RECALLS 2 - NP1

D. provides his or her own beliefs on how to solve A. Any event that results in multiple deaths. A. How the family expresses and manages emotions
problems B. Devastation that covers a broad geographic area. B. The communication patterns between the patient
Situation 1 C. Devastation that cannot be relieved without and parents
6. Public Health Nurse Silang is educating a group of assistance. C. Names and relationships among family members
The family Nursing Care Plan is designed to provide
residents in Community Marahas about RABIES. A D. The event results in multiple injuries, deaths and D. The meaning that the patient’s suicide attempt has
ways in solving health-related problems of the family as
participant asks, “How can you get the virus?” The property damage for family members
a whole. The nursing process is used to make this type
Nurse explains that the virus can be transmitted by
of care plan.
which source 12. Nurse Nikito is guided by the ICN framework of 17. Which of the following is the BEST QUESTION for the
1. In conducting a family assessment, which source of A. Saliva disaster nursing competencies. This framework consists nurse to ask to assess a family’s ability to cope?
data would be MOST helpful? B. Blood of four areas in the continuum of disaster management A. “Do you think your family copes effectively?”
A. Input from other members of the health team. C. Urine that corresponds to the four stages of disaster. What B. “What do you think of the current family problem?”
B. Information from other cooperating health care D. Stool consists of the FIRST stage? C. “What strengths does your family have?”
agencies. A. Response D. “Can you describe how you successfully handled one
7. She emphasized that the bites, which are responsible B. Preparedness family problem?”
C. Review of family members’ charts and medical record
for nearly 99 percent of human rabies infections, are C. Prevention
data.
those of the infected __________. D. Recovery 18. The mother of Albert asks the nurse, “Why do you
D. Observation and interaction with the family
A. monkeys want to do a family assessment? My teenager is the
members.
B. dogs 13. Nurse Nikito has invited several agencies in the patient, not the rest of us.” What is the BEST response
2. In completing a family assessment, the public health C. bats community to a meeting to discuss the disaster plan for of the nurse?
nurse should BEGIN by ___________. D. cats the community. Which of the following BEST describes A. “Family dysfunction might have caused the mental
A. gathering the health data from all family members the purpose of this meeting? To _______. illness.”
8. Nurse Silang explains that there are situations which A. Enhance communication among agencies in the B. “Every family member ‘s perception of events is
B. Testing the family’s ability to cope
increase the risk of rabies. These are ________. community different and adds to the total picture.”
C. evaluating communication patterns
A. stray of dogs B. Increase stability in the community C. “Family members provide more accurate information
D. Identification of the geographic location of resources
B. All of these C. Manage response to disasters in the community than the patient.”
for the family.
C. unprovoked bites D. Improve overall community functioning D. “Family assessment is a protocol for care of all
3. Which of the following would be better understood D. animals display abnormal behavior patients with mental illness.”
by the nurse after using a FAMILY MAP? 14. Nurse Nikito adapts professional nursing skills in
9. In another health education session, Nurse Silang recognizing and meeting the physical and emotional 19. Which information is the nurse MOST likely to find
A. Roles and relationship within the family
explains about LEPROSY. Which of the following should needs resulting from a disaster. For people who are when assessing the family of a patient with mental
B. Recognition of the leader who speaks for the family.
be included? willing to talk ensuing a disaster, which of the following illness?
C. Description of the social and economic status of the
1. leprosy is curable in the MOST appropriate approach? A. Power in the family is maintained in the parental
family.
2. not all leprosy patients are infectious A. “I am with you. It is good you are trying to release dyad and rarely delegated.
D. Identification of the geographic location of resources
3. leprosy is hereditary your distress by crying. It will make you feel better. “ B. Several family members have serious problems with
for the family.
4. casual contact with a patient causes leprosy B. “What you need to do now is to wait for instructions their psychological health.
4. The nurse discusses with the family some actions that 5. regular and adequate treatment is essential and services to be provided.” C. Stress that living with a mentally ill member has
needed to be taken and refers to the wife in the family A. 1, 3, 5
C. “Don’t feel bad. Others are in the same situation as challenged the family’s function.
as an outstanding organizer. Which of the following B. 2, 4, 5 yours.” D. The family exhibits many characteristics of
goals is the nurse trying to achieve by making this C. 1, 2, 5 D. “You need not cry. You need to move on and build dysfunctional families.
statement? D. 2, 3, 4 your life again.”
A. Making then husband proud that he had married his 20. Parents of Albert say, “We have never known
10. Nurse Silang stated that a definitive diagnosis of 15. As he passed by a road going to an evacuation anymore who was mentally ill. We have no one to talk
wife.
leprosy is obtained through _________. center, Nurse Nikito encountered a flash flood. A flash to because none of our friends understand the
B. Reinforcing for the family some of the strengths of
A. blood examinations flood _______. problems we are facing.” Which of the following is the
one of their family members.
B. tuberculin testing A. Occurs suddenly and for a short duration nurse’s MOST helpful intervention?
C. Encouraging the wife to volunteer to follow through
C. skin smears/ biopsies B. Is caused by the blocking of drains A. Facilitate achievement of normal developmental
on all the needed actions.
D. nasal smears C. Is caused by heavy rains tasks of the family.
D. Making the wife feel very complimented and proud.
Situation 2 D. Occurs in urban areas B. Build the parent’s self-concept as coping patterns.
5. In implementing family-centered care, the public C. Teach the parents techniques of therapeutic
Nurse Nikito is assigned in a disaster- prone province in Situation 3
health nurse _____________. communication.
the Visayas. He is aware that with increase frequency of
A. works with clients to help them accept limitations for Albert is a 15-year-old adolescent who lives with his D. Refers the parents to a support group.
disaster happening, he has to respond quickly and mother father, and several siblings. He is hospitalized in
their actions.
efficiently to assist the population affected by a provincial hospital after a suicide attempt. Situation 4
B. assists family members to assume dependent roles
calamities. In public health service, good record system is
C. offers information about necessary self-care abilities.
16. When performing a family assessment, select what important in the delivery of quality care to clients. As a
11. Which of the following BEST defines a disaster? the nurse must first determine.
public health nurse, you have the responsibility of 26. The need for supervision may arise from the 31. Nurse Sisa collects data and monitors the health D. Seek a balance between individual’s need and the
assisting in the preparation, maintenance of good following: status of the population. Which of the following core community’s needs.
records and reports. 1. Lack of motivation public functions is being implemented?
2. Conflict between personal and organizational A. Assurance 37. In regard to informed consent, which of the
21. You want to distinguish between records and goals. B. Policy development following statements is TRUE?
reports. As applied to public health, the following are 3. Lack of knowledge and skills C. Assessment A. Client may not be told about costs and alternatives to
the type of RECORDS, EXCEPT _______. 4. Desire for promotion or job permanency D. Prevention treatment.
A. Events such as births, illness, deaths 5. Achieve health goals for the agency B. Consent must be voluntary.
B. Analysis of a problem situation A. 2, 3, 5 32. Nurse Sisa included in her data collection the C. Only parents themselves should give consent for
C. Clinic consultation B. 1, 3, 4 number and proportion of persons aged 25 or older minor children.
D. Written data on home visit C. 1, 2, 4 with less than a high school education. Which of the D. Legally incompetent adults can give consent.
D. 2, 4, 5 following BEST describes this data?
22. REPORTS are prepared usually for administrative A. Health status data 38. The client has a living will in which he states he does
purposes. Which of the examples below is NOT a 27. Ms. Mahilom would require information regarding B. Health care resource information not want to be kept alive by artificial means even at
report? the supervisory needs of the midwives which can be C. Health risk factors home. The client’s family wants to disregard the client’s
A. Summary of services delivered taken from which of the following? D. Sociodemographic data wishes and have him maintained on artificial life
B. Accomplishments and failures of services 1. Review of records and reports support. The most appropriate initial course of action
C. Description of a program and planned services 2. Interview of the midwives 33. Working in the community with an for the nurse would be to:
D. Client information and profile 3. Review of literature aggregate/population, who does Nurse Sisa MOST likely A. Allow the family to ventilate their feelings and
to interact with? concerns, while maintaining the role of client advocate.
23. There are commonly used record and reports in 4. Observation of the midwives at work
5. Results of survey among the staff A. Students in a local high school B. Tell the family that they have no legal rights.
public health nursing practice. The individual clinical B. Patients at the local hospital C. Report the situation to the hospital’s Ethics
record contains which of the following information? A. 2, 3, 5
B. 1, 3, 4 C. Residents who play basketball Committee.
1. Socio-demographic characteristics D. Christians in the community D. Advise the family that they have the right to ignore
2. Patient’s chief complaint C. 1, 2, 4
D. 2, 4, 5 the living will as the patient cannot speak.
3. Physical Examination findings 34. Nurse Sisa has a clear understanding of population-
4. Prescription of drugs 28. Ms. Mahilom prioritizes supervisory needs and focused practice. Which of the following characteristics 39. During a routine visit, the nurse noted that Perlita,
5. Frequency of clinic check up would she MOST likely display? 20-year old wife and mother, has several bruises at
problems based on the following criteria, EXCEPT
6. Attendance to community settings ________. A. Improving the effectiveness of care provided various stages of healing. She tells the nurse that she
A. 1, 3, 5, 6 A. convenience to both parties to address needs B. Sponsoring a fund-raising project fell down. Failure to report your findings is an example
B. 1, 2, 3, 4 B. degree of importance of the identified need C. Volunteering for a community action of ____________.
C. 1, 2, 4, 5 C. availability of resources needed D. Providing health interventions for individuals A. malpractice
D. 3, 4, 5, 6 D. activities needed to meet the identified need B. reasonable prudence
35. Nurse Sisa is working to improve population-focused C. maleficence
24. The family Service and Progress Record (FSPR) 29. During the actual supervisory visit, which of the care in the community. Which of the following BEST D. negligence
serves as a tool to operationalize the concept of the following is NOT expected of Ms. Mahilom? She described a key opportunity for nurses like her to
family as the unit of care. The FSPR consists of four accomplish this goal? 40. Which of the following examples would indicate
________.
parts, the FIRST being _________. A. discusses the objective of the visit A. Assuming traditional nursing roles observance of client confidentiality?
A. Health and nursing problems B. expresses appreciation and support given for the visit B. Conducting community assessments A. Reading a friend’s chart in another health care
B. Nursing care plan C. conveys a formal, strict approach to the midwives C. Specializing in community health practice facility.
C. Assessment of the family and the environment D. explains the process and outcomes of the visit D. Influencing public health policy B. Describing a difficulty with a client in a health team
D. Service and Progress Notes conference.
30. After setting the objectives and selecting the Situation 7 C. Using a client’s name in a social conversation.
25. Which of the following relates to the family’s activities, Ms. Mahilom would need to identify the Ethical issues on a day-to-day basis often involve D. Talking about the client’s symptoms in front of family
NURSING PROBLEM? indicators for evaluation. Which one is NOT included? patient communication and advocacy. It may also
members.
A. Inability to assume health tasks with respect to A. Needs met questions about end-of-life care. Nurses are often the
health problems B. Performance increased one working closet with patients and families while Situation 8
B. Crisis situation or developmental deficit C. Promotion achieved administering care. Non Communicable Diseases (NCDs) remain to be the
C. Health threats, risks or hazards D. Quality of service improved major health challenges in the Philippines and globally.
D. Strained relationships or disunity 36. What is the appropriate approach for the The specific population group that are mostly afflicted
community/public health nurse in balancing individual
Situation 6 by these chronic conditions, such as diabetes and
Situation 5 As a public health nurse, Ms. Sisa intends to focus on a privacy and community’s needs for safety and security? cardiovascular diseases, are those aged 60 and above.
Ms. Mahilom, a public Health Nurse Supervisor, is a specific population to advocate, educate, collaborate A. Fulfill agency policies first.
preparing a supervisory plan for midwives under her with members from a community to improve health of B. Implement professional standards of nursing 41. When caring for a patient with type 2 diabetes who
charge. A supervisory plan is a written document on the people. practice. has been discharged, which topic will be MOST
how to organize and systematizes supervisory activities. C. Remember the group needs outrank individual needs. important to include in your health teaching?
A. Impact of the patient’s family history on likelihood of Situation 9 50. With the stated problems, the nurse and the properly use a new vital sign monitor. Which type of
developing diabetes. Assessment at the community-level of care is a community prioritize these using a set of criteria. Which education did the nurse receive?
B. Symptoms indicating that the patient should contact multidisciplinary undertaking that involves the member of the following criteria refers to the probability of A. Career counseling
the health care provider. of the health team. The public health nurse uses data reducing, controlling or eradicating the problem? B. Continuing education
C. Effect of endogenous insulin on transportation of that have already been collected and are available and A. Modifiability of the problem C. Pre-employment education
glucose into cells or gathers primary data for community diagnosis. B. Preventive potential D. In-service education
D. Function of the liver in formation of glycogen and C. Magnitude of the problem
gluconeogenesis 46. Assessment is the first step in the nursing process. D. Nature of the problem Section 12
In the setting, which of the following objectives of The Public Health Foundation, an NGO, defines quality
42. To obtain the MOST complete information when assessment by the public health nurse is NOT included? Situation 11 improvement in public health as “the use of a
doing an assessment for a 75-year-old patient, you will A. Identify specific risk factors related to health and Professional and personal developments are required in deliberate and defined improvement process, such as
_________. health problems. order to maintain and enhance professional standards the PDCA which is focused on activities that are
A. ask the patient to write down medical problems and B. Define the nature of the health status and health- and to provide quality, competent and safe patient responsive to community needs and improving
medications related problems care. population health.” Public Health Nurse Rosita learned
B. use a geriatric assessment instrument to evaluate the C. Identify clients who should be given priority for care. this management process during her undergraduate
patient. D. Determine who should be referred to different 51. Identify the element that is the BEST indicator of studies in Nursing.
C. interview both the patient and the primary patient health care facilities. increasing accountability in the profession of Nursing:
caregiver A. Increasing salary scale for nurses. 56. The acronym PDCA stands for _______.
D. review the patient’s chart for the history of medical 47. Conducting a community assessment leads to a B. Improved public image of nurses in social media A. Plan-Do-Check-Act
community diagnosis, its products consists of a profile C. Increasing number of nurses with doctoral degree B. Program-Design-Check-Act
problems
of the community’s state of health. As a process, the D. Demonstrate competency and high- quality care C. Plan-Draft-Certify-Act
43. Which information about a 77-year-old patient who public health nurse actively participates in community D. Prepare-Do-Check-Achieve
is being assessed by the public health nurse us of diagnosis. The MOST common method of data 52. Which of the following is the MOST important
UTMOST concern? The patient __________. collection that is accurate and provides the biggest bulk element in nursing’s attempt to gain full autonomy of 57. Public Health Nurse Rosita will use the PDCA when :
A. says, “I don’t go on my daily walks since I had of community data is the ________. practices? 1. Working towards continuous improvement
pneumonia two months ago.” A. Observation A. Maintaining the education system for nurses as it is 2. Implementing any change
B. tells the nurse, “I prefer to manage my life without B. Community census now 3. Developing a new design of a process or
B. Economic well-being and welfare of nurses service
much help from others.” C. Interview
C. uses three different medications for chronic heart D. Records review C. Restricting the latitude of decisions made by nurses 4. Completing a designed project
and joint problems. D. Gaining and maintaining control of nursing practice 5. Planning data collection and analysis to
D. organizes medications in a marked pillbox “so I don’t 48. The data on health and disease can be gathered by nurses. prioritize problems
forget them.” from different sources. Which of the following sources A. 1, 2, 4
provide a MOST accurate set of data? 53. What is the BEST method for nurses to prepare for B. 2, 3, 4
44. When caring for an older adult who lives in a rural A. Population health profile from school and factory future professional practice? C. 1, 3, 4, 5
area, you will ____________. clinics. A. Train other health care workers to whom delegation D. 1, 2, 3, 5
A. ensure transportation to appointments with the B. Births and death from city/municipality registrar. of tasks can be given.
B. Understand and explore the issues involved in 58. Using the PDCA cycle as a model for defining most
health care provider. C. Morbidity data from filed personnel.
B. Assess the patient for chronic diseases that are D. Mortality cases from medical death certificates. professional practice of the work processes the following are some areas of
unique to rural areas. C. Establish a coalition with professional health its applications, EXCEPT ____________.
C. obtain adequate medications for the patient to last 49. Data analysis involves qualification, description and organizations A. Needs analysis
for 4 to 6 months. classification of data which would reveal community D. Take additional courses in the use of computers and B. Overall strategic planning
D. suggest that the patient move to an urban area for health problems. An analysis of the social, economic, telemetry C. Staff goal setting and evaluation
better health care environmental and political factors that influence health D. Delegation of work to lower levels
is categorized as: 54. What allows a nurse to exert legitimate power over
45. Which of these patients assigned to you is MOST A. Health resources problems a client when providing nursing care? 59. Public Health Nurse Rosita knows that the purpose
LIKELY to need planning for long-term nursing B. Health status problems A. The ability to perform procedures to alleviate of continuous quality improvement (CQI) is to
management? C. Health-related problems patient’s discomfort _____________.
A. 71 year-old with appendicitis who has had an D. Comprehensive problems B. The ability to provide the client and family incentives A. Provide opportunity for staff members to participate
emergency appendectomy. and for self care in self-governance
B. 60 year-old with bilateral knee osteoarthritis who Situation 10 C. The power given to the nurse by reason of licensure B. Restructure health care delivery to improve cost
weighs 350 lbs. (159kg) Collaboration is being able to work cooperatively and examination and registration savings
C. 54 year-old with cholecystitis who has had a efficient with co-workers and any other people the D. The establishment of a professional and personal C. Deliver appropriate nursing care at tertiary level of
laparoscopic cholecystectomy nurse may have to interact with. This includes other relationship with the clientS service
health professionals, clients, and their families and D. Monitor processes involved in the provision of safe,
D. 62 year-old with acute sinusitis who will require 55. A nurse is employed by a health care agency that
communities. effective client care
antibiotic therapy for 5 day provides an informal training session on how to
60. Public Health Nurse Rosita is implementing quality 64. The occupational nurse has advocated the use of 70. Common uses and application of public health A. Eating only organic vegetables
performance standards in a public health department. ramps and assistive equipment for physically challenged surveillance include which of the following examples? B. Washing food very well
Which of the following BEST describes the importance workers. This is good example of which of the following 1. Detecting individual persons with malaria C. Cooking food properly
of this action? Quality performance standards levels of prevention? so that they can receive prompt and D. Boiling of water from questionable source.
___________. A. Health promotion appropriate treatment.
A. Can be used as hiring guidelines for nurses B. Secondary 2. Helping public health officials decide how 75. Giardiasis is a disease caused by a flagellated
B. Are used to guide improvement in the public health C. Tertiary to allocate their disease control resource. protozoan and its prevalence is associated with which
system D. Primary 3. Identifying changes over time in the of the following conditions?
C. Guide administrators to monitor public health at the proportion of children with elevated blood 1. Poor environmental sanitation
national level 65. Every employee has right to privacy and should be levels in a community. 2. Poor hygiene
D. Rigidly control public health protected from unauthorized and inappropriate 4. Documenting changes in varicella (chicken 3. Improper cooking of food
disclosure of personal information. Which situation pox) incidence, after a law mandating varicella 4. Overcrowding
Situation 13 does NOT provide exception to employee’s right to vaccination in the Expanded Program of 5. Malnutrition
The World Health Organization stated that occupational privacy? Immunization took effect. A. 2, 4, 5
health services, provided at the workplace to address A. Authorization by the employee to release A. 1, 2, 3 and 4 B. 1, 3, 4
the health care needs of working populations, have information B. 1 and 2 C. 1, 2, 4
been identified as an important component of the B. Life-threating emergencies C. 1, 2, and 3 D. 2, 3, 5
public health strategy. C. Compliance with government laws and regulations D. 2 and 4
D. Request from community leaders Situation 16
61. Occupational health services can make a significant Public health Nurse Tess wants to increase her
Situation 15
contribution to government initiative. These include the Situation 14 You are a newly-assigned Rural Health Nurse and you knowledge a familiarity with the elements of a research
following, reducing: Public Health Nurse Alma is a member of the health have the based on the latest health information of the publication.
