NP4 - A Rationale

Situation 1
Because of the serious consequences of
severe burns, management requires a
multidisciplinary approach. You have
important responsibilities as a nurse.

1. While Sergio was lighting a barbecue grill

with a lighter fluid his shirt burst into
flames. The most effective way to
extinguish the flames with as little further
damage as possible is to:
A. Log roll on the grass / ground
B. Slap the flames with his hands
C. Remove the burning clothes
D. Pour cold liquid over the flames

1. While Sergio was lighting a barbecue grill

with a lighter fluid his shirt burst into
flames. The most effective way to
extinguish the flames with as little further
damage as possible is to:
A. Log roll on the grass / ground
B. Slap the flames with his hands
C. Remove the burning clothes
D. Pour cold liquid over the flames

2. Once the flames are extinguished, it is

most important to:
A. Cover Sergio with a warm blanket
B. Give him sips of water
C. Calculate the extent of his burns
D. Assess the Sergios breathing

2. Once the flames are extinguished, it is

most important to:
A. Cover Sergio with a warm blanket
B. Give him sips of water
C. Calculate the extent of his burns
D. Assess the Sergios breathing

3. Sergio is brought to the ER after the

barbecue grill accident. Based on the
assessment of the physician, Sergio
sustained superficial partial thickness burns
on his trunk, right upper extremities and right
lower extremities. His wife asks what that
means. Your most accurate response would
be:
A. Structures beneath the skin are damaged
B. Dermis is partially damaged
C. Epidermis and dermis are both damaged
D. Epidermis is damaged

3. Sergio is brought to the ER after the

barbecue grill accident. Based on the
assessment of the physician, Sergio
sustained superficial partial thickness burns
on his trunk, right upper extremities and right
lower extremities. His wife asks what that
means. Your most accurate response would
be:
A. Structures beneath the skin are damaged
B. Dermis is partially damaged
C. Epidermis and dermis are both damaged
D. Epidermis is damaged

3. Sergio is brought to the ER after the

barbecue grill accident. Based on the
assessment of the physician, Sergio
sustained superficial partial thickness burns
on his trunk, right upper extremities and right
lower extremities. His wife asks what that
means. Your most accurate response would
be:
A. Structures beneath the skin are damaged
B. Dermis is partially damaged
C. Epidermis and dermis are both damaged
D. Epidermis is damaged

4. During the first 24 hours after thermal

injury, you should assess Sergio for:
A. Hypokalemia and hypernatremia
B. Hypokalemia and hyponatremia
C. Hyperkalemia and hyponatremia
D. Hyperkalemia and hypernatremia

4. During the first 24 hours after thermal

injury, you should assess Sergio for:
A. Hypokalemia and hypernatremia
B. Hypokalemia and hyponatremia
C. Hyperkalemia and hyponatremia
D. Hyperkalemia and hypernatremia

5. Teddy, who sustained deep partial

thickness and full thickness burns of the

face, whole anterior chest and both upper
extremities 2 days ago begins to exhibit
extreme restlessness. You recognize that
this most likely indicates that Teddy is
developing:
A. Cerebral hypoxia
B. Hypervolemia
C. Metabolic acidosis
D. Renal failure

5. Teddy, who sustained deep partial

thickness and full thickness burns of the

face, whole anterior chest and both upper
extremities 2 days ago begins to exhibit
extreme restlessness. You recognize that
this most likely indicates that Teddy is
developing:
A. Cerebral hypoxia
B. Hypervolemia
C. Metabolic acidosis
D. Renal failure

Situation 2
You are now working as a staff nurse in a
general hospital. You have to be prepared
to handle situations with ethico-legal and
moral implications.

6. You are on night duty in the surgical ward. One

of your patients, Martin, is a prisoner who
sustained an abdominal gunshot wound. He is
being guarded by policemen from the local
police unit. During your rounds you heard a
commotion. You saw the policeman trying to
hit Martin. You asked why he was trying to hurt
Martin. He denied the matter. Which among
the following activities will you do first?
A. Write an incident report
B. Call security officer and report the incident
C. Call your nurse supervisor and report the
incident
D. Call the physician on duty

6. You are on night duty in the surgical ward. One

of your patients, Martin, is a prisoner who
sustained an abdominal gunshot wound. He is
being guarded by policemen from the local
police unit. During your rounds you heard a
commotion. You saw the policeman trying to
hit Martin. You asked why he was trying to hurt
Martin. He denied the matter. Which among
the following activities will you do first?
A. Write an incident report
B. Call security officer and report the incident
C. Call your nurse supervisor and report the
incident
D. Call the physician on duty

7. You are on morning duty in the medical ward.

You have 10 patients assigned to you. During
your endorsement rounds, you found out that
one of your patients was not in bed. The
patients next to him informed you that he went
home without notifying the nurses. Which
among the following will you do first?
A. Make an incident report
B. Call security to report the incident
C. Wait for 2 hours before reporting
D. Report the incident to your supervisor

7. You are on morning duty in the medical ward.

You have 10 patients assigned to you. During
your endorsement rounds, you found out that
one of your patients was not in bed. The
patients next to him informed you that he went
home without notifying the nurses. Which
among the following will you do first?
A. Make an incident report
B. Call security to report the incident
C. Wait for 2 hours before reporting
D. Report the incident to your supervisor

8. You are on duty in the medical ward. You

were asked to check the narcotics
cabinet. You found out that what is on
record does not tally with the drugs used.
Which among the following will you do
first?
A. Write an incident report and refer the
matter to the nursing director
B. Keep your findings to yourself
C. Report the matter to your supervisor
D. Find out from the endorsement any
patient who might have been given
narcotics

8. You are on duty in the medical ward. You

were asked to check the narcotics
cabinet. You found out that what is on
record does not tally with the drugs used.
Which among the following will you do
first?
A. Write an incident report and refer the
matter to the nursing director
B. Keep your findings to yourself
C. Report the matter to your supervisor
D. Find out from the endorsement any
patient who might have been given
narcotics

9. You are on duty in the medical ward. The

mother of your patient who is also a
nurse came running to the nurses station
and informed you that Piolo went into
cardiopulmonary arrest. Which among
the following will you do first?
A. Start basic life support measures
B. Call for the Code
C. Bring the crash cart to the room
D. Go to see Piolo and assess for airway
patency and breathing problems

9. You are on duty in the medical ward. The

mother of your patient who is also a
nurse came running to the nurses station
and informed you that Piolo went into
cardiopulmonary arrest. Which among
the following will you do first?
A. Start basic life support measures
B. Call for the Code
C. Bring the crash cart to the room
D. Go to see Piolo and assess for airway
patency and breathing problems

10. You are admitting Jorge to the ward and

you found out that he is positive for HIV.
Which among the following will you do
first?
A. Take note of it and plan to endorse this
to next shift
B. Keep this matter to your self
C. Write an incident report
D. Report the matter to your head nurse

10. You are admitting Jorge to the ward and

you found out that he is positive for HIV.
Which among the following will you do
first?
A. Take note of it and plan to endorse this
to next shift
B. Keep this matter to your self
C. Write an incident report
D. Report the matter to your head nurse

Situation 3
Colorectal cancer can affect old and
younger people. Surgical procedures and
other modes of treatment are done to
ensure quality of life. You are assigned in
the Cancer Institute to care of patients with
this type of cancer.

