ANSWER KEY FOR APPLICATION EXAMS FOR TEST TAKING STRATEGIES

1. The primary modalities of treatment for Stage I and II of cervical cancer include the following:
a. Procedures c. Surgery and radiation
b. Radiation therapy d. Surgery

ANSWER C – global answer

2. Carmella was admitted to the hospital with signs and symptoms of CVA. Her Glasgow Coma
Scale is 6 on admission. A central venous catheter was inserted and an IV infusion was
started. What will be your priority goal?
a. Preserve muscle function c. Prevent skin breakdown
b. Promote urinary elimination d. Maintain a patent airway

ANSWER D – Use of ABC

Strategy: Prioritization. ABC.

3. A client with terminal cancer tells a nurse, “I’ve given up and I have no hope left. I’m ready to
die,” Which of the following responses is most therapeutic?
a. “You’ve given up hope.”
b. “We should talk about dying to a social worker.”
c. “You should talk to your physician about your fears of dying so soon.”
d. “No, you shouldn’t give up hope. There are cures for cancer found everyday.”

ANSWER A – restating – Patient-focused “YOU”

Option B – referral
Option D – false reassurance
Strategy: Similar distractors -SHOULD

4. Some lifetime habits and hobbies affect post-operative respiratory function. If the client
smokes 3 packs of cigarettes a day for the past 10 years, the nurse will anticipate increased
risk for:
a. Delayed coagulation time c. Perioperative anxiety and stress
b. Delayed wound healing d. Post-operative respiratory function

ANSWER D.
Strategy: Similar word - Post-operative respiratory function

5. Records management and Archives Offices of the DOH are responsible for implementing its
policies on record disposal. The nurse knows that the institution is covered by this policy if:
a. It obtained permit to operate from DOH
b. Your hospital is in Metro Manila
c. Your hospital is considered tertiary
d. Your hospital is Phil Health Accredited

ANSWER A.
Strategy: Similar distractors- YOUR HOSPITAL.
6. The nurse gave instruction because Elena is expressing her anxiety about Intravenous
Pyelography (IVP) procedure and her low pain threshold. The instruction include:
a. Assure the client that contrast medium will be given orally.
b. Assure the client that the procedure is painless.
c. Assure the client that the pain is associated with warm sensation during the
administration of the Hypaque by I.V.
d. Assure the client that X-ray procedure like IVP is only done by experts.

ANSWER C.
Option A- contrast medium is given intravenously and not orally.
Option B- false reassurance
Option D- Incorrect because of the word ONLY.
Strategy: Longest answer

7. How can the head nurse in the OR improve the effectiveness of clinical alarm system?
a. Limit suppliers to a few so that quality is maintained
b. Implement a regular inventory of supplies and equipment
c. Implement a regular maintenance and testing of alarm systems
d. Adherence to manufacturer’s recommendation.

ANSWER C.
Strategy: Similar word strategy –ALARM SYSTEM

8. Which of the following method of prevention and control is the role of the nurse?
a. Proper waste disposal c. Seminar of food handlers
b. Health education d. House to house immunization

ANSWER B –global answer

Options A, C, D are specific answers which could be included in option B
Strategy: Umbrella Answer

9. What nursing intervention would be most helpful in preparing the patient for radiotherapy?
a. Instruct the patient of the possibility of radiation burn.
b. Offer tranquilizers and anti-emetics
c. Map out the precise course of treatment
d. Emphasis on the therapeutic value of the treatment

ANSWER A.
Strategy 1: Similar Word - Radiotherapy and radiation burn
Strategy 2: C & D – Similar Distractors “TREATMENT”
B – medical intervention

10. Shiela underwent pelvic surgery. The nurse must observe her for sign of developing
thrombophlebitis which is:
a. A pitting edema of the ankle c. Pruritus on the calf and ankle
b. A tender painful area on the leg d. A reddened area at the ankle

ANSWER B.
Strategy: Similar distractors - ANKLE
11. After surgery, a client with diabetes complains of nausea, appears lethargic and flushed, with
BP of 108/78 mmHg, PR – 100, RR – 24. What is the next action?
a. Call the MD c. Give an anti-emetic
b. Check the client’s glucose d. Change the IV infusion rate

ANSWER B Assessment.
Option A – intervention (last option)
Option C – giving of meds intervention
Option D – intervention
Strategy: Nursing Process

12. Samantha is diagnosed to have breast cancer. She subsequently underwent modified radical
mastectomy. Samantha states, “I know I am not attractive anymore.” The best response of
the nurse will be:
a. “Would you wish to discuss this with me?”
b. “That’s not important. It is only a benign thing.”
c. “Of course you are still attractive. You can always have prosthesis later.”
d. “Have you discussed this with your husband?”

