DIAGNOSTIC EXAM (INHOUSE) 9.

To maintain constant level of relief for a 3 year old child

1. Which of the following IV solutions can safely be suffering leukemic pains. A patient controlled analgesia (PCA)
administered to patients with increased ICP? * infusion pump has been connected yet the child doesn’t have
a. Hypotonic solution the ability to follow instructions regarding the proper use of the
b. Hypertonic solution device. The nurse instruct the parents of the child regarding the
c. .33 NaCl and Plain NSS proper use of the machine. *
d. .45 NaCl a. Living will
b. PCA by proxy
b  c. Advance directive
d. Durable power of attorney
2. Using the 11-point pain intensity scale in the evaluation of
intensity of pain experience of a client, the client states that he b 
can’t concentrate reading her favorite novel. The nurse would 10. Which of the following groups of signs and symptoms is
rate the pain as: * manifested by clients who are suffering from heat stroke? *
a. 2-mild pain a. Weakness, increased PR and excessive perspiration
b. 4-moderate pain b. Headache, weakness and hypotension
c. 6-severe pain c. Hypotension, tachycardia and tachypnea
d. 8-very severe pain d. Weakness, headache and wet skin
none 
b
11. Which of the following collaborative managements would
3. A toddler, accompanied by her mother seek consultation. As
be beneficial for a client who is admitted to the emergency
the nurse caring for the child which of the following activities
department following complaints of weakness and headache
would you recommend? *
after joining a 100 kilometer marathon? *
a. Lego
a. Administration of Chlorpromazine
b. Blowing bubbles
b. Placing in the client in NPO
c. Playing basketball with other children
c. Offering the client oral rehydration solution
d. Answering mathematical equations
d. Administration of Diazepam IV as ordered
b
c 
4. Applying the gate control theory of pain, an effective nursing
12. Passive external rewarming methods in the management of
intervention for a patient with lower back pain would be to: *
hypothermia includes: *
a. Encouraging regular use of analgesics
a. Induction of warm peritoneal dialysate
b. Applying moist heating pad to the area at prescribed interval
b. Administration of warm humidified oxygen by ventilator
c. Reviewing the pain experience with the patient
c. Warm fluid administration
d. Ambulating the patient after medicating him or her
d. Provision of warm blankets
b d

13. The primary inhibitory neurotransmitter that affects the

5. During the transmission phase of nociception, which method
reticular formation: *
of pain control is most effective? *
a. Prostglandin
a. Tricyclic antidepressants
b. Gamma aminobutyric acid
b. Opioids
c. Lactic Acid
c. Ibuprofen
d. Sulfuric acid
d. Distraction
b 
c 
14. Sleep deprivation is defined as: *
6. Using the Sedation scale, which of the following observations
a. Decreased REM stage
of the nurse would yield a rate of 3? *
b. Less than 2 hours of sleep for within 24 hours
a. Patient is awake and alert
c. Absence of sleep for 30 hours
b. Patient is somnolent
d. Absence of breathing for 20 second during sleep
c. Patient drifts off to sleep during conversations
d. Patient is slightly drowsy none 
15. When you interview a 40-year old client, she tells you that
 none
she never grieve that death of her 20 year old son because she
7. Which of the following parameters indicate that a nurse can
knows that he is in a nicer place now. This type of grief is best
resume giving morphine to a client who had respiratory
described as: *
distress? *
a. Abbreviated grief
a. Patient opens his eyes
b. Anticipatory grief
b. RR is higher than 9
c. Dysfunctional grief
c. Patient responds to pain
d. Disenfranchised grief
d. Patient complains of pain
none none 
8. Mrs. Young is receiving under patient-controlled-analgesia. 16. Stiffening of the body after death is termed as: *
Her husband worries that her wife will be overdosed with the a. Algor Mortis
drug. The nurse must explain to her husband that overdose is b. Rigor Mortis
prevented by what feature of the PCA machine? * c. Livor Mortis
a. Automatic antidote push d. Lochia Rubra
b. Lock-out interval 
c. Patient-controlled- antidote b 
d. Push-Patient-Interval 17. A Weber positive, conductive hearing loss suggests that : *
a. Sound is heard in both ears
b  b. Sound is better heard in the unaffected ear
c. Sound is better heard in the affected ear d. Palpating over the bones of the foot, on an imaginary line
d. Sound is better heard in either of the ears drawn from the middle of the ankle to the space between the
c big and second toes
18. A positive Rinne test indicates: * none 
a. Air conduction is greater than bone conduction 26. To decrease anxiety and promote cooperation in a child to
b. Bone conduction is greater that air conduction be taken pulse rate the nurse must: *
c. Air conduction is equal to bone a. Demonstrate the procedure to the child using a stuffed
conduction animal of doll
d. Bone conduction is equal to or longer than air conduction b. Allow the child to handle stethoscope before beginning the
procedure
none  c. You teach the mother the proper procedure in taking pulse
19. Clients with conductive hearing loss tend to have: * and let the mother obtain the pulse rate
a. Weber negative, Rinne positive d. Count the pulse prior to other comfortable procedure
b. Rinne negative, Weber positive
c. Weber positive, Rinne positive none 
d. Rinne negative, Weber negative 27. A pattern of respirations in which there is an alternating
periods of deep rapid breathing followed by periods of apnea. *
none  a. Cheyne-stoke respiration
20. The nurse palpates above each eye when assessing which of b. Biot’s Respiration
the following sinuses * c. Pulsus Alterans
a. Frontal sinuses d. Pulsus Bisferans
b. Ethmoidal sinuses
c. Sphenoidal sinuses none 
d. Maxillary sinuses 28. The nurse plans to assess the temperature of a client by
using infrared sensors to detect heat given off by the tympanic
a  membrane. The nurse does the skill correctly when? *
21. When the nurse has difficulty auscultating for the apical a. The nurse points the probe posteriorly away from the
pulse the nurse must: * eardrum
a. Placed the client in a prone position b. The nurse inserts probe slowly upward and backward
b. Let the client turn to the left side c. The nurse angles the thermometer towards the jaw line
c. Placed in a supine position head of bead lower that than foot  d. Attaching a tympanic prove cover after taking the
d. Place the client in a reverse trendelenburg position temperature

none  none 
22. The nurse should know normal variations in vital signs that 29. The nurse is to use a Doppler ultrasound stethoscope assess
occur. Which of the following statements is incorrect regarding the posterior tibial pulse. The nurse holds the probe against the
alterations in body temperature? * skin over the pulse site. The nurse hears an intermittent sound
a. Body temperature is usually about 0.6 degrees Celsius lower that varies with respiration the nurse must: *
in the early morning than late in the afternoon and late in the a. Reposition the probe
evening. b. Increase the amount of gel used
b. Research indicates that the peak elevation of a person’s c. Document the finding
temperature occurs in the late afternoon between 4 and 7 p.m. d. Clean the transducer with water based solution
c. Body temperature of infants and children changes more none 
rapidly in response to both heat and cold air temperatures. 30. A client has Impaired Verbal Communication as a result of
d. Men tend to have more fluctuations in body temperature temporary tracheostomy following a laryngectomy. In planning
