Drills 4

Situations - You are caring clients with hypertension at your ward.

1. Which assessment findings is INDICATIVE of the diagnosis of

hypertension?
A. Family members with high blood pressure
B. Elevation of blood cholesterol level
C. Stressful work environment
D. Consistent elevation of blood pressure

2. Identify the MOST appropriate diagnostic examination that confirms the

incidence of hypertension among residents.
A. Chest X-ray
B. Electrocardiogram
C. Ultrasound
D. BP monitoring

3. Which medication will be prescribed to control and maintain the blood

pressure of patients at normal level?
A. Lidocaine
B. Epinephrine
C. Amlodipine
D. Furosemide

4. Nurse Mary had observed that most patients with hypertension stop
taking their medication and heard them saying “I feel good already”. Which is
the APPROPRIATE nursing diagnosis?
A. Impaired gas exchange
B. Anxiety
C. Knowledge deficit
D. Ineffective coping

5. During the conduct of his health teaching to the patients, which should
the nurse emphasize to maintain blood pressure at normal level?
1. Smoke in moderation
2. Exercise regularly
3. Consume less salt
4. Maintain normal weight
5. Less stress

A. 2, 3, 4, 5
B. 1, 2, 3, 4
C. 1, 2, 4, 5
D. 1, 3, 4, 5

6. Patient Ximena was seen by the physician and was ordered for a
medication that is larger than the standard dose for hypertension. What
should the nurse do?
A. Give the drug as prescribed.
B. Inform the supervisor
C. Give the average dose of the medication
D. Discuss the prescription of the physician

7. Christian 29- year old refuses to take the medication for hypertension
because it causes diarrhea. Nurse Jesson explain the action of the drug but
the patient vehemently refuses the medication. What should the INITIAL
action of the nurse?
A. Discuss with a family member the need for the patient to take the
medication.
B. Document the patient’s refusal to take the medication.
C. Notify the physician of the patient’s refusal to take the medication.
D. Explain again to the patient the consequences of refusing to take
medication.

8. As a strong believer of her faith and the need for spiritual guidance,
patient Jona requests that she wants that clergy will visit her. How did nurse
Lhito function when she initiate the visit?
A. Dependently
B. Theologically
C. Interdependently
D. Independently

9. The incoming nurse on duty reported, the nurse is administering a

medication, the patient says, “This pill looks different from the one I had taken
before.” What is the APPROPRIATE action of the nurse?
A. Explain the purpose of the medication
B. Encourage the patient to take the medication
C. Check the original medication prescription
D. Ask what the other pill looked like

10. Take home medication given to Patient Lily includes digitalis therapy
which was given to patient , which of the following would the nurse anticipate
with patient’s drug therapy?
A. Addition of herbal diuretic (Sambong)
B. Addition of diuretic (Mannitol)
C. Addition of diuretic (Spironolactone)
Addition of diuretic (Furosemide)

Situation – Mr. Lar, a 44 year-old, male obese, married was rushed to the
Emergency room because of feeling nauseated with shortness of breath and
severe chest pain radiating to the back.

11. As a nurse, what is your PRIORITY step to be done in this situation?

A. Assess heart rate
B. Assess nail bed if cyanotic
C. Assess temperature
D. Assess Respiratory rate
12. A 12 lead EKG was ordered by the physician. Which finding in the EKG
is specific suggestive evidence that the patient has Myocardial Infarction (MI)?
A. Prominent segment elevation
B. ST segment elevation
C. Peaked T wave
D. ST Depression

13. The physician confirmed that the patient is suffering from MI. She was
advised to be hospitalized and was given streptokinase. Which of the
following is the DESIRED effect of the drug?
A. Dissolve clot formation
B. Reduce tissue damage of the heart
C. Prevent dysrhythmia
D. Reduced edema formation

14. As a nurse you are aware that the heart muscles damage after an
attack without treatment becomes permanent within___ hours?
A. 7-9
B. 10-12
C. 4-6
D. 1-3

15. In designing a care plan, which modifiable risk factors have to be

emphasized to the patient to prevent for another heart attack to happen?
1. Smoking
2. High blood pressure
3. High cholesterol
4. Overweight

A. 1, 2 & 3
B. 3&4
C. 1&2
D. 1, 2, 3 & 4

Situation - You are assigned in Medicine ward caring patient with acute
coronary syndrome.