11. Larry, 55 y/o, who is suspected of having

colorectal cancer, is admitted to the CI.
After taking the history and vital signs,
the physician does which test as a
screening test for colorectal cancer:
A. Barium enema
B. Carcinoembryonic antigen
C. Annual digital rectal examination
D. Proctosigmoidoscopy

11. Larry, 55 y/o, who is suspected of having

colorectal cancer, is admitted to the CI.
After taking the history and vital signs,
the physician does which test as a
screening test for colorectal cancer:
A. Barium enema
B. Carcinoembryonic antigen
C. Annual digital rectal examination
D. Proctosigmoidoscopy

12. To confirm his impression of colorectal

cancer, Larry will require which
diagnostic study?
A. Carcinoembryonic antigen
B. Proctosigmoidoscopy
C. Stool hematologic test
D. Abdominal computed tomography
(CT) test

12. To confirm his impression of colorectal

cancer, Larry will require which
diagnostic study?
A. Carcinoembryonic antigen
B. Proctosigmoidoscopy
C. Stool hematologic test
D. Abdominal computed tomography
(CT) test

13. The following are risk factors for

colorectal cancer, EXCEPT:
A. Inflammatory bowels
B. High fat, high fiber diet
C. Smoking
D. Genetic factors-familial adenomatous
polyposis

13. The following are risk factors for

colorectal cancer, EXCEPT:
A. Inflammatory bowels
B. High fat, high fiber diet
C. Smoking
D. Genetic factors-familial adenomatous
polyposis

14. Symptoms associated with cancer of the

colon include:
A. Constipation, ascites and mucus in
the stool
B. Diarrhea, heartburn and eructation
C. Blood in the stools, anemia and
pencil-shaped stools
D. Anorexia, hematemesis, and
increased peristalsis

14. Symptoms associated with cancer of the

colon include:
A. Constipation, ascites and mucus in
the stool
B. Diarrhea, heartburn and eructation
C. Blood in the stools, anemia and
pencil-shaped stools
D. Anorexia, hematemesis, and
increased peristalsis

15. Several days prior to bowel surgery,

Larry may be given Sulfasuxidine and
Neomycin primarily to:
A. Promote rest of the bowel by
minimizing peristalsis
B. Reduce the bacterial content of the
colon
C. Empty the bowel of solid waste
D. Soften the stool by retaining water in
the colon

15. Several days prior to bowel surgery,

Larry may be given Sulfasuxidine and
Neomycin primarily to:
A. Promote rest of the bowel by
minimizing peristalsis
B. Reduce the bacterial content of the
colon
C. Empty the bowel of solid waste
D. Soften the stool by retaining water in
the colon

Situation 4
Enterostomal therapy is now considered a
specialty in nursing. You are participating
in the ostomy care class.

16. You plan to teach Fermin how to irrigate

the colostomy when:
A. The perineal wound heals and Fermin
can sit comfortably on the commode
B. Fermin can lie on the side
comfortably, about the 3rd postoperative
day
C. The abdominal incision is closed and
contamination is no longer a danger
D. The stool starts to become formed,
around the 7th post-operative day

Colostomy Irrigation
Purpose
- to distend the bowel sufficiently to
stimulate peristalsis, which stimulates
evacuation

16. You plan to teach Fermin how to irrigate

the colostomy when:
A. The perineal wound heals and Fermin
can sit comfortably on the commode
B. Fermin can lie on the side
comfortably, about the 3rd postoperative
day
C. The abdominal incision is closed and
contamination is no longer a danger
D. The stool starts to become formed,
around the 7th post-operative day

17. When preparing to teach Fermin how to

irrigate his colostomy, you should plan to
do the procedure:
A. When Fermin would have normal
bowel movement
B. At least 2 hours before visiting hours
C. Prior to breakfast and morning care
D. After Fermin accepts alteration in
body image

17. When preparing to teach Fermin how to

irrigate his colostomy, you should plan to
do the procedure:
A. When Fermin would have normal
bowel movement
B. At least 2 hours before visiting hours
C. Prior to breakfast and morning care
D. After Fermin accepts alteration in
body image

Rationale
Irrigation should be performed at the time
the client normally defecated.

18. When observing a return demonstration of a

colostomy irrigation, you know that more
teaching is required if Fermin:
A. Lubricates the tip of the catheter prior to
inserting into the stoma
B. Hangs the irrigating bag on the bathroom
door cloth hook during fluid insertion
C. Discontinues the insertion of fluid after only
500 mL of fluid has been instilled
D. Clamps off the flow of fluid when feeling
uncomfortable

18. When observing a return demonstration of a

colostomy irrigation, you know that more
teaching is required if Fermin:
A. Lubricates the tip of the catheter prior to
inserting into the stoma
B. Hangs the irrigating bag on the bathroom
door cloth hook during fluid insertion
C. Discontinues the insertion of fluid after only
500 mL of fluid has been instilled
D. Clamps off the flow of fluid when feeling
uncomfortable

Rationale
The irrigation bag should be hung 18-20 inches
above the level of the stoma
A clothes hook is too high which can create
increase pressure and sudden intestinal
distention and cause abdominal discomfort to the
patient
For most clients, a relatively small amount of fluid
(300-500 mL) stimulates evacuation

19. You are aware that teaching about

colostomy care is understood when
Fermin states, I will contact my
physician and report :
A. If I have any difficulty inserting the
irrigating tube into the stoma
B. If I notice a loss of sensation to touch
in the stoma tissue
C. The expulsion of flatus while the
irrigating fluid is running out
D. When mucus is passed from the
stoma between irrigations.

19. You are aware that teaching about

colostomy care is understood when
Fermin states, I will contact my
physician and report :
A. If I have any difficulty inserting the
irrigating tube into the stoma
B. If I notice a loss of sensation to touch
in the stoma tissue
C. The expulsion of flatus while the
irrigating fluid is running out
D. When mucus is passed from the
stoma between irrigations.

Rationale
Difficulty of inserting the irrigating tube
indicates stenosis of the stoma and should
be reported to the physician.
Abdominal cramps and passage of flatus
can be expected during colostomy
irrigations.
The procedure may take longer than half
an hour.

20. You would know after teaching Fermin that

dietary instruction for him is effective when
he states. It is important that I eat:
A. Soft food that are easily digested and
absorbed by my large intestines
B. Bland food so that my intestines do not
become irritated
C. Food low in fiber so that there is less
stool
D. Everything that I ate before the
operation, while avoiding foods that cause
gas

20. You would know after teaching Fermin that

dietary instruction for him is effective when
he states. It is important that I eat:
A. Soft food that are easily digested and
absorbed by my large intestines
B. Bland food so that my intestines do not
become irritated
C. Food low in fiber so that there is less
stool
D. Everything that I ate before the
operation, while avoiding foods that cause
gas

Situation 5
A patient just arrived in the Oncology unit
from the Post Anesthesia Care Unit (PACU)
following a Left Modified Radical
Mastectomy because of Inflammatory Breast
Cancer (IBC). She has a pressure dressing
over the surgical site and two drains.
Assessment shows her vital signs are
stable, fully awake and claims that pain is
under control. Felis is the nurse assigned to
the patient.

21. From the following data obtained from

the chart by Felis, which is NOT a risk factor
which could have predisposed the client to
breast cancer?
A. Age 55
B. Menarche at age 13
C. Height 52, weight 160 lbs
D. Mother died of colon cancer

21. From the following data obtained from

the chart by Felis, which is NOT a risk factor
which could have predisposed the client to
breast cancer?
A. Age 55
B. Menarche at age 13
C. Height 522, weight 160 lbs
D. Mother died of colon cancer

22. Felis read a literature which says that by the time

inflammatory Cancer (IBC) is diagnosed, 50%-75% have
palpable auxillary nodes; as many as 30% have gross
distant metastasis; and as few as 30% of patients have an
underlying breast mass. Which of the following
APPROPRIATE interpretation of this research findings?
A. Auxillary nodes were palpated on 20 out of 30 women
positive for IBC3
B. Out of 20 women who were positive for IBC, only 5 have
metastasis
C. If there were 10 women diagnosed with IBC, 3 have
positive lymph nodes
D. Breast mass was identified on 8 out of 30 women
positive for IBC

22. Felis read a literature which says that by the time

inflammatory Cancer (IBC) is diagnosed, 50%-75% have
palpable auxillary nodes; as many as 30% have gross
distant metastasis; and as few as 30% of patients have an
underlying breast mass. Which of the following
APPROPRIATE interpretation of this research findings?
A. Auxillary nodes were palpated on 20 out of 30 women
positive for IBC3
B. Out of 20 women who were positive for IBC, only 5 have
metastasis
C. If there were 10 women diagnosed with IBC, 3 have
positive lymph nodes
D. Breast mass was identified on 8 out of 30 women
positive for IBC

23. Felis recognizes that adjuvant

chemotherapy for breast cancer may include
any of the following EXCEPT:
A. Monoclonal antibody
B. Proton pump inhibitors
C. Antibiotics
D. Anti-estrogen

23. Felis recognizes that adjuvant

chemotherapy for breast cancer may include
any of the following EXCEPT:
A. Monoclonal antibody
B. Proton pump inhibitors
C. Antibiotics
D. Anti-estrogen

