MEDICAL- SURGICAL NURSING

(Prepared by: Prof. Rex B. Yangco)

GENERAL INSTRUCTIONS:
1. This test drill contains 100 test questions.
2. Read INSTRUCTIONS TO EXAMINEE printed on your answer sheet.
3. Shade only one (1) box for each question on your answer sheet. Use a No. 2 pencil only. Two or more boxes shaded will invalidate your answer.
4. AVOID ERASURES.

NAME: ____________________________________________________________________ SCORE: ___________________

Situation 1 – Surgery is a unique human experience that creates stress and necessitates physical and psychosocial changes. Nurses must draw up
plans to meet the needs of these clients.
1. A female client is being prepared for a surgery. When the nurse asks the client to remove her wedding ring, the client refuses. Which of the
following would be the most appropriate response by the nurse?
A. Encourage the client to use soapy water to remove the ring if it is tight
B. Explain that the hospital cannot be responsible for jewelry worn during surgery
C. Notify the surgeon’s office that the surgeon must see the client in the preoperative holding area
D. Tape the ring in place before the client is transported to the preoperative holding area

2. The nurse has taught the client to perform deep breathing and coughing exercises. The nurse determines that the client needs more teaching
when the client is observed doing which of the following activities?
A. Sitting upright before performing deep breathing and coughing exercises
B. Taking deep breaths before attempting to cough
C. Placing both hands vertically and lightly on either side of the incision
D. Using a pillow for splinting during coughing

3. An operating room nurse is position a client on the operating room table to prevent the client’s extremities from dangling over the sides of the
table. A nursing student who is observing for the day asks the nurse why this is so important. The nurse responds that this is done primarily to
prevent:
A. An increase in pulse rate C. Nerve and muscle damage
B. A drop in blood pressure D. Muscle fatigue in the extremities

4. The nurse is caring for a postoperative client who has received a general anesthetic. Which of the following observations is the priority to be
immediately reported.
A. Complaints of nausea C. Decreased urine output
B. Mild hypertension D. Rising body temperature

5. The postsurgical unit nurse is implementing measure to prevent thrombophlebitis. Which of the following is the priority action of the nurse?
A. Apply ordered antiembolic stockings C. Assess the legs with each set of vital signs
B. Reinforce importance of smoking cessation D. Teach the client to report Homan’s sign

Situation 2 – Cancer is a common health problem today. As a nurse, you can have a vital impact in educating clients about cancer prevention and
early detection methods.
6. When the nurse is counselling a client about preventive measures for cancer, one of the most important behaviors to emphasize is to:
A. Decrease fat intake C. Avoid smoking
B. Avoid exposure to the sun D. Obtain adequate rest and avoid stress

7. A nurse educating a group of clients on cancer screening practices. Which of the following instructions should the nurse include as a
recommended screening pattern?
A. Annual Pap and pelvic examination should begin at age 40
B. Annual cancer check-ups for all persons over age 40
C. Annual mammography should begin at age 30
D. Annual fecal occult blood test and colonoscopy at age 40

8. After completing health risk assessment on a client, you determine health teaching and education is necessary because of an increased risk for
laryngeal cancer caused by which of the following risk factors?
A. Past infection with Epstein-Barr virus
B. Past exposure to asbestos
C. Smoking marijuana for recreational drug use
D. Smoking cigarettes and consuming large quantities of alcohol daily

9. The nurse should instruct a client that which of the following is the most effective prevention against bladder cancer?
A. Drink 8 to 10 glasses of fluid per day C. Stop smoking
B. Void at least five times per day D. Take herbal supplements
10. A client is experiencing severe, intractable pain from cancer complaints that the pain medication is not handling the pain at all. The nurse has
given the client all the medicine she can receive. The next nursing action is to:
A. Emotionally support the client and tell her she will receive the next dose of medication as soon as possible.
B. Contact the physician’s behalf to increase the pain dose or change the medication.
C. Suggest the client try breathing or other alternative techniques to cope with the pain.
D. Explore the nature of the pain an d help the client perceive it in a different way.

Situation 3 – The nurse must fully understand that care of clients with heart disease serves to improve the outcomes and quality of life in order to
reduce morbidity and mortality.
11. An adult is admitted to the coronary care unit to rule out a myocardial infarction. The client states, “I am not sure if it is just angina, and I cannot
understand the difference between the angina and heart attack pain.” Which response is most appropriate for the nurse to make?
A. Anginal pain usually stops after resting
B. Anginal pain produces clenching of the fists over the client while acute MI pain does not
C. Anginal pain requires morphine for relief
D. Anginal pain radiates to the left arm while acute MI pain does not

12. To evaluate a client’s condition following cardiac catheterization, the priority intervention is to palpate the:
A. In all extremities C. Distal to the catheter insertion
B. At all insertion site D. Above the catheter insertion

13. A priority nursing intervention for a client with a suspected myocardial infarction who has just been admitted is to:
A. Monitor his intake and output
B. Explain to the client the relationship between heart work and need for oxygen
C. Intervene for anxiety management
D. Insist on complete bedrest

14. The nurse is caring for an adult who is being treated for a myocardial infarction. Oxygen is ordered. Administering oxygen to this client is
related to which of the following client problems?
A. Anxiety C. Ineffective myocardial perfusion
B. Chest pain D. Alteration in heart rate, rhythm, or conduction

15. An adult client has experienced a cardiac arrest and the nurse is performing CPR. What is the correct hand position on the client’s chest?
A. Over the upper half of the sternum C. Two finger widths above the Xiphoid process
B. Two finger widths below the sternal notch D. Over the Xiphoid process

Situation 5 – Clients with lung disorders:

16. A 64-year old has been smoking since he was 11 years old. He has a long history of emphysema and is admitted to the hospital because of a
respiratory infection that has not improved with outpatient therapy. Which finding would the nurse expect to observe during the client’s nursing
assessment?
A. Electrocardiogram changes C. Slow, labored respiratory pattern
B. Increased anterior-posterior chest diameter D. Weight-height relationship indicating obesity

