NP3 - test

BS in Nursing (Central Mindanao University)

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 REFRESHER COURSE: PRE-BOARD EXAMINATION
Nursing Practice III: Care of Clients with Physiologic and
Psychosocial Alterations (Part A)
GENERAL INSTRUCTIONS:
1. This test questionnaire contains 100 test questions
2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalid your answer.
3. AVOID ERASURES.
4. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set.
5. Write the subject title “NURSING PRACTICE V” on the box provided.

Situation: Florenda, 52 years old, was transported to D. Uterus, urinary bladder, two ovaries, right and left fallopian
the Operating Room for Total Abdominal Hysterectomy tubes
Situation: Jasmine is working in the cardiac unit
1. The scrub nurse ensures that aseptic technique is
with a nurse floater. Together, they made their
maintained throughout the procedure. When she serves the
rounds while Kristine assessed the nurse’s
right gloves to the surgeon, which of the following is the correct
knowledge on the commonly used cardiac drugs.
technique to be followed by the scrub nurse?
A. Keep thumbs away from the cuff
B. Pick up the gloves and place the palm towards you 6. Jasmine asked the floater why nitroglycerin is given to a
C. Maintain fingers of the gloves facing you client with angina. The correct response of the nurse is that
D. Slide the gloves by holding under the glove cuff and spread nitroglycerine:
to create wide opening A. increases preload
B. increases afterload
C. dilates the veins
2. The surgeon uses electrosurgical equipment to cauterize D. constricts the arteries
blood vessels. Which of the following nursing activity should
have been done by the circulating nurse to ensure safety? 7. Being new in the cardiac unit, Jasmine emphasized to the
A. Correctly drape electro cautery cable and cord floater that the long standing hallmark in nursing
B. Electro cautery equipment is placed appropriately at the intervention for clients taking Digoxin (Lanoxin) is:
back of the surgeon A. Take the apical pulse for one full minute
C. Grounding pad is connected to grounding cable properly B. Monitor intake and output hourly
placed under the patent’s buttocks C. Check the blood pressure reading with the same BP
D. Electro cautery pencil is made easily available each time the apparatus
surgeon uses it D. Palpate the radial pulse for one full minute

3. The surgeon passed the specimen to the scrub nurse. Which 8. Jasmine tests the floater’s readiness for the assignment
of the following is the correct action of the scrub nurse? by asking this question “When you find a client in cardiac
A. Place specimen in a basin moistened with saline solution arrest, which of the following drugs would you be ready to
B. Wipe specimen with sponge
administer?” The correct answer of the nurse floater is:
C. Wipe specimen with surgical sponge (OS)
A. Atropine sulfate
D. Pass the specimen to the circulating nurse
B. Lidocaine 2%
C. Morphine sulfate
4. The surgeon asked a suture to close the peritoneum. Which D. Epinephrine
of the following should have been done by the scrub nurse 9. One of the hypertensive clients assigned to the nurse
before suture is handed to the surgeon? floater is on Captopril (Capoten), an Angiotensin Converting
A. Specimen passed to the circulating nurse Enzyme (ACE) Inhibitor. Which of the following nursing
B. Needle holder passed to the surgeon
interventions should be included in the plan of care?
C. Needle mounted on the needle holder
A. Monitor sugar level
D. “Surgical count” completed
B. Observe complete bed rest
5. The surgeon tells the scrub nurse that the procedure done C. Measure intake and output carefully
was total abdominal hysterectomy with bilateral sphingo- D. Monitor for bruising, petechiae, or bleeding
oophorectomy. The scrub nurse understands that the specimen
she received would consist of which of the following organs? 10. The nurse floater is instructing one of her clients on
A. Right and left ovaries, uterus, a fallopian tube Clopidogrel bisulfate (Plavix). Which of the following
B. Uterus, fallopian tube, ovary, and urinary bladder
indicates that her client understands the effect of the drug?
C. Uterus, right and left fallopian tubes, and ovaries
A. “I should slow down on my carbohydrate intake.”
B. “I should take liberal amount of fluid while on this drug.” which diet prescription prior to the examination?
C. “I should use caution in taking over the counter drugs that A. Low fat diet
might cause bleeding.” B. Low protein diet
D. “I may gain weight while on this drug.” C. Purine free diet
D. Low purine diet
Situation: Virgilio, 40 years old, was admitted for
check- up. He was diagnosed with 19. During the acute attack, the pain of the affected foot can
essential hypertension a year ago. Upon be so intense that even the weight of the linen can be
admission, his blood pressure is 170/90, slightly unbearable. The MOST appropriate nursing intervention is to:
dysneic, dizzy and with blurred vision. A. Apply splint on the affected
B. Place a foot cradle on the bed
11. The admitting nurse understands that increased diastolic C. Elevate the affected foot
D. Apply bandage around the affected foot
pressure indicates which of the following?
A. Generalized vasoldilation
B. Loss of elasticity of the aorta and arteries 20. Colchicine is prescribed during the acute attack phase. Nurse
C. Increased peripheral resistance and increased workload of Karmela is aware that the action of the drug is to:
the left ventricle A. Provide fast symptomatic relief
D. Widening of the lumen of the arteries B. Lower serum uric acid
C. Block the conduction of pain sensation
12. Virgilio has been taking Atenolol (Tenormin) 50 mg. orally D. Interfere with the inflammation response of uric
once daily. The nurse understands that the specific action is to acid crystals in the joints
block:
A. Beta receptor stimulation of the heart Situation: Henry, 65 year old underwent
B. Effects of the angiotensin II on receptors Transurethral Prostatectomy (TURP). He was
C. Calcium entry into the myocardium cells admitted to the Post Anesthesia Care Unit (PACU).
D. Alpha receptors in vascular smooth muscle The following questions apply.

