NAME: ID#:_____________ SCORE:

Situational I – The nurse is preparing the medications for his clients in the ward. Administration of medication is the responsibility of the nurse as part of
management of client’s health needs. He prepares various oral, parenteral and other medications for 8 am.

1. When he enters the room, he finds the client in bed. She says that she is “afraid to choke on her medications because she sometimes has a hard time
swallowing.” Which nursing action is most appropriate?
A. Ask the client to assume sitting position.
B. Mix the medication in client’s soup.
C. Put the client in supine position.
D. Mix the capsule in a banana for her to chew.
Answer: B
Since the client verbalized that she has difficulty swallowing medication, the best way to give it is to dissolve it and mix it with the client’s food.
Assuming a sitting or supine position (option A and C) will not solve the client’s burden. Capsules (Option D) are not allowed to be chewed.

2. The nurse is going to instill otic drops to a client. He instructs the client to lie on his side opposite the ear to be medicated. To administer the otic
medication the nurse will straighten the ear canal by pulling the pinna:
A. upward and forward. B. downward and backward.
C. upward and backward. D. from side to side.
Answer: C
Pulling the pinna up and back is the best way to instill otic medication. Option B is for children 3 years and below. Since the situation did not mention
the age of the client, the best way is still Option C.

3. When giving subcutaneous injection to an obese client, the nurse should pinch the skin at site and inject medication at which angle?
A. 45 degrees B. 20 degrees
C. 50 degrees D. 90 degrees
Answer: D
Subbcutaneous medications should be given at 45 degrees but the situation clearly stated that the client is obese, thus medication should be given at
90 degrees.

4. The nurse will next administer an intramuscular injection preparation to another client. The nurse safely administers the drug using the Z track
technique of injection for the following reasons, EXCEPT:
A. this method leaves a zigzag path to seal the needle track.
B. this technique requires that the medication be injected slowly to allow it to disperse evenly in muscle tissue.
C. this technique is best when medication for IM injection is irritating to tissue.
D. the skin is pulled sideways and the needle is injected at 45 degree angle.
Answer: D
Pulling sideways is ID and 45 degrees is Subcutaneous.

5. The nurse prepared Penicillin for skin test. He uses a tuberculin syringe with gauge 25 needle and performs the procedure correctly by:
A. withdrawing needle quickly to minimize bleeding
B. pinching the skin over site and injecting medication slowly
C. stretching skin over site and inserting needle slowly at 10 to 15 degree angle
D. massaging the injection site
Answer: C
This is the correct technique in administering ID medicatons. Option B is for IM medications.

Situation 2 – Using team approach when providing care helps promote quality and continuity of care for the client from the pre-admission phase to
discharge and follow-up care.

6. The nurse discusses with the client’s wife health promoting activities that can help the client with cirrhosis of the liver in his activities of daily living at
home. Which among the following is the most appropriate measure the nurse can suggest?
A. Avoid crowded areas.
B. Good nutrition, avoid infection and abstain from alcohol.
C. Ensure adequate rest, sleep and exercise.
D. Take a glass of milk at bedtime.

7. The staff nurses in the medical unit are planning total parenteral nutrition prevent complication when administered through a central line. Which of
the following interventions are most appropriate?
1. Follow strict clean technique for all dressing change.
2. Promote adequate rest and limited activities.
3. observe strict aseptic technique.
4. cover insertion site with air occlusive dressing.
5. cover the insertion site with moisture-proof dressing.

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

8. The nurse is assigned to a client with a diagnosis of cancer of the bladder, with attachment to an appliance for a standard urine collection at night. The
nurse discusses with the wife the reason for the attachment. The best explanation should be to:
A. prevent urine leakage.
B. prevent urine reflux into the stoma and ureters.
C. prevent urine drainage into the stoma.
D. restrict fluid intake.

9. The nurses in the renal unit are reviewing the laboratory result of the clients. Which of the following laboratory blood results will NOT improve by
dialysis treatment?
A. Elevated sodium level. B. Elevated potassium level.
C. Low hemoglobin. D. Elevated BUN and creatinine.

10. The incoming nurses in the renal unit are discussing the assessment findings of a 66-year-old client, male, with chronic renal failure, and
hypertension. He has crackles in the lungs and weight gain from 145 lbs to 160 lbs. The nursing diagnosis that is appropriate for the above findings is:
A. fluid volume excess related to inability of the kidney to maintain fluid balance.
B. increase fluid intake related to chronic renal failure.
C. fluid volume deficit related to renal failure.
D. fluid volume excess related to malfunctioning kidneys.

