ANSWER AND RATIONALE

COMPREHENSIVE I
Level II JUNE 2007
Situation 1: When a person becomes ill,
hygienic practices frequently becomes
secondary to her functions. People who
are ill often lack the energy to attend to
their hygienic needs and therefore
require assistance from the nurse in
this aspect.
1. Which of the following hygienic care is
most appropriate for the nurse to provide
to her bedridden client during afternoons?
a. Changing clients pajamas
b. Assisting with a bed bath
c. Straightening bed linens
d. Providing backrub
2. The skin has several functions. For the
function to regulate body temperature,
which of the following factors will guide
your nursing actions when bathing a
client.
a. Bathing
removes
excess
body
secretions
b. Use of comforter can promote heat
conservation
c. Bath water temperature should be
warm enough
d. Moisturizers prevent skin dryness and
protect the skin
3. Which of the following describe normal
condition but create high risk for impaired
skin functions among adolescence?
a. Absence of established hygienic habits
b. Reduced skin resiliency and moisture,
shrinking of elastic collagen fibers
c. Increased hormone level and glandular
activity
d. Skin externally thin, epidermis and
dermis loosely bound together
4. Which of the following guidelines is not
appropriate when providing a one-day
postoperative female patient with any
type of bath?
a. Accept clients dependency
b. Maintain safety
c. Provide privacy of clients
d. Maintain warmth
5. When caring for a diabetic clients feet
and nails, the nurse routinely performs
which of the following?
a. Trim away calluses with a sterile blade
or scissors
b. Soak the clients feet for 10-20 minutes
before trimming nails
c. Check the femoral pulses

d. Cut the nails straight across below the

tips of the toes.

1. D

2. C

3. C

4. A

5. D

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Situation 2: In order to be effective in

teaching her clients, the nurses must
utilize various principles of patient
education and observe considerations
appropriate to the needs of their clients
and relate their teaching activity to
nursing process.
6. Which of the following teaching activity is
closely related with nursing diagnosis?
a. Write learning objectives with the
client
b. Conduct group discussion as a
strategy
c. Identify the learning needs of the
client
d. Determine the different learning
materials appropriate to the level of
the patient
7. In order that patients with STD will fully
cooperate in their medical regimen, the
nurse plans to focus her teaching on the
pathophysiology of STD. Which of the
following verbs is the MOST appropriate
to use in writing the teaching plan
relative to patients knowledge about her
illness?
a. Comprehend
c. Know
b. Understand
d. Explain
8. The use of demonstration would be the
BEST method in teaching self-injection to
which of the following developmental
group?
a. Adult
c. Pre-school
b. Adolescent
d. Toddler
9. The use of role-play would be most
effective for which of the following
developmental level?
a. Adolescent
c. Adult
b. Pre-school
d. Toddler
10.Which of the following are the major
factors influencing an individuals ability
to learn?
1. developmental level
2. Age group 4. Height and weight
3. Physical ability
5.
Nutritional
status
a. 1,2,and 5
c. 1,2 and 3
b. 1,3 and 4
d. 2,3 and 4

11.The nurse observes a client who is

undergoing dialysis to be crying. The
client states, I feel like I am losing
control of my life. I have this fistula in my
arm and have to be attached to the
machines two times a week. Which of
the following is the most effective
response that will meet the psychosocial
needs of this client?
a. Reassure the client that all patients
who undergo dialysis experience the
same feelings.
b. Set up a meeting with the doctor to
explore alternative treatment
c. Encourage the client to express his
emotions and concerns
d. Refer the client and family to a
support group

6. C

7. D

8. A

9. B

10. A

Situation
3

Therapeutic
communication
is
a
recognized
interaction based on trust and aimed at
identifying
patient
needs
and
developing mutual goals and patient
centered nursing care. An Application
of these can be gleaned in the following
varied situations.