16. A client has chest pain rated at 8 on a 10 point visual analog scale. The
12-lead electrocardiogram reveals ST elevation in the inferior leads and
Troponin levels are elevated. What is the highest priority for nursing
management of this client at this time?
A. Monitor daily weights and urine output.
A. Permit unrestricted visitation by family and friends.
B. Provide client education on medications and diet.
C. Reduce pain and myocardial oxygen demand.

17. A client with chest pain is prescribed intravenous nitroglycerin (Tridil).

Which assessment is of greatest concern for the nurse initiating the
nitroglycerin drip?
A. Serum potassium is 3.5 mEq/L.
B. Blood pressure is 88/46.
C. ST elevation is present on the electrocardiogram.
D. Heart rate is 61.

18. The nurse is caring for a client diagnosed with an anterior myocardial
infarction 2 days ago. Upon assessment, the nurse identifies a new systolic
murmur at the apex. The nurse should first:
A. Assess for changes in vital signs.
B. Draw an arterial blood gas.
C. Evaluate heart sounds with the client leaning forward.
D. Obtain a 12 Lead electrocardiogram.

19. A client with acute chest pain is receiving I.V. morphine sulfate. Which
of the following results are intended effects of morphine in this client? Select
all that apply.
1. Promotes increase blood flow
2. Promotes reduction in respiratory rate.
3. Prevents ventricular remodeling.
4. Reduces blood pressure and heart rate.
5. Reduces anxiety and fear.

A. 1,4,5
B. 1&2
C. 1,3,4
D. 1,2,3,4,5

20. A 65-year-old client is admitted to the emergency department with a

fractured hip. The client has chest pain and shortness of breath. The health
care provider orders nitroglycerin tablets. Which should the nurse instruct the
client to do for fastest absorption?
A. Put the tablet under the tongue until it is absorbed.
B. Swallow the tablet with 120 mL of water.
C. Chew the tablet and put the tablet under the tongue until it is
dissolved.
D. Place the tablet between his cheek and gums.

Situation - Nurse Jonas assigned in cardiovascular ward and caring client with
cardiovascular disease.

21. The nurse has completed an assessment on a client with a decreased

cardiac output. Which findings should receive the highest priority?
A. BP 110/62, atrial fi brillation with HR 82, bibasilar crackles.
B. Confusion, urine output 15 mL over the last 2 hours, orthopnea.
C. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower
extremities
D. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.

22. The nurse notices that a client’s heart rate decreases from 63 to 50
beats per minute on the monitor. The nurse should first:
A. Administer Atropine 0.5 mg I.V. push.
B. Auscultate for abnormal heart sounds.
C. Prepare for transcutaneous pacing.
D. Take the client’s blood pressure.

23. A 60-year-old male client comes into the emergency department with a
complaint of crushing substernal chest pain that radiates to his shoulder and
left arm. The admitting diagnosis is acute myocardial infarction (MI).
Immediate admission orders include oxygen by nasal cannula at 4 L/minute,
blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg
of morphine sulfate given I.V. The nurse should first:
A. Administer the morphine.
B. Obtain a 12-lead ECG.
C. Obtain the blood work.
D. Order the chest radiograph.

24. When administering a thrombolytic drug to the client experiencing a

myocardial infarction (MI), the nurse explains that the purpose of the drug is
to:
A. Help keep him well hydrated.
B. Dissolve clots that he may have.
C. Prevent kidney failure.
D. Treat potential cardiac arrhythmias.

25. A client admitted for a myocardial infarction (MI) develops cardiogenic

shock. An arterial line is inserted. Which of the following orders should the
nurse question?
A. Call for urine output < 30 mL/hour for 2 consecutive hours.
B. Metoprolol (Lopressor) 5 mg I.V. push.
C. Prepare for a pulmonary artery catheter insertion.
D. Titrate Dobutamine (Dobutrex) to keep systolic BP > 100.

Situation - A 58-year-old female with a family history of CAD is being seen for
her annual physical exam. Fasting lab test results include: Total cholesterol
198; LDL cholesterol 120; HDL cholesterol 58; Triglycerides 148; Blood sugar
102; and C-reactive protein (CRP) 4.2. The health care provider informs the
client that she will be started on a statin medication, diuretics and aspirin.

