RECALLS 6 NP1 1 point

Situation: In the Philippine Health Care Delivery A. Quality Education

System, the Department of Health remains to be the
B. Good Health and Well-Being
national government’s biggest health care provider.
C. No Poverty
1. One of the laws passed to implement a more
responsive and accountable health delivery system is D. Zero Hunger
the Local Government Code. Which among the following
Situation: Nurse Raul conducted a home visit in
is the Local Government Code of 1991?
Barangay Batabate. As part of his standard
* responsibilities, he assessed the Victoria Family.
The household has 5 members. The father works as
1 point
a jeepney driver while the mom cares for their three
A. Republic Act 7601 son. During the visit, Nurse Raul noticed that there
is open drainage that seems to be stagnant.
B. Republic Act 7106 Containers, tires, and basins that were discarded are
left uncovered.
C. Republic Act 7610
6. Nurse Raul educated the family regarding the 4S
D. Republic Act 7160
against Dengue. He emphasized on cleaning open
2. As the national authority of health in the Philippines, drainage from clogging and cover containers even if
the Department of Health is mandated to perform discarded. This would eliminate mosquito habitats
different functions. All of which are roles / functions of reducing chances for the family to get infected with
DOH, except _____ . vector-borne diseases. Given the situation, what level of
prevention was shown?
*
*
1 point
1 point
A. Administrator of General Services
A. Immediate Prevention
B. Administrator of Specific Services
B. Primary Prevention
C. Enabler and Capacity Builder
C. Secondary Prevention
D. Leadership in Health
D. Tertiary Prevention
3. The Vision of the Department of Health is ______
7. One of the vectors for Dengue is the Aedes aegypti
* which commonly bites during the day. Which among the
1 point following is another vector for Dengue?

A. Filipinos are among the healthiest people in Asia by *

2040 1 point
B. Filipinos are among the healthiest people in Asia by A. Female Anopheles minimus flavirostris
2030
B. Female Culex
C. To steward the development of an Effective, Resilient,
Equitable, and People-Centered health system for C. Aedes Albopictus
Universal Health Care
D. Aedes Poecillus
D. To develop, implement, enable, and coordinate Social
8. Three days later, Mr. and Mrs. Victoria’s son, Eric, is
Welfare Development policies and programs for and with
observed to have sudden high fever and mild rashes.
the poor, vulnerable, and disadvantaged
Nurse Raul conducted a Tourniquet Test and counted a
4. The National Objectives for Heath serves as blueprint total of 22 petechial spots. Given the situation, what level
of the DOH to accomplish the goal of universal health of prevention was shown?
care. All of which are determinants of Health, except for
*
______ .
1 point
*
A. Immediate Prevention
1 point
B. Primary Prevention
A. Gender
C. Secondary Prevention
B. Health Services
D. Tertiary Prevention
C. Social Support Networks
9. One of the most common vector of Malaria is the
D. Disease
Anopheles minimus flavirostris. Which among the
5. The 17 Sustainable Developmental Goals were following is most common cause of Malaria in the
adopted at the UN Sustainable Development Summit in Philippines?
New York in September 2015. Which among the
*
following represents SDG 3?
1 point
*
A. Plasmodium vivax Stella then reviewed the children's immunization records,
identified missed doses, and referred them for catch-up
B. Plasmodium falciparum
immunization. What level of prevention is demonstrated
C. Plasmodium malariae in this situation?

D. Plasmodium ovale *

10. Mansonia mosquitoes are responsible for 1 point

transmitting Brugia malayi, one of the causative agent of
A. Immediate Prevention
Lymphatic Filariasis. Which among the following is the
vector of Lymphatic Filariasis? B. Primary Prevention

* C. Secondary Prevention

1 point D. Tertiary Prevention

A. Wuchereria bancrofti 14. During a follow-up visit, Nurse Stella checks on

Mang Isko, the Cananas family's grandfather, who was
B. Aedes aegypti
recently diagnosed with hypertension and has suffered a
C. Aedes poecillus mild stroke. The family shares that Mang Isko now has
difficulty with walking and speech. Nurse Stella provides
D. Plasmodium falciparum health teaching on home-based rehabilitation exercises,
proper diet for hypertensive patients, and ensures that
Situation: Community Health Nurse Stella visited the
Mang Isko takes his maintenance medications regularly.
Cananas family in Silang, Cavite. Their household
She also refers the family to a community-based rehab
has five children and they live with the
center for continued support. What level of prevention is
grandparents. The family live in a small residence
demonstrated in this situation?
with two small windows, one front door, and one
bedroom. Their 3x5 square meter unit has poor *
ventilation, limited natural light, and is shared by
nine family members. During her assessment, Nurse 1 point
Stella observed that the home environment is damp,
A. Immediate Prevention
with signs of mold on the walls. One of the children,
6-year-old Ana, has been diagnosed with Asthma B. Primary Prevention
and frequently experiences nighttime coughing and
C. Secondary Prevention
wheezing.
D. Tertiary Prevention
11. To help manage Ana’s asthma, Nurse Stella
educated the family about minimizing exposure to dust 15. Nurse Stella observed that the Cananas family
and mold, demonstrated how to properly use a nebulizer, obtains their daily water supply from a communal deep
and referred Ana for regular asthma check-ups at the well shared by several other households. The source is
nearest health center. What level of prevention was about 200 meters from their home, and the family
demonstrated? manually collects and stores the water in containers.
There is no piped distribution system or household tap
*
available. Which type of water facility is the family using?
1 point
*
A. Immediate Prevention
1 point
B. Primary Prevention
A. Level I (Point Source)
C. Secondary Prevention
B. Level II (Communal Faucet System)
D. Tertiary Prevention
C. Level III (Waterworks/Household Tap)
12. Considering the cramped and poorly ventilated living
D. Level IV (Private Well System)
conditions, Nurse Stella suspected the possibility of
tuberculosis (TB) exposure. She then performed a Situation: Mr. Santos plans to open a small eatery in
symptom checklist and referred the children to the Rural Barangay San Lorenzo where he will serve rice
Health Unit for a chest X-ray and sputum test. What level meals and grilled dishes. As part of the barangay's
of prevention is Nurse Stella implementing? public health efforts, Community Health Nurse Liza
conducts health education sessions for small
*
business owners planning to operate food
1 point establishments. During her visit, she reminded Mr.
Santos about essential health and sanitation
A. Immediate Prevention
practices that reduce the risk of food- and water-
B. Primary Prevention borne diseases. She also emphasized the
importance of complying with public health policies
C. Secondary Prevention before starting operations.
D. Tertiary Prevention 16. What is the most important step Mr. Santos must
complete before legally opening his food business, in
13. Upon interview about their immunization history, the
line with Nurse Liza’s public health reminders?
family shared that they have not consulted the Rural
Health Unit (RHU) for DPT (Diphtheria, Pertussis, *
Tetanus) vaccination for their younger children. Nurse
1 point A. They are the main sources of energy and are needed
in large amounts to maintain body functions
A. Attend a culinary skills seminar organized by the
barangay B. They help prevent micronutrient deficiencies like
anemia and goiter
B. Submit a weekly cleaning schedule for review by the
RHU C. They are only important for children, pregnant
women, and older adults
C. Secure a sanitary permit and ensure all food handlers
have valid health certificates D. They are primarily used by the body for immune
system function and hormone regulation
D. Provide his employees with new uniforms and
hairnets Situation: In Barangay Maginhawa, the Rural Health
Unit (RHU) promotes the use of approved herbal
17. Which of the following practices best illustrates
medicines as part of the Department of Health's
adherence to the Four Rights of Food Safety?
Traditional and Alternative Medicine Program
* (TAMA). Nurse Jordan is conducting a community
seminar to educate residents on the safe use of
1 point herbal remedies for common illnesses. While
encouraging the community to recognize the
A. Ordering bottled water and frozen goods in bulk from
benefits of local medicinal plants, he also
an unfamiliar supplier recommended by a neighboring
emphasizes the importance of proper identification,
vendor
preparation, and consultation with health
B. Washing utensils only at the end of the day to professionals before using herbal medicine.
conserve water and cleaning materials
21. A resident asks Nurse Jordan if they can use any
C. Storing cooked rice in open containers at room herbal plant they find in the backyard for treating
temperature overnight common illnesses. What is the most appropriate
response of the nurse?
D. Ensuring that meat is thoroughly cooked and served
immediately after preparation *

18. To promote retention and standardization in her 1 point

health teaching, what strategy should Nurse Liza apply
A. “Yes, as long as it is a plant your grandparents used
when educating food handlers like Mr. Santos?
traditionally.”
*
B. “No need to ask a health worker as herbal medicines
1 point are natural and safe.”

A. Use printed materials written in English to maintain C. “You may refer to the list of scientifically validated
consistency and reinforce the key messages herbal medicines approved by the Department of
Health.”
B. Allow Mr. Santos to determine the lesson content and
flow based on his personal experiences D. “You can experiment with any local plant as long as it
looks healthy and green.”
C. Focus more on verbal teaching rather than printed
materials, regardless of client preference 22. During the seminar, Nurse Jordan reminded
participants that improper preparation of herbal
D. Avoid using written materials to ensure information is medicines may cause harm. Which of the following is the
passed down through demonstration only safest practice when using herbal remedies at home?
19. Which of the following should Nurse Liza emphasize *
as the most effective way to prevent the spread of
infection in a food establishment? 1 point

* A. Boil the plant leaves for any length of time until it

smells strong enough.
1 point
B. Dry herbal leaves under direct sunlight for faster
A. Washing hands properly before and after food processing.
preparation
C. Use only the recommended plant part and follow
B. Wearing gloves at all times when handling food proper preparation techniques as prescribed by DOH.
C. Using antibacterial sprays to clean kitchen counters D. Mix different plant parts to make the medicine more
D. Avoiding direct contact with customers during food effective.
service 23. A mother approaches Nurse Jordan and asks if she
20. During her visit, Nurse Liza explained that can give Niyug-Niyogan seeds to her 1-year-old son who
carbohydrates, proteins, and fats are macronutrients. has not had deworming recently. What is the nurse’s
Why is it important for Mr. Santos to include these in his most appropriate response?
meals? *
* 1 point
1 point A. “Only one seed should be given to minimize any risk
of side effects.”
B. “No, this remedy is not recommended for children C. Participating in a local seminar on advanced nursing
below four years old.” practices and organizing a learning session to share
knowledge with staff
C. “Yes, as long as the seeds are from dried and newly
opened fruits.” D. Delegating all training and education matters to the
nursing education office while focusing only on
D. “Yes, but crush the seeds and mix them with milk for
operations
easier intake.”
27. Which of the following actions by a registered nurse
24. Nurse Jordan is teaching a group of mothers how to
is most aligned with the responsibilities outlined in
properly prepare and administer Lagundi decoction for
Section 28 of RA 9173?
their children’s cough. Which of the following statements
requires further teaching? *