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wanted to initiate some changes in the

nursing care delivery system with the
approval of the chief nurse.
16.For patient assignment, she explained to
the staff that each one will be responsible
to a certain number of patients for the
whole 24 hrs and are expected to prepare
a 24 hr nursing care plan for each
assigned patient. This method of nursing
care delivery is termed which of the
following
a. Team approach
c.
Case
management
b. Primary nursing
d. Functional
method

11. C

12.In which of the following conditions is

health teaching MOST effective?
a. When he is physical and mentally
ready for learning.
b. When he feels full and contented after
a hearty meal
c. When he appears calm and sedated
d. When patient is in good mood
13.In which of the following is the
establishment
of
a
therapeutic
relationship BEST manifested between
the nurse and a client?
1. Role appropriate behavior
2. Treating the client as an individual
3. Sharing personal anecdotal stories
4. Terminating relationship as expected
in the contract
5. Testing trust of patient
a. 2,3 and 4
c. 1,2 and 3
b. 1,2 and 4
d. 2,3 and 5
14.Gina, 16 years old is withdrawn. She
refused to join the other patients and
prefers to stay in her room. Which of the
following is an appropriate short-term
goal for her?
a. She will interact appropriately with the
student nurses
b. She will attend all group activities
c. She will disclose feelings with the ward
staff
d. She will begin to interact consistently
with the nurse assigned to her.
15.An 80-year-old client is found crying in
her room. According to his development
age, he is in the stage of integrity vs.
despair. Which of the following BEST
characterized this stage?
a. Recalling beautiful and meaningful
memories at times with misgivings
b. Establishing relationship
c. A sense of personal identity
d. Productivity as a responsible citizen in
the community

12. A

13. B

14. D

15. A

Situation 4: Miss Ababa is a new head

nurse in the newly opened ward. She
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b. Submit a disclaimer to the chief nurse

of the hospital
c. Respect her feelings with the peer
group
d. Clarify from the head nurse the basis
for her evaluation

16.B

17.Even if individual patients are assigned to

a particular nurse, the head nurse is still
accountable for all the nursing care
services rendered in the ward. This belief
is an application of which of the following
management principle?
a. Unity of command
b. Proper channel of communication
c. Scalar principle
d. Command responsibility
18.For systematic and orderly management
of care, the head nurse confers with the
staff for 10-15 minutes to organize the
work for the day. Which of the following
sequence
of
structuring
tasks
is
CORRECT?
1. Assign tasks to the team
2. Present to the team the needs of the
patients for the day
3. Match the task with the abilities of
each staff members
4. Asks for suggestion from the staff
a. 4,2,3 and 1
c. 2,4,3 and 1
b. 3,2,1,and 4
d. 1,2,3, and 4
19.Per hospital, when a member of the staff
commits an error, the head nurse
prepares an incident report. In making an
incident report, which of the following
information should be included?
1. Includes all pertinent facts regarding
the incident
2. Names all involved in the incident
3. Includes her appraisal of the incident
4. Signature of all parties involve
a. 1,2 and 4
c. 1 and 2
b. 1 and 3
d.1, 3 and 4
20.In the hospital where Miss Abaya is
working, nurses are evaluated by the
head nurse every six months. Which of
the following actions should the nurse
take if she feels she is unfairly evaluated?
a. Share her feelings with the peer group

Situation 5: After three years of

working as a staff nurse in a medical
ward, Miss Federes was promoted as a
head nurse of a new unit on the basis of
the
leadership
that
she
has
demonstrated with her co-nurses.
21.As a good leader, Ms. Federes provide
that she can:
a. Influence her co-workers to work for
the achievement of the goals of
nursing service
b. Always follow all the instructions and
mandates
of
the
hospital
administration regardless of nurses
welfare
c. Be subservient to nursing authorities
in the hospital
d. Exert pressure to her co-workers to
achieve the objectives of the unit.
17. A

18. C

19. C

20. D

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proper in teaching the wife to provide

bladder training for the sick husband?
a. Clamping for 20 minutes, unclamp for
20 minutes, repeat continuously
b. Clamping the catheter for 1 hour
every other hours
c. Clamping for 30 minutes, then
unclamp for two hours
d. Clamping the catheter every few hours
for 20 minutes then release
27.Which of the following food should
frequently be included in the diet of a 15year-old patient with iron deficiency
anemia
a. Green beans
c. roast beef
b. Fish
d. eggs