1. Health insurance Team that is tasked by the Rural Health Unit to identify, municipality, food- and water- transmitted parasitic
2. Health inequalities define and measure major health problems of interest. 76. Public health Nurse Tess is analyzing a research
infections are prevalent. article. What section in the article can she expect to find
3. Social exclusion
4. Sickness absence 66. Public health surveillance includes the following 71. The factors that contribute to the occurrence of the research question and study purpose?
5. Overall burden of ill health activities, EXCEPT _________. food-transmitted diseases are the following, EXCEPT A. Discussion
A. Data analysis B. Results
A. 2, 3, 4, and 5 ___________.
B. 1, 3, and 4 B. Data collection A. consumption of improperly cooked food C. Methods
C. 2, 4, and 5 C. Disease control B. eating habits of the population such as eating raw D. Introduction
D. 1, 2, 3, and 4 D. Data interpretation food 77. Public health Nurse Tess is looking for a description
67. Public Health surveillance can be BEST described C. lack of fuel for cooking food of the type of measurement used in the study. She will
62. The nurse is a key figure involved in delivering D. overconsumption of locally available food
quality occupational health services. She/He works PRIMARILY as which of the following find this which section of the article?
independently or as part of a larger interprofessional A. A system for collecting health-related information 72. Paragonimus westermani or the oriental lung fluke A. Conclusion
health team. She performs, along with others a job B. A method to monitor occurrences of public health causes in the human population by eating inadequately B. Introduction
problems C. Results
safety analysis. In doing such, the following methods cooked crabs. Patients with paragonimiasis are usually
may be employed, EXCEPT: C. A program to control disease outbreaks misdiagnosed to have ___________. D. Methods
A. Review of records, interviews, surveys D. A system for monitoring persons who have been B. Bacillary dysentery
exposed to a communicable disease 78. A brief explanation of data collection and analysis
B. Walk-through, process and output reviews C. typhoid fever procedure is found in which section of the article?
C. Observation, focused group discussion 68. Which of the following is NOT a criterion for D. pulmonary tuberculosis A. Abstract
D. Racial background check prioritizing health problems for surveillance? B. Conclusion
73. The eggs of Taenia solium or taenia saginata may
63. The head of the health team creates a workplace A. Incidence of the problem be ingested by the pigs or cattle who serve as C. Discussion
safety report for a new clinic. He makes a strict B. Number of previous studies of the problem intermediate hosts. Which of the following measures D. Introduction
recommendation to ensure that sharps are properly C. Social and economic impact of the problem will PREVENT access of animals from ingesting Taenia
D. Public concern about the problem 79. Public health Nurse Tess wants to go over the list of
disposed in a puncture-proof container to decrease the eggs? references used in the study which can be found
risk of needle-prick injuries. This upholds safety under 69. Current public health surveillance targets the A. quarantine or isolate the animals Foods ____________.
which of the following categories? following. Which one is NOT included? B. Feeding the pigs and cattle with clean foods. A. at the end of the article
A. Physical A. Chronic disease C. Proper disposal of human faces B. in the results section
B. Chemical B. Population migration D. Protect the animals by giving them vitamins. C. as part of the literature review
C. Biological infections C. Communicable disease D. in the introduction
D. Psychosocial 74. Prevention of Infection from Entamoeba
D. Occupation Hazards histolytica is BEST done through which of the following 80. Public health Nurse Tess believes that research is
practices? significant to the nursing profession, hence, the study
results should be disseminated. This is because research D. Violation of a rule and regulation is not the same as B. Pre-interaction A. Intra-sectoral collaboration
allows _________. violation of the nursing Practice Act. C. Working B. Coalition building
A. a specialized body of knowledge to be generated for D. Orientation C. Inter-sectoral collaboration
use in health care delivery. 85. The patient, injured at work, was seen by the D. Network linkage
B. the scope of nursing practice to be expanded into factory occupational nurse. The nurse treated the 90. During the INITIAL home visit, the nurse lets the
areas formerly reserved for other disciplines. wound and instructed the patient to get a tetanus patient know that the visits are expected to end in 96. Which of the following is NOT recognized as part of
C. nursing responsibility to be more specifically defined antitoxin injection at the City Health Center. The patient about a month. Which phase of the helping relationship the nurse’s role as member of the health team?
D. liability within the practice of nursing to be failed to follow instructions, developed tetanus, and is the nurse in with this patient A. Care manager and supervisor
decreased subsequently filed a suit against the nurse. What is the A. Working B. Provider of care and education
most likely result of the ensuing trial? The nurse is B. Preinteraction C. Patient advocate and supporter
Situation 19 __________. C. Orientation D. Performing physician’s functions with supervision
Nurses perform duties that require physical A. liable, because there was no follow-up to ensure that D. Termination
assessments, critic thinking, and collaborative the patient receive the injection 97. The health team has brainstormed for ideas on
treatment plans, to name a few. Thus, nurses must B. not liable for damages, because the nurse has a right Situation 21 creating a more collaborative environment in a health
understand the laws that affect their practice, as well as to expect that instructions will be followed. After passing the Nurses Licensure Examination, Nurse care facility. Which idea or action would be the BEST to
their legal responsibilities in their professional roles. C. liable, because tetanus is easily treatable after Tawi-Tawi takes her first job in a Rural Health Unit in develop further?
diagnosis Municipality Z. She reviews concepts and principles in A. Develop a plan for the different team members to
81. A nurse must follow laws that protect public health, D. not liable, because tetanus is a reportable disease Primary Health Care (PHC). follow and show impact of their work.
safety, and welfare. Which law is the nurse following? and B. Emphasize that no one profession has all the
A. Code of Ethics 91. The key global agency that initiated the Alma Ata necessary competence to provide all care.
B. Standards of Practice Situation 20 conference on Primary Health Care is the __________. C. Hold education sessions regarding collaboration for
C. Continuing Professional Development The ability to communicate is a very important skill for A. World Bank each unit.
D. Nursing Practice Act every nurse to have. The nurse must do so in an B. World Health Organization (WHO) D. Institute collaborative strategies that are traditionally
effective, caring and professional manner, especially C. CARE International practiced.
82. Which situation supports the charge of malpractice when communicating with patients and their families. D. United Nations Children’s Fund (UNICEF)
against a professional nurse? 98. Which patient scenario describes the BEST example
92. Which Asian country is considered among the FIRST
A. A failure on the part of the nurse to establish a 86. A nurse wants to present information about of professional collaboration?
therapeutic relationship with the patient. influenza immunization to the older adults in the to adopt the principle of PHC? A. The nurse, physician, and physical therapist have all
B. A failure on the part of the nurse to ensure that community. Which type of communication should the A. Malaysia visited separately with the patient.
patients only receive care for which they could pay. nurse use? B. Indonesia B. The nurse mentions to the physical therapist that the
C. A failure on then part of then nurse to exercise A. signified meaning is wrong C. Thailand patient may benefit from muscle strengthening
reasonable and prudent care in treating a patient. B. affect is appropriate D. Philippines evaluation
D. A failure on the part of the nurse to allay a patient’s C. personal space was violated 93. Nurse Tawi-Tawi is aware that she has to use “tools C. The nurse and physician discuss the patient’s muscle
fears about an upcoming procedure. D. vocabulary is poor and methods that are suitable and acceptable to the weakness and initiate a referral for physical therapy.
families and communities” that she serve. This PHC D. The nurse, physical therapist, and physician have all
83. What does the court consider in determining the 87. A nurse is standing beside then patient’s bed. Nurse: developed separate care plans for the patient.
nurse’s liability for standards of care? “how are you doing?” Patient: “I don’t feel good.” principle is referred to as __________.
A. Professional education, experience, and specific Which of the following communication ELEMENTS is A. Cultural application 99. Which activities are appropriate for the nurse to
conduct. categorized as feedback? B. Appropriate application collaborate with a patient?
B. Professional experience, but not education or A. “How are you doing?” C. essential methodology 1. Prescribing a new medication dose
conduct. B. “I don’t feel good.” D. community participation 2. Health Promotion activities
C. Professional conduct, but not experience or C. Nurse is standing 94. Nurse Tawi-Tawi recognizes that health services 3. End-of-life comfort decisions
education D. Patient in bed offered are to in accordance to the prevailing beliefs 4. Interpreting laboratory results
D. Professional education, but not experience or and practices of the intended clients of care. This PHC 5. Lifestyle changes to improve health
88. A smiling patient angrily states, “I will not cough and A. 2, 3, 5
conduct. principle is known as _________.
deep breathe.” How will the nurse interpret the B. 2, 4, 5
84. The board of nursing has brought action against a finding? The patient’s ___________. A. Availability
B. Acceptability C. 1, 4, 5
nurse’s license based upon violation of a regulation. A. signified meaning is wrong D. 1,3, 4
What is TRUE about this scenario? B. affect is inappropriate C. Affordability
A. Rules and Regulations are internal to the Board, not C. personal space was violated D. Accessibility 100. The Rural Health Nurse and the Rural Health
the nurse. D. vocabulary is poor 95. Collaboration and cooperation is crucial to the Physician are explaining the home care that will be
B. Rules and regulations are only suggested standards achievement of PHC goals. The referral system among needed by a patient with Tuberculosis. The patient’s
or care and do not have to be followed. 89. BEFORE meeting the patient, a nurse talks to other spouse states angrily that it will not be possible to
caregivers about the patient. Which phase of the the RHU, non-government organization, and local social
C. These rules and regulations have the force of law. welfare and development office is classified as what provide the care recommended. What is the BEST
helping relationship is the nurse in with this patient? response by the nurse?
A. Termination type of relationship?
 RECALLS 2 – NP2
A. “I would like to listen to your concerns about the C. Standard of Care
prescribed care.” D. Focus Format
B. “It is important that you do. What the physician has Situation 1
prescribed.” Situation 2
Patient Natalie, 15 years old, G0P1, AOG 39 weeks, has
C. “I can come back after you talk with your spouse This is the first postoperative day for patient Shiela who
been admitted at 6:30 in the morning for lumbo-sacral
about the care.” delivered by caesarean section (CS). Nurse Gemma a
pains and strong uterine contractions every 10 minutes.
D. “Let me review what is needed again, then I’ll talk to newly hired staff was assigned to her.
Nurse Gracie was there to admit her. She uses Focus,
you later.” Data, Action and Response (FDAR) as the form of 6. Patient Shiela asks the nurse why she has to get up
charting. and walk the day after surgery. Which of the following is
the BEST response of the nurse? Walking hastens
1. In any type of charting or documentation, which of
_________.
the following should the nurse refer to and use to
A. Hastens lactation
generate and describe the status of patient Fe? Nursing
B. Relieves pain
__________.
C. Heals wounds
A. Assessment
D. Fast recovery from anesthesia
B. Process
C. actions 7. Which laboratory finding should the nurse assess on
D. diagnosis the patient 24 hours after caesarian section delivery
upon doctor’s request?
2. Which of the following are the purposes of
A. Trace 1+ proteinuria
documentation? To ________.
B. Hematocrit 35%
I. Ensure the development of organized
C. White blood cell count 20,000/cu.mm
comprehensive care plan
D. Hemoglobin 7.0 g/Dl
II. Have a clear and accurate record of what
was done to the patient. 8. Patient Shiela complains of “afterpains”. What should
III. Have an evidence of the health care be the nurse IMMEDIATE action?
member’s accountability in giving care A. Advise her to stop breast-feeding for a day
IV. Detect patients who are clinically B. Encourage her to drink more water
deteriorating C. Assess vital signs and pain level
A. II, III, IV D. Administer an analgesic STAT
B. I, II, III, IV
C. I, II, III 9. Patient Shiela is to be discharge 3 days after CS
D. I, III, IV delivery. Which of the following observations of the
nurse would cause the delay of her discharge and would
3. Which of the following is the CORRECT definition of warrant notification to the physician?
focus charting? A. Moderate amount of lochia rubra
A. It is an electronically form of documentation of B. Fundus is firm at umbilicus
nursing care done to a patient by a registered nurse. C. Pulse rate of 61 beats/minute taken in 24 hours
B. It is a note, written or electronically generated, to D. Five voidings totaling 240 cc in 12 hours
provide documentation related to a specific focus.
C. It is a nurse-centered way of documentation that 10. On the third postpartum day, Patient Shiela reports
describes the patient status and nursing care rendered. that she has voided five times that morning. What
D. It is a nurse-centered approach to documentation. should the nurse INITIALLY do?
A. Insert a Foley catheter
4. In the given situation, which is the FOCUS B. Collect the next voiding and measure the urine
A. Patient Natalie as the admitting nurse amount
B. Lumbo-sacral pains and strong uterine contractions C. Catheterize the client to check for residual urine
C. 15 years old, G0P1, AOG of 36 weeks D. Call the physician
D. Admission at 6:30 in the morning
Situation 3
5. What is the term used to describe the patient’s data Patient Apple, 19 years old, is in her first trimester of
or assessment, the action done based on the pregnancy. Because it is her first pregnancy, she went
assessment and response based on the action made: for her prenatal check-up with her mother. She asked a
A. Progress Note lot of questions which she expects the nurse to answer
B. Flow sheets her.
11. The nurse asked for the personal data of the patient was on knowledge deficit of Mother and Baby Friendly of their future children. Nurse Susane was there to help body rigidity followed by general jerking movements.
which, to some, Patient Apple did not like to answer. Hospital Initiative (MBFHI). them. Scottie vomits immediately after seizure.
And so she asked: “Why do you need to know if I am
married?” what should be a good response of the 16. What is the FIRST step among the ten steps for 21. Heather asks what she must do in order to be 26. Which of the following would be the PRIORITY
nurse? “I asked your marital status because _________. successful breastfeeding? healthy in case she becomes pregnant. Which among nursing diagnosis for Scottie?
A. If you do not have a husband, then that can pose a A. Have a written breastfeeding policy that is routinely the answers of Nurse Susane should NOT be followed A. Fluid volume deficit related to vomiting.
big problem for you.” communicated to all staff. by Heather? B. Altered family processes related to chronic illness.
B. If you are married then your husband will also suffer B. Inform all pregnant women about the benefits and A. Get support from husband and family. C. High risk for infection related to vomiting.
from discomforts like you.” management of breastfeeding. B. May have a massage from a lay midwife. D. Risk for aspiration related to loss of consciousness.
C. You need your husband to accompany you every C. Foster the establishment of breastfeeding support C. To readily accept her pregnancy.
27. Which of the following would be the LEAST
prenatal check-up.” groups. D. Early prenatal check-up
D. Train all health care staff in skills necessary to PRIORITY nursing care for a child with seizure disorder?
D. Your husband is your best support system during 22. Patrick asks what possible contribution he could give A. Observation and recording all seizures.
your pregnancy.” implement the policy.
for the normal development of the baby. Nurse Susane B. Ensuring safety and protection from injury.
12. The patient asked what is the term for signs such as 17. When practicing rooming-in, how long should the agreed that his BEST contribution would be the C. Teaching the family about anticonvulsant drug
breast changes, urinary frequency, fatigue, morning baby stay with the mother? ______ hours. following EXCEPT __________. therapy: indication, dosage, route and effects.
sickness and amenorrhea? A. 8 A. Stroke Heather’s abdomen and talk to baby D. Assessing for signs and symptoms of Increased
A. Probable signs B. 24 B. Provide Heather nutritious food and drinks Intracranial Pressure.
B. Presumptive signs C. 12 C. Join wife during prenatal check-up
D. 10 D. May smoke once in a while 28. Scottie will be taking phenytoin (Dilantin) regularly
C. Possible signs for seizure control. Which of the following will be the
D. Positive signs 18. What is the CORRECT time for which the mother 23. For the normal developmental of the fetus, Nurse MOST important teaching to Scottie’s family?
13. The patient asked what causes newborn babies with should initiate breastfeeding? It should be _______ Susane taught the couple that Heather should prevent A. Administer acetaminophen to promote sleep.
total absence of extremities. The nurse answered that hours after birth. Folic Acid Deficiency anemia by good diet, correct way B. Serve a diet that is high in iron
the cause for Amelia is intake of which of the following A. ½ of cooking vegetables and taking Folic Acid C. Maintain good oral hygiene and dental care
medications during pregnancy ___________. B. 1 supplements. Which of the following is NOT included D. Omit medication if the child is seizure free.
A. Anti-emetics C. 3 among the outcomes of folic acid deficiency to the
D. 2 baby? 29. After teaching the parents about their child’s unique
B. Antibiotics psychological needs related to a seizures disorder and
C. analgesics A. Cleft lip
19. Jubilee learned that newborn infants should ONLY B. Cleft palate possible stressors, which of the following concerns
D. anti-bacterials be given, which of the following? voiced by them would indicate the need for additional
C. Neural tube defect
14. The patient complained that every morning, she A. Fruit juice D. Fractures of all types teaching? The child’s ___________.
becomes nauseated and oftentimes, she would vomit B. Breastmilk A. Feeling different from peers
excessively. “What could be the cause of this,” she C. water 24. Heather asks the nurse what possible diseases B. Cognitive delays
asked? The nurse’s answer is: “It is due to increase level D. cow’s milk should she avoid that would guarantee health for the C. Poor self-image
of ________.” baby? These are: D. Dependency
20. Which is the LAST part of the initiative, as 1. Rubella
A. Heart burn recommended by WHO and UNICEF, for the MBFHI 30. Which of the following is NOT a focus for teaching
B. Estrogen 2. Rheumatic fever
external team to do before its final designation as 3. Anemia plan for an adolescent with a seizure disorder?
C. heart rate MBFHI Hospital? A. Obtaining a driver’s license
D. Progesterone 4. Chronic hypertension
A. Assess business facilities if they follow the 10 steps A. 1, 2, 3 B. Increase risk for infections
15. The nurse advised patient Patient Apple to report to for successful breastfeeding. B. 1, 2, 3, 4 C. Peer pressure
her physician which of the following MOST important B. Develop a research on the benefits of breastfeeding C. 1, 2, 4 D. Drug and alcohol use
sign, if ever she will suffer from it? within the institution. D. 2, 3, 4
C. Disseminate the benefits of breastfeeding to Situation 7
A. Cough Any pregnancy may pose a risk. A pregnant woman
B. Vaginal bleeding communities. 25. Nurse Susane advised the couple that the BEST way
D. Follow up mothers if they are exclusively to check the condition of the mother and the baby is to must therefore submit herself for regular pre-natal
C. Headache consultation in any health facility near her place of
D. strong fetal movement breastfeeding. have _________.
A. Regular well-selected exercise abode. A nurse can play an important role in making
Situation 4 Situation 5 B. Regular prenatal check-up these pregnant women aware of these risks in all stages
Heather is 23 years old. She and her boyfriend, Patrick, of pregnancy.