Situation 3 – You were asked to attend a seminar on basic infection control where standard and universal precautions are emphasized.

11. Your nursing action which indicates your observance of standard precautions would be when you:
A. protect yourself from infections through contact with blood or body fluid borne viruses.
B. dispose needles, scalpel blades, sharp instrument in double bags.
C. protect yourself from contact with blood, open wounds, and body fluids.
D. practice frequent hand washing including washing of contaminated gloves.

12. You have mild cough, runny nose and low fever but you still reported to work. Which of the following actions is NOT an effective way to control
infection?
A. Minimize working with clients highly susceptible to infections.
B. Cover your mouth and nose when you sneeze or cough.
C. Use mask, gloves and gown while working.
D. Do frequent hand washing.

13. Understanding the risks of infection, who among the clients listed below should receive immediate attention and care?
A. Adult male with fresh second degree burns on arms and chest.
B. Teenager who is bleeding due to a cut on the finger.
C. An elderly male with diabetes mellitus and toe infection.
D. Adult female with Vitamin B deficiency due to chronic alcohol intake.

14. While taking care of clients, the nurse practices basic personal hygiene when she:
A. uses perfume to smell clean and fresh to avoid unpleasant body odor
B. fixes her hair so that it does not fall to her face
C. wears ornate jewelry to look pleasant to her clients and colleagues
D. uses light colored nail polish to protect her nails from infectious material

15. During the seminar the nurses are informed that Intensive Care Unit (ICU) patients have a high risk of contracting hospital-acquired infections. Which
of the following explanations is TRUE?
A. Many procedures done in the ICU expose clients to more pathogens
B. ICU is never empty so disinfection of this special area is difficult to accomplish
C. Clients are critically ill and highly susceptible to infection
D. ICU personnel are less strict with asepsis since clients are on antibiotics all the time

Situation 4 – The nurse in the Pediatric Unit is preparing medications a child for surgery. His weight is 22.9 kg. The physician ordered Atropine Sulfate 0.2
mg to be administered subcutaneously. An Intravenous infusion of 0.9% Normal Saline solution 500 ml was started to run for 24 hours.

16. In determining the volume for subcutaneous injection for infants and small children, the nurse should be guided that the maximum amount is:
A. 1.5 ml B. 0.1 ml C. 1 ml D. 0.5 ml

17. The safe dose of Atropine Sulfate for children is 0.01 mg/kg. The nurse computed the safe dose for the prescribed Atropine Sulfate. She computed
the correct dose if she obtained:
A. 0.3 mg B. 0.4 mg C. 0.1 mg D. 0.2 mg

18. After arriving at the safe dose of Atropine Sulfate, the nurse analyzes the desired dose ordered. Which of the following conclusions should guide the
nurse in administering the drug?
A. Desired dose is within safe dose range.
B. Weight of child is not proportional to the desired dose.
C. Desired dose is more or less adequate for the child’s weight.
D. Computed dose is more than the desired dose.

19. The nurse is using an IV infusion device for the intravenous fluid. A total of 500 ml of 0.9% Normal Saline solution is to infuse over 24 hours. At what
hourly rate should the nurse program the IV infusion device?
A. 30 ml/hr B. 41 ml/hr C. 15 ml/hr D. 21 ml/hr

20. While the nurse changes the patient’s gown, the infusion pump alarm turned on. The nurse’s priority should be to check first the:
A. container if empty. B. intravenous site for occlusion.
C. tubing for kinks. D. presence of air in the tubing.

Situation 5 – Before accepting you as a staff nurse in the hospital, your knowledge and skills are tested to ensure safe nursing practice. Some basic
questions are asked.

21. The vital signs sheet of a client reads 104/100/90. The reading of “100” is interpreted appropriately as the pressure level when the:
A. sound has a whooshing quality.
B. last sound is heard.
C. first thumping sound is heard.
D. sound becomes muffled.

22. There is an order to obtain the patient’s arterial blood oxygen saturation (SaO2). What will you prepare to do the test?
A. Intravenous pump B. Ventilator
C. Spirometer D. Pulse oximeter

23. The equipment set an alarm and gave a reading of 70% SaO2. When ask for initial action in the situation, your most appropriate response is to:
A. call the physician and report the reading immediately.
B. check the connection of the equipment.
C. assess the client’s vital signs.
D. change the position of the client.