24. Felis understands that when the

antineoplastic agent leaks through the
peripheral vascular access during a
chemotherapy procedure, which of the
following is expected to be done FIRST?
A. Refer to the physician
B. Stop the chemotherapy infusion
C. Cleanse site with saline solution
D. Call another nurse to check the
intravenous site

24. Felis understands that when the

antineoplastic agent leaks through the
peripheral vascular access during a
chemotherapy procedure, which of the
following is expected to be done FIRST?
A. Refer to the physician
B. Stop the chemotherapy infusion
C. Cleanse site with saline solution
D. Call another nurse to check the
intravenous site

25. A clinical trial is currently being undertaken

to test treatments for Inflammatory Breast
Cancer. The research team leader wishes to
include the patient as a participant in the study.
As a patient advocate, which of the following
will Felis do FIRST?
A. Obtain informed consent from the patient
B. Explain to the patient the scope of the
clinical trial
C. Inquire from the team leader benefits for the
patient
D. Read more related literatures

25. A clinical trial is currently being undertaken

to test treatments for Inflammatory Breast
Cancer. The research team leader wishes to
include the patient as a participant in the study.
As a patient advocate, which of the following
will Felis do FIRST?
A. Obtain informed consent from the patient
B. Explain to the patient the scope of the
clinical trial
C. Inquire from the team leader benefits for the
patient
D. Read more related literatures

Situation 6
Infection can cause debilitating
consequences when host resistance is
compromised and virulence of
microorganisms and environmental factors
are favorable. Infection control is one
important responsibility of the nurse to
ensure quality of care.

26. Honrad, who has been complaining of anorexia

and feeling tired, develops jaundice. After a
workup he is diagnosed of having Hepatitis A.
His wife asks you about gamma globulin for
herself and her household help. Your most
appropriate response would be:
A. Dont worry your husbands type of
hepatitis is no longer communicable
B. Gamma globulin provides passive immunity
for hepatitis B
C. You should contact your physician
immediately about getting gamma globulin
D. A vaccine has been developed for this
type of hepatitis

26. Honrad, who has been complaining of anorexia

and feeling tired, develops jaundice. After a
workup he is diagnosed of having Hepatitis A.
His wife asks you about gamma globulin for
herself and her household help. Your most
appropriate response would be:
A. Dont worry your husbands type of
hepatitis is no longer communicable
B. Gamma globulin provides passive immunity
for hepatitis B
C. You should contact your physician
immediately about getting gamma globulin
D. A vaccine has been developed for this
type of hepatitis

27. Voltaire develops a nosocomial respiratory

tract infection. He asks you what that means?
Your best response would be:
A. You acquired the infection after you have
been admitted to the hospital
B. This is a highly contagious infection
requiring complete isolation
C. The infection you had prior to
hospitalization flared up
D. As a result of medical treatment, you have
acquired a secondary infection

27. Voltaire develops a nosocomial respiratory

tract infection. He asks you what that means?
Your best response would be:
A. You acquired the infection after you have
been admitted to the hospital
B. This is a highly contagious infection
requiring complete isolation
C. The infection you had prior to
hospitalization flared up
D. As a result of medical treatment, you have
acquired a secondary infection

28. As a nurse, you know that one of the

complications that you have to watch out
for when caring for Omar who is
receiving total parenteral nutrition is:
A. Stomatitis
B. Hepatitis
C. Dysrhythmia
D. Infection

28. As a nurse, you know that one of the

complications that you have to watch out
for when caring for Omar who is
receiving total parenteral nutrition is:
A. Stomatitis
B. Hepatitis
C. Dysrhythmia
D. Infection

29. A solution used to treat Pseudomonas

wound infection is:
A. Dakins solution
B. Half-strengthen hydrogen peroxide
C. Acetic acid
D. Betadine

29. A solution used to treat Pseudomonas

wound infection is:
A. Dakins solution
B. Half-strengthen hydrogen peroxide
C. Acetic acid
D. Betadine

29. A solution used to treat Pseudomonas

wound infection is:
A. Dakins solution
B. Half-strengthen hydrogen peroxide
C. Acetic acid
D. Betadine

30. Which of the following is most reliable in

diagnosing a wound infection?
A. Culture and sensitivity
B. Purulent drainage from a wound
C. WBC of 20,000/uL
D. Gram stain testing

30. Which of the following is most reliable in

diagnosing a wound infection?
A. Culture and sensitivity
B. Purulent drainage from a wound
C. WBC of 20,000/uL
D. Gram stain testing

Situation 7
As a nurse you need to anticipate the
occurrence of complications of stroke so
that life threatening situations can be
prevented.

31. Wendy is admitted to the hospital with

signs and symptoms of stroke. Her
Glasgow Coma Scale is 6 on admission.
A central venous catheter was inserted
and an IV infusion was started. As a
nurse assigned to Wendy, what will be
your priority goal?
A. Prevent skin breakdown
B. Preserve muscle function
C. Promote urinary elimination
D. Maintain a patent airway

31. Wendy is admitted to the hospital with

signs and symptoms of stroke. Her
Glasgow Coma Scale is 6 on admission.
A central venous catheter was inserted
and an IV infusion was started. As a
nurse assigned to Wendy, what will be
your priority goal?
A. Prevent skin breakdown
B. Preserve muscle function
C. Promote urinary elimination
D. Maintain a patent airway

32. Knowing that for a comatose patient

hearing is the last sense to be lost, as

Judys nurse, what should you do?
A. Tell her family that probably she cant
hear them
B. Talk loudly so that Wendy can hear
you
C. Tell her family who are in the room not
to talk
D. Speak softly then hold her hands
gently

32. Knowing that for a comatose patient

hearing is the last sense to be lost, as

Judys nurse, what should you do?
A. Tell her family that probably she cant
hear them
B. Talk loudly so that Wendy can hear
you
C. Tell her family who are in the room not
to talk
D. Speak softly then hold her hands
gently

33. Which among the following interventions

should you consider as the highest
priority when caring for June who has
hemiparesis secondary to stroke?
A. Place June on an upright lateral
position
B. Perform range of motion exercises
C. Apply anti-embolic stockings
D. Use hand rolls or pillows for support

33. Which among the following interventions

should you consider as the highest
priority when caring for June who has
hemiparesis secondary to stroke?
A. Place June on an upright lateral
position
B. Perform range of motion exercises
C. Apply anti-embolic stockings
D. Use hand rolls or pillows for support

34. Ivy, age 40, was admitted to the hospital with a

severe headache, stiff neck and photophobia.
She was diagnosed with a subarachnoid
hemorrhage secondary to ruptured aneurysm.
While waiting for surgery, you can provide a
therapeutic environment by doing which of the
following?
A. Honoring her request for a television
B. Placing her bed near the window
C. Dimming the light in her room
D. Allowing the family unrestricted visiting
privileges

34. Ivy, age 40, was admitted to the hospital with a

severe headache, stiff neck and photophobia.
She was diagnosed with a subarachnoid
hemorrhage secondary to ruptured aneurysm.
While waiting for surgery, you can provide a
therapeutic environment by doing which of the
following?
A. Honoring her request for a television
B. Placing her bed near the window
C. Dimming the light in her room
D. Allowing the family unrestricted visiting
privileges

35. When performing a neurologic

assessment on Walter, you find that his
pupils are fixed and dilated. This
indicated that he:
A. Probably has meningitis
B. Is going to be blind because of trauma
C. Is permanently paralyzed
D. Has received a significant brain injury

35. When performing a neurologic

assessment on Walter, you find that his
pupils are fixed and dilated. This
indicated that he:
A. Probably has meningitis
B. Is going to be blind because of trauma
C. Is permanently paralyzed
D. Has received a significant brain injury

Situation 8
You admitted Engelbert, male, 70 years old,
because of pulmonary edema. He has a
history of Congestive Heart Failure, type 2
diabetes mellitus and hypertension.

