RECALLS 4: EXAM NP3 assuming a supine position.

The BEST action of

the Nurse is ___________.
Situation: Rica, a Pediatric Cardiovascular Nurse
is assigned to take care of 3 children in her unit. A. Let the mother continue the position of her
She just admitted a 12- year- old female patient child if she feels comfortable with it.
suffering from Rheumatic Fever (RF) B. Divert the child’s attention by letting her join
the nurses’ rounds
1. When doing an assessment, which ONE of C. Put her on bed and start to administer oxygen
the following conditions is NOT present based inhalation
on the Jones Criteria? D. Discourage the child and let her lie on bed
with 2 pillows instead.
A. Erythema Marginatum
B. Subcutaneous nodules 5. Another patient in the Unit is Letty, 8 years
C. Chorea old, waiting to be scheduled for surgery because
D. Bronchopneumonia of a Coarctation of the Aorta. With this disorder,
Letty will manifest which one of the following
2. In Rheumatic fever, the factor contributory symptoms?
to the development of this disease process is
brought about by __________.
A. Murmur and bruit of the lungs
B. Central and peripheral edema
A. Auto-immune reaction to streptococcal C. Hypertension and diminished pulses in the
infection extremities.
B. Auto-immune reaction to collagen disease D. Hepatomegaly and shortness of breath
C. Parents had rheumatic heart disease
D. Exposure to colds and droplet infection Situation: Mr. John is 55 year old, married, a car
dealer has consulted the ER because of on and
3. Leny, 6 years old, is receiving digitals for fever, indigestion, weight loss, right abdominal
having Patent Ductus Arteriosus with heart pain, body malaise, and itchiness of the skin.
failure with heart failure. Prior to the Based on the health history the patient has been
administration of the medicines, which of the a chain smoker and drinks alcoholic beverages
following nursing actions should be done by almost every day especially when he has clients
nurse Rica? to entertain. His physical examination showed
he has suspected liver cirrhosis. He was advised
A. Take the carotid pulse rate for one full for admission for further work-up and
minute. treatment.
B. Take the heart rate for one full minute
C. Take the respiratory rate 6. You are the nurse on duty when Mr. John was
D. Take the blood pressure admitted in the pay floor. In your observational
data what additional EARLY SIGN of liver
4. While Nurse Rica was doing her regular cirrhosis do you expect patient to manifest?
rounds, one of the mothers approached her
saying that her child who has a Tetralogy of A. Gonadal atrophy
Fallot preferred to squat on bed rather than B. Hypotension
C. Splenomegaly
D. Ankle edema 10. Mr. John started to develop ascites and
complained of heaviness of the lower
7. Which of the following statements is TRUE of extremities to the physician. An order of
liver cirrhosis? Spironolactone (Aldactone) 25 mg. /day. What
adverse effect of the drug should you monitor?
1. Nutritional deficiency with decreased protein
intake attributes to liver damage.
2. Cirrhosis can happen to people with alcohol A. Hyperkalemia
intake B. Palpitation
3. Women are at greater risk for the C. Irregular pulse rate
development of alcohol-induced liver disease D. Hypokalemia
4. Most patients affected by liver cirrhosis are
between 40 to 60 years of age.
Situation: Mr. Perez is a surgical nurse in a
medical center and he had been practicing for
A. 1, 2, 3, and 4
almost five years in this unit. The staff’s go on
B. 1 & 2
shift rotation. For that shift, he had two patients
C. 1, 2 & 3
for operation. One is for Lobectomy and another
D. 2 & 3
is for Nephrectomy
8. During Mr. John’s confinement he developed
11. When is the BEST time for the operative
further itchiness of the skin and jaundice. Which
consent is be signed by his patients?
of the following nursing actions is NOT
recommended as this will induce skin
A. As soon as the surgical procedure is explained
breakdown?
to the patient
B. On admission when the relatives are around
A. Add baking soda when bathing the patient.
C. A day before the surgery
B. Massage the skin with emollients every 2
D. Before any pre-op medications are
hours.
administered
C. Use of commercial soaps and alcohol-based
lotions.
12. Which of the following nursing goals are
D. Rub the itchy skin with knuckles instead of
achieved when early ambulation is done by post-
using the nails.
surgery patients?
9. At early stage of Mr. John’s disease process,
1. Improved circulatio
the physician ordered this SPECIFIC diet for Mr.
2. Improved respiratory function
John, You emphasized to the dietitian that he
3. Prevent venous stasis
should be served foods that is _________.
4. Prevent emboli formation
A. High carbohydrate and low sodium
A. 3 and 4
B. High calorie and high carbohydrate
B. 1, 2, 3,4
C. 1, 3, 4
C. Low protein and high fat
D. 1 and 2
D. High protein and high fat
13. Which of the following patients is MOST at employer on behalf her “sick” mother.
risk during the induction of anesthesia?
17. Riza is a BSN graduate but did not take the
A. 6-year-old with history of allergy National Licensure exams. She is in dire need of
B. 65 year old diabetic woman money so she applied and was accepted in a
C. 35 year old TB case health facility. As a nurse she submitted a fake
D. 25 year old Polio Case PRC license in order to be given a job. Riza is
liable to be charged of ___________.
14. As a circulating nurse, which of the following
is your PRIORITY nursing action to promote A. False statement
safety of your patient? B. Misrepresentation
C. fraud and deceit
A. Prevent peri-operative position injury D. malpractice
B. Provide adequate lighting during the
procedure 18. Ms. Paras an R.N was invited as a resource
C. Optimize surgeon’s access to surgical site person in a nursing conference. The curriculum
D. Maintain surgical aseptic technique during vitae she submitted to the PRC Continuing
the procedure Professional Development Council reflects the
word Masters of Arts in Nursing (MAN) after her
15. Being the nurse in the Post-Anesthesia Care name. She only completed academic
Unit, which of the following is your PRIORITY requirements but not her thesis writing. Which
concern after surgery? of the following did Ms. Paras violate?