17. When caring for a client diagnosed with pulmonary edema who is receiving oxygen, the nurse observes that she frequently removes her oxygen
mask even though she is dyspneic. The appropriate nursing intervention:
A. Change from O2 mask t O2 cannula C. Tighten the strap on the O2 mask
B. Increase the liter flow of O2 to 10L/min D. Change O2 administration to a Venturi mask

18. Percussion, vibration and postural drainage are ordered for a 15-year-old client hospitalized for pneumonia. Prior to providing this intervention,
the priority action is to:
A. Instruct the client in diaphragmatic breathing C. Auscultate lung fields
B. Assess vital signs D. Assess characteristics of her sputum

19. A client on a ventilator. The ventilator alarm goes off. The nurse assesses the client and observes increased respiratory rate, use of accessory
muscles, and agitation. What should be the nurse’s first action?
A. Remove the client from the ventilator and ambu bag the client, while continuing to assess to determine the cause of the client’s distress
B. Call respiratory therapy to check the ventilator
C. Notify the physician
D. Turn off the alarm

20. An adult has a chest tube to a Pleur-evac drainage system attached to wall suction. An order to ambulate the client has been received. How
should the nurse ambulate the client safely?
A. Clamp the chest tube and carefully ambulate the client a short distance
B. Question the order to ambulate the client
C. Carefully ambulate the client, keeping Pleur-evac lower than the client’s chest
D. Disconnect the Pleur-evac from the client’s chest tube, leave it attached to the bed, ambulate the client, and then reconnect the chest tube
when he is returned to bed.

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Situation 5 – Paulo, 36 years old, was admitted in the hospital diagnosed with Grave’s disease and is being scheduled for surgery.
21. A physician has prescribed propylthiouracil (PTU) for Paulo and the nurse develops a plan of care for the client. A priority nursing assessment
to be included in the plan regarding this medication is to assess for:
A. Relief of pain C. Signs and symptoms of hyperglycemia
B. Signs of renal toxicity D. Signs and symptoms of hypothyroidism

22. Paulo is schedules for a subtotal thyroidectomy and potassium iodide (Lugol’s solution) is prescribed. A nurse prepares to administer the
medication, knowing that the therapeutic effect of this medication is to:
A. Replace the thyroid hormone C. Increase thyroid hormone production
B. Prevent the oxidation of iodide D. Suppress thyroid hormone production

23. A nurse is performing as assessment on Paulo following a thyroidectomy and notes that Paulo has developed hoarseness and a weak voice.
Which nursing action is appropriate?
A. Check for signs of bleeding
B. Administer calcium gluconate
C. Assess patient’s vital signs
D. Reassure Paulo that this is usually a temporary condition

24. Paulo is subject to complications during the first 48 hours after surgery. The nurse should obtain and keep equipment at the bedside to:
A. Begin Total Parenteral Nutrition C. Prevent the oxidation of iodide
B. Start a cutdown infusion D. Perform a tracheostomy

25. Paulo is 6 hours post-thyroid surgery. The nursing assistant reports that the client is upset because there is blood on his gown. Which of the
following is the priority action of the nurse?
A. Assess Paulo’s breath sounds and respiratory effort
B. State it is normal to have some bleeding and ask the nurse aide to change the gown
C. Reassure the client that some bleeding is normal, and then assess Paulo’s level of pain
D. Reinforce the dressing, change the gown, and call the surgeon.

SITUATION 6 – Nurse Sunshine is assigned in the medical-surgical unit and most of the clients assigned to her were elderly clients.
26. For a client complaining of mild musculoskeletal pain, the nurse will anticipate that the treatment for this client’s level of discomfort will include
which of the following?
A. Diazepam C. Fentanyl
B. Meperidine hydrochloride D. Acetaminophen

27. Sunshine was to inject Vitamin B intramuscularly to another elderly patient. Before injecting, the nurse explained that the client may feel some
discomfort. This is an example of:
A. Reducing pain perception C. Self-preservation
B. Anticipatory response D. Distraction

28. Mr. Aquino, 71 years old has a history of chronic back pain. He thinks that his family perceives him as “weakling” because he often ask for pain
medication. Which of the following is the most therapeutic response of the nurse?
A. “It seems that you are worried. Which matters to you more? What people will say or getting relief from your pain?”
B. “Taking pain medication as prescribed will help you become more active and your family will be happy to see you up and about.”
C. “Chronic back pain is very difficult to manage; use pain medication because that is what it is for.”
D. “Don’t you think your family wants you to be more comfortable, and the only way is to take your medicine?”

29. Mang Berting has chronic pain due to osteoarthritis but has impaired speech. Which of the following is the MOST appropriate to determine his
medication needs for pain?
A. Record frequency of patient’s complaint of pain and administer medication accordingly
B. Medicate the client with analgesic as often as ordered
C. Asking the client to rate his pain on a scale of 0 to 10 by writing on a magic slate
D. Observe typical pain behavior through facial expressions

30. Aling Tekla, 67, diabetic, complained of elevated blood glucose since she strained her back a week ago despite following her diet and drug
prescription. Your best explanation would be:
A. Client is consuming more food as a coping mechanism
B. Physiologic and Psychologic stress can elevate blood glucose level
C. It is a usual occurrence among the elderly
D. Parasympathetic stimulation from the body’s normal response to pain

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Situation – 7 Postoperative infection complication is still a concern in surgical client’s care. Hospital staff needs to review practices to adhere to the
standards of care to improve quality and safe care delivery.
31. Nurse Cynthia is setting up for an emergency caesarian section. The linen packs were damp although these were just taken from the sterilizer.
The nurse’s APPROPRIATE action is:
A. Bring the linen packs back to the Central Supply Section for quality control
B. Change the damp linen pack
C. Open the linen pack and allow to dry
D. Do not use the damp linen

