FORMATIVE 5

NLE NOV 2018

1. The steps involved in conducting a quantitative study are fairly standard; researchers
usually progress in a linear fashion from asking research questions to answering them. In
some studies, the steps overlap, whereas in others, certain steps are unnecessary. Still,
there is a general flow of activities that is typical of a quantitative study. A group of
researchers are conducting a study regarding the Effects of Maternal Exercise to the Pain
felt by Mothers during a Normal Spontaneous Delivery. The researchers are deducing the
data after having been statistically treated using chi-square method. This activity is included
in which phase of the research process?
A. Empirical Phase
B. Design and Planning Phase
C. Analytic Phase
D. Dissemination Phase
2. A cohort research design is a form of a longitudinal study design. This may be
prospective or retrospective in nature. Which of the following studies would involve the use
of a retrospective design?
A. Effect of attendance of mothers to a child-rearing session on the grades of their
children
B. Long-term effects of the use of Malunggay as an Anti-diabetic agent
C. Evaluation of a school-based poison prevention program
D. Birth Defects surveillance study of the last decade
3. Some functions of the board are considered to be quasi-legislative. Which of the following
functions belong to this category?
A. Ensure quality nursing education by examining prescribed facilities of colleges of
nursing
B. Monitor and enforce quality standards of nursing education in the Philippines
C. Prescribe, adopt and promulgate guidelines, regulations, measures and decisions
as maybe necessary for the improvement of the nursing practice.
D. Issue, suspend and revoke certificates of registration for the practice of nursing
4. The PNA after having deliberated whom to nominate to PRC must have at least how many
candidates for the two positions?
A. Two
B. Four
C. Six
D. Eight
5. Upon passing the licensure examination, which of the following is a priority action for
Stephen?
A. Take an oath of profession before the Board of Nursing
B. Apply for registration with the Professional Regulation Commission
C. Apply for membership to the Philippine Nurses Association
D. Prepare credentials for job hunting.
6. A Certificate of Registration is a stamp given by the government that one individual is
now in possession of knowledge, skills and competence to practice one’s profession. He was
issued a certificate of registration be the Board of Nursing. Which of the following
information should be shown in the certificate?
1. Full name of the registrant
2. Serial number
3. Signature of the chairperson of the commission and the member of the board
4. Official seal of the Commission
5. Signature of the President of the Accredited Professional organization
A. 1,2,3
B. 1,2,4,5
C. 1,2,3,4
D. 1,2,3,
7. Which of the following information is NOT indicated in the professional identification card
issued to Stephen?
A. Date of examination
B. Registration date
C. Date of issuance and expiration
D. License number
8. He dreams of pursuing a career as a Clinical Faculty someday. Which of the following
qualifications is NOT mandatory?
A. He must have one year clinical practice in the field of specialization
B. Be a registered nurse in the Philippines
C. Member of good standing in the accredited Professional Organization of Nurses
D. Must have 3 years of clinical practice in any field of nursing
9. As a nurse, he should be guided by the Nursing Law in the country. Which is NOT a
provision of this law?
A. Increases the composition of the Board from five to seven representing nursing
education, service and community health nursing
B. Requires those nurses who have been away from practice to undergo one month
of didactic training and five months of practicum before returning to the workforce
C. Recognition of nursing specialty organizations in coordination with the accredited
professional organization
D. Provides for incentives and benefits system for nurses and their dependents.
10. She sets her eyes to be in the Nurse Manager of the Critical Care Department someday.
Which of the following requirement is NOT a legal requirement in order to qualify for the
position?
A. Membership in the accredited professional organization
B. Has at least 2 years experience in general nursing administration
C. 9 units in administration and management in the graduate level
D. Master’s degree in nursing
11. A nurse is monitoring the respiratory status of a client after creation of a tracheostomy.
The nurse understands that oxygen saturation measurements obtained by pulse oximetry
may be inaccurate if the client has which of the following coexisting problems?
A. Hypotension
B. Fever
C. Respiratory Failure
D. Epilepsy
12. Asthma is considered as the most common chronic disease of childhood. Allergy is the
strongest predisposing factor for asthma. Which of the following acid-base disorder is the
most common finding in acute asthma?
A. Respiratory alkalosis (low PaCo2)
B. Respiratory acidosis (high PaCo2)
C. Metabolic acidosis (low HCO3)
D. Metabolic alkalosis (high HCO3)
13. A nurse enters a client’s room with pulse oximetry machine and tells the client that the
physician has ordered continuous oxygen saturation readings. The nurse client’s face
changes to one of apprehension. The nurse would quickly and effectively alleviate the
client’s anxiety by stating that pulse oximetry?
A. Is painless and safe
B. Causes only mild discomfort at the site
C. Requires insertion of only a very small catheter
D. Has an alarm to signal dangerous drops in oxygen saturation levels
14. The nurse is caring for a client immediately following a bronchoscopy. The client
received sedation and a topical anesthetic for the procedure. In order to provide a safe
environment for the client at this time, the nurse plans to:
A. Place a padded tongue blade at the bedside in case of a seizure
B. Connect the client to a bedside ECG to monitor for dysrhythmias
C. Place a water seal chest drainage set at the bedside in case of a pneumothorax
D. Check the bedside to ensure that no food or fluid is within the client’s reach to
prevent aspiration
15. A bronchoscopy is usually ordered for direct visual examination of the larynx, trachea
and bronchi with a BRONCHOSCOPE. Nurse Sarah is caring for a client after a bronchoscopy
and biopsy. Which of the following signs if noted in the client should be reported
immediately to the physician?
