NURSING PRACTICE III Care of Clients with Physiologic and Psychosocial Alterations (PART A)

Situation 1 Ludy, a staff nurse is assigned in the medical unit during the morning shift. She is preparing
medications for patients assigned to her.
1. One of the patients is receiving antacids therapy for gastric ulcer. Ludy understands that the pain reducing effect of
antacids is due to which of the following?
A. Increase pepsin activity
B. Block histamine receptors
C. Acid neutralizing capacity
D. Release of carbon dioxide gas in the stomach
2. Ludy prepares Esomeprazole Magnesium (Nexium) for her patient with gastroesophageal reflux disease (GERD).
This drug is classified as
A. a Histamine H2 receptor antagonist
C. an alkaline chemical agent
B. a synthetic prostaglandin compound
D. a proton pump inhibitor
3. When Ludy administers liter of Dextrose 5% in Water to infuse over 8 hours to her client, which of the following will
she consider as a specific precautionary measure to ensure that the right dose is administered to the right client?
A. Administer only what you have prepared
B. Check client's identification
C. Use appropriate measuring device
D. Adhere closely to the administration scheduled time
4. As Ludy checks the medication orders for her clients in the chart, she noted marked variations in the documentation of
medications administered to the patient in the medication administration record (MAR). Which of the following is the
most appropriate action of the nurse to ensure improvement in the nurses' documentation?
A. Remind the nurse through a note on the chart to complete the documentation
B. Fold the MAR with incomplete documentation and report
C. Note those with incomplete documentation and report during the unit meeting
D. Recommend to the unit manager that a team be organized to solve the problem
5. Ludy continuously identify risks for error in medication administration documentation.
Which of the following risks identified by Ludy requires immediate attention and correction?
A. Prescribed medication sometimes lack route of administration
B. Nurses sign but never-print their names.
C. Nurses forget to identify the MAR with the patient's name.
D. Standard abbreviations are not followed.
Situation 2 - The hospital can be hazardous to fire like any other establishments.
6. Which of the 3 elements present in the workplace would support combustion most?
A. linen, vials of drugs, syringes
C. oxygen tank, suction machine, water cylinder
B. disposable drapes, gases, people
D. disposable drapes, gas tanks, open windows
7. A staff nurse is called to a client's room. When the nurse arrived in the room, she noted that the waste basket is on
fire. However the client has been moved out of the room. Which of the following is the PRIORITY action of the nurse?
A. Activate the fire alarm
C. Extinguish the fire
B. Evacuate the unit
D. Confine the fire
8. In a semi-private ward of four patients, which of the following clients would you move out FIRST in case of fire?
A. A post thyroidectomy patient with discharge order.
B. A two-day post radical mastectomy patient with I.V. infusion.
C. A post below-knee amputation patient with referral for crutches walking.
D. A post herniorrhaphy patient under spinal anesthesia and maintained flat on bed for two hours.
9. You are preparing to discharge a 70 year old client who lives alone. You determine if there are fire hazards in the home.
Which of the following statements by the client should alert you to explore further?"
A. "I keep my matches on a high shelf'.
B. "I should attend fire drills conducted by the Red Cross"
C. "I cook my food occasionally"
D. "My refrigerator is 3 feet from the wall"
10. The essential requisites of a fire extinguisher that a nurse should be aware of are the following EXCEPT:
A. location of the fire extinguisher
C. disposal of the fire extinguisher
B. expiry date
D. indication
Situation 3 - Marianne, 42 years old was brought to the OR suite for vaginal hysterectomy under spinal
anesthesia.
11. The circulating nurse welcomes the client to the OR suite. Which of the following is the PRIORITY nursing
intervention at this point?'
A. Validates if the client observed NPO appropriately.
B. Validates the OR schedule.
C. Checks the client for presence of denture, ring and nail polish.
D. Checks the ID bracelet and call the client by name.
12. Because of the complexity of the surgical environment each member of the surgical team has a vital role to play.
Who is the guardian of asepsis while Marianne is undergoing the procedure?
A. The scrub nurse
C. The circulating nurse
B. The anesthesiologist
D. The surgeon
13. Marianne will be assisted to assume the lithotomy position for the operation. This position can damage the
peripheral blood vessels, nerve, and joints if not done properly. Which of the following precautionary measures
should be observed by the circulating nurse?
