Situation1- Nurse Stephanie just finished emergency and disaster training for one month

in the Disaster and Risk Reduction Management conducted by the Department of Health.

1. To Nurse Stephanie’s knowledge, the key difference between emergencies and

disaster is that:

A. Emergencies can typically be handled by avoidable emergency services.

B. Disaster results from man-made error. (It can be man-made or natural)
C. Disasters typically involve local emergency services and no other agencies. (Requires
diff. Agencies)
D. Emergencies are controlled. (Not controlled)

2. Stephanie understands that emergency is any actual threat to public safety or public
health. Which of the following is NOT applicable?

A. “Hostage crisis. In Jolo Sulu last December 2018 emergency crisis

B. “I cannot find my mobile phone”. (will not cause loss of lives)
C. “My son has not come home from school”. (Emergency crisis) after 24hrs report (blotter) to
facilitate findings
D. “A plane is about to crash”.

3. During an earthquake, the impact is greatest at areas close to the epicenter. Injuries
arise primarily from falling objects and collapsing buildings. Direct impact on health
includes high mortality from severe crash injuries. Stephanie arrives at the scene as the
first responder. Which action is MOST appropriate to assure safety?

A. Clear the walking wounded using verbal instructions. “If you can walk, move over
there” (clear area of the ambulatory pt.)
B. Give priority to dying victims. (Tag as black)
C. Tag patients
D. Stop at each victim and quickly assess their respiration.

4. Cardiopulmonary resuscitation maybe given to the victims. How many Seconds will
Stephanie consider for perfusion to be present?

A Ten seconds
B. One second
C. Five seconds
D. Two seconds

5. A group of passengers enters the emergency room with complaints of cough,

tightness in the throat, and extreme periorbital swelling. There is a strong odor that
exudes from their clothes. They report exposure to “bomb that was placed in the bus
terminal. What is the PRIORITY action of the ER nurse?
A. Direct clients to the clean zone for immediate treatment.
B. Assist clients in the decontamination area.
C. Readily transfer patients and visitors from the area.
D. Check vital signs and auscultate lung sounds.

Three zones in hazardous substance release site;

1. Exclusion zone (hot zone)
-with actual or potential contamination
-do not enter without PPE
2. Contamination/Reduction Zone
-decontamination zone
-transition are b/w exclusion and support zones
-enter and exit the exclusion
3. The support zone or Cold zone
-free from contamination and that may be safely used as a planning or staging area.

Situation 2- Nurse Anne is part of the emergency team of hospital x. She collaborates
with other members of the health to Provide quality care to patients

6. Nurse Anne understands that collaborative interventions are therapies that require
the participation of health professionals. Which of the following personnel participates in
collaborative efforts? The______

A. Physician and the nurses intervention

B. patient and the nurse's intervention
C. patient and the physicians intervention
D. multiple health care professionals

7. Nurse Anne understands that health care professionals have a role in collaboration.
Which of the following statements BEST Explains the role of the nurse in the plan of care
for patients? The nurse_____

A. collaborates with colleagues and the patient’s Family to provide combined expertise in
planning care
B. works independently to plan and deliver care and should not depend on other staff
members for assistance
C. depends on the latest literature to complete and excellent plan of care for patients
D. consults the physician for direction in establishing goals for the patients

8. In one of her shifts, Nurse Anne admits a 35 year old female for head injury sustained
in a car accident. Nurse Anne notifies the neurosurgeon. The later assesses the condition
of the patient using the objective measurement of three essential components of a
neurological examination. Which of the following responses is Not an essential
component?
A. Best non-verbal response
B. Best motor response
C. Spontaneity of eye opening
D. Best verbal response

9. The neurosurgeon determines, that the patient has increasing intracranial pressure.
Which of the following interventions would be MOST appropriate for nurse Anne to
perform? She should

A. provide a quiet and brightly lit environment

B. elevate the head 15 to 30 degrees
(promote venous drainage from the brain) POC: neutral position
DOC: MANNITOL osmotic diuresis
-Foley catheter
Contraindicated with HPN
ICP normal- 0-15 mmHg
-more than 25 mmHg (consired increased ICP)
C. encourage the victim to drink clear fluids
D. teach controlled coughing and deep breathing

10. The patient was assessed to have a Glascow Coma Scale score of 3. In order to
protect the airway, nurse Anne collaborates with the health care team to assist with
which of the following?

A. Endotracheal intubation.
- prophylactic intubation <8
Pressure ET cuff (20-25 mmHg)
Increased pressure- necrosis
Decreased pressure- aspiration/dislodgement
B. Assessment of bowel sounds.
C. Questioning the patient regarding difficulty of breathing.
D. Monitoring oxygen saturation.

Situation 3 – Nurse Ditas cares for a male patient with HIV. She conducts a study on
HIV.

11. Nurse Ditas wants to find out the lived experiences of a patient with HIV. This is an
example of phenomenology as a:

A. phenomenon theory
B. concept
C. Research design
D. philosophy- guide in the organization to attain specific goals.
-values and beliefs to guide the org.
Mission-statement of goals and how they are going to met goals
Vision-Aspires to be in the future
Goal- General statement
Objectives- SMART
Grounded theory- have a number of cancer pt. Ask for specific themes

12. A characteristic or phenomenological study in for the researcher to understand the

lived experience from the point of view of the

A. Subject
B. close family member
C. nurse
D. researcher

3 criteria of random sampling:

Simple random technique- fishbowl technique
Systematic- bubunot and then kapag nabunot 4, (every 4th yung ang pipiliin)
Cluster- group of sample of people base on geographic location.
Stratified- base on characteristics

13. A process in phenomenology where the researcher takes into account his/her own
beliefs and feelings Identity which he/she expect to discover and deliberately puts these
ideas aside is called:

A. recursive abstraction- quali data analysis (analyze interview data)

B. Saturation- overuse of the subject or research team
C. bracketing- set aside own belief
D. coding

14. Nurse Ditas interviews her patient. She observes that he is hostile and does not
respond openly towards her questions. This is known as ____effect.