A. Blood-streaked sputum
B. Dry cough
C. Hematuria
D. Bronchospasm
16. The “low exhaled volume” alarm sounds on a mechanical ventilator attached to a client
with an endotracheal tube. The nurse anticipates that the cause of this alarm may be a
result of which of the following?
A. Excessive secretions
B. The presence of a mucous plug
C. Kinks in the ventilator circuits
D. Displacement of the endotracheal tube
17. A nurse is suctioning an unconscious client who has a tracheostomy. The nurse needs to
avoid which of the following actions when performing this procedure?
A. Keeping a supply of suction catheters at the bedside
B. Auscultating breath sounds tp determine the need for suctioning
C. Hyperoxygnating the client before, during, and after suctioning
D. Placing suction on the catheter for at least 30 seconds to ensure that all
secretions are removed
18. A nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy
tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the
opening in the outer cannula. Which of the following nursing interventions are required
before plugging the tube?
A. Place the inner cannula into the tube
B. Deflate the cuff on the tube
C. Ensure that the client is able to swallow
D. Ensure that the client is able to speak
19. The essential principles when caring for patients with a tracheostomy are based on
maintaining patient safety facilitating communication and preventing complications
associated with the procedure. Nurse Bailey is performing tracheostomy care and has
replaced the tracheostomy ties. Nurse Bailey ensures that the holder is not too tight by
checking to see if:
A. The client nods that he or she feels comfortable
B. Two fingers can be slid comfortably under the ties
C. Four fingers can be slid comfortably under the ties
D. The tracheostomy does not move more than a ½ inch when the client is coughing
20. The nurse is changing the tapes on the tracheostomy tube of Mrs. Powers. The client
coughs and the tube is dislodged. The priority nursing action is to:
A. Cover the tracheostomy site with a sterile dressing to prevent infection
B. Call the physician to reinsert the tube
C. Grasp the retention sutures to spread the opening
D. Call the respiratory therapy department to reinsert the tracheostomy
21. Chest tubes may be inserted to drain fluid or air from any of the three compartments of
the thorax. During the nurse’s rounds, the nurse found the client in the bathroom and his
tubing was dislodged from his chest. Upon assessment, the nurse heard air coming out of
the incision site. The nurse’s priority action would be:
A. Cover chest insertion site with a non-occlusive sterile gauze
B. Immerse the tip of the tubing in a saline container with sterile water
C. Place a sterile gauze with petrolatum gauze over the insertion site
D. Assist the client in her bed then notify the physician
22. Nurse Daniel is performing a thorough respiratory assessment on a client with
pneumonia. He asks the client to say “ninety-nine” several times. Using his stethoscope, he
listens and hears the words clearly and more intense than normal over the client’s left lower
lobe. What term should Nurse Daniel use to document this finding?
A. Bronchophony
B. Tactile fremitus
C. Egophony
D. Whispered pectoriloquy
23. A client suddenly complained of difficulty breathing. The physician ordered oxygen
therapy via a nasal cannula for the client. The nurse understands that this method of
oxygen delivery does which of the following?
A. Delivers a constant concentration of oxygen
B. Delivers a high concentration of oxygen
C. Mixes room air with oxygen
D. Restricts the client from coughing and talking while wearing the device
24. The client has a nursing diagnosis of ineffective airway clearance related to excessive
secretions and is at risk for infection because of retained secretions. Part of the nurse’s care
plan is to loosen and remove excessive secretions in the airway. The nurse will now proceed
to percussion and vibration of the client’s thorax. The nurse demonstrated sufficient
knowledge about the difference of these procedures if he stated that:
A. In percussion, only one hand is used while in vibration, both hands are used.
B. Percussion delivers cushioned blows to the chest with cupped palms while
vibration gently shakes secretion loose on the exhalation cycle
C. In both percussion and vibration, the hands are on top of each other and hand
action is in tune with client’s breath rhythm
D. Percussion involves striking of the chest with cupped hands to loosen secretions
while vibration shakes the secretions along with the inhalation of air
25. Suctioning may be done through an endotracheal tube, tracheostomy tube or through
the nose or mouth into the trachea. Nurse Pirena is going to suction an adult client with a
tracheostomy who has copious amounts of respiratory secretions. Nurse Pirena does which
of the following to perform this procedure safely?
A. Sets the suction pressure range between 160-180 mmHg
B. Hyperoxygenates the client using a manual resuscitation bag
C. Applies continuous suction in the airway for up to 20 seconds
D. Occludes the Y-port of the suction catheter while advancing it into the
tracheostomy
26. The term thorax identifies the portion of the body extending from the base of the neck
superiorly to the level of the diaphragm inferiorly. The lungs, distal portion of the trachea,
and the bronchi, are located in the thorax and constitute the lower respiratory system. You
are performing chest auscultation to a patient admitted for routine physical examination.
