NP 1 December 2007 4.

George, a 43 year old executive is scheduled

MULTIPLE CHOICE for cardiac bypass surgery. While being
prepared for the surgery, he says to the nurse “I
1. Nurse Suzie is administering 12:00 PM am not going to have the surgery. I may die
medication in Ward 4. Two patients have to because of the risk.” Which response by the
receive Lanoxin. What should Nurse Suzie do nurse is most appropriate?
when one of the clients does NOT have a A. “Without the surgery you will most likely die
readable identification band? sooner.”
A. Ask the client if she is Mrs. Santos B. “There are always risks involved with
B. Ask the client his name surgery.”
C. Ask the room mate if the client is Mrs. Santos C. “There is a client in the other room who had
D. Compare the ID band with the bed tag successful surgery and you can talk to
him.”
2. Lizette, a head nurse in a surgical unit, hears D. “This must be very frightening for you. Tel me
one of the staff nurses say that she does not how you feel about the
touch any client assigned to her unless she surgery.”
performs nursing procedures or conducts
physical assessment. To guide the staff nurse in 5. A client is ordered to take Lasix, a diuretic, to
the use of touch, which of the following would be taken orally daily. Which of the following is
be BEST response of Lizette? an appropriate instruction by the nurse?
A. “Use touch when the situation calls for it”. A. Report to the physician the effects of the
B. “Touch serves as a connection between the medication on urination.
nurse and the patient”. B. Take the medicine early in the morning
C. “Use touch with discretion”. C. Take a full glass of water with the medicine
D. “Touch is used in physical assessment”. D. Measure frequency of urination in 24 hours

3. You are asked to teach the client, Mr. Lapuz, 6. Nurse Glenda gets a call from the neighbor
who has right sided weakness the use of a cane. who tells her that his 3 years old daughter has
Which observation will indicate that Mr. Lapuz is been vomiting and has fever and asks for advice.
using the cane correctly? Which of the following is the most
A. The cane and one foot or both feet are on the appropriate action of the nurse?
floor at all times A. Observe the child for an hour. If the child
B. He advances the cane followed by the left leg does not improve, refer to the physician in
C. Client keeps the cane on the right side along the neighborhood.
the weak leg B. Recommend to bring the child immediately to
D. Client leans to the left side which is stronger the hospital
C. Assess the child, recommend observation and
administer acetaminophen. If
symptoms continue, bring to the hospital.
D. Tell the neighbor to observe the child and
give plenty of fluids. If the child does not
improve, bring the child to the hospital.
7. Wilfred, 30 years old male, was brought to 11. Which of the following situations would
the hospital due to injuries sustained from a possibly cause a nurse to be sued due to
vehicular accident. While being transported to negligence?
the X-ray department, he straps accidentally A. Nurse gave a client wrong medication, and an
broke and the client fell to the floor hitting to hour later, client complained of dyspnea
his head. In this situation, the nurse is: B. While preparing a medication, the nurse
A. not responsible because of the doctrine of notices that instead of 1 tablet, she put two
respondent superior tablets into the client’s medicine cup
B. free from any negligence that caused harm to C. As the nurse was about to administer
the patient medication, the client questioned why the
C. liable along with the employer for the use of medication is still given when in fact the
a defective equipment that physician discontinued it.
harms the client D. Nurse administered 2 tablets of analgesic
D. totally responsible for the negligence instead of 1 tablet as prescribed. Patient
noticed the error and complained.
8. While going on evening round, Nurse Edna
saw Mrs. Pascual meditating and afterwards 12. Your nurse supervisor asks you who among
started singing prayerful hymns. What is the the following clients is most susceptible to
BEST response of Edna? getting infection if admitted to the hospital?