A. Both legs are placed simultaneously and adjusted to the stirrups.
B. Legs are raised one at a time slowly and simultaneously placed on padded stirrups.
C. Legs are placed slowly on well padded stirrups one at a time.

D. Both legs are raised slowly and placed simultaneously on well-padded stirrups
14. While the surgery is on-going, the circulating nurse has to monitor the needs of the scrub nurse and the rest of the
team. What is the safe distance from the sterile area for her to avoid contaminating the sterile field?
A. Anywhere behind the scrub nurse
B. Arm-length from the sterile area
C. As long as you can see the operative field
D. Within hearing distance from the surgical team
15. Research studies have shown that client's awareness during intraoperative period may be greater than once
believed. For this reason the circulating nurse should consistently remind the surgical team to keep the
conversation during surgical procedure:
A. tolerated
C. professional
B. modulated
D. limited
Situation 4 - The operating room is one area where the team members can communicate their therapeutic
presence.
16. A client in the holding area communicates that she has not received instructions not to take her usual antihypertensive
drug. She states "I am so nervous about my surgery." Which response of the nurse is MOST appropriate?
A. "You need not worry; your surgeon has done a lot of this kind of surgery before."
B. "You seem nervous about your impending surgery?"
C. "Stop worrying. It will do you no good but make you nervous all the more".
D. "Relax, the whole surgical team is here to attend to your needs."
17. Among the other interventions, the OR nurse called the ward nurse to verify if the preanesthetic drugs have
been administered as prescribed. The nurse anticipates the following effects of the preanesthetic drugs to be
as follows EXCEPT:
A. reduction of preoperative pain.
B. potentiation of anesthetic effects.
C. reduction of anxiety
D. facilitation of the induction of anesthesia.
18. The nurse welcomes a preoperative client as she enters the operating room suite. The nurse shall interpret that
the client appreciated her presence if the client:
A. clasped the nurse's hands.
B. closed her eyes as though asleep.
C. turned to the opposite direction from the nurse.
D. put her blanket all the way to cover her face.
19. What positive indicator would the nurse look for in a client who is aware about his/her impending surgery?
A. Asks if he/she will be awake during the surgery.
B. Expresses concern about postoperative pain.
C. Verbalizes his or her fears to the family and significant others.
D. Participates willingly in the preoperative preparation.
20. Because clients who undergo anesthesia or moderate sedation experience temporary sensory/perceptual
alteration or loss, the nurse MOST critical role at this time is as:
A. consultant
C. advocate
B. guardian
D. arbiter
Situation 5 - Charice, a 50 year old mother of three school aged, children was diagnosed with cholelithiasis and
admitted for possible surgical removal of the gall bladder,
21. When performing initial history and physical examination, the admitting nurse would expect the client to describe
pain as:
A. sudden onset, intense, boring in the mid-epigastrium, radiates to left upper quadrant.
B. gnawing, burning, in the epigastric region, sometimes radiating to the back,
C. severe, episodic in the right upper quadrant, radiates to the right shoulder or scapula.
D. cramping on the periumbilical area, increasing in intensify and shifts to right lower quadrant,
22. To be able to determine associated symptoms with pain, which of the following is the LEAST relevant
question, the nurse may ask the client?
A. "Do you have allergies to food? What are they? How do you react?"
B. "Do you have indigestion, flatulence? What causes this?"
C. "Are there foods you cannot tolerate"?
D. "What are your food likes and dislikes?"
23. The physician ordered the following diagnostic tests. Which of the following will the nurse consider as the TEST
intended to identify obstructed bile flow?
A. Serum amylase and lipase
C. Complete blood count
B. Lactate dehydrogenase(LDH)
D. Serum bilirubin
24. During the teaching session preoperatively, the client asked the nurse why she experiences pain whenever she
takes food rich in fat. Which of the following is the CORRECT response of the nurse?
A. "When digested, fats cause the gallbladder to contract to excrete bile; if obstructed with gall stones, tissue
spasm occur."
B. "Gallbladder contracts when fats are absorbed; pain results from muscle contractions attempting to move
gallstones."
C. "When gallstones obstruct bile flow in the gallbladder duct, pain is felt due to tissue spasms."
D. "When-fats get to the duodenum, gallbladder contracts, if bile duct is obstructed with gallstones, pain is
experienced"
25. The patient was discharged the day after surgery. Which of the following behaviors of the client indicates that the
nurse needs to RE-INSTRUCT?