21. A

22.Miss Federes and her current staff (in the

ward) agreed together on their goals and
targets. She is managing by
a. Objectives
c. exception
b. Contingency
d. values

28.Which of the following nursing actions

would BEST relieve itching of a rash in a
6year
old
patient
admitted
for
chickenpox?
a. Bathe the patient 2-3 times a day
b. Apply talcum powder freely as needed
c. Apply calamine lotion to affected area
as ordered
d. Apply cold wet compress
22. A

23.Miss was tasked to decide how many staff

is needed too provide quality-nursing care
in her unit. The specific tasks would
primarily require which of the following
skills?
a. Cognitive skills
c. evaluation skills
b. Managerial skills d. communication
24.Miss federes assigned two new team
leaders for one month. As a team leader,
the initial activity would be.
a. Evaluate the performance of the staff
b. Get the patient assignment
c. Organize the work load
d. Document all nursing care rendered by
the staff
25.After one month, Miss Federes was
evaluated by her supervisor and was
found to have obtained her attainment of
her goals and targets when asked what
management style she used, she
answered none in particular but I deal
with the situation as it arises. This implies
that she is leading by:
a. Contingency
c. laissez-faire
b. Objectives
d. consultation
Situation 6: Nurses are responsible for
providing basic care and comfort to
patients regardless of their age,
physical condition or setting.
26.One patient in the ward you are assigned
has been catheterized for several months.
Which of the following techniques is

23. A

24. C

25. A

26. A

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27. D

28.C

29.Constipation is a common complaint

among pregnant mothers. Which of the
following
which
of
the
following
interventions would you suggest to them
in order to prevent constipation
a. Eat whole grains bread, green
vegetables and cereals
b. Eat cooked cereals several times a day
c. Limit fluid intake before bedtime
d. Use glycerin suppository as needed
30.One patient in the ward is diagnosed to
have sleep pattern disturbance by the
nurse.
Is
the
appropriate
nursing
intervention to this problem?
a. Put eye patch on the patient at
bedtime to prevent glare
b. Provide quite environment and render
comfort measures
c. Refer the patient to the doctor for a
sedative
d. Have the patient exercise before
bedtime.
Situation 7: Health education is a
function that is included in the scope of
the nursing practice. It is one of the
important components in the care of all
clients.
31.Which of the following is the first step
that a nurse must remember in
implementing a health education program
for all her clients?
a. Establish clients goals
b. Assess the clients readiness to learn
c. Prioritize the health needs of her
clients
d. Assist the family to define their goals

32.The implementation of a health education

program for clients is best conducted in
which of the following ways.
a. With some degree of creativity to
avoid confusion on the part of the
client
b. By adhering strictly to the initial plan
c. With flexibility and willingness to make
changes as necessary
d. By considering only the client during
its implementation
33.Which of the following nursing actions will
ascertain
that
health
teachings
particularly
about
diet,
exercise,
medications and the like are effectively
followed after discharge?
a. Allow the client to have a return
demonstration of relevant procedures
b. Re-enforce appropriate learning during
discharge
c. Arrange for a follow-up visit at home
by a public health nurse
d. Use of teaching aids during health
instruction
34.For effective health teaching by the
nurse, which of the following should BEST
describe the planned goals for her clients
learning?
a. Established by the nurse for her
clients
b. Selected from the list of already
prepared goals
c. Within the regular diet regimen and
clients activity in order to get his
cooperation
d. In
accordance
with
the
needs
perceived by the client
29. A

30. B

31. B

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following is the direction of the needle

during a skin testing?
a. 15 degree angle
b. 45 degree angle
c. Needle is almost parallel to the skin
d. 90 degree angle

32. C

38.A 60 yr old patient is admitted for body

weakness. A venoclysis, D5w, 1 liter was
ordered. How will you regulate the
infusion initially while waiting for the
doctor to complete his orders?
a. 20gtts/min c. 10gtts/min
b. 20ml/min
d. 10ml/min
33. C