A. Ignore the incidence A. Diabetic client type2
B. Report the incidence to the head nurse B. Client with chronic obstructive pulmonary
C. Respect the client’s actions as this provides disease (COPD)
structure and support to the C. Client with second degree burns
client D. Client with psoriasis
D. Call her attention so she can go to sleep
13. Mr. Chris Martinez has been confined for
9. A client asks for advice on low cholesterol three days. His wife helped take care of him and
food. You advise the client to eat the following: he has observed her to be “too involved” in his
A. Chicken liver, cow liver, eggs care. He complained to the head nurse about
B. Lean beef and pork, egg ewhite, fish this. Which of the following would be the BEST
C. Balut, salted eggs, duck and chicken egg response of the nurse?
D. Pork liempo, cow brain, lungs and kidney A. “Don’t worry. I will call the attention of your
wife.”
10. The code of ethics for nurses has an B. “Your wife is just trying to help because she is
interpretative statement that provides: worried about you.”
A. continuity of care for the improvement of the C. “What are your thoughts about your wife’s
client involvement in your care?”
B. guide for carrying out nursing responsibilities D. “Your wife can assist you well in your care
that provide quality care and and recovery.”
for the ethical obligation of the profession
C. standards of care in carrying out nursing
responsibilities
D. identical care to all clients in any setting
14. The nurse is in the hospital canteen and 16. You are to administer an intramuscular
hears two staff nurses talking about the client injection to Dulce, 1 1⁄2 year old girl. The most
confined in Room 612. They mentioned his appropriate site to administer the drug is:
name and discussed details of his condition. A. dorso gluteal region C. vastus lateralis
Which of the following actions should the nurse B. ventral forearm D. gluteal region
take?
A. Approach the two nurses and tell them that 17. An infant is ordered to receive 500ml of
their actions are inappropriate D5NSS for 24 hours. The intravenous drip is
especially in a public place running at 60 drops/minute. How many drops
B. Wait till the nurses finish the discussion and per minute should the flow rate be?
report the situation to the supervisor A. 60 drops per minute C. 30 drops per minute
C. Say nothing to avoid embarrassing the staff B. 21 drops per minute D. 15 drops per minute
nurses
D. Remain quiet and ignore the discussion 18. Following surgery, Henry is to receive 20
mEq (milliequivalent) of potassium chloride to
15. The son of Mr. Rosario, a 76 year old man, be added to 1000 ml of D5W to run for 8 hours.
reports to the nurse in the community health The intravenous infusion set is calibrated at 20
center that his father has been getting out of drops per milliliter. How many drops per minute
bed at night and walks around the house in the should the rate be to infuse 1 liter of D5W for 8
early hours of the morning causing him to fall hours?
and injure himself. Which instruction would you A. 42 drops C. 60 drops
give? B. 20 drops D. 32 drops
A. Apply restraints during night hours only
B. Advise hospitalization to prevent future 19. Mr. Lagro is to receive 1 liter of D5LR to run
accidents for 12 hours. The drop factor of the IV infusion
C. Keep a radio or TV for company and to orient set is 10 drops per minute. Approximately how
the client many drop per minutes should the IV be
D. Have someone check on the client frequently regulated?
at night A. 13-14 drops C. 10-12 drops
B. 17-18 drops D. 15-16 drops
SITUATIONAL
Situation 1 – Preparation and administration of 20. The physician ordered Nembutal Na gr XX.
medications is a nursing function that The bottle contains 100mg/capsule. How many
cannot be delegated. It is important that the capsule will be administered to the client?
nurse has a deep understanding of this A. 1 capsule C. 2 capsule
responsibility that is meant to save patient’s B. 1 1⁄2 capsule D. 1⁄2 capsule
lives.
