NURSING PRACTICE 3

Situation: Nurse Kimmy has newly admitted

patients in the Medicine Ward who are for 5. Patient Revi likes to eat melons
workup. and strawberries. On the day of her
specimen collection for fecal
1. Jason is a 25-year-old patient
occult blood, she claimed that she
suspected to have chronic myelogenous
has been bingeing on these fruits
leukemia. He is advised to undergo bone
since 5 days ago. What will be its
marrow biopsy. The following bones
implication on the test/results?
may be used for the procedure, except:
a. Results can become falsely positive
a. Posterior superior iliac crest
for occult blood.
b. Anterior superior iliac spine
b. Results can become falsely negative for
c. Sternum
occult blood.
d. Triquetrum
c. Increased intake of fruits will confirm
2. Nurse Kimmy knows that 24-hour presence of occult blood in stool.
urine collection is needed in determining d. Stool specimen will become
the following, except: claycolored.
Situation: Because it is already her
a. Vanillylmandelic acid (VMA) in
board exams in a few days, Jennifer
pheochromocytoma
practices computing medications
b. Uric acid in gouty arthritis
dosages with the following scenarios.
c. Culture and sensitivity of causative agent
in urinary tract infections 6. Mannitol 0.25g/kg/day was
d. Creatinine clearance in acute kidney prescribed to a 7-year-old patient
injury (AKI) with meningitis. The patient weighs
28.6 lbs. How much mannitol
3. Immediately after obtaining blood for
should the nurse give?
an arterial blood gas examination, Nurse
Kimmy instructs the patient to do which
a. 32.5 g
of the following?
b. 3.25 mg
c. 3.25 g
a. Perform ROM exercise on the proximal d. 0.325 g
joint.
b. Apply pressure for 5-10 minutes 7. Nurse Jeniffer administered 2 tablets
c. Elevate extremity above heart level. of
d. Increase oral fluid intake. Losartan to Patient Miranda within the
past 24 hours. According to the doctor’s
4. A patient with suspected pneumonia is orders, Patient Kikay is to receive
ordered to have sputum culture and 100mg of valsartan a day. With this
sensitivity. Nurse Kim Bok Chiu orders information, Angeline Jolie knowsthat
the patient to cough up how much the stock dose Nurse Jennifer has on
sputum into the container? hand is:
a. 15-30mL a.Losartan 1 mg/tablet
b. 1-5 mL b.Losartan 25 mg/tablet
c. 4-10mL c. Losartan 20mg/tablet
d. 250mL d. Losartan 50 mg/tablet
8. Nurse Jennifer received an order of
enalapril 10 mg OD for a hypertensive
patient. How many tablets will she give
to the patient if they have a stock dose
of 20mg/tablet?

a. 1/2 tablet
b. 1 tablet
c. 1 ½ tablets
d. 2 tablets
 d. orange juice, pouched egg, brown
rice and ham.
9. Phenytoin (Dilantin) 200mg PO 13. When doing a health teaching to a
BID was prescribed to a patient. The patient, the nurse determine this as the
medication label reads 0.1 g/capsule. For FIRST step ____________.
each dose, the nurse prepares how
many capsules to give to the patient? A. readiness to learn
B. adaptation to learning styles
a. 500 b ......Error! Bookmark not defined. C. learning needs
c ................................................................2 D. capacity to learn
d ................................................................2
14. You are teaching a group of patients
who are having hemodialysis every week
10. Amoxicillin 250 mg oral
regarding their dietary plan. You should
suspension is prescribed to a patient
explain to them that intake of protein is
q8h. Nurse Jennifer checked the stock
necessary because it __________.
dose and saw that the bottle reads
Erythromycin Oral Suspension
a. reduces demand for liver functioning
125mg/5mL. How much will Nurse Joan
b. increases nitrogenous waste products
administer to the patient in a day?
c. maintains osmotic pressure
d. induces frequent urination
a. 6 mL
b. 12 mL 15. You are tasked to do a health
c. 10mL teaching class on Thursday morning
d. 30mL with several patients forpossible
discharge. You have a diabetic patient
for discharge. He is taking a medication
Situation – Mr. Zander, 58 year old is Carvedilol. Which one of the following
admitted for a suspected heart failure. He instructions has to be REITERATED
has shortness of breath, mild chest pain, during your discharge teaching?
fast breathing, and has crackles on the
bases of both lungs. Your head nurse (HN) a. Observe skin care because the drug
instructed you to prepare nitroglycerin to be can decrease tissue perfusion
administered by Intravenous route. You b. Monitor blood sugar level because
confirmed from your head nurse why such the drug can cause hyperglycemia
medication is going to be given to patient c. Monitor pulse rate, sugar levels because
Tulfo.
the drug may mask hyperglycemia
11. The HN who has a role to teach
nurses answered you correctly by d. Check pulse rate every 6 hours because
the drug can cause palpitation
saying:” This is to _______.”
Situation- Donna is now 15 years old. She
A. “reduce after load” goes to an elite school but she seldom
B. “increase after load” interacts with her classmates nor is
C. “increase preload” interested to join school activities. Her
D. “reduce preload” mother brought her to an adolescent
specialist and was diagnosed of
12. There is a doctor’s order for your malnutrition.
patient with heart failure to be
discharged after two days. The diet order 16. A commercial (ads) on television is
is for him to limit his sodium intake to said to be a contributory factor for
only 2 gms. Identify which of the obesity. What could be a GOOD advice
following breakfast selection should be to adolescents like Cyclone about ads
included in your plan. that can be contributory to malnutrition?

