1. The physician instructed the nurse to collect a specimen 12.

12. In the hospital, what should the nurse do to stimulate the

from the patient's catheter. In order to collect a fresh appetite of the client who is not eating well?
specimen, the nurse should initially: A. Have the family bring attractive portions of food to provide
A. Empty the drainage collection bag and collect thereafter in the client
the bag when it is half full B. Provide food that the client likes and relieve Sx of illness
B. Put the drainage collection bag in the freezer C. provide treatments before mealtime so the client doesn't
C. Insert a new catheter have to think them while eating
D. Clamp the catheter for 30 minutes D. Provide large meals after the client has been active in
increasing his appetite
2. In obtaining a stool specimen, nurses should know that the
appropriate container to be used is: 13. If the client is unconsious, the ff are appropriate nursing
A. Clean container B. Sterile container measure when providing oral care EXCEPT:
C. Dirty container D. Used container A. Place the patient in lateral position
B. Use-hard bristled tooth brush
3. The patient is suspected to have a lung cancer stage 1. The C. Use cotton swabs
nurse knows that the doctor might order: D. Irrigate the mouth with water using asepto syringe and
A. Routine sputum B. AFB staining suction the solution adequately
C. Cytology exam D. None of the above
14. For almost 8 hours already, Nurse Jerby notices that the
4. Mr. Rodriguez, an alcoholic drinker and a chain smoker, patient was able to pass out loose watery stools every 3
suffered sever stomach pain upon eating his lunch. The hours. He tried to intervene by letting the patient drink an
doctor initially diagnoses him with peptic ulcer disease. What adequate amount of fluid. He also suggested that the patient
food will you let the patient refrain from eating if the doctor should eat:
orders an occult blood test: A. Oatmeal with pineapple toppings in it.
A. Guava jam B. Egg sandwich B. Cabbage, mushroom, and onions with oyster sauce
C. Plain rice D. French fries C. Toast bread with banana jam
D. Fresh buko juice mixed with pandan gelatin
5. The Rural Health Nurse i serves that the patient's
Benedict's Test Results indicates (➕➕) two positive signs. 15. Accurate objective and legible recording is fundamental
This means that the nurse should expect what color of the for safe practice because:
patient's urine? A. The chart reflects medical care given
A. Brick red B. Blue C. Green D. Yellow B. The chart is a means to communicate the progress on the
patient's condition
6. Heat and Acetic Acid Test is used to determine what C. The chart is a legal document
disorder: D. The chart is acceptable as an evidence in court against the
A. Albuminuria B. Glucosuria doctor, the nurse, the patient
C. Proteinuria D. Both A and C
16. A client is to receive a backrub to help relax. The best
7. To ensure accuracy of results, how should the nurse position for the nurse to assume in this procedure is to:
educate the patient in obtaining sputum specimen? A. The narrower the base of support and the lower the center
A. Instruct the patient to hack up sputum of the gravity, the grater the stability of the nurse
B. Eat a well-balanced diet B. Stooping with the hips flexed, knees straight, and tuck in
C. Adequate rest periods good alignment distributes the workload among the largest
D. CBR and strongest muscle groups
C. Facing the opposite direction of the door to prevent
8. In a catheterized urine specimen, nurses would obtain the abnormal twisting of the spine
specimen from where: D. The nurse bends from the knees when she reaches out the
A. Urinary meatus B. Along the y-port patient's back and feet apart is maintained to promote
C. Drainage collection bag D. In the patient's urinals stability

9. The doctor ordered a sputum exam for a patient suspected 17. You are surprised to detect an elevated temperature
of having TB and thus, AFB staining was given. Until how (38.5°C) in a patient scheduled for surgery. The patient has
many days will you collect the specimen? been afebrile and shows no other signs of being febrile. The
A. Within 24 hours to make sure that it is fresh first thing that you should do is to:
B. With an alcoholic mouthwash the first hour in the morning A. Inform the surgeon B. Validate your finding
C. Within a week so that continuous care must be needed C. Inform the charge nurse D. Document your finding
D. Within 3 days as instructed
18. To alleviate a client's anxiety during the health history and
10. Schilling's Test for Pernicious Anemia is taken in what kind assessment, the nurse could do which of the following?
of Urine Specimen Collection? A. Play soft music in the background
A. Clean Catch Midstream Urine B. Finish the interview and assessment as soon as possible
B. 24 hour urine collection C. Use a non-threatening and non-judgmental attitude
C. Second voided urine specimen D. Explain it is normal to have feelings of panics during this
D. Catheterized urine specimen time

11. To reduce pressure to the sacral area, the nurse should 19. The nurse would attempt to gather which of the following
position the patient in the: information while obtaining a health history from a client?
A. Lateral position B. Supine position A. Physical, Psychosocial, and Spiritual well-being
C. Dorsal recumbent position D. Semi-fowler's position B. Reaction to past hospitalizations
C. Type of insurance and financial problems
D. Personal goals related to healthcare 27. Lola Myrna complains that she frequently goes to comfort
room to urinate but upon reaching it, the desire to urinate
20. The first nursing intervention to implement when a client subsides. This is termed as:
is having a problem sleeping is to: A. Emergency B. Frequency
A. Check physician order to see if the client has a sleeping pill C. Urgency D. Incontinence
ordered
B. Provide client with a back rub 28. Three year old Rina asks her mother that she wanted to
C. Determine client's normal bedtime ritual urinate. Her mother who cannot speak because of a
D. Reduce environmental noise congenital defect during her childhood would still want her
child to urinate well. As a nurse, how can you manage the
21. At the conclusion of visiting hours, the mother of 14-year problem?
old female scheduled for orthopedic surgery the following A. Instruct the mother to let Rina drink a large amount of
day hands the nurse a bottle of capsules and says, "These are water
for my daughter's allergy. Will you be sure she takes one B. Catheter should be inserted to irrigate the urine well
about 9 tonight?" The nurse's best response would be: C. Scare and surprise Rina in a play therapy so she might
A. One capsule at 9pm? Of course I will give it. suddenly pass out of urine
B. Did you ask the doctor if she should have this tonight? D. Bring Rina to the CR and open a faucet in order to produce
C. I am certain the doctor knows about your daughter's a sound
allergy.
D. I will ask your daughter's doctor to write an order so I can 29. Which of the following data provides the best assessment
give this medication to her. of client's activity tolerance?
A. Vital capacity and breath sounds
22. To evaluate effectiveness of suctioning, the nurse should: B. Degree of joint flexibility
A. Assess the respiratory rate B. Check the skin color C. Muscle strength and incoordination
C. Auscultate the breath sounds D. Palpate the pulse rate D. V/S before, during and after the activity

23. Which of the following method would be most effective 30. The nurse aid is not around so Nurse Jake immediately
for an ambulatory care nurse to use when trying to determine prepares the hospital bed. Nurse Kim wanted to help him by
the priority health related learning needs of a client? giving the correct way of putting several sheets in the bed
A. Carefully review the physician's orders starting from:
B. Conduct a thorough nursing assessment 1. Pillow 4. Draw sheet
C. Determine the amount of time required to present the 2. Rubber sheet 5. Top sheet
information 3. Bottom sheet 6. Blanket
D. Ask the client what learning needs he or she has about
current state of health A. 3, 2, 4, 5, 6, 1 B. 3, 4, 2, 5, 1, 6
C. 3, 2, 5, 4, 1, 6 D. 3, 4, 5, 2, 6, 1
24. The primary essence of nursing is reaching out and
helping people in need. This makes nursing one of the noblest 31. Upon discharge, the nurse teaches a hemiplegic patient
professions. As a student nurse, you know for a fact that on how to massage the affected area of his body. At home,
nursing comes from what Latin word that would mean the patient does petrissage on the paralytic area of his body
nourish? on his own while he was resting on the couch. This type if
A. Nutriques B. Afriques exercise is known as:
C. Nutrix D. Mediatrix A. Active Assistive Range of Motion
B. Passive Range of Motion
25. In the nursing home, the patient was left alone with no C. Isotonic Exercise
family to be with. Ms. Melena, her nurse, has always been D. Active ROM
there for her and offers ample time with her everyday to help
her discuss and verbalize her problems. At the same time, Ms. 32. The nurse was able to see an old lady almost eating and
Melena objectively knows the procedures that were given as sleeping everyday beside the road. The old lady wears rugged
this may aid in promoting the well being of the patient. clothes and eats with what is left in a nearby grocery store.
Therefore, nursing in this situation is best defined as: You know as a nurse that this type of client needs:
A. A caring and loving profession that involves intimate A. An immediate counseling therapy
relationship with the patient B. Basic needs like food, shelter, and clothing
B. A stressful job having no personal life at all and focuses to C. Appreciation and encouragement
a patient among other patients D. Respect, love and attention
C. A very complicated job that needs efficiency and
assumptions at all times 33. Mr. Si is one of the most famous businessmen in his time.
D. An artistic way of helping other people with the use of He was able to travel around the world and was able to put a
scientific explanations lot of businesses here and in different parts of the country.
However, he is not happy and still thinks that something is
26. Kathy, a high school student, is fond of eating street lacking. In what level of Maslow's hierarchy of needs is not
foods. A week later she complained of abdominal pain, accomplished?
weakness, and a yellowish skin discoloration. Hepatitis is A. Physiologic needs B. Self-esteem
suspected. What further assessments will give Nurse Jacky C. Safety and security D. Self-actualization
that Kathy might have Hepatitis?
A. Steatorrhea B. Acolic stool 34. Michael, a grade 1 pupil, is fond of role playing his
C. Hematochezia D. Meconium favorite cartoon characters. He believes that he will not die
because Batman will save him. This could be possible because
Michael's concept of death is:
A. Final B. Reversible C. Inevitable D. Avoidable
35. The patient of Nurse Lennie died and she is preparing the 44. It is now midnight and a client is still unable to fall asleep.
post mortem care for her patient. The following parts should What should the nurse do to help him sleep?
have an ID band EXPECT: A. Bring him a glass of iced tea
A. Wrist B. Ankle C. Neck D. Shroud B. Suggest that he walk up and down the hall until he
becomes tired enough to sleep
36. The nurse sees that the head of the client's bed is C. Open the window or turn down the thermostat to bring
elevated about 60° and her kneed are slightly elevated. The the room temperature to below 19 degrees celsius
nurse appropriately charts the client to be in which of the D. Limit the noise and schedule history taking tomorrow
following positions?
A. Supine B. Fowler's C. Sim's D. Prone 45. Medical treatment of CAD includes which of the following
procedures?
37. A nurse has given medication instructions to a client who A. Cardiac catheterization
is receiving phenytoin (Dilantin). The nurse evaluates that the B. Coronary artery bypass surgery
client has an adequate understanding if the client states that: C. Oral medication administration
A. The nurse medication dose may be self-adjusted D. Percutaneous transluminal coronary angioplasty
depending on side effects
B. Alcohol is not contraindicated while taking this medication 46. The safest way to verify a patient's identity initially is to:
C. Good oral hygiene is needed including brushing and A. Ask the patient his name
flossing B. State the patient's name, and have him repeat it
D. The morning dose of the medication should be taken C. Check the identification on the patient's wrist
before a serum drug level is drawn D. Check the bed number, room number, and the patient's
name with the name assigned to the bed
38. Sandy, a terminally ill patient, already prepared her
clothes that she might wear when she dies. She also 47. If you harm a patient by administering a medication
suggested that her coffin should be color pink. In what level (wrong drug, wrong dose, etc.) ordered by a physician, which
of grieving process does she belong? of the following is true?
A. Bargaining B. Denial A. You are not responsible, since you were merely following
C. Depression D. Acceptance the doctor's order
B. Only you are responsible, since you actually administered
39. When leaving a client's room after providing care, it is the medication
important to evaluate the client's ability to do which of the C. Only the physician is responsible, since he or she actually
following? ordered the drug
A. Ambulate to the bathroom D. Both you and the physician are responsible for your
B. Push the call light to see if the client is able to activate it respected actions
when needed
C. Turn the TV on and off 48. Which of the following needs are considered by the nurse
D. Use the telephone to call the family as she implements reverse isolation for the client with
leukemia?
40. Which of the following should the nurse do to be most A. Physiologic care B. Self-esteem
effective in helping to liquefy or thin a client's respiratory C. Love and belongingness D. Safety and security
secretions?
A. Assist the client to ambulate frequently 49. A client is 2 days post op. The vital signs are: BP=120/70,
B. Encourage coughing and deep breathing HR=110, RR=26, and Temp=38°C. The client suddenly
C. Instruct client to increase fluid intake becomes profoundly SOB, skin color is gray. Which
D. Teach the correct use of the incentive spirometer assessment would have alerted the nurse first to the client's
change in condition?
41. The following are the appropriate nursing interventions to A. HR B. Temperature C. BP D. RR
promote normal respiratory function EXCEPT:
A. Adequate fluid intake 50. An order client is being started on a new antihypertensive
B. Minimize cigarette smoking medication. In teaching the client about the medication, the
C. DBE and coughing exercises nurse should:
D. Frequent change of position among bedridden client A. Allow the client to express himself or herself and ask
questions
42. To help prevent injury to a patient with bone B. Speak loudly
demineralization, the nurse should first: C. Present the information once
A. Apply emollients to the skin everyday D. Expect the client to understand the information quickly
B. Have the patient walk in the hall once daily
C. Encourage the patient to drink 2500ml of fluid daily 51. The physician orders NGT insertion to irrigate a client's
D. Support the patient's joints when turning and removing stomach. Which of the following insertion techniques would
most likely make it more difficult for the nurse to insert the
43. The nurse must auscultate the lungs of a client in tube?
isolation. Which of the following is the best way to prevent A. Lubricating the tube with water-soluble lubricant
the spread of microorganism to other clients? B. Asking the client to swallow while the tube is advanced to
A. Detach a contaminated needle from its syringe before the stomach
disposal C. Sitting the client upright in a Fowler's position
B. Double-bag soiled equipment with impervious bags before D. Having the client tilt the head toward the chest while
removing it from the client's room inserting the tube in the nose
C. Keep the stethoscope used for the client in the room
D. Remove personal protective equipment just outside the
client's door
52. The term gavage indicates 60. Which of the following best exhibit placement of the NGT
A. Administration of a liquid feeding into the stomach tube?
B. Visual examination of the stomach A. Gastric secretions pH of 6
C. Irrigation of the stomach with a solution B. Gurgling sound at epigastric region
D. A surgical opening through the abdomen to the stomach C. X-ray result tube dislodged at the right lobe of the lung
D. Bloody gastric secretions
53. A nurse is preparing to remove a NGT from a client. The
nurse would instruct the client to do which of the following 61. During NGT feedings, the nurse is safely able to
just before the nurse removes the tube? administer:
A. To perform a Valsalva maneuver A. Antiobiotics B. Syrup-based medications
B. To take and hold a deep breath C. Enteric-coated tablets D. Liquid vitamin preparations
C. To exhale
D. To inhale and exhale quickly 62. Before the insertion of the NGT, the physician should be
notified of:
54. Organize the steps in chronological order for client who is A. Patent nares B. Absent bowel sounds
having a NGT removed C. Evident gag reflex D. Impaired swallowing
1. Assist client into semi-fowler's position
2. Ask client to hold her breath 63. A client with severe IBD is receiving TPN. When
3. Assess bowel function by auscultation of peristalsis administering TPN, the nurse must take care to maintain the
4. Flush tube with 10ml of NSS prescribed flow rate because stopping the TPN abruptly may
5. Withdraw the tube gently and steadily cause:
6. Monitor client for nausea and vomiting A. Hypotension B. Hypoglycemia
C. Hyperglycemia D. Air embolism
A. 314625 B. 314526 C. 314256 D. 315426
64. What position will the nurse recommend to the patient
55. Which of these interventions indicate the nurse needs during TPN administration?
more information regarding how to safely ensure proper NGT A. High Fowler's position B. Trendelenburg position
placement? C. Semi-fowler's position D. Left sims lateral
A. When confirming tube placement, place the tube's end in a
container of water 65. A patient who requires a central vein access for
B. Use a tongue blade and penlight to examine mouth and parenteral nutrition is to receive a solution of:
throat for signs of coiled section of tubing A. Fat emulsion B. 5% dextrose
C. Stop advancing tube when tapemark reaches the client's C. Amino acids D. 10% dextrose
nostril
D. Inject 10cc of air into tube. At the same time, auscultate 66. Which of the following techniques is considered the best
for air sounds with stethoscope placed over the epigastric way to determine whether an NGT is positioned in the
region stomach?
A. Aspirating with a syringe and checking pH of gastric
56. The healthcare provider order reads "aspirate NG feeding contents
tubes every 4 hours and check pH of aspirate." The pH of the B. Irrigating with normal saline and observing for the return
aspirate is 10. Which action should the nurse take? of the solution
A. Apply intermittent suction to the feeding tube C. Placing the tube's free end in the water and observing for
B. Hold the tube feeding and notify the provider air bubbles
C. Administer the tube feeding as scheduled D. Instilling air and auscultating over the epigastric area for
D. Irrigate the tube with diet cola soda the presence of the tube