24. A client is reported to have orthostatic hypotension. Which of the following would you consider a sign?
A. A drop of 30 mm Hg in BP from a supine to a standing position with a rise in pulse of 40 beats/minute.
B. Increase in pulse of 40 beats/minute and decrease in BP of 30 mm Hg from a sitting to a standing position.
C. Decrease in pulse by 20 beats/minute and increase in BP by 20 mm Hg from supine to standing position.
D. A sudden drop in BP of 30 mm Hg systolic and 10 mm Hg diastolic from lying to sitting or sitting to standing position.

25. You demonstrate the correct technique in taking thigh blood pressure. Which of the following should you do first?
A. Locate the popliteal artery. - 4
B. Expose the thigh. - 2
C. Wrap the cuff around the mid thigh. - 3
D. Help client assume a prone position. - 1

Situation 6 – The nurse is preparing the plan of care for a newly admitted 45-year-old client with complaint of disturbed sleep. He frequently takes a nap
during daytime.

26. Variations in sleep pattern in the different age groups are evident. Which of the following is TRUE regarding sleep required among middle-aged
group?
A. The frequency of nocturnal awakening tends to increase while satisfaction with the quality of sleep tends to decrease.
B. Circadian rhythm tends to be prominent with increasing age.
C. The satisfaction with the quality of sleep increases as one approaches the middle-age level.
D. Sleep and rest fluctuates in relation to job-related stress and parenting responsibilities.

27. The goal for the client is that he will:

A. verbalize orientation to night and day.
B. increase nocturnal sleep.
C. gain satisfaction from nocturnal sleep.
D. sleep more at night and less during the day.

28. One of the interventions formulated by the nurse is to provide activities during the day including exposure to natural light and outdoor environment.
This is beneficial because:
A. outdoor environment activities involves controlled artificial circadian rhythm.
B. the sleep-wake pattern is closely linked with other circadian rhythms that affect certain hormone levels.
C. light exposure is communicated through the retina to the suprachiasmatic nucleus helping to set the circadian clock.
D. circadian rhythms follow a biological cycle of about 24 hours.

29. Which of the following is the best time for the client to take a nap?
A. Time of day near the midpoint of the nocturnal sleep period.
B. Mid afternoon for at least one hour.
C. Mid morning and should be 30 minutes or less.
D. Time of day opposite to the midpoint of the nocturnal sleep period.

30. With the interventions carried out as planned, the expected outcome is that the client will:
A. increase night time sleep by 20% over the next two weeks.
B. refrain from taking nap during the day to help set circadian rhythm.
C. report variation in sleep pattern.
D. have longer quality time sleeping during night time.

Situation 7 – The nurse is taking care of a 45-year-old male client diagnosed with chronic obstructive pulmonary disease (COPD).

31. The client has difficulty raising respiratory secretions. Which of the following actions should the nurse perform to reduce the tenacity of the
secretions?
A. Serve low salt, low fat diet.
B. encourage fluid intake from 2 to 3 liters per day.
C. Maintain client semi-Fowler’s position.
D. Administer oxygen inhalation.

32. The client asks the nurse why postural drainage is ordered by the physician. The nurse informs the client that his procedure is done to:
A. move secretions from lower to the upper segment of the lungs.
B. improve respiration by clearing the alveoli.
C. help decongest the lungs through drainage of all lung segments.
D. facilitate drainage after percussion has loosened the secretions.

33. The nurse knows that the principle used in postural drainage, cause the secretions to move through:
A. sweeping motion during respiration.
B. force of gravity.
C. pleural space to the apical lung segment.
D. anterior to posterior lung segment.

34. Oxygen administration at 2 L/min through nasal cannula is prescribed for this client. When the client asks why he needs oxygen therapy, your most
appropriate response is that in his condition low oxygen level serves to:
A. eliminate respiratory drive.
B. balance carbon dioxide content.
C. restore normal breathing pattern.
D. act as stimulus for breathing.

35. The nurse teaches the client how to conserve energy. To meet this goal the nurse instructs the client to:
A. exhale then inhale with pursed lips when lifting objects.
B. inhale then exhale with pursed lips when lifting objects.
C. draw a deep breath through pursed lips when lifting objects.
D. blow slowly through pursed lips when lifting objects.

Situation 8 – You are taking care of several clients whose problems include fluid imbalance.

36. A client is admitted with IV fluid due to severe diarrhea. While monitoring the flow rate of the client’s IV fluid, you assess his response to the
treatment. The most important assessment that will show expected outcome for this client is:
A. hourly urine output. B. presence of edema.
C. daily weight. D. skin turgor.

