Situation: Noel is 45-year-old obese client who has been

struggling to pass out stool for the past few days. He has been
worried that he might have cancer. The following questions apply.

1. After taking the history and vital signs, the physician does
which test as a screening test for colorectal cancer?
a. Double contrast barium enema
b. Carcinoembryonic antigen
c. Annual digital rectal examination
d. Proctosigmoidoscopy

2. To confirm an impression of colorectal cancer, Noel will

require which diagnostic study?
a. Carcinoembryonic antigen
b. Stool hematologic test
c. Abdominal computed tomography (ct) test
d. Colonoscopy

3. Which of the following would you expect to see in Noel's

history which predisposes him to colon cancer, except:
a. Inflammatory bowels
b. High fat, high fiber diet
c. Smoking
d. Genetic factors-familial adenomatous polyposis

4. Symptoms associated with cancer of the colon include:

a. constipation, ascites and mucus in the stool
b. blood in the stools, anemia and pencil-shaped stools
c. diarrhea, heartburn and excruciating pain
d. anorexia, hematemesis, and increased peristalsis
5. A tumor was seen in Noel's diagnostic workup and the doctor
prescribed excision of the mass. Several days prior to bowel
surgery, Noel may be given sulfasuxidine and neomycin primarily
to:
a. Reduce the bacterial content of the colon
b. Promote rest of the bowel by minimizing peristalsis
c. Soften the stool by retaining water in the colon
d. Empty the bowel of solid waste

SITUATION: Nurse Peeta has observed that they are having

difficulty stabilizing ET tubes.

6. Before data gathering, which of the following should be

initiated by Nurse Peeta?
a. Begin with a concept and seek how to best implement the
concept into client care
b. Develop the question or problem statement that best defines
the need
c. Secure consent from the clients for their involvement
d. Organize a team to conduct the study and obtain their comment

7. The next step that the nurses should do is:

a. Define the problem
b. Formulate framework
c. Analyze the extent of literature
d. Secure evidence

8. Following the review and evaluation of the data, the nurses

should:
a. Choose the most relevant information
b. Recommend measures to meet the need
c. Extrapolate information
d. Decide the level of evidence

9. With the information obtained to promote evidence-based

practice, the nurse should:
a. Apply findings to clients with endotracheal tube
b. Conduct a pilot study to selected clients in several units of
the study
c. Make recommendation and apply into endotracheal tube practices
in the unity
d. Communicate findings to nurses in other units

10. Following the success in stabilizing endotracheal tube in

their unit, Nurse Peeta share the literature they found on
endotracheal tube stabilization with nurses in the ICU. In order
to reflect currently published knowledge, which of the following
appropriate actions should critical nurses do?
a. Review all the studies, summarize findings, and completely
revise NGT stabilization policy.
b. Revise practice-based guidelines and procedures of clinical
intervention
c. Gather enough evidence to substantiate the findings of the
nurses in the medical unit
d. Conduct similar research in the ICU

Situation: Nurse Nadine is a nurse in the burn unit. The

following questions apply.

11. Nurse Nadine is caring for Teresa who sustained

circumferential thermal burns of the right upper extremity and
chest. Nurse Nadine noted that pulse could not be appreciated on
the right arm. Which of the following will Nurse Nadine do first?
a. Notify the physician immediately as this requires emergency
intervention
b. Remove the dead tissues which impede circulation
c. Try to take the pulse in the uninjured extremity
d. Elevate the injured extremity to increase blood flow to the
heart

12. Vhong is a truck driver for 10 years. While loading

containers with chemicals from a truck, he accidentally spilled
the whole can of corrosive chemicals all over his body. Which of
the following would Nurse Nadine consider as the priority
intervention in the emergency management of Vhong?
a. Wash the chemical off with cool water
b. Maintain a patent airway
c. Assess for associated injuries
d. Remove all clothing containing the chemicals

13. Nurse Nadine is also managing patient Edel who sustained

partial thickness burns on the face and inquires about skin care
after discharge. Which of the following should Nurse Nadine
include in her discharge teaching?
a. Wear a pressure garment daily for one year
b. Avoid sunlight for the next three months
c. Avoid facial makeup for a year
d. Continue to eat high caloric food for the next month