* 1 point

1 point A. Delegating health teaching responsibilities to

midwives to focus on administrative tasks
A. “I’ll boil the Lagundi leaves in two glasses of water
until only one glass remains.” B. Organizing a community outreach program that
includes health education, preventive care, and referral
B. B. “I will strain the decoction before giving it to my
coordination
child.”
C. Administering intravenous chemotherapy drugs under
C. “I will collect the Lagundi leaves while the plant is in
the guidance of a senior physician, without additional
bloom to get the best potency.”
specialized training
D. “I will give the same dose of Lagundi decoction to my
D. Requiring student nurses to perform procedures
3-year-old and my 10-year-old child.”
independently to help them build confidence early in
25. The Department of Health (DOH) in the Philippines their training
has endorsed certain medicinal plants proven to be safe
28. Which of the following best describes a practicing
and effective for common illnesses. Which of the
professional nurse according to Section 3 of the IRR of
following are among the ten (10) herbal medicines
RA 9173?
approved by the DOH?
*
1. Niyug-Niyogan (Quisqualis indica)
1 point
2. Sambong (Blumea balsamifera)
A. A nurse engaged in any activity—regularly or
3. Aloe Vera (Aloe barbadensis)
occasionally—that requires nursing knowledge and
4. Lagundi (Vitex negundo) skills, even if employed in a non-hospital setting

5. Tsaang Gubat (Carmona retusa) B. A nurse who works only in hospitals or community
clinics and holds an active PRC ID
6. Ginger (Zingiber officinale)
C. A nurse whose main duty is academic instruction and
* is not included in the definition of nursing practice
1 point D. A person employed under the Department of Health
but does not engage in direct patient care, and thus not
A. 1, 2, 4, and 5
considered a nursing practitioner
B. 1, 3, 4, and 6
29. Nurse Carlo, after years of professional experience
C. 2, 3, 5, and 6 and service as a nurse leader, is now being considered
for appointment as a member of the Professional
D. 1, 2, 3, and 6 Regulatory Board of Nursing. Which of the following
Situation: Nurse Carlo has recently been promoted qualifications would most likely justify Nurse Carlo’s
to a supervising nurse position in a district hospital. eligibility for the appointment, in accordance with RA No.
As part of his new role, he is expected to 9173?
demonstrate leadership, ensure continuous staff *
development, and support the delivery of safe,
quality nursing care through evidence-based 1 point
practices.
A. Must have completed at least a doctoral degree in
26. Which of the following actions best reflects Nurse nursing
Carlo’s compliance with RA 9173’s mandate for nurses
B. Must have worked as a nurse abroad for at least five
to engage in lifelong learning and continuing
(5) years
professional development?
C. Must be endorsed by the Department of Health or
*
PRC
1 point
D. Must have at least 10 years of continuous practice,
A. Completing only the required CPD units for license the last 5 of which must be in the Philippines
renewal and skipping additional training
30. Which of the following duties best illustrates the
B. Waiting for hospital management to enroll him in regulatory function of the Board of Nursing as outlined in
development programs before taking any initiative RA No. 9173?
* A. Refer the child to Inpatient Therapeutic Care (ITC) for
further assessment and management.
1 point
B. Continue weekly RUTF provision and monitor again in
A. Issuing memoranda and circulars for all private
the next follow-up.
hospitals nationwide
C. Advise the caregiver to increase the frequency of
B. Granting funding for new nursing education facilities
feeding at home.
across regions
D. Replace RUTF with high-protein homemade meals to
C. Accrediting continuing professional development
stimulate appetite.
providers for nurses
34. Upon admission to Inpatient Therapeutic Care (ITC)
D. Conducting hearings and investigations on complaints
for severe acute malnutrition (SAM), which of the
against nurses for unethical conduct
following assessments should be prioritized first in a
Situation: Nurse Gia has been assigned to a rural child presenting with bilateral pitting edema and poor
health unit (RHU) as part of the public health nursing appetite?
team. In the course of her community work, she
*
encounters multiple cases of malnutrition among
preschool-aged children. As a frontline health 1 point
worker, she is responsible for assessing nutritional
A. Check for hypoglycemia, hypothermia, and signs of
status, implementing intervention programs,
shock
educating parents, and referring cases as necessary.
She collaborates with barangay nutrition scholars, B. Perform anthropometric measurements to assess
midwives, and other stakeholders to address malnutrition severity
protein-energy malnutrition and other community
health concerns. C. Provide caregiver orientation and explain the
treatment protocol
31. During a community nutrition survey, Nurse Gia
assesses a 3-year-old child who presents with pitting D. Begin the feeding with ready-to-use therapeutic food
edema, moon face, flag-sign, and skin changes. Which (RUTF)
condition should the nurse most likely suspect?
35. During nutritional screening at a barangay health
* station, Nurse Gia measures the mid-upper arm
circumference (MUAC) of a 2-year-old child and obtains
1 point a reading of 11.3 cm. Based on the Department of
Health CMAM guidelines, how should this child’s
A. Marasmus
nutritional status be classified?
B. Kwashiorkor
*
C. Iron-deficiency anemia
1 point
D. Vitamin A deficiency
A. Mild undernutrition
32. A 2-year-old child diagnosed with severe acute
B. At risk for growth faltering
malnutrition (SAM) without complications is being
managed at the community level. Based on national C. Moderate Acute Malnutrition (MAM)
guidelines, which of the following interventions is MOST
appropriate in this case? D. Severe Acute Malnutrition (SAM)

* Situation: Nurse Erika is a newly assigned rural

health nurse in Barangay Magsikap, a
1 point geographically isolated and disadvantaged area
(GIDA). The barangay has limited access to potable
A. Initiate intravenous fluids to correct dehydration and
water, poor road connectivity, and limited health
provide immediate antibiotics.
literacy among residents. As part of her role, she is
B. Refer the child to the nearest tertiary hospital for expected to provide comprehensive community-
admission and continuous monitoring. based services, promote health education, and work
closely with local officials and health volunteers to
C. Enroll the child in a community-based therapeutic
improve health outcomes.
care program using Ready-to-Use Therapeutic Food
(RUTF). 36. In line with the Primary Health Care (PHC) approach,
which strategy is best demonstrated when Nurse Erika
D. Begin a high-protein household diet and advise
partners with barangay officials to train local health
regular weight monitoring at home.
volunteers on basic hygiene and disease prevention?
33. During an outpatient consultation, a nurse evaluates
*
a child diagnosed with severe acute malnutrition (SAM)
who has been receiving ready-to-use therapeutic food 1 point
(RUTF) for a week. On follow-up, the child is noted to
A. Equitable distribution of health resources
have developed bilateral pedal edema and refuses to
eat. What is the most appropriate next step in B. Intersectoral collaboration
management?
C. Use of appropriate technology
*
D. Community participation
1 point
37. Nurse Erika observes a spike in diarrhea cases and A. Vitamin A
suspects contamination in the community’s water
B. Vitamin C
source. What should be her initial action?
C. Vitamin D
*
D. Vitamin E
1 point
42. Deficiency of which vitamin most commonly leads to
A. Send water samples for laboratory analysis
rickets in children?
B. Refer the cases to the nearest hospital
*
C. Conduct home visits and health teaching on water
1 point
boiling
A. Vitamin C
D. Distribute anti-diarrheal medications

38. To assess and confirm the presence of an outbreak, B. Vitamin B₃ (Niacin)

Nurse Erika should first: C. Vitamin B₁ (Thiamin)
* D. Vitamin D
1 point 43. Which vitamin’s primary role is to facilitate blood
A. Implement community-wide disinfection efforts coagulation by aiding synthesis of clotting factors?

B. Compare current disease data with the usual number *

of cases (baseline) 1 point
C. Immediately conduct stool sampling and send for lab A. Vitamin K
analysis
B. Vitamin C
D. Wait for DOH central office confirmation before acting
C. Vitamin A
39. In responding to a waterborne outbreak, which
sector should Nurse Erika coordinate with to ensure D. Vitamin E
restoration of potable water?
44. A child presents with pale conjunctiva and fatigue.
* Lab shows microcytic, hypochromic red blood cells.
Which mineral deficiency is most likely?
1 point
*
A. Department of Social Welfare and Development
(DSWD) 1 point

B. Department of Labor and Employment (DOLE) A. Calcium

C. Department of Education (DepEd) B. Zinc

D. Local Water Utilities Administration (LWUA) C. Iron

40. Which of the following best demonstrates Nurse D. Iodine

Erika’s role in primary prevention?
45. A goiter (thyroid enlargement) in school-aged
* children in an inland province is most often caused by
deficiency of which mineral?
1 point
*
A. “Operation Timbang” for early malnutrition detection.
1 point
B. Administering antibiotics to diagnosed cholera
patients A. Iodine

C. Conducting epidemiological investigation of B. Magnesium

waterborne cases
C. Phosphorus
D. Promoting hand washing and safe water practices in
D. Fluoride
schools
Situation: Nurse Lana has been tasked to lead a
Situation: Nurse Khai is conducting a micronutrient
Community Organizing and Participatory Action
screening and education session at the Rural Health
Research (COPAR) project in Barangay Luntian. She
Unit, part of the Barangay Nutrition Program. She
will engage residents in identifying local health
assesses dietary intake, identifies deficiency risks,
problems, planning interventions, implementing
and teaches families about key vitamins and
activities, and evaluating outcomes together with
minerals essential for growth and health.
community stakeholders.
41. Which of the following vitamins is classified as water-
46. Which of the following best describes the primary
soluble and must be supplied daily in the diet?
goal of COPAR in community health nursing?
*
*
1 point
1 point
A. To implement top-down health programs designed by following the steps of the nursing process in a
experts community setting.

B. To train community volunteers in clinical procedures 51. A mother brings her 8-month-old infant to Nurse Ivan.
Which method should he use to obtain the most practical
C. To generate academic publications on community
and safe measurement of the child’s body temperature
health
in the field?
D. To empower communities to identify and solve their
*
own health issues
1 point
47. In a COPAR cycle, what comes immediately after the
community has identified and prioritized its health A. Rectal thermometer
concerns?
B. Axillary thermometer
*
C. Oral thermometer
1 point
D. Tympanic thermometer
A. Evaluation of implemented actions
52. During the assessment, Nurse Ivan finds the infant’s
B. Planning of joint interventions axillary temperature is 38.8 °C, pulse 150 bpm, and
respirations 40 rpm. The infant’s skin is warm and dry.
C. Data dissemination through academic forums
Which nursing diagnosis is most appropriate?
D. Securing external funding only
*
48. Which data-collection tool is most appropriate for the
1 point
initial community assessment phase of COPAR?
A. Acute pain
*
B. Deficient fluid volume
1 point
C. Risk for fluid volume deficit
A. Focus Group Discussions with key informants
D. Impaired thermoregulation
B. Randomized controlled trials
53. Which short-term outcome is most appropriate for
C. Laboratory diagnostic tests
the infant with fever and risk for dehydration?
D. Standardized patient simulations
*
49. During the action phase of COPAR, Nurse Lana
1 point
notices low turnout at community clean-up events.
Which strategy best reflects the participatory spirit of A. Infant will have at least six wet diapers
COPAR to address this?
B. Infant will tolerate 50 mL of oral fluids every 2 hours
* for the next 24 hours.

