1
Q
SITUATION: Harpe was brought to the emergency room after receiving a penetrating wound on the abdomen, and an emergency exploratory laparotomy was done. He was then transported to the post-anesthesia care unit (PACU), where Nurse Ronan is on duty.
- Nurse Ronan’s primary concern upon receiving Harpe in the unit is to check:
A. Proper positioning
B. Presence of flatus
C. For bleeding
D. Urine output
A
A. Proper positioning
B. Presence of flatus
C. For bleeding
D. Urine output
2
Q
- The blood on Harpe’s surgical dressing is about the size of a ten-centavo coin. What will Nurse Ronan do next?
A. Re-enforce the dressing
B. Encircle the edge of the bloody area with ballpen
C. Call the physician immediately
D. Do nothing as slight bleeding is a normal occurrence post-operatively
A
A. Re-enforce the dressing
B. Encircle the edge of the bloody area with ballpen
C. Call the physician immediately
D. Do nothing as slight bleeding is a normal occurrence post-operatively
3
Q
- The following are potentially life-threatening post-operative complications, EXCEPT?
A. Hemorrhage
B. Infection
C. Absence of peristalsis
D. Secondary Pneumonia
A
A. Hemorrhage
B. Infection
C. Absence of peristalsis - Expected
D. Secondary Pneumonia
4
Q
- Upon reassessment, Harpe’s BP now drops to 80/60. In order to promote increased venous return from the legs without interfering cardiac output, Nurse Ronan will position him in what
manner?
A. Trendelenburg
B. Modified Trendelenburg
C. Supine position
D. Side lying
A
A. Trendelenburg
B. Modified Trendelenburg
C. Supine position
D. Side lying
5
Q
- To prevent respiratory and circulatory complications, Harpe was asked to ambulate as soon as possible. Nurse Ronan decides to assist. Ambulation is BEST started with which of the following activities?
A. The client sitting on the bed and dangling feet over the side for a few minutes before placing him on a chair, then assisting him to walk around the bed.
B. The client lying down on his bed for two days to regain his energy before finally assisting him to ambulate.
C. The client having full diet established so that he will be strong enough when he starts ambulating.
D. The client being assisted to stand up from the bed for five minutes before transferring him to a chair and finally ambulating around the bed.
A
A. The client sitting on the bed and dangling feet over the side for a few minutes before placing him on a chair, then assisting him to walk around the bed.
B. The client lying down on his bed for two days to regain his energy before finally assisting him to ambulate.
C. The client having full diet established so that he will be strong enough when he starts ambulating.
D. The client being assisted to stand up from the bed for five minutes before transferring him to a chair and finally ambulating around the bed.
6
Q
SITUATION: The burden of infectious diseases in our country is still heavy, as announced by the Department of Health. One of the leading causes of morbidity is still Pulmonary Tuberculosis (PTB).
- Tuberculosis is primarily a respiratory disease caused by tubercle bacilli. Which mode of transmission is extremely contagious?
A. Animal handling
B. Skin contact
C. Airborne
D.Ingestion of food
A
A. Animal handling
B. Skin contact
C. Airborne
D.Ingestion of food
7
Q
- Which of the following should a nurse do to confirm the case of PTB?
A. Blood smear
B. PPD testing
C. Organ Biopsy
D. Sputum Culture
A
A. Blood smear - malaria
B. PPD testing - exposure to tb
C. Organ Biopsy
D. Sputum Culture
8
Q
- Which one of the following is a primary objective in PTB control?
A. Identification of positive cases
B. Sputum treatment
C. BCG immunization
D. Reduction of transmission risk - break mode of transmission
A
A. Identification of positive cases
B. Sputum treatment
C. BCG immunization
D. Reduction of transmission risk — break mode of transmission
9
Q
- As a nurse, which of the following basic preventive actions is done to eradicate PTB?
A. Improvement of social condition
B. Health teaching
C. Distribution of medicines
D. Referral to health centers
A
A. Improvement of social condition
B. Health teaching
C. Distribution of medicines
D. Referral to health centers
10
Q
- When a person is affected with PTB, which of the following measures will you advise to effectively prevent the spread of the disease to other members of the family?