14. Baby Joy who sustained severe burn injury on three fourths of
her body and she is in the emergent phase of burn injury. Nurse
Nadine noted the following laboratory results: hemoglobin
12.5g/100mL., hematocrit 49 %, serum Na 130 mEq/L. How will you
explain the laboratory results?
a. They are slightly abnormal but will normalize once IV fluids
have been started
b. These are due to hemodilution from rapid IV fluid replacement
c. All the laboratory tests are within normal range
d. These are due to a loss of serum and interstitial fluid
through the burn wounds

15. Rads is fond of eating Betamax and isaw on the streets.

Recently, he has been complaining of anorexia and is always
feeling tired, develops jaundice. After a work-up, he is
diagnosed of having Hepatitis A. Rads asks you about gamma
globulin for himself and their household help. Your most
appropriate response would be:
a. "Don't worry, your hepatitis is no longer communicable."
b. "Gamma globulin provides passive immunity for Hepatitis B."
c. "You should contact your physician immediately about getting
gamma globulin."
d. "A vaccine has been developed for this type of hepatitis."

Situation: Nurse Ramil is a member of Philippine Oncology Nurses

Association. He has been an advocate of cancer prevention in the
community. The following questions apply.

16. Nurse Ramil is a member of the task force to plan activities

for the Cancer Consciousness week in the community. His committee
has 4 months to plan and implement the plan. The group was
assigned to contact the various cancer support groups in the
hospital. What will be the priority activity?
a. Clarify objectives of the activity with the task force before
contacting the support groups
b. Find out if there is budget for this activity
c. Determine the VIPs and celebrities who will be invited
d. Find out how many support groups there are in the hospital and
get the contact numbers of their president

17. Nurse Ramil will also do the medical mission activity of his
alumni association. In the planning stage, everybody is expected
to identify what they can do during the medical mission and what
resources are needed. He thought it is also his chance to share
what he can do to others. What will be her most important role
where he can demonstrate the impact of nursing in health?
a. Act as a coordinator
b. Take the initial history and document findings
c. Be a triage nurse
d. Conduct health education on healthy lifestyle

18. One of the patients in the ward Nurse Jaja and asked about
brachytherapy for cervical cancer. Which one of the following
nursing interventions would be most helpful in preparing her for
brachytherapy?
a. Instruct the patient of the possibility of radiation burn
b. Offer tranquilizers and antiemetics
c. Map out the precise course of treatment
d. Emphasis on the therapeutic value of the treatment

Situation: Nurse Jaja is radiation therapy nurse and she is

handling several patients in the radiation ward. The following
questions apply.

19. What side effects are most apt to occur during radiation
therapy to the pelvis?
a. Urinary retention
b. Abdominal, vaginal, or perineal discharge
c. Paresthesia of the lower extremities
d. Nausea, vomiting, and diarrhea

20. Yujin soon developed skin irritation after the radiation

therapy. Which of the following can be used on the irradiated
skin?
a. Adhesive tape
b. Mineral oil
c. Talcum powder
d. Zinc oxide treatment

21. Which of the following is the earliest sign of skin reaction

Nurse Jaja would expect for Yujin to manifest?
a. Desquamation
b. Erythema
c. Atrophy
d. Pigmentation

22. Rei received an internal implant. What is the purpose of

wearing a film badge while caring for the patient who is
radioactive?
a. Identify the nurse who is assigned to care for such patient
b. Prevent radiation-induced sterility
c. Protect the nurse from radiation effects
d. Measure the amount of exposure to radiation

Situation: Nurse Juan is aware that healthcare-associated

infections occur in both adult and pediatric patients.
Bloodstream infections, followed by pneumonia and urinary tract
infections are the most common healthcare-associated infections
in children; urinary tract infections are the most common
healthcare-associated infections in adults.
23. Joshua develops a nosocomial respiratory tract infection. He
asks Nurse Juan what that means. Nurse Juan response would be:
a. "You should contact your physician immediately about getting
gamma globulin."
b. "This type of infection usually resolves on its own."
c. "You acquired infection after you have been admitted to the
hospital."
d. “This is a highly contagious infection which requires complete
isolation.”