Upon assessment of the trachea, you heard high-pitch sounds of loud amplitude. The quality
of the lung sounds was a bit harsh. You know that this type of normal breath sounds is
called:
A. Bronchial
B. Vesicular
C. Pleural friction rub
D. Bronchovesicular
27. Direct percussion, involves striking of the area to be percussed directly with the pads of
two, three, or four fingers, or with the pad of the middle finger. You are to perform a
complete physical assessment to Mr. Mogul Khan, 48 years old, diagnosed with a certain
chronic obstructive pulmonary disease. You expect to hear which of the following sounds
during percussion of his lung fields?
a. Resonance
b. Hyperresonance
c. Tympany
d. Dullness
28. When assessing the abdomen, the nurse performs in sequence, inspection, auscultation,
percussion, and lastly palpation. You are to perform abdominal assessment to your patient
who has been complaining of pain on the left upper quadrant. You know that to properly
execute the procedure, you should:
a. Palpate the affected area first
b. Palpate the left upper quadrant last
c. Palpate any quadrant first
d. Percuss before auscultate
29. The child acquires normal 20/20 vision by 6 years of age. After Nurse Tinker has
performed visual assessment, using a Snellen chart, to her patient Drow Ranger, she
documented that this patient’s visual acuity is 20/40. She understands that:
a. It is a normal finding.
b. He is technically blind.
c. The patient can read at distance of 20 feet away from the Snellen chart, that an
individual with normal vision can read from 40 feet distance.
d. Drow Ranger was able to read from 40 feet away from the Snellen chart, that an
individual with normal vision can read at 20 feet away.
30. In using the Glasgow Coma Scale, an assessment totaling to 15 points indicates that the
client is alert and fully oriented. Mr. Grand Magus was admitted to the hospital after falling
from the stairs. Upon examination, Nurse Neruvian called the patient’s name and that’s the
only time he opened his eyes. The patient raised his legs and hands when asked to do so.
The patient was also oriented to time, place, and person. The patient’s GCS score is:
a. M: 6, V: 5, E: 3
b. M: 5, V: 5, E: 3
c. M: 6, V: 5, E: 4
d. M: 5, V: 4, E: 4
31. Community participation is a fundamental requirement to achieve health and
sustainable development. Community organizing is the social development methodology
being used to achieve this. Which of the following is not true of community participation?
A. A process to help people develop their capability to assume greater responsibility
for assessing their health needs and problems.
B. It encourages them to rely on the plans and actions of the government towards
sustainable development.
C. It creates and maintains organization in support of these efforts.
D. It evaluates the effects and brings about necessary adjustments in goals and
collective action.
32. Nurse Martha is trying to think of strategies on how to increase community
participation. She consulted her friend who works in the marketing department of a certain
company on how they attract customers. Which among the following advices from her friend
is plausible for you as a community health nurse?
A. Hold a Pabingguhanand Pa-KTV ng Barangay to attract members of the
community to join in your program
B. Your programs should be congruent with the desire and health needs of the
people
C. Invite showbiz personalities to increase community participation
D. Give monetary incentives to people who will participate in your program
33. An adjunct to community organization is community development. The term
“development” can be viewed as a continuing and related process once the community has
been organized and prepared for action. Preparatory phase is the first phase in organizing
the community. Which of the following is the initial step in the preparatory phase?
A. Community profiling
B. Entry in the community
C. Area selection
D. Integration with the people
34. Community organization involves bringing together people who have similar needs and
interests to exchange and share ideas, give support to each other and undertake projects
together. In community organization, connections, relationships and collaboration between
people, sectors and institutions are formed and/or strengthened. The most important factor
in determining the proper area for community organizing is that this area should:
A. Be already served by another organization
B. Be able to finance the projects
C. Have problems and needs assistance
D. Have people with expertise to be developed as leaders.
35. Community organizing is a process by which the people, health services and agencies of
the community are brought together. All of the following are part of the Organization phase,
except:
A. Core group formation
B. Social preparation
C. Spotting and developing potential leaders
D. Leadership formation activities
36. The pre-entry phase of COPAR is considered to be the (SIMPLEST) phase. Nurse Henry
Jdrian would be correct in doing which of the following activities during the pre-entry phase?
A. Defining the roles and functions of the core group
B. Training of the research team
C. Conduct a preliminary social investigation
D. Deepening social investigation
37. The crucial stage of COPAR is the Entry phase which is also known as social preparation.
Nurse Kim Tony is in this phase of COPAR if he is doing which of the following activities?
A. Development of management systems and procedures
B. PIME (project implementation monitoring and evaluation)
C. SALT (self-awareness leadership training)
D. Setting up linkages and network referral systems
38. The actual exercise of people power in COPAR occurs during:
A. Integration
B. Mobilization
C. EDSA Revolution
D. Immersion
39. Integration is the process of establishing rapport with the people in the community. It
can BEST be achieved by:
A. Giving out gifts in order to win acceptance of the people in the community
B. Conversing with the people where they are and participating in various social
activities in their community
C. Cleaning the house and offering to do all the household chores
D. Sponsoring a sports festival to have an opportunity to interact with the people,
and promote healthy lifestyle
40. Data presentation will depend largely on the type of data obtained. Observations of
events in the community are presented in the form of tables or graphs. Which graph will be
used by Nurse Elisse if she would like to present the correlation of data for two variables?
A. Bar graphs
B. Line graphs
C. Histograms
D. Scattered Diagram
41. Rabies is a human infection that occurs after a transdermal bite or scratch by an
infected animal, like dogs and cats. It can be transmitted when infectious material, usually
saliva, comes into direct contact with a victim’s fresh skin lesions. To achieve the goal (To
eliminate human rabies by the year 2020) of updated RABIES PREVENTION AND CONTROL
PROGRAM there are strategies identified by the DOH, one of the strategies is health
education, which of the following is not included under health education?