A. Hawthorne- subject modify their behavior

B. Rosenthal-internalization of expectations from a perceived authority figure by the recipient.
C. phenomenological
D. Pygmalion-other term for rosenthal effect

15. Nurse Ditas collects data for the research. Which is the MOST common technique of
analyzing qualitative data?

A. statistical analysis
B. content analysis
C. participant impression
D. observer Impression

Situation 4 –Mark a 63-year old had been suffering from heart failure for 3years He had
been adviced by his cardiologist for a pacemaker to help his heartbeat which is – slow.
16. Mark asked Nurse Julia what it is that he will expect before, during and after the
procedure. Which among the health teachings is NOT an appropriate response?

A. Your doctor will recommend that you avoid vigorous exercise and heavy lifting for
about a month.
B. You will likely be awake during the surgery to implant the pacemaker and You will
have IV line for your medication.
C. Insulated wires will be inserted into the minor veins, and will be guide using X-ray
images.-major veins
D. You’ll stay a day in the hospital after having a pacemaker implanted.

Tip place in the Right ventricle (thick)

Right atrium- thin
Heart condition na pwedeng lagyan ng pacemaker- degree heart block
1st degree heart block- PR interval prolongation
2nd degree heart block-
Type 1- gradual prolongation that may occur drop beat
Type 2 -no gradual prolongation and the QRS complex are more than 1

Endocardial lead positioning

-This is the most common procedure for implanting a pacemake
- You will be awake throughout the procedure.
-You will be given a sedative to help you relax and local anesthetics in areas that are involved in the procedure
(usually the upper chest area).
-A thin, flexible tube (catheter) will be inserted into a blood vessel and, using a fluoroscope (similar to an X-ray
picture to visualize the catheter), threaded into the heart.
-Once in the heart, will be attached to the inside lining.
-The leads will be tested to ensure they are working correctly. From time to time, you may be asked to take
deep breaths or cough vigorously in order to test the placement of the leads. Once the leads are in the best
locations, they will be plugged into the pulse generator.
-The pulse generator will be slipped into a small pocket made just beneath the skin of your upper chest or
your abdomen. You may feel slight pressure while the leads and pulse generator are
being inserted into the pocket.

At home:
-When you return home, keep an eye on your incisions.
-Some bruising is normal but contact your doctor if you experience increased pain redness, swelling, bleeding
or other draining from an incision, fever, or chills.
-Most people are aware of their pacemaker for a short time following its implantation, but this sensation
usually decreases with time.
- It is OK to take a shower, bathe or engage in usual sexual activity. During the initial eight weeks, avoid
sudden, jerky rovements with your arms, stretching or reaching over your head or touching the pacemaker.
- After this time, just avoid putting pressure on the chest area over the implant.
17. Before the cardiologist decided Patient Mark to have his pacemaker implanted, which
one of the following tests is NOT done to find the cause of his irregular heart beat?

A. Holter Monitoring and Smartwatch

B. electrocardiogram and echocardiogram
C. Stress Tests
D. SGOT (AST) - damage in heart, e.g ischemia and SGPT (ALT)- enzymes if the liver is damage

18. Patient Mark asked if he can travel by plane with his implantable cardioverter
defibrillator (ICD)
Which of the following is an INAPPROPRIATE response of Nurse Julia?

A. “Be sure you” have ID card with you”

B. “Yes you can travel by airplane if cleared by your Cardiologist”
C. “Let the airport security staff know you have A pacemaker.”
D. “You can travel immediately after the pacemaker is implanted.”

19. Patient Mark asked further “Do cellphones interfere with pacemaker? Nurse Julia’s
response are the following EXCEPT

A. “Use the phone on the opposite ear “

B. “Its best to avoid keeping cellphones in your breast pockets on the side of the device”
C. “cellphone less than watts do not appear to interfere with pacemaker”
- 6 inches away from implantation to be safe
D. “cellphone more than 3 watts do appear to interfere with pacemaker

20. Nurse Julia health instructions to patient Mark is to contact the doctor immediately if
the following sign occur. Which one is not priority?

A. Weight gain and swelling of the ankles- sign of heart failure

B. Fainting and dizzy spells-
C. Frequent urination
(decrease UO)- it should be oliguria
D. Difficulty in breathing

Heart- inability of the heart to pump enough bld to perfuse

L sided heart failure- pulmonary edema, pulmonary HPN, syncope
R sided- ascites, jugular vein distention, edema, water retention

Situation 5- Nurse Ceny assists in the care of several male patients with fluid volume
deficit.

21. Nurse Ceny reads the medical diagnoses of the patients assigned to her which
patient with the following medical conditions is at risk for fluid volume deficit? A patient
with
A. Congestive Heart Failure
B. Chronic Obstructive Pulmonary Disease- can cause right sided congestive heart failure (Cor
Pulmonale
C. Cirrhosis - fluid vol. excess
D. Colostomy- continuous drainage
Electrolyte imbalance: hypokalemia
Gastric lavage- metab. Alka
Diarrhea/colostomy drainage: metab. Acid

22. Nurse Ceny assesses the skin turgor on a 35 year old male patient. Which of the
following is an indicator of fluid volume deficit?

A. There is skin tenting.- sign of DHN

B. The skin immediately flattens after release.
C. The skin is dry and pale
D. The skin returns to a normal position within 1 or 2 seconds after pinching and lifting
the skin.

23. The physician prescribes an intravenous infusion of 750 ml Normal Saline to a 78-
year old male patient with fluid volume deficit and urinary tract infection. After a rapid
IV infusion, the patient begins to cough. The nurse raises the head part of the bed the
patient’s breathing. Nurse Ceny observes that the patient’s jugular veins distended and
respiratory rate is increased. Which of the following conditions is the patient
experiencing?

Becks triad- hypotension, distended jugular vein, muffled heart sound

A. Beginning hypotonic water intoxication-

-manifestation hyponatremia (sign- increased ICP)
-sign is neurologic
B. Worsening of fluid volume deficit
C. Developing hypervolemia
D. Respiratory compromise due to ascites

24. Nurse Ceny inspects the tongue and oral mucosa of a 40-year old patient and notes
that they are dry. The patient had cough, fever. Nausea and vomiting which started
three days before he was admitted to the medical unit. The patient further complains of
feeling weak and dizzy. Which vital sign measurement would provide the BEST indicator
of the patient’s current fluid status?