As a newly-hired staff nurse of the hospital, Jubilee C. Music therapy
learned that the hospitals have an in-service training for are planning to get married in a couple of months. D. Good food
Thereafter, they plan to have three babies. For this 31. What CHIEF ingredient of the prenatal vitamin for
its staff. The in-service trainings conducted are based on pregnancy nutrition that the patient should look for?
hospital and staff’s needs. One of the identified needs reason they sought reproductive health counseling for Situation 6
their benefit and the proper growth and development A hospitalized adolescent Scottie suddenly has a seizure A. Vitamin B12
while his family is visiting. Nurse Nisha notes whole B. Potassium
C. Vitamin C A. “After age 2, surgery is very frightening and should B. Esophageal discomfort is experienced after a heavy 47.When is the placenta, which is the source of
D. Folic Acid. be avoided if possible.” meal. estrogen and progesterone, fully developed?
B. “The eruption of the 2-year molars often complicates C. Weight gain of 20lbs in the 1st and 2nd Trimester
32. A woman in labor is at risk for abruptio placenta. the surgical procedure.” D. Fetus moves very frequently It is on the __________ weeks of pregnancy?
Which of the following assessments would MOST C. “Surgery should be performed before the child starts A. 8
convince you and the pregnant woman to believe that to use faulty speech patterns.” 42. When a patient is on an imposed bedrest, which of
B. 20
this has happened? D. “As he gets older the palate gets wider and more the following can help the patient cope? These are the
C. 16
A. Painless vaginal bleeding and downward trend of BP. difficult to repair.” following, EXCEPT __________.
D.28
B. And increased blood pressure and scanty urination. A. Let the patient lie on her side to allow more blood to
C. Pain at the lower quadrant and increased pulse rate. 37. The head nurse continued to ask Nurse Hannah, “A the uterus. 48.Mrs. Paula related that she oftentimes feel
D. Sharp fundal pain and discomfort between cleft lip predispose an infant to infections PRIMARILY B. Increase fluid intake to 8 glasses a day to prevent nauseated in the afternoon. Which of the following
contractions. because of which of the following reasons?” constipation. should Nurse Cynthia advise her to do?
A. Waste products that accumulate along the defect. C. Discourage participation of family in patient care to A. Eat sky flakes and follow it up with water
33. A woman 2 ½ months pregnant calls you by B. Inadequate circulation in the defective area. prevent further anxiety. B. Drink iced carbonated drinks
telephone because she passed out some “berry-like” C. Deficient nutrition from ineffective feeding. D. Use relaxation techniques to help cope with stress C. Drink hot chocolate or coffee
blood clots and now has continued dark brown vaginal D. Mouth breathing that dries the oropharyngeal such as music and books. D. Eat frequent but small amount of foods.
bleeding. Which of the following is the BEST instruction mucous membranes.
you should give her? 43. MgSo4 injections are painful to the patient. Which 49.Which of the following periods of pregnancy does
A. “Continue normal activity but take your pulse and 38. Which SIGNIFICANT statement of the mother of the following is the BEST route for injection to organogenesis occur?
respiratory rate every 4 hours.” predisposes her son to cleft lip or palate? prevent such negative experience for patient Joyce? A. Third
B. “Come to the health facility if uterine contractions A. “On my 6 months of pregnancy, I saw a rabbit with A. Intravenous injection at the main IV line. B. First
start.” the same case of my son.” B. Intravenous injection given through “piggy back”. C. Second
C. “Come to the health facility with any vaginal material B. “I am asthmatic and I usually take steroids.” C. Intramuscular on each of the deltoid muscle. D. Fourth
passed out.” C. “My mother- in- law doesn’t like me, that’s why she D. Deep intramuscular using z-track technique on
D. “Maintain bedrest and count the number of perineal cursed me.” buttocks. 50.What sign of pregnancy is morning sickness
pads used every hour.” D. “I believe my enemy did some forms of witchcraft on characterized by nausea?
me.” 44. The nurse must be alert to MgSo4 toxicity. Which of A. Probable, subjective
34. A woman, 33 weeks pregnant, with preterm rupture the following in NOT included? B. Presumptive, subjective
of membranes had blood work ordered daily. Which 39. For an infant born with a unilateral cleft lip and A. Fetal bradycardia C. Probable, objective
laboratory report would be MOST important to read palate, which of the following type of feeding will be B. Urine output of <30 ml per hour D. Presumptive, objective
daily BEST to use? C. Respiration of <12 per min
A. Serum creatinine A. Rubber-tipped syringe or medicine dropper. D. Increase in maternal pulse rate Situation 11
B. Red blood cell count B. Full breast feeding. A mother in her first trimester of pregnancy is asthmatic
C. Sodium and potassium levels C. IV fluids on limited number of ounces. 45. Which of the following hospital environment will be and has taken steroids. This resulted to her baby with
D. White blood cell count D. Cross-cut rubber nipple. MOST conducive to Joyce’s condition? A room that is / cleft lip and cleft palate.
with ____________.
35. An 18 –year –old delivers to an 8 –pound – baby 40. Which of the following is the number ONE A. Bright and well-ventilated 51.While assessing a newborn with cleft lip, the nurse
after 10 hours of labor. In the post-partal period, which consideration in the care of an infant after the surgical B. 2 or three other patients should be alerted on which of the following that will
of the following would be a PRIORITY concern to assess repair of a cleft lip? C. Quiet and non-stimulating MOST likely be compromised?
for by the nurse? A. Preventing the infant from crying D. A call button for watcher’s use. A. Locomotion
A. Endometritis B. Feeding the infant with a spoon for 2 days after B. Respiratory status
B. Thrombophlebitis surgery Situation 10 C. GI function
C. Bleeding C. Placing the infant in a semi-sitting position Mrs. Paula, 20 years old, visited the prenatal clinic with D. Sucking ability
D. Amniotic embolus D. Keeping the infant NPO for 1 say after surgery. her husband Christian. Nurse Cynthia noted that the
fundus is at the level of the umbilicus. Being her first 52.What is the MOST APPROPRIATE response of the
Situation 8 Situation 9 pregnancy, the patient asks the clinic nurse about nurse to the mother’s question as to when the child will
Head nurse Eva supervises Nurse Hannah who is Joyce, on her 35 weeks of gestation, is admitted pregnancy and childbearing. be ready for a cleft palate repair? Cleft palate repair is
assigned to take care of a newborn baby boy named because of hypertension, BP of 185/110, severe usually done _______.
Edwin with a cleft palate. headache and blurred vision. She was placed on 46.Based from the assessment of the nurse, what would A. When a large-holed feeding bottle is ineffective for
imposed bedrest without toilet privileges. The physician be the estimated age of gestation, in WEEKS, if then his feeding
36. The mother asks the head nurse why the fundus is at the level of the umbilicus? B. When the child is completely weaned from bottle
orders MgSo4. Nikita is the nurse assigned to her.
pediatrician recommended that closure of the palate A. 8 feeding
should be done before he is 6 months old. She asked 41. Which of the following would Nurse Nikita B. 10 C. Prior to the development of speech
Nurse Hannah to answer her. Which of the following is anticipate in then patient’s maternal history? C. 6 D. After the child has been toilet trained
Nurse Hannah’s APPROPRIATE response? A. On and off vaginal spotting D.12
53. Elbow restraints are the choice during the patient’s D. The possibility of error is greater in the giving of the bottle with her hands to warm up the solution to C. Hospital Client Advocacy
operation. When is the right time to introduce the use medication to children than to adults. prevent dizziness for _________. D. Patient’s Bill of Rights
of these restraints? It should be during the _________ A. 10 minutes
phase. 58.In children and infants, which part is often used for B. 5 minutes 68.Which of the following principles of bioethics is
A. Pre-operative intramuscular injection to reduce the risk of vascular C. 3-5 minutes referred to when Nurse Worms provides information
B. Rehabilitative and peripheral nerve (sciatic) injuries? D. 1 to 2 minutes and supports her client and family in making a decision?
C. intra- operative A. Deltoid muscle A. Fidelity
D. post- operative B. Gluteus maximus 63.After washing her hands and gently cleaning any B. Nonmaleficense
C. Dorsogluteal discharge that can be removed easily from the outer C. Justice
54.Before bringing the child to the operating room, D. Vastus lateralis ear, Nurse Olive positions the child. Which of the D. Autonomy
what condition of the patient needs immediate following steps follows?
notification of the surgeon by the nurse that will 59.Comprehensive surveys of research reports and case A. Gently press the tragus of the ear four times in a 69.When Nurse Worms values client advocacy, she
warrant suspension of surgery? study literature about intramuscular injections revealed pumping motion. follows which of the following guidelines?
A. Colic that administering medication intramuscularly can B. Drop the medicine into the ear canal. A. She is more loyal to the hospital than to her client.
B. Atopic dermatitis produce a variety of serious adverse effects. When C. Gently pull the outer ear B. She chooses the client’s well-being over client’s
C. nasopharyngitis asked by the Headnurse what possible complications D. Keep the up for five minutes autonomy.
D. eye deviation can arise, Nurse Yuuh should include which of the C. She gives priority to the good of the individual client
following? 64.Based on her knowledge on otitis media, Nurse rather than to the good of society in general.
55.Include in the post-op plan of care is collaboration 1. Skin and tissue trauma Romana recalls that children are predisposed to AOM D. She makes decisions for her clients who are not
and referral of the patient with cleft palate to which of 2. Muscle fibrosis and contracture due to their Eustachian tubes being, which of the aware of their rights and privileges.
the following APPROPRIATE health care provider? 3. Nerve palsies and paralysis following? Select all that apply.
A. Speech therapist 4. Infectious processes such as abscesses or 1. Shorter 70.Which of the following actions best describe the use
B. Dentist gangrene 2. More horizontal of the professional value of altruism?
C. dietetian A. 1, 3, and 4 3. More prone to obstruction by enlarge A. Protects the privacy of client regarding the client’s
D. gynecologist B. 1, 2, 3, 4 adenoids health condition.
C. 2, 3, 4 4. Longer B. Demonstrates an understanding of the culture of her
Situation 12 D. 1, 2, 3 A. 1, 2, 4 client.
The giving of medication to a pediatric patient is a C. Lobbies for universal access to healthcare.
B. 1 and 3
serious responsibility of a nurse. The need for accuracy 60.Prior to administering the drugs ordered by the C. 3 and 4 D. Becomes a mentor to her novice nurses.
in giving medication is greater than with adult patients. Pediatrician, Nurse Yuuh needs to know if she is giving D. 1, 2 and 3
Nurse Yuuh has just been assigned to the Pediatric the ordered medication to the right patient. The FIRST Situation 15
Wards. step is __________. 65.To promote drainage and reduce pressure from fluid, Miss Greigh an OB Nurse Specialists, was invited in a
A. Check patient’s identification bracelet. Nurse Olive’s nursing intervention is to have the child forum. The topic was about HIV-AIDS and the group was
56. Dosage, when giving medicine to pediatric patients, B. Compare medication to order to identification assume any of the following positions, EXCEPT: composed of ten pregnant women, and five newly
varies according to which of the following? Select all bracelet and patient’s stated name and birth date. A. Have the child sit up married women whose husbands are seafarers.
that apply C. Verify patient’s allergies with chart and with patient. B. Put the pillows behind the head
1. Size 71. Miss Greigh’s first topic was on HIV transmission.
D. Ask patient to state their name and birth date. C. Lie on the non-affected area After explaining the different transmission modes, she
2. Surface area D. Lie on the affected ear
3. Age of child Situation 13 asked the group: “Which among the following is the
4. Height Nicole, 5 years of age, is admitted to the Pediatric Ward Situation 14 MAJOR mode of transmission of the disease?”
A. 3 only due to severe otalgia, fever and irritability. The mother Itchy, 16 years of age, has been ordered to be A. Blood Transfusion
B. 1 and 2 informed Nurse Olive, who is assigned to Nicole that discharged. Nurse Worms is faced with a dilemma as B. Needle pricks
C. 1, 2, 3 patient had upper respiratory infection three weeks Itchy refuse to be discharge. C. Sexual intercourse
D. 1, 2, 3, 4 prior to admission. The admission diagnosis is acute D. Kissing
66.Which of the moral problems is Nurse Worms faced
otitis media (AOM). 72. One of the pregnant women asked the BEST way to
57. Nurse Yuuh is being reviewed by her Headnurse on with?
administering oral medication on pediatric patients. 61.Nurse Olive makes her INITIAL assessment on Nicole. A. Ethical sensitivity prevent HIV transmission from a pregnant HIV (+)
Which of the following statements below is CORRECT? The patient keeps on crying and constantly pulls her B. Ethical responsiveness mother to child?
A. The child should be told to place the tablet in the right ear. What is her MOST APPROPRIATE action? C. Ethical valuing A. Deliver the child via normal delivery with cervical
middle of his tongue and to drink water, fruit juice, milk A. Assess the description and frequency of pain. D. Ethical reasoning support
B. Stop pregnancy by abortion
in order to wash down the tablet. B. Take Karen’s vital signs.
B. A child’s reaction to a dose ordered by a physician is C. Request parent to carry the child. 67.Which of the following are the rights and C. Drink antiviral medicines as prescribed by physician
not less predictable than adult’s reaction. D. Refer to the attending physician. responsibilities of Nurse Worms’ client while confined in D. Prenatal check-up more than the standards
C. When giving oral medication, the child as young as the hospital?
62.Nurse Olive is preparing to administer ofloxacin A. Code of Ethics 73. A 20-year-old newly-wed woman, whose husband
two years of age CANNOT be taught to swallow drugs. has recently been diagnosed with HIV, asked: “Will my
eardrop on Nicole per Doctor’s order. She needs to hold B. Bioethical Ethics
baby have HIV too?” What is the BEST answer that Miss In terms of legalities, which of the following should 81. Rob is noted to be very conversant. To make her 86. Tiana thought that one of her activities would be
Greigh should give the client? Nurse Patty explain t Cathlyn? discharge instructions clear, Nurse Yuuh should health teaching and counseling. Which of the following
A. “No, definitely not because your child has not been A. II, III, IV emphasize which of the following? statements by the client regarding premenstrual
exposed to any type of HIV transmission.” B. I, II, III I. Tell Rob that he can clarify or ask questions. syndrome would need a further explanation?
B. “Yes, because HIV is definitely transmitted to the C. I, II, III, IV II. Tell him that it is alright to interrupt if he had A. “I will limit my intake of sodas, coffee and tea.”
child form the mother through the placenta. D. I, II, IV to ask a question to clarify B. “I will make sure that I will eat small frequent
C. “One way of transmitting HIV from the mother to the III. Advise him to listen ,well balanced meals.”
baby is through the placenta. However, your child may 77. Nurse Kris can also explain the purpose of security IV. Ask for the presence of his mother C. “I will stop any physical exercise one week prior to
or may not have been transmitted with HIV virus.” measures for data protection which is to maintain the A. 4 only menstruation to conserve my energy.”
D. “It depends on the viral load of the mother and many availability, integrity and confidentiality of personal B. 1 and 2 D. “I will decrease my intake of high sodium containing
other factors. Let us just see you after you give birth.” data of all patients. C. 1, 2 and 3 foods such as canned goods.”
I. Unlawful destruction D. 1 only
74. Miss Greigh continued with her health teaching. This II. Alteration 87.The nurse read on how to make a nursing diagnosis
time she describes four main routes of HIV III. Disclosure 82. Nurse Yuuh’s discharge instruction should contain, for premenstrual syndrome. Which of the following is
transmission. Which one is NOT included? IV. Unlawful processing which of the following? NOT TRUE about premenstrual syndrome?
A. Childbirth and breastfeeding Which of the following actions of anybody is against I. Take home medication, if any. A. Signs and symptoms of premenstrual period recur in
B. Unprotected vaginal and anal or oral sex personal data protection? II. Date to follow up the luteal phase of the menstrual cycle.
C. Breathing the same air as someone living with HIV A. I,II, III III. Activity and exercise B. Signs and symptoms of premenstrual period recur in
does B. II, III, IV IV. Diet the luteal phase of the menstrual cycle.
D. Sharing unsterilized injecting drug equipment. C. I, II, III, IV A. 2, 3 and 4 C. Symptom-free period occurs in the follicular phase
D. I, III, IV B. 1, 2 and 3 and must include 7 symptom-free days.
75. Miss Greigh gave a few questions to her audience C. all the options D. Symptoms are severe enough to have an impact on
about HIV transmission to find out if they were able to 78. To erase the doubt of Kylie as to whether she has D. 3 and 4 work, lifestyle and relationship.
learn about it. “Which of the following is the LEAST been infected with HIV by her BF, what is the BEST
among HIV transmission that can directly enter the advice of the nurse? 83.To make Nurse Yuuh’s discharge instructions to be 88.Nurse Tiana read about the nursing management of
body via the blood stream or mucous membranes?” A. Wait until you have access to the diagnosis of your more effective the following strategies should be used, primary dysmenorrhea. Which of these should Tiana
This can be through the ___________. BF. EXCEPT _____________. render?
A. Urethra or inside the foreskin of the penis B. Submit herself for Elisa Test considering window A. Treat him as a child. I. Use of cold compress
B. Lining of the vagina, cervix or womb period. B. Use simple understandable words II. Soft rhythmic rubbing of the abdomen
C. Dermis of the skin C. Wait until the baby is born. C. Eye to eye contact to show interest on what is being III. Analgesics as ordered
D. Lining of the anus D. Go for Elisa Test immediately said IV. Antispasmodics as ordered.
D. Ask for feedback A. II, III, IV
Situation 16 79.In case the personal data of Kylie’s BF has been B. I, II, III
Kylie is 19 years old, a grade 12 student. She recently accessed accidentally by “somebody”, who has the right 84.To get feedback on the discharge instructions, which C. I, III, IV
confessed to Nurse Kris that she had sexual intercourse to file a complaint? questions should Nurse Yuuh ask? D. I, II, IV
with her boyfriend (BF), 18 years old classmate of hers. A. Cathlyn’s BF A. Can you repeat to me what my instructions were?
She believes that she is pregnant because she missed B. The other guy B. If you understood my instructions then you surely be 89.What is the condition wherein menstrual interval is
menstruating for 3 months. She also related that her BF C. the parents well 45-50 days?
has recently been confined for pneumonia after an on D. Cathlyn C. Did you understand my instructions? A. Metrorrhagia
and off flu-like symptoms. She suspects he has HIV D. Are my instructions clear? B. Menorrhagia
because of his “closeness to a guy who has overtly 80.How long should personal data of an HIV patient be C. Dysmenorrhea
expressed his feelings on him.” stored on laptops or other portable devices which 85.The BEST statement of goodbye that Nurse Yuuh is D. Oligomenorrhea
permits his identification? For as long as __________. _________.
76. Kylie wants to know his BF’s real diagnosis even A. The patient likes A. “Bye Rob.” 90.What is the condition whereby during menstruation,
through a private message in Facebook. The following B. His doctor likes B. “Bye Rob. See you again in the hospital.” the patient feels lower abdominal pain that radiates to
information that all employees are enjoined to observe C. It is needed as part of an international or national C. “Bye Rob. I don’t want to see you again in the her back down to her thighs?
strictly. research hospital.” A. Hypergonadotrophic amenorrhea
I. Operate and hold diagnosis under D. It is necessary for the purpose for which it was D. “Bye Rob. Remember all my instructions. Keep well.” B. Secondary dysmenorrhea
strict confidentiality collected and processed C. Hypogonadotrophic amenorrhea
II. Sign a non-disclosure agreement between Situation 18 D. Primary dysmenorrhea
nurses and their patients. Situation 17 Tiana is the new nurse assigned at Fertility Clinic of an
III. Abide with the institution’s privacy and Rob, 15 years old, has been informed that she is due for OB Specialty Center. She had to review about the Situation 19
security policies. discharge. He has an emergency appendectomy. Nurse female reproductive cycle, menstrual disorders and Anne, head nurse at the OB-DR Ward, is planning to
Yuuh give him some discharge instructions. appropriate management. have an in-service training for 25 staff nurses. Based
IV. Disclose only the result of the best to the
patient himself.
