to do physical assessment on several clients while under the
supervision of a staff nurse. Your basic knowledge in Anatomy and Physiology as well as scientific basis for certain nursing
procedures are important.
36. Mrs. Lopez, 53 years old, is your client. She had complaints of generalized weakness and is in the ward for observation and
evaluation. During physical assessment, you ask the client to make her chin touch the chest. As Mrs. Lopez performs the
movements as instructed, you assess the function of which of muscle?
A. Sternocleidomastoid
B. Trapezius
C. Deltoid muscle
D. Supraspinatus muscle

37. While inspecting the jugular veins of Mrs. Lopez foe distention, you should place her in which BEST position?
A. lateral position
B. high-Fowlers position
C. dorsal recumbent
D. semi-Fowlers position
38. You will assess the clients chest and you are also to perform breast palpation. Which of the following is the most appropriate
position of the client?
A. Supine position
B. Sims position
C. Sitting position
D. Semi-Fowlers position
39. Mrs. Lopez confesses that she has a lump on her left breast. Which of the following id the APPROPRIATE action of the
nurse?
A. Lift the clients hand to palpate the breast where she noted the lump
B. Assess the breast with the lump first
C. Palpate both breast simultaneously to compare
D. Start assessment of the normal breast
40. When you auscultate the abdomen of Mrs. Lopez for vascular sounds such as from the aorta, which of the following regions
of the abdomen will you consider?
A. umbilical area
B. left hypochondriac area
C. epigastric area
D. right lumbar area

SITUATION: A 21 year old female is admitted to the Surgical Ward and is placed in traction. She has been in bed and is very
frustrated because she cannot do her usual daily activities.
41. The nursing diagnosis that is most appropriate for this client is:
A. Potential for immobility
B. Impaired physical mobility
C. Activity intolerance
D. Risk for injury and pathologic fracture

42. Limitations in the activity-exercise routine of a client affect her self-esteem. To help increase the clients self-esteem, the
nurse understands that:
A. Self-esteem depends upon having a feeling of usefulness and independence
B. Being confined in bed with no productive activity causes depression
C. Self-esteem is dictated by ones state of physical health and beauty
D. The current problem exacerbates the clients already low self-esteem
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 43. The nurse maintains the clients good body alignment while she is on traction in order to:
A. Promote proper body balance and optimal brain functioning
B. Maintain body posture and strength
C. Promote efficient circulation and enhance lung expansion
D. Decreased workload of the heart

44. The nurse considers the following statements when taking care of a client with traction EXCEPT:
A. Steady pull from both directions keep the fractured bone in place
B. Weights should be kept resting on the floor
C. Clients on traction need adequate skin care and proper positioning
D. Traction can be used to correct or prevent deformities

45. Part of nursing care for the client in traction is giving instructions for isometric exercises in order to:
A. Prevent decubitus ulcer
B. Improve lung capacity
C. Normalize blood pressure
D. Maintain muscle strength

SITUATION: Accuracy in the computation and administration of medications ordered is extremely important when preparing
medications.

46. A client is ordered to receive 20 mEq of Potassium Chloride. The bottle is labeled KCL elixir 10 mEq/ml. How many ml
should be given?

A. 1.5 ml C. 0.5 ml
B. 2 ml D. 1 ml

47. A client is ordered to receive Digoxin 0.325 mg OD. The stock is 0.25 mg per tablet. How many tablets should be given to
the client?

A. 2 tablets C. 1.5 tablets

B. 3 tablets D. tablet

48. Dilantin 5 mg /kg body weight is ordered to a client who weighs 50 lbs. The drug is to be administered in 3 equal doses. The
label reads Dilantin suspension 125 mg/ml. How much medication should be administered to the client?

A. 1.8 ml C. 1.0 ml
B. 1.5 ml D. 0.5 ml

49. A male client had exploratory laparotomy and has an order for Meperidine Hydrochloride 50 mg IM every four hours PRN.
The multiple dose vial is labeled 50 mg/ml. What is the correct dose to be administered to this client when he complains of
pain?

A. 0.5 ml C. 1.0 ml
B. 2.0 ml D. 1.5 ml

50. An order is given to a young adult to receive 1 million units of Penicillin IM. The stock on hand is Penicillin 500,000 units
and the direction reads: add 1.3 ml to yield 2 ml. What is the correct amount to be administered?

A. 3 ml C. 4 ml
B. 2 ml D. 2.5 ml

SITUATION: Nurses communication skills are often put to test when interacting with clients assigned to them.

51. A 70-year-old client is admitted to the hospital for difficulty of breathing and chest pain. He is accompanied by his son who
asks the nurse what he should do about his fathers hearing problem. Which of the following responses by the nurse reflects
therapeutic communication?

A. I will ask your father for more information.

B. What kind of hearing problems does your father have?
C. Your father will be referred to a specialist after a hearing test is done.
D. Hearing problems occur as people get older.

52. While conducting nursing rounds, the nurse found a 30-year-old, post mastectomy client, lying on her side facing the wall.
When the nurse approached her, she says, Leave me alone, I need rest. The nurse responds by saying:

A. I understand you. C. You sound upset.

B. I will be back. D. Dont worry; you can cover up the loss.
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 53. While waiting for three hours to be called in the doctors clinic, a client suddenly shouts, Why is this taking so long? I have
been waiting for several hours and nobody attends to us? What should be the initial response of the nurse?

A. Approach the client and tell her that there are other clients to be attended to.
B. Instruct the client to be quiet and assure her that she will be attended to soon.
C. Talk to the client and determine her immediate needs.
D. Pacify the client and send her to the adjacent room.

54. A 26-year-old mother of 8-month-old twins brought one infant to the doctors clinic for fever and cough. She tells the nurse,
I cant handle this anymore with other children to attend to, this is overwhelming for me. Which of the following is the best
initial response by the nurse?

A. You will survive this crisis, just like other mothers in similar situations.
B. I will refer you to the social services for assistance.
C. You should know what is best for the infant.
D. What seems to be the problem? It must be tough having other children to attend to.

55. The day prior to surgery, a 40-year-old client says to the nurse, Im nervous. Is the doctor competent in this kind of surgery?
Are there other clients with similar surgery who survived the procedure? How should the nurse respond?

A. Several clients who have undergone similar surgery always recover.

B. Do you want to talk with the client who has similar surgery and has fully recovered?
C. You seem concerned about your surgery.
D. Your doctor is very competent.

SITUATION: Urethral catheterization requires a physicians order. Special care and strict aseptic technique must be observed for
clients with indwelling catheter.

56. A day after the insertion of the urinary retention catheter, the client complains of discomfort in the bladder and urinary
meatus. The initial action of the nurse would be to:

A. Establish patency of the catheter.

B. Milk the catheter towards the collecting receptacle.
C. Check the bladder if distended.
D. Inform the head nurse.

57. The nurse is preparing to irrigate the indwelling urinary catheter of the client. As ordered by the physician, the client is to
have closed intermittent catheter irrigation. The nurse performs the procedure in the following order:

1. Aspirate sterile solution into the syringe

2. Using aseptic technique, put sterile solution in sterile graduated cup
3. Clamp indwelling retention catheter
4. Withdraw syringe, leave solution for around 20 minutes
5. Slowly inject sterile irrigant into the catheter and bladder
6. Remove the clamp and allow irrigant to drain into the collection bottle/bag

A. 2, 1, 3, 5, 4, 6 C. 2, 3, 1, 4, 5, 6
B. 3, 2, 1, 4, 5, 6 D. 1, 2, 3, 5, 4, 6

58. When a client has a retention catheter, the nurse is expected to:

A. Clean the urinary meatus and adjacent skin periodically.

B. Encourage liberal amount of fluid intake.
C. Flush the catheter as needed.
D. Perform perineal flushing as needed.

59. An order to discontinue catheterization of the client was implemented. She complains of difficulty in her first attempt to
urinate. The nurse explains that this is due to:

A. Attempt of the body to adjust to normal reflex mechanism

B. Fluid and electrolyte imbalance
C. Irritation of the urethra
D. Irritation of the urinary bladder

60. When considering the safety needs of a client with a urinary catheter, which of the following should the nurse observe?