a. orange juice, bacon, fried egg, and a. “Check nutritional contents before buying
steamed rice foods.”
b. orange juice, fried salted fish, and b. “Follow your desire for food and drinks.”
steamed rice. c. “What you see is what you get.”
c. orange juice, toast bread, pouched d. “There is no truth in advertisements.”
egg and jam.
 Medication inadvertently omitted.
Supervisor notified.
c. Medication given to patient A instead
17. Dona scheduled an appointment to to patient B. Patient advised.
see a nutritionist. She is overweight for
d. Wrong dose of medicine
her height. What is the normal weight, in
administered to patient. Sorry.
POUNDS, for Cyclone who is 5 feet tall?
22. An eight-year-old- patient is to
receive Aminophylline 3 mg/kg TID. If the
a) 90 girl weights 25 kg, how much
b) 75 Aminophylline should she receive daily?
c) 85
d) 80 a. 125 mg
18. ALL but ONE are true statements b. 225 mg
about malnutrition. Malnutrition is for: c. 200 mg
d. 100 mg
a. Both the urban and rural areas 23. Mrs. Spectre is receiving Digoxin
b. Both the poor and the rich 0.325 mg p.o. because of her heart
c. The underweight as family income ailment. The stock is 0.250 mg per
increases tablet. How many TABLETS should the
d. The overweight as family income nurse request for 7 days supply for the
increases patient? a. 9
19. How can Dona reduce her weight? b. 7
She can be advised to cut intake of c. 10
which of the following? d. 8
24. Nurse Jessica emphasized that
a. Salt, protein and fats patient safety is___________.
b. Carbohydrates, vitamins and salts
c. Carbohydrates, fats and salts a. Preventing errors and adverse
d. Fats, protein and sweets reactions to patients associated with health
20. Which of the following can Dona do care
to with her obesity problem? b. Being careful in caring for patients at
all times
a. Skip one full meal a day. c. Providing treatment and care to
b. Drink 6 glasses of water every day. patients and documenting the same
c. Take weight reducing pills. d. Being mindful of the needs of others
d. Exercise 30 minutes three times a week. at all times
25. In administering insulin to a diabetic
patient, the nurse must use an
Situation - Nurse Sofia is helping in the APPROPRIATE needle size and length,
service training of nurses in St. Joseph which among the following will this be?
Hospital. Based from the needs
assessment, the nurses need improvement a) 23 G, 3/8
on patient’s safety. The first lecture was on b) 22 G, 2/8
medication administration. Nurse Sofia gave c) 24 G, 4/8
the following problems for the nurse to d) 25 G, 5/8
practice.
Situation I – Nurse Marta is a staff nurse in
the medical ward. Most of her patients are
21. Nurse Sofia has provided afflicted with intestinal and rectal disorders.
instructions that all care provided by 26. Which of the following is the MOST
nurses must be documented, as one of appropriate nursing diagnoses for a
their legal responsibilities. In case errors patient in acute exacerbation of
occur, which is the correct way of ulcerative colitis?i. Imbalanced nutrition
documenting it? less than body requirements R/T
impaired absorptionii. Risk for deficient
a. Wrong medicine given to wrong patient. fluid volume R/T abnormal fluid
Physician notified. Patient observed b. lossiii.Risk for ineffective tissue
perfusion R/T low hemoglobiniv. Acute knows that the rationale behind this
Diarrhea R/T inflammation of the bowel intervention is that:

a. ii& iii a. Oxygen helps to decrease the work of

b. I, ii, & iii breathing
c. I, ii, iii, & iv b. Oxygen is contraindicated in heart failure
d. I & ii so the order is questionable
27. In terms of therapeutics, which of the c. Oxygen is given to reduce anxiety
following medications can be used for d. Oxygen is administered through
inflammatory bowel diseases? mechanical ventilation only
32. Given the following assessment
a. Corticosteroids cues, Nurse Harvey creates a nursing
b. Atropine sulfate care plan with the priority nursing
c. Dulcolax diagnosis of:
d. Maalox
a. Anxiety related to actual threat to
28. Which systemic complication can be biological integrity secondary to heart failure
expected from a patient with Crohn’s b. Ineffective breathing patterns related
Disease? to decreased respiratory depth secondary to
pain
a. Perforation c. Activity intolerance related to
b. small bowel obstruction compromised oxygen transport system
c. Hemorrhage secondary to heart failure
d. Megacolon d. Activity intolerance related to
29. Upon assessment, which of the compromised oxygen transport system
following differentiates Crohn’s disease secondary to heart muscle dysfunction
from ulcerative colitis? 33. Nurse Harvey prepares to perform
the following interventions for the
a. Presence of bleeding: severe in Crohn’s immediate management of Mr. Fred
disease while in Ulcerative Colitis bleeding excluding:
is mild.
B. Presence of diarrhea: severe in Crohn’s a. Establish an IV line and administer
disease in ulcerative colitis it is mild C. PNSS immediately
Affected area: Crohn’s disease is the b. Monitor heart rate and dysrhythmia by
descending while Ulcerative colitis is the using a cardiac monitor
ascending colon. c. Continuously assess level of
D. Course of the disease: Crohn’s disease consciousness
is prolonged and variable, Ulcerative colitis d. Provide reassurance and support to the
has a remission and exacerbation patient
30. In order to accurately diagnose 34. Fred has been diagnosed with heart
ulcerative colitis, which of the following failure. Nurse Harvey expects this
laboratory studies is needed? patient to not exhibit the following signs
and symptoms EXCEPT:
a. Proctosigmoidoscopy
b. Albumin study a. Pulse rate of 48 bpm
c. colonoscopy b. Murmurs C. Respiratory rate of 18
d. ultrasound cpm
Situation – Mr. Fred, a 62 year-old male, D. Strong, bounding pulse
complains of shortness of breath, dyspnea 35. The nurse knows that the
on exertion, palpitation, and expectorating management of a patient with heart
frothy, blood-tinged sputum. He was failure requires interprofessional
brought to the emergency room of Hospital collaboration. Fred asks Nurse Harvey
C. During the interview, he also complained from whom can he ask for assistance
of easy fatigability and weakness. and counsel regarding home care
31. The doctor ordered oxygen services. Nurse Harvey responds that
administration for the patient. The nurse the professional who can help him with
his concern and who assists the
continuing care nurse with planning the 40. After ovulation has occurred, the
patient's discharge is the: nurse teaches women in the fertility
clinic that the ovum is through to remain
a. Physical therapist viable for many HOURS?
b. social worker
c. Psychologist a. 24 to 36
d. Head nurse b. 12 to 18
c. 48 to 72
d. 1 to 6
SITUATION: Raul rushed to the ER due to
Situation one of the responsibilities of a severe abdominal pain radiating to the
nurse in fertility clinic is to provide health scapular region. Health history revealed that
teaching to the patient in relation to timing of his meals were mostly from Jollibee. Patient
intercourse to achieve pregnancy. appeared jaundiced with facial grimaces.
The physician on duty (POD) examined him
36. The nurse explained the ovulation and an impression of Cholelithiasis was
occurs on which of the following given by the POD. Patient was ordered to
conditions? be admitted for further work-up and possible
surgery.
a. Chorionic gonadotropin level is high
b. Luteinizing hormone level is high 41. One of the most common
c. Oxytocin level is high complications post-operatively is:
d. Progesterone level is high
a. Pleurisy
37. Which instruction to patient b. Bronchopneumonia
addresses the BEST time to have sex to c. Pneumonia
achieve a pregnancy? d. COPD