 RECALLS 2 – NP3
from needs assessment, the training will be on Lactation A. Nursing Audit 5. Mr. GI Joe started to develop ascites and complained
for 3 days. B. Focus Group Discussion of heaviness of the lower extremities to the physician.
C. Phenomenological Situation 1 An order of Spironolactone (Aldactone) 25 mg. /day.
91.In order to make the activity a success, which of the D. Survey What adverse effect of the drug should you monitor?
Mr. GI Joe is 55 year old, married, a car dealer has
following resources would be MOST important? A. Hyperkalemia
consulted the ER because of on and fever, indigestion,
A. Number of speakers 98. What is the term used to describe the arrangement B. Palpitation
weight loss, right abdominal pain, body malaise, and
B. Location of venue of statistical data that exhibits the number of times the C. Irregular pulse rate
itchiness of the skin. Based on the health history the
C. Number of Participants values of a variable occurs? D. Hypokalemia
patient has been a chain smoker and drinks alcoholic
D. Budget Allocation A. Frequency distribution
beverages almost every day especially when he has
B. Frequency Situation 2
92.Which of the following resources should be clients to entertain. His physical examination showed he
C. Skewness Juliet, a Pediatric Cardiovascular Nurse is assigned to
requisitioned as TRAINING MATERIAL/ SUPPLY? has suspected liver cirrhosis. He was advised for
D. Survey take care of 3 children in her unit. She just admitted a
A. Bond Paper admission for further work-up and treatment.
12- year- old female patient suffering from Rheumatic
B. Sound system 99. In statistics, what is the definition of percentage? It Fever (RF)
1. You are the nurse on duty when Mr. GI Joe was
C. food and drinks is __________.
admitted in the pay floor. In your observational data
D. tables and chairs A. Whole population 6. When doing an assessment, which ONE of the
what additional EARLY SIGN of liver cirrhosis do you
B. A value on a scale of 100 following conditions is NOT present based on the Jones
93.Based from the studies, which among the following expect patient to manifest?
C. A share of profits Criteria?
is the MOST needed resource of nurses in order to A. Gonadal atrophy
D. Part of a whole expressed in hundredths A. Erythema Marginatum
attend in-service training programs? B. Hypotension
B. Subcutaneous nodules
A. Clothes 100. Based from the study’s findings, to whom are the C. Splenomegaly
C. Chorea
B. Time study’s recommendations generally addressed? D. Ankle edema
D. Bronchopneumonia
C. Drinks Using the situation a forecited, the recommendation
2. Which of the following statements is TRUE of liver
D. Notebooks should be addressed to _________. 7. In Rheumatic fever, the factor contributory to the
cirrhosis?
I. Nursing educators development of this disease process is brought about by
94.Evaluation of the training is an important form of 1. Nutritional deficiency with decreased protein
II. Staff nurses __________.
feedback in order to improve future offerings. Which of intake attributes to liver damage.
III. Nursing Service Administrators A. Auto-immune reaction to streptococcal infection
the following should be given MOST emphasis? 2. Cirrhosis can happen to people with alcohol
IV. Hospital Administrators B. Auto-immune reaction to collagen disease
A. Taste and amount of food serve. intake
A. I, II, III C.Parents had rheumatic heart disease
B. Discipline of participants 3. Women are at greater risk for the
B. I, III, IV D.Exposure to colds and droplet infection
C. Convenience of the venue development of alcohol-induced liver disease
C. I, II, III, IV
D. Knowledge and skills gained 4. Most patients affected by liver cirrhosis are 8. Marimar, 6 years old, is receiving digitals for having
D. II, III, IV
between 40 to 60 years of age. Patent Ductus Arteriosus with heart failure with heart
95.When asking mothers to become real models for A. 1, 2, 3, and 4 failure. Prior to the administration of the medicines,
demonstrating breastfeeding, the nurse’s MOST B. 1 & 2 which of the following nursing actions should be done
important responsibility is which of the following? C. 1, 2 & 3 by nurse Rica?
A. Word of thanks D. 2 & 3 A. Take the carotid pulse rate for one full minute.
B. Stipend/honorarium B. Take the heart rate for one full minute
C. Priority care 3. During Mr. GI Joe’s confinement he developed
C. Take the respiratory rate
D. Free hospitalization further itchiness of the skin and jaundice. Which of the
D. Take the blood pressure
following nursing actions is NOT recommended as this
Situation 20 will induce skin breakdown? 9. While Nurse Juliet was doing her regular rounds, one
Nurses Patti and Aika are doing research on, “The A. Add baking soda when bathing the patient. of the mothers approached her saying that her child
common errors regarding Standard of Nursing B. Massage the skin with emollients every 2 hours. who has a Tetralogy of Fallot preferred to squat on bed
Documentation in the Obstetrics Ward of Medical C. Use of commercial soaps and alcohol-based lotions. rather than assuming a supine position. The BEST action
Center.” D. Rub the itchy skin with knuckles instead of using the of the Nurse is ___________.
96. Which could be the MAJOR Purpose of the study? nails. A. Let the mother continue the position of her child if
To __________. she feels comfortable with it.
4. At early stage of Mr. GI Joe’s disease process, the
A. Improve the clarity of documentation B. Divert the child’s attention by letting her join the
physician ordered this SPECIFIC diet for Mr. GI Joe, You
B. Duplicate the study in other hospitals nurses’ rounds
emphasized to the dietitian that he should be served
C. Reduce, if not eliminate, errors in documentation C. Put her on bed and start to administer oxygen
foods that is _________.
D. Protect the hospital and staff from being sued inhalation
A. High carbohydrate and low sodium
D. Discourage the child and let her lie on bed with 2
97. Which of the following could be the BEST Method to B. High calorie and high carbohydrate
pillows instead.
gather the research data? C. Low protein and high fat
D. High protein and high fat
10. Another patient in the Unit is Nikki, 8 years old, A. Monitor vital signs vomited clear liquids about three times during your 27. Which of the following is the primary reason why
waiting to be scheduled for surgery because of a B. Observe surgical site for bleeding shift. Her vital signs include: temp-37.9 degree C. the physician wanted to clarify the process?
Coarctation of the Aorta. With this disorder, Nikki will C. Validate doctor’s orders 138/84 PR-78/min and RR- 26/min. her surgical incision A. Measures the turnaround time of medication
manifest which one of the following symptoms? D. Check level of consciousness is intact, slight bleeding, swilling and tenderness with B. Better communication with patient and result
A. Murmur and bruit of the lungs slight pain. C. Identify gap in the medication administration
B. Central and peripheral edema 16. There are several factors contributory to the D. Improve care management in drug administration
C. Hypertension and diminished pulses in the development of these conditions. Which of the 21. Which of the following manifestations would
extremities. following are the PRIORITY causative factors that should indicate the development of wound infection? 28. While the medical director is conducting his rounds
D. Hepatomegaly and shortness of breath be emphasized by Nurse Lydia in her health teaching? A. Presence of elevated red blood cells count. he observed the presence of scattered supplies and
A. Cigarette smoking B. Profuse and increasing perspiration. equipment along the corridor as well as 02 tank not
Situation 3 B. Aging process and alcohol intake C. Increased blood pressure, respiratory rate and pulse properly secured. The Quality Circle (QC) team was
Mr. Gaudencio Suarez is a surgical nurse in a medical C. Stress and overacidity rate. informed about this observation. Which of the following
center and he had been practicing for almost five years D. Sedentary life and obesity D. Increasing pain on the surgical incision. is the BEST strategies to be adopted by the team with
in this unit. The staffs go on shift rotation. For that shift, this concern?
he had two patients for operation. One is for Lobectomy 17. Mr. Jesse is admitted due to congestive heart 22. If the wound draining is serosanguineous, it means A. Adopt the 5 S audit.
and another is for Nephrectomy failure. Nurse Brilliantina would expect that if the failure that the secretion is colored ______. B. Identify and prioritize the problem
is on the right side of the heart, the patient will A. Yellow-tinged C. Select Alternative Solution.
11. When is the BEST time for the operative consent is manifest which of the following. B. Pinkish-red D. Enhance Continuous quality improvement.
be signed by his patients? A. Juguar vein distention C. Green-tinged
A. As soon as the surgical procedure is explained to the B. Crackles on auscultation D. Bright-red 29. The approach adopted by quality circle team was
patient C. Dry productive cough presented to top management. Which of the following
B. On admission when the relatives are around D. Improved bowel elimination 23. Later during the day, Gloria became confused, tools is APPROPRIATE to be utilized as a guide for their
C. A day before the surgery started to pull out her IV fluids as well as her wound time management?
D. Before any pre-op medications are administered 18. The patient has been receiving, Digoxin 0.25 mg per dressings. Complained of severe pain over the wound A. Pre chart
day to regulate his heart rate. Which of the following area. The PRIORITY action of the NURSE is to ________. B. Radar chart
12. Which of the following nursing goals are achieved outcomes would indicate that his medication is A. Apply sterile dressings over the surgical wound C. Process of flow chart
when early ambulation is done by post-surgery achieving its desired effects? B. Call the surgeon at once for the health status of the D. Gantt chart
patients? A. Improved appetite patient
1. Improved circulation B. Increased pedal edema C. Administer the pain medication at once 30. In order to determine if the implementation of the
2. Improved respiratory functions C. Increased urine elimination D. Restrain the hands of the patient activity is successful, the First step to be done by the
3. Prevent venous stasis D. Improved bowel elimination team is ______________.
4. Prevent emboli formation 24. The drug of choice of pain relief to patient Gloria A. Prioritize the problem
A. 3 and 4 19. The other patient of Nurse Brilliantina is suffering considering score of 8 which was assessed by the nurse B. Coordinate with the different units
B. 1, 2, 3,4 from Buerger’s disease. He has been complaining of based on the rating scale of 0-10 (0-lowest, 10 is the C. Have a random report to the supervisor
C. 1, 3, 4 intermittent claudication of the lower extremities which highest) is ________. D. Develop a monitoring plan
D. 1 and 2 has been giving him so much discomfort. What is the A. Morphines S04
Best nursing action she should perform to address the B. Ibuprofen 31. Mr. Anthony, 38 years old, is scheduled for
13. Which of the following patients is MOST at risk patient’s complaint? C. Demerol Laparoscopic Cholecystectomy in the morning the next
during the induction of anesthesia? A. Allow the patient to lie flat on bed D. Paracetamol day. He verbalizes to you and says, “Dr. Unido will open
A. 6-year-old with history of allergy B. Teach him foot care and leg exercises. me up to remove my gallstones?” which of the
B. 65 year old diabetic woman C. Place affected extremities in a dependent position 25. When patient is receiving opioid medication, the following is your BEST response?
C. 35 year old TB case D. Apply hot water bag to the affected extremities nurse should observe complications from the side A. “Let us discuss with the surgeon your operation
D. 25 year old Polio Case effects by ______. before you go to the OR.”
20. Which of the following information is NOT True of A. Checking for the presence of loose bowel movement B. “I know the surgeon will remove your stones with a
14. As a circulating nurse, which of the following is your Buerger’s disease? B. Observing signs and symptoms of addiction new technique.”
PRIORITY nursing action to promote safety of your A. Small and medium arteries and veins are mostly C. Assessing changes of circulatory status C. “Let me call the OR supervisor to discuss the
patient? affected. D. Assessing wakefulness of the patient at least every 2 procedure with you.”
A. Prevent peri-operative position injury B. Smoking is a major cause of Buerger’s disease. hours D. “I will call the anaesthesiologist to explain more the
B. Provide adequate lighting during the procedure C. Incidence of Buerger’s disease is high in men than procedure.”
C. Optimize surgeon’s access to surgical site women. 26. When the physician clarifies the process of Drug
Administration, this Quality Improvement Process is
D. Maintain surgical aseptic technique during the D. A strong relationship exists between diabetes and 32. A critical component before Mr. Anthony goes for
procedure Buerger’s disease. known as surgery is the nurse’ preoperative teaching. Which of
A. System analysis the following is NOT advisable prior to surgery?
15. Being the nurse in the Post-Anesthesia Care Unit, Situation 5 B. Root cause Analysis A. Teach him deep breathing exercises
which of the following is your PRIORITY concern after Gloria, 58 years old, beautician has undergone bowel C. Problem identification
surgery? obstruction surgery. During his first day post-op. she D. Pareto Chart
B. Fast at midnight, but can drink water if he becomes 3. Suction Apparatus A. Use of anti-inflammatory drugs. B. Accept the recruitment offer and go Absence without
thirsty. 4. Endotracheal B. Vital signs BP- 140/90, PR- 88/min.PR24/min. official leave.
C. Instruct him to void before going to the operating A. 1, 2, 4 C. abdominal pain (3 in a scale of 10) C. Write a letter of resignation to your employer 30
room. B. 1, 2, 3, 4 D. Tense, rigid abdomen days before leaving.
D. Teach him leg and coughing exercises C. 1, 2, 3 D. Accept recruiter’s offer and give an excuse to
D. 2, 3, 4 42. You have formulated your Nursing Diagnosis for the employer on behalf her “sick” mother.
33. While giving health instructions to Anthony. He patient and wrote in the nursing care plan. Which ONE
looks very anxious and said to you, “I might not be able 38. Which of the following emergency medicines should of the following? 47. Karylle is a BSN graduate but did not take the
to wake from anesthesia after my operation.” Your BEST be available at the emergency cart at the Cardio Ward? A. Deficient Fluid Volume R/T vomiting of blood and National Licensure exams. She is in dire need of money
response is _________. 1. Epinephrine gastric secretion. so she applied and was accepted in a health facility. As a
A. “Do not worry, everything will be alright.” 2. Demerol B. Non-compliance R/T alcohol and medication intake. nurse she submitted a fake PRC license in order to be
B. “Let me tell to your family your fear.” 3. Valium C. Fear of death R/T unknown cause of bleeding. given a job. Riza is liable to be charged of ___________.
C. “I will not let you go to the OR until I have talked to 4. Coumadin D. Risk for Aspiration R/T active bleeding. A. False statement
your surgeon.” A. 1, 3 B. Misrepresentation
D. “Don’t Say that, I will discuss your concerns with your B. 1, 2 43. The physician orders insertion of nasogastric tube C. fraud and deceit
anaesthesiologist.” C. 2, 4 with lavage to Mr. Nelson. What kind of solution will D. malpractice
D. 3, 4 you expect to be written in the doctor’s order when a
34. Mr. Anthony returned back to the ward, after patient will undergo a lavage? 48. Ms. Kendall an R.N was invited as a resource person
recovering from anaesthesia. He complain of pain over 39. When stocking fluids in the emergency cart. What A. Normal Saline Solution in a nursing conference. The curriculum vitae she
the scapular region. Which of the following nursing should Nurse Meg instruct the nurses? B. Distilled Water submitted to the PRC Continuing Professional
actions should you do? 1. Put the recently- delivered at the back of the C. Tap warm water Development Council reflects the word Masters of Arts
A. Apply heating pad over the painful area. old stock D. Dextrose 5% in water in Nursing (MAN) after her name. She only completed
B.Turn client from side to side. 2. Put the old stock in front of the newly- academic requirements but not her thesis writing.
C. Give demerol as ordered. delivered ones 44. When a patient has a gastro-intestinal bleeding and Which of the following did Ms. Paras violate?
D. Apply cold pack over the affected area. 3. Check the fluids for sediments and there is a presence of hematemesis, how should you A. RA 9173 of Nursing Law
discoloration describe this in your documentation? B. Code of Professional Ethics for Teachers
35. After 5 days, Mr. Anthony is ready to go home. His 4. Keep the fluids inside the cooler A. Bloody vomitus appearing as fresh, bright red or C. Magna Carta for Health Workers
discharge instructions include observations of the “Coffee-ground” in appearance.
A. 1, 2 D. Code of Ethics for Registered Nurse
following complications, EXCEPT: B. 1, 4 B. Brownish vomitus appearing as “Chocolate” in
A. Palpitation C. 3, 4 appearance from a previous Food Intake. 49. It is a hospital policy for nurses in a health facility
B. Loss of appetite D. 2, 3 C. Black, tarry stools in appearance often foul smelling, that reporting time is 15 minutes before the official
C. Increased body temperature from a previous food intake. designated time. Nurse Khloe reported 30 minutes late
D. Bleeding 40. How will Nurse Meg arrange the patients in the D. Small amounts of fresh blood observed either and requested her co-staff to sign in for her. This is an
ward? Put the ______________. through gastric secretions or stools. example of __________.
36. How will your distribute the patients to the 3 A. Primary Care in between the Ambulatory Care A. Dishonesty
Registered Nurses and 2 Nursing Assistants? patients. 45. The following are the practice guidelines in B. Falsification of document
A. 2 Registered Nurse for Total Care patients, 1 documentation. Which ONE of these is NOT
B. Primary Care and Ambulatory Care patients together C. Unprofessional conduct
Registered Nurse and 1 Nursing Assistant for Primary and Total Care at the corner of the room. recommended to be written in your charting? D. All of the options
Care Patients, 1 Nursing Assistant for Total Care. C. Total Care patients near the nurses and the A. Had urine output of 600 cc during the whole shift.
B. 1 Registered Nurse and 1 Nursing Assistant for Total Ambulatory farthest B. “Appears to be comfortable with good night rest and 50. What ethical justification is observed when
Care Patients, 1 Registered Nurse and 1 Nursing D. Ambulatory Care patients near the Total Care ones. sleep” administering Opioids despite the possibility of
Assistant for Primary Care Patient, 1 Registered Nurse C. Refused to eat her dinner as she feels nauseated at hastening death.
for Ambulatory Care patients. Situation 9 meal time A. Rule of double effect
C. 2 Registered Nurse for Total Care patients, 2 Nursing Mr. Nelson, 62 year old, an Executive of a shoe D. Slept from 11 PM to 6 AM after Valium 5mg. was B. Rule of single effect
Assistant for Primary Care Patients, 1 Registered Nurse company was brought to the hospital after having given. C. Maleficence
for Ambulatory Care Patients. vomited bright red blood immediately after supper. He D. Justice
D. 1 Registered Nurse for Total Care patients, claimed he had drinking session with his former Situation 10
Registered Nurse and 1 Nursing Assistant for Primary classmates in college. He was already advised by their The following situations are related to ethical practices 51. Which component of chest physiotherapy involves
Care patients, 1 Registered Nurse and 1 Nursing family physician not to drink alcohol due to a suspected in the workplace. rhythmic clapping with cupped hands on the chest wall
Assistant for Ambulatory Care patients fatty liver. You are the nurse-on-duty when he was over the area being drained?
46. Jillian a registered nurse has signed a contract for
admitted. A. Postural drainage
37. In as much as this is a cardio-ward what basic two years in a medical center. A recruitment agency has B. Percussion
equipment/materials should be available at all times? 41. Based on your assessment and history taking for Mr. offered her a “fat” salary for foreign employment. If you C. Nebulization
1. o2 Nelson which PRIORITY FINDINGS should you document are in the position of Jillian, what should you do? D. Vibration
2. Ambu Bag and report to the physician? A. Discuss your plans with your parents
52. Which among these would indicate that coughing C. call his junior resident to rewrite his orders 61. Which of the following example is a well stated among human beings. The declaration of Helsinki
was ineffective? D. complete the orders by rewriting what is in the chart. objectives for this proposal? includes which of the following ethical standards?