A. Monitor vital signs

B. Observe surgical site for bleeding A. RA 9173 of Nursing Law
C. Validate doctor’s orders B. Code of Professional Ethics for Teachers
D. Check level of consciousness C. Magna Carta for Health Workers
D. Code of Ethics for Registered Nurse

Situation: The following situations are related to

ethical practices in the workplace.
19. It is a hospital policy for nurses in a health
facility that reporting time is 15 minutes before
16. Len a registered nurse has signed a
the official designated time. Nurse Claire
contract for two years in a medical center. A
reported 30 minutes late and requested her co-
recruitment agency has offered her a “fat” salary
staff to sign in for her. This is an example of
for foreign employment. If you are in the
__________.
position of Len, what should you do?
A. Dishonesty
B. Falsification of document
A. Discuss your plans with your parents
C. Unprofessional conduct
B. Accept the recruitment offer and go Absence
D. All of the options
without official leave.
C. Write a letter of resignation to your employer
20. What ethical justification is observed when
30 days before leaving.
administering Opioids despite the possibility of
D. Accept recruiter’s offer and give an excuse to
hastening death. patient’s complaint?

A. Rule of double effect A. Allow the patient to lie flat on bed

B. Rule of single effect B. Teach him foot care and leg exercises.
C. Maleficence C. Place affected extremities in a dependent
D. Justice position
D. Apply hot water bag to the affected
21. There are several factors contributory to the extremities
development of these conditions. Which of the
following are the PRIORITY causative factors that 25. Which of the following information is NOT
should be emphasized by Nurse Lydia in her True of Buerger’s disease?
health teaching?
A. Small and medium arteries and veins are
A. Cigarette smoking mostly affected.
B. Aging process and alcohol intake B. Smoking is a major cause of Buerger’s disease.
C. Stress and over acidity C. Incidence of Buerger’s disease is high in men
D. Sedentary life and obesity than women.
D. A strong relationship exists between diabetes
22. Mr. Jacob is admitted due to congestive and Buerger’s disease.
heart failure. Nurse Lydia would expect that if
the failure is on the right side of the heart, the Situation: Mia, 58 years old, beautician has
patient will manifest which of the following. undergone bowel obstruction surgery. During
his first day post-op. she vomited clear liquids
A. Jugular vein distention about three times during your shift. Her vital
B. Crackles on auscultation signs include: temp-37.9 degree C. 138/84 PR-
C. Dry productive cough 78/min and RR- 26/min. her surgical incision is
D. Improved bowel elimination intact, slight bleeding, swilling and
tenderness with slight pain.
23. The patient has been receiving, Digoxin 0.25
mg per day to regulate his heart rate. Which of 26. Which of the following manifestations
the following outcomes would indicate that his would indicate the development of wound
medication is achieving its desired effects? infection?