36. Based on Engelberts health history, you

specifically noted that he regularly takes lanoxin
(Digoxin). Which of the following is the SPECIFIC
action of this drug on the patient?
A. Improves myocardial contractility, decreases the
heart rate and reduces oxygen consumption
B. Causes vasoconstriction, increase preload and
dilates the ventricles
C. Reduces peripheral vascular resistance and
afterload, reducing myocardial work
D. Interfere with the production of angiostensin II
resulting in improved cardiac output and reducing
pulmonary congestion

36. Based on Engelberts health history, you

specifically noted that he regularly takes lanoxin
(Digoxin). Which of the following is the SPECIFIC
action of this drug on the patient?
A. Improves myocardial contractility, decreases the
heart rate and reduces oxygen consumption
B. Causes vasoconstriction, increase preload and
dilates the ventricles
C. Reduces peripheral vascular resistance and
afterload, reducing myocardial work
D. Interfere with the production of angiostensin II
resulting in improved cardiac output and reducing
pulmonary congestion

37. Which of the following specific positions

would be most helpful for Engelbert to facilitate
and trap excess fluids in the lower extremities?
A. Head bent forward on an overbed table
supported with pillows
B. Upright sitting position with the legs
dangling
C. Lateral position with the upper leg flexed
and lower leg extended
D. Fowlers position with the patient lying on
his left side

37. Which of the following specific positions

would be most helpful for Engelbert to facilitate
and trap excess fluids in the lower extremities?
A. Head bent forward on an overbed table
supported with pillows
B. Upright sitting position with the legs
dangling
C. Lateral position with the upper leg flexed
and lower leg extended
D. Fowlers position with the patient lying on
his left side

38. Furosemide (Lasix) 20 mg was

administered by IV push at 10:00 am, with
urinary output from indwelling foley catheter
at the level of 120 cc. At 10:15 am, the
nurse observed that the urinary output did
not change. Which of the following will you
check FIRST?
A.Foley catheter connecting tube of kinks
B.Intravenous site for swelling
C. Foley catheter for leakage
D. Patients hypogastrium for urinary
retention

38. Furosemide (Lasix) 20 mg was

administered by IV push at 10:00 am, with
urinary output from indwelling foley catheter
at the level of 120 cc. At 10:15 am, the
nurse observed that the urinary output did
not change. Which of the following will you
check FIRST?
A.Foley catheter connecting tube of kinks
B.Intravenous site for swelling
C. Foley catheter for leakage
D. Patients hypogastrium for urinary
retention

39. While preparing the medication, you

checked the medication, which was
dispensed by the pharmacist, with the
written order to the physician. Which of the
following actions will you do FIRST if you
found that instead to Regular insulin, the
pharmacist dispensed NPH insulin?
A.Validate order with the physician
B.Ask the pharmacist to change the drug
C. Document error
D. Report the error to the unit manager

39. While preparing the medication, you

checked the medication, which was
dispensed by the pharmacist, with the
written order to the physician. Which of the
following actions will you do FIRST if you
found that instead to Regular insulin, the
pharmacist dispensed NPH insulin?
A.Validate order with the physician
B.Ask the pharmacist to change the drug
C. Document error
D. Report the error to the unit manager

40. You administered morphine sulfate 1

mg, intravenously as ordered. The following
are intended actions of this drug EXCEPT:
A. Improve efficacy of breathing
B. Decrease anxiety
C. Reduce reload
D. Relieve pain

Morphine Sulfate Action

1.Relieves pain
2.Reduces anxiety
3.Reduces cardiac workload
4.Decreases the BP
Adverse Effect:
1.Hypotension
2.Respiratory depression

40. You administered morphine sulfate 1

mg, intravenously as ordered. The following
are intended actions of this drug EXCEPT:
A. Improve efficacy of breathing
B. Decrease anxiety
C. Reduce reload
D. Relieve pain

Situation 9
A disaster is a large-scale emergency even a small
emergency left unmanaged may turn into a disaster.
Disaster preparedness is crucial and is everybodys
business. There are agencies that are in charge of
ensuring prompt response. Comprehensive
Emergency Management (CEM) is an integrated
approach to the management of emergency
programs and activities for all four emergency
phases (mitigation, preparedness, response, and
recovery), for all types of emergencies and disasters
(natural, man-made, and attack) and for all levels of
government and the private sector.

MITIGATION
Continuing effort to lessen the impact
disasters have on people and property.
"sustained action that reduces or
eliminates long-term risk to people and
property from natural hazards and their
effects."

PREPAREDNESS
Plans or procedures designed to save
lives and to minimize damage when an
emergency occurs.
Planning, training, and disaster drills
are the essential elements of
preparedness.

RESPONSE
Actions taken to save lives and prevent
further damage in a disaster or
emergency situation
Damage assessment, search and rescue,
fire fighting, and sheltering victims.

RECOVERY
Actions taken to return the community to
normal following a disaster
Repairing, replacing, or rebuilding property
are examples of recovery.

41. Which of the four phases of emergency

management is defined as sustained
action that reduces or eliminates longterm risk to people and property from
natural hazards and their effects?
A. Recovery
B. Mitigation
C. Response
D. Preparedness

41. Which of the four phases of emergency

management is defined as sustained
action that reduces or eliminates longterm risk to people and property from
natural hazards and their effects?
A. Recovery
B. Mitigation
C. Response
D. Preparedness

42. You are a community health nurse

collaborating with the Red Cross and working
with disaster relief following a typhoon which
flooded and devastated the whole province.
Finding safe housing for survivors, organizing
support for the family, organizing counseling
debriefing sessions and securing physical care
are the services you are involved with. To
which type of prevention are these activities
included:
A. Tertiary prevention
B. Primary prevention
C. Aggregate care prevention
D. Secondary prevention

42. You are a community health nurse

collaborating with the Red Cross and working
with disaster relief following a typhoon which
flooded and devastated the whole province.
Finding safe housing for survivors, organizing
support for the family, organizing counseling
debriefing sessions and securing physical care
are the services you are involved with. To
which type of prevention are these activities
included:
A. Tertiary prevention
B. Primary prevention
C. Aggregate care prevention
D. Secondary prevention

43. During the disaster, you see a victim with a

green tag, you know that the person:
A. Has injuries that are significant and
require medical care but can wait hours with
threat to life or limb
B. Has injuries that are life threatening but
survival is good with minimal intervention
C. Indicates injuries that are extensive and
chances of survival are unlikely even with
definitive care
D. Has injuries that are minor and treatment
can be delayed from hours to days

43. During the disaster, you see a victim with a

green tag, you know that the person:
A. Has injuries that are significant and
require medical care but can wait hours with
threat to life or limb
B. Has injuries that are life threatening but
survival is good with minimal intervention
C. Indicates injuries that are extensive and
chances of survival are unlikely even with
definitive care
D. Has injuries that are minor and treatment
can be delayed from hours to days

43. During the disaster, you see a victim with a

green tag, you know that the person:
A. Has injuries that are significant and
require medical care but can wait hours with
threat to life or limb
B. Has injuries that are life threatening but
survival is good with minimal intervention
C. Indicates injuries that are extensive and
chances of survival are unlikely even with
definitive care
D. Has injuries that are minor and treatment
can be delayed from hours to days

44. The term given to a category of triage

that refers to life threatening or
potentially life threatening injury or illness
requiring immediate treatment:
A. Immediate
B. Emergent
C. Non-acute
D. Urgent

44. The term given to a category of triage

that refers to life threatening or
potentially life threatening injury or illness
requiring immediate treatment:
A. Immediate
B. Emergent
C. Non-acute
D. Urgent

44. The term given to a category of triage

that refers to life threatening or
potentially life threatening injury or illness
requiring immediate treatment:
A. Immediate
B. Emergent
C. Non-acute
D. Urgent

45. Which of the following terms refer to a

process by which the individual receives
education about recognition of stress
reactions and management strategies for
handling stress which may be instituted
after a disaster?
A. Clinical incident stress management
B. Follow up
C. Debriefing
D. Defusion

45. Which of the following terms refer to a

process by which the individual receives
education about recognition of stress
reactions and management strategies for
handling stress which may be instituted
after a disaster?
A. Clinical incident stress management
B. Follow up
C. Debriefing
D. Defusion

Situation 10
As a member of the health and nursing team
you have a crucial role to play in ensuring
that all the members participate actively is
the various task agreed upon