A. Public awareness will be strengthened through the Information, Education, and
Communication (IEC) campaign.
B. The rabies program shall be integrated into the elementary.
C. In coordination with the Department of Agriculture, the DOH shall intensify the
promotion of dog vaccination, dog population control,
D. The rabies awareness and advocacy campaign is a year-round activity highlighted
on two occasions – March as
42. Rabies is a highly fatal viral disease of CNS which is transmitted to man by a bite of
rabid animal. The disease has clinical features of maniacal behavior, painful spasms of
muscles of deglutition at the mere sight of water the so called Hydrophobia. Sight and
sound of water, as well as drip of the faucet highly disturb a patient with rabies. The priority
nursing management;
A. Keep patient clean and quiet
B. Place patient near the window
C. Sponge face with warm water
D. Cover IV bottle with brown paper.
43. The goal of the National Rabies Prevention Program is a Rabies Free Philippines. The
program is jointly implemented by the Department of Agriculture, DOH, DepEd, DILG, NGO.
To support this goal, the following strategies are implemented.
1. Manpower development
2. Social Mobilization
3. Enforcement of Ordinance of Dog Control Measures
4. Dog Immunization
A. 1, 2, 3, 4
B. All except 1
C. All except 2
D. All except 3
44. The variables of disease as to person, time, and place are reflected in distinct patterns
of occurrence and distribution in a given community. In a given year, there are a few cases
of Rabies in the Philippines. In some weeks, a few cases are scattered throughout the
country. These cases however, are not related to the cases in other areas. Nurse Avery does
not need further teaching if he regards this as:
a. Sporadic Occurrence
b. Pandemic Occurrence
c. Epidemic Occurrence
d. Endemic Occurrence
45. The National Rabies Prevention and Control Program is jointly implemented by the
Department of Agriculture, Department of Health, DECS, Department of Interior and Local
Government and Non-Government Organizations. A community health nurse is conducting a
seminar on responsible pet ownership in Barangay Westeros. Which of the following
statement signifies an incorrect statement?
A. “You are responsible for any of your pet’s actions.”
B. “You should never allow your pets to roam at the streets.”
C. “Have your pet immunized every month.”
D. “Take care of your pet and provide them with their basic needs.”
46. Abortion is the termination of pregnancy by the removal or expulsion from the uterus of
a fetus or embryo prior to viability. Sophie, 10 weeks AOG, arrives at the hospital with some
vaginal spotting and abdominal cramping. Nurse Sarry performs vaginal examination and
reveals that her cervix is 2cm dilated. Based on the manifestations, Nurse Sarry would
conclude that Sophie is having a/an:
A. Complete abortion
B. Threatened abortion
C. Inevitable abortion
D. Incomplete abortion
47. The most common cause of spontaneous abortion during the first trimester is
chromosomal abnormalities of the embryo or fetus. Jessy, 10 weeks pregnant, comes to the
hospital because she experiences spotting and abdominal cramping. Upon internal
examination by the midwife, her cervix is 0cm dilated. What would be the best intervention
that Nurse Matteo should implement or advise her?
A. Rest at home, and do not move until bleeding stops. Complete bed rest can stop
bleeding. Save and count the number of pads saturated with blood.
B. Avoid sexual intercourse for 2 weeks
C. Administer Misoprostol as prescribed. Avoid strenuous activities for 1 week.
D. Support the mother emotionally. Explain fully the main intervention which is
dilatation and curettage.
48. A pregnant client in her last trimester has been admitted to the hospital with complaints
of blurring of vision and epigastric pain with a diagnosis of severe preeclampsia. The nurse
monitor for complications associated with the diagnosis and assesses the client for:
A. Enlargement of the breast
B. Periods of fetal movement followed by periods quiet periods
C. Pale conjunctiva, mucous membranes and nail beds
D. Complaints of feeling hot when the room is cool
49. Eclampsia is used to describe preeclampsia that has progressed to include maternal
tonic-clonic seizures or coma. The nurse prepares a plan of care for the client and
documents in the plan that if the client progresses from preeclampsia to eclampsia, the
nurse’s first action is to:
A. Administer magnesium sulfate intravenously
B. Clear and maintain an open airway
C. Assess the blood pressure and fetal rate
D. Administer oxygen by face mask
50. Manifested by sharp stabbing pain in the fundus of the uterus is Abruptio Placenta
caused when a correctly implanted uterus begins to separate prematurely. While she was
doing the chores this morning, Melwine suddenly experiences a stabbing pain
in her fundus accompanied by heavy vaginal bleeding. The uterus is tense and painful upon
palpation. Several tests have been conducted and it was found out that fetal distress is
already present. Which of the following interventions must be immediately carried out in
this condition?
A. Administer fluids and oxygen as prescribed to address fetal distress.
B. Position the mother in left-side lying to prevent pressure on the vena cava.
C. Assess mother and fetus further. Assist in performing internal examination to
determine if vaginal birth is possible.
D. Assist in termination of the pregnancy.
51. The nurse is assessing a pregnant client with a diagnosis of abruptio placenta. Which
manifestations of this condition should the nurse expect to note?