26. Which of the following is an expected outcome when a client is

recieving an I.V. administration of furosemide?
A. Increased blood pressure.
B. Increased urine output.
C. Decreased pain.
D. Decreased premature ventricular contractions.

27. Client had a myocardial infarction and is now stable., the hospitalized
client is taught to move the legs while resting in bed. This type of exercise is
recommended primarily to help:
A. Prepare the client for ambulation.
B. Promote urinary and intestinal elimination.
C. Prevent thrombophlebitis and blood clot formation.
D. Decrease the likelihood of pressure ulcer formation

28. Which of the following reflects the principle on which a client’s diet will
most likely be based during the acute phase of myocardial infarction?
A. Liquids as desired.
B. Small, easily digested meals.
C. Three regular meals per day.
D. Nothing by mouth.

29. Crackles heard on lung auscultation indicate which of the following?

A. Cyanosis.
B. Bronchospasm.
C. Airway narrowing.
D. Fluid-filled alveoli.

30. Which of the following is an expected outcome for a client on the

second day of hospitalization after a myocardial infarction (MI)? The client:
A. Has severe chest pain.
B. Can identify risk factors for MI.
C. Agrees to participate in a cardiac rehabilitation walking program.
D. Can perform personal self-care activities without pain

Situation - Nurse Jomar assigned to client with chronic heart failure has atrial
fibrillation and a left ventricular ejection fraction of 15%.

31. The client is taking warfarin (Coumadin). The expected outcome of this
drug is to:
A. Decrease circulatory overload.
B. Improve the myocardial workload.
C. Prevent thrombus formation.
D. Regulate cardiac rhythm

32. Client has been taking several medications, including furosemide

(Lasix), digoxin (Lanoxin) and potassium chloride. The client has nausea,
blurred vision, headache, and weakness.Nurse Jomar notes that the client is
confused. Nurse Jomar should assess the client for signs of which condition?
A. Hyperkalemia.
B. Digoxin toxicity.
C. Fluid deficit.
D. Pulmonary edema.

33. Which of the following positions should a client be placed in by the

nurse?
A. Semi-sitting (low Fowler’s position).
B. Lying on the right side (Sims’ position).
C. Sitting almost upright (high Fowler’s position).
D. Lying on the back with the head lowered (Trendelenburg’s position).
34. The nurse should teach the client that signs of digoxin toxicity include
which of the following?
A. Rash over the chest and back.
B. Increased appetite.
C. Visual disturbances such as seeing yellow spots.
D. Elevated blood pressure.

35. The nurse should be especially alert for signs and symptoms of digoxin
toxicity if serum levels indicate that the client has a:
A. High Magnesium level.
B. High glucose level.
C. High calcium level.
D. Low potassium level.

Situation - Nurse assigned in Acute care unit caring client with chronic
obstructive pulmonary disease (COPD).

36. Client has a new prescription for a combined fluticasone and

salmeterol inhaler and the client asks the nurse the purpose of using two
drugs. Which of the following information is the basis for the nurse’s
response?
A. One drug decreases inflammation, and the other is a
bronchodilator.
B. It is a combination of long-acting and slow-acting bronchodilators.
C. The combination of two drugs works more quickly in an acute asthma
attack.
D. The two drugs work together to block the effects of histamine on the
bronchioles

37. The nurse is evaluating the effectiveness of therapy for a client who
has received treatment during an asthma attack. Which of the following
findings is the best indicator that the therapy has been effective?
A. No wheezes are audible.
B. Oxygen saturation is >92%.
C. Accessory muscle use has decreased.
D. Respiratory rate is 16 breaths/minute.