A. Decreased normal breath sounds A. Utilize the Universal health precaution in dealing with
B. Clearing of adventitious breath sounds 58. One of the patients of Mr. Berroya told him that self and environment. 1. Investigator should protect life, privacy and
C. Sputum expectoration according to his attending physician he would be B. Understand the health precaution in dealing with self dignity of human subjects
D. Patient’s report of swallowed sputum transferred to the surgical unit because of a suspected and environment. 2. Investigator should protect from harm in
stone in the gall bladder causing his on and off pain C. Know the value of Universal health precaution in therapeutic studies
53. Postural drainage improves clearance and drainage later in the evening. The wife however, told Mr. Berroya dealing with self and environment. 3. Informed consent is not essential when doing
of secretions by which principle? “No, the physician told me, my husband will still be in D. Acquire knowledge on health precaution in dealing research among human subjects
A. Entropy this unit for 2 more days”. The BEST action of the Nurse with self and environment. 4. Investigator should conduct research when
B. Enthalpy should ____________ objectives outweigh risks and burdens to the
C. Gravity A. call the physician to clarify management of care for 62. The group came up with an effective Strategy in the subjects
D. Motion the patient. teaching of Universal Health precaution to the A. 1, 2, 3 & 4
B. instruct the couple and family members wait for the attendees. Which of the following is the BEST strategy B. 1 & 2
54. A goal for a post-operative patient using an decision of the health team. for this program? C. 1, 2, & 4
incentive spirometry is: C. inform the patient that sometimes the physician A. Film Showing D. 2 & 3
A. Decrease pulmonary ventilation need to have more data available. B. Case Analysis
B. Expand collapsed alveoli D. inform the couple that the decision of the physician C. Lecture with interactive discussion 67. Nurse Kim, was sent by her chief nurse to attend a
C. Potentiate effects of general anesthesia is sometimes not fixed. D. demonstration and return demonstration Forum conducted by the Philippine Nursing Research
D. Thicken respiratory secretions Society on the topic “Effectiveness and Efficacy of the
59. The members of the health team in the medical unit 63. Before the implementation of the program, it is wound dressing to patients with bed injury”. She would
55. As safety precautions for clients receiving oxygen, has been reacting negatively to a patient who has been important to know pertinent information about the like to adopt intervention in their unit. What is the
which among these should Nurse Tin not do? branded as “Very demanding” He has a diagnosis of participants. Which of the following INITIAL steps MOST appropriate action to be done by Nurse Kim
A. Place a “No Smoking” sign on the client’s door and at Emphysema and had been confined for almost 2 weeks should be undertaken by the organizing committee? when she returns to their hospital?
the foot or head of the bead. in the ward. Family members come and go to visit him. A. Prepare a budget plan for the program. A. Pilot the study to determine if results will be the
B. Replace woolen blankets with cotton blankets. B. Organize the learners into groups per gender. same
C. Place and arrange substances like acetone, alcohol, C. Present the detailed program to management. B. Incorporate the intervention into their hospital
The best approach of the health team should be
and oils at the bedside.
_______________. D. Come up with the learning needs of the participant. manual
D. Ensure that all electric devices are in good working C. Convince the chief nurse to change their wound
A. request a chaplain to regularly visit the patient.
order. 64. A Gantt Chart has been devised by the Organizing management practices
B. hold a team conference on how to approach the
Committee as the program will be conducted for 4 D. Request investigator if she can adopt the research
Situation 12 issue
weeks’ time. protocol in their unit
Mr. Berroya, who has just finished his one (1) year C. request for a psychological counseling
A. Determining possible budgetary implications.
period as a registered nurse in a medical center, is D. talk with the family members and discuss the
B. Schedule for meeting the objectives for the program. 68. The quality assurance nurse who works closely with
assigned in the medical unit on 3-11 shift. He is having a demanding behavior of the father.
C. Coordination needed between and among the nurse Kim request her to conduct a study by comparing
difficulty interacting with the patient’s family so he participants. the average length of hospitalization of cardiac patient
60. Nurse Berroya is taking care of Ms. Gonzaga with a
consulted his senior Nurse regarding this matter.
multi-organ disorder. The health care team believes D. time frame for the completion of the program with in a regular ward with that of patients with same
56. The BEST approach to be employed by Mr. Berroya that patient’s survival rate is only 50%. Which of the set goals. disorders in an intensive care unit.
upon the advise of his senior nurse is __________. following nursing actions is MOST APPROPRIATE to be What statistical test is MOST appropriate to use in this
65. Which of the following statements of the
A. send the family members home done by Nurse Berroya?
participants indicate that the program is effective? study?
B. confront with the family regarding their behavior A. Avoid discussion of death when family members are
A. Its good we have earned our CPD unites required. A. Analysis of variance
C. ignore family’s behavior present.
B. We gain weight after the completion of the program. B. T-test
D. use active-listening technique B. Arrange with the family the available funeral parlors
C. There should be more time allotted to the session. C. Chi-square
incase of death of the patient.
57. The Senior Resident in the medical unit was making D. I am happy that we have met all the objectives set. D. Coefficient of correlation
C. Request the husband to prepare a living will.
his regular rounds with the medical interns and Nurse D. Inform the family members that there is a palliative Situation 14 69. The research team together with the gastro-
Berroya was called to receive his orders for Mr. Peeta care available. Nurse Kim, a research coordinator is aware of the intestinal department also conducted a study on the
who has been confined in the unit for almost a week. concept of research as a competency expected as a
Situation 13 alcohol consumption of patients as heavy drinkers and
Nurse Berroya could not understand some of the graduate nurse, especially in this era of evidence based
The coordinator of the In-Service nursing department developed liver cirrhosis over a 20 year period.
written order orders of the physician in the chart.
nursing practice. The following questions relate to A. Follow-up
Which of the following is the appropriate action of the prepared an enhancement program for a newly board
research in nursing practice. B. Cross-sectional
nurse? passers on Universal Health Precaution as part of their
personal and professional development. C. Trend
A. refer to the nurse supervisor to validate the 66. The ethical codes in research have greatly
D. Panel
Physician’s orders. influenced the conduct of scientific studies especially
B. approach the physician and clarify his orders
70. Jenny with her team would like to conduct a D. moderate 79. When the nurse explores thoughts and feelings D. watcher
research on “Perceptions of professional Health about the patient’s surgery, this phase in the helping-
practitioners on the competence and level of 75. In educating effectively the patient and family on relationship is in _______________. 84. Nurse Zanjoe made a conference with a
acceptance on Nurse-Led Clinic”. how to use a pain rating scale, the following are the A. introductory phase preoperative patient on important data related to her
STEPS to be followed by the nurse __________. B. termination phase illness. To practice confidentiality of information, Nurse
1. discuss pain as a broad concepts C. resolution phase Zanjoe MUST consider which of the following?
What type of research design should nurses Kim and
2. set goals for comfort and function D. working phase A. Documents the process of conservation to serve as
her team adopt?
3. explain parts of the rating scale proof for future reference.
A. Experimental
4. show pain rating scale and purpose 80. Which of the following major types of learning B. Apply technology for easier and faster
B. Correlational
5. verify if patient understands broad concepts strategies can you offer for a Geriartric patient who has communication and documentation.
C. Descriptive
of pain. difficulty in hearing? C. Conducts the conference in a private place where
D. Quasi-experimental S
6. ask patient to practice the pain rating scale A. practice conversation is not heard.
Situation 15 A. 1, 2, 3, 4, 6 & 5 B. demonstration D. Invites others to interpret the discussion if patient is
Nurse Liza is assigned on a 3-11 shift in the female B. 4, 3, 1, 5, 6 & 2 C. printed learning materials deaf to unfamiliar with the language.
medical ward of a Tertiary Hospital. Patient Alma has C. 2, 4, 3, 1, 6 & 5 D. role playing
D. 3, 1, 2, 5, 4 & 6 85. A patient refuses to undergo surgery after a
been complaining of excruciating abdominal pain and
Situation 17 conference with her doctor. Which of the following
was asking for pain medication. She was referred to the
76. Nurse Helen is taking of an older person and has Nurse Zanjoe is assigned in the Medical Ward for 7 ethical principle applies when Nurse Zanjoe and doctor
physician on duty (POD) for an immediate relief of pain
been waiting for almost two hours for her son to arrive. years. He is well appreciated by his colleagues and respect the decision of the patient in the spite
71. In addition to the identification bracelet worn by the She is ready for discharge. Which of the following patients because he intercedes with patient’s need, he encouragement and pieces of advise given?
patient, how can the nurse on duty (NOD) verify the statements is an example of a therapeutic has good decision making ability, and respect the A. Autonomy
identity of her patient when administering the drugs? communication? patients’ rights and cultural practices. He helps B. Beneficence
A. Ask the question, “Are you Ms. Alma?” A. “I can call your son by cellphone to remind him that colleagues beyond call of duty. C. Veracity
B. Read the patient’s name at the foot of the bed you are waiting.” D. Self-Determination
B. “Your son must be in a traffic jam right now.” 81. A patient who has craniotomy was referred by
C. Ask the patient’s name from the watcher.
C. “I’ll stay with you until your son arrives.” Nurse Greg to Department of Social Welfare (DSWD) Situation 18
D. Ask the patient’s husband’s name
D. “Would you want to watch the television while because he has problem on paying his unsettled Len, a 35 year old dressmaker has been experiencing
72. The physician orders a PRN pain medication to hospital bill amounting to 80 thousand pesos. The recurrent episodes of abdominal pain, nausea and
waiting?”
patient Alma. When will Nurse Liza administer a PRN relatives are afraid the patient will not be discharged vomiting and feels her stomach is bloated. She has been
drug? 77. You are teaching a 66 year old male diabetic client soon. Which of the following function BEST describe the taking contraceptive pills in the past. She is married
A. A standing order is carried out as specified until about the effects of insulin. He is ready for discharge action of Nurse Greg? with three children. She consulted the OPD and was
discontinued for another order. the next week. Which of the following is a statement of A. Advocate advised by the physician to be admitted for suspected
B. When the physician writes the drug as needed in the a helping relationship with the patient? B. Caregiver Pancreatitis.
order sheet. A. “In a few days I’ll review what you have S about C. Educator
actions and effects of your insulin.” D. Clinician 86. Nurse Gladys started her admission care to Ms. Len.
C. A single dose of the drug, carried out by the nurse at
B. “You keep on forgetting what I said but will try to Which of the following laboratory examinations do you
a time specified by the physician.
82. Nurse Zanjoe notice a colleague taking frequent expect the physician to order for the patient?
D. An order written by the physician that has to be repeat some of them.”
C. “I already mentioned those actions and effects of breaks, working over-time, inaccurate drug accounts A. Serum lipase and Amylase
carried out immediately.
insulin, I think you forgot some of them. and displaying inappropriate behavior during meetings B. Creatinine & Phospotase
73. When a patient is in pain, what PRIORITY D. “Would you like me to discuss the information to and conferences. Nurse Zanjoe suspects her colleague is C. Serum Transaminase
consideration should Nurse Liza observe? your wife? She can assist you?” ___________. D. Urea Nitrogen Substance
A. Goal of treatment of the health professionals. A. a victim of domestic violence
78. A patient is scheduled for cholecystectomy. She B. with personality disorder 87. As a nurse, which of the following assessment data
B. Perception of pain of the individual.
verbalizes to the nurse in an anxious manner “Will my C. on substance abuse you will MOST likely NOT to find on patient Len?
C. Harmful effects of the drugs.
surgery be too long?” The BEST response of the nurse is A. Abdominal and back pain with tenderness
D. Cost of the pain medication. D. not mindful of mindful work output
__________. B. Cramping pains before intake of heavy meals.
74. Prior to the administration of pain medication, A. “I have undergone the same surgery, its a very quick 83. Nurse Zanjoeis assigned on night shift and noted a C. Pain unrelieved by intake of antacids
Nurse Liza assesses the degree of the pain of patient operation.” co-worker with a tourniquet wrapped around the upper D. Mid-epigastric pain acute in onset after heavy meals.
before and after the drug administration. Using the B. “Your doctor is an expert, don’t worry about how arm. The co-worker is about to insert needle attached
to a syringe containing a clear liquid into the antecubital 88. The MOST useful diagnostic test is to validate
numeric scale of 0-10 (0 is the lowest and 10 is the long.” whether Ms. Len is suffering from Pancreatitis is for her
highest) on pain, when the patient has rated her pain as C. “Your surgery is at 9AM tomorrow. And you’ll stay in area. Zanjoe’s initial action is to call the
______________. to undergo ___________.
7 it means it is ____________. the recovery room for an hour. You will be back in the
A. nurse supervisor A. Endoscopic Retrograde Cholangio Pancreatography
A. severe room before 12 noon.”
B. physician B. Endoscopic Ultrasonography
B. tolerated D. “The operation will not last long. By the time you are
C. security guard C. Percutaneous Transhepatic Cholangiography
C. Slight awake you will be already in your room.” D. Cholesterol Serum level
89. When managing a patient with acute pancreatitis 95. When formulating a Nursing diagnosis for Ms. D. lowered blood pressure
the first priority is to ____________. Norilee who is suffering from type I diabetes mellitus
RECALLS 2 – NP4
A. insert urinary catheter for adequate elimination. with ketoacidocis, which of the following will be the top Situation 2
B. encourage oral fluids to improve elimination. priority? A 65-year old male is admitted for prostate cancer. On
C. insert nasogastric tube to decompress stomach A. impaired tissue integrity Situation 1 assessment, the nurse determines that the patient has
D. administer IV fluids to replace electrolytes lost. B. deficient fluid volume Nurse Alex cares for a terminally ill client with cancer. experienced incontinence. The nurse knows that
C. Imbalance nutrition incontinence is the first most common symptom of
90. One of the SAFETY alerts that the Nurse-on-duty 1.Nurse Yolan assesses the client for depression. Which prostate cancer.
D. Risk for infection of the following is a key indicator for clinical
(NOD) will have to watch for patient with acute
pancreatitis is ___________. Situation 20 depression? 6. Based on information gathered, the nurse writes a
A. Anger due to pain experience nursing diagnosis. Which of the following diagnoses is
A. Diabetes insipidus Ms. Arce is the Research Coordinator of the Medical
B. Respiratory distress Center who is concerned about the increased incidence B. Feeling of excessive guilt MOST appropriate
C. Hypercalcemia of nosocomial infection in the hospital and has C. Anorexia and weight loss A. Deficient knowledge related to self-care and risk
D. Pericarditis convinced the management to allot a budget for the D. Inability to care for one’s physical self prevention.
conduct of research on the clinical problem. B. Fear secondary to the diagnosis of cancer.
Situation 19 2.The client has difficulty sleeping. Which of the C. Risk for urinary infection
Norilee, an accountant, 29 years was rushed by her 96. What type of research is appropriate for this study? following interventions is LEAST helpful for Nurse Yolan D. Risk for impaired urinary elimination
husband in the ER because of body weakness, A. Quasi-experimental to incorporate in her care plan?
palpitation, confusion and diaphoresis. Her blood B. Experimental A. Instruct the client to drink herbal tea. 7. To help manage incontinence, the nurse instructs the
glucose is 450 mg./dl with fruity acetone smell on her C. Historical B. Give warm milk at bedtime patients to do which of the following:
breath. She was diagnosed to be suffering from type I D. Descriptive-correlational C. Perform relaxation routine such as massage, imagery A. Eat foods rich in fiber
diabetes mellitus 6 months ago. or music B. Increase fluid intake.
97. Which of the following is the best tool for data D. Instruct the client to drink black tea. C. Take in medications to manage pain.
91. Which of the following the clinical characteristics gathering? D. Perform perineal muscle exercises
are of Type I diabetes mellitus EXCEPT: A. use of laboratory data 3.The care plan for the client includes family support.
A. often have islet cell antibodies B. questionnaire Which of the following is MOST appropriate for the 8. The patient asks for treatment option for his
family to establish a relationship with the health care condition. The Nurse explains that treatment options
B. Ketosis prone when insulin is absent. C. interview schedule
C. Onset any age, above 30 year old, usually obese D. observation team? Nurse Yolan should ___________: are based on which of the following
D. Onset any age, below 30 year old, usually thin A. Give permission to the family to take time to A. gender
98. During the data collection, Ms. Rita encountered a maintain friendship with the health care team. B. ability of the patient to manage physical and
92. Patient Norilee upon admission has a breath patient who does not want to talk to him. Which of the B. Discuss the roles of the family members to the health emotional implications of incontinence
characteristics of fruity acetone, this is brought about following is a limitation of the study care team. C. Socio-economic status
by the presence of ______________. A. Contacts of patients with history of fever and cough. C. Explain the roles of all members of the D. grade and stage of the disease
A. lactic acids B. Patient’s refusal to fully divulge information. interdisciplinary team.
B. uric acid C. Patient’s with the history of fever and cough 9. The patient asks the nurse what the physician meant
D. Provide a brief explanation to the family member
C. nitric acid D. Patients admitted or who seek consultation at the ER about his prostate cancer as Stage C or T3. The nurse
about the care being delivered to the client.
D. ketoacids and doctor’s offices. explains that the tumor is ______________:
4.The client appears to be dehydrated. The family A. palpable and has spread to other organs and often to
93. Based on the presenting manifestations of patient 99. In the statement, “Frequent hand washing of health members are discussing whether their loved one should distant sites such as bones and lymph nodes.
Norilee you expect that the physician will likely order workers decreases the incidence of nosocomial be given intravenous fluid. Which of the following B. palpable and has spread beyond the prostate but not
which of the following treatment infections among post-surgery patients”, the dependent concepts about dehydration in terminally ill clients to other organs.
A. 50% dextrose variable is __________. should guide Nurse Yolan? C. confined to the prostate and was not palpable during
B. 5% Lactated ringers A. frequent hand washing A. Peripheral edema occurs because of fluid overload. digital rectal examination.
C. Dextrose 10% in water B. incidence of nosocomial infection B. Thirst is an indication of dehydration. D. confined to the prostate and was not palpable during
D. normal Saline solution C. health workers C. Terminally ill clients are hydrated through oral and digital rectal examination.
D. post-surgery patients intravenous routes.
94. When caring for patient Norilee, which of the 10. The nurse recalls the staging and classification of
D. All interventions for terminally ill client should be
following should be included in your teaching plan? 100. Her colleague asks about the EXTERNAL validity of prostate cancer. Which of the following statements is
directed towards comfort and reduction of symptoms.
1. Signs and symptoms of hypoglycemia the research findings. Which of the following is the TRUE?
2. Self-glucose monitoring APPROPRIATE response of Ms. Rita? 5. The client show signs of imminent death. Nurse Yolan A. the gleason grading system is usually used for
3. Administration of insulin A. it is reflected as a result of extraneous variables. recognizes cardiovascular indicators of imminent death hematological cancers but not prostate cancer.
4. Meal planning and exercise B. the findings are free of selection biases. which are the following EXCEPT __________: B. the normal prostate specific antigen (PSA) range
A. 2, 3, 4 C. the result is shown only from the effect of the A. bradycardia under 40 years of age is less than 4 to 6 ng/mL.