13. Hydrochlorothiazide (Hytaz) 12.5mg 1 tablet orally once 21. The Operating Room (OR) nurse endorsed the ongoing
daily has been prescribed for the client. The specific action of intravenous infusion of Dextrose 5% Ringer’s Lactate,
this thiazide diuretic is to: 500ml, running at 40ml per hour at the level of 300ml. The
A. Promote excretion of sodium and chloride be decreasing nurse who received the client in PACU at 1500H,would
absorption in the distal tubule expect the present infusion to be consumed at:
B. Increase osmotic draw of the urine inhibiting water re- A. 2400H
absorption B. 0100H
C. Inhibit sodium and chloride re-absorption in the ascending C. 2200H
loop of Henle D. 0300H
D. Inhibit sodium- potassium exchange in the distal tubule
22. The client has an indwelling triple catheter to continuous
14. From the results of the laboratory test prescribed by the bladder irrigation (CBI) with Normal Saline Solution (NSS)
physician, which of the following will the nurse consider as an infusing at 200ml per hour. After four hours, the nurse
indication of impaired renal function? Elevated levels of; emptied the drainage bag and obtained and output of 1,080
A. Creatinine ml. Which of the following will the nurse record as the
B. Hematocrit client’s urinary output?
C. Potassium A. 180ml
D. Total Cholesterol B. 1,080 ml
C. 800ml
15. “Risk for excess fluid volume” is a nursing diagnosis D. 280ml
identified by the nurse. The following are acceptable indicators
of excess fluid volume, EXCEPT: 23. The surgeon’s order reads: “Maintain traction on the
A. Intake and output record indwelling triple lumen catheter.” Which of the following is
B. Compliance to sodium restriction the MOST appropriate action of the nurse?
C. Vital signs reading A. Tape the catheter to the abdomen and keep client
D. Weight changes in supine position
B. Pull the catheter taut and tape to the thigh
Situation: Conrado sought admission for acute gout of alternately every 6 hours
the right foot. Nurse Karmela was in-charge of the C. Instruct the client to keep both legs together and
client. extended all the time
D. Pull the catheter taut, tape to one thigh and keep
16. Nurse Karmela performs initial assessment. Which of the the leg extended all the time
following types of joint pain supports the physician’s diagnosis?
A. Bilateral 24. The nurse understands that Normal Saline Solution (NSS) is
B. Symmetrical used for CBI to prevent which of the following?
C. Polyarticular A. Later intoxication
D. Monoarticular B. Elevation of specific urine gravity
C. Dehydration
17. Which of the following examinations would the nurse D. Formation of stones
expect to be ordered?
A. Bone marrow aspiration 25. The nurse assigned to the client monitored and maintained
B. Knee-jerk examination the CBI rate of NSS at 200 ml per hour. This intervention is
C. Synovial fluid analysis critical because it:
D. Bone density A. Washes out remaining fragments of stones
B. Avoids postoperative infection
18. The client is for 24- hour urine collection for uric acid C. Decreases bleeding and keep the bladder free from
determination. To have a reliable result, the nurse anticipates
 blood clot (NGT). She understands that the primary indication of NGT in
D. Maintains adequate hydration. Jayson’s case is for:
A. irrigation
Situation: The nurse is assigned to admit a 27 B. feeding
year old female patient with protruding eyeballs and C. medication administration
an enlarged neck. Physician’s diagnosis is Grave’s D. decompression
disease.
34. While making her rounds, Jayson’s mother showed nurse
26. The nurse performs initial assessment and confers with the Remy the child’s brown stool. What is the appropriate action
medical resident. Which of the following will the nurse of the nurse?
consider as the correct description of Grave’s disease? A. bring the stool to the laboratory
A. Antibodies bind to TSH receptors causing increased B. instruct the mother to dispose the stool properly
C. document the characteristics of the stool
thyroid hormone
D. reports the passage of stool to the physician
B. Multiple thyroid nodules resulting in thyroid hyper
function
C. Increased in thyroid secretion of T3 cause unknown 35. Nurse Remy reviewed a certain literature where the
D. Uncontrolled secretion of T3 and T4 form benign classical triad of pain, palpable sausage-shaped abdominal
thyroid tumor mass and currant jelly-like stool occurred only in 15% of
children when they are seen initially. Which of the following is
27. During the interview, nurse found out that the client takes nurse Remy’s correct interpretation of this finding, if there are
Prophylthiouracil (Prophyl-Thracil) daily. Which of the following 60 sick children as the population?
is the specific action of this drug? A. The classic triad of symptoms was observed in 9
A. Beta-adreneric blocking drug out of 60 sick children
B. Decreases blood flow to the thyroid gland B. Approximately 15 sick children experienced the
C. Destroys thyroid cells classic triad of symptoms
D. Blocks thyroid hormone production
C. When seen initially, 30 sick children did not show
any of the symptoms
28. The nurse identified the nursing diagnosis “Disturbed
D. Among the 60 children, there were 25 who showed
sensory perception related to exophthalmus.” Which of the
the classic triad of symptoms
following nursing interventions is intended to promote decrease
in periorbital fluid?
Situation: The primary goal of nursing research is
A. Cover eyes
B. Administer artificial tears as prescribed to develop a scientific knowledge base for nursing
C. Elevate head at 45 degrees practice. Nursing research includes all students
D. Use cool moist eye compress concerning nursing practice, nursing education, and
nursing administration.
29. The client is scheduled for subtotal thyroidectomy. Strong
iodine solution is prescribed. The nurse prepares to administer 36. Researcher Bea conducted a research of the effect of using
the medication knowing that therapeutic effect of the an agent in giving oral hygiene in the nursing care of the
medication is to: acutely ill surgical patients. In this type of study, it necessary
A. increase thyroid hormone to:
B. replace the thyroid hormone A. conduct a pilot study
C. suppress thyroid hormone production B. administer treatment
D. prevent oxidation of iodide C. conduct interview
D. develop a questionnaire
30. Following thyroidectomy, the nurse notes the very weak
and hoarse voice of the client. Which nursing intervention is 37. Of the following listed designs below, which one would allow
most appropriate at this time? the researcher to have the most confidence that the oral
A. Caution the client not to force herself to talk care with agent is effective in helping acutely ill surgical
B. Notify the surgeon immediately client attain health outcome?
C. Reassure the client this is usually a temporary condition A. One-shot case study
D. Offer the client warm NSS gargle B. Non-equivalent control group design
C. Post-test only control group design
Situation: Nurse Remy is assigned in the pediatric D. One-group pre-test post-test group design
ward. She was in charge of a 20 month-old child,
Jayson, diagnosed with intussusception 38. A team of researchers conducted a study on the relationship
of the completed surgical cases and the extent of
31. Nurse Remy is reviewing the chart of Jayson. What will she performance of standard competencies among level 3
expect to read as symptoms of her client? nursing students assigned in the Operating Room, in
A. Foul-smelling, watery stool correlational study, the researcher examines the:
B. Nausea and vomiting A. questionnaire used to collect data from large samples
C. Projectile vomiting B. difference between two correlated groups
D. Crampy and intermittent severe abdominal pain C. relationship between or among two or more variables
D. cause and effect relationship
32. A nursing student was with Nurse Remy. She wants to fully
understand the case and so she asks the nurse to describe the 39. The statistical tool that is used in determining the magnitude
case. The appropriate definition of intussusception is the: and direction of the relationship between two variables is:
A. herniation of the small intestine into the abdominal opening A. Test of relationship
B. telescoping of bowel into the adjacent segment B. Analysis of variance
C. Mechanical obstruction from the inadequate motility of the C. Pearson r coefficient of correlation
small intestine D. Spearman rho coefficient of correlation
D. protrusion of the bowel through an abdominal opening
40. A researcher conducted a study on assessment of the
33. Nurse Remy prepares for the insertion of nasogastric tube psychosocial problems of cancer patients in Metro Manila.
 Which of the following instruments was used to collect data technique
from large samples? 2. Change the contaminated gloves using the open glove
A. Descriptive statistics technique
B. Inferential statistics 3. One member of the surgical sterile team is to glove the
C. Questionnaire and interview assistant surgeon
D. Controlled laboratory setting 4. The circulating nurse the sterile gloves to the assistant
surgeon
Situation: Statistics from nursing research show A. 3 and 4
that structured health teaching programs have B. 1 and 2
resulted in modified client behavior and improved C. 1 and 3
health status. D. 2 and 3