1 point C. Caregiver will list three signs of dehydration by

tomorrow.
A. Mandate attendance through barangay ordinance
D. Infant’s weight will increase by 200 g by the next
B. Offer financial incentives to participants
home visit.
C. Hold a community meeting to explore barriers and co-
54. To meet the planned fluid-intake goal, which action
create solutions
should Nurse Ivan perform?
D. Replace clean-ups with expert-led spraying teams
*
50. Which of the following indicators would best
1 point
demonstrate sustainable community ownership at the
end of a COPAR project? A. Encourage the caregiver to offer breast milk or
formula every 2 hours.
*
B. Teach the caregiver to prepare and administer an oral
1 point
rehydration solution (Pedialyte).
A. Number of research papers published
C. Administer intravenous fluids in the barangay health
B. Continued community-led health committees without station.
external funding
D. Encourage the caregiver to offer small amounts of
C. Volume of external grants secured fruit juice between feeds.

D. Frequency of nurse-led workshops 55. At the next home visit, Nurse Ivan notes the infant
has taken 600 mL of fluids over 24 hours, temperature is
Situation: Nurse Ivan is conducting a post-flood 37.4 °C, and pulse is 120 bpm. Which statement best
home-visit program in Barangay Maligaya. As part of indicates the planned outcome has been achieved?
the initiative, he screens infants and young children
for fever and dehydration, administers antipyretics, *
educates caregivers, and monitors fluid intake—all
1 point
A. Infant’s weight-for-age percentile has improved since 1 point
the last visit.
A. Intradermal – inner forearm
B. The infant's fluid intake meets the scheduled goal and
B. Subcutaneous – upper arm
vital signs are stable.
C. Intramuscular – deltoid region
C. Caregiver can explain signs of dehydration correctly.
D. Oral – buccal mucosa
D. Infant is smiling and engaging in normal play
activities. Situation: Nurse Arman is leading a Family Health
Nursing project in Barangay Payapa, where he uses
Situation: Nurse Lea leads the Expanded Program
family assessment tools to understand household
on Immunization (EPI) outreach in Barangay
dynamics, health risks, and support systems. He will
Kasukdulan. She reviews children’s immunization
engage four volunteer families to diagram their
records, educates caregivers, administers vaccines,
relationships, identify health threats, and formulate
and tracks coverage—ensuring safe practice and
family-centered care plans.
compliance with the Philippine EPI schedule.
61. In community health nursing, which is considered the
56. Which Tetanus Toxoid dose provides 80 % protection
primary client?
against neonatal tetanus and 3 years’ immunity for the
mother? *
* 1 point
1 point A. Individual
A. TT₁ – as early as possible during pregnancy B. Family
B. TT₃ – ≥ 6 months after TT₂ C. Population group

C. TT₂ – ≥ 4 weeks after TT₁ D. Community

D. TT₄ – ≥ 1 year after TT₃ 62. Which family assessment tool best illustrates the
flow of energy and support between a household and its
57. Which TT dose raises protection to 95 % and
external networks?
extends maternal immunity to 5 years?
*
*
1 point
1 point
A. Genogram
A. TT₁ – first dose
B. Family-life chronology
B. TT₄ – fourth dose
C. Ecomap
C. TT₃ – ≥ 6 months after TT₂
D. Functional diagram
D. TT5 – ≥ 1 year after TT₄
63. Which family assessment tool is best for mapping
58. Which TT dose confers 99 % protection with health patterns and medical history across three
10 years’ immunity? generations?
* *
1 point 1 point
A. TT₁ – first dose A. Ecomap
B. TT₃ – third dose B. Functional diagram
C. TT₄ – ≥ 1 year after TI₃ C. Genogram
D. TT5 – fifth dose D. Family-life chronology
59. Which TT dose completes the series for lifelong 64. During data analysis in family health nursing, first-
maternal protection? level assessment data are categorized into:
* *
1 point 1 point

A. TT₂ – second dose A. Nursing diagnoses and action plans

B. TT₃ – third dose B. Wellness states, health threats, deficits, stress points

C. TT₄ – fourth dose C. Individual vital signs and lab results

D. TT5 – fifth dose D. Financial, social, psychological domains

60. For adult women, the correct route and site for TT 65. What is the primary purpose of a family nursing
administration is: diagnosis?

* *
1 point *

A. To state the family’s inability to perform health tasks, 1 point

that guides interventions
A. Demographic variables
B. To explain why a problem exists without planning care
B. Health and illness patterns
C. To prescribe specific medical treatments
C. Material resources
D. To document only the family’s strengths
D. Community action potential
Situation: Nurse Dara is conducting a problem-
Situation: Nurse Mariel is conducting a family
oriented community diagnosis in Barangay
planning class at the Barangay Health Station. She
Masagana, where mining tailings have contaminated
discusses natural and artificial methods of family
the river. She uses rapid appraisal and participatory
planning, including their advantages, limitations,
methods to define the affected population,
and safety considerations. Couples are encouraged
categorize data, and assess the community’s
to ask questions to clarify misconceptions and to
capacity for action.
make informed choices.
66. Which step comes first in a rapid appraisal for
71. Which of the following is considered a natural
community diagnosis?
method of family planning?
*
*
1 point
1 point
A. Immersion in the community to gain initial insights
A. Basal body temperature method
B. Establishing a working relationship with leaders
B. Oral contraceptive pills
C. Planning data-collection methods and tools
C. Intrauterine device (IUD)
D. Summarizing and disseminating results
D. Male condom
67. Which method is most participatory, drawing data
72. Which family planning method requires insertion by a
directly from residents during appraisal?
trained health professional and provides long-term
* contraception?

1 point *

A. Household surveys 1 point

B. Secondary data review A. Injectable contraceptive

C. Environmental sampling B. Intrauterine device (IUD)

D. Focus group discussions C. Male condom

68. In defining the study population for a problem- D. Cervical mucus method
oriented diagnosis, the nurse’s primary consideration
73. Which artificial method of family planning also offers
should be the:
protection against sexually transmitted infections (STIs)?
*
*
1 point
1 point
A. Availability of funding
A. Oral contraceptive pills
B. Objectives of the community diagnosis
B. Injectable contraceptives
C. Time of year (seasonality)
C. Male condom
D. Nurse’s schedule constraints
D. Intrauterine device
69. When categorizing first-level assessment data,
74. Which permanent method of family planning is
“health threats” include:
performed on the female partner?
*
*
1 point
1 point
A. Prevalence of anemia among children
A. Tubal ligation
B. Presence of abandoned mining tailings along the
B. Vasectomy
riverbank
C. IUD insertion
C. Community ecomap of social support networks
D. Oral contraceptive pills
D. Number of barangay health workers available
75. Which statement best describes oral contraceptive
70. Which aspect of a community assessment most
pills?
directly measures the residents’ capacity to mobilize
resources and take collective health actions? *
1 point 80. Which statement is TRUE about condoms as a
method of family planning?
A. They are taken by males to suppress sperm
production. *

B. They prevent ovulation when taken daily by women. 1 point

C. They permanently stop fertility in women. A. They permanently prevent fertility once used regularly.

D. They provide protection against STIs. B. They require insertion by a health professional.

Situation: Nurse Jerome is facilitating a counseling C. They provide both pregnancy prevention and STI
session at the Rural Health Unit for couples protection.
interested in family planning. He provides
D. They must be taken daily to maintain effectiveness.
information on both natural and artificial methods,
ensuring clients understand effectiveness, safety, Situation: Nurse Gabriela is following the WHO’s
and cultural acceptability. His role is to help couples Integrated Management of Childhood Illness (IMCI)
make an informed and voluntary choice. protocol for under-5 children at the barangay health
center. She systematically checks for danger signs,
76. Which natural family planning method involves
main symptoms, and assesses nutrition and
identifying the fertile and infertile phases of the
immunization status before classifying, treating,
menstrual cycle based on cervical mucus changes?
counseling, or referring.
*
81. What is considered a general danger sign in IMCI
1 point that requires immediate hospital referral?

A. Calendar-rhythm method *

B. Lactational amenorrhea method 1 point

C. Cervical mucus or Billings ovulation method A. Fever of 38 °C

D. Coitus interruptus B. Cough for more than 14 days

77. The Lactational Amenorrhea Method (LAM) is C. Ear pain with discharge
considered effective only under which condition?
D. Convulsions
*
82. Which of the following is considered a "main
1 point symptom" in the IMCI assessment for children aged 2–
59 months?
A. Infant is below 6 months, mother exclusively
breastfeeding, and menstruation has not resumed *

B. Infant is below 1 year, mother partially breastfeeding, 1 point

and menstruation resumed
A. Weight loss
C. Mother is breastfeeding at night only
B. Ear problems
D. Infant is already taking complementary foods
C. Skin rash
78. Which artificial method of family planning provides
D. Daytime drowsiness
about 3 months of protection per injection and requires
follow-up for repeat doses? 83. In IMCI’s color-coded classification system, which
color represents a condition that should be managed at
*
a health facility with specific outpatient treatment?
1 point
*
A. Male condom
1 point
B. Oral contraceptive pills
A. Green
C. Injectable contraceptives
B. Pink
D. Intrauterine device (IUD)
C. Blue
79. Which permanent method of family planning is a
D. Yellow
simple surgical procedure done on males to cut or tie the
vas deferens? 84. During the IMCI process, after assessing danger
signs and main symptoms, what should be evaluated
*
next?
1 point
*
A. Tubal ligation
1 point
B. Vasectomy
A. Immunization, nutrition, and Vitamin A status
C. IUD insertion
B. Family’s socioeconomic status
D. Oral contraceptive pills
C. Environmental sanitation
D. School attendance C. Demonstrate proper technique once a year

85. According to IMCI steps, what is the first action a D. Lead participatory hand-washing sessions before
health worker should take upon examining a sick child lunch
under 5?
90. When a student is found with persistent wheezing
* during screening, the school nurse should:

1 point *

A. Provide first dose of antibiotic 1 point

B. Record immunization history A. Recommend daily exercise

C. Check for danger signs B. Send the student home immediately

D. Counsel on feeding practices C. Call the principal for disciplinary action

Situation: Nurse Elaine serves as the School Nurse D. Refer to a physician for follow-up evaluation
at Makabayan National High School. She conducts
Situation: Nurse Lydia has just been appointed as
periodic health appraisals (screenings), oversees
Supervising Public Health Nurse in her municipality.
the school feeding program, manages
To effectively run the Rural Health Unit, she applies
immunizations, delivers age-appropriate health
the five management functions—planning,
education, and ensures timely referrals for students
organizing, staffing, directing, and controlling—to
with identified health issues.
ensure delivery of quality community health
86. Which routine screening is most critical for early services.
detection of learning-related vision problems among
91. Which among the following contains the mission and
schoolchildren?
vision of an organization?
*
*
1 point
1 point
A. Dental caries check
A. Strategic Plan
B. Height and weight measurement
B. Nursing Care Plan
C. Blood pressure reading
C. Operational Plan
D. Snellen visual acuity test
D. Nursing Service Plan
87. As part of the school feeding program, the nurse
92. Which organizational principle stipulates that each
should prioritize monitoring for:
employee is accountable to—and takes direction from—
* only a single superior?