24. Angel is currently receiving total parenteral nutrition. As a

nurse, Nurse Juan knows that one of the complications that have
to watch out for when caring for Angel is:
a. Stomatitis
b. Hepatitis
c. Infection
d. Dysrhythmia

25. Nurse Juan is aware that patient Erik who sustained major
burn injury has sustained Pseudomonas aeruginosa infection. Nurse
Juan is a competent nurse if he would assume that the solution
used to treat pseudomonas wound infection is:
a. Dakin's solution
b. Half strength hydrogen peroxide
c. Acetic acid
d. Betadine

26. Which of the following is most reliable in diagnosing and

treating wound infection?
a. Reverse Transcription-Polymerase Chain Reaction
b. WBC count of 10,000/μl
c. Gram staining
d. Culture and sensitivity

27. Rita is a patient with bipolar disorder. During her manic

episode, she accidentally dislodges her IV line and bleeds. Blood
oozes on the bed table and hospital bed. It is most appropriate
that Nurse Juan instruct the housekeeper to clean the table with:
a. Acetone
b. Alcohol
c. Ammonia
d. Bleach

28. Nurse Juan is a member of the infection control team of the

hospital. Based on a feedback during a meeting of the committee,
there is an increased incidence of MRSA infection in the burn
unit (3 out of 10 patients had positive blood and wound culture).
What is the nurse's priority activity?
a. Meet with the nursing group working in the burn unit and
discuss problem with them
b. Establish policies of surveillance and monitoring
c. Assign point persons who can implement policies
d. Do data gathering about the possible sources of infection

29. Nurse Eun-chae is a nurse in the diabetes clinic. 5 patients

came to the clinic today for a health teaching. How would you
start prioritizing your activities?
a. Determine their learning needs then prioritize
b. Bring your diabetes teaching kit and start your session taking
into consideration their distance from your office
c. Contact the nurse-in-charge and find out from her the reason
for the referral
d. Involve the whole family in the teaching class
30. Which statement made by Nurse Karina about the goal of total
quality management or continuous quality improvement in a health
care setting is correct?
a. "It is to observe reactive service and product problem
solving."
b. "Improvement of the processes in a proactive, preventive mode
is paramount."
c. "A chart audits to find common errors in practice and outcomes
associated with goals."
d. "A flow chart to organize daily tasks is critical to the
initial stages."

31. The nurse manager states that "staff will form a task force
to investigate and develop potential solutions to the problem,
and report on this at the next staff meeting." The nurse
manager's leadership style is best described as:
a. Participative
b. Laissez-faire
c. Autocratic
d. Group

32. Nurse Bea informs the nursing staff at morning report that
the clinical nurse specialist will be conducting a research study
on staff attitudes towards the prevention of Catheter associated
urinary tract infection. All staff are invited to participate in
the study if they wish. This affirms the ethical principle of:
a. Participativeness
b. Autonomy
c. Anonymity
d. justice
33. As a nurse, to which of the following groups are you best
prepared to join?
a. Transport group
b. Treatment group
c. Triage group
d. morgue department

34. There are important principles that should guide the triage
team in disaster management that you have to know if you were to
volunteer as part of the triage team. The following principles
should be observed in disaster triage, except:
a. Any disaster plan should have resources available to triage at
each facility and at the disaster site if possible
b. Do the greatest good for the greatest number of casualties
c. Make the most efficient use of available resources
d. Training on disaster is not important to the response in the
event of a real disaster because each disaster is unique in
itself

35. Which of the following patients should be considered first

priority in a disaster?
a. Mariam, a patient with increased intracranial pressure and
abnormal mental status
b. Lina, a patient with Crohn's Disease
c. Sara, a patient with pneumonia
d. Margo, a patient with a bleeding leg

36. A guideline that is utilized in determining priorities is to

assess the status of the following, except:
a. Perfusion
b. Locomotion
c. Respiration
d. Mentation
37. Induction of vomiting is indicated for the accidental
poisoning patient who has ingested:
a. Acetylsalicylic acid
b. rust remover
c. gasoline
d. toilet bowl cleaner

