1.

Using the principles of standard precautions, the nurse would wear gloves in what nursing
interventions?

A. Providing a back massage

B. Feeding a client
C. Providing hair care
D. Providing oral hygiene

2. The nurse is preparing to take vital sign in an alert client admitted to the hospital with
dehydration secondary to vomiting and diarrhea. What is the best method used to assess the
client’s temperature?

A. Oral
B. Axillary
C. Radial
D. Heat sensitive tape

3. A nurse obtained a client’s pulse and found the rate to be above normal. The nurse
document this findings as:

A. Tachypnea
B. Hyperpyrexia
C. Arrhythmia
D. Tachycardia

4. Which of the following actions should the nurse take to use a wide base support when
assisting a client to get up in a chair?

A. Bend at the waist and place arms under the client’s arms and lift
B. Face the client, bend knees and place hands on client’s forearm and lift
C. Spread his or her feet apart
D. Tighten his or her pelvic muscles

5. A client had oral surgery following a motor vehicle accident. The nurse assessing the
client finds the skin flushed and warm. Which of the following would be the best method to
take the client’s body temperature?
A. Oral
B. Axillary
C. Arterial line
D. Rectal

6. A client who is unconscious needs frequent mouth care. When performing a mouth care,
the best position of a client is:

A. Fowler’s position
B. Side lying
C. Supine
D. Trendelenburg

7. A client is hospitalized for the first time, which of the following actions ensure the safety of
the client?

A. Keep unnecessary furniture out of the way

B. Keep the lights on at all time
C. Keep side rails up at all time
D. Keep all equipment out of view

8. A walk-in client enters into the clinic with a chief complaint of abdominal pain and diarrhea.
The nurse takes the client’s vital sign hereafter. What phrase of nursing process is being
implemented here by the nurse?

A. Assessment
B. Diagnosis
C. Planning
D. Implementation

9. It is best describe as a systematic, rational method of planning and providing nursing care
for individual, families, group and community

A. Assessment
B. Nursing Process
C. Diagnosis
D. Implementation

10. Exchange of gases takes place in which of the following organ?

A. Kidney
B. Lungs
C. Liver
D. Heart

11. The chamber of the heart that receives oxygenated blood from the lungs is the:

A. Left atrium
B. Right atrium
C. Left ventricle
D. Right ventricle

12. A muscular enlarge pouch or sac that lies slightly to the left which is used for temporary
storage of food…

A. Gallbladder
B. Urinary bladder
C. Stomach
D. Lungs

13. The ability of the body to defend itself against scientific invading agent such as baceria,
toxin, viruses and foreign body

A. Hormones
B. Secretion
C. Immunity
D. Glands

14. Hormones secreted by Islets of Langerhans

A. Progesterone
B. Testosterone
C. Insulin
D. Hemoglobin

15. It is a transparent membrane that focuses the light that enters the eyes to the retina.

A. Lens
B. Sclera
C. Cornea
D. Pupils

16. Which of the following is included in Orem’s theory?

A. Maintenance of a sufficient intake of air

B. Self perception
C. Love and belongingness
D. Physiologic needs

17. Which of the following cluster of data belong to Maslow’s hierarchy of needs

A. Love and belonging

B. Physiologic needs
C. Self actualization
D. All of the above

18. This is characterized by severe symptoms relatively of short duration.

A. Chronic Illness
B. Acute Illness
C. Pain
D. Syndrome

19. Which of the following is the nurse’s role in the health promotion
A. Health risk appraisal
B. Teach client to be effective health consumer
C. Worksite wellness
D. None of the above

20. It is describe as a collection of people who share some attributes of their lives.

A. Family
B. Illness
C. Community
D. Nursing

21. Five teaspoon is equivalent to how many milliliters (ml)?

A. 30 ml
B. 25 ml
C. 12 ml
D. 22 ml

22. 1800 ml is equal to how many liters?

A. 1.8
B. 18000
C. 180
D. 2800

23. Which of the following is the abbreviation of drops?

A. Gtt.
B. Gtts.
C. Dp.
D. Dr.

24. The abbreviation for micro drop is…

A. µgtt
B. gtt
C. mdr
D. mgts

25. Which of the following is the meaning of PRN? Pro re nata

A. When advice
B. Immediately
C. When necessary
D. Now

26. Which of the following is the appropriate meaning of CBR?

A. Cardiac Board Room

B. Complete Bathroom
C. Complete Bed Rest
D. Complete Board Room

27. One (1) tsp is equals to how many drops?

A. 15
B. 60
C. 10
D. 30

28. 20 cc is equal to how many ml?

A. 2
B. 20
C. 2000
D. 20000

29. 1 cup is equals to how many ounces?

A. 8
B. 80
C. 800
D. 8000

30. The nurse must verify the client’s identity before administration of medication. Which of
the following is the safest way to identify the client?

A. Ask the client his name

B. Check the client’s identification band
C. State the client’s name aloud and have the client repeat it
D. Check the room number

31. The nurse prepares to administer buccal medication. The medicine should be placed…

A. On the client’s skin

B. Between the client’s cheeks and gums
C. Under the client’s tongue
D. On the client’s conjunctiva

32. The nurse administers cleansing enema. The common position for this procedure is…

A. Sims left lateral

B. Dorsal Recumbent
C. Supine
D. Prone

33. A client complains of difficulty of swallowing, when the nurse try to administer capsule
medication. Which of the following measures the nurse should do?

A. Dissolve the capsule in a glass of water

B. Break the capsule and give the content with an applesauce
C. Check the availability of a liquid preparation
D. Crash the capsule and place it under the tongue

34. Which of the following is the appropriate route of administration for insulin?
A. Intramuscular
B. Intradermal
C. Subcutaneous
D. Intravenous

35. The nurse is ordered to administer ampicillin capsule TID p.o. per oram or mouth.The
nurse should give the medication…

A. Three times a day orally

B. Three times a day after meals
C. Two time a day by mouth
D. Two times a day before meals

36. Back Care is best describe as:

A. Caring for the back by means of massage

B. Washing of the back
C. Application of cold compress at the back
D. Application of hot compress at the back

37. It refers to the preparation of the bed with a new set of linens

A. Bed bath
B. Bed making
C. Bed shampoo
D. Bed lining

38. Which of the following is the most important purpose of handwashing

A. To promote hand circulation

B. To prevent the transfer of microorganism
C. To avoid touching the client with a dirty hand
D. To provide comfort

39. What should be done in order to prevent contaminating of the environment in bed
making?
A. Avoid fanning soiled linens
B. Strip all linens at the same time
C. Finished both sides at the time
D. Embrace soiled linen

40. The most important purpose of cleansing bed bath is:

A. To cleanse, refresh and give comfort to the client who must remain in bed
B. To expose the necessary parts of the body
C. To develop skills in bed bath
D. To check the body temperature of the client in bed

41. Which of the following technique involves the sense of sight?

A. Inspection
B. Palpation
C. Percussion
D. Auscultation

42. The first techniques used examining the abdomen of a client is:

A. Palpation
B. Auscultation
C. Percussion
D. Inspection

43. A technique in physical examination that is use to assess the movement of air through
the tracheobronchial tree:

A. Palpation
B. Auscultation
C. Inspection
D. Percussion

44. An instrument used for auscultation is:

A. Percussion-hammer
B. Audiometer
C. Stethoscope
D. Sphygmomanometer

45. Resonance is best describe as:

A. Sounds created by air filled lungs

B. Short, high pitch and thudding
C. Moderately loud with musical quality
D. Drum-like

46. The best position for examining the rectum is:

A. Prone
B. Sim’s
C. Knee-chest
D. Lithotomy

47. It refers to the manner of walking

A. Gait
B. Range of motion
C. Flexion and extension
D. Hopping

48. The nurse asked the client to read the Snellen chart. Which of the following is tested:

A. Optic
B. Olfactory
C. Oculomotor
D. Trochlear

49. Another name for knee-chest position is:

A. Genu-dorsal
B. Genu-pectoral
C. Lithotomy
D. Sim’s

50. The nurse prepare IM injection that is irritating to the subcutaneous tissue. Which of the
following is the best action in order to prevent tracking of the medication

A. Use a small gauge needle

B. Apply ice on the injection site
C. Administer at a 45° angle
D. Use the Z-track technique

Answers and Rationale

1. Answer: D. Providing oral hygiene

Doing oral care requires the nurse to wear gloves.

2. Answer: B. Axillary

Axilla is the most accessible body part in this situation.

3. Answer: D. Tachycardia

Tachycardia means rapid heart rate. Tachypnea (Option A) refers to rapid respiratory rate.
Hyperpyrexia (Option B) means increase in temperature. Arrhythmia (Option C) means irregular
heart rate.

4. Answer: B. Face the client, bend knees and place hands on client’s forearm and lift

This is the proper way on supporting the client to get up in a chair that conforms to safety and proper
body mechanics.

5. Answer: B. Axillary
Taking the temperature via the oral route is incorrect since the client had oral surgery. Choice C and
D are unnecessary. Taking the temperature via the axilla is the most appropriate route.

6. Answer: B. Side lying

An unconscious client is best placed on his side when doing oral care to prevent aspiration.

7. Answer: C. Keep side rails up at all time

Although the other choices seem correct, they are not the best answer.

8. Answer: A. Assessment

Assessment is the first phase of the nursing process where a nurse collects information about the
client. Diagnosis is the formulation of the nursing diagnosis from the information collected during the
assessment. In Planning, the nurse sets achievable and measurable short and long term goals.
Implementation is where nursing care is given.

9. Answer: B. Nursing Process

The statement describes the Nursing Process. The Nursing Process is the essential core of practice
for the registered nurse to deliver holistic, patient-focused care.

10. Answer: B. Lungs

11. Answer: A. Left atrium

The left atrium receives oxygenated blood from the lungs and pumps it to the left ventricle. The
right atrium receives blood from the veins and pumps it to the right ventricle. The right
ventricle receives blood from the right atrium and pumps it to the lungs, where it is loaded with
oxygen. The left ventricle (the strongest chamber) pumps oxygen-rich blood to the rest of the body,
its vigorous contractions create the blood pressure.

12. Answer: C. Stomach

13. Answer: C. Immunity

14. Answer: C. Insulin

The Islets of Langerhans are the regions of the pancreas that contain its endocrine cells.
Progesterone (Choice A) is produced by the ovaries. Testosterone (Choice B) is secreted by the
testicles of males and ovaries of females. Hemoglobin (Choice D) is a protein molecule in the red
blood cells that carries oxygen from the lungs to the body’s tissues and returns carbon dioxide.

15. Answer: C. Cornea

The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber.
The cornea is like the crystal of a watch.

16. Answer: A. Maintenance of a sufficient intake of air

Dorothea Orem’s Self-Care Theory defined Nursing as “The act of assisting others in the provision
and management of self-care to maintain or improve human functioning at home level of
effectiveness.” Choices B, C, and D are from Abraham Maslow’s Hierarchy of Needs.

17. Answer: D. All of the above

All of the choices are part of Maslow’s Hierarchy of Needs.

18. Answer: B. Acute Illness

Chronic Illness (Choice A) are illnesses that are persistent or long-term.

19. Answer: B. Teach client to be effective health consumer

20. Answer: C. Community

Family is defined as a group consisting typically of parents and children living together in a
household.

21. Answer: B. 25 ml

One teaspoon is equal to 5ml.

22. Answer: A. 1.8

23. Answer: B. Gtts.

Gtt (Choice A) is an abbreviation for drop. Dp and Dr are not recognized abbreviation for
measurement.

24. Answer: A. µgtt

25. Answer: C. When necessary

PRN comes from the Latin “pro re nata” meaning, for an occasion that has arisen or as
circumstances require.

26. Answer: C. Complete Bed Rest

CBR means complete bed rest. For more abbreviations, please see this post.

27. Answer: B. 60

One teaspoon (tsp) is equal to 60 drops (gtts).

28. Answer: B. 20

One cubic centimeter is equal to one milliliter.

29. Answer: A. 8

One cup is equal to 8 ounces.

30. Answer: B. Check the client’s identification band

The identification band is the safest way to know the identity of a patient whether he is conscious or
unconscious. Ask the client his name only after you have checked his ID band.

31. Answer: B. Between the client’s cheeks and gums

32. Answer: A. Sims left lateral

This position provides comfort to the patient and an easy access to the natural curvature of the
rectum.

33. Answer: C. Check the availability of a liquid preparation

The nurse should check first if the medication is available in liquid form before doing Choice A.
Placing it under the tongue is not the intended way of administering an oral medication.

34. Answer: C. Subcutaneous

The subcutaneous tissue of the abdomen is preferred because absorption of the insulin is more
consistent from this location than subcutaneous tissues in other locations.

35. Answer: A. Three times a day orally

TID is the Latin for “ter in die” which means three times a day. P.O. means per orem or through
mouth.

36. Answer: A. Caring for the back by means of massage

37. Answer: B. Bed making

38. Answer: B. To prevent the transfer of microorganism

Hand washing is the single most effective infection control measure.

38. Answer: A. Avoid fanning soiled linens

Fanning soiled linens would scatter the lodged microorganisms and dead skin cells on the linens.

40. Answer: A. To cleanse, refresh and give comfort to the client who must remain in bed

41. Answer: A. Inspection

Palpation is a method of feeling with the fingers or hands during a physical
examination. Percussion is a method of tapping on a surface to determine the underlying structure,
and is used in clinical examinations to assess the condition of the thorax or
abdomen. Auscultation (based on the Latin verb auscultare “to listen”) is listening to the internal
sounds of the body, usually using a stethoscope.

42. Answer: D. Inspection

For abdominal exam, auscultation is performed before palpation because the act of palpation could
change what was auscultated. Remember the mnemonic “I-A-Per-Pal”.

43. Answer: B. Auscultation

44. Answer: C. Stethoscope

45. Answer: A. Sounds created by air filled lungs

46. Answer: C. Knee-chest

To assume the genupectoral position the person kneels so that the weight of the body is supported
by the knees and chest, with the buttocks raised. The head is turned to one side and the arms are
flexed so that the upper part of the body can be supported in part by the elbows.

47. Answer: A. Gait

48. Answer: A. Optic

Cranial Nerve II or the optic nerve is tested through the use of the Snellen chart.

49. Answer: B. Genu-pectoral

50. Answer: D. Use the Z-track technique

During the procedure, skin and tissue are pulled and held firmly while a long needle is inserted into
the muscle. After the medication is injected, the skin and tissue are released. The needle track that
forms during this procedure takes the shape of the letter “Z,” which gives the procedure its name.
This zigzag track line is what prevents medication from leaking from the muscle into surrounding
tissue.

1. The most appropriate nursing order for a patient who develops dyspnea and shortness of
breath would be…

A. Maintain the patient on strict bed rest at all times

B. Maintain the patient in an orthopneic position as needed
C. Administer oxygen by Venturi mask at 24%, as needed
D. Allow a 1 hour rest period between activities

2. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She
elevates the head of the bed to the high Fowler position, which decreases his respiratory
distress. The nurse documents this breathing as:

A. Tachypnea
B. Eupnea
C. Orthopnea
D. Hyperventilation

3. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The
nurse is responsible for:

A. Instructing the patient about this diagnostic test

B. Writing the order for this test
C. Giving the patient breakfast
D. All of the above

4. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on
a 500-mg low sodium diet. These include:

A. A ham and Swiss cheese sandwich on whole wheat bread

B. Mashed potatoes and broiled chicken
C. A tossed salad with oil and vinegar and olives
D. Chicken bouillon
5. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an
anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:

A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
B. Reporting an APTT above 45 seconds to the physician
C. Assessing the patient for signs and symptoms of frank and occult bleeding
D. All of the above

6. The four main concepts common to nursing that appear in each of the current conceptual
models are:

A. Person, nursing, environment, medicine

B. Person, health, nursing, support systems
C. Person, health, psychology, nursing
D. Person, environment, health, nursing

7. In Maslow’s hierarchy of physiologic needs, the human need of greatest priority is:

A. Love
B. Elimination
C. Nutrition
D. Oxygen

8. The family of an accident victim who has been declared brain-dead seems amenable to
organ donation. What should the nurse do?

A. Discourage them from making a decision until their grief has eased
B. Listen to their concerns and answer their questions honestly
C. Encourage them to sign the consent form right away
D. Tell them the body will not be available for a wake or funeral

9. A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m.
shift. What should she do?

A. Complain to her fellow nurses

B. Wait until she knows more about the unit
C. Discuss the problem with her supervisor
D. Inform the staff that they must volunteer to rotate

10. Which of the following principles of primary nursing has proven the most satisfying to the
patient and nurse?

A. Continuity of patient care promotes efficient, cost-effective nursing care

B. Autonomy and authority for planning are best delegated to a nurse who knows the patient well
C. Accountability is clearest when one nurse is responsible for the overall plan and its
implementation.
D. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.

11. If nurse administers an injection to a patient who refuses that injection, she has
committed:

A. Assault and battery

B. Negligence
C. Malpractice
D. None of the above

12. If patient asks the nurse her opinion about a particular physicians and the nurse replies
that the physician is incompetent, the nurse could be held liable for:

A. Slander
B. Libel
C. Assault
D. Respondent superior

13. A registered nurse reaches to answer the telephone on a busy pediatric unit, momentarily
turning away from a 3 month-old infant she has been weighing. The infant falls off the scale,
suffering a skull fracture. The nurse could be charged with:

A. Defamation
B. Assault
C. Battery
D. Malpractice
14. Which of the following is an example of nursing malpractice?

A. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The
patient experiences an allergic reaction and has cerebral damage resulting from anoxia.
B. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal
cramping.
C. The nurse assists a patient out of bed with the bed locked in position; the patient slips and
fractures his right humerus.
D. The nurse administers the wrong medication to a patient and the patient vomits. This information
is documented and reported to the physician and the nursing supervisor.

15. Which of the following signs and symptoms would the nurse expect to find when
assessing an Asian patient for postoperative pain following abdominal surgery?

A. Decreased blood pressure and heart rate and shallow respirations

B. Quiet crying
C. Immobility, diaphoresis, and avoidance of deep breathing or coughing
D. Changing position every 2 hours

16. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and
severe abdominal pain. Which of the following would immediately alert the nurse that the
patient has bleeding from the GI tract?

A. Complete blood count

B. Guaiac test
C. Vital signs
C. Abdominal girth

17. The correct sequence for assessing the abdomen is:

A. Tympanic percussion, measurement of abdominal girth, and inspection

B. Assessment for distention, tenderness, and discoloration around the umbilicus.
C. Percussions, palpation, and auscultation
D. Auscultation, percussion, and palpation

18. High-pitched gurgles head over the right lower quadrant are:
A. A sign of increased bowel motility
B. A sign of decreased bowel motility
C. Normal bowel sounds
D. A sign of abdominal cramping

19. A patient about to undergo abdominal inspection is best placed in which of the following
positions?

A. Prone
B. Trendelenburg
C. Supine
D. Side-lying

20. For a rectal examination, the patient can be directed to assume which of the following
positions?

A. Genupectoral
B. Sims
C. Horizontal recumbent
D. All of the above

21. During a Romberg test, the nurse asks the patient to assume which position?

A. Sitting
B. Standing
C. Genupectoral
D. Trendelenburg

22. If a patient’s blood pressure is 150/96, his pulse pressure is:

A. 54
B. 96
C. 150
D. 246
23. A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8
a.m. is 99.8 F (37.7 C) This temperature reading probably indicates:

A. Infection
B. Hypothermia
C. Anxiety
D. Dehydration

24. Which of the following parameters should be checked when assessing respirations?

A. Rate
B. Rhythm
C. Symmetry
D. All of the above

25. A 38-year old patient’s vital signs at 8 a.m. are axillary temperature 99.6 F (37.6 C); pulse
rate, 88; respiratory rate, 30. Which findings should be reported?

A. Respiratory rate only

B. Temperature only
C. Pulse rate and temperature
D. Temperature and respiratory rate

26. All of the following can cause tachycardia except:

A. Fever
B. Exercise
C. Sympathetic nervous system stimulation
D. Parasympathetic nervous system stimulation

27. Palpating the midclavicular line is the correct technique for assessing

A. Baseline vital signs

B. Systolic blood pressure
C. Respiratory rate
D. Apical pulse
28. The absence of which pulse may not be a significant finding when a patient is admitted to
the hospital?

A. Apical
B. Radial
C. Pedal
D. Femoral

29. Which of the following patients is at greatest risk for developing pressure ulcers?

A. An alert, chronic arthritic patient treated with steroids and aspirin

B. An 88-year old incontinent patient with gastric cancer who is confined to his bed at home
C. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula
D. A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get
out of bed.

30. The physician orders the administration of high-humidity oxygen by face mask and
placement of the patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse
writes the following nursing diagnosis: Impaired gas exchange related to increased
secretions. Which of the following nursing interventions has the greatest potential for
improving this situation?

A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours
B. Place a humidifier in the patient’s room.
C. Continue administering oxygen by high humidity face mask
D. Perform chest physiotherapy on a regular schedule

31. The most common deficiency seen in alcoholics is:

A. Thiamine
B. Riboflavin
C. Pyridoxine
D. Pantothenic acid

32. Which of the following statement is incorrect about a patient with dysphagia?
A. The patient will find pureed or soft foods, such as custards, easier to swallow than water
B. Fowler’s or semi Fowler’s position reduces the risk of aspiration during swallowing
C. The patient should always feed himself
D. The nurse should perform oral hygiene before assisting with feeding.

33. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the
nurse measures his hourly urine output. She should notify the physician if the urine output
is:

A. Less than 30 ml/hour

B. 64 ml in 2 hours
C. 90 ml in 3 hours
D. 125 ml in 4 hours

34. Certain substances increase the amount of urine produced. These include:

A. Caffeine-containing drinks, such as coffee and cola.

B. Beets
C. Urinary analgesics
D. Kaolin with pectin (Kaopectate)

35. A male patient who had surgery 2 days ago for head and neck cancer is about to make his
first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and
that his vision was unaffected by the surgery. Which of the following nursing interventions
would be appropriate?

A. Encourage the patient to walk in the hall alone

B. Discourage the patient from walking in the hall for a few more days
C. Accompany the patient for his walk.
D. Consult a physical therapist before allowing the patient to ambulate

36. A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested
by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. An
appropriate nursing diagnosis would be:
A. Ineffective airway clearance related to thick, tenacious secretions.
B. Ineffective airway clearance related to dry, hacking cough.
C. Ineffective individual coping to COPD.
D. Pain related to immobilization of affected leg.

37. Mrs. Lim begins to cry as the nurse discusses hair loss. The best response would be:

A. “Don’t worry. It’s only temporary”

B. “Why are you crying? I didn’t get to the bad news yet”
C. “Your hair is really pretty”
D. “I know this will be difficult for you, but your hair will grow back after the completion of
chemotheraphy”

38. An additional Vitamin C is required during all of the following periods except:

A. Infancy
B. Young adulthood
C. Childhood
D. Pregnancy

39. A prescribed amount of oxygen s needed for a patient with COPD to prevent:

A. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2)
B. Circulatory overload due to hypervolemia
C. Respiratory excitement
D. Inhibition of the respiratory hypoxic stimulus

40. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is
the most significant symptom of his disorder?

A. Lethargy
B. Increased pulse rate and blood pressure
C. Muscle weakness
D. Muscle irritability

41. Which of the following nursing interventions promotes patient safety?

A. Asses the patient’s ability to ambulate and transfer from a bed to a chair
B. Demonstrate the signal system to the patient
C. Check to see that the patient is wearing his identification band
D. All of the above

42. Studies have shown that about 40% of patients fall out of bed despite the use of side
rails; this has led to which of the following conclusions?

A. Side rails are ineffective

B. Side rails should not be used
C. Side rails are a deterrent that prevent a patient from falling out of bed.
D. Side rails are a reminder to a patient not to get out of bed

43. Examples of patients suffering from impaired awareness include all of the following
except:

A. A semiconscious or over fatigued patient

B. A disoriented or confused patient
C. A patient who cannot care for himself at home
D. A patient demonstrating symptoms of drugs or alcohol withdrawal

44. The most common injury among elderly persons is:

A. Atheroscleotic changes in the blood vessels

B. Increased incidence of gallbladder disease
C. Urinary Tract Infection
D. Hip fracture

45. The most common psychogenic disorder among elderly person is:

A. Depression
B. Sleep disturbances (such as bizarre dreams)
C. Inability to concentrate
D. Decreased appetite

46. Which of the following vascular system changes results from aging?
A. Increased peripheral resistance of the blood vessels
B. Decreased blood flow
C. Increased workload of the left ventricle
D. All of the above

47. Which of the following is the most common cause of dementia among elderly persons?

A. Parkinson’s disease
B. Multiple sclerosis
C. Amyotrophic lateral sclerosis (Lou Gehrig’s disease)
D. Alzheimer’s disease

48. The nurse’s most important legal responsibility after a patient’s death in a hospital is:

A. Obtaining a consent of an autopsy

B. Notifying the coroner or medical examiner
C. Labeling the corpse appropriately
D. Ensuring that the attending physician issues the death certification

49. Before rigor mortis occurs, the nurse is responsible for:

A. Providing a complete bath and dressing change

B. Placing one pillow under the body’s head and shoulders
C. Removing the body’s clothing and wrapping the body in a shroud
D. Allowing the body to relax normally

50. When a patient in the terminal stages of lung cancer begins to exhibit loss of
consciousness, a major nursing priority is to:

A. Protect the patient from injury

B. Insert an airway
C. Elevate the head of the bed
D. Withdraw all pain medications

Answers and Rationale

The answers and rationale below will give you a better understanding of the exam. Counter-check
your answers to those below. If you have any disputes or objects, please direct them to the
comments section.

1. Answer: B. Maintain the patient in an orthopneic position as needed

When a patient develops dyspnea and shortness of breath, the orthopneic position encourages
maximum chest expansion and keeps the abdominal organs from pressing against the diaphragm,
thus improving ventilation. Bed rest and oxygen by Venturi mask at 24% would improve oxygenation
of the tissues and cells but must be ordered by a physician. Allowing for rest periods decreases the
possibility of hypoxia.

2. Answer: C. Orthopnea

Orthopnea is difficulty of breathing except in the upright position. Tachypnea is

rapid respiration characterized by quick, shallow breaths. Eupnea is normal respiration – quiet,
rhythmic, and without effort.

3. Answer: C. Giving the patient breakfast

A platelet count evaluates the number of platelets in the circulating blood volume. The nurse is
responsible for giving the patient breakfast at the scheduled time. The physician is responsible for
instructing the patient about the test and for writing the order for the test.

4. Answer: B. Mashed potatoes and broiled chicken

Mashed potatoes and broiled chicken are low in natural sodium chloride. Ham, olives, and chicken
bouillon contain large amounts of sodium and are contraindicated on a low sodium diet.

5. Answer: D. All of the above

All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. The
normal activated partial thromboplastin time is 16 to 25 seconds and the normal prothrombin time is
12 to 15 seconds; these levels must remain within two to two and one half the normal levels.
All patients receiving anticoagulant therapy must be observed for signs and symptoms of frank and
occult bleeding (including hemorrhage, hypotension, tachycardia, tachypnea, restlessness, pallor,
cold and clammy skin, thirst and confusion); blood pressure should be measured every 4 hours and
the patient should be instructed to report promptly any bleeding that occurs with tooth brushing,
bowel movements, urination or heavy prolonged menstruation.

6. Answer: D. Person, environment, health, nursing

The focus concepts that have been accepted by all theorists as the focus of nursing practice from
the time of Florence Nightingale include the person receiving nursing care, his environment, his
health on the health illness continuum, and the nursing actions necessary to meet his needs.

7. Answer: D. Oxygen

Maslow, who defined a need as a satisfaction whose absence causes illness, considered oxygen to
be the most important physiologic need; without it, human life could not exist. According to this
theory, other physiologic needs (including food, water, elimination, shelter, rest and sleep, activity
and temperature regulation) must be met before proceeding to the next hierarchical levels on
psychosocial needs.

8. Answer: B. Listen to their concerns and answer their questions honestly

The brain-dead patient’s family needs support and reassurance in making a decision about organ
donation. Because transplants are done within hours of death, decisions about organ donation must
be made as soon as possible. However, the family’s concerns must be addressed before members
are asked to sign a consent form. The body of an organ donor is available for burial.

9. Answer: C. Discuss the problem with her supervisor

Although a new head nurse should initially spend time observing the unit for its strengths and
weakness, she should take action if a problem threatens patient safety. In this case, the supervisor
is the resource person to approach.

10. Answer: D. The holistic approach provides for a therapeutic relationship, continuity, and
efficient nursing care.

Studies have shown that patients and nurses both respond well to primary nursing care units.
Patients feel less anxious and isolated and more secure because they are allowed to participate in
planning their own care. Nurses feel personal satisfaction, much of it related to positive feedback
from the patients. They also seem to gain a greater sense of achievement and esprit de corps.

11. Answer: A. Assault and battery

Assault is the unjustifiable attempt or threat to touch or injure another person. Battery is the unlawful
touching of another person or the carrying out of threatened physical harm. Thus, any act that a
nurse performs on the patient against his will is considered assault and battery.

12. Answer: A. Slander

Oral communication that injures an individual’s reputation is considered slander. Written

communication that does the same is considered libel.

13. Answer: D. Malpractice

Malpractice is defined as injurious or unprofessional actions that harm another. It involves

professional misconduct, such as omission or commission of an act that a reasonable and prudent
nurse would or would not do. In this example, the standard of care was breached; a 3-month-old
infant should never be left unattended on a scale.

14. Answer: A. The nurse administers penicillin to a patient with a documented history of
allergy to the drug. The patient experiences an allergic reaction and has cerebral damage
resulting from anoxia.

The three elements necessary to establish a nursing malpractice are nursing error (administering
penicillin to a patient with a documented allergy to the drug), injury (cerebral damage), and proximal
cause (administering the penicillin caused the cerebral damage). Applying a hot water
bottle or heating pad to a patient without a physician’s order does not include the three required
components. Assisting a patient out of bed with the bed locked in position is the correct nursing
practice; therefore, the fracture was not the result of malpractice. Administering an incorrect
medication is a nursing error; however, if such action resulted in a serious illness or chronic problem,
the nurse could be sued for malpractice.

15. Answer: C. Immobility, diaphoresis, and avoidance of deep breathing or coughing

An Asian patient is likely to hide his pain. Consequently, the nurse must observe for objective signs.
In an abdominal surgery patient, these might include immobility, diaphoresis, and avoidance of deep
breathing or coughing, as well as increased heart rate, shallow respirations (stemming from pain
upon moving the diaphragm and respiratory muscles), and guarding or rigidity of the abdominal wall.
Such a patient is unlikely to display emotion, such as crying.

16. Answer: B. Guaiac test

To assess for GI tract bleeding when frank blood is absent, the nurse has two options: She can test
for occult blood in vomitus, if present, or in stool – through guaiac (Hemoccult) test. A complete
blood count does not provide immediate results and does not always immediately reflect blood loss.
Changes in vital signs may be cause by factors other than blood loss. Abdominal girth is unrelated to
blood loss.

17. Answer: D. Auscultation, percussion, and palpation

Because percussion and palpation can affect bowel motility and thus bowel sounds, they should
follow auscultation in abdominal assessment. Tympanic percussion, measurement of abdominal
girth, and inspection are methods of assessing the abdomen. Assessing for distention, tenderness
and discoloration around the umbilicus can indicate various bowel-related conditions, such as
cholecystitis, appendicitis and peritonitis.

18. Answer: C. Normal bowel sounds

Hyperactive sounds indicate increased bowel motility; two or three sounds per minute indicate
decreased bowel motility. Abdominal cramping with hyperactive, high pitched tinkling bowel sounds
can indicate a bowel obstruction.

19. Answer: C. Supine

The supine position (also called the dorsal position), in which the patient lies on his back with his
face upward, allows for easy access to the abdomen. In the prone position, the patient lies on his
abdomen with his face turned to the side. In the Trendelenburg position, the head of the bed is tilted
downward to 30 to 40 degrees so that the upper body is lower than the legs. In the lateral position,
the patient lies on his side.
20. Answer: D. All of the above

All of these positions are appropriate for a rectal examination. In the genupectoral (knee-chest)
position, the patient kneels and rests his chest on the table, forming a 90 degree angle between the
torso and upper legs. In Sims’ position, the patient lies on his left side with the left arm behind the
body and his right leg flexed. In the horizontal recumbent position, the patient lies on his back with
legs extended and hips rotated outward.

21. Answer: B. Standing

During a Romberg test, which evaluates for sensory or cerebellar ataxia, the patient must stand with
feet together and arms resting at the sides—first with eyes open, then with eyes closed. The need to
move the feet apart to maintain this stance is an abnormal finding.

22. Answer: A. 54

The pulse pressure is the difference between the systolic and diastolic blood pressure readings – in
this case, 54.

23. Answer: D. Dehydration

A slightly elevated temperature in the immediate preoperative or post operative period may result
from the lack of fluids before surgery rather than from infection. Anxiety will not cause an elevated
temperature. Hypothermia is an abnormally low body temperature.

24 Answer D. All of the above

The quality and efficiency of the respiratory process can be determined by appraising the rate,
rhythm, depth, ease, sound, and symmetry of respirations.