39.Mrs Canson was to receive an antibiotic

intramuscularly. Which of the following
factors might influence the nurses
decision on the route of administration?
a. Presence of kidney disorder
b. Clients age and level of alertness
c. Permeability of the skin surface
d. Condition of the muscle tissue
40.Which of the following gauge of the
needles is most appropriate for skin
testing?
a. Gauge 23
c. gauge 21
b. Gauge 26
d. gauges 18

34.D

35.In which of the following ways does mild

anxiety affect learning?
a. Must be increased until client s non
compliance to health teaching and
other regimen
b. Is
associated
with
clients
non
compliance top health teaching and
other regimen
c. Is a motivating factor in learning
d. Must be relieved before learning can
take place
Situation
8:
Nurses
have
both
independent and dependent functions
in the care of patients. The only
dependent
functions
involve
administration
of
medication
and
treatment.
36.Which of the following is the most
preferred site in administering IM
injection among infants and toddlers?
1. vastus lateralis
3.
dorsogluteal
2. ventro gluteal
4. Deltoid
a. 1 and 3
c. 1 and 4
b. 1 and 2
d. 2 and 4

Situation 9: Under the law, every

individual nurse is responsible to
maintain and improve her knowledge
and skills through continuing education
with
in
the
professional
nursing
organizations.
41.Which of the following refers to
continuing professional education?
a. Responsibility of each practicing nurse
b. May eventually result to an academic
degree
c. It is always voluntary
d. A responsibility of the school
35. C

36.A

37.9 year old patient is to be given penicillin

injection IM. Before it is carried out, skin
testing has to be done. Which of the

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37. A

a. Integrated
registered
nurses
association of the Philippines
b. National league of government nurses
c. Nurse specially certification council
d. Philippine nurses association
44.The international council of Nurses (ICN)
was established to assist national
association of member countries. Which
of the following is not an objective of ICN?
a. Serve as authoritative voice of nurses
and nursing internationally.
b. Primarily works for the welfare of
Filipino nurses
c. Improve status of nursing and promote
development
of
strong
nursing
association
d. Improve standard of nursing and
competence of nursing

38. C

39. A

45.Which of the following professional

organizations can you becomes a
member to improve your social and
professional life as advance practice
nurse?
a. Specific interest groups/ organization
b. Alumni Association
c. Philippine Red Cross
d. World Health Organization

40. B

41. A

42.Which of the following refers to in-service

education? it is
a. Offered to inform nurses not employed
by
the
hospital
regarding
administrative
innovations
and
practices relative to TQM.
b. Administered by the employer during
interview as part of the preemployment qualification
c. Offered by employer to inform staff
nurses about a new equipment and its
uses as well as current developments
in nursing
d. Offered by the school to its alumni in
order to enhance the graduates
employability and competence
43.One way nurses can demonstrate
professional commitment is by active
involvement in professional organization.
In which of the following is generally not
possible for most nurses to become
actively involved?

Situation 10: Nursing as a profession

demands constant interaction others
client
and
their
families,
health
providers and co-workers. Because of
this,
nurses
must
demonstrate
competence in communication skills.
46.Which of the following levels of
communication normally exist between
the nurse and her clientele?
a. Public
c.
Meta
communication
b. Interpersonal
d. Intrapersonal

42. C

43. A

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d. Stereotyping
49.Which of the following statements by the
nurse
could
be
considered
false
reassurance
and
therefore
non
therapeutic?
a. Being
your
first
hospitalization
experience,
it
must
really
be
frightening to you
b. It must really be difficult to you, but
be assured that I am willing to listen at
your convenient time
c. Most people are really afraid of
surgery, but at your age, theres really
nothing to worry about.
d. I lost my mother because of cancer
that I understand how difficult it must
be for you.

44. B

50. Which of the following is MOST important

in establishing effective communication
with a school-age child?
a. Informing the child about anticipated
discomfort related to a procedure
b. Providing comfortable environment
and observing privacy.
c. Understanding
the
influence
of
development on language and thought
processes.
d. Talking with the child at eye level.