A. Improved appetite A. Presence of elevated red blood cells count.

B. Increased pedal edema B. Profuse and increasing perspiration.
C. Increased urine elimination C. Increased blood pressure, respiratory rate and
D. Improved bowel elimination pulse rate.
D. Increasing pain on the surgical incision.
24. The other patient of Ms. Lydia is suffering
from Buerger’s disease. He has been 27. If the wound draining is serosanguineous, it
complaining of intermittent claudication of the means that the secretion is colored ______.
lower extremities which has been giving him so
much discomfort. What is the Best nursing A. Yellow-tinged
action she should perform to address the B. Pinkish-red
C. Green-tinged from the NOD.
D. Bright-red
31. When the physician clarifies the process of
28. Later during the day, Mia became confused, Drug Administration, this Quality Improvement
started to pull out her IV fluids as well as her Process is known as
wound dressings. Complained of severe pain
over the wound area. The PRIORITY action of the A. System analysis
NURSE is to ________. B. Root cause Analysis
C. Problem identification
D. Pareto Chart
A. Apply sterile dressings over the surgical
wound 32. Which of the following is the primary reason
B. Call the surgeon at once for the health status why the physician wanted to clarify the process?
of the patient
C. Administer the pain medication at once A. Measures the turnaround time of medication
D. Restrain the hands of the patient B. Better communication with patient and result
C. Identify gap in the medication administration
29. The drug of choice of pain relief to patient D. Improve care management in drug
Mia considering score of 8 which was assessed administration
by the nurse based on the rating scale of 0-10
(0-lowest, 10 is the highest) is ________. 33. While the medical director is conducting his
rounds he observed the presence of scattered
A. Morphines S04 supplies and equipment along the corridor as
B. Ibuprofen well as 02 tank not properly secured. The Quality
C. Demerol Circle (QC) team was informed about this
D. Paracetamol observation. Which of the following is the BEST
strategies to be adopted by the team with this
30. When patient is receiving opioid medication, concern?
the nurse should observe complications from
the side effects by ______. A. Adopt the 5 S audit.
B. Identify and prioritize the problem
A. Checking for the presence of loose bowel C. Select Alternative Solution.
movement D. Enhance Continuous quality improvement.
B. Observing signs and symptoms of addiction
C. Assessing changes of circulatory status 34. The approach adopted by quality circle team
D. Assessing wakefulness of the patient at least was presented to top management. Which of
every 2 hours the following tools is APPROPRIATE to be
utilized as a guide for their time management?

Situation: Mr. Santos, a post- operative, was

A. Pre chart
given Amoxycillin at 12 midnight by the nurse on
B. Radar chart
duty (NOD). The physician asked the patient
C. Process of flow chart
during his rounds if he has receive the drug, the
D. Gantt chart
patient answered “NO”. The physician clarified
the claim from the chart and from the chart and
35. In order to determine if the implementation not be able to wake from anesthesia after my
of the activity is successful, the First step to be operation.” Your BEST response is _________.
done by the team is ______________.
A. “Do not worry, everything will be alright.”
A. Prioritize the problem B. “Let me tell to your family your fear.”
B. Coordinate with the different units C. “I will not let you go to the OR until I have
C. Have a random report to the supervisor talked to your surgeon.”
D. Develop a monitoring plan D. “Don’t Say that, I will discuss your concerns
with your anaesthesiologist.”

39. Mr. Rostum, returned back to the ward,

Situation: Nurse Aida is assigned in the Surgical
after recovering from anesthesia. He complain
Ward of a Tertiary Medical Center with several
of pain over the scapular region. Which of the
patients who are for diagnostic tests and for
following nursing actions should you do?
surgery.
A. Apply heating pad over the painful area.
36. Mr. Rustom, 38 years old, is scheduled for
B. Turn client from side to side.
Laparoscopic Cholecystectomy in the morning
C. Give demerol as ordered.
the next day. He verbalizes to you and says, “Dr.
D. Apply cold pack over the affected area.
Alex will open me up to remove my gallstones?”
which of the following is your BEST response?
40. After 5 days, Mr. Rostum is ready to go
home. His discharge instructions include
A. “Let us discuss with the surgeon your
observations of the following complications,
operation before you go to the OR.”
EXCEPT:
B. “I know the surgeon will remove your stones
with a new technique.”
A. Palpitation
C. “Let me call the OR supervisor to discuss the
B. Loss of appetite
procedure with you.”
C. Increased body temperature
D. “I will call the anaesthesiologist to explain
D. Bleeding
more the procedure.”