A. Rate and depth of respiration

B. Body temperature
C. Pulse oximetry reading at rest
D. Blood pressure and pulse taken in lying and standing positions
25. Nurse Ceny assesses a 50-year old made with liver failure due to cirrhosis. The
patient complains of a distended abdomen and dizziness, upon standing. The patient
looks pale, has weak radial pulse, and with delayed hand vein filling. Based on the
assessment data, Nurse Ceny writes a nursing diagnosis. Which of the following is the
MOST appropriate nursing diagnosis? Fluid volume

A. Deficit related to hormonal disturbances

B. deficit related to third space tied shifts
C. excess related to hormonal disturbances
D. excess related to third space fluid shifts
Liver excrete:
-albumin (decrease) Normal- 3.5-5.5
-bilirubin (not conjugate to direct to indirect) more than 1 mg/dL
Prothrombin time- prolong (at risk for bleeding)

Situation 6 -The nurse cares for teenage male with allergic rhinitis

26. Which of the following clinical manifestations would the nurse expect to find in the
client with rhinitis?

A. Nasal congestion, rhinorrhea and sneezing

B. Nasal congestion, pyrexic and rhinorrhea
C. Headache sore throat and sneezing
D. Nasal congestion, headache and sore throat

Type 1 hypersensitivity reaction- IgE mediated - immediate (e.g allergies, anaphylactic shock)
Type 2 antibody mediated- e.g Myasthenia Gravis
Type 3 antibody antigen complex- (e.g SLE)
Type 4 cell mediated- (e.g contact dermatitis)

27. The physician prescribes decongestant intranasal spray. They instructs the client on
the proper use of the pay. Which of the following procedures is the CORRECT method

A. Finish installation of spray into one nostril before

B. Inhale quickly to prevent irritation of the mucous membranes- inhale normally
C. Blow the nose after spraying to prevent medications from entering the throat
D. Tilt the head slightly forward and angle the bottle toward the side of the nostril-
backward

28. The client asks the nurse about using decongestant nasal spray which of the
following statements by the nurse is CORRECT regarding its use?

A. “nasal sprays should be used sparingly because they can exacerbate a cough.”
B. “It would take several days of using nasal sprays before any effect on congestion is
noted”
C. “Nasal sprays should not be used for more than three days because it can worsen
congestion”
D. “They should be used along with corticosteroid nasal sprays for maximum benefit.”

29. The nurse would determine that her teaching goal on the use of a decongestant
nasal spray has been met when the client says

A. The spray should be used round-the-clock at equally spaced intervals. - not round the
clock
B. “Nasal sprays must be combined with an oral antihistamine to achieve relief.”- not true
C. overuse can result in nosebleeds and mucosal ulceration- cannot cause nosebleed
D “Rebound rhinitis (rhinitis medicamentosa) is common with continued use”

First line - oral histamine

2nd nasal spray (e.g phynelliprine can cause HPN)

30. The physician orders cromolyn sodium (mast cell stabilizer) (nasal crom) for the client.
The nurse instructs the client that the most effective administration schedule is

A. when manifestations peak only, with two or three doses per day
B. at the start of the allergy season with a dose of once-a-day -
C. one week before the allergy season begins with four to six doses per day
D. just after manifestations begin with a dose of twice-a-day

Situation 7 – Ms. Simon newly registered nurse. She upgrades her nursing competencies
by attending seminars and workshops on advanced Nursing procedures. A workshop she
recently participated is on Physical as assessment. She applies her skills in the female
medical wait where she is assigned

31. Ms. Sinon inspects the abdomen of patient which of the following sequences
represent the order assessing: patient’s abdomen?

A. Palpate, percuss, auscultate, observe

B. Observe, auscultate, percuss, Palpate- prevent alteration in the bowel sound
Normal sound in a minute period- 6 to 10 per minute
Hyperactive bowel sounds 20/min
Obstructive bowel sound:
Complete obstruction- paralytic ileus (no bowel sound)
Partial obstruction- high pitched sound
C. Percuss, palpate, auscultate, observe
D. auscultate, observe, percuss, palpate

32. Ms. Simon auscultate for breath sounds. What type of data should auscultation
produce?

A Secondary
B. Subjective
C. Primary
D. Objective- can observe by other ppl.

33. Ms. Simon proceeds to palpate a patient’s body to detect warmth. What part of her
hand should she use?

A Finger tips
B. Back or dorsal surface
C. Ulnar surface
D. Finger pads

34. Ms. Simon assesses a patient for gag reflex. Which part of the same should she
place the tongue blade?

A. On the middle of the tongue and ask the patient to cough

B. On the uvula
C. Lightly on the posterior aspect of the tongue
D. On the front of the tongue and ask the patient to say “ahh”

35. Ms. Simon takes and records the body temperature of a patients the temperature
registers a reading of 38°C. Which of the following conditions will the patient MOST likely
demonstrate?

A. Increased pulse rate

B. Precordial pain- chest pain
C. Dyspnea
D. Elevated blood pressure

Situation 8 – You are a nurse manager of a female and male medical unit. You realize
that being a manager entails a great responsibility. One of your major responsibilities is
implement quality improvement initiatives in our unit.

36. You collaborate with the maintenance personnel to prepare a safety program. The
program includes periodic inspection of electrical equipment, conduct of tire drills and
proper disposal of hazardous waste materials. These activities illustrate a component of
which quality program?

A. Total quality management

B. Quality assurance
C. Risk management
D. Quality improvement

37. You call for a staff meeting. You remind the nurses to improve the quality of care to
patients. Which of the following activities is MOST important to safeguard nursing
practice?
A. Know own strengths and limitations.
B. Provide nursing care competently and efficiently.
C. Document care accurately.
D. Understand professional, legal, ethical obligations and responsibilities.