57. An appropriate technique or the nurse to implement 67. Three days after admission for a CVA, a client has an NGT
during NGT insertion is to: inserted and is receiving intermittent feedings. To best
A. Use sterile gloves evaluate if prior feeding has been absorbed, the nurse
B. Have the client mouth-breath should:
C. Advance the tube quickly when the client cough A. Evaluate the intake in relation to the output
D. Bend the client's backward after the tube is through the B. Aspirate for the residual volume and re-instill it
nasopharynx C. Instill air into the stomach while auscultating
D. Compare the client's body weight to the baseline data
58. What position will the nurse recommend to the patient
during NGT insertion? 68. An appropriate technique for NGT insertion is for the
A. Semi-fowler's position B. Trendelenburg nurse to:
C. High-fowler's position D. Left Sim's lateral A. Position the client supine
B. Ice the plastic tube
59. After NGTs have been inserted, the nurse can mostly C. Advance the tube while the client swallows
determine in the tube is in the proper place if which of the ff D. Measure the tube length from the nose to the sternum
can be demonstrated?
A. The client is no longer gagging or coughing 69. What position will the nurse recommend to the patient
B. The pH of the aspirated fluid is measured during TPN insertion?
C. Thirty mm of normal saline can be injected without A. High Fowler's position B. Trendelenburg
difficulty C. Semi-fowler's position D. Left sims lateral
D. A "whoosing" sound is auscultated when 10mL of air is
inserted
70. A client recovering from an infected abdominal wound. D. The current pulse is compared with previous pulse
Which of the following foods should the nurse encourage the measurements for differences
client to eat to support wound healing and recovery from
infection? 81. A nurse needs to assess a client's pulse pressure. What is
A. Chicken and orange slices the correct procedure?
B. Cheese omelet and bacon A. Subtract apical from radial pulse
C. Cheeseburger and French fries B. Subtract systolic from diastolic blood pressure
D. Gelatin salad and tea C. Subtract radial from apical pulse
D. Subtract diastolic from systolic
71. A 45-year-old client has a permanent colostomy. Which of
the following foods should be avoided? 82. The following are correct nursing actions when taking the
A. Peanut butter and jelly sandwich and milk radial pulse EXCEPT
B. Corn beef and cabbage and boiled potatoes A. Put the palms downward
C. Oatmeal, whole wheat toast, and milk B. Use 2-3 fingertips to palpate pulse
D. Tuna, whole wheat bread, and iced tea C. Use the thumb to palpate the artery
D. Assess the pulse rate, rhythm, volume, and bilateral
72. The nurse is caring for a client who has been admitted to equality
the hospital with a diagnosis of malnutrition. The nurse most
effectively monitors the client's status by which measure? 83. In accessing a client's apical pulse, you know that the PMI
A. Intake measurement B. Calorie count is usually at which area of the heart?
C. Skinfold measurements D. Daily weight A. LMCL, 5 ICS B. LMCL, 4 ICS
C. LMCL, 2 ICS D. RMCL, 2 ICS
73. The most concentrated source of energy in the body is
A. Protein B. Carbohydrates 84. A pulse is normally palpated by applying moderate
C. Fats D. Macro minerals pressure using
A. The thumb B. The index finger
74. The nurse is preparing to feed the client with mild C. The palm D. The middle three fingers
dysphagia. The nurse should do which of the following to
assist the client with swallowing? 85. A nursing instructor teaches a group of students about
A. Place the food on the tip of the client's tongue BLS. The instructor asks a student to identify the most
B. Provide foods that have a soft consistency appropriate location to assess the pulse of an infant under 1
C. Use water to help the client swallow the food in the mouth year of age. Which of the following if stated by the student
D. Place the equivalent of 30ml of food on the fork understand the appropriate procedure?
A. Carotid B. Brachial
75. A postoperative client is on a clear liquid diet, which of C. Radial D. Popliteal
the following are allowed on a clear liquid diet?
A. Ice cream, butter, yoghurt, vegetable juices 86. The nurse should report an assessment of
B. Mashed potatoes, fish, bananas, vegetable juices A. 14 respiration per minute of an adult client
C. Gelatin, hard candy, tea, popsicles B. 16 respiration per minute for an 8 year old client
D. Milk, gelatin, canned fruits, bread C. 25 respiration per minute for a toddler
D. 38 respiration per minute for a newborn
76. Which of the following menu is appropriate for one with
low sodium diet? 87. The nurse find it necessary to recheck the blood pressure
A. Instant noodles, fresh fruits, and iced tea reading. In case of such reassessment, the nurse should wait
B. Ham and cheese sandwich, fresh fruits, and vegetables a period of
C. White chicken sandwich, vegetable salad and tea A. 15 seconds B. 1-2 minutes
D. Canned soup, potato salad, and diet soda C. 30 minutes D. 15 minutes

77. Obtain the BMI of the 32-year old patient with a height of 88. A false high blood pressure reading may be obtained if
5' 5" and weight 172 lbs. the nurse
A. 24.98 B. 28.74 C. 27.86 D. 23.45 A. Deflates the cuff to slowly
B. Has the client's arm above heart level
78. Interpret this BMI reading: 28.74 C. Holds the stethoscope too firmly over the antecubital fossa
A. Underweight B. Overweight D. Repeats the blood pressure assessments too quickly
C. Normal D. Obese
89. Blood pressure measurement is performed on the lower
79. Ms. FX has been admitted with right upper quadrant pain extremities when the client has
and has been placed on low fat diet. Which of the following A. An IV in the right arm B. A left arteriovenous shunt
trays would be acceptable for her? C. A right mastectomy D. Bilateral upper extremity casts
A. Liver, fried potatoes, and avocado
B. Ham, mashed potatoes, and cream peas 90. If the arm is said to be elevated when taking the BP, it will
C. Whole milk, rice and pastry create a
D. Skim milk, lean fish, tapioca pudding A. False high reading B. False low reading
C. True false reading D. Indeterminate
80. To conduct an assessment of a possible pulse deficit
A. A nurse measures the pulse after the client exercises 91. The nurse during the health teaching in a client for
B. Two nurse check the same pulse on opposite sides of the teaching feces for occult blood informs the client about what
body can produce false positive results. What should the nurse
C. Two nurses assess the apical and radial pulses and emphasize?
determine the differences
A. If you have eaten red meat or raw radishes and melons. In B. Discard the first voiding, and save all subsequent voiding
the last couple of days, the test may be positive and it may be during 24-hour time period
inaccurate. C. Place the container on ice or refrigerator
B. If you have taken more than 250 mg of vitamin C, it may D. Have the client void at the end time, and place the
produce a reading that is too high but is inaccurate. specimen in the container
C. If you have recently eaten any colored vegetables, it may
color the stool and produce an inaccurate test result 98. A nurse is to collect a sputum specimen for C/S from a
D. If you have been drinking tea, the result might be elevated client. Which action should the nurse take first?
A. Assist with oral hygiene
92. The nurse finds a container with the client's urine B. Ask client to cough sputum into container
specimen sitting on the counter in the bathroom. The client C. Have the client take several deep breaths
states that the specimen has been sitting in the bathroom at D. Provide an appropriate specimen container
least 2 hours. What would be the nurse's most appropriate
action? 99. The physician orders a urine C/S for a 36-year old patient
A. Discard the urine and obtain a new specimen with an indwelling Foley catheter. Which of the following
B. Send the urine to the laboratory as quickly as possible action by the nurse is best?
C. Add fresh urine to the collected specimen and send the A. The nurse clamps the catheter tubing below the level of
specimen to the laboratory the port for 1 hour
D. Place the specimen in the refrigerator until it can be B. The nurse removes 20ml from the catheter bag and places
transported to the laboratory it in a sterile container
C. The nurse separates the catheter from the tubing and
93. After IVP, a renal stone was confirmed, a left allows 30ml of urine to drain into a sterile cup
nephrectomy was done. Her postop care includes daily urine D. The nurse clamps the catheter just below the insertion site
specimen to be sent to the laboratory. Imelda has a foley for 20 minutes
catheter to a urinary drainage system. How will you collect
the urine specimen? 100. The nurse collects a urine specimen for routine urinalysis
A. Remove urine from drainage tube with sterile needle and from a client. She is aware that:
syringe and empty urine from the syringe into the specimen A. A sterile specimen is required
container B. Standing at room temperature for a prolonged period may
B. Empty a sample urine from the collecting bag into the alter the urine chemistry
specimen container C. The external meatus should be cleaned with antiseptic
C. Disconnect the drainage tube from the indwelling catheter soap and water before voiding
and allow urine to flow from the catheter into the specimen D. A clean-catch, midstream specimen is required
container
D. Disconnect the drainage from the collecting bag and allow 101. Which assessment finding would be most indicative of
the urine to flow from the catheter into the specimen obstructed drainage tubing?
container A. Bladder distention B. Concentrated urine
C. Increased urge to void D. Complaint of burning
94. A patient is admitted to the hospital with complaints if
nausea, vomiting, diarrhea, and severe abdominal pain. 102. What is the priority of care after the urinary catheter is
Which of the following would immediately alert the nurse removed?
that the patient has bleeding from the GIT? A. Encourage the client to eliminate fluid intake
A. CBC B. Guaiac test B. Document size of catheter and client's tolerance of
C. Vital signs D. Abdominal girth procedure
C. Evaluate the client for normal voiding
95. A midstream urine specimen is ordered, and the nurse D. Documentation of client's teaching
teaches the client how to collect the specimen correctly.
Which of the following should the nurse include in the 103. Which priority is first when inserting an indwelling
instructions? urinary catheter?
A. Void directly into the sterile specimen container A. Aseptic technique
B. Save the first voided urine B. Instilling water into the balloon
C. Stop collecting urine after the bladder is empty C. Taping the catheter to the leg
D. Cleanse the urethral meatus after obtaining the specimen D. Inserting the catheter to the point where the urine