1. Uterine irritability
2. Uterine tenderness
3. Bright red vaginal bleeding
4. Abdominal and low back pain
5. Strong and frequent contractions
6. Nonreassuring fetal heart rate patterns
A. 1, 3, 5
B. 1, 2, 4, 6
C. 2, 4, 5
D. 2, 3, 6
52. A maternity nurse is preparing for the admission of a client in the third trimester of
pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta
previa. The nurse reviews the physician’s prescriptions and would question which order?
A. Prepare the client for an ultrasound.
B. Obtain equipment for a manual pelvic examination.
C. Prepare to draw a hemoglobin and hematocrit blood sample.
D. Obtain equipment for external electronic fetal heart rate monitoring
53. Mira, a nurse midwife, advised a 39-week gestation gravid to take evening primrose oil
2500 mg daily as a complementary therapy. This suggestion was made because evening
primrose has been shown to perform which of the following actions?
A. Relieve back strain.
B. Improve development of colostrum.
C. Ripen the cervix.
D. Reduce the incidence of hemorrhoids.
54. Whenever a placenta is dislodged, either by spontaneous birth or by surgical or medical
intervention at any point in pregnancy, blood from the placental villi (the fetal blood) may
enter the maternal circulation. The physician has ordered an injection of RhoGam for a
client with blood type A negative. The nurse understands that RhoGam is given to:
A. Provide immunity against Rh isoenzymes
B. Prevent the formation of Rh antibodies
C. Eliminate circulating Rh antibodies
D. Convert the Rh factor from negative to positive
55. Rho (D) immune globulin (RhoGAM) is prescribed for a client after delivery and the
nurse provides information to the client about the purpose of the medication. The nurse
determines that the woman understands the purpose if the woman states that it will protect
her next baby from which condition?
A. Having Rh-positive blood
B. Developing a rubella infection
C. Developing physiological jaundice
D. Being affected by Rh incompatibility
56. Tetralogy of Fallot is a type of cyanotic congenital heart disease that is characterized by
four anomalies: ventricular septal defect, overriding aorta, hypertrophic right ventricle, and
pulmonary stenosis.Nurse Ariana is doing discharge teaching to the parents of a child with
Tetralogy of Fallot about “tet spells” or hypoxic episodes. Nurse Ariana is correct if he says
that when a tet spell occurs, the parents should:
A. Position the child to a side-lying position
B. Place the child in the knee-chest position
C. Lay the child in a supine position
D. Let the child assume a tripod position
57. VSD is an acyanotic heart disease where in there is an opening between two ventricles.
An infant recently admitted to the pediatric unit has been diagnosed with a Patent Ductus
Arteriosus. When doing a physical assessment of this infant, the nurse should expect which
of these findings?
A. Cyanosis, increased anterior-posterior diameter of chest
B. Extreme difficulty feeding, irritability
C. Machine-like murmur, shortness of breath
D. Systolic murmur, no other significant signs
58. A child was diagnosed with congenital heart defect. Upon health history and physical
examination, you noted that the child experiences fatigue and had some pallor in his palms
and conjunctiva. You also auscultated a loud harsh murmur in the lower border of the
sternum. These findings suggest:
A. Patent Ductus Arteriosus
B. Tetralogy of Fallot
C. Atrial Septal Defect
D. Ventricular Septal Defect
59. Coarctation of Aorta is the narrowing of aortic lumen. This narrowing causes decreased
blood flow distal to the structure, and the backup of blood flow in the heart. An infant born
at 39 weeks gestation is sent to the intensive care nursery. The nurse suspects a possible
cardiac anomaly when the admission assessment reveals:
A. Projectile vomiting
B. An irregular respiratory rhythm
C. Hyperreflexia of the extremities
D. Unequal peripheral blood pressures
60. RHF is a systemic inflammation that affects the brain, heart, joint and subcutaneous
tissues. A nurse is told that a child with rheumatic fever will be arriving in the nursing unit
for admission. On admission, the nurse prepares to ask the mother which question to elicit
assessment information specific to the development of Rheumatic Fever:
A. “Has the child has any nausea or vomiting”
B. “Has the child complained of headaches”
C. “Has the child complained of back pain”
D. “Did the child have a sore throat or an unexpected fever within the last 2 months”
61. Tonsillitis is the infection and inflammation of the palatine tonsils and tonsillectomy is
the surgery done to remove it. 8-yearold Flor has had three incidents of tonsillitis in just one
year so her physician recommended a tonsillectomy. At her immediate postoperative day,
the nurse should do none of the following interventions except:
A. Observing the back of the neck to check for bleeding
B. Placing Flora May on her abdomen with a pillow under the chest
C. Serving ice cream to soothe her throat
D. Observe for decreasing pulse and respiratory rate
62. Pharyngitis is infection and inflammation of the throat. The peak incidence occurs
between 4 and 7 years old. A 6-year old child was rushed into the Emergency Department.
Upon assessment, the child has increased temperature, headache, and petechiaes on his
palate. Streptococcal pharyngitis is suspected. All of the following is appropriate, except?
A. A course of oral penicillin therapy may be given to the child.
B. The child will be asked to return to the clinic 2 weeks after the treatment.
C. A urine specimen around 2 weeks after treatment may be obtained from the
patient.
D. Instruct the family to stop giving the child antibiotics if the symptoms have been
resolved
63. Positioning is one of the important nursing interventions to a patient with problem in
feeding because there are risks to have aspiration. An infant has just returned to the
nursing unit following a surgical repair of a cleft lip located on the right side of the lip. The
nurse places the infant in which most appropriate position when resting?