than women  for communication with this client, the nurse would avoid
d  which of the following methods because it would be least
23. In which of the following situations does convection takes helpful for this particular client?
place? * a. Use of hand or fingers signals
a. The body gives off heat from uncovered sources b. Nodding and shaking the head for yes or no
b. An oscillating fan blows currents of cool air across the c. Use of picture board
surface of a warm body d. Use of pencil and paper
c. Body fluid in the form of perspiration
d. The body transfer heat to an ice pack b 
d  31. A nurse has completed tracheostomy care for a client whose
24. The pulse varies according to a number of factors. The nurse tracheostomy tube has a non disposable inner cannula. The
considers which of the following factor’s when assessing a nurse reinserts the inner cannula into the tracheostomy
client’s pulse? * immediately after: *
a. As age increases, pulse rate gradually increases a. Suctioning the client’s airway
b. Loss of blood from the vascular system decrease pulse rate b. Rinsing it with sterile water
c. Stress decreases the rate of pulse c. Shaking it to dry
d. Sitting and standing position increases heart rate d. Drying it thoroughly with a soft tissue
none  none 
32. A client has returned to the nursing unit following a
  tracheostomy. The nurse would place highest priority on a
25. The nurse assesses pedal pulse by: * assessing which of the following? *
a. Palpating the anterior aspect of the bicep muscles of the arm a. Respiratory rate and breath sounds
or medially in the antecubital space b. Amount of oxygen ordered to be delivered
b. Palpating the bone on the thumb side of the inner aspect of c. How long ago client received any pain medication
the wrist d. Status of tracheostomy dressing
c. Palpating the medial surface of the ankle
none 
33. The nurse is caring for a client postoperatively following d. Coil the tubing and place it under the thigh when sitting to
creation of a colostomy. Which nursing diagnosis should the avoid tugging on the bladder
nurse include in the plan of care? *  
a. Sexual dysfunction
b. Body image, disturbed  none
c. Fear related to poor prognosis 40. A nurse is administering a cleansing enema to a client with a
d. Nutrition, more than body requirements, imbalanced fecal impaction. Before administering the enema, the nurse
places the client in which of the following positions? *
none  a. On the left side of the body, with the head of the bed elevated
34. The nurse is performing colostomy irrigation on a client. 45 degrees
During the irrigation, the client begins to complain of b. On the right side of the body, with the head of the bed
abdominal cramps. What is the appropriate nursing action? * elevated 45 degrees
a. Notify the physician c. Left Sims’ positions
b. Stop the irrigation temporarily d. Right Sims’ position
c. Increase the height of the irrigation c 
d. Medicate for pain and resume the irrigation 41. A client has an order for “enemas until clear” before major
bowel surgery. After preparing the equipment and solution, the
b  nurse assists the client into which of the following positions to
35. A client diagnosed with a nosocomial infection caused by administer the enema? *
methicillin-resistant Staphylococcus aureus and contact a. Left Lateral Sim’s position 
precautions are initiated. The nurse prepares to provide b. Right Lateral Sim’s position
colostomy care ton the client and obtains which of the following c. Left side lying with head of bed elevated 45 degrees
protective items needed to perform this procedure? * b. Right side lying with head of bed elevated 45 degrees
a. Gloves and gown
b. Gloves and goggles a
c. Gloves, gown, and shoe protectors 42. A 46 year old male client has had a central venous catheter
d. Gloves, gown, goggles and a face shield inserted in the subclavian vein recently so that he can be
d  started on total parenteral nutrition (TPN) therapy. Which of
the following assessment findings best indicates the client may
  have a pneumothorax? *
36. A nurse has an order to obtain a urinalysis from a client a. Client complains of sharp chest pain
with an indwelling urinary catheter. The nurse avoids which of b. Pulse oximetry is 90% on room air
the following, which would contaminate the specimen? * c. Catheter insertion site is red and swollen
a. Obtaining the specimen from the urinary drainage bag d. Radial pulse is rapid
b. Clamping the tubing of the drainage bag
c. Aspirating a sample from the port on the drainage bag a 
d. Wiping the port with an alcohol swab before inserting the 43. Total parenteral nutrition (TPN) is being started on a client
syringe with malabsorption syndrome. Prior to starting the infusion,
nursing responsibilities will include which of the following? *
a  a. Calculating the nutrients needed for an individualized
37. A nurse is performing a bladder catheterization and is formula
inserting an indwelling Foley catheter. The nurse understands b. Obtaining a baseline weight
that which of the following represents an unsafe action when c. Ensuring an EKG is done on client prior to starting infusion
performing this procedure? * d. Checking for allergies to wheat
a. Inflating the balloon to test patency before catheter insertion
b. Advancing the catheter an additional 2.5 to 5 cm (1 to 2 b 
inches) once urine appears in the catheter tubing 44. A client receiving total parenteral nutrition (TPN) infusing
c. Inflating the balloon with 4 to 5 mL more than the balloon has disconnected the tubing from the central line catheter. A
capacity nurse assesses the client and suspects an air embolism. The
d. Placing the drainage bag lower than bladder level, with no nurse should immediately place the client in which position? *
kinks in the tubing a. On the left side, with head lower than the feet 
b. On the left side, with head higher than the feet
c  c. On the right side, with head lower than the feet
38. The nurse-manager tells another nurse to hold down a d. On the right side, with head higher than the feet
patient to insert a catheter. The patient says that he doesn’t
want the catheter inserted. The nurse understands that the a 
patient isn’t confused. If the nurse bodily restrains the patient, 45. A client is receiving nutrition by means of parenteral
she’s committing: * nutrition (PN) support. A nurse monitors the client for
a. Assault complications of the therapy an assesses the client for which of
b. Battery  the following signs of hyperglycemia? *
c. Libel a. Fever, weak pulse and thirst
d. Negligence b. Nausea, vomiting, and oliguria
c. Sweating, chills, and abdominal pain
b  d. Weakness, thirst, and increased urine output
39. A female client is being discharged from the hospital to d 
home with an indwelling urinary catheter following surgical 46. A client with a central venous catheter who is receiving total
repair of the bladder following trauma. The nurse determines parenteral nutrition (TPN) suddenly becomes short of breath,
that the client understands the principles of catheter complains of chest pain, and is tachycardic, pale, and anxious.
management if the client states to: * The nurse, suspecting an air embolism, places the client in
a. Cleanse the perineal area with soap and water once a day lateral Trendelenburg position on the left side and then: *
b. Keep the drainage bag lower than the level of the bladder a. Slows the rate of the TPN after checking the lines of air
c. Limit fluid intake so the bag won’t become full so quickly b. Clamps the catheter and notifies the physician
c. Monitor vital signs every 30 minutes  53. A nurse is caring for a client with a nasogastric tube that is
d. Boluses the client with 500 mL normal saline to break up the attached to low suction. The nurse assesses the client for
air embolus symptoms of which acid-base disorder? *
a. Metabolic acidosis
none  b. Metabolic alkalosis
47. A client has experienced an adverse reaction shortly after a c. Respiratory acidosis
blood transfusion is initiated. The nurse documents the vent d. Respiratory alkalosis
according to hospital policy and does which of the following
with the remainder of the blood that has not been transfused? * b 
a. Discards the blood in the appropriate biohazard bag 54. A nurse is preparing to administer an intermittent tube
b. Returns the blood to the blood bank feeding through a nasogastric tube. The nurse assesses gastric
c. Sends the blood to the chemistry laboratory for analysis residual before administering the tube feeding to: *
d. Sends the blood to the infection control and department a. Confirm proper nasogastric tube placement
none  b. Determine patency of the tube
48. A physician tells that a client needs blood transfusion and c. Assess fluid and electrolyte status
that a blood sample must be drawn first for blood typing and d. Evaluate absorption of the last feeding
crossmatch. After the physician leaves. The client asks the d 
nurse, “what exactly is a blood type, anyway?” The nurse
responds with which of the following statements? * 55. A nurse assists the physician with the removal of a chest
a. “The blood type represents an antigen found on the surface tube. During removal of the chest tube, the nurse instructs the
of the red blood cells.”  client to: *
b. “The blood type represents an antibody found on the surface a. Breathe out forcefully
of red blood cells.” b. Breathe in deeply
c. “The blood type represents an antibody that normally c. Exhale and bear down
circulates in the blood plasma.” d. Breathe normally
d. “the blood type represent an antigen that normally
none 
circulates in the blood plasma.”