37. A critical component before Mr. Rostum Situation: Nadia is assigned as charge nurse at
goes for surgery is the nurse’ preoperative the Cardiovascular Ward in a Medical Center.
teaching. Which of the following is NOT There are 20 patients, classified as follows: 2
advisable prior to surgery? Total Care (TC), Partial Care (PC) and 9
Ambulatory Care (AC). The ward’s morning duty
A. Teach him deep breathing exercises are 3 staff nurses and 2 nursing attendants (NA).
B. Fast at midnight, but can drink water if he
becomes thirsty. 41. How will your distribute the patients to the
C. Instruct him to void before going to the 3 Registered Nurses and 2 Nursing Assistants?
operating room.
D. Teach him leg and coughing exercises A. 2 Registered Nurse for Total Care patients, 1
Registered Nurse and 1 Nursing Assistant for
38. While giving health instructions to Rostum. Primary Care Patients, 1 Nursing Assistant for
He looks very anxious and said to you, “I might Total Care.
B. 1 Registered Nurse and 1 Nursing Assistant for 1. Put the recently- delivered at the back of the
Total Care Patients, 1 Registered Nurse and 1 old stoc
Nursing Assistant for Primary Care Patient, 1 2. Put the old stock in front of the newly-
Registered Nurse for Ambulatory Care patients. delivered ones
C. 2 Registered Nurse for Total Care patients, 2 3. Check the fluids for sediments and
Nursing Assistant for Primary Care Patients, 1 discoloration
Registered Nurse for Ambulatory Care Patients. 4. Keep the fluids inside the cooler
D. 1 Registered Nurse for Total Care patients,
Registered Nurse and 1 Nursing Assistant for A. 1, 2
Primary Care patients, 1 Registered Nurse and 1 B. 1, 4
Nursing Assistant for Ambulatory Care patients C. 3, 4
D. 2, 3
42. In as much as this is a cardio-ward what
basic equipment/materials should be available 45. How will Nurse Nadia arrange the patients in
at all times? the ward? Put the ______________.

1. o2 A. Primary Care in between the Ambulatory Care

2. Ambu Bag patients.
3. Suction Apparatus B. Primary Care and Ambulatory Care patients
together and Total Care at the corner of the
4. Endotracheal room.
C. Total Care patients near the nurses and the
A. 1, 2, 4 Ambulatory farthest
B. 1, 2, 3, 4
C. 1, 2, 3 D. Ambulatory Care patients near the Total Care
D. 2, 3, 4 ones.

43. Which of the following emergency

Situation: Mr. Bang, 62 year old, an Executive of
medicines should be available at the emergency
a shoe company was brought to the hospital
cart at the Cardio Ward?
after having vomited bright red blood
immediately after supper. He claimed he had
1. Epinephrine
drinking session with his former classmates in
2. Demerol
college. He was already advised by their family
3. Valium
physician not to drink alcohol due to a suspected
4. Coumadin
fatty liver. You are the nurse-on-duty when he
was admitted.
A. 1, 3
B. 1, 2
46. Based on your assessment and history
C. 2, 4
taking for Mr. Bang which PRIORITY FINDINGS
D. 3, 4
should you document and report to the
physician?
44. When stocking fluids in the emergency cart.
What should nurse Nadia instruct the nurses?
A. Use of anti-inflammatory drugs.
B. Vital signs BP- 140/90, PR- 88/min.PR24/min.
C. abdominal pain (3 in a scale of 10) A. Had urine output of 600 cc during the whole
D. Tense, rigid abdomen shift.
B. “Appears to be comfortable with good night
47. You have formulated your Nursing Diagnosis rest and sleep”
for the patient and wrote in the nursing care C. Refused to eat her dinner as she feels
plan. Which ONE of the following? nauseated at meal time
D. Slept from 11 PM to 6 AM after Valium 5mg.
A. Deficient Fluid Volume R/T vomiting of blood was given.
and gastric secretion.
B. Non-compliance R/T alcohol and medication
Situation. Nurse Cora admits Mr. De Guzman, 31
intake.
year-old, who was brought to the Emergency
C. Fear of death R/T unknown cause of bleeding.
room by his co-worker because of severe
D. Risk for Aspiration R/T active bleeding.
abdominal pain. He was observed to be very
anxious; holding his abdomen with his right hand
48. The physician orders insertion of nasogastric
while bending towards his right side. The
tube with lavage to Mr. Bang. What kind of
Emergency Room doctor made his initial
solution will you expect to be written in the
assessment and referred the patient to the
doctor’s order when a patient will undergo a
Surgical doctor on duty for further assessment.
lavage?