Situation 2 – The nurse supervisor is observing 24. The nurse who makes clinical judgment can
the staff nurses in her hospital to see how be depended upon to improve the quality of
quality of care provided to clients can be care of clients. Nurse Julie uses such good
improved. clinical judgment when she gives priority care to
this client:
21. The nurse supervisor is not satisfied with the A. Roman, a client who is ambulatory and for
bed bath that is provided by Nurse Arthur. To surgery tomorrow
improve the care provided to the patients in the B. A post operative client, Rey, who has a blood
unit by Nurse Arthur, the nurse supervisor pressure of 90/50 mmHg
should: C. Mr. Abad, a client who needs instructions for
A. tell the nurse how to give bed baths correctly home medications
B. ask another staff nurse to do bed baths D. Fred, a client who received pain medications
instead 5 minutes ago
C. provide a manual to be read on giving bed
baths 25. A good nursing care plan is dependent on a
D. bring the staff nurse to a client’s room and correctly written nursing diagnosis. It defines a
demonstrate client’s problem and its possible cause. The
following is an example of a well written nursing
22. The staff nurse discusses with the novice diagnosis:
nurse the type of wound dressing that is best to A. Acute pain related to altered skin integrity
use for a client. Together, they observe how well secondary to hysterectomy
the dressings absorb the drainage. In what B. Electrolyte imbalance related to
step of the decision making process are they? hypocalcemia
A. Testing options C. Altered nutrition related to high fat intake
B. Considering effects on results secondary to obesity
C. Defining the problem D. Knowledge deficit related to
D. Making final decisions proctosigmoidoscopy

23. To check if the nurses under her supervision Situation 3– You are taking care of Mrs. Leyba,
use critical thinking, Mrs. David observes if the 66 years old, who is terminally ill with
nurses act responsibly when at work. Which of ovarian cancer stage IV.
the following actions of the nurse demonstrates
the attitude of responsibility? 26. When caring for a dying client, you will
A. Thinking of alternative methods of nursing perform which of the following activities?
care A. Encourage the client to reach optimal health
B. Sharing ideas regarding patient care B. Assist client perform activities of daily living
C. Following standards of practice C. Assist the client towards a peaceful death
D. Planning other approaches for patient care D. Motivate client to gain independence
27. The client prepares for her eventual death 31. Ramil’s right leg is injured and Nurse Karen
and discusses with the nurse and her family has to move him from the bed to w wheel chair.
how she would like her funeral to look like and Which of the following is the appropriate
what dress she will use. This client is in the nursing action of Nurse Karen?
stage of: A. Put the client on the edge of the bed and
A. acceptance C. denial place the wheelchair at her back
B. resolution D. bargaining B. Face the client and place the wheelchair on
her left side
28. The nurse is to administer Demerol 50 mg C. Put the client on the edge of the bed and
IM to Mrs. Leyba. Demerol is available in a place the wheelchair on the other side of
multidose vial labelled 100 mg/ml and Vistaril the bed
comes in an ampule labelled 50 mg/ml. You are D. Put the client on the edge of the bed and
to give the both medications in one injection. place the wheelchair on the client’s
You will: left side
A. withdraw the medication from the vial first
then from the ampule 32. Carlo has to be maintained on a dorsal
B. inject air into the vial, then into the ampule recumbent position. Which of the following
C. inject air into the ampule, aspirate the should be prevented?
desired dose, then into the vial A. adduction of the shoulder
D. withdraw medication from the ampule then B. Lateral flexion of the sternocleidomastoid
from the vial muscle
C. Hyperextension of the knees
29. When giving Demerol 50 mg from a D. Anterior flexion of the lumbar curvature
multidose vial labelled 100 mg/ml and Vistaril
50 mg/ml from an ampule labelled 50 mg/ml, 33. Joseph prefers to be in high fowler’s position
what is the total volume that you will inject to most of the time. The nurse should prevent
the client? which of the following?
A. 2 ml C. 1.5 ml A. Posterior flexion of the lumbar curvature
B. 1 ml D. 1.75 ml B. Internal rotation of the shoulder
C. External rotation of the hip
30. Mrs. Leyba is emaciated and is at risk for D. Adduction of the shoulder
developing which problem in skin integrity?
A. Blisters C. Pressure sores 34. Anthony asks to be assisted to move up the
B. Reddening of the skin D. Pustules bed. Which of the following should Nurse Diana
do first?