A. Talks about reducing fat intake while keeping her weight stable.
B. Anxiously look forward to resuming daily work activities.

C. Appropriately care for her incisions.

D. Verbalized understanding of initial activity restrictions.
Situation 6 - Nurse Maris is caring for a retired 76 year old judge who is on insulin. He just came in from the
Recovery Room after an amputation of the right foot below the knee.
26. The nurse observed swelling of the right thigh. Nurse would do which nursing intervention to relieve congestion of
the right leg?
A. Remove the dressings of the stump.
C. Elevate the right thigh.
B. Apply warm compress.
D. Remove the elastic bandage.
27. When Maris made her rounds, the client complained of severe pain. The client has a prescription of every four hour
narcotic. The last dose of the narcotic was given 3 hours ago. The PRIORITY action of the nurse is to:
A. instruct the client to wait for another hour.
C. administer the prescribed dose right away.
B. administer 1/2 of the prescribed dose.
D. refer to the attending physician.
28. The client verbalized to the nurse "Could you please check on my twisted right foot? I have so much pain on my right
leg." The nurse would regard this as a:
A. delayed reaction to pain
C. pain intolerance
B. perceived pain
D. phantom pain
29. The nurse demonstrated the correct stump-wrapping from the distal to the proximal extremity in preparation for the
patient's discharge. This is intended to prevent pooling of fluid by
A. promoting arterial flow.
C. enhancing movement of extremity.
B. increasing venous return.
D. keeping skin intact.
30. As the nurse is giving the discharge health instructions, the client's wife asked, "Can I give the client Aspirin for
pain?" The nurse's MOST appropriate response would be.
A. "Pain is usually bearable by then."
C. "Aspirin should be taken after meals."
B. "Give prescribed medicine only."
D. "Aspirin increases hypoglycemic episodes."
Situation 7 - Lorene came to the Medical Center for parathyroidectomy for hyperparathyroidism. Her chief
complaints are fatigue and muscle weakness accompanied by pain.
31. While doing the admission history and assessment, the client asks the nurse if parathyroid and thyroid glands are
the same. The CORRECT response of the nurse is:
A. The thyroid glands regulate metabolism while the parathyroid glands regulate calcium and phosphates."
B. "The thyroid glands secrete iodine While the parathyroid glands secrete calcium and magnesium."
C. "Both are located in the dorsal area of the neck responsible for regulating breathing and voice respectively.
D. "Both glands are secreting hormones that regulate body processes."
32. During the history taking, Lorelie states that she is taking Furosemide (Lasix). You understand that the
indication of the medication is to:
A. lower sodium level.
B. interfere with calcium resorption.
C. Increase renal clearance of calcium.
D. lower calcium level.
33. Lorelie was put on low calcium diet to decrease the total intake of calcium and prevent renal calculi. You will
instruct the client to AVOID which foods?
A. oats, potatoes, soybean
C. rice, malunggay leaves, carrots
B. oranges, yogurt, spinach
D. whole grain, leafy vegetables, milk
34. The doctor orders: "Monitor for signs of renal stones". What is the MOST appropriate nursing intervention to
accomplish such doctor's order?
A. Visually examine urine every after urination.
B. Observe color of urine every after urination.
C. Use glass container when measuring urinary output.
D. Strain all urinary output.
35. First day post parathyroidectomy, the nurse assessed tingling around the mouth, hand and feet. Which of the
following will the nurse do first?
A. Check most recent serum calcium level
B. Check for signs of hypotension and bradycardia
C. Perform tests for Chvostek's and Trousseau's sign
D. Auscultate to check for laryngospasm
Situation 8 - Professional nurses' fear of being involved in legal suits is increasing with the growth in
complexity of health care and awareness of the clients of their rights.
36. The rule of personal liability means:
A. every person is liable for his own tortous conduct.
B. ignorance of the law excuses no one
C. nobody is above the law.
D. the staff and supervisor, are both answerable.
37. Carmela, a Registered Nurse, performed venipuncture. The client complained of severe pain and hematoma around
the punctured site. Carmela was being charged of malpractice because of which of the following:
A. Carmela did not perform the procedure with due care.
B. Carmela is not currently certified as IV therapist.
C. Supervision was not sought by Carmela.
D. Carmela was in charge of the patient.
38. The doctor's order is, "Garamycin 1 gm IV, initially after a negative skin test; then 500 mg IV push every 6 hours for
23 days."The order was countersigned by the head nurse. When the doctor made his rounds the following day, he
found out that 1 gm Garamycin was given IV push every 6 hours. Who among the following may be held liable?