B. 2, 3 independent variable. B. Irregular heart rate C. at least two separate biopsy specimens are graded
C. 1, 2 D. it is generalized to other settings or samples. C. tachycardia based on their differentiation from normal prostate
D. 1, 2, 3, 4 cells.
D. A score of D is less invasive than a score of B in the C. Distribution and consumption of resources such as 20. The surgeon orders glucocorticoid Dexamethasone B. 1, 2, 4
cancer staging system. time, supplies, drugs, staff and personnel. (Decadron) to be given following craniotomy. The nurse C. 2, 3, 4
D. Financial viability of nursing department. recognizes that this drug: D. 1, 3, 5
Situation 3 A. Creates a feeling of euphoria, which is beneficial in
You are newly promoted charge nurse of a department 15. While touring the department where you are the early post-operative period. 23. The legal definition of death that facilitate organ
in a tertiary hospital. You review management concepts assigned, you noticed that the supply room is stacked B. Promotes excretion of water which aids in reducing donation is the cessation of ________ :
to prepare you for the position. The following questions with medical supplies and equipment. Which of the ICP. A. Function of the entire brain
pertain to management of resources. following is the BEST action you will take? C. Enhances venous return and thus reduce ICP B. Pulse
A. Create a task force to assess the situation and report D. Reduces cerebral edema thus reducing ICP. C. Circulatory and respiratory functions
11. You are oriented on health care economics. The the findings. D. Respiration
study of economics focuses on how choices are made to
B. Take an inventory of the supplies and equipment. Situation 5
overcome a scarcity of resources. Which of the C. Request maintenance to sort out the supplies and A Nurse in the intensive care unit attends to a 20 – year 24. The patient is pronounced dead by the physician.
following statements BEST illustrates health care check the medical equipment to determine if they are old female who was involved in a vehicular accident Which of the following nursing actions VIOLATES the
economics __________: still functional. three days prior to admission. The prognosis is very standards of care for a dead person?
1. Providing less health care services that is D. Call for a staff meeting and discuss how best to utilize poor. No brain activity was detected after two electro A. Removing soiled dressing and tubes.
optimal in order to contain costs. the available resources. encephalograms (EEGs) were taken. B. Keeping the dead person in a sitting position until the
2. Using individuals with less knowledge and family has arrived and said their goodbyes.
skill to perform health care services usually Situation 4 21. The family decides to wean the patient from the C. Placing identification tags on both the shroud and
performed by people with advanced knowledge A 34 year old female client complains of experiencing ventilator support. The family talks to the nurse about ankle.
and training. double vision and frequent headaches. The client claims their decision to get the nurses’ support. Which of the D. Preparing to transfer the body to the morgue.
3. Taking economic risks as a health care to be forgetful and has mood swings. A diagnosis of following actions is NOT appropriate? The Nurse
provider. right frontal lobe lesion was made and the client was ___________. 25. The family goes through the stages of grieving.
4. Providing adequate or appropriate care admitted for craniotomy. a. Checks the physician’s orders for sedation and What are the stages in the grieving process?
minimize risk of expensive utilization. analgesia and make sure that the anticipated death is 1. Acceptance
A. 1 and 2 16. The client claims to have a diagnostics work up in comfortable and dignified. 2. Depression
B. 3 and 4 the outpatient unit before she was admitted. The b. Explains to the family what will happen each phase of 3. Denial
C. 1 and 4 admitting nurse prepares the client for which of the the weaning and offer support. 4. Bargaining
procedure that will MOST likely confirm the presence of 5. Anger
D. 2 and 3 c. Tells the family that death will occur almost
brain tumor? immediately after the patient is removed from the A. 3, 5, 1, 4, 2
12. Which of the following statement is TRUE regarding A. Myelogram ventilator support. B. 3, 5, 4, 2, 1
health care economics? B. CT Scan d. Participates in the decision-making process by C. 1, 5, 3, 4, 2
A. Contemporary health care is characterized as a C. Lumbar puncture offering the family information D. 1, 2, 5, 4, 3
business struggling to balance cost and quality. D. Skull x-ray
B. Profit in health care is synonymous with billing 22. Two hours after the ventilator support was Situation 6
privileges. 17. While the client is being interviewed, she had a discontinued, the patient dies. The nurse discusses with A male teenager was wheeled in the Emergency
C. Health care economics is a new concept in nursing. seizure. The initial intervention of the nurse must be the family the possibility of donating the deceased Department (ED) for injured.
directed towards:
D. Health care is becoming affordable and clients are person’s organs. The following are guidelines in organ 26. The nurse assesses the patient for complications.
demanding quality care. A. Protecting the client or tissue donation.
B. Controlling the Seizure Which are the MOST COMMON complications?
1. Religious beliefs in organ donation and 1. Urinary leakage
13. You understand that a key factor that influence C. Reducing circulation to the brain transplantation must be respected.
client care is the cost involved in the delivery of health D. Restraining the client 2. Delayed bleeding from damage
2. Donors must be free of infectious disease and 3. Abscess formation
services. Which of the following resources is NOT cancer.
required to support the services delivered by nurses? 18. After surgery, it is important for the nurse to 4. Paralytic ileus
position the head of the client properly to: 3. Consent or written orders by the physician 5. Renal failure
A. Time are necessary for referral to an organ
B. Client’s environment A. Facilitate venous drainage A. 4 & 5
B. Prevent hemorrhage on the suture line. procurement organization. B. 3 & 4
C. People 4. The family of the deceased should be offered
D. Equipment C. Provide for client comfort C. 1 & 2
D. Maintain patent airway an opportunity to speak with a knowledge D. 2 & 3
14. You are aware that there is a need for you to organ procurement coordinator.
understand how to manage the cost of client care as it 19. The Nurse is aware that one of the measures listed 5. The person requesting for organ donation 27. The nurses knows that with renal trauma, further
below is contraindicated in post-operative pulmonary does not have to believe in the benefits of complications may occur such as: .
relates to clinical practice. Which of the following are
nurses accountable for? toilet. organ donation but should support the process 1. Secondary hemorrhage usually due to
A. Decision regarding cost effective practices. A. Suctioning with a positive attitude. Which of the guidelines infection
B. The Client’s hospital charges B. Deep Breathing should the nurse observe? 2. Renal artery stenosis
C. Turning A. 1, 2, 3, 4, 5 3. Renal atrophy
D. Coughing 4. Hypotension
 5. Hydronephrosis 32. Nurse Ashley reads that the drug Cyclophosphamide 37. The head nurse reviews reports on nurse staffing. 42. Nurse Mirasol assesses the skin of the patient.
Which are the POSSIBLE complications? ( Cytoxan ) is given to patients with breast cancer. Nurse The following findings result to better patient outcomes Which phase of skin changes occur FIRST and are
A. 2, 3, 4, 5 Ashley understand that this drug is ______: EXCEPT: A higher _______: usually painless and symmetrical?
B. 1, 2, 3, 4, 5 A. Cell cycle phase-non-specific A. Nurse to patient ratio shortens lengths of patient A. Indurative
C. 1, 2, 3, 5 B. A hormonal medication stay in the hospital. B. Primary
D. 1, 3, 4, 5 C. An antimetabolite B. Nurse to patient ratio results to reduced patient C. Curative
D. Cell cycle phase-specific mortality. D. Edematous
28. The nurse assesses the patient to determine the C. Number of nurses, infection rates fall.
extent of injury. Which of the following signs is a 33. Nurse Ashley reads in the literature that a patient D. Nurse to patient ratio increases costs. 43. Nurse Mirasol writes a nursing diagnosis for the
CARDINAL sign of renal trauma? with breast cancer taking Cytoxan should observe the patient. Which of the following is a PRIORITY nursing
A. Shock following. Given a case what should nurse Ashley 38. The head nurse determines to reduce medication diagnosis?
B. Lumbar pain instruct a patient to do? errors in the trauma unit. She recognizes that A. Social isolation
C. Abdominal pain A. Decrease sodium intake while on medication. medication errors often occur in relation to the B. Impaired skin integrity
D. Hematuria B. Take the medication with food. following EXCEPT: C. Disturbed body image
C. Increase potassium intake while on medication. A. Preparing the wrong concentration and administering D. Low self-esteem
29. The nurse writes a nursing diagnosis for the patient D. Increase fluid intake 2000 to 3000 mL daily. the medication via the correct route.
with stab wound. The MOST appropriate nursing B. Failure to question unclear medication errors. 44. Nurse Mirasol assists the patient in coping with the
diagnosis is ____________. 34. Nurse Ashley understands that patients receiving C. Lack of knowledge about medication. disorder. During the early stages of a chronic disease,
A. Nutrition imbalance, less than body requirements, antineoplastic medications should do which of the D. Failure to identify non-therapeutic client responses. patients tend to focus on which of the following
related to nausea from renal trauma following? behaviors?
B. Deficient fluid volume related to blood in the urine 1. Drinks beverages containing alcohol in 39. The head nurse suggests that to reduce medication A. Understanding the disease process
C. Acute pain in the abdominal area related to renal moderate amounts. errors, several measures will be instituted. Which of the B. Impact on lifestyle changes
trauma 2. Consult with the physician before receiving following is MOST appropriate? C. Interpretations of symptoms
D. Acute pain in the lumbar area related to renal trauma immunizations. A. Use point-of-care technology to access drug D. Schedule of medications
3. Be sure to receive flu and pneumonia reference information.
30. The physician prescribes Magnetic Resonance immunizations. B. Use of drug index 45. Nurse Mirasol prepares a discharge plan of care for
Imaging (MRI) of both kidneys to confirm clinical 4. Take aspirin (Acetylsalicylic Acid, ASA) as for C. Nurses must help educate patients and their families the patient. Which of the following objectives are MOST
suspicion and determine the severity of the injury. appropriate? The patient should _______________.
headache. regarding proper medication administration.
Which of the following activities is a PRIMARY nursing A. 2 only D. Patients must become more involved in managing 1. Try to prevent breakdown of the skin and
consideration in preparing the patient for MRI? B. 3 & 4 their care. ulceration
A. Administer all medications scheduled before the test. C. All of the options 2. Avoid activities that trigger pain
B. Report findings of metal screening ; sedate the D. 1 & 2 40. The head nurse is aware that managing and 3. Modify diet to include legumes
patient before sending him for MRI. improving quality care in the trauma unit requires 4. Avoid exposure to extreme cold temperature
C. Coordinate the MRI with other patient care activities 35. An incident was described in the literature where a which of the following? A. 1, 2, 3, 4
and inform the patient about the test. patient developed stomatitis after receiving a course od A. Personalized attention to patient’s needs and their B. 1, 2, 3
D. Ensure the patient is on NPO and hold all antineoplastic medications. Which of the following families. C. 1, 2, 4
medications until test is completed. actions would be BEST for a nurse to do? B. A blame – free environment. D. 2, 3, 4
A.Swab the mouth daily with lemon and glycerine. C. All of the choices.
Situation 7 B.Avoid foods and fluids for the next 24 hours. D. A clean and orderly trauma unit. Situation 10
Nurse Ashley is a staff nurse in the oncology unit of a C.Brush the teeth and use waxed dental floss 3x a day. Nurse Bessie is a nurse manager of trauma unit. She
tertiary hospital. She reads literature on antineoplastic D.Rinse the mouth with diluted baking soda or saline. Situation 9 supervises the staff nurses and regularly holds
medications. Nurse Mirasol is the attending nurse of a 40-year old conferences with them and other unit personnel. In one
Situation 8 female admitted in the medical unit with a probable meeting she reorients the staff nurses on their various
31. Nurse Ashley understands the importance of The head nurse of a trauma unit introduce changes to diagnosis of Scleroderma. functions. She cites clinical situations related to a nurses
continuing professional development. Which of the dependent, interdependent, and collaborative
improve the quality of care of trauma patients.
following is the MAIN purpose of continuing 41. The patient complains of pain in her fingertips and functions.
professional development? To ____________ 36. The head nurse presented a set of goals to the staff pallor followed by blanching of the extremities and
A. Update one’s professional knowledge and nurses. Which of the following goals is NOT relevant to redness. Nurse Mirasol knows that these symptoms are 46. An interdependent function of nurse is when the
competence improving quality of care? No_______: characteristic of which of the following disorders? nurse _______:
B. Acquire a certificate of attendance to add to one’s A. Legal suits. A. Swan-neck deformity A. Irrigates a feeding tube that appears obstructed.
curriculum vitae B. Needless deaths. B. Raynaud’s phenomenon B. Gives ice chips to a client who has an order of NPO.
C. Establish networking within the nursing profession C. Waste of resources. C. Joint swelling and effusion C. Applies a dry sterile dressing to an abdominal
D. Fulfill requirements for an advanced degree in D. Needless pain or suffering. D. Symmetric Polyarthritis incision.
nursing D. Helps a client choose foods rich in protein from an
ordered diet.
47. A nurse decides to give a partial bath to a D. “What is it that you don’t like being in the hospital?” 56. The nurse writes a care plan for the client. The 61. The nurse is aware that clients with COPD are at risk
client instead of a complete bath. The nurse is Nurse is aware that this disorder is a/an ________. for ineffective respirations EXCEPT which of the
working __________: 53. Marcela tells Nurse Marie that her younger sister A. disease caused by over exposure to sunlight following _________?
A. Independently was recently diagnosed with cancer. She is concerned B. Local rash that occurs as a result of allergy. A. Clients undergoing thoracic or abdominal surgery
B. Interdependently because she is aware that breast cancer “ runs in the C. inflammatory disease of collagen contained in B. Clients with rib fractures and kyphosis
C. Dependently family” but she could not recall any family member connective tissues. C. Clients with neuromuscular disorders such as
D. Collaboratively diagnosed with bone or lung cancer. Nurse Marie’s BEST D. disease caused by the continuous release of Guillain-Barre’ syndrome
response would be: histamine in the body. D. Clients with fluid volume deficit
48. A nurse works with a skin care team. The nurse is A. “ I am sorry to hear about your sister. I think you
functioning _________: should meet with all of your family members and share 57. The nurse includes in the care plan dietary 62. Nursing interventions for clients with respiratory
A. Dependently with them their increased risk for developing lung and instructions. Which of the food items should the nurse acidosis include the following EXCEPT to __________.
B. Interdependently bone cancer.” instruct the client to AVOID? A. monitor arterial blood gases (ABGs), pH, PCO2, and
C. Collaboratively B. “ Apparently your sister is so unfortunate . it is rare A. steak HCO3
D. Independently to have three such unrelated cancers at one time.” B. broccoli B. administer oxygen and medication as ordered
C. “ I think it is important for you to be tested for lung C. legumes C. monitor hourly vital signs and respiratory status
49. A nurse initiates a visit from member of the clergy cancer as soon as possible , because it has hereditary D. fish D. administer sedation as ordered by the physician to
for a terminally ill client. The nurse is functioning link.” relax the client
___________: D. “ I am sorry to hear about your sister’s recant 58. The nurse is aware that fatigue is experienced by
A. Interdependently diagnosis. Most probably your sister has a breast cancer patients with SLE. Which of the following activities 63. The nurse understands that excess acid in the body
B. Collegially should be a component in the care plan for the client to acts as CNS depressant. Clients with acidosis may
that has metastasized or spread to the bone and lungs.”
C. Independently manage fatigue? To ________. exhibit which of the following symptoms:
D. Dependently 54. Nurse Marie has another patient, Cena who was 1. sit whenever possible 1. reduced level of consciousness
recently diagnosed with ductal cell carcinoma of the 2. take a hot shower in the morning 2. confusion
50. When a nurse uses a straight catheter to obtain a breast. Her oncologist described Cena’s cancer as T2, 3. avoid long periods of rest 3. lethargy
urine specimen for laboratory test, the nurse is N1, Mx. Cena asked Nurse Marie to repeat to her what “ 4. engage in moderate low impact exercise 4. coma
functioning ________: all those letters and numbers mean.” Nurse Marie when not fatigued A. all of the options
A. Dependently replies that it means the following: 5. maintain a balance diet B. 1, 3, & 4
B. Interdependently
A. Two tumours present, one lymph node involved, and A. 2, 3, 5 C. 1, 2, 3
C. Independently many sites of metastasis. B. 1, 2, 3 D. 1 & 3
D. Collegially B. One large tumour present, nodal involvement in one C. 1, 2, 3, 4, 5
region, and metastasis was present. D. 1, 4, 5 64. The goal for treatment for respiratory acidosis is to
Situation 11 improve ventilation. Which of the following measures is
Marie, an oncology nurse assists in the care of patients C. Two tumours present, one lymph node involved and
metastasis was present. 59. The physician schedules the client for appropriate for clients with COPD experiencing
with cancer. plasmapheresis. The client asks the nurse what is respiratory acidosis?
D. One tumor present, which is larger than 2.5
51. One of her patients is a 50-year old female named centimeters, nodal involvement in one region, and plasmapheresis. The nurse explains that it is a method A. Bronchodilators
Marcela is in the terminal stage of breast cancer. She metastasis was unable to be determined. that will __________. B. Administer medications as ordered
tells Nurse Marie. “I have given responses of Nurse A. prevent foreign antibodies from damaging various C. Ambulation
Marie is MOST therapeutic? 55. Patient Cena tells Nurse Marie “How did I acquire body tissues D. Spirometers
A. “You have given up hope?” breast cancer?” Nurse Marie explains that there are risk B. decrease the damage to organs caused by attacking
factors that may have contributed to her condition. T-lymphocytes 65. The nurse understands that respiratory acidosis
B. “You should talk to your physician about your fears of occurs when __________:
dying.” Which of the following statements is TRUE concerning C. eliminate eosinophils and basophils from the blood
the risk factors for breast cancer? D. remove antibody-antigen complexes from circulation A. the body retains too much carbon dioxide
C. “You should talk about dying with your spiritual B. the client is unable to exhale carbon dioxide
adviser.” A. Hormones are not a risk factor for breast cancer.
B. Other types of cancer history have no correlation 60. The nurse monitors the client undergoing C. the client hyperventilates
D. “You should not give up hope. There are research plasmapheresis. Which of the following reactions
with breast cancer. D. there is loss of acid or retention of base in the body
studies being done to cure cancer.” should the nurse observe?
C. Ethnicity is a risk factor. Situation 14
52. Marcela says to Nurse Marie. “ I don’t like to spend D. Environment is not a risk factor for breast cancer. A. shortness of breath
B. numbness and tingling Nurse Mark is assigned in the oncology unit of a tertiary
my final days on earth in a hospital.” The BEST response hospital. He is aware of the increase in number of
of Nurse Marie would be : Situation 12 C. transfusion reactions
A 35-year old female client presents herself in the D. high blood pressure colorectal cancer patient in his unit. He and a colleague
A. “Can you please tell me more how you are feeling
outpatient Department with complaints of rashes plan to conduct a study of the incidence of colorectal
right now?” Situation 13 cancer in the Philippines.
B. “I know how you feel. It must be hard to know that particularly on the face, across the bridge of the nose
and on the cheeks. The client is suspected of having The nurse assists in the care of clients with chronic
you are dying.” obstructi pulmonary disease (COPD). 66. Nurse Mark formulates a possible title for the study.
C. “If I were in your place, I should have refused being systematic lupus erythematous (SLE). She is admitted to Which of the following is the MOST appropriate title
admitted to the hospital knowing that I will die soon. the female medical unit. A. “Incidence of Colorectal Cancer in the Philippines”
B. “Perceptions of the Filipinos on Colorectal Cancer” B. Urine specific gravity below 1.0008 D. provide evidence of a hospital’s accountability C. consults the physician for direction in establishing
C. “Colorectal Cancer in the Philippines: It’s Risk Factors C. Serum osmolality below 280mOsm/kg goals for clients.
and Interventions” D. Serum osmolality above 295mOsm/kg 77. You are oriented on the hospital policy that when a D. depends on the latest literature to complete an
D. “A Comparative Study of Gastrointestinal Cancer patient is readmitted, the patient’s file maybe retrieved excellent plan of care.