96. The nurse is reviewing with a client how to collect a clean 104. During an assessment, the nurse expects that the
catch urine specimen. Which sequence is appropriate average daily primary output for the adult client will be:
teaching? A. 500 to 1000ml B. 700 to 1500ml
C. 1200 to 1500ml D. 2000 to 3000ml
A. Void a little, clean the meatus, then collect specimen
B. Clean the meatus, begin the voiding, then catch urine 105. Nurse Jane evaluates a client with diagnosis of
stream dehydration to have which of the following specific gravity
C. Clean the meatus, then urinate into container reading?
D. Void continuously and catch some of the urine A. 1.000 B. 1.017 C. 1.023 D. 1.035

97. A nurse has an order to obtain 24-hour urine collection on 106. In an attempt to promote urination, the nurse first tries
a client with renal disorder. The nurse avoids which of the A. Running water nearby
following to ensure proper collection of the 24-hour urine B. Having the client lay down
specimen? C. Applying pressure over the bladder
A. Have the client void at the start time, and place the D. Administering medication to stimulate voiding
specimen in the container
107. Nurse Lian has collected a urine specimen. An expected A. Assist the client to assume lateral position
outcome of the client's urinary specimen is when the urine is B. Hold the thermometer in place for 1 minute
A. Dark yellow B. Clear and straw-colored C. Lubricate thermometer with water-soluble lubricant before
C. Showing some sediments D. Pink-tinged and slightly cloudy use
D. Instruct client to strain during insertion of the
108. Mrs. Ong, 78, reports accidental loss of urine before she thermometer
is able to reach the toilet. She is aware of the urge to void but
states, "Because of my stroke, I sometimes can't get there 117. You are to assess the temperature of the client the next
soon enough." Nurse John suspects morning and found out he is eating ice cream. How many
A. Functional incontinenceB. Stress incontinence minutes will you wait before assessing the client's oral
C. Reflex incontinence D. Urge incontinence temperature?
A. 10 minutes B. 20 minutes
109. Nurse Angie monitors an increase incidence of stress C. 30 minutes D. 15 minutes
incontinence in a client during which of the following
activities? 118. A remittent fever is described as:
A. Eating B. Sleeping A. One marked by febrile periods alternating with periods of
C. Walking D. Laughing normal body temperature
B. One in which body temperature varies over 24 hours and
110. A nurse discusses changes due to aging with a group at remains elevated
the senior citizen center. The nurse knows that which of the C. Elevated body temperature that returns to normal within
following changes in the pattern of urinary elimination 24 hours
normally occur with aging? D. Hypothermia
A. Decrease frequency B. Incontinence
C. Residual urine decreases D. Formation of bladder stone 119. A client has just had a cup of coffee and the nurse needs
to measure the body temperature. The nurse should:
111. For women who have experienced UTI, nurses need to A. Take a rectal temperature
provide instruction about ways to or prevent a recurrence. B. Take an axillary temperature
The following guidelines are useful for anyone except: C. Wait for 30 minutes before taking the temperature
A. Consuming milk and milk products D. Postpone the measurement for 5 minutes
B. Voiding immediately after intercourse
C. Taking Vitamin C 120. When inserting a rectal thermometer, the nurse
D. Taking showers rather than bath tubs encounters resistance. The nurse should
A. Apply mild pressure to advance
112. The nurse is preparing to collect a sterile urine specimen B. Ask the client to take a deep breathe
from a client who has an indwelling Foley catheter. The nurse C. Remove the thermometer immediately
clamped the catheter and returns to the client to collect the D. Remove the thermometer and re-insert it gently
specimen 30 minutes later. The correct order of priority that
the nurse should take to collect the specimen is 121. When evaluating the client's temperature level, the
1. Explain procedure to the client nurse expects the client's temperature to be lower
2. Unclamp the catheter A. In the morning B. After exercising
3. Draw urine into the syringe C. During periods of stress D. During the postoperative period
4. Insert needle into the port
5. Place urine into the specimen container 122. The nurse notes that a 2-year old child recovering from a
6. Cleanse the needle entry port tonsillectomy has a temperature of 98.2°F at 8:00am. At
7. Label the specimen according to agency protocol 10:00am, the child's mother reports that the child "feels very
warm" to touch. The first action by the nurse should be to:
A. 1,2,6,4,3,5,7 B. 1,6,4,3,5,2,7 A. Reassure the mother that this is normal
C. 1,4,6,3,5,2,7 D. 1,2,4,6,3,5,7 B. Offer the child with cold oral fluids
C. Reassess the child's temperature
113. What type of fever would the nurse document if the D. Administer the prescribed acetaminophen
client had a wide range of temperature fluctuations over
normal for a period of 24 hours? 123. When obtaining the rectal temperature, the nurse
A. Intermittent B. Remittent should insert the thermometer
C. Relapsing D. Constant A. 0.5 inch into the rectum B. 1 inch into the rectum
C. 2 inches into the rectum D. 3 inches into the rectum
114. The client with fever had been observed to experience
elevated body temperature of 39.2 by 8am, then 38.2 by 124. In assessing oral temperature, how long should the
9am, then 37 by 12nn. What type of fever is he experiencing? nurse wait prior to reading the thermometer?
A. Intermittent fever B. Remittent fever A. 5 minutes B. 2-3 minutes
C. Relapsing fever D. Constant fever C. 1 minutes D. 7-10 minutes

115. Which if the following is not an appropriate mursing 125. Skin temperature is best assessed by the nurse using the
action when taking oral temperature? A. Fingertips B. Thumb and index finger
A. Wipe thermometer from bulb to stem before C. Palms of the hand D. Dorsum of the hand
B. Take oral temperature for 3 minutes
C. Place the thermometer at lateral sublingual pouch 126. The nurse reads the medication order for Mr. Jose as
D. Normal body temperature ranges from 36.5-37.5 follows: 1000ml PNSS for 12 hours. Drop factor: 15 gtts/mL
The nurse prepares to set the flow rate at how many drops
116. Which of the following nursing actions is inappropriate per minute?
when taking the rectal temperature? A. 42 gtt/min B. 21 gtt/min
C. 16 gtt/min D. 32 gtt/min
127. The physician's order reads KCl 30 mEq to be added to A. Re-explain to the client why she cannot drink
1000ml normal saline to be administered over a 10-hour B. Offer ice chips every hour to decrease thirst
period. The label on the medication bottle reads 40 mEq KCl C. Offer the client frequent oral hygiene care
per 20ml. The nurse prepares how many ml of KCl to D. Divert the client's attention by turning on the television
administer the correct dose of the medication?
A. 10 ml B. 15 ml C. 20 ml D. 30 ml 136. The nurse has explained to a client scheduled for surgery
that he will not be able to eat or drink after midnight. The
128. The physician orders an IV dose of 400,000 units of client asks whether he can smoke after that time. Which of
penicillin G benzathine (Bicillin). The label on the 10ml the following responses by the nurse would be most
ampule sent from the pharmacy reads penicillin G benzathine appropriate?
(Bicillin), 300,000 units per milliliter. A nurse prepares how A. "Smoking is not allowed because it will make you more
much medication to administer the correct dose? thirsty"
A. 13 ml B. 10 ml C. 1.3 ml D. 1.5 ml B. "I'll check with your surgeon"
C. "You can smoke because it will suppress your appetite
129. A physician orders 3000 ml of 5% dextrose in water before surgery"
(D5W) to infuse over a 24-hour period. The drop factor is 10 D. "Smoking is not permitted because it stimulates stomach
drops per 1 ml. A nurse sets the flow rate at how many drops secretion"
per minute?
A. 24 drops per minute B. 21 drops per minute 137. The nurse is assigned to care for a group of clients. On
C. 17 drops per minute D. 15 drops per minute review of the client's medical records, the nurse determines
that which client is at risk for deficient fluid volume?
130. A client with a left leg fracture is to be taught the 3-point A. A client with a colostomy
gait before discharged. Which instruction should the nurse B. A client with congestive heart failure
give to this client? C. A client with decreased kidney function
A. Advance your right crutch, swing the left foot forward, D. A client receiving frequent wound irrigations
advance the left crutch, and then bring the right foot forward
B. Move your right crutch and left foot forward together, and 138. The nurse knows that a person who is on bland diet may
then swing the right foot and left crutch in one movement lack which essential nutrient?
C. While partially bearing weight on your left leg, advance A. Vitamin C B. Carbohydrates
both crutches and then bring your right leg forward C. Protein D. Vitamin A
D. Using one movement, advance your left foot and both
crutches and then bring your right leg forward 139. The nurse is conducting a dietary assessment on a client
who is on a vegan diet. The nurse plans to provide dietary
131. Ms. Kelly has had a CVA and has severe right-sided teaching focusing on foods high in which vitamin that may be
weakness, she has been taught to walk with a cane. The lacking in a vegan diet?
nurse is evaluating her use of the cane prior to discharge. A. Vitamin A B. Vitamin B12
Which of the following reflects correct use of the cane? C. Vitamin C D. Vitamin E
A. Holding the cane in her left hand, client moves the cane
forward first then her right leg, then finally her left leg 140. The nurse is instructing a woman in a low-fat, high-fiber
B. Holding the cane in her right hand, client moves the cane diet. Which of the following food choices, if selected by the
forward first, then her left leg, then finally her right leg client, indicate an understanding of a low-fat, high-fiber diet?
C. Holding the cane in her right hand, client moves the cane A. Tuna salad sandwich on whole wheat bread
and her right leg forward, then moves her left leg forward B. Vegetable soup made with vegetable stock, carrots, celery,
D. Holding the cane her left hand, client moves the cane and and legumes served with toasted oat bread
her left leg forward then moves her right leg forward C. Chef's salad with hard boiled eggs and fat-free dressing
D. Broiled chicken stuffed with chopped apples and walnuts
132. The nurse is assigned to a 70-lb client in skin traction.
The nurse plans care to maintain effective countertraction by 141. An eleven-month-old infant is brought to the pediatric
doing which of the following? clinic. The nurse suspects that the child has iron deficiency
A. Elevating the head of the bed anemia. Because iron-deficiency anemia is suspected, which
B. Adding weights to the existing traction of the following is the most important information to obtain
C. Placing the bed in Trendelenburg position from the infant's parents?
D. Keeping the bed flat A. Normal dietary intake
B. Relevant socio-cultural background of the family
133. In providing nursing care to a client with major head C. Any evidence of blood in the stools
trauma who is about to receive bolus enteral feeding, the D. History of maternal anemia during pregnancy
most important nursing action is to?
A. Check albumin level B. Monitor glucose levels 142. As home health nurse, you are taking an admission
C. Measure I and O D. Increase enteral feeding history for a client who has a deep vein thrombosis and is
taking warfarin (Coumadin) 2 mg daily. Which statement by
134. You would be most concerned about which client having the client is the best indicator that additional teaching about
an order for TPN fat emulsion warfarin may be needed?
A. A client with gastrointestinal obstruction A. "I have started to eat more healthy foods like green salads
B. A client with severe anorexia nervosa and fruit"
C. A client with chronic diarrhea and vomiting B. "The doctor said that it is important to avoid becoming
D. A client with a fractured femur constipated"
C. "Coumadin makes me feel a little nauseated unless I take it
135. A client who is NPO is constantly asking for a drink. with food"
Which of the following would be the most appropriate D. "I will need to have some blood testing done once or twice
nursing intervention? a week"
143. Which of the following are low-risk therapies? C. Start IV Dextrose 5% with 0.33% normal saline
1. Herbs 3. Touch 5. Relaxation D. Activate charcoal per pharmacy
2. Prayer 4. Massage 6. Acupuncture
151. The nurse prepares a client for discharge who needs
A. 1,2,3,5 B. 2,3,4,5 intermittent antibiotic infusions through a peripherally
C. 1,3,4,6 D. 2,3,4,6 inserted central catheter (PICC) line. Which should the nurse
include in client teaching about daily infusion care in the
144. A nurse is caring for an elderly Vietnamese patient in the home?
terminal stages of lung cancer. Many family members are in A. Keep the affected arm immobilized
the room around the clock performing unusual rituals and B. Aspirate 3ml of blood from the PICC line
bringing ethnic foods. Which of the following actions should C. Maintain a continuous intravenous infusion
the nurse take? D. Check the site for redness and swelling
A. Restrict visiting hours and ask the family to limit visitors to
two at a time. 152. An 85-year old male patient has been bedridden for 2
B. Notify visitors with a sign on the door that the patient is weeks. Which of the following complaints by the patient
limited to clear fluids only with no solid food allowed indicates to the nurse that he is developing a complication of
C. If possible, keep the other bed in the room unassigned to immobility?
provide privacy and comfort to the family A. Stiffness of the ankle joint B. Short term memory loss
D. Contact the physician to report the unusual rituals and C. Soreness of the gums D. Decrease appetite
activities
153. The patient who had a stroke needs to be fed. What
145. What will the nurse encourage a client, who has had a instruction should you give to the nursing assistant who will
modified right mastectomy, to do which is appropriate as feed the patient?
initial therapy 24 hours after surgery? A. Position the patient sitting up in bed before you feed her
A. Self-feeding and hair combing B. Check the patient's gag and swallowing reflexes
B. Passive/active flexion and extension of the elbow and C. Feed the patient quickly because there are 3 more waiting
pronation and supination of the wrist D. Suction the patient secretions between bites of food
C. Abduction and external rotation of the right shoulder
D. Early ambulation and active extension and flexion of the 154. Which action by the healthcare worker indicates a need
elbow for further teaching?
A. The nursing aide wears gloves while giving the client a bath
146. On turning a client who has had a right modified B. The nurse wears gloves while drawing blood from the
mastectomy to her left side, the nurse notes a moderately client
large amount of serosanguinous drainage on the bedsheet, C. The doctor washes his hands before examining the client
the nurse should D. The nurse wears gloves to take the client's vital signs
A. Remove the dressing to ascertain the origin of the bleeding
B. Milk the hemovac tubing using a downward motion 155. Which of the following techniques is correct for
C. Note vital signs, reinforce the dressing, and notify the obtaining a wound culture specimen from a surgical site?
surgeon immediately A. Thoroughly irrigate the wound before collecting the
D. Recognize that this is a frequent occurrence with this type specimen
of surgery B. Use a sterile swab and wipe the crusty area around the
outside of the wound
147. Which of the following factors should be the primary C. Gently roll a sterile swab from the center of the wound
focus of nursing management in a patient with acute outward to collect drainage
pancreatitis? D. Use a sterile swab to collect drainage from the dressing
A. Nutrition management balance C. Fluid and electrolyte
B. Pain control management D. Hypoglycemia 156. Under which circumstance may a nurse communicate
medical information without the client's consent?
148. A 50-year old blind and deaf patient has been admitted A. When certifying the client's absent from work
to your floor. As the charge nurse, your primary responsibility B. When requested by the client's family
for this patient is? C. When treating client's public safety who have a sexually
A. Let others know about the patient's deficits transmitted disease (STD)
B. Communicate with your supervisor your patient's safety D. When ordered by another physician
concerns
C. Continuously update the patient on the social environment 157. The nurse has emptied a Jackson Pratt wound drainage
D. Provide a secure environment for the patient device and needs to reestablish suction to the tube. Which of
the following actions should the nurse take to accomplish this
149. Nurse Jinky is assessing a client with heart failure. To objective?
assess hepatojugular reflux, the nurse should A. Ensure the tubing has no kinks
A. Elevate the client's head to 90° B. Squeeze the collection chamber
B. Press the right upper abdomen C. Wipe the port with alcohol
C. Press the left upper abdomen D. Close the cap on the device
D. Lie the client flat in bed
158. A patient with Parkinson's disease has a nursing
150. A child who ingested 15 maximum strength diagnosis of Impaired Physical Mobility related to
acetaminophen tablets 45 minutes ago is seen in the neuromuscular impairment. You observe a nursing assistant
emergency department. Which of these orders should the performing all of these actions. For which action must you
nurse do first? intervene?
A. Gastric lavage prn A. The NA assist the patient to ambulate to the bathroom and
B. Acetylcysteine (Mucomyst) for age per pharmacy back to bed
B. The NA reminds the patient not to look at his feet when he from the roof. Which of the following methods to open the
is walking airway would be most appropriate?
C. The NA performs the patient's complete bath and oral care A. Jaw-thrust method B. Chest to cheek method
D. The NA sets up the patient's tray and encourages patient C. Head tilt chin lift technique D. Chin to sternum method
to feed himself
167. The nurse is preparing to start an IV infusion. Before
159. You have suffered a needle stick injury after giving a inserting the needle into a vein, the nurse would apply a
patient an IM injection, but you have no information about tourniquet to the client's arm to accomplish which of the
the client's HIV status. What is the most appropriate method following?
for obtaining this information about the patient? A. Distend the vein B. Stabilize vein
A. You should ask the patient to authorize HIV testing as soon C. Occlude arterial circulation D. Immobilize the arm
as possible
B. The nurse manager for the unit is responsible for obtaining 168. A 7-year old child is clutching his throat and cannot talk.
the information. Which of the following should the nurse do?
C. The occupational health nurse should discuss HIV status A. Call for help and administer oxygen
with the patient B. Perform Heimlich maneuver
D. HIV testing should be done the next time blood is drawn C. Start CPR
for other tests D. Open windows for ventilation