38. Prior to the start of the shift, the nurse manager gave a
trivial quiz. Which of these clients would the nurse put first on
the list to be discharged in order to make a room available for
new admission?
a. Steve Rogers, an elderly client with a history of
hypertension, hypercholesterolemia and lupus, and was admitted
with Steven-Johnson Syndrome that morning
b. Thor, a young adult with diabetes mellitus type 1 for over 10
years and admitted with antibiotic-induced diarrhea 24 hours ago
c. Tony Stark, a middle-aged client with a history of being
ventilator dependent for over 5 years and admitted with bacterial
pneumonia five days ago
d. Bruce Banner, an adolescent with a positive HIV test and
admitted for acute cellulitis of the lower leg 48 hours ago

39. Nurse Gabda has several clients who arrived in the emergency
department within 15 minutes. Which client should the triage
nurse send back to be seen first?
a. Baby Antman, a 2-month-old infant with a history of rolling
off the bed and has bulging fontanels with crying
b. Nebula, a person who got a singed beard while camping
c. Hawkeye, a middle-aged client with intermittent pain behind
right scapula
d. Black Widow, an elderly client with complaints of frequent
liquid brown-colored stools
Situation: Nurse Jennie, a registered nurse, witnessed an old man
hit by a pedicab while crossing a train railway. The old man fell
at the railway. Jennie rushed at the scene.

40. As a registered nurse, Jennie knew that the first thing that
he will do at the scene is:
a. Stay with the person and encourage her to remain still and
immobilize the leg while waiting for the ambulance
b. Leave the person for a few moments to call for help
c. Reduce the fracture manually
d. Move the person to a safer place

41. Jennie suspects a hip fracture when she noticed that the old
woman's leg is:
a. Lengthened, abducted and internally rotated
b. Shortened, abducted and externally rotated
c. Shortened, adducted and internally rotated
d. Shortened, adducted and externally rotated

42. The old man complains of pain. Nurse Jennie noticed that the
knee is reddened, warm to touch and swollen. Bea interprets that
this signs and symptoms are likely related to:
a. Infection
b. Inflammation
c. Thrombophlebitis
d. Degenerative disease

43. Ryan, the old man was now immobilized and brought to the
emergency room. The x-ray shows a fractured femur and pelvis. The
ER nurse would carefully monitor Teddy for which of the following
sign and symptoms?
a. Tachycardia and hypotension
b. Fever and bradycardia
c. Bradycardia and hypertension
d. Fever and hypertension

44. Which of the following serious complications can occur with

long bone fractures?
a. Air embolism
b. Fat embolism
c. Platelet embolism
d. Serous embolism

Situation: Nurse Jeric is a newly hired operating room nurse. As

he observes the movement of nurses in the operating room. The
following questions apply.
45. Nurse Kim is setting up for an emergency gastrectomy. The
linen packs were damp although these were just taken from the
sterilizer. The nurses' appropriate action is:
a. Bring the linen packs back to the central supply section for
quality control
b. Open the linen pack and allow to dry
c. Change the damp linen pack
d. Do not use the damp linen

46. The clinical instructor assigned a nursing student to assist

in the operation. When the nursing student entered the OR suite,
her curly long hair was not completely covered by the head cap.
What would the circulating nurse do?
a. Do not allow the nursing student to scrub in
b. Welcome the nursing student to the OR
c. Request the clinical instructor to tell the nursing student to
use the head cap properly
d. Assist the nursing student to tuck-in all her hair inside the
head cap
47. After Dr. Jisoo finished doing the surgical hand scrub, he
came into the OR suite swinging his hands casually. The scrub
nurse would do which of the following appropriate action?
a. Offer a sterile towel to dry her hands
b. Serve the surgeon her sterile gown and gloves as usual
c. Tell the circulating nurse to pour alcohol 70% to the
surgeon's hands
d. Remind the surgeon to scrub again
48. When the resident did the skin prep and catheterized the
client, the circulating nurse noticed when the intern withdrew
the catheter from the vagina. What is your appropriate and
immediate action?
a. Hold the hand of the intern to stop him from reinserting the
catheter
b. Stop the intern and do the catheterization yourself
c. Offer to change the catheter
d. Alcoholize the tip of the catheter before reinserting the
catheter
49. After the last stitch, the surgeon is ready to apply dressing
to the incision wound. Which of the following does the nurse
expect
the surgeon to do?
a. Apply the dressings and remove his gloves to apply the tape
b. Remove his gloves and apply the dressings
c. Apply the dressings and tape and then remove his gloves
d. Tape the dressings and remove his gloves
Situation: Nurse Patricio is a medical surgical nurse handling
several cases for the shift. Nurse Patricio is also has a
preceptee named, Kristen.
50. Nurse Patricio is aware that acromegaly is a condition when
growth hormone occurs in excess in adulthood or after epiphyses
of the long bones have fused. Nurse Patricio asked Kristen of
which of the following are the typical physical features of the
disorder, except:
a. The soft tissues continue to grow
b. Hands and feet are enlarged
c. Client grows taller
d. Broad and bulbous nose