a. 14 days before the next period is 42. In a patient with obstructive jaundice,
expected which of the following assessment
b. Immediately after menses end findings would you expect?
c. Midway between periods
d. 14 days after the beginning of the last a. Itchiness of the abdomen
period b. Clay-colored stool
c. Reddish-colored urine and stool
38. When teaching clients to determine d. Presence of urobilinogen in the urine
the time of ovulation by taking the basal
temperature, the nurse explains that the 43. Mr. Raul bile duct exploration with
change in the basal temperature during open cholecystectomy. A t-tube was
ovulation is shown in which of the connected to drain after surgery. After
following observations? The 12 hours, there was a marked decrease
temperature_____________. in output from 260 ml to 90 ml. What is
the nurse’s priority action?
a. Drops markedly and remains lower
b. Rises markedly and remains high a. Call the physician stat
c. Drops slightly and then rises again b. Assess the tube for any obstruction
d. Rises suddenly and then falls down c. Irrigate the tube with normal saline
d. Change the position.
39. In response to a client’s question on
the main function of progesterone, which 44. Which dietary restriction should be
of the following would be the CORRECT recommended by the nurse to help
answer? It _________________. prevent recurrence of stone formation?

a. Stimulates the follicles for ovulation a. orange juice, pan de sal

to occur b. Whole milk, dairy crème, fried chicken
b. Establishes the secondary male sex breast
characteristics c. Steamed lapu-lapu, nilagang okra,
c. Prepares the uterus to receive a salabat
fertilized ovum d. Nilagangsaba, vegetable salad
d. Develops the female reproductive
organs
45. Which of the following questions Situation: In her 15 years of being a ward
should be asked by the nurse to nurse, Jennifer has witnessed and taken
accurately describe biliary colic? cared of several terminally-ill patients and
their families.
a. Nararamdaman niyo po ba ang sakit
50. Which among the following is not
bago matulog?
true regarding grief in the older
b. Nararamdaman niyo po ba ang sakit sa
population?
kaliwang parte ng inyong tiyan?
c. Panandalian lamang po ba ang sakit?
a. Many older adults exhibit resilience
d. Nararamdaman niyo po ba ang sakit
in facing losses.
matapos kumain?
b. They are not at risk for complicated
Situation- Spencer, 3 years old, was
grieving.
admitted to Pediatrics Ward because of
c. Their increased age increases their
watery stools four times in 30 minutes
likelihood of having faced multiple losses. d.
together by vomiting, abdominal pain and
Positive reappraisal helps older adults
temperature of 38.1 degrees centigrade.
adapt to significant losses.
Nurse Aida admitted the patient
51. Which among the following is not
considered palliative care?
46. Which of the following can be the
LEAST source of data for this case? a. Administering anti-emetics to a cancer
patient who underwent chemotherapy b.
a. Vital signs Frequently turning the position of a
b. Laboratory Findings comatose patient post-CVA
c. Intake and output c. Removing the tumor in a Stage I breast
d. Immunization record cancer
d. Providing pain relief to a cancer patient
47. Which of the following should be the
PRIMARY consideration by the nurse 52. What is the immediate focus of
when charting the Chief Complaint? The nurses in caring for a grieving family
___________. who just lost their father from cancer?