160. Dina sustained a fracture of the ulna and a cast will be 169. The nurse is instructing the client about the prevention
applied. What nursing action before cast application is most of carbon monoxide poisoning. Which of the following
important for nurse Roque to do? statements from the client indicates that more teaching is
A. Use baby powder to reduce irritation under the cast needed?
B. Assess sensation of each arm A. "A high concentration of carbon monoxide can cause
C. Evaluate skin temperature in the area death"
D. Check radial pulses bilaterally and compare B. "I can detect the presence of carbon monoxide by strong
odor"
161. When performing external cardiac compression, the C. "I can purchase a carbon monoxide detector for my home"
nurse should exert downward vertical pressure by placing: D. "I should inspect my carbon monoxide detector annually"
A. The fleshy part of a clenched fist on the lower sternum
B. The heels of each hand side by side, extending the fingers 170. Which of the following classes of medication protects
over the chest the ischemic myocardium by blocking sympathetic nerve
C. The fingers of 1 hand on the sternum and the fingers of the stimulation?
other hand on top of them A. Beta-adrenergic blockers B. CCB
D. The heel of one hand on the sternum and the heel of the C. Narcotics D. Nitrates
other on top of it, interlocking the fingers
171. You are caring for Conrad who has a brain tumor and
162. A client receiving chemotherapy is experiencing a low increased ICP. Which intervention should you include in your
white blood cell (WBC) count. The nurse should teach the plan to reduce ICP?
client to avoid contact with which of the following family A. Administer bowel softener
members? B. Position Conrad with his head turned toward the side of
A. 34-year old nephew with HIV infection the tumor
B. 9-year old grandchild recently exposed to chickenpox C. Provide sensory stimulation
C. 68-year old husband with a history of tuberculosis D. Encourage coughing and deep breathing
D. 31-year-old daughter who is 4 months pregnant
172. Which of the following drugs is most commonly used to
163. The client with cystitis has a routine urinalysis (UA) done. treat cardiogenic shock?
Pyuria is noted on the report, which means the urine has: A. Dopamine (inotropin) B. Enalapril (Vasotec)
A. Serosanguinous discharges C. Blood clots C. Furosemide (Lasix) D. Metoprolol (Lopressor)
B. Mucus and white blood cells D. Creatinine
173. The doctor has ordered furosemide (lasix) 80mg IV push
164. Which of the following clients would qualify for hospice over 5 minutes. The nurse should give priority to the:
care? A. Assessment of the client's output
A. A client with metastatic cancer B. Assessment of the client's BP
B. A client with left-sided paralysis after a stroke C. Assessment of the client's RR
C. A client who had coronary artery bypass surgery 1 week D. Assessment of the client's neuro signs
ago
D. A client who is undergoing treatment for heroin addiction 174. A 6 month old is being treated for thrush with Nystatin
(mycostatin) oral suspension. The nurse should administer
165. When caring for a dying client, you will perform which of the medication by:
the following activities? A. Placing it in a small amount of applesauce
A. Encourage the client to reach optimal health B. Using cotton tipped swab
B. Assist client perform activities of daily living C. Adding it to the infant's formula
C. Assist the client towards a peaceful death D. Placing it in 2-3 oz of water
D. Motivate client to gain independence
175. The physician has prescribed iron dextran (imferon) for a
166. A nurse finds a bedridden client unresponsive and is client with severe anemia. The nurse should administer the
preparing to open the client's airway. On assessment, the medication:
bystanders told the ER department that the patient has fallen A. Orally in orange juice B. Orally in milk
C. Subcutaneous injection D. Intramuscular Z-track injection
176. The physician has ordered cortisporin ear drops for a 2 D. The nasal cannula positioned below the nares
year old. To administer the ear drops, the nurse should:
A. Pull the ear straight out B. Pull the ear up and back 186. An unexpected outcome of oxygen use is:
C. Pull the ear down and back D. Leave the ear undisturbed A. Decrease anxiety B. An increased pulse rate
C. A decreased RR D. An increased LOC
177. Which of these findings indicate that a pump to deliver a
basal rate of 10ml per hour plus PRN for pain break through 187. The proper technique to use for administering oxygen to
for morphine drip is not working? a client with an artificial airway is:
A. The client complains of discomfort at the IV insertion site A. Applying sterile gloves
B. The client states "I just can't get relief from my pain" B. Leaving fluid in the tubing
C. The level of drug is 100ml at 8am and is 80ml at noon C. Attaching the T tube to the humidified oxygen source
D. The level of the drug is 100ml at 8am and is 50ml at noon D. Monitoring the response to the oxygen with hourly ABG
levels
178. When teaching a client with CAD about nutrition, the
nurse should emphasize 188. Nurse Nikka is teaching a client on how to properly use
A. Eating 3 balanced meals a day an incentive spirometry to a client. Teaching is effective if
B. Adding complex carbohydrates which of the following sequence is onserved:
C. Avoiding very heavy meals A. The client holds the spirometry upright position, exhales
D. Limiting sodium to 7gms per day normally, seal the lips tightly around the mouthpiece, takes a
slow deep breath for 2 seconds to keep the balls elevated
179. A client has been newly diagnosed with hypothyroidism B. Exhales normally, hold the spirometer upright, seals the
and will take le evothyroxin (Synthroid) 50mcg/day by mouth. mouthpiece, takes a fast shallow breath and holds breath for
As part of the teaching plan, the nurse emphasizes that this 5 seconds to keep the balls elevated
mediaction: C. Holding the spirometer above the head, seal the
A. Should be taken in the morning mouthpiece, and exhaling slowly for 3 seconds
B. May decrease the client's energy level D. Holding the spirometer above the head, seal the
C. Must be stored in a dark container mouthpiece around the lips, and holding breath for a while
D. Will decrease the client's heart rate
189. The following nursing interventions are appropriate for a
180. You attached a pulse oximeter to the client. You know nursing diagnosis of Ineffective Airway Clearance related to
that the purpose is to: obesity, EXCEPT?
A. Determine if the client's hemoglobin is low and if he needs A. Diversional Activity
BT B. Start weight reduction
B. Check level of client's tissue perfusion C. Place patient in High Fowler's position
C. Measure the efficacy of the client's anti-HPN medications D. Have a client cough and deep breath every 2 hours while
D. Detect O2 sat of arterial blood before a Sx of hypoxemia awake
develops
190. The primary reason in teaching pursed-lip breathing to
181. While the client has pulse oximeter on his fingertip, you persons with emphysema is to help:
notice that the sunlight is shining on the area where the A. Promote oxygen intake
oximeter is. Your action will be to: B. Strengthen the diaphragm
A. Set and turn on the alarm of the oximeter C. Strengthen the intercostal muscles
B. Do nothing since ther is no identified problem D. Promote CO2 elimination
C. Cover the fingertip sensor with a towel or bedsheet
D. Change the location of the sensor every four hours 191. Complications associated with a tracheostomy tube
include:
182. A nurse informs a client that the alarm in the pulse A. Decreased Cardiac output C. Pneumothorax
oximeter will not sound when: B. Damage to the laryngeal nerve D. RDS
A. The client moves the probe
B. The probe falls off 192. A priority goal for the hospitalized client with a new
C. The SpO2 falls below the set limit tracheostomy would be to:
D. The display reaches full strength during each cardiac cycle A. Decreased secretions
B. Instruct the client in caring for the tracheostomy
183. A client with COPD has a bluish tinge around the lips. C. Relieve anxiety related to the device
Which of the following accurately describes the client's D. Maintain patent airway
condition?
A. Cyanosis B. Hypoxemia 193. A client has a tracheostomy tube. The nurse knows that
C. Hypoxia D. Dyspnea the obturator is kept at the client's bedside because:
A. The obturator is kept at the client's bedside in case the
184. For a client with COPD, a nurse anticipates the use of tube becomes dislodged and needs to be reinserted
oxygen equipment: B. The obturator is a guide in inserting the tube
A. Face tent B. Face mask C. The obturator, after insertion, will be kept by the client
C. Nasal cannula D. Nonbreathing mask D. The obturator will be used to make an opening for the
tube
185. Assessment of the proper functioning of an oxygen
device includes: 194. The nurse is cleaning the incision site and tube flange of
A. No mist in the face tent a client with tracheostomy. A sterile applicator soaked in
B. The reservoir of the rebreathing mask collapsing on what solution is used in removing crusty secretions?
inhalation A. Isopropyl alcohol
C. A flow rate between 1 and 6L/min for the nasal cannula B. Hydrogen peroxide (Full strength)
C. Hydrogen peroxide (Half-strength solution mixed with 203. Which of the following measures should the nurse
sterile normal saline) perform in relation to suctioning a tracheostomy tube?
D. Ammonia A. Apply suction while inserting the suction catheter into the
tube
195. Tracheostomy tubes used among adults often have cuffs. B. Change the tracheostomy tube after suctioning the client
This inflatable cuff functions to: C. Select a suction catheter that approximates the diameter
A. Producing an airtight seal to prevent aspiration or of the tracheostomy tube
oropharyngeal secretions and air leakage D. Hyperoxygenate before suctioning the client
B. Anchoring the tube in place
C. Distributing a low even pressure over the trachea 204. After suctioning a client's tracheostomy tube, the nurse
D. A guide for easy removal of the tracheostomy tube waits a few minutes before suctioning again. The nurse would
use intermittent suction primarily to help prevent:
196. Which of the following statements contains one of the A. Stimulating the client's cough reflex
basic rules to follow when caring for a client with a chest tube B. Depriving the client of sufficient oxygen supply
and water-seal drainage system? C. Dislocating the tracheostomy tube
A. Ensure that the air vent on the water-seal drainage system D. Obstructing the suctioning catheter with secretions
is capped when the suction is off
B. Strip the chest and drainage tubes at least every 4 hours if 205. Which method is best for the nurse to evaluate the
excessive bleeding occurs effectiveness of tracheal suctioning?
C. Ensure that the collection and suction bottles are at the A. Note subjective data such as, "My breathing is much
client's chest level at all times improved now"
D. Ensure that the collection and suction bottles are below B. Note objective findings such as decreased RR and PR
the client's chest level at all times C. Consult with respiratory therapist to determine
effectiveness
197. In an under water-seal drainage system, cessation of D. Auscultate the chest for change or clearing in adventitious
fluid fluctuation in the chest and drainage tubes generally breath sounds
means that the:
A. Lung has fully expanded 206. Organize the following steps of suctioning in
B. Lung has collapsed chronological order:
C. Chest tube is in the pleural space 1. Put on sterile glove
D. Mediastinal space has decreased 2. Lubricate catheter with normal saline
3. Apply suction for 5-10 seconds
198. The chest tube drainage of Aileen has continuous 4. Explain procedure to the client
bubbling in the water-seal drainage. After an hour, you 5. Wash hands thoroughly
notices that the bubbling stops. Which of the following A. 54132 B. 45213 C. 54123 D. 45132
condition is the possible cause of the malfunctioning sealed
drainage? 207. A nurse is performing oropharyngeal suctioning on the
A. A suction being too high B. An air leak unconscious client. Which if the following actions is safe?
C. A tube being too small D. A tension pneumothorax A. Insert the catheter approximately 20cm while applying
suction
199. While you were making endorsement, you found out the B. Allow 20 to 30 second intervals between each suction, and
chest tube of a client was disconnected. What would be your limit suctioning to a total of 15 minutes
appropriate action? C. Gently rotate the catheter while applying suction
A. Assist the client back to his bed and place him on the D. Apply suction for 5 minutes while inserting and continue
affected side for another 5 seconds before withdrawing
B. Cover the end of the test tube with sterile gauze
C. Reconnect the tube to the chest tube system 208. Applying suction in the nasopharynx for too long may
D. Put the end of the test tube into a cup of sterile normal cause secretions to increase or decrease, therefore the nurse
saline should:
A. Allow 20 to 30 second intervals between each suction, limit
200. Dr. Black Daclis asked you to assist him with the removal suctioning to 5 minutes in total
of Jeld's chest tube. You would instruct the client to: B. Allow 2 to 3 minutes between suction when possible
A. A continuously breathe normally during the normal of the C. Allow 5 minutes between each suction
chest tube D. Allow 1-2 minutes between each suction
B. Take a deep breath, exhale and bear down
C. Exhale upon the actual removal of the tube 209. The correct pressure of the wall suction unit when
D. Hold breath until the chest tube is pulled out suctioning a child patient is?
A. 95 — 100mmHg B. 50 — 95 mmHg
201. Chest tube diameter is measured or expressed in: C. 100 — 120 mmHg D. 10 — 15 mmHg
A. French B. Gauge
C. Milliliters D. Inches 210. A nurse suctioning a client through a tracheostomy tube.
The nurse plans to apply suction during the withdrawal of the
202. When transporting clients with chest tube, the system catheter for a period of time no greater than?
should be: A. 10 seconds B. 15 seconds
A. Disconnected C. 20 seconds D. 30 seconds
B. Closed
C. Placed lower than the patient's chest 211. Which if the following should the nurse include when
D. Placed between the legs of the client to prevent breakage suctioning a client's tracheostomy?
A. Instill a sterile saline down the trachea to stimulate a
cough then suction with continuous suctioning
B. Suction the client's mouth before entering the trachea A. Ann Preston B. Florence Nightingale
C. Insert the catheter until a cough reflex is obtained or until C. Jean Watson D. Linda Richards
resistance is felt
D. Adjust the wall suction to 150mmHg for the procedure 222. She viewed the person as an irreducible whole, the
whole being greater than the sum of its parts. This nursing
212. When auscultating the client's blood pressure, the nurse theory was developed by:
hears the following: From 150mmHg to 130mmHg, silence. A. Martha Rogers B. Dorothy Johnson
Then a thumping sound continuing down to 100mmHg, C. Imogene King D. Virginia Henderson
muffled sound continuing down to 80mmHg and then silence.
What is the client's BP? 223. She introduced and defined her interpersonal concepts
A. 130/80 B. 150/100 in 1952. Central to her theory is the use of a therapeutic
C. 100/80 D. 150/100 relationship between the nurse and the client
A. Hildegard Peplau B. Dorothy Johnson
213. A nurse has deflated BP cuff too fast. How will this affect C. Imogene King D. Virginia Henderson
the nurse's reading?
A. Erroneously low systolic and high diastolic reading 224. She believes that the practice of caring is central to
B. Erroneously high systolic and low diastolic reading nursing. It is a unifying focus for practice. According to this
C. Inconsistent nursing theorist, there are two major assumptions that
D. NOTA underlie human care (Carative factors):
A. Hildegard Peplau B. Dorothy Johnson
214. When assessing the pulse of a client on digitalis, what C. Dorothea Orem D. Jean Watson
rate would the nurse expect as compared with the pulse prior
to starting digitalis? 225. Her nursing concept focuses on the individual as a
A. It would be doubled B. It would be slightly higher biophysical adaptive system, this nursing concept refers to
C. It would not change D. It would decrease the concept of?
A. Imogene King B. Jean Watson
215. Prior to evaluating the client's respiration, the nurse is C. Dorothy Johnson D. Sister Callista Roy
aware of factors that affect respirations. What are these
factors? 226. Considered as "Florence Nightingle" of Iloilo?
1. Pain 3. Fear 5. Pneumothorax A. Jessica Daclis B. Anastacia Giron Tupas
2. Sleep 4. Coma 6. Acid-Base Imbalance C. Loreto Tupaz D. Rodenie Olete
A. 123 B. 456 C. All except 5 D. AOTA
227. Founder of Philippine Nurses Association (PNA)
216. A nurse documents deep respirations on the client's A. Benjamin O. Daclis B. Anastacia Giron Tupas
record. Which criteria were most likely assessed? C. Loreto Tupaz D. Aileen Daclis
A. A large amount of air inhaled and a small amount exhaled
B. A large amount of air inhaled and a large amount exhaled 228. Self-care Deficit Theory was developed by:
C. A small amount of air inhaled and a small amount exhaled A. Dorothy Johnson B. Dorothea Orem
D. A small amount of air inhaled and a large amount exhaled C. Betty Neuman D. Sister Callista Roy