46. While eating his meal, Matthew

accidentally dislodges his IV line and
bleeds. Blood oozes on the surface of
the over bed table. It is most appropriate
that you instruct the housekeeper to
clean the table with:
A. Acetone
B. Alcohol
C. Ammonia
D. Bleach

46. While eating his meal, Matthew

accidentally dislodges his IV line and
bleeds. Blood oozes on the surface of
the over bed table. It is most appropriate
that you instruct the housekeeper to
clean the table with:
A. Acetone
B. Alcohol
C. Ammonia
D. Bleach

47. You are a member of the infection control team

of the hospital. Based on a feedback during
the meeting of the committee there is an
increased incidence of pseudomonas infection
in the Burn Unit (3 out of 10 patients had
positive blood and wound culture). What is
your priority activity?
A. Establish policies for surveillance and
monitoring
B. Do data gathering about the possible
sources of infection (observation, chart review,
interview)
C. Assign point persons who can implement
policies
D. Meet with the nursing group working in the
burn unit and discuss problem with them

47. You are a member of the infection control team

of the hospital. Based on a feedback during
the meeting of the committee there is an
increased incidence of pseudomonas infection
in the Burn Unit (3 out of 10 patients had
positive blood and wound culture). What is
your priority activity?
A. Establish policies for surveillance and
monitoring
B. Do data gathering about the possible
sources of infection (observation, chart review,
interview)
C. Assign point persons who can implement
policies
D. Meet with the nursing group working in the
burn unit and discuss problem with them

48. Part of your responsibility as a member of the

diabetes core group is to get referrals from the
various wards regarding diabetic patients
needing diabetes education. Prior to discharge
today, 4 patients are referred to you. How
would you start prioritizing your activities?
A. Bring your diabetes teaching kit and start
your session taking into consideration their
distance from your office
B. Contact the nurse in-charge and find out
from her the reason for the referral
C. Determine their learning needs then
prioritize
D. Involve the whole family in the teaching
class

48. Part of your responsibility as a member of the

diabetes core group is to get referrals from the
various wards regarding diabetic patients
needing diabetes education. Prior to discharge
today, 4 patients are referred to you. How
would you start prioritizing your activities?
A. Bring your diabetes teaching kit and start
your session taking into consideration their
distance from your office
B. Contact the nurse in-charge and find out
from her the reason for the referral
C. Determine their learning needs then
prioritize
D. Involve the whole family in the teaching
class

49. You have been designated as a member of the

task force to plan activities for the Cancer
Consciousness Week. Your committee has 4
months to plan and implement the plan. You are
assigned to contact the various cancer support
groups in your hospital. What will be your priority
activity?
A. Find out if there is a budget for this activity
B. Clarify objectives of the activity with the task
force before contacting the support groups
C. Determine the VIPs and celebrities who will be
invited
D. Find out how many support groups there are in
the hospital and get the contact number of their
president

49. You have been designated as a member of the

task force to plan activities for the Cancer
Consciousness Week. Your committee has 4
months to plan and implement the plan. You are
assigned to contact the various cancer support
groups in your hospital. What will be your priority
activity?
A. Find out if there is a budget for this activity
B. Clarify objectives of the activity with the task
force before contacting the support groups
C. Determine the VIPs and celebrities who will be
invited
D. Find out how many support groups there are in
the hospital and get the contact number of their
president

50. You are invited to participate in the medical

mission activity of your alumni association. In the
planning stage, everybody is expected to identify
what they can do during the medical mission and
what resources are needed. You thought it is also
your chance to share what you can do for others.
What will be your most important role where you
can demonstrate the impact of nursing in health?
A. Conduct health education on healthy life style
B. Be a triage nurse
C. Take the initial history and document findings
D. Act as a coordinator

50. You are invited to participate in the medical

mission activity of your alumni association. In the
planning stage, everybody is expected to identify
what they can do during the medical mission and
what resources are needed. You thought it is also
your chance to share what you can do for others.
What will be your most important role where you
can demonstrate the impact of nursing in health?
A. Conduct health education on healthy life style
B. Be a triage nurse
C. Take the initial history and document findings
D. Act as a coordinator

51. Irma is terminally ill, she speaks to you in

confidence. You now feel that Irmas family
could be helpful if they knew what Irma has
told you. What should you do first?
A. Tell the physician who in turn could tell the
family
B. Obtain Irmas permission to share the
information with the family
C. Tell Irma that she has to tell her family what
she told you
D. Make an appointment to discuss the
situation with the family

51. Irma is terminally ill, she speaks to you in

confidence. You now feel that Irmas family
could be helpful if they knew what Irma has
told you. What should you do first?
A. Tell the physician who in turn could tell the
family
B. Obtain Irmas permission to share the
information with the family
C. Tell Irma that she has to tell her family what
she told you
D. Make an appointment to discuss the
situation with the family

52. Ruby who has been told she has terminal

cancer turns away and refuses to respond to
you. You can best help her by:
A. Coming back periodically and indicating
your availability if she would like you to sit with
her
B. Insisting that Ruby should talk with you
because it is not good to keep everything
inside
C. Leaving her alone because she is
uncooperative and unpleasant to be with
D. Encouraging her to be physically active as
possible

52. Ruby who has been told she has terminal

cancer turns away and refuses to respond to
you. You can best help her by:
A. Coming back periodically and indicating
your availability if she would like you to sit with
her
B. Insisting that Ruby should talk with you
because it is not good to keep everything
inside
C. Leaving her alone because she is
uncooperative and unpleasant to be with
D. Encouraging her to be physically active as
possible

53. Leo, who is terminally ill and recognizes

that he is in the process of losing
everything and everybody he loves is
depressed. Which of the following would
best help him during his depression?
A. Arrange for visitors who might cheer
him
B. Sit down and talk with him for a while
C. Encourage him to look at the brighter
side of things
D. Sit silently with him

53. Leo, who is terminally ill and recognizes

that he is in the process of losing
everything and everybody he loves is
depressed. Which of the following would
best help him during his depression?
A. Arrange for visitors who might cheer
him
B. Sit down and talk with him for a while
C. Encourage him to look at the brighter
side of things
D. Sit silently with him

54. Which of the following statements would

best indicate that Ruffy, who is dying,
has accepted his impending death?
A. Im ready to go
B. I have resigned myself to dying
C. Whats the use
D. Im giving up

54. Which of the following statements would

best indicate that Ruffy, who is dying,
has accepted his impending death?
A. Im ready to go
B. I have resigned myself to dying
C. Whats the use
D. Im giving up

55. Maria, 90 y/o has planned ahead for her

death philosophically, socially,
financially and emotionally. This is
recognized as:
A. Acceptance that death is inevitable
B. Avoidance of the true situation
C. Denial with planning for continued life
D. Awareness that death will soon occur

55. Maria, 90 y/o has planned ahead for her

death philosophically, socially,
financially and emotionally. This is
recognized as:
A. Acceptance that death is inevitable
B. Avoidance of the true situation
C. Denial with planning for continued life
D. Awareness that death will soon occur

Situation 12
Brain tumor, whether malignant or benign,
has serious management implications. As
a nurse, you should be able to understand
the consequences of the disease and the
treatment.