A. Continue taking PTB medications until symptoms subside
B. X-ray members of the family
C. Cover mouth and nose with hand when coughing or sneezing
D. Isolate the person
A
A. Continue taking PTB medications until symptoms subside
B. X-ray members of the family
C. Cover mouth and nose with hand when coughing or sneezing
D. Isolate the person
11
Q
SITUATION: Rufus, age fifty-two was admitted to the hospital with a diagnosis of chronic obstructive lung disease. Nurse Hwarin gathers his history of smoking 2 packs of cigarettes daily for the past twenty years.
- Which manifestation is characteristic of a patient with chronic obstructive pulmonary emphysema?
A. Hypermobility of the diaphragm
B. Periods of apnea alternating with periods of hypercapnia
C. Improvement in pulmonary ventilation during periods of moderate physical mobility
D. Persistent breathlessness with prolonged expiratory phase
A
A. Hypermobility of the diaphragm
B. Periods of apnea alternating with periods of hypercapnia - For Inc. ICP
C. Improvement in pulmonary ventilation during periods of moderate physical mobility
D. Persistent breathlessness with prolonged expiratory phase
12
Q
- Postural drainage is ordered for Rufus. Immediate nursing care following postural drainage is:
A. Feeding the patient
B. Administration of oral hygiene
C. Administration of IV normal saline
D. Giving oral medications
A
A. Feeding the patient
B. Administration of oral hygiene
C. Administration of IV normal saline
D. Giving oral medications
13
Q
- Which exercise would Nurse Hwarin expect a patient with emphysema will perform?
A. Abdominal exercises to increase inspiration
B. Panting exercises
C. Blowing rapidly into a paper bag
D. Blowing into a balloon
A
A. Abdominal exercises to increase inspiration
B. Panting exercises
C. Blowing rapidly into a paper bag
D. Blowing into a balloon
14
Q
- Rufus’s most productive and extensive periods of coughing are likely to occur:
A. When humidity is low
B. Late in the day
C. Upon awakening
D. Soon after eating
A
A. When humidity is low
B. Late in the day
C. Upon awakening
D. Soon after eating
15
Q
- Nurse Hwarin is developing a discharge plan for Rufus. What information should she include in the plan? People with COPD:
A. Develop respiratory infections easily
B. Usually maintain their current status
C. Require less supplemental oxygen
D. Show permanent improvement
A
A. Develop respiratory infections easily
B. Usually maintain their current status
C. Require less supplemental oxygen
D. Show permanent improvement
16
Q
Situation: You are caring for patients with fluid and electrolyte imbalances assigned under your care for the shift. The following questions apply.
- Which of the following fluids is the preferred treatment for patients with burns?
A. 0.9% NaCl
B. Lactated Ringer’s solution
C. 5% dextrose in water
D. 0.45% NaCl
A
A. 0.9% NaCl
B. Lactated Ringer’s solution
C. 5% dextrose in water
D. 0.45% NaCl
17
Q
- A patient, CD, who has shown muscle weakness, fatigue, headache, irritability, and impaired balance was prescribed with 3% NaCl intravenous fluids. While hooking the IV fluids to the patient, which of the following will you NOT consider for the IV fluids? (-)
A. A hypertonic solution was prescribed to treat symptomatic hyponatremia
B. It must be given slowly and cautiously
C. Assists in removing intravascular fluid excess
D. Supplies no calories
A
A. A hypertonic solution was prescribed to treat symptomatic hyponatremia — for inc ICP
B. It must be given slowly and cautiously
C. Assists in removing intravascular fluid excess
D. Supplies no calories
18
Q
- After the administration of the prescribed IV fluids for patient CD, the patient exhibited the following: (+) crackles, distended jugular veins and edema over the sacrum. Which of the following will you NOT include in the nursing care plan for the patient? (-)
A. Sodium restriction in diet
B. Weigh the patient daily
C. Promote exercise to promote diuresis
D. None of the above
A
A. Sodium restriction in diet
B. Weigh the patient daily
C. Promote exercise to promote diuresis
D. None of the above
19
Q
- You expect hyponatremia in patients with the following conditions, except?