38. Client has a new prescription for a combined fluticasone and

salmeterol inhaler and the client asks the nurse the purpose of using two
drugs. Which of the following information is the basis for the nurse’s
response?
A. One drug decreases inflammation, and the other is a
bronchodilator.
B. It is a combination of long-acting and slow-acting bronchodilators.
C. The combination of two drugs works more quickly in an acute asthma
attack.
D. The two drugs work together to block the effects of histamine on the
bronchioles

39. The nurse is assessing a young adult client in the outpatient clinic who
has a new diagnosis of emphysema and does not have a history of smoking.
Which of the following information should the nurse anticipate teaching the
client about?
A. Test for Anti elastase
B. Use of the nicotine patch
C. Continuous pulse oximetry
D. Effects of leukotriene modifiers

40. The nurse is caring for a client with chronic bronchitis who has a
nursing diagnosis of impaired breathing pattern related to anxiety. Which of
the following nursing actions is best to include in the plan of care?
A. Titrate oxygen to keep saturation at least 90%.
B. Discuss a high-protein, high-calorie diet with the client.
C. Suggest the use of over-the-counter sedative medications.
D. Teach the client how to effectively use pursed lip breathing.

Situation - The nurse assesses the respiratory status of a clients who are
experiencing an exacerbation of chronic obstructive pulmonary disease
(COPD) and give interventions to the clients.

41. The nurse is instructing a client with COPD how to do pursed-lip

breathing. In which order should the nurse explain the steps to the client?
1. “Breathe in normally through your nose for 2 counts (while counting to
yourself, one, two).”
2. “Relax your neck and shoulder muscles.”
3. “Pucker your lips as if you were going to whistle.”
4. “Breathe out slowly through pursed lips for 4 counts (while counting to
yourself, one, two, three, four).”

A. 2,1,3,4
B. 2,3,1,4
C. 4,3,2,1
D. 4,2,1,3

42. Which of the following physical assessment fi ndings are normal for a
client with advanced chronic obstructive pulmonary disease (COPD)?
A. Increased anteroposterior chest diameter.
B. Underdeveloped neck muscles.
C. Collapsed neck veins.
D. Increased chest excursions with respiration.

43. When instructing clients on how to decrease the risk of chronic

obstructive pulmonary disease (COPD), the nurse should emphasize which of
the following?
A. Participate regularly in aerobic exercises.
B. Maintain a high-protein diet.
C. Avoid exposure to people with known respiratory infections.
D. Abstain from cigarette smoking

44. Which of the following is an expected outcome of pursed-lip breathing

for clients with emphysema?
A. To promote oxygen intake.
B. To strengthen the diaphragm.
C. To strengthen the intercostal muscles.
D. To promote carbon dioxide elimination.

45. Which of the following indicates that the client with chronic obstructive
pulmonary disease (COPD) who has been discharged to home understands
his care plan?
A. The client promises to do pursed-lip breathing at home.
B. The client states actions to reduce pain.
C. The client says that he will use oxygen via a nasal cannula at 5
L/minute.
D. The client agrees to call the physician if dyspnea on exertion
increases

Situation - A 34-year-old female with a history of asthma is admitted to the

emergency department.
46. The nurse notes that the client is dyspneic, with a respiratory rate of 35
breaths/minute, nasal flaring, and use of accessory muscles. Auscultation of
the lung fields reveals greatly diminished breath sounds. Based on these
findings,Physician ordered bronchodilator, oxygen therapy, ABG analysis and
Chest x-ray. Which action should the nurse take to initiate first?
A. Initiate oxygen therapy and reassess the client in 10 minutes.
B. Draw blood for an arterial blood gas analysis and send the client for a
chest X-ray.
C. Encourage the client to relax and breathe slowly through the mouth.
D. Administer bronchodilators as ordered.

47. A client is prescribed short-term corticosteroid therapy. Which is the

expected outcome for the use of steroids in clients with asthma?
A. Promote bronchodilation.
B. Act as an expectorant.
C. Have an anti-inflammatory effect.
D. Prevent development of respiratory infections

48. Which of the following is an appropriate expected outcome for an adult

client with well controlled asthma?
A. Chest X-ray demonstrates minimal hyperinflation.
B. Temperature remains lower than 100° F (37.8° C).
C. Arterial blood gas analysis demonstrates a decrease in PaO2 .
D. Breath sounds are clear.

49. Which of the following fi ndings would most likely indicate the presence
of a respiratory infection in a client with asthma?
A. Cough productive of yellow sputum.
B. Bilateral expiratory wheezing.
C. Chest tightness.
D. Respiratory rate of 30 breaths/minute.

50. Which of the following health promotion activities should the nurse
include in the discharge teaching plan for a client with asthma?
A. Incorporate physical exercise as tolerated into the daily routine.
B. Monitor peak fl ow numbers after meals and at bedtime.
C. Eliminate stressors in the work and home environment.
D. Use sedatives to ensure uninterrupted sleep at night.