56. A physician is inserting a chest tube. The nurse selects
a  which of the following materials to be used as the first layer of
49. A nurse is teaching a client how to stand on crutches. The the dressing at the chest tube insertion site? *
nurse tells the client to place the crutches: * a. Sterile 4 x 4 gauze pad
a. 3 inches to the front and side of the toes b. Absorbent Kerlix dressing
b. 6 inches to the front and side of the toes  c. Gauze impregnated with povidone-iodine
c. 15 inches to the front and side of the toes d. Petroleum jelly gauze
d. 20 inches to the front and side of the toes
none 
b  57. A nurse is planning care for a client with a chest tube
50. A client being measured for crutches asks the nurse why attached to Pleurevac drainage system. The nurse avoids which
crutches cannot rest up underneath the arm for extra support. of the following activities to prevent a tension pneumothorax? *
The nurse’s response is based on the understanding that this a. Adding water to the suction chamber as it evaporates
could result in: * b. Taping the connection between the chest tube and the
a. A fall and further injury drainage system
b. Injury to the brachial plexus nerves  c. Maintaining the collection chamber below the client’s waist
c. Skin breakdown in the area of the axilla d. Clamping the chest tube
d. Impaired range of motion while the client ambulates none 
58. The nurse calls the physician regarding a new medication
b  order because the dosage prescribed is higher than the
51. A nurse orientee is preparing to insert a nasogastric tube, recommended dosage. The nurse is unable to locate thy
and a nurse educator is observing the procedure. Which of the physician and the medication is due to be administered. Which
following supplies if obtained by the nurse orientee would action should the nurse take? *
indicate a need for further education regarding this a. Contact the nursing supervisor.
procedure? * b. Administer the dose prescribed.
a. Half-inch or one-inch tape c. Hold the medication until the physician can be contacted.
b. Oil-soluble lubricant d. Administer the recommended dose until the physician can
c. A glass of tap water with a straw be located.
d. A 50-mL catheter tip syringe
a 
b  59. The nurse gives an inaccurate dosage of medication to a
52. A registered nurse is observing a new orientee who is client. Following assessment of the client, the nurse completes
inserting a nasogastric tube in an adult client. The new orientee an incident report. The nurse notifies the nursing supervisor of
is determining the length of tube insertion. Which of the the medication error and calls the physician to report the
following observations indicates accurate measurement of the occurrence. The nurse who administered the inaccurate
length of the tube to be inserted? * medication understands that: *
a. The new orientee places the tube at the tip of the nose and a. The error will result in suspension
measures by extending the tube to the earlobe and then down b. The incident will be reported to the board of nursing
to the xyphoid process. c. The incident will be documented in the personnel file.
b. The new orientee places the tube at the tip of the nose and d. A incident report needs to be completed and is a method of
measures by extending the tube to the earlobe and then down promoting quality care and risk management.
to the top of the sternum. d  
c. The new orientee marks the tube at 10 inches.
d. The new orientee marks the tube at 32 inches. 60. A nurse who works on the night shift enters the medication
room and finds a co-worker with a tourniquet wrapped around
a  the upper arm. The co-worker is about to insert a needle,
attached to a syringe containing a clear liquid, into the d  
antecubital area. The appropriate initial action by the nurse is
which of the following? * 67. A fetus is considered at term at 37 weeks for which of the
a. Call security. following reasons? *
b. Call the police. a. The testes has already descended
c. Call the nursing supervisor. b. The L/S Ratio is 2:1
d. Lock the co-worker in the medication room until help is c. The lungs is fully functional
obtained. d. The placenta is large enough to supply oxygen to the fetus to
c  prepare for the labor process
61. The doctor has ordered a medication that’s highly irritating
b 
to the skin to be given I.M. The nurse uses an I.M injection
68. During pregnancy the vagina changes its color from pink to
method that prevents leakage of the medication into the
violet. This finding is termed as: *
subcutaneous tissue. This method is known as: *
a. Hegar’s sign
a. Deltoid injection
b. Goodell’s sign
b. Intraosseous
c. Chadwick’s sign
c. X-track
d. Probable sign
d. Z-track
c 
d 
69. Ms. Megan Young, 19 weeks pregnant, has been admitted to
62. The nurse is monitoring the cuff pressure. To minimize the the emergency department following. Contractions are noted
risk of tracheal tissue necrosis the nurse should maintain the which lasted 35 seconds, and cervix dilated at 7cm. She has
pressure to: * passed tissue fragments and no fetal heart was heard upon
a. 40 - 45 mmHg auscultation. Obstetrical history tells that he had a previous
b. 20 – 25 mmHg cesarean section 3 years ago due to placenta previa at 39th
c. 30 – 35 mmHg week AOG. Her first pregnancy successfully ended via normal
d. 10 – 15 mmHg spontaneous vaginal delivery giving birth to twins born at 38th
week. What is her obstetrical score? *
b  a. G-3, T-2, P-1, A-0, L-2
63. Brenda, a freshman student asked you “how does the b. G-3, T-2, P-0, A-1, L-2
menstrual cycle begin?” You would be right if you respond by c. G-2, T-2, P-1, A-0, L-2
saying: * d. G-3, T-3, P-0, A-1, L-3
a. The hypothalamus is triggered by theincreased level of
estrogen thus stimulating the anterior pituitary gland. none 
b. The anterior pituitary gland is triggered by the 70. Ms. Lally has just given birth to her 4th baby. She had a
hypothalamus to release follicle stimulating hormome and missed abortion 4 years ago and her second baby was born pre-
leutenizing hormone. term. Ms. Lally is considered as: *
c. The absence of a sex initiates menstrual cycle by causing the a. G3, P2
endometrium to slough off during menstrual period b. G3, P1
d. The hypothalamus triggers the anterior pituitary gland to c. G4, P3
release estrogen and progesterone. d. G4, P2
none 
b 
64. The union of the ovum and spermatozoon referred to as 71. Ms.Miriam visited the pre-natal clinic asked asked you
fertilization occurs in the outer third of the fallopian tube which “When will I be giving birth?” To be able to respond accurately,
is known as the: * what information should you obtain from Ms. Miriam? *
a. Isthmus a. The last time she had menses
b. Infundibulum b. When did she have sex with her husband
c. Ampulla c. When did she know about her pregnancy
d. Interstitial d. First day of the last menstrual period
c 
none 
65. Explaining the development of her baby, you identified in
72. Suppose Ms. Miriam had her last menstrual period for 4
chronological order the growth of the fetus as it occurs in
days and the menstrual flow ended May 5, 2019. What would be
pregnancy as: *
her expected date of confinement? *
a. Ovum, embryo, zygote, fetus, infant
a. February 5, 2019
b. Zygote, ovum, embryo, fetus, infant
b. February 9, 2019
c. Zygote, ovum, fetus, embryo, infant
c. January 29, 2019
d. Ovum, zygote, embryo, fetus, infant
d. January 5, 2019
d 
none 
 
73. Pyrosis and flatulence, common in the first trimester, are
66. Gloria who is pregnant for 9 weeks visited a pre-natal clinic
most likely the result of which of the following? *
and asked the nurse-receptionist, “Is it possible for me to listen
a. Decreased plasma HCG levels
to my baby’s fetal heart beat?” Which of the following responses
b. Decreased intestinal motility
by the nurse would be appropriate? *
c. Elevated human placental lactogen
a. “We can listen to your baby’s heart beat with a Doppler but
d. Elevated estrogen levels
we still have to wait for additional 4 weeks.”
b. “Fetoscope is best used during the 16th week of your none 
pregnancy to listen to the baby’s heart beat.” 74. During the third trimester of pregnancy, pregnant women
c. “The heart beats 8 weeks before delivery so I don’t think you usually experience episodes of leg cramps due to the pressure
can listen to it now.” of the uterus to the nerves supplying the lower extremities.