41. Nurses are aware that normal aging affects the changes in 48. The scrub nurse aids the assistant surgeon apply the sterile
client’s cognition. Therefore, when teaching a 72 year old drape. The scrub nurse understands that once the drapes are
diabetic client how to administer insulin, the nurse should: positioned over the prepped incision site, the drapes must not
A. demonstrate faster because the client tires easily be:
B. present all information at one time A. marked
C. demonstrate by using audio visual technology B. folded
D. frequently repeat information for reinforcement C. aligned
D. moved
42. Considering the sensory changes in the elderly, which of the
following techniques would be most helpful to enhance 49. You are circulating in an Exploratory Laparotomy for a ruptured
client’s recall? appendicitis. The scrub nurse asks for “normal saline solution
A. use of colors to emphasize data and dose (NSS) wash”. You immediately opened one liter of NSS and
B. use properly labeled individual containers began to pour to the sterile basin of the scrub nurse. Before
C. highlight date and dose you can empty the NSS container, the scrub nurse signal you
D. label all medications with number in bold ink “enough”. What is your appropriate action with the remaining
NSS?
43. When teaching a client drug self-administration, which of the A. Discard the remaining NSS
following behaviors reflect that the client is not ready to learn? B. Pour the remaining NSS to another sterile basin in the
A. Arranges the medication in the container provided for back table
B. Hears without reaction C. Cover the remaining NSS bottle aseptically right away
C. Agrees to schedule of teaching D. Transfer the remaining NSS to smaller sterile
D. Notes medication, dose and time container