Situation - On June 1, a vehicular accident occurs near the hospital, and the
emergency response calls the emergency department to notify the ER. When
the patient arrived at 1 p.m., the doctor quickly placed a chest tube
thoracotomy into the client’s thoracic cavity. Nurse J is assigned to a client
who has suffered chest injuries.

51. The nurse Jona evaluating the patient and the client's significant others
asked the nurse "Which signs and symptoms suggest that my client has
pneumothorax?"
A. Bronchovesicular lung sounds and bradypnea.
B. Unequal lung expansion and dyspnea.
C. Frothy, bloody sputum and consolidation.
D. Barrel chest and polycythemia.

52. At 3 p.m., a right-sided chest tube was inserted for a pneumothorax.

What should Nurse Jona do if the water-seal chamber is not moving
(tidaling)?
A. Obtain an order for a STAT chest x-ray.
B. Increase the amount of wall suction.
C. Check the tubing for kinks or clots.
D. Monitor the client’s pulse oximeter reading.

53. Nurse J is caring for a client and the right-sided chest tube is
accidentally pulled out of the pleural space. Which action should the nurse
implement first?
A. Notify the health-care provider to have chest tubes reinserted STAT.
B. Instruct the client to take slow shallow breaths until the tube is
reinserted.
C. Take no action and assess the client’s respiratory status every 15
minutes.
D. Tape a petroleum jelly occlusive dressing on three (3) sides to the
insertion site.

54. Which action should Nurse J implement for the client with right-sided
chest tube with excessive bubbling in the Suction compartment?
A. Check the amount of wall suction being applied.
B. Assess the tubing for any blood clots.
C. Milk the tubing proximal to distal.
D. Encourage the client to cough forcefully.
55. Today is June 5, Nurse Jona evaluated a client who had a chest tube
thoracotomy. Which evaluation data show that CTT is effective in treating the
client?
A. Gentle bubbling in the suction compartment.
B. No fluctuation (tidaling) in the water-seal compartment.
C. The drainage compartment has 250 mL of blood
D. The client is able to deep breathe without any pain.

Situation - A client has chest pain rated at 8 on a 10 point visual analog scale.
The 12-lead electrocardiogram reveals ST elevation in the inferior leads and
Troponin levels are elevated initial diagnosis is Myocardial Infarction

56. After taking a client's history, the nurse should query which of the
following orders if the client has an active peptic ulcer?
A. Nitroglycerin SL
B. Oxygen by nasal cannula
C. Morphine IV
D. Aspirin PO

57. After a myocardial infarction, a client has concerns about when it is

safe to resume sexual activity. The most appropriate response by the nurse is
A. “You should really talk to your doctor about that.”
B. “Continue with the sexual practice with which you are most
comfortable.”
C. “You need to first undergo a cardiac stress test.”
D. “When you’re able to climb two flights of stairs comfortably.”

58. Which of the following should the nurse include in the preoperative
teaching for a client scheduled for coronary artery bypass graft (CABG)
surgery?
A. A liquid diet will be ordered for the first 4 to 5 days
postoperatively
B. Coughing is to be avoided in order to protect the sternal incision
C. The hospital stay is generally about 2 months
D. High-calorie supplements are encouraged in the first few weeks
postoperative

59. The nurse is teaching the client what to expect after coronary artery
bypass graft surgery (CABG). Which of the following client statements
demonstrates that the client correctly understood the teaching?
A. “I will be given a pen and paper to communicate, because I will
still have a breathing tube in my throat.”
B. “I will be fed with a tube into my stomach until I can eat again.”
C. “Pain medicine is generally not needed after this surgery.”
D. “The nurses will be checking on me every 4 hours.”

Situation - An industrial health nurse at a large printing plant finds a male

employee’s blood pressure to be elevated on two occasions 1 month apart
and refers him to his private physician. The employee is about 25 lb
overweight and has smoked a pack of cigarettes daily for more than 20
years.Client diagnosed with hypertension.