d. “Your obstetrician would probably use the Doppler to check However, a pregnant woman may also experience leg cramps
for fetal heart tones, she may let you listen to it.” during the 1st trimester for which of the following reasons? *
a. Calcium and Phosphorous imbalance 82. Complications of abuptio placenta include hemorrhage and
b. High level of estrogen disseminated intravascular coagulation. The color of the uterus
c. High levels of human placental lactogen may also turn to purple accompanied by a board-like and rigid
d. Elevated levels of Human Chorionic Gonadotrophin abdomen cause by accumulation of blood in the interstitial
myometrium. This condition is termed as: *
a  a. Couvelaire uterus
75. Ms. Margie Moran, 8 months pregnant complains of b. Ladin’s sign
dizziness especially when she lies on her back. Which of the c. Uterine Cyanosis
following would be the best instruction given to Ms. Moran to d. Hegar’s sign
address her complaint? * none 
a. Elevate legs on the wall for 30 minutes
b. Wear loose bra  
c. Drink in between meals 83. Which labor room assignment would the nurse give to a
d. Rest in a left side-lying position client diagnosed with gestational hypertension? *
a. Near the elevator so she can be transported quickly
none  b. A room across from the nurses’ station so that she can be
76. Marites, a primi gravida, wanted to be pregnant but she is observed closely
not enjoying it now that she is experiencing symptoms such as c. In a back hallway where there’s a quiet private room
nausea and vomiting. This leads to some degree of: * d. Close to the nursery so she’ll maintain hope of a positive
a. Grief outcome
b. Narcissism none 
c. Ambivalence 84. A nurse in a prenatal clinic is assessing a 28 y/o woman
d. Denial who’s 24 weeks pregnant. Which findings would lead this nurse
c  to suspect that the client has mild preeclampsia? *
77. As a Marites’ abdomen begins to grow, Eduardo perceives a. Glycosuria, hypertension, seizure
himself as growing larger, too, and he experiences physical b. Hematuria, blurry vision, reduced urine output
symptoms such as nausea and vomiting. These symptoms c. Burning on urination, hypotension, abdominal pain
suggest: * d. Hypertension, edema, proteinuria
a. Mimicry
b. Couvade Syndrome none 
c. Narcissism 85. Prior to giving Magnesium Sulfate, assessment must be done
d. Fantasizing to prevent toxicity. All of the following would stop the nurse
none  from administering the drug except: *
a. A urine output of 30 ml in 2 hours
78. During a contraction stress test, a decrease in the fetal heart b. A positive patellar reflex
rate occurs with the onset of contractions. The best nursing c. A respiratory rate of 8
action would be to: * d. A urine output of 60 ml in 4 hours
a. Reposition the client 
b. Continue monitoring the client b 
c. Stop oxytocin administration 86. The physician estimates that the fetus weighs at least 4,500
d. Notify the physician g (10 lb). Korina asks, “What causes the baby to be so large?”
The nurse’s response is based on the understanding that fetal
none  macrosomia is usually related to which of the following? *
79. The nurse does the Umbillical Grip or Leopolds Manuever a. Family history of large infants
number 2. She palpated a hard, smooth and resistant plane on b. Fetal anomalies
the right side of the mother’s abdomen. This implies: * c. Fetal Hyperinsulinism
a. The fetus is in a cephalic presentation d. Maternal Ketoacidosis
b. The fetus is engaged c 
c. The best site for fetal heart tone assessment would be at the 87. Glycosylated hemoglobin level is obtained to determine
right side of the abdomen compliance to treatment plan for GDM.A level of 8% indicates: *
d. The placenta is on the upper left portion of the uterus a. The client is a candidate for above the knee amputation to
prevent further complications
none 
b. There is a risk for spontanoues abortion
80. Before surgery to remove ectopic pregnancy, which of the
c. Client’s education in blood sugar control is adequate
following would alert the nurse to the possibility of tubal
d. Client needs further instruction regarding the treatment
rupture? *
plan for GDM 
a. Amount of vaginal bleeding
none
b. Falling hematocrit and hemoglobin levels
88. The insulin dosage during throughout pregnancy is: *
c. Slow, bounding pulse rate of 80 bpm
a. Increased throughout the duration of pregnancy
d. Marked abdominal edema
b. Decreased during the second trimester an increase during
none  the first and third trimester
81. The quality of pain commonly experiences by women who c. Increased during the first trimester and decreased on the
has had ectopic pregnancy is: * second and third trimester
a. Diffused lower abdominal pain radiating to the right d. Decreased during the first trimester of pregnancy and
shoulders increased on the second and third trimester
b. Diffused lower abdominal pain radiating to the left none 
shoulders 89. Immediately before expulsion, which of the following
c. Unilateral lower abdominal pain radiating to the neck and cardinal movements occur? *
shoulders a. Descent
d. Right lower abdominal pain b. Flexion
c  c. Extension
d. Restitution
none  c. Bleuler
90. The nurse plans to teach the client how to do Kegel’s  
exercise several times a day. The nurse should explain that the d. Freud
primary purpose of these exercise is to: *
a. Prevent vulvar edema c 
b. Relieve lower back discomfort 99. Which of the following statements would indicate that
c. Strengthen the perineal muscles teaching about naltrexone (ReVia) has been effective? *
d. Strengthen the abdominal muscles a. “I’ll get sick if I use heroin while taking this medication.”
b. “This medication will block the effects of any opioid
none  substance I take.”
91. The uncontrollable urge to push that is felt by the mother c. “If I use opioids while taking naltrexone, I’ll become
during the transition phase of labor is known as: * extremely ill.”
a. Ferragamo Reflex d. “Using naltrexone may make me dizzy”
b. Ferguson’s Reflex
c. Fulgoso Reflex b 
d. Ferdinand Reflex 100. Clonidine (Catapres) is prescribed for symptoms of opioid
withdrawal. Which of the following nursing assessments is
none  essential before giving a dose of this medication? *
92. Modified Ritgen’s Maneuver is appropriately done by: * a. Assess the client’s blood pressure
a. Applying downward pressure to the head during extension b. Determine the client when the client last used an opiate
to prevent perineal laceration c. Monitor the client for tremors
b. Palpating the fundus during contractions d. Complete a thorough physical assessment
c. Pulling the cord after delivery of the baby
d. Massaging the uterus after placental delivery to prevent a 
uterine atony 101. Which of the following would the nurse recognize as signs
of alcohol withdrawal? *
a  a. Coma, disorientation, and hypervigilance
93. HELLP Syndrome is: * b. Tremulousness, sweating, and elevated blood pressure
a. Hemolysis, Elevated Liver Enzyme, Low Platelet c. Increased temperature, lethargy, and hypothermia
b. High Blood Pressure, Elevated Lecithin Spyngomyelin Ratio, d. Talkativeness, hyperactivity, and blackouts
Low Potassium
c. Hypochondriasis, Endocarditis, Lung Colapse, Low b 
Phosphorous 102. The nurse is caring for a client with conversion disorder.