a. Number of significant accompanying a. Post-mortem care

symptoms b. Return patient’s belongings (watch,
b. Objective symptom presented clothes, etc.) to the family
c. Subjective symptom presented c. Obtaining consent for autopsy
d. Significant reason for the child’s d. Provide and facilitate time for mourning
hospitalization
53. Which nursing action of Jennifer will
48. Using the FDAR (Focus Data Action promote a dying, elderly patient’s dignity
and Response) Charting, which of the and self-esteem?
following presenting data would be
PRIMARY “Focus” a. Providing him regular baths and
good hygiene
a. Vomiting in small amount b. Instructing the patient’s family
b. Watery stools 4x in 30 minutes members to decide for his food choices
c. Generalized abdominal pain c. Calling the elderly patient by his first
d. Temperature of 38.1 centigrade name only
d. Encouraging his siblings to join
49. When documenting the data on the during your private conversations with the
subjective symptom of the abdominal patient
pain, which of the following should the
nurse RELY on? 54. Which among the following
statements from Jennifer assesses the
a. Mother’s verbal complaint social support systems of a person
b. Result of the abdominal percussion experiencing grief from the death of his
c. Patient’s verbal complaint sister?
d. Result of auscultation of the abdomen
a. “What does this loss mean to you?”
b. “Tell me how you are feeling.”
c. “Which friends or family members do you
wish were here with you?” a. “Pinaluluwag nito ang daluyan ng
d. “Tell me about your relationship with your hangin.”
sister.” b. “Iniiwasan nito na magkaroon pa ng
allergic attack si Portia.”
55. To ensure full medication distribution c. “Iniiwasan nito na atakihin ng epilepsy si
in using metered-dose inhalers (MDI),
Portia”
you instruct a patient to:
d. “Binabawasan nito ang pamamaga ng
baga”
a. Shake MDI vigorously for 10 times.
b. Position the mouthpiece 4 inches from
the mouth.
c. Hold his breath for 10 seconds after
puffing the medication.
d. Loosely hold the mouthpiece with lips.
Situation: Portia, while going on a date with
Adam, suddenly complains “I can’t breathe”. 61. Nurse Stephen asks two more nurses
Adam sent her immediately in the ER. She to help him logroll a patient. Where
was given Theophylline and Cromolyn should Stephen place the patient’s arms
sodium for the attack. prior to logrolling?

56. Upon administration of theophylline, a. Along the sides

you are monitoring Portia for which drug b. Crossed on the chest
induced adverse effect? c. Overhead, extended
d. Behind the hips
a. Bradycardia
b. Diarrhea
c. Constipation 62. Stephen is caring for a patient with
d. Restlessness an arm cast. He knows that the
57. The following are expected functional position of the wrist and
assessment findings for Portia except: fingers is which among the following:

a. Decreased tactile fremitus a. Wrist in extension, fingers and

b. Resonant to tympanitic thumb in flexion
c. Wheezing sounds b. Wrist in flexion, fingers in flexion,
thumb in extension
d. Crackles
c. Wrist in flexion, fingers and thumb in
58. Upon administration of Theophylline, flexion
the therapeutic effect that you would d. Wrist in extension, fingers in flexion,
expect is: thumb in extension

a. Decrease in breath sounds

b. Increase in body temperature 63. Stephen is teaching a patient with
c. Decrease in wheezing crutches how to go up the stairs. Which
d. Pruritus 59. Adam brought food in among the following should he instruct
Portia’s room. Which of the following the patient with?
food should be restricted for Athena in
consideration to her therapeutic a. When moving the affected leg up, the
regimen? body weight should be on the crutches. b.
The unaffected leg goes up the step after
a. White Chocolate Mocha drink the affected leg.
b. Mango juice c. Patient should keep his feet together
c. One piece chicken with rice at the bottom of the stairs
d. One peach mango pie d. The crutches and the affected leg go
up the step together.