217. Mr. K, age 13 is diagnosed with chronic bronchitis. He is 229. The human becoming theory discusses quality of life
very dyspneic and must sit up to breath. An abnormal from each person's own perspective as the goal of nursing
condition in which there is discomfort in breathing in any practice. The proponent of this theory is:
lying position is A. Rosemarie Parse B. Faye Abdellah
A. Cheyne-stokes B. Orthopnea C. Madeleine Leininger D. Linda Richards
C. Eupnea D. Dyspnea
230. A theorist whose major theme is the idea of
218. Which technique is the best for assessing the respiration transcultural nursing and caring nursing is:
of a 3-year old? A. Dorothea Orem B. Madeleine Leininger
A. Use a stethoscope and auscultate the lungs C. Sister Callista Roy D. Virginia Henderson
B. Place one hand against the chest when counting
C. Observe the rise and fall of the abdomen 231. A 46-year old female is admitted to the hospital with a
D. Tell the child you will check his breathing diagnosis of renal calculi kidney stones. She is experiencing
severe flank pain and complains of nausea. Her temperature
219. The client's meal is composed of 83 grams of CHO, 27 is 37.9°C. The immediate nursing goal should be to
grams of fats, and 45 grams of protein. What is the total A. Prevent urinary tract complications
kcalories? B. Alleviate nausea
A. 745 kcal B. 845 kcal C. Alleviate pain
C. 855 kcal D. 755 kcal D. Maintain F and E balance

220. Documentation of a client with Kaussmaul's breathing is 232. A priority nursing diagnosis for the client who
made when the nurse assesses? experiences wound dehiscence postop after an abdominal
A. Very slow respirations hysterectomy would be
B. Abnormally but deep respirations A. High risk for infection
C. Abnormally slow and irregular respirations B. FVE
D. Irregular periods of apnea and hyperventilation C. Ineffective airway clearance
D. Altered nutrition less than body requirements
221. The person who is considered the founder of modern
nursing and who established the theoretical base for nursing 233. Body image is defined as
is: A. The way a person looks and the style of clothing he wears
B. The way the body functions and looks at a certain age C. Potential for altered nutrition: Less than body
C. The way a person perceives his appearance and function, requirements as evidenced by 15-lb weight loss in 3 weeks
and how he compares himself to others D. Potential for self-esteem disturbance r/t change in body
D. A body of normal weight and height in which all body parts image
are present
242. An 80-year old client is in the Emergency Department.
234. A client is having diarrhea and vomiting, the priority The client complains of diarrhea and vomiting for the past
nursing diagnosis is: two days. In assessing the client, you note that his skin is dry
A. Altered nutrition less than body requirements r/t vomiting and can be tented. He has lost eight pounds. Which NANDA
and diarrhea diagnosis would be most appropriate to use with this client in
B. F and E imbalance r/t vomiting and diarrhea making his plan of care?
C. Altered elimination pattern r/t diarrhea A. Risk for deficient fluid volume r/t prolonged diarrhea and
D. FVE r/t increased intake of ORT vomiting
B. Risk for fluid volume excess r/t prolonged diarrhea and
235. Which of the following statements regarding the nursing vomiting
process is true? C. Risk for normal fluid volume r/t prolonged diarrhea and
A. It is useful mainly in outpatient settings vomiting
B. It focuses on the patient, not the nurse D. Risk for hidden fluid r/t prolonged diarrhea and vomiting
C. It progresses in separate, unrelated steps
D. It provides the solution to all patient health problems 243. A client who is having a mastectomy expresses sadness
about losing her breast. The most appropriate nursing
236. The nurse performs a neurologic exam on a patient. diagnosis is
After the exam, which of the following should be recorded as A. Ineffective Individual Coping B. Anticipatory Grieving
objective data? C. Knowledge Deficit D. Fear
A. +4 patellar reflexes in both of the patient's legs
B. Patient's description of ringing in his ears 244. Which of the following nurses is a competent
C. Patient's sensations of numbness in his right arm practitioner according to Benner?
D. Patient's statement, "The room is spinning" A. The nurse is able to use maxims as a guide for what to
consider in a new situation and views the clients holistically
237. All of the following components may be part of a client's B. The nurse who does not require rules or guidelines in
medical record. Which one is the major source of subjective making analysis and decisions in a new situation but instead
data about the client's health status? uses intuitive and analytical skills
A. Health history B. Physical findings C. The nurse is able to coordinate the complex care demands
C. Laboratory test results D. Radiologic findings of a client who is newly admitted and the other clients in the
unit
238. Which of the following nursing diagnoses uses the PES D. The nurse who is able to recognize the meaningful aspects
format? of a situation where a client was newly diagnosed with
A. Fluid Volume Deficit r/t prolonged vomiting diabetes
B. Risk for Impaired Skin Integrity as manifested by poor skin
turgor and old age 245. A nursing student or a beginning staff nurse who has not
C. Ineffective Airway Clearance r/t infectious process as yet experienced enough real situations to make judgements
manifested by excessive mucous and retained secretions about them is in what stage of Nursing Expertise?
D. Ineffective Airway Clearance as manifested by secretions in A. Novice B. Newbie
the bronchi, presence of allergies, and airway spasm C. Advanced Beginner D. Competent