A. Fluid overload - dilution
B. Hypothyroidism
C. Prolonged exercise
D. Excess in aldosterone levels - hypervolemia, hypernatremia
A
A. Fluid overload - dilution
B. Hypothyroidism
C. Prolonged exercise
D. Excess in aldosterone levels — hypervolemia, hypernatremia
20
Q
- You are caring for a 70-year-old patient who was admitted and is showing signs of hypernatremia. As a nurse assigned to his care, which of the following will you least likely include in his plan of care?
A. Advise the patient to drink when thirsty
B. Parenteral fluid replacement
C. I&O monitoring
D. Observe changes in neurologic status
A
A. Advise the patient to drink when thirsty
B. Parenteral fluid replacement
C. I&O monitoring
D. Observe changes in neurologic status
21
Q
- In a patient with a serum potassium level of 2.9 mEq/L, which of the following will you expect to see in the patient? (N: 3.5-5)
A. Abdominal distention
B. Decreased bowel motility
C. ECG: tall tented T waves
D. None of the above
A
A. Abdominal distention
B. Decreased bowel motility
C. ECG: tall tented T waves
D. None of the above
22
Q
- In acute digoxin toxicity, which of the following electrolyte imbalance will you expect to happen?
A. Hypermagnesemia
B. Hyperkalemia
C. Hypocalcemia
D. All of the above
A
A. Hypermagnesemia
B. Hyperkalemia
C. Hypocalcemia
D. All of the above
23
Q
- Which of the following organs is mostly responsible for maintaining potassium balance?
A. Bowel and sweat
B. Lungs
C. Liver
D. Kidney
A
A. Bowel and sweat
B. Lungs
C. Liver
D. Kidneys
24
Q
- What would the healthcare member be testing if you’ve seen them tapping the muscle just below the zygomatic arch?
A. Chvostek sign
B. Trousseau sign
C. Rovsing’s sign
D. Blumberg’s sign
A
A. Chvostek sign — cheek tap
B. Trousseau sign — hand bends inward
C. Rovsing’s sign — press left, pain right
D. Blumberg’s sign — Rebound Tenderness
25
25. In administering potassium, which of the following is the most appropriate route of administration?
A. IV push
B. IM administration
C. Infusion pump
D. Slow IV push
A. IV push
B. IM administration
**C. Infusion pump**
D. Slow IV push
RATIO: k is not IV
26
26. A client with prolonged vomiting is admitted to the unit and develops metabolic alkalosis. Laboratory results show elevated serum bicarbonate levels. Among which organ is primarily responsible for correcting this imbalance by adjusting bicarbonate reabsorption and excretion?
A. Kidneys
C. Lungs’
B. Liver
D. Heart
**A. Kidneys**
C. Lungs’
B. Liver
D. Heart
RATIO: Bicarbonate -> buffer (balances acidity) -> neutralizer
27
27. A patient is admitted due to severe diarrhea for 2 days, presenting with deep, rapid breathing, abdominal cramping, warm flushed skin, and weakness. ABG results show pH of 7.30, HCO3 of 16 mEq/L, and PaCO2 of 30 mmHg Based by the findings, which acid-base imbalance is most likely experienced by the patient?
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Respiratory acidosis
A. Metabolic alkalosis
B. Respiratory alkalosis
**C. Metabolic acidosis**
D. Respiratory acidosis
28
28. Another patient with a history of chronic obstructive pulmonary disease (COPD) is admitted for shortness of breath and confusion. Nurse Kyra observes shallow, slow respirations and cyanosis of the lips. Which arterial blood gas (ABG) results correspond to the most likely acid-
base imbalance?