44. Modifying the teaching program because the learner has 50. Immediately before opening and presenting any sterile item
difficulty in comprehending involves which appropriate nursing to the sterile field, the circulating nurse should inspect for
action? which of the following indicators?
A. postponing the teaching until client’s condition 1. Package integrity
improves 2. Date when manufactures
B. contacting family members to assist in the goal 3. Sterilization indicator
development to learn 4. Expiration date
C. changing the terms in the teaching pamphlet so that 5. Purchase price
the learner can understand it 6. Device specification
A. 1,2,3,5
D. altering the content of the program
B. All of these
C. 1,3,4 only
45. Nursing actions that can be used to motivate clients learn the D. 1,2,3,6
health programs include all of the following except: Situation: Zyra, a 32 year old woman was rushed to
A. negative criticism is emphasized at once
the nearest community hospital after obtaining
B. the establishment of realistic goals based on individual
burns in the anterior chest, both upper extremities
client needs
and half of her face. Nurse Lulu was assigned to her.
C. creation of a conducive atmosphere for client’s
privacy
D. feedback when a client has been unsuccessful 51. Nurse Lulu reads the chart and finds out that NGT placement
was ordered for her patient. Nurse Lulu performs the
Situation: Integral to quality management in the procedure correctly if she does the following except:
Operating Room is the observance of the basic A. Tilts the patient’s nose upward before inserting the
tube.
principles and practices to establish and maintain a
B. Asks the patient to swallow when the tube is in the
sterile field by the sterile team involved in the surgical
nasopharynx.
intervention. C. Prepare the patient NPO 6-8 hours prior to the
insertion.
46. Once a scrubbed personnel dons a sterile gown and gloves, D. Apply water soluble lubricant at the tip of the tube.
he/she is considered “sterile”. This connotes that he/she can:
A. assist in positioning the client for surgery 52. After the procedure, the nurse checks if the tube is properly
B. touch sterile instrument on the sterile field placed. She is correct of she states that the most accurate
C. hand suture as needed to the scrub
method of checking tube placement is:
D. “prep” the surgical site
A. pH measurement of the aspirate
B. Air auscultation
47. The assistant surgeon accidentally contaminated his gloves C. Visual assessment of the aspirate
while adjusting the retractor. As a perioperative nurse you D. X-ray visualization
know that there are two methods that the surgeon can choose
from. What are these methods? 53. Patient Zyra was about to take her lunch. Before the
1. Change the contaminated gloves by the closed glove administration of osteorized food, the tube must be
 irrigated. Nurse Lulu has an accurate understanding of the D. Inspection
situation if she uses this fluid in tube irrigation:
A. Bottled water Situation: Cancer is one of the leading causes of
B. Tap water disability and death worldwide. Various treatments
C. Normal saline solution and medical regimen have been discovered to halt or
D. D5LRs minimize the progression of the said disease.