A. All the nurses who administered the drug every 6 hours.
B. The head nurse and the nurse who gave the first dose for having erroneously transcribed the order.
C. Only the head nurse under the principle of command responsibility

D. All nurses involved including the head nurse

39. Clients are sensitive of the kind of patient- nurse relationship they observe during their confinement in the hospital.
Which health worker behavior would likely prompt a client to file a case in court against a health care worker even
with the SLIGHTEST form of misconduct?
A. Health care workers who render detailed and skillful care.
B. Those who are so busy with technical processes.
C. Nurses who are slow but respectful.
D. Those who are very demonstrative of their authority.
40. If a nurse encounters a client who refuses therapeutic treatment despite explanation from the health care worker, the
CORRECT action of the nurse so that she would not be held liable is:
A. call the nurse supervisor on duty
B. notify the physician in charge
C. respect the decision of the client
D. delay treatment until the client is convinced
Situation 9 - Anita, a staff nurse with 4 years work experience is assigned to work with Lyka, newly hired
registered nurse. They are working during the morning shift in a pediatric unit with 5 patients assigned to them.
41. Anita admitted a 6 year old with Cushing syndrome to be prepared for surgical removal of the adrenal tumor. Anita
understands that the manifestations observed on the patient is due to which of the following?
A. Increased secretion of mineralcorticoids
C. Deficiency of corticosteroids
B. Oversecretion of glucocorticoids
D. Decreased adrenocorticotropic hormone
42. Before Lyka performed tracheostomy suctioning to a 5 year old post cardiac surgery patient, Anita reminded her to
apply suction only while withdrawing the catheter for 5-10 seconds. Which of the following is the CORRECT
action of Lyka?
A. Question the instruction for time is too short for effective suctioning.
B. Refer instruction of Anita to the head nurse for validation
C. Modify by suctioning for 5-10 seconds, rotate catheter, then withdraw.
D. Follow strictly instruction of Anita to prevent irritation and over suctioning.
43. A 10 year old boy, with severe anemia, receives a transfusion of packed RBC. After checking the vital signs of the
patient 15 minutes after initiation of transfusion, which of the following is a PRIORITY action of Lyka?
A. Compare vital signs with the vital signs before blood transfusion.
B. Document in the chart the vital signs.
C. Assess for signs of blood transfusion reactions.
D. Report to Anita, the senior nurse, the vital signs taken.
44. Because of infiltration, Lyka discontinued the intravenous infusion of an 8 year old girl, dehydrated due to
persistent diarrhea. The mother refused to have the intravenous infusion resumed. Which of the following
principles would primarily guide Lyka in determining the MOST appropriate action to be taken?
A. Autonomy
C. Fidelity
B. Justice
D. Paternalism
45. While Anita is endorsing her patient to the afternoon shift, Lyka approached her and reported that instead of having
administered Lanoxin to the 5 year old boy with congestive heart failure, she gave the medication to the patient with
Cushing syndrome. Which of the following is the PRIORITY action of Anita?
A. Check the chart of the patient with Cushing syndrome.
B. Check on the 5 year old boy with congestive heart failure.
C. Finish endorsement and report error to the head nurse.
D. Ask Lyka for more information regarding the error.
Situation 10 - A client who is in labor pains is transferred from the Delivery Room to the OR for emergency
Cesarean Section.
46. As you reviewed the record of the client, you found out that the indication for emergency Cesarean section is "fetal
distress". Which of the following findings would confirm this condition?
A. Fetal heart rate is 180 beats per minute.
B. Non progressing labor pains.
C. Cervix dilatation of 2 cm.
D. Maternal pulse rate is 87 beats per minute.
47. The circulating nurse would place the client in which APPROPRIATE position for the Cesarean Section?
A. Lithotomy position
B. Reversed Trendelenburg's position.
C. Semi Fowler's position with pillows under the knees.
D. Supine position with wedge support under the right hip.
48. The initial nursing care of the newborn done by the scrub nurse is:
A. wiping the mouth nose and eyes with sterile OS (operating sponge)
B. milking and clamping the umbilical cord
C. resuscitating the newborn
D. slapping the newborn to induce breathing
49. Prior to closing the endometrium, the scrub nurse does which legal responsibility?
A. Report sponge count
C. Change gloves
B. Report blood loss
D. Change drapes
50. The nurse knows that the appropriate suture for closing is
A. plain cutgut
C. chromic cutgut
B. silk suture
D. nylon suture
Situation 11 - Nurse Melba provides instructions in the surgical pediatric ward. She has cleft lip and palate
cases waiting for their surgery schedules.