51. To describe a sensation of severe pain felt

A. Normal Saline Solution
for ruptured appendicitis, Nurse Cora applies
B. Distilled Water
deep pressure of her finger into the abdomen at
C. Tap warm water
a point away from the pain and then releases.
D. Dextrose 5% in water
This maneuver is termed as __________.
49. When a patient has a gastro-intestinal
A. Perforation
bleeding and there is a presence of
B. McBurney’s Point
hematemesis, how should you describe this in
C. Rovsing’s sign
your documentation?
D. Rebound tenderness

52. Mr. De Guzman was diagnosed with

A. Bloody vomitus appearing as fresh, bright red
ruptured appendicitis. When the appendix is
or “Coffee-ground” in appearance.
suspected ruptured, a generalized abdominal
B. Brownish vomitus appearing as “Chocolate” in
pain is felt and becomes ____________.
appearance from a previous Food Intake.
C. Black, tarry stools in appearance often foul
A. Merely a discomfort and steady rather that
smelling, from a previous food intake.
intermittent
D. Small amounts of fresh blood observed either
B. Intense and the patient guards the area by
through gastric secretions or stools.
living room
C. Rigid, stiff and board like feeling
50. The following are the practice guidelines in
D. Tender and focused on the umbilical cord
documentation. Which ONE of these is NOT
region
recommended to be written in your charting?

53. Immediate surgery was done on Mr. De

Guzman. Which of the following measures for bed. Which position should you put the child to
pain control is NOT advisable to be done by ease his discomfort?
Nurse Cora while patient De Guzman is having
post-op pain? A. Lying on his side
B. Prone position
C. High Fowler’s Position
A. Coughing exercises D. Supine position
B. Deep breathing
C. High-fowler’s position 58. The Pediatrician ordered theophylline by IV
D. Semi-fowler’s position route. The effect(s) of this drug is __________.

54. After operation, a nasogastric tube (NGT) A. Decrease gastric acid secretion
was inserted to Patient De Guzman. The B. Causes coronary vasoconstriction
rationale for this surgical measure is to C. Relaxes the smooth muscle of the bronchial
_________. tree
A. Prevent use of antibiotics D. Stimulation of the peripheral nervous system
B. Decrease hospitalization to two days
C. Decrease pain after the operation 59. What APPROPRIATE activity should you
D. Avoid the use of analgesics advise the child while in the hospital?

55. Nurse Cora assesses the pain intensity of Mr. A. Talk on the phone with his classmates
De Guzman. The pain assessment tool B. Finish his assignments in school
APPROPRIATE to be used for Mr. De Guzman is C. Watch cartoon movies on TV
_____________. D. Play with his teddy bear

A. Faces Pain Rating scale 60. The patient is ready to go home. What
B. Visual Rating Scale health teachings can you give to him and to his
C. World Rating Scale mother?
D. Numeric Rating Scale
1. Prevent the child from exposure to dust and
pollutants
Situation: You are the nurse on night duty in the
2. Avoid exposure to extreme hot or cold
medical ward. You were assigned by Ms. Felipe,
weather
the Charge Nurse of the unit to monitor the
3. Increase fluid intake
status of a 9 year old boy with bronchial asthma.
4. Avoid hyper-allergenic food

56. Which of the following manifestations of the

A. 1 and 2
child would cause you to be alarmed?
B. 2, 3, 4
C. 1, 2, 3, 4
A. Excessive sweating
D. 1 only
B. Choking sensation
C. Cough with phlegm
D. Generalized chest tightness Situation: Maya, 65 year-old cook, restless and
obese was brought to the Emergency Room due
57. You would like the child to be comfortable in to right abdominal pain, nausea and vomiting for
a week. She frequently changes her position to a _______.
more comfortable one due to intense pain. You
are the nurse in charge who admitted the A. Quiet environment
patient after the B. Positioning
attending doctor diagnosed her with Acute C. Administering analgesic
Cholelithiasis. D. Back rub

61. Patient Maya’s vomiting can be treated with

a nasogastric tube insertion with a suction 65. Immediate postoperative care of Nurse
attachment. This measure will remove the Mags includes providing careful instructions to
gastric juice stimulating painful contractions of Ms. Maya. Which of the following interventions
the gallbladder which is __________. should be delegated to the caregiver?

A. Cholecystokinin A. Administration of intravenous therapy

B. Ecchymosis B. Reinforce information on exercise
C. Lithotripsy C. T-tube care and changing
D. Acalculus D. Instructions for the reduction of pain

62. Patient Maya, was ordered by the physician

Situation: Dave, 40 years old, came to the
to undergo several diagnostic tests. You expect
hospital for a diagnostic work-up for a
that patient will have an elevation of ________.
cholelithiasis prior to surgery.
A. Bromsulphalein excretion
66. Which of the following clinical
B. Lactate dehydrogenase
manifestations would you MOST likely to
C. Serum gamma glutamyltranspeptidase
observe when a patient is suffering from
D. Alkaline phosphatase
Cholelithiasis?
63. Nurse Mags provides important instructions
A. Indigestion, pain on the right upper quadrant
to Ms. Maya on the prevention of Cholelithiasis.
radiating pain to the shoulder
Select all that apply.
B. Vague left upper quadrant pain radiating to
the scapula
1. Maintain ideal weight
C. Feeling of abdominal tenderness after waking-
2. Adapt low fat diet
up in the morning
3. Regular exercise
D. Feeling of abdominal fullness after taking
4. Prevent pregnancy
meals
A. 2, 3 ,4
67. Which ONE of the following vitamins is
B. 1, 3, 4
interfered when there is obstruction of the bile
C. 1, 2, 3
flow in cholecystitis?
D. 1, 2, 4