51. The client was prescribed Ocreotide acetate (Sandostatin).

Nurse Patricio should instruct Kristen to monitor for which of
the following side effects?
a. Dysuria
b. Hypotension
c. Abdominal pain
d. Constipation
52. Choi, a patient with acromegaly, was prescribed with
Ocreotide acetate. Kristen knows that this must be administered
by which appropriate route three times weekly?
a. Intravenously
b. Subcutaneously
c. Orally
d. Intramuscularly
53. Priority discharge plans should include which of the
following? Select all that apply.
1. Fasting blood sugar
2. Bone assessment
3.Intake and output
4. Urine output
a. 2 and 3
b. all except 1
c. 1, 2 and 3
d. 1 and 2
54. Acromegaly often develops insidiously that nurses should
understand that the client with disorder would seek medical care
because of:
a. Alteration in fat and carbohydrate metabolism changes in blood
sugar level
b. Changes in appearance
c. Alteration in their voice
d. none of the options

SITUATION: Kimberly a status post Billroth II was admitted to the

post anesthesia care unit (PACU) from the OR. The client is still
sedated but responsive to commands. She has nasogastric tube
(NGT) draining orange-yellow fluid to a drainage bottle.
55. The nurse who admitted the patient recognizes that Billroth
II procedure means:
a. Esophagojunostomy
b. Gastroduodenostomy
c. Gastrojejunostomy
d. Enterostomy
56. After admitting Kimberly the PACU, the first action of the
nurse should be:
a. Assess patency of the airway
b. Assess the client's pain
c. Monitor vital signs
d. Check the rate of the IV infusion

57. Nurse Tunying monitors Kimberly and she notices a bright red
spot on the dressings which measure 2 cm in diameter. The nurse
would initially do which appropriate nursing intervention?
a. Notify the client's surgeon of a potential hemorrhage
b. Assess for presence of drainage
c. Change the top dressing
d. Continue to monitor the vital signs
58. Kimberly was taught pre-operatively to perform deep breathing
exercises, coughing and turning to sides. which nursing action
would be most helpful for the client?
a. Restate the importance of respiratory exercises
b. Give the client reassurance that he can cough, breathe deeply,
and turn to sides safely
c. Administer the prescribed analgesics round the clock
d. Apply abdominal splint while coughing
59. Kimberly suddenly complained of abdominal pain, nausea, and
vomiting, with abdominal distention. The nurse anticipates which
of the following priority management after referring to the
surgeon?
a. Possible surgery
b. Endoscopy
c. Rectal tube insertion
d. Gastric decompression

Situation: Nurse Jill should be aware of the rules and

regulations governing the nursing profession. The following
question apply.
60. For failure of the nurse to check the nasogastric tube
placement before administering feeding, the patient aspirated and
died. The nurse may incur:
a. Administrative liability
b. Civil liability
c. All liability may be filed
d. Criminal liability
61. The following are sources of laws/rules/policies that affect
the nursing practice in the Philippines:
1. International Council of Nurses/ Philippine Nurses Association
Advisories
2. Board of Nursing Promulgations e.g., Resolutions and
Memorandum
3. DOH Administrative Order and CHED Memorandum Order
4. House Bills/ Senate Bills

a. All are recognized sources

b. 1 and 4
c. 2 and 3
d. 1 and 4

62. Jackie plans to take the NLE this year. The following are
true about the requirements for applying to take the Licensure
Examination in the Philippines except:

1. The applicant must be a person of Good Moral Character

2. The applicant must have gotten an average of 75% with no grade
lower than 60% in any subject in the NLE
3. The applicant must have finished a BSN degree from an
accredited school
4. The applicant must be a Filipino citizen

a. 1 and 3
b. 1 and 4
c. 1, 3, and 4
d. only 2

63. ASEAN countries now engage in Mutual Recognition Arrangement

(MRA) negotiations consistent with liberalization measures of the
General Agreement on Trade in Services (GATS). The applicable
mode for this kind of agreement is:
a. Via Reciprocity
b. Via Examination
c. Via Temporary/ Special permit
d. Via Movement of Natural Persons
Situation: Toni, a 20-year-old patient was admitted for the
treatment of Grave's disease. The physician prescribed
Propylthiouracil to treat the disorder.
64. Before the nurse administers the medication, which of the
following is most relevant for the nurse to ask?
a. "When was your last menstruation?"
b. "Do you experience gastric discomforts?"
c. "Do you prefer a liquid form of medication?"
d. "When was the last time you took alcohol?"

65. Toni is prepared for thyroidectomy in about 10 days time.

Luaol's solution 4 gtts P.O. was prescribed for 10 days. The
client asked the nurse for the purpose of the drug. Which
response of the nurse is correct?

a. It eliminates the need to take hormone replacements

b. It decreases the risk of bleeding
c. It decreases the risk for thyroid crisis
d. It stabilizes your immune system to withstand surgery

66. When Toni returns to the unit after surgery, which technique
is most appropriate to monitor bleeding from the incision?
a. Assess for dampness at the back of the client's neck
b. Weigh all gauze dressing before and after changing wound
dressings
c. Remove the dressings to directly inspect the incision wound
d. Pass a flashlight across the incision wound on top of the
dressings

67. Which of the following assessment findings when observed in a

post thyroidectomy client is indicative of a thyroid crisis?
a. Spasm in the hand
b. Falling blood pressure
c. Regular and noisy respiration
d. High fever

68. Toni, a post-thyroidectomy, was prescribed with

Levothyroxine. The nurse must monitor for side effects. Which
side effects would the nurse expect to assess? Select all that
apply.
1. Hypertension
2. Tremors
3. Hirsutism
4. Insomnia
5. Tachycardia
6. Hyperglycemia
a. 1, 2, 4 and 5
b. 3, 4, 5 and 6
c. 1, 2, 3 and 5
d. 1, 3, 4 and 5

69. Which admission assessment would make you suspect that

Nairobi has hypothyroidism? Select all that apply.

1. Heat intolerance
2. Diarrhea
3. Bradycardia
4. Coarse and dry skin
5. Somnolence
6. Decreased appetite
a. 2, 3, 5, 6
b. All except 5
c. 3, 4, 5, 6
d. 1, 2, 3, 4
70. Rio was ordered to undergo radioactive iodine uptake the
following day. The nurse understands that this test determines
which of the following?
a. Absorption of the iodine isotope
b. Ingestion of the iodine isotope
c. Stimulation of the iodine isotope
d. Reaction of the iodine isotope

71. If the doctor will prescribe Basal Metabolic Rate (BMR) to

Rio, which of the following is NOT indicated?
a. Nothing by mouth for 10-12 hours
b. Blood extraction upon waking up
c. Instruct the client not to get out of bed until the test is
over
d. A good night sleep of 8-10 hours

72. Cytomel (Liothyronine) was prescribed to Rio. Before

administering the drug, Nurse Karen should not only verify the
doctors order but also:
a. Take the BP and PR
b. Take the temperature and respiratory rate
c. Take the weight of the client
d. Advise the client to stay in bed

73. Rio asked the nurse which diet is most appropriate for her.
The correct response of the nurse would be:
a. Low salt, low fat
b. Low calorie and high fiber
c. High calorie and high fiber
d. High protein but low residue
Situation: You are a nurse in Japan who has been assigned as part
of the triage team in the recent earthquake in the capital city.
You assess and prioritize patients according to their status and
needs. Different emergency nursing concepts apply during this
process.
74. Which of these should be done during your secondary survey of
the patients?
a. Cervical spine stabilization
b. Establishing a patent airway.
c. Splinting of suspected fractures
d. Immediate closed reductions on pulseless extremity