d. Hematochezia, Emesis, Low Level of Prolactin Which of the following assessments will the nurse expect to
see? *
a  a. Extreme distress over the physical symptom
94. One of the goals in the management of placenta previa is to b. Indifference about the physical symptom
increase fetal lung maturity by administering: * c. Labile mood
a. Oxytocin d. Multiple physical complaints
b. Betamethasone
c. Narcan b 
d. Magnesium Sulfate 103. A child is taking pemoline (Cylert) for ADHD. The nurse
must be aware of which of the following side effects? *
  a. Decreased thyroid-stimulating hormone
95. The best position for both clients with placenta previa and b. Decreased red blood cell count
abruptio placenta would be: * c. Elevated white blood cell count
a. Reverse trendelenburg postion to reverse possible d. Elevated liver function tests
development shock d
b. Semi-fowlers to prevent accumulation of blood in the uterine
cavity  
c. Knee-chest position to prevent cord prolapse 104. Teaching for methylphenidate (Ritalin) should include
d. Left lateral recumbent position ensure adequate which of the following? *
fetoplacental perfusion a. Give the medication after meals
b. Give the medication when the child becomes over active
none  c. Increase the child's fluid intake when he or she is taking the
96. The serum parameters for a therapeutic response to lithium medicine
are: * d. Take the child’s temperature daily
a. 0.2 to 0.6 mEq/L
b. 0.6 to 1.2 mEq/L a 
c. 1 to 1.6 mEq/L 105. A client with delirium is attempting to remove the
d. 2 to 3 mEq/L intravenous tubing from his arm, saying to the nurse, “Get off
me! Go away1” The client is experiencing which of the
b  following? *
97. Schizophrenia may be associated with elevated levels of: * a. Delusions
a. Norepinephrine b. Hallucinations
b. Dopamine c. Illusions
c. Serotonin d. Disorientation
d. Acetylcholine
b 
 b 106. A 35 year old client with a diagnosis of bipolar disorder,
98. The term schizophrenia was coined by: * mixed and borderline personality disorder was brought to the
a. Morel Emergency Department after taking a handful of pills and
b. Kraepelin calling 911. The nurse overheard a staff member saying of the
client, “Oh, here she comes again. If she was serious about financial problems. She decides to sign a DNR form. What
committing suicide, she’d have done it by now.” The nurse ethical principle did Carol & her family utilize as a basis for
considers which of the following when preparing to see the their decision to sign a DNR? *
client? * a. Justice
a. Client’s with personality disorders rarely kill themselves b. Autonomy
b. People who talk about suicide or have a history of suicidal c. Beneficence
behavior are at serious risk of self-harm and each event must d. Advocacy
be taken seriously
c. The nurse should not reinforce manipulative behaviors,  none
therefore the nursing assessment must be brief and 113. Diana, a staff nurse working in a cancer unit, is considered
exploration of suicidal ideations must be kept to a minimum a role model not only by her colleagues but also by her patients.
d. The nurse should anticipate that the client will be admitted She goes out of her way to help others. She is very active in
directly to the inpatient unit their professional organization and she practices what she
teaches. What ethical principle is she practicing? *
 b a. Beneficence
107. The client is transferred to the psychiatric inpatient unit of b. Autonomy
a general hospital from the surgical ICU after being treated for a c. Advocacy
self-inflicted gunshot wound. The nurse schedules time to meet d. Justice
with the client on a one-to-one basis with which of the none 
following goals in mind? * 114. An older person collapsed and nobody seems to notice her.
a. The client will explore current life events that led to the Someone tried to make her sit down but she remained
suicidal attempt unconscious. You saw what happened and you decided to help.
b. The client will initiate contact with the nurse spontaneously With help, you brought the patient to the nearest hospital. You
c. The client will identify past suicidal ideations and behavior learned later that woman was diabetic. She was on her way to
d. The client will begin group therapy as soon as he is able to the diabetes clinic to have her fasting blood sugar tested. She
ambulate and remain seated for 50 minutes developed hypoglycemia. You were able to save a life. You felt
 none good. What principle was applied? *
a. Advocacy
108. A client admitted to the psychiatric inpatient unit b. Beneficence
following expressed suicidal ideations tell the nurse the next c. Justice
day that she feels fine, is at peace, and wants to go home now. d. Autonomy
The nurse understands that the client: *
a. Has resolved her feelings and is no longer at risk for self-  b
harm 115. The code of ethics serves which of the following purpose? *
b. Is probably ready to be discharged to home since the a. It is the profession’s negotiable ethical standard
suicidal intent has been resolved b. It is an expression of nursing’s own understanding of its
c. Remains at risk, may have sufficient psychic energy to act commitment to the society
out on the suicidal ideation, and requires further assessment c. It articulates the legal obligations of nurses promulgated by
d. Has reached a realistic self-appraisal of the serious nature of the state’s legislative body
her suicidal intentions d. It is a list of legally-binding duties of nurses that must be
c  met
109. The priority nursing diagnosis for a client with suicidal
ideations and intent is: *  none
a. Risk for violence, self-directed 116. You are the morning Nurse Supervisor-on-duty when you
b. Ineffective individual coping heard a doctor complaining about a staff nurse who failed to
c. Hopelessness give the “stat” medication. Applying the principle of “line of
d. Defensive coping authority,” you are expecting the doctor to: *
a. Reassure the patient that next time the nurse will not miss
 a the medication
110. Which of the ff. is the purpose of the ethical review b. Report the incident to the chief nurse
committee? * c. Ask the staff nurse to explain the incident
a. Promote implementation of general standards d. Talk to you as the head nurse about the doctor’s complaint
b. Enhance health care provider’s liability  none
c. Increase individuals responsibility for decision making 117. University of Pangasinan Medical Center just opened its
d. Decrease public scrutiny of health care provider’s action new Performance Improvement Department. Catriona is
appointed as the Quality Control Officer. She commits herself to
 a her new role and plans her strategies to realize the goals and
111. Maria who is admitted to the hospital with autoimmune objectives of the department. Catriona prepares the process
thrombocytopenia and a platelet count of 20,000/æL develops standards. Which of the following is NOT a process standard? *
epistaxis and melena. Treatment with corticosteroids and a. Initial assessment shall be done to all patients within
immunoglobulin has not been successful. Her physician twenty-four hours upon admission.
recommended splenectomy. Maria states “I don’t need surgery. b. Informed consent shall be secured prior to any invasive
This will go away on its own.” In considering your response to procedure
Maria, you must depend on the ethical principle of: * c. Patients’ reports 95% satisfaction rate prior to discharge
a. Beneficence from the hospital.
b. Justice d. Patient education about their illness and treatment shall be
c. Autonomy provided for all patients and their families.
d. Advocacy
c   none
112. Carol is terminally ill & is experiencing severe pain. She 118. The nurse in the medication unit passes the medications
has bone & liver metastasis. She has been on morphine for for all the clients on the nursing unit. The head nurse is making
several months now. Carol is aware that they are having rounds with the physician and coordinates clients’ activities
with other departments. The nurse assistant changes the bed b. False imprisonment
lines and answers call lights. A second nurse is assigned for c. Battery
changing wound dressings; a licensed practitioner nurse takes d. Invasion of privacy
vital signs and bathes the clients. This illustrates of what
method of nursing care? *  a
a. Case management method 124. The nursing staff is sitting in the lounge taking their
b. Primary nursing method morning break. A nursing assistant tells the group that she
c. Team method thinks that the unit secretary has AIDS. The nursing assistant
d. Functional method proceeds to tell the nursing staff that the secretary probably
 none contacted the disease from her husband who is supposedly a
119. A newly hired nurse on an adult medicine unit with 3 drug addict. Which legal tort has the nursing assistant
months experience was asked to float to pediatrics. The nurse violated? *
hesitates to perform pediatric skills and receive an interesting a. Slander 
assignment that feels overwhelming. The nurse should: * b. Assault
a. Resign on the spot from the nursing position and apply for a c. Libel
position that does not require floating d. Negligence
b. Inform the nursing supervisor and the charge nurse on the
 a
pediatric floor about the nurse’s lack of skill and feelings of
125. A professional nurse with a commitment to social justice is
hesitations and request assistance
most apt to: *
c. Ask several other nurses how they feel about pediatrics and
a. Provide honest information
find someone else who is willing to accept the assignment
b. Promote universal access to healthcare
d. Refuse the assignment and leave the unit requesting a
c. Plan care in partnership with patients
vacation a day
d. Document care accurately and honestly
 b
 b
120. Eloisa, an RN and two other nurses were summoned to
126. A professional nurse committed to the principle of
appear before the Board of Nursing due to an administrative
autonomy would be careful to: *
case filed against them for alleged negligence, which caused the
a. Provide the information and support a patient needed to
death of a certain Mr. Santibañ ez, who was admitted due to
make decisions to advance her own interests
COPD. Eloisa is ordered by the Legal Department to bring along
b. Treat each patient fairly, trying to give everyone his or her
with her the initial assessment form and the progress notes she
due
used for the patient. What legal order from the hearing officer
c. Keep any promises made to a patient of another professional
refers to this? *
care giver
a. Subpoena duces tecum
d. Avoid causing harm to a patient
b. Subpoena ad testificandum
c. Summon  a
d. Writ 127. A friend asks you about the new Bill of Rights for nurses.