38. You take time to review reports for your staff. One report records the Incidence of
patients falling off from their beds and other falls, which of the following approaches is
MOST appropriate to manage the situation

A. Implement quality assurance measures.

B. Apply risk management principles.
C. Apply total quality management principles in the unit.
D. Implement a systems approach to the situation.

39. A staff nurse in your unit administers a drug incorrectly to a diabetic patient who
needs more than one type of insulin. The staff nurse’s action causes serious negative
effects on the patient. What would be the MOST appropriate action that you as the nurse
manager should take?

A. Refer the state nurse to the quality assurance committee

B. Refer the staff nurse to the risk management committee.
C. Refer the patient to the attending physician immediately.
D. Ask the staff nurse to write a detailed incident report.

40. A patient in the unit had episodes of seizures. Sometime during the Patient on the
floor. As a nurse manager: you ask the nurse involved in finds the Incident to write an
incident report. Which of the following statements is NOT true about incident reports?
The report

A. is a part of the patient’s medical record

B. can be used in a court of law
C. identifies the people involved, the date, time and location of the incident
D. serves as a record of facts surrounding the incident

Situation 9 – Nurse Gloria is assigned in the emergency department and takes care of
patients with different cases.

41. A client with multiple injuries is rushed after head on car collision. Which assessment
Nurse Gloria takes priority?

A. Unequal pupils- sign brain herniation

B. Irregular apical pulse- increased ICP
C. A deviated trachea- tension pneumothorax
Dressing for pneumothorax: cover the opening with a dressing tape in three side/vaselinized gauze
D. Ecchymosis in the flank area

42. The ambulance has transported a male client with severe chest pain. As the client is
being transferred to the emergency stretcher Gloria noted that the client is unresponsive
not breathing and no palpable pulse. Which of the following emergency measures will
Nurse Gloria anticipates to do?

A. Starting bag valve mask ventilation.

B. Performing chest compressions
C. Placing the defibrillator pads
D. Aiding with oral intubation

43. A child with fever has been admitted to the emergency department for several
hours. Cooling measures are ordered by the physician in order for the temperature to
come down. Which task would be appropriate for Nurse Gloria to do?

A. Educate the need for giving cool fluids

B. Prepare and administer a tepid bath
c. Tell the parent to use acetaminophen instead of aspirin.
D. Assist the child in removing out garments

44. When Gloria conducts primary assessment on a trauma patient. Which of the
following is considered one of the priority elements?

A. Complete vital signs

B. Brief neurologic assessment
C. Initiation of pulse oximetry
D. client's allergy history

Secondary Survey
-performed once the patient has been resuscitated and stabilised.
- more thorough head-to-toe examination → aim is to detect other significant but not immediately life-
threatening injuries.

History
Use the AMPLE acronym to assist with gathering pertinent information:
1. Allergies
2. Medication
3. Past medical history including tetanus status
4. Last meal
5. Events leading to injury

45. Triage is the process of determining the priority of patients treatments based on the
severity of their condition. The purpose of reverse triage is to
A. Save those persons who are in the most critical condition.
B. Save scarce resources for future use
C. Do the greatest good for the greatest number with limited resources - UTILITARIANISM
D. The first responders on the tiring classification category

Situation 10 - The nurse manager of the Oncology Unit Invites an oncology nurse
specialist to conduct an educational session to the nursing staff on the topic Hodgkin’s
disease.

46. The nurse specialist explains the disease, which of the following is not a
characteristic of Hodgkin’s Characteristics of Hodgkin’s disease?

A. There is presence of Reed-Sternberg cells.

B. The disease occurs most often in the older adult. - common in adolescent
C. The lymph nodes, spleen, and liver are involved.- Non hodgkin
D. The prognosis depends on the stage of the disease.
Hodgkin- Reed stenberg cell, affect lymph nodes only
Non-hodgkin- metastasizes in other organs
-both have fever
-both have painless adenopathy

Hodgkin's lymphoma
-formerly known as Hodgkin's disease-cancer of the lymphatic system, which is part of your immune system.
-most common: between 20 and 40 years old and those over 55.
-In Hodgkin's lymphoma, cells in the lymphatic system grow abnormally and may spread beyond it.
• (+) REED-STERNBERG CELLS

B symptoms: Systemic (fever, cachexia)

DOC: Cyclophosphamide (non cell cycle specific)
-hemorrhagic cystitis
Mngt: increased fluid intake prior to chemo.
-full bladder (para after chemo iiihi nya yung gamot)
-to prevent hemorrhagic cystitis
Adreamycin- antibiotic/antichemotherapy
-can cause cardiotoxicity

47. The nurse specialist describes the stages of Hodgkin’s disease. Which of the
following symptoms is MOST commonly an EARLY Indicator of Stage I?

A. Chest and back pains

B. subnormal body temperature
C. Unexplained fever, night sweats - constitutional symptoms
D. swelling of extremities

Stage I
-Involvement of single lymph node region or single extralymphatic site
Stage II
-Involvement of two or more lymph node regions on same side of diaphragm; may include localized
extralymphatic
Stage III
-Involvement of lymph node regions on both sides of the diaphragm; may include spleen or localized
extralymphatic
Stage IV
-Diffuse extralymphatic disease (e.g. in liver, bone marrow, lung, skin)

48. The nurse specialist emphasizes the importance of preventing complications. Which
of the following conditions are complications of Hodgkin’s disease?

1. Nausea
2. Myocardial infarction
3. Anemia
4. Infection
5. Hypotension

A. 1,2,3,5
B. 1, 2, 3, 4, 5
C. 1.3.4
D. 2, 3, 4, 5

49. The nurse specialist cites à situation. It a patient experiences episodes of severe
nausea and vomiting with more than 1000 ml. Of vomitus within a period of four hours,
which of the following is the nurses’ MOST appropriate action?