32. The clinical instruction assigned a nursing student to assist in the operation. When the nursing student entered the OR suite, her curly long hair
was not completely covered by the head cap. What would the circulating nurse do?
A. Do not allow the nursing student to scrub in
B. Welcome the nursing student to the OR
C. Request the clinical instructor to tell the nursing student to use the head cap properly
D. Assist the nursing student to tuck-in all her hair inside the head cap

33. After the surgeon finished doing the surgical hand scrub, she came in to the OR suite swinging her hands casually. The scrub nurse would do
which of the following APPROPRIATE action?
A. Tell the circulating nurse to pour alcohol 70% to the surgeon’s hands
B. Serve the surgeon her sterile gown and gloves as usual
C. Remind the surgeon to scrub again
D. Offer a sterile towel to dry her hands

34. When the intern in-charge did the skin prep and catheterized the client, the circulating nurse noticed when the intern withdrew the catheter from
the vagina. What is your APPROPRIATE and IMMEDIATE action?
A. Hold the hand of the intern to stop him from reinserting the catheter.
B. Alcoholise the tip of the catheter before reinserting the catheter
C. Offer to change the catheter
D. Stop the intern and do the catheterization yourself

35. After the last stitch, the surgeon is ready to apply dressing to the incision wound. Which of the following does the nurse expect the surgeon to
do?
A. Apply the dressings and tape and then remove his gloves
B. Tape the dressing and remove gloves
C. Remove his gloves and apply dressings
D. Put the dressings and remove his gloves to apply the tape

Situation 8 – Marian, a newly hired staff nurse in the medical surgical unit was assigned to work with a senior nurse. A female client was admitted
with a diagnosis of diabetic foot, gangrene left toe, type 2 diabetes. Marian assisted the senior nurse during the admission of the client.
36. From the nursing history obtained from the client, which information is MOST likely related to the development of gangrene of the client’s left
toe?
A. Accidental cut on big toe while cutting toenails
B. Type 2 diabetic diagnosed 15 years ago
C. Father had type 2 diabetic; post above knee amputation right leg
D. Preferred open toed sandals to closed leather shoes

37. The physician ordered bilateral lower extremities Doppler ultrasound. Which of the following is the physician interested to find out through his
diagnostic test?
A. Occlusion of large vessels and arterioles C. Oxygenation of tissues in the lower extremities
B. Distalparesthesias D. Isolated peripheral neuropathies

38. The senior nurse asked Marian to list nursing interventions for the diagnosis “Ineffective tissue perfusion: peripheral”. From the following list
prepared by Marian which intervention will the senior nurse consider to be CONTRAINDICATED?
A. Maintain both extremities in a dependent position C. Regular passive and active exercises of all extremities
B. Encourage frequent change positions D. Keep extremities warm using a foot cradle

39. When Marian checked the capillary blood glucose of the client at 6 pm before meals as instructed by the senior nurse, the result showed
65mg/dl. Which of the following will Marian do FIRST?
A. Look for the senior nurse and report C. Give juice as prescribed in the insulin scale pre-meals
B. Check the physician’s order in case CBG is below 70mg/dl D. Re-check CBG

40. The senior nurse observes that Marian occasionally does not follow agreed upon interventions. The senior nurse reports that Marian should
improve in which of the following?
A. Compliance to standards C. Demonstration of proper decorum
B. Attitude toward criticism D. Identifying own learning needs

Situation 9 – A 57 year old male client, post Bilroth II was admitted to the Post Anesthesia Care Unit (PACU) from the OR. The client is still sedated
but responsive to commands. He has a nasogastric tube (NGT) draining orange-yellow fluid to a drainage bottle.
41. The nurse who admitted the patient recognizes that Bilroth II procedure means:
A. Gastrojejunostomy C. Enterostomy
B. Esophagojejunostomy D. Gastroduodenostomy

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42. After admitting the client to the PACU, the FIRST action of the nurse should be:
A. Assess the client’s pain C. Assess patency of airway
B. Monitor vital signs D. Check the rate of IV infusion

43. As the nurse monitors the client she notices a bright red spot on the dressings which measures 4 cm in diameter. The nurse would initially do
which APPROPRIATE nursing intervention?
A. Assess for presence of drain C. Continue to monitor the vital signs
B. Notify the client’s surgeon of a potential hemorrhage D. Change the top dressing
44. In assisting the client to do deep breathing, coughing and turning to the sides on the first postoperative day, which nursing action would be most
helpful for the client?
A. Administer the prescribed analgesics round the clock as prescribed
B. Apply abdominal splint (pillow) while coughing
C. Restate the importance of respiratory exercise
D. Give the client reassurance that he can cough, breathe deeply and turn to sides safely

45. The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following
PRIORITY management after referring to the surgeon?
A. Gastric decompression C. Endoscopy
B. Possible surgery D. Rectal tube insertion

Situation 10 – Pain brings client to hospital more than any other symptom. Nurses would therefore be skillful to assess pain and reduce discomfort
both for the client and family.
46. Matthew came to the hospital with chest pain and fever. After thorough assessment by the doctor, he was admitted for pericarditis
management. The nurse positions the client to reduce pain and discomfort. Describe this position.
A. Supine lying on either left or right side with one pillow to elevate the head.
B. Sit the client upright and lean forward
C. Prone position with one pillow to support the head
D. Put two pillows to elevate the head and one pillow under the knees

47. The nurse is aware that pericarditis pain varies from mild to severe and is typically aggravated by:
A. Coughing, talking and eating
B. Inspiration, coughing and movement of the upper body
C. Breathing, coughing and voiding
D. Coughing, inspiration and movement of the lower extremities

48. Matthew’s mother asks why the client’s breathing is shallow. The CORRECT response of the nurse would be:
A. “That is good because the client is not wasting the much needed oxygen.”
B. “The client is conserving his energy.”
C. “He is preventing unnecessary movement.”
D. “Respiratory movement intensifies pericardial pain.”