56. You are caring for Conrad who has a

brain tumor and increased Intracranial
Pressure (ICP). Which intervention
should you include in your plan to reduce
ICP?
A. Administer bowel softener
B. Position Conrad with his head turned
toward the side of the tumor
C. Provide sensory stimulation
D. Encourage coughing and deep
breathing

56. You are caring for Conrad who has a

brain tumor and increased Intracranial
Pressure (ICP). Which intervention
should you include in your plan to reduce
ICP?
A. Administer bowel softener
B. Position Conrad with his head turned
toward the side of the tumor
C. Provide sensory stimulation
D. Encourage coughing and deep
breathing

57. Keeping Conrads head and neck in

alignment results in:

A. Increased intrathoracic pressure
B. Increased venous outflow
C. Decreased venous outflow
D. Increased intra-abdominal pressure

57. Keeping Conrads head and neck in

alignment results in:

A. Increased intrathoracic pressure
B. Increased venous outflow
C. Decreased venous outflow
D. Increased intra-abdominal pressure

58. Which of the following activities may

increase ICP?
A. Raising the head of the bed
B. Manual hyperventilation
C. Use of osmotic diuretics
D. Valsalvas maneuver

58. Which of the following activities may

increase ICP?
A. Raising the head of the bed
B. Manual hyperventilation
C. Use of osmotic diuretics
D. Valsalvas maneuver

59. After you assessed Conrad, you

suspected increased ICP. Your most

appropriate respiratory goal is to:
A. Maintain partial pressure of arterial O2
(PaO2) above 80 mmHg
B. Lower arterial pH
C. Prevent respiratory alkalosis
D. Promote CO2 elimination

59. After you assessed Conrad, you

suspected increased ICP. Your most

appropriate respiratory goal is to:
A. Maintain partial pressure of arterial O2
(PaO2) above 80 mmHg
B. Lower arterial pH
C. Prevent respiratory alkalosis
D. Promote CO2 elimination

60. Conrad underwent craniotomy. As his

nurse, you know that drainage on a
craniotomy dressing must be measured
and marked. Which findings should you
report immediately to the surgeon?
A. Foul-smelling drainage
B. Yellowish drainage
C. Greenish drainage
D. Bloody drainage

60. Conrad underwent craniotomy. As his

nurse, you know that drainage on a
craniotomy dressing must be measured
and marked. Which findings should you
report immediately to the surgeon?
A. Foul-smelling drainage
B. Yellowish drainage
C. Greenish drainage
D. Bloody drainage

Situation 13
As a nurse, you have specific
responsibilities as professional. You have
to demonstrate specific competencies.

61. The essential components of

professional nursing practice are all the
following, EXCEPT:
A. Culture
B. Care
C. Cure
D. Coordination

61. The essential components of

professional nursing practice are all the
following, EXCEPT:
A. Culture
B. Care
C. Cure
D. Coordination

61. The essential components of

professional nursing practice are all the
following, EXCEPT:
A. Culture
B. Care
C. Cure
D. Coordination

62. You are assigned to care for 4 patients.

Which of the following patients should
you give first priority?
A. Grace, who is terminally ill with breast
cancer
B. Emy, who was previously lucid but is
now unarousable
C. Aris, who is newly admitted and is
scheduled for an executive check-up
D. Claire, who has cholelithiasis and is
for operation on call

62. You are assigned to care for 4 patients.

Which of the following patients should
you give first priority?
A. Grace, who is terminally ill with breast
cancer
B. Emy, who was previously lucid but is
now unarousable
C. Aris, who is newly admitted and is
scheduled for an executive check-up
D. Claire, who has cholelithiasis and is
for operation on call

63. Brenda, the Nursing Supervisor of the ICU is

not on duty when a staff nurse committed a
serious medication error. Which statement
accurately reflects the accountability of the
nursing supervisor?
A. Brenda should be informed when she goes
back on duty
B. Although Brenda is not on duty, the nursing
supervisor on duty decides to call her if time
permits
C. The nursing supervisor on duty will notify
Brenda at home
D. Brenda is not duty therefore it is not
necessary to inform her

63. Brenda, the Nursing Supervisor of the ICU is

not on duty when a staff nurse committed a
serious medication error. Which statement
accurately reflects the accountability of the
nursing supervisor?
A. Brenda should be informed when she goes
back on duty
B. Although Brenda is not on duty, the nursing
supervisor on duty decides to call her if time
permits
C. The nursing supervisor on duty will notify
Brenda at home
D. Brenda is not duty therefore it is not
necessary to inform her

64. Which barrier should you avoid to

manage your time wisely?
A. Practical planning
B. Procrastination
C. Setting limits
D. Realistic personal expectation

64. Which barrier should you avoid to

manage your time wisely?
A. Practical planning
B. Procrastination
C. Setting limits
D. Realistic personal expectation

65. You are caring for Vincent who has just been
transferred to the private room. He is anxious
because he fears he wont be monitored as
closely as he was in the Coronary Care Unit.
How can you allay his fear?
A. Move his bed to a room far from nurses
station to reduce
B. Assign the same nurse to him when
possible
C. Allow Vincent uninterrupted period of time
D. Limit Vincents visitors to coincide with CCU
policies

65. You are caring for Vincent who has just been
transferred to the private room. He is anxious
because he fears he wont be monitored as
closely as he was in the Coronary Care Unit.
How can you allay his fear?
A. Move his bed to a room far from nurses
station to reduce
B. Assign the same nurse to him when
possible
C. Allow Vincent uninterrupted period of time
D. Limit Vincents visitors to coincide with CCU
policies

Situation 14
As a nurse in the Oncology Unit, you have to
be prepared to provide safe, efficient and
effective care to your patients.

66. Which one of the following nursing

interventions would be most helpful in
preparing the patient for radiation
therapy?
A. Offer tranquilizers and anti-emetics
B. Instruct the patient of the possibility of
radiation burn
C. Emphasis on the therapeutic value of
the treatment
D. Map out the precise course of
treatment

66. Which one of the following nursing

interventions would be most helpful in
preparing the patient for radiation
therapy?
A. Offer tranquilizers and anti-emetics
B. Instruct the patient of the possibility of
radiation burn
C. Emphasis on the therapeutic value of
the treatment
D. Map out the precise course of
treatment

67. What side effects are most apt to occur

to patient during radiation therapy to the
pelvis?
A. Urinary retention
B. Abnormal vaginal or perineal
discharge
C. Paresthesia of the lower extremities
D. Nausea and vomiting and diarrhea

67. What side effects are most apt to occur

to patient during radiation therapy to the
pelvis?
A. Urinary retention
B. Abnormal vaginal or perineal
discharge
C. Paresthesia of the lower extremities
D. Nausea and vomiting and diarrhea

68. Which of the following can be used on

the irradiated skin during a course of
radiation therapy?
A. Adhesive tape
B. Mineral oil
C. Talcum powder
D. Zinc oxide ointment

68. Which of the following can be used on

the irradiated skin during a course of
radiation therapy?
A. Adhesive tape
B. Mineral oil
C. Talcum powder
D. Zinc oxide ointment

Zinc Oxide
Applied to the skin as a mild astringent, as
a soothing and protective application to
slight excoriation in napkin rash, areas
around stoma, bedsores and postradiation skin sites

69. Earliest sign of skin reaction to radiation

therapy is:
A. Desquamation
B. Erythema
C. Atrophy
D. Pigmentation

69. Earliest sign of skin reaction to radiation

therapy is:
A. Desquamation
B. Erythema
C. Atrophy
D. Pigmentation

70. What is the purpose of wearing a film

badge while caring for the patient who is
radioactive?
A. Identify the nurse who is assigned to
care for such a patient
B. Prevent radiation-induced sterility
C. Protect the nurse from radiation effects
D. Measure the amount of exposure to
radiation

70. What is the purpose of wearing a film

badge while caring for the patient who is
radioactive?
A. Identify the nurse who is assigned to
care for such a patient
B. Prevent radiation-induced sterility
C. Protect the nurse from radiation effects
D. Measure the amount of exposure to
radiation

Situation 15
In a disaster there must be a chain of
command in place that defines the roles of
each member of the response team.
Within the health care group there are preassigned roles based on education,
experience and training on disaster.

71. As a nurse, to which of the following

groups are you best prepared to join?
A. Treatment group
B. Triage group
C. Morgue management
D. Transport group

71. As a nurse, to which of the following

groups are you best prepared to join?
A. Treatment group
B. Triage group
C. Morgue management
D. Transport group

72. There are important principles that should guide

the triage team in disaster management that you
have to know if you were to volunteer as part of
the triage team. The following principles should be
observed in disaster triage EXCEPT:
A. Any disaster plan should have resources
available to triage at each facility and at the
disaster site if possible
B. Make the most efficient use of available
resources
C. Training on disaster is not important to the
response in the event of a real disaster because
each disaster is unique in itself
D. Do the greatest good for the greatest number of
casualties

72. There are important principles that should guide

the triage team in disaster management that you
have to know if you were to volunteer as part of
the triage team. The following principles should be
observed in disaster triage EXCEPT:
A. Any disaster plan should have resources
available to triage at each facility and at the
disaster site if possible
B. Make the most efficient use of available
resources
C. Training on disaster is not important to the
response in the event of a real disaster because
each disaster is unique in itself
D. Do the greatest good for the greatest number of
casualties

73. Which of the following categories of

conditions should be considered first
priority in a disaster?
A. Intracranial pressure and mental
status
B. Lower gastrointestinal problems
C. Respiratory infection
D. Trauma

II. Do a Primary Survey

-

organization of approach so that

immediate threats to life are rapidly
identified and effectively manage.