A. Withhold fluids for four hours.

B. Notify the physician
c. Observe the patient for another four hours
D. Place the patient on a liquid diet

50. The nurse specialist explain that chemotherapy is extremely toxic to the bone
marrow and the patient may develop thrombocytopenia. What is the PRIORITY goal of
the nurse? To take precautions to control

A. Bleeding
C. Infection- neutropenia
B. Hypotension
D. Diarrhea

Methotrexate- folic acid antagonist

Principle of chemo: affect both normal and abnormal cells
-rapidly multiplying
Megaloblastic anemia-
Methotrexate-Leucovorin
SE: Bone marrow suppression

Tumor lysis syndrome- madaming cancer cells ang namatay

Electrolytes in cell:
1. Increased Potassium
2. Increased Phosphate
3. Increased Magnesium
4. Uric acid
Mngt for TLS: hydration
Gout DOC:
-allopurinol
-febuxostat
Uricosoric drugs: probenecid
Decrease inflammation in gout: colchicine (first line to administer before allo.)

Situation 11 – Nurse Clara assists in the care of a male patient who has developed acute
respiratory acidosis.

51. Nurse Clara recalls the causes of Respiratory acidosis. Which of the following are
causes of acute respiratory acidosis?

1. Chronic obstructive pulmonary disease (COPD)- Emphysema, Chronic Bronchitis

2. Pneumonia- inflammation in the alveoli
3. Pulmonary edema- impaired Gas exhange
4. Atelectasis- lung collapse
5. Bronchitis- inflammation of the lining in the airway

A. 1, 2, 3, 4, 5
B. 2,3,4,5
C. 1,3,4,5
D. 1,2,3,4

Bronchitis- Right side of heart 'cor pulmonale'

Respiratory arrest- common for patient with asthma having respi. Acid
Slow to act-kidney
Fast to act- lungs
Buffer system: kidney and lungs

52. Nurse Clara further recalls that respiratory acidosis nearly always results from which
of the following conditions?

A. Hyperventilation
B. Hypoventilation
C. Decrease amount of acid in body fluids
D. Low production of carbon dioxide
53. Nurse Clara reviews the results of the arterial blood gases. Which of the following
would the nurse expect to read in the report?

A. pH 7.25, PCO2 50 mm Hg- respiratory acidosis

B. pH 7.40, PC02 52 mm Hg
C. pH 7.35, PC02 40 mm Hg
D. pH 7.50, PC02 30 mm Hg

54. The patient is worried about his kidneys being affected because of his condition. The
nurse explains that usually kidneys _________.

A. can achieve optimal compensation in about 72 hours- kidney is slow to act

B. can achieve optimal compensation immediately
C. will compensate within 24 hours
D. are unable to compensate

55. Based on assessment data gathered, Nurse Clara writes a nursing diagnosis. Which
of the following is the MOST appropriate nursing diagnosis?

A. Risk for injury

B. Ineffective breathing pattern
C. Risk for respiratory infection
D. Ineffective tissue perfusion

Situation 12 - Ms. E.D., 45-year old is admitted to the medical ward because of
complaints of muscle weakness, fatigue, ptosis and diplopia. The admitting diagnosis is
myasthenia gravis.
Myasthenia gravis- destroy the acetylcholine receptor sites.
Tensillon test:
Endrophonium chloride- (short acting) weak diagnosis for (+) myasthenia gravis
(-) there will be no improvement.
Acetylcholinesterase- physostigmine/mestinon (pyridostigmine)---LONG ACTING
Myasthenic crisis- improve after giving tensilon test
Cause: underdose
Cholinergic crisis- after giving tensilon worsen the sx.
Cause: overdosage
Parasympathetic overactivity (increased salivation, diarrhea, increased urination)-CANNOT BE SEEN IN
MYASTHENIC CRISIS.
Mngt: Give Atropine Sulfate
Enzymes that breaks down acetylcholine- acetylcholinesterase
Give mestinon- to improve the muscle weakness
56. Based on the complaints of the patient, the nurse formulates a nursing diagnosis.
Which of the following is MOST appropriate?

A. Activity intolerance related to muscle weakness and fatigue

B. Imbalance nutrition: less than body requirements related to muscle weakness and
dysphgia
C. Ineffective airway clearance related to chest muscle weakness and impaired cough
and gag reflex.
D. Ineffective breathing patterns related to weakness of chest muscle and fatigue

57. The nurse administers anticholinesterase medication. When is the BEST time to give
the medication?

A. 30minutes before meals- To improve swallowing

B. Before the patient sleeps at night
C. Early in the morning
D. When the patient has eaten a full meal

58. The nurse observes that the client had not been compliant with her medication
regimen of Pyridostigmine (Mestinon). The patient missed several doses. Which of the
following complications should the nurse watch for?

A. Gastrointestinal symptoms
B. Respiratory distress
C. Bradycardia
D. Vertigo

59. The nurse prepares Ms. E.D. for diagnostic test. Which of the following is NOT a
diagnostic for myasthenia gravis.

A. Tensilon test
B. Position Emission Tomography (PET)- measure level of metabolism in part of the body
Alzheimer's- brain atrophy
- decreased metabolism (seen in PET scan:dark areas)
C. Serum assay for circulating Ach receptor antibodies
D. Electromyography (EMG)- test to measure the muscle contractility

Myasthenia Gravis
Diagnostic tests:
1) Edrophonium chloride (Tensilon) test: >90% sensitivity, but low specificity
2) Antibody testing (most specific for MG)
3) CT scan of chest for the presence of thymoma 4) Electromyography w/ repetitive nerve stimulation

Treatment options:
1) Cholinesterase Inhibitors
2) Chronic immunosuppressive agents
3) Rapid immunotherapy agents
4) Thymectomy- removal of thymus gland
60. The nurse should always keep which of these drugs at the bedside of a client with
myasthenia gravis.

A. Atropine- anticholinergic
B. Tensilon
C. Inderal- propanolol (beta blocker)
D. Neostigmine

Situation 13 - You are a new registered nurse in the surgical unit. You admit a 30 year
old male with head injury sustained in a motor cycle accident. You understand that
reporting information is a critical part of documentation.

61. You are aware that documentation should reflect objective data. Based on your
assessment of the neurological function of the patient's LOC. you chart the following
observations. Which of the following is an objective data?