1 point *

A. Diabetes mellitus 1 point

B. Vitamin A toxicity A. Coordination

C. Iodine deficiency B. Unity of Command

D. Protein-energy undernutrition C. Span of Control

88. Which immunization is typically administered on- D. Authority and responsibility

campus to adolescents?
93. Under the Philippine government’s compensation
* framework, what salary grade is assigned to newly
appointed Staff Nurse I?
1 point
*
A. Bacille Calmette–Guérin (BCG)
1 point
B. Oral polio vaccine
A. SG 14
C. Measles–rubella (MR) vaccine
B. SG 15
D. Tetanus-diphtheria booster
C. SG 16
89. In delivering health education, the school nurse’s
best strategy to promote hand-washing among students D. SG 17
is to:
94. When Public Health Nurse Lydia supervises
* midwives during a community newborn immunization
clinic—ensuring each vaccine is administered correctly
1 point
and safely—which management function is she
A. Show a lecture on germ theory performing?

B. Distribute pamphlets for home use *

1 point
A. Planning B. New extrapulmonary TB cases

B. Organizing C. Patients who failed or relapsed after Category I

treatment
C. Staffing
D. All close household contacts of smear-positive cases
D. Directing
100. According to the National Tuberculosis Control
95. Which of the following is not one of the four
Program, which is the primary case-finding diagnostic
components of the control process in nursing
tool?
management?
*
*
1 point
1 point
A. Chest X-ray
A. Establishing performance standards
B. PPD skin test
B. Measuring actual performance
C. Direct Sputum Smear Microscopy (DSSM)
C. Staffing and scheduling
D. Clinical symptom screening only
D. Comparing actual performance against standards

Situation: Nurse Aileen coordinates the TB Control

Program at the Rural Health Unit. She implements
the DOTS strategy—ensuring political commitment,
case finding, standardized treatment, uninterrupted
drug supply, and systematic monitoring—while
supervising sputum collection, patient follow-up,
and contact tracing.

96. What does “DOTS” stand for in TB control?

1 point

A. Directly Observed Treatment Schedule

B. Drug-Oriented Tuberculosis Strategy

C. Directly Observed Treatment, Short-course

D. Direct Observation of Tubercle Symptoms

97. Under standard DOTS Category I, when is the first

follow-up sputum smear typically performed?

1 point

A. End of month 1

B. End of month 2

C. End of month 4
RECALLS 6 NP2
D. At treatment completion
Situation: Nurse Maria works in the Family Planning
98. Which of the following lists the standard first-line Clinic of the City Community Health Center. She
anti-tuberculosis drugs used in a DOTS regimen? provides contraceptive counseling to adolescents
and adults, fitting clients for barrier methods,
*
instructing on correct use and timing, interpreting
1 point home pregnancy tests, and explaining the hormonal
basis of early pregnancy detection.
A. Ciprofloxacin, Amikacin, Ethionamide
1. Which benefit of the cervical cap should the nurse
B. Amoxicillin, Clarithromycin, Levofloxacin emphasize when instructing a client about its use?
C. Rifabutin, Moxifloxacin, Linezolid A. It remains effective for up to 48 hours without
reapplication of spermicide
D. Isoniazid, Rifampicin, Pyrazinamide, Ethambutol
B. It can be purchased without a prescription and
99. Which patients are eligible for Category II DOTS re-
discarded after a single use
treatment?
C. It allows spermicide to be applied up to 2 hours
*
before intercourse
1 point
D. It virtually eliminates the risk of allergic reactions to its
A. New smear-negative pulmonary cases material
2. A male client demonstrates understanding of correct B. Improved access to family planning and skilled birth
condom use by stating: attendance

A. “I’ll lubricate the condom with oil to prevent tearing.” C. Greater investment in hospital infrastructure only

B. “I’ll unroll it completely and inspect it for holes before D. Promotion of natural methods of fertility regulation
use.”
9. What is a key gender-related barrier to reproductive
C. “I’ll hold the rim when withdrawing to prevent health care?
spillage.”
A. Lack of male nurses in clinics
D. “I’ll start intercourse without it and put it on just before
B. Strict age limits for service access
ejaculation.”
C. Women needing permission from partners to access
3. When teaching a client using a diaphragm for
services
contraception, the nurse should instruct her to:
D. Low literacy rates in men
A. Remove it within 1 hour after intercourse
10. Which of the following is identified as a critical
B. Leave it in place for at least 6 hours afterward
component of ensuring reproductive rights for
C. Keep it in place for up to 12 hours to maximize adolescents?
protection
A. Comprehensive sexuality education
D. Wear it continuously for 28 hours to reduce infection
B. Limiting media access
risk
C. Abstinence-only education
4. After a client reports a positive result on an at-home
pregnancy test, the nurse evaluates her understanding D. Delaying access to contraceptives until age 18
when she says:
Situation: Nurse Carla is assigned to the community
A. “So I must have ovulated within the last 24 hours.” health center and manages maternal and child
health (MCH) services. She organizes prenatal
B. “A positive test means I am definitely not pregnant.”
checkups, supervises midwives during deliveries,
C. “It tells me there’s growing trophoblastic tissue, but I leads breastfeeding promotion campaigns, monitors
might still need confirmation.” child growth, and ensures immunizations are
delivered according to schedule.
D. “It confirms that I am pregnant right now.”
11. Which of the following best reflects Nurse Carla’s
5. The nurse explains that at-home pregnancy tests work
role when she ensures all infants are immunized
by detecting which hormone in the client’s urine?
according to schedule?
A. Human chorionic gonadotropin (hCG)
A. Planning
B. Estrogen
B. Controlling
C. Follicle-stimulating hormone (FSH)
C. Directing
D. Progesterone
D. Organizing
Situation: Reproductive health (RH) encompasses
12. When Nurse Carla arranges staff assignments so
the responsible exercise of reproductive rights,
that all pregnant women are seen during clinic hours,
aiming to prevent illness and injury related to
which management function is being carried out?
sexuality and reproduction.
A. Organizing
6. Which of the following is not one of the stated goals of
reproductive health? B. Planning

A. Ensuring every pregnancy is planned C. Staffing

B. Promoting healthy maternal and neonatal outcomes D. Directing

C. Mandating artificial contraceptive use for all married 13. Which of the following actions by Nurse Carla
couples demonstrates planning?

D. Helping families achieve their desired size A. Reassigning midwives to fill in staff shortages

7. Globally, the international reproductive health B. Conducting a post-immunization follow-up

framework places primary emphasis on:
C. Setting objectives for next month’s breastfeeding
A. Population groups aged over 40 campaign

B. Maternal and women’s health across the lifespan D. Supervising vaccine administration during outreach

C. Displaced persons with RH problems 14. Which indicator best evaluates the effectiveness of
the child growth monitoring program?
D. Infertile couples
A. Number of staff attending trainings
8. Which of the following is emphasized as essential for
reducing maternal mortality? B. Percentage of children within the normal weight-for-
age range
A. Legalization of abortion alone
C. Amount of supplies purchased A. Coordination

D. Frequency of immunization sessions conducted B. Span of control

15. Which principle of organization is observed when C. Authority and responsibility

Nurse Carla gives midwives clear instructions and
D. Unity of command
maintains accountability for overall results?
Situation: Nurse Martha is assigned to the Maternal
A. Span of control
and Child Health (MCH) unit of the Rural Health Unit.
B. Authority and responsibility She conducts prenatal check-ups, provides nutrition
counseling to pregnant mothers, supervises
C. Unity of command
deliveries conducted by midwives, and promotes
D. Coordination exclusive breastfeeding. She also facilitates
newborn screening and postpartum home visits to
Situation: Nurse Angela is the Public Health Nurse ensure maternal and neonatal well-being.
assigned to a coastal barangay. She is in charge of
implementing the Environmental Sanitation 21. During a prenatal outreach session, Nurse Martha
Program, which includes water safety inspections, supervises community health workers as they educate
waste management education, and coordination with expectant mothers on recognizing early signs of
barangay officials for community clean-up drives. pregnancy complications. Which management function
She also supervises sanitary inspectors, responds is she performing?
to disease outbreaks, and promotes proper food
A. Controlling
handling in households and food establishments.
B. Directing
16. When Nurse Angela sets specific goals for reducing
cases of diarrhea in her barangay over the next three C. Organizing
months, which management function is she performing?
D. Planning
A. Directing
22. Which of the following indicators best measures the
B. Organizing effectiveness of the post-partum home visit program?

C. Planning A. Percentage of mothers exclusively breastfeeding at 6

weeks post-partum
D. Controlling
B. Number of home visits conducted by Nurse Martha
17. Which action of Nurse Angela demonstrates
directing? C. Number of midwives trained in breastfeeding
counseling
A. Assigning sanitary inspectors to different sitios
D. Amount of iron supplements distributed
B. Preparing a list of households needing safe water
containers 23. Nurse Martha schedules midwives so that at least
one staff member is available for 24-hour delivery care
C. Evaluating waste disposal practices after a clean-up
at the birthing station. Which management function does
drive
this represent?
D. Supervising sanitary inspectors during water sampling
A. Controlling
18. What would be the best process indicator to assess
B. Planning
the success of the waste management education
program? C. Organizing

A. Decrease in reported cases of leptospirosis D. Staffing

B. Number of households attending waste segregation 24. When Nurse Martha sets a target to reduce cases of
sessions post-partum hemorrhage by 20% in the next six months,
which function is she demonstrating?
C. Percentage of households with proper composting
bins A. Directing

D. Reduction in uncollected garbage in public areas B. Planning

19. When Nurse Angela evaluates the quality of food C. Controlling

handling in local eateries to ensure compliance with
D. Staffing
sanitary standards, which function of management is
being exercised? 25. Nurse Martha notices that a midwife is not following
the prescribed infection-control protocol during
A. Planning
deliveries. Which action reflects the controlling function?
B. Controlling
A. Asking the midwife to explain her practice
C. Staffing
B. Correcting the procedure and reinforcing the proper
D. Directing standard

20. Which principle of organization is Nurse Angela C. Allowing the midwife to continue as she is
observing when she makes sure sanitary inspectors
D. Reassigning the midwife to post-partum care only
report directly to her and not to barangay officials during
the program?
Situation: Nurse Mariel is assigned to a busy labor C. Place the baby under a radiant warmer
and delivery unit. She is caring for several clients in
D. Notify the pediatrician
different stages of pregnancy and the postpartum
period. During her shift, she must accurately assess 32. A mother asks why the nurse applies antibiotic
maternal conditions, anticipate complications, and ointment to the newborn’s eyes after birth. Which
provide evidence-based nursing interventions for explanation is most accurate?
both mother and baby.
A. To prevent irritation from the birth canal
26. When preparing to perform Leopold’s maneuvers on
a laboring client, which action should Nurse Mariel take B. To prevent gonococcal and chlamydial infections
first?
C. To remove meconium-stained secretions
A. Position the client in a supine position
D. To improve visual acuity
B. Have the client void
33. Which assessment finding in a newborn requires
C. Wash her hands in warm water immediate intervention?