45. A

46. B

47.The nurse enters the room of a postappendectomy patient and observed the
facial expression of discomfort and
considers the factors that may be causing
her pain. This level of communication is
BEST classified as:
a. Public
c. Interpersonal
b. Intrapersonal
d. Private
48.Both
verbal
and
nonverbal
communication involves transmission of a
message. Which of the following can be a
non-therapeutic technique since it takes
decision away from clients thus inhibiting
spontaneity and problem solving by the
client?
a. Giving an opinion
b. Sharing approval/disapproval
c. Offering false reassurance

Situation 11-There are several situation

and areas in the practice of nursing
that a nurse maybe confronted with
bioethical dilemma.
51.One of these areas is in matters
concerning blood transfusion. What would
you do if a relative asks you to
discontinue it because the patient is
dying anyway?
a. Continue giving the blood transfusion
without addressing the concern of the
relative
b. Finish the current blood transfusion
but do not continue with the 2nd bag
c. Discuss the matter with the doctor
d. Obey the request of a relative

47. C

48. B

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d. Continue
all
medications
and
procedures unless ordered so by the
physician
53.The nurse accompanied a spiritual
adviser to visit a dying patient as
requested. Later, a sister asks the nurse
to tell her what transpired during the
visit. What is the most appropriate thing
for the nurse to do?
a. Should be selective in revealing some
information to the sister
b. Tell the sister to keep out of the
spiritual affairs of the patient
c. She should not reveal anything
because
it
is
a
privilege
communication
d. Ask the sister to inquire from the other
nurses

49. C

50. C

54.A nurse who is a member of Couples for

Christ was asked to assist in bilateral
salpingectomy operation. The head nurse
tells her that she has nothing to worry
about. What is the most appropriate way
of responding to the situation?
a. Seek further advise from her spiritual
adviser
b. Excuse herself for the meantime and
wait until she becomes a licensed
midwife
c. Report the whole thing to the proper
authorities
d. Assist in the operation despite her
moral conviction because she believes
in the program

51. C

52.A patient with terminal cancer has

showed signs of acceptance and told the
nurse to discontinue all efforts to prolong
her life. Which of the following is the
MOST appropriate thing for the nurse to
do?
a. Share your observation with other
nurses before taking any further
drastic decision
b. Disregard patients request and seek
further advise from others
c. Interact with the patient and continue
the care and support for the patient

55.Before getting the client to sign the

consent for operation, which of the
following should be primarily considered
by the nurse?
a. Sedate the client to make sure that
she is relax enough to sign the
consent
b. Withhold all medications at least four
hours before obtaining the consent
c. Ascertain that the surgeon has
comprehensively
explained
the
procedure and its consequence
d. Evaluate
the
clients
level
of
consciousness and intellectual ability
Situation 12: Ms. Angelina is assigned
in the surgical ward of a government
hospital. Because of the malpractice bill
filed in congress, she is more than
aware of the ethico-legal aspects of her
practice.
56.Ms. Angelina read in the Internet that a
male nurse performed an unusual
procedure on his male client while under
restraint. This nurse can most likely be
accused of which of the following?
a. Slander
c. Libel

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10

b. Malpractice
52. D

d. Assault

after he allegedly applied a renewal of his

PRC identification card. This nurse can be
accused of which of the following?
a. Forgery
b. Dishonorable conduct
c. Malpractice
d. Misrepresentation
58.In her care of patients, Ms Angelina
always put in mind the patients bill of
rights discussed in her class. Which of the
following best describes the status of the
Patients Bill of Rights in the Philippines?
a. It is a written standard of care for
clients
b. It is universally observed in all
countries
c. It is good guideline in dealing with
clients
d. It has legal mandate

53. C

59.Ms. Angelina was informed that the

afternoon duty nurse couldnt report that
day. She was asked to extend her duty up
to 11:00 pm. which of the following action
would place her at greatest risk of legal
liability?
a. Submit a written protest to the nurse
administration
b. Inform the supervisor that she cannot
tackle the job
c. Inform the supervisor she is going
home at 3:00pm just the same
d. Refuse the assignment in writing