 none What can you tell her that accurately reflects the concern of the
drafter of these rights? *
121. A client is brought to the emergency room by the
a. The Bill of Rights was drafted by nurses who care more
emergency medical services after being hit by a car. The name
about themselves that they do about patients
of the client is unknown. The client has sustained a severe head
b. The Bill of Rights was drafted by union nurses who are
injury, multiple fractures, and is unconscious. An emergency
always looking for a reason to strike
craniotomy is required. Regarding informed consent for the
c. The Bill of Rights was drafted to empower nurses and
surgical procedure, which of the following is the best action? *
improve the conditions of workplace 
a. Call the police to identify the client and locate the family
 c
b. Obtain a court order for the surgical procedure
128. Jamie wants to call an ethics consult to clarify treatment
c. Ask the emergency medical services team to sign the
goals for a patient no longer able to speak for himself. She
informed consent.
believes that his dying is being prolonged painfully. She is
d. Transport the victim to the operating room for the
trouble when the patient’s doctor tells her that she’ll be fired if
procedure 
she raises questions about his care or calls the consult. This a
 d
good example of: *
122. The nurse gives two pills instead of the ordered one pill.
a. Ethical uncertainty
The physician is notified. The client is carefully monitored and
b. Ethical distress
no untoward effects happen. Can the client sue the nurse for
c. Ethical dilemma
malpractice? *
d. Ethical conflict
a. No, the client was not harmed
b. No, the nurse notified the physician  b
c. Yes, a breach of duty exists 129. When a state attorney decides to charge a nurse with
d. Yes, foresee ability is present manslaughter for allegedly administering a lethal medication
order, this is an example of: *
 a
a. Public law
123. A client arrives in the E.R. & is assessed by the nurse. The
b. Private law
client is staggering and confused. The client complains of
c. Civil law
headache from drinking alcohol & is asking for medication. The
d. Criminal law 
nurse explains to the client that the physician will need to
 none
perform an assessment before the administration of
130. If you wanted to find a list of violations that can result in
medication. When the client becomes verbally abusive, the
disciplinary action against a nurse, you should read: *
nurse obtains leather restraints and threatens to place the
a. Nurse Practice Act
client in restraints. With which of the following can the client
b. Code of Ethics for nurses
legally charge the nurse as a result of the nursing action? *
c. Nurse’s Bill of Rights
a. Assault
d. American Journal of Nursing compromise cause by their play mate. To prevent this, which of
the following types of play must be encourage? *
 none a. Associative pay
131. An 85 year old client in a nursing home tells a nurse, “I b. Imaginative play 
signed the papers for that research study because the doctor c. Solitary play
was so insistent and I want him to continue taking care of me”. d. Parallel play
Which client right is being violated? *
A. Right of self determination  none
B. Right to privacy and confidentialit  138. During assessment of extremities in children, which of the
C. Right to full disclosure following should a nurse document as abnormal that may
D. Right not to be harmed warrant further management? *
a. Babinski reflex present in a 3 year-old child
 none b. “Toddling” in a 2-year old child
132. A nurse administers Digoxin 0.25mg instead of the c. Genu varum observed in 2 year-old
prescribed order of 0.125mg. The nurse discovers the error d. Genu valgum present in a 2 year-old
while charting the medication. The nurse completes an incident
report and notifies the physician of the incident. The nurse  a
takes which additional action? * 139. An 8-month old infant is seen in the well child clinic for a
A. Gives the client a copy of the incident report routine check-up. The nurse should expect the infant to be able
B. Makes a copy of the incident report and sends it to the to do which tasks? *
physician’s office a. Say mama and dada with specific meaning
C. Documents the incident in the clients record b. Walks independently
D. Places the incident report in the clients record c. Stack two blocks
 none d. Transfer object from hand-to-hand
133. The nurse has made an error in documenting an  d
assessment finding on a client and obtains the client’s record to
correct the error. The nurse corrects the error by: * 140. The hemodynamic consequences of Patent Ductus
A. Trying to erase the error for space to write in the correct Arteriosus depend on the size of the ducts. Which of the
data following pathophysiological events may occur due to the
B. Using whiteout to delete error and writing in the correct failure of the fetal ductus arteriousus to close? *
data a. Blood shunts from the aorta to the pulmonary artery
C. Following the agency protocol b. Decreased pulmonary vascular congestion
D. Documenting a late entry into the client’s record c. Blood shunts from the pulmonary artery to the aorta
d. Increased work load of the right side of the heart
 none
134. Nurse C, a clinical coordinator, has read an interesting  a
research study that supports a change in the current 141. Nephrotic syndrome is a clinical state which includes: *
instructions being given to new mothers who are breastfeeding. a. Proteinuria
She posts the article with a summary of findings in all the b. Hypertension
nurse’s station in the maternity unit. Nurse C is using what c. Hyperalbuminemia
leadership style? * d. Polyuria
a. Quantum leadership
 a
b. Autocratic leadership
142. In attempt to increase tubular reabsorption of sodium and
c. Laissez – faire leadership
water, the posterior pituitary gland releases antidiuretic
d. Democratic leadership
hormone which is stimulated by: *
 none a. Hyperlipidemia
135. Nurse D is troubled by the plight of women and children in b. Hypoalbuminemia
the city where she lives. She united with other nurses and c. Hypovolemia
health care professionals to design and implement strategies to d. Hypoxemia
meet their needs. Within 18 months a nursing center is funded
 c
and running, improving maternal-child outcomes in the area.
143. A nurse is caring for a newly admitted 12-year old patient
What leadership style is exemplified in this situation? *
with a diagnosis of bacterial meningitis. On assessment, the
a. Transformational leadership
nurse attempts to the flex the patient’s neck while the patient is
b. Democratic leadership
in supine position. The nurse is trying to elicit which of the
c. Autocratic leadership
following? *
d. Quantum leadership
a. Kernig’s sign
 none
b. Brudzinski sign 
136. You’ve seen two children playing with dolls, borrowing c. Ferguson’s reflex
articles from each other and engaging into similar conversation, d. Trendelenburg reflex
but neither directs the other’s actions or establishes rules
 b
regarding the limits of the play session. This is an example of
144. the nurse has identified a problem of anxiety for a 4-year
what type of play? *
old child preparing for a tonsillectomy. The nurse should tell
a. Parallel play
the child: *
b. Associative play
a. “You will have many sore throats after your tonsils are
c. Cooperative play
removed”
d. Conservative play 
b. “The doctor will put you to sleep so you do not feel
none anything,”
c. “You’ll be fine. Your teddy bear will be with you throughout
137. A pair of toddlers will engage in considerable combat the procedure.”
because their personal needs cannot tolerate delay or
d. “When it is done, you will get to see your mommy and get an  c
ice pop.” 153. In preparing medicinal plants, decoction is best done by: *
a. Boiling the recommended part of the plant material in water
 none for 20 minutes
145. What toy should the nurse include as part of a recreational b. Soaking the plant in hot water, much like in making a tea for
therapy plan of care for a 3-year-old child hospitalized with 10 - 15 minutes
pneumonia and cystic fibrosis? * c. Directly applying recommended plant material on the part
a. 100-piece jigsaw puzzle affected, usually used on bruises, wounds, or rashes
b. Child’s favorite doll d. Mixing the plant material with food
c. Fuzzy stuffed animal
d. Scissor, papers, and paste  a
154. Ulasimag bato is recommended for people who have: *
 none a. Gouty arthritis
146. Based on Kohlberg’s theory, what is the stage of moral b. Thyphoid fever
development that a pre-schooler belong? * c. Dysmenorrhea
a. No concept of morality d. Urolithiasis
b. Naïve instrumental orientation
c. Good boy- nice girl‖  a
d. Social contact 155. On a medical-surgical floor, the nurse is caring for a cluster
of clients who have been diagnosed with diabetes mellitus.