60. Portia asks the nurse why Adam

needs Theophylline. The best response 64. Stephen is assisted by another staff
of the nurse is: nurse in lifting a patient. Which among
the following actions will prevent injury 68. What is the IMPORTANT nursing care
to Stephen? of an infant with increased intracranial
pressure?
a. Keeping the feet wide apart and knees
extended a. Check the infant’s reflexes at regular
b. Positioning himself close to the patient intervals.
c. Using the muscles of the back in lifting b. Monitor the infant’s level of
d. Rotating at the waist in lifting consciousness by stimulating frequently.
c. Weight the infant daily before feeding.
d. Elevate the infant’s head higher than the
65. In applying restraints, Stephen hips.
should employ which type of tie?
69. What is the drug that will lessen CSF
production that nurse Lorena will
a. Half-bow anticipate the doctor to order?
b. Surgical tie
c. Double knot a. Osmitrol
d. Two-throw knot b. Lasix
Situation - Baby Boy Troy, 6 months old, c. Mannitol
was diagnosed to have communicating
d. Diamox
hydrocephalus. Nurse Nicole is preparing
nursing care plan for this baby who is a 70. Nurse Riva understands that
candidate for ventriculo-peritoneal shunting. hydrocephalus, if left untreated, can
cause mental retardation because of
which of the following rationales?
66. Baby Troy has undergone a surgery
to have ventriculoperitoneal shunt. His
a. Hypertonic CSF disturbs normal
parents were worried about the
plasma concentration, depriving nerve cells
prognosis. What information should
of vital nutrients.
Nurse Rive give to the parents to reduce
b. Gradually increasing size of the
their worry?
ventricles presses the brain against the
bony cranium; anoxia and decreased blood
a. The shunt may need to be revised as supply result.
the child grows older. c. Increasing head size necessitates
b. If any brain damage has occurred, it more oxygen and nutrients than normal
is reversible during the first year of life. blood flow can supply.
c. Hydrocephalus usually is self- d. CSF dilutes blood supply, causing
limiting by 2 years of age and then the cells to atrophy.
shunt is removed.
d. The prognosis is excellent and the
valve is permanent. Situation – Mr. Steve, 71 years old, a former
67. When explaining the baby’s problem car dealer has been chronically ill due to
for the parents to understand, which of Emphysema. He was in and out of the
the following should be Nurse Riva hospital for the past 2 years. He decided to
ACCURATE explanation? have a living will so he asked his eldest
daughter to contact their lawyer.
a. “The CSF is prevented from
adequate absorption by a blockage in the
ventricles of the brain.” 71. A waitress from the bar was admitted
b. “Too much Cerebro Spinal Fluid because she was suspected to be
(CSF) is produced within the ventricles of suffering from HIV. The waitress is
the brains.” single, but with a boyfriend working in
c. “The flow of CSF through the brain the Middle East. During the shift report
cells does not empty effectively into the of the nurses, the outgoing morning shift
spinal cord.” was discussing the case in a very loud
d. “There is a part of the brain surface voice and being heard by some patients
that usually absorbs CSF after its in the ward. The Nurse, can be charged
production that is not functioning for_________.
adequately.
a. Unfair practices
b. Oral defamation C. Injustice 75. A Nurse is assigned in the critical
D. Non-maleficence care unit for almost 3 years and has
attended several patients who have died
under her shift. She was emotionally
72. Which of the following conditions is affected with this situation but remains
APPROPRIATE to have a living will? silent and opts not to discuss it every
When a patient is __________. time she reports for duty. The BEST way
for the Nurse to cope with this feeling is
a. on a stage of drowsiness and to ________.
receiving sedatives
b. incapacitated but conscious and on a. consult a psychologist regarding this
a terminal condition feeling
c. with family members who are around b. discuss this feeling with the other
and can make decisions for him members of the staff
d. in a critical condition and receiving c. neglect this behavior and go out with
lifesaving care friends
d. request the supervisor to transfer
her to another unit

73. Which of the following actions of the

Nurse can be classified as intentional
tort?
Situation: Nurse Frank is reviewing
concepts and practicing skills on
a. Refusing a patient to sign a waiver intravenous transfusions.
so he can go home. 76. How often should Nurse Frank
b. Failure to instruct the nursing aid to observe a patient with intravenous
put up the side rails of an older patient infusions?
resulting to fall.
c. Administering a blood transfusion to a. Every 2 hours
a wrong patient. b. Every 6 hours
d. Failure to report to the physical the
c. Every 8 hours
untoward reaction of a drug.
d. Every 12 hours