54. C

60. Mr. Rodney, the afternoon duty nurse,

finally arrived 2 hrs late. Ms. Angelina
suspected that he is under the influence
of alcohol. Which of the following actions
does Ms. Angelina best do initially?
a. Casually mention her observation to the
supervisor
b. Write an incident report recording
specific date and time and behavior
observed
c. Confront Mr. Rodney why he is late and
drunk
d. Ask to be transferred to another ward

55. C

56. B

57.She has known that a colleague in the ER

was discovered to have a fake license

Situation 13: Proper food and nutrition

are important factors that contribute to
fast recovery and rehabilitation of
patients.
As
such,
meeting
the
nutritional needs of patients must be a
major part of the nursing care plan.
61.Mr. Cruz, 55 years old, is undergoing
dialysis once a week. He has a chronic
renal problem and is on low sodium diet.
Which of the following is most appropriate
for him?
a. Arrozcaldo, melon, tea
b. Canned fish, fresh cucumber, diet coke
c. Ham and cheese sandwich, banana
and coffee

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11

d. MCDO burger, papaya, ice tea

57. A

58. D

59. C

62.A hypertensive patient in the OPD was

advised by the doctor to have low
cholesterol diet. Which of the following
menus would you BEST recommend?
a. Chicken salad, omelet, milk
b. Ampalaya salad, broiled fish, tea
c. Fried chicken, French fries, coffee
d. Broiled shrimp, steamed okra and
coke
63.A 3-year old child was brought to the
health center for diarrhea for 2 days. For
a clear liquid diet, which of the following
is BEST to the child?
a. Water
c. Pedialyte
b. Orange juice d. Broth
64.Which of the following should be include
in the teaching plan for a patient with
ulcerative colitis who is about to be
discharge?
a. High protein diet 3. High residue diet
b. Low protein diet
4. Bland diet
a. 2 and 4
c. 2 and 3
b. 1 and 4
d. 1 and 3
65.A 10-month-old baby has had measles.
He had loose bowel movement while in
the hospital. Which of the following would
you advice the mother to continue
hydration therapy at home?
a. Rice based solution or am
b. Diluted soup and tea
c. Orange juice or coke
d. Discontinue breast milk

60. B
Situation 14- Changes in nursing have
expanded the roles of nurses to include
increased
emphasis
on
health
promotion and illness prevention as
well as concern for the client as a
whole.
66.Which of the following roles does a nurse
BEST demonstrate when she delays the
taking of a routine BP reading to allow an
extended nap of a patient?
a. Comforter c. Care giver
b. Manager
d. Decision-maker

61. A

67.In which of the following communitybased nursing practice does a nurse

function with the highest level of
independence in providing a variety of
health related services?
a. Home-care nursing
b. Community health nursing
c. Occupational health nursing
d. School nursing
68.Which of the following roles is central to
all other nursing roles?
a. Manager
c. Communicator
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12

b. Teacher

62. B

63. C

64. B

65. A

66. A

67. B

d. Care giver

69.Which of the following career roles is

most evident when the functions of a
nurse are that of a clinician, educator,
manager, consultant, and researcher
within a specialized practice area?
a. Clinical nurse specialist
b. Nurse practitioner
c. Nurse educator
d. Nursing service director
70.Which of the following influences in
nursing practice serves as guidelines for
providing care and criteria for evaluating
nursing care?
a. Promulgated Standards of Nursing
Practice
b. Nurse Practice Act of 2006
c. Promulgated Code of Ethics for Nurses
d. Implementing Rules and Regulations
of R.A. 9173
Situation 15- Every year, the nurse in
the
university
infirmary
performs
physical examination for new coming
students.
71.When preparing a client for a physical
health
examination,
which
of
the
following should be done FIRST by the
nurse?
a. Explain the purpose of the exam and
what to expect.
b. Offer a glass of water to relieve
anxiety.
c. Omit draping in order to facilitate
inspection of the clients body.
d. Secure a consent form first
72.Which of the following may be examined
with palpation?
a. Headache
c. Gait and balance
b. Thyroid glands d. Bowel sounds
73.Tympany is the sound produced when
percussing which of the following?
a. Stomach
c. Back
b. Chest
d. Lungs
74.Which of the following is a sign of good
nutritional condition?
a. Falling hair
c. Bleeding gums
b. Cyanotic nail beds d. Clear eyes