25. Answer: D. Temperature and respiratory rate

Under normal conditions, a healthy adult breathes in a smooth uninterrupted pattern 12 to 20 times a
minute. Thus, a respiratory rate of 30 would be abnormal. A normal adult body temperature, as
measured on an oral thermometer, ranges between 97° and 100°F (36.1° and 37.8°C); an axillary
temperature is approximately one degree lower and a rectal temperature, one degree higher. Thus,
an axillary temperature of 99.6°F (37.6°C) would be considered abnormal. The resting pulse rate in
an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal.

26. Answer: D. Parasympathetic nervous system stimulation

Parasympathetic nervous system stimulation of the heart decreases the heart rate as well as the
force of contraction, rate of impulse conduction and blood flow through the coronary vessels. Fever,
exercise, and sympathetic stimulation all increase the heart rate.

27. Answer: D. Apical pulse

The apical pulse (the pulse at the apex of the heart) is located on the midclavicular line at the fourth,
fifth, or sixth intercostal space. Base line vital signs include pulse rate, temperature, respiratory rate,
and blood pressure. Blood pressure is typically assessed at the antecubital fossa, and respiratory
rate is assessed best by observing chest movement with each inspiration and expiration.

28. Answer: C. Pedal

Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not
necessarily a significant finding. However, the presence or absence of the pedal pulse should be
documented upon admission so that changes can be identified during the hospital stay. Absence of
the apical, radial, or femoral pulse is abnormal and should be investigated.

29. Answer: B. An 88-year old incontinent patient with gastric cancer who is confined to his
bed at home

Pressure ulcers are most likely to develop in patients with impaired mental status, mobility, activity
level, nutrition, circulation and bladder or bowel control. Age is also a factor. Thus, the 88-year old
incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at
greater risk.

30. Answer: A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours

Adequate hydration thins and loosens pulmonary secretions and also helps to replace fluids lost
from elevated temperature, diaphoresis, dehydration and dyspnea. High- humidity air and chest
physiotherapy help liquefy and mobilize secretions.
31. Answer: A. Thiamine

Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition.

32. Answer: C. The patient should always feed himself

A patient with dysphagia (difficulty swallowing) requires assistance with feeding. Feeding himself is a
long-range expected outcome. Soft foods, Fowler’s or semi-Fowler’s position, and oral hygiene
before eating should be part of the feeding regimen.

33. Answer: A. Less than 30 ml/hour

A urine output of less than 30ml/hour indicates hypovolemia or oliguria, which is related to kidney
function and inadequate fluid intake.

34. Answer: A. Caffeine-containing drinks, such as coffee and cola.

Fluids containing caffeine have a diuretic effect. Beets and urinary analgesics, such as
Pyridium (Phenazopyridine), can color urine red. Kaopectate is an antidiarrheal medication.

35. Answer: C. Accompany the patient for his walk.

A hospitalized surgical patient leaving his room for the first time fears rejection and others staring at
him, so he should not walk alone. Accompanying him will offer moral support, enabling him to face
the rest of the world. Patients should begin ambulation as soon as possible after surgery to decrease
complications and to regain strength and confidence. Waiting to consult a physical therapist is
unnecessary.

36. Answer: A. Ineffective airway clearance related to thick, tenacious secretions.

Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness of breath are signs of
ineffective airway clearance. Ineffective airway clearance related to dry, hacking cough is incorrect
because the cough is not the reason for the ineffective airway clearance. Ineffective individual
coping related to COPD is wrong because the etiology for a nursing diagnosis should not be a
medical diagnosis (COPD) and because no data indicate that the patient is coping ineffectively. Pain
related to immobilization of affected leg would be an appropriate nursing diagnosis for a patient with
a leg fracture.

37. Answer: D. “I know this will be difficult for you, but your hair will grow back after the
completion of chemotherapy”

“I know this will be difficult” acknowledges the problem and suggests a resolution to it. “Don’t worry..”
offers some relief but doesn’t recognize the patient’s feelings. “..I didn’t get to the bad news yet”
would be inappropriate at any time. “Your hair is really pretty” offers no consolation or alternatives to
the patient.

38. Answer: B. Young adulthood

Additional Vitamin C is needed in growth periods, such as infancy and childhood, and during
pregnancy to supply demands for fetal growth and maternal tissues. Other conditions requiring extra
vitamin C include wound healing, fever, infection and stress.

39. Answer: D. Inhibition of the respiratory hypoxic stimulus

Delivery of more than 2 liters of oxygen per minute to a patient with chronic obstructive pulmonary
disease (COPD), who is usually in a state of compensated respiratory acidosis (retaining carbon
dioxide (CO2)), can inhibit the hypoxic stimulus for respiration. An increased partial pressure of
carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest. Circulatory
overload and respiratory excitement have no relevance to the question.

40. Answer: C. Muscle weakness

Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include muscle
weakness, chronic fatigue, and cardiac dysrhythmias. The combined effects of inadequate food
intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems.

41. Answer: D. All of the above

Assisting a patient with ambulation and transfer from a bed to a chair allows the nurse to evaluate
the patient’s ability to carry out these functions safely. Demonstrating the signal system and
providing an opportunity for a return demonstration ensures that the patient knows how to operate
the equipment and encourages him to call for assistance when needed. Checking the patient’s
identification band verifies the patient’s identity and prevents identification mistakes in drug
administration.

42. Answer: D. Side rails are a reminder to a patient not to get out of bed

Since about 40% of patients fall out of bed despite the use of side rails, side rails cannot be said to
prevent falls; however, they do serve as a reminder that the patient should not get out of bed. The
other answers are incorrect interpretations of the statistical data.

43. Answer: C. A patient who cannot care for himself at home

A patient who cannot care for himself at home does not necessarily have impaired awareness; he
may simply have some degree of immobility.

44. Answer: D. Hip fracture

Hip fracture, the most common injury among elderly persons, usually results from osteoporosis. The
other answers are diseases that can occur in the elderly from physiologic changes.

45. Answer: A. Depression

Sleep disturbances, inability to concentrate and decreased appetite are symptoms of depression, the
most common psychogenic disorder among elderly persons. Other symptoms include diminished
memory, apathy, disinterest in appearance, withdrawal, and irritability. Depression typically begins
before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors

46. Answer: D. All of the above

Aging decreases elasticity of the blood vessels, which leads to increased peripheral resistance and
decreased blood flow. These changes, in turn, increase the workload of the left ventricle.

47. Answer: D. Alzheimer’s disease

Alzheimer;s disease, sometimes known as senile dementia of the Alzheimer’s type or primary
degenerative dementia, is an insidious; progressive, irreversible, and degenerative disease of the
brain whose etiology is still unknown. Parkinson’s disease is a neurologic disorder caused by lesions
in the extrapyramidal system and manifested by tremors, muscle rigidity, hypokinesia, dysphagia,
and dysphonia. Multiple sclerosis, a progressive, degenerative disease involving demyelination of
the nerve fibers, usually begins in young adulthood and is marked by periods of remission and
exacerbation. Amyotrophic lateral sclerosis, a disease marked by progressive degeneration of the
neurons, eventually results in atrophy of all the muscles; including those necessary for respiration.

48. ANswer: C. Labeling the corpse appropriately

The nurse is legally responsible for labeling the corpse when death occurs in the hospital. She may
be involved in obtaining consent for an autopsy or notifying the coroner or medical examiner of a
patient’s death; however, she is not legally responsible for performing these functions. The attending
physician may need information from the nurse to complete the death certificate, but he is
responsible for issuing it.

49. Answer: B. Placing one pillow under the body’s head and shoulders

The nurse must place a pillow under the decreased person’s head and shoulders to prevent blood
from settling in the face and discoloring it. She is required to bathe only soiled areas of the body
since the mortician will wash the entire body. Before wrapping the body in a shroud, the nurse
places a clean gown on the body and closes the eyes and mouth.

50. Answer: A. Protect the patient from injury

Ensuring the patient’s safety is the most essential action at this time. The other nursing actions may
be necessary but are not a major priority.

1. Which element in the circular chain of infection can be eliminated by preserving skin
integrity?

A. Host
B. Reservoir
C. Mode of transmission
D. Portal of entry
2. Which of the following will probably result in a break in sterile technique for respiratory
isolation?

A. Opening the patient’s window to the outside environment

B. Turning on the patient’s room ventilator
C. Opening the door of the patient’s room leading into the hospital corridor
D. Failing to wear gloves when administering a bed bath

3. Which of the following patients is at greater risk for contracting an infection?

A. A patient with leukopenia

B. A patient receiving broad-spectrum antibiotics
C. A postoperative patient who has undergone orthopedic surgery
D. A newly diagnosed diabetic patient

4. Effective hand washing requires the use of:

A. Soap or detergent to promote emulsification

B. Hot water to destroy bacteria
C. A disinfectant to increase surface tension
D. All of the above

5. After routine patient contact, hand washing should last at least:

A. 30 seconds
B. 1 minute
C. 2 minute
D. 3 minutes

6. Which of the following procedures always requires surgical asepsis?

A. Vaginal instillation of conjugated estrogen

B. Urinary catheterization
C. Nasogastric tube insertion
D. Colostomy irrigation
7. Sterile technique is used whenever:

A. Strict isolation is required

B. Terminal disinfection is performed
C. Invasive procedures are performed
D. Protective isolation is necessary

8. Which of the following constitutes a break in sterile technique while preparing a sterile
field for a dressing change?

A. Using sterile forceps, rather than sterile gloves, to handle a sterile item
B. Touching the outside wrapper of sterilized material without sterile gloves
C. Placing a sterile object on the edge of the sterile field
D. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile
container

9. A natural body defense that plays an active role in preventing infection is:

A. Yawning
B. Body hair
C. Hiccupping
D. Rapid eye movements

10. All of the following statement are true about donning sterile gloves except:

A. The first glove should be picked up by grasping the inside of the cuff.
B. The second glove should be picked up by inserting the gloved fingers under the cuff outside the
glove.
C. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the
glove over the wrist
D. The inside of the glove is considered sterile

11. When removing a contaminated gown, the nurse should be careful that the first thing she
touches is the:
A. Waist tie and neck tie at the back of the gown
B. Waist tie in front of the gown
C. Cuffs of the gown
D. Inside of the gown

12. Which of the following nursing interventions is considered the most effective form or
universal precautions?

A. Cap all used needles before removing them from their syringes
B. Discard all used uncapped needles and syringes in an impenetrable protective container
C. Wear gloves when administering IM injections
D. Follow enteric precautions

13. All of the following measures are recommended to prevent pressure ulcers except:

A. Massaging the reddened area with lotion

B. Using a water or air mattress
C. Adhering to a schedule for positioning and turning
D. Providing meticulous skin care

14. Which of the following blood tests should be performed before a blood transfusion?

A. Prothrombin and coagulation time

B. Blood typing and cross-matching
C. Bleeding and clotting time
D. Complete blood count (CBC) and electrolyte levels.

15. The primary purpose of a platelet count is to evaluate the:

A. Potential for clot formation

B. Potential for bleeding
C. Presence of an antigen-antibody response
D. Presence of cardiac enzymes

16. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?
A. 4,500/mm³
B. 7,000/mm³
C. 10,000/mm³
D. 25,000/mm³

17. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to
exhibit fatigue, muscle cramping and muscle weakness. These symptoms probably indicate
that the patient is experiencing:

A. Hypokalemia
B. Hyperkalemia
C. Anorexia
D. Dysphagia

18. Which of the following statements about chest X-ray is false?

A. No contradictions exist for this test

B. Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above
the waist
C. A signed consent is not required
D. Eating, drinking, and medications are allowed before this test

19. The most appropriate time for the nurse to obtain a sputum specimen for culture is:

A. Early in the morning

B. After the patient eats a light breakfast
C. After aerosol therapy
D. After chest physiotherapy

20. A patient with no known allergies is to receive penicillin every 6 hours. When
administering the medication, the nurse observes a fine rash on the patient’s skin. The most
appropriate nursing action would be to:

A. Withhold the moderation and notify the physician

B. Administer the medication and notify the physician
C. Administer the medication with an antihistamine
D. Apply corn starch soaks to the rash

21. All of the following nursing interventions are correct when using the Z-track method of
drug injection except:

A. Prepare the injection site with alcohol

B. Use a needle that’s a least 1” long
C. Aspirate for blood before injection
D. Rub the site vigorously after the injection to promote absorption

22. The correct method for determining the vastus lateralis site for I.M. injection is to:

A. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac
crest
B. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm
C. Palpate a 1” circular area anterior to the umbilicus
D. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds,
and select the middle third on the anterior of the thigh

23. The mid-deltoid injection site is seldom used for I.M. injections because it:

A. Can accommodate only 1 ml or less of medication

B. Bruises too easily
C. Can be used only when the patient is lying down
D. Does not readily parenteral medication

24. The appropriate needle size for insulin injection is:

A. 18G, 1 ½” long
B. 22G, 1” long
C. 22G, 1 ½” long
D. 25G, 5/8” long

25. The appropriate needle gauge for intradermal injection is:

A. 20G
B. 22G
C. 25G
D. 26G

26. Parenteral penicillin can be administered as an:

A. IM injection or an IV solution
B. IV or an intradermal injection
C. Intradermal or subcutaneous injection
D. IM or a subcutaneous injection

27. The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is:

A. 0.6 mg
B. 10 mg
C. 60 mg
D. 600 mg

28. The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What would
the flow rate be if the drop factor is 15 gtt = 1 ml?

A. 5 gtt/minute
B. 13 gtt/minute
C. 25 gtt/minute
D. 50 gtt/minute

29. Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?

A. Hemoglobinuria
B. Chest pain
C. Urticaria
D. Distended neck veins

30. Which of the following conditions may require fluid restriction?

A. Fever
B. Chronic Obstructive Pulmonary Disease
C. Renal Failure
D. Dehydration

31. All of the following are common signs and symptoms of phlebitis except:

A. Pain or discomfort at the IV insertion site

B. Edema and warmth at the IV insertion site
C. A red streak exiting the IV insertion site
D. Frank bleeding at the insertion site

32. The best way of determining whether a patient has learned to instill ear medication
properly is for the nurse to:

A. Ask the patient if he/she has used ear drops before

B. Have the patient repeat the nurse’s instructions using her own words
C. Demonstrate the procedure to the patient and encourage to ask questions
D. Ask the patient to demonstrate the procedure

33. Which of the following types of medications can be administered via gastrostomy tube?

A. Any oral medications

B. Capsules whole contents are dissolve in water
C. Enteric-coated tablets that are thoroughly dissolved in water
D. Most tablets designed for oral use, except for extended-duration compounds

34. A patient who develops hives after receiving an antibiotic is exhibiting drug:

A. Tolerance
B. Idiosyncrasy
C. Synergism
D. Allergy

35. A patient has returned to his room after femoral arteriography. All of the following are
appropriate nursing interventions except:
A. Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours
B. Check the pressure dressing for sanguineous drainage
C. Assess a vital signs every 15 minutes for 2 hours
D. Order a hemoglobin and hematocrit count 1 hour after the arteriography

36. The nurse explains to a patient that a cough:

A. Is a protective response to clear the respiratory tract of irritants

B. Is primarily a voluntary action
C. Is induced by the administration of an antitussive drug
D. Can be inhibited by “splinting” the abdomen

37. An infected patient has chills and begins shivering. The best nursing intervention is to:

A. Apply iced alcohol sponges

B. Provide increased cool liquids
C. Provide additional bedclothes
D. Provide increased ventilation

38. A clinical nurse specialist is a nurse who has:

A. Been certified by the National League for Nursing

B. Received credentials from the Philippine Nurses’ Association
C. Graduated from an associate degree program and is a registered professional nurse
D. Completed a master’s degree in the prescribed clinical area and is a registered professional
nurse.

39. The purpose of increasing urine acidity through dietary means is to:

A. Decrease burning sensations

B. Change the urine’s color
C. Change the urine’s concentration
D. Inhibit the growth of microorganisms

40. Clay colored stools indicate:

A. Upper GI bleeding
B. Impending constipation
C. An effect of medication
D. Bile obstruction

41. In which step of the nursing process would the nurse ask a patient if the medication she
administered relieved his pain?

A. Assessment
B. Analysis
C. Planning
D. Evaluation

42. All of the following are good sources of vitamin A except:

A. White potatoes
B. Carrots
C. Apricots
D. Egg yolks

43. Which of the following is a primary nursing intervention necessary for all patients with a
Foley Catheter in place?

A. Maintain the drainage tubing and collection bag level with the patient’s bladder
B. Irrigate the patient with 1% Neosporin solution three times a daily
C. Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticity
D. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by
gravity

44. The ELISA test is used to:

A. Screen blood donors for antibodies to human immunodeficiency virus (HIV)

B. Test blood to be used for transfusion for HIV antibodies
C. Aid in diagnosing a patient with AIDS
D. All of the above
45. The two blood vessels most commonly used for TPN infusion are the:

A. Subclavian and jugular veins

B. Brachial and subclavian veins
C. Femoral and subclavian veins
D. Brachial and femoral veins

46. Effective skin disinfection before a surgical procedure includes which of the following
methods?

A. Shaving the site on the day before surgery

B. Applying a topical antiseptic to the skin on the evening before surgery
C. Having the patient take a tub bath on the morning of surgery
D. Having the patient shower with an antiseptic soap on the evening before and the morning of
surgery

47. When transferring a patient from a bed to a chair, the nurse should use which muscles to
avoid back injury?

A. Abdominal muscles
B. Back muscles
C. Leg muscles
D. Upper arm muscles

48. Thrombophlebitis typically develops in patients with which of the following conditions?

A. Increases partial thromboplastin time

B. Acute pulsus paradoxus
C. An impaired or traumatized blood vessel wall
D. Chronic Obstructive Pulmonary Disease (COPD)

49. In a recumbent, immobilized patient, lung ventilation can become altered, leading to such
respiratory complications as:

A. Respiratory acidosis, atelectasis, and hypostatic pneumonia

B. Apneustic breathing, atypical pneumonia and respiratory alkalosis
C. Cheyne-Stokes respirations and spontaneous pneumothorax
D. Kussmaul’s respirations and hypoventilation

50. Immobility impairs bladder elimination, resulting in such disorders as

A. Increased urine acidity and relaxation of the perineal muscles, causing incontinence
B. Urine retention, bladder distention, and infection
C. Diuresis, natriuresis, and decreased urine specific gravity
D. Decreased calcium and phosphate levels in the urine

Answers and Rationale

Gauge your performance by counter checking your answers to the answers below. Learn more
about the question by reading the rationale. If you have any disputes or questions, please direct
them to the comments section.

1. Answer: D. Portal of entry

In the circular chain of infection, pathogens must be able to leave their reservoir and be transmitted
to a susceptible host through a portal of entry, such as broken skin.

2. Answer: C. Opening the door of the patient’s room leading into the hospital corridor

Respiratory isolation, like strict isolation, requires that the door to the door patient’s room remain
closed. However, the patient’s room should be well ventilated, so opening the window or turning on
the ventricular is desirable. The nurse does not need to wear gloves for respiratory isolation, but
good hand washing is important for all types of isolation.

3. Answer: A. A patient with leukopenia

Leukopenia is a decreased number of leukocytes (white blood cells), which are important in resisting
infection. None of the other situations would put the patient at risk for contracting an infection; taking
broad-spectrum antibiotics might actually reduce the infection risk.

4. Answer: A. Soap or detergent to promote emulsification

Soaps and detergents are used to help remove bacteria because of their ability to lower the surface
tension of water and act as emulsifying agents. Hot water may lead to skin irritation or burns.

5. Answer: A. 30 seconds

Depending on the degree of exposure to pathogens, hand washing may last from 10 seconds to 4
minutes. After routine patient contact, hand washing for 30 seconds effectively minimizes the risk of
pathogen transmission.

6. Answer: B. Urinary catheterization

The urinary system is normally free of microorganisms except at the urinary meatus. Any procedure
that involves entering this system must use surgically aseptic measures to maintain a bacteria-free
state.

7. Answer: C. Invasive procedures are performed

All invasive procedures, including surgery, catheter insertion, and administration of parenteral
therapy, require sterile technique to maintain a sterile environment. All equipment must be sterile,
and the nurse and the physician must wear sterile gloves and maintain surgical asepsis. In the
operating room, the nurse and physician are required to wear sterile gowns, gloves, masks, hair
covers, and shoe covers for all invasive procedures. Strict isolation requires the use of clean gloves,
masks, gowns and equipment to prevent the transmission of highly communicable diseases by
contact or by airborne routes. Terminal disinfection is the disinfection of all contaminated supplies
and equipment after a patient has been discharged to prepare them for reuse by another patient.
The purpose of protective (reverse)isolation is to prevent a person with seriously impaired resistance
from coming into contact who potentially pathogenic organisms.

8. Answer: C. Placing a sterile object on the edge of the sterile field

The edges of a sterile field are considered contaminated. When sterile items are allowed to come in
contact with the edges of the field, the sterile items also become contaminated.

9. Answer: B. Body hair

Hair on or within body areas, such as the nose, traps and holds particles that contain
microorganisms. Yawning and hiccupping do not prevent microorganisms from entering or leaving
the body. Rapid eye movement marks the stage of sleep during which dreaming occurs.

10. Answer: D. The inside of the glove is considered sterile

The inside of the glove is always considered to be clean, but not sterile.

11. Answer: A. Waist tie and neck tie at the back of the gown

The back of the gown is considered clean, the front is contaminated. So, after removing gloves and
washing hands, the nurse should untie the back of the gown; slowly move backward away from the
gown, holding the inside of the gown and keeping the edges off the floor; turn and fold the gown
inside out; discard it in a contaminated linen container; then wash her hands again.

12. Answer: B. Discard all used uncapped needles and syringes in an impenetrable protective
container

According to the Centers for Disease Control (CDC), blood-to-blood contact occurs most commonly
when a health care worker attempts to cap a used needle. Therefore, used needles should never be
recapped; instead they should be inserted in a specially designed puncture resistant, labeled
container. Wearing gloves is not always necessary when administering an I.M. injection. Enteric
precautions prevent the transfer of pathogens via feces.

13. Answer: A. Massaging the reddened area with lotion

Nurses and other health care professionals previously believed that massaging a reddened area
with lotion would promote venous return and reduce edema to the area. However, research has
shown that massage only increases the likelihood of cellular ischemia and necrosis to the area.

14. Answer: B. Blood typing and cross-matching

Before a blood transfusion is performed, the blood of the donor and recipient must be checked for
compatibility. This is done by blood typing (a test that determines a person’s blood type) and cross-
matching (a procedure that determines the compatibility of the donor’s and recipient’s blood after the
blood types has been matched). If the blood specimens are incompatible, hemolysis and antigen-
antibody reactions will occur.

15. Answer: A. Potential for clot formation

Platelets are disk-shaped cells that are essential for blood coagulation. A platelet count determines
the number of thrombocytes in blood available for promoting hemostasis and assisting with blood
coagulation after injury. It also is used to evaluate the patient’s potential for bleeding; however, this
is not its primary purpose. The normal count ranges from 150,000 to 350,000/mm3. A count of
100,000/mm3 or less indicates a potential for bleeding; count of less than 20,000/mm3 is associated
with spontaneous bleeding.

16. Answer: D. 25,000/mm³

Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the blood.
Normal WBC counts range from 5,000 to 100,000/mm3. Thus, a count of 25,000/mm3 indicates
leukocytosis.

17. Answer: A. Hypokalemia

Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate
potassium level), which is a potential side effect of diuretic therapy. The physician usually orders
supplemental potassium to prevent hypokalemia in patients receiving diuretics. Anorexia is another
symptom of hypokalemia. Dysphagia means difficulty swallowing.

18. Answer: A. No contradictions exist for this test

Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. However, if a chest
X-ray is necessary, the patient can wear a lead apron to protect the pelvic region from radiation.
Jewelry, metallic objects, and buttons would interfere with the X-ray and thus should not be worn
above the waist. A signed consent is not required because a chest X-ray is not an invasive
examination. Eating, drinking and medications are allowed because the X-ray is of the chest, not the
abdominal region.

19. Answer: A. Early in the morning

Obtaining a sputum specimen early in this morning ensures an adequate supply of bacteria for
culturing and decreases the risk of contamination from food or medication.

20. Answer: A. Withhold the moderation and notify the physician

Initial sensitivity to penicillin is commonly manifested by a skin rash, even in individuals who have
not been allergic to it previously. Because of the danger of anaphylactic shock, he nurse should
withhold the drug and notify the physician, who may choose to substitute another drug.
Administering an antihistamine is a dependent nursing intervention that requires a written physician’s
order. Although applying corn starch to the rash may relieve discomfort, it is not the nurse’s top
priority in such a potentially life-threatening situation.

21. Answer: D. Rub the site vigorously after the injection to promote absorption

The Z-track method is an I.M. injection technique in which the patient’s skin is pulled in such a way
that the needle track is sealed off after the injection. This procedure seals medication deep into the
muscle, thereby minimizing skin staining and irritation. Rubbing the injection site is contraindicated
because it may cause the medication to extravasate into the skin.

22. Answer: D. Divide the area between the greater femoral trochanter and the lateral femoral
condyle into thirds, and select the middle third on the anterior of the thigh

The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is viewed by many
clinicians as the site of choice for I.M. injections because it has relatively few major nerves and blood
vessels. The middle third of the muscle is recommended as the injection site. The patient can be in a
supine or sitting position for an injection into this site.

23. Answer: A. Can accommodate only 1 ml or less of medication

The mid-deltoid injection site can accommodate only 1 ml or less of medication because of its size
and location (on the deltoid muscle of the arm, close to the brachial artery and radial nerve).

24. Answer: D. 25G, 5/8” long

A 25G, 5/8” needle is the recommended size for insulin injection because insulin is administered by
the subcutaneous route. An 18G, 1 ½” needle is usually used for I.M. injections in children, typically
in the vastus lateralis. A 22G, 1 ½” needle is usually used for adult I.M. injections, which are typically
administered in the vastus lateralis or ventrogluteal site.

25. Answer: C. 25G

Because an intradermal injection does not penetrate deeply into the skin, a small-bore 25G needle is
recommended. This type of injection is used primarily to administer antigens to evaluate reactions
for allergy or sensitivity studies. A 20G needle is usually used for I.M. injections of oil-based
medications; a 22G needle for I.M. injections; and a 25G needle, for I.M. injections; and a 25G
needle, for subcutaneous insulin injections.

26. Answer: A. IM injection or an IV solution

Parenteral penicillin can be administered I.M. or added to a solution and given I.V. It cannot be
administered subcutaneously or intradermally.

27. Answer: D. 600 mg

gr 10 x 60 mg/gr 1 = 600 mg

28. Answer: C. 25 gtt/minute

100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute

29. Answer: A. Hemoglobinuria

Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic reaction
(incompatibility of the donor’s and recipient’s blood). In this reaction, antibodies in the recipient’s
plasma combine rapidly with donor RBC’s; the cells are hemolyzed in either circulatory or
reticuloendothelial system. Hemolysis occurs more rapidly in ABO incompatibilities than in Rh
incompatibilities. Chest pain and urticaria may be symptoms of impending anaphylaxis. Distended
neck veins are an indication of hypervolemia.

30. Answer: C. Renal Failure

In real failure, the kidney loses their ability to effectively eliminate wastes and fluids. Because of this,
limiting the patient’s intake of oral and I.V. fluids may be necessary. Fever, chronic obstructive
pulmonary disease, and dehydration are conditions for which fluids should be encouraged.

31. Answer: D. Frank bleeding at the insertion site

Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. solutions or
medications), mechanical irritants (the needle or catheter used during venipuncture or cannulation),
or a localized allergic reaction to the needle or catheter. Signs and symptoms of phlebitis include
pain or discomfort, edema and heat at the I.V. insertion site, and a red streak going up the arm or leg
from the I.V. insertion site.

32. Answer: D. Ask the patient to demonstrate the procedure

Return demonstration provides the most certain evidence for evaluating the effectiveness of patient
teaching.

33. Answer: D. Most tablets designed for oral use, except for extended-duration compounds

Capsules, enteric-coated tablets, and most extended duration or sustained release products should
not be dissolved for use in a gastrostomy tube. They are pharmaceutically manufactured in these
forms for valid reasons, and altering them destroys their purpose. The nurse should seek an
alternate physician’s order when an ordered medication is inappropriate for delivery by tube.

34. Answer: D. Allergy

A drug-allergy is an adverse reaction resulting from an immunologic response following a previous

sensitizing exposure to the drug. The reaction can range from a rash or hives to anaphylactic shock.
Tolerance to a drug means that the patient experiences a decreasing physiologic response to
repeated administration of the drug in the same dosage. Idiosyncrasy is an individual’s unique
hypersensitivity to a drug, food, or other substance; it appears to be genetically determined.
Synergism, is a drug interaction in which the sum of the drug’s combined effects is greater than that
of their separate effects.

35. Answer: D. Order a hemoglobin and hematocrit count 1 hour after the arteriography
A hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected.
The other answers are appropriate nursing interventions for a patient who has undergone femoral
arteriography.

36. Answer: A. Is a protective response to clear the respiratory tract of irritants

Coughing, a protective response that clears the respiratory tract of irritants, usually is involuntary;
however it can be voluntary, as when a patient is taught to perform coughing exercises. An
antitussive drug inhibits coughing. Splinting the abdomen supports the abdominal muscles when a
patient coughs.

37. Answer: C. Provide additional bedclothes

In an infected patient, shivering results from the body’s attempt to increase heat production and the
production of neutrophils and phagocytic action through increased skeletal muscle tension and
contractions. Initial vasoconstriction may cause skin to feel cold to the touch. Applying additional bed
clothes helps to equalize the body temperature and stop the chills. Attempts to cool the body result
in further shivering, increased metabolism, and thus increased heat production.

38. Answer: D. Completed a master’s degree in the prescribed clinical area and is a
registered professional nurse.

A clinical nurse specialist must have completed a master’s degree in a clinical specialty and be a
registered professional nurse. The National League of Nursing accredits educational programs in
nursing and provides a testing service to evaluate student nursing competence but it does not certify
nurses. The American Nurses Association identifies requirements for certification and offers
examinations for certification in many areas of nursing., such as medical surgical nursing. These
certification (credentialing) demonstrates that the nurse has the knowledge and the ability to provide
high quality nursing care in the area of her certification. A graduate of an associate degree program
is not a clinical nurse specialist: however, she is prepared to provide bed side nursing with a high
degree of knowledge and skill. She must successfully complete the licensing examination to become
a registered professional nurse.

39. Answer: D. Inhibit the growth of microorganisms

Microorganisms usually do not grow in an acidic environment.

40. Answer: D. Bile obstruction

Bile colors the stool brown. Any inflammation or obstruction that impairs bile flow will affect the stool
pigment, yielding light, clay-colored stool. Upper GI bleeding results in black or tarry stool.
Constipation is characterized by small, hard masses. Many medications and foods will discolor stool
– for example, drugs containing iron turn stool black.; beets turn stool red.

41. Answer: D. Evaluation

In the evaluation step of the nursing process, the nurse must decide whether the patient has
achieved the expected outcome that was identified in the planning phase.

42. Answer: A. White potatoes

The main sources of vitamin A are yellow and green vegetables (such as carrots, sweet potatoes,
squash, spinach, collard greens, broccoli, and cabbage) and yellow fruits (such as apricots, and
cantaloupe). Animal sources include liver, kidneys, cream, butter, and egg yolks.

43. Answer: D. Maintain the drainage tubing and collection bag below bladder level to
facilitate drainage by gravity

Maintaining the drainage tubing and collection bag level with the patient’s bladder could result in
reflux of urine into the kidney. Irrigating the bladder with Neosporin and clamping the catheter for 1
hour every 4 hours must be prescribed by a physician.

44. Answer: D. All of the above

The ELISA test of venous blood is used to assess blood and potential blood donors to human
immunodeficiency virus (HIV). A positive ELISA test combined with various signs and symptoms
helps to diagnose acquired immunodeficiency syndrome (AIDS)

45. Answer: A. Subclavian and jugular veins

Total Parenteral Nutrition (TPN) requires the use of a large vessel, such as the subclavian or jugular
vein, to ensure rapid dilution of the solution and thereby prevent complications, such as
hyperglycemia. The brachial and femoral veins usually are contraindicated because they pose an
increased risk of thrombophlebitis.

46. Answer: D. Having the patient shower with an antiseptic soap on the evening before and
the morning of surgery

Studies have shown that showering with an antiseptic soap before surgery is the most effective
method of removing microorganisms from the skin. Shaving the site of the intended surgery might
cause breaks in the skin, thereby increasing the risk of infection; however, if indicated, shaving,
should be done immediately before surgery, not the day before. A topical antiseptic would not
remove microorganisms and would be beneficial only after proper cleaning and rinsing. Tub bathing
might transfer organisms to another body site rather than rinse them away.

47. Answer: C. Leg muscles

The leg muscles are the strongest muscles in the body and should bear the greatest stress when
lifting. Muscles of the abdomen, back, and upper arms may be easily injured.

48. Answer: C. An impaired or traumatized blood vessel wall

The factors, known as Virchow’s triad, collectively predispose a patient to thrombophlebitis; impaired
venous return to the heart, blood hypercoagulability, and injury to a blood vessel wall. Increased
partial thromboplastin time indicates a prolonged bleeding time during fibrin clot formation,
commonly the result of anticoagulant (heparin) therapy. Arterial blood disorders (such as pulsus
paradoxus) and lung diseases (such as COPD) do not necessarily impede venous return of injure
vessel walls.

49. Answer: A. Respiratory acidosis, atelectasis, and hypostatic pneumonia

Because of restricted respiratory movement, a recumbent, immobilize patient is at particular risk for
respiratory acidosis from poor gas exchange; atelectasis from reduced surfactant and accumulated
mucus in the bronchioles, and hypostatic pneumonia from bacterial growth caused by stasis of
mucus secretions.