51. Nurse Melba provides instructions to mothers of an infant with cleft lip and palate regarding the safe way to

feed. Which statement made by the mother would need reinstruction?

A. "I will gently rub the nipple on the lower lip of my child."
B. "I will use a small - hole nipple to avoid choking."
C. "I will allow time for my child to swallow."
D. "Much time is needed to breast feed to avoid accident of aspiration."
52. Nurse Melba taught the mothers to use the "ESSR" method of feeding the child with cleft lip. Select the steps
below to illustrate the Correct ESSR method.
1 Engorge the nipple.
2 Enlarge the nipple.
3 Simulate the sucking reflex.
4 Stimulate the sucking reflex.
5 Swallow
6 Reposition the child to the other breast.
7 Rest to finish swallowing.
A. 1, 3, 5, 7
C. 2, 3, 4, 7
B. 2, 4, 5, 6
D. 1, 4, 5, 6
53. After cheiloplasty, which of the following is Nurse Melba's primary nursing intervention during the post operative
care to prevent crusting?
A. Administer sedation to prevent picking at the incision wound.
B. Keep the infant on NPO.
C. Restraint all extremities to prevent rubbing of face and lips.
D. Clean the suture lines.
54. Which would Nurse Melba consider her PRIORITY nursing intervention immediately following cheiloplasty?
A. Position the child in prone position.
B. Assess presence of edema of the tongue, lips and mucous membrane
C. Encourage parents to talk and touch the child
D. Restraint the child's arms with blanket.
55. The MOST effective restraint that Nurse Melba would use in this case is:
A. elbow restraints
C. blanket restraint for the entire body
B. mittens for both hands
D. blanket restraint for all extremities
Situation 12 - Nurses should adhere to the rules in drug administration to promote quality care.
56. Nurse Nimfa is caring for a client with heparin lock. There is an order of antibiotic IV push through the heparin lock.
Which of the following is the right order of injection of the solutions?
A. NSS, Antibiotics, NSS, Heparin
C. Heparin, NSS, Antibiotics, NSS
B. Antibiotics, NSS, Heparin, Antibiotics
D. NSS, Heparin, NSS, Antibiotics
57. The nurse is caring for a 7 year old boy with throat infection. Before inserting the peripheral I.V. catheter to enhance
efficient venipuncture on the child, which of the following action of the nurse is LEAST relevant to gain cooperation of
the child?
A. Apply topical anesthetic to the I.V. site as ordered.
B. Explain the procedure immediately before insertion.
C. Instruct the mother to hold the child's hand during the procedure.
D. Ask the child which hand does he useto draw.
58. Nurse Precy received an order for a 44Ibs. preschooler who is being treated for wound infection. The order is:
Dexamethasone Elixir 10 ml per orem every 6 hours. The elixir comes in a concentration of 0.5 mg/ml. How
many mg does the client receive per dose?
A. 0.5 mg
C. 5 mg
B. 15 mg
D. 10 mg
59. A 4 and 1/2 year old boy is to receive 25 ml per hour of I.V. solution. The nurse would use an infusion set calibrated at
60 microdrops/ml. How many microdrops/min would the nurse regulate I.V.?
A. 35
C. 30
B. 15
D. 25
60. Nurse Jocelyn's niece who is an adolescent is being treated with corticosteroids for her inflammatory bowel
disease. The niece asks why she has proliferation of acne. Which is the CORRECT response of the nurse?
A. "That can be treated easily by low fat diet and increased fluids"
B. "Don't worry that is normal among adolescent girls like yap."
C. "This is an adverse reaction of the cortocosteroids therapy"
D. "That will disappear as soon as you start menstruating"
Situation 13 - The rapidly changing health care modality has directly impacted the professional nurse and must
expand role to include analytical decision making process in serious consideration to ethical and moral
scenario.