A. Vitamin C
64. Ms. Maya is prepared for surgery. Nurse
B. Vitamin B
Mags provides comfort measures to relieve pain
C. Vitamin B12
with the following nursing intervention, EXCEPT
D. Vitamin K
 71. Which of the following is a form of dispute
68. The patient was ordered Endoscopic resolution and considered a legal technique
Retrograde Cholangiopancreatography (ERCP). which is outside the court?
He was put on a mild sedation. As a Nurse, what
should you check as a PRIORITY action when he A. Suppression
returns to the ward? B. Arbitration
C. Bribe
A. Irritation of oropharynx D. Negotiation
B. Nausea and vomiting
C. cough and gag reflex 72. Change is defined “as making something
D. Signs of bleeding different from what it was”. If you become a unit
manager in the future, which of the following is
69. Which of the following conditions is NOT a your FIRST step as an agent in promoting
side effect of anticholinergic drugs? successful change in your health care setting?

A. Constipation A. Revisit Institutional Vision-Mission and adhere

B. Blurred vision to its commitment
C. Dryness of the mouth B. Obtain majority agreements when issues are
D. Increased blood pressure presented
C. Include obsessed people as part of your Task
70. When a client has a nasogastric tube (NGT) force for change
due to abdominal distention post surgery. Which D. Ignore organizational conflict as possible
of the following nursing responsibilities should
you do? 73. Decision-making in an organizational
structure comes at many levels. The level which
1. Measure gastric secretion every shift is considered empowering to staff-member is
2. Observe and record color, viscosity of when the unit manager does which one of the
secretion following?
3. Ensure that the gastric tube is patent
4. Assist patient to assume a comfortable
A. Makes a decision when she reads the
position
reported concerns
B. Ask direct report from personnel to decide on
A. 1, 2, 3 and 4
a solution
B. 1, 2 and 3
C. Makes a decision after convening a core
C. 1 and 2
group to analyze the concerned issues
D. 2, 3, and 4
D. Makes a decision by herself and assumes
responsibility for her action
Situation: The hospital director of a tertiary
hospital is alarmed with the recent report of the 74. The nurse manager is receiving some
head Human Resource Department Office feedback that one of her staff-nurses has been
(HRDO) that there is so much conflict going on observed to be always irritated, “bossy”, and
among the health care professionals which is indifferent to her patients and some co-workers.
affecting quality patient care. Which of the following PRIORITY nursing actions
should the manager implement?
 further check-up. Which of the following
diagnostic tests do you expect to be ordered by
A. Conduct a joint meeting of both parties the diabetologist as an indicator that the patient
involved is compliant to her prescribed diet?
B. Request the concerned patients and co-
workers to submit an Incident report A. Oral glucose tolerance test
C. Call the nurse concerned and talk to her B. Glycosylated hemoglobin level (hgb, Alc)
privately about the observations C. Finger glucose findings for one day
D. Give a memo to the nurse involved D. Fasting blood glucose level

75. A team building session was conducted by 78. While Nurse Ellen was completing her
the HRDO task force to come up with strategies assessment, she discovered the following
for conflict resolution. Which of the following is findings. Which of the following should she refer
a WIN-WIN approach in conflict management. immediately to the physician?