60. When teaching a client about propranolol, the nurse should base the
information on the knowledge that propranolol:
A. Blocks beta-adrenergic stimulation and thus causes decreased
heart rate, myocardial contractility, and conduction.
B. Blocks beta-adrenergic stimulation and thus decreased norepinephrine
secretion and decreases blood pressure and heart rate.
C. Blocks beta-adrenergic stimulation and become potent arterial and
venous vasodilator that reduces peripheral vascular resistance and lowers
blood pressure.
D. Blocks beta-adrenergic stimulation and become angiotensin-converting
enzyme inhibitor that reduces blood pressure by blocking the conversion of
angiotensin I to angiotensin II.

61. Which of the following actions should the nurse in the hypertension
clinic take in order to obtain an accurate blood pressure (BP) ?
A. Obtain a BP reading in each arm and average the results.
B. Deflate the BP cuff at a rate of 5–10 mm Hg/second.
C. Have the client sit in a chair.
D. Assist the client to the supine position for BP measurements

62. The nurse has just finished teaching a client about the newly
prescribed quinapril. Which of the following client statements indicates that
more teaching is needed?
A. “The medication may not work as well if I take any Aspirin.”
B. “My health care provider may order a blood potassium level
occasionally.”
C. “I will call my health care provider if I notice that I have a frequent
cough.”
D. “I won’t worry if I have a little swelling around my lips and face.”

63. In addition about the new medication quinapril. Which of the following
information is important to include when teaching the client?
A. Check BP daily before taking the medication.
B. Increase fluid intake if dryness of the mouth is a problem.
C. Include high-potassium foods such as bananas in the diet.
D. Change position slowly to help prevent dizziness and falls.

64. Example of Beta 2 andrenergic blocker?

A. Metropolol
B. Paracetamol
C. Albuterol
D. Ascorbic acid

Situation - On June 1, a vehicular accident occurs near the hospital, and the
emergency response calls the emergency department to notify the ER. When
the patient arrived at 1 p.m., the doctor quickly placed a chest tube
thoracotomy into the client’s thoracic cavity. Nurse J is assigned to a client
who has suffered chest injuries.

65. The nurse Jona evaluating the patient and the client's significant others
asked the nurse "Which signs and symptoms suggest that my client does not
have pneumothorax?"
A. Bronchovesicular lung sounds and bradypnea.
B. Unequal lung expansion and dyspnea.
C. Frothy, bloody sputum and consolidation.
D. Both lungs have normal breath sounds.

66. At 3 p.m., a right-sided chest tube was inserted for a pneumothorax.

What should Nurse Jona do if the collecting chamber is not moving (tidaling)?
A. Obtain an order for a STAT chest x-ray.
B. Increase the amount of wall suction.
C. Check the tubing for kinks or clots.
D. Nothing to worry

67. Nurse J is caring for a client and the right-sided chest tube is
accidentally pulled out from the bottle. Which action should the nurse
implement first?
A. Notify the health-care provider to have chest tubes reinserted STAT.
B. Instruct the client to take slow shallow breaths until the tube is
reinserted.
C. Reinsert the tubings and assess the client’s respiratory status
every 15 minutes.
D. Tape a petroleum jelly occlusive dressing on three (3) sides to the
insertion site.

68. Which action should Nurse J implement for the client with right-sided
chest tube with excessive bubbling in the water-seal compartment?
A. Check the amount of wall suction being applied.
B. Assess the tubing for any air-leak.
C. Milk the tubing proximal to distal.
D. Encourage the client to cough forcefully.

69. Today is June 5, Nurse Jona evaluated a client who had a chest tube
thoracotomy. Which evaluation data show that CTT is effective in treating the
client?
A. Gentle bubbling in the suction compartment.
B. No fluctuation (tidaling) in the water-seal compartment.
C. The drainage compartment has 250 mL of blood
D. The client is able to deep breathe without any pain.