75. In a reversed advanced (REMOVE THE DEATH) type of triage,

whom would you give prioritization to?
a. A gasping patient, with estimated blood loss of 900mL
b. An elderly client with a fractured femur, mobile, can respond
to voice command
c. A head trauma patient, unconscious, HR 40bpm, RR 10
cycles/min, BP 145/70
d. A pulseless infant, with cold and clammy skin

76. Critical incident stress management is what type of

prevention in disaster management?
a. Primordial
b. Secondary
c. Primary
d. Tertiary
77. Following the triage system, which among these patients would
you highly prioritize?
a. An unresponsive patient with capillary refill time of more
than 2 seconds, and an RR of 10 breaths/min
b. A pregnant client, with rib fractures, responsive to voice
commands, HR 120bpm, RR 20cycles/min
c. A patient with sustained head injuries, gasping for air, with
bluish appearance
d. A patient with severe blood loss, PR of 75 bpm, RR of 10
cycles/min
78. Which of these principles is not included in performing START
triage in emergencies and disasters?
a. Never go against the flow and go back to a previous casualty
b. Tag under the black category those persons who are
unresponsive.
c. Provide treatment for all patients requiring intensive care
d. Begin where you stand…

79. Nurse Even is giving the 8:00pm medication to a client who

happens to have slid down the bed from the fowler's position.
Which of the following interventions is most effective when the
nurse repositions the client?
a. Raise the head of the bed to the height of the center of
gravity
b. Ask the client to flex the hips and knees and position the
feet for effective pushing up
c. Remove all pillows then place against the head of the bed
d. Adjust the head of the bed to a flat position or as low as the
client can tolerate
80. Russel asked the nurse how to use the trapeze in his bead.
Using an overhead trapeze for repositioning the client can be
accomplished by instructing the client to grasp the:
a. Overhead trapeze with one hand and push with the heels upward
b. Overhead trapeze with both hands and lift and pull during the
move
c. Head of the bed with one hand and maneuvering for an upward
movement
d. Head of the bed with one arm and the overhead trapeze with the
other arm then lift and pull upward
81. Hands on bed rest is rolled to a lateral position by the
nurse. The nurse is negotiating the move correctly when he:
a. Positions himself at the mid part of the bed and places both
hands at the back of the client and roll client onto side
b. Places one hand on the client's far hip and the other on the
client's far shoulder, rock backward and roll onto side of the
body facing him
c. Assume a broad stance with the foot nearest the bed placing
his arms under the client's thighs and shoulder and roll client
onto side
d. Supports the back and buttocks of the client and shifts his
own weight from the forward to the backward foot and roll the
client onto side

82. Darlene with an injured left leg due to a vehicular accident

is sitting on the bed preparing to transfer to a wheelchair. The
nurse is assisting the client and positions the wheelchair on
the:
a. Foot part of the bed
b. Client's right side
c. Head part of the bed
d. Client's left side

83. Colyn has difficulty walking and needs a wheelchair to

facilitate performance of daily activities. Anticipating the
needs of the client, the nurse should have the wheelchair ready
by placing it at:
a. 80-degree angle
b. 45-degree angle
c. 90-degree angle
d. 30-degree angle
84. Nurse Nina is currently conducting a discharge teaching on
how to do pulmonary hygiene measures at home. The following
improve clearance of airway secretion, except:
a. Postural drainage
b. Complete bed rest
c. Effective coughing
d. Measure fluid intake

85. Intramuscular supplementation of Iron causes local pain and

can cause stain in the skin. If you are the nurse, what the best
technique of administration will you use?
a. Z-track
b. IV bolus
c. Vigorous rubbing of the injection site after injection
d. Use the gluteus maximus muscle

Situation: Upin and Ipin, a scrub nurse and circulating nurse

respectively, are preparing for cholecystectomy, their last case
for the day.
86. Upin discovered a cut in his palm while she was opening the
sterile packs, Ipin should:
a. Scrub but put on double gloves
b. Ask to be relieved as a scrub nurse
c. Scrub if the cut is properly bandaged
d. Scrub after writing an incident report
87. Before any member of the surgical team proceed to do the
surgical hand scrub, he/she should have complete operating room
(OR) attire. Identify all the attire appropriate for this case:

1. Head Cap, Goggles

2. Face mask

3. Sterile gown
4. Gloves

a. 2,3,4
b. 1,2,3
c. 1,2
d. All of the above

88. A sterile set up has been prepared. The OR was notified of a

delay in transporting the client from the ward to the OR. Which
of the following guidelines should the circulating nurse follows?
a. Cover appropriately "sterile set up"
b. Keep door of the operating room closed all the time to
maintain the "sterile set up"
c. "Sterile set up" should be replaced after an hour
d. Prepare another "sterile set up"
89. Identify which appropriate gloving technique will the
assistant surgeon use when he performs the skin preparation?
a. Gloving self-closed technique
b. Scrub nurse serves the gloves
c. Any gloving technique is accepted
d. Gloving self-open technique
90. The first assist contaminated his gown while the surgery is
ongoing. He is expected to change his gown and gloves. Which of
the following is the CORRECT technique to be followed?
a. The first assist removes his gown and gloves then puts on
another sterile gown and gloves.
b. The circulating nurse unties the gown. The first assist
removes his gown then removes the gloves and puts another sterile
gown and gloves.
c. The first assist removes his gloves, then his gown does a 3-
minute hand scrub and don another sterile gown and gloves
d. The first assist unties his gown removes his gown and put on
another gown and gloves.

91. Maddy has a family history of cervical cancer and came to the
clinic for screening. With your knowledge of cervical cancer,
which of these would you include in your teaching on its risk
factors? Select all that apply.

I.
II.
III.
IV.

V.
VI.
a. i, iii iv, v
b. ii, iv

Monogamous
Sexual contact with males whose partners have had cervical cancer
Underweight
Folic acid deficiency
Exposure to HPV6 (GENITAL WARTS)
Never had any sexual contact

c. ii, iii, iv, v, vi

d. i, iii, iv, vi
92. Maddy was diagnosed with cervical cancer and metastasis was
noted. What is commonly the first metastatic location of cervical
neoplasms?
a. Inguinal lymph node
b. Cervical node
C. Pelvic lymph nodes
d. Axillary lymph nodes

93. A surgery is suggested to treat Maddy. However, she exclaims

that she still plans to bear a child. Which of the following
procedures may be done to the patient granting her wish?
a. Radical hysterectomy
b. Radical vaginal hysterectomy
c. Radical trachelectomy
d. Simple bilateral salphingoectomy
94. Jera underwent hysterectomy and was transferred to your ward
3 hours post-surgery. Which of these assessments would warrant
you to notify the doctor?
a. Pain on the incision site
b. Chest pain
c. Vaginal bleeding
d. Post-operative edema
95. Early ambulation for Jera who underwent surgery for cervical
cancer is encouraged to prevent:
a. Severe hemorrhage
b. Contractures
c. Deep vein thrombosis
d. Bladder retention
96. Jesa was diagnosed with Stevens Johnson Syndrome. While you
take your history, which of these signs and symptoms would be
part of the prodromal stage of the syndrome?
a. Dysuria
b. Sore throat
c. Corneal lesion
d. Vaginal stenosis

97. Which of these statements by the patient would give you an

information of the cause of the syndrome?
a. "I am not sure if I am able to drink at least 8 glasses of
water because of my busy schedule."
b. "I am fond of eating grilled barbecue and isaw after work. I
buy and eat them almost everyday."
c. "I take penicillin whenever I feel like I will have cough or
colds."
d. "Paracetamol is my go-to medication, especially when I started
feeling weak."
98. The physician requested a laboratory workup of the patient.
Which of these laboratory findings do you expect her to manifest?
a. Elevated arterial blood pH
b. Elevated C-reactive protein
c. Decreased partial thromboplastin time
d. Decreased platelet count

99. Which of these complaints by the patients indicate a

progression to a complication of SJD?
a. "I have a difficulty swallowing liquids."
b. "My eyes feel like they are drying."
c. "My whole body is itching terribly."
d. "Anything that touches my skin causes extreme pain."
100. Which of these interventions would you not include in caring
for the patient?
a. Shift to nasogastric gavage from IV infusions in fluid
administration as soon as possible.
b. Prescribed topical antibiotic may be applied in conjunction
with hydrotherapy in a tub.
c. Ask the patient to limit blinking and eye movement to prevent
aggravating the complication.
d. Administer analgesics before the painful procedures or
treatments are done.