Primary Survey

- Airway/Cervical Spine
- Establish Patent Airway
- Maintain Alignment
193

B Breathing
- Assess Breath Sounds
- Observe for Chest Wall Trauma
- Prepare for chest compression

C Circulation
- Monitor VS
- Maintain Vascular Access
- Direct Pressure
194

D Disability
- Evaluate LOC
- Re-evaluate clients LOC

E Exposure
- Remove clothing
- Maintain Privacy
- Prevent Hypothermia

195

73. Which of the following categories of

conditions should be considered first
priority in a disaster?
A. Intracranial pressure and mental
status
B. Lower gastrointestinal problems
C. Respiratory infection
D. Trauma

74. A guideline that is utilized in determining

priorities is to assess the status of the
following, EXCEPT:
A. Perfusion
B. Locomotion
C. Respiration
D. Mentation

Managing the Scene

Remember the
Mnemonic
R - RESPIRATION
P - PERFUSION
M MENTAL
STATUS

74. A guideline that is utilized in determining

priorities is to assess the status of the
following, EXCEPT:
A. Perfusion
B. Locomotion
C. Respiration
D. Mentation

74. A guideline that is utilized in determining

priorities is to assess the status of the
following, EXCEPT:
A. Perfusion
B. Locomotion
C. Respiration
D. Mentation

75. The most important component of

neurologic assessment is:
A. Pupil reactivity
B. Vital sign assessment
C. Cranial nerve assessment
D. Level of consciousness /
responsiveness

75. The most important component of

neurologic assessment is:
A. Pupil reactivity
B. Vital sign assessment
C. Cranial nerve assessment
D. Level of consciousness /
responsiveness

Situation 16
You are going to participate in a Cancer
consciousness week. You are assigned to
take charge of the women to make them
aware of cervical cancer. You reviewed its
manifestations and management.

76. The following are risk factors for cervical

cancer, EXCEPT:
A. Immunosuppressive therapy
B. Sex at an early age, multiple partners,
exposure to STDs, male partners habits
C. Viral agents like Human Papilloma
Virus
D. Smoking

76. The following are risk factors for cervical

cancer, EXCEPT:
A. Immunosuppressive therapy
B. Sex at an early age, multiple partners,
exposure to STDs, male partners habits
C. Viral agents like Human Papilloma
Virus
D. Smoking

76. The following are risk factors for cervical

cancer, EXCEPT:
A. Immunosuppressive therapy
B. Sex at an early age, multiple partners,
exposure to STDs, male partners habits
C. Viral agents like Human Papilloma
Virus
D. Smoking

77. Late signs and symptoms of cervical

cancer include the following EXCEPT
A. Urinary / bowel changes
B. Pain in pelvis, leg or flank
C. Uterine bleeding
D. Lymph edema of lower extremities

77. Late signs and symptoms of cervical

cancer include the following EXCEPT:
A. Urinary / bowel changes
B. Pain in pelvis, leg or flank
C. Uterine bleeding
D. Lymph edema of lower extremities

Cervical Cancer
Signs and Symptoms
Abnormal vaginal bleeding (most common
sign)
- thin, watery, blood-tinged at first which
progresses to spotting & frank bleeding
Prolonged menstrual period
Contact bleeding after intercourse
Anemia

77. Late signs and symptoms of cervical

cancer include the following EXCEPT
A. Urinary / bowel changes
B. Pain in pelvis, leg or flank
C. Uterine bleeding
D. Lymph edema of lower extremities

78. When a panhysterectomy is performed

due to cancer of the cervix, which of the
following organs are removed?
A. The uterus, cervix, and one ovary
B. The uterus, cervix, and 2/3 of the
vagina
C. The uterus, cervix, tubes and ovaries
D. The uterus and cervix

78. When a panhysterectomy is performed

due to cancer of the cervix, which of the
following organs are removed?
A. The uterus, cervix, and one ovary
B. The uterus, cervix, and 2/3 of the
vagina
C. The uterus, cervix, tubes and ovaries
D. The uterus and cervix

79. The primary modalities of treatment for

Stage I and IIA cervical cancer include the
following:
A. Surgery, radiation and hormone therapy
B. Surgery
C. Radiation therapy
D. Surgery and radiation therapy

79. The primary modalities of treatment for

Stage I and IIA cervical cancer include the
following:
A. Surgery, radiation and hormone therapy
B. Surgery
C. Radiation therapy
D. Surgery and radiation therapy

80. A common complication of hysterectomy

is:
A. Thrombophlebitis of the pelvic and
thigh vessels
B. Diarrhea due to over stimulation
C. Atelectasis
D. Wound dehiscence

80. A common complication of hysterectomy

is:
A. Thrombophlebitis of the pelvic and
thigh vessels
B. Diarrhea due to over stimulation
C. Atelectasis
D. Wound dehiscence

Situation 17
The body has regulatory mechanism to
maintain the needed electrolytes.
However, there are conditions / surgical
interventions that could compromise life.
You have to understand how management
of these conditions are done.

81. You are caring for Leda who is

scheduled to undergo total thyroidectomy
because of a diagnosis of thyroid cancer.
Prior to total thyroidectomy, you should
instruct Leda to:
A. Perform range and motion exercises
on the head and neck
B. Apply gentle pressure against the
incision when swallowing
C. Cough and deep breath every 2 hours
D. Support head with the hands when
changing position

81. You are caring for Leda who is

scheduled to undergo total thyroidectomy
because of a diagnosis of thyroid cancer.
Prior to total thyroidectomy, you should
instruct Leda to:
A. Perform range and motion exercises
on the head and neck
B. Apply gentle pressure against the
incision when swallowing
C. Cough and deep breath every 2 hours
D. Support head with the hands when
changing position

82. As Ledas nurse, you plan to set up an

emergency equipment at her bedside

following thyroidectomy. You should
include:
A. An airway and rebreathing tube
B. A tracheostomy set and oxygen
C. A crash cart with bed board
D. Two ampules of sodium bicarbonate

82. As Ledas nurse, you plan to set up an

emergency equipment at her bedside

following thyroidectomy. You should
include:
A. An airway and rebreathing tube
B. A tracheostomy set and oxygen
C. A crash cart with bed board
D. Two ampules of sodium bicarbonate

83. Which of the following nursing

interventions is appropriate after a total

thyroidectomy?
A. Place pillows under your patients
shoulders
B. Raise the knee-gatch to 30 degrees
C. Keep your patient in a high-fowlers
position
D. Support the patients head and neck
with pillows and sandbags

83. Which of the following nursing

interventions is appropriate after a total

thyroidectomy?
A. Place pillows under your patients
shoulders
B. Raise the knee-gatch to 30 degrees
C. Keep your patient in a high-fowlers
position
D. Support the patients head and neck
with pillows and sandbags

84. If there is an accidental injury to the

parathyroid gland during a
thyroidectomy, which of the following
might Leda develop postoperatively?
A. Cardiac arrest
B. Dyspnea
C. Respiratory failure
D. Tetany

84. If there is an accidental injury to the

parathyroid gland during a
thyroidectomy, which of the following
might Leda develop postoperatively?
A. Cardiac arrest
B. Dyspnea
C. Respiratory failure
D. Tetany

85. After surgery, Leda develops peripheral

numbness, tingling and muscle twitching

and spasm. What would you anticipate to
administer?
A. Magnesium sulfate
B. Calcium gluconate
C. Potassium iodide
D. Potassium chloride

85. After surgery, Leda develops peripheral

numbness, tingling and muscle twitching

and spasm. What would you anticipate to
administer?
A. Magnesium sulfate
B. Calcium gluconate
C. Potassium iodide
D. Potassium chloride

Situation 18
Nurses are involved in maintaining a safe
and healthy environment. This is part of
quality care management.