50. Answer: B. Urine retention, bladder distention, and infection

The immobilized patient commonly suffers from urine retention caused by decreased muscle tone in
the perineum. This leads to bladder distention and urine stagnation, which provide an excellent
medium for bacterial growth leading to infection. Immobility also results in more alkaline urine with
excessive amounts of calcium, sodium and phosphate, a gradual decrease in urine production, and
an increased specific gravity.

1. The four major concepts in nursing theory are the

A. Person, Environment, Nurse, Health

B. Nurse, Person, Environment, Cure
C. Promotive, Preventive, Curative, Rehabilitative
D. Person, Environment, Nursing, Health

2. The act of utilizing the environment of the patient to assist him in his recovery is theorized
by

A. Nightingale
B. Benner
C. Swanson
D. King

3. For her, Nursing is a theoretical system of knowledge that prescribes a process of analysis
and action related to care of the ill person

A. King
B. Henderson
C. Roy
D. Leininger

4. According to her, Nursing is a helping or assisting profession to persons who are wholly
or partly dependent or when those who are supposedly caring for them are no longer able to
give care.

A. Henderson
B. Orem
C. Swanson
D. Neuman

5. Nursing is a unique profession, Concerned with all the variables affecting an individual’s
response to stressors, which are intra, inter and extra personal in nature.

A. Neuman
B. Johnson
C. Watson
D. Parse

6. The unique function of the nurse is to assist the individual, sick or well, in the performance
of those activities contributing to health that he would perform unaided if he has the
necessary strength, will and knowledge, and do this in such a way as to help him gain
independence as rapidly as possible.

A. Henderson
B. Abdellah
C. Levin
D. Peplau

7. Caring is the essence and central unifying, a dominant domain that distinguishes nursing
from other health disciplines. Care is an essential human need.

A. Benner
B. Watson
C. Leininger
D. Swanson

8. Caring involves 5 processes: KNOWING, BEING WITH, DOING FOR, ENABLING and
MAINTAINING BELIEF.

A. Benner
B. Watson
C. Leininger
D. Swanson
9. Caring is healing, it is communicated through the consciousness of the nurse to the
individual being cared for. It allows access to higher human spirit.

A. Benner
B. Watson
C. Leininger
D. Swanson

10. Caring means that person, events, projects and things matter to people. It reveals stress
and coping options. Caring creates responsibility. It is an inherent feature of nursing
practice. It helps the nurse assist clients to recover in the face of the illness.

A. Benner
B. Watson
C. Leininger
D. Swanson

11. Which of the following is NOT TRUE about profession according to Marie Jahoda?

A. A profession is an organization of an occupational group based on the application of special

knowledge
B. It serves specific interest of a group
C. It is altruistic
D. Quality of work is of greater importance than the rewards

12. Which of the following is NOT an attribute of a professional?

A. Concerned with quantity

B. Self directed
C. Committed to spirit of inquiry
D. Independent

13. The most unique characteristic of nursing as a profession is

A. Education
B. Theory
C. Caring
D. Autonomy

14. This is the distinctive individual qualities that differentiate a person to another

A. Philosophy
B. Personality
C. Charm
D. Character

15. Refers to the moral values and beliefs that are used as guides to personal behavior and
actions

A. Philosophy
B. Personality
C. Charm
D. Character

16. As a nurse manager, which of the following best describes this function?

A. Initiate modification on client’s lifestyle

B. Protect client’s right
C. Coordinates the activities of other members of the health team in managing patient care
D. Provide in service education programs, Use accurate nursing audit, formulate philosophy and
vision of the institution

17. What best describes nurses as a care provider?

A. Determine client’s need

B. Provide direct nursing care
C. Help client recognize and cope with stressful psychological situation
D. Works in combined effort with all those involved in patient’s care

18. The nurse questions a doctors order of Morphine sulfate 50 mg, IM for a client with
pancreatitis. Which role best fit that statement?
A. Change agent
B. Client advocate
C. Case manager
D. Collaborator

19. These are nursing intervention that requires knowledge, skills and expertise of multiple
health professionals.

A. Dependent
B. Independent
C. Interdependent
D. Intradependent

20. What type of patient care model is the most common for student nurses and private duty
nurses?

A. Total patient care

B. Team nursing
C. Primary Nursing
D. Case management

21. This is the best patient care model when there are many nurses but few patients.

A. Functional nursing
B. Team nursing
C. Primary nursing
D. Total patient care

22. This patient care model works best when there are plenty of patient but few nurses

A. Functional nursing
B. Team nursing
C. Primary nursing
D. Total patient care
23. RN assumes 24 hour responsibility for the client to maintain continuity of care across
shifts, days or visits.

A. Functional nursing
B. Team nursing
C. Primary nursing
D. Total patient care

24. Who developed the first theory of nursing?

A. Hammurabi
B. Alexander
C. Fabiola
D. Nightingale

25. She introduces the NATURE OF NURSING MODEL.

A. Henderson
B. Nightingale
C. Parse
D. Orlando

26. She described the four conservation principle.

A. Levin
B. Leininger
C. Orlando
D. Parse

27. Proposed the HEALTH CARE SYSTEM MODEL.

A. Henderson
B. Orem
C. Parse
D. Neuman
28. Conceptualized the BEHAVIORAL SYSTEM MODEL

A. Orem
B. Johnson
C. Henderson
D. Parse

29. Developed the CLINICAL NURSING – A HELPING ART MODEL

A. Swanson
B. Hall
C. Weidenbach
D. Zderad

30. Developed the ROLE MODELING and MODELING theory

A. Erickson,Tomlin,Swain
B. Neuman
C. Newman
D. Benner and Wrubel

31. Proposed the GRAND THEORY OF NURSING AS CARING

A. Erickson, Tomlin, Swain

B. Peterson,Zderad
C. Bnner,Wrubel
D. Boykin,Schoenhofer

32. Postulated the INTERPERSONAL ASPECT OF NURSING

A. Travelbee
B. Swanson
C. Zderad
D. Peplau

33. He proposed the theory of morality that is based on MUTUAL TRUST

A. Freud
B. Erikson
C. Kohlberg
D. Peters

34. He proposed the theory of morality based on PRINCIPLES

A. Freud
B. Erikson
C. Kohlberg
D. Peters

35. Freud postulated that child adopts parental standards and traits through

A. Imitation
B. Introjection
C. Identification
D. Regression

36. According to them, Morality is measured of how people treat human being and that a
moral child strives to be kind and just

A. Zderad and Peterson

B. Benner and Wrubel
C. Fowler and Westerhoff
D. Schulman and Mekler

37. Postulated that FAITH is the way of behaving. He developed four theories of faith and
development based on his experience.

A. Giligan
B. Westerhoff
C. Fowler
D. Freud
38. He described the development of faith. He suggested that faith is a spiritual dimension
that gives meaning to a persons life. Faith according to him, is a relational phenomenon.

A. Giligan
B. Westerhoff
C. Fowler
D. Freud

39. Established in 1906 by the Baptist foreign mission society of America. Miss rose nicolet,
was it’s first superintendent.

A. St. Paul Hospital School of nursing

B. Iloilo Mission Hospital School of nursing
C. Philippine General Hospital School of nursing
D. St. Luke’s Hospital School of nursing

40. Anastacia Giron-Tupas was the first Filipino nurse to occupy the position of chief nurse in
this hospital.

A. St. Paul Hospital

B. Iloilo Mission Hospital
C. Philippine General Hospital
D. St. Luke’s Hospital

41. She was the daughter of Hungarian kings, who feed 300-900 people everyday in their gate,
builds hospitals, and care of the poor and sick herself.

A. Elizabeth
B. Catherine
C. Nightingale
D. Sairey Gamp

42. She dies of yellow fever in her search for truth to prove that yellow fever is carried by a
mosquitoes.
A. Clara louise Maas
B. Pearl Tucker
C. Isabel Hampton Robb
D. Caroline Hampton Robb

43. He was called the father of sanitation.

A. Abraham
B. Hippocrates
C. Moses
D. Willam Halstead

44. The country where SHUSHURUTU originated

A. China
B. Egypt
C. India
D. Babylonia

45. They put girls clothes on male infants to drive evil forces away

A. Chinese
B. Egyptian
C. Indian
D. Babylonian

46. In what period of nursing does people believe in TREPHINING to drive evil forces away?

A. Dark period
B. Intuitive period
C. Contemporary period
D. Educative period

47. This period ended when Pastor Fliedner, build Kaiserwerth institute for the training of
Deaconesses
A. Apprentice period
B. Dark period
C. Contemporary period
D. Educative period

48. Period of nursing where religious Christian orders emerged to take care of the sick

A. Apprentice period
B. Dark period
C. Contemporary period
D. Educative period

49. Founded the second order of St. Francis of Assisi

A. St. Catherine
B. St. Anne
C. St. Clare
D. St. Elizabeth

50. This period marked the religious upheaval of Luther, Who questions the Christian faith.

A. Apprentice period
B. Dark period
C. Contemporary period
D. Educative period

51. According to the Biopsychosocial and spiritual theory of Sister Callista Roy, Man, As a
SOCIAL being is

A. Like all other men

B. Like some other men
C. Like no other men
D. Like men

52. She conceptualized that man, as an Open system is in constant interaction and
transaction with a changing environment.
A. Roy
B. Levin
C. Neuman
D. Newman

53. In a CLOSED system, which of the following is true?

A. Affected by matter
B. A sole island in vast ocean
C. Allows input
D. Constantly affected by matter, energy, information

54. Who postulated the WHOLISTIC concept that the totality is greater than sum of its parts?

A. Roy
B. Rogers
C. Henderson
D. Johnson

55. She theorized that man is composed of sub and supra systems. Subsystems are cells,
tissues, organs and systems while the suprasystems are family, society and community.

A. Roy
B. Rogers
C. Henderson
D. Johnson

56. Which of the following is not true about the human needs?

A. Certain needs are common to all people

B. Needs should be followed exactly in accordance with their hierarchy
C. Needs are stimulated by internal factors
D. Needs are stimulated by external factors

57. Which of the following is TRUE about the human needs?

A. May not be deferred
B. Are not interrelated
C. Met in exact and rigid way
D. Priorities are alterable

58. According to Maslow, which of the following is NOT TRUE about a self actualized person?

A. Understands poetry, music, philosophy, science etc.

B. Desires privacy, autonomous
C. Follows the decision of the majority, uphold justice and truth
D. Problem centered

59. According to Maslow, which of the following is TRUE about a self actualized person?

A. Makes decision contrary to public opinion

B. Do not predict events
C. Self centered
D. Maximum degree of self conflict

60. This is the essence of mental health

A. Self awareness
B. Self actualization
C. Self esteem
D. Self worth

61. Florence Nightingale was born in

A. Germany
B. Britain
C. France
D. Italy

62. Which is unlikely of Florence Nightingale?

A. Born May 12, 1840
B. Built St. Thomas school of nursing when she was 40 years old
C. Notes in nursing
D. Notes in hospital

63. What country did Florence Nightingale train in nursing?

A. Belgium
B. US
C. Germany
D. England

64. Which of the following is recognized for developing the concept of HIGH LEVEL
WELLNESS?

A. Erikson
B. Madaw
C. Peplau
D. Dunn

65. One of the expectations is for nurses to join professional association primarily because
of

A. Promotes advancement and professional growth among its members

B. Works for raising funds for nurse’s benefit
C. Facilitate and establishes acquaintances
D. Assist them and securing jobs abroad

66. Founder of the PNA

A. Julita Sotejo
B. Anastacia Giron Tupas
C. Eufemia Octaviano
D. Anesia Dionisio
67. Which of the following provides that nurses must be a member of a national nurse
organization?

A. R.A 877
B. 1981 Code of ethics approved by the house of delegates and the PNA
C. Board resolution No. 1955 Promulgated by the BON
D. RA 7164

68. Which of the following best describes the action of a nurse who documents her nursing
diagnosis?

A. She documents it and charts it whenever necessary

B. She can be accused of malpractice
C. She does it regularly as an important responsibility
D. She charts it only when the patient is acutely ill

69. Which of the following does not govern nursing practice?

A. RA 7164
B. RA 9173
C. BON Res. Code Of Ethics
D. BON Res. Scope of Nursing Practice

70. A nurse who is maintaining a private clinic in the community renders service on maternal
and child health among the neighborhood for a fee is:

A. Primary care nurse

B. Independent nurse practitioner
C. Nurse-Midwife
D. Nurse specialist

71. When was the PNA founded?

A. September 22, 1922

B. September 02, 1920
C. October 21, 1922
D. September 02, 1922

72. Who was the first president of the PNA ?

A. Anastacia Giron-Tupas
B. Loreto Tupas
C. Rosario Montenegro
D. Ricarda Mendoza

73. Defines health as the ability to maintain internal milieu. Illness according to him/her/them
is the failure to maintain internal environment.

A. Cannon
B. Bernard
C. Leddy and Pepper
D. Roy

74. Postulated that health is a state and process of being and becoming an integrated and
whole person.

A. Cannon
B. Bernard
C. Dunn
D. Roy

75. What regulates HOMEOSTASIS according to the theory of Walter Cannon?

A. Positive feedback
B. Negative feedback
C. Buffer system
D. Various mechanisms

76. Stated that health is WELLNESS. A termed define by the culture or an individual.
A. Roy
B. Henderson
C. Rogers
D. King

77. Defined health as a dynamic state in the life cycle, and Illness as interference in the life
cycle.

A. Roy
B. Henderson
C. Rogers
D. King

78. She defined health as the soundness and wholness of developed human structure and
bodily mental functioning.

A. Orem
B. Henderson
C. Neuman
D. Clark

79. According to her, Wellness is a condition in which all parts and subparts of an individual
are in harmony with the whole system.

A. Orem
B. Henderson
C. Neuman
D. Johnson

80. Postulated that health is reflected by the organization, interaction, interdependence and
integration of the subsystem of the behavioral system.

A. Orem
B. Henderson
C. Neuman
D. Johnson
81. According to them, Well being is a subjective perception of BALANCE, HARMONY and
VITALITY

A. Leavell and Clark

B. Peterson and Zderad
C. Benner and Wruber
D. Leddy and Pepper

82. He describes the WELLNESS-ILLNESS Continuum as interaction of the environment with

well being and illness.

A. Cannon
B. Bernard
C. Dunn
D. Clark

83. An integrated method of functioning that is oriented towards maximizing one’s potential
within the limitation of the environment.

A. Well being
B. Health
C. Low level Wellness
D. High level Wellness

84. What kind of illness precursor, according to DUNN is cigarette smoking?

A. Heredity
B. Social
C. Behavioral
D. Environmental

85. According to DUNN, Overcrowding is what type of illness precursor?

A. Heredity
B. Social
C. Behavioral
D. Environmental

86. Health belief model was formulated in 1975 by who?

A. Becker
B. Smith
C. Dunn
D. Leavell and Clark

87. In health belief model, Individual perception matters. Which of the following is highly
UNLIKELY to influence preventive behavior?

A. Perceived susceptibility to an illness

B. Perceived seriousness of an illness
C. Perceived threat of an illness
D. Perceived curability of an illness

88. Which of the following is not a PERCEIVED BARRIER in preventive action?

A. Difficulty adhering to the lifestyle

B. Economic factors
C. Accessibility of health care facilities
D. Increase adherence to medical therapies

89. Conceptualizes that health is a condition of actualization or realization of person’s

potential. Avers that the highest aspiration of people is fulfillment and complete development
actualization.

A. Clinical Model
B. Role performance Model
C. Adaptive Model
D. Eudaemonistic Model

90. Views people as physiologic system and Absence of sign and symptoms equates health.
A. Clinical Model
B. Role performance Model
C. Adaptive Model
D. Eudaemonistic Model

91. Knowledge about the disease and prior contact with it is what type of VARIABLE
according to the health belief model?

A. Demographic
B. Sociopsychologic
C. Structural
D. Cues to action

92. It includes internal and external factors that leads the individual to seek help

A. Demographic
B. Sociopsychological
C. Structural
D. Cues to action

93. Influence from peers and social pressure is included in what variable of HBM?

A. Demographic
B. Sociopsychological
C. Structural
D. Cues to action

94. Age, Sex, Race etc. is included in what variable of HBM?

A. Demographic
B. Sociopsychological
C. Structural
D. Cues to action

95. According to Leavell and Clark’s ecologic model, All of this are factors that affects health
and illness except
A. Reservoir
B. Agent
C. Environment
D. Host

96. Is a multi dimensional model developed by PENDER that describes the nature of persons
as they interact within the environment to pursue health

A. Ecologic Model
B. Health Belief Model
C. Health Promotion Model
D. Health Prevention Model

97. Defined by Pender as all activities directed toward increasing the level of well being and
self actualization.

A. Health prevention
B. Health promotion
C. Health teaching
D. Self actualization

98. Defined as an alteration in normal function resulting in reduction of capacities and

shortening of life span.

A. Illness
B. Disease
C. Health
D. Wellness

99. Personal state in which a person feels unhealthy

A. Illness
B. Disease
C. Health
D. Wellness
100. According to her, Caring is defined as a nurturant way of responding to a valued client
towards whom the nurse feels a sense of commitment and responsibility.

A. Benner
B. Watson
C. Leininger
D. Swanson

Answers & Rationale

Gauge your performance by counter-checking your answers to those below. If you have disputes or
further questions, please direct them to the comments section.

1. Answer: D. Person, Environment, Nursing, Health

Theorist always describes The nursing profession by first defining what is NURSING, followed by the
PERSON, ENVIRONMENT and HEALTH CONCEPT. The most popular theory was perhaps
Nightingale’s. She defined nursing as the utilization of the persons environment to assist him
towards recovery. She defined the person as somebody who has a reparative capabilities mediated
and enhanced by factors in his environment. She describes the environment as something that
would facilitate the person’s reparative process and identified different factors like sanitation, noise,
etc. that affects a person’s reparative state.

2. Answer: A. Nightingale

Florence Nightingale do not believe in the Germ Theory, and perhaps this was her biggest mistake.
Yet, her theory was the first in nursing. She believed that manipulation of environment that includes
appropriate noise, nutrition, hygiene, light, comfort, sanitation etc. could provide the client’s body the
nurturance it needs for repair and recovery.

3. Answer: C. Roy

Remember the word “theoROYtical” for Callista Roy. Nursing is a theoretical body of knowledge that
prescribes analysis and action to care for an ill person. Roy introduced the Adaptation Model and
viewed a person as a biopsychosocial being. She believed that by adaptation, a person can maintain
homeostasis.

4. Answer: B. Orem

In self care deficit theory, Nursing is defined as a helping or assistive profession to person who are
wholly or partly dependent or when people who are to give care to them are no longer available. Self
care are the activities that a person do for himself to maintain health, life and well being.

5. Answer: A. Neuman

Neuman divided stressors as either intra, inter and extra personal in nature. She said that NURSING
is concerned with eliminating these stressors to obtain a maximum level of wellness. The nurse
helps the client through PRIMARY, SECONDARY AND TERTIARY prevention modes.

6. Answer: A. Henderson

Remember this definition and associate it with Virginia Henderson. Henderson also describes the
NATURE OF NURSING theory. She identified 14 basic needs of the client. She describes nursing
roles as:

 Substitutive: Doing everything for the client;

 Supplementary: Helping the client; and
 Complementary: Working with the client.
Breathing normally, eliminating waste, eating and drinking adequately, worship and play are some of
the basic needs according to her.

7. Answer: C. Leininger

There are many theorists that describes nursing as CARE. The most popular was JEAN WATSON’S
Human Caring Model. But this question pertains to Leininger’s definition of caring. CUD I LIE IN
GER? [ Could I Lie In There ] Is the Mnemonics I am using not to get confused. C stands for
CENTRAL , U stands for UNIFYING, D stands for DOMINANT DOMAIN.

8. Answer: D. Swanson
Caring according to Swanson involves 5 processes. Knowing means understanding the client. Being
with emphasizes the Physical presence of the nurse for the patient. Doing for means doing things for
the patient when he is incapable of doing it for himself. Enabling means helping client transcend
maturational and developmental stressors in life while Maintaining belief is the ability of the Nurse to
inculcate meaning to these events.

9. Answer: B. Watson

The deepest and spiritual definition of caring came from Jean Watson. For her, caring expands the
limits of openness and allows access to higher human spirit.

10. Answer: A. Benner

11. Answer: B. It serves specific interest of a group

A profession should serve the whole community and not just a specific interest of a group. All other
choices are correct.

12. Answer: A. Concerned with quantity

A professional is concerned with quality and not quantity. In nursing, We have methods of quality
assurance and control to evaluate the effectiveness of nursing care. Nurses, are never concerned
with quantity of care provided.

13. Answer: C. Caring

Caring and caring alone, is the most unique quality of the Nursing Profession. It is the one the
delineate nursing from other professions.

14. Answer: B. Personality

Personality are qualities that make us different from each other. These are impressions that we
made, or the footprints that we leave behind. This is the result of the integration of one’s talents,
behavior, appearance, mood, character, morals and impulses into one harmonious whole.
Philosophy is the basic truth that fuel our soul and give our life a purpose, it shapes the facets of a
person’s character. Charm is to attract other people to be a change agent. Character is our moral
values and belief that guides our actions in life.

15. Answer: D. Character

Character is our moral values and belief that guides our actions in life.

16. Answer: D. Provide in service education programs. Use accurate nursing audit, formulate
philosophy and vision of the institution

A refers to being a change agent. B is a role of a patient advocate. C is a case manager while D
basically summarized functions of a nurse manager. If you haven’t read Lydia Venzon’s Book :
NURSING MANAGEMENT TOWARDS QUALITY CARE, I suggest reading it in advance for your
management subjects in the graduate school. Formulating philosophy and vision is in PLANNING.
Nursing Audit is in CONTROLLING, In service education programs are included in DIRECTING.
These are the processes of Nursing Management, I just forgot to add ORGANIZING which includes
formulating an organizational structure and plans, Staffing and developing qualifications and job
descriptions.

17. Answer: A. Determine client’s need

You can never provide nursing care if you don’t know what are the needs of the client. How can you
provide an effective postural drainage if you do not know where is the bulk of the client’s secretion.
Therefore, the best description of a care provider is the accurate and prompt determination of the
client’s need to be able to render an appropriate nursing care.

18. Answer: B. Client advocate

As a client’s advocate, nurses are to protect the client’s rights and promotes what is best for the
them. Knowing that morphine causes spasm of the Sphincter of Oddi and will lead to further
increase in the client’s pain, the nurse should know that the the best treatment option for the client
was not provided and intervene to provide the best possible care.

19. Answer: C. Interdependent

Interdependent functions are those that needs expertise and skills of multiple health professionals.
20. Answer: A. Total patient care

This is also known as case nursing. It is a method of nursing care wherein, one nurse is assigned to
one patient for the delivery of total care. These are the method use by nursing students. Private duty
nurses and those in critical or isolation units.

21. Answer: D. Total patient care

Total patient care works best if there are many nurses but few patients.

22. Answer: A. Functional nursing

Functional nursing is task oriented. One nurse is assigned on a particular task leading to task
expertise and efficiency. The nurse will work fast because the procedures are repetitive leading to
task mastery. This care is not recommended as this leads fragmented nursing care.

23. Answer: C. Primary nursing

Your keyword in Primary Nursing is the 24 hours. This does not necessarily mean the nurse is
awake for 24 hours. The nurse can have secondary nurses that can take care of the the patient
during shifts where the primary nurse is not around.

24. Answer: D. Nightingale

Hammurabi is a king of Babylon that introduced the “Lex Taliones” law or better be described as “an
eye for an eye and a tooth for a tooth.” Alexander the Great was the son of King Philip II and is from
Macedonia but he ruled and conquered Greece, Persia and Egypt. He is known to use a hammer to
crush a dying soldier’s medulla giving a speedy death. Fabiola was a beautiful Roman matron who
converted her house into a hospital.

25. Answer: A. Henderson

Refer to question # 6.

26. Answer: A. Levin

Myra Levin described the 4 Conservation principles which are concerned with the Unity and Integrity
of an individual.

 Energy: Output to facilitate meeting our needs.

 Structural Integrity: Maintaining the integrity of our organs, tissues and systems to
prevent harmful agents from entering one’s body.
 Personal Integrity: These refers to one’s self-esteem, self worth, self concept, identity and
personality.
 Social Integrity: Reflects one’s societal roles to one’s society, community, family, friends
and fellow individuals.
27. Answer: D. Neuman

Betty Neuman asserted that nursing is a unique profession and is concerned with all the variables
affecting the individual’s response to stressors. These are INTRA or within ourselves, EXTRA or
outside the individual, INTER means between two or more people.

She proposed the Health Care System Model which states that by the three levels of prevention —
primary, secondary, tertiary — the nurse can help the client maintain stability against these
stressors.

28. Answer: B. Johnson

According to Dorothy Johnson, each person is a behavioral system that is composed of seven (7)
subsystems. Man adjusts or adapts to stressors by a using a learned pattern of response. Man uses
his behavior to meet the demands of the environment, and is able to modify his behavior to support
these demands.

29. Answer: C. Weidenbach

The Helping Art of Clinical Nursing was developed by Ernestine Wiedenbach. It defines nursing as
the practice of identifying a patient’s need for help through the observation of presenting behavior
and symptoms, exploration of the meaning of those symptoms, determination of the cause of
discomfort, the determination of the patient’s ability to resolve the patient’s discomfort, or
determining if the patient has a need of help from the nurse or another health care professional.

30. Answer: A. Erickson, Tomlin, Swain

Modeling and Role Modeling theory was developed by Helen C. Erickson, Evelyn M. Tomlin, and
Mary Ann P. Swain. It enables nurses to care for and nurture each client with an awareness of and
respect for the individual’s uniqueness which exemplifies theory-based clinical practice that focuses
on the clients’ needs.

31. Answer: D. Boykin,Schoenhofer

This theory was called GRAND THEORY because Boykin and Schoenhofer thinks that “all men are
caring” and that nursing is a response to this unique call. According to them, caring is “a moral
imperative” meaning all people will tend to help a man even if he is not trained to do so.

32. Answer: A. Travelbee

Travelbee’s theory was referred to as Interpersonal Theory because she postulated that nursing “is
to assist the individual and all people that affects this individual to cope with illness, recover and find
meaning to this experience.” For her, nursing is a human to human relationship that is formed during
illness.

33. Answer: C. Kohlberg

Kohlber states that relationships are based on mutual trust. He postulated the levels of morality
development. At the first stage called the premoral or preconventional. A child do things and label
them as bad or good depending on the punishment or reward they get.

34. Answer: D. Peters

Peters believes that morality has 3 components:

 Emotions or how one feels;

 Judgement or how one reasons;
 Behavior or how one actuates his emotions and judgement.
35. Answer: C. Identification

A child, according to Freud adopts parental standards, traits, habits and norms through identication.
A good example is the corned beef commercial ” WALK LIKE A MAN, TALK LIKE A MAN ” Where
the child identifies with his father by wearing the same clothes and doing the same thing.
36. Answer: D. Schulman and Mekler

According to Schulman and Mekler, there are 2 components that makes an action MORAL : The
intention should be good and the Act must be just. A good example is ROBIN HOOD, His intention is
GOOD but the act is UNJUST, which makes his action IMMORAL.

37. Answer: B. Westerhoff

There are only 2 theorist of FAITH that might be asked in the board examinations. Fowler and
Westerhoff. What differs them is that, FAITH of fowler is defined abstractly, Fowler defines faith as a
FORCE that gives a meaning to a person’s life while Westerhoff defines faith as a behavior that
continuously develops through time.

38. Answer: C. Fowler

Refer to # 37

39. Answer: B. Iloilo Mission Hospital School of Nursing

This is the first School of Nursing in the Philippines which started in 1906 and produced the three
graduate nurses in 1909. Now, the School of Nursing was transferred at Central Philippine
University.

40. Answer: C. Philippine General Hospital

In 1917, Tupas was named the first Filipino chief nurse and superintendent of the Philippine General
Hospital School of Nursing. She also headed the committee that prepared the bill systematizing
Philippine nursing education passed in 1919. In 1959, through the initiative of the Civic Assembly of
Women of the Philippines, she received the Presidential medal of merit.

41. Answer: A. Elizabeth

Saint Elizabeth of Hungary was a daughter of a King and is the patron saint of nurses. She build
hospitals and feed hungry people everyday using the kingdom’s money. She is a princess, but
devoted her life in feeding the hungry and serving the sick.
42. Answer: A. Clara Louise Maass

Clara Louise Maass sacrificed her life in research of YELLOW FEVER. People during her time do
not believe that yellow fever was brought by mosquitoes. To prove that they are wrong, She allowed
herself to be bitten by the vector and after days, She died.

43. Answer: C. Moses

More than 1000 years before Christ, Moses was recognized as the “Father of Sanitation.” He wrote
rules for sanitation. He stated that all people preparing and serving public food must be neat and
clean. Moses also required that serving dishes and cooking utensils be washed between customers
and public restaurants.

44. Answer: C. India

45. Answer: A. Chinese

Chinese believes that male newborns are demon magnets. To fool those demons, they put female
clothes to their male newborn.

46. Answer: B. Intuitive period

Egyptians believe that a sick person is someone with an evil force or demon that is inside their
heads. To release these evil spirits, They would tend to drill holes on the patient’s skull and it is
called TREPHINING.

47. Answer: A. Apprentice period

What delineates apprentice period among others is that, it ENDED when formal schools were
established. During the apprentice period, There is no formal educational institution for nurses. Most
of them receive training inside the convent or church. Some of them are trained just for the purpose
of nursing the wounded soldiers. But almost all of them are influenced by the christian faith to serve
and nurse the sick. When Fliedner build the first formal school for nurses, It marked the end of the
APPRENTICESHIP period.

48. Answer: A. Apprentice period

Apprentice period is marked by the emergence of religious orders the are devoted to religious life
and the practice of nursing.

49. Answer: C. St. Clare

The poor St. Clare is the second order of St. Francis of Assisi. The first order was founded by St.
Francis himself. St. Catherine of Sienna was the first lady with the lamp. St. Anne is the mother of
Mary. St. Elizabeth is the patron saint of Nursing.

50. Answer: B. Dark period

Protestantism emerged with Martin Luther questions the Pope and Christianity. This started the Dark
period of nursing when the christian faith was smeared by controversies. These leads to closure of
some hospital and schools run by the church. Nursing became the work of prostitutes, slaves,
mother and least desirable of women.

51. Answer: B. Like some other men

According to ROY, Man as a social being is like some other man. As a spiritual being and Biologic
being, Man are all alike. As a psychologic being, No man thinks alike. This basically summarized her
BIOPSYHOSOCIAL theory which is included in our licensure exam coverage.

52. Answer: A. Roy

OPEN system theory is ROY. As an open system, man continuously allows input from the
environment. Example is when you tell me Im good looking, I will be happy the entire day, Because I
am an open system and continuously interact and transact with my environment. A close system is
best exemplified by a CANDLE. When you cover the candle with a glass, it will die because it will
eventually use all the oxygen it needs inside the glass for combustion. A closed system do not allow
inputs and output in its environment.

53. Answer: B. A sole island in vast ocean

54. Answer: B. Rogers

The holistic theory by Martha Rogers states that MAN is greater than the sum of all its parts and that
his dignity and worth will not be lessen even if one of this part is missing. A good example is ANNE
BOLEYN, The mother of Queen Elizabeth and the wife of King Henry VIII. She was beheaded
because Henry wants to marry another wife and that his divorce was not approved by the pope.
Outraged, He insisted on the separation of the Church and State and divorce Anne himself by
making everyone believe that Anne is having an affair to another man. Anne was beheaded while
her lips is still saying a prayer. Even without her head, People still gave respect to her diseased body
and a separate head. She was still remembered as Anne Boleyn, Mother of Elizabeth who lead
England to their GOLDEN AGE.

55. Answer: B. Rogers

According to Martha Rogers, Man is composed of 2 systems : SUB which includes cells, tissues,
organs and system and SUPRA which includes our family, community and society. She stated that
when any of these systems are affected, it will affect the entire individual.

56. Answer: B. Needs should be followed exactly in accordance with their hierarchy

Needs can be deferred. I can urinate later as not to miss the part of the movie’s climax. I can save
my money that are supposedly for my lunch to watch my idols in concert. The physiologic needs can
be meet later for some other needs and need not be strictly followed according to their hierarchy.

57. Answer: D. Priorities are alterable

58. Answer: C. Follows the decision of the majority, uphold justice and truth

A,B and D are all qualities of a self actualized person. A self actualized person do not follow the
decision of majority but is self directed and can make decisions contrary to a popular opinion.

59. Answer: A. Makes decision contrary to public opinion

60. Answer: B. Self actualization

The peak of Maslow’s hierarchy is the essence of mental health.

61. Answer: D. Italy

Florence Nightingale was born in Florence, Italy, May 12, 1820. Studied in Germany and Practiced
in England.

62. Answer: A. Born May 12, 1840

63. Answer: C. Germany

64. Answer: D. Dunn

According to Dunn, High level wellness is the ability of an individual to maximize his full potential
with the limitations imposed by his environment. According to him, An individual can be healthy or ill
in both favorable and unfavorable environment.

65. Answer: A. Promotes advancement and professional growth among its members

66. Answer: B. Anastacia Giron Tupas

Anastasia Giron Tupas is the founder of PNA (formerly Filipino Nurses Association) and the Dean of
Philippine Nursing. Founded on September 2, 1922 as Filipino Nurses Association (FNA) in a
meeting of 150 nurses, the FNA was incorporated in 1924.