49. Matthew is prescribed NSAID every four hours to relieve fever, inflammation and pericardial pain. To maximize the effect of the drug, the nurse
would administer it:
A. When the client is awake only C. On an empty stomach
B. When the client asks for it D. Round the clock on a consistent basis

50. The nurse wants to know if the client is aware of the side effects of NSAID. What would be the MOST appropriate question of the nurse?
A. “Are you aware that you can be addicted to this drug?”
B. “Have you noticed something unusual with your urination?”
C. “How familiar are you with the drug?”
D. “Have you ever vomited blood or noticed very black stools?”

Situation 11 – Nurse Brittany is in charge of a client who was admitted for management of acute episode of cholecystitis.
51. Nurse Britanny did her admission assessment. She understands that the pain is characterized as:
A. Tenderness that is generalized in the upper epigastric area
B. Pain of the left upper quadrant radiating to the left shoulder
C. Tenderness and rigidity at the left epigastric area radiating to the back
D. Tenderness and rigidity of the upper right abdomen radiating to the midsternal area

52. To confirm the diagnosis of cholecystitis, the attending physician ordered the procedure that can detect gallstones as small as 1 to 3 cm and
inflammation. Nurse Britanny would prepare the client for which specific diagnostic procedure?
A. Gall bladder series C. Cholangiography
B. OralCholecystogram D. Ultrasonograpy

53. The diagnosis was confirmed as cholecystitis with gallstones. The doctor prepared the client for the removal of his gallbladder. The client asks
the nurse “how will this procedure affect my digestion?” The nurse’s MOST correct response would be:
A. “The removal of the gallbladder usually interferes with digestion but can be remedied by dietary modifications.”
B. “The removal of the gallbladder does not usually interfere with digestion.”
C. “Your body system will adjust in due time.”
D. “The removal of the gall bladder would significantly interfere only with the digestion of fatty foods.”

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54. Reviewing the laboratory findings of the client, the nurse found which finding are elevated?
1. White blood cell count 4. Red bold cell count
2. Total serum bilirubin 5. Cholesterol
3. Alkaline phosphate 6. Serum amylase
A. 2, 3, 4 B.1, 2, 3 C.3, 5, 6 D.1, 2, 6

55. A T-tube was inserted and the doctor ordered: “Monitor the amount, color, consistency and odor of drainage.” Which of the following procedures
can the nurse perform without the doctor’s order?
A. Clamping B.Aspirating C.Irrigating D.Emptying the drainage

Situation - Basic knowledge on fluid imbalances and intravenous solutions is necessary for care of clients with problems with fluids and electrolytes.
56. A nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for
deficient fluid volume?
A. A client with colostomy C. A client with decreased kidney function
B. A client with congestive heart failure D. A client receiving frequent wound irrigation

57. You are caring for a 75-year old male patient with congestive heart failure who is receiving IV fluids. You notice that he is becoming increasingly
restless and short of breath. His blood pressure and respiratory rate are increasing and he has a moist sounding cough. You also noted that he
has neck vein distention up to the jaw angle in the sitting position. You hear medium rales (crackles) throughout both posterior lung fields. The
best nursing intervention would be:
A. Elevation of the foot of the bed to aid venous return- shock/ Modified Trendelenburg
B. Slowing down of the intravenous fluid to keep open rate and notify physician.
C. Continuing to monitor vital signs
D. Encouraging the patient to cough and breathe deeply to improve alveolar ventilation.

58. The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that the client’s IV is cool,
pale and swollen and the solution is not infusing. The nurse concludes that which of the following complications has been experienced by the
client?
A. Infection B. Phlebitis C. Infiltration- cool D. Thrombophelibitis

59. An elderly patient is scheduled for radiographic tests, which require cleansing enema and fasting for eight hours. During this period, which of
these nursing diagnoses is MOST important to include in the patient’s care plan?
A. High risk for impaired skin integrity. C. High risk for fluid volume deficit
B. Bowel incontinence D. Alteration in nutrition (more than body requirements)

60. When evaluating an elderly client for fluid volume imbalance, which of the following is the LEAST reliable indicator?
A. Fluid intake and output C. Daily body weight
B. Skin turgor D. Urine specific gravity

Situation – Since electrolyte imbalances are common, the nurse must understand the underlying causative disorders to help clients achieve the most
positive health outcome.
61. To determine if a patient has symptoms of hyperkalemia, which of these assessments would provide the MOST accurate information?
A. Test the patient’s patellar reflex- Mg loss of patellar reflex C. Evaluate the patient’s heart rhythm
B. Auscultate the patient’s abdomen D. Take the patient’s blood pressure

62. The nurse evaluates which of the following clients to be at risk for developing hypernatremia?
A. 62-year-old with congestive heart failure taking loop diuretics C. 39-year-old with diarrhea and vomiting
B. 50-year-old with pneumonia, diaphoresis, and high fever D. 60-year-old with lung cancer and SIADH

63. A client is receiving an intravenous magnesium infusion to correct a serum level of 1.4 mEq/L. Which of the following assessments would alert
the nurse to immediately stop the infusion? Mg- 1.5 to 2.5 mEq/L
Toxicity:
1. Absence DTR
2. RR below 12 cpm
3. Decrease urination
4. Mg- potent vasodilator- hypotension
A. Diarrhea C. Premature ventricular contractions
B. Absent patellar reflex D. Increase in blood pressure

64. The nurse is caring for a bedridden client admitted with multiple myeloma and a serum calcium level of 13 mEq/dL. Which of the following is the
MOST appropriate nursing action?
Multiple Myeloma- abnormal proliferation of plasma cell in the bone marrow
A. Provide passive ROM exercises and encourage fluid intake.
B. Teach the client to increase intake of green leafy vegetables.
C. Place a tracheotomy tray at the bedside
D. Administer calcium gluconate IM as ordered.

65. An older adult admitted with heart failure and a sodium level of 113 mEq/L is behaving aggressively towards the staff and does not recognize
family members. When the family expresses concern about the client’s behaviour, the nurse would respond MOST appropriately by stating

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 A. “The client may be suffering from dementia, and the hospitalization has worsened the confusion.”
B. “Older adults get confused in the hospital.”
C. “The sodium level is low, and confusion will resolve as levels normalize.”
D. “The sodium level is high and the behaviour is a result of dehydration.”