D. Apply sterile lubricant to the abdomen A. Irregular respirations at 40 breaths per minute

27. One hour after delivery, Mariel notes the mother’s B. Acrocyanosis of the hands and feet
uterus is one fingerbreadth below the umbilicus and
C. Axillary temperature of 35.5°C (95.9°F)
shifted to the right. What should be her priority action?
D. Flexed posture
A. Assist the mother to void
34. While teaching a mother about umbilical cord care,
B. Vigorously massage the fundus
which statement by the mother indicates understanding?
C. Administer oxytocin
A. “I’ll keep the cord covered with a clean diaper at all
D. Give a tocolytic intravenously times.”

28. During the second stage of labor, which clinical B. “I’ll clean the cord and keep it dry.”
finding indicates that the fetus is about to be delivered?
C. “I’ll apply powder on the cord to absorb moisture.”
A. Engagement
D. “I’ll remove the cord clamp myself after it dries.”
B. Crowning
35. On the second postpartum day, Clarisse notices a
C. Placental separation mother’s breasts are firm, warm, and slightly tender.
What should she recommend?
D. Full cervical dilation
A. Stop breastfeeding until the discomfort resolves
29. A client in labor has contractions every 5 minutes for
7 hours. Which finding will confirm that she is in true B. Apply cold compresses and bind the breasts
labor?
C. Continue breastfeeding frequently to relieve
A. Cervical effacement and dilation engorgement

B. Increasing contraction intensity D. Avoid fluid intake until the breasts soften

C. Rupture of membranes Situation: Nurse Janine is assigned to the high-risk

pregnancy unit. She is caring for mothers with
D. The fact that this is her second pregnancy conditions such as pre-eclampsia, gestational
diabetes, and preterm labor. She must prioritize
30. While assessing a laboring client, Mariel observes a
maternal and fetal safety through careful monitoring
loop of the umbilical cord protruding from the vagina.
and timely interventions.
What should she do immediately?
36. A client at 32 weeks of gestation with pre-eclampsia
A. Call the physician
reports a severe headache and blurred vision. What
B. Place a moist, sterile towel over the cord should Janine do first?

C. Turn the client on her side and listen to fetal heart rate A. Check the client’s reflexes

D. Apply upward pressure on the presenting part and B. Place the client on left lateral position and assess
place the mother in a knee-chest position blood pressure

Situation: Nurse Clarisse is assigned to the newborn C. Administer an analgesic

nursery and postpartum unit. She is responsible for
D. Prepare for immediate delivery
assessing newly delivered infants, ensuring
thermoregulation, teaching mothers proper newborn 37. A woman with gestational diabetes asks why her
care, and recognizing early signs of complications in blood glucose must be tightly controlled during
both mother and baby. pregnancy. Which is the best response?
31. Clarisse observes that a newborn is jittery and has a A. “It prevents hypoglycemia during labor.”
weak cry. Which of the following should be her first
action? B. “It ensures your baby will not be overweight at birth.”

A. Assess the baby’s blood glucose level C. “It will prevent you from developing type 2 diabetes
later on.”
B. Feed the baby immediately
D. “It helps avoid respiratory distress syndrome in your C. Every month
baby.”
D. Only if she feels contractions
38. Which finding in a 30-week gestation client on
44. A teenage mother asks about the lactational
magnesium sulfate for preterm labor requires immediate
amenorrhea method (LAM) for family planning. Which
intervention?
condition must be met for this method to be effective?
A. Deep tendon reflexes are 2+
A. The infant is less than 6 months old and
B. Fetal heart rate is 140 bpm breastfeeding is exclusive

C. Urine output is 50 mL/hour B. She is supplementing with formula every 4 hours

D. Respiratory rate is 10 breaths per minute C. Her menstrual periods have resumed

39. Which statement by a pregnant woman receiving D. The infant is already taking solid foods
corticosteroids for fetal lung maturity indicates the need
45. During a home visit, Elena notices the umbilical
for further teaching?
stump of a newborn is red and foul-smelling. What is the
A. “This medication will help my baby’s lungs develop nurse’s priority action?
faster.”
A. Apply alcohol to the stump
B. “I might need additional doses if I don’t deliver soon.”
B. Refer the infant immediately for medical evaluation
C. “I should expect the medication to stop my
C. Teach the mother proper cord care
contractions.”
D. Schedule a follow-up visit in 2 days
D. “It is given to reduce the risk of respiratory problems
in my baby.” Situation: Nurse Sofia is working in the neonatal
intensive care unit (NICU). She is caring for preterm
40. Janine notes clonus when assessing a client with
and low-birth-weight infants who require specialized
preeclampsia. This finding suggests which complication
monitoring, thermoregulation, and nutritional
is likely to develop?
support. She must also teach parents how to care
A. Preterm labor for their fragile newborns.

B. Respiratory depression 46. Sofia is caring for a preterm infant who is placed in
an incubator. Which assessment finding indicates the
C. Eclampsia
infant is maintaining adequate thermoregulation?
D. Placenta previa
A. Axillary temperature of 35.5°C (95.9°F)
Situation: Nurse Elena is assigned to the community
B. Crying continuously
health clinic where she provides prenatal education
and follow-up for adolescent mothers. She also C. Mottled skin and increased irritability
organizes immunization drives and teaches family
D. Pink skin and relaxed posture
planning methods to promote maternal and child
health in the community. 47. Which intervention should Sofia implement to reduce
the risk of necrotizing enterocolitis (NEC) in a preterm
41. During a prenatal class, Elena is asked why iron
infant?
supplementation is important in pregnancy. Which is the
best response? A. Administer high-volume formula feedings early
A. “It helps prevent constipation during pregnancy.” B. Delay feedings until the infant gains weight
B. “It ensures proper fetal lung development.” C. Encourage breastfeeding and give small, frequent
feeds
C. “It prevents maternal anemia and supports fetal
growth.” D. Use hypertonic solutions to stimulate bowel motility
D. “It prevents premature rupture of membranes.” 48. A very-low-birth-weight infant suddenly develops
abdominal distention, bloody stools, and lethargy. What
42. While reviewing the vaccination record of a 6-week-
is Sofia’s priority action?
old infant, Elena notes that the child has not received the
BCG vaccine. What should she do? A. Continue feedings to maintain nutrition
A. Refer the child for catch-up immunization B. Notify the physician immediately
B. Wait until the infant is 6 months old C. Place the infant in a prone position
C. Administer vitamin A supplementation instead D. Massage the abdomen to relieve gas
D. Begin the DPT series first before giving BCG 49. Which statement by parents of a NICU infant
indicates correct understanding of kangaroo (skin-to-
43. A 16-year-old pregnant client asks how often she
skin) care?
should visit the clinic for prenatal checkups in the first 28
weeks of pregnancy. What should Elena advise? A. “We should only do this after our baby is discharged
from the NICU.”
A. Every week
B. “We’ll place our baby upright on our bare chest for at
B. Every 2 weeks
least 1 hour daily.”
C. “We should wrap the baby in multiple blankets first.” B. Place the client in Trendelenburg position

D. “We’ll wait until our baby is full-term to begin C. Give oral fluids
kangaroo care.”
D. Reassure the client that anxiety is common
50. A preterm infant in the NICU is receiving oxygen postpartum
therapy. Which finding should alert Sofia to possible
Situation: Nurse Hannah is assigned to the
oxygen toxicity?
outpatient lactation clinic. She supports mothers
A. Peripheral cyanosis experiencing breastfeeding difficulties such as
nipple trauma, engorgement, mastitis, and concerns
B. Retinopathy of prematurity (ROP) changes in the
about milk supply. She also educates parents on the
eyes
benefits of exclusive breastfeeding and proper
C. Slight nasal flaring latching techniques.

D. Periodic breathing patterns 56. A breastfeeding mother reports cracked nipples and
pain during feeds. Which instruction from Hannah is
Situation: Nurse Veronica is working in the most appropriate?
postpartum unit. She is caring for mothers at risk of
complications such as hemorrhage, infection, and A. Stop breastfeeding until the nipples heal
thromboembolic disorders. She must assess
B. Apply soap and water after every feeding
mothers closely, intervene promptly, and provide
discharge education on danger signs. C. Switch to bottle-feeding permanently

51. Veronica notes a postpartum client with a saturated D. Ensure proper latch and position the baby correctly
perineal pad in 30 minutes and a boggy uterus. What is
57. Hannah teaches a mother how to prevent breast
her priority action?
engorgement. Which statement indicates
A. Call the physician immediately understanding?

B. Start IV fluids A. “I should feed my baby every 2–3 hours on demand.”

C. Perform fundal massage B. “I should avoid breastfeeding at night to let my

breasts rest.”
D. Administer analgesics
C. “I’ll use tight breast binders after each feeding.”
52. A postpartum woman complains of severe perineal
pain and pressure but has minimal visible bleeding. D. “I should only feed from one breast each time.”
Which complication does Veronica suspect?
58. A mother presents with fever, breast redness, and
A. Uterine atony pain. Which nursing action is most appropriate?

B. Vaginal hematoma A. Discontinue breastfeeding until symptoms resolve

C. Endometritis B. Continue breastfeeding and start prescribed

antibiotics
D. Subinvolution
C. Massage the affected breast vigorously
53. Veronica is teaching a mother at discharge about
warning signs of postpartum infection. Which statement D. Apply ice continuously for 24 hours
indicates the teaching was effective?
59. Which practice supports adequate milk supply in a
A. “I will call if I have light vaginal bleeding.” breastfeeding mother?