67. Answer: C. Board resolution No. 1955 Promulgated by the BON

This is an old board resolution. The new Board resolution is No. 220 series of 2004 also known as
the Nursing Code Of Ethics which states that “A nurse should be a member of an accredited
professional organization which is the PNA.”

68. Answer: C. She does it regularly as an important responsibility

69. Answer: A. RA 7164

7164 is an old law. This is the 1991 Nursing Law which was repealed by the newer RA 9173.

70. Answer: B. Independent nurse practitioner

71. Answer: D. September 02, 1922

According to the official PNA website, they are founded September 02, 1922.

72. Answer: C. Rosario Montenegro

Anastacia Giron Tupas founded the FNA, the former name of the PNA but the first President was
Rosario Montenegro.

73. Answer: B. Bernard

According to Bernard, Health is the ability to maintain and Internal Milieu and Illness is the failure to
maintain the internal environment.

74. Answer: D. Roy

According to ROY, Health is a state and process of becoming a WHOLE AND INTEGRATED
Person.

75. Answer: B. Negative feedback

The theory of Health as the ability to maintain homeostasis was postulated by Walter Cannon.
According to him, There are certain FEEDBACK Mechanism that regulates our Homeostasis. A good
example is that when we overuse our arm, it will produce pain. PAIN is a negative feedback that
signals us that our arm needs a rest.

76. Answer: C. Rogers

Martha Rogers states that HEALTH is synonymous with WELLNESS and that HEALTH and
WELLNESS is subjective depending on the definition of one’s culture.

77. Answer: D. King

Emogene King states that health is a state in the life cycle and Illness is any interference on this
cycle. I enjoyed the Movie LION KING and like what Mufasa said that they are all part of the CIRCLE
OF LIFE, or the Life cycle.

78. Answer: A. Orem

Orem defined health as the SOUNDNESS and WHOLENESS of developed human structure and of
bodily and mental functioning.

79. Answer: C. Neuman

Neuman believe that man is composed of sub parts and when this sub parts are in harmony with the
whole system, Wellness results. Please do not confuse this with the SUB and SUPRA systems of
Martha rogers.

80. Answer: D. Johnson

Once you see the phrase BEHAVIORAL SYSTEM, answer Dorothy Johnson.

81. Answer: D. Leddy and Pepper

According to Leedy and Pepper, Wellness is subjective and depends on an individuals perception of
balance, harmony and vitality. Leavell and Clark postulated the ecologic model of health and illness
or the AGENT-HOST-ENVIRONMENT model. Paterson and Zderad developed the HUMANISTIC
NURSING PRACTICE theory while Benner and Wrubel postulate the PRIMACY OF CARING
MODEL.

82. Answer: C. Dunn

83. Answer: D. High level Wellness

84. Answer: C. Behavioral

Behavioral precursors includes smoking, alcoholism, high fat intake and other lifestyle choices.
Environmental factors involved poor sanitation and over crowding. Heredity includes congenital and
diseases acquired through the genes. There are no social precursors according to DUNN.

85. Answer: D. Environmental

86. Answer: A. Becker

According to Becker, The belief of an individual greatly affects his behavior. If a man believes that he
is susceptible to an illness, He will alter his behavior in order to prevent its occurrence. For example,
If a man thinks that diabetes is acquired through high intake of sugar and simple carbohydrates, then
he will limit the intake of foods rich in these components.

87. Answer: D. Perceived curability of an illness

If a man think he is susceptible to a certain disease, thinks that the disease is serious and it is a
threat to his life and functions, he will use preventive behaviors to avoid the occurrence of this threat.

88. Answer: A. Difficulty adhering to the lifestyle or B. Economic factors

Perceived barriers are those factors that affects the individual’s health preventive actions. Both A
and B can affect the individual’s ability to prevent the occurrence of diseases. C and D are called
Preventive Health Behaviors which enhances the individual’s preventive capabilities.

89. Answer: D. Eudaemonistic Model

Smith formulated 5 models of health. Clinical model simply states that when people experience sign
and symptoms, they would think that they are unhealthy therefore, Health is the absence of clinical
sign and symptoms of a disease. Role performance model states that when a person does his role
and activities without deficits, he is healthy and the inability to perform usual roles means that the
person is ill. Adaptive Model states that if a person adapts well with his environment, he is healthy
and maladaptation equates illness. Eudaemonistic Model of health according to smith is the
actualization of a person’s fullest potential. If a person functions optimally and develop self
actualization, then, no doubt that person is healthy.

90. Answer: A. Clinical Model

Refer to question # 89.

91. Answer: C. Structural

Modifying variables in Becker’s health belief model includes DEMOGRAPHIC : Age, sex, race etc.
SOCIOPSYCHOLOGIC : Social and Peer influence. STRUCTURAL : Knowledge about the disease
and prior contact with it and CUES TO ACTION : Which are the sign and symptoms of the disease
or advice from friends, mass media and others that forces or makes the individual seek help.

92. Answer: D. Cues to action

93. Answer: B. Sociopsychologic

94. Answer: A. Demographic

95. Answer: A. Reservoir

According to L&C’s Ecologic model, there are 3 factors that affect health and illness. These are the
AGENT or the factor the leads to illness, either a bacteria or an event in life. HOST are persons that
may or may not be affected by these agents. ENVIRONMENT are factors external to the host that
may or may not predispose him to the AGENT.

96. Answer: C. Health Promotion Model

Pender developed the concept of HEALTH PROMOTION MODEL which postulated that an
individual engages in health promotion activities to increase well being and attain self actualization.
These includes exercise, immunization, healthy lifestyle, good food, self responsibility and all other
factors that minimize if not totally eradicate risks and threats of health.

97. Answer: B. Health promotion

98. Answer: B. Disease

Diseases are alteration in body functions resulting in reduction of capabilities or shortening of

lifespan.

99. Answer: A. Illness

Illness is something personal in perspective. Unlike disease, illnesses are in which a person feels a
state of being unhealthy. An old person may think he is ill but in fact, he is not, due to diminishing
functions and capabilities of his body.
100. Answer: B. Watson

This is Jean Watson’s definition of Nursing as caring.

1. When the General adaptation syndrome is activated, FLIGHT OR FIGHT response sets in.
Sympathetic nervous system releases norepinephrine while the adrenal medulla secretes
epinephrine. Which of the following is true with regards to that statement?

A. Pupils will constrict

B. Client will be lethargic
C. Lungs will bronchodilate
D. Gastric motility will increase

2. Which of the following response is not expected to a person whose GAS is activated and
the FIGHT OR FLIGHT response sets in?

A. The client will not urinate due to relaxation of the detrusor muscle
B. The client will be restless and alert
C. Clients BP will increase, there will be vasodilation
D. There will be increase glycogenolysis, Pancrease will decrease insulin secretion

3. State in which a person’s physical, emotional, intellectual and social development or

spiritual functioning is diminished or impaired compared with a previous experience.

A. Illness
B. Disease
C. Health
D. Wellness

4. This is the first stage of illness wherein, the person starts to believe that something is
wrong. Also known as the transition phase from wellness to illness.

A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
5. In this stage of illness, the person accepts or rejects a professionals suggestion. The
person also becomes passive and may regress to an earlier stage.

A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role

7. In this stage, the person tries to find answers for his illness. He wants his illness to be
validated, his symptoms explained and the outcome reassured or predicted

A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role

8. The following are true with regards to aspect of the sick role except

A. One should be held responsible for his condition

B. One is excused from his societal role
C. One is obliged to get well as soon as possible
D. One is obliged to seek competent help

9. Refers to conditions that increases vulnerability of individual or group to illness or

accident

A. Predisposing factor
B. Etiology
C. Risk factor
D. Modifiable Risks

10. Refers to the degree of resistance the potential host has against a certain pathogen
A. Susceptibility
B. Immunity
C. Virulence
D. Etiology

11. A group of symptoms that sums up or constitute a disease

A. Syndrome
B. Symptoms
C. Signs
D. Etiology

12. A woman undergoing radiation therapy developed redness and burning of the skin
around the best. This is best classified as what type of disease?

A. Neoplastic
B. Traumatic
C. Nosocomial
D. Iatrogenic

13. The classification of CANCER according to its etiology Is best described as:

1. Nosocomial
2. Idiopathic
3. Neoplastic
4. Traumatic
5. Congenital
6. Degenrative

A. 5 and 2
B. 2 and 3
C. 3 and 4
D. 3 and 5

14. Term to describe the reactiviation and recurrence of pronounced symptoms of a disease
A. Remission
B. Emission
C. Exacerbation
D. Sub acute

15. A type of illness characterized by periods of remission and exacerbation

A. Chronic
B. Acute
C. Sub acute
D. Sub chronic

16. Diseases that results from changes in the normal structure, from recognizable anatomical
changes in an organ or body tissue is termed as

A. Functional
B. Occupational
C. Inorganic
D. Organic

17. It is the science of organism as affected by factors in their environment. It deals with the
relationship between disease and geographical environment.

A. Epidemiology
B. Ecology
C. Statistics
D. Geography

18. This is the study of the patterns of health and disease. Its occurrence and distribution in
man, for the purpose of control and prevention of disease.

A. Epidemiology
B. Ecology
C. Statistics
D. Geography
19. Refers to diseases that produced no anatomic changes but as a result from abnormal
response to a stimuli.

A. Functional
B. Occupational
C. Inorganic
D. Organic

20. In what level of prevention according to Leavell and Clark does the nurse support the
client in obtaining OPTIMAL HEALTH STATUS after a disease or injury?

A. Primary
B. Secondary
C. Tertiary
D. None of the above

21. In what level of prevention does the nurse encourage optimal health and increases
person’s susceptibility to illness?

A. Primary
B. Secondary
C. Tertiary
D. None of the above

22. Also known as HEALTH MAINTENANCE prevention.

A. Primary
B. Secondary
C. Tertiary
D. None of the above

23. PPD In occupational health nursing is what type of prevention?

A. Primary
B. Secondary
C. Tertiary
D. None of the above

24. BCG in community health nursing is what type of prevention?

A. Primary
B. Secondary
C. Tertiary
D. None of the above

25. A regular pap smear for woman every 3 years after establishing normal pap smear for 3
consecutive years Is advocated. What level of prevention does this belongs?

A. Primary
B. Secondary
C. Tertiary
D. None of the above

26. Self monitoring of blood glucose for diabetic clients is on what level of prevention?

A. Primary
B. Secondary
C. Tertiary
D. None of the above

27. Which is the best way to disseminate information to the public?

A. Newspaper
B. School bulletins
C. Community bill boards
D. Radio and Television

28. Who conceptualized health as integration of parts and subparts of an individual?

A. Newman
B. Neuman
C. Watson
D. Rogers

29. The following are concept of health:

1. Health is a state of complete physical, mental and social wellbeing and not merely an absence of
disease or infirmity.
2. Health is the ability to maintain balance
3. Health is the ability to maintain internal milieu
4. Health is integration of all parts and subparts of an individual

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

30. The theorist the advocated that health is the ability to maintain dynamic equilibrium is

A. Bernard
B. Selye
C. Cannon
D. Rogers

31. Excessive alcohol intake is what type of risk factor?

A. Genetics
B. Age
C. Environment
D. Lifestyle

32. Osteoporosis and degenerative diseases like Osteoarthritis belongs to what type of risk
factor?

A. Genetics
B. Age
C. Environment
D. Lifestyle

33. Also known as STERILE TECHNIQUE

A. Surgical Asepsis
B. Medical Asepsis
C. Sepsis
D. Asepsis

34. This is a person or animal, who is without signs of illness but harbors pathogen within his
body and can be transferred to another

A. Host
B. Agent
C. Environment
D. Carrier

35. Refers to a person or animal, known or believed to have been exposed to a disease.

A. Carrier
B. Contact
C. Agent
D. Host

36. A substance usually intended for use on inanimate objects, that destroys pathogens but
not the spores.

A. Sterilization
B. Disinfectant
C. Antiseptic
D. Autoclave

37. This is a process of removing pathogens but not their spores

A. Sterilization
B. Auto claving
C. Disinfection
D. Medical asepsis

38. The third period of infectious processes characterized by development of specific signs
and symptoms

A. Incubation period
B. Prodromal period
C. Illness period
D. Convalescent period

39. A child with measles developed fever and general weakness after being exposed to
another child with rubella. In what stage of infectious process does this child belongs?

A. Incubation period
B. Prodromal period
C. Illness period
D. Convalescent period

40. A 50 year old mailman carried a mail with anthrax powder in it. A minute after exposure,
he still hasn’t developed any signs and symptoms of anthrax. In what stage of infectious
process does this man belongs?

A. Incubation period
B. Prodromal period
C. Illness period
D. Convalescent period

41. Considered as the WEAKEST LINK in the chain of infection that nurses can manipulate to
prevent spread of infection and diseases

A. Etiologic/Infectious agent
B. Portal of Entry
C. Susceptible host
D. Mode of transmission

42. Which of the following is the exact order of the infection chain?

1. Susceptible host
2. Portal of entry
3. Portal of exit
4. Etiologic agent
5. Reservoir
6. Mode of transmission

A. 1, 2, 3, 4, 5, 6
B. 5, 4, 2, 3, 6, 1
C. 4, 5, 3, 6, 2, 1
D. 6, 5, 4, 3, 2, 1

43. Markee, A 15 year old high school student asked you. What is the mode of transmission
of Lyme disease. You correctly answered him that Lyme disease is transmitted via

A. Direct contact transmission

B. Vehicle borne transmission
C. Air borne transmission
D. Vector borne transmission

44. The ability of the infectious agent to cause a disease primarily depends on all of the
following except

A. Pathogenicity
B. Virulence
C. Invasiveness
D. Non Specificity

45. Contact transmission of infectious organism in the hospital is usually cause by

A. Urinary catheterization
B. Spread from patient to patient
C. Spread by cross contamination via hands of caregiver
D. Cause by unclean instruments used by doctors and nurses

46. Transmission occurs when an infected person sneezes, coughs or laugh that is usually
projected at a distance of 3 feet.

A. Droplet transmission
B. Airborne transmission
C. Vehicle transmission
D. Vector borne transmission

47. Considered as the first line of defense of the body against infection

A. Skin
B. WBC
C. Leukocytes
D. Immunization

48. All of the following contributes to host susceptibility except

A. Creed
B. Immunization
C. Current medication being taken
D. Color of the skin

49. Graciel has been injected TT5, her last dosed for tetanus toxoid immunization. Graciel
asked you, what type of immunity is TT Injections? You correctly answer her by saying
Tetanus toxoid immunization is a/an

A. Natural active immunity

B. Natural passive immunity
C. Artificial active immunity
D. Artificial passive immunity
50. Agatha, was hacked and slashed by a psychotic man while she was crossing the railway.
She suffered multiple injuries and was injected Tetanus toxoid Immunoglobulin. Agatha
asked you, What immunity does TTIg provides? You best answered her by saying TTIg
provides

A. Natural active immunity

B. Natural passive immunity
C. Artificial active immunity
D. Artificial passive immunity

51. This is the single most important procedure that prevents cross contamination and
infection

A. Cleaning
B. Disinfecting
C. Sterilizing
D. Handwashing

52. This is considered as the most important aspect of handwashing

A. Time
B. Friction
C. Water
D. Soap

53. In handwashing by medical asepsis, hands are held…

A. Above the elbow, The hands must always be above the waist
B. Above the elbow, The hands are cleaner than the elbow
C. Below the elbow, Medical asepsis do not require hands to be above the waist
D. Below the elbow, Hands are dirtier than the lower arms

54. The suggested time per hand on handwashing using the time method is

A. 5 to 10 seconds each hand

B. 10 to 15 seconds each hand
C. 15 to 30 seconds each hand
D. 30 to 60 seconds each hand

55. The minimum time in washing each hand should never be below

A. 5 seconds
B. 10 seconds
C. 15 seconds
D. 30 seconds

56. How many ml of liquid soap is recommended for handwashing procedure?

A. 1-2 ml
B. 2-3 ml
C. 2-4 ml
D. 5-10 ml

57. Which of the following is not true about sterilization, cleaning and disinfection?

A. Equipment with small lumen are easier to clean

B. Sterilization is the complete destruction of all viable microorganism including spores
C. Some organism are easily destroyed, while other, with coagulated protein requires longer time
D. The number of organism is directly proportional to the length of time required for sterilization

58. Karlita asked you, How long should she boil her glass baby bottle in water? You correctly
answered her by saying

A. The minimum time for boiling articles is 5 minutes

B. Boil the glass baby bottler and other articles for atleast 10 minutes
C. For boiling to be effective, a minimum of 15 minutes is required
D. It doesn’t matter how long you boil the articles, as long as the water reached 100 degree Celsius

59. This type of disinfection is best done in sterilizing drugs, foods and other things that are
required to be sterilized before taken in by the human body
A. Boiling Water
B. Gas sterilization
C. Steam under pressure
D. Radiation

60. A TB patient was discharged in the hospital. A UV Lamp was placed in the room where he
stayed for a week. What type of disinfection is this?

A. Concurrent disinfection
B. Terminal disinfection
C. Regular disinfection
D. Routine disinfection

61. Which of the following is not true in implementing medical asepsis

A. Wash hand before and after patient contact

B. Keep soiled linens from touching the clothings
C. Shake the linens to remove dust
D. Practice good hygiene

62. Which of the following is true about autoclaving or steam under pressure?

A. All kinds of microorganism and their spores are destroyed by autoclave machine
B. The autoclaved instruments can be used for 1 month considering the bags are still intact
C. The instruments are put into unlocked position, on their hinge, during the autoclave
D. Autoclaving different kinds of metals at one time is advisable

63. Which of the following is true about masks?

A. Mask should only cover the nose

B. Mask functions better if they are wet with alcohol
C. Masks can provide durable protection even when worn for a long time and after each and every
patient care
D. N95 Mask or particulate masks can filter organism as mall as 1 micromillimeter

64. Where should you put a wet adult diaper?

A. Green trashcan
B. Black trashcan
C. Orange trashcan
D. Yellow trashcan

65. Needles, scalpels, broken glass and lancets are considered as injurious wastes. As a
nurse, it is correct to put them at disposal via a/an

A. Puncture proof container

B. Reused PET Bottles
C. Black trashcan
D. Yellow trashcan with a tag “INJURIOUS WASTES”

66. Miranda Priestly, An executive of RAMP magazine, was diagnosed with cancer of the
cervix. You noticed that the radioactive internal implant protrudes to her vagina where
supposedly, it should be in her cervix. What should be your initial action?

A. Using a long forceps, Push it back towards the cervix then call the physician
B. Wear gloves, remove it gently and place it on a lead container
C. Using a long forceps, Remove it and place it on a lead container
D. Call the physician, You are not allowed to touch, re insert or remove it

67. After leech therapy, Where should you put the leeches?

A. In specially marked BIO HAZARD Containers

B. Yellow trashcan
C. Black trashcan
D. Leeches are brought back to the culture room, they are not thrown away for they are reusable

68. Which of the following should the nurse AVOID doing in preventing spread of infection?

A. Recapping the needle before disposal to prevent injuries

B. Never pointing a needle towards a body part
C. Using only Standard precaution to AIDS Patients
D. Do not give fresh and uncooked fruits and vegetables to Mr. Gatchie, with Neutropenia
69. Where should you put Mr. Alejar, with Category II TB?

A. In a room with positive air pressure and atleast 3 air exchanges an hour
B. In a room with positive air pressure and atleast 6 air exchanges an hour
C. In a room with negative air pressure and atleast 3 air exchanges an hour
D. In a room with negative air pressure and atleast 6 air exchanges an hour

70. A client has been diagnosed with RUBELLA. What precaution is used for this patient?

A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution

71. A client has been diagnosed with MEASLES. What precaution is used for this patient?

A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution

72. A client has been diagnosed with IMPETIGO. What precaution is used for this patient?

A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution

73. The nurse is to insert an NG Tube when suddenly, she accidentally dip the end of the tube
in the client’s glass containing distilled drinking water which is definitely not sterile. As a
nurse, what should you do?

A. Don’t mind the incident, continue to insert the NG Tube

B. Obtain a new NG Tube for the client
C. Disinfect the NG Tube before reinserting it again
D. Ask your senior nurse what to do
74. All of the following are principle of SURGICAL ASEPSIS except

A. Microorganism travels to moist surfaces faster than with dry surfaces

B. When in doubt about the sterility of an object, consider it not sterile
C. Once the skin has been sterilized, considered it sterile
D. If you can reach the object by overreaching, just move around the sterile field to pick it rather than
reaching for it

75. Which of the following is true in SURGICAL ASEPSIS?

A. Autoclaved linens and gowns are considered sterile for about 4 months as long as the bagging is
intact
B. Surgical technique is a sole effort of each nurse
C. Sterile conscience, is the best method to enhance sterile technique
D. If a scrubbed person leaves the area of the sterile field, He/she must do handwashing and gloving
again, but the gown need not be changed.

76. In putting sterile gloves, Which should be gloved first?

A. The dominant hand

B. The non dominant hand
C. The left hand
D. No specific order, Its up to the nurse for her own convenience

77. As the scrubbed nurse, when should you apply the goggles, shoe cap and mask prior to
the operation?

A. Immediately after entering the sterile field

B. After surgical hand scrub
C. Before surgical hand scrub
D. Before entering the sterile field

78. Which of the following should the nurse do when applying gloves prior to a surgical
procedure?
A. Slipping gloved hand with all fingers when picking up the second glove
B. Grasping the first glove by inserting four fingers, with thumbs up underneath the cuff
C. Putting the gloves into the dominant hand first
D. Adjust only the fitting of the gloves after both gloves are on

79. Which gloves should you remove first?

A. The glove of the non dominant hand

B. The glove of the dominant hand
C. The glove of the left hand
D. Order in removing the gloves Is unnecessary

80. Before a surgical procedure, Give the sequence on applying the protective items listed
below

1. Eye wear or goggles

2. Cap
3. Mask
4. Gloves
5. Gown

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

81. In removing protective devices, which should be the exact sequence?

1. Eye wear or goggles

2. Cap
3. Mask
4. Gloves
5. Gown

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

82. In pouring a plain NSS into a receptacle located in a sterile field, how high should the
nurse hold the bottle above the receptacle?

A. 1 inch
B. 3 inches
C. 6 inches
D. 10 inches

83. The tip of the sterile forceps is considered sterile. It is used to manipulate the objects in
the sterile field using the non sterile hands. How should the nurse hold a sterile forceps?

A. The tip should always be lower than the handle

B. The tip should always be above the handle
C. The handle and the tip should be at the same level
D. The handle should point downward and the tip, always upward

84. The nurse enters the room of the client on airborne precaution due to tuberculosis. Which
of the following are appropriate actions by the nurse?

1. She wears mask, covering the nose and mouth

2. She washes her hands before and after removing gloves, after suctioning the client’s secretion
3. She removes gloves and hands before leaving the client’s room
4. She discards contaminated suction catheter tip in trashcan found in the clients room

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

85. When performing surgical hand scrub, which of the following nursing action is required to
prevent contamination?
1. Keep fingernail short, clean and with nail polish
2. Open faucet with knee or foot control
3. Keep hands above the elbow when washing and rinsing
4. Wear cap, mask, shoe cover after you scrubbed

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

86. When removing gloves, which of the following is an inappropriate nursing action?

A. Wash gloved hand first

B. Peel off gloves inside out
C. Use glove to glove skin to skin technique
D. Remove mask and gown before removing gloves

87. Which of the following is TRUE in the concept of stress?

A. Stress is not always present in diseases and illnesses

B. Stress are only psychological and manifests psychological symptoms
C. All stressors evoke common adaptive response
D. Hemostasis refers to the dynamic state of equilibrium

88. According to this theorist, in his modern stress theory, Stress is the non specific
response of the body to any demand made upon it.

A. Hans Selye
B. Walter Cannon
C. Claude Bernard
D. Martha Rogers

89. Which of the following is NOT TRUE with regards to the concept of Modern Stress
Theory?
A. Stress is not a nervous energy
B. Man, whenever he encounters stresses, always adapts to it
C. Stress is not always something to be avoided
D. Stress does not always lead to distress

90. Which of the following is TRUE with regards to the concept of Modern Stress Theory?

A. Stress is essential
B. Man does not encounter stress if he is asleep
C. A single stress can cause a disease
D. Stress always leads to distress

91. Which of the following is TRUE in the stage of alarm of general adaptation syndrome?

A. Results from the prolonged exposure to stress

B. Levels or resistance is increased
C. Characterized by adaptation
D. Death can ensue

92. The stage of GAS where the adaptation mechanism begins

A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion

93. Stage of GAS Characterized by adaptation

A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion

94. Stage of GAS wherein, the Level of resistance are decreased

A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion

95. Where in stages of GAS does a person moves back into HOMEOSTASIS?

A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion

96. Stage of GAS that results from prolonged exposure to stress. Here, death will ensue
unless extra adaptive mechanisms are utilized

A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion

97. All but one is a characteristic of adaptive response

A. This is an attempt to maintain homeostasis

B. There is a totality of response
C. Adaptive response is immediately mobilized, doesn’t require time
D. Response varies from person to person

98. Andy, a newly hired nurse, starts to learn the new technology and electronic devices at
the hospital. Which of the following mode of adaptation is Andy experiencing?

A. Biologic/Physiologic adaptive mode

B. Psychologic adaptive mode
C. Sociocultural adaptive mode
D. Technological adaptive mode
99. Andy is not yet fluent in French, but he works in Quebec where majority speaks French.
He is starting to learn the language of the people. What type of adaptation is Andy
experiencing?

A. Biologic/Physiologic adaptive mode

B. Psychologic adaptive mode
C. Sociocultural adaptive mode
D. Technological adaptive mode

100. Andy made an error and his senior nurse issued a written warning. Andy arrived in his
house mad and kicked the door hard to shut it off. What adaptation mode is this?

A. Biologic/Physiologic adaptive mode

B. Psychologic adaptive mode
C. Sociocultural adaptive mode
D. Technological adaptive mode

Answers and Rationale

Here are the answers and rationale for this 100-item Fundamentals of Nursing exam. If you have
any disputes or questions, direct them to the comments section below! Tell us also your scores!

1. Answer: C. Lungs will bronchodilate

To better understand the concept, the autonomic nervous system is composed of

the sympathetic and parasympathetic nervous system. It is called autonomic because it is
involuntary and stimuli-based. You cannot dictate your heart to beat 60 per minute, nor tell your
blood vessels when to constrict and dilate. Sympathetic nervous system is the “fight or flight”
mechanism.

2. Answer: C. Clients BP will increase, there will be vasodilation

If vasodilation will occur, the BP will not increase but decrease.

3. Answer: A. Illness
Disease is a proven fact based on a medical theory, standards, diagnosis and clinical features.
Illness, on the other hand, is a subjective state of not feeling well based on subjective appraisal,
previous experience, peer advice and etc.

4. Answer: A. Symptom Experience

Assumption of the sick role is when a client accepts he is ill. Medical care contact is where the client
asks someone to confirm what he is experiencing. During this stage, the client seeks professional
advice for validation, reassurance clarification and explanation of the symptoms he is
experiencing. Last stage of illness is the recovery stage where the patient gives up the sick role and
assumes the previous normal functions.

5. Answer: D. Dependent patient role

In the dependent patient role stage, patients needs professionals for help. They have a choice either
to accept or reject the professional’s decisions but patients are usually passive and accepting.
Regression tends to occur more in this period.

6. Answer: B. Assumption of sick role

Acceptance of illness occurs in the assumption of sick role phase of illness.

7. Answer: C. Medical care contact

At this stage, The patient seeks for validation of his symptom experience. He wants to find out if
what he feels are normal or not normal. He wants someone to explain why is he feeling these signs
and symptoms and wants to know the probable outcome of this experience.

8. Answer: A. One should be held responsible for his condition

The nurse should not judge the patient and not view the patient as the cause or someone
responsible for his illness. A sick client is excused from his societal roles, oblige to get well as soon
as possible and obliged to seek competent help.

9. Answer: C. Risk factor

10. Answer: A. Susceptibility

Immunity is the absolute resistance to a pathogen considering that person has an intact immunity.
Susceptibility is the degree of resistance or how well would the individual combat the pathogens and
repel infection or invasion of these disease causing organisms. A susceptible person is someone
who has a very low degree of resistance to combat pathogens. An immune person is someone that
can easily repel specific pathogens.

11. Answer: A. Syndrome

Symptoms are individual manifestation of a certain disease (i.e., tics in Tourette syndrome) but a
symptom alone is not enough to diagnose the patient as other diseases may have the symptom
manifestation. Syndrome, on the other hand, means collection of these symptoms that occurs
together and has a pattern that characterizes a certain disease.

12. Answer: D. Iatrogenic

Iatrogenic diseases refers to those that resulted from treatment of a certain disease. For example, a
child develops redness and partial thickness burns over his chest area due to frequent exposure to
X-ray. Neoplastic diseases are malignant diseases caused by proliferation of abnormally growing
cells. Traumatic are brought about by injuries like vehicular accidents. Nosocomial are infections that
are acquired inside the hospital.

13. Answer: B. 2 and 3 (Idiopathic and Neoplastic)

14. Answer: C. Exacerbation

15. Answer: A. Chronic

Chronic diseases are characterized by periods of remissions and exacerbations and persists longer
than six (6) months that is why remissions and exacerbations are observable. The duration of acute
and sub acute diseases are too short to manifest remissions.

16. Answer: D. Organic

Organic diseases are caused by a change in structure of a certain organ and organ systems.
Inorganic diseases, on the other hand, are synonymous with functional diseases where there is no
evident structural, anatomical or physical change in the structure of the organ or organ system but its
function is altered due to other causes.

17. Answer: B. Ecology

Ecology is the science that deals with the ecosystem and its effects on living things in the biosphere.
It deals with diseases in relationship with the environment. Epidemiology is simply the study of
diseases and its occurrence and distribution in man for the purpose of controlling and preventing
diseases.

18. Answer: A. Epidemiology

19. Answer: C. Inorganic

20. Answer: C. Tertiary

Primary refers to the measures that aim in preventing the diseases (i.e., healthy lifestyle, good
nutrition, knowledge seeking behaviors, etc). Secondary prevention are those measures that deal
with early diagnostics, case finding treatments (i.e, breast self exam, X-rays, antibiotic treatment to
cure infection, iron therapy for anemia, etc). Tertiary prevention aims on maintaining optimum level
of functioning during or after the impact of disease that threatens to alter the normal body functioning
(i.e., prosthesis fitting for an amputated leg, glucose monitoring among diabetics, and TPA therapy
after stroke).

21. Answer: D. None of the above.

The nurse never increases the person’s susceptibility to illness but rather, LESSEN the person’s
susceptibility to illness.

22. Answer: B. Secondary

Secondary prevention is also known as health maintenance prevention.

23. Answer: A. Primary

Personal Protective Devices or PPD are worn by workers in a hazardous work environment to
protect them from injuries. This is considered as primary prevention because the nurse prevents the
occurrence of injuries.

24. Answer: A. Primary

25. Answer: B. Secondary

Pap-smear is a diagnostic procedure thus falls under the secondary level of prevention.

26. Answer: C. Tertiary

27. Answer: D. Radio and Television

The best way to disseminate information to the public is via television followed by radio. The two
media outlets have the widest reach and this is how the Department of Health (DOH) establishes its
IEC programs.

28. Answer: B. Neuman

The supra and subsystems are theories of Martha Rogers but the parts and subparts are Betty
Neuman’s. She stated that health is a state where in all parts and subparts of an individual are in
harmony with the whole system. Margarex Newman defined health as an expanding consciousness.

29. Answer: D. 1,2,3,4

Rationale:All of the following are correct statement about health. The first one is the definition by
World Health Organization (WHO). The second is taken from Walter Cannon’s Homeostasis Theory.
The third is from Claude Bernard’s concept of Health as Internal Milieu. The last one is from
Neuman’s theory.

30. Answer: C. Cannon

Walter Cannon advocated health as homeostasis or the ability to maintain dynamic equilibrium.
Hans Selye postulated concepts about stress and adaptation. Bernard defined health as the ability to
maintain internal milieu and Rogers defined Health as Wellness that is influenced by individual’s
culture.

31. Answer: D. Lifestyle

32. Answer: B. Age

33. Answer: A. Surgical Asepsis

Surgical Asepsis is otherwise known as the “sterile technique,” while Medical Asepsis is
synonymous with the “clean technique.”

34. Answer: D. Carrier

35. Answer: B. Contact

36. Answer: B. Disinfectant

Disinfectants are used on inanimate objects. Antiseptics are intended on persons and other living
things. Both can kill and inhibit growth of microorganisms but cannot kill spores. Autoclaving or
steam under pressure kills almost all types of microorganisms including their spores.

37. Answer: C. Disinfection

38. Answer: C. Illness period

In incubation period, the disease has been introduced to the body but no sign and symptom appear
because the pathogen is not yet strong enough to cause it and may still need to multiply. The
second period is called prodromal period where appearance of non-specific signs and symptoms
sets in. Illness period is characterized by appearance of specific signs and symptoms. Acme is the
peak of an illness while convalescent period is characterized by the abatement of the disease or its
gradual dissipation.

39. Answer: B. Prodromal period

40. Answer: A. Incubation period

Anthrax can have an incubation period of hours to seven (7) days with an average of 48 (hours).
Since the question stated exposure, we can assume that the mailman is in the incubation phase.