68. C
75.Which of the following methods should be
used when conducting a nutritional
interview?
a. Suggestive questions
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b. Direct questioning approach

c. A non-directive approach
d. A firm no nonsense approach

69. B

70. B

71. A

72. B

73. A

74. D

Situation
16Documentation
and
recording are activities of the nurse
that
can
free
her
from
legal
responsibilities if they are done with
accuracy and truthfulness.
76.Which of the following actions is BEST if
another nurse asked you to document her
nursing care?
a. Find out the hospital policies regarding
documentation.
b. Do her the favor of documenting the
nursing interventions if you know her
well.
c. Review the provision of the nursing
law.
d. Refuse the request outright.
77.A nurse reliever from another unit gave
medication to the wrong client. The nurse
asserted that the client responded to the
name when called. Which of the following
is the MOST appropriate documentation
as a consequent to the medication error?
a. Do not record in the patients chart
since there are no untoward reactions
anyway.
b. Note the clients orientation level
c. Complete a proper record and incident
report.
d. Correct the error by erasing the
providers entry in the nurses notes.
78.Which of the following purposes of
documenting health
care
is BEST
exemplified when a nurse document
clients response
and the nurses
appropriate action to a medication error?
a. Research
c. Legal
b. Communication
d. Education
79.Which of the following is considered
objective assessment data?
a. Patient says she feels thirsty
b. Patient complains of pain in the back
c. + + Urine glucose level
d. Patient complains of difficulty of
breathing.
80.Which of the following is the correct
method of signing a nurses note?
a. Susan Velasco
c. SGV/RN
b. Susan Velasco, nurse
d.
Susan
Velasco, R.N.

75. B
Situation 17- Mr. James is admitted to
the hospital for gastric bleeding. The
physician ordered a blood transfusion.

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81.Before blood transfusion, the nurse

assesses Mr. James for which of the
following?
a. Sodium level
c.
Clotting time
b. Hematocrit level
d. Vital signs
82.Before administering the transfusion, the
nurse must start an IV infusion as
ordered. Which of the following is
commonly ordered before a blood
transfusion?
a. Sterile water solution
b. Dextrose 5 % in water
c. Plasma
d. Normal saline solution
76. D

77. C

81. D

82. D

83.Which of the following is the appropriate

needle for blood transfusion?
a. A G21 angiocatheter
c. A G18
angiocatheter
b. A G25 angiocatheter
d.
A
butterfly needle
84.Which of the following is NOT expected to
be done by the nurse in case of whole
blood transfusion?
a. Assess the patient closely for any
reaction
b. Make sure the drip chamber of the IV
tubing is particularly filled with blood
c. Prepare the blood transfusion using
microdrip tubing
d. Assess the venipuncture site for
evidence of hematoma
85.Which
of
he
following
is
the
recommended initial rate flow for the first
30 minutes in cases of blood transfusion?
a. 20 gtts/ min c. 40 gtts/min
b. 10 gtts/min d. 60 gtts/min

78. C

79. C

80. D

Situation 18- After teaching maternal

and child concepts for two years Miss
Rama wanted to find out knowledge of
senior and junior students about
contraceptive use and conception.
86.Which of the following is the BEST
statement
of
a
research
problem
pertinent to the professors goal?
a. is there a difference in the knowledge
of Third and Fourth Year Students of
School X on Contraceptive Use and
Conception?
b. What do Third and Fourth Year
Students of School X know about
Contraceptive Use and Conception/
c. Knowledge about Contraceptive Use
and Conception among Third and
Fourth Year Students of School X
d. Improving the Knowledge of Third
and Fourth Year Students of School X
on
Contraceptive
Use
and
Conception.
87.In the process of doing this and future
studies, Mrs. Rama is very careful not to
disclose the name of her subjects and
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their scores. This is an application of

which of the following principle?
a. Anonymity
c. Confidentiality
b. Informed consent d. Protection of
clients
88. A
88.Which of the following research design
would be MUST appropriate for
a. Experimental
c.
Case
study
b. Ex post-facto
d. Survey
89.In the process of planning this research
study, the statement of facts, age range
of the students, sex, marital status and
initial course, if any, is BEST included in
what part of the study?
a. Presentation and analysis of data
b. Introduction
c. Scope and limitation of the study
d. Related literature
83. C