74. A patient is admitted in the unit

77. Nure Frank is selecting a vein for an
because of rectal bleeding and need a
intravenous transfusion in a 62-year-old
blood transfusion. Being a Jehovah
patient. He wants to dilate and distend
witness, he refused the order of the
the veins for easier insertion. He does
physician. The wife secretly talked with
the following methods, except:
the Nurse and the physician to
administer the blood transfusion after
a. Tapping the selected vein multiple times
taking his medication which side effect
b. Placing extremity in a dependent position
is drowsiness. What is the BEST action
if there are no contraindications c. Applying
of the health care professionals in this
warm washcloth on to the extremity for
situation.
several minutes
d. Stroking the extremity from distal to
a. Refer the case to the minister so he
proximal below his desired site
can convince the patient
b. Proceed with giving of blood
transfusion as this is highly needed
c. Refuse the suggestion of the wife for 78. Which among the following catheters
the husband might be awake is used for less than 24 hours?
d. Talk with the wife that she is
violating the husband’s request a. Butterfly needle
b. Midline catheter
c. Plastic indwelling cannula
d. Angiocath 83. Tania, 55 yr old is another patient of
Nurse Sarah who is having an asthmatic
79. Six hours after initiating an IV line in
attack, with extreme difficulty of
a patient, Nurse Frank noticed that the IV
breathing and presence of sternal
site was red and warm. The patient
retraction. The physician who was
complained that it was painful. Nurse
making his rounds examined the patient
Daniel would suspect which of the
and ordered the drug of choice that will
following?
relieve patient’s problems. Which of the
following will be likely be written by the
a. Phlebitis physician, carried out and recorded by
b. Extravasation the Nurse in the Medication chart?
c. Infiltration
d. Clot formation a. Nor-epinephrine
80. What should be the size/gauge of the b. Epinephrine C. Prednisone
needle Nurse Frank would use in D. Albuterol
administering IV infusions for trauma
patients?

a. 18
b. 22
c. 20
d. 24
84. Nurse Sarah is preparing for her
Situation - Nurse Sarah is assigned in the endorsements with the members of her
Female Medical ward and assigned to team in the ward, when she was
patients with varying health conditions. She approached by her junior nurse who
believes that documentation is a vital aspect asked regarding a physician order.
of the nursing process, patient safety, and Which of the following orders should the
important for the role as a Nurse especially nurse question if this has been ordered
on record keeping and reporting. by a doctor?

a. twenty four hour ambulatory EKG for a

81. In formulating nursing diagnosis to hypertensive patient
her patient Ms. Paulsen who is suffering b. stress test monitoring for an obese adult
from hemolytic anemia, you will expect c. a high dose of insulin for a diabetic
Nurse Sarah to write in the Nursing care adolescent
plan which one of the following d. blood transfusion for an anemic elderly
PRIORITIES? 85. The physician on duty (POD) ordered
a specific diet for patient Paulsen
a. Ineffective airway clearance R/T poor gas diagnosed with hemolytic anemia. Which
exchange. of the following diet prescriptions will
b. Activity Intolerance R/T to fatigue. Nurse Sarah transmit to dietary
c. Poor tolerance to heat R/T increased department?
metabolism.
d. Imbalanced Nutrition: less body weight. a. High protein, high caloric diet.
82. When Nurse Sarah indicates basic b. High fiber, less fat, high protein diet.
care information, skills and referral c. High fats, high protein diet.
services that the patients may need d. High carbohydrate, less fiber, low protein
before being released from the health diet.
facility is an entry of what Situation -Dr. Stevenson is a PhD graduate
documentation in the chart? in Nursing, and has been appointed as a
consultant in a tertiary hospital to help
a. Multidisciplinary notes administration to create strategies that will
b. Physician orders C. Discharge further enhance culture of team work and
Plan quality improvement (QI) among health
D. Nurses notes personnel in the workplace. One day, Dr.
Stevenson while conducting her rounds, safe and quality patient model, the
observing a charge nurse (CN) facilitating a collaboration process as a strategy is an
team on reducing post-operative example of _________.
complications in her unit of assignment. The
nurse was stressing the four (4) essential a. Feed-back mechanism
steps of the QI process. b. Through – put C. output
D. Input
86. While undergoing the QI process,
three (3) members of the team where 90. The CQI team have observed that the
having conflict in what management to incidence of FALL among older persons
do. Which of the following can be an have increased by half. This data have
EFFECTIVE strategy to resolve this reached Dr. Stevenson and have
conflict? instructed the team to conduct which
one of the following PRIORITY
a. Reprimand the three members of the measures?
team of their behavior
b. Assign the three members of the a. Provide a cash incentive for units with 0
team in the different shifts incidence of Fall.
c. Assign an Administration to solve b. Intensify the in-service program for the
the conflict unit with the highest incidence of Fall.
d. Have the three members confront c. Identification of the root cause of Fall.
with each other d. Decrease the benefits of these personnel
who are involved in the Fall incidence.
87. The FIRST phase of this activity is
__________. Situation- Remy, 3 years old, who had
ventricular septal defect repair, is placed on
a. Review cause/s of the problems a maintenance dosage of digoxin (Lanoxin)
b. List of problems & prioritize elixir. Nurse Ursula, who is knowledgeable
c. Conduct root cause analysis about the disease, is assigned to him.
d. Analyze the problems carefully