61. Which statement best described morality?
A. Commitment to an individual value system.
B. Being dependent on the 4 Principles of behavior.
C. Adherence to defined institution defined rules of behavior.
D. Adherence to specific Codes of Conduct.
62. When a nurse makes a decision based on the reasoning that good consequences will outweigh bad
consequences", she is following which theory?
A. Formalist theory
C. Utilitarian theory
B. Moralist theory
D. Deontological theory
63. During the nurse tour of duty, very often they are confronted with ethical dilemma. In their decision making, which of
the following would-require application of the Principle of Beneficence?
A. A young father of three boys with advanced lung cancer asks that all known regime be done to prolong his
life despite no improvement

B. A confused 70 year old lady needs restraints for protection from fall even if this makes her more agitated
C. A 3rd day post cholecystectomy client requires narcotic injection every 4 hours
D. A young patient who has asked not to receive tube feeding due to intense pain
64. A client who is under your care is with a "DO NOT RESUSCITATE order. The patient requires frequent dose of
narcotic for excruciating pain. After the client request for pain medication the nurse assessed a decreasing
respiratory rate The MOST appropriate action of the nurse would be to:
A. give a fraction of the prescribed dose.
B. withhold the pain medication until the doctor is contacted.
C. give pain medication as requested by the client.
D. ask the client to wait some more minutes and reassess the respiratory rate.
65. One of your terminally ill clients asks you if she is dying. Which of the following is the MOST appropriate action
of the nurse?
A. Refer to chaplain
C. Provide the true information to the client
B. Confer with the family first
D. Consult the attending physician
Situation 14 - Nurse Nena admitted a 15 month old child with cryptorchidism. The child was brought to the
hospital by his mother.
66. While the nurse was taking the history of the child from the mother, she should be guided by the knowledge that
the incidence of this disorder is directly related to which of the following?
A. Birth weight and gestational age.
C. Prolonged labor and forceps delivery.
B. Full term in high risk mothers.
D. Dry labor and prematurity.
67. During the initial assessment, which major manifestation should the nurse note in children with cryptorchidism?
A. Testes are retracted into the inguinal ring,
B. Absence of one or both testes in the scrotum
C. Enlarged one or both testes.
D. Testes are palpable in the abdomen.
68. The child was scheduled for repair of cryptorchidism. The surgical procedure being referred to is:
A. Hydrocoelectomy
C. Orchiopexy
B. Circumcision
D. Herniotomy
69. The mother, aware of the age of her child, asks the nurse what is usually the BEST time that this procedure is
done. The correct response of the nurse would be:
A. before the child starts to walk
C. between 2 and 3 years of age
B. between 6 and 24 months
D. before the child goes to school
70. Considering the sequelae of testicular cancer and infertility among male children with cryptorchidism, the nurse
should include in her discharge plan which of the following?
A. Life-long hormonal therapy.
C. Life-long follow up.
B. Use of scrotal support.
D. Periodic ultrasonography of the testes.
Situation 15 - Geronimo, 65 years old, post open heart surgery was admitted because of severe chest pain
and fever. Physician's diagnosis is Acute pericarditis.
71 The nurse auscultates the heart sounds of the patient. Which of the following assessment findings CORRELATES
with the patient's complaint of severe substernal pain?
A. Presence of pericardial friction rub
B. Identification of extra heart sounds on systole an diastole.
C. Audibility for murmurs
D. Increase of pleural friction rub.
72 From the result of the diagnostic tests prescribed by the physician, which of the following results will the nurse
consider as indicative of acute inflammation of the pericardium?
A. Erythrocyte sedimentation rate elevated.
B. Increased central venous pressure.
C. Decreased QRS amplitude in the ECG leads.
D. Chest x-ray result of cardiac enlargement.
73. In the nursing care plan prepared by the nurse for the patient, "MAINTAIN a position of comfort" was noted as a
priority intervention. Which of the following will the nurse consider as the. MOST comfortable position for the client?
A. Dorsal recumbent position with both knees supported by two pillows.
B. Sitting upright and slightly leaning forward supported by two pillows.
C. Side lying on a high backrest with soft pillows at the back and between the legs.
D. Left lateral position with the head on one pillow and one pillow between the legs
74. "Ineffective breathing pattern" was identified as a priority nursing diagnosis. The nurse relates this primarily to:
A. heart movement restriction
C. pericardial adhesions
B. pericardial pain
D. pulmonary complications
75. Non steroidal anti-inflammatory drug (NSAID) was prescribed to be administered every four hours. The nurse
recalled during the nursing history taking that client is taking Metformin HCL 1000 mg. orally twice a day. The nurse
decided to verify the physician's order because of which of the following possible complications?