84. C

85. B

86. C

87. C

89. C

90.Having more or less 300 students in the

third and fourth year nursing students,
the BEST method of gathering desired
information is which of the following?
a. Questionnaire
c. Interview
b. Structured interview
d. Checklist
Situation 19 By ensuring a safe
environment, a nurse can promote
health and prevent illnesses and/or
disorders in her individual clients as
well as in the community?
91.Which of the following is the SAFEST
hospital practice in ensuring a safe
environment?
a. Decontaminating all used instruments
and gloves before washing them with
gloved hands.
b. Throwing used needles into a garbage
can together with other hospital
wastes.
c. Keeping
pick-up
forcep
in
a
disinfectant solution where it can be
discarded after 24 hours.
d. Hanging a no smoking sign only
around the oxygen tank.
92.Which of the following will LEAST likely
endanger individual safety in the
community?
a. Catching up with the lifestyle of the
upper
class
and
well-known
personalities.
b. Keeping pet dogs at home
c. Providing opportunities for recreational
activities
by promoting
billiards,
badminton, lotto, etc.
d. Participating in safety awareness
activities
93.Which
of
the
following
nursing
interventions promote safety in the
hospitalized pre-school child?
a. Play nursery rhymes and songs in the
cassette

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b. Provide spoon and fork during

mealtime.
c. Put-up bedside rail in one side before
rendering nursing care
d. Provide matchbox toys so he could
play on the floor.
94.Which of the following age
vulnerable to GREATEST risk of
to accidents?
a. 9-15 years old
c.
old
b. 12-18 years old
d.
old

93. C

group is
death due
5-8 years
1-5 years

95.Which of the following are MOSTLY

associated with majority of death among
school age children?
a. Accidents
c.
Accidental
poisoning
b. Infectious diseases d.
Congenital
disorders
Situation 20- Albert, 14 ears old, is
admitted in the hospital for the second
time. He is diagnosed to have acute
lymphatic leukemia
96.Albert suspects that he will not live long.
The nurse however talks about pleasant
things with him and show cheerful
matters around him. As a result of such
behavior, Albert will most likely develop
which of the following?
a. Relief
c. Hopefulness
b. Isolation
d. Hopelessness
90. D

94. B

95. B

96. C

97.Current
approach
in
dealing
with
terminally ill patients, include telling the
family as much about Alberts disease
and prognosis as:
a. The
nurse
believes
they
can
understand
b. The priest/pastor think is advisable for
them to know
c. They wish to know
d. the physician can tell them

91. A

92. D

98.The nurse who is most effective when

caring for Albert and when helping his
family cope with death is one who
demonstrates which of the following?
a. Views dying persons as distinct
population of people in need of
comfort
b. Has contemplated her own death and
morality
c. Provide thorough and efficient physical
care
d. Attend seminars on death and dying

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99.Albert is observed to be increasingly

prone to outbursts concerning his
treatments. Which of the following
approaches by the nurse would likely be
MOST helpful in gaining his cooperation?
a. Promise to tell him stories after every
meal if he does not make a fuss about
the treatment.
b. Tell him to be a good boy and not
make the treatment any harder for the
staff.
c. Describe the probable effect on his
body that missing each treatment
would have.
d. Tell him how the treatment can be
expected to help him each time.
100. Which of the following possible
behavior of Albert would indicate MOST
clearly his need for emotional support?
a. He complains about his diet
b. He refuses to have his regular bath
c. He wants to have someone with him at
all times.
d. He teases his sister about her new
boyfriend.

99. C

100. B

One of the things I keep learning is

that the secret of being happy is
doing things for other people.

97. C

98. A

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