Cases among Filipinos” 72. The nurse monitors the patient for signs and from the hospital records department. From which file
symptoms of complications. The nurse knows that one may be a readmitted patient’s record be retrieved? 82. Nurse Gina is aware that collaborative interventions
67. What research design is the MOST suitable to gather of the PRIMARY risks when treating hypernatremia is A. physician’s ledger are therapies that require the following: Which of the
data for the study? ___________: B. master patient index file. collaborative interventions is the MOST therapeutic?
A. Quasi Experimental A. renal shutdown C. civil service file A. Nurse and patient intervention
B. Correlational Study B. cerebral edema D. hospital library records B. Multiple health care professionals
C. Descriptive study C. cellular dehydration C. Physician and nurse intervention
D. Developmental study D. RBC destruction 78. You orient your staff on the common system used in D. Patient and physician intervention
recording nursing interventions. The system used is a
68. In gathering data for the study, ethical guidelines on 73. In planning the care for this patient the nurse nursing index card or Kardex. What information is NOT 83. To initiate an intervention in collaboration with the
basic human rights will be observed? Which of the includes the following interventions. Which of the included in the Kardex? health team, Nurse Gina must be competent in which of
ethical principles is applicable? following actions should the nurse NOT include in the A. Drug regimen of the patient. the following areas?
1. Justice plan of care? B. Allergies if any of the patient. A. Leadership, autonomy, and skills
2. Privacy and dignity A. observe for possible increase in temperature C. Progress notes of the physician. B. Experience, advanced education, and skills
3. Respect B. observe and prepare for possible seizure attack. D. Dietary requirements of the patient. C. Knowledge, function, and specific skills
4. Confidentiality C. monitor intake and output D. Leadership, finances, and skills
A. 1, 2, 3, 4 D. restrict fluids to 1,200 mL per day. 79. A patient’s record contains information of the
B. 2, 3, 4 medications and treatments administered, and 84. Nurse Gina is aware that there are nursing activities
C. 1, 2, 3 74. The nurse understands that a patient with observations of the patient’s condition. Which of the that may be delegated to other health care team
D. 2, 3 hyperatremia is at high risk for seizure. Which of the following data MUST be filled up in the patient’s chart members. Which principle should guide the nurse in
following safety measures is MOST appropriate? Use of when he/she is discharged from the hospital? delegating tasks?
69. Nurse Mark formulates an assumption for the study. _________. A. Religion A. Delegation occurs only upon a physician’s order.
Which of the following is MOST acceptable? A. pillows placed at the head B. Nursing Diagnosis B. The delegated personnel is accountable for the care.
A. Liver cancer cases have decreased in 2017 due to B. padded tongue blades C. Final medical diagnosis C. Delegation may reduce the patient’s cost of care.
intensive public awareness C. padded restraints D. Educational attainment D. The nurse has the primary responsibility for the
B. More Filipinos regardless of gender are diagnosed D. padded side rails quality of patient care.
with colorectal cancer. 80. You are familiar with the ethical aspects of patients
C. Male Filipinos are prone to colorectal cancer than 75. The nurse formulates a nursing diagnosis for the and hospital records. Which of the following statements 85. Nurse Gina is a potential team leader of the health
liver cancer. patient. Which of the following nursing diagnoses is is NOT true? team. Which of the following skills should she develop?
D. The leading cause of colorectal cancer among NOT appropriate for this patient? A. Health records are the property of the locality where A. Collaborative skills
Filipinos is high consumption of alcohol. A. Impaired Electrolyte, Sodium related vomiting. the patient is treated. B. Management
B. imbalanced Nutrition, more that body requirements, B. Hospital records maybe released without the C. Supervisory skills
70. Which of the following is the MOST appropriate related to excess intake of foods rich in sodium. patient’s consent when required in investigation for D. Patient advocacy
recommendation Nurse Mark should propose? C. Risk for injury, bleeding, related to the interference serious criminal offense.
A. Warning signs of the effects of alcohol should be with blood coagulation secondary to sodium excess. C. Confidential records must be protected against loss, Situation 18
printed on bottles and cans of alcoholic beverages. D. impaired skin integrity, related to peripheral edema damage, unauthorized access, modification and Nurse Rolly, a triage nurse admits clients in the
B. Health professionals should educate the public on the secondary to sodium and water excess. disclosure. Emergency Department (ED) of X hospital. The following
risk factors of CRC. D. Patients have the right to confidential treatment of are situations in the ED Nurse Rolly encounters.
C. DOH only should intensify its campaign on colorectal Situation 16 information they provide to health professionals.
You are a nurse manager of a tertiary hospital. One of 86. Four victims are brought to the ED after a motor
cancer awareness. vehicle crash. Who among the following victims require
D. Congress should pass a bill banning all cancer- your responsibilities is to keep a record of all patients Situation 17
admitted in the hospital. Ms. Gina is a staff nurse in a medical unit of x hospital. the HIGHEST priority for the treatment?
producing foods and beverages. A. 21 year-old male with fracture of the face jaw.
She collaborate with other members of the health team
Situation 15 76. You are aware of the importance of keeping hospital to provide safe and quality patient care. B. 20 year-old female with misaligned right leg.
The nurses cares for a 30 year old patient who is records. Which of the following statements is NOT rue C. 35 year-old male complaining of abdominal pain.
admitted for severe vomiting. The diagnosis of the about hospital records? Hospital records 81. Which of the following statements BEST explains the D. 62 year-old female with palpitation and chest pain.
_____________. role of the nurse in collaborating with others to plan for
patient is hypernatremia. 87. Four victims of a car crash are brought to the ED.
A. provide data on health information system the patient’s care? The nurse _____________.
71. The nurse reads the laboratory results. Which of the B. are a key source of data for medical research on A. collaborates with colleagues and the patient’s family Nurse Rolly assesses the victims. Select who among the
following values indicate that the patient is statistical reports. to provide combined expertise in planning care. following has the HIGHEST priority for treatment.
experiencing hypernatremia? C. provide personal information about the physicians B. works independently to plan and deliver care and A. Absence of peripheral pulses
A. Potassium level of 5.5mEg/L and nurses assigned to care for the patients. does not depend on other staff for assistance. B. A suckling chest wound
C. Severe bleeding of facial and head lacerations 93. To determine whether the client is infected with thoracic aorta and abdominal aorta. Which of the
D. An open femur fracture with profuse bleeding HIV, the physician writes an order for HIV antibody following areas is an AAA most commonly located?
testing. What test would confirm a positive ELISA test? A. Proximal to the renal arteries
88. Nurse Rolly performs primary assessment on one of A. CD4 cell count B. Distal to the iliac arteries
the trauma victims, and determines that the client has a B. Easter Blot test C. Distal to the renal arteries
patent airway. The NEXT assessment by Nurse Rolly C. HIV antigen test D. Adjacent to the aortic arch
should be to ___________. D. Western Blot test
A. palpate for the presence of peripheral pulses 99. The patient complains of severe lower back pain.
B. check the level of consciousness 94. The client is being treated for thrush. The patient Which of the following is the PRIORITY action by the
C. examine the client for any external bleeding asks if there are any side effects of the medication she nurse?
D. observe/assess client’s breathing or respiratory effort is receiving for thrush. Which of the following should A. take the vital signs and document results
the nurse include in her teaching? B. administer pain medication as prescribed
89. A 45 year-old male client was brought in the ED with A. “There are few side effects associated with the C. notify the physician
head and neck trauma sustained in a motorcycle medications to treat thrush” D. observe for signs of abdominal distention.
accident. The FIRST action of Nurse Rolly is to B. “Hepatitis can develop as a side effect.”
___________. C. “Nausea, vomiting, and diarrhea are common side 100. The nurse is aware that rupture of the aneurysm is
A. suction of the mouth and oropharynx effects.” a life-threatening emergency. Which of the following
B. obtain venous access D. “Skin discoloration is a common side effect.” groups of symptoms indicates a ruptured AAA?
C. immobilize the cervical spine A. Intermittent lower back pain, decreased blood
D. administer supplemental oxygen 95. The client complains of increasing pain in her feet pressure, decreased RBC count, increased WBC count.
and legs. The nurse realizes that the client is B. Severe back pain, decreased blood pressure,
90. Jerome, 65 years old who works as a carpenter fell demonstrating a/an _________: decreased RBC count, increased WBC count.
from a ladder while fixing the roof of a neighbor. He A. nervous system manifestation of the disease C. Lower back pain, increased blood pressure,
was brought to the ED by family members. He is B. reaction to a medication decreased RBC count, increased WBC count.
unconscious. Nurse Rolly does a primary assessment on C. opportunistic infection D. Severe lower back pain, decreased blood pressure,
client Jerome which is to : D. secondary cancer decreased RBC count, increased WBC count.
A. Ask the family about Jerome’s medical condition
B. Assess the vital signs Situation 20
C. Attach a cardiac ECG monitor An adult male is wheeled in the Emergency Department
D. Obtain a Glasgow Coma Scale Score with complaints of nausea and vomiting, abdominal
pain and lower back pain. The physician writes a
Situation 19 medical diagnosis of abdominal aortic aneurysm (AAA)
A 30 year-old female is admitted for fever, fatigue,
lymphadenopathy, thrush, diarrhea and muscle and 96. The nurse assesses the patient with AAA. Which of
joint pains. She also has a rash in her torso and arms. the assessment findings is related to the aneurysm?
1. Pulsatile abdominal mass
91. The nurse assesses the client. What question should 2. Hyperactive bowel sounds
she ask to determine the client’s possible exposure to 3. Systolic bruit over the area of the mass
HIV? 4. Subjective sensation of “heart beating” in the
A. “Do you use public toilet seats?” abdomen
B. Did you shake hands with a person infected with A. 1, 3, 4
HIV?” B. 1, 2, 3, 4
C. “Did you receive blood transfusion recently?” C. 2, 3, 4
D. “Do you practice safe sex?” D. 1, 2, 3
92. The nurse writes a care plan for the client. Included 97. The nurse auscultates the abdominal area of the
in the care plan is to provide health teachings. Before patient with AAA. Which of the following sounds can be
the nurse performs any teaching, what should the nurse DISTINCTLY heard over the area?
do FIRST? A. Dullness
A. Evaluate the client’s existing level of knowledge B. Bruit
about HIV infection.
C. Friction rubs
B. Assess the client’s immediate clinical status. D. Crackles
C. Assess the emotional status of the client.
D. Focus on potential problems the client may 98. The nurse recalls specific anatomic sites for
encounter during the illness. aneurysm. The most common sites are the aortic arch,
RECALLS 2 – NP5
b. Sit quietly with the patient until the crying episode is a. Discuss how to change dysfunctional family patterns 14. You want to examine the difference in the eating
over b. Teach the client to identify defensive behavior. behaviors between two groups of high school students.
Situation 1 c. Tell the patient that the behavior is unacceptable c. Agree not to tell the client what to do about problem Which of the following research designs would you use
You’re assigned as a staff nurse in the Stroke Unit of the d. Attempt to divert the patient’s attention d. Arrange for the client to participate in social to answer the research question?
Medical Ward. One of your responsibilities is to provide activities. a. Case study
5. To prevent joint deformities of the arm and hands of b. Correlation study
health teachings to the stroke patients and to the other
a hemiplegic patients what are the APPROPRIATE 9. Which of the following nursing actions would be c. Comparative design
members of the family. The following questions refer to
position will you include in your health teachings of the more appropriate when speaking with this client about d. Survey study
these statements.
family member? SELECT all that apply. the trauma she experienced?
1. You are teaching a patient about taking prophylactic 1) Placing a pillow in the axilla so the arm is way a. Listen attentively 15. In a study on the relationship between personality
warfarin sodium (Coumadin). Which of these statement from the body b. Request the client write what is being said make-up and obesity, a Pearson r=.8 would mean:
indicate that the patient understands how to take the 2) Inserting a pillow under the slightly flexed c. Ask question to convey an interest in the details a. a high, negative correlation
drug. SELECT all that apply: arm so the hand is higher than the elbow d. Obtain validation of what the client says from b. a moderate, positive correlation
1) “The drug’s action peak in two hours” 3) Immobilizing the extremity with a sling another party c. a high, positive correlation
2) “Maximum dosage is not achieved until 3 to 4 4) Placing a hand cone so the finger are barely d. a low, positive correlation
flexed 10. Which of the following nursing actions would you
days after starting the medication”
5) Keeping the arm at the sides using a pillow include in the plan of care for this client who keeps Situation 4
3) “Effects of the drug continue for 4 to 5 days
a. 2, 3, 4 saying that the trauma she experienced was just a case Ella, a 10-year old grade four pupil in a private school
after discontinuing the medication
b. 1, 3, 5 of bad luck? has just lost her best friend, Lory, who died of
4) “Protamine Sulfate is the antidote for
a. Assist the client in defining the experience as a Leukemia. Her mother brought her to the emergency
Warfarin” c. 1, 2, 4
d. 2, 4, 5 trauma room who reported that Ella has been gloomy and often
5) “I should have my blood levels tested
b. Encourage the client to verbalize the experience expresses feeling of joining Lory in heaven.
periodically”
Situation 2 c. Work with the client to accept positive and negative
a. 2, 4, 5 16. Which of the following is the precipitating factor for
You are a community health nurse assisting a family in feelings
b. 2, 3, 5 Ella’s feeling of wanting to die?
the care of their daughter suffering from the past
c. 1, 4, 5 Situation 3 a. The death of Lory
traumatic stress disorder.
d. 1, 3, 4 One of the competencies expected of you as a b. Her age
6. While caring for this client, the family notices that beginning professional nurse is to have a positive c. Her authoritative mother
2. Maintaining oral hygiene for a stroke patient is
loud noises cause a serious anxiety response. Which of attitude toward research. d. Her fear of death
important in his care. You are teaching a family member
the following explanations by you would help the family
how to give oral care to the stroke patient. Which of the 11. You plan to study the effectiveness of films in 17. Ella’s feeling of joining Lory in heaven is
understand the client’s response?
following nursing measure is NOT APPROPRIATE when teaching active exercises to post stroke patients. Which manifestation of:
a. After a trauma, the client cannot respond to stimuli in
giving oral care to such patient? of the following research designs will give you the most a. Suicidal intent
an appropriate manner
a. Cleaning the patient’s mouth and teeth with a soft- confidence to answer the research problem? b. Suicidal threat
b. Clients often experience extreme fear about normal
bristled toothbrush a. time- series design c. Paranoia
environmental stimuli
b. Keeping portable suctioning equipment at the b. non-equivalent control group design d. Suicidal ideation
c. Environmental triggers can cause the client to react
bedside c. one-group pre-test, post-test design
emotionally 18. Ella state “I will hang myself”. This is a manifestation
c. Opening the patient’s mouth with a padded tongue d. post-test only, control group design
d. The response indicates that another emotion of:
depressor
problem needs investigation 12. Which of the following sampling techniques is the a. Denial
d. Placing the patient on his back with a small pillow
under the head 7.Which of the following instructions should you include most appropriate to answer a research question on the b. Suicidal threat
about relationships for this client with post-traumatic effectiveness of active exercise on the mobility of post c. Suicidal intent
3. Your patient has paraplegia. In giving instruction to stroke patients? d. Paranoia
stress disorder?
the watcher when changing the patient’s position in a. convenience sampling
a. Assess the client’s discomfort when talking about 19. Which of the following is the best predictor of
bed, which of the following is NOT APPROPRIATE? b. purposive sampling
feelings to family member. adolescents attempting suicide?
a. Lifting the patient when moving him up in bed c. quota sampling
b. Explain that avoiding emotional attachment protects a. Depressed mood
b. Rolling the patient unto the side d. random sampling
against anxiety. b. Joyful mood
c. Using a trapeze to help the patient lift off the bed
c. Warn the client that she will have a tendency to be 13. You want to develop a tool for measuring the level c. Feeling of euphoria
d. Sliding the patient to move up in bed
overdependent in relationships of consciousness of stroke patients. This is what type of d. feeling of hopelessness
4. A patient is experiencing mood swings after stroke. d. Encourage the client to resume former roles as soon research?
Often times she has episodes of crying that are as possible a. Historical study 20. Ella state “I wish I were dead. I cannot stand
distressed to the family members. What is the BEST b. Case study anymore not having Lory around.” Your most
8. Which of the following nursing intervention would appropriate nursing action would be:
TECHNIQUE that you will advise the family members c. Comparative study
best help this client and her family handle interpersonal a. Do nothing because Ella will not do it
when the patient is having crying spells? d. Methodological study
conflict at home? Have the family: b. Refer Ella to your supervisor
a. Ignore the patient during this time
c. Stay with Ella d. Transferring Bianca to a bedside chair three times a 1) Bursitis measures will you institute to ensure the safety of the
d. Explore Ella’s feeling day to prevent posture hypotension 2) Carpal Tunnel Syndrome hospital staff and the other patients?