A. Keep a closed sterile drainage system.

B. Irrigate the catheter daily.
C. Keep the bag lower than the bed.
D. Measure intake and output daily/

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SITUATION: The nurse noted encrustations around the stoma of a client with tracheostomy. The client is due for routine tracheostomy
care.

61. The nurse informs the client about the procedure then prepares the equipment needed. When cleaning the tracheostomy tube
site, which of the following should the nurse observe to reduce the transmission of microorganisms?

A. Wash hands thoroughly.

B. Use eye protection and mask.
C. Wear clean gown.
D. Wash hands, don clean disposable gloves and mask.

62. In addition to observing appropriate infection control measures, the nurse should d which of the following interventions prior
to the removal of the inner cannula?

A. Open small sterile brush package

B. Suction tracheostomy prior to cleaning
C. Open sterile supplies as needed
D. Remove oxygen source

63. The nurse is correctly performing the removal of the inner cannula when he/she:

A. Rinses the neck plate of the tracheostomy tube then pulling the inner cannula gently in line with its curvature
B. Pulls gently the inner cannula clockwise
C. Unlocks inner cannula by turning counterclockwise and gently withdrawing in line with its curvature
D. Picks up the inner cannula with glove that is considered sterile

64. After thoroughly cleansing the lumen and the entire inner cannula in hydrogen peroxide solution, the nurse is now ready to
return the cannula to the tracheostomy site. To ensure that the cannula is in place, the nurse should:

A. Replace the inner cannula following the curve of the tube, lock by rotating the external ring clockwise until it clicks into
place.
B. Insert the flange of the tube and lock until it clicks into place.
C. Secure the flange of the inner cannula to the outer cannula.
D. Return the inner cannula, lock by rotating the external ring counterclockwise until it click into place.

65. The nurse is changing the tracheostomy ties of the client. The most appropriate technique to follow when changing soiled
tracheostomy ties is to:

A. Bring ties together on both sides of the neck and pull tight.
B. Insert one end of tape on the other side of the tracheostomy from back to front.
C. Thread end of tie through trach flange then through slit in tie and pull tight.
D. Tie the two ends of the tape with square knot at the side of the neck.

SITUATION: You are conducting a class on proper nutrition as part of health promotion.

66. Part of your teaching plan that helps address nutrition problems in the community includeall EXCEPT:

A. Building healthy nutrition related practices

B. Aiming for ideal body weight in all age brackets
C. Choosing food wisely focusing on food pyramid guide
D. Eating small meals frequently

67. Through health education, the nurse disseminates information about nutrition related problems that could lead to serious non-
communicable diseases (NCD). The nurse discourages this eating practice to avoid NCD:

A. Skipping meals then binging on favorite food

B. Eating single food diets for long periods
C. Increased salt and increased processed food intake
D. Early introduction of child to cows milk and solid food

68. The nurse observes that childhood obesity is more common now. The frequent cause of this is the Filipino parents belief that:

A. Cheese and hotdogs are good meals rich in protein.

B. A fat child is healthy, a thin child is sickly.
C. Fast food is nutritious and convenient.
D. Colorful food has more nutritional value.

69. In nutrition education, your targeted participants include all EXCEPT:

A. Food handlers C. Food service people

B. Young children D. Mothers
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 70. One mother asks the nurse why eating food cooked in vegetable oil is considered healthy. The nurses most appropriate
response is that:

A. Gravy has fat drippings and is very tasty.

B. Vegetable oil is safer than animal oil.
C. Food rich in saturated fat is generally good.
D. Vegetable oil increases energy intake and helps prevent vitamin A deficiency.

SITUATION: A nurses understanding of death as a natural part of mans cycle allows her to help her clients.

71. A client, 37 years old, married and a mother of two children ages ten (10) and eight (8), was diagnosed with advanced
metastatic breast cancer. She is depressed and expressed concern about the welfare of her family. Which of the following
actions should the nurse plan to do first for a client who is experiencing depression?

A. Provide recreational activities.

B. Allow the client to spend time with her family.
C. Assist the patient to express feelings, beliefs and values
D. Refer the client to the priest or minister

72. The nurse ensures that the client is treated with dignity and assists her in determining her own physical, psychological and
social priorities. Part of the nurses challenge that should be incorporated in the plan of care is:

A. Focusing on the clients needs

B. Hopefulness in cancer treatment
C. Providing measures related to physical changes
D. Cooperation during treatment

73. To provide a sense of dignity for the client, the nurse should aim for the client to achieve which of the following?

A. Acceptance of the diagnosis

B. Hopefulness in cancer treatment
C. Manifestation of physical wellness during the treatment
D. Cooperation during the treatment

74. While the nurse is assisting the client in her care, the client starts to cry and strikes her. The behavior that the client is
manifesting best describes which of the following stages of death and dying?

A. Bargaining C. Anger
B. Depression D. Denial

75. When planning for the care of a dying person, the essential elements that the nurse should consider are the following except?

A. Maintain the clients confidentiality.

B. Schedule time to be available with the client.
C. Help in clarifying distorted pattern.
D. Provide factual information to queries of client and families.

SITUATION: Bed rest is a therapeutic intervention that achieves beneficial effect. However, prolonged bed rest can be
counterproductive to a clients recovery. The inactivity imposed by bed rest may cause structural changes in joints and
shorten muscles. Moving, turning and positioning of clients are essential aspects of nursing care.

76. A nurse is giving 8:00 AM medication to a client who happens to have slid down the bed from the Fowlers position. Which
of the following interventions is most effective when the nurse repositions the client?

A. Raise the head of the bed to the height of the center of gravity.
B. Remove all pillows then place against the head of the bed.
C. Ask the client to flex the hips and knees and position the feet for effective pushing up.
D. Adjust the head of the bed to a flat position or as low as the client can tolerate.

77. Using an overhead trapeze for repositioning the client can be accomplished by instructing the client to grasp the:

A. Overhead trapeze with one hand and push with the heels upward
B. Head of the bed with one hand and maneuvering for an upward movement
C. Head of the bed with one arm and the overhead trapeze with the other arm then lift and pull upward
D. Overhead trapeze with both hands and lift and pull during the move

78. A client on bed rest is rolled to a lateral position by the nurse. The nurse is negotiating the move correctly when he:

A. Positions himself at the mid-part of the bed and places both hands at the back of the client and roll client onto side
B. Places one hand on the clients far hip and the other on the clients far shoulder rock backward and roll onto side of the
body facing him
Page 8 of 22
 C. Assumes a broad stance with the foot nearest the bed placing his arms under the clients thighs and shoulder and roll client
onto side
D. Supports the back and buttocks of the client and shifts his own weight from the forward to the backward foot and roll the
client onto side

79. A client with injured left leg is sitting on the bed preparing to transfer to a wheel chair. The nurse is assisting the client and
positions the wheel chair on the:

A. Foot part of the bed C. Clients right side

B. Head part of the bed D. Clients left side

80. A client has difficulty walking and needs a wheelchair to facilitate performance of daily activities. Anticipating the needs of
the client, the nurse should have the wheel chair ready by placing it at:

A. 60-degree angle to the bed C. 90-degree angle to the bed

B. 45-degree angle to the bed D. 30-degree angle to the bed

SITUATION: To ensure continuity of care and for the management to be effective, it is essential that the client adheres to the medical
regimen. Nurses play a very essential role in enhancing clients adherence.