54. Enteral feeding poses patients receiving it to various 61. A patient who was admitted in the oncology ward had his
complications. Appropriate interventions must done for the chart placed in the station. As the nurse browses the chart, she
following except: notices TIS, N0, and M0 written on the patient’s diagnosis.
A. Diarrhea She correctly interprets the data if she states that TIS, N0, M0
B. Pasty, unformed stool
C. Constipation means :
A. No evidence of primary tumor, Regional lymph node can’t
D. Hyperglycemia be assessed and distant metastasis
B. Primary Tumor can’t be assessed, No regional lymph node
55. Zyra who was in NGT was prescribed a timed-release tablet.
metastasis and distant metastasis can’t be assessed
What action of the nurse indicates the she had an accurate
C. Carcinoma in situ, No regional lymph node metastasis and
understanding of the situation upon giving the drug? no distant metastasis
A. Powderized the tablet and dissolve in water. D. Tumor less than 2 cm, One regional node involvement and
B. Give it as prescribed. distant metastasis can’t be assessed
C. Call the physician to change the medication
D. Consult the pharmacist for an alternative form of the
drug. 62. Tristana, a 38 year old woman was also admitted in the
ward. She was diagnosed of having stage 2 cervical cancer and
Situation: Mr. John Skarner, a 57 year-old lawyer was scheduled a radiation therapy specifically cervical
was confined after complaining persistent and implants. Which of the following room locations is best for
productive cough accompanied by shortness of patient Tristana?
A. Near the nurses’ station
breath. History was taken and it revealed that he B. Away from the hallway
started smoking at the age of 15 and was able to C. Somewhere near the ward exit
consume 10 cigarettes in a day. D. In front of the ward’s common rest room

56. Based on the situation, how many pack years does Mr. 63. As you make your rounds, you noticed that there are
Skarner have? implants in the patient’s bed. Initially, what should the nurse
A. 42 years do?
B. 28years A. Pick up the implants using a gloved hand and place it in the
C. 21 years
trash bin.
D. 36 years
B. Call the attention of the maintenance and let him dispose of
the implants.
57. The patient was diagnosed of Chronic Bronchitis has a C. Pick up the implants using long forceps and place it in a lead
correct understanding of the situation if she states that Chronic container.
bronchitis is the presence of cough and sputum production for D. Have the patient pick the implants and insert it back.
how long?
A. at least 2 months in each 3 consecutive years
B. at least 3 months in each 2 consecutive years 64. Another patient was also admitted in the same ward and
C. more or less 3 months in each 3 consecutive year diagnosed of stage 3 lung cancer. He was advised to
D. more than 3 months in a year undergo chemotherapy. The following statements indicate
that the patient has an accurate understanding regarding
58. One night, the patient prompted the nurse because of the effects of chemotherapy except:
difficulty in breathing. The patient requested the nurse to raise A. I will use soft-bristled toothbrush for my oral care.
the oxygen level from what is being prescribed. The nurse has B. Imgonna eat nutritious foods like fresh fruits and
an accurate understanding of the situation if she does what vegetables.
action? C. I prefer artificial rather than fresh flowers in my room.
A. Follow the client’s wish to facilitate breathing. D. I should avoid engaging in contact sports.
B. Discontinue the oxygen therapy because the patient is no
longer responsive to it. 65. The patient started to worry why his hair had started to
fall off. You came off with a diagnosis of body image
C. Give the client expectorant immediately to expel retained
secretions. disturbance. The patient asked if his hair would grow back.
D. Maintain the regulation and assess for other potential The nurse has a correct understanding of the situation if she
problems. stated that:
A. “Hair loss is temporary and it will grow back right after
59. Mr. Skarner was ordered for a postural drainage. The the treatment.”
patient asked the nurse when it will be done. The nurse is B. “Your hair will never grow back and wearing of wigs is
correct if she stated that CPT is best performed: recommended for life.”
A. Early in the morning before breakfast. C. “Your hair will grow back some time after the therapy
B. In the morning after eating merienda. but it is not the same as before.”
C. In the afternoon before dinner. D. “Worrying is the cause of hair loss and not the
D. Thirty minutes after the patient took his lunch. treatment so stop worrying.”