B. “A slight fever in the first 24 hours is normal, so I won’t A. Supplementing with formula after every feeding
worry.”
B. Increasing breastfeeding frequency and duration
C. “If I notice foul-smelling lochia, I will contact my
C. Limiting fluid intake to reduce engorgement
healthcare provider.”
D. Offering both breasts only every 6 hours
D. “I don’t need to monitor my temperature at home.”
60. A mother asks about storing expressed breast milk.
54. Which postpartum client is at the greatest risk for
Which teaching is correct?
developing a deep vein thrombosis (DVT)?
A. “It can be kept at room temperature for up to 24
A. A mother who ambulates 12 hours after delivery
hours.”
B. A mother with a cesarean birth, obesity, and varicose
B. “I should microwave breast milk before feeding.”
veins
C. “I can refreeze milk once thawed.”
C. A multipara who delivered vaginally without
lacerations D. “Refrigerated breast milk is safe for up to 4 days.”
D. A mother who is exclusively breastfeeding Situation: Nurse Rafael is working in a busy medical-
surgical ward. He is responsible for medication
55. A mother reports sudden shortness of breath and
administration, infection control, patient mobility,
chest pain 4 days postpartum. What should Veronica do
and preparing patients for diagnostic procedures.
first?
He must prioritize safe and effective nursing
A. Apply oxygen and notify the physician interventions while preventing complications.
61. Rafael enters a patient’s room and finds a small fire C. Having different nurses care for the child each shift
in the trash can. What should be his first action?
D. Postponing all schooling until discharge
A. Get the fire extinguisher and put out the fire
68. When preparing to physically assess a sleeping 8-
B. Activate the fire alarm and call for help month-old infant, what should Allan do first?

C. Rescue any people in the room, starting with the least A. Auscultate the heart and lungs
mobile
B. Measure head circumference
D. Close all doors and windows
C. Check for the red reflex in the eyes
62. Before starting a peripheral IV infusion, which action
D. Wake the baby before starting
by Rafael is most important?
69. A hospitalized preschooler believes her illness is a
A. Apply a tourniquet below the chosen vein
punishment for being “bad.” Which developmental
B. Inspect the IV solution for particles or contamination concept explains this belief?

C. Secure the client’s arm to prevent movement A. Identity vs. role confusion

D. Place a cool compress over the vein B. Autonomy vs. shame and doubt

63. When admitting a bedridden patient, how can Rafael C. Initiative vs. guilt
best prevent external rotation of the patient’s legs?
D. Trust vs. mistrust
A. Place a pillow under the knees
70. Allan is giving anticipatory guidance to the parents of
B. Flex the hips and knees with a blanket roll a 3-year-old. Which instruction is most important for
preventing accidental poisoning?
C. Place a pillow under the lower legs
A. Store syrup of ipecac at home and keep poisons
D. Use a trochanter roll alongside the thighs
locked away
64. Which nursing action is most appropriate after
B. Place the child in a rear-facing car seat at all times
discovering a medication error?
C. Begin formal drug and alcohol education
A. Complete an incident report
D. Teach the child to use sports equipment properly
B. Notify the physician
Situation: Nurse Paolo is caring for children
C. Check the patient’s condition for adverse effects
recovering from various medical conditions in the
D. Document the error on the medication sheet pediatric ward. He provides pain management,
assists with procedures, and supports the emotional
65. Rafael is teaching a patient how to self-administer needs of both patients and their families during
oral medications at home. Which approach ensures the hospitalization.
patient’s understanding?
71. A 4-year-old child is scheduled for a minor surgical
A. Give the patient written instructions procedure. Which intervention will best reduce the child’s
anxiety before the procedure?
B. Demonstrate the correct technique
A. Allow the child to observe the operating room
C. Ask the patient to verbalize and demonstrate the
procedure B. Explain the procedure using age-appropriate words
and play
D. Schedule daily phone reminders
C. Let the child watch a video of the surgery
Situation: Nurse Allan is assigned to the pediatric
ward. He is caring for children of various ages who D. Provide detailed written instructions for the parents
require safety interventions, growth monitoring, and only
support during hospital stays. He also provides
anticipatory guidance to parents about child 72. Paolo is caring for a 10-year-old post-appendectomy
development and accident prevention. patient who rates their pain as 7/10. Which is the most
appropriate action?
66. While conducting discharge teaching for the mother
of a 1-month-old infant, which safety instruction is most A. Encourage deep breathing and relaxation only
appropriate?
B. Explain that pain is expected and will go away
A. Cover electrical outlets at home
C. Distract the child with games instead of medication
B. Remove hazardous objects from low areas
D. Administer the prescribed analgesic and reassess
C. Lock all cabinets containing cleaning supplies
73. A toddler with pneumonia is prescribed IV antibiotics.
D. Avoid shaking or vigorously jiggling the baby’s head Before administration, which step is Paolo’s priority?

67. Allan admits a child who will be hospitalized for more A. Verify the child’s allergies
than a week. Which approach best reduces stress and
B. Ask the parents if the child is hungry
promotes consistency of care?
C. Allow the toddler to choose the injection site
A. Allowing open peer visitation
D. Encourage the child to drink fluids
B. Assigning a primary nurse
74. Paolo notices that a school-age child is withdrawn 80. Which comfort measure provided by Bianca during
and refuses to participate in group activities. Which the first stage of labor promotes relaxation and
nursing action is most appropriate? decreases pain perception?

A. Force the child to join group play to encourage A. Offering ice chips frequently
socialization
B. Applying firm fundal pressure during contractions
B. Allow the child to stay alone until they feel ready
C. Encouraging ambulation and upright positions
C. Engage the child in one-on-one activities to build trust
D. Allowing the patient to hold her breath during
D. Ask the parents to stay in the hospital at all times contractions

75. Paolo teaches parents of a hospitalized toddler Situation: Nurse Celine is assigned as the charge
about separation anxiety. Which statement shows they nurse in the labor and delivery unit. Aside from
understand? monitoring clients, she is also tasked with
overseeing a small nursing research project on pain
A. “Our child may seem unconcerned when we leave but
management methods during labor. She must
will miss us later.”
ensure patient safety, uphold research ethics, and
B. “Separation anxiety usually begins in the school-age provide evidence-based interventions to mothers in
years.” different stages of labor.

C. “Our child will be fine as long as the nurses give 81. While assisting in the research project, a laboring
attention.” client expresses that she does not want to participate.
What should Celine do?
D. “We should avoid visiting too often to reduce stress.”
A. Encourage her to participate since the project is
Situation: Nurse Bianca is working in the labor and beneficial
delivery unit. She is responsible for monitoring labor
progress, providing comfort measures, assisting in B. Explain that refusal may delay her care
delivery, and intervening promptly when
C. Respect her decision and withdraw her from the study
complications arise.
D. Request the physician to convince her to continue
76. Bianca is monitoring a client in active labor. Which
finding requires immediate intervention? 82. One of Celine’s clients in active labor shows variable
decelerations on the fetal heart monitor. Which initial
A. Contractions lasting 60 seconds every 3 minutes
action is most appropriate?
B. Fetal heart rate of 110–160 bpm
A. Position the mother on her side
C. Fetal heart rate decelerations that mirror contractions
B. Increase the oxytocin infusion
D. Persistent late decelerations after contractions
C. Prepare for immediate delivery
77. A client’s membranes rupture spontaneously during
D. Apply firm fundal pressure
labor. What is Bianca’s priority action?
83. In planning the nursing research project, which factor
A. Document the time and characteristics of the fluid
must Celine prioritize?
B. Assess the fetal heart rate
A. The availability of physician approval
C. Prepare the client for delivery
B. Adequate funding for supplies
D. Ask the client if she feels an urge to push
C. Ensuring informed consent and confidentiality
78. A laboring client is requesting pain relief and is 8 cm
D. The number of nurses available to collect data
dilated. Which analgesic approach is most appropriate at
this stage? 84. A client at 9 cm dilation requests pain relief. Which
intervention is safest at this stage?
A. Administer systemic opioids immediately
A. Administer systemic narcotics
B. Prepare for a pudendal block
B. Prepare for a pudendal nerve block
C. Offer general anesthesia
C. Apply continuous epidural anesthesia
D. Delay all pain medication until full dilation
D. Offer general anesthesia
79. Bianca is caring for a client on oxytocin infusion.
Which assessment finding requires the infusion to be 85. Celine is documenting the research process. Which
discontinued? activity reflects the analysis phase of research?

A. Contractions every 2–3 minutes lasting 60 seconds A. Writing the research proposal

B. Uterine resting tone of 20 mmHg B. Collecting pain scores from participants

C. Fetal heart rate of 140 bpm C. Presenting findings at a staff meeting

D. Contractions lasting longer than 90 seconds without D. Using statistics to interpret the pain scores
adequate rest
Situation: Nurse Janelle is working in the pediatric
ward caring for children with varying medical and
surgical conditions. She must ensure safe nursing
care, follow legal and ethical principles, and respect C. Hold the pinna gently but firmly in its normal position
parental rights while managing the needs of her
D. Hold the pinna against the skull
patients.
92. When assessing a 4-year-old child with a persistent
86. A 5-year-old is scheduled for an appendectomy, but
cough, the nurse would assess respirations by observing
Janelle notices that the consent form is unsigned. What
which muscle group?
should she do first?
A. Thoracic
A. Ask the parents to quickly sign the consent form
B. Intercostal
B. Proceed with preparing the child for surgery
C. Accessory
C. Notify the surgeon that the consent form is not signed
D. Abdominal
D. Have a nurse manager sign on behalf of the parents
93. The nurse who is examining a child understands that
87. A child’s cousin, who is a physician, asks Janelle to
visual acuity of 20/20 as measured by the Snellen chart
see the patient’s chart. What should Janelle do?
is reached by age:
A. Allow the cousin to review the chart privately
A. 2 years
B. Ask the cousin to wait until the parents arrive
B. 4 years
C. Request the attending physician’s permission
C. 6 years
D. Obtain parental authorization and supervise chart
D. 8 years
review
94. A 1-year-old male child is scheduled for a routine
88. The parents of a hospitalized child decide to
exam at the pediatric clinic. The child's birth weight was
discharge the patient against medical advice (AMA).
8 lbs. 2 oz. The child now weighs 18 lbs. 4 oz. The nurse
Which document must they sign?
knows that this weight is:
A. Hospital discharge summary
A. Below the expected weight
B. An AMA form releasing the hospital and physician
B. Appropriate for the child's age
from liability
C. Above the expected weight
C. A consent form for discontinuation of care
D. Individualized and thus unpredictable
D. A general waiver of treatment
95. At what age is it appropriate to change the sequence
89. Janelle is informed by the parents that their child has
of the examination of the child from that of chest and
a living will be prepared two years ago. What should she
thorax first to head-to-toe?
advise?
A. Infant
A. “It is still valid and does not need review.”
B. Toddler
B. “You should review it annually with your physician.”
C. Preschool child
C. “You need to consult your lawyer about this.”
D. School-age child
D. “We cannot use living wills in pediatric cases.”
Situation: Nurse Alyssa is on duty in a pediatric
90. A nurse observes that a colleague may be misusing
ward. She is responsible for ensuring children
narcotics. What is the best action?
receive safe care.
A. Report the colleague immediately to the nursing
96. What is the most important sign of readiness to
board
watch for when toilet training the child?
B. Review medication records and report to the nurse
A. Ability to walk
supervisor
B. Able to indicate that the diaper is wet
C. Avoid assigning the colleague to patients receiving
narcotics C. Physical and psychological readiness
D. Confront the colleague directly about the suspicion D. Exhibits willingness to please parents
Situation: Nurse Marin is assigned to the pediatric 97. The mother of a 12-month-old infant who is
outpatient clinic, where she routinely performs hospitalized is upset that she must leave her baby to go
physical assessments, growth monitoring, and home for a short time. What should the nurse suggest to
developmental screenings for children at various this concerned parent?
stages. Her responsibilities include using
appropriate techniques during examinations, A. Return as soon as possible to attend to her daughter's
evaluating physical findings, and providing needs.
anticipatory guidance based on age-specific norms.
B. Leave a personal article with the child and reassure
91. When using the otoscope to examine the ears of a 2- her that she will return.
year-old child, the nurse should:
C. Call a family relative to stay at all times with the child
A. Pull the pinna up and back when the mother leaves.