81. Because a client with human immunodeficiency virus (HIV) is scheduled to begin several medications to manage the
infection, the nurse will need to provide client education. Which of the following client characteristics is most likely to
predict adherence with the treatment regimen?

1. Educational level
2. A trusting relationship with the health care provider
3. An expectation that the medications will be helpful
4. Being able to take the medications twice daily instead of four times daily.
5. Gender

a. 1, 2, 3, 5 C. 2, 3, 4, 5
b. 2, 3, 4 D. 1, 2, 3

82. Which one of the following might be the best way to measure adherence to a prescribed medication regime?

a. Direct observation of medication administration.

b. Evidence of illness complications or exacerbations.
c. Monitoring laboratory values of elements influenced by the medication
d. Questioning the client about his or her medication routine.

83. When determining the risk for medication non-adherence, which of the following assessment questions is inappropriate?

a. Do you think your medications are helping?

b. How many tablets do you take every day?
c. Are you having side effects from any of your medications?
d. Why do you spit out the medications?

84. Which of the following does not influence adherence?

a. Clients motivation to become well C. Overall cost of prescribed therapy

b. Clients excused absent in the workplace D. Degree or lifestyle change necessary

85. Which of the following is not important to take in identifying non-adherence?

a. Encourage negative reinforcements. C. Use aids to reinforce teaching.

b. Demonstrate caring. D. Establish a therapeutic relationship.

SITUATION: Assessments importance in the nursing process cannot be overemphasized. It precedes the other phases of the nursing
process. It is even continuously done during the other phases. Therefore, nurses must be extra careful and skillful when
assessing their clients.

86. In an interview the nurse says, Thank you for your time and help. The questions you have answered will be helpful in
planning your nursing care. This is typical of what stage of an interview?

a. Opening C. Closing
b. Body D. Re-opening

87. The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the
following?

a. correlation of the data with other members of the health care team
b. demonstration of cost-effective care
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 c. utilization of creativity and intuition in creating a plan of care
d. collection of all necessary information for a thorough appraisal

88. A client is admitted to the health care facility with acute chest pain. When obtaining the clients health history, which
question would be most helpful for the nurse to ask?

a. Do you need anything now?

b. Why do you think you had a heart attack?
c. What were you doing when the pain started?
d. Has anyone in your family been sick lately?

89. A client complains of severe abdominal pain. To elicit as much information as possible about the pain, the nurse should ask:

a. Do you have the pain all the time? C. Where does it hurt the most?
b. Can you describe the pain? D. Is the pain stabbing like a knife?

90. A nurse is taking the health history of an 85-year-old. Which information will be most useful to the nursing for planning care?

a. General health for 10 years C. Family history of diseases

b. Current health promotion D. Marital status

SITUATION: The physician prescribed 1 liter of Dextrose 5% in Water to be administered at 50 mL per hour.

91. Considering the physicians order, the intravenous infusion should last:

A. 22 hours C. 18 hours
B. 16 hours D. 20 hours

92. The intravenous infusion was started at 10:00 AM. When the nurse checked the patient at 2:00 PM, she noted the level of the
solution to be 850 mL. How much solution should have been infused at this time?

A. 200 ml C. 250 ml
B. 150 ml D. 100 ml

93. The nurse is analyzing the remaining fluid of 850 ml. Based form the amount to be consumed at 50 ml/hr, the nurse assessed
that the infusion is:

A. Running fast C. Within the prescribed time

B. Delayed D. Slightly ahead of time

94. Maintaining the prescribed flow rate of 50 ml/hr, in how many hours should the remaining 850 ml of 5% Dextrose in Water
be consumed?

A. 17 hours C. 18 hours
B. 16 hours D. 15 hours

95. At 10 AM, maintaining the prescribed flow rate of 50 ml/hr and considering the remaining 850 ml, how many drops per minute
should the nurse regulate the IV infusion of the drop factor is 15 drops/ml?

A. 20 drops/min C. 10 drops/min
B. 16 drops/min D. 13 drops/min

SITUATION: It is a rainy season and the pediatric clinic where you are assigned is filled with children and mothers waiting for
attention and treatment.
96. Many children in the clinic have upper Respiratory Tract Infection (URTI). Alice has two children with her at the clinic. To
prevent the spread of URTI, the BEST instruction to give mothers like Alice will be to:
A. Teach the child to use sleeve to wipe off nasal discharges
B. Instruct mother and child to wear protective masks at all times
C. Wipe off nasal discharge so that no mucous crust forms on the nostrils
D. Wash hands thoroughly with soap and water after handling mucous discharge

97. The nurse teaches Alice and the other parents that URTI spreads through droplets after coughing and sneezing. Your health
instructions are effective when the parents do the following EXCEPT:
A. Deposit sputum in tissue and discard used tissue in a trash can
B. Cover mouth and nose when coughing or sneezing
C. Wash and dry hands by using a towel provided in the lavatory
D. Wash hands thoroughly after contact with mucous secretions

98. Following the nurses instructions on how to prevent spread of infection, Alice teaches her children how to prevent infecting
their playmates when they have URTI. Which of the following actions would be considered INEFFECTIVE in preventing
spread of infection?
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 A. Washing hands after blowing nasal discharges
B. Covering mouth and nose when sneezing or coughing with their skirt or shirt
C. Covering nose and mouth with hands when sneezing then continue playing
D. Pinning a handkerchief or face towel to wipe off mucous secretions or cover nose

99. You demonstrate proper hand washing technique to the parents in the clinic as a step to prevent spread of infection. The
parents perform the practical procedure correctly when they:
A. Rub hands together, in between fingers, using soap and rinse with running water
B. Rub hands together for friction under running water
C. Wash hands with soap and rinse with water in a basin
D. Wash hands with antimicrobial soap, apply rubbing alcohol, dry hands by allowing alcohol to evaporate

100.At home, Alice observes principle of infection control when she:

A. Avoids shaking linen, clothes and towels used by a sick child
B. Keeps kitchen utensils and plates in cupboards where leftover food are stored
C. Places handbags and baskets on food preparation areas
D. Avoids shaking and stores used clothes and linen in the clothes cabinet

SITUATION: A nurse is assigned to several clients and her functions include giving intravenous (IV) medications and fluids. During
the end of shift endorsement she receives incoming doctors orders to run some IV fluids for clients assigned to her.
101.Mr. Shanks, 49 years old, has a doctors order to receive 1 Liter of normal Saline solution to run for 24 hours. The nurse
would set intravenous fluid to infuse at how many milliliters (ml) per hour and how many drops per minute if the drop rate of
the IV tubing is 15drops/ml?
A. 42ml/hour, 10drops/minute C. 50ml/hour, 18drops/minute
B. 48ml/hour, 15drops/minute D. 36ml/hour, 7drops/minute
102.Franky, 8 years old, has an order for D5 Lactated Ringers 250ml to infuse for hour hours, starting at 8AM, using IV tubing
set with a drop factor of 60microdrops (gtts)/ml. What should be the rate of flow if the IV is to be consumed at 12 noon?
A. 48gtts/minute C. 43gtts/minute
B. 63gtts/minute D. 58gtts/minute
103.While reading the doctors orders for the other clients, you will seek clarification from the doctor for which of the following
orders?
a. Infuse 0.9% normal saline to keep vein open (KVO)
b. Incorporate 20mEq potassium chloride in 1 Liter D5 Water at 50ml/hour
c. Flush peripherally inserted catheter (PICC) with 10ml normal saline every 6 hours
d. Infuse 500ml of normal saline for 2 hours