41. Answer: D. Mode of transmission

Mode of transmission is the weakest link in the chain of infection. It is easily manipulated by the
nurses using the tiers of prevention, either by instituting transmission based precautions, universal
precaution or isolation techniques.

42. Answer: C. 4,5,3,6,2,1

Source is the etiological agent itself, this is where the chain of infection starts. The source will first
proliferate on a reservoir and will need a portal of exit to be able to transmit itself using a portal of
entry to a susceptible host.

43. Answer: D. Vector borne transmission

Lyme’s disease is caused by borrelia burgdorferi and is transmitted via a tick bite.

44. Answer: D. Non Specificity

To be able to cause a disease, a pathogen should have a target organ and should be specific to
these organs to cause an infection.

45. Answer: C. Spread by cross contamination via hands of caregiver

A caregiver’s hands like any other healthcare workers is the main cause of cross-contamination in a
hospital setting. Handwashing is the single most important procedure to prevent the occurrence of
cross-contamination and nosocomial infections.

46. Answer: A. Droplet transmission

47. Answer: A. Skin

Remember that intact skin and mucous membrane is our first line of defense against infection.
48. Answer: A. Creed

Creed, Faith or religious belief do not affect person’s susceptibility to illness. Medication like
corticosteroids could supress a person’s immune system that will lead to increase susceptibility.
Color of the skin could affect person’s susceptibility to certain skin diseases. A dark skinned person
has lower risk of skin cancer than a fair skinned person. Fair skinned person also has a higher risk
for cholecystitis and cholelithiasis.

49. Answer: C. Artificial active immunity

TT1 and TT2 are considered the primary doses while TT3, TT4 and TT5 are booster doses. A
woman with a complete immunization of DPT need not to receive the primary doses TT1 and TT2.
Tetanus toxoid is an actual but weakened and inactivated toxin produced by clostridium tetani. It is
artificial because it did not occur in the course of an actual illness or infection.

50. Answer: D. Artificial passive immunity

In this scenario, Agatha was already wounded and has injuries. Giving the Tetanus Toxoid vaccine
itself would not be beneficial to her as it will take time before the body can produce antitoxins. What
Agatha needs now is a ready made antitoxin in the form of ATS or TTIg which is
considered artificial because her body did not produce it and passive because her immune system
was not stimulated but rather, given a ready-made immunoglobulin to immediately suppress the
infection.

51. Answer: D. Handwashing

TIP: Most of the time, when you see the word handwashing as one of the options, there is a big
chance that it is the correct answer.

52. Answer: B. Friction

The most important aspect of handwashing is friction. The rest of the components will just enhance
friction. Soap lowers the surface tension thereby increasing the effectiveness of friction. Water helps
remove transient bacteria by working with soap to create lather that reduces surface tension. Time,
on the other hand, is of the essence but friction is the most essential aspect of handwashing. It’s
friction whether you like it or not.
53. Answer: D. Below the elbow, Hands are dirtier than the lower arms

Hands are put below the elbow in medical asepsis in contrast with surgical asepsis where hands are
required to be kept above the waist. In medical asepsis, hands are considered dirtier than the elbow
and therefore, to limit contamination of the lower arm, the hands should always be below the elbow.

54. Answer: C. 15 to 30 seconds each hand

Each hand requires 15 to 30 seconds of hand washing as a minimum to effectively remove transient
germs.

55. Answer: B. 10 seconds

According to Kozier, the minimum time required for watching each hands is 10 seconds and should
not be lower than that. The recommended time, again, is 15 to 30 seconds.

56. Answer: C. 2-4 ml

If a liquid soap is to be used, 1 tsp (5 ml) of liquid soap is recommended for handwashing procedure.

57. Answer: A. Equipment with small lumen are easier to clean

Equipment with large lumen are easier to clean compared to those with small lumen. Other choices
are correct.

58. Answer: C. For boiling to be effective, a minimum of 15 minutes is required

Boiling is the most common and least expensive method of sterilization used in home. For it to be
effective, you should boil articles for at least 15 minutes.

59. Answer: D. Radiation

If food and drugs are to be sterilized by boiling water, ethylene oxide gas and autoclave, most
probably they’ll be ineffective after the process. Ethylene oxide gas is toxic to humans, boiling food
will alter its consistency and lower it nutritional value. Autoclaving food may sound fun but it is the
dumbest thing to do. Radiation using a microwave oven or an ionization penetrate foods and drugs
thus, sterilizing them.

60. Answer: B. Terminal disinfection

Terminal disinfection refers to practices to remove pathogens that stayed in the belongings or
immediate environment of an infected client who has been discharged. Concurrent disinfection
refers to ongoing efforts implemented during the client’s stay to remove or limit pathogens in his
supplies, belongings, immediate environment in order to control the spread of the disease.

61. Answer: C. Shake the linens to remove dust

Never shake soiled linens. Once soiled fold it inwards with the clean surface facing out. Shaking the
linen can dislodge and further spread pathogens harbored in its fabric.

62. Answer: C. The instruments are put into unlocked position, on their hinge, during the
autoclave

Metals with locks, like clamps and scissors should be unlocked in order to minimize stiffening
caused by autoclaving the hinges. Not all microorganisms are destroyed by autoclaving, there are
still microorganisms that are invulnerable to extreme heat. Autoclaved instruments are to be used
within two (2) weeks. Only the same type of metals should be autoclaved as this will alteration in
plating of these metals.

63. Answer: D. N95 Mask or particulate masks can filter organism as mall as 1
micromillimeter

Mask should cover both nose and mouth and will not function optimally when wet. They should
never be worn greater than four (4) hours and will gradually lose its effectiveness after four (4)
horus. N95 masks or particulate masks can filter organisms as small as one (1) micromillimeter.

64. Answer: D. Yellow trashcan

Infectious waste like blood and blood products, wet diapers and dressings are thrown in yellow-
colored trashbins.
65. Answer: A. Puncture proof container

Needles, scalpels and other sharps are to be disposed in a puncture proof container.

66. Answer: C. Using a long forceps, Remove it and place it on a lead container

A dislodged radioactive cervical implant in brachytherapy are to be picked by a long forceps and to
be stored in a lead container in order to prevent damage on the client’s normal tissue. Calling the
physician is the most appropriate action among the choices, a nurse should never attempt to put it
back nor touch it with her bare or even gloved hands.

67. Answer: A. In specially marked BIO HAZARD Containers

Leeches, in leech therapy or leech phlebotomy are to be disposed on a BIOHAZARD container.

They are never re used as this could cause transfer of infection. These leeches are hospital grown
and not the usual leeches found in swamps because that would just be disgusting.

68. Answer: A. Recapping the needle before disposal to prevent injuries

Never recap needles. After using, they are directly disposed in a puncture proof container after used.
Recapping could cause injury to the nurse and spread infection. Choices B, C and D are all
appropriate. Standard precaution is sufficient for a patient with HIV. A client with neutropenia are not
given fresh and uncooked fruits and vegetables as it may cause severe infection due to
immunosuppression.

69. Answer: D. In a room with negative air pressure and atleast 6 air exchanges an hour

Patients with tuberculosis should have a private room with a negative air pressure and at least 6 to
12 air exchanges per hour. Negative pressure rooms will prevent air inside from escaping. Air
exchanges are necessary since the client’s room do not allow air to get out of the room.

70. Answer: C. Droplet precaution

Droplet precaution is sufficient on client’s with RUBELLA or german measles.

71. Answer: B. Airborne precaution

Measles is highly communicable and more contagious than Rubella. It requires airborne precaution
as it is spread by small particle droplets that remains suspended in air and dispersed by air
movements.

72. Answer: D. Contact precaution

Impetigo causes blisters or sores in the skin. It is generally caused by GABS or Staph Aureaus. It is
spread by skin to skin contact or by scratching the lesions and touching another person’s skin.

73. Answer: A. Don’t mind the incident, continue to insert the NG Tube

The digestive tract is not sterile, and therefore, simple errors like this would not cause harm to the
patient. NGT tube need not be sterile, and so is colostomy and rectal tubes. Clean technique is
sufficient during NGT and colostomy care.

74. Answer: C. Once the skin has been sterilized, considered it sterile

Human skin is impossible to be sterilized. It contains normal flora of microorganism. A, B and D are
all correct.

75. Answer: C. Sterile conscience, is the best method to enhance sterile technique

Sterile conscience, or the moral imperative of a nurse to be honest in practicing sterile technique, is
the best method to enhance sterile technique. Autoclaved linens are considered sterile only within
two (2) weeks even if the bagging is intact. Surgical technique is a team effort of each nurse. If a
scrubbed person leave the sterile field and area, he must do the process all over again.

76. Answer: B. The non dominant hand

Gloves are put on the non dominant hands first and then, the dominant hand. The rationale is simply
because humans tend to use the dominant hand first before the non dominant hand. Out of 10
humans that will put on their sterile gloves, 8 of them will put the gloves on their non dominant hands
first.

77. Answer: C. Before surgical hand scrub

The nurse should put his goggles, cap and mask prior to washing the hands. If he wash his hands
prior to putting all these equipments, he must wash his hands again as these equipments are said to
be unsterile.

78. Answer: D. Adjust only the fitting of the gloves after both gloves are on

The nurse should only adjust fitting of the gloves when they are both on the hands. Not doing so will
break the sterile technique. Only 4 fingers are slipped when picking up the second gloves. You
cannot slip all of your fingers as the cuff is limited and the thumb would not be able to enter the cuff.
The first glove is grasp by simply picking it up with the first 2 fingers and a thumb in a pinching
motion. Gloves are put on the non dominant hands first.

79. Answer: A. The glove of the non dominant hand

Gloves are worn in the non dominant hand first, and is removed also from the non dominant hand
first. Rationale is simply because in 10 people removing gloves, 8 of them will use the dominant
hand first and remove the gloves of the non dominant hand.

80. Answer: D. 2,3,1,4,5

81. Answer: A. 4,3,5,1,2

When removing protective devices, one must remove the gloves first, followed by the mask and
gown, then other devices like cap, shoe cover, and etc. Doing it in this manner will prevent
contamination of hair, neck and face area. Go ahead, try removing your mask, hair cap and others
before removing your soiled and bloodied gloves.

82. Answer: C. 6 inches

Even if you do not know the answer to this question, you can answer it correctly by imagining. If you
pour the NSS into a receptacle 1 to 3 inch above it, chances are, the mouth of the NSS bottle would
dip into the receptacle as you fill it, making it contaminated. If you pour the NSS bottle into a
receptacle 10 inches above it, that is too high, chances are, as you pour the NSS, most will spill out
because the force will be too much for the buoyant force to handle. It will also be difficult to pour
something precisely into a receptacle as the height increases between the receptacle and the bottle.
6 inches is the correct answer. It is not too low nor too high.
83. Answer: A. The tip should always be lower than the handle

Sterile forceps are usually dipped into a disinfectant or germicidal solution. If the tip is higher than
the handle, the solution will flow down into the handle and into your hands, and as you use the
forceps, you’ll eventually lower its tip making the solution in your hand flow to the tip thus
contaminating the sterile area of the forceps. To prevent this, the tip should always be lower than the
handle.

84. Answer: C. 1,2,3,4

All soiled equipment used in an infectious patient are disposed inside the client’s room to prevent
contamination outside the room. Using the mask to cover both nose and mouth is correct. Hands are
washed before removing the gloves and before and after your enter the client’s room. Gloves and
contaminated suction tip are thrown in the trash found in the client’s room.

85. Answer: C. 1,2,3

Caps, masks and shoe covers are worn before scrubbing in.

86. Answer: D. Remove mask and gown before removing gloves

Gloves are the dirtiest personal protective device used and therefore, should be the first to be
removed to prevent spread of microorganisms as you remove your masks and gown.

87. Answer: C. All stressors evoke common adaptive response

All stressors evoke common adaptive response. A psychologic fear like nightmare and a real fear or
real perceive threat evokes common manifestation like tachycardia, tachypnea, sweating, increase
muscle tension etc. ALL diseases and illness causes stress. Stress can be both real or imaginary.
Hemostasis refers to the arrest of blood flowing abnormally through a damage vessel. Homeostasis
is the one that refers to dynamic state of equilibrium according to Walter Cannon.

88. Answer: A. Hans Selye

Hans Selye is the only theorist who proposed an intriguing theory about stress that has been widely
used and accepted by professionals today. He conceptualized two types of human response to
stress, The GAS or general adaptation syndrome which is characterized by stages of ALARM,
RESISTANCE and EXHAUSTION. The local adaptation syndrome controls stress through a
particular body part.

89. Answer: B. Man, whenever he encounters stresses, always adapts to it

Man do not always adapt to stress. Sometimes, stress can lead to exhaustion and eventually, death.
Choices A, C and D are all correct.

90. Answer: A. Stress is essential

Stress is ESSENTIAL. No man can live normally without stress. It is essential because it is evoked
by the body’s normal pattern of response and leads to a favorable adaptive mechanism that are
utilized in the future when more stressors are encountered by the body. Man can encounter stress
even while asleep (i.e., nightmares).

Disease are multifactorial and are not caused by a single stressor. Stress is sometimes favorable
and are not always a cause for distress.

91. Answer: D. Death can ensue

Death can ensue as early as the stage of alarm. Exhaustion results to a prolonged exposure to
stress. Resistance is when the levels of resistance increases and characterized by being able to
adapt.

92. Answer: A. Stage of Alarm

Adaptation mechanisms begin in the stage of alarm. This is when the adaptive mechanism are
mobilized.

93. Answer: B. Stage of Resistance

94. Answer: A. Stage of Alarm

Resistance are decreased in the stage of alarm. Resistance is absent in the stage of exhaustion.
Resistance is increased in the stage of resistance.
95. Answer: B. Stage of Resistance

96. Answer: D. Stage of Exhaustion

97. Answer: C. Adaptive response is immediately mobilized, doesn’t require time

Aside from having limits that leads to exhaustion, adaptive response requires time for it to act. It
requires energy, physical and psychological taxes that needs time for our body to mobilize and
utilize.

98. Answer: D. Technological adaptive mode

99. Answer: C. Sociocultural adaptive mode

Sociocultural adaptive modes include language, communication, dressing, acting and socializing in
line with the social and cultural standard of the people around the adapting individual.

100. Answer: B. Psychologic adaptive mode

1. The coronary vessels, unlike any other blood vessels in the body, respond to sympathetic
stimulation by

A. Vasoconstriction
B. Vasodilatation
C. Decreases force of contractility
D. Decreases cardiac output

2. What stress response can you expect from a patient with blood sugar of 50 mg / dl?

A. Body will try to decrease the glucose level

B. There will be a halt in release of sex hormones
C. Client will appear restless
D. Blood pressure will increase

3. All of the following are purpose of inflammation except

A. Increase heat, thereby produce abatement of phagocytosis
B. Localized tissue injury by increasing capillary permeability
C. Protect the issue from injury by producing pain
D. Prepare for tissue repair

4. The initial response of tissue after injury is

A. Immediate Vasodilation
B. Transient Vasoconstriction
C. Immediate Vasoconstriction
D. Transient Vasodilation

5. The last expected process in the stages of inflammation is characterized by

A. There will be sudden redness of the affected part

B. Heat will increase on the affected part
C. The affected part will lose its normal function
D. Exudates will flow from the injured site

6. What kind of exudates is expected when there is an antibody-antigen reaction as a result of

microorganism infection?

A. Serous
B. Serosanguinous
C. Purulent
D. Sanguinous

7. The first manifestation of inflammation is

A. Redness on the affected area

B. Swelling of the affected area
C. Pain, which causes guarding of the area
D. Increase heat due to transient vasodilation
8. The client has a chronic tissue injury. Upon examining the client’s antibody for a particular
cellular response, Which of the following WBC component is responsible for phagocytosis in
chronic tissue injury?

A. Neutrophils
B. Basophils
C. Eosinophils
D. Monocytes

9. Which of the following WBC component proliferates in cases of Anaphylaxis?

A. Neutrophils
B. Basophils
C. Eosinophil
D. Monocytes

10. Icheanne, ask you, her Nurse, about WBC Components. She got an injury yesterday after
she twisted her ankle accidentally at her gymnastic class. She asked you, which WBC
Component is responsible for proliferation at the injured site immediately following an injury.
You answer:

A. Neutrophils
B. Basophils
C. Eosinophils
D. Monocytes

11. Icheanne then asked you, what is the first process that occurs in the inflammatory
response after injury, You tell her:

A. Phagocytosis
B. Emigration
C. Pavementation
D. Chemotaxis

12. Icheanne asked you again, What is that term that describes the magnetic attraction of
injured tissue to bring phagocytes to the site of injury?
A. Icheanne, you better sleep now, you asked a lot of questions
B. It is Diapedesis
C. We call that Emigration
D. I don’t know the answer, perhaps I can tell you after I find it out later

13. This type of healing occurs when there is a delayed surgical closure of infected wound

A. First intention
B. Second intention
C. Third intention
D. Fourth intention

14. Type of healing when scars are minimal due to careful surgical incision and good healing

A. First intention
B. Second intention
C. Third intention
D. Fourth intention

15. Imelda, was slashed and hacked by an unknown suspects. She suffered massive tissue
loss and laceration on her arms and elbow in an attempt to evade the criminal. As a nurse,
you know that the type of healing that will most likely occur to Miss Imelda is

A. First intention
B. Second intention
C. Third intention
D. Fourth intention

16. Imelda is in the recovery stage after the incident. As a nurse, you know that the diet that
will be prescribed to Miss Imelda is

A. Low calorie, High protein with Vitamin A and C rich foods

B. High protein, High calorie with Vitamin A and C rich foods
C. High calorie, Low protein with Vitamin A and C rich foods
D. Low calorie, Low protein with Vitamin A and C rich foods
17. Miss Imelda asked you, What is WET TO DRY Dressing method? Your best response is

A. It is a type of mechanical debridement using Wet dressing that is applied and left to dry to remove
dead tissues
B. It is a type of surgical debridement with the use of Wet dressing to remove the necrotic tissues
C. It is a type of dressing where in, The wound is covered with Wet or Dry dressing to prevent
contamination
D. It is a type of dressing where in, A cellophane or plastic is placed on the wound over a wet
dressing to stimulate healing of the wound in a wet medium

18. The primary cause of pain in inflammation is

A. Release of pain mediators

B. Injury to the nerve endings
C. Compression of the local nerve endings by the edema fluids
D. Circulation is lessen, Supply of oxygen is insufficient

19. The client is in stress because he was told by the physician he needs to undergo surgery
for removal of tumor in his bladder. Which of the following are effects of sympatho-adreno-
medullary response by the client?

1. Constipation
2. Urinary frequency
3. Hyperglycemia
4. Increased blood pressure

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

20. The client is on NPO post midnight. Which of the following, if done by the client, is
sufficient to cancel the operation in the morning?

A. Eat a full meal at 10:00 P.M

B. Drink fluids at 11:50 P.M
C. Brush his teeth the morning before operation
D. Smoke cigarette around 3:00 A.M

21. The client place on NPO for preparation of the blood test. Adreno-cortical response is
activated and which of the following below is an expected response?

A. Low BP
B. Decrease Urine output
C. Warm, flushed, dry skin
D. Low serum sodium levels

22. Which of the following is true about therapeutic relationship?

A. Directed towards helping an individual both physically and emotionally

B. Bases on friendship and mutual trust
C. Goals are set by the solely nurse
D. Maintained even after the client doesn’t need anymore of the Nurse’s help

23. According to her, A nurse patient relationship is composed of 4 stages : Orientation,

Identification, Exploitation and Resolution

A. Roy
B. Peplau
C. Rogers
D. Travelbee

24. In what phase of Nurse patient relationship does a nurse review the client’s medical
records thereby learning as much as possible about the client?

A. Pre Orientation
B. Orientation
C. Working
D. Termination

25. Nurse Aida has seen her patient, Roger for the first time. She establish a contract about
the frequency of meeting and introduce to Roger the expected termination. She started taking
baseline assessment and set interventions and outcomes. On what phase of NPR Does Nurse
Aida and Roger belong?

A. Pre Orientation
B. Orientation
C. Working
D. Termination

26. Roger has been seen agitated, shouting and running. As Nurse Aida approaches, he
shouts and swear, calling Aida names. Nurse Aida told Roger “That is an unacceptable
behavior Roger, Stop and go to your room now.” The situation is most likely in what phase of
NPR?

A. Pre Orientation
B. Orientation
C. Working
D. Termination

27. Nurse Aida, in spite of the incident, still consider Roger as worthwhile simply because he
is a human being. What major ingredient of a therapeutic communication is Nurse Aida
using?

A. Empathy
B. Positive regard
C. Comfortable sense of self
D. Self awareness

28. Nurse Irma saw Roger and told Nurse Aida “ Oh look at that psychotic patient “ Nurse
Aida should intervene and correct Nurse Irma because her statement shows that she is
lacking?

A. Empathy
B. Positive regard
C. Comfortable sense of self
D. Self awareness
29. Which of the following statement is not true about stress?

A. It is a nervous energy
B. It is an essential aspect of existence
C. It has been always a part of human experience
D. It is something each person has to cope

30. Martina, a tennis champ was devastated after many new competitors outpaced her in the
Wimbledon event.
She became depressed and always seen crying. Martina is clearly on what kind of situation?

A. Martina is just stressed out

B. Martina is Anxious
C. Martina is in the exhaustion stage of GAS
D. Martina is in Crisis

31. Which of the following statement is not true with regards to anxiety?

A. It has physiologic component

B. It has psychologic component
C. The source of dread or uneasiness is from an unrecognized entity
D. The source of dread or uneasiness is from a recognized entity

32. Lorraine, a 27 year old executive was brought to the ER for an unknown reason. She is
starting to speak but her speech is disorganized and cannot be understood. On what level of
anxiety does this features belongs?

A. Mild
B. Moderate
C. Severe
D. Panic

33. Elton, 21 year old nursing student is taking the board examination. She is sweating
profusely, has decreased awareness of his environment and is purely focused on the exam
questions characterized by his selective attentiveness. What anxiety level is Elton
exemplifying?
A. Mild
B. Moderate
C. Severe
D. Panic

34. You noticed the patient chart : ANXIETY +3 What will you expect to see in this client?

A. An optimal time for learning, hearing and perception is greatly increased

B. Dilated pupils
C. Unable to communicate
D. Palliative Coping Mechanism

35. When should the nurse starts giving XANAX?

A. When anxiety is +1
B. When the client starts to have a narrow perceptual field and selective inattentiveness
C. When problem solving is not possible
D. When the client is immobile and disorganized

36. Which of the following behavior is not a sign or a symptom of Anxiety?

A. Frequent hand movement

B. Somatization
C. The client asks a question
D. The client is acting out

37. Which of the following intervention is inappropriate for client’s with anxiety?

A. Offer choices
B. Provide a quiet and calm environment
C. Provide detailed explanation on each and every procedures and equipments
D. Bring anxiety down to a controllable level

38. Which of the following statement, if made by the nurse, is considered not therapeutic?
A. “How did you deal with your anxiety before?”
B. “It must be awful to feel anxious.”
C. “How does it feel to be anxious?”
D. “What makes you feel anxious?”

39. Marissa Salva, Uses Benson’s relaxation. How is it done?

A. Systematically tensing muscle groups from top to bottom for 5 seconds, and then releasing them
B. Concentrating on breathing without tensing the muscle, Letting go and repeating a word or sound
after each exhalation
C. Using a strong positive, feeling-rich statement about a desired change
D. Exercise combined with meditation to foster relaxation and mental alacrity

40. What type of relaxation technique does Lyza uses if a machine is showing her pulse rate,
temperature and muscle tension which she can visualize and assess?

A. Biofeedback
B. Massage
C. Autogenic training
D. Visualization and Imagery

41. This is also known as Self-suggestion or Self-hypnosis

A. Biofeedback
B. Meditation
C. Autogenic training
D. Visualization and Imagery

42. Which among these drugs is NOT an anxiolytic?

A. Valium
B. Ativan
C. Milltown
D. Luvox
43. Kenneth, 25 year old diagnosed with HIV felt that he had not lived up with God’s
expectation. He fears that in the course of his illness, God will be punitive and not be
supportive. What kind of spiritual crisis is Kenneth experiencing?

1. Spiritual Pain
2. Spiritual Anxiety
3. Spiritual Guilt
4. Spiritual Despair

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

44. Grace, believes that her relationship with God is broken. She tried to go to church to ask
forgiveness everyday to remedy her feelings. What kind of spiritual distress is Grace
experiencing?

A. Spiritual Pain
B. Spiritual Alienation
C. Spiritual Guilt
D. Spiritual Despair

45. Remedios felt “EMPTY” She felt that she has already lost God’s favor and love because of
her sins. This is a type of what spiritual crisis?

A. Spiritual Anger
B. Spiritual Loss
C. Spiritual Despair
D. Spiritual Anxiety

46. Blake is working with a schizophrenic patient. He noticed that the client is agitated,
pacing back and forth, restless and experiencing Anxiety +3. Blake said “You appear
restless” What therapeutic technique did Blake used?
A. Offering general leads
B. Seeking clarification
C. Making observation
D. Encouraging description of perception

47. Ronny told Blake “I see dead people.” Blake responded, “You see dead people?” This
exchange is an example of what therapeutic communication technique?

A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification

48. Ronny told Blake, “Do you think I’m crazy?” Blake responded, “Do you
think you’re crazy?” Blake uses what example of therapeutic communication?

A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification

49. Myra, 21 year old nursing student has difficulty sleeping. She told Nurse Blake “I really
think a lot about my ex-boyfriend recently.” Blake told Myra “And that causes you difficulty
sleeping?” Which therapeutic technique is used in this situation?

A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification

50. Myra told Blake “I cannot sleep, I stay away all night.” Blake told her “You have difficulty
sleeping?” This is what type of therapeutic communication technique?

A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification

51. Myra said “I saw my dead grandmother here at my bedside a while ago.” Blake responded
“Really? That is hard to believe. How do you feel about it?” What technique did Blake used?

A. Disproving
B. Disagreeing
C. Voicing Doubt
D. Presenting Reality

52. Which of the following is a therapeutic communication in response to “I am a GOD, bow

before me or ill summon the dreaded thunder to burn you and purge you to pieces!”

A. “You are not a GOD, you are Professor Tadle and you are a PE Teacher, not a Nurse. I am Glen,
your nurse.”
B. “Oh hail GOD Tadle, everyone bow or face his wrath!”
C. “Hello Mr. Tadle, You are here in the hospital, I am your nurse and you are a patient here”
D. “How can you be a GOD Mr. Tadle? Can you tell me more about it?”

53. Erik John Senna, Told Nurse Blake “ I don’t want to that, I don’t want that thing.. that’s too
painful!” Which of the following response is NON THERAPEUTIC?

A. “This must be difficult for you, but I need to inject you this for your own good”
B. “You sound afraid”
C. “Are you telling me you don’t want this injection?”
D. “Why are you so anxious? Please tell me more about your feelings Erik”

54. Mr. Poncho was caught by the police because of his illegal activities. When he got home
after paying for the bail, he shouted at his son. What defense mechanism did Mr. Poncho
used?

A. Restitution
B. Projection
C. Displacement
D. Undoing
55. Later that day, he bought his son ice cream and food. What defense mechanism is Mr.
Poncho unconsciously doing?

A. Restitution
B. Conversion
C. Redoing
D. Reaction formation

56. Crisis is a sudden event in ones life that disturbs a person’s homeostasis. Which of the
following is NOT TRUE in crisis?

A. The person experiences heightened feeling of stress

B. Inability to function in the usual organized manner
C. Lasts for 4 months
D. Indicates unpleasant emotional feelings

57. Which of the following is a characteristic of crisis?

A. Lasts for an unlimited period of time

B. There is a triggering event
C. Situation is not dangerous to the person
D. Person totality is not involved

58. Levito Devin, the Italian prime minister, is due to retire next week. He feels depressed due
to the enormous loss of influence, power, fame and fortune. What type of crisis is Devin
experiencing?

A. Situational
B. Maturational
C. Social
D. Phenomenal

59. Estrada, the Philippine president, has been unexpectedly impeached and was out of office
before the end of his term. He is in what type of crisis?
A. Situational
B. Maturational
C. Social
D. Phenomenal

60. The tsunami in Thailand and Indonesia took thousands of people and change million
lives. The people affected by the tsunami are saddened and do not know how to start all over
again. What type of crisis is this?

A. Situational
B. Maturational
C. Social
D. Phenomenal

61. Which of the following is the BEST goal for crisis intervention?

A. Bring back the client in the pre crisis state

B. Make sure that the client becomes better
C. Achieve independence
D. Provide alternate coping mechanism

62. What is the best intervention when the client has just experienced the crisis and still at
the first phase of the crisis?

A. Behavior therapy
B. Gestalt therapy
C. Cognitive therapy
D. Milieu Therapy

63. Therapeutic nurse client relationship is describes as follows

1. Based on friendship and mutual interest

2. It is a professional relationship
3. It is focused on helping the patient solve problems and achieve health-related goals
4. Maintained only as long as the patient requires professional help
A. 1,2,3
B. 1,2,4
C. 2,3,4
D. 1,3,4

64. The client is scheduled to have surgical removal of the tumor on her left breast. Which of
the following manifestation indicates that she is experiencing Mild Anxiety?

A. She has increased awareness of her environmental details

B. She focused on selected aspect of her illness
C. She experiences incongruence of action, thoughts and feelings
D. She experiences random motor activities

65. Which of the following nursing intervention would least likely be effective when dealing
with a client with aggressive behavior?

A. Approach him in a calm manner

B. Provide opportunities to express feelings
C. Maintain eye contact with the client
D. Isolate the client from others

66. Whitney, a patient of nurse Blake, verbalizes… “I have nothing, nothing… nothing! Don’t
make me close one more door, I don’t wanna hurt anymore!” Which of the following is the
most appropriate response by Blake?

A. Why are you singing?

B. What makes you say that?
C. Ofcourse you are everything!
D. What is that you said?

67. Whitney verbalizes that she is anxious that the diagnostic test might reveal laryngeal
cancer. Which of the following is the most appropriate nursing intervention?

A. Tell the client not to worry until the results are in

B. Ask the client to express feelings and concern
C. Reassure the client everything will be alright
D. Advice the client to divert his attention by watching television and reading newspapers

68. Considered as the most accurate expression of person’s thought and feelings

A. Verbal communication
B. Non verbal communication
C. Written communication
D. Oral communication

69. Represents inner feeling that a person do not like talking about.

A. Overt communication
B. Covert communication
C. Verbal communication
D. Non verbal communication

70. Which of the following is NOT a characteristic of an effective Nurse-Client relationship?

A. Focused on the patient

B. Based on mutual trust
C. Conveys acceptance
D. Discourages emotional bond

71. A type of record wherein each person or department makes notation in separate records.
A nurse will use the nursing notes, the doctor will use the Physician’s order sheet etc. Data is
arranged according to information source.

A. POMR
B. POR
C. Traditional
D. Resource oriented

72. Type of recording that integrates all data about the problem, gathered by members of the
health team.
A. POMR
B. Traditional
C. Resource oriented
D. Source oriented

73. These are data that are monitored by using graphic charts or graphs that indicated the
progression or fluctuation of client’s Temperature and Blood pressure.

A. Progress notes
B. Kardex
C. Flow chart
D. Flow sheet

74. Provides a concise method of organizing and recording data about the client. It is a series
of flip cards kept in portable file used in change of shift reports.

A. Kardex
B. Progress Notes
C. SOAPIE
D. Change of shift report

75. You are about to write an information on the Kardex. There are four (4) available writing
instruments to use. Which of the following should you use?

A. Mongol #2
B. Permanent Ink
C. A felt or fountain pen
D. Pilot Pentel Pen marker

76. The client has an allergy to Iodine-based dye. Where should you put this vital information
in the client’s chart?

A. In the first page of the client’s chart

B. At the last page of the client’s chart
C. At the front metal plate of the chart
D. In the Kardex
77. Which of the following is NOT TRUE about the Kardex

A. It provides readily available information

B. It is a tool of end of shift reports
C. The primary basis of endorsement
D. Where Allergies information are written

78. Which of the following, if seen on the Nurses notes, violates characteristic of good
recording?

A. The client has a blood pressure of 120/80, Temperature of 36.6 C, Pulse rate of 120 and
Respiratory rate of 22
B. Ate 50% of food served
C. Refused administration of betaxolol
D. Visited and seen by Dr. Santiago

79. The physician ordered: Mannerix a.c , what does a.c means?

A. As desired
B. Before meals
C. After meals
D. Before bed time

80. The physician ordered, Maalox, 2 hours p.c, what does p.c means?
A. As desired
B. Before meals
C. After meals
D. Before bedtime

81. The physician ordered, Maxitrol, Od. What does Od means?

A. Left eye
B. Right eye
C. Both eye
D. Once a day
82. The physician ordered, Magnesium Hydroxide cc Aluminum Hydroxide. What does cc
means?

A. without
B. with
C. one half
D. With one half dose

83. Physician ordered, Paracetamol tablet ss. What does ss means?

A. without
B. with
C. one half
D. With one half dose

84. Which of the following indicates that learning has been achieved?

A. Martin starts exercising every morning and eating a balance diet after you taught her mag HL tayo
program
B. Donya Delilah has been able to repeat the steps of insulin administration after you taught it to her
C. Marsha said “ I understand “ after you a health teaching about family planning
D. John rated 100% on your given quiz about smoking and alcoholism

85. In his theory of learning as a BEHAVIORISM, he stated that transfer of knowledge occurs
if a new situation closely resembles an old one.