239. Using Maslow's hierarchy of basic human needs. Which 246. Benner's "Proficient" nurse level is different from the
of the following nursing diagnoses has the highest priority? other levels in nursing expertise in the context of having
A. Anxiety r/t impending surgery, as evidenced by insomnia A. The ability to organize and plan activities
B. Impaired verbal communication r/t tracheostomy, as B. Having attained an advanced level of education
evidenced by inability to speak C. A holistic understanding and perception of the client
C. Ineffective breathing pattern r/t pain, as evidenced by SOB D. Intuitive and analytic ability in new situations
D. Risk for injury r/t autoimmune dysfunction
247. The nurse performs many roles in the practice of
240. Which statement does not describe an appropriate nursing. Which role is defined as "the protection of human
guideline for writing a nursing diagnosis? legal rights and the securing of quality care for each patient?"
A. State the diagnosis in terms of a problem, not a need A. Advocate B. Communicator
B. Use medical terminology to describe the probable cause of C. Counselor D. Leader
the patient's response
C. Use nursing terminology to describe the patient's response 248. Delegation is the process of assigning tasks that can be
D. Use statements that assist in planning the independent performed by subordinate. The RN should always be
nursing interventions accountable and should not lose his accountability. Which of
the following is a role of include delegation?
241. Which of the following statements is a correctly written A. The RN must supervise all delegated tasks
ACTUAL nursing diagnosis? B. After a task has been delegated, it is no longer a
A. Impaired physical mobility as evidenced by decreases ROM responsibility of the RN
in left shoulder from 180 to 190 degrees of flexion and C. The RN is responsible and accountable for the delegated
extension r/t left shoulder pain task in adjunct with the delegate
B. Ineffective airway clearance r/t thickened bronchial D. Follow up with a delegate task necessary only if the
secretions as evidenced by adventitious lung sounds over the assistive personnel is not trustworthy
periphery of the right and left lung fields
249. An RN in charge is preparing the assignments for the 260. Which of the following is the best example of an
day. The RN assigns a nursing assistant to make beds and accurate report?
bathe one of the clients on the unit and assigns another A. The wound drained a large amount of serous drainage
nursing assistant to fill the water pitchers and to serve juice B. The client acts as though he has had little discomfort
to all the clients. Another RN is assigned to administer all C. Bowel sounds were auscultated on the right upper
medications. Based on the assignments designed by the RN in quadrant
charge, which type of nursing care is being implemented? D. The client appeared to have discomfort while ambulating
A. Functional nursing B. Team nursing
C. Exemplary model of nursing D. Primary nursing 261. The following are the general guidelines when recording
in the client's chart. Which is a correct procedure?
250. In Dunn's high-level wellness grid, a person suffering A. Recording should be done before providing nursing care
from CVA and confined in the healthcare facility falls under B. All entries on the record are made in pencil so that the
which quadrant? necessary changes can be made
A. High-level wellness in a favorable environment C. Each recording on the nurse's notes is signed by the nurse
B. Emergent high-level wellness in an unfavorable making it
environment D. Leave a blank space for a colleague to chart later
C. Protected poor health in a favorable environment
D. Poor health in an unfavorable environment 262. The nurse receives a telephone order from the physician.
Her most appropriate nursing action following a telephone
251. In the health belief model by Risenstick and Becker, order is:
individual perception matters. The following are likely to A. Copy the order in the chart and sign the physician's name
influence preventive behavior, except: as close to his original signature as possible
A. Perceived susceptibility to an illness B. Write the order in the client's chart and have another
B. Perceived seriousness of an illness nurse co-sign it
C. Perceived threat of an illness C. Tell the physician that you cannot take the telephone order
D. Perceived curability of an illness but you will call the nurse supervisor
D. Write the order and repeat the order back to the
252. The first true nursing law is also known as physician, copy onto the order sheet and indicate that it is a
A. RA 2280 B. RA 2080 C. Act 2080 D. Act 2808 telephone order

253. The first Philippine board examination for nurses held in 263. The nurse committed a mistake when writing an entry in
Manila was: the client's record. The nurse should take which action
A. 1944 B. 1923 C. 1919 D. 1920 A. Draw a line through the mistake
B. Draw a line through the mistake and write "mistaken
254. The nurse has organized an immunization clinic for entry" above it
healthy babies and preschool children. This would be an C. Draw a line through the mistake and write "mistaken
example of what level of preventive health care? entry" next to the original entry with the nurse's name or
A. Curative B. Primary C. Secondary D. Tertiary initials
D. Erase the mistaken entry using the correction fluid, write
255. A prompt intervention and treatment belongs to what the correct entry then place the name/initials and date
level of preventive health care?
A. Curative B. Primary C. Secondary D. Tertiary 264. Which of the following qualities are relevant in
documenting the care of the clients?
256. The nurse is teaching a diabetic patient how to inject 1. Accuracy and conciseness
insulin and the dosages necessary for optimal control. This 2. Legible, properly dated and signed
would be an example of what level of health care 3. Systematic and orderly
A. Curative B. Primary C. Secondary D. Tertiary 4. Thoroughness and appropriateness
5. Use of locally accepted abbreviations
257. Which of the following is an example of primary A. 2,3,4 and 5 B. 1,2,3 and 4
preventive measure? C. 1,2,3 and 5 D. 1,3,4 and 5
A. Participating in a cardiac rehabilitation program
B. Obtaining an annual physical examination 265. A client who speaks little English has emergency
C. Practicing monthly BSE gallbladder surgery. During discharge preparation, which
D. Avoiding overexposure to the sun nursing action would best help this client understand wound
care instructions?
258. An employer establishes a physical exercise area in the A. Asking frequently whether the client understands the
workplace and encourages all employees to use it. This is an instructions
example of which level of health promotion? B. Asking an interpreter to relay the instructions to the client
A. Primary prevention B. Secondary prevention C. Writing out the instructions and having a family member
C. Tertiary prevention D. Passive prevention read them to the client
D. Demonstrating the procedure and having the client return
259. Which statement reflects appropriate documentation in the demonstration
the medical record of a hospitalized client?
A. Small pressure ulcer noted on left leg 266. The nurse orients an elderly client to the safety features
B. "Client seems to be mad at the physician" in her hospital room. A vital component of this admission on
C. "Client had a good day" routine is to:
D. "Client's skin is moist and cool" A. Explain how to use the telephone
B. Introduce the client to her room mate
C. Review the hospital policy on visiting hours
D. Explain how to operate the call bell
267. A nurse received sexually oriented images sent via text Florence Nightingale have an idea of what nursing is all
in her cellular phone that really annoyed her. The message about?
came from a male co-worker in the hospital. What is the most A. Florence Nightingale school of nursing
appropriate action of the nurse? B. St. Elizabeth of Hungary Academy
A. Reply with vulgar words to let him know that you are mad C. Kaiserwerth foundation
B. Report to the NBI D. Kozier University
C. Call the police
D. Call the nursing supervisor and report the incident 5. Nurses are perceived in this generation are people who can
cater the needs of the people well and can professionally
268. A nurse calls a physician in regard to a new medication manage physical and psychological alterations of the different
order because the dosage prescribed is higher than the kinds of patient in any health care setting. However, nursing
recommended dosage. The nurse is unable to locate the history would also give us an idea that nurses long ago are
physician and the medication is due to be administered. least desirable women of the society. This existed during:
Which of the following actions would the nurse take? A. Dark period B. Intuitive period
A. Hold the medication until the physician can be contacted C. Contemporary period D. Educative period
B. Administer the dose prescribed
C. Administer the recommended dose until the physician can 6. Nursing care is continuously modified as we continue to
be located face the world of globalization. More and more
D. Contact the nursing supervisor advancements are given to uplift the lives of our patients
such as the use of laser surgeries and radiation therapies.
269. Among the clients the nurse is assigned to take care of, During this time, nursing care is based on:
who is the MOST susceptible to infection? A. Experience in giving the effectiveness of the intervention
A. An 18-year old with a surgical repair of a torn knee B. Instinctive reasoning in giving procedures
ligament C. Upgraded knowledge and skills in any health care setting
B. A 35-year old with an uncomplicated appendectomy D. Experience and trainings in the clinical area
C. A 42 year old with diabetes
D. A 72 year old with a broken hip 7. WHO defines health as a complete state of physical,
mental, emotional, and social well being and not merely the
270. When making an occupied bed, it is important for the absence of disease or infirmity. This organization was
nurse to: established during:
A. Keep the bed in the low position A. Intuitive nursing B. Educative Nursing
B. Use a bath blanket or top sheet for warmth and privacy C. Apprentice Nursing D. Contemporary Nursing
C. Constantly keep the side rails raised on both sides
D. Move back and forth from one side to the other when 8. Mang Toning, a resident of Purok Tres, is a farmer who
adjusting the linens always burn the rice stalks after harvesting them. Because of
this, many people would complain of the inhaled smoke out
1. Mr. Lim is about to take his first nursing comprehensive of the burned stalks. Nurse Rita conducted a seminar on
exam. He reviewed badly and familiarizes himself with the proper waste disposal and help Mang Toning how to dispose
nursing history. Which of the following is the chronological the stalks properly. A month later, Mang Toning buries the
sequence of how nursing started? stalks and made them as fertilizers. What role did Nurse Rita
1. Caregivers stealing food and money from their patient play in this situation?
2. Nursing practice is purely based on experience A. Manager B. Researcher
3. Laser surgeries and radiation therapies emerges C. Care Provider D. Change Agent
4. The use of white magic to combat the black magic
5. Florence Nightingale as the Mother of Modern Nursing 9. May it be any health care setting, the nurse must protect
A. 14532 B. 35124 C. 54321 D. 42153 the client from any other harm or injustices specifically
related to health because nurses should be patient-centered.
2. The history of nursing dates back from ancient were Which of the following situations best describe this
indigenous people are living with the dinosaurs making statement?
human life impossible. However, nursing is an expression of A. Nurse Melay who frequently gives jokes to her patients
helping out other people in need. Which of the following best because laughter is the best medicine
describes this scenario: B. Nurse Princess who reports to the finance department that
A. The community depends on religious ministries to receive her patient no longer pays the hospital bills and thus
food and to take good care of them discharge is prohibited
B. People would use amulets made from stones for them to C. Nurse Tom who charts the patient's vital signs always as
become immortal normal without undergoing assessment
C. Patients are left alone in the hospitals with no any other D. Nurse Patria who discusses the case of her patient to her
help coming from a health care team member nurse supervisor because the patient's physician no longer
D. Florence Nightingale helps the people in need especially follows up the patient's treatment regimen
the wounded soldiers during the Crimean war
10. The month of July is said to be the Philippine Nutrition
3. High priests are often believed as descendants of Gods. Month. It is one of the nurse's primary responsibilities to
That is why many people follow their orders and take conduct health teaching to far flung areas so as to promote
command from them. This period existed during: adequate nutrition in the people living in those areas. What
A. Intuitive nursing B. Educative nursing role of the nurse might be played if she conducts health
C. Dark ages of nursing D. Contemporary nursing teaching?
A. Leader
4. Educative period marks one of the significant events in B. Trainor
nursing history. This is made possible with the utmost C. Educator
contribution of Florence Nightingale. In what institution did D. Counselor
11. In the rural health unit, Nurse Nilo instructed the
Barangay Health Workers assigned to him to disseminate the 21. The nurse palpates the client's body to detect warmth.
information about cleaning the environment and eliminating What part of the hand should the nurse use?
vector sites to control the spread of Dengue Hemmorhagic A. Wrists of the hands B. Fingertips
Fever in the place. With this, Nurse Nilo is doing the role of a: C. Back dorsal or dorsal face D. Ulnar surface
A. Nurse Counselor B. Nurse Leader
C. Nurse Researcher D. Nurse Manager 22. During nurses' rounds, the nurse observes that the
patient's fever is fluctuating above the normal range and
12. Ms. B.A., RN is assigned to a hospice care with elderly would return to normal at the end of the day. This type of
patients to deal with. One day while doing her rounds, Lola fever is known as:
Trining verbalizes her problems and asks the nurse for advice. A. Relapsing B. Constant
What role could probably Ms. B.A. Portray to effectively C. Intermittent D. Remittent
manage Lola Trining's problem?
A. Dietician B. Penetrator 23. Nurse Bryan is observing a dying patient's breathing
C. Counselor D. Educator pattern. He notices that the patient's respiration goes faster
and faster until it reaches a period of apneic episodes. What
13. After attending a seminar on Proper Handling of Labor breathing pattern is this?
and Delivery, Aling Munding, one of the traditional birth A. Kussmaul's respiration B. Biot's respiration
attendants was able to deliver a healthy baby boy in the C. Cheyne stokes respiration D. Apneustic respiration
house of Mrs. Mino. A day after the delivery, the community
health nurse follows up and carefully assesses the well being 24. The ICU nurse observes that the pulsation of the patient
of the baby. The role being performed is: upon auscultation is loud enough to be heard and further
A. Researcher B. Teacher assessment would reveal that the patient has full pulsation.
C. Communicator D. Leader Therefore, the nurse would score the patient's pulse
amplitude as:
14. The first nursing board exam happened in Luzon in what A. 1 B. 2 C. 3 D. 4
year?
A. 1946 B. 1920 C. 1933 D. 2006 25. Mrs. Amanda, 50 yearsmold, is having her menopause
and would complain feeling warm at a certain time of the
15. Nursing was able to become institutionalized here in the day. Nurse Cindy would manage this situation by increasing
Philippines through the establishment of nursing schools and the rate of electric fan from slower to a faster one. What type
colleges. Who established nursing as profession in the of heat loss does it involve?
Philippines? A. Radiation B. Conduction
A. Julita Sotejo B. Conchita Tan C. Convection D. Evaporation
C. Anastacia Giron Tupaz D. Cesaria Ruiz
26. Baby Mara, 6 days old, has a fast breathing of 70 breaths
16. The first college of nursing in the Philippines was made per minute. As a nurse, you know that this is termed as:
possible in the year 1946 by what school? A. Tachypnea B. Bradypnea
A. Pamantasan ng Lungsod ng Maynila C. UP in the Visayas C. Dyspnea D. Apnea
B. Centro Escolar University D. UST
27. The student nurse is about to enter the room of the
17. Donna, a high school graduate, wanted to enroll herself in patient and was instructed to take the BP of the patient. His
one of the earliest schools of nursing so she can have a better clinical instructor asked him what pulse is commonly used in
background of what nursing in the Philippines is all about. As BP taking. The appropriate answer would be:
a nirse, you know that the following options below are A. Apical pulse B. Radial pulse
nursing schools except: C. Carotid pulse D. Brachial pulse
A. PGH School of Nursing
B. Manila Central University 28. In the following situations, the nurse would expect
C. Iloilo Mission Hospital School of Nursing sympathetic nervous system stimulation except:
D. St. Paul's Manila A. The patient is pacing along the highway and is very
talkative
18. Filipino nurses also made an organized system in terms of B. A mother watching a television and would react to the
the Philippines' Health Care Delivery System. This significant villain of the teleserye
achievement was able to materialize in the person of Socorro C. A cheer leader who failed to win the contest and does not
Diaz because she is the first editor of the PNA magazine want to go to school anymore
entitled: D. A muscle man who wanted to do several exercises
A. Notes on Nursing B. Notes on Hospital everyday
C. The Message D. The Filipino Nurse
29. Miko, the youngest child of the family, was brought to the
19. The ER nurse is assessing the patient who is moaning and hospital because of Bell's Palsy. The nurse knows that she
calling for help. The patient is bleeding profusely in the ER. should avoid what route in taking the body temperature?
The nurse might expect that the blood pressure of the patient A. Tympanic B. Oral C. Rectal D. Axilla
will:
A. Remarkably increase B. Drastically decrease 30. After getting the BP of his patient, Nurse Anthony
C. Cannot be determined D. Return to normal determines the pulse pressure of the patient. He knows that
the result is within normal range if it is:
20. What specific organ of the brain that regulates the A. 30-40 mmHg B. 120/80 mmHg
balance between heat production and heat loss? C. 80/40 mmHg D. Less than 15 mmHg
A. Cerebellum B. Cerebrum
C. Medulla oblongata D. Hypothalamus
31. In the following situations, which nurse is demonstrating A. Imbalanced Nutrition: More than body requirements
the assessment phase of the nursing process? related to nutrient deficiency
B. Ineffective individual coping
A. The nurse who observes that the client's pain was relieved C. Chronic pain related to immobility
with pain medication D. Risk for infection related to an open wound
B. The nurse who changes the bed linens after the client is
incontinent of feces 40. Which of the following diagnosis is stated as a potential
C. The nurse who asks the client how much lunch was eaten health problem?
D. The nurse who works with the client to set desired A. Anxiety C. Sleep pattern disturbance
outcome goals B. Risk for Injury D. Ineffective individual coping