37. You are administering 3% Sodium Chloride solution to a client who has a diagnosis of Hyponatremia. Continuous assessment is done to ensure that
the client is safe from serious side effect of fluid volume excess. Your assessment will focus on the client’s:
A. pedal edema B. urinary output
C. peripheral pulses D. lung sounds

38. As people age they become more susceptible to dehydration even without excessive physical exertion or fever. When instructing the elderly to do
self-assessment you will emphasize increasing fluid intake when the following condition is present:
A. Feeling thirsty
B. Rapid heart rate
C. Irregular pulse rate
D. Feeling of dryness of the mucosa of inner cheek and gum

39. A client with fluid imbalance asks the nurse which food will be best to eat to avoid retaining excess fluids?
A. Fluid salad of banana, apple, pineapple, watermelon.
B. Vegetable salad with pickles, vinegar and oil dressing.
C. Fried rice and dried fish.
D. Hamburger and cola drink.

40. The nurse is assigned to take care of several clients. Who among these clients would be considered a high risk for fluid volume deficit?
A. 30-year-old female who will undergo Dilatation and Curettage.
B. 28-year-old pregnant woman who has nausea and vomiting the whole day.
C. Teenager who just played basketball who has a body temperature of 40oC.
D. 55-year-old make with 15% burns in the body.

Situation 9 – High quality documentation and record management are vital in providing efficient and individualized client care.

41. An incident report should consist of the following, EXCEPT:

A. action taken immediately following the incident.
B. report of pertinent factors relating to the incident.
C. description of the incident as factually as possible.
D. derogatory comments expressed by the client.

42. Which of the following steps should be included in reporting an incident?

A. Record, investigate, notification action.
B. Discovery, notification, investigation, consultation, action and record.
C. Notification, investigation, action and record.
D. Investigate, report, action and record.

43. A nursing service policy manual serves the following purposes, EXCEPT:
A. a reference when unexpected problems arise.
B. defines the scope of departmental responsibility within the facility.
C. a guide in attaining the vision mission of the nursing service.
D. a tool for orienting staff or foundation in which to develop administrative procedures.

44. Implementation of new policies and procedures bring about changes. New or revised materials should be distributed as soon as possible after it is
approved and ready for distribution. Which of the following should be attached to the policy manual?
A. Memorandum
B. Instruction on implementation
C. Schedule on the demonstration of new policy
D. Written copies of the process

45. Technology is an essential tool for all health service professionals. A computer based information system serves several purposes, EXCEPT:
A. improve operational efficiency.
B. promote organizational innovation.
C. build strategic resources for timely and relevant data.
D. use for decision making and communication.

Situation 10 – The nurse researcher determined the effect of therapeutic touch on the client’s comfort. Quasi-experimental design was used.

46. Of the following preliminary tasks, which of the following should the researcher do to obtain available knowledge in her area of interest?
A. Select the variables B. Identify the population
C. Review literature D. State the problem
47. When the researcher predicted that therapeutic touch significantly affects level of comfort of the client, the researcher was doing which step of the
conceptual phase of the research process?
A. Delimiting the problem.
B. Stating relationships of variables.
C. Formulating hypothesis.
D. Developing protocol for intervention.

48. The researcher used an interview schedule to ascertain the feelings of the clients when touched therapeutically by a nurse. If you were the
researcher who among the following will you consult to evaluate the content validity of the instrument?
A. Research adviser B. Subjects of the study
C. Experts in the field D. Statistician

49. In the selection of the size of the sample, which of the following statements show the correct use of sampling principles in the selection of the sample
size?
A. The smaller the sample size, the more accurate the inferences drawn for a given sample.
B. The greater the sample size, the greater will be the uncertainty for a given sample size.
C. The greater the sample size, the more accurate will be the estimate of the true population mean.
D. The smaller the sample size, the more accurate the difference between the statistics and the true population mean.

50. Which of the following is considered the final step of the research process?
A. Research critique.
B. Communication of findings.
C. Recommendation and implication.
D. Putting research evidence into nursing practice.

Situation 11 – In an effort to maintain the quality of health care provided to clients’ evaluation is needed. This evaluation may be limited to the
performance of one nurse or by the whole agency. This is done by looking into the structure, process and outcome of care provided.