A. Bloom
B. Lewin
C. Thorndike
D. Skinner

86. Which of the following is TRUE with regards to learning?

A. Start from complex to simple

B. Goals should be hard to achieve so patient can strive to attain unrealistic goals
C. Visual learning is the best for every individual
D. Do not teach a client when he is in pain

87. According to Bloom, there are 3 domains in learning. Which of these domains is
responsible for the ability of Donya Delilah to inject insulin?

A. Cognitive
B. Affective
C. Psychomotor
D. Motivative

88. Which domains of learning is responsible for making John and Marsha understand the
different kinds of family planning methods?

A. Cognitive
B. Affective
C. Psychomotor
D. Motivative

89. Which of the following statement clearly defines therapeutic communication?

A. Therapeutic communication is an interaction process which is primarily directed by the nurse

B. It conveys feeling of warmth, acceptance and empathy from the nurse to a patient in relaxed
atmosphere
C. Therapeutic communication is a reciprocal interaction based on trust and aimed at identifying
patient needs and developing mutual goals
D. Therapeutic communication is an assessment component of the nursing process

90. Which of the following concept is most important in establishing a therapeutic nurse
patient relationship?

A. The nurse must fully understand the patient’s feelings, perception and reactions before goals can
be established
B. The nurse must be a role model for health fostering behavior
C. The nurse must recognize that the patient may manifest maladaptive behavior after illness
D. The nurse should understand that patients might test her before trust is established
91. Which of the following communication skill is most effective in dealing with covert
communication?

A. Validation
B. Listening
C. Evaluation
D. Clarification

92. Which of the following are qualities of a good recording?

1. Brevity
2. Completeness and chronology
3. Appropriateness
4. Accuracy

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

93. All of the following chart entries are correct except

A. V/S 36.8 C,80,16,120/80

B. Complained of chest pain
C. Seems agitated
D. Able to ambulate without assistance

94. Which of the following teaching method is effective in client who needs to be educated
about self injection of insulin?

A. Detailed explanation
B. Demonstration
C. Use of pamphlets
D. Film showing

95. What is the most important characteristic of a nurse patient relationship?

A. It is growth facilitating
B. Based on mutual understanding
C. Fosters hope and confidence
D. Involves primarily emotional bond

96. Which of the following nursing intervention is needed before teaching a client post
spleenectomy deep breathing and coughing exercises?

A. Tell the patient that deep breathing and coughing exercises is needed to promote good breathing,
circulation and prevent complication
B. Tell the client that deep breathing and coughing exercises is needed to prevent Thrombophlebitis,
hydrostatic pneumonia and atelectasis
C. Medicate client for pain
D. Tell client that cooperation is vital to improve recovery

97. The client has an allergy with penicillin. What is the best way to communicate this
information?

A. Place an allergy alert in the Kardex

B. Notify the attending physician
C. Write it on the patient’s chart
D. Take note when giving medications

98. An adult client is on extreme pain. He is moaning and grimacing. What is the best way to
assess the client’s pain?

A. Perform physical assessment

B. Have the client rate his pain on the smiley pain rating scale
C. Active listening on what the patient says
D. Observe the client’s behavior

99. Therapeutic communication begins with?

A. Knowing your client

B. Knowing yourself
C. Showing empathy
D. Encoding

100. The PCS gave new guidelines including leaflets to educate cancer patients. As a nurse,
When using materials like this, what is your responsibility?

A. Read it for the patient

B. Give it for the patient to read himself
C. Let the family member read the material for the patient
D. Read it yourself then, Have the client read the material

Answers and Rationale

Countercheck your answers to those below. Rationales are not given on this exam. If you have any
disputes or clarifications, please direct them to the comments section.

1. Answer: B. Vasodilatation

Sympathetic activation to the heart results in coronary vasodilation and increased coronary flow due
to increased metabolic activity (increased heart rate, contractility) despite direct vasoconstrictor
effects of sympathetic activation on the coronaries. This is termed “functional sympatholysis.”

2. Answer: D. Blood pressure will increase

Blood pressure elevation secondary to hypoglycemia has been demonstrated in human

experimentation through the activation of the sympathoadrenal system.

3. Answer: A. Increase heat, thereby produce abatement of phagocytosis

The inflammatory response is a defense mechanism that evolved in higher organisms to protect
them from infection and injury. Its purpose is to localize and eliminate the injurious agent and to
remove damaged tissue components so that the body can begin to heal. The response consists of
changes in blood flow, an increase in permeability of blood vessels, and the migration of fluid,
proteins, and white blood cells (leukocytes) from the circulation to the site of tissue damage. An
inflammatory response that lasts only a few days is called acute inflammation, while a response of
longer duration is referred to as chronic inflammation.

4. Answer: C. Immediate Vasoconstriction

Inflammation can be divided into several phases. The earliest, gross event of an inflammatory
response is temporary vasoconstriction, i.e. narrowing of blood vessels caused by contraction of
smooth muscle in the vessel walls, which can be seen as blanching (whitening) of the skin.

5. Answer: C. The affected part will lose its normal function

A fifth consequence of inflammation is the loss of function of the inflamed area, a feature noted by
German pathologist Rudolf Virchow in the 19th century. Loss of function may result from pain that
inhibits mobility or from severe swelling that prevents movement in the area.

6. Answer: C. Purulent

Purulent effluent refers to a thick yellow, gray or green drainage that comes out of a wound when
infection invades the area. The fluid contains pathogenic microorganisms along with white cells,
inflammatory cells and dead or dying bacteria. When the wound is infected, the volume of the
purulent exudate increases.

7. Answer: A. Redness on the affected area

Vasodilation occurs first at the arteriole level, progressing to the capillary level, and brings about a
net increase in the amount of blood present, causing the redness and heat of inflammation.

8. Answer: D. Monocytes

Monocytes and their macrophage and dendritic-cell progeny serve three main functions in the
immune system. These are phagocytosis, antigen presentation, and cytokine production.
Phagocytosis is the process of uptake of microbes and particles followed by digestion and
destruction of this material. Monocytes can perform phagocytosis using intermediary (opsonising)
proteins such as antibodies or complement that coat the pathogen, as well as by binding to the
microbe directly via pattern-recognition receptors that recognize pathogens.
9. Answer: C. Eosinophil

It is known that eosinophils appear as an aftermath of anaphylaxis in sensitized tissues that are
reexposed to specific antigens.

10. Answer: A. Neutrophils

Activated neutrophils are capable of presenting antigens via MHCII, thereby stimulating T-cell
activation and proliferation.

11. Answer: C. Pavementation

Pavementation or the sticking of white blood cells to the linings of the finest blood vessels
(capillaries) when inflammation occurs is the first process that occurs in the inflammatory response
after injury.

12. Answer: D. I don’t know the answer, perhaps I can tell you after I find it out later

13. Answer: C. Third intention

Healing by third intention is a method of closing a grossly contaminated wound in which the wound is
left open until contamination has been markedly reduced and inflammation has subsided and then is
closed by first intention. Also called delayed primary closure.

14. Answer: A. First intention

Healing by first intention aka. primary wound healing or primary closure describes a wound closed
by approximation of wound margins or by placement of a graft or flap, or wounds created and closed
in the operating room.

15. Answer: B. Second intention

Healing by second intention aka. secondary wound healing or spontaneous healing Describes a
wound left open and allowed to close by epithelialization and contraction.

16. Answer: B. High protein, High calorie with Vitamin A and C rich foods
Even if you do not currently have any aches or pains, adding these foods into your diet can help
prepare your body for healing if you should happen to get hurt.

17. Answer: A. It is a type of mechanical debridement using Wet dressing that is applied and
left to dry to remove dead tissues

This type of mechanical debridement is done by placing a wet (or moist) gauze dressing on your
wound and allowing it to dry, wound drainage and dead tissue can be removed when you take off
the old dressing.

18. Answer: C. Compression of the local nerve endings by the edema fluids

Chemicals that stimulate nerve endings are released, making the area much more sensitive and the
inflamed area is likely to be painful, especially when touched.

19. Answer: B. 1,3,4

20. Answer: D. Smoke cigarette around 3:00 A.M

The phrase “NPO After Midnight” is one of the most common in medicine. It is present not only in
physician’s pre-operative orders, but repeated by nurses, ward secretaries and dietary workers. The
goal of “NPO after midnight” was to ensure an empty stomach for the morning procedure.

21. Answer: B. Decrease Urine output

22. Answer: A. Directed towards helping an individual both physically and emotionally

Therapeutic nurse-patient communication helps nurses to build positive relationships with patients
by showing warmth, respect, and empathy. It also increases confidence of the nurse by enabling
nurses to ask for support, open up for feedbacks, and overcome anxiety. Therefore allows nurses to
provide the best possible care for patients. Effective nurse-healthcare provider communications
assure optimal patient-centered care.

23. Answer: B. Peplau

Peplau published her Theory of Interpersonal Relations in 1952, and in 1968, interpersonal
techniques became the crux of psychiatric nursing. The nursing model identifies four sequential
phases in the interpersonal relationship: orientation, identification, exploitation, and resolution.

24. Answer: A. Pre Orientation

Pre-orientation phase begins when the nurse is assigned to the patient. It includes all that the nurse
thinks and does before interacting with the patient such as when the nurse review the client’s
medical records.

25. Answer: B. Orientation

Orientation Phase begins when the nurse and the patient meet for the patient. In this phase,
parameters of the relationship is done. Explanation of roles is also done during this phase which
includes the responsibilities and expectation of the patient and nurse, with the expectations of both
parties of what they can and can’t do. It is during the orientation phase when the nurse begins to
know the patient.

26. Answer: C. Working

The working phase is highly individualized. it is more structured than the orientation phase- meaning
most of the therapeutic work is done during this phase.

27. Answer: B. Positive regard

Unconditional positive regard often described as acceptance is the third core condition and this
involves taking a non-judgemental attitude towards the client accepting and respecting them for who
and what they are.

28. Answer: B. Positive regard

Refer to #27

29. Answer: A. It is a nervous energy

Stress is a normal physical response to events that make you feel threatened or upset your balance
in some way. A nervous energy is more part of anxiety.

30. Answer: D. Martina is in Crisis

Martina is in Crisis. She feels sad and down during this tough time. She can have intense negative
feelings for weeks, months or more.

31. Answer: D. The source of dread or uneasiness is from a recognized entity

Anxiety is a general term for several disorders that cause nervousness, fear, apprehension, and
worrying. These disorders affect how we feel and behave, and they can manifest real physical
symptoms. Mild anxiety is vague and unsettling, while severe anxiety can be extremely debilitating,
having a serious impact on daily life.

32. Answer: D. Panic

Panic is the highest level of anxiety and is associated with dread, terror and a sense of impending
doom. You may not be able to communicate, function or concentrate because you are unable to
think rationally. You may start uncontrollably pacing and become increasingly active without absolute
purpose.

33. Answer: B. Moderate

At this level, you lose the broader picture and focus only on the cause of the anxiety. You may not
be able to pay attention like usual, and even though your perceptual field is narrowed, you are still
able to solve a problem. Mild and moderate levels of anxiety are considered normal.

34. Answer: B. Dilated pupils

35. Answer: B. When the client starts to have a narrow perceptual field and selective
inattentiveness

36. Answer: C. The client asks a question

37. Answer: A. Offer choices

38. Answer: D. “What makes you feel anxious?”

39. Answer: B. Concentrating on breathing without tensing the muscle, Letting go and
repeating a word or sound after each exhalation

The Relaxation Response is essentially the opposite reaction to the “fight or flight” response.
According to Dr. Benson, using the Relaxation Response is beneficial as it counteracts the
physiological effects of stress and the fight or flight response.

40. Answer: A. Biofeedback

Biofeedback is a technique you can use to learn to control your body’s functions, such as your heart
rate. With biofeedback, you’re connected to electrical sensors that help you receive information
(feedback) about your body (bio). This feedback helps you focus on making subtle changes in your
body, such as relaxing certain muscles, to achieve the results you want, such as reducing pain.

In essence, biofeedback gives you the power to use your thoughts to control your body, often to help
with a health condition or physical performance. Biofeedback is often used as a relaxation technique.

41. Answer: C. Autogenic training

Autogenic Therapy (AT) is a powerful mind and body technique involving simple relaxation and body
awareness exercises. These reduce the intensity of the body’s stress response, and replace it with a
calmer physiological state in which self-healing naturally begins to occur.

42. Answer: D. Luvox

Luvox (fluvoxamine) is a selective serotonin reuptake inhibitor (SSRI) antidepressant. Fluvoxamine

affects chemicals in the brain that may become unbalanced and cause obsessive-compulsive
symptoms. It is frequently used along with benzodiazepine anxiolytics in clinics.

43: Answer: B. 2,3

Spiritual anxiety is the expression of fear of God’s wrath and punishment; fear that God might not
take care of one, either immediately or in the future; and/or worry that God is displeased with one’s
behavior. Spiritual guilt is an expression suggesting that one has failed to do the things which he
should have done in life and/or done things which were not pleasing to God; articulation of concerns
about the “kind” of life one has lived. Spiritual pain is the expression of discomfort of suffering
relative to one’s relationship with God, verbalization of feelings of having a void or lack of spiritual
fulfillment, and/or a lack of peace in terms of one’s relationship to one’s creator. And spiritual despair
is the expression suggesting that there is no hope of ever having a relationship with God or of
pleasing Him and/or a feeling that God no longer can or does care for one.

44. Answer: B. Spiritual Alienation

Spiritual alienation is the expressions of loneliness or the feeling that God seems very far away and
remote from one’s everyday life, verbalization that one has to depend upon one’s self in times of trial
or need, and/or a negative attitude toward receiving any comfort or help from God.

45. Answer: B. Spiritual Loss

Spiritual loss is the expression of feelings of having temporarily lost or terminated the love of God,
fear that one’s relationship with God has been threatened, and/or a feeling of emptiness with regard
to spiritual things.

46. Answer: C. Making observation

Making observation is a therapeutic observation that is verbalizing what is observed or perceived.

47. Answer: B. Restating

Restating lets client know whether an expressed statement has or has not been understood.

48. Answer: A. Reflecting

Reflecting directs questions or feelings back to client so that they may be recognized and accepted.

49. Answer: A. Reflecting

Reflecting is directing back to the patient questions, feelings, and ideas.

50. Answer: B. Restating

Restating is repeating the main idea expressed.

51. Answer: C. Voicing Doubt

Voicing doubt is expressing uncertainty as to the reality of client’s perception.

52. Answer: C. “Hello Mr. Tadle, You are here in the hospital, I am your nurse and you are a
patient here”

This is an example of presenting reality. It is clarifying misconceptions that client may be expressing.

53. Answer: D. “Why are you so anxious? Please tell me more about your feelings Erik”

Requesting an explanation is an ineffective behavior and response.

54. Answer: C. Displacement

Displacement is the redirecting of thoughts feelings and impulses directed at one person or object,
but taken out upon another person or object. People often use displacement when they cannot
express their feelings in a safe manner to the person they are directed at.

55. Answer: A. Restitution

Restitution is the mechanism of relieving the mind of a load of guilt by making up or reparation
(paying up with interest).

56. Answer: C. Lasts for 4 months

57: Answer: B. There is a triggering event

Crisis is any event that is, or is expected to lead to, an unstable and dangerous situation affecting an
individual, group, community, or whole society.

58. Answer: B. Maturational

Maturational crisis a life crisis in which usual coping mechanisms are inadequate in dealing with a
stress common to a particular stage in the life cycle or with stress caused by a transition from one
stage to another.

59. Answer: A. Situational

Situational crisis is an unexpected crisis that arises suddenly in response to an external event or a
conflict concerning a specific circumstance.

60. Answer: C. Social

Social Crisis is the crisis which hampers the social life of an individual. It can include recession,
World War, terrorism etc., these are the major factor which is responsible for social crisis.

61. Answer: D. Provide alternate coping mechanism

One of the goals for crisis intervention is that the victim and the counselor begin to collaboratively
generate and explore alternatives for coping. Although this situation will be unlike any other
experience before, the counselor should assist the individual in looking at what has worked in the
past for other situations; this is typically the most difficult to achieve in crisis counseling.

62. Answer D. Milieu Therapy

The goal of milieu therapy is to manipulate the environment so that all aspects of the client’s hospital
experience are considered therapeutic.

63. Answer: C. 2,3,4

A therapeutic nurse-client relationship is established for the benefit of the client. It includes nurses
working with the client to create goals directed at improving their health status. Goals are centered
on the client’s values, beliefs and needs. A partnership is formed between nurse and client. The
nurse empowers patient and families to get involved in their health. This relationship has three
phases, a beginning (first time contact/introduction), a middle (develop a relationship to deliver care)
and an end (the patient is no longer dependant on the nurse).

64. Answer: A. She has increased awareness of her environmental details

Mild anxiety is anxiety that is manageable without any additional techniques. Mild anxiety tends to be
when you have irritating symptoms that don’t seem to go away, but otherwise don’t control you.

65. Answer: B. Provide opportunities to express feelings

Providing opportunities for the client to express his or her feelings will likely trigger his or her
aggressiveness more.

66. Answer: D. What is that you said?

Clarification should be sought at each step of the way. The patient is usually quite aware when he is
not being understood. Eventually he may cease trying to communicate. Peplau states that it is
always possible to ask: What is that you said?

67. Answer: B. Ask the client to express feelings and concern

Asking the client to verbalize what she or he perceives may relieve the tension the client is feeling
and he or she might be less likely to take action on ideas that are harmful or frightening.

68. Answer: B. Non verbal communication

Non verbal communication is considered as the most accurate expression of person’s thought and
feelings. Nonverbal communication represents two-thirds of all communication.

69. Answer: B. Covert communication

“Overt” means “done or shown openly or plainly apparent” in the Oxford English dictionary. This can
refer to all sorts of actions which are done in plain sight or with clear manifestations. “Covert,” on the
other hand, means the exact opposite of overt – not openly acknowledged or displayed.

70. Answer: D. Discourages emotional bond

Emotional support is important in order for a nurse-client relationship to be effective. It is giving and
receiving reassurance and encouragement done through understanding.

71. Answer: D. Resource oriented

72. Answer: A. POMR

Problem-oriented medical record (POMR) is a method of recording data about the health status of a
patient in a problem-solving system. The POMR preserves the data in an easily accessible way that
encourages ongoing assessment and revision of the health care plan by all members of the health
care team.

73. Answer: D. Flow sheet

Flowsheet (in a patient record) is a graphic summary of several changing factors, especially the
patient’s vital signs or weight and the treatments and medications given.

74. Answer: A. Kardex

The Kardex is a trademark for a card-filing system that allows quick reference to the particular needs
of each patient for certain aspects of nursing care.

75. Answer: A. Mongol #2

Kardexes are a huge risk factor for med errors that is why they are written in pencil. They are not
legal documents and are discarded when the patient is transferred out. And they are only as good as
the nurse responsible for checking the orders

76. Answer: C. At the front metal plate of the chart

77. Answer: C. The primary basis of endorsement

Refer to #75.

78. Answer: A. The client has a blood pressure of 120/80, Temperature of 36.6 C Pulse rate of
120 and Respiratory rate of 22

Shortcuts would be safe to use on records when commenting on blood pressure, temperature, pulse
rate, and respiratory rate respectively. Do not use an abbreviation unless you are sure that it is
commonly understood and in general use.
79. Answer: B. Before meals

80. Answer: C. After meals

81. Answer: D. Once a day

82. Answer: B. with

83. Answer: C. one half

84. Answer: A. Martin starts exercising every morning and eating a balance diet after you
taught her mag HL tayo program

Learning has been achieved by the patient if he or she applies and acts upon the teachings of the
health care provider or the nurse. Verbalizing such learning does not guarantee an effective nurse
teaching.

85. Answer: C. Thorndike

After several experiments on animals and learning development, Thorndike posited that learning
was actually merely a change in behavior as a result of a consequence. Furthermore, if an action
brought a reward, it was stamped into the mind and available for recall later. These two suppositions
together came to be known as the Law of Effect, and now inform much of what we know about
operant conditioning and behaviorism.

86. Answer: D. Do not teach a client when he is in pain

Pain tells us something is wrong. Pain does not suggest that the patient is ready to listen and
perceive properly the teaching that the nurse may impart.

87. Answer: C. Psychomotor

Bloom’s Taxonomy model is in three parts, or ‘overlapping domains’. Again, Bloom used rather
academic language, but the meanings are simple to understand: The learner should benefit from
development of knowledge and intellect (Cognitive Domain); attitude and beliefs (Affective Domain);
and the ability to put physical and bodily skills into effect – to act (Psychomotor Domain).
88. Answer: A. Cognitive

Refer to #87.

89. Answer: C. Therapeutic communication is a reciprocal interaction based on trust and

aimed at identifying patient needs and developing mutual goals

Therapeutic communication is a process in which the nurse consciously influences a client or helps
the client to a better understanding through verbal or nonverbal communication. Therapeutic
communication involves the use of specific strategies that encourage the patient to express feelings
and ideas and that convey acceptance and respect.

The goal of therapeutic communication is to increase self-worth or decrease psychological distress

by collecting information to determine the illness, assessing and modifying the behavior, and
providing health education.

90. Answer: D. The nurse should understand that patients might test her before trust is
established

A therapeutic nurse-patient relationship is defined as a helping relationship that’s based on mutual

trust and respect, the nurturing of faith and hope, being sensitive to self and others, and assisting
with the gratification of your patient’s physical, emotional, and spiritual needs through your
knowledge and skill.

91. Answer: A. Validation

92. Answer: D. 1,2,3,4

Documentation in nursing is also an integral part of providing quality and safe care to patients.
Qualities of a good recording include Brevity, Completeness and chronology, Appropriateness and
Accuracy.

93. Answer: C. Seems agitated

Being accurate is very important. For example, do not use vague terms such as “good urine output.”
How many cc’s are “good?” Chart the specific amount and be accurate on things that you see and
observe.

94. Answer: B. Demonstration

In teaching through demonstration, patients are set up to potentially conceptualize material more
effectively.

95. Answer: A. It is growth facilitating

You can help your patient achieve harmony in mind, body, and spirit when engaging in a therapeutic
relationship based on effective communication that incorporates caring behaviors. It’s a win-win
situation in which you and your patient can experience growth by sharing “the moment” with each
other.

96. Answer: A. Tell the patient that deep breathing and coughing exercises is needed to
promote good breathing, circulation and prevent complication

Deep breathing and coughing will decrease your risk for a lung infection. Take a deep breath and
hold it for as long as you can. Let the air out and then cough strongly. Deep breaths help open your
airway. You may be given an incentive spirometer to help you take deep breaths. Put the plastic
piece in your mouth and take a slow, deep breath. Then let the air out and cough. Repeat these
steps 10 times every hour.

97. Answer: B. Notify the attending physician

98. Answer: C. Active listening on what the patient says

Assessment of the patient experiencing pain is the cornerstone to optimal pain management.
However, the quality and utility of any assessment tool is only as good as the clinician’s ability to
thoroughly focus on the patient. This means listening empathically, believing and legitimizing the
patient’s pain, and understanding, to the best of his or her capability, what the patient may be
experiencing. A health care professional’s empathic understanding of the patient’s pain experience
and accompanying symptoms confirms that there is genuine interest in the patient as a person. This
can influence a positive pain management outcome.
99. Answer: B. Knowing yourself

It is important for the nurse to know herself to identify kinds of behavior of ideas that make her
anxious and to seed help for her problems. Otherwise, she is likely to add new problems to those
with which the patient is already struggling.

100. Answer: D. Read it yourself then, Have the client read the material

NURSING PROCESS
1. She is the first one to coin the term “NURSING PROCESS.” She introduced three (3) steps
of nursing process which are: Observation, Ministration and Validation.

A. Nightingale
B. Johnson
C. Rogers
D. Hall

2. The American Nurses Association formulated an innovation of the Nursing process. Today,
how many distinct steps are there in the nursing process?

A. APIE – 4
B. ADPIE – 5
C. ADOPIE – 6
D. ADOPIER – 7

3. They are the first ones to suggest a four (4) step nursing process called APIE or
assessment, planning, implementation, and evaluation.

1. Yura
2. Walsh
3. Roy
4. Knowles
A. 1,2
B. 1,3
C. 3,4
D. 2,3

4. Which characteristic of nursing process is responsible for proper utilization of human

resources, time and cost resources?

A. Organized and Systematic

B. Humanistic
C. Efficient
D. Effective

5. Which characteristic of nursing process addresses the INDIVIDUALIZED care a client must
receive?

A. Organized and Systematic

B. Humanistic
C. Efficient
D. Effective

6. A characteristic of the nursing process that is essential to promote client satisfaction and
progress. The care should also be relevant with the client’s needs.

A. Organized and Systematic

B. Humanistic
C. Efficient
D. Effective

7. Rhina, who has Menieres disease, said that her environment is moving. Which of the
following is a valid assessment?

1. Rhina is giving an objective data

2. Rhina is giving a subjective data
3. The source of the data is primary
4. The source of the data is secondary
A. 1,3
B. 2,3
C. 2.4
D. 1,4

8. Nurse Angela, observe Joel who is very apprehensive over the impending operation. The
client is experiencing dyspnea, diaphoresis and asks lots of questions. Angela made a
diagnosis of ANXIETY R/T INTRUSIVE PROCEDURE. This is what type of Nursing Diagnosis?

A. Actual
B. Probable
C. Possible
D. Risk

9. Nurse Angela diagnosed Mrs. Delgado, who have undergone a BKA. Her diagnosis is SELF
ESTEEM DISTURBANCE R/T CHANGE IN BODY IMAGE. Although the client has not yet seen
her lost leg, Angela already anticipated the diagnosis. This is what type of Diagnosis?

A. Actual
B. Probable
C. Possible
D. Risk

10. Nurse Angela is about to make a diagnosis but very unsure because the S/S the client is
experiencing is not specific with her diagnosis of POWERLESSNESS R/T DIFFICULTY
ACCEPTING LOSS OF LOVED ONE. She then focus on gathering data to refute or prove her
diagnosis but her plans and interventions are already ongoing for the diagnosis. Which type
of Diagnosis is this?

A. Actual
B. Probable
C. Possible
D. Risk
11. Nurse Angela knew that Stephen Lee Mu Chin, has just undergone an operation with an
incision near the diaphragm. She knew that this will contribute to some complications later
on. She then should develop what type of Nursing diagnosis?

A. Actual
B. Probable
C. Possible
D. Risk

12. Which of the following Nursing diagnosis is INCORRECT?

A. Fluid volume deficit R/T Diarrhea

B. High risk for injury R/T Absence of side rails
C. Possible ineffective coping R/T Loss of loved one
D. Self esteem disturbance R/T Effects of surgical removal of the leg

13. Among the following statements, which should be given the HIGHEST priority?

A. Client is in extreme pain

B. Client’s blood pressure is 60/40
C. Client’s temperature is 40 deg. Centigrade
D. Client is cyanotic

14. Which of the following need is given a higher priority among others?

A. The client has attempted suicide and safety precaution is needed

B. The client has disturbance in his body image because of the recent operation
C. The client is depressed because her boyfriend left her all alone
D. The client is thirsty and dehydrated

15. Which of the following is TRUE with regards to Client Goals?

A. They are specific, measurable, attainable and time bounded

B. They are general and broadly stated
C. They should answer for WHO, WHAT ACTIONS, WHAT CIRCUMSTANCES, HOW WELL and
WHEN.
D. Example is : After discharge planning, Client demonstrated the proper psychomotor skills for
insulin injection.

16. Which of the following is a NOT a correct statement of an Outcome criteria?

A. Ambulates 30 feet with a cane before discharge

B. Discusses fears and concerns regarding the surgical procedure
C. Demonstrates proper coughing and breathing technique after a teaching session
D. Reestablishes a normal pattern of elimination

17. Which of the following is a OBJECTIVE data?

A. Dizziness
B. Chest pain
C. Anxiety
D. Blue nails

18. A patient’s chart is what type of data source?

A. Primary
B. Secondary
C. Tertiary
D. Can be A and B

19. All of the following are characteristic of the Nursing process except

A. Dynamic
B. Cyclical
C. Universal
D. Intrapersonal

20. Which of the following is true about the NURSING CARE PLAN?

A. It is nursing centered
B. Rationales are supported by interventions
C. Verbal
D. At least 2 goals are needed for every nursing diagnosis

21. A framework for health assessment that evaluates the effects of stressors to the mind,
body and environment in relation with the ability of the client to perform ADL.

A. Functional health framework

B. Head to toe framework
C. Body system framework
D. Cephalocaudal framework

22. Client has undergone Upper GI and Lower GI series. Which type of health assessment
framework is used in this situation?

A. Functional health framework

B. Head to toe framework
C. Body system framework
D. Cephalocaudal framework

23. Which of the following statement is true regarding temperature?

A. Oral temperature is more accurate than rectal temperature

B. The bulb used in Rectal temperature reading is pear shaped or round
C. The older the person, the higher his BMR
D. When the client is swimming, BMR Decreases

24. A type of heat loss that occurs when the heat is dissipated by air current

A. Convection
B. Conduction
C. Radiation
D. Evaporation

25. Which of the following is TRUE about temperature?

A. The highest temperature usually occurs later in a day, around 8 P.M to 12 M.N
B. The lowest temperature is usually in the Afternoon, Around 12 P.M
C. Thyroxin decreases body temperature
D. Elderly people are risk for hyperthermia due to the absence of fats, Decreased thermoregulatory
control and sedentary lifestyle.

26. Hyperpyrexia is a condition in which the temperature is greater than

A. 40 degree Celsius
B. 39 degree Celsius
C. 100 degree Fahrenheit
D. 105.8 degree Fahrenheit

27. Tympanic temperature is taken from John, A client who was brought recently into the ER
due to frequent barking cough. The temperature reads 37.9 Degrees Celsius. As a nurse, you
conclude that this temperature is

A. High
B. Low
C. At the low end of the normal range
D. At the high end of the normal range

28. John has a fever of 38.5 Deg. Celsius. It surges at around 40 Degrees and go back to 38.5
degrees 6 times today in a typical pattern. What kind of fever is John having?

A. Relapsing
B. Intermittent
C. Remittent
D. Constant

29. John has a fever of 39.5 degrees 2 days ago, But yesterday, he has a normal temperature
of 36.5 degrees. Today, his temperature surges to 40 degrees. What type of fever is John
having?

A. Relapsing
B. Intermittent
C. Remittent
D. Constant

30. John’s temperature 10 hours ago is a normal 36.5 degrees. 4 hours ago, He has a fever
with a temperature of 38.9 Degrees. Right now, his temperature is back to normal. Which of
the following best describe the fever john is having?

A. Relapsing
B. Intermittent
C. Remittent
D. Constant

31. The characteristic fever in Dengue Virus is characterized as:

A. Tricyclic
B. Bicyclic
C. Biphasic
D. Triphasic

32. When John has been given paracetamol, his fever was brought down dramatically from 40
degrees Celsius to 36.7 degrees in a matter of 10 minutes. The nurse would assess this event
as:

A. The goal of reducing john’s fever has been met with full satisfaction of the outcome criteria
B. The desired goal has been partially met
C. The goal is not completely met
D. The goal has been met but not with the desired outcome criteria

33. What can you expect from Marianne, who is currently at the ONSET stage of fever?

A. Hot, flushed skin

B. Increase thirst
C. Convulsion
D. Pale,cold skin
34. Marianne is now at the Defervescence stage of the fever, which of the following is
expected?

A. Delirium
B. Goose flesh
C. Cyanotic nail beds
D. Sweating

35. Considered as the most accessible and convenient method for temperature taking

A. Oral
B. Rectal
C. Tympanic
D. Axillary

36. Considered as Safest and most non invasive method of temperature taking

A. Oral
B. Rectal
C. Tympanic
D. Axillary

37. Which of the following is NOT a contraindication in taking ORAL temperature?

A. Quadriplegic
B. Presence of NGT
C. Dyspnea
D. Nausea and Vomitting

38. Which of the following is a contraindication in taking RECTAL temperature?

A. Unconscious
B. Neutropenic
C. NPO
D. Very young children
39. How long should the Rectal Thermometer be inserted to the clients anus?

A. 1 to 2 inches
B. .5 to 1.5 inches
C. 3 to 5 inches
D. 2 to 3 inches

40. In cleaning the thermometer after use, The direction of the cleaning to follow Medical
Asepsis is :

A. From bulb to stem

B. From stem to bulb
C. From stem to stem
D. From bulb to bulb

41. How long should the thermometer stay in the Client’s Axilla?

A. 3 minutes
B. 4 minutes
C. 7 minutes
D. 10 minutes

42. Which of the following statement is TRUE about pulse?

A. Young person have higher pulse than older persons

B. Males have higher pulse rate than females after puberty
C. Digitalis has a positive chronotropic effect
D. In lying position, Pulse rate is higher

43. The following are correct actions when taking radial pulse except:

A. Put the palms downward

B. Use the thumb to palpate the artery
C. Use two or three fingers to palpate the pulse at the inner wrist
D. Assess the pulse rate, rhythm, volume and bilateral quality
44. The difference between the systolic and diastolic pressure is termed as

A. Apical rate
B. Cardiac rate
C. Pulse deficit
D. Pulse pressure

45. Which of the following completely describes PULSUS PARADOXICUS?

A. A greater-than-normal increase in systolic blood pressure with inspiration

B. A greater-than-normal decrease in systolic blood pressure with inspiration
C. Pulse is paradoxically low when client is in standing position and high when supine.
D. Pulse is paradoxically high when client is in standing position and low when supine.