A. Client appears confused.

B. Client looks lethargic.
C. Vital signs are stable.
D. Patient has a score of 3-4-3 on the Glasgow Coma Scale.

62. You assess the pupils of the patient and record your observations. Which of the
following is LEAST important to record?

A. Symmetry
B. Size
C. Color
D. Reaction to light.
Acute glaucoma- close angle glaucoma
Chronic glaucoma- open angle glaucoma (increased IOP) will cause tamponade "compressed bld. Vessel"
Glaucoma- peripheral visual field loss
-manifested by permanent vision loss
Mngt:
-to prevent further visual field loss

Accomodation-ability to focus (lens)

Opaque lens- cataract (increased opacity in the lens)
Senile cataract- common in older ppl.
Removal of the lens- cataract extraction
2 types of cataract extraction
1. Extracapsular cataract extraction
2. Intracapsular cataract extraction (ICCE)- entire lens is removed
Aphakik- no lens (farsightedness)

ECCE-
Myopia- (nearsightedness) in front of the retina
Use concave lens
Hyperopia far behind the retina
Convex lens (FBEX)
Astigmatism- irregular surface
Mngt: use cylindrical lens
Surgery to correct refractive error: LASIK (Laser Assisted in Situ Keratomeliosis)

MORPHINE/CODEINE/NARCOTIC DRUGS -- DOWNER (constrict)

Antidote: naloxone/narcan/naltroxene
BENZODIAZEPINES- Flumazenil
AVERSION THERAPY- DISULFIRAM
Streptokinase- aminocaproic acid/amicar
Mercury-dimercaprone
Cyanide- sodium nitrates
Iron toxicity (hemochromatosis) WOF for liver and spleen- deferoxamine

63. Based on the information you gathered from the patient, you write a nursing
diagnosis. Which of the following is NOT a well-written nursing diagnosis?

A. Disturbed sensory perception related to cerebral injury.

B. Fatigue related to cerebral injury.
C. Acute confusion related to altered cerebral blood flow.
D. Lethargy related to non-specific cause.

64. Based on the nursing diagnosis, you record an evaluation of the outcomes. Which
outcome is NOT well-written? The patient will _______?

A. rest as needed
B. be conscious, oriented and will perform own self-care
C. have functional sensory status.
D. feel lethargic.

65. You are aware that the primary purpose(s) of documentation are the following:
EXCEPT: to ________.

A. allow the nurse to express his or her opinion on patient care.

B. provide legal protection for the nurse in case of lawsuit.
C. collect data to improve quality of nursing care.
D. communicate patient information to other members of the health team.

Situation 14 – The nurse admits a male patient with complaints of epigastric pain,
fatigue, anorexia, weight loss and pain in the right upper quadrant. The probable
diagnosis is primary liver cancer.
66. The nurse prepares the patient for the test ordered by the physician. Which of the
following procedures would confirm the diagnosis of liver cancer?

A. Computed tomography (CT) scan - triphasic abdominal UTZ

B. Abdominal ultrasound
C. Abdominal flat plate x-ray
D. Cholangiogram- see obstruction

67. The physician performs a liver biopsy on the patient. Which of the following
complications should the nurse monitor IMMEDIATELY after the procedure?

A. Nausea and vomiting

B. Abdominal cramping
C. Hemorrhage
D. Potential infection

68. The physician prescribes Adriamycin for the patient. Which of the following
considerations has the HIGHEST priority when preparing to administer the medication to
a patient with liver cancer? __________of the medication.

A. Metabolism
B. Necessity
C. Purpose
D. Frequency

69. Based on of the information gathered, the nurse writes a nursing diagnosis. Which of
the following is the PRIORITY nursing diagnosis for the patient?

A. Acute pain related to abdominal pressure

B. Risk for infection related to complications of liver biopsy
C. Knowledge deficit related to self-care and cancer risk prevention
D. Fear and anxiety related to actual or potential lifestyle changes

70. The nurse understands the two basic types of liver cancer which are primary and
secondary. Which of the following statements is TRUE regarding primary liver cancer?

A. Women experience more primary liver cancer than men.

B. It is more common in developed countries.
C. It is more common in the presence of chronic renal disease.
D. Prognosis is poor: there is <20percent survival rate.
Primary-galing sa liver
Secondary- galing sa ibang organ nag metastasized lang sa liver
Risk factor
Hepa B and C
Alcohol
Infxn.
Situation 15 - A 55-year old male is admitted to the medical unit with a diagnosis
Myocardial Infarction (MI).He complains of difficulty of breathing, excessive sweating,
nausea and vomiting and chest pain.

71. The nurse performs pain assessment. Which of the following characteristics of pain is
manifested in MI?
PERICARDITIS- pain radiating to trapezius (NOT MI)
Cardiac in origin (chest pain)
Musculoskeletal (pain during movement)
Pain during deep inhalation- pleurisy
1. The patient may experience crushing substernal pain.
2. Pain may radiate to the jaw, back and leftarm.
3. Pain may occur without cause, primarily early in the morning.
4. Pain is unrelieved by rest or nitroglycerin and is relieved only by opiods.
5. Pain lasts 30 minutes or longer.

A. 2, 3, 4
B. 3, 4, 5
C. 1, 3, 5
D. 1, 2, 3, 4, 5

72. The physician orders laboratory tests on the patient. Which of the following findings
would MOST concern the nurse?

A. Creatine kinase: (CK): 150 ar U/ml

B. Hematocrit (HCT) 42 (Normal 35-45%)
C. Serum glucose: 100mg /dL (Normal 70-110)
D. Erythrocyte sedimentation rate (ESR):10mm/h (Normal 9-16)

73. The physician further orders an arterial blood gas measurement. The nurse obtains
the specimen. What is the MOST appropriate action of the nurse immediately after
obtaining the specimen? The nurse should _________.