3) Tendonitis a. Provide the same assessment and care to the client
Situation 5 Situation 6 4) Dupuytrens b. Use restraints
You are a staff nurse in the Out-Patient Department. Jennylyn Abad, 40-years old woman, has a history of a. 1 and 2 c. Lock the ER door against entry if security is in
Mrs. D brought her 9-year old daughter Bianca for Rheumatoid Arthritis for the last ten years. The b. 2 and 3 question
consultation. Bianca is complaining of sore throat, following questions refer to this situation. c. 3 and 4 d. Never release the hand or ankle restraint
muscle tenderness, weakness of the arms and a general d. 1 and 3
feeling of not being well. The attending physician’s 26. which of the following is common sign/symptom of 38. In using restraints to patients, which of the following
impression is Infectious Polyneuritis. rheumatoid arthritis? 32. Which of the following is NOT considered a guidelines will you follow?
a. Presence of crepitus over joints
conservative treatment for inflammatory conditions of a. Apply restraints because the patient needs it
21. Initially, what assessment data would be the BEST b. Symptoms aggravated by humidity the shoulder? b. Apply restraints according to the hospital policy
c. Deformity and displacement of proximal joints a. Non-steroid Anti-inflammatory Drugs c. Restraint is the most effective nursing intervention to
IMPORTANT for you to make? d. Presence of Heberden’s nodes
a. Exposure to an infectious disease b. Intermittent ice and heat application to the joint minimize aggressive behavior
b. Difficulty in swallowing 27. which of the following would NOT be a common c. Laser photo-therapy d. Maintain respect for the client when applying
c. Difficulty in urinating laboratory findings in rheumatoid arthritis? d. Resting of the extremity restraints
d. Diet intake for the last 24 hours a. Low hemoglobin 33. Impaired movement of the rotator cuff of the 39. You have observed that a group of students are
b. Positive RA factor shoulder is generally termed as Impingement implementing their research project on the effect of hot
22. Bianca was admitted to the Pediatric ward. What c. Positive Lupus Erythematosus (LE) prep
would be your PRIORITY nursing action when caring for Syndrome. Edema, which is an early manifestation of and cold application to febrile patients without
d. Increase white blood count this syndrome, is due to ________. informing the participants properly. What ethical
her?
a. Providing a diversional activity for Bianca 28. Jennylyn has been taking steroids for the last five a. acute trauma of the shoulder principle was violated by the students?
b. Evaluating Bianca’s bilateral muscle strength years to control her arthritis. Which of the following is a b. muscle spasm a. Nonmaleficence
c. Making a game of range-of motion exercise common side effects of steroid therapy? c. hemorrhage of the structures involved b. Autonomy
d. Assessing Bianca’s ability to follow simple commands a. Hyponatremia d. atrophy due to disuse c. Justice
b. Hyperkalemia d. Respect for person
23. The pediatric ward nurse ask Bianca to cough every 34. For a persistent shoulder pain and weakness, this
c. Increase blood glucose usual treatment modality performed is _______. 40. A researcher should pay particular attention in
now and then. She also assesses Bianca’s speech for d. Protein anabolism
decreased volume and clarity, the underlying rationale a. Pulse-magnetic field protecting the rights of certain vulnerable groups.
for these assessments is to determine the ________. 29. Which of the following diet is best suited to b. Laser photo-therapy Which of the following is NOT considered vulnerable?
a. regression to an earlier developmental phase decrease the side effects of Jennylyn’s steroid therapy? c. Radio-frequency ablation a. Prisoners
b. involvement of facial and cranial nerves a. Normal carbohydrate, high protein, high potassium d. Arthroscopic Synovectomy b. Children
c. increased intracranial pressure b. Low carbohydrate, high protein, high potassium c. Mentally-challenged persons
35. One of the most common foot problems is Callus. d. Postpartum mother with normal delivery
d. inflammation of the larynx and epiglottis c. Low carbohydrate, high protein, low potassium This condition precedes the formation of a Callus _____.
d. High carbohydrate, low protein, low potassium a. External pressure on the foot Situation 9
24. Assessment findings revealed that Bianca has weak
gag and cough reflexes. During this acute phase of 30. Jennylyn was on Ibuprofen which has been stopped b. Faulty foot mechanics You are a staff nurse in the Neurologic Unit of the
Bianca’s illness, which of the following problems should when the steroid therapy was started. Which was the c. Flexion deformity of the interphalangeal joint Pediatric Department. Several problems have been
receive the HIGHEST PRIORITY? main reason for stopping the Ibuprofen once the steroid d. Penetrating nail plate in the surrounding skin of the reported in relation to ventriculo-peritoneal shunt for
a. Impaired swallowing related to neuromuscular therapy was started? foot hydrocephalus patients. The initial investigation on the
impairment. a. The two drugs taken together increase the risk of GI care of patient with this shunt revealed that majority of
Situation 8 the staff nurses have little experience on caring for such
b. Risk for infection due to an altered immune system bleeding You are a staff nurse working in a hospital and
c. Ineffective breathing pattern to neuromuscular b. The Ibuprofen would interfere with the action of the patients. It was decided to look into their level of
encounter situations with ethico-moral implications. knowledge and skills to serve as baseline data for
impairment steroid
d. Total urinary incontinence related to fluid losses c. The Ibuprofen was not needed with the steroid 36. Which of the following nursing actions will you do if improving the nursing care of hydrocephalic patients on
d. The two drugs together would cause severe liver the patient is unconscious and unable to make ventriculo-peritoneal shunt. The following questions
25. Bianca was placed on a medical ventilator. Which of damage decisions? This fact should be: refer to this situation.
the following nursing actions should the ward nurse a. reported to the nurse supervisor
give emphasis to? Situation 7 41. a four-year old hydrocephalic preschooler is
b. reported to the attending physician scheduled to have a ventriculo-peritoneal shunt at the
a. Turning Bianca slowly and gently from side to side to You are a staff nurse in the Musculo-skeletal Unit of the c. documented in the patient’s chart
prevent respiratory complication hospital. You are taking care of the patients with varied right side of the head. Which of the following positions
d. reported to the police should the child be placed immediately after surgery?
b. Engaging Bianca in vigorous passive range-of- motion musculo-skeletal conditions.
c. Maintaining Bianca in a supine position to prevent 37. A patient came in from prison for emergency a. Supine, with the head of the bed flat
31. which of the following inflammatory conditions treatment. Which of the following precautionary b. On the left side with the head of the flat
unnecessary nerve stimulation
commonly occurs in the shoulder? c. Prone, with the head of the bed elevated
d. On the right side, with the foot of the bed elevated 46. In providing tracheostomy care which of the d. literally spitting in other people’s face 58. You have observed that Angela is manifesting
following is the nurse’s PRIORITY nursing action? The persistent hallucination. What is the MOST EFFECTIVE
42. What nursing action should the nurse do when nurse _____. 52. When assessing a patient with BPD which of the therapy in treating patient with a condition like that of
providing post-operative nursing care to a child after a. cut the dressing using sterile scissors following information would you focus on? Angela’s?
insertion of a ventriculo-peritoneal shunt? b. cleans the incision with iodine-based antiseptic a. Ability to get people on his/her side a. Cognitive-behavior therapy
a. Monitoring for the increased temperature c. secure clean ties before removing soiled ones b. Disruption in some aspect of his/her life b. Crisis intervention
b. Check the urine for glucose and protein d. used clean technique c. desire for intimate relationship c. Psycho-pharmacologic treatment
c. Administer narcotics for pain control d. Increase acceptance from other people d. Anti-psychotic drug
d. Test cerebrospinal fluid leakage for protein 47. which of the following nursing actions should the
nurse TEACH the patient’s care giver regarding 53. Lorena revealed she has a tendency to manipulate 59. Which of the following is the GOAL of nursing
43. An infant who has hydrocephalus is irritable, others. What would be the MOST APPROPRIATE short-
tracheostomy care? intervention for a patient who is hallucination.
lethargic, and difficult to feed before the ventriculo- a. Remove the tracheostomy tube if obstruction occurs term goal for her? For Lorena to _____. a. To help the patient to have an increased awareness
peritoneal shunt is placed. To maintain the infant’s b. Leave the tracheostomy ties in place until the a. have an intimate relationship that in symptoms she is experiencing is not real
nutritional status, which of the following nursing action physician change them b. acknowledge her own behavior b. To help the patient to identify what triggers her
is the MOST APPROPRIATE? c. Remove and clean the inner cannula daily c, stop arguing with other people hallucination
a. Feeding the infant just before doing any procedures d. Never put a covering over the tracheostomy stoma d. express her feelings verbally c. To encourage the patient to verbalized her fear,
b. Giving the infant small, frequent feedings anxiety, and anger
c. Scheduling the feeding every six hours 48. After a tracheostomy procedure, the nurse 54. Patient with BPD manifest transient psychotic
symptoms. What is the drug of choice to treat these d. To help the patient to go back to her real world
d. Feeding the infant in a horizontal position documents important observations made during the
procedures such as _______. symptoms? 60. What communication technique would be Most
44. The parent of a school-age child with ventriculo- a. response of the patient after the procedure a. Mood stabilizer effective to achieve the nursing goal for patient with
peritoneal shunt were given discharge teaching. Which b. vital signs of the patient during the procedure b. Benzodiazepines hallucination?
of the following signs of a blocked shunt would the c. amount, color, and consistency of sputum and c. Lithium a. Listening
parents be able to identify that the discharge teaching is appearance of the incision d. Antipsychotics b. Facilitative communication
successful? d. behavior of the patient during the procedure c. One-on-one discussion
a. Irritability and increase difficulty with eating 55. Lorena has a history of alcohol abuse so she was
started on Antabuse. Which of the following is a d. Social interaction
b. Elevated temperature and reddened incisional site 49. What is the purpose of a tracheostomy? To _____.
c. Decreased urine output with stable intake a. establish an airway COMMON side effect of this drug? Situation 13
d. Tensed fontanel and increased head circumference b. establish a pathway for nutrition a. Hypertension Charting is part of the professional nurse’s responsibility
c. monitor respiratory functions b. Bradycardia related to record management. The following questions
45. After a six-year old child underwent placement of d. maintain the patency of the airway c. Depression refer to this statement.
ventriculo-peritoneal shunt, he was put on I.V. d. Elation
medication. The head nurse observed that many of the 50. which of the following can be a MAJOR PROBLEM 61. One of the characteristics of charting is brevity.
staff nurses are disconnecting the flush syringe first and for a patient with tracheostomy? Situation 12 Which of the following example of charting shows this
then clamping the intermittent infusion device. The a. Breathing Angela, a 40-year old, single mom of two preschool characteristics?
staff nurse seem not to understand the benefits of b. Ambulating children, aged two (2) and five (5) years old respectively a. Nurse brought the patient to OR via stretcher at
positive pressure techniques. Which of the following c. Swallowing was admitted to the Psychiatric Unit for attempting to 10:15
strategies would be the MOST EFFECTIVE way to d. Singing kill her two children. b. Patient left for surgery via stretcher at 10:15 am
improve the staff nurses technique in giving I.V. 56. Angela says “My dead mother ordered me to kill my c. To surgery via stretcher at 10:15
medication? Situation 11 d. patient brought by the nurse to OR via stretcher at
You are staff nurse in the Psychiatric Unit of a private two children before the devil could get them”. What
a. Post an evidence-based article on the topic in the unit behavior is being manifested by Angela? 10:15 accompanied by the “bantay”
b. Create a poster presentation on the topic with a hospital. Lorena, a 20-year old stage actress was
admitted with the chief complaints of getting angry a. Auditory hallucination 62.Which of the following is NOT a requirement for a
required post test b. Visual hallucination
c. Send a memorandum on the importance of clamping easily and inability to tolerate being alone. She claimed late entry in charting?
that she has also the tendency to manipulate people c. Tactile stimulation a. nurse’s initials above the time
the device first d. Olfactory hallucination
d. Ask each nurse if they are aware that their practice is and feels unhappy most of the time. She was diagnosed b. may be made if something has been forgotten
not current to be suffering from Borderline Personality Disorder 57. You ask Angela to touch a 25-centavo coin and a c. circle it and write “late entry”
(BPD). one-peso coin. You have observed that Angels was d. reason for the late entry
Situation 10 having difficulty differentiating one coin from the other.
You are a staff nurse in the Stroke Unit of the Medical 51. You have observed that Lorena is manifesting 63. There is a black space after your last entry in your
“spitting”. This characteristic of BPD is BEST defined as This is manifestation of _____. charting. You will ______.
ward. You have a stroke patient with a tracheostomy. In a. astereognosis
the unit’s last meeting it was discussed that there has ______. a. draw a double line after your last entry
a. viewing people and objects as parts, either good or b. kinesthetic b. sign your full name after your last entry
been increasing complaints on the nurse incompetence c. agraphestesia
in caring for a patient with tracheostomy. The following bad c. draw a horizontal line through the center of an empty
b. having two personalities d. cenesthetic line
questions related to this situation.
c. talking about other people behind their back d. draw a perpendicular line across the empty space
64. Which of the following should the nurse’s notes 70. Which of the following would your best advice to b. “I’m so glad no blood tests are necessary while I’m especially in the low frequencies. Clarita was diagnosed
focus on? the community people during summer time to prevent taking this.” with Otosclerosis.
a. Immediate past and the present dehydration? c. “I’m so glad Valiums won’t affect my driving skills”
b. The present only a. Use a hat or an umbrella when going out of the house d. “I’m so glad I will only have to take this until I learn to 81. Otosclerosis is a common cause of what condition?
c. The future b. Just stay home and relax be less anxious” a. Premature labor
d. The recent past c. drink plenty of fluids b. Meningitis Auditory nerve
d. wear light-colored clothing Situation 16 c. Sensori-neural hearing loss
65. Which of the following sample charting would show As a professional nurse, one of your roles is an advocate d. Conductive hearing loss
the characteristic of ACCURACY? Situation 15 for the patient’s rights. The following questions refer to
a. intake from 700-1000 ml: 80 ml of coffee; 240 ml of Lizbeth, a 30-year old registered nurse with two this statement. 82. The audiogram also confirms a sensori-neural
hearing loss. What ear structure is damaged when this
orange juice; 500ml of water children, legally separated from her husband was
b. Patient on forced fluid but refused to take it most of admitted to the psychiatric unit three weeks ago. 76. You were invited by a women’s organization to be condition is present?
the time the resource speaker on “Violence against women and a. Outer and/or middle ear
c. Patient on forced fluids observed 71. You are the nurse attending to Lizbeth. You have children”. Women and their children are protected b. Tympanic membrane
d. Given fluid at frequent intervals but takes only a few observed that she has a habit of washing her hands against violence under Republic Act No.__. c. Cochlear nerve
sips repeatedly for a long period of time. This is a a. 9173 d. Stapes
manifestation of what kind of behavior? b.9211
Situation 14 a. Negative c.9262 83. Clarita was given Sodium Flouride. What is the
During summer season incidence of heat stroke rises. As b. Hyperactive d.9160 rationale for giving this to her?
a community health nurse you should disseminate c. Ritualistic a. To mature the spongy bone growth
information on this as part of your role as a health d. Nonconformist 77. One of the violence acts is sexual violence. Which of b. To remove the diseased stapes
educator. the following does NOT constitute sexual violence? c. To prevent further complications
72. Lizbeth engages in this behavior to _____. a. Acts of lasciviousness d. To restore hearing
66. A patient came in with sign of heat stroke. Which of a. protect herself from undesirable people b. Rape
the following are signs/symptoms of profound CNS b. relieve her anxiety c. Treating a child as a sex object 84. A surgical procedure was recommended for Clarita.
dysfunction? c. occupy herself with purposeful activity d. Economic abuse Which of the following surgical procedures is useful in
correcting her condition?
a. Elevated temperature d. call the attention of other
b. Hot, dry skin 78. What would be the nurse’s MAIN concern when a a. Myringotomy
c. Tachypnea, hypotension, tachycardia 73. A new nurse introduce herself to Lizbeth and asks case of abuse, maltreatment, or neglect is suspected in b. Ossicular reconstruction
d. Confusion, delirium, bizarre behavior her name. Lizbeth responds “I am an obsessive- a patient? c. Cochlear transplant
compulsive neurotic. I have had psychoanalysis for ten a. Reporting the incident to proper authorities d. to restore hearing
67. Which of the following is the primary goal in the years. What do you think can you do for me?” Your b. Safety and welfare of the patient
85. After her surgery, Clarita was placed on her left side
care of patient with a heat stroke? BEST response would be _____. c. Referring the patient to a mental health worker
a. To maintain cardiac functions a. “Can we talk about that Lizbeth?” d. Just keep quiet about the matter with the head of the bed elevated. What is the rationale
b. To reduce immediately the high temperature b.” I need to know you better Lizbeth” for placing her in this position?
c. To restore normal body temperature c.” You seem to feel hopeless” 79. What is the MOST common clinical manifestation of a. To minimize the pressure in the middle ear
d. To prevent further complication d.” who was your psychoanalyst?” child neglect? b. To prevent complication of bleeding
a. Missed appointment with health care provider c. To ensure patient safety
68. Which of the following is the best advice you would 74. Lizbeth tells you “That the new nurse makes me b. Fracture d. To prevent vomiting
give to an athlete to prevent heat stroke? angry. Like you, she does not understand what my real c. Unexplained bruises
a. To monitor fluid losses and weight lost during problem is”. Your BEST reply would be _____. d. Malnutrition and dehydration Situation 18
workout activities and to replace fluids. a. “You seems to be upset. I will come back later” Ms. Ligaya Co is a chief nurse in a secondary level
b. To avoid immediate exposure to high temperature b. “You have the right to be upset when people don’t 80. What should be the FOCUS of care for patients who hospital with nursing staff consisting of registered staff
c. To maintain adequate fluid intake seem to understand” are suspected to be abused, maltreated, or neglected nurses, nursing assistants and aides.
d. To avoid planning outdoor activities between 10 a.m. c. “That’s a common feeling. I understand. Let’s talk a. Immediate treatment of any injury
b. Consequences of the act 86. Ms. Co stresses the importance of promoting ‘esprit
and 2 p.m. about it” d corps’ among the nursing staff. Which of the following
d. “I know what your problem is. You are an obsessive- c. Prevention of further injury
statement indicates that they understand the meaning
69. to prevent heat stroke, the following pieces of compulsive personality” d. Referral to legal authorities
advice are given to the community, EXCEPT: of the term?
a. Avoid direct exposure to the sun especially late in the 75. Diazepam (Valium) was prescribe for Lizbeth. You Situation 17 a. “In order that we achieve the goals of the institute,
morning gave her instructions on effects of the drug. What You are a staff nurse at the Ear Unit of the Medical we must follow the directives coming from above.”
b. Always drink plenty of water statement would indicate that Lizbeth needs further Ward of a government hospital. Clarita, a 25-year old b. “We will ensure that all resources we need are
c. Use a hat or an umbrella when going out of the house health teaching about the medication? stage actress was admitted with the chief complaint of available when needed”
d. Just stay home and relax a. “I’m so glad I can still eat chocolate while I’m taking on and off tinnitus at the right ear. The audiogram c. “Let’s work together in harmony; we need to be
this.” confirms conductive hearing loss or mixed loss supportive of one another.”
d. “We need to show our competence to the higher 92. Which of the following reinforces a person to d. Bochy language
management level.” continue drinking coffee?
a. Feeling of unpleasant symptoms when drinking is 99. Which of the following give meaning and context to
87. She assert the importance of promoting a positive abruptly stopped. the message?
organizational culture among the nursing staff. Which b. Drinking coffee at Starbucks is the “in-thing a. Process
of the following behaviors indicate that this has been c. Feeling of well-being b. Phrases and sentences
attained? d. The price of coffee is getting lower c. Context
a. Obedient and uncomplaining d. Thoughts and feelings
b. Powerful and oppositional 93. Ana was given Luminal 60 mg./day p.o. this drugs is
c. Competitive and perfectionist a/an _____/ 100. Which of the following situation is an example of
incongruent message?
d. Caring and nurturing with one another a. intermediate-acting sedative
b. short-acting sedative a. When the nurse means what she says
88. Ms. Co is a visionary strategist, and desires to be a c. hypnotic drug b. When the words and behavior of the nurse agree
committed leader. Which of the following types of d. long-acting sedative c. When what the nurse says and does do not agree
leadership do these behaviors reflect? d. When content and process agree
a. Servant 94. While doing your assessment Ana complained of
b. Transactional nausea. Which of the following would be you PRIORITY
c. Connective nursing action?
d. Transformational a. Refer Ana to the attending physician immediately
b. Let Ana put her head in-between her legs
89. She knows that as a leader, she has to strategize in c. Administer an anti-emetic drug
order to create followership in response to authority. d. Offering Ana some ice chips
This capacity to act or the strength to accomplish a goal
is referred to as _____. 95. you have observed Ana to be pacing in the room,
a. power restless, and stutters when your speaking to her. You
b. accountability would assess Ana as manifesting which of the following
c. responsibility global anxiety response?
d. authority a. Cognitive
b. Behavioral
90. Ms. Co gathered the nursing staff and other health c. Motor
care worker in the hospital who support the idea of d. Biological
having a meeting to discuss problems that affect the
delivery of care and to agree to speak with one voice. Situation 20
This power mechanism is called ______. You are a staff nurse in a psychiatric unit, use of
a. coalition therapeutic communication is one of your nursing
b. upward appeal responsibilities.
c. rationality
d. assertiveness 96. Verbal communication is the use of words when
talking to your patient.
Situation 19 a. understandable phase
Ana, a 28-year old supervisor in a business processing b. content
office, consult at the Out-patient department of the c. the circumstances
hospital with the chief complaints of headache, d. understandable sentences
drowsiness, nausea, and vomiting. She revealed that
one week before consult she stopped drinking coffee 97. Context of a verbal communication is the:
which she used to take three to five times a day. She a. use of understandable sentences
was diagnosed with Caffeine Discontinuation Syndrome b. use of literal words
(CDS). c. use of clear sentence
d. environmental where communication occurs
91. What are the effects of drinking coffee two to three
cups a day on the central nervous system? 98. Non-verbal communication is the behavior that
a. Feeling motivated and energized, less fatigue accompanies verbal communication. Which of the
b. Feeling motivated and energized, headache following is NOT an indicator of this?
c. Feeling motivated and drowsy, headache a. Eye Contact
d. Headache, less fatigue b. Word representing an object
c. Grunts and groans