46. Which of the following is TRUE about respiration?

A. I:E 2:1
B. I:E : 4:3
C I:E 1:1
D. I:E 1:2

47. Contains the pneumotaxic and the apneustic centers

A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies

48. Which of the following is responsible for deep and prolonged inspiration

A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies

49. Which of the following is responsible for the rhythm and quality of breathing?
A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies

50. The primary respiratory center

A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies

51. Which of the following is TRUE about the mechanism of action of the Aortic and Carotid
bodies?

A. If the BP is elevated, the RR increases

B. If the BP is elevated, the RR decreases
C. Elevated BP leads to Metabolic alkalosis
D. Low BP leads to Metabolic acidosis

52. All of the following factors correctly influence respiration except one. Which of the
following is incorrect?

A. Hydrocodone decreases RR
B. Stress increases RR
C. Increase temperature of the environment, Increase RR
D. Increase altitude, Increase RR

53. When does the heart receives blood from the coronary artery?

A. Systole
B. Diastole
C. When the valves opens
D. When the valves closes

54. Which of the following is more life threatening?

A. BP = 180/100
B. BP = 160/120
C. BP = 90/60
D. BP = 80/50

55. Refers to the pressure when the ventricles are at rest

A. Diastole
B. Systole
C. Preload
D. Pulse pressure

56. Which of the following is TRUE about the blood pressure determinants?

A. Hypervolemia lowers BP
B. Hypervolemia increases GFR
C. HCT of 70% might decrease or increase BP
D. Epinephrine decreases BP

57. Which of the following do not correctly correlates the increase BP of Ms. Aida, a 70 year
old diabetic?

A. Females, after the age 65 tends to have lower BP than males

B. Disease process like Diabetes increase BP
C. BP is highest in the morning, and lowest during the night
D. Africans, have a greater risk of hypertension than Caucasian and Asians.

58. How many minutes are allowed to pass if the client had engaged in strenuous activities,
smoked or ingested caffeine before taking his/her BP?

A. 5
B. 10
C. 15
D. 30

59. Too narrow cuff will cause what change in the Client’s BP?
A. True high reading
B. True low reading
C. False high reading
D. False low reading

60. Which is a preferable arm for BP taking?

A. An arm with the most contraptions

B. The left arm of the client with a CVA affecting the right brain
C. The right arm
D. The left arm

61. Which of the following is INCORRECT in assessing client’s BP?

A. Read the mercury at the upper meniscus, preferably at the eye level to prevent error of parallax
B. Inflate and deflate slowly, 2-3 mmHg at a time
C. The sound heard during taking BP is known as KOROTKOFF sound
D. If the BP is taken on the left leg using the popliteal artery pressure, a BP of 160/80 is normal.

62. Which of the following is the correct interpretation of the ERROR OF PARALLAX

A. If the eye level is higher than the level of the meniscus, it will cause a false high reading
B. If the eye level is higher than the level of the meniscus, it will cause a false low reading
C. If the eye level is lower than the level of the meniscus, it will cause a false low reading
D. If the eye level is equal to that of the level of the upper meniscus, the reading is accurate

63. How many minute/s is/are allowed to pass before making a re-reading after the first one?

A. 1
B. 5
C. 15
D. 30

64. Which of the following is TRUE about the auscultation of blood pressure?
A. Pulse + 4 is considered as FULL
B. The bell of the stethoscope is use in auscultating BP
C. Sound produced by BP is considered as HIGH frequency sound
D. Pulse +1 is considered as NORMAL

65. In assessing the abdomen, Which of the following is the correct sequence of the physical
assessment?

A. Inspection, Auscultation, Percussion, Palpation

B. Palpation, Auscultation, Percussion, Inspection
C. Inspection, Palpation, Auscultation, Percussion
D. Inspection, Auscultation, Palpation, Percussion

66. The sequence in examining the quadrants of the abdomen is:

A. RUQ, RLQ, LUQ, LLQ

B. RLQ, RUQ, LLQ, LUQ
C. RUQ, RLQ, LLQ, LUQ
D. RLQ, RUQ, LUQ, LLQ

67. In inspecting the abdomen, which of the following is NOT DONE?

A. Ask the client to void first

B. Knees and legs are straighten to relax the abdomen
C. The best position in assessing the abdomen is Dorsal recumbent
D. The knees and legs are externally rotated

68. Dr. House is about to conduct an ophthalmoscope examination. Which of the following, if
done by a nurse, is a correct preparation before the procedure?

A. Provide the necessary draping to ensure privacy

B. Open the windows, curtains and light to allow better illumination
C. Pour warm water over the ophthalmoscope to ensure comfort
D. Darken the room to provide better illumination
69. If the client is female, and the doctor is a male and the patient is about to undergo a
vaginal and cervical examination, why is it necessary to have a female nurse in attendance?

A. To ensure that the doctor performs the procedure safely

B. To assist the doctor
C. To assess the client’s response to examination
D. To ensure that the procedure is done in an ethical manner

70. In palpating the client’s breast, which of the following position is necessary for the patient
to assume before the start of the procedure?

A. Supine
B. Dorsal recumbent
C. Sitting
D. Lithotomy

71. When is the best time to collect urine specimen for routine urinalysis and C/S?

A. Early morning
B. Later afternoon
C. Midnight
D. Before breakfast

72. Which of the following is among an ideal way of collecting a urine specimen for culture
and sensitivity?

A. Use a clean container

B. Discard the first flow of urine to ensure that the urine is not contaminated
C. Collect around 30-50 ml of urine
D. Add preservatives, refrigerate the specimen or add ice according to the agency’s protocol

73. In a 24 hour urine specimen started Friday, 9:00 A.M, which of the following if done by a
Nurse indicate a NEED for further procedural debriefing?

A. The nurse ask the client to urinate at 9:00 A.M, Friday and she included the urine in the 24 hour
urine specimen
B. The nurse discards the Friday 9:00 A M urine of the client
C. The nurse included the Saturday 9:00 A.M urine of the client to the specimen collection
D. The nurse added preservatives as per protocol and refrigerates the specimen

74. This specimen is required to assess glucose levels and for the presence of albumin the
the urine

A. Midstream clean catch urine

B. 24 hours urine collection
C. Postprandial urine collection
D. Second voided urine

75. When should the client test his blood sugar levels for greater accuracy?

A. During meals
B. In between meals
C. Before meals
D. 2 Hours after meals

76. In collecting a urine from a catheterized patient, Which of the following statement
indicates an accurate performance of the procedure?

A. Clamp above the port for 30 to 60 minutes before drawing the urine from the port
B. Clamp below the port for 30 to 60 minutes before drawing the urine from the port
C. Clamp above the port for 5 to 10 minutes before drawing the urine from the port
D. Clamp below the port for 5 to 10 minutes before drawing the urine from the port

77. A community health nurse should be resourceful and meet the needs of the client. A
villager ask him, “Can you test my urine for glucose?” Which of the following technique
allows the nurse to test a client’s urine for glucose without the need for intricate instruments.

A. Acetic Acid test

B. Nitrazine paper test
C. Benedict’s test
D. Litmus paper test
78. A community health nurse is assessing client’s urine using the Acetic Acid solution.
Which of the following, if done by a nurse, indicates lack of correct knowledge with the
procedure?

A. The nurse added the Urine as the 2/3 part of the solution
B. The nurse heats the test tube after adding 1/3 part acetic acid
C. The nurse heats the test tube after adding 2/3 part of Urine
D. The nurse determines abnormal result if she noticed that the test tube becomes cloudy

79. Which of the following is incorrect with regards to proper urine testing using Benedict’s
Solution?

A. Heat around 5ml of Benedict’s solution together with the urine in a test tube
B. Add 8 to 10 drops of urine
C. Heat the Benedict’s solution without the urine to check if the solution is contaminated
D. If the color remains BLUE, the result is POSITIVE

80. “+++ Positive” result after Benedicts test is depicted by what color?

A. Blue
B. Green
C. Yellow
D. Orange

81. Clinitest is used in testing the urine of a client for glucose. Which of the following, if
committed by a nurse, indicates error?

A. Specimen is collected after meals

B. The nurse puts 1 clinitest tablet into a test tube
C. She added 5 drops of urine and 10 drops of water
D. If the color becomes orange or red, It is considered postitive

82. Which of the following nursing intervention is important for a client scheduled to have a
Guaiac Test?
A. Avoid turnips, radish and horseradish 3 days before procedure
B. Continue iron preparation to prevent further loss of Iron
C. Do not eat read meat 12 hours before procedure
D. Encourage caffeine and dark colored foods to produce accurate results

83. In collecting a routine specimen for fecalysis, which of the following, if done by a nurse,
indicates inadequate knowledge and skills about the procedure?

A. The nurse scoop the specimen specifically at the site with blood and mucus
B. She took around 1 inch of specimen or a teaspoonful
C. Ask the client to call her for the specimen after the client wiped off his anus with a tissue
D. Ask the client to defecate in a bedpan, Secure a sterile container

84. In a routine sputum analysis, which of the following indicates proper nursing action
before sputum collection?

A. Secure a clean container

B. Discard the container if the outside becomes contaminated with the sputum
C. Rinse the client’s mouth with Listerine after collection
D. Tell the client that 4 tablespoon of sputum is needed for each specimen for a routine sputum
analysis

85. Who collects blood specimen?

A. The nurse
B. Medical technologist
C. Physician
D. Physical therapist

86. David, 68 year old male client is scheduled for Serum Lipid analysis. Which of the
following health teaching is important to ensure accurate reading?

A. Tell the patient to eat fatty meals 3 days prior to the procedure
B. NPO for 12 hours pre procedure
C. Ask the client to drink 1 glass of water 1 hour prior to the procedure
D. Tell the client that the normal serum lipase level is 50 to 140 U/L
87. The primary factor responsible for body heat production is the

A. Metabolism
B. Release of thyroxin
C. Muscle activity
D. Stress

88. The heat regulating center is found in the

A. Medulla oblongata
B. Thalamus
C. Hypothalamus
D. Pons

89. A process of heat loss which involves the transfer of heat from one surface to another is

A. Radiation
B. Conduction
C. Convection
D. Evaporation

90. Which of the following is a primary factor that affects the BP?

A. Obesity
B. Age
C. Stress
D. Gender

91. The following are social data about the client except

A. Patient’s lifestyle
B. Religious practices
C. Family home situation
D. Usual health status

92. The best position for any procedure that involves vaginal and cervical examination is
A. Dorsal recumbent
B. Side lying
C. Supine
D. Lithotomy

93. Measure the leg circumference of a client with bipedal edema is best done in what
position?

A. Dorsal recumbent
B. Sitting
C. Standing
D. Supine

94. In palpating the client’s abdomen, Which of the following is the best position for the client
to assume?

A. Dorsal recumbent
B. Side lying
C. Supine
D. Lithotomy

95. Rectal examination is done with a client in what position?

A. Dorsal recumbent
B. Sims position
C. Supine
D. Lithotomy

96. Which of the following is a correct nursing action when collecting urine specimen from a
client with an Indwelling catheter?

A. Collect urine specimen from the drainage bag

B. Detach catheter from the connecting tube and draw the specimen from the port
C. Use sterile syringe to aspirate urine specimen from the drainage port
D. Insert the syringe straight to the port to allow self sealing of the port
97. Which of the following is inappropriate in collecting mid stream clean catch urine
specimen for urine analysis?

A. Collect early in the morning, First voided specimen

B. Do perineal care before specimen collection
C. Collect 5 to 10 ml for urine
D. Discard the first flow of the urine

98. When palpating the client’s neck for lymphadenopathy, where should the nurse position
himself?

A. At the client’s back

B. At the client’s right side
C. At the client’s left side
D. In front of a sitting client

99. Which of the following is the best position for the client to assume if the back is to be
examined by the nurse?

A. Standing
B. Sitting
C. Side lying
D. Prone

100. In assessing the client’s chest, which position best show chest expansion as well as its
movements?

A. Sitting
B. Prone
C. Sidelying
D. Supine

Answers
Here are the answers for this examination. Countercheck your answers to those below. If you have
any disputes or clarifications, please direct them to the comments section.

1. Answer: D. Hall

The term Nursing Process was first used by Lydia E. Hall where she introduced the 3
steps: observation, administration of care and validation.Florence Nightingale introduced the
Environmental Theory. Dorothy Johnson is known for her Behavioral Systems Model while Martha
Rogers introduced the Theory of Unitary Human Beings.

2. Answer: C. ADOPIE – 6

ADOPIE stands for: Assessment, Diagnosis, Outcome Identification, Planning, Intervention and
Evaluation.

3. Answer: A. 1,2

Helen Yura and Mary B. Walsh are the first ones to suggest a four step nursing process.

4. Answer: C. Efficient

Other than being efficient, a nursing process should also be effective in planning care, and
utilization of resources.

5. Answer: B. Humanistic

In the humanistic approach, a plan to care is developed and implemented by taking into
consideration the unique needs of the individual client. It also states that no two person has the
same health needs even if they have the same health condition or illness.

6. Answer: D. Effective

See rationale for #4.

7. Answer: B. 2,3
The data is subjective and primary since it was said by the client herself. Objective data are
observable by the nurse.

8. Answer: A. Actual

An actual nursing diagnosis describes a clinical judgement that the nurse has validated because of
the presence of major defining characteristics.

9. Answer: D. Risk

A risk nursing diagnosis describes a clinical judgement that an individual or group is more vulnerable
to develop the problem than others in the same or a similar situation because of risk factors.

10. Answer: C. Possible

Possible nursing diagnosis is not a type of diagnosis as are actual, risk, and syndrome. These are
the diagnostician option to indicate that some data are present to confirm a diagnosis but are
insufficient at this time.

11. Answer: D. Risk

See rationale for #9.

12. Answer: B. High risk for injury R/T Absence of side rails

13. Answer: D. Client is cyanotic

Cyanosis (cyanotic) is the appearance of a blue or purple coloration of the skin or mucous
membranes due to the tissues near the skin surface having low oxygen saturation. Following the
principles of Airway, Breathing, and Circulation, the first priority should be option D.

14. Answer: D. The client is thirsty and dehydrated

Based on Abraham Maslow’s Hierarchy of Needs, physiological needs should be prioritized first. The
other options are not physiological needs.
15. Answer: B. They are general and broadly stated

16. Answer: D. Reestablishes a normal pattern of elimination

17. Answer: D. Blue nails

18. Answer: B. Secondary

19. Answer: D. Intrapersonal

20. Answer: A. It is nursing centered

21. Answer: A. Functional health framework

22. Answer: C. Body system framework

23. Answer: B. The bulb used in Rectal temperature reading is pear shaped or round

24. Answer: A. Convection

25. Answer: A. The highest temperature usually occurs later in a day, around 8 P.M to 12 M.N

26. Answer: D. 105.8 degree Fahrenheit

27. Answer: D. At the high end of the normal range

28. Answer: C. Remittent

29. Answer: A. Relapsing

30. Answer: B. Intermittent

31. Answer: C. Biphasic

32. Answer: D. The goal has been met but not with the desired outcome criteria
33. Answer: D. Pale,cold skin

34. Answer: D. Sweating

35. Answer: A. Oral

36. Answer: D. Axillary

37. Answer: A. Quadriplegic

38. Answer: B. Neutropenic

39. Answer: B. .5 to 1.5 inches

40. Answer: B. From stem to bulb

41. Answer: C. 7 minutes

42. Answer: A. Young person have higher pulse than older persons

43. Answer: B. Use the thumb to palpate the artery

44. Answer: D. Pulse pressure

45. Answer: B. A greater-than-normal decrease in systolic blood pressure with inspiration

46. Answer: D. I:E 1:2

47. Answer: B. Pons

48. Answer: B. Pons

49. Answer: B. Pons

50. Answer: A. Medulla oblongata

51. Answer: B. If the BP is elevated, the RR decreases

52. Answer: C. Increase temperature of the environment, Increase RR

53. Answer: B. Diastole

54. Answer: B. BP = 160/120

55. Answer: A. Diastole

56. Answer: D. Epinephrine decreases BP

57. Answer: A. Females, after the age 65 tends to have lower BP than males

58. Answer: D. 30

59. Answer: C. False high reading

60. Answer: D. The left arm

61. Answer: A. Read the mercury at the upper meniscus, preferably at the eye level to prevent
error of parallax

62. Answer: B. If the eye level is higher than the level of the meniscus, it will cause a false low
reading

63. Answer: A. 1

64. Answer: B. The bell of the stethoscope is use in auscultating BP

65. Answer: A. Inspection, Auscultation, Percussion, Palpation

66. Answer: D. RLQ,RUQ,LUQ,LLQ

67. Answer: B. Knees and legs are straighten to relax the abdomen
68. Answer: D. Darken the room to provide better illumination

69. Answer: D. To ensure that the procedure is done in an ethical manner

70. Answer: A. Supine

71. Answer: A. Early morning

72. Answer: B. Discard the first flow of urine to ensure that the urine is not contaminated

73. Answer: A. The nurse ask the client to urinate at 9:00 A.M, Friday and she included the
urine in the 24 hour urine specimen

74. Answer: D. Second voided urine

75. Answer: C. Before meals

76. Answer: B. Clamp below the port for 30 to 60 minutes before drawing the urine from the
port

77. Answer: C. Benedict’s test

78. Answer: B. The nurse heats the test tube after adding 1/3 part acetic acid

79. Answer: D. If the color remains BLUE, the result is POSITIVE

80. Answer: D. Orange

81. Answer: Specimen is collected after meals

82. Answer: A. Avoid turnips, radish and horseradish 3 days before procedure

83. Answer: C. Ask the client to call her for the specimen after the client wiped off his anus
with a tissue

84. Answer: C. Rinse the client’s mouth with Listerine after collection
85. Answer: B. Medical technologist

86. Answer: B. NPO for 12 hours pre procedure

87. Answer: A. Metabolism

88. Answer: C. Hypothalamus

89. Answer: B. Conduction

90. Answer: C. Stress

91. Answer: A. Patient’s lifestyle

92. Answer: D. Lithotomy

93. Answer: A. Dorsal recumbent

94. Answer: A. Dorsal recumbent

95. Answer: B. Sims position

96. Answer: C. Use sterile syringe to aspirate urine specimen from the drainage port

97. Answer: C. Collect 5 to 10 ml for urine

98. Answer: A. At the client’s back

99. Answer: A. Standing

100. Answer: A. Sitting

1. Which one of the following is NOT a function of the Upper airway?

A. For clearance mechanism such as coughing

B. Transport gases to the lower airways
C. Warming, Filtration and Humidification of inspired air
D. Protect the lower airway from foreign mater

2. It is the hair that lines the vestibule which function as a filtering mechanism for foreign
objects

A. Cilia
B. Nares
C. Carina
D. Vibrissae

3. This is the paranasal sinus found between the eyes and the nose that extends backward
into the skull

A. Ehtmoid
B. Sphenoid
C. Maxillary
D. Frontal

4. Which paranasal sinus is found over the eyebrow?

A. Ehtmoid
B. Sphenoid
C. Maxillary
D. Frontal

5. Gene De Vonne Katrouchuacheulujiki wants to change her surname to something shorter,

The court denied her request which depresses her and find herself binge eating. She
accidentally aspirate a large piece of nut and it passes the carina. Probabilty wise, Where will
the nut go?

A. Right main stem bronchus

B. Left main stem bronchus
C. Be dislodged in between the carina
D. Be blocked by the closed epiglottis
6. Which cell secretes mucus that help protect the lungs by trapping debris in the respiratory
tract?

A. Type I pneumocytes
B. Type II pneumocytes
C. Goblet cells
D. Adipose cells

7. How many lobes are there in the RIGHT LUNG?

A. One
B. Two
C. Three
D. Four

8. The presence of the liver causes which anatomical difference of the Kidneys and the
Lungs?

A. Left kidney slightly lower, Left lung slightly shorter

B. Left kidney slightly higher, Left lung slightly shorter
C. Right kidney lower, Right lung shorter
D. Right kidney higher, Right lung shorter

9. Surfactant is produced by what cells in the alveoli?

A. Type I pneumocytes
B. Type II pneumocytes
C. Goblet cells
D. Adipose cells

10. The normal L:S Ratio to consider the newborn baby viable is

A. 1:2
B. 2:1
C. 3:1
D. 1:3
11. Refers to the extra air that can be inhaled beyond the normal tidal volume

A. Inspiratory reserve volume

B. Expiratory reserve volume
C. Functional residual capacity
D. Residual volume

12. This is the amount of air remained in the lungs after a forceful expiration

A. Inspiratory reserve volume

B. Expiratory reserve volume
C. Functional residual capacity
D. Residual volume

13. Casssandra, A 22 year old grade Agnostic, Asked you, how many spikes of bones are
there in my ribs? Your best response is which of the following?

A. We have 13 pairs of ribs Cassandra

B. We have 12 pairs of ribs Cassandra
C. Humans have 16 pairs of ribs, and that was noted by Vesalius in 1543
D. Humans have 8 pairs of ribs. 4 of which are floating

14. Which of the following is considered as the main muscle of respiration?

A. Lungs
B. Intercostal Muscles
C. Diaphragm
D. Pectoralis major

15. Cassandra asked you : How many air is there in the oxygen and how many does human
requires? Which of the following is the best response :

A. God is good, Man requires 21% of oxygen and we have 21% available in our air
B. Man requires 16% of oxygen and we have 35% available in our air
C. Man requires 10% of oxygen and we have 50% available in our air
D. Human requires 21% of oxygen and we have 21% available in our air
16. Which of the following is TRUE about Expiration?

A. A passive process
B. The length of which is half of the length of Inspiration
C. Stridor is commonly heard during expiration
D. Requires energy to be carried out

17. Which of the following is TRUE in postural drainage?

A. Patient assumes position for 10 to 15 minutes

B. Should last only for 60 minutes
C. Done best P.C
D. An independent nursing action

18. All but one of the following is a purpose of steam inhalation

A. Mucolytic
B. Warm and humidify air
C. Administer medications
D. Promote bronchoconstriction

19. Which of the following is NOT TRUE in steam inhalation?

A. It is a dependent nursing action

B. Spout is put 12-18 inches away from the nose
C. Render steam inhalation for atleast 60 minutes
D. Cover the client’s eye with wash cloth to prevent irritation

20. When should a nurse suction a client?

A. As desired
B. As needed
C. Every 1 hour
D. Every 4 hours
21. Ernest Arnold Hamilton, a 60 year old American client was mobbed by teen gangsters
near New york, Cubao. He was rushed to John John Hopio Medical Center and was
Unconscious. You are his nurse and you are to suction his secretions. In which position
should you place Mr. Hamilton?

A. High fowlers
B. Semi fowlers
C. Prone
D. Side lying

22. You are about to set the suction pressure to be used to Mr. Hamilton. You are using a
Wall unit suction machine. How much pressure should you set the valve before suctioning
Mr. Hamilton?

A. 50-95 mmHg
B. 200-350 mmHg
C. 100-120 mmHg
D. 10-15 mmHg

23. The wall unit is not functioning; You then try to use the portable suction equipment
available. How much pressure of suction equipment is needed to prevent trauma to mucus
membrane and air ways in case of portable suction units?

A. 2-5 mmHg
B. 5-10 mmHg
C. 10-15 mmHg
D. 15-25 mmHg

24. There are four catheter sizes available for use, which one of these should you use for Mr.
Hamilton?

A. Fr. 18
B. Fr. 12
C. Fr. 10
D. Fr. 5
25. Which of the following, if done by the nurse, indicates incompetence during suctioning an
unconscious client?

A. Measure the length of the suction catheter to be inserted by measuring from the tip of the nose, to
the earlobe, to the xiphoid process
B. Use KY Jelly if suctioning nasopharyngeal secretion
C. The maximum time of suctioning should not exceed 15 seconds
D. Allow 30 seconds interval between suctioning

26. Which of the following is the initial sign of hypoxemia in an adult client?

1. Tachypnea
2. Tachycardia
3. Cyanosis
4. Pallor
5. Irritability
6. Flaring of Nares

A. 1,2
B. 2,5
C. 2,6
D. 3,4

27. Which method of oxygenation least likely produces anxiety and apprehension?

A. Nasal Cannula
B. Simple Face mask
C. Non Rebreather mask
D. Partial Rebreather mask

28. Which of the following oxygen delivery method can deliver 100% Oxygen at 15 LPM?

A. Nasal Cannula
B. Simple Face mask
C. Non Rebreather mask
D. Partial Rebreather mask
29. Which of the following is not true about OXYGEN?

A. Oxygen is odorless, tasteless and colorless gas.

B. Oxygen can irritate mucus membrane
C. Oxygen supports combustion
D. Excessive oxygen administration results in respiratory acidosis

30. Roberto San Andres, A new nurse in the hospital is about to administer oxygen on patient
with Respiratory distress. As his senior nurse, you should intervene if Roberto will:

A. Uses venture mask in oxygen administration

B. Put a non rebreather mask in the patient before opening the oxygen source
C. Use a partial rebreather mask to deliver oxygen
D. Check for the doctor’s order for Oxygen administration

31. Which of the following will alert the nurse as an early sign of hypoxia?

A. Client is tired and dyspneic

B. The client is coughing out blood
C. The client’s heart rate is 50 BPM
D. Client is frequently turning from side to side

32. Miguelito de balboa, An OFW presents at the admission with an A:P Diameter ratio of 2:1,
Which of the following associated finding should the nurse expect?

A. Pancytopenia
B. Anemia
C. Fingers are Club-like
D. Hematocrit of client is decreased

33. The best method of oxygen administration for client with COPD uses:

A. Cannula
B. Simple Face mask
C. Non rebreather mask
D. Venturi mask
34. Mang Dagul, a 50 year old chronic smoker was brought to the E.R because of difficulty in
breathing. Pleural effusion was the diagnosis and CTT was ordered. What does C.T.T Stands
for?

A. Chest tube thoracotomy

B. Chest tube thoracostomy
C. Closed tube thoracotomy
D. Closed tube thoracostmy

35. Where will the CTT be inserted if we are to drain fluids accumulated in Mang dagul’s
pleura?

A. 2nd ICS
B. 4th ICS
C. 5th ICS
D. 8th ICS

36. There is a continuous bubbling in the water sealed drainage system with suction. And
oscillation is observed. As a nurse, what should you do?

A. Consider this as normal findings

B. Notify the physician
C. Check for tube leak
D. Prepare a petrolatum gauze dressing

37. Which of the following is true about nutrition?

A. It is the process in which food are broken down, for the body to use in growth and development
B. It is a process in which digested proteins, fats, minerals, vitamins and carbohydrates are
transported into the circulation
C. It is a chemical process that occurs in the cell that allows for energy production, energy use,
growth and tissue repair
D. It is the study of nutrients and the process in which they are use by the body

38. The majority of the digestion processes take place in the

A. Mouth
B. Small intestine
C. Large intestine
D. Stomach

39. All of the following is true about digestion that occurs in the Mouth except

A. It is where the digestion process starts

B. Mechanical digestion is brought about by mastication
C. The action of ptyalin or the salivary trypsin breaks down starches into maltose
D. Deglutition occurs after food is broken down into small pieces and well mixed with saliva

40. Which of the following foods lowers the cardiac sphincter pressure?

A. Roast beef, Steamed cauliflower and Rice

B. Orange juice, Non fat milk, Dry crackers
C. Decaffeinated coffee, Sky flakes crackers, Suman
D. Coffee with coffee mate, Bacon and Egg

41. Where does the digestion of carbohydrates start?

A. Mouth
B. Esophagus
C. Small intestine
D. Stomach

42. Protein digestion begins where?

A. Mouth
B. Esophagus
C. Small intestine
D. Stomach

43. All but one is true about digestion that occurs in the Stomach
A. Carbohydrates are the fastest to be digested, in about an hour
B. Fat is the slowest to be digested, in about 5 hours
C. HCl inhibits absorption of Calcium in the gastric mucosa
D. HCl converts pepsinogen to pepsin, which starts the complex process of protein digestion

44. Which of the following is NOT an enzyme secreted by the small intestine?

A. Sucrase
B. Enterokinase
C. Amylase
D. Enterokinase

45. The hormone secreted by the Small intestine that stimulates the production of pancreatic
juice which primarily aids in buffering the acidic bolus passed by the Stomach

A. Enterogastrone
B. Ghrelin
C. Pancreozymin
D. Enterokinase

46. When the duodenal enzyme sucrase acts on SUCROSE, which 2 monosaccharides are
formed?

A. Galactose + Galactose
B. Glucose + Fructose
C. Glucose + Galactose
D. Fructose + Fructose

47. This is the enzyme secreted by the pancrease that completes the protein digestion

A. Trypsin
B. Enterokinase
C. Enterogastrone
D. Amylase

48. The end product of protein digestion or the “Building blocks of Protein” is what we call
A. Nucleotides
B. Fatty acids
C. Glucose
D. Amino Acids

49. Enzyme secreted by the small intestine after it detects a bolus of fatty food. This will
contract the gallbladder to secrete bile and relax the sphincter of Oddi to aid in the
emulsification of fats and its digestion.

A. Lipase
B. Amylase
C. Cholecystokinin
D. Pancreozymin

50. Which of the following is not true about the Large Intestine?

A. It absorbs around 1 L of water making the feces around 75% water and 25% solid
B. The stool formed in the transverse colon is not yet well formed
C. It is a sterile body cavity
D. It is called large intestine because it is longer than the small intestine

51. This is the amount of heat required to raise the temperature of 1 kg water to 1 degree
Celsius

A. Calorie
B. Joules
C. Metabolism
D. Basal metabolic rate

52. Assuming a cup of rice provides 50 grams of carbohydrates. How many calories are there
in that cup of rice?

A. 150 calories
B. 200 calories
C. 250 calories
D. 400 calories
53. An average adult Filipino male requires how many calories in a day?

A. 1,000 calories
B. 1,500 calories
C. 2,000 calories
D. 2,500 calories

54. Which of the following is true about an individual’s caloric needs?

A. All individual have the same caloric needs

B. Females in general have higher BMR and therefore, require more calories
C. During cold weather, people need more calories due to increase BMR
D. Dinner should be the heaviest meal of the day

55. Among the following people, who requires the greatest caloric intake?

A. An individual in a long state of gluconeogenesis

B. An individual in a long state of glycogenolysis
C. A pregnant individual
D. An adolescent with a BMI of 25

56. Which nutrient deficiency is associated with the development of Pellagra, Dermatitis and
Diarrhea?

A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin B6

57. Which Vitamin is not given in conjunction with the intake of LEVODOPA in cases of
Parkinson’s Disease due to the fact that levodopa increases its level in the body?

A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin B6
58. A vitamin taken in conjunction with ISONIAZID to prevent peripheral neuritis

A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin B6

59. The inflammation of the Lips, Palate and Tongue is associated in the deficiency of this
vitamin

A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin B6

60. Beri beri is caused by the deficiency of which Vitamin?

A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin C

61. Which of the following is the best source of Vitamin E?

A. Green leafy vegetables

B. Vegetable oil
C. Fortified Milk
D. Fish liver oil

62. Among the following foods, which food should you emphasize giving on an Alcoholic
client?

A. Pork liver and organ meats, Pork

B. Red meat, Eggs and Dairy products
C. Green leafy vegetables, Yellow vegetables, Cantaloupe and Dairy products
D. Chicken, Peanuts, Bananas, Wheat germs and yeasts
63. Which food group should you emphasize giving on a pregnant mother in first trimester to
prevent neural tube defects?

A. Broccoli, Guava, Citrus fruits, Tomatoes

B. Butter, Sardines, Tuna, Salmon, Egg yolk
C. Wheat germ, Vegetable Oil, soybeans, corn, peanuts
D. Organ meats, Green leafy vegetables, Liver, Eggs

64. A client taking Coumadin is to be educated on his diet. As a nurse, which of the following
food should you instruct the client to avoid?

A. Spinach, Green leafy vegetables, Cabbage, Liver

B. Salmon, Sardines, Tuna
C. Butter, Egg yolk, breakfast cereals
D. Banana, Yeast, Wheat germ, Chicken

65. Vitamin E plus this mineral works as one of the best anti oxidant in the body according to
the latest research. They are combined with 5 Alpha reductase inhibitor to reduce the risk of
acquiring prostate cancer

A. Zinc
B. Iron
C. Selenium
D. Vanadium

66. Incident of prostate cancer is found to have been reduced on a population exposed in
tolerable amount of sunlight. Which vitamin is associated with this phenomenon?