104.Mr. Roldan is newldy admitted to the ward and before administering IV medications you read in his chart that he has
peripherally inserted catheter (PICC) that is now 4 weeks old. Upon examination, you observed that the site is clean and free
from manifestations of infiltration, irritation and infection. Your most appropriate action would be to:
A. Document observation in the nurses notes to inform physician and other nurses
B. Discontinue the PICC line since it is 4 weeks old
C. Administer the medication as ordered
D. Give medications through oral or IM route
105.While assessing Mr. Doflamingos IV site, you noticed redness, swelling and tenderness above the site. Your most
APPROPRIATE nursing action would be:
A. Apply cold compress to the site C. Flush the catheter with normal saline solution
B. Stop infusing IV fluids D. Massage extremity to facilitate drainage by gravity
SITUATION: While in the ward, you are assigned to clients with problems related to the gastrointestinal tract.
106.The nurse is preparing Mr. Lim for cleansing enema. When administering enema, the maximum height at which the enema
can should be held from the level of the bed is:
A. 14 inches
B. 10 inches
C. 16 inches
D. 12 inches

107.While administering the enema, Mr. Lim complains of abdominal cramps. Which of the following would be the MOST
appropriate action of the nurse?
A. Clamp the tubing for a few minutes till the cramps subside, then continue
B. Pull the rectal tube slowly till the cramps subside
C. Stop the procedure and refer to the attending physician
D. Lower the enema can to slow down the inflow of enema solution

108.Following the surgery, Mrs. Mora developed abdominal distention. The physician ordered a rectal tube insertion to relieve
distention. To achieve maximum effectiveness, how long should the rectal tube be left in place?
A. 5 minutes
B. 15 minutes
C. 30 minutes
D. 60 minutes

109.After ensuring that the nasogastric tube (NGT) is in place, the nurse prepares to feed Mrs. Mora using open system. With a
30ml syringe, the nurse proceeds with the feeding following this sequence.
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 1. Hold the NGT high to prevent backflow and then clamp
2. Open clamp and raise or lower the syringe to regulate flow of formula
3. Remove the plunger of the syringe and attach to NGT
4. Fill up the syringe with feeding formula
5. Add 30 to 60 ml of water to irrigate syringe allowing it to run down the NGT
A. 2, 3, 4, 1, 5
B. 1, 3, 2, 5, 4
C. 3, 4, 2, 5, 1
D. 4, 3, 1, 2, 5

110.The nurse is to perform gastric gavage. What should be the best position of the client while the gastric tube is being inserted?
A. Supine position
B. High fowlers position
C. Trendelenburg position
D. Low fowlers position
SITUATION: Problems with bowel movement may be experienced by people of different ages. It can cause enough discomfort or
health problems to individuals that require nursing intervention.
111. An active woman in her mid-twenties has been on weight loss diet of low carbohydrates and high protein diet. She is
successful in losing weight but is experiencing constipation. Which of the following should the nurse advice the client to
AVOID constipation?
a. Take over-the-counter laxatives to ease bowel movement
b. Try another type of diet that have less animal fat like fish, chicken and low carbohydrates
c. Eat nutrient dense food that are low calorie but have high nutrient value and fiber like broccoli, berries
d. Increase exercise activities to improve peristalsis

112.You are administering soapsuds enema to a client. During the procedure, the client complains of abdominal cramping. Your
appropriate initial nursing action would be to:
a. Clamp the enema tubing to stop flow of the fluids
b. Push further tubing by 2 inches
c. Ask the client to inhale and exhale slowly
d. Lower the height of the enema container

113.You are taking care of a client with fecal incontinence. You are aware that the client has a risk for injury due to:
a. Falls when trying to go to the bathroom
b. Dehydration and malnutrition
c. Increased abdominal cramping
d. Perineal and anal skin breakdown

114.A client is brought to the hospital due to severe diarrhea. Which of the following is a major problem of the client requiring
immediate management by the health team?
a. Excessive passing of flatus
b. Irritation of anal sphincter
c. Severe abdominal cramping
d. Severe fluid electrolyte imbalance

115.A client had abdominal surgery under general anesthesia and is still in the recovery room. You are aware that clients who
went through general anesthesia would most likely experience:
a. Paralytic ileus
b. Tolerance for solid food immediately after surgery
c. Immediate return of gastrointestinal motility
d. Excessive flatus
SITUATION: Proper nutrition and elimination are important to health and the nurse has an important role to play in assisting people
from various age groups obtain proper information.
116.Roman, 36 years old, is diagnosed with peptic ulcer and asks you what food is best to add to his diet so as not to exacerbate
the symptoms. Your best response would be for him to take:
A. Leafy green vegetable dishes
B. Citrus fruit juices or shakes
C. Mocha, caf latte and other similar drinks
D. Milk regularly 3-4 times daily

117.You are assigned to Mrs. Dulay, a client with an order for cleansing enema. While doing the procedure, the client groans and
complains of abdominal cramping. Your MOST appropriate initial nursing action would be to:
A. Reduce the flow of the fluid by clamping the enema tubing
B. Instruct the client to relax, inhale and exhale slowly
C. Lower the height of the enema container
D. Push the rectal tube further in by 2 inches

118.An elderly client you are taking care of has fecal incontinence for 3 days now. He is able to tolerate food but has no control of
his bowel movement. He has soft watery stools and uses adult diapers. While caring for this client, you will watch out closely
for risk of:
A. Increased abdominal cramping
B. Perineal and anal skin breakdown
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 C. Malnutrition and weight loss
D. Falls when he tries to go to the bathroom

119.Dennis, 5 year old, is brought to the hospital for severe diarrhea. You are aware that a major problem that may develop that
will adversely affect Dennis would be:
A. Severe abdominal cramping
B. Excessive passing of flatus
C. Severe fluid electrolyte imbalance
D. Irritation of the anal sphincter

120.Miss Reyes, a client who had abdominal surgery under general anesthesia, is still in the recovery room. You are aware that
clients who went through general anesthesia will most likely experience:
A. Absence of peristalsis
B. Tolerance for soft diet immediately after operation
C. Immediate return of gastrointestinal motility
D. Excessive gas formation noted upon auscultation

SITUATION: Mariza, a staff nurse in the surgical ward, has been assigned to take care of Mrs. Jose, a 58 year old client who has an
endotracheal tube.
121.Nurse Marizas objective is to improve clients respiration after she noted thickened, tenacious secretions. To loosen the
secretions, the MOST appropriate nursing intervention is to:
A. Instill mucomyst into the endotracheal tube and frequently turn client unless contraindicated
B. Administer humidified oxygen and place in side lying or prone position unless contraindicated
C. Increase fluid intake and ask client to do deep breathing and coughing exercise
D. Assess clients respiratory status and perform clapping to loosen secretions

122.Nurse Mariza performs endotracheal suctioning. The nurse probably does the suctioning procedure when she performs which
of the following?
A. Rotates the catheter gently and suctions for not more than 10 seconds each time
B. Observes and records the amount and character of the secretions after each suctioning
C. Assesses the respiratory and circulatory status after a cluster of 5-8 times suctioning
D. Observes how long the client tolerates the catheter during the suctioning process

123.In the care if this client, the nurse monitors the cuff pressure and takes care to reduce the risk of tracheal tissue necrosis by
maintaining the cuff pressure to:
A. 30-35mmHg
B. 10-15mmHg
C. 40-45mmHg
D. 20-25mmHg