Situation:

70. First time mother Ask you about the proper nutrition in infancy. You
response correctly when you stated that;
A. New foods every 4 -7 days
B. Evaluate the food does your child like
C. Food must heat in microwave
D. Shellfish is good if you cook it properly

71. other ask you what is the reason of introducing new food to my child?
Best response of the nurse is ?
A. Evaluate allergy
B. Try all food
C. Evaluate what child’s like
D. To evaluate the favorite food of a child

72. You are taking care of client receiving digoxin and as a nurse you are
well educated about this medication. Which of the following is the best
intervention if the client vomits after giving medication?
A. Give another dose
B. Double the dose
C. Don’t give another dose
D. Give half dose

73. Caring client with acyanotic congenital heart disease in pediatric ward
will receive digoxin medication and which statement by the mother must relay
immediately to health care provider?
A. “ My child missed two digoxin doses because of vomiting”
B. “ My child vomits after giving 1 dose of digoxin”
C. “ My child was given digoxin while eating. ”
D. “ My child consumes bananas on a daily basis.”

74. 7 months old client with Tetralogy of Fallot having a hypercyanotic spell
what is the best intervention to do first?
A. Administer oxygen
B. Position client in Squatting position
C. Give morphine
D. Start IV Fluids

75. Client arrived at Emergency department diagnosed with Tetralogy of

fallot, Which of the following laboratory result may indicated of respiratory
insufficiency?
A. Increased RBC
B. Increased WBC
C. Increased Platelet count
D. ABG results of Respiratory Alkalosis

76. You are taking care of client receiving digoxin and as a nurse you are
well educated about this medication. Which of the following is the best
medication readily available at bedside?
A. Digibind
B. Potassium chloride
C. Sodium Bicarbonate
D. Paracetamol
77. Toddler bring by his mother to health care facility and her son
diagnosed with Rheumatic fever, which of the following history taking by the
nurse is most appropriate about the condition of the client?
A. History of taking paracetamol
B. History of Pharyngeal infection
C. History of high Fever
D. History of Joint pain

78. You are educating newly mother about the gross motor skills of the
infant, which statement by the nurse is correct?
A. “ You may observe palmar grasp on 6 month old baby”
B. “ 1 year old baby can throw object”
C. “ Your baby can lift head at the age of 60 days”
D. “ 4 years old can ride a tricycle”

79. Fine motor skills of 9 months old client?

A. Can transfer object from one hand to another”
B. Observed Grasp reflex
C. Able to throw Object
D. Having a palmar grasp

80. Client with Rheumatic fever will receive acetylsalicylic acid, Which of
the following response by the mother needs further instruction?
A. Medication is for Pain
B. Medication is for fever
C. Medication is for inflammation
D. Medication is for clotting

81. You are assigned in Pediatric ward and care client with cleft lip, vital
signs taken by nursing aid and notice mother being emotional about her child.
Which priority nursing diagnosis for parents?
A. Anticipatory grieving
B. Disturbed body image
C. Impaired communication
D. Acute pain

82. 17 years old client admitted in pediatric ward, Vital signs taken within
normal rang and having difficulty of breathing and student nurse report and
ask you about the most often afraid of the client? Which statement by the
nurse is correct?
A. Pimples
B. Separation with mother
C. Stranger
D. Body Mutilation

83. Mother of teenage as you why is her child never talk to her about their
secrets, you response correctly when you state that the most significant
person of teenager is?
A. Family
B. Teacher
C. Peer
D. Father

84. Which of the following statement by the client who is 15 years of age is
correct about changes of his physical appearance? Except?
A. Voice a bit lower than before
B. Much pubic hair
C. Muscle building
D. Enlarge penis

85. An infant is admitted to the pediatric unit with a diagnosis of

hypertrophic pyloric stenosis after vomiting for several days. Which of the
following nursing diagnoses should be the priority?
A. Deficient fluid volume related to prolonged vomiting.
B. Ineffective airway clearance related to impaired swallowing.
C. Imbalanced nutrition: Less than body requirements related to
prolonged vomiting.
D. Bowel incontinence related to abdominal pain

86. A father brings his 5-year-old to the doctor's office for a well-child visit.
The father is embarrassed by his child's behavior during the visit. The father
states that every time the child comes for an immunization she begins to cry
and scream. An appropriate response to this father is:
A. "All children have a major fear of needles; preschoolers often
believe pain is a punishment.“
B. "Your child most likely had a traumatic experience at an early age.“
C. "Next time the mother should accompany the child for an
immunization.“
D. "It is best to ignore this type of behavior as the child is seeking
attention

87. Whenever the parents of a 15-month-old leave their hospitalized child

for short periods, he begins to cry and scream. The nurse explains that this
behavior demonstrates that the child:
A. Needs to remain with his parents at all times.
B. Is experiencing separation anxiety.
C. Is experiencing discomfort.
D. Is extremely spoiled.