A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D

67. Micronutrients are those nutrients needed by the body in a very minute amount. Which of
the following vitamin is considered as a MICRONUTRIENT
A. Phosphorous
B. Iron
C. Calcium
D. Sodium

68. Deficiency of this mineral results in tetany, osteomalacia, osteoporosis and rickets.

A. Vitamin D
B. Iron
C. Calcium
D. Sodium

69. Among the following foods, which has the highest amount of potassium per serving?

A. Cantaloupe
B. Avocado
C. Raisin
D. Banana

70. A client has HEMOSIDEROSIS. Which of the following drug would you expect to be given
to the client?

A. Acetazolamide
B. Deferoxamine
C. Calcium EDTA
D. Activated charcoal

71. Which of the following provides the richest source of Iron per area of their meat?

A. Pork meat
B. Lean red meat
C. Pork liver
D. Green mongo

72. Which of the following is considered the best indicator of nutritional status of an
individual?
A. Height
B. Weight
C. Arm muscle circumference
D. BMI

73. Jose Miguel, a 50 year old business man is 6’0 Tall and weights 179 lbs. As a nurse, you
know that Jose Miguel is :

A. Overweight
B. Underweight
C. Normal
D. Obese

74. Jose Miguel is a little bit nauseous. Among the following beverages, Which could help
relieve JM’s nausea?

A. Coke
B. Sprite
C. Mirinda
D. Orange Juice or Lemon Juice

75. Which of the following is the first sign of dehydration?

A. Tachycardia
B. Restlessness
C. Thirst
D. Poor skin turgor

76. What Specific gravity lab result is compatible with a dehydrated client?

A. 1.007
B. 1.020
C. 1.039
D. 1.029

77. Which hematocrit value is expected in a dehydrated male client?

A. 67%
B. 50%
C. 36%
D. 45%

78. Which of the following statement by a client with prolonged vomiting indicates the initial
onset of hypokalemia?

A. My arm feels so weak

B. I felt my heart beat just right now
C. My face muscle is twitching
D. Nurse, help! My legs are cramping

79. Which of the following is not an anti-emetic?

A. Marinol
B. Dramamine
C. Benadryl
D. Alevaire

80. Which is not a clear liquid diet?

A. Hard candy
B. Gelatin
C. Coffee with Coffee mate
D. Bouillon

81. Which of the following is included in a full liquid diet?

A. Popsicles
B. Pureed vegetable meat
C. Pineapple juice with pulps
D. Mashed potato

82. Which food is included in a BLAND DIET?

A. Steamed broccoli
B. Creamed potato
C. Spinach in garlic
D. Sweet potato

83. Which of the following if done by the nurse, is correct during NGT Insertion?

A. Use an oil based lubricant

B. Measure the amount of the tube to be inserted from the Tip of the nose, to the earlobe, to the
xiphoid process
C. Soak the NGT in a basin of ice water to facilitate easy insertion
D. Check the placement of the tube by introducing 10 cc of sterile water and auscultating for
bubbling sound

84. Which of the following is the BEST method in assessing for the correct placement of the
NGT?

A. X-Ray
B. Immerse tip of the tube in water to check for bubbles produced
C. Aspirating gastric content to check if the content is acidic
D. Instilling air in the NGT and listening for a gurgling sound at the epigastric area

85. A terminally ill cancer patient is scheduled for an NGT feeding today. How should you
position the patient?

A. Semi fowlers in bed

B. Bring the client into a chair
C. Slightly elevated right side lying position
D. Supine in bed

86. A client is scheduled for NGT Feeding. Checking the residual volume, you determined
that he has 40 cc residual from the last feeding. You reinstill the 40 cc of residual volume and
added the 250 cc of feeding ordered by the doctor. You then instill 60 cc of water to clear the
lumen and the tube. How much will you put in the client’s chart as input?
A. 250 cc
B. 290 cc
C. 350 cc
D. 310 cc

87. Which of the following if done by a nurse indicates deviation from the standards of NGT
feeding?

A. Do not give the feeding and notify the doctor of residual of the last feeding is greater than or equal
to 50 ml
B. Height of the feeding should be 12 inches about the tube point of insertion to allow slow
introduction of feeding
C. Ask the client to position in supine position immediately after feeding to prevent dumping
syndrome
D. Clamp the NGT before all of the water is instilled to prevent air entry in the stomach

88. What is the most common problem in TUBE FEEDING?

A. Diarrhea
B. Infection
C. Hyperglycemia
D. Vomiting

89. Which of the following is TRUE in colostomy feeding?

A. Hold the syringe 18 inches above the stoma and administer the feeding slowly
B. Pour 30 ml of water before and after feeding administration
C. Insert the ostomy feeding tube 1 inch towards the stoma
D. A Pink stoma means that circulation towards the stoma is all well

90. A client with TPN suddenly develops tremors, dizziness, weakness and diaphoresis. The
client said “I feel weak” You saw that his TPN is already empty and another TPN is scheduled
to replace the previous one but its provision is already 3 hours late. Which of the following is
the probable complication being experienced by the client?
A. Hyperglycemia
B. Hypoglycemia
C. Infection
D. Fluid overload

91. To assess the adequacy of food intake, which of the following assessment parameters is
best used?

A. Food likes and dislikes

B. Regularity of meal times
C. 3 day diet recall
D. Eating style and habits

92. The vomiting center is found in the

A. Medulla Oblongata
B. Pons
C. Hypothalamus
D. Cerebellum

93. The most threatening complication of vomiting in client’s with stroke is

A. Aspiration
B. Dehydration
C. Fluid and electrolyte imbalance
D. Malnutrition

94. Which among this food is the richest source of Iron?

A. Ampalaya
B. Broccoli
C. Mongo
D. Malunggay leaves

95. Which of the following is a good source of Vitamin A?

A. Egg yolk
B. Liver
C. Fish
D. Peanuts

96. The most important nursing action before gastrostomy feeding is

A. Check V/S
B. Assess for patency of the tube
C. Measure residual feeding
D. Check the placement of the tube

97. The primary advantage of gastrostomy feeding is

A. Ensures adequate nutrition

B. It prevents aspiration
C. Maintains Gastro esophageal sphincter integrity
D. Minimizes fluid-electrolyte imbalance

98. What is the BMI Of Budek, weighing 120 lbs and has a height of 5 feet 7 inches.

A. 20
B. 19
C. 15
D. 25

99. Which finding is consistent with PERNICIOUS ANEMIA?

A. Strawberry tongue
B. Currant Jelly stool
C. Beefy red tongue
D. Pale [ HYPOCHROMIC ] RBC

100. The nurse is browsing the chart of the patient and notes a normal serum lipase level.
Which of the following is a normal serum lipase value?
A. 10 U/L
B. 100 U/L
C. 200 U/L
D. 350 U/L

Answers and Rationale

Here are the answers for this exam. Gauge your performance by counter checking your answers to
those below. If you have any disputes or clarifications, please direct them to the comments section.

1. Answer: A. For clearance mechanism such as coughing

The the function of the cough reflex is to dislodge foreign substances from the trachea. The upper
respiratory tract refers to the external nose, nasal cavity, pharynx and associated structures while
the lower respiratory tract includes the larynx, trachea, bronchi, and lungs. However, there are
alternative definitions just like the larynx being placed on the upper respiratory tract.

2. Answer: D. Vibrissae

Vibrissae are the thick hairs which grow inside the nostrils to help keep large particles from entering
the nasal passages. Cilia are hair-like projection lining the bronchus that move microbes and debris
up and out of the airways.

3. Answer: A. Ehtmoid

The ethmoidal sinuses are formed from several discrete air cells within the ethmoid bone between
the nose and the eyes. The maxillary sinuses, also called the maxillary antrechea and the largest of
the paranasal sinuses, are under the eyes, in the maxillary bones. The frontal sinuses, superior to
the eyes, are in the frontal bone, which forms the hard part of the forehead. The sphenoidal sinuses
are in the sphenoid bone.

4. Answer: D. Frontal

The frontal sinuses are found superior to the eyes and eyebrows in the frontal bone, which forms the
hard part of the forehead.
5. Answer: A. Right main stem bronchus

Foreign objects that enter the trachea usually lodge in the right main bronchus, because it is more
vertical than the left main bronchus and therefore for in direct line with the trachea.

6. Answer: C. Goblet cells

Goblet cells are found scattered among the epithelial lining of organs, such as the intestinal and
respiratory tracts. They are found inside the trachea, bronchus, and larger bronchioles in respiratory
tract. The main role of goblet cells is to secrete mucus in order to protect the mucosae where they
are found.

7. Answer: C. Three

The right lung has three lobes called the superior, middle and inferior lobes. the left lung, on the
other hand, has only two lobes namely the superior and inferior lobes.

8. Answer: C. Right kidney lower, Right lung shorter

The kidneys are paired retroperitoneal structures that are normally located between the transverse
processes of T12-L3 vertebrae, with the left kidney typically somewhat more superior in position than
the right. The right lung, meanwhile, has a higher volume, total capacity and weight, than that of the
left lung. Although it is 5 cm shorter due to the diaphragm rising higher on the right side to
accommodate the liver, it is broader than the left lung due to the cardiac notch of the left lung.

9. Answer: B. Type II pneumocytes

Pulmonary surfactant is a surface-active lipoprotein complex (phospho lipoprotein) formed by type II

alveolar cells.

10. Answer: B. 2:1

An L–S ratio of 2 or more indicates fetal lung maturity and a relatively low risk of infant respiratory
distress syndrome, and an L/S ratio of less than 1.5 is associated with a high risk of infant
respiratory distress syndrome.
11. Answer: A. Inspiratory reserve volume

Inspiratory reserve volume is the maximal amount of additional air that can be drawn into the lungs
by determined effort after normal inspiration. Average inspiratory reserve volumes in healthy adults
are 3.0 L in men and 1.9 L in women.

12. Answer: D. Residual volume

Residual volume is the volume of air remaining in the lungs after a maximal exhalation. Average
residual volumes in healthy adults are 1.2 L in men and 1.1 L in women.

13. Answer: B. We have 12 pairs of ribs Cassandra

Humans have 24 ribs (12 pairs). The first seven sets of ribs, known as “true ribs” (costae verae), are
directly attached to the sternum through the costal cartilage. The following five sets are known as
“false ribs” (costae spuriae), three of these sharing a common cartilaginous connection to the
sternum, while the last two (eleventh and twelfth ribs) are termed floating ribs (costae fluctuantes) or
vertebral ribs.

14. Answer: C. Diaphragm

The main muscle of breathing is the diaphragm, therefore it gets its own page. The muscles of
inspiration elevate the ribs and sternum, and the muscles of expiration depress them. The primary
inspiratory muscles are the external intercostals and the diaphragm.

15. Answer: D. Human requires 21% of oxygen and we have 21% available in our air

Air is a mixture of 21% oxygen, 78% nitrogen, and approximately 1% other trace gases, primarily
argon; to simplify calculations this last 1% is usually treated as if it were nitrogen. The gas is
essential for living, but only up to a point. Humans can only breathe 21 percent oxygen.

16. Answer: A. A passive process

Expiration is a passive process. That means that we don’t have to expend any energy to exhale.
When our diaphragm has stopped contracting for inspiration, it can now begin to relax.
17. Answer: A. Patient assumes position for 10 to 15 minutes

Postural drainage is the positioning techniques that drain secretions from specific segments of the
lugs and bronchi into the trachea. The client is instructed to remain in each position for 10 to 15
minutes. During this time, perform percussion and vibration, as ordered.

18. Answer: D. Promote bronchoconstriction

Steam inhalation is a method of introducing warm, moist air into the lungs via the nose and throat for
therapeutic benefit. Essential oils are often added to provide additional relief. Inhaling steam is a
great treatment for respiratory complications and is recommended for dealing with common cold, flu,
bronchitis, sinusitis, asthma, and allergies. Dry air passages are moistened, and mucus is
loosened/eliminated easier by coughing or blowing the nose. The moist air also alleviates difficulty
breathing, throat irritation and inflammation.

19. Answer: C. Render steam inhalation for atleast 60 minutes

A common method of inhaling steam is to boil a few cups of filtered water and then pour the
steaming water into a large bowl. Essential oils can be added at this point if desired. Next, a towel
can be placed over the head, while leaning over the bowl of water, breathing deeply through the
nose for approximately 15 minutes. Humidifiers also provide a gentle form of steam inhalation.

20. Answer: B. As needed

A nurse should suction a patient as needed and indicated to maintain patency and integrity of
airway.

21. Answer: D. Side lying

Position the unconscious client in a side-lying position facing you. A side-lying position facilitates
drainage of secretions by gravity and prevents aspiration.

22. Answer: C. 100-120 mmHg

Turn on suction device and adjust pressure: infants and children, 50 to 75 mm Hg; adults, 100 to 120
mm Hg. Excessive negative pressure traumatizes mucosa and can induce hypoxia.
23. Answer: C. 10-15 mmHg

The pressure for a portable suction equipment depends on the age of the patient. For adults (10-15
mmHg), for children (5-10 mmHg) and for infants (2-5 mmHg).

24. Answer: A. Fr. 18

Appropriate-sized catheter: infants, 5 to 8 Fr; children, 8 to 10 Fr; adults, 12 to 18 Fr.

25. Answer: A. Measure the length of the suction catheter to be inserted by measuring from
the tip of the nose, to the earlobe, to the xiphoid process

Determine the depth the suction device will be inserted, by measuring the device against the
distance from the corner of the patient’s mouth to the tip of the earlobe on the same side.

26. Answer: B. 2,5

Restlessness, irritability and tachycardia are early signs of hypoxia. Chronic hypoxemia may result in
cognitive changes, such as memory changes.

27. Answer: A. Nasal Cannula

Among the methods of oxygenation, nasal cannulas least likely produce anxiety and apprehension.
However, patients with nasal cannulas sometimes complain of nasal dryness, particularly when
receiving oxygen at high levels. New devices can help with this by adding moisture and warmth to
the delivery process.

28. Answer: C. Non Rebreather mask

A non rebreather mask has a reservoir bag that is inflated with pure oxygen. Between the mask and
the bag is another one-way valve that allows the patient to breathe in the oxygen supplied by the
source as well as oxygen from the reservoir. This provides the patient with an oxygen concentration
of nearly 100%. A piece of tubing, usually connected to extension tubing, connects the mask to the
oxygen source.

29. Answer: D. Excessive oxygen administration results in respiratory acidosis

Oxygen, in its natural state, is a colorless, odorless, and tasteless gas. Oxygen is considered to be
the most important of all the elements to life. Oxygen does not burn, but it does support combustion.
Oxygen may also dry out the nasal mucosa and can irritate the nares.

30. Answer: B. Put a non rebreather mask in the patient before opening the oxygen source

In using a non rebreather mask, nurses should connect oxygen flow meter to an oxygen source first
and preset the oxygen flow to 15 liters per minute and check the system before placing the mask
over patient’s face covering the nose and mouth.

31. Answer: D. Client is frequently turning from side to side

Restlessness, irritability and tachycardia are early signs of hypoxia.

32. Answer: C. Fingers are Club-like

The normal AP to Lateral diameter in normal adult is 1:2. Signs of possible chronic pulmonary
disease include clubbing, barrel chest (the increased anterior-posterior diameter of the chest present
in some patients with emphysema), and pursed lip breathing. Clubbing is enlargement of the
fingertips (or toes) due to proliferation of connective tissue between the fingernail and the bone.

33. Answer: A. Cannula

The nasal cannula is used when a low-flow oxygen is indicated. The room air mixes with the oxygen
from the tank. It can deliver 24-40 percent of oxygen at 2-6 liters per minute. The cannula is used for
patients with COPD, asthma, emphysema, and uncomplicated heart attack.

34. Answer: B. Chest tube thoracostomy

CTT stands for Chest tube thoracostomy. It is done to drain fluid, blood, or air from the space around
the lungs. Some diseases, such as pneumonia and cancer, can cause an excess amount of fluid or
blood to build up in the space around the lungs (called a pleural effusion).

35. Answer: D. 8th ICS

Chest tubes are indicated when the normally airtight pleural space has been penetrated through
surgery or trauma, when a defect in the alveoli allows air to enter the intrapleural space, and when
there is an accumulation of fluid, as from pleural effusion. In some cases one tube is inserted higher
in the thorax (usually in the 2nd intercostal space) to remove air, and a second tube is placed lower
(in the 8th or 9th intercostal space) to drain off fluids.

36. Answer: C. Check for tube leak

Intermittent bubbling in water seal chamber with forced expiration or cough is okay. Continuous
bubbling in the water seal is abnormal and indicates an air leak. IF the nurse notes that there is
CONTINUOUS bubbling in the water seal chamber, check for leaks in the system. With physician’s
order, RN places padded clamp closest to dressing. If leak stops, air leak is at insertion site. If
bubbling continues, leak is between clamp and drainage system.

37. Answer: D. It is the study of nutrients and the process in which they are use by the body

The science or study that deals with food and nourishment, especially in humans. It is the process of
nourishing or being nourished, especially the process by which a living organism assimilates food
and uses it for growth and for replacement of tissues.

38. Answer: B. Small intestine

Chemical processes that contribute to digestion begin in the mouth with action of saliva on food.
However, most of the chemical digestive processes occur in the stomach and small intestine –
where the partly-digested materials are subjected to gastric juices, pancreatic juice, succus entericus
and so on. To be slightly more detailed, most digestion takes place in the duodenum section of the
small intestine.

39. Answer: C. The action of ptyalin or the salivary trypsin breaks down starches into maltose

Salivary amylase (ptyalin) starts the breakdown of high-molecular-weight carbohydrates while trypsin
breaks down proteins.

40. Answer: D. Coffee with coffee mate, Bacon and Egg

Certain foods and drinks loosen the lower esophageal sphincter. These include chocolate,
peppermint, caffeine-containing beverages (such as coffee, tea, and soft drinks), fatty foods, and
alcohol.

41. Answer: A. Mouth

Chemical processes that contribute to digestion begin in the mouth with action of saliva on food.

42. Answer: D. Stomach

Protein digestion occurs in the stomach and duodenum in which 3 main enzymes, pepsin secreted
by the stomach and trypsin and chymotrypsin secreted by the pancreas, break down food proteins
into polypeptides that are then broken down by various exopeptidases and dipeptidases into amino
acids.

43. Answer: C. HCl inhibits absorption of Calcium in the gastric mucosa

Hydrochloric acid, or HCL, is secreted in the stomach during digestion to begin breakdown of dietary
fats. HCL is needed for absorption of calcium in the duodenum, which is the first part of small
intestine. The duodenum is where calcium is actively absorbed from food into the body through the
intestinal wall into the bloodstream.

44. Answer: C. Amylase

Amylase is an enzyme that helps digest carbohydrates. It is produced in the pancreas and the
glands that make saliva.

45. Answer: C. Pancreozymin

Pancreozymin is a hormone of the duodenal mucosa that stimulates the external secretory activity of
the pancreas, especially its production of amylase; identical with cholecystokinin.

46. Answer: B. Glucose + Fructose

Sucrose is a disaccharide combination of the monosaccharides glucose and fructose with the
formula C12H22O11.
47. Answer: A. Trypsin

In the duodenum, trypsin catalyzes the hydrolysis of peptide bonds, breaking down proteins into
smaller peptides. The peptide products are then further hydrolyzed into amino acids via other
proteases, rendering them available for absorption into the blood stream. Tryptic digestion is a
necessary step in protein absorption as proteins are generally too large to be absorbed through the
lining of the small intestine.

48. Answer: D. Amino Acids

Twenty percent of the human body is made up of protein. Protein plays a crucial role in almost all
biological processes and amino acids are the building blocks of it.

49. Answer: C. Cholecystokinin

CCK mediates a number of physiological processes, including digestion and satiety. It is released by
I cells located in the mucosal epithelium of the small intestine (mostly in the duodenum and
jejunum). CCK also causes the increased production of hepatic bile, and stimulates the contraction
of the gall bladder and the relaxation of the Sphincter of Oddi (Glisson’s sphincter), resulting in the
delivery of bile into the duodenal part of the small intestine. Bile salts form amphipathic micelles that
emulsify fats, aiding in their digestion and absorption.

50. Answer: C. It is a sterile body cavity

The large intestine is the end section of the intestine. It is about 5 ft (1.5 m) long, is wider than the
small intestine, and has a smooth inner wall. In the first half, enzymes from the small intestine
complete digestion, and bacteria produce many B vitamins and vitamin K. Over 24–30 hours,
churning movements break down tough cellulose fibres and expose chyme to the colon’s walls,
which absorb water and electrolytes; absorption is its main function, along with storing fecal matter
for expulsion.

51. Answer: A. Calorie

Calorie, a unit of energy or heat variously defined. The calorie was originally defined as the amount
of heat required at a pressure of 1 standard atmosphere to raise the temperature of 1 gram of water
1° Celsius.
52. Answer: B. 200 calories

Determine if your food is a carbohydrate, protein, or fat. The conversion multiple is different for each
type of food. 1 gram of carbohydrate is equal to 4 calories. Therefore, a cup of rice having 50 grams
of carbohydrates contains 200 calories.

53. Answer: C. 2,000 calories

The Department of Health consultant on non-communicable diseases, noted that the recommended
calorie intake for women is 1,500 and 2,000 for men daily. It is advisable that Filipinos should aim for
500 calories a meal only.

54. Answer: C. During cold weather, people need more calories due to increase BMR

Temperature affects how many calories we burn. According to the American Dietetic Association
Complete Food and Nutrition Guide, both the heat and cold raise the BMR. If we are too cold we
shiver. Shivering burns up much energy from the constant contraction and relaxation of muscle cells
trying to produce heat to maintain body temperature. When we are hot we also burn more energy
through the process of sweating.

55. Answer: A. An individual in a long state of gluconeogenesis

The human body requires glucose for the brain and nervous system, and a diet that has very few or
no dietary carbohydrates forces it to generate this glucose from protein through gluconeogenesis,
with an efficiency of approximately 57% (protein and carbohydrate are approximately equal in
calorific value; each has about four kilocalories per gram, but gluconeogenesis can produce only 57g
of glucose from 100g of protein). This could be a significant contributor to metabolic advantage.

56. Answer: C. Vitamin B3

Also known as vitamin B3 or nicotinic acid, Niacin deficiency is a condition that occurs when a
person doesn’t get enough or can’t absorb niacin or tryptophan. Severe deficiency, called pellagra,
can cause symptoms related to the skin, digestive system, and nervous system.

57. Answer: D. Vitamin B6

Vitamin B6 reduces the effectiveness of levodopa, a medication used to treat Parkinson’s disease.
However, your doctor may be able to determine a dose of B6 that can help reduce side effects of
levodopa without interfering with the drug’s action. Taking vitamin B6 along with levodopa should be
done only under the strict guidance of a physician.

58. Answer: D. Vitamin B6

Vitamin B6 (pyridoxine) supplementation during isoniazid (INH) therapy is necessary in some

patients to prevent the development of peripheral neuropathy. In vivo pyridoxine is converted into
coenzymes which play an essential role in the metabolism of protein, carbohydrates, fatty acids, and
several other substances, including brain amines, INH apparently competitively inhibits the action of
pyridoxine in these metabolic functions. The reported frequency of INH-induced neuropathy in
various studies is reviewed and population groups at relatively high risk of developing this
complication are identified. The routine use of pyridoxine supplementation to prevent peripheral
neuropathy in high risk populations is recommended.

59. Answer: B. Vitamin B2

Riboflavin deficiency is also called ariboflavinosis. In humans the classical syndrome affects the
mouth (sore throat, inflammation of the lining of mouth and tongue), angular cheilitis), the eyes
(photophobia with bloodshot, itchy, watery eyes), the skin (moist, scaly skin particularly affecting the
scrotum or labia majora and the nasolabial folds) and the blood (decreased red blood cell count with
normal cell size and hemoglobin content i.e. normochromic normocytic anemia). In children it also
results in reduced growth.

60. Answer: A. Vitamin B1

Beriberi is a disease brought on by a Vitamin B-1 (thiamine) deficiency. There are two types of the
disease: wet beriberi and dry beriberi. Wet beriberi can effect heart function and, in the most
extreme cases, heart failure. Dry beriberi damages the nerves and can lead to a loss of muscle
strength and, eventually, muscle paralysis. If left unchecked and untreated, beriberi will cause death.

61. Answer: B. Vegetable oil

Because vitamin E is naturally present in plant-based diets and animal products and is often added
by manufacturers to vegetable oils and processed foods, intakes are probably adequate to avoid
overt deficiency in most situations.

62. Answer: A. Pork liver and organ meats, Pork

It is important for alcoholics to avoid refined sugars and caffeine, as they stress blood sugar control
mechanisms and may increase the craving for alcohol. In one study, excluding caffeine, junk food,
dairy products, and peanut butter was compared to a control diet for six months. Excellent food
sources of thiamine include asparagus, mushrooms, peanuts, pork, soybeans, sunflower seeds, and
yeast.

63. Answer: D. Organ meats, Green leafy vegetables, Liver, Eggs

Foods rich in folic acid such as leafy green vegetable, yeast, wheat germ, nuts, eggs, bananas,
oranges, and organ meats taken during the first trimester of pregnancy can help prevent spina bifida.

64. Answer: A. Spinach, Green leafy vegetables, Cabbage, Liver

Certain foods and beverages can make it so warfarin doesn’t effectively prevent blood clots. In order
to maintain stable PT/INR levels one should not eat more than 1 serving of a high vitamin K food,
and no more than 3 servings of a food with moderate amounts of vitamin K. What is important is that
your intake of vitamin K stays consistent. The nurse must instruct the client to avoid eating or
drinking large amounts of Kale, Spinach, Brussels sprouts, Parsley, Collard greens, Mustard greens,
Chard, and Green tea.

65. Answer: C. Selenium

Lycopene (as beta-carotene) and selenium supplementation have been associated with a reduced
risk of prostate cancer in nested case-control studies, but only in subgroups of men with low
baseline plasma lycopene (or beta-carotene) and selenium levels respectively. The Prostate Cancer
Prevention Trial prospectively evaluated finasteride, a 5-alpha-reductase inhibitor, as
chemoprevention.

66. Answer: D. Vitamin D

Vitamin D is made naturally by the body when exposed to sunlight. A study in patients with prostate
cancer suggested that medium or high levels of vitamin D in the blood may be linked with better
outcomes than lower levels. These findings indicate that vitamin D levels may play a role in whether
or not the disease will worsen and may be a factor in predicting outcome in prostate cancer patients.

67. Answer: B. Iron

Micronutrients are nutrients for humans required in small quantities throughout life. The
microminerals or trace elements include at least iron, cobalt, chromium, copper, iodine, manganese,
selenium, zinc and molybdenum. Micronutrients also include vitamins, which are organic compounds
required as nutrients in tiny amounts by an organism.

68. Answer: C. Calcium

Calcium and phosphorus are needed to keep bones healthy and strong. A mild lack it may not cause
symptoms but can cause tiredness and general aches and pains. A more severe lack can cause
serious problems such as rickets (in children) and osteomalacia (in adults). Vitamin D is also
important because it increases the rate at which calcium is absorbed into your blood.

69. Answer: B. Avocado

Cantaloupe: 267 mg Potassium, Avocado: 485 mg Potassium, Banana: 358 mg Potassium

70. Answer: B. Deferoxamine

Combined therapy with deferoxamine and hemofiltration offers promises as an effective means of
iron mobilization in dialysis patients with hemosiderosis.

71. Answer: C. Pork liver

Pork liver has 23 mg of iron in every 100 g while lean red meat only has 3.7 mg of iron in every 100
g.

72. Answer: D. BMI

Body Mass Index (BMI) is a number calculated from a person’s weight and height. BMI provides a
reliable indicator of body fatness for most people and is used to screen for weight categories that
may lead to health problems.

73. Answer: C. Normal

74. Answer: A. Coke

One of the ingredients in coke is sodium bicarbonate, or baking soda. This is an alkaline substance,
and therefore can help balance the pH level in the stomach. So, if the cause of the nausea has to do
with too much acid in the stomach, or acid rising from the stomach into the esophagus, coke can
have a relieving effect on the condition. Doctors recommend letting the soda go flat before drinking,
or adding a pinch of salt over the top.

75. Answer: C. Thirst

Dehydration can be mild, moderate or severe, depending on how much of your body weight is lost
through fluids. Two early signs of dehydration are thirst and dark colored urine. This is the body’s
way of trying to increase water intake and decrease water loss.

76. Answer: C. 1.039

Adults generally have a specific gravity in the range of 1.000 to 1.030. Increases in specific gravity
(hypersthenuria, i.e. increased concentration of solutes in the urine) may be associated with
dehydration, diarrhea, emesis, excessive sweating, urinary tract/bladder infection, glucosuria, renal
artery stenosis, hepatorenal syndrome, decreased blood flow to the kidney (especially as a result of
heart failure), and excess of anti-diuretic hormone caused by Syndrome of inappropriate anti-diuretic
hormone. A specific gravity greater than 1.035 is consistent with frank dehydration.
77. Answer: A. 67%

Higher than normal hematocrit levels represent abnormally elevated red blood cell counts. High
hematocrits can be seen in people living at high altitudes and in chronic smokers. Dehydration
produces a falsely high hematocrit that disappears when proper fluid balance is restored. Some
other infrequent causes of an elevated hematocrit are lung disease, certain tumors, a disorder of the
bone marrow known as polycythemia rubra Vera, and abuse of the drug erythropoietin (Epogen) by
athletes for “blood doping” purposes.

78. Answer: D. Nurse, help! My legs are cramping

The effects of low potassium include may cause the following symptoms: weakness, tiredness, or
cramping in arm or leg muscles, sometimes severe enough to cause inability to move arms or legs
due to weakness (much like a paralysis).

79. Answer: D. Alevaire

Alevaire is a Mucolytic Agent.

80. Answer: C. Coffee with Coffee mate

A clear liquid diet consists of clear liquids — such as water, broth and plain gelatin — that are easily
digested and leave no undigested residue in your intestinal tract. A tea or coffee without milk or
cream is considered a clear liquid diet.

81. Answer: A. Popsicles

A clear liquid diet is made up of only clear fluids and foods that turn to clear fluids when they are at
room temperature. It includes things like clear broth, tea, cranberry juice, Jell-O, and Popsicles.

82. Answer: B. Creamed potato

The bland diet omits all foods that are bowel stimulants and are irritating to the gastrointestinal tract.
Potatoes allowed include potato, mashed, creamed, baked, or broiled without skins, sweet potato or
yams. Rice. Spaghetti, noodles or macaroni are also allowed. Avoid potato chips and potato skins.
83. Answer: B. Measure the amount of the tube to be inserted from the Tip of the nose, to the
earlobe, to the xiphoid process

To measure the length of the tube to be inserted, stand to the patient’s right, if you are right handed,
and measure from the tip of the nose to the earlobe and to the xiphoid process. Experience has
shown that in tall people, it may be necessary to add 2 inches to the length of the tube to ensure
entrance into the stomach. If you are measure the tube for an infant, extend it from the tip of the
nose to the earlobe and then from the nose to a point half-way between the xiphoid process and the
umbilicus, because the body proportions are different in infants and adults. Mark the tube with a
piece of tape.

84. Answer: A. X-Ray

The gold standard for nasoenteric feeding tube placement is radiographic confirmation with chest
and abdominal x-rays.

85. Answer: B. Bring the client into a chair

This minimizes the possibility of aspiration (inhaling food into the lungs) and its inherent complication
(pneumonia). If choking or difficulty of breathing occurs during a feeding, stop the feeding and call
the doctor immediately.

86. Answer: D. 310 cc

250 cc of feeding ordered by the doctor plus the 60 cc of water to clear the lumen and the tube is
310 cc.

87. Answer: C. Ask the client to position in supine position immediately after feeding to
prevent dumping syndrome

It is important to sit up or prop your patient’s head up while receiving feeding and remain in that
position for 30-60 minutes. This minimizes the possibility of aspiration (inhaling food into the lungs)
and its inherent complication (pneumonia).

88. Answer: A. Diarrhea

The most common reported complication of tube feeding is diarrhea, defined as stool weight > 200
mL per 24 hours.

89. Answer: B. Pour 30 ml of water before and after feeding administration

The tube should be flushed with water before and after feeds.

90. Answer: B. Hypoglycemia

Hypoglycemia upon abrupt discontinuation of TPN is a complication that may result from
endogenous insulin levels not adjusting to the sudden reduction in dextrose.

91. Answer: C. 3 day diet recall

A 3 day diet recall provides more representative intake information.

92. Answer: A. Medulla Oblongata

The medulla oblongata is the lower half of the brainstem, which is continuous with the spinal cord;
the upper half being the pons. It is often referred to simply as the medulla. The medulla contains the
cardiac, respiratory, vomiting and vasomotor centers and therefore deals with the autonomic
(involuntary) functions of breathing, heart rate and blood pressure.

93. Answer: A. Aspiration

Impaired consciousness with drug or alcohol abuse, general anaesthesia, seizures, sedation, acute
stroke, central nervous system lesions or head injury are considered risk factors for aspiration.
Others include swallowing disorders such as esophageal stricture, dysphagia, stroke, bulbar palsy,
pharyngeal disease (eg, malignancy), neuromuscular disorders (eg, multiple sclerosis).

94. Answer: C. Mongo

Bean sprouts have the richest source of amino acids (for protein), vitamins and minerals, and also
contain a good amount of fiber. They contain all types of vitamins (A, B, C, D, E and K), folate and
are an excellent source of iron, potassium, calcium, phosphorous, magnesium and zinc.
95. Answer: B. Liver

Liver is a particularly rich source of vitamin A, although this means you may be at risk of having too
much vitamin A if you eat liver more than once a week.

96. Answer: B. Assess for patency of the tube

A gastrostomy tube allows the delivery of supplemental nutrition and medications directly into the
stomach. Maintaining its patency is the most important nursing action to be considered before
gastrostomy feeding in order for it to be successful.

97. Answer: C. Maintains Gastro esophageal sphincter integrity

One of the advantages of gastrostomy feeding is that it maintains the integrity of the
gastroesophageal sphincter.

98. Answer: B. 19

99. Answer: C. Beefy red tongue

Pernicious anemia is a type of anemia caused by a lack of vitamin B12. Not having enough vitamin
B12, or being unable to absorb it, can lead to symptoms such as nerve damage, confusion,
dementia, memory loss, depression, nausea, heartburn, weight loss, and a smooth, beefy red
tongue.

100. Answer: C. 200 U/L