124.When taking care of Mrs. Jose, Mariza performs oral and nasal care every 2-4 hours to promote hygiene and comfort. As a
precautionary measure for possible biting down the of the oral endotracheal tube, the nurse should:
A. Request an assistant to hold the patient down
B. Use an oropharyngeal airway
C. Provide humidified air prior to the procedure
D. Place the client on a left side lying position

125.The nurse reminds nurse Mariza about measures that must be strictly observed when suctioning the client through the
endotracheal tube. This measure is:
A. Turning on the suctioning apparatus during catheter insertion
B. Suction by rotating 2 to 3 times before withdrawing the catheter
C. Always use rubber gloves when suctioning to prevent infection
D. Hyperoxygenating the client before and after the procedure

SITUATION: Clients record is a structured device where all tasks concerning the diagnostic and treatment process done on the client
are documented. An account of what has occurred between the client or the health care team has to be recorded once the interaction
has been undertaken.
126.An entry in the nurses notes for a client with urinary tract infection states: Encouraged fluid intake to 2500ml per day.
What description of the nurses statement applies?
A. Describes the amount of fluid intake desired
B. It establishes accuracy using an exact amount
C. It is incorrect as it lacks accuracy of measurement
D. It does not specify fluids allowed

127.The nurse is recording the treatments administered to her clients. The following information should be included in her
charting, EXCEPT:
A. Health teaching
B. Clients response compared to previous treatment
C. Time administered
D. Equipment used

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 128.A male nurse is giving a change of shift report for all clients in the medical unit at the nurses station. During this reporting,
the nurse is expected to:
A. Review the condition of the client by reading the documented information
B. Report the condition of the client and compare with what the incoming staff need to know
C. Provide significant information about the client as baseline for the next shift
D. Read the data about the client objectively

129.The nurse is preparing Mr. Nick Gomez for transfer from the Intensive Care Unit to his private room. To promote continuity
of care, what information should be included in the transfer report?
1. Clients name, age, physical and medical diagnosis and allergies
2. Correct health status of the client at the time of transfer
3. Any critical observation and intervention to help the receiving nurse
4. Need for special equipment
A. 1 and 2
B. 3 and 4
C. 1 2 3 and 4
D. 1 2 and 4

130.Mr. Douglas Nava, a 55 year old executive, requests the nurse if he can read his medical records upon discharge. What is the
most appropriate action of the nurse?
A. Allow the client to read his chart because of his clients right
B. Tell the client that he is not allowed to read his chart
C. Ask the client to write a written request
D. Refer the request of the client to the physician
SITUATION: DonquixoteDoflamingo, 54 years old, is admitted to the medical unit for executive check-up. His admitting notes
reveal: temperature: 36.8C; pulse rate: 86/minute; respiratory rate: 18/minute; BP: 160/90 mmHg.
131.When admitting Mr. Doflamingo, your most important INITIAL nursing action would be to:
A. Take him around the ward to show him the unit set-up
B. Introduce Mr. Doflamingo to the other staff in the unit
C. Obtain Mr. Doflamingos nursing history
D. Identify the needs of Mr. Doflamingo that may require immediate management
132.The charts admission note states the Mr. Doflamingo has bi-pedal edema. During assessment, you VERIFY this by:
A. Doing palpation C. Doing inspection
B. Interviewing the client D. Checking the results of the laboratory tests
133.Mr. Doflamingo asks you what he should do to help reduce swelling of his feet and ankles. Your most appropriate response
would be the following EXCEPT:
A. Elevate his feet while seated or while lying in bed
B. Reduce intake of salty foods
C. Request the doctor for diuretics
D. Inform him that edema is caused by problem with his kidney
134.Mr. Doflamingo has blood extraction for hematology, blood chemistry, lipid profile, FBS. The laboratory results are in. Of the
following, which is NOT within normal?
A. Cholesterol: 4.28 mmol/L C. FBS: 6.5 mmol/L
B. HBA1c: 5.7% D. Hematocrit: 42%
135.You are planning Mr. Doflamingos discharge from your unit. Your nursing responsibilities include all EXCEPT:
A. Making a final assessment of the client
B. Replying to queries regarding his hospital bill
C. Giving instructions regarding some medications
D. Arranging for his transportation home
SITUATION: Therapeutic communication forms a connection between the client and the nurse. Furthermore, it facilitates the
establishment of the nurse-client relationship and fulfills the purposes of nursing practice.
136.Mrs. Hayley Atwell, 45 years old, has terminal cancer of the breast. She cries and tells the nurse, Why do I have to suffer
this kind of illness? There is no cure for this and I wish my family would not hope for a cure. Which of the following is the
most appropriate response of the nurse?
A. Is your family ready to accept your condition?
B. You feel angry that your family hopes for a cure for your illness?
C. You sound that you are likely to die.
D. I think you and your family should discuss your condition with your physician.
137.While on your way to the cafeteria, you were greeted by a friend who happens to be visiting a client under your care. She
asks about the clients condition. Which of the following would be the most appropriate response of the nurse?
A. I am not in a position to discuss her condition but you are my friend. I can tell you that she is on her way to recovery.
B. If you want to know her condition, why dont you talk to her attending physician?
C. I cannot discuss the status of the client with you.
D. Confidentially, I can tell you that her condition is stable.
138.An 18 year old client has been in the hospital for 3 days with infection of chlamydia. While administering her 12:00 noon
medication, the client tells the nurse that she has a secret which she wants the nurse to but asked the nurse not to tell anybody.
Which of the following is the most appropriate response of the nurse?
A. What you will tell me will be properly documented.
B. Yes, I promise to protect you when entrusting your secret to me.
C. Yes, you can trust me not to divulge your secret.
D. I cannot promise to keep a secret if it affects your health and safety.

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 139.A depressed client tells the nurse that she is very disappointed following her loss of job. Im a failure and cannot perform
my work right. The following are appropriate responses of the nurse EXCEPT:
A. Provide experiences that will enhance her self-esteem
B. Reassure the client that everything will be better soon
C. Stay with the client and listen to what she says
D. Motivate the client by giving positive reinforcement and encouragement
140.The nurse is interacting with a client who verbalized that she is hearing voices telling her that she is a bad girl. Which of
the following responses is most appropriate?
A. I understand what you feel but keep calm.
B. Nobody is around except the two of us.
C. Dont worry it will not harm you.
D. Its difficult for you to understand all that you are experiencing right now.

SITUATION: Nursing practice act requires nurses to maintain a safe environment for their clients. Nurses must act to identify and
minimize risks to clients.
141.A nurse is taking care of Mr. Roronoa Zoro who is receiving oxygen therapy. A watcher approached her saying there is a fire
burning in the trash basket inside the medication room in the nurses station. What INITIAL action should the nurse do?
A. Turn off the oxygen and remove all clients from the room
B. Get the fire extinguisher to put off the fire
C. Calm the clients and escort them to a safe area
D. Ask for helps from the visitors

142.What action is essential when Mr. Zoro is to have oxygen administration at home?
A. Assist the client and family to check all electrical appliances in the vicinity for extension cords
B. Turn off all electrical devices inside the room of the client
C. Instruct the clients to install a carpet inside the room
D. Instruct relatives to have fire extinguisher ready

143.Erza, a charge nurse in the pediatric unit is assessing the area for fire hazards. The following situation is considered the
GREATEST fire hazard:
A. Cleaning supplies and cardboard boxes stored in the room with oxygen tank
B. Closet of clients filled with clothing and newspapers
C. Personal item of clients kept under the bed
D. Some staff smoking in the rest room

144.While doing her rounds, the nurse passed through a private room and saw flames and smelled smoke. Which of the following
should be the INITIAL action of the nurse?
A. Evacuate all clients in the building C. Evacuate the clients out the burning room
B. Ask for assistance D. Evacuate any client first