A. Each party involved agree to respond to A. Tingling sensation of the hands and feet
majority vote B. Changes in the peripheral vision
B. Each participants agree to resolve conflicts by C. Beginning ulceration of the left big toe
adhering to the Institutional Vision and Mission D. Fruity odor breath
C. Each participants will give way to 60-40% of
their agreements
D. Disagreements are settled with respective 79. Nurse Ellen, the nurse in charge of patient
compromises on issues presented Juvy, informed her physician that her serum
glucose level is 38mmol/L and quite
unresponsive to verbal questioning. The nurse
Situation: Juvy, a retired Barangay Health
suspects that she is starting to develop Diabetes
Worker, came to the OPD for her check-up for
Ketoacidosis (DKA). Which of the following
her diabetes mellitus. She had been diabetic
manifestations is UNIQUE to this condition?
since she was 37 years old. She has been taking
her maintenance medications which she
A. Shallow slow respirations
sometimes does not comply with.
B. Increased serum potassium
C. Rapid deep respirations
76. There are metabolic abnormalities in the
D. Decreased serum albumin
development of type 2 Diabetes. Which of the
following is NOT included in these
80. Nurse Ellen’s counseling role includes
abnormalities?
lifestyle changes as well as pharmacologic
regimen. Juvy’s family were interested to know
A. Inappropriate production of the liver
information regarding insulin. She differentiated
B. Increased ability of the pancreas to produce
an intermediate acting insulin from that of
insulin
short-acting which is _________.
C. Insulin resistance
D. Altered production of hormones by adipose
A. Regular onset is 2 hrs. Peak is 3 ½ hr.,
tissues
duration -7 hrs., administered 20-30 min. before
meal
77. Ms. Juvy was admitted to the hospital for
B. Regular onset is 2-4 hr., peak is 4-12 hr., B. Changing the sterile field after sterile water
duration is 8 hr., administered 20-30 min. after spilled on it
meal C. Placing sterile dressing 2 cm from the edge of
C. Regular, onset is 1 ½ hr, peak is 3-4 hrs, the sterile field.
duration is 6 hrs. administered 20-30 min after D. Cleaning the wound in circular motion from
meal outer towards the ulcer site
D. Regular onset is 1 ½ - 1hr, peak is 2-3 hr., 4-
6hr duration administered 20-30 min. before 84. Nurse Mich after foot care encourages
Patient Aileen to do which of the following
Situation: Nurse Mich admitted Aileen, 38 years APPROPRIATE measures?
old, who was diagnosed by her physician with
Type I Diabetes Mellitus. She complains of easy A. Apply lanolin generously between the toes
fatigability and increased tiredness. Nurse Mich, B. Cut toenails rounded at the edges and close
during the assessment, noted the presence of a to the skin
foot ulcer which Aileen was trying to hide. C. Apply alcohol after cleansing feet to improve
infection
81. Nurse Mich holds the hands of Aileen while D. Wear a shoe-type slipper at home
doing her assessment. Her hands were cold and
clammy, she suspected that the patient was 85. Ms. Aileen was administered NPH insulin at 8
having hypoglycemia. To relieve her condition, am. At what time would Nurse Mich expect the
an immediate action is to offer her _________. patient to be at risk for hypoglycemic reaction.

A. Candy A. 11 am
B. Full meal B. Noon
C. Sandwich C. 6 pm
D. Fruits D. 4 pm

82. Nurse Mich watches Ms. Aileen while

Situation: A 6-year old boy is suffering from pain
sleeping. An EXCELLENT guideline to
on his right inguinal region. His
differentiate if a patient is just sleeping or
mother brought him
experiencing hypoglycemic reaction is when one
to the hospital and was diagnosed to have
is observed to be _______.
incarcerated hernia. He had a scheduled
herniotomy.
A. With dyspnea
B. Snoring
86. What will be your FIRST pre-operative
C. With diaphoresis
nursing measure?
D. Grunting his teeth

A. Get informed consent from the mother.

83. Nurse Mich practiced surgical asepsis during
B. Change the boy’s street clothes to surgical
foot care. Which of the following techniques has
gown
to be observed?
C. Shave the operative site
D. Call the OR nurse for scheduling
A. Opening container of sterile water after
putting gloves on.
87. The boy is transferred to the operating
room. What is the BEST mode to be used in 91. The Professional Regulation Commission,
transferring the patient? Board of Nursing (PRC– BoN) as a regulatory
board has the legal functions and responsibilities
A. Nurses’ carry EXCEPT in ONE of the following ___________.
B. Stretcher
C. mother’s carry A. ensure the quality nursing education by jointly
D. wheelchair monitoring with the Commission on Higher
Education (CHED) adherence to its guidelines,
88. The nurse must prepare the OR environment policies and standards
to be safe and comfortable for the child by B. Monitor and enforce quality standards and
reducing the air conditioning temperature so as nursing practice in the Philippines to ensure
to prevent ___________. efficient, ethical, moral, technical professional
standards
A. Hypoventilation C. Issue, suspend or revoke certificates of
B. Hyperventilation registration for the practice of nursing
C. Hypothermia D. Recognize specialty organizations in
D. Hyperthermia coordination with the accredited professional
organization and collect fees to upgrade the
89. The scrub nurse has to prepare for a conditions of Nurses
pediatric herniotomy. Which of the following
should be ready? 92. You are a nurse in Las Pinas Doctors Hospital
and have just completed a 2 year experience in
A. Subcuticular 3/0 round, absorbable the surgical unit. One day, your supervisor
B. Subcuticular 3/0 cutting, absorbable ordered you to go on a float to the Intensive
C. Monofilament 3/0 cutting, absorbable Care Unit (ICU) as two of the nurses called “on
D. Monofilament 3/0 round, absorbable sick” in the said unit. What is the MOST
important action you should do in this situation?
90. The mother was afraid to submit the child
for surgery. What is the BEST response to the A. Explain to your supervisor that you might not
Nurse in this situation? be able to perform safely your duty as a nurse in
the unit
A. “It is alright to feel that way but you cannot B. File a leave instead and call your husband to
do anything now.” fetch you in the hospital
B. “It is the doctor's order; you’ll have to accept C. Refuse the order and tell your supervisor your
the situation.” don’t want to put your license in jeopardy
C. “Your child’s condition is an emergency case. D. Report to the surgical ward of your
If he is not operated on, he will die.” assignment and request one of your nurses to
D. “I understand your feelings, but your child replace you instead as floater in the ICU.
needs to be operated on.”
93. Janna, a 35-year old, married to an insurance
Situation: There are extensive legal aspects that agent, was diagnosed with colon cancer only a
guide the Filipino nurses in terms of regulation month ago. The couple have very limited
in practice of her profession. information about this condition. One day, you
saw the husband in the room reading the chart
which was inadvertently left by a medical intern. C. 1 & 2
What PRIORITY Nursing actions should you do in D. 1 & 3
this situation?