51. This process of evaluation is called:

A. quality assurance B. nursing audit
C. quality insurance D. process evaluation

52. A client is confined in your unit. He says that he has difficulty sleeping because of the “ambience” in the unit. When evaluating the effect the setting
has on the quality of care provided to the client the evaluation being done is called:
A. quality assurance B. outcome evaluation
C. structure evaluation D. quality improvement

53. The client is given a sponge bath, vital signs are checked, and medications are given on time. The evaluation of the care provided to him by the nurse
is referred to as:
A. process evaluation B. nursing audit
C. outcome evaluation D. quality improvement

54. As a result of the comfort measure done and medications administered to the client, some demonstrable changes are observed. These changes in the
client’s condition when evaluated is referred to as:
A. outcome evaluation B. nursing evaluation
C. quality improvement D. outcome identification

55. The head nurse wants to evaluate the time it takes for the nurse to respond to client’s call. This type of quality evaluation is called:
A. nursing audit B. structure evaluation
C. process evaluation D. quality improvement

Situation 12 – The fast-paced demanding environment calls for the nurse leader to learn new roles and develop new skills.

56. A nurse who has been working in the medical unit for one year now was called by the nursing supervisor to help in the delivery room. The nurse feels
she is not qualified so she refused the assignment. The supervisor insists that she is the most qualified person. Which of the following is the most
appropriate action of the supervisor?
A. Use appropriate negotiation strategy and apply closure and follow-up.
B. Report to the director of nursing service the concern of the staff nurse.
C. Insist on what she wants at the expense of the nurse.
D. Call the head nurse in the delivery room to convince her.

57. A training program for staff nurse is designed. When selecting trainees from each service unit, the most appropriate consideration would be to select
one who:
A. possesses competence for roles assigned.
B. provides knowledge and emotional support, can role model and adjust teaching to each learner as needed.
C. uses a variety of skills to facilitate team work.
D. interacts very well and can influence others.

58. A nurse leader assumes a critical role in planning, implementing and evaluating patient care outcomes. Which of the following is TRUE about patient
care management?
A. Assess patient acuity and prepare appropriate care.
B. Focus of care in patient population rather than individual patient.
C. Integration of patient information management into the system.
D. Equal allocation of resources in all service units.

59. Evidence-based practice uses cutting edge research and best practices to make the most effective decision about patient care. Which of the following
is TRUE about evidence-based care?
A. Uses outcome research to develop care strategies and delivery.
B. Relies on patient satisfaction data.
C. Relies on biomedical parameters or diagnostic tests for needed health intervention.
D. Uses the best evidence that fits the current protocol.

60. The head nurse is developing strategies to determine how well staff nurses carry out their duties. The following strategies would assist her in moving
the staff toward excellence EXCEPT:
A. mentoring. B. understanding needs of adult learners.
C. staffing needs. D. networking.

Situation 13 – You are a newly hired staff nurse in a tertiary hospital. You learned that a “strong work ethic” is the most important characteristic your
employer expects from each employee.

61. Considering such expectation you should observe which of the following?
1. Positioning your job as a high priority in your life.
2. Staying focused and leaving personal problems at home.
3. Taking a thorough approach to getting the work done right the first time.
4. Exercising self-discipline and self-control.

A. 1, 3 and 4 B. 1, 2, 3 and 4
C. 1, 2 and 4 D. 1 and 2

62. As an employee of the organization, you agree to follow rules and regulation, support its mission and abide by its values. Which of the following
should you do to support the mission and values?
A. Learn by heart the mission vision of the organization and take pride in being associated with it.
B. Get a copy of the administrative manual and use it as a reference when needed.
C. Learn everything about the organization and talk intelligently about it in public.
D. “Walk the talk” especially when performing the tasks as expected of a professional nurse.

63. In the performance of your duty, you must possess knowledge to perform your job appropriately. The organization mission is “Quality is in the
details.” Which of the following statements supports this mission?
A. Contributing to quality improvement throughout the organization to highest degree.
B. Performing one’s job to the best of one’s ability guided by principles and scientific rationale.
C. Requiring competence and diligence in meeting the goals of the organization.
D. Making the smallest error or overlooking details can have a negative impact on quality.

64. As a member of the nursing staff, you are bound to demonstrate commitment to the job. You can accomplish this by manifesting the following
characteristics EXCEPT?
A. attitude and enthusiasm. B. reliability and accountability.
C. attendance and punctuality. D. compliance and submission.