A. obtain ice for the specimen

B. apply a sterile dressing to the site
C. apply direct pressure to the site- to prevent oozing of bld.
D. observe the site for hematoma formation

74. The nurse reviews the arterial blood gas results of the patient. The laboratory report
indicates a pH of 7.30. PC02 of 58mmHg, PO2 of 80 mmHg, and a HCO3 of 27mEq/L.
Which acid-base disturbance is the patient experiencing?

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

75. The nurse administers medications as prescribed by the physician. The nurse
monitors the blood pressure closely after giving the medications. If the blood is pressure
less than 100 systolic or 25 mmHg lower than the previous reading, what is the INITIAL
action of the nurse?

A. Elevate the head of the bed and notify the physician.

B. Lower the head of the bed and notify the physician.
C. Take the BP three times, get the average and report to the physician.
D. Reassure the patient. Explain that his BP is normal in his condition.

Situation 16 - You are a newly hired registered nurse in a tertiary hospital. You are
required to attend an orientation activity on legal implications of nurses actions.

76. You are aware that you need a license to practice in the Philippines. Licensure is
primarily required to protect which of the following?

A. The patients under her/his care.

B. The school where the nurse obtained his/her nursing education and training
C. The hospital where s/he is employed.
D. Nurses because they are vulnerable to lawsuits.

77. The facilitator discusses negligence and malpractice. Which of the following factors is
unique to malpractice?

1. There is a contractual relationship between the nurse and the patient.

2. An inappropriate care is an act of commission.
3. The patient is harmed as a result of care.
4. The action of the nurse did not meet standards of care.

A. 3 only
B. 3 & 4
C. 1 only
D. 1 & 2

78. The facilitator cites a situation. Nurse x used a medical equipment improperly which
harmed the patient. The nurse may be charged with ________:

A. Negligence
B. Assault
C. Malpractice
D. Battery

79. The facilitator gave an example of a nurse who gave the wrong medication to a
patient. The result was severe allergic reaction. The nurse could be sued for _________:
A. Battery
B. Malpractice
C. Negligence
D. Assault

80. The nurse could be sued for which of the following if s/he says to a patient, "If you
don't stop complaining, I will not allow you to see your family when they visit."

A. Battery
B. Assault
C. Libel
D. Negligence

Situation 17- Nurse Luisa is assigned in the coronary care unit of a tertiary hospital. She
reviews the cardiovascular system before caring for patients with heart diseases.

81. Given a set of statements regarding the physiology of the cardiovascular system,
which of the following statements is TRUE?

A. When a person has heart muscle disease, the heart muscles stretches as far as is
necessary in order to maintain good function.
B. The heart rate increases when the parasympathetic system is stimulated.
C. The QRS interval on the electrocardiogram represents the electrical impulses passing
through the ventricles.
D. When there is a decrease in stroke volume, the heart rate decreases.

82. Nurse Luisa collects data from a patient with primary diagnosis of heart failure. The
patient reports that he has experienced the following disorders. Which disorder does
NOT precipitate heart failure?

A. recent upper respiratory infections

B. thyroid disorders
C. nutritional anemia
D. peptic ulcer disease

Gastric ulcer-pain occurs after eating meals; poor man's ulcer; risk for cancer (PPI-Omeprazole)
Duodenal ulcer- pain relieved with meals rich ulcer; produced high hcl acid
H. Pylori - most common cause of Gastritis and Gastric Ulcer
Antibiotics: amox.
NSAID/STEROID- can also cause gastric ulcer
Confirmatory test- endoscopy (refer to gastroenterologist to perform biopsy to rule out the problem)

83. Nurse Luisa has a patient admitted for palpitations and mild shortness of breath. An
electrocardiogram (ECG) was taken. The results revealed a normal P wave, P-R interval,
and QRS complex with a regular rhythm and rate of 108 beats per minute. Nurse Luisa
recognizes this cardiac dysrhythmia as _________:

A. Sinus dysrhythmia (not existed)

B. Supraventricular tachycardia- wide QRS and no P wave
Non pharmacologic Mngt: carotid massage
Pharmacologic Mngt: adenosine
C. Sinus tachycardia- regular P wave, regular QRS but tachycardia (-)
DOC: propanolol (beta-blocker)
❌ Give propanolol (beta blocker) to asthmatic patient.
D. Ventricular tachycardia- proceed to Vfib

84. The electrical activity of the patient's heart is being continuously monitored.
Suddenly the patient has a short burst of ventricular tachycardia followed by ventricular
fibrillation (-) pulse. Nurse Luisa should IMMEDIATELY ___________:

A. Run to the nurse's station quickly and call a code.

B. Administer atropine as ordered. - give to SINUS BRADYCARDIA
C. Prepare the patient for surgical placement of a pacemaker.
D. Call for help and initiate cardiopulmonary resuscitation.

85. Nurse Luisa attends to a patient who has continuous ECG monitoring. She observes
that the monitor shows that the rhythm has changed to ventricular tachycardia. Which
of the following interventions is the FIRST action by the nurse?

A. Quickly assess the level of consciousness, blood pressure, and pulse.

B. Administer a precordial thump- close fist apply a forceful blow to the sternum (❌ use anymore)
C. Administer intravenous lidocaine following emergency protocol.
D. Quickly obtain a defibrillator and defibrillate the patient.

Situation 18 - A 61 year old male seeks consultation in the OPD. He complains of blood
in the urine, pain on urination and frequent urination. Medical diagnosis is bladder
cancer.

86. The male client is admitted to the oncology unit. A cystostomy is performed, a tumor
is visualized and biopsied. The nurse recognizes that the activity most often associated
with bladder tumors is _______:
A. Drinking three cans of carbonated beverages every day.
B. Smoking two packs of cigarettes a day.
C. Jogging 6 km a day.
D. working with a heavy equipment everyday

87. The client receives a radiation implant for the treatment of bladder cancer. Which of
the following intervention is appropriate?
Teletherapy also known as External radiation therapy ❌soap, no lotion
Brachytherapy - (sealed-local dislodge implant (place implant in a lead container with a a forcep)
Min. distance- farther to 6 ft. (The farther the better)
Internal systemic radiation therapy- unsealed- common to thyroid disorders)
-systemic (freely circulating in the body- oral)
-flush the toilet 2 or more
❌Scrub the vomits, instead cover it and then throw to
Radioactive-ihi, tae

A. Place client in isolation.

B. Encourage fluid intake- ❌ dislodgement of the implant
Mngt: catetherize, empty bladder/bowel, BED REST to prevent dislodgement of the implant
C. Monitor client for signs and symptoms of cystitis.
D. Restrict fluid intake.