86. The first step in decontamination is:

A. To immediately apply a chemical
decontamination foam to the area of
contamination
B. A thorough soap and water wash and
rinse of the patient
C. To immediately apply personal
protective equipment
D. Removal of the patients clothing and
jewelry and then rinsing the patient with
water

86. The first step in decontamination is:

A. To immediately apply a chemical
decontamination foam to the area of
contamination
B. A thorough soap and water wash and
rinse of the patient
C. To immediately apply personal
protective equipment
D. Removal of the patients clothing and
jewelry and then rinsing the patient with
water

87. For a patient experiencing pruritus, you

recommend which type of bath
A. Water
B. Colloid
C. Saline
D. Sodium bicarbonate

87. For a patient experiencing pruritus, you

recommend which type of bath
A. Water
B. Colloid
C. Saline
D. Sodium bicarbonate

POLYCYTHEMIA VERA
Management for Generalized Pruritus
athing in tepid or cool water
- aking soda dissolve in bath water

A pply Cocoa butter or oatmeal-based lotion

T oweling (Avoid vigorous)
H ot water (avoid)

88. Induction of vomiting is indicated for the

accidental poisoning of a patient who has
ingested:
A. Rust remover
B. Gasoline
C. Toilet bowl cleaner
D. Aspirin

88. Induction of vomiting is indicated for the

accidental poisoning of a patient who has
ingested:
A. Rust remover
B. Gasoline
C. Toilet bowl cleaner
D. Aspirin

89. Which of the following term most

precisely refer to an infection acquired in
the hospital that was not present or
incubating at the time of hospital
admission?
A. Secondary bloodstream infection
B. Nosocomial infection
C. Emerging infectious disease
D. Primary bloodstream infection

89. Which of the following term most

precisely refer to an infection acquired in
the hospital that was not present or
incubating at the time of hospital
admission?
A. Secondary bloodstream infection
B. Nosocomial infection
C. Emerging infectious disease
D. Primary bloodstream infection

90. Which of the following guidelines is not

appropriate to helping family members
cope with sudden death
A. Obtain orders for sedation of family
members
B. Provide details of the factors attendant
to the sudden death
C. Show acceptance of the body by
touching it and giving the family
permission to touch
D. Inform the family that the patient has
passed on

90. Which of the following guidelines is not

appropriate to helping family members
cope with sudden death
A. Obtain orders for sedation of family
members
B. Provide details of the factors attendant
to the sudden death
C. Show acceptance of the body by
touching it and giving the family
permission to touch
D. Inform the family that the patient has
passed on

Situation 19
As a nurse you are expected to participate in
initiating or participating in the conduct of
research studies to improve nursing
practice. You have to be updated on the
latest trends and issues affecting
profession and the best practices arrived
at by the profession

91. You are interested to study the effects of

meditation and relaxation on the pain
experienced by cancer patients. What
type of variable is pain?
A. Dependent
B. Correlational
C. Independent
D. Demographic

91. You are interested to study the effects of

meditation and relaxation on the pain
experienced by cancer patients. What
type of variable is pain?
A. Dependent
B. Correlational
C. Independent
D. Demographic

91. You are interested to study the effects of

meditation and relaxation on the pain
experienced by cancer patients. What
type of variable is pain?
A. Dependent
B. Correlational
C. Independent
D. Demographic

Rationale:

The independent variable is meditation and

relaxation and the dependent variable is
pain.

92. You would like to compare the support system of

patients with chronic illness to those with acute illness.
How will you best state your problem?
A. A Descriptive Study To Compare The Support
System Of Patients With Chronic Illness And Those
With Acute Illness In Terms Of Demograhic Data And
Knowledge About Interventions
B. The Effect Of The Type Of Support System Of
Patients With Chronic Illness And Those With Acute
Illness
C. A Comparative Analysis Of The Support System Of
Patients With Chronic Illness And Those With Acute
Illness
D. A Study To Compare The Support System Of
Patients With Chronic Illness And Those With Acute
Illness

92. You would like to compare the support system of

patients with chronic illness to those with acute illness.
How will you best state your problem?
A. A Descriptive Study To Compare The Support
System Of Patients With Chronic Illness And Those
With Acute Illness In Terms Of Demograhic Data And
Knowledge About Interventions
B. The Effect Of The Type Of Support System Of
Patients With Chronic Illness And Those With Acute
Illness
C. A Comparative Analysis Of The Support System Of
Patients With Chronic Illness And Those With Acute
Illness
D. A Study To Compare The Support System Of
Patients With Chronic Illness And Those With Acute
Illness

93. You would like to compare the support

system of patients with chronic illness to
those with acute illness. What type of
research is this?
A. Correlation
B. Descriptive
C. Experimental
D. Quasi-experimental

93. You would like to compare the support

system of patients with chronic illness to
those with acute illness. What type of
research is this?
A. Correlation
B. Descriptive
C. Experimental
D. Quasi-experimental

93. You would like to compare the support

system of patients with chronic illness to
those with acute illness. What type of
research is this?
A. Correlation
B. Descriptive
C. Experimental
D. Quasi-experimental

Rationale:
Descriptive research, also known as
statistical research, describes data and
characteristics about the population or
phenomenon being studied. Descriptive
research answers the questions who, what,
where, when, "why" and how...

94. You are shown a Likert Scale that will be

used in evaluating your performance in
the clinical area. Which of the following
questions will you not use in criticizing
the Likert Scale?
A. Are the techniques to complete and
score the scale provided?
B. Are the reliability and validity
information on the scale described?
C. If the Likert Scale is to be used for a
study, was the development process
described?
D. Is the instrument clearly described

94. You are shown a Likert Scale that will be

used in evaluating your performance in
the clinical area. Which of the following
questions will you not use in criticizing
the Likert Scale?
A. Are the techniques to complete and
score the scale provided?
B. Are the reliability and validity
information on the scale described?
C. If the Likert Scale is to be used for a
study, was the development process
described?
D. Is the instrument clearly described

Rationale:
After the questionnaire is completed, each
item may be analyzed separately or in some
cases item responses may be summed to
create a score for a group of items. Hence,
Likert scales are often called summative
scales

95. In any research study where individual

persons are involved it is important that an
informed consent for the study is obtained.
The following are essential information
about the consent that you should disclose
to the prospective subjects EXCEPT:
A. Consent to incomplete disclosure
B. Description of benefits, risks, and
discomforts
C. Explanation of procedure
D. Assurance of anonymity and
confidentiality

95. In any research study where individual

persons are involved it is important that an
informed consent for the study is obtained.
The following are essential information
about the consent that you should disclose
to the prospective subjects EXCEPT:
A. Consent to incomplete disclosure
B. Description of benefits, risks, and
discomforts
C. Explanation of procedure
D. Assurance of anonymity and
confidentiality

Situation 20
Because severe burn can affect the persons
totality, it is important that you apply
interventions focusing on the various
dimensions of man. You also have to
understand the rationale of the treatment.

96. What type of debridement involves

proteolytic enzymes?
A. Interventional
B. Mechanical
C. Surgical
D. Chemical

96. What type of debridement involves

proteolytic enzymes?
A. Interventional
B. Mechanical
C. Surgical
D. Chemical

97. Which topical antimicrobial is most

frequently used in burn wound care?
A. Neosporin
B. Silver nitrate
C. Silver sulfadiazine
D. Sulfamylon

97. Which topical antimicrobial is most

frequently used in burn wound care?
A. Neosporin
B. Silver nitrate
C. Silver sulfadiazine
D. Sulfamylon

98. Hypertrophic burn scars are caused by:

A. Exaggerated contraction
B. Random layering of collagen
C. Wound ischemia
D. Delayed epithilialization

98. Hypertrophic burn scars are caused by:

A. Exaggerated contraction
B. Random layering of collagen
C. Wound ischemia
D. Delayed epithilialization

99. The major disadvantage of whirlpool

cleansing of burn wound is:
A. Patient hypothermia
B. Cross contamination of wounds
C. Patient discomfort
D. Excessive manpower requirement

99. The major disadvantage of whirlpool

cleansing of burn wound is:
A. Patient hypothermia
B. Cross contamination of wounds
C. Patient discomfort
D. Excessive manpower requirement

100. Oral analgesics are most frequently

used to control burn injury pain:

A. Upon patient request
B. During the emergent phase
C. After hospital discharge
D. During the acute phase

100. Oral analgesics are most frequently

used to control burn injury pain:

A. Upon patient request
B. During the emergent phase
C. After hospital discharge
D. During the acute phase