65. Your supervisor asks you and two of your co-staff to proofread a report to make sure the statements are accurate. Since this is not within your job
description, one of the staff nurse members responded by saying “That’s not my job!” Which of the following should be your appropriate action?
A. Politely turn down the request and study the matter later.
B. Report the matter to the chief nurse and think of finding another job.
C. Refer the matter to the appropriate person and then make sure he/she follows through.
D. Go ahead and perform the task because you are capable of doing it.

Situation 14 – A nurse uses principles of communication to gain her client’s trust and gather data to be of assistance to her clients. The following situation
gives the nurse a chance to use therapeutic communication.

66. A client is scheduled for surgery and the nurse infers from his body language that he is anxious. The nurse’s most therapeutic response in this
situation would be:
A. “If you are worried about the surgery, you shouldn’t. We have the best surgical team in this hospital.”
B. “You seem worried. Would you like to talk about it?”
C. “I know how you feel. I had surgery once before.”
D. “Think about how healthy you could be after the surgery.”

67. While talking to a 73 years old female client, the nurse notices that she does not have her hearing aid on. To ensure that the client can hear her, the
nurse should:
A. speak slowly and distinctly and directly face the client.
B. speak aloud to client’s “good” ear.
C. enunciate and exaggerate her lip movements.
D. talk in a high pitched voice slowly.

68. The client says “being in the hospital makes me nervous.” The nurse’s most appropriate response would be to say:
A. “You feel nervous?”
B. “It is normal to feel nervous. Is this your first time to be in a hospital?”
C. “Why? What about being in the hospital makes you nervous?”
D. “Don’t worry, nurses are on duty round the clock and they will help you.”

69. While talking about the loss of her husband a few months ago, the client becomes teary eyed and soon stops talking. The nurse’s most therapeutic
response would be to:
A. tell the client it is normal to be sad under such circumstances.
B. change the topic conversation so she won’t feel sad.
C. remain silent, sit with the client.
D. leave the client so she can have some privacy.
70. The client is informed that she has malignant breast cancer and should have radical mastectomy as soon as possible. The nurse finds her sobbing
uncontrollably saying “I should have gone to the doctor sooner. Now my kids will grow up without a mother.” The nurse’s most therapeutic response
would be:
A. “Don’t lose hope. Surgery and radiotherapy work wonders.”
B. “It is natural to feel that way. Most clients do.”
C. “You feel that if you had been diagnosed earlier things would be different?”
D. “Is your husband close to your children?”

Situation 15 – A nurse is often called upon to give information or simple instructions in various situations. Therefore, the nurse should be prepared to
give health instructions.

71. A 68 years old female client is for discharge. The daughter asks the nurse what she could do to prevent injuries at home since the client has poor
vision. You instruct the daughter to:
A. put the client on bed rest to prevent possible accidents.
B. keep the house well lighted at all times.
C. use wheelchair in the house.
D. maintain position of furniture in the house.

72. A 30-year-old female client states that she has frequent urinary tract infection and asked the nurse how she could prevent recurrence. Which of the
following is the appropriate instruction of the nurse?
A. Wipe perineal area dry after every voiding.
B. Wear cotton underwear with pantyliners all the time.
C. Regular intake of 2 glasses of apple juice daily.
D. Drink eight (8) ounce glasses of water daily.

73. An 8 years old child is diagnosed with iron deficiency anemia. When assessing the child’s fingernails, the nurse instructed the mother to look for:
A. presence of Beau’s line. B. spoon nail.
C. pale nail beds. D. clubbing.

74. A client is a heavy smoker consuming 4 packs or more daily. He asks the nurse why he can’t seem to quit smoking easily. Your best explanation is that
nicotine:
A. is in the body system for a long time and causes relaxation.
B. decreases heart rate and respiratory rate.
C. affects mood and behavior and causes tolerance.
D. is associated with a “cool” image of a young man.

75. When giving health teachings to people who are experimenting with cigarette smoking, the nurse explains the following problems caused by smoking
EXCEPT:
A. smoking greatly increases risk for ischemic heart disease.
B. pregnant women can smoke without risk to fetus.
C. many types of cancer such as lung, oropharyngeal, laryngeal, are related to smoking.
D. smoking is a major risk factor for cardiovascular problems.

Situation 16 – A 58-year-old woman is hospitalized with diagnosis of pneumonia, left lower lobe.