A. Hypoglycemia
C. Gastric irritation
B. Bleeding
D. No pain relief in 48 hours
Situation 16 - Patient's records are the best evidence of care received by clients while in the health care facility.
76. This is your first assignment in the unit. While reviewing the patient's record, which of the following observations
violate the patient's privacy?
A. All records identified with patient's names.
B. Patient's diagnosis posted on the chart cover.
C. Allergies of patient noted in the admission notes.
D. Personal data sheet attached.
77. A nursing student came to you asking if she can photocopy the patient's record for their case presentation. How

will you BEST handle the student's request?

A. Tell the student to talk and ask permission from the client himself.
B. Tell the student to do it discreetly
C. Allow the student to photocopy the chart, anyway she is in charge of the patient.
D. Allow the student to just read and take note of the information that she needs.
78. A client's visitor requested to take pictures of the bulletin board. The APPROPRIATE response is:
A. "Pictures can only be taken by the hospital staff'
B. "Pictures cannot be published without the medical director's permission"
C. "Pictures can be published if colored"
D. "Pictures may be taken only during hospital week celebration"
79. You observed that a clinical instructor was intently reading the chart of a client who underwent bilateral
mammoplasty. This client was not assigned to any of her students. You evaluate this action of the clinical
instructor as:
A. inappropriate because she is not assigned to the client.
B. permissible because she is also a nurse
C. gaining information to assist student learning
D. not a violation to client's privacy
80. An elderly client signed a document outlining selected medical treatments when he loses his ability to decide. This
document referred to as:
A. Consent form
C. Nursing care plan
B. Treatment sheet
D. Advance directive
Situation 17 - A 55 year old male client sought admission to the Medical Center for pain and discomfort. The
admitting physician noted "a typical peptic ulcer" case.
81. The nurse took the history and initial assessment. Which pain description best describes that of a client suffering from
peptic ulcer?
A. The pain tends to recur at intervals of hours to days.
B. Pain is felt near the midline in the episgastrium radiating to the back.
C. The pain is periumbilical and felt in-between meals.
D. The pain is gnawing, burning usually, rhythmic when the stomach is empty
82. The client claims that he has been very careful not to miss a meal and avoiding highly seasoned foods. He inquires
which could have been the cause of his disease. The nurse cites the two most common causes of peptic ulcer.
Identify these causes.
1. H. pylori infection
2. Playing mahjong
3. Genetic predisposition
4. Non Steroidal Anti-Inflammatory Drugs intake
5. Dietary indiscretions
A. 1 and 5
C. 3 and 4
B. 2 and 3
D. 1 and 4
83. The medication history of the client reveals intermittent use of several medications. The nurse would teach the client to
avoid which of the following medications?
A. Sucrafate (Carafate)
C. Ibuprofen (Motrin)
B. Omepazole(Pilosec)
D. Nizatidine (Axid)
84. The doctor's order reads "Monitor for signs of perforation. Which assessment findings of the nurse would indicate
perforation of the ulcer?
A. A rigid broadlike abdomen
C. Blood in the stool
B. Nausea and vomiting
D. Numbness in the legs
85. The client is ordered Ranitidine (Zantac) 300mg once daily. For greatest protection of the gastric mucosa, the nurse
should give the drug at which time schedule?
A. Before dinner
C. At bedtime
B. After lunch
D. Before breakfast
Situation 18 - Nurse Leah whose father died of Pulmonary Tuberculosis is assigned in the medical ward. She has
developed keen interest in caring for her PTB cases.
86. A senior nursing student was assigned with Leah to take care of a client with PTB. The two were discussing about
managing and preventing the risk of exposure. Which of the following would you consider the LEAST "risk of
exposure"?
A. Farmers working .4 to 6 hours in the farm.
B. Social norm of living together in extended family group.
C. Metropolitan areas where people lived in cramped housing.
D. Factory workers in closed bodega style building.
87. Which test is the MOST reliable and cost effective way of identifying infectious TB and should be the FIRST test done
when, investigating client with pulmonary TB symptoms?
A. Magnetic Resonance Imaging (MRI)
C. Sputum culture
B. Chest x-ray
D. Sputum Smear Microscopy
88. Nurse Leah was instructing the clients that TB treatment adherence is a major factor in the successful outcome of TB
treatment. Which is considered the LEAST indicator of adherence?