88. The physician plans to do a cystectomy-removal of the bladder and ideal conduit on the
male client. The nurse prepares the client for the procedure. Which of the following is an
appropriate action of the nurse?

A. Perform cleansing enema and give laxatives as ordered.

B. Teach the client muscle-tightening exercises.
C. Demonstrate to the client the procedure for irrigating the stoma.
D. Limit fluid intake for 24 hours. (Increased fluid intake)

89. The client undergoes a radical cystectomy and has conduit. Which of the following
postoperative assessment findings should the nurse observe and report to the physician
immediately?

A. Slight observe bleeding from the stoma when changing the appliance.
B. A urine output of more than 30 mL per hour
C. A red moist stoma.- normal (beefy red)
D. A dusky, colored stoma - sign of necrosis

90. Which of the following instructions should the nurse give to the client with an ideal
conduit skin care at the stoma site?

A. Clean the skin around the stoma with mild soap and water and dry the area
thoroughly.
B. Leave the stoma open to air while changing the appliance.- may cover dapat
C. Cut the faceplate or wafer of the appliance no more than 4mm layer than stoma.
D. Change the appliance before going to sleep.- drain the appliance for 1/3 full

Situation 19 - According to Peter Drucker "Management is doing things right" Resource

management is the process by which manager manage their resources effectively. These
resources can be intangible (people and time) and tangible (equipment, materials and
finances).It involves planning so that right resources are assigned to the right tasks.

91. Currently, patients in the unit are bathed in the morning between 8 to 11 in the
morning. The nursing staff is considering changing the schedule to bathing the patients
in the evening between 7 to 9 p. m. Which statement reflects an assumption that might
affect the nursing staff's ability to think critically about the change?

1. "The day shift just wants to shift work onto the evening shift."
2. "Everyone likes to bathe right before bed."
3. "If we let them change this, they will want to make lots of other changes."
4. "I read a research article that reported that clients sleep better if they have been
bathed right before bedtime."

A. 3, 4
B. 2, 3, 4
C. 1, 2, 3
D. 1, 2

92. A serious disagreement has arisen between two staff nurses. The head nurse choose
not to make decision regarding the disagreement until more evidence is collected. Which
part of the nursing process does this head nurse's critical thinking reflect?

A. planning
B. Diagnosis
C. evaluation
D. assessment

93. A nurse supervisor who is retiring is helping the new supervisor learn about the
position, A part of this education the current supervisor make all the decisions that can
be made under certainty. What conditions will these decisions have in common?

1. There is risk associated in decision.

2. The alternatives are known
3. The conditions of each alternative are clear.
4. The decision is complex and dynamic.

A. 2, 4
B. 1, 2
C. 2, 3
D. 3, 4

94. A disagreement has arisen between two staff nurses. Both have discussed the
situation with the head nurse. The head nurse feels that the problem is likely sell
solving. How should the head nurse approach this situation?
1. Allow sometime to pass to see if the situation resolves
2. Support both nurses as they work thru issue.
3. Provide any resources the nurses may need to help solve the problem.
4. Intervene if the problem begins affect client care.

A. 1, 2, 3, 4
B. 1, 2, 3
C. 1, 4
D. 2, 3, 4

95. Which statement by a formal leader of a surgical unit reflects the personality
required to energize the staff and promote creativity?

1. "This is the decision I have made, and there is no room for discussion.
2. "I would like to thank everyone for you hard work and dedication while we have been
short staffed.
3. "I am certain that our new assignment system is going to make workload more
equitable."
4. "I know this week has been rough"

A. 3, 4
B. 2, 3, 4
C. 1, 2
D. 1, 2, 3

Situation 20 - Nurse Lory is assigned in the oncology unit of x hospital. She assists in
the care of a 40 year old female with bone cancer.

96. The patient complains of pain. Nurse Lory assesses the patient. Which of the
following statements is a MOST important information Lory gathers during the initial
assessment? The

A. patient's self-reporting of her pain experience

B. results of assessment of the physical examination
C. amount of pain medication the patient is taking
D. response of the family toward the illness of the patient

97. The patient informs nurse Lory that she is taking medications to control the pain.
Which of the following statements verbalized by the patient Indicates that the patient
needs further teachings about medications to control pain?

A. "It is okay to take my pain medication even if I am not having any pain."
B. "I should take my pain medication periodically so I don't get addicted to the drug."
C. I should contact the nurse if the pain is not effectively controlled by my medication."
D. "I should take my medications around-the-clock to control the pain."
98. The patient receives chemotherapy: Nurse Lory writes a nursing diagnosis for the
patient. Which of the following nursing diagnoses is MOST appropriate

A. Altered body image

B. Pain related to treatment
c. Impaired physical mobility
D. Risk for infection- b/c bone marrow depression

99. Nurse Lory is aware that a patient receiving chemotherapy is at risk for bone
marrow depression. She instructs the patient on how to prevent infection at home when
she is discharged. Which of the following should nurse Lory communicate to the patient?

A. "Wash your hands frequently and maintain good hygiene."

B. "Avoid physical contact with other people while receiving chemotherapy."
C. "Do not share the bathroom with young children or with any pregnant member of the
family."
D. Visit the laboratory every week for a WBC analysis."

100. Nurse Lory observes that the patient gets irritable and angry with the
medical/nursing staff whenever a procedure or treatment is done on her. Which of the
following approaches would be BEST to diffuse the anger of the patient?

A. Let the patient and family members have time for each other.
B. Direct the discussion and allow the patient to express her feelings.
C. Arrange a meeting between the patient and another person with bone cancer.
D. Request the social worker of the psychiatrist in the hospital to talk to the patient.