Situation 4 – You are assigned to work in an A. Move the patient to the edge of the bed near
orthopedic ward where clients are expected to the nurse
have problems in mobility and immobility. B. Adjust the bed to flat position
C. Lock the wheels of the bed
D. Raise the bed rails opposite the nurse
35. Which of the following supportive devices 39. Mr. Lozano, 50 year old executive, is
can be used most effectively by Nurse Arnold to recovering from severe myocardial infarction.
prevent external rotation of the right leg? For the past 3 days, Mr. Lozano’s hygiene and
A. Sandbags C. Pillow grooming needs have been met by the nursing
B. Firm mattress D. High foot board staff. Which of the following activities should be
implemented to achieve the goal of
Situation 5 – As you begin to work in the independence for Mr. Lozano?
hospital where you are on probation, you are A. Involving family members in meeting client’s
tasked to take care of a few patients. The clients personal needs
have varied needs and you are expected to B. Meeting his needs till he is ready to perform
provide care for them. self-care
C. Preparing a day to day activity list to be
36. An ambulatory client. Mr. Zosimo, is being followed by client
prepared for bed. Which of the following D. Involving Mr. Lozano in his care
nursing actions promote safety for the client?
A. Turning off the lights to promote rest and 40. Mr. Ernest Lopez is terminally ill and he
sleep choose to be at home with his family. What
B. Instructing the client about the use of call nursing action are best initiated to prepare the
system family of Mr. Lopez?
C. Raising the side rails A. Talk with the family members about the
D. Placing the bed in high position advantage of staying in the hospital for
proper care
37. Mikka, a 25 year old female client, is B. Provide support to the family members by
admitted with right lower quadrant abdominal teaching ways to care for their
pain. The physician diagnosed the client with loved one
acute appendicitis and an emergency C. Convince the client to stay in the hospital for
appendectomy was performed. Twelve hours professional care
following surgery, the patient complained of D. Tell the client to be with his family
pain. Which of the following is the most
appropriate nursing diagnosis? Situation 6 – Myrna, a researcher, proposes a
A. Impaired mobility related to pain secondary study on the relationship between health
to an abdominal incision values and the health promotion activities of
B. Impaired movements related to pain due to staff nurses in a selected college of nursing.
surgery
C. Impaired mobility related to surgery 41. In both quantitative and qualitative
D. Severe pain related to surgery research, the used of a frame of reference is
required.
38. You are preparing a plan of care for a client Which of the following items serves as the
who is experiencing pain related to incisional purpose of a framework?
swelling following laminectomy. Which of the A. Incorporates theories into nursing’s body of
following should be included in the nursing care knowledge
plan? B. Organizes the development of study and links
A. Encourage the client to log roll when turning the findings to nursing’s body
B. Encourage the client to do self-care of knowledge
C. Instruct the client to do deep breathing C. Provides logical structure of the research
exercises findings
D. Ambulate the client in ward premises every D. Identifies concepts and relationships
twenty minutes between concepts
42. Myrna need to review relevant literature Situation 7 – While working in a tertiary
and studies. The following processes are hospital, you are assigned to the medical ward.
undertaken in reviewing literature EXCEPT:
A. locating and identifying resources 46. Your client, Mr. Diaz, is concerned that he
B. reading and recording notes can not pay his hospital bills and professional
C. clarifying a research topic fees. You refer him to a:
D. using the library A. Nurse supervisor
B. Social worker
43. The primary purpose for reviewing literature C. bookkeeping department
is to: D. physician
A. organize materials related to the problem of
interest 47. Mr. Magno has lung cancer and is going
B. generate broad background and through chemotherapy. He is referred by the
understanding of information related to the oncology nurse to a self-help group of clients
research problem of interest with cancer to:
C. select topics related to the problem of A. receive emotional support
interest B. to be a part of a research study
D. gather current knowledge of the problem of C. provide financial assistance
interest D. assist with chemotherapy

44. In formulating the research hypotheses, 48. A diabetic hypertensive client, Mrs. Linao,
researcher Myrna should state the research needs a change in diet to improve her health
question as: status. She should be referred to a:
A. What is the response of the staff nurses to A. nutritionist C. physician
the health values? B. dietitian D. medical pathologist
B. How is variable “health value” perceived in a
population? 49. When collaborating with other health team
C. Is there a significant relationship between members, the best description of Nurse Rita’s
health values and health role is:
promotion activities of the staff nurses? A. encourages the client’s involvement in his
D. How do health values affect health care
promotion activities of the staff nurses? B. shares and implements orders of the health