A. pH 7.50, PaCO, 28 mmHg, HCO; 22 mEq/L
B. pH 7.25, PaCO, 55 mmHg, HCO; 26 mEq/L
C. pH 7.35, PaCO, 40 mmHg, HCO; 24 mEq/L
D. pH 7.48, PaCO, 38 mmHg, HCO; 30 mEq/L
A. pH 7.50, PaCO, 28 mmHg, HCO; 22 mEq/L
**B. pH 7.25, PaCO, 55 mmHg, HCO; 26 mEq/L**
C. pH 7.35, PaCO, 40 mmHg, HCO; 24 mEq/L
D. pH 7.48, PaCO, 38 mmHg, HCO; 30 mEq/L
RATIO: COPD (chronic obstructive pulmonary disease)/CAL (chronic airflow limitation)
~ barrel chest (pathog)= AP diameter=transverse
~ air retention/trapping -> respiratory acidosis
Types:
~ Chronic bronchitis -> inc goblet cells -> inc mucus production (blue bloaters -> cyanotic)
~ Emphysema -> loss of elastic recoil -> air trapping -> retention (pink puffer)
29
SITUATION: Nurse Julian, a newly-registered nurse, has been assigned to care for patients with urinary and elimination imbalances.
29. Nurse Julian is assessing a patient's daily intake and output. The patient's total urine output for the day is 300 mL. How should Nurse Julian classify this patient's urine output?
A. Anuria
C. Polyuria
B. Oliguria
D. Normal urine output
A. Anuria (<100 ml/ Day)
C. Polyuria
**B. Oliguria** (<500ml/day)
D. Normal urine output (30ml/hour)
RATIO:
Anuria: < 100ml/day
Oliguria: < 500ml/day
Normal: 30ml/hour
30
30. A medium-built, Filipino, 48-year-old man is admitted and requires urinary catheterization. Which Foley catheter size in French is most appropriate for this patient
A. 8
B. 12
C.10
D. 14
A. 8
B. 12
C.10
**D. 14**
RATIO: Adult Male: French 14
31
31. A 40-year-old man was admitted after a car accident. On assessment, he is hypotensive, tachycardic, and shows reduced urine output. Laboratory tests reveal that his blood urea nitrogen is significantly higher than normal, his creatinine is elevated. Considering the patient's
findings, which type of acute kidney injury is most likely?
A. Prerenal
B. Intrarenal
C. Postrenal
D. Chronic kidney disease
**A. Prerenal**
B. Intrarenal
C. Postrenal
D. Chronic kidney disease
RATIO: BUN (Blood Urea Nitrogen)
Pre renal: circulation
Intra renal: direct damage
Post renal: obstruction
32
32. Nurse Julian notices that an elderly patient with loose bowel movement (LBM) has soiled the wheelchair and some feces has fallen on the floor. Which appropriate action should the nurse take?
A. Ask the janitor to clean the floor with a mop.
B. Clean the floor with soap and water .
C.Wipe the areas with disposable paper, then clean the floor with the recommended disinfectant.
D. Ask the janitor to wipe the wheelchair and floor with paper.
A. Ask the janitor to clean the floor with a mop.
B. Clean the floor with soap and water .
**C. Wipe the areas with disposable paper, then clean the floor with the recommended disinfectant.**
D. Ask the janitor to wipe the wheelchair and floor with paper.
RATIO:
Antiseptic: use in human beings
Disinfectant: objects
33
33. After assisting a client with profuse diarrhea, Nurse Julian cleans and disinfects the soiled wheelchair, floor, and disposable cleaning materials. To ensure proper infection control and compliance with hospital waste management protocols, into which color-coded trash bin should
these contaminated items be disposed?
A. Yellow
B. Black
C. Green
D. Red
**A. Yellow (Infectious)**
B. Black
C. Green
D. Red
RATIO:
Black: for storage of non-biodegradable general waste.
Green: for storage of biodegradable general waste.
Yellow: for storage of infectious and pathological waste.
Orange: for storage of radioactive waste.
Red: for storage of sharps and pressurized containers (or punctured-proof containers for
sharps).
Yellow with black band: for storage of chemical waste.
34
**SITUATION:** A 36 years old patient came into the clinic and has been diagnosed to have Acquired Immune Deficiency Syndrome. He worked as an entertainer on a cruise ship.