Situation: Honey, 23 year old, a dental student

A. Get the chart from the husband so he will not
has been having frequent bouts of tonsillitis in
be able to read the diagnosis of his wife
the past. One day, she developed low grade
B. Explain to the husband as per policy, relatives
fever, dyspnea, dizziness, syncope, and fainting
are not allowed to read the chart
spells while preparing for her final examination.
C. Report immediately to the supervisor on duty
She was rushed to the hospital by her parents
and submit an incident report
and was seen in the Emergency room by the
D. Ask the husband what information he would
physician on duty (POD), Ms. Jenny was the
like to ask from the health care professional
nurse-on-duty. The POD ordered a 12 lead
regarding medical plan and diagnosis
Electro-cardiogram (EKG) and other laboratory
tests.
94. Nurse Nicole, is assisting Mr. Caca who just
came from the Recovery unit for a thoracic
96. What specific information is essential for the
surgery. She noted that the dressings are
Health professionals to know when this EKG is
saturated with blood, but the Surgeon just
ordered for patient Honey?
reassured the Nurse to reinforce the dressings
and monitor him closely. After an hour, Mr. Caca
A. Rate, rhythm and pressure within the blood
went into shock and died. The family filed
vessels
charges against the Doctor and the Nurse. What
B. Rate, rhythm, axis and circulation
is the lawsuit involved in this case?
C. Rate, rhythm, axis, hypertrophy, and
infarction
A. Murder
D. Rate, hypertrophy and blockage to the
B. Assault
chambers of the heart
C. Battery
D. Malpractice
97. Aside from the EKG and laboratory studies,
the POD ordered patient Honey to undergo
95. What is the MOST important Nursing
cardiac catheterization to establish further the
measure that Nurse Nicole should have done to
medical diagnosis of Valvular heart disease.
avoid this situation?
Which of the following is NOT true as part of
Nurse Jenny instructions to the patient
1. Monitor and record closely the vital signs
regarding this procedure?
until stable
2. Report to the surgeon the vital signs and
A. Signing of consent is optional
degree of bleeding from operative site
B. Normal procedure is less than 2 hours
3. Call the supervisor on duty to assist you in
C. Fasting should be 8 to 12 hours
referring the patient to the surgeon
D. Presence of pounding sensation in the chest
4. Ask the family members to call the surgeon
during the procedure
to see the patient

98. Nurse Jenny must be alert that certain

A. 2 & 3
complications may arise after the procedure.
B. 1, 2 & 3
What PRIORITY nursing assessment should she
observe?

A. Tingling sensation
B. Signs of bleeding at the puncture site
C. Blurring vision
D. Disorientation

99. When teaching patient Honey about self-

management following cardiac catheterization,
Nurse Jenny should emphasize to AVOID which
ONE of the following?

A. Diet high in Protein and Carbohydrates to low

cholesterol and fats
B. Lifting objects heavier than five (5) lbs
C. Taking shower with the site covered after 24
hours
D. Light exercise program within 48 hours when
tolerated

100. The POD established Honey’s diagnosis that

she is suffering from acquired valvular heart
disease. This condition is brought about by
_______.

A. Rheumatic fever
B. Drug abuse
C. alcohol consumption
D. heredity