ANSWER A – offering self

Option B – incorrect because of the word ONLY – belittling feelings
Option C- incorrect because of the word ALWAYS -- advising
Option D –referral to another. The question does not indicate if Samantha is married.
Strategy: Therapeutic communication

13. Mrs. Belen is complaining that the back pain prevents her from having a restful night. Which
of the following intervention will be of least help?
a. Administering a soothing back rub c. Turning the radio to soft relaxing music
b. Administering an analgesic d. Having the client talk about her pain

ANSWER B. negative response. (medical intervention)

Options A, C, D –positive response
Strategy: Negative stem = Negative response

14. The following are risk factors for coronary artery disease, except:
a. Hypertension c. Hereditary
b. Diabetes Mellitus d. None of the above

ANSWER D. Negative response “None of the above”

Strategy: Negative stem = Negative response

15. A low protein diet is ordered for Gwen with acute renal failure. What is the rationale the nurse
would give to the client for this type of diet?
a. Minimize protein breakdown c. Decrease sodium intoxication
b. Reduce metabolic rate d. Minimize the development of edema

ANSWER A.
Strategy: Similar word strategy. “PROTEIN”
16. Nurses should be aware that older adults are at risk of underrated pain. Nursing assessment
and management of pain should address the following EXCEPT:
a. Older patients seldom tend to report pain than the younger ones.
b. Pain is a sign of weakness
c. Older patients do not believe in analgesics; they are tolerant
d. Complaining of pain will lead to being labeled a “bad patient”.

ANSWER C is a negative answer because of the word “NOT”.

Options A, B, & D are all beliefs. Older patient’s belief is that pain is a normal component of aging
and should be expected and tolerated. (Positive answers)
Strategy: Negative stem = Negative response

17. Physical dependence occurs in anyone who takes opioids over a period of time. What do you
tell a mother of a ‘dependent’ when asked for advice?
a. Start another drug and slowly lessen the opioid dosage
b. Indulge in recreational outdoor activities
c. Isolate opioid dependent to a restful resort
d. Instruct slow tapering of the drug dosage and alleviate physical withdrawal
symptoms

ANSWER D.
Strategy: Similar word strategy. PHYSICAL
Strategy 2: Longest answer

18. Waste disposal possess a big problem for the hospital. Biological wastes (i.e: amputated
limbs) disposal should be coordinated with the following agencies, EXCEPT:
a. Crematorium c. MMDA
b. DOH d. DILG

ANSWER A is the exemption, Crematorium is where a dead boy is burned to ashes.

Options B, C, D are all agencies.
STRATEGY: Similar Distractors

19. Nurse Rita is successful in collaborating with health team members about the care of Mr.
Linao. This is because she has the following competencies:
a. Communication, Trust, Decision making
b. Conflict management, Trust, Negotiation
c. Negotiation, Decision making
d. Mutual respect, Negotiation, Trust

ANSWER A.
Strategy: Similar word distractors – “NEGOTIATION”

20. The nurse who makes clinical judgment can be depended upon to improve the quality of care
of clients. Nurse Julie uses such good clinical judgment when she provide priority care to his
client:
a. Roman, a client who is ambulatory and for surgery tomorrow
b. A post-operative client, Rey, who has a blood pressure of 90/50 mmHg.
c. Mr. Abad, a client who needs instructions for home medications.
d. Fred, a client who received pain medication 5 minutes ago
ANSWER B - Following the ABC, a client with a BP of 90/50 mmHg (abnormal vital signs) has
compromised circulation.
Strategy: Prioritization, ABC + abnormal vital signs

21. The effectiveness of your nursing care plan for your clients is determined by:
a. The number of nursing procedures performed to comfort the client
b. The amount of medications administered to the client as ordered.
c. The number of times the client calls the nurse
d. The outcome of nursing interventions based on plan of care

ANSWER D - The effectiveness of the nursing care plan is determined by the evaluation.
Evaluation is a planned, ongoing, purposeful activity in which the client and health care
professionals determine the client’s progress towards the achievement of goal and the
effectiveness of the nursing care plan.
Strategy: Similar Word – “care plan & plan of care”

22. A nurse is observing a nursing assistant talking to a client who is hearing impaired. The nurse
would intervene if the nursing assistant did which of the following during communication with
the client?
a. Spoke in a normal tone
b. Spoke clearly to the client
c. Faced the client when speaking
d. Spoke directly into the impaired ear