A. On the right side
B. Prone
C. On the left side
D. Upright
64. Cleft lip and palate is a condition wherein there is a failure of soft tissue and/or or bony
structure to fuse during the embryonic development; may occur separately or together and
involve one or both sides of the palate’s midline. A 3-month-old infant just had a right cleft
lip repair. To prevent trauma to the operative site, Nurse Jessie should do which of the
following?
A. Give the infant pacifier to prevent him from crying.
B. Lie the infant in prone position.
C. Position the child to her left side and never touch the suture line.
D. Place the infant’s arms in soft elbow restraints.
65. A home nurse is providing safety instructions to the mother of a child with hemophilia.
Which of the following instructions should the nurse provide to the mother to promote a
safe environment for the child?
A. Allow the child to play indoors only and to avoid any outdoor play or playgrounds
B. Place a helmet and elbow pads on the child every day as soon as the child awakes
C. Allow the child to use play equipment only when a parent is present
D. Eliminate any toys with sharp edges from the child’s play area
66. Mr. and Mrs. Smith’s child has hemophilia; which of the following actions would you
instruct to void?
A. Immobilizing the joint
B. Lowering the injured area
C. Applying cold to the area
D. Applying pressure
67. Disorders of the respiratory system are common and are encountered by nurses in
every setting from the community to the intensive care unit. A client is admitted due to
COPD three days ago has developed PTB. The rationale behind the development of infection
is that patients with COPD are prone to respiratory infections because of an altered function
of which type of alveolus:
A. Type I cells
B. Type II cells
C. Type III cells
D. Type IV cells
68. Assessment of the thorax includes the palpation of the tracheal position. Mr. Buenavista
has been recently admitted to the unit because of chest trauma due to a vehicular accident.
Dyspnea, anxiety, tachypnea and tachycardia suddenly developed. Hyperresonance of the
right lung field is observed. Tension pneumothorax of the right lung is suspected. Which of
the following assessment findings if found by the nurse would indeed confirm the suspicion
of tension pneumothorax?
A. Tracheal position at midline in the suprasternal notch
B. Tracheal deviation to the front
C. Tracheal deviation to the right
D. Tracheal deviation to the left
69. Pneumonia is an inflammation of the lung parenchyma caused by various
microorganisms. It is the second most common nosocomial infection A client was admitted
suspected of having ureteroliathisis. After 36 hours inside the hospital, the client was noted
to have fever, crackles in the lower lobes of the lungs, and cough productive of rust-colored
sputum. This type of pneumonia is most likely:
A. Hospital-acquired pneumonia
B. Community-acquired pneumonia
C. Pneumocystis carinii pneumoniae
D. Aspiration pneumonia
70. Atelectasis is defined as the lack of gas exchange within alveoli, due to alveolar collapse
or fluid consolidation. Chichay, a 4-year old child, was rushed to the ER after swallowing
several pieces of clay. After undergoing x-ray, the child is diagnosed with atelectasis of the
right lung due to complete obstruction in the right bronchus. Stat surgery is to be done.
Which of the following assessment findings would the nurse most likely find?
A. Tracheal shift to the left, breath sounds absent in the left lung, present in the left,
hyperresonance percussion in the left lung
B. Tracheal shift to the right, breath sounds absent in the right lung, present in the
left, resonance percussion in the left lung
C. Tracheal shift to the right, breath sounds absent in the right lung, present in the
left, dull percussion on the right lung
D. Tracheal shift to the left, breath sounds absent in both lung fields, dull percussion
in the right lung
71. Chronic obstructive pulmonary disease (COPD) is a disease state characterized by
airflow limitation that is not fully reversible. Nurse Will caring for a client diagnosed with
chronic bronchitis 2 years ago is reviewing the client’s laboratory results. Which of the
following results shall Nurse Will not expect?
A. Hypercapnia
B. Polycythemia
C. Leukopenia
D. None of the above
72. “Emphysema” is a pathological term that describes an abnormal distention of the air
spaces beyond the terminal bronchioles, with destruction of the walls of the alveoli. Nurse
Shireen is documenting the assessment findings of a client with emphysema.
Which of the following findings is indicative of emphysema:
A. Decreased breath sounds and sudden weight gain
B. Decrease ciliary activity and adventitious breath sound with wheezing
C. Hyperresonance of the chest upon percussion
D. Pigeon chest and distended neck veins
73. Asthma is considered as the most common chronic disease of childhood. Allergy is the
strongest predisposing factor for asthma. Which of the following acid-base disorder is the
most common finding in acute asthma?
A. Respiratory alkalosis (low PaCo2)
B. Respiratory acidosis (high PaCo2)
C. Metabolic acidosis (low HCO3)
D. Metabolic alkalosis (high HCO3)
74. Chest tube thoracostomy involves placing a hollow plastic tube between the ribs and
into the chest to drain fluid or air from around the lungs. A client is scheduled to have a
chest tube removed. What is the most important intervention for the nurse to perform prior
to the removal?