team to ensure quality care
45. The proposed study shows the relationship C. she listens to the individual views of the team
between the variables. Which of the following is members
the independent variable? D. helps client set goals of care and discharge
A. Staff nurses in a selected college of nursing
B. Health values 50. Nurse Rita is successful in collaborating with
C. Health promotion activities health team members about the care of Mr.
D. Relationship between health values and Linao. This is because she has the following
health promotion activities competencies:
A. Communication, trust, and decision making
B. Conflict management, trust, negotiation
C. Negotiation, decision making
D. Mutual respect, negotiation and trust
Situation 8 – The practice of nursing goes with 54. You are assigned to Mrs. Amado, age 49,
responsibilities and accountability whether who was admitted for possible surgery. She
you work in a hospital or in the community complained of recurrent pain at the right upper
setting you main objective is to quadrant of the abdomen 1-2 hours after
provide safe nursing to your clients? ingestion of fatty food. She also had frequent
bouts of dizziness, blood pressure of 170/100,
51. To provide safe, quality nursing care to hot flashes. Which of the above symptoms
various clients in any setting, the most would be an objective cue?
important tool of the nurse is: A. Blood pressure measurement of 170/100
A. critical thinking to decide appropriate nursing B. Complaint of hot flashes
actions C. Report of pain after ingestion of fatty food
B. understanding of various nursing diagnoses D. Complaint of frequent bouts of dizziness
C. observation skills for data collection
D. possession of in scientific knowledge about 55. While talking with Mrs. Amado, it is most
client needs important for the nurse to:
A. schedule the laboratory exams ordered for
52. You ensure the appropriateness and safety her
of your nursing interventions while caring for B. do an assessment of the client to determine
various client groups by: priority needs
A. creating plans of care for particular clientele C. tell the client that your shift ends after eight
B. identifying the correct nursing diagnoses for hours
clients D. have the client sign an informed consent
C. making a thorough assessment of client
needs and problems Situation 9 – Oral care is an important part of
D. using standards of nursing care as your hygienic practices and promoting client comfort.
criteria for evaluation
56. An elderly client, 84 years old, is
53. The effectiveness of your nursing care plan unconscious. Assessment of the mouth reveals
for your clients is determined by excessive dryness and presence of sores. Which
A. the number of nursing procedures performed of the following is BEST to use for oral care?
to comfort the client A. lemon glycerine C. Mineral oil
B. the amount of medications administered to B. hydrogen peroxide D. Normal saline solution
the client as ordered
C. the number of times the client calls the nurse 57. When performing oral care to an
D. the outcome of nursing interventions based unconscious client, which of the following is a
on plan of care special consideration to prevent aspiration of
fluids into the lungs?
A. Put the client on a sidelying position with
head of bed lowered
B. Keep the client dry by placing towel under
the chin
C. Wash hands and observe appropriate
infection control
D. Clean mouth with oral swabs in a careful and
an orderly progression
58. The advantages of oral care for a client
include all of the following, EXCEPT: 62. Miscommunication of drug orders was
A. decreases bacteria in the mouth and teeth identified as a probable cause of medication
B. reduces need to use commercial mouthwash errors. Which of the following is safe medication
which irritate the buccal practice related to this?
mucosa A. Maintain medication in its unit dose package
C. improves client’s appearance and self- until point of actual administration
confidence B. Note both generic and brand name of the
D. improves appetite and taste of food medication in the Medication
Administration Method
59. A possible problem while providing oral care C. Only officially approved abbreviations maybe
to unconscious clients is the risk of fluid used in prescription orders
aspiration to lungs. This can be avoided by: D. Encourage clients to ask question about their
A. Cleaning teeth and mouth with cotton swabs medications.
soaked with mouthwash to avoid
rinsing the buccal cavity 63. The hospital has an ongoing quality
B. swabbing the inside of the cheeks and lips, assurance program. Which of the following
tongue and gums with dry cotton swabs indicates implementation of process standards?