B. Pull the pinna down and back

D. Ask a nurse to sit at the child's bedside in her
absence.

98. Piaget identifies that the 2- to 7-year-old child is in

the preoperational stage. During assessment, the nurse
observes a toddler take a toy from another child. The
nurse recognizes that this behavior, showing the child is
unable to put themselves in another’s place, is best
described as:

A. Centration

B. Negativism

C. Egocentrism

D. Selfishness

99. The mother discusses with the nurse that her toddler
asks every night for a bedtime story. The mother asks
why the child does this. The nurse would explain that
this behavior demonstrates:

A. Ritualism

B. Object permanence

C. Dependency

D. Conservation

100. A teenager refuses to wear the clothes his mother

bought for him. He states he wants to look like the other
kids at school and wear clothes like they wear. The
nurse explains this behavior is an example of teenage
rebellion related to internal conflicts of:

A. Autonomy vs. shame and doubt

B. Trust vs. mistrust

C. Identity vs. role confusion

D. Initiative vs. inferiority

RECALLS 6 NP3
Situation: Nurse Greg is working on a busy surgical
floor. He is responsible for caring for patients pre-
and post-operatively, maintaining sterile technique,
and ensuring early detection of complications such
as infections, pressure ulcers, or thromboembolism.

1. Greg notices that a patient scheduled for surgery has

a temperature of 102°F (38.9°C) but appears otherwise
stable. What is Greg’s first action?

A. Notify the surgeon

B. Notify the charge nurse

C. Validate the temperature reading

D. Document the temperature in the chart

2. While performing a sterile dressing change, which

action by Greg would break sterile technique?

A. Opening the first flap of a sterile package away from

himself

B. Keeping his hands above his waist

C. Turning his back to the sterile field

D. Adding sterile items by dropping them onto the field

3. Greg is transferring a post-stroke patient with right-

sided weakness from the bed to a wheelchair. Which
positioning is best?
A. Place the wheelchair parallel and close to the bed B. “I will take one tablet every 5 minutes up to 3 doses if
chest pain continues.”
B. Position the wheelchair on the patient’s weaker side
C. “I will store the tablets in the refrigerator for
C. Keep the wheelchair one foot away from the bed
freshness.”
D. Lock the bed but not the wheelchair
D. “I can take as many tablets as needed until pain is
4. A patient recently transferred to Greg’s unit is unable gone.”
to ambulate. Which factor places this patient at greatest
10. A patient with heart failure is being discharged.
risk for pressure ulcer development?
Which teaching by Darryl is most important?
A. Limited mobility and need for assistance to move from
A. “You should weigh yourself daily at the same time.”
bed to chair
B. “Avoid eating any foods that contain sodium.”
B. Eating only half of most meals
C. “You can skip diuretics on days you feel well.”
C. Mild apathy but oriented to time and place
D. “Check your blood pressure only if you feel dizzy.”
D. Good skin turgor and normal capillary refill
Situation: Nurse Fiona is caring for patients on a
5. Greg is opening a sterile package from central supply.
respiratory care unit. She is responsible for
Which direction should the first flap be opened?
managing clients with chronic respiratory
A. Toward himself conditions, maintaining oxygen therapy safety, and
recognizing early complications of airway problems
B. Away from himself or infections.
C. To the left or right 11. Fiona is caring for a client with a new tracheostomy
tube. After cleaning the reusable inner cannula, what
D. It does not matter
should she do before reinsertion?
Situation: Nurse Darryl is caring for patients with
A. Dry it thoroughly with sterile gauze
cardiovascular conditions in a telemetry unit. He
must recognize early warning signs of B. Suction the client’s airway
complications, manage medications, and provide
accurate patient education before discharge. C. Tap the cannula gently against a sterile surface

6. A patient with a recent myocardial infarction is D. Rinse it with sterile saline

admitted with chest pain and diaphoresis. What is
12. Fiona is preparing to initiate continuous IV therapy.
Darryl’s first action?
What is the most important step before venipuncture?
A. Order an ECG
A. Apply a tourniquet below the selected vein
B. Administer prescribed morphine sulfate
B. Inspect the IV solution for particles or contamination
C. Start an IV line
C. Place a cool compress over the vein
D. Measure vital signs
D. Secure the client’s arm with a splint
7. A patient is discharged after a myocardial infarction
13. A patient on the unit with tuberculosis needs a chest
and asks why metoprolol (Lopressor) was prescribed.
X-ray. Which action by Fiona is most appropriate when
What is Darryl’s best explanation?
preparing for transport?
A. “It increases your heart rate so the heart pumps more
A. Notify radiology so personnel can wear masks
effectively.”
B. Apply a mask to the client
B. “It dilates your coronary arteries to improve blood
flow.” C. Gown and mask the client

C. “It makes your heart contract stronger to increase D. Use a full isolation transport team
blood supply.”
14. During assessment, Fiona notes a pulsating mass in
D. “It slows your heart rate and decreases the workload a client’s periumbilical area. Which action is most
so your heart can heal.” appropriate?

8. A heart failure patient is prescribed digoxin and *

furosemide. Which meal would Darryl recommend?
1 point
A. Grilled chicken, baked potato, and cantaloupe
A. Palpate the mass for size and tenderness
B. Eggs and ham
B. Auscultate the mass for a bruit
C. Grilled cheese sandwich and French fries
C. Measure its length with a tape measure
D. Pepperoni pizza
D. Percuss the abdomen
9. A patient is taught how to take sublingual nitroglycerin
15. A post-operative client suddenly becomes
for angina. Which statement shows correct
profoundly short of breath and gray in color. Which
understanding?
earlier assessment finding would have been the first sign
A. “I can swallow the tablet if it burns my tongue.” of deterioration? *
1 point *

A. Temperature 100.4°F (38°C) 1 point

B. Respiratory rate of 26/min A. Recent weight loss

C. Heart rate of 110 bpm B. Worsening indigestion after meals

D. Blood pressure of 120/70 mmHg C. Awakening at night with epigastric pain

Situation: Nurse Lara is assigned to the D. Frequent episodes of vomiting

gastrointestinal surgical ward. She is caring for
Situation: Nurse Ramon is caring for patients with
patients undergoing diagnostic procedures and
renal and urologic conditions. His role includes
recovering from abdominal surgeries. Her
monitoring fluid balance, preventing complications
responsibilities include providing pre- and post-
of altered renal function, and teaching clients about
operative teaching, preventing complications, and
dietary and medication adherence.
ensuring patients follow dietary modifications.
21. A client with altered renal function is being
16. Lara is preparing a patient for a barium swallow
managed at home. Which assessment provides the most
and gastroduodenoscopy. Which instruction should she
accurate indicator of fluid balance? *
give? *
1 point
1 point
A. Measuring intake and output
A. “You’ll need to eat a low-residue diet the day before
B. Assessing mucous membrane moisture
and be NPO for 6–12 hours before the test.”
C. Checking skin turgor
B. “You’ll be NPO for 24 hours after the test to ensure
you can D. Monitoring daily weight
tolerate food.” 22. A client with chronic kidney disease is prescribed a
low sodium diet. Which food selection shows the client
C. “You’ll have a nasogastric tube for 24 hours after the
understands the instructions? *
test for
1 point
drainage.”
A. Canned vegetable soup
D. “You’ll be placed under general anesthesia and
recover in the OR.” B. Fresh apple slices
17. A client recovering from gastrectomy asks Lara how C. Processed cheese
to prevent dumping syndrome. Which advice is most
appropriate? * D. Pickled cucumbers

1 point 23. Ramon is caring for a client with a new

arteriovenous (AV) fistula for hemodialysis. Which
A. “You should eat 5–6 small meals a day indefinitely.” nursing action is appropriate? *
B. “Limit fluids during meals and for 1 hour afterward.” 1 point
C. “Increase your carbohydrate and salt intake.” A. Draw blood samples from the fistula arm
D. “Increase activity for 1 hour after meals to help B. Apply a blood pressure cuff to the fistula arm
digestion.”
C. Assess for a bruit and thrill over the fistula daily
18. In the recovery room, a patient who underwent
gastric resection complains of nausea. What is Lara’s D. Use the arm for routine IV infusions
priority action? *
24. A patient with renal calculi is encouraged to
1 point increase fluid intake. What is the goal of this
intervention? *
A. Check the patency of the nasogastric tube
1 point
B. Administer an antiemetic as ordered
A. Dilute urine and reduce stone formation
C. Place the patient in semi-Fowler’s position
B. Flush out electrolytes
D. Provide a narcotic analgesic for pain
C. Decrease protein metabolism
19. Which diagnostic test confirms pyloric stenosis?*
D. Promote blood pressure control
1 point
25. A client with end-stage renal disease reports itchy,
A. Flat plate of the abdomen dry skin. Which nursing measure is most appropriate? *
B. Colonoscopy 1 point
C. Electrolyte levels A. Restrict fluids further
D. Upper GI series B. Bathe the client twice daily using hot water
20. A client with a duodenal ulcer is admitted. Which C. Apply emollient lotion after bathing
symptom does Lara expect to find?
D. Avoid all forms of soap Situation: Nurse Maricel is assigned to the
neurology unit. She cares for clients recovering from
Situation: Nurse Andrea is assigned to the
head injuries, strokes, and spinal cord injuries. She
endocrine unit where she cares for patients with
must monitor for complications, ensure proper
hormonal disorders. She provides pre-operative and
positioning, and teach families how to assist with
post operative teaching, monitors for complications,
daily care.
and offers lifestyle counseling for patients with
chronic endocrine conditions. 31. Maricel is transferring a client with a possible spinal
injury from a stretcher to a bed. Which technique is
26. Andrea is caring for a client diagnosed with
best?
hypopituitarism. Which assessment finding should she
expect? * *