Situation 14 – Patrick, 55 years old music teacher sought permission to the hospital because of laryngeal tumor. Patient is scheduled for total
Laryngectomy.
66. Before the nurse can develop a relevant care plan, the nurse understands that is post total laryngectomy, the trachea and the esophagus are
permanently separated. Therefore, which of the following will the nurse expect?
A. No risk of aspiration during swallowing; speech is lost
B. Unable to communicate with difficulty of swallowing and breathing
C. Normal speaking, breathing and swallowing are restored
D. Permanent tracheostomy created; normal speech is lost

67. Preoperatively, the assigned nurse identified the nursing diagnosis, “KNOWLEDGE DEFICIT: Postoperative communication strategies.” Which
of the following is a RELEVANT nursing intervention?
A. Arrange a visit to a postlaryngectomy client who effectively uses an alternative form of verbal communication
B. Illustrate means communicating postoperatively
C. Explain that total laryngectomy results in loss of ability to verbally communicate
D. Clarify information on purpose, anticipate benefits and consequences of total laryngectomy

68. In the immediate postoperative period, the nurse assesses coarse, high pitched sound on inspiration by listening over the trachea with a
stethoscope. The nurse should IMMEDIATELY:
A. Reassure the client that he is doing fine C. Report to the surgeon
B. Suctionthe tracheostomy tube D. Position client to Fowler’s

69. Which of the following expected outcomes for the patient is MOST relevant for the nursing diagnosis, “at risk for imbalanced nutrition related to
impaired swallowing”?
A. Oral intake increased C. Swallowing of soft foods facilitated
B. Appropriate body weight maintained D. Fear of choking relieved

70. The nurse is preparing Patrick for discharge. The following are instructions regarding stoma and postlaryngectomy care EXCEPT:
A. Avoid exposure to persons with upper respiratory disease. C. Avoid swimming and use care when using the shower.
B. Instruct client to assume supine position as necessary. D. Prevent foreign body from entering the stoma.

Situation 15 – “Sponge count” should be performed by two member of the surgical team, in any surgical procedure where there is a possibility that
the sponge can be retained.
71. Scrub and circulating nurse should perform sponge count during which phases of an abdominal hysterectomy procedure. Select all that apply.
1. Before the procedure 4. At the skin closure
2. Before closing the endometrium 5. When the scrub nurse goes for a lunch break
3. Before the closing of the peritoneum
A. All except 1 B. All except 5 C. All except 2 D. 3 and 4 only

72. The OR nurse knows that the correct way to cont sponges is:
A. Scrub nurse count singly followed by the circulating nurse
B. Scrub nurse and circulating nurse count audibly by packs of fifties
C. Scrub nurse and circulating nurse count singly, audibly and concurrently
D. Scrub nurse and circulating nurse count by packs of tens

73. The scrub nurse and the circulating nurse also counted the sharps and miscellaneous items like instruments before the procedure. Continuous
accounting for these items can primarily:
A. Shorten surgical cases turnover by 15 to 30 minutes
B. Improve hospital miscellaneous revenue
C. Minimize injuries and or liabilities to sterile surgical team
D. Expedite the procedure thus shortening the surgical time

74. The circulating nurse will document “surgical count” in which of the following?
A. Intraoperative record B. Observation form C. Nurse’s notes D. Checklist

75. When the surgeon asked for surgeon to close the abdomen, sponge count has not been completed. Which off the following is the
APPROPRIATE action of the scrub nurse?
A. Continues to count the sponges
B. Requests the surgeon to recheck the abdomen for sponges if any
C. Informs the surgeon that sponge count has not been completed
D. Hands obligingly the suture for closure to the surgeon

Situation 17 – Drug administration is one of the collaborative functions of the nurse that requires a written order of the physician. To date, errors in
medications continue to be a problem in the health care setting across the globe.
76. A nurse is obligated to carry out a physician’s order EXCEPT:
A. When a client refuses C. Believes an order to be inappropriate or inaccurate
B. When the nurse does not understand the order D. When the nurse is very busy

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77. When do you carry out the order of a physician?
A. When the physician has signed his orders
B. When the consent has been signed by the client or any appropriate person
C. When the guardian of the client is present
D. As soon as the medicine or therapy is available

78. A nurse encounters a client who refuses to take a prescribed medication. What is the APPROPRIATE action off the nurse?
A. Let the client sign a waiver
B. Explore the possible reason why the client refuses the prescribed medication
C. Refer client to the attending physician
D. Tell the client that he will be subjected to another mode of treatment like surgery

79. In case of telephone order, the concerned physician needs to countersign the order within:
A. As soon as possible C. A timeframe according to hospital policy
B. The shift D. The day

80. The nurse should ensure that all components of medications are documented. Identify all these components.
1. Dosage, route and frequency 4. Dosage, route, frequency and strength
2. Names of client and medication 5. Physician’s signature and specialty
3. Date and time the medication was ordered 6. Physician’s signature and PRC licensure number
A. All except 5 and 6 C. All except 3 and 5
B. All except 4 and 5 D. All except 4 and 6

Situation 18 – A nursing student was assigned to take care of a client who was diagnosed of polycythemia vera.
81. You planned the nurse care of the client together with the nursing student. You asked the nursing student to enumerate the clinical
manifestation of a client with polycythemia vera. You expected the nursing student to enumerate the following manifestations EXCEPT:
A. Generalized pruritus C. Splenomegaly
B. Ruddy complexion D. Hepatomegaly

82. The nursing student reviews the laboratory findings and finds which blood results are elevated?
A. BP, WBC and hematocrit C. RBC, WBC and platelet counts
B. Bilirubin, RBC and platelet D. WBC, platelet and cholesterol