76. When conducting assessment, the nurse is expected to obtain which of the following significant findings?
1. Cough, fever and chest pain
2. Cough and hypoxia
3. Dyspnea, tachypnea, tachycardia
4. Crackles and wheezes

A. 3 only B. 1 only C. 2 and 4 D. 1 and 3

77. With the above data, the nursing diagnosis should be stated as:
A. impaired gas exchange related to presence of infectious exudate in the left lobe of the lung.
B. impaired oxygenation related to cough and shortness of breath.
C. impaired oxygenation related to pneumonia with infectious exudate in the left lobe of the lung.
D. impaired circulation related to productive cough and pain in the left chest.

78. The nurse classified the nursing intervention for this client. Which of the following statements refers to this?
A. Circulatory status: adequate blood exchange.
B. Airway management: facilitation of gas exchange.
C. Airway management: facilitation of patency of air passages.
D. Respiratory status: gas exchange.

79. The nurse formulates plan of care with the client and states the expected outcome as:
A. speaks comfortably.
B. reports relief of dyspnea.
C. demonstrates return of temperature to 37oC.
D. expresses comfort and well being.

80. The nurse instructs the client how to do effective coughing techniques. The expected outcome of this technique that will benefit the client is:
A. improved breathing. B. adequate tissue perfusion.
C. increased clearance of exudates. D. patent airway.

Situation 17 – Health care professionals are faced with many issues in their day-to-day practice. To address these issues nurses should provide services
that will positively affect patient treatment and institutional outcome.
81. An elderly client in the Medical Unit tells the nurse that he is tired of the treatment, sees no improvement and he would rather take all his medication
to end his sufferings. Which of the following should be the initial action of the nurse?
A. Assess the client and make the appropriate referrals.
B. Recommend to the client to seek advocacy support.
C. Communicate the client’s wishes to his family.
D. Call the attention of the wife and watch the client closely.

82. A middle age client is frantic (EMOTIONALLY UNSTABLE) and uptight (UNEASY, NERVOUS). The client has an order of Benadryl 25 mg p.o. p.r.n. for
itching. The nurse administered Benadryl. The best description for the nurse’s action is:
A. malpractice. B. negligence.
C. battery. D. appropriate.

83. A female client has an order of repositioning every 2 hours. The nurse failed to change the position of the client as specified in plan of care. The
nurse’s action constitutes a violation of:
A. standardized Nursing Care Plan B. Nurse Practice Act
C. Medical Practice Act. D. Standards of Practice.

84. The nurse is taking care of an elderly client who is restless and tense. To protect the nurse from being sued for unlawful restraints, which of the
following should be her appropriate action?
A. Explain to the family that a restraint is needed for the protection of the client.
B. Tell the client that a restraint is to be applied for his own protection.
C. Contact the physician for orders and document the reason for using restraints.
D. Ask the family to be on the alert to protect the client from harming himself.

85. The nurse calls the physician to report a change in the condition of the client. The nurse is unable to reach the attending physician but left the
message to his secretary. After an hour the secretary called back and relayed the verbal order of the physician. Which of the following is the MOST
appropriate action of the nurse?
A. Take the message and ask for the signature of the physician during the visit.
B. Insist on talking to the physician.
C. Refuse to take the order from the secretary.
D. Accept the verbal order as it comes from the physician and record appropriately.

Situation 18 – Hospitalized clients may require special dietary considerations depending upon their physical condition. The nurse should be aware of
these considerations while taking care of different clients.
86. A hospitalized client has an order for nasogastric feeding. Before starting the feeding you check if the tube is in place. The best way to do this is to:
A. lower the tube and allow the secretions to drain then examine secretions.
B. aspirate gastric content and check the pH level.
C. introduce 10 to 15 ml of air and auscultate to listen to the gurgling sound.
D. reinsert a new nasogastric tube.

87. A client recovering from breast surgery asks you what type of food would fight “free radicals” to increase protection from cancer. Your best response
would be:
A. “Do you want reading materials in cancer fighting food?”
B. “Food rich in beta-carotene, vitamins A, C, E seem to fight free radicals.”
C. “Have you tried the herbal products in the market?”
D. “Eat food that are rich in antioxidants and phytochemicals.”

88. You are taking care of a client who has weakness on the right side of the body. You assess that client has a high risk for aspiration while feeding. Your
most appropriate nursing intervention when feeding the client would be to:
A. place the food on the unaffected side of the mouth.
B. raise the head part of the bed.
C. use straw.
D. feed clear liquid diet.

89. The elderly are more at risk of nutritional deficiency and dehydration. While talking to a client who is for discharge, he tells you about his plans to
keep himself well nourished and hydrated. Which of the following statements by the client will indicate that he needs some health instructions from
you?
A. “At night, I eat less food and avoid coffee so I won’t go to the bathroom frequently.”
B. “I don’t drink too much at night so I won’t have to wake up to go to the bathroom.”
C. “I drink water or juice whenever I get thirsty.”
D. “I consume at least a glass of water or juice with every meal.”