32. Before palpating the abdomen during an assessment, the 41. A nursing diagnosis focuses on:
nurse should do which of the following? A. The Pathophysiology of the client's disease
A. Elevate the client's head B. Put on sterile gloves B. Determining the baseline data
C. Auscultate bowel sounds D. Percuss all four C. The client's ability to react or adjust when health is
quadrants compromised
D. Describing the physician's actions to manage the problem
33. The nurse would document which if the following in the
medical record as objective data obtained during the client 42. The most important benefit of the nursing process for the
assessment? clients is that it:
A. Detailed description of pain in the extremity A. Gives additional salaries to the nurses
B. Complaint of numbness in the right hand B. Entails nurses for a promotion in the position
C. Loss of hair on bilateral lower legs C. Offers praises to patients
D. Report of scalp itching each evening D. Helps ensure quality care that meets individual needs

34. When the nurse sets goals for 35-year-old Aling Aning in a 43. Which of the following steps is under the planning phase
care plan addressing Aling Aning nutritional problems, who is of the nursing process?
the most important person with whom the nurse should A. Comparing data against standards
collaborate? B. Performing nursing interventions
A. Aling Aning B. The dietician C. Selection of Nursing Interventions
C. Aling Aning's physician D. The pharmacist D. Identify the problem

35. All of the following would be considered objective 44. Twenty minutes after administering a pain medication to
assessment data for a patient admitted with diabetes the client, the nurse returns to ask if the client's level of pain
mellitus, except: has decreased. The nurse is engaging in which phase of the
A. +2 urine glucose level nursing process?
B. Chemstrip reading of 240 mg/dL A. Diagnosis B. Planning
C. Patient complains of polydipsia C. Implementing D. Evaluating
D. Serum glucose level of 263 mg/dL
45. A nurse who is taking care of the patient with severe
36. According to NANDA, Diagnosis is defined as the clinical dehydration due to LBM decides to first provide the patient
judgment about the individual, family or community with liquids and juices and give health instruction on
regarding their responses to actual or potential nursing sanitation and hygiene. The nurse doing these activities is
problems. What format do you use in formulating diagnostic performing what element in the nursing process?
statements? A. Implementation B. Evaluation
A. Etiology, Disease Process, Laboratories C. Planning D. Assessment
B. Assessment, Causative Agent, Signs and Symptoms
C. Problem, "Related to", Manifestations 46. You are assigned to Mrs. Ambrosio, age 49, who was
D. Problem, Etiology, Signs and Symptoms admitted for possible surgery. She complained of recurrent
pain at the right upper quadrant of the abdomen 1-2 hours
37. The nurse documents the following outcome goal on the after ingestion of fatty food. She also had frequent bouts of
care plan: "Anxiety will be relieved within 20-40 minutes dizziness, BP of 170/100, hot flashes. Which of the above
following administration of Lorazepam (Ativan)." The nurses symptoms would be an objective cue?
have just performed an activity in which of the following A. BP measurement of 170/100
phases of the nursing process? B. Complaint of hot flashes
A. Assessment B. Planning C. Report of pain after ingestion of fatty foods
C. Implementation D. Evaluation D. Complaint of frequent bouts of dizziness

38. An 82-year old man with Alzheimer's lives with his 47. The final phase of nursing process is evaluation. Lumen, a
daughter and her family. The client has become progressively nurse, is aware that the primary reason for this phase is to:
debilitated, needing constant supervision. After wandering A. To establish observable cues from the patient
out of the house at night several times, the family is B. To develop an analysis base on assessment
reluctantly considering placing the client in a residential care C. Determine if the expected patient outcomes were
center. An appropriate nursing diagnosis: accomplished
A. Neglect B. Hopelessness D. Evaluate the nurse's efficiency and knowledge in treating a
C. Caregiver role strain D. Depression particular patient