145.The nurse is explaining universal precaution to the client. The primary purpose of universal precaution as part of maintaining
safe environment is:
a. Prevent health workers from acquiring communicable diseases
b. Reduce the spread of the disease
c. Prevent nosocomial infection
d. Prevent the spread of communicable diseases

SITUATION: Total quality improvement is based on the premise that the process is ongoing and that quality can always be improved.
146.While giving care to a client in the Medical Unit, the nurse observes that a 65 year old male bedridden client has a reddened
area with no break in the skin in his coccyx. A clean dressing has been put over the site in order to:
a. Protect the area from injury
b. Provide comfort to the client
c. Make healing faster
d. Allow light to get through

147.A bedridden client has a nasogastric tube and an intravenous line. The client appears disoriented and attempts to remove both
contraptions. What action of the nurse should be done to protect the client from injuring himself?
a. Ask a family to stay with the client
b. Stay with the patient
c. Apply restraint
d. Ask the physician for an order for wrist restraint

148.The nurse is taking care of client receiving chemotherapy. She is concerned about the clients nutritional status and aims to
improve the appetite of the client. The nurse would:
a. Administer medications before meals
b. Improve food flavor
c. Offer hot soup
d. Offer white meat

149.The nurse is evaluating the nutritional status of the client. Which of the following parameters should be observed by the
nurse?
a. Stable weight
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 b. Extent of nausea and vomiting
c. Improve appetite
d. Amount of food intake

150.While completing the final preparations for a 12 year old client who is scheduled for appendectomy, the nurse sees the
mother applying hot water bag in the childs abdomen for relief of pain. The nurse should tell the mother that the hot water
bag may:
a. Arrest progression of the disease
b. Increase abdominal contraction
c. Increase abdominal peristalsis
d. Cause the appendix to rupture

SITUATION: Teaching clients about healthy food intake for health promotion and disease prevention is important function of the
nurse. Nutritional deficiency is preventable if individuals and families have adequate knowledge about normal nutrition.
151.The nurse is teaching a family to take food with high protein content. She discovers that the familys consideration is the high
cost of food. Which of the following affordable high protein food should the nurse recommend?
a. Peas and beans
b. Beef steak and vegetables
c. Fried rice and dried fish
d. Spaghetti and bread

152.During the follow-up visit, the client asks the nurse foods that are in complete protein. Which of the following should the
nurse recommend?
a. Oatmeal with raisins
b. Toast with peanut butter
c. Eggs cooked in any style
d. Lentil soup

153.A mother asks the nurse what finger food is safe for her toddler. Knowing that children can easily choke on food, the nurse
should advice the mother to feed the toddler which of the following foods?
a. Caramelized popcorn
b. Cereals like cheerio
c. Grilled hotdogs
d. Salted nuts

154.A client diagnosed with peptic ulcer asks you what food is best to add to his diet so as not to exacerbate his symptoms. Which
of the following is the MOST appropriate food for the client?
a. Citrus fruit juices
b. Caf latte and similar drinks
c. Green vegetable dishes
d. Frequent intake of milk

155.A therapeutic relationship exists when the:

a. Nurse and client work together to talk about how clients needs may be met
b. Nurse informs the client the goals and priorities for his care after a thorough assessment
c. Nurse explores the clients thoughts and actions for the clients benefit
d. Various nursing procedures are used to help meet the clients needs

SITUATION: Understanding clients needs depends upon the ability of the nurse to communicate therapeutically.
156.A client in his early twenties was recently diagnosed with breast cancer. She says to the nurse, Why did this happen to me?
Do I deserve this when I have been very good to others? which of the following would be the appropriate action of the
nurse?
a. Provide comfort by telling her that she doesnt deserve this
b. Provide reassurance by recognizing how difficult her situation must be
c. Call the chaplain to assist the client in accepting her fate
d. Encourage her to seek another opinion

157.The nurse found a 28 year old client who had hysterectomy crying while alone in her room. What should be the nurses initial
approach?
a. Ask her what seems to be troubling her
b. Reassure that her crying is a normal reaction
c. Reassure that her attending physician will order hormonal replacement therapy
d. Leave the room quietly

158.The doctor orders the insertion of a nasogastric tube for the client who refuses to eat. She has severe weight loss. She
removed the tube and says, I dont need that thing. The most appropriate response is:
a. Do you want your condition to deteriorate further? Why did you pull out the tube?
b. You should have not done that. You need to improve your circulation.
c. You doctor will be upset and order reinsertion of the tube.
d. Tell me what you dont like about the tube?

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 159.A client is admitted to the hospital for diabetes accompanied by his son. The son is telling the nurse about his difficulty in
taking care of his mother. The nurse is using non-therapeutic communication when she says:
a. Maybe putting her in a home for you elderly people will be best for her.
b. Lets look more closely about your concern.
c. It appears that you are concerned with your mother.
d. You seem to be anxious about this time. Tell me more about your concerns.

160.The nurse is establishing her presence to the client as part of her nursing care. This is best interpreted as:
a. Being with the client always
b. Offering of closeness with the client physically, psychologically and physically
c. Personally performing nursing care activities for the client
d. Sharing vital information with the client

SITUATION: Henry, 65 years old, underwent Transurethral Prostatectomy (TURP). He was admitted to the Post Anesthesia Care Unit
(PACU). The following questions apply.

161.The Operating Room (OR) nurse endorsed the ongoing intravenous infusion of Dextrose 5% Ringers Lactate, 500 ml,
running at 40 ml per hour at the level of 300 ml. The nurse, who received the client in the PACU at 1500H, would expect the
present infusion to be consumed at:

A. 2400H C. 2200H
B. 0100H D. 0300H

162.The client has an indwelling triple catheter irrigation (CBI) with Normal Saline Solution (NSS) infusing at 200 ml per hour.
After four hours, the nurse emptied the drainage bag and obtained an output of 1,080 ml. Which of the following will the
nurse record as the clients urinary output?

A. 189 ml C. 800 ml
B. 1,080 ml D. 280 ml

163.The surgeons order reads, Maintain traction on the indwelling triple lumen catheter. Which of the following is the MOST
appropriate action of the nurse?

A. Tape the catheter to the abdomen and keep client in supine position.
B. Pull the catheter taut and tape to the thigh alternatively every 6 hours.
C. Instruct the client to keep both legs together and extended all the time.
D. Pull the catheter taut, tape to one thigh and keep the leg extended all the time.

164.The nurse understands that normal saline solution (NSS) is used for CBI to prevent which of the following?

A. Water intoxication C. Dehydration

B. Elevation of specific urine gravity D. Formation of stones

165.The nurse assigned to the client monitored and maintained the CBI rate of NSS at 200 ml per hour. This intervention is
critical because it:

A. Washes out remaining fragments of stones

B. Avoids postoperative infection
C. Decreases bleeding and keep the bladder free from blood clot
D. Maintains adequate hydration
SITUATION: Records management is a critical function of the nurse to ensure continuum of care. The following questions apply.

166.A client with myocardial infarction is receiving IV infusion of heparin sodium at 1,500 units per hour. The concentration in
the bag is 25,000 units per 500 ml. How many ml should the nurse document as intake form the infusion for an eight shift?

A. 300 ml C. 450 ml
B. 400 ml D. 240 ml

167.The nurse understands that that the specific indication of Heparin in the management of myocardial infarction is to:

A. Maintain patency of affected coronary artery.

B. Improve blood pressure.
C. Maintain patency of affected coronary artery.
D. Enhance blood flow to the kidneys.

168.The laboratory results were chronologically arranged in the patients chart along with other forms. The nurse understands that
the basis of the Heparin dose is determined and based on which laboratory result?