83. Phlebotomy was ordered as part of therapy. You instructed the client and emphasized that the procedure can be repeated. The client inquired,
“What is the primary aim of the procedure?” The client inquired, “What is the primary aim of the procedure?” Your APPROPRIATE response is:
A. “Remove the excess blood and donate to patients of the same blood type”
B. “Prevent headache and dizziness”
C. “Keep the BP reading within normal range”
D. “Keep the hematocrit within normal range”

84. The campaign asks why the client was advised to avoid iron supplements or vitamins. The CORRECT response of the nurse would be:
A. “Actually the patient does not need these supplements”
B. “It is best that the client gests these supplements from natural sources”
C. “These supplements enhance the production of RBC”
D. “The vitamins and iron can suppress bone marrow function”

85. The client complained of generalized pruritus. The following are appropriate nursing intervention EXCEPT:
A. Administer routine antihistamine around the clock
B. Wearing light material loose fitting camiseta
C. Regulate room temperature to 25 degrees lower
D. Bathe in tepid or cool water followed by cocoa-based lotion application

Situation 20 – The behavior or action of any professional nurse specially while on duty are often the reflection of their values.
86. Mrs. J, Alcantara is currently enrolled in the masters program at the State University and is currently writing her thesis. She applied as a chief
nurse in St. Joey’s hospital and was accepted. Since here assumption to office, she has been signing documents as a Master’s graduate
affixing “RN, MAN” to her name. The action of the chief nurse constitutes a:
A. Misinterpretation B. Misdemeanour C. Malpractice D. Personification

87. The charge nurse reported to the chief nurse that Demerol 50cc vial has been incorrect for the last 24 hours. The MOST appropriate action of
the narcotic nurse is:
A. Make fraction dosage like 0.5ml as 1ml
B. Must loge every injection of Demerol
C. Review endorsement of clients who received Demerol within the last 24 hours
D. Demerol inventory must be checked every endorsement by the narcotic nurse

88. A staff nurse was found charting blood glucose result without actually doing the procedure. What is the APPROPRIATE initial action of the
senior nurse?
A. Write an incident report
B. Explain to the patient
C. Write and submit an explanation and reprimand as necessary
D. Go on leave without pay

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89. While making your PM shift endorsement, you saw the nursing attendant receiving a package from a patient’s watcher. Your APPROPRIATE
action would be:
A. Endorse to the incoming shift for the proper action
B. Remind the patient that gift giving to any hospital staff is not allowed
C. Reprimand the nursing attendant right away
D. Review with the nursing attendant the hospital policy

90. The Code of Ethics states that the nurse’s primary commitment is to the client whether an individual or family, group or community. Which
nursing activity would BEST demonstrate the ethical principle called justice?
A. The nurse providing care on a “first come-first serve” basis
B. The client’s preference is least considered
C. Referring the client for evaluation to the social worker on duty regarding her socio-economic status
D. The nurses providing care to maximize health according to available resources

Situation – Acid-base imbalances may be caused by disorders of any body system. Along with other health care professionals, nurses are
responsible for preventing, detecting, and intervening in acid-base imbalances.
91. A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO 2 of 74, HCO3 of 28 mEq/L, and PO2 of 45. Which of
the following is the MOST appropriate nursing intervention? Respiratory Acidosis Partially Compensated
A. Administer a sedative C. Place client in high-fowler’s position
B. Place client in a left lateral position D. Assist the client to breathe into a paper bag

92. A client with COPD feels short of breath after walking to the bathroom on 2L of oxygen via nasal cannula. The morning ABG’s were: pH of 7.36,
PaCO2 of 62, HCO3 of 35 mEq/L, and an O2 sat of 88% on 2L. Which of the following should be the nurse’s FIRST intervention? Respiratory
Acidosis Fully Compensated
A. Call the physician and report the change in client’s condition.
B. Turn the client’s O2 up to 4L via nasal cannula.
C. Encourage the client to sit down and to take deep breaths.
D. Encourage the client to rest and to use pursed-lip breathing technique.

93. A client with renal failure enters the emergency room after skipping three dialysis treatments. Which of the following sets of ABG’s would
indicate to the nurse that the client is in a state of metabolic acidosis?
A. pH of 7.43, PCO2 of 36, HCO3 of 26- C. pH of 7.33, PCO2 of 35, HCO3 of 17
B. pH of 7.41, PCO2 of 49, HCO3 of 30 D. pH of 7.25, PCO2 of 56, HCO3 of 28

94. A client with a small bowel obstruction has had an NGT connected to low intermittent suction for two days. The nurse should monitor for clinical
manifestations of which acid-base disorder?
A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis

95. A client who suffers from an anxiety disorder is very upset, has a respiratory rate of 32, and is complaining of light headedness and tingling in
the fingers. ABG values are: pH of 7.48, PaCO 2 of 29, HCO3 of 24 mEq/L, and O2 sat of 93% on room air. The nurse performs which of the
following as a priority nursing intervention? Respiratory Alkalosis Uncompensated
A. Monitor intake and output
B. Encourage client to increase activity increase RR
C. Institute pursed-lip breathing exercises every hour losing CO2
D. Provide reassurance to the client and administer sedatives

Situation – Cancer is the third leading cause of death in the country with mortality rates of up to 50,000 deaths among Filipinos and growing by five
percent every year as per our population growth and increase in smoking prevalence.
96. According to the Department of Health, which of the following is the leading type of cancer for males?
A. Prostate cancer B. Testicular cancer C. Lung cancer D. Colon cancer

97. According to the Department of Health, which of the following is the most common cancer afflicting the female population?
A. Breast cancer B. Cervical cancer C. Lung cancer D. Colon cancer

98. A client diagnosed with malignant breast cancer asks the nurse how a tumor could spread into her body and increase in size. The nurse’s most
comprehensive response should be based on the knowledge that
A. Tumors can spread by entering the lymphatic system and lodging into the lymph nodes.
B. Malignant cells can be distributed in the body through the blood stream.
C. Malignant cells can induce formation of new capillaries to meet their needs for growth.Angiogenesis
D. Cancer cells get their blood supply through angiogenesis and spread through lymph and blood.