A. Improvement in symptoms.
C. Improve appetite.
B. Smear conversion from positive to negative.
D. Increase in body weight.
89. Nurse Leah cautioned the nursing student that client can develop multi drug resistant TB even to the most powerful
anti TB agents. The MOST powerful antiTB agent according to World Health Organization are:
A. Isoniazid and Rifampicin
C. Rifampicin and Ethambutol
B. Isoniazid and Ethambutol
D. Rifampicin and Streptomycin

90. Nurse Leah and the nursing student prepared the client for discharge. They made sure that the client would submit
sputum for TB treatment monitoring. Which is the CORRECT schedule for sputum smear analysis?
A. At the end of the 1st, 3rd and 6th month.
B. At the end of the first, 3rd and 5th month.
C. At the end of the 2nd, 5th and 6th month.
D. At the beginning of the 1st, 3rd and 6th month.
Situation 19 - You are assigned in the cardiac ward for the first time. A client who underwent Coronary artery
bypass grafting (CABG) a week ago was assigned to your care.
91. You are aware that this surgical procedure involves revascularization in which conduits are harvested for bypass
grafting of the coronary stenosis. The most common sources of grafts are the following EXCEPT:
A. Saphenous veins from the legs.
C. Jugular veins from the neck
B. Radial arteries from the arm
D. Internal mammary arteries
92 Throughout the hospitalization, the nurse supports a rapid recovery principle. The client is conscious about her
incision and asks if the bulge on top of the sternal incision is permanent. The nurse best explanation would be:
A. "You are lucky. Others develop keloid that would need another surgery."
B. "The bulge on top of the sternal incision is normal and subsides in four to six weeks."
C. "That is a normal body reaction to the wire suture."
D. "Don't worry. The bulge is a normal reaction and will subside."
93. When you visited the client, you noticed that he was trying to do deep breathing but complained of pain. How
can you assist the client at this point?
A. Frequently turn to sides.
B. Teach the use of "cough pillow" to splint chest incision.
C. Encourage to cough vigorously.
D. Ambulate around the room.
94. Recovery is unprecedented for clients who undergo surgery like "coronary bypass with graft" if disorientation or
disturbed thought process is addressed promptly. This can be avoided or minimized by the following nursing
interventions EXCEPT:
A. Involving the family in the reorientation.
B. Explaining all procedures before, performing them.
C. Administering sedatives
D. Providing current information regarding day, date and time.
95. While giving discharge instruction, the patient asks, "If I gain weight of more than a pound in two days, what will I
do'?" Which of the following is the APPROPRIATE instruction from the nurse?
A. Reduce intake of food
B. Record weight and observe for another day
C. Report immediately to the physician.
D. Weigh twice a day
Situation 20 A newly admitted client, 35 year old executive secretary with cough, fever and chest pain, was
endorsed to you Admission diagnosis is acute bacterial pneumonia.
96. An order to collect sputum specimen for culture and gram stain was endorsed to you. What critical instruction would
you give to the client before collection of the specimen?
A. No oral antibiotic until specimen is obtained.
B. Normal salt solution gargle
C. Warm water gargle.
D. Antiseptic mouth wash.
97. Based on the initial assessment, the priority nursing diagnosis is 'ineffective breathing related to chest pain."
Relevant nursing, interventions would include: all the following EXCEPT:
A. Suctioning prn
B. Frequent changes in position
C. Increase fluid intake.
D. Use of cough suppressant round the clock.
98. The nurse continues to monitor the client. The client describes her chest pains to be sharp, localized and increases
with breathing and coughing. The nurse would report this to the physician as
A. localized chest pain
C. pleural friction rub
B. respiratory distress
D. pleuritic pain
99. Identify which breathing pattern would the nurse teach the client that will promote lung expansion?
A. Using assistive devices like inhaler.
C. Breathing in a paper bag.
B Slow abdominal breathing.
D. Rapid and deep breathing.

100. The effectiveness of nurse's teaching regarding take home prescribed antibiotic self administration is
indicated in which statement of the client?
A. "I will see to it that the medication schedule is synchronized with my daily routine."
B. "I have read the prescription and its specific instructions"
C. "I fully understand the beneficial effects of the antibiotic"
D. "I will report side effects immediately."