ANSWER D - When communicating with a hearing impaired client, the nurse should speak in a
normal tone to the client and should not shout. The nurse should talk directly to the client while
facing the client and speak clearly. If the client does not seem to understand what is said, the
nurse should express the statement differently. Moving closer to the client and toward the better
ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear.
Strategy: Similar Word. “IMPAIRED”

23. A client has been newly diagnosed with diabetes mellitus. The nurse does which of the
following as the first step in teaching the client about the disorder?
a. Decide on the teaching approach
b. Plan for the evaluation of the session
c. Gather all available resource materials
d. Identify the client’s knowledge and needs

ANSWER D - Determining what to teach a client begins with an assessment of the client’s own
knowledge and learning needs. Once these have been determined, the nurse can effectively plan
a teaching approach, the actual content, and resource materials that may be needed. The
evaluation is done after teaching is completed.
Strategy: Priority setting, Nursing Process – Assessment “IDENTIFY”

24. A nurse is reviewing a plan of care for a child with juvenile idiopathic arthritis (JIA). The nurse
determines which of the following is a priority nursing diagnosis?
a. Acute pain
b. Risk for injury
c. Disturbed body image
 d. Bathing/hygiene self-care deficit

ANSWER A - Physiological needs receives highest priority

Option B- Safe and security needs
Option C- Self-esteem needs
Option D- Physiological needs but less priority as compared with acute pain.
Strategy: Priority setting, Maslow Hierarchy of needs

25. A nurse is caring for a client with a brainstem injury. The nurse monitors which of the following
as a priority?
a. Urine output
b. Electrolyte results
c. Peripheral vascular status
d. Respiratory rate and rhythm

ANSWER D - Relates to airway. Monitoring the respiratory status is a PRIORITY in a client with
a brainstem injury, although the nurse may also monitor laboratory status, urine output and
peripheral vascular status.
Strategy: Priority setting, ABC

26. A hospitalized client with type 1 diabetes mellitus tells the nurse that she feels like she is
having a hypoglycemic reaction. The nurse would first:
a. Obtain a blood glucose reading
b. Give the client 4 oz of orange juice
c. Prepare to administer 50% dextrose intravenously
d. Prepare to administer subcutaneous glucagon hydrochloride

ANSWER A - Assessment and data collection

Strategy: Priority setting, Nursing Process

27. A community health nurse is assisting residents involved in a hurricane and flood. Many of
the older residents are emotionally despondent and refuse to evacuate their homes. With
regard to rescue and relocation of the older residents the nurse plans to first:
a. Contact families
b. Attend to emotional needs
c. Attend to nutritional and basic needs.
d. Arrange for transportation to shelters.

ANSWER C - basic physiological needs.

Options A, B, D - addresses psychosocial needs and may be appropriate at a later date.
Strategy: Priority setting, Maslow Hierarchy of needs

28. A nurse at a playground witnesses a child fall off a swing. The nurse rushes to the child and
suspects that he has a broken right leg. The nurse takes which priority action?
a. Immobilizes the leg
b. Calls for an ambulance
c. Tells the child that everything will be fine
d. Removes the child’s shoes
ANSWER A – When a fracture is suspected, the area is immobilized and splinted before the victim
is moved. Shoes are not removed because this action can cause increased trauma. Emergency
help is called for and the nurse should remain with the child and provide realistic reassurance.
Telling the child that everything will be fine is non-therapeutic
Strategy: Priority setting, Intervention

29. Artificial rupture of the membranes is done to induce labor in a client. Following this procedure
the nurse immediately:
a. Checks the fetal heart rate (FHR)
b. Cleans the client’s perineal area
c. Places the client in a comfortable position
d. Tells the client that a wet feeling in the perineal area is normal and expected

ANSWER A – FHR and fetal patterns should be monitored immediately and for several minutes
following the procedure to ascertain fetal well-being.
Options B, C, D – although appropriate procedures they are not the priority concern.
Strategy: Similar Distractors. “CLIENT”.

30. A client in the third trimester of pregnancy seen in the clinic is experiencing urinary frequency.
Which of the following self-care measures will the nurse provide to the client?
a. Perform Kegel’s exercises
b. Avoid fluid intake after 6:00 PM.
c. Avoid emptying the bladder frequently.
d. Sip on small amounts of fluids during the day restricting intake to 1000ml.

ANSWER A –Positive Response. Kegel exercises strengthens the perineal muscles.

Options B, C, D: Negative Response
Option B: avoid
Option C: avoid
Option D: restricting
Strategy: Positive Stem= Positive Response