34. Which method of transmission is COMMON to contract AIDS?
A. Blood transfusion
B. Sexual contact
C. Body fluids
D. Syringe and needles
A. Blood transfusion
**B. Sexual contact**
C. Body fluids
D. Syringe and needles
35
35. Causative organism in AIDS is one of the following:
A. Retrovirus
B. Fungus
C. Parasite
D. Bacteria
**A. Retrovirus**
B. Fungus
C. Parasite
D. Bacteria
36
36.What primary health teaching would you give to the patient?
A. Daily exercise
B. Proper nutrition
C. Reverse isolation
D. Prevent Infection
A. Daily exercise
B. Proper nutrition
C. Reverse isolation
**D. Prevent Infection**
37
SITUATION: Nurse Ley is a staff nurse in a tertiary hospital of a remote town in the north. As a knowledgeable nurse assigned in the medical ward, she takes care of patients with varied cases.
37. Zero, one of the patients, has been diagnosed with multiple myeloma, where malignant
plasma cells produce nonfunctional immunoglobulins. Nurse Ley knows that these malignant plasma cells are usually found in:
A. Spleen
B. Bone marrow
C. Plasma of the blood
D. Kidney
A. Spleen
**B. Bone marrow**
C. Plasma of the blood
D. Kidney
38
38. Early detection of cancer is crucial and it is the nurse's responsibility to provide proper health teaching. When performing testicular self-examination (TSE), what position should the patient assume during palpation?
A. Standing
B. Supine
C. Lithotomy position
D. Knee-chest
**A. Standing**
B. Supine
C. Lithotomy position
D. Knee-chest
RATIO: Warm environment > relax scrotum > easier palpation
39
39. Callisto has a family history of breast cancer. It is vital that she should be taught to perform regular breast self-examination (BSE) for early detection of breast tumors. This BSE is usually performed:
A. Second week after her menstruation
B. A day after her menstruation
C. First week after her menstruation
D. Three to four days before her menstruation
A. Second week after her menstruation
B. A day after her menstruation
**C. First week after her menstruation**
D. Three to four days before her menstruation
RATIO: Breast is not affected by Hormone
40
40. Patient Europa has been diagnosed with uterine cancer. Her gynecologist decides to have her undergo a panhysterectomy. Which of the following parts will be removed during the surgery?
A. Uterus, cervix, fallopian tubes and ovaries
B. Uterus, cervix, vagina, fallopian tubes and ovaries
C. Uterus, fallopian tubes and ovaries
D. Uterus, vagina, fallopian tubes and ovaries
**A. Uterus, cervix, fallopian tubes and ovaries**
B. Uterus, cervix, vagina, fallopian tubes and ovaries
C. Uterus, fallopian tubes and ovaries
D. Uterus, vagina, fallopian tubes and ovaries
41
41. You noticed that the patients who are diagnosed with kidney diseases are getting younger. A 26-year-old patient was diagnosed with acute kidney injury and asked you how he can avoid kidney injuries in the first place. Which of the following will you **not** include in your health teaching?
A. Avoid chronic use of analgesics, particularly NSAIDs
B. Prevent and treat infections promptly.
C. Indwelling catheters may stay as long as the client requests it
D. None of the above
A. Avoid chronic use of analgesics, particularly NSAIDs
B. Prevent and treat infections promptly.
C**. Indwelling catheters may stay as long as the client requests it**
D. None of the above
RATIO: Kidney injury -> urinary stasis -> recurren
42
42. In providing care for patients with AKI, pulmonary function is also given attention to. Which of the following will be the basis of your teaching if the patient is not compliant with the pulmonary exercises?
A. This is to prevent atelectasis and respiratory tract infection
B. This is to prevent further damage to the kidneys
C. This is to regulate acid-base balance through the respiratory system
D. All of the above
**A. This is to prevent atelectasis and respiratory tract infection**
B. This is to prevent further damage to the kidneys
C. This is to regulate acid-base balance through the respiratory system
D. All of the above
RATIO: Atelactasis: Lung collapse > stabilize Alveoli
43
43. Patients with end-stage kidney disease usually exhibit clinical manifestations that virtually
affect every body system. Patients with ESKD usually present with malaise, general fatigability,
and decreased activity tolerance; in conducting health teaching, which of the following will you
least likely include?