C. use fingers wrapped with wet cotton A. The nurses check client’s identification band
washcloth to rub inside the cheeks, tongue, before giving medications
lips and ums B. The nurse reports adverse reaction to drugs
D. suctioning as needed while cleaning the C. Average waiting time for medication
buccal cavity administration is measured

60. Your client has difficulty of breathing and is D. The unit has well ventilated medication room
mouth breathing most of the time. This causes
dryness of the mouth with unpleasant odor. 64. Which of the following actions indicate that
Oral hygiene is recommended for the client and Nurse Jerome is performing outcome evaluation
in addition, you will keep the mouth moistened of quality care?
by using: A. Interviews nurses for comments regarding
A. salt solution C. petroleum jelly staffing
B. water D. mentholated ointment B. Measures waiting time for client’s per nurse’s
call
Situation 10 – Errors while providing nursing C. Checks equipment for its calibration schedule
care to patients must be avoided and minimized D. Determines whether nurses perform skin
at all time. Effective management of available assessment every shift
resources enables the nurse to provide safe,
quality patient care. 65. An order for a client was given and the nurse
in charge of the client reports that she has no
61. In the hospital where you work, increased experience of doing the procedure before.
incidence of medication error was identified as Which of the following is the most appropriate
the number one problem in the unit. During the action of the nurse supervisor?
brainstorming session of the nursing service A. Assign another nurse to perform the
department, probable causes were identified. procedure
Which of the following is process related? B. Ask the nurse to find way to learn the
A. interruptions C. lack of knowledge procedure
B. use of unofficial abbreviations D. failure to C. Tell the nurse to read the procedure manual
identify client D. Do the procedure with the nurse
Situation 11 – Mr. Jose’s chart is the permanent 70. A telephone order is given for a client in
legal recording of all information that relates your ward. What is your most appropriate
tohis health care management. As such, the action?
entries in the chart must have accurate data. A. Copy the order on to the chart and sign the
physician’s name as close to his
66. Mr. Jose’s chart contains all information original signature as possible
about his health care. The functions of records B. Repeat the order back to the physician, copy
include all except: onto the order sheet and
A. means of communication that health team indicate that it is a telephone order
members use to communicate their C. Write the order in the client’s chart and have
contributions to the client’s health care the head nurse co-sign it
B. the client’s record also shows a document of D. Tell the physician that you can not take the
how much health care agencies will order but you will call the nurse supervisor
be reimbursed for their services
C. educational resource for student of nursing Situation 12 – Nurse Roque, a newly hired
and medicine nurse, is asked to take over an absent nurse in
D. recording of actions in advance to save time another unit. She will take care of clients with
various conditions.
67. An advantage of automated or
computerized client care system is: 71. Which of the following client conditions
A. The nursing diagnoses for a client’s data can should be Miss Roque’s priority in the pediatric
be accurately determined unit?
B. Cost of confinement will be reduced A. The baby whose fantanelle is bulging and firm
C. Information concerning the client can b easily while asleep
updated B. The infant who is brought in for upper
D. The number of people to take care of the respiratory tract infection whose
client will be reduced temperature is slightly elevated
C. A baby who is wailing after being awakened
68. Information in the patient’s chart is by the banging door
inadmissible in court as evidence when: D. A baby boy whose circumcision has yellowish
A. The client’s family refuses to have it used exudate
B. The client objects to its use
C. The handwriting is not legible 72. When suctioning the endotracheal tube, the
D. It has too many abbreviations that are nurse should:
“unofficial” A. Explain procedure to patient; insert catheter
gently applying suction. Withdrawn
69. Nursing audit aims to: using twisting motion
A. provide research data to hospital personnel B. Insert catheter until resistance is met, then
B. study client’s illness and treatment regimen withdraw slightly, applying
closely suction intermittently as catheter is withdrawn
C. compare actual nursing done to established C. Hyperoxygenate client insert catheter using
standards back and forth motion
D. provide information to health-care providers D. Insert suction catheter four inches into the
tube, suction 30 seconds using twirling
motion as catheter is withdrawn
73. Nurse Roque is giving instructions to Doris, 77. Surgical sepsis is observed when:
the daughter of a comatose patient, to give a A. inserting an intravenous catheter
sponge bath. While Doris is doing spone bath, B. disposing of syringes and needles in puncture
what action of Doris needs correction? proof containers
A. Answering the phone while wearing gloves C. washing hands before changing wound
used for sponge bath dressing
B. Rolling the patient like a log to do back rub D. placing dirty soiled linen in moisture resistant
C. Lining the rubber mat with bed sheet as bags
incontinence pad for the patient
D. Turning the patient on the left side with head 78. A client with viral infection will most likely
slightly elevated manifest which of the following during the
illness stage of the infection?