A. Hemoglobin and hematocrit count

B. Clotting time
C. Blood cell concentration
D. Activated partial thromboplastin time (aPTT)
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 169.Unlike Coumadin, Heparin is administered parenterally. When you are asked to inject heparin in the abdomen, the nurse will
do all the following EXCEPT:

A. Massage after the injection.

B. Administer by deep subcutaneous injection.
C. Position the needle at 90 degree angle.
D. Use a gauge 25 to 28 needle.

170.Throughout the heparin therapy, the nurse will record and report promptly which evidences of bleeding when observed?

A. Excessive menstrual flow, nose bleeding, gum bleeding, vertigo

B. Pallor, hematuria, neuralgia, hematoma
C. Nose bleeding, hemoptysis, hemiparesis, pruritus
D. Hematemesis, hematuria, bleeding gums, unexplained abdominal pain

SITUATION: A nurse admitted a 20 year old college student. Her chief complaints are fatigue, weakness and sometimes dizziness.
The patient is pale. The admitting diagnosis is iron deficiency anemia.

171.The nurse prepared the client for complete blood count is normal if the result is:

1. Red blood cells - 3.6 to 5.0 million/mm3

2. Reticulocyte - 1.0% to 1.5% of total RBC
3. Hemoglobin - 14-16.5% g/dl
4. Hematocrit - 3 to 4 %
5. Hemoglobin - 6 to 9 g/dl
6. Hematocrit - 40% to 50%

A. 1, 2, 3, 6 C. 1, 2, 3, 4
B. 1, 3, 5, 6 D. 1, 2, 4, 5

172.After a thorough assessment and based on the laboratory findings, the diagnosis of iron deficiency anemia is confirmed. The
client asks the nurse what is the role of iron in the body? The CORRECT response of the nurse is:

A. Iron prevents bleeding.

B. Iron gives the red color of our blood.
C. The body cannot synthesize hemoglobin without iron.
D. Iron helps in the conduction of nutrients to the body.

173.Which of the following food enhance absorption of iron?

A. Cereals C. Dairy products

B. Citrus fruits D. Green leafy vegetables

174.The client was prescribed ferrous sulfate as iron supplement. For better absorption, the nurse would instruct the client to take
this supplement:

A. With meals C. After breakfast

B. 1 hour before D. Before going to bed

175.Intramuscular supplementation of iron causes local pain and can cause stain in the skin. If you are the nurse, which BEST
technique of administration will you use?

A. Z track technique
B. IV bolus
C. Vigorous rubbing of the injection site after injection
D. Intramuscular using the deltoid muscle
SITUATION: Medication errors are common problems in health care with potentially fatal consequences. It is acknowledged that
medication error is a multidisciplinary problem which requires multidisciplinary solutions.

176.Of the following types of medication error, which error may reach the patient?

A. Dispensed wrong drug C. Documented wrong dose

B. Inability to administer right dose D. Prepared wrong drug

177.Which of the following is an organizational practice which may result to medication error?

A. Illegible handwriting of the physician C. Manufacturers labeling and packaging

B. Drug name confusion D. Excessive workload for the staff nurses

178.The hospital set a patient safety goal to improve effectiveness of communication among the nurses. Which of the following
strategies is related to this goal?
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 A. Inform nurses of look-alike and sound-alike drugs.
B. Use at least two patient identifiers.
C. Provide reference guide to verify generic and brand names of drugs.
D. Standardize abbreviations.

179.Illegible handwriting of prescribers is a source of medication error. Which of the following is a preventive measure related to
this?

A. Have a pharmacist review medication orders.

B. Clarify order with the prescriber.
C. Utilize medication administration schedule.
D. Administer only fully labeled medications.

180.A nurse found out the medication she is supposed to administer is not available in the patients cubicle. Which of the
following is a safety practice to be followed by the nurse?

A. Adjust schedule of the drug administration.

B. Wait for the pharmacy to dispense.
C. Skip the current dose.
D. Borrow medication from another patients medication cubicle.

SITUATION: Primary prevention involves health promotion as protection against disease. Activities of this type generally apply to the
healthy individuals before any disease or dysfunction occurs.
181.Nurses play a big role in the primary level of prevention. Examples of nurse activities showing primary prevention are the
following, EXCEPT:
A. Referrals to client support groups like those of cancer patients
B. Teaching patients of toddlers about prevention of poisoning and accidents at home
C. Family planning classes to newly weds
D. Giving immunizations to children

182.Secondary prevention includes health maintenance activities which involves the following, EXCEPT:
A. Nursing care to maintain integrity of a diabetic client
B. Giving medications and treatments to discharged clients
C. Proper positioning of clients with disability in the home setting
D. Smoking cessation program

183.When teaching your clients about nutrition, you include the following food as rich sources of good cholesterol, EXCEPT:
A. Fish C. Soya
B. Beef D. Olive oil

184.A community based hospital offers acute care in addition to adult outpatient services, exercise and yoga classes for young and
old. This hospital provides which type of services?
A. Tertiary and illness prevention
B. Primary and tertiary
C. Secondary and tertiary
D. Primary and secondary

185.Mr. Donghit, 48 years old is attending a smoking cessation program to be held at the nearby high school conducted by the
school nurse. This program is classified as:
A. Diagnosis and treatment C. Rehabilitation and screening
B. Health restoration D. Health promotion

SITUATION: The nurse is assigned to take care of elderly female clients with different needs while in the medical ward.
186. While examining and elderly female client, the nurse notes musky sour body odor of the client indicating poor hygiene.
Which of the following is the MOST appropriate action of the nurse?
A. Give alcohol rub to cleanse skin and reduce body odor
B. Assist the client to apply moisturizing lotion daily
C. Obtain prescription for antifungal skin medication
D. Help the client bathe several times weekly

187.The client is weak and needs to be moved up in her bed. To reduce shearing force when moving the client, the nurse should:
A. Apply lotion to body parts in contact with bed sheet
B. Give the client a thorough explanation of the process
C. Ask for staff assistance when lifting the client
D. Use a draw sheet to put the client in correct position

188.The client has been on bed rest and has reddening of the skin and bony prominences. When moving the client up in her bed,
the nurse places her arms across her chest. This is done to:
A. Make the clients body more aligned
B. Protect the clients extremities during the procedure
C. Reduce the surface area that will come in contact with the client
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 D. Make the body more compact to facilitate movement
.
189.The nurse reports that a client appears uncomfortable and covers herself with bed sheets on a warm day. The nurse asks
permission to pull out the sheet but noted urine smell and wet bed sheets. She persuades the client to get up and shower. The
client refuses and becomes teary eyed. The most appropriate therapeutic statement by the nurse would be to:
A. Just allow me to clean you up and you will see how good I am in this kind of nursing procedure.
B. You should not be embarrassed since I am used to taking care of clients who are incontinent.
C. I am here to help make you feel comfortable.
D. I understand how you feel but it is my responsibility to take care of you.

190.The client agrees to take a shower. While the client is being assisted to bathroom, she begins to fall. Which of the following
should be the initial action of the nurse?
A. Call for immediate help
B. Quickly assist the client in a nearby chair and lower the head between the knees
C. Call the relatives to get back the clients head
D. Refer the client to the attending physician

SITUATION: A client is diagnosed with active tuberculosis. Airborne precaution is observed and he is placed in isolation. He resents
the isolation and appears angry.

191.Your best nursing intervention for the behavior manifested by this client is to:

A. Comfort the client to keep him from becoming angry.

B. Limit the visitors to reduce the risk of spreading the infection.
C. Explain the isolation procedure and provide meaningful stimulation.
D. Provide a quiet and non-stimulating environment.