A. Be compliant with erythropoietin therapy
B. Take prescribed vitamins, such as Vit B12 or folate
C. Take prescribed iron supplements
D. Be diligent in receiving blood transfusions weekly
A. Be compliant with erythropoietin therapy
B. Take prescribed vitamins, such as Vit B12 or folate
C. Take prescribed iron supplements
**D. Be diligent in receiving blood transfusions weekly**
44
44. In patients taking antihypertensive medications, which of the following will alert the nurse?
A. "My antihypertensive medications work for me since I maintain my blood pressure in normal ranges, sometimes even lower."
B. "I always bring the record for my blood pressure readings with me every time I have my check-up"
C. "I went to my physician to ask if my medications will change since I got diagnosed with kidney disease too."
D. None of the above
**A. "My antihypertensive medications work for me since I maintain my blood pressure in normal ranges, sometimes even lower."**
B. "I always bring the record for my blood pressure readings with me every time I have my check-up"
C. "I went to my physician to ask if my medications will change since I got diagnosed with kidney disease too."
D. None of the above
45
45. Which of the following reads as hypertensive urgency (180/120) in stable patients without target organ damage?
A. SBP greater than 160 mm Hg
B. DBP greater than 100 mm Hg
C. SBP greater than 180 mm Hg
D. DBP greater than 110 mm Hg
A. SBP greater than 160 mm Hg
B. DBP greater than 100 mm Hg
**C. SBP greater than 180 mm Hg**
D. DBP greater than 110 mm Hg
RATIO: Together with 120/80 (No organ Damage)
46
46. Which of the following refers to the evaluation method used to inspect the medical record after the client's discharge for documentation of compliance with the standards?
A. Retrospective audit
B. Concurrent audit
C. Peer review audit
D. Patient experience audit
**A. Retrospective audit**
B. Concurrent audit
C. Peer review audit
D. Patient experience audit
47
47. To initiate change in ward practices regarding proper waste disposal, you based your plan on Lewin's basic concept of change. Which stage would you refer to when you are planning a change in the proper waste disposable of the unit?
A. Unfreezing
B. Moving
C. Refreezing
D. Planning
A. Unfreezing
**B. Moving**
C. Refreezing
D. Planning
RATIO:
~Unfreezing: is the **first** phase of the process, during which the problem is identified and individuals involved gather facts and evidence supporting a basis for change.
~During the moving and changing phase: change is planned and implemented.
~Refreezing: is the **last** phase of the process, during which the change becomes stabilized
48
48. One of your QI projects also aims to reduce fall incidence in the unit, which of the following will you **not** expect to be included for risk for falls assessment?
A. Assess for any previous accidents
B. Assess with the client any concerns about their immediate environment
C. Alert all personnel to the client's risk for falling
D. None of the above
A. Assess for any previous accidents
B. Assess with the client any concerns about their immediate environment
**C. Alert _all_ personnel to the client's risk for falling**
D. None of the above
RATIO: All, Always (avoid because quantifying words)
49
49. To avoid falls, which of the following will you **not** expect to see in the primary healthcare provider's prescription for restraint?
A. Type of restraint
B. Identify specific client behaviors for which restraints are to be used
C. Evaluation of client's response
D. Identify a limited time frame for use.
A. Type of restraint
B. Identify specific client behaviors for which restraints are to be used
**C. Evaluation of client's response**
D. Identify a limited time frame for use.
50
50. In delegation of tasks among the team, which of the following is UNTRUE?
A. Even though a task may be delegated to a nursing assistant, the ultimate accountability rests on the nursing assistant
B. The knowledge and skills of the person being delegated to need to be assessed
C. When delegating a task to a nursing assistant, the tasks need to match the person's skills and abilities
D. The nurse cannot delegate any activity that involves nursing judgment
**A. Even though a task may be delegated to a nursing assistant, the ultimate accountability rests on the nursing assistant**
B. The knowledge and skills of the person being delegated to need to be assessed
C. When delegating a task to a nursing assistant, the tasks need to match the person's skills and abilities
D. The nurse cannot delegate any activity that involves nursing judgment
Closed Door
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