88. The nurse determines that teaching about sudden infant death
syndrome (SIDS) has been effective when the clients states:
A. “No definite cause of death is found at autopsy.”
B. “The cause is a brain malformation.’
C. “Breast- feeding causes sudden infant death.’
D. “Genetic disorders are the cause of SIDS.”

89. Which one of the following children is at most common risk factor for
sudden infant death syndrome (SIDS)?
A. Infant who is 3 months old.
B. 2-year-old who has apnea lasting up to 5 seconds.
C. First-born child whose parents are in their early forties.
D. 6-month-old who has had two bouts of pneumonia.

90. The parents report that their 1-day-old is drooling and having choking
episodes with excessive amounts of mucus and color changes, especially
during feedings. When contacting the physician about these symptoms the
nurse should request:
A. A referral to a lactation consultant.
B. That the physician further assess the client.
C. An order for an x-ray with orogastric catheter placement.
D. A serum blood glucose level per laboratory.

Situation - Even if still a staff nurse, Minda, can well contribute with the
management of the resources and environment of her unit.

91. The electric fan in the unit sparks occasionally but continues to function
relatively well. Nurse Minda knows though that she _____.
A. Has to ask one of the staff to preliminary check it
B. Will just wait until the fan stops to function
C. Should alert the unit staff to closely observe the fan
D. Must have it checked by maintenance department immediately

92. The electric fan stop now stops to work every now and then and
continues to spark at interval. The BEST thing to DO NEXT is to _______.
A. Turn off the fan immediately
B. Call the maintenance immediately
C. Let it continue to function
D. Request for another fan as soon as possible

93. The last fire in the hospital was due to a malfunction equipment. The
fire extinguisher was no where to be found. What should have been
practiced?
A. A dedicated fire extinguisher must be in every strategic place.
B. Place one extinguisher between two units
C. A fire extinguisher can be replaced with fire sensors
D. Borrowing fire extinguisher may be tolerated if on the same floor

94. The staff assigned to check the fire extinguisher failed to monitor the
“whereabouts” of assigned equipment. The following statements are true
except:
A. All employees are lazy
B. Monitoring staff is important
C. Not all staff are diligent in their task
D. Two errors added together can be potentially devastating

95. Because of the failure to replace the defective electric fan immediately,
a fire broke out and it became big enough to burn a major portion of the unit
because a fire extinguisher was missing. What lesson can be gained from
this?
A. Punishment must be imposed on erring employees.
B. Reorientation of the new staff
C. Refer the erring employee to HR
D. Every protocol must be followed

Situation - The 3-year-old child has just finished ingesting the kerosene stored
in a lemo-lime bottle. When the mother saw the child, she immediately
brought him to the nearest hospital.

96. The assessment of the patient with ingested poison must include
_________.
I. Determining the poison ingested and the amount
II. The time from ingestion and the signs and symptoms
III. Weight of the patient
IV. Patient’s immunization history

A. I, II, III and IV

B. I, II and IV
C. I, II and III
D. II, III and IV

97. In case of poisoning, the nurse is aware that the main goals in
poisoning are to__________.
I. Inactivate the poison
II. Administer the specific antidote
III. Induce the patient to vomit
IV. Support vital organ functions

A. I, II and IV
B. I, II and III
C. I, III and IV
D. II, III and IV

98. To remove the ingested poisonous substance, the physician ordered a

gastric lavage. What is the role of the nurse immediately prior to the
procedure?
A. Get the right size of the nasogastric tube
B. Remind parents to be careful next time
C. Obtain and informed consent immediately
D. Tell the parent that they are negligent

99. The nurse is aware that the proper management of poisoning includes
the following EXCEPT to ________.
A. Perform hemoperfusion
B. Remove the toxin through dialysis
C. Dilute the ingested substance
D. Induce vomiting after ingestion of the caustic substance or
petroleum distillate
100. Discharge instruction made by the nurse to the parents should
include________.
A. Close monitoring of the toddler
B. Disciplining the child every time
C. Poison-proofing the home
D. Lecturing the child on safety

Prepared by:
Sir. Darryl Custodio Locañas, RN, MScN