60. You noticed that the patient still have productive cough. Situation: Diabetes Mellitus is one of the leading
Which method is best used for assessing breath sounds? debilitating diseases in the world. It is related to
A. Palpation sedentary lifestyle, improper diet and genetics.
B. Auscultation
C. Percussion 66. Nurse Annie was assigned in the Diabetes enter. She is
 aware that insulin is mainly responsible for controlling the
levels of glucose in the blood. Insulin is produced by what 75. As you prepare the patient for surgery, you noticed that the
cell? patient is fidgeting, going in and out of his bed and frequently
A. Alpha-cells asks about the procedure. These behaviors of the patient most
B. Beta-cells likely suggest?
C. Delta-cells A. The patient does not have enough sleep last night.
D. Goblet cells B. Client is pressed between financial burden and family
responsibilities.
67. A type I DM client experiences Diabetic Ketoacidosis. C. She drank too much coffee during breakfast
Based on your knowledge, the acid-base balance most likely D. She is anxious about the surgery.
seen in the patient is:
A. Metabolic acidosis Situation: Sterilization is the process of removing all
B. Respiratory alkalosis living microorganisms. To be free of all living
C. Metabolic alkalosis microorganisms is sterility.
D. Respiratory acidosis 76. There are three general types of sterilization used in the
hospital. Which is not included?
68. A type II DM client is asking the nurse what is the best A. Steam sterilization
time to buy shoes. The nurse is correct if she replied: B. Chemical Sterilization
A. Morning C. Dry heat Sterilization
B. Anytime of the day will do D. Sterilization Boiling
C. Time is not a relevant factor
D. Late in the afternoon 77. Autoclave on steam under pressure is the most common
method of sterilization in the hospital. The nurse knows that
69. The nurse is instructing a diabetic client about foot care. the temperature and time is set to the optimum level to destroy
The patient needs no further instruction if he states the not only the microorganism, but also the spores. Which of the
following except: following is the ideal setting of the autoclave machine?
A. “I will walk barefooted in the house to promote circulation”. A. 10,0000C for 1 hour
B. “ I’m gonna avoid soaking my feet in the water for long B. 5,0000C for 30 minutes
time”.
C. 370C for 15 minutes
C. “I will cut my toe nails straight”.
D. “I will eat nutritious food recommended by my dietician”. D. 1210C for 15 minutes