 none Which client should the nurse assess first? *
147. While assessing a newborn with cleft lip, the nurse would a. An 80-year old client with a blood glucose level of 350 mg/dl
be alert that which of the following will most likely be b. A 20 year old client with a blood glucose level of 70 mg/dl
compromised? * c. A 60 year old client experiencing nausea and vomiting
a. Sucking ability d. A 55 year old client complaining of chest pressure
b. Respiratory status  d
c. Locomotion
d. GI function 156. A nurse is developing a teaching plan for a client diagnosed
wth diabetes insipidus. The nurse should include information
 a about which hormone that’s lacking in clients with diabetes
148. Which of the following toys should the nurse recommend insipidus? *
for a 5-month-old? * a. Antidiuretic hormone
a. A small car b. Thyroid stimulating hormoe
b. A teddy bear with button eyes c. Follicle-stimulatng hormone
c. A push-pull wooden truck d. Leutinizing hormone
d. A colorful busy box
 d  a
149. The ratio of public health nurse to community population 157. A client with a history of hypertension is diagnosed with
is: * primary hyperaldosteronism. This diagnosis indicates that the
a. 1: 5,000 client’s hypertension is caused by excessive hormone secretion
b. 1: 10, 000 from which gland? *
c. 1: 15,000 a. Adrenal cortex
d. 1: 20,000 b. Pancreas
 d c. Adrenal medulla
150. The DOH has published the implementing rules and d. Parathyroid
regulations of Chapter III of PD 856 to define sanitation
requirements for the operation of food establishments. The  a
inspection and evaluation of the compliance of food 158. Mr. Bean was diagnosed with cirrhosis, the nurse observes
establishments to the set standards of PD 856 is the duty of: * sign of hepatic encephalopathy which is asterixis. If the nurse
a. Public Health Nurse assesses the client with asterixis, he can expect to find? *
b. Rural Health Physician a. Irregualr movement of the wrist
c. Sanitation Inspector b. Enlargement of the breasts
d. City Medical Officer c. Dialted veinds around the umbilicus
 none d. Redness of the palmar surfaces

   a
151. Nurse Jordan is investigating about the high incidence rate 159. Which lab finding confirms the diagnosis of pancreatitis? *
of diarrhea in Barangay Malamig, Mandaluyong City To verify a. Blood glucose of 260mg/dL
the certification of potability of the existing water sources of b. White cell count of 21,000cu/mm
the households, she should get in touch with the office of the: * c. Platelet count of 250,000cu/mm
a. Private laboratories d. Serum amylase level of 600 unts/Dl
b. National Office for drinking water  d
c. Secretary of Health or Local health authority 160. A nurse is caring for a client with diabetes insipidus who is
d. Water Works System receiving vasopressin (Pitressin). The nurse monitors the client,
knowing that which of the following is a therapeutic effect of
 c this medication? *
152. The Traditional and Alternative Medicine Act is otherwise a. Increased urine output 
known as: * b. Vasodilation of vascular vessels
a. PD 996 c. Increased reabsorption of water by the renal tubules
b. EO 51 d. Decreased gastrointestinal tract smooth muscle tone and
c. RA 8423 contractions
d. EO 92
 none
161. A client is diagnosed with pheochromocytoma. A nurse 169. A client, recently diagnosed with Bell’s palsy, has many
prepares a plan of care for the client; while planning, the nurse questions about the course of the disease. The nurse should
understands that pheochromocytoma is a condition that: * explain that: *
a. Causes profound hypotension a. It causes hearing loss
b. Is manifested by severe hypoglycemia b. It is a permanent disability that results in inability to chew
c. Is not curable and is treated symptomatically c. It causes temporary facial paralysis resulting from damage to
d. Causes the release of excessive amount of catecholamines the facial nerve (CN 7)
 d d. It is caused by an injury to the maxillary sinuses
162. For the first 72 hours after thyroidectomy surgery, a nurse
would assess a client for Chvostek’s and Trousseau’s signs  c
because they indicate: * 170. The nurse notes a cloudy appearance to the lens of an 80-
a. Hypocalcemia year-old client’s eye. Which of the following additional
b. Hpercalcemia assessment findings would help confirm the diagnosis of
c. Hypokalemia cataracts? *
d. Hyperkalemia a. Sense of a curtain falling over the visual field
b. Persistent, dull eye pain
 none c. Painless central vision loss
163. What laboratory finding is the primary diagnostic d. Double vision
indicator for pancreatitis? *
a. Elevated blood urea nitrogen (BUN)  c
b. Elevated serum lipase 171. The nurse learns that the client uses timolol maleate
c. Elevated aspartate aminotransferase (AST) (Timoptic) eye drops. The nurse would understand that this B-
d. Increased lactate dehydrogenase (LD) adrenergic blocker helps control glaucoma by: *
a. Constricting the pupils
 b b. Dilating the canals of Schlemm
164. Nurse Jenjen is instructing client Luci newly diagnosed c. Reducing aqueous humor formation
with hypoparathyroidism about the regimen used to treat this d. Improving the ability of the ciliary muscle to contract
disorder. The nurse should state that the physician probably
will order daily supplements of calcium and: *  c
a. Folic acid 172. Scleral buckling is commonly done to patients with: *
b. Vitamin D a. Open angle glaucoma
c. Potassium b. Closed angle glaucoma
d. Iron c. Retinal detachment
d. Cataract
 b
165. Another Client with PUD, Akiko is scheduled for a  c
vagotomy and asks nurse Rhae about the purpose of this 173. A client is scheduled for removal of a cataract of the right
procedure. Which response by rhea best describes the purpose eye. Before surgery, the nurse is to instill drops of
of a vagotomy? * phenylephrine hydrochloride (Neo-Synephrine) into the client’s
a. Halts stress reactions right eye. This preparation acts in the eye to produce? *
b. Reduces the stimulus to acid secretions a. Constriction of the pupil
c. Heals the gastric mucosa b. Dilation of the pupil and constriction of the blood vessels
d. Decreases food absorption in the stomach c. Constriction of the pupil and constriction of blood vessels
d. Constriction of the pupil and dilation of blood vessel
 b
166. Nurse Kristian is caring for client Barbi following a Billroth  b
II procedure. Billroth II is: * 174. The client is discharged on the day of the cataract surgery.