A. Disconnect the drainage system from the tube.
B. Obtain a chest X-ray to document re-expansion.
C. Obtain an arterial blood gas level to document oxygen status
D. Sedate the client, and the physician will slip the tube out without warning the
client
75. A nurse performs an admission assessment on a client with a diagnosis of tuberculosis.
The nurse reviews the result of which <diagnostic test that will confirm this diagnosis>
A. Chest x-ray
B. Bronchoscopy
C. Sputum Culture
D. Tuberculin Skin Test
76. In obtaining sputum sample, ask the client to breathe deeply and then cough up 1 to 2
teaspoons (4 to 10 mL) of sputum. Nurse Sarah is preparing to obtain a sputum specimen
from a client. Which of the following nursing actions will facilitate obtaining the specimen?
A. Limiting fluids
B. Having the client take three deep breaths
C. Asking the client to spit into the collection container
D. Asking the client to obtain the specimen after eating
77. A client diagnosed with acquired immunodeficiency syndrome (AIDS) has a T4 count of
150/mm³, and a T4:T8 ratio that is less than 2. The nurse interprets from these laboratory
values that the client is:
A. In stable condition
B. Clinically improved
C. Malnourished
D. At risk for opportunistic infection
78. The nurse assesses the client with acquired immunodeficiency syndrome (AIDS) for
early signs of Kaposi’s sarcoma. The nurse observes the client for lesion(s) that are:
A. Unilateral, raised and bluish-purple in color
B. Unilateral, red, raised, and resembling a blister
C. Bilateral, flat, and brownish and scaly in appearance
D. Bilateral, flat, and pink, turning to dark violet or black in color
79. A client is tested for human immunodeficiency virus (HIV) infection with an enzyme-
linked immunosorbent assay (ELISA), and the test result is positive. The nurse tells the
client that:
A. HIV infection has been confirmed.
B. A positive test result is normal and does not mean that the client has acquired
HIV.
C. The test will need to be confirmed with a Western blot.
D. The client probably has a gastrointestinal infection.
80. A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy
with zidovudine (Retrovir) (also called azidothymidine (AZT)). Then nurse monitors the
results of which laboratory blood study for adverse effects of therapy?
A. Complete blood count (CBC)
B. Blood urea nitrogen (BUN) level
C. Creatinine level
D. Potassium concentration
81. A client with acquired immunodeficiency syndrome (AIDS) complains of dyspnea on
exertion, tachypnea, and a dry cough on auscultation of the lungs, the nurse notes crackles.
Then nurse reports the findings to the physician, knowing that the most likely cause of
these symptoms is:
A. Cryptosporidiosis
B. Malignant lymphoma
C. Pneumocystis jiroveci pneumonia
D. Toxoplasmosis
82. A client with human immunodeficiency virus infection is diagnosed with herpes simplex.
The nurse prepares the client for which of the following diagnostic tests to determine the
presence of herpes virus infection?
A. Chest x-ray study
B. Neurological exam
C. Stool culture
D. Viral culture
83. A nurse has been assigned caring for a client with an immune disorder. In developing a
plan of care for this client, the nurse incorporates knowledge that the immune system
consists of specific major types of cells. Which of the following types of cells are associated
with the immune system? Select all that apply.
I. B lymphocytes
II. Helper T lymphocytes
III. Dendritic cells
IV. Red blood cells
V. Cytolytic T lymphocytes
A. I, V
B. II,II,IV
C. I,II,IV
D. I,II,III,V
84. A nurse mentor is describing the phases of the immune response to a recent nursing
graduate. The mentor determines that the graduate needs additional information if the
graduate states that which of the following is a phase of the immune response?
A. Recognition phase
B. Activation phase
C. Effector phase
D. Memory phase
85. A nurse is reviewing the diagnostic tests performed in an adult client with a connective
tissue disorder. The erythrocyte sedimentation rate (ESR) is reported as 40 mm/hr. the
nurse interprets this finding as:
A. Normal
B. Indicating mild inflammation
C. Indicating moderate inflammation
D. Indicating severe inflammation
86. John Paul was rushed to the hospital by his wife complaining that the patient suffered
from an acute blindness after being involved in a hit-and-run accident. The doctor revealed
that diagnostic testing cannot identify any organic reason why the patient cannot see.
Which of the following will be the focus of a mental health consult?
a. Dissociative disorder
b. Conversion disorder
c. Psychosis
d. Repression
87. Nurse Darwin is caring for a client diagnosed with Conversion disorder who has
developed paralysis of her legs. Diagnostic tests fail to identify a physiological cause. During
the working phase of the nurse-patient relationship, the client says to Nurse Darwin,
“You think I could walk if I wanted to, don’t you?” What would be Nurse Darwin’s best
response?
A. “Tell me why you’re concerned about what I think.”
B. “I think you are unable to walk now, whatever the cause.”
C. “Yes, if you really wanted to walk, you could”
D. “Do you think you could walk if you wanted to?”
88. Upon hearing this statement, the nurse would be able to conclude that the patient has
hypochondriasis.
A. “I’m frequently nauseous lately. Am I pregnant?”
B. “I’m having another terrible migraine and pain killers don’t seem to work.”
C. “I’m glad that tests show I do not have leukemia. I thought I was dying.”
D. “I’m having a second opinion. I can’t believe there’s nothing wrong with me.”
89. Ruby, a client diagnosed with hypochondriasis complains to the nurse about others’
doubting the seriousness of her disease. She is angry, frustrated, and anxious. Which
nursing intervention will you prioritize as her nurse?
A. Remind the client that lab tests showed no evidence of physiological problems.
B. Acknowledge the client’s frustration without fostering continued focus on physical
illness.