70. A client is taking Glyburide (Micronase) for her type II 78. It is important that before a nurse prepares the material to be
DM. Which statement from the patient would alert the nurse? sterilized a chemical indicator strip, preferably a Muslin Sheet,
A. The client stays up late when he overtimes at work. should be placed above the package. What is the color of the
B. I limit my alcohol intake up to 2 glasses everytime we stripe produced after autoclaving?
have a night out. A. Black
B. Blue
C. I do not recommend this drug to my pregnant diabetic
C. Gray
friends. D. Purple
D. I usually experience headache after taking this medication.
79. Chemical indicators communicate that:
Situation: In the OR, there are safety protocols that A. The items are sterile.
should be followed. The OR nurse should be well B. The items have undergone sterilization process but
versed with all these to safeguard the safety and not necessarily sterile.
quality of patient delivery outcome. C. The items are disinfected.
D. The items have undergone disinfection process but
71. Which of the following should be given highest priority not necessarily disinfected
when receiving patient in the OR?
A. Assess level of consciousness 80. If a nurse will sterilize a heat and moisture label instruments, it
B. Verify patient identification and informed consent is according to AORN recommendation to use which of the
C. Assess vital signs
methods of sterilization?
D. Check for jewelry, gown, manicure and dentures
A. Ethylene oxide gas
72. Surgeries like I and D (Incision and Drainage) and debridement B. Autoclaving
are relatively short procedures but considered “dirty cases.” C. Flash sterilizer
When are these procedures best scheduled? D. Alcohol immersion
A. Last case
B. In between cases Situation: Nurses hold a variety of roles when
C. According to the availability of the anesthesiologist providing care to a peri-operative patient.
D. According to the surgeon’s preference
81. Which of the following role would be the responsibility of the
73. Katarina, an active cheerleader complains flashes of lights scrub nurse?
appearing and a shadow covering the upper vision of her left A. Assess the readiness of the client prior to the surgery
eye. You suspect that Katarina sustained a: B. Ensure that the airway is adequate
A. Retinal Detachment C. Account for the number of sponges, needles,
B. Glaucoma supplies used during the surgical procedure
C. Cataract D. Evaluate the type of anesthesia appropriate for the
D. Macular degeneration surgical client

74. Based on the situation, you plan to position the client on: 82. As a peri-operative nurse, how can you best meet the safety
A. Side-lying on the affected eye need of the client after administering pre-operative narcotic?
B. Lateral on the affected eye A. Put side rails up and ask the client not to get out of
C. Dependent position on the area affected bed
D. Independent position on the side affected B. Send the client to OR with the family
 C. Assist client to get up to go to the comfort room consider that tenure-years are nothing if these are not parallel
D. Obtain consent form with one’s personal-professional growth and maturity. This
implies:
83. It is the responsibility of the pre-op nurse to do skin prep for a. Simply earning years of job-related service until we
patients undergoing surgery. If hair at the operative site is retire from service.
not shaved, what should be done to make suturing easy and b. Extending assistance to our less-fortunate
lessen the chance of incision infection? fellow nurses.
A. Draped c. Progressive upgrading of competencies in terms of
B. Pulled knowledge, skills, attitudes, and values as
C. Clipped
professional nurse.
D. Shampooed
d. Volunteering our services wherever needed.
84. It is also the nurse’s function to determine when infection
89. We often give our best in caring but despite all efforts, the
has developed in the surgical incision. The perioperative
reality of facing death is inevitable. Our brand and core values
nurse should observe for what signs of impending infection?
of nursing will always extend beyond the ordinary levels of
A. Localized heat and redness
B. Serosanguinous exudates and skin blanching promotive, preventive, curative, and rehabilitative care. This
C. Separation of the incision culturally-bound, Filipino values of nursing likewise needs to be
D. Blood clots and scar tissue are visible nurtured:
A. Psychological care
B. Emotional care
85. Which of the following nursing interventions is done when
C. Spiritual care
examining the incision wound and changing dressing? D. Relational care
A. Observe the dressing, and type and odor of drainage if
any
B. Get patient’s consent 90. It is important to not only enrich one’s mind with
C. Wash hands progressive technical upgrades but equip one’s self with
D. Request the client to expose the incision wound holistic personal and professional development believing that:
A. we are also God’s angels of mercy on earth
B. we may also find real holism in the service we render
Situation: Enrolling as nursing students taught
you what the nursing profession has in store for you C. we and the beneficiaries of our care are made up of
and to recognize that each one came from different body, soul, and spirit and each component do have
environs, different influences, different past and health needs intertwined
present. As you journey through nursing, you saw D. should we encounter terminal patients, we may
yourselves transform “from the person you were” to understand how to support them to their dying stage
the “aspiring nurse” you have become. Now that you
have graduated and now taking your Nurse Licensure Situation: Nurse Jade is in charge of a client who was
Examination (NLE) there is only the “YOU, who is the admitted for management of acute episodes of
nurse.” cholecystitis.