a. Gastroduodenostomy Which of the following nursing diagnoses would be most
b. Gastrojejunostomy appropriate for the client at this time? *
c. Esophagogastroduodenostomy a. Deficient Diversional activity related incisional limitations
d. Esophagogastrojejunostomy after surgery
b. Chronic pain related to postoperative incisional discomfort
 b c. Risk for injury related to limited vision after surgery
167. Kristian is providing discharge instruction to Client Lemon d. Feeding self-care deficit related to inability to see food
following gastrectomy and instructs Lemon to take which
measure to assist in preventing dumping syndrome? *  c
a. Ambulate following a meal 175. Which of the following activities should be avoided to
b. Limit the fluids taken with meals achieve the goal of decreasing intraocular pressure after eye
c. Eat high carbohydrate foods surgery? *
d. Sit in a high fowler’s position during meals a. Lying supine
b. Coughing
 b c. Deep breathing
168. Nurse Kristian is monitoring client Erika for the early signs d. Ambulation
and symptoms of dumping syndrome. Which of the following
indicate this occurrence? *  b
a. Sweating and pallor 176. On a visit to the clinic, a client reports the onset of early
b. Double vision and chest pain symptoms of rheumatoid arthritis. Which of the following
c. Bradycardia and indigestion would the nurse most likely assess? *
d. Abnormal cramping and pain a. Limited motion of joints
 none b. Deformed joints of the hands
c. Early morning stiffness
d. Rheumatoid nodules
 c c. Wheel chair
177. A client with rheumatoid arthritis tells the nurse, “I know d. Buck’s Tractions
it is important to exercise my joints so that I won’t lose
mobility, but my joints are so stiff and painful that exercising is  b
difficult.” Which of the following responses by the nurse would 184. Walker The degree of detail an eye can discern an image or
be most appropriate? * visual acuity is tested by using an E-chart. In a 20/40 vision
a. “You are probably exercising too much. Decrease your means, 20 is the: *
exercise to every other day” a. Denominator
b. “Tell the doctor about your symptoms. Maybe your analgesic b. Distance a normal eye can read the chart
medication can be increased” c. Distance of the nurse from the client
c. “Stiffness and pain are part of the disease. Learn to cope by d. Distance of the patient from the chart
focusing on activities you enjoy”  d
d. “Take a warm tub bath or shower before exercising. This 185. Which client has the greatest risk for developing intra-
may help with your discomfort”  renal failure? *
 d a. A dialysis client who gets influenza
178. The nurse has completed instructions on health b. A teenager who has an appendectomy
maintenance for a client diagnosed with osteoarthritis. The c. A pregnant woman who has a fractured femur
nurse verifies that the client understood the instructions if the d. A client with diabetes who has a heart catheterization
client states that participation in which of the following sports
 none
would be beneficial? *
186. Which of the following should the nurse suspect as an
a. Tennis
iatrogenic cause of acute renal failure? *
b. Jogging
a. Alcohol
c. Swimming
b. Diet
d. Volleyball
c. Nephrotic medications
 c d. Exercise
179. Which of the following statements best describes the  c
underlying pathology of osteoarthritis (OA)? * 187. Which of the following organs is involved in the Renin-
a. Changes in the composition of the articular cartilage Angiotensin Aldosterone Activating System. Lungs i. Kidneys ii.
contribute to increased friction during joint movement (wear Liver iii. Adrenal Cortex iv. Pancreas *
and tear)  A. All except v
b. Joint inflammation occurs secondary to the presence of B. All except ii
immune complexes within the joint cavity (autoimmune) C. All except i
c. Excessive bone necrosis within the joint occurs secondary to D. All except iii
increased osteoclastic activity
 none
d. Faulty metabolism of purine
188. A client who has developed renal failure following
 a diagnosis of acute glumerulonephitis. The client has been
180. Proper functioning of facial muscles and nerves is essential inserted a Swan-ganz catheter. Which of the following
for a person utter words well. A client with parkinson’s diseases diagnostic results will obtained: *
has a problem in the articulation of words. This condition is a. A central venous pressure of 2 mmHg
termed as: * b. A pulmonary artery pressure of 5 mmHg
a. Microphonia c. A central venous pressure of 20 mmHg
b. Microphagia d. A pulmonary artery pressure of 25 mmHg
c. Dysarthria
 none
d. Dysphagia
189. Which of the following drugs will most likely be prescribed
 none and administered intravenously to client who is in the first
181. A client is receving Eldepryl (Selegiline Hcl) for the stage of renal failure: *
treatment of parkinosism. What is the mechanism of action of a. Low potassium diet
the drug? * b. Insulin
a. It acts to stimulate dopamine receptors c. Kayexalate enema
b. It is a precursor of dompamine d. Spironolactone
c. It inhibits breakdown of dopamine  none
d. It increases the amount of levedopa in the brain 190. A client in the first phase of renal failure has undergone
 c various laboratory test to determine prognosis and possible
182. Cerebrovascular accident is defined as a sudden neurologic development of complications. Which of the following
deficit due to insufficient blood supply to the brain. Which of laboratory results indicates that client’s condition is
the following conditions would put a client at risk for embolic improving? *
stroke? * a. A central venous pressure of 20 mmHHg
a. Atrial fibrillation b. A creatinine level is .5 g/hour
b. Hyperetension c. A Blood urean nitrogen level of 30 mmol/L
c. Aneurysm d. A serum potassium level of 10 mEq/dl
d. Arteriovenous malformation
 none
 none
191. Diabetes Mellitus type 1 patients differ from DM Type 2
183. The use of assistive devices is an important element of the
patients because DM Type 1 patient experiences: *
rehabilitative phase of patient care in clients who have suffered
a. Weight gain
paralysis secondary to cerebrovascular accident. The best
b. Weight loss and ketonuria
assistive device to be used by clients who suffered from stroke
c. Hypoglycemia
would be: *
d. Tremors
a. Crutches
b. Quad Cane  none
192. Which of the following is a contraindication of the use of a to 30 beats per minute or a drop in blood pressure systolic of
glucometer? * 10 mmHg or 20mmHg diastolic indicates orthostatic
a. Malnutrition hypotension.
b. Peripheral arterial insufficiency c. Place the client in a supine position for 10 minutes, record
c. Asthma the client’s pulse and blood pressure. Assist the client to slowly
d. Obesity sit or stand. Immediately recheck the client’s pulse rate and
blood pressure in the same site. Repeat the pulse and blood
 b pressure after 3 minutes. Record the results. A rise in 15 to 30
193. What is the normal SPaO2? * beats per minute or a drop in blood pressure systolic of 20
a. 85 – 90% mmHg or 10mmHg diastolic indicates orthostatic hypotension.
b. 90 – 95%  
c. 92 – 98% d. Place the client in a supine position for 15 minutes, record
d. 100% the client’s pulse and blood pressure. Assist the client to slowly
 d sit or stand. Wait for 15 minutes and recheck the client’s pulse
rate and blood pressure in the same site. Record the results. A
 
rise in
194. Breastfeeding reduces the risk of: *
a. Hemolytic disease of the newborn c
b. Sudden Infant Death Syndrome
c. Bell’s palsy
d. Patent Ductus Arteriosus

 b
195. What should be the initial action of the nurse prior to
inserting an oropharyngeal airway? *
a. Suction the patient
b. Hyperoxygenate the patient
c. Check for airway obstruction that could be pushed further in
to the airway
d. Position the patient to high fowler’s position

 c
196. Prevention of thromboembolism must be done: *
a. During admission
b. Prior to discharge
c. While the patient is in bed
d. All throughout the patient’s confinement
 

 d
197. What is the normal BMI? *
a. 15 – 18
b. 18.5 – 25
c. 15 – 35
d. 10 – 15

 b
198. What is central venous pressure? *
a. The pressure in the right ventricle
b. The pressure in the pulmonary artery
c. The pressure in the right atrium and vena cava
d. The pressure in the coronary artery

 c
199. What are the signs of septic shock? *
a. Hypertension, Tachycardia, Tachypnea, Hypothermia
b. Tachypnea, Hyperthermia, Hypertension, Bradycardia
c. Hypotension, Tachycardia, Bradypnea,ZHypothermia
d. Elevated temperature, Tachypnea, Hypotension, Tachycardia
 d
200. Which is the correct method of assessing for orthostatic
hypotension? *
a. Place the client in a supine position for 30 minutes, record
the client’s pulse and blood pressure. Assist the client to slowly
sit or stand. Wait for 5 minutes and recheck the client’s pulse
rate and blood pressure in the same site. Record the results. A
rise in 15 to 30 beats per minute or a drop in blood pressure
systolic of 20 mmHg or 10mmHg diastolic indicates orthostatic
hypotension.
b. Place the client in a supine position for 10 minutes, record
the client’s pulse and blood pressure. Assist the client to slowly
sit or stand. Immediately recheck the client’s pulse rate and
blood pressure in the same site. Record the results. A rise in 15