74. Dina sustained a fracture of the ulna and a A. Client was exposed to the infection 2 days
cast will be applied. What nursing action before ago but without any symptoms
cast application is most important for Nurse B. Oral temperature shows fever
Roque to do? C. Acute symptoms are no longer visible
A. Use baby powder to reduce irritation under D. Client “feels sick” but can do normal activities
the cast
B. Assess sensation of each arm 79. Which of the following laboratory test result
C. Evaluate skin temperature in the area indicate presence of an infectious process?
D. Check radial pulses bilaterally and compare A. Erythrocyte sedimentation rate (ESR) 12
mm/hr
75. To obtain specimen for sputum culture and B. White blood cells (WBC) 18,000/mm3
sensitivity, which of the following instruction is C. Iron 90 g/100ml
best? D. Neutrophils 67%
A. Upon waking up, cough deeply and
expectorate into container 80. Among the clients you are assigned to take
B. Cough after pursed lip breathing care of, who is the most susceptible to
C. Save sputum for two days in covered infection?
container A. Diabetic client
D. After respiratory treatment, expectorate into B. Client with burns
a container C. client with pulmonary emphysema
D. client with myocardial infarction
Situation 13 – Infections are quite commonly
the reasons for a client’s hospitalization. Situation 14 – You are a newly hired nurse in a
Appropriate interpretation of diagnostic tests tertiary hospital. You have finished your
and measures for infection control are helpful in orientation program recently and you are
the management of patient care. beginning to assimilate the culture of the
profession.
76. Dorothy underwent diagnostic test and the
result of the blood examination are back. On 81. Using Benner’s stages of nursing expertise,
reviewing the result the nurse notices which of you are a beginning nurse practitioner. You will
the following as abnormal finding? rank yourself as a/an:
A. Neutrophils 60% A. competent nurse C. proficient nurse
B. White blood cells (WBC) 9000/mm B. novice nurse D. advanced beginner
C. Erythrocyte sedimentation rate (ESR) is 39
mm/hr
D. Iron 75 mg/100 ml
82. Benner’s “Proficient” nurse level is different 87. Part of your lesson plan is to talk about
from the other levels in nursing expertise in the etiology or cause of stroke. The types of stroke
context of having: based on cause are the following EXCEPT:
A. the ability to organize and plan activities A. Embolic stroke C. diabetic stroke
B. having attained an advanced level of B. Hemorrhagic stroke D. thrombotic stroke
education
C. a holistic understanding and perception of 88. Hemmorhagic stroke occurs suddenly
the client usually when the person is active. All are causes
D. intuitive and analytic ability in new situations of hemorrhage, EXCEPT:
A. phlebitis C. damage to blood vessel
83. As you become socialized into the nursing B. trauma D. aneurysm
“culture” you become a patient advocate.
Advocacy is explained by the following EXCEPT: 89. The nurse emphasizes that intravenous drug
A. respecting a person’s right to be autonomous abuse carries a high risk of stroke. Which drug
B. demonstrating loyalty to the institution’s is closely linked to this?
rights A. Amphetamines C. shabu
C. shared respect, trust and collaboration in B. Cocaine D. Demerol
meeting health needs
D. protecting and supporting another person’s 90. A participant in the STROKE class asks what
rights is a risk factor of stroke. Your best response is:
A. “More red blood cells thicken blood and
84. Modern day nursing has led to the led make clots more possible.”
development of the expanded role of the nurse B. “Increased RBC count is linked to high
as seen in the function of a: cholesterol.”