99. A client asks the nurse, “what did the doctor mean when he said that I have a benign tumor? Is that the same as malignant?” The nurse should
respond knowing that benign and malignant tumors are alike in that both
A. Press on normal tissues and compete with normal cells for nutrients
B. Usually grow very rapidlt
C. Invade nearby tissues or disperse cells to colonize distant parts of the body
D. Contain cells that closely resemble the tissue of origin benign

100. A 36-year-old woman had a Papanicolaou (Pap) smear that shows stage 1 cervical cancer. In counselling this woman, the nurse should know
that
A. The cancer is likely to progress rapidly if her mother received DES

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 B. Cervical cancer is the least malignant type of cancer
C. The cure rate is very high for stage 1 cervical cancer- early diagnosis, good prognosis
D. Because of her young age, the outcome is likely to be poor

Situation – Derek, a 59-year-old male, was admitted to the hospital complaining of nausea, vomiting, weight loss of 20 lbs in 2 months, periods of
constipation and diarrhea. A diagnosis of carcinoma of the colon was made.
101. The best dietary recommendation to reduce the risk of some cancers, like colorectal cancer, include
A. Daily consumption of dairy products or red meat, green leafy vegetables, and low calorie-diet
B. High fiber, variety of fruits and vegetables, low fat & low calorie-diet
C. Fish and poultry as primary protein source, high fiber, occasional alcohol consumption
D. Limited smoked and nitrate-preserved foods, low fiber and low calorie-diet

102. The nurse is collecting a health history on Derek. Which of the following questions would be a priority to ask this client?
A. “Have you noticed any blood in the stool?”-melena/ hematochezia C. “Do you have any back pain?”
B. “Have you been experiencing nausea?” D. “Have you noticed your abdomen has swollen?”

103. The physician performed an abdominoperineal resection with permanent sigmoid colostomy to remove the tumor. Post-operative nursing care
should include which of the following?
A. Keeping the skin around the opening clean and dry C. Withholding fluids
B. Limiting visitors D. Limiting fluid intake

104. During the irrigation of the colostomy, Derek complains of abdominal cramps. The nurse should
A. Discontinue the irrigation C. Advance the catheter about one inch
B. Clamp the catheter for a few minutes D. Add cooler water

105. The MOST appropriate time & place for Derek to do the colostomy irrigation is
A. After meals, at the bedside C. Before meals, in the bathroom
B. Before meals, on a commode D. After meals, while sitting on the toilet

Situation - Mr. Oliver, a long term heavy smoker, is admitted to the hospital for a diagnostic workup. His possible diagnosis is cancer of the lung.
106. Mr. Oliver’s diagnosis has been confirmed as small cell lung carcinoma. Which of the following observations would be a priority that the nurse
should report immediately?
A. Weight loss C. Headache
B. Serum sodium less than 130 mEq/Ml d. Urinary output greater than 60 mL/hour

107. Mr. Oliver had a lobectomy 48 hours ago. Which of the following should the nurse include in the plan of care for this client?
A. Position the client on the operative side only.
B. Avoid administering narcotic pain medication.
C. Maintain strict bed rest.
D. Instruct the client on the importance of coughing and deep breathing.

108. Despite of the surgery, Mr. Oliver’s cancer remains aggressive and continues to spread. Due to lymphatic obstruction he developed superior
vena cava syndrome. The nurse should include which of the following interventions?
A. Restrict visitors, since the client will be anxious. C. Instruct the client in Valsava’s maneuver.
B. Withhold chemotherapy until the syndrome resolves. D. Elevate the head of the bed.

109. Physical examination was conducted by his physician and the impression was early stage prostatic tumor. Which of the following symptoms
would you NOT expect to find with this diagnosis ?
A. Dysuria C. Urgency of voiding
B. Back bone pain D. Frequency of voiding

110. The spouse of Mr. Jensen asks the nurse, “Why isn’t the physician treating my husband’s cancer?” The nurse’s BEST response should be
based on which of the following?
A. Watchful waiting is often appropriate for men over age 70.
B. The client must really have Stage IV cancer, which is not curable.
C. All prostate cancers should be treated, and this client should get another opinion.
D. The client is being treated with hormonal manipulation, which isn’t perceived as treatment by clients.

Situation – The nurse who cares for a patient with a burn injury requires a high level of knowledge about the physiologic changes that occur after a
burn, assessment skills the ability to provide sensitive, compassionate care to patients who are critically ill and must initiate rehabilitation early in the
course of care.
111. Mr. Lino , line man from Meralco , sustained 2 nd and 3rd degree burns while in line duty. Lino was admitted in the surgical ward with burns all
over the right extremity 9 and anterior chest 18. Approximately the percentage of the burned area is :
A. 27% B. 12% C. 32% D. 40%

112. The nurse is caring for a client during the emergent phase of a burn injury. Which of the following assessments would provide the nurse with the
moist accurate information regarding the client’s full thickness burns?
A. Leathery, dry, hard skin C. Massive edema at the injury site

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 B. Red, fluid-filled vesicles D. Serous exudates from a shiny dark-brown wound

113. Joni, 32 years old was rushed to the hospital due to burns sustained from a disco. Which of the following is the correct sequence of
management upon admission in the ER?
I. Establish and maintain airway
II. Assess for associated injuries
III. Establish an IV line with a large gauge needle
IV. Apply antimicrobial cream on the burned area
A. I, II, III, IV B. I, III, II, & IV C. II, I, III, IV D. II, III, I, IV

114. Using an open method of skin care, which of the following should the nurse include when caring for a client with deep-partial thickness burns of
both legs?
A. Ensure that sterile water is used in the debridement tank.
B. Apply topical silver sulfadiazine (Silvadene) with sterile gloves.
C. Use clean gloves to remove the dressings and wash the wounds
D. Wrap the wound with gauze impregnated with silver sulfadiazine (Silvadene)