91. Considering Remy’s age, which of

88. Dr. Stevenson was establishing some the following is the BEST approach by
innovative activities in the medical the nurse when giving medication?
center for a continuous quality
improvement (CQI) in patient care a. “You will feel better if you take your
services. A policy has been adopted for medication.”
nursing staff every shift to conduct an b. “Would you like to take your medicine
hourly rounds for patients with from a spoon or a cup?”
PRIORITY health problems and attached c. “Do you want to take this pretty red
policy was being complied with by the medicine?”
nurses in the first few weeks. She found d. This is your medicine and you must
out in the succeeding dates, it was no take it all right now.”
longer followed. What is the PRIORITY
action of Dr. Lu in this situation? 92. Remy is 7.2 kg and the dosage is 0.07
mg/kg/day. The physician orders the
a. Assign one Nurse per shift to Digoxin to be given twice daily. How
conduct the hourly rounds much Digoxin should Nurse Rita prepare
b. Conduct a general meeting with the to administer at each dose?
staff and determine why such policy is NOT
complied with a) 2.5 mg
c. Conduct a general meeting with the b) 0.5 mg
staff and explain the benefits of the hourly c) 0.37 mg
rounds d) 0.25 mg
d. Call to the office nurses who fail to 93. Which of the following order about
comply the hourly rounds ORAL pediatric medications is TRUE as
89. A part of the CQI that Dr. Stevenson these interfere with milk and milk
wanted to practice is the partnership products or food eaten by young
children? Oral medication should be
given_____________.
97. Nurse Arnold teaches an incontinent
patient bowel training. Which among the
a. With meals always
following would Dora not include in her
b. On an empty stomach
health teaching?
c. ½ hour after meals
d. With the night time formula
a. Opioids are avoided to prevent decrease
in bowel peristalsis.
b. Regular exercise is encouraged.
94. Remy has a blood pressure of 92/78 c. Leaning backward at the hips while sitting
mmHg; resting pulse of 60; respirations on the toilet will help stimulate colon
28 and a potassium level of 4.8 mEg/L. emptying.
He is irritable and has vomited twice
d. A hot tea or fruit juice may be taken
since the morning dose of digoxin.
before the patient defecates.
Which finding is most indicative of
digoxin toxicity? 98. An enema to provide relief from
gaseous distention is prescribed to a
a) Vomiting patent. Arnold knows that this is a/an:
b) Lethargy
c) Bradycardia a. Oil retention enema
d) Irritability b. Carminativeenema
c. Soapsuds enema
d. Fleet enema

95. Nurse Ursula gives home care

instructions to the parents of Marco
99. To prevent urinary tract infection in a
regarding the procedure for the
female patient with an indwelling
administration of digoxin (Lanoxin).
catheter, Arnold instructs her to
Which statement, if made by the parent,
decrease intake of which of the following
indicated the need for further
fruit juices?
instructions?
a. Pineapple juice
a. “If the child vomits after medication
b. Prune juice
administration, I will repeat the dose.”
c. Apple juice
b. “If more than one dose is missed, I
d. Cranberry juice
will call the physician.”
c. “I will take the child’s pulse before
administering the medication.”
100. Nurse Arnold knows that the
d. “I will not mix the medication with
approximate length of a normal female
any food and drinks.”
urethra is:

a. 1.5-2.5 cm
Situation: Nurse Arnold handles various
b. 4-6.5 cm
patients with elimination problems. She
c. 20-25 cm
always performs her best nursing care to
d. 10-12 cm
these patients.

96. After inserting a nasogastric tube,

Dora checks its placement by measuring
the pH of the aspirate. Dora knows that
proper placement has likely been made if
the aspirate has a pH of:

a. pH 3.0
b. pH 7.0
c. pH 9.0
d. pH 7.4