A. Clinical nurse specialist C. “More red blood cell increases hemoglobin
B. Critical care nurse content.”
C. community health nurse D. “High RBC count increases blood pressure.”
D. staff nurse
Situation 16 – Accurate computation prior to
85. You join a continuing education program to drug administration is a basic skill all nurses
help you: must have.
A. Earn credits for license renewal
B. Get in touch with colleagues in nursing 91. Rudolf is diagnosed with amoebiasis and is
C. Enhance your basic knowledge to received Metronidazole (Flagyl) tablets 1.5
D. Update your knowledge and skills related to gm daily in 3 divided doses for 7 consecutive
field of interest days. Which of the following is the correct dose
of the drug that the client will received per oral
Situation 15 – When creating your lesson plan administration?
for cerebrovascular disease or STROKE. It is A. 1,000 mg tid C. 1,500 mg tid
important to include the risk factors of stroke. B. 500 mg tid D. 50 mg tid

86. The most important risk factor is:

A. Cigarette smoking C. binge drinking
B. Hypertension D. heredity
92. Rhona, a 2 year old female was prescribed 95. When Nurse Norma was about to administer
to receive 62.5 mg suspension three times a the medications of client Lennie, the relative of
day. The available dose is 125 mg/ml. which of Lennie told the nurse that they buy her
the following should Nurse Paolo prepare for medicines and showed the container of
each oral dose? medications of the client. Which of the
A. 0.5 ml C. 2.5 ml following is the most appropriate action by the
B. 1.5 ml D. 10 ml nurse?
A. Hold the nurse administration of the client’s
93. The physician ordered Potassium Chloride medication and refer to the head nurse
(KCL) in D5W 1 liter to be infused in 24 hours for B. Put aside the medications she prepared and
Mrs. Gomez. Since Potassium Chloride is a high instead administer the client’s
risk drug, Nurse Robert used an intravenous medications
pump. Which of the following should Nurse C. Tell the client that she will inform the
Robert do to safely administer this drug? physician about this
A. Check the pump setting every 2 hours D. Bring the medications of the client to the
B. Teach the client how the infusion pump nurse’s station and prepare accordingly
operates
C. Have another nurse check the infusion pump Situation 17 – You are taking care of Mrs.
setting Santillan a 48 year old woman who is
D. Set the alarm of the pump loud enough to be unconscious after a cerebrovascular accident.
heard You are aware that there are many physical
complications due to immobility.
94. Baby Liza, 3 months old, with a congenital
heart deformity, has an order from her 96. You should be alert for the following
physician: “give 3.00 cc of Lanoxin today for 1 complications she may experience EXCEPT:
dose only”. Which of the following is the most A. Impaired mobility
appropriate action by the nurse? B. Contractures and muscle atrophy
A. Clarify order with the attending physician C. hypostatic pneumonia
B. Discuss the order with the pediatric heart D. pressure sores
specialist in the unit
C. Administer Lanoxin intravenously as it is the 97. Proper positioning of an immobilized
usual route of administration unconsciousness client is important for the
D. Refer to the medication administration record following reasons EXCEPT:
for previous administration of Lanoxin A. Maintain skin integrity
B. Promotes optimal lung expansion
C. Prevent injuries and deformities of the
musculo-skeletal system
D. Facilitates rest and sleep

98. When positioning your client, you should

observe good body mechanics for yourself and
the client. This means that the nurse:
A. Uses back muscles
B. Assumes correct body alignment and efficient
use of muscles to avoid injury
C. Observes rhythmic movements when moving
about
D. Uses large muscles only
99. You are going to move Mrs. Santillan, a 150
lbs unconscious woman. Some principles to use
when moving the client include the following
EXCEPT:
A. prepare to move client by taking deep breath
and tightening abdominal and gluteal
muscles
B. maintain wide base of support with feet and
with knees flexed
C. push and pull using arms and legs instead of
lifting
D. move close to the object to be moved leaning
or bending at the waist

100. After moving Mrs. Santillan to the desired

position, which action will you avoid?
A. Avoid friction between bony prominences
B. Place pillows to position client’s extremities
C. Apply restraints
D. Raise bed rails