115. Which of the following fluid and electrolyte imbalances is expected in a client during the emergent/resuscitative phase of burns?
A. Hyperkalemia & Hyponatremia C. Hypernatremia & Hyperkalemia
B. Hypokalemia & Hypernatremia D. Hyponatremia & Hypokalemia

Situation - Immunodeficiency (or immune deficiency) is a state in which the immune system's ability to fight infectious disease is compromised or
entirely absent.
116. Blood and saliva of a patient suspected to have HIV can be tested for presence of antibodies in which of the following procedures?
A. Western blot assay - C. Polymerase chain reaction test
B. Enzyme-linked immunosorbent assay D. Viral load test

117. A patient comes to the OPD with a complaint of frequent respiratory infection. He was given antibiotics, and sent home. After a few weeks, the
patient comes back and reports that he took the medications religiously but they did not help. The physician suspects B-cell deficiency. If this is
so, the nurse will be expected to do which of the following?
A. Discontinue the antibiotic regimen immediately as this may cause superinfection.
B. Prepare the patient for transfusion of whole blood to expand plasma volume.
C. Give the patient IVIg replacement therapy to provide the patient with antibodies.
D. Administer attenuated live virus vaccines to stimulate antibody production.

118. A patient with DiGeorge Syndrome has oral candidiasis. Which of the following is the most appropriate nursing diagnosis for this patient?
A. Risk for Infection related to immunosuppresion
B. Fatigue related to chronic infection
C. Impaired Oral Mucous Membranes related to oral lesions
D. Imbalanced Nutrition related to inadequate food intake secondary to side effects of medications

119. A nurse in the OB-GYN ward is assigned to a woman who just had birth 8 hours ago. The patient is also positive for HIV. In planning care for
this patient, the nurse should keep in mind to
A. Do not allow visitors and place the patient in a private room.
B. Practice standard & contact precautions when handling bodily fluids.
C. Encourage breastfeeding to ensure maternal-child bonding.
D. Practice droplet precautions until 72 hours of antibiotic therapy.

120. Which of the following should be the priority nursing diagnosis for a patient positive for HIV?
A. Risk for Infection related to immunosuppression
B. Activity intolerance related to fatigue secondary to chronic infection
C. Anxiety related to uncertainty of the outcome of diagnosis
D. Knowledge deficit related to unavailable sources of information about HIV

Situation - The nurse who cares for diabetic patients must assist them to develop self-care management skills.

121. A nurse teaches a client newly diagnosed with Diabetes Mellitus about differentiating between hypoglycemia and hyperglycemia. The client
demonstrates an understanding of the teaching by stating which of the following?
A. “I would have to eat if I experience shakiness.” C. “I would have to eat if I experience blurred vision.”
B. “I would have to eat if I begin to urinate frequently.” D. “I would have to eat if I notice that I have fruity breath.”

122. A patient came to the clinic for consultation and was diagnosed with type 1 diabetes mellitus. Which finding would the nurse expect to note with
this patient to differentiate type 1 from type 2 diabetes mellitus?
A. Obesity C. Weight loss
B. Hyperglycemia D. Slow wound healing

123. A patient with a diagnosis of Diabetic Ketoacidosis (DKA) is being treated in an emergency room. Which of the following should the nurse do to
care for this patient?
A. Administer 50% dextrose. C. Correct fluid volume excess through diuretics.
B. Provide an IV bolus of regular insulin. D. Give Phenytoin (Dilatin) to prevent seizures.

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124. A client with type 2 diabetes mellitus has a blood glucose level higher than 600 mg/dl. As the nurse reviews the physician’s documentation, she
notes that a diagnosis of Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) has been made. Which of the following symptoms further
supports this diagnosis?
A. Polydipsia, weight loss, and lethargy C. Tachycardia, weight gain, and diarrhea
B. Polyuria, weakness, and hypertension D. Headache, ketonuria, and hunger

125. A 10-year-old child known to have type 1 diabetes mellitus suddenly becomes unconscious and was brought to the school clinic. After
assessing that the blood glucose was 15 mg/dl, the nurse should
A. Have the child drink a glass of orange juice. C. Bring the child to the hospital immediately.
B. Administer glucagon intramuscularly. D. Administer insulin intravenously.

126. The capillary blood glucose of a client with type 2 diabetes mellitus should be measured every 4 hours. The night shift nurse documents the
following CBG levels. 50 mg/dl at 3:00 AM and 190 mg/dl at 7:00 AM. The nurse interprets this as
A. Dawn Phenomenon C. Somogyi Phenomenon Rebound Hyperglycemia
B. Hypoglycemic Unawareness D. Hypoglycemic Reactions

127. A diabetic patient for 15 years is found to be in the early phases of retinopathy. In planning care for this patient, the nurse should prioritize which
of the following?
A. Maintain a normal blood glucose level. C. Remove clutter in the patient’s immediate environment.
B. Explore the patient’s feeling about possible vision loss. D. Encourage the patient’s family to visit.

128. The nurse should have knowledge of the different microvascular complications of diabetes. One of these is the damage to the capillaries of the
glomeruli of the kidneys which is knows as
A. Diabetic Retinopathy B. Diabetic Neuropathy C. Diabetic Nephropathy D. Autonomic Neuropathy

129. The nurse is caring for a client with DM type II who received 6 units of regular insulin at 7:30 AM. The nurse should monitor the client for
hypoglycaemia at which of the following times?
A. 9:30 AM to 10:30 AM B. 8:00 AM to 8:30 AM C. 1200 noon to 2:00 PM D. 3:00 PM to 5:00 PM

130. A patient who has just been diagnosed with diabetes and started on oral medications says, “I feel strange and my mouth feels numb.
Something is wrong!” You note that his hands are trembling and he is perspiring. What is your BEST response?
A. “These are common symptoms of diabetes. They will go away soon.”
B. “Let’s check your blood sugar. It is probably low.”
C. “Your doctor will probably need to increase your medication dose.”
D. “This is very unusual. I will call your physician.”

12 BRAINHUB 2021 NLE