90. The supervisor assigns you to feed an elderly client and you were told that he has difficulty swallowing. She simply tells you to “be careful, he might
choke.” While feeding this client, you will watch out for which signs of dysphagia?
1. Coughing while eating
2. Delayed swallowing
3. Anorexia
4. Abnormal movements of the mouth and tongue
5. Weak or uncoordinated speech

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

Situation 19 – Considering the ethical and moral responsibilities inherent in nursing practice, nurses need to examine their own value system to
determine the BEST approach in managing the care of clients whose values differ.

91. A 16 year old female client, got pregnant and was abandoned by her boyfriend. She visited a doctor’s clinic and asked the nurse if she could have an
abortion. What should be the initial response of the nurse?
A. “You seek advise from your parents.”
B. “You should not feel that way.”
C. “What are your feelings about abortion?”
D. “Why not think it over and then decide after careful assessment of the situation.”

92. A 45-year-old female client, is admitted to a semi-private room for elective surgery. She tells the nurse that her prayer group will be coming to pray
for her. The group arrived, starting chanting inside the room. What should be the appropriate action of the nurse?
A. Arrange for the group to go to the prayer room or chapel if available.
B. Ignore the prayer group and allow their chanting.
C. Call the attention of the group and pray quietly.
D. Ask the client’s roommate for their understanding and respect the other client’s wish.

93. A 40 year old male client has been confined in a semi-private room for 2 days until another client came. He asks the nurse what the condition of the
client is. Which of the following should be the nurse’s response?
A. Ask the client what he wants to know.
B. Explain in layman’s term the condition of the new client.
C. Advise him that all client’s condition are held in confidence.
D. Tell him to ask the new client himself.

94. A nurse who functions from an ethic of care is best illustrated when she/he:
A. listens to clients.
B. shows sensitivity to unequal relationship.
C. provides a person-to-person encounter.
D. uses touch to provide comfort.

95. The nurse has a responsibility to perform nursing care activities based upon standards of practice. This means that:
A. minimum level of performance is accepted to ensure high quality care.
B. nursing action performed by the nurse is based on scientific knowledge.
C. practices observed by nurses ensure quality care.
D. nursing activities performed by the nurse are at an acceptable level.

Situation 20 – As a new nurse in a tertiary hospital, you were tasked to take the vital signs of the clients assigned to you. Accuracy in recording of the vital
signs is of utmost importance in the management of patient care.

96. Special considerations to be observed when taking vital signs include the following EXCEPT:
A. Wait at least 30 minutes after exercising, eating or smoking before taking vital signs.
B. Clients with acute neurologic deficits must be checked frequently.
C. Use of games and stories to decrease anxiety in infants to assess vital signs.
D. Frequent measurement of vital signs for immediate post-operative clients.

97. The nurse considers which of these to be CORRECT as when taking vital signs?
A. Standard and uniform equipment are used to measure vital signs for all clients in the ward.
B. Baseline data of the client’s physiologic functioning are established through accurate measurement of vital signs.
C. Blood pressure is routinely assessed in young infants and children to assess cardiac functioning.
D. Measurement and interpretation of vital signs can be delegated to nursing aides who have been well trained.

98. The nurse obtained a blood pressure reading of 120/80 when the client was in supine position. After an hour, the nurse rechecked the blood pressure
and obtained a reading of 132/78 in supine position and 110/60 in a sitting position. The most appropriate action by the nurse is to:
A. get the client’s blood pressure reading in the other arm.
B. report the readings to the supervisor for appropriate nursing action.
C. conduct a physical assessment of the client.
D. assist the client to return to a supine position.

99. The nurse has to take the client’s thigh blood pressure. You will assist the client assume which correct position?
A. Fowler’s B. Sim’s
C. Side lying D. Supine, knees flexed

100. The nurse obtained a prior blood pressure reading of 70/40 mm Hg a male client. This time she could not obtain a reading by auscultation. The most
appropriate nursing action would be to:
A. report to the physician immediately for proper intervention.
B. take the client’s blood pressure by palpation reporting to the physician any 20 mm Hg change in reading.
C. ask a nursing assistant to take the blood pressure by auscultation.
D. leave the blood pressure cuff on the client so as not to disturb when checking the blood pressure again.