39. A nurse is caring for an obese 62 year old patient with 48. Revision of the nursing care plan is being done if the
arthritis who has developed an open reddened area over his intervention is not effective for our client. What phase of the
sacrum. A priority nursing diagnosis is:
nursing process serves as the basis for revising the nursing 32. B. Basic needs like food, shelter, and clothing
care plan? 33. D. Self-actualization
A. Planning B. Evaluation 34. D. Avoidable
C. Assessment D. Implementation 35. C. Neck
36. B. Fowler's
49. In CHN, despite the availability and use of many 37. C. Good oral hygiene is needed including brushing and
equipment and devices to facilitate the job of the community flossing
health nurse, the best tool any nurse should be well-prepared s/e: gingival hylerplasia
to apply is a scientific approach. This approach ensures 38. D. Acceptance
quality of care even at the community setting. This nursing 39. B. Push the call light to see if the client is able to activate
parlance is nothing less than the: it when needed
A. Nursing research B. Nursing protocol 40. C. Instruct client to increase fluid intake
C. Nursing process D. Nursing diagnosis 41. B. Minimize cigarette smoking
AVOID cigarette smoking, not minimize
50. The nurse knows that the guidelines for writing an 42. D. Support the patient's joints when turning and removing
appropriate nursing diagnosis include all of the following 43. C. Keep the stethoscope used for the client in the room
EXCEPT: 44. D. Limit the noise and schedule history taking tomorrow
A. State the diagnosis in terms of a problem, not a need 45. C. Oral medication administration
B. Use nursing terminology to describe the patient's response 46. C. Check the identification on the patient's wrist
C. Use statements that assist in planning independent nursing Wrist band, then ask patient's name.
interventions 47. D. Both you and the physician are responsible for your
D. Use medical terminology to describe the probable cause of respected actions
the patient's responses Principle of Respondeat superior.
48. D. Safety and security
49. D. RR
ANSWER AND RATIONALE ABCPainFever
1. D. Clamp the catheter for 30 minutes 50. A. Allow the client to express himself or herself and ask
2. B. Sterile container questions
3. C. Cytology exam 51. D. Having the client tilt the head toward the chest while
4. A. Guava jam inserting the tube in the nose
5. D. Yellow 52. A. Administration of a liquid feeding into the stomach
6. D. Both A and C 53. B. To take and hold a deep breath
7. A. Instruct the patient to hack up sputum 54. C. 314256
8. B. Along the y-port 55. A. When confirming tube placement, place the tube's end
9. D. Within 3 days as instructed in a container of water
10. B. 24 hour urine collection 56. B. Hold the tube feeding and notify the provider
11. A. Lateral position 57. B. Have the client mouth-breath
12. B. Provide food that the client likes and relieve Sx of 58. C. High-fowler's position
illness 59. D. A "whoosing" sound is auscultated when 10mL of air is
13. B. Use-hard bristled tooth brush inserted
14. C. Toast bread with banana jam B is vague. The pH should be accurately measured.
BRAT diet 60. B. Gurgling sound at epigastric region
15. C. The chart is a legal document 61. D. Liquid vitamin preparations
16. D. The nurse bends from the knees when she reaches out 62. B. Absent bowel sounds
the patient's back and feet apart is maintained to Indicates non-functional GIT, thus, making NGT useless.
promote stability 63. B. Hypoglycemia
17. B. Validate your finding 64. C. Semi-fowler's position
18. C. Use a non-threatening and non-judgmental attitude 65. C. Amino acids
19. A. Physical, Psychosocial, and Spiritual well-being D is only an emergency bedside solution in case TPN is
It is holistic. stopped abruptly.
20. C. Determine client's normal bedtime ritual 66. A. Aspirating with a syringe and checking pH of gastric
Assess first. ADPIE technique contents
21. D. I will ask your daughter's doctor to write an order so I C is an old method. D is correct but A is more
can give this medication to her. confirmative.
22. C. Auscultate the breath sounds Sequence:
23. D. Ask the client what learning needs he or she has about X-ray
current state of health pH
24. C. Nutrix Auscultation
25. D. An artistic way of helping other people with the use of 67. B. Aspirate for the residual volume and re-instill it
scientific explanations NOTE: Do not give next feeding if residual volume is
26. B. Acolic stool greater then 50%
A and B are correct. However, B is more confirmative 68. C. Advance the tube while the client swallows
because steatorrhea may not happen as there are still 69. B. Trendelenburg
pancreatic enzymes to digest fats. 70. A. Chicken and orange slices
27. C. Urgency 71. B. Corn beef and cabbage and boiled potatoes
28. D. Bring Rina to the CR and open a faucet in order to 72. D. Daily weight
produce a sound 73. C. Fats
29.D. V/S before, during and after the activity 74. B. Provide foods that have a soft consistency
30. A. 3, 2, 4, 5, 6, 1 75. C. Gelatin, hard candy, tea, popsicles
31. A. Active Assistive Range of Motion 76. C. White chicken sandwich, vegetable salad and tea
77. B. 28.74 Lowest temp: 4-6 am
78. B. Overweight Highest temp: 4-6 pm
79. D. Skim milk, lean fish, tapioca pudding 122. C. Reassess the child's temperature
80. C. Two nurses assess the apical and radial pulses and 123. B. 1 inch into the rectum
determine the differences 124. C. 1 minutes
81. D. Subtract diastolic from systolic 125. D. Dorsum of the hand
82. C. Use the thumb to palpate the artery 126. B. 21 gtt/min
83. A. LMCL, 5 ICS 127. B. 15 ml
84. D. The middle three fingers 128. C. 1.3 ml
85. B. Brachial 129. B. 21 drops per minute
86. B. 16 respiration per minute for an 8 year old client 130. C. While partially bearing weight on your left leg,
NORMAL RR: advance both crutches and then bring your right leg
Adult: 12 - 20 forward
Child: 20-30 131. A. Holding the cane in her left hand, client moves the
Infant: 30-60 cane forward first then her right leg, then finally her
87. B. 1-2 minutes left leg
88. A and D 132. C. Placing the bed in Trendelenburg position
89. D. Bilateral upper extremity cast Body serves as countertraction
90. B. False low reading 133. C. Measure I and O
91. A. If you have eaten red meat or raw radishes and 134. D. A client with a fractured femur
melons. In the last couple of days, the test may be Risk for fat embolism
positive and it may be inaccurate. 135. C. Offer the client frequent oral hygiene care
92. A. Discard the urine and obtain a new specimen 136. D. "Smoking is not permitted because it stimulates
Collected urine should be transported within 30 stomach secretion"
minutes to 1 hour. 137. A. A client with a colostomy
93. A. Remove urine from drainage tube with sterile needle 138. A. Vitamin C
and syringe and empty urine from the syringe into the 139. B. Vitamin B12
specimen container It is usually found in meat and meat products.
94. B. Guaiac test 140. B. Vegetable soup made with vegetable stock, carrots,
95. D. Cleanse the urethral meatus after obtaining the celery, and legumes served with toasted oat bread
specimen 141. A. Normal dietary intake
Clean, Void, Collect, Void, Clean 142. A. "I have started to eat more healthy foods like green
96. B. Clean the meatus, begin the voiding, then catch urine salads and fruit"
stream They are rich in Vitamin K. Vitamin K impairs
97. A. Have the client void at the start time, and place the anticoaguability of warfarin.
specimen in the container 143. B. 2,3,4,5
98. A. Assist with oral hygiene 144. C. If possible, keep the other bed in the room unassigned
99. A. The nurse clamps the catheter tubing below the level to provide privacy and comfort to the family
of the port for 1 hour 145. B. Passive/active flexion and extension of the elbow and
100. B. Standing at room temperature for a prolonged period pronation and supination of the wrist
may alter the urine chemistry Less pain after surgery
A and D can be done, but not necessarily required. 146. C. Note vital signs, reinforce the dressing, and notify the
C is incorrect. Water is only used to wash, as surgeon immediately
antiseptic soap may alter urine chemistry. 147. C. Fluid and electrolyte
101. A. Bladder distention 148. D. Provide a secure environment for the patient
102. C. Evaluate the client for normal voiding 149. D. Lie the client flat in bed
103. A. Aseptic technique To distend jugular vein.
104. B. 700 to 1500ml 150. A. Gastric lavage prn
Normal output per hour: 30ml 151. D. Check the site for redness and swelling
30ml x 24 = 720ml 152. A. Stiffness of the ankle joint
105. D. 1.035 153. A. Position the patient sitting up in bed before you feed
106A. Running water nearby her
107. B. Clear and straw-colored 154. D. The nurse wears gloves to take the client's vital signs
108. A. Functional incontinence 155. C. Gently roll a sterile swab from the center of the
109. D. Laughing wound outward to collect drainage
110. B. Incontinence 156. C. When treating client's public safety who have a
111. A. Consuming milk and milk productsMilk and milk sexually transmitted disease (STD)
products are alkaline in nature. Public safety is the PRIORITY
112. B. 1,6,4,3,5,2,7 157. B. Squeeze the collection chamber
113. B. Remittent 158. C. The NA performs the patient's complete bath and oral
114. A. Intermittent fever care
115. B. Take oral temperature for 3 minutes Nurses should promote independence.
116. D. Instruct client to strain during insertion of the 159. C. The occupational health nurse should discuss HIV
thermometer status with the patient
117. C. 30 minutes 160. D. Check radial pulses bilaterally and compare
118. B. One in which body temperature varies over 24 hours 161. D. The heel of one hand on the sternum and the heel of
and remains elevated the other on top of it, interlocking the fingers
119. C. Wait for 30 minutes before taking the temperature 162. B. 9-year old grandchild recently exposed to chickenpox
120. C. Remove the thermometer immediately 163. B. Mucus and white blood cells
121. A. In the morning 164. A. A client with metastatic cancer
165. C. Assist the client towards a peaceful death 205. D. Auscultate the chest for change or clearing in
166. A. Jaw-thrust method adventitious breath sounds
167. A. Distend the vein 206. C. 54123
168. B. Perform Heimlich maneuver 207. C. Gently rotate the catheter while applying suction
169. B. "I can detect the presence of carbon monoxide by 208. A. Allow 20 to 30 second intervals between each suction,
strong odor" limit suctioning to 5 minutes in total
170. A. Beta-adrenergic blockers INTERVAL
171. A. Administer bowel softener Oro and naso: 20-30 seconds
172. A. Dopamine (inotropin) Tracheo: 2-3 minutes
173. B. Assessment of the client's BP TOTAL TIME
174. B. Using cotton tipped swab All: 5 minutes
175. D. Intramuscular Z-track injection 209. A. 95 — 100mmHg
176. C. Pull the ear down and back WALL SUCTION
177. C. The level of drug is 100ml at 8am and is 80ml at noon Infant: 50 — 95 mmHg
178. C. Avoiding very heavy meals Child: 95 — 110 mmHg
179. A. Should be taken in the morning Adult: 100 — 120 mmHg
180. D. Detect O2 sat of arterial blood before a Sx of 210. A. 10 seconds
hypoxemia develops DURATION
181. C. over the fingertip sensor with a towel or bedsheet Oro and naso: 5-10 seconds, MAX: 15 seconds
182. D. The display reaches full strength during each cardiac Tracheo: 5-10 seconds, MAX: 10 seconds
cycle 211. C. Insert the catheter until a cough reflex is obtained or
183. A. Cyanosis until resistance is felt
184. C. Nasal cannula A and D are wrong. In choice B, trachea should be
Low O2 flow to prevent loss of hypoxic drive. suction first (Sterile) before mouth (Unsterile).
UPDATE: As tolerated by patient. 212. A. 130/80
185. C. A flow rate between 1 and 6L/min for the nasal 213. A. Erroneously low systolic and high diastolic reading
cannula 214. D. It would decrease
A. Has mist As digitalis has been given, cardiac muscles get stronger
B. The reservoir of the rebreathing mask PARTIALLY contractions. Thus, compensatory mechanism (increased
collapsing on inhalation PR) also normalizes (decreases).
D. The nasal cannula positioned INSIDE the nares 215. D. AOTA
186. B. An increased pulse rate 216. B. A large amount of air inhaled and a large amount
Other choices are expected outcomes. exhaled
187. C. Attaching the T tube to the humidified oxygen source 217. B. Orthopnea
188. A. The client holds the spirometry upright position, 218. C. Observe the rise and fall of the abdomen
exhales normally, seal the lips tightly around the 219. D. 755 kcal
mouthpiece, takes a slow deep breath for 2 seconds to CHO: 83 grams x 4 cal = 332 kcal
keep the balls elevated Fats: 27 grams x 9 cal = 243 kcal
189. A. Diversional Activity CHON: 45 grams x 4 cal = 180 kcal
190. D. Promote CO2 elimination TOTAL: 755 kCal
It lengthens exhalation, thereby, increasing CO2 expiration. 220. B. Abnormally but deep respirations
191. B. Damage to the laryngeal nerve 221. B. Florence Nightingale
192. D. Maintain patent airway 222. A. Martha Rogers
193. A. The obturator is kept at the client's bedside in case 223. A. Hildegard Peplau
the tube becomes dislodged and needs to be 224. D. Jean Watson
reinserted 225. D. Sister Callista Roy
Choice B only states the function. 226. C. Loreto Tupaz
194. C. Hydrogen peroxide (Half-strength solution mixed with 227. B. Anastacia Giron Tupas
sterile normal saline) 228. B. Dorothea Orem
195. A. Producing an airtight seal to prevent aspiration or 229. A. Rosemarie Parse
oropharyngeal secretions and air leakage 230. B. Madeleine Leininger
196. D. Ensure that the collection and suction bottles are 231. C. Alleviate pain
below the client's chest level at all times 232. A. High risk for infection
It promotes flow of drainage. 233. C. The way a person perceives his appearance and
RATIO function, and how he compares himself to others
A. Ensure that the air vent on the water-seal drainage 234. B. F and E imbalance r/t vomiting and diarrhea
system is capped when the suction is ON, not OFF 235. B. It focuses on the patient, not the nurse
B. Stripping the chest and drainage tubes may lead to RATIONALE
Tension Pneumothorax A It is useful in ALL SETTINGS
C. Should be below C It progresses in INTERRELATED steps
197. A. Lung has fully expanded D Not all solutions (extreme choice)
198. B. An air leak
199. D. Put the end of the test tube into a cup of sterile 236.
normal saline A. +4 patellar reflexes in both of the patient's legs
200. B. Take a deep breath, exhale and bear down RATIONALE
201. A. French All other choices are subjective data.
202. C. Placed lower than the patient's chest
203. D. Hyperoxygenate before suctioning the client 237.
It prevents hypoxia. A. Health history
204. B. Depriving the client of sufficient oxygen supply RATIONALE
 All other choices are sources of objective data. B and C are incorrect. It should be based on the patient's
238. C. [P] Ineffective Airway Clearance [E] r/t infectious perspective, not by the nurse.
process [S] as manifested by excessive mucous and 260. C. Bowel sounds were auscultated on the right upper
retained secretions quadrant
RATIONALE RATIONALE
A. [P] Fluid Volume Deficit [E] r/t prolonged vomiting A The word "large" is inaccurate. It should be measurable.
B. [P] Risk for Impaired Skin Integrity [S] as manifested by B and D are incorrect. It should be based on the patient's
poor skin turgor and old age perspective, not by the nurse.
D. [P] Ineffective Airway Clearance [S] as manifested by 261. C. Each recording on the nurse's notes is signed by the
secretions in the bronchi, presence of allergies, and nurse making it
airway spasm RATIONALE
239. C. Ineffective breathing pattern r/t pain, as evidenced by A Recording should be done EVERY AFTER providing
SOB nursing care
RATIONALE B All entries on the record are made in PERMANENT INK
Physiological. D Every blank space should be properly filled in
All other choices belong to Safety and Security level. 262. D. Write the order and repeat the order back to the
240. B. Use medical terminology to describe the probable physician, copy onto the order sheet and indicate that
cause of the patient's response it is a telephone order
RATIONALE 263. C. Draw a line through the mistake and write "mistaken
It should be NURSING terminology, not medical terminology. entry" next to the original entry with the nurse's name
Other choices describe an appropriate nursing diagnosis. or initials
241. B. Ineffective airway clearance r/t thickened bronchial 264. B. 1,2,3 and 4
secretions as evidenced by adventitious lung sounds RATIONALE
over the periphery of the right and left lung fields 5 Use of GLOBALLY accepted abbreviations
RATIONALE 265. D. Demonstrating the procedure and having the client
A An actual diagnosis but not following the PES format. return the demonstration
C and D are potential problems. 266. D. Explain how to operate the call bell
267. D. Call the nursing supervisor and report the incident
242. A. Risk for deficient fluid volume r/t prolonged diarrhea RATIONALE
and vomiting Following proper line of authority.
RATIONALE 268. D. Contact the nursing supervisor
The patient may be dehydrated.242 269. D. A 72 year old with a broken hip
243.B. Anticipatory Grieving RATIONALE
244. C. The nurse is able to coordinate the complex care It has 2 counts of risk: Age and broken hip
demands of a client who is newly admitted and the A 1 count: surgery
other clients in the unit B 1 count: surgery
RATIONALE C 1 count: DM
A Proficient 270. B. Use a bath blanket or top sheet for warmth and
B Expert privacy
D Advance Beginner RATIONALE
245. A. Novice A Keep the bed at proper height with regards to the nurse
246. C. A holistic understanding and perception of the client comfort; able to use the proper body mechanics
RATIONALE C Only 1 side rail so the nurse can work on the other side
A Competent D The work should be organize, able to finish from one
B Advance beginner side to the other side.
D Expert
247. A. Advocate 1. D. 42153
248. C. The RN is responsible and accountable for the RATIONALE
delegated task in adjunct with the delegate Nursing History in chronological order:
249. A. Functional nursing 1 Intuitive
RATIONALE 2 Apprentice
Functional nursing focuses on duties. 3 Dark Age
250. C. Protected poor health in a favorable environment 4 Educative
251. D. Perceived curability of an illness 5 Contemporary
RATIONALE
Not included in the health belief model of Risenstick 2. B. People would use amulets made from stones for them to
and Becker. become immortal
252. D. Act 2808 RATIONALE
253. D. 1920 Indigenous people belong to the Intuitive stage.
254. B. Primary 3. A. Intuitive nursing
255. C. Secondary 4. C. Kaiserwerth foundation
256. D. Tertiary 5. A. Dark period
257. D. Avoiding overexposure to the sun 6. C. Upgraded knowledge and skills in any health care setting
RATIONALE 7. D. Contemporary Nursing
A Tertiary 8. D. Change Agent
B and C are Secondary 9. D. Nurse Patria who discusses the case of her patient to her
258. A. Primary prevention nurse supervisor because the patient's physician no
259. D. "Client's skin is moist and cool" longer follows up the patient's treatment regimen
RATIONALE 10. C. Educator
A The word "small" is inaccurate. It should be measurable. 11. D. Nurse Manager
12. C. Counselor 38. C. Caregiver role strain
13. C. Communicator 39. D. Risk for infection related to an open wound
14. B. 1920 40. B. Risk for Injury
15. A. Julita Sotejo 41. C. The client's ability to react or adjust when health is
16. D. UST compromised
17. B. Manila Central University 42. D. Helps ensure quality care that meets individual needs
18. C. The Message 43. C. Selection of Nursing Interventions
RATIONALE RATIONALE
A and B Florence Nightingale A Assessment
D Conchita Ruiz B Intervention
19. B. Drastically decrease D Diagnosis
RATIONALE 44. D. Evaluating
Bleeding ▶️⬇️BV ▶️Shock ▶️⬇️BP 45. C. Planning
20. D. Hypothalamus RATIONALE
RATIONALE Tip: The word "decides" means the nurse has yet to
Functions of Hypothalamus implement the nursing interventions, entailing that
1. Temperature regulation the nurse is on the planning phase.
2. Thirst 46. A. BP measurement of 170/100
3. Feeding centers 47. C. Determine if the expected patient outcomes were
4. Emotions accomplished
5. Sexual desire 48. B. Evaluation
6. Circadian rhythm RATIONALE
21. C. Back dorsal or dorsal face Evaluation phase is where the nurse will know
22. C. Intermittent whether the possible outcomes set in the planning
RATIONALE phase are met or not met.
A Fluctuating, within several days/weeks, backs to 49. C. Nursing process
normal 50. D. Use medical terminology to describe the probable
B High fever cause of the patient's responses
D Fluctuating, within 24°, never back to normal
23. C. Cheyne stokes respiration
24. D. 4
RATIONALE
0 - Absent - dead
1 - Thready - dying
2 - Weak - depressed
3 - Normal - discharged
4 - Bounding - Palpitations

25. C. Convection
26. A. Tachypnea
RATIONALE
0-2 mos : 60bpm and above
2-12 mos : 50 bpm and above
12mos-5yo : 40 bpm and above
27. D. Brachial pulse
28. C. A cheer leader who failed to win the contest and does
not want to go to school anymore
29. B. Oral
30. A. 30-40 mmHg
RATIONALE
Pulse Pressure is obtained by subtracting DBP from SBP.
SBP — DBP = Pulse Pressure

31. C. The nurse who asks the client how much lunch was
eaten
RATIONALE
A Evaluation
B Intervention
D Planning
32. D. Percuss all four quadrants
RATIONALE
Assessment of the abdomen follows the IAPePa method.
33. C. Loss of hair on bilateral lower legs
RATIONALE
Pain (Option A), numbness (Option B), and itching (option
D) are all subjective data.
34. A. Aling Aning
35. C. Patient complains of polydipsia
36. D. Problem, Etiology, Signs and Symptoms
37. B. Planning