86. As an aspirant, a beginning nurse practitioner after your 91. Nurse Jade did her admission assessment. She
basic nursing education, the “YOU, who is a professional understands that the pain is characterized as:
nurse” means: A. Tenderness that is generalized in the upper
A. I have simply fine tuned myself, my needs, my epigastric area
wants, my idiosyncrasies, to fit in the profession of B. Tenderness and rigidity at the left epigastric area
nursing. radiating to the back
B. The I in me and the nurse in me are two C. Tenderness and rigidity of the upper right abdomen
distinct identities that even my patients have radiating to the midsternal area
to learn to respect. D. Pain of the left upper quadrant radiating to the left
C. I have simply retained my former self but shoulder
acquired the knowledge, skills, attitudes, and
values expected of a nurse. 92. To confirm the diagnosis of cholecystitis, the attending
D. The person I am and the professional nurse I aspire physician ordered the procedure that can detect gallstones as
to be have now developed into one Filipino Nurse. small as 1 to 2 cm and inflammation. Nurse Jade would
We are one and the same identity. prepare the client for which specific diagnostic procedure?
A. cholangiography
B. gall bladder series
87. As you progress in developing your nursing competencies, C. oral cholecystogram
you have to thread a career-path according to the culture D. ultrasonography
and design of Philippine Nursing. This means:
a. Serving in other countries and learning new and 93. The diagnosis was confirmed as cholecystitis with
modern ways of doing nursing and sharing these back in gallstones. The doctor prepared the client for the removal of
the Philippines. his gallbladder. The client asks the nurse: “How will this
b. Progressing as nurse-generalist in a multitude of procedure affect my digestion?” The nurse’s most correct
choice-practice settings to that of expert nurse- response would be:
practitioner also in choice-practice-settings A. c. “Your body system will adjust in due time.”
c. Avoiding personal and professional stagnation by “The removal of the gallbladder usually interferes with
updating and upgrading one’s self digestion but can be remedied by dietary modifications.”
d. Constantly upgrading one’s self through advanced B. “The removal of the gallbladder would significantly
technological means and strategies interfere only with the digestion of fatty food.”
C. “The removal of gallbladder does not usually
88. It is important to remember that while RNs value “job interfere with digestion.”
tenure” because the years in service spell variety of
experiences in nursing practice, it is far more valuable to 94. While reviewing the laboratory findings of the client, Nurse
 Jade found out that which findings are elevated?
1. white blood cell count
2. total serum bilirubin
3. alkaline phosphate
4. red blood cell count
5. cholesterol
6. serum amylase
A. 3,5,6
B. 1,2,6
C. 1,2,3
D. 2,3,4
95. A T-tube was inserted and the doctor ordered: “Monitor the
amount, color, consistency and odor of drainage.” Which of
the following procedures can the nurse perform without the
doctor’s order?
A. clamping
B. emptying
C. aspirating
D. irrigating

Situation: Alfonsus sought hospital confinement for

pleuritic pain, fever, and cough. The attending
physician had a chest x-ray taken STAT. Result
revealed presence of lung infiltrates. The client was
assigned to Kianne the staff nurse.

96. When Kikay performed chest auscultation, she observed

short discreet bubbling sounds over the lower region of the
right lung. Which of the following abnormal findings will
Kikay consider?
A. Friction rub
B. Murmur
C. Wheezes
D. Crackles

97. Kikay put her priority nursing diagnosis as “Ineffective

airway clearance related to increased secretions and
ineffective coughing.” Which nursing intervention would be
considered to facilitate coughing with the LEAST discomfort?
A. Splinting chest wall with pillow when coughing
B. Putting the client in semi-Fowler’s position all the time
C. Taking cough med q4 hours round the clock
D. Utilizing the purse-lip technique of breathing

98. The physician prescribes oral penicillin 500 mg every six

hours for seven days. On the fifth day, before Kikay
administers the first dose for the day, she computed for the
total amount in the milligrams of the oral penicillin that has
been received by the client. Which of the following is the
correct amount?
A. 2,500 mg
B. 15,000 mg
C. 10,000 mg
D. 8,000 mg

99. Standard precaution dictates that the nurse observes which

of the following when caring for a client with streptococcal
pneumonia?
A. Use of face mask
B. Use of sterile gloves
C. Observe two-feet distance when giving care
D. Use clean gloves

100. Sputum cultures are to be obtained to establish the

client’s specific antibiotic treatment. Kikay would BEST
collect the specimen:
A. Early in the morning
B. Early morning after an antiseptic gargle
C. After brushing the client’s teeth
D. Anytime of the day after a warm salt solution gargle