192.The psychological implication of isolation to the client includes which of the following?

A. Altered body image

B. Depressed and rejected
C. Sense of loneliness due to disruption of normal social relationship
D. Accepts the isolation technique for the protection of the family

193.Which of the following interventions must be carried out by the nurse to improve the clients sensory stimulation during
isolation?

A. Provide a telephone inside the isolation room.

B. Maintain a clean and pleasant environment and allow recreational activities.
C. Talk with family members to avoid expression of disgust.
D. Provide all the personal items needed by the client.

194.The client was visited by friends. What instruction should you give the visitors who will come in contact with the client?
A. Talk with the relatives outside the clients room.
B. Perform hand hygiene after coming in contact with the client.
C. Leave the facility immediately to avoid long exposure with the client.
D. Wear gloves when entering the room.

195.Research has shown that the most effective infection control procedure is:

A. Hand washing before and after the client contact

B. Wearing gloves and masks for direct client care
C. Isolation precautions
D. Broad-spectrum prophylactic antibiotics

Situation 12 While taking care of different clients the nurses use of the nursing process is important.
196.The nurse is taking care of a client with tracheostomy. The most appropriate nursing diagnosis is:
A. Alteration in comfort; pain related to tracheostomy
B. Ineffective airway clearance related to tracheobronchial secretions
C. Risk for impaired skin integrity related to tracheal incision
D. Impaired verbal communication related to absence of speaking ability
197.Mari developed a fine reddened rash around the area where betadine was applied. Your nursing documentation should be to:
A. State time on the record and encircle where rash was noted
B. Suggest need for application of corticosteroid to decrease inflammation
C. Explain rash to the client and family
D. Include a notation on the allergy list for client and inform his physician
198.Your client is a 90 year old woman, bedridden, weighs 80 lbs, with dry and wrinkled skin, incontinent of urine and stools.
Which nursing diagnosis would the nurse use to apply to clients condition?
A. Impaired physical mobility
B. Impaired skin integrity
C. Risk for activity intolerance
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 D. Risk for altered skin integrity
199.The nurse is taking care of Mang Isko who has dyspnea, intermittent cough and irregular respiratory rate. The most
appropriate nursing diagnosis would be:
A. Ineffective airway clearance
B. Risk for injury
C. Excess fluid volume
D. Impaired spontaneous ventilation
200.To obtain accurate information about the health history of Mr. Cruz, 49 years old, the nurse should possess which if the
following important skills?
A. Psychomotor and intellectual skills
B. Communication and critical thinking skills
C. Application of steps of the nursing process
D. Inspection, palpation and auscultation
Situation 19 Control of infection is emphasized in the vare of clients and must not be compromised. An understanding of the
infection process and appropriate methods to prevent transmission of infection is important. The following questions apply.
201.The nurse in the health center is explaining standard precautions to the client. This involves which of the following
actions?
A. Wear protective equipment when doing any nursing procedures
B. Wash hands thoroughly using antimicrobial soap and hot water
C. Use clean gloves when handling items like blood, body fluids, non-intact skin.
D. Recap used needles with both hands before discarding in puncture resistant container
202.The nurse is to perform a sterile procedure while assisting in minor surgery. Which of the following actions of the nurse
maintains aseptic technique?

A. Talking to others over the sterile field

B. Keeping the sterile field within the line of vision
C. Handling the medicine to the physician over the sterile field
D. Using sterile gloves in opening sterile packages
203.Observation of contact precaution when caring for Lailani who has scabies is ordered. As a precautionary measure when
giving a bath, the nurse is expected to use:
A. sterile gloves and isolation cap
B. face mask and gloves
C. gloves and gowns
D. isolation cap and face mask

204.Mrs. De Vera is to go through bronchoscopy and in order to prevent transmission/spread of disease droplet precaution is
observed. This entails:
A. wearing cap and gown
B. consistently washing hands before and after entering room of client
C. wearing gloves when giving care
D. use of surgical mask within 3 feet of client
205.Changing the wound dressing of the client requires utmost care to prevent infection. When doing wound care, the most
appropriate action of the nurse would be to:
A. wear sterile gloves whenever on contact with the wound area
B. remove old dressings with sterile gloves
C. pour antiseptic solution out of the container.
D. open the sterile dressings with sterile gloves

SITUATION: The scope of applicable law in nursing has considerably expanded. The nurse has legal responsibilities to clients and
should be aware of the legal principles associated with nursing practice. The following questions apply to this.
206.An elderly client woke up at midnight to go to the bathroom. She gets out of bed unassisted but fell. The nurse prepares an
Incident Report. When completing the Incident Report the nurse understands that its main purpose is to:
A. Identify the person responsible for the incident
B. Document factual incident for legal action
C. Describe relevant information on the clients chart
D. Identify patterns of risk for corrective action plans to take place

207.The nurse is preparing to change the dressing of the client, Mr. Marquez, who refuses and tells the nurse to do it later. The
nurse says. If you do not let me change the dressing now you will not be allowed to receive visitors. This situation
illustrates an example of:
A. Negligence
B. Assault
C. Malpractice
D. Battery
208.The nurse is preparing to administer the 10:00 PM sleep medication of Mr. Marquez. As she is about to administer the
medication she assesses that the client appears to be asleep. Which of the following actions should the nurse do?
A. Administer later when the vital signs are to be taken
B. Withhold the medication since the client is already asleep
C. Allow the client to sleep and inform the physician
D. Awaken the client to administer the medication

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 209.The nurse is assisting the physician during his visit to Mr. Marquez. While the physician is writing his order the nurse noted
that the order of medication is larger than the standard dose. Which of the following is the most APPROPRIATE action of the
nurse?
A. Administer the drug as orders
B. Call the attention of the physician
C. Administer the standard dose
D. Discuss the order with the physician

210.The client, Mr. Marquez, asks the nurse to explain further a Living Will. The nurses explanation in correct when she states
that a Living Will:
A. Enables the client to decide how his life end humane or dignified manner
B. Gives consent to the physician to perform life-sustaining medical intervention during an emergency
C. Provides instructions to the physician about withholding or withdrawing life sustaining procedures
D. Allows the client t donate any part of his organ to others who may need a transplant to sustain life
SITUATION: Values and ethical principles are important in the practice of nursing. As the nurse faces various situations in the care of
clients, ethical principles guide nursing actions.
211.An activity of the nurse that would be an example of autonomy in his/her nursing practice is:
A. Having a governing body to enforce rules and regulations
B. Being paid for nursing services.
C. Becoming a member of a professional organization
D. Making nursing diagnoses and deciding nursing actions while caring for a client
212.Your female client has stage 2 breast cancer and has to decide whether she will have surgery or not. She is afraid to die but
you inform the client about the benefits and challenges of surgery so that she and her family can arrive at a decision. This is
an example of.
A. Veracity
B. Autonomy
C. Beneficence
D. Fidelity
213.You decide to take graduate studies and take continuing professional development courses to keep yourself updated so that
you can always provide competent care to your clients. This is an example of:
A. Accountability
B. Non-maleficence
C. Fidelity
D. Justice
214.You are kind but firm in ensuring that your client practices deep breathing and coughing exercise postoperatively to prevent
post operative complication of pneumonia. You are demonstrating:
A. Beneficence
B. Non-malifecence
C. Accountability
D. Autonomy
215.Your client gave you verbal instruction not to resuscitate him if he goes into cardiac arrest. You have sworn to uphold life and
this puts you in a conflict. This situation is an example of:
A. Ethical dilemma
B. Medico-legal problem
C. Conflicting state
D. Beneficence

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