C. Document client’s unwillingness to accept anxiety as the source of the illness.
D. Discuss with the client’s family ways to avoid secondary gains associated with
physical complaints
90. Nursing management of pain consists of both independent and collaborative nursing
actions. Mr. Dolor complains that it seems that his left foot is still there even though it was
already amputated. The nurse correctly documents this assessment finding as a/an:
A. Referred pain
B. Phantom sensation
C. Intractable pain
D. Phantom pain
91. Dissociative identity disorder (DID) was formerly called multiple personality disorder.
This disorder is characterized by the existence of two or more personalities in a single
individual. Only one of the personalities is evident at any given moment, and one of them is
dominant most of the time over the course of the disorder. The nurse is assessing a client
experiencing dissociative identity disorder (DID). The nurse anticipates the client to make
which statement?
a. “My father wasn’t around much.”
b. “I feel good about myself.”
c. “I can recall many traumatic events from childhood.”
d. “My father loved me one day and hit me the next day.”
Rationale
92. The five types of amnesia are the following: 1. LOCALIZED AMNESIA: The inability to
recall all incidents associated with the traumatic event for a specific time period following
the event (usually a few hours to a few days). 2. SELECTIVE AMNESIA: The inability to
recall only certain incidents associated with a traumatic event for a specific
period after the event. 3. CONTINUOUS AMNESIA: The inability to recall events occurring
after a specific time up to and including the present. 4. GENERALIZED AMNESIA: The rare
phenomenon of not being able to recall anything that has happened during the individual’s
entire lifetime, including personal identity. 5. SYSTEMATIZED AMNESIA: With this type of
amnesia, the individual cannot remember events that relate to a specific category of
information (e.g., one’s family) or to one particular person or event. The nurse is assessing
a client with dissociative amnesia. Which circumstance would most likely contribute to this
condition?
a. Binge drinking
b. A hostage situation
c. A closed-head injury
d. A fight with a family member
93. During assessment, the nurse will anticipate that Kaye, the client who has a diagnosis of
Body Dysmorphic disorder, will have which of the following symptoms?
A. Dissatisfaction with body shape and size
B. Fantasizing oneself as changed into an ideal appearance
C. A history of eight or more plastic surgeries on various body parts
D. Preoccupation with an imagined or exaggerated defect in appearance
94. Which among the following statements made by Kaye would lead Nurse Roan to suspect
that her client has Body Dysmorphic Disorder?
A. “This cough is terrible, I know I have pneumonia.”
B. “My hair is so thin that is why I always wear a hat.”
C. “I can’t possibly go to work with all this pain.”
D. “I don’t know why I’m so sick when I’m so young.”
95. Paraphilia is a condition in which the sexual instinct is expressed in ways that are
socially unacceptable o prohibited or are biologically undesirable. One example of paraphilia
is scatophilia. The nurse is teaching the family of a client with scatophilia. Which response
by the nurse is most accurate in teaching about the characteristics of this disorder?
a. Uses telephone for sexual arousal
b. Uses nonliving objects such as women’s underwear for sexual gratification
c. Aroused through contact with children
d. Aroused by rubbing against nonconsenting person
96. Some theories suggest that a dysfunctional family pattern may have an etiological
influence in the development of homosexuality. They suggest that gay men often have a
dominant, overly protective mother and a weak, remote, or hostile father. The nurse is
working with a client with a gender identity disorder. The client recently started living as a
member of the opposite sex. Which of the following is an inappropriate outcome criterion for
this nurse-client relationship?
a. The client discusses feelings about reactions expected from family and friends
b. The client discusses feelings and issues regarding living in another gender role
c. The client schedules a date for sex-change surgery as a result of the discussion
d. The client identifies support persons may be helpful during the change from one
gender to another
97. Gender identity (determining whether one is male or female) is usually established by
the age of 2 to 3 years. Sexual identity (determining whether one is heterosexual or
homosexual or both) may continue to evolve throughout one’s lifetime. A nurse is caring for
several clients with gender identity disorders. Which client category is at highest risk for
anxiety related to transsexualism?
a. Elderly
b. Adolescent
c. Young adult
d. Prepubescent child
98. Gender identity disorder in adult involves the discomfort with one’s gender or the role of
that gender. In adult, this disorder can include the desire to live as the other gender or can
involve feelings and reactions of the other gender.
What is the gender identity disorder that results in the person believing he or she is the
opposite sex?
a. Exhibitionism
b. Homosexuality
c. Transsexualism
d. Transvestitism
99. The individual desiring sexual reassignment is generally in psychotherapy for 6 to 12
months. A transsexual client wishes to have a sexual reassignment operation and tells the
nurse he’s ready to begin hormonal therapy. Which fact about the client must be true before
estrogen therapy is administered?
a. He has cross-dressed and lived as the opposite sex for several years
b. He has decides against undergoing the operation
c. He has decided he needs more psychotherapy
d. He has been functioning sexually as a female
100. An individual who is transgendered has the self-perception of being of the opposite
gender. Individuals with this disorder do not feel comfortable wearing the clothes of their
assigned gender and often engage in cross-dressing. A 14-year-old female client admits to
having transsexual feelings and states, “I would rather die than live in this body.” What
is the most appropriate initial intervention by the nurse?
a. Explain to her that she is too young to have these feelings
b. Call her parents and let them know about her feelings
c. Encourage her to verbalize her feelings
d. Ask her if she plans to kill herself