1 point 1 point

A. Increased blood pressure A. Move the client segmentally in small parts

B. Truncal obesity B. Logroll the client with assistance

C. Increased cardiac output C. Use a draw sheet and lift from behind the shoulders

D. Hyperactivity and increased energy levels D. Sit the client up and transfer slowly

27. A client recovering from a hypophysectomy reports 32. A stroke patient with right-sided hemiparesis needs
clear nasal drainage. What is Andrea’s initial action? * to transfer from bed to wheelchair. Which is the safest
approach?
1 point
*
A. Notify the surgeon immediately
1 point
B. Encourage the client to blow their nose
A. Move the client segmentally in small parts
C. Test the drainage for glucose
B. Logroll the client with assistance
D. Place the client in Trendelenburg position
C. Use a draw sheet and lift from behind the shoulders
28. After a hypophysectomy, Andrea teaches the client to
monitor for which possible complication? D. Sit the client up and transfer slowly

* 33. A client with a spinal cord injury needs to be

repositioned in bed. Which action will Maricel take? *
1 point
1 point
A. Cushing’s disease
A. One nurse lifts the patient by the arms
B. Grave’s disease
B. Two nurses use a draw sheet to lift the client
C. Diabetes mellitus
C. One nurse rolls the patient toward the stronger side
D. Hypopituitarism
D. Ask the client to scoot up the bed
29. A client with diabetes insipidus is prescribed
vasopressin (Pitressin). What is the purpose of this 34. While caring for a patient with a head injury, which
medication? sign should Maricel report immediately? *

* 1 point

1 point A. Complaints of mild headache

A. Stimulate pancreatic insulin production B. Low-grade fever

B. Slow glucose absorption in the intestines C. Mild photophobia

C. Increase reabsorption of water in the renal tubules D. Increasing drowsiness and difficulty arousing

D. Increase blood pressure 35. A patient recovering from a stroke has mild
dysphagia. Which nursing intervention is most
30. Andrea is teaching dietary management to a client
appropriate? *
with Addison’s disease. Which advice is appropriate?
1 point
*
A. Place the patient in an upright position when
1 point
eating
A. Eat a high-protein, high-calcium, low-calorie diet
B. Offer a clear liquid diet
B. Avoid salt in all meals
C. Tilt the patient’s head back while swallowing
C. Increase carbohydrate intake and limit potassium-rich
foods D. Provide dry finger foods like crackers

D. Consume foods rich in sodium and moderate Situation: Nurse Isabel is assigned to the oncology
carbohydrates unit. She cares for patients receiving chemotherapy,
radiation therapy, and palliative care. Her
responsibilities include monitoring for C. Encourage the patient to increase oral fluids
complications, ensuring adherence to treatment
D. Recheck the temperature in one hour
protocols, and providing emotional and ethical
support to patients and families. Option 5
36. A patient undergoing chemotherapy develops Situation: Nurse Leo is assigned to a post-operative
painful mouth ulcers. What is Isabel’s most appropriate surgical ward. He is responsible for closely
intervention? * monitoring patients' vital signs, ensuring
medications are administered correctly, and
1 point
maintaining safe care practices. He must also be
A. Encourage frequent use of alcohol-based mouthwash aware of legal and ethical implications of negligence
or malpractice in nursing practice.
B. Provide soft, bland foods and perform saline
41. A nurse overhears a physician tell a patient
rinses
derogatory remarks about the nursing staff. Which legal
C. Advise the patient to brush vigorously with a firm violation applies to the physician’s actions?

bristled toothbrush *

D. Recommend citrus juices to promote healing 1 point

37. A cancer patient tells Isabel that a lawyer will be A. Libel

coming to prepare a living will and asks if she can be a
B. Slander
witness. How should Isabel respond?
C. Assault
*
D. Negligence
1 point
42. Leo notices a patient’s condition deteriorates over
A. Agree to serve as a witness to help the patient
several hours, but he does not act on the changes. The
B. Refuse and avoid discussing the matter further patient later requires emergency surgery. This inaction is
considered:
C. Explain that nurses caring for the patient cannot serve
as witnesses *

D. Call the attending physician to resolve the issue 1 point

38. Which of the following should Isabel include in A. Tort

discharge teaching for a patient who has undergone
B. Misdemeanor
external radiation therapy?
C. Common law
*
D. Statutory law
1 point
43. A post-operative patient complains of severe pain
A. Apply lotion daily to the radiation site
despite receiving narcotics. Leo suspects the assigned
B. Avoid exposing the treated skin to direct sunlight LPN may be diverting narcotics. What should he do first?

C. Use heating pads on the treated area for comfort *

D. Scrub the area daily with strong soap 1 point

39. A patient with terminal cancer expresses a desire to A. Avoid assigning the LPN to patients receiving
stop aggressive treatment. Which ethical principle narcotics
supports Isabel’s decision to honor the patient’s request?
B. Review the medication records and report the
* situation to the nurse supervisor

1 point C. Ask the physician to increase the narcotic dosage

A. Justice D. Confront the LPN directly

B. Autonomy 44. A patient is scheduled for surgery but the consent

form is unsigned. What is the best action for Leo to
C. Beneficence take?
D. Nonmaleficence *
40. Isabel observes that a patient receiving 1 point
chemotherapy has a temperature of 38.5°C (101.3°F).
What should she do first? A. Obtain the patient’s signature immediately

* B. Inform the physician that the consent is missing

1 point C. Allow the surgery because it is implied consent

A. Administer acetaminophen as ordered D. Have a family member sign the consent form

B. Notify the physician immediately

45. During the night shift, Leo discovers that a patient B. Restrict bathroom privileges and elevate legs
wants to leave the hospital against medical advice
C. Administer anticoagulants to all postpartum clients
(AMA). Which statement about the AMA form is correct?*
D. Initiate breastfeeding as soon as possible
1 point
50. Ms. H. is admitted to the coronary care unit to rule
A. It confirms the patient’s control over care
out a myocardial infarction. She tells the nurse she is
B. It is used during readmission sure it is just angina and cannot understand what the
difference is between angina and infarct pain. Which
C. It releases the physician and hospital from liability for
response is most appropriate for the nurse to make?
the patient’s health status
*
D. It documents the patient’s refusal to pay
1 point
Situation: Nurse Rafael is working in a
cardiovascular step-down unit. He is caring for A. Anginal pain usually only lasts 3–5 minutes
clients who have undergone vascular surgeries and
B. Anginal pain produces clenching of the fists over the
those with chronic cardiovascular conditions. His
chest while acute MI pain does not
responsibilities include assessing for complications,
preventing thromboembolic events, and providing C. Anginal pain requires morphine for relief
patient education about lifestyle modifications and
medications. D. Anginal pain radiates to the left arm while acute MI
pain does not
46. Rafael is administering a fluid challenge to a client in
hypovolemic shock. Which assessment finding shows Situation: Kiera has felt constipated and bloated for
the client is responding favorably? quite a while now. Two days ago, she was
complaining of moderate cramping in her
* abdomen. Upon assessment, she is febrile with two
episodes of vomiting before arriving to the
1 point
emergency department.
A. Urine output increases from 25 mL/hr to 40 mL/hr
Nurse Eliza suspects that she has diverticulitis. The
B. Systolic BP increases from 80 mmHg to 90 mmHg following questions apply.

C. Central venous pressure (CVP) increases from 5 cm 51. Nurse Eliza is aware that, most commonly, the
H₂O to 7 cm H₂O location of diverticulitis is found in which area of the
abdomen?
D. PaO₂ increases to 90% saturation
> Diverticulosis
47. Four hours after an aortic-femoral bypass graft,
Rafael cannot palpate pulses in the operative leg, and A. Right upper quadrant
the patient reports pain. What should he do first?
B. Right lower quadrant
*
C. Left upper quadrant
1 point
D. Left lower quadrant
A. Massage the leg and apply warm towels
52. Nurse Eliza differentiates diverticulitis from
B. Elevate the leg and recheck the pulse diverticulosis. She in incorrect when she states which of
the following statement to describe the disorders?
C. Call the physician immediately
A. Diverticulosis develops as a result of high (Low)
D. Assist the patient to ambulate intake of fiber and fast colonic transit time
48. A client with peripheral vascular disease is being B. Diverticulitis develops when one or more diverticula is
discharged. Which modifiable risk factor is most inflamed
important for Rafael to address?
C. Diverticulosis forms when the mucosal layers of the
* colon herniate through the muscular wall
1 point 53. Which of the following dietary recommendation can
A. Orthostatic hypotension Nurse Eliza provide Kiera to manage her condition?

B. Age A. Fluid intake of 2 liters a day

C. Smoking B. Foods low in fiber

D. Hypoglycemia C. High fat diet

49. Rafael is caring for a client 6 hours postpartum and D. Regular diet
wants to prevent thrombophlebitis. What is the best 54. The diagnostic procedure of choice to confirm
nursing action? diverticulitis and reveal any perforation or abscess is
* done through?

1 point > IV – if with perforation

A. Encourage early ambulation and increased fluid > ORAL – c/I if w/ perforation
intake
A. Abdominal CT scan with contrast D. Stage 4 pressure injury

B. Abdominal X-ray

C. CBC with elevated WBC count

D. Prescence of frank blood in the stool

55. A few hours later, Kiera reports sudden severe

abdominal pain that radiates to the back and
shoulder, upon assessment the abdomen appears
rigid and board like with absent bowel sounds. Kiera
has a weak and thready pulse and nauseated. Which
of the following priority intervention should nurse Eliza
perform immediately?

A. Administer fleet enema as ordered

B. Insert an NG tube

C. Notify the Physician 59. To minimize moisture on the skin, the most
inappropriate measure for Nurse Llyana to apply would
D. Administer Psyllium as ordered
be? (-)
Situation: Critically ill patients with prolonged
A. Wash soiled skin with mild soap and water
pressure due to immobility poses great risk for
pressure injury. As an ICU nurse. Nurse Llyana B. Lubricate the skin with a bland lotion
initiates intervention to prevent the occurrences of
these injuries. C. Put absorbent pads in the skin

56. In order to assess for risk for pressure injury. Nurse D. Apply drying agents and powders
llyana can perform all of the following nursing actions, 60. Which nursing intervention is most crucial for the
except. (-) prevention of pressure injuries
A. Evaluate the level of mobility A. Frequent position changes
B. Assess the neurovascular status B. Elevate the head of bed to more than 30 degrees
C. Determine the presence of incontinence C. Eliminate protein from the diet- important for wound
D. Evaluate the use of skin care products healing

57. The most common site or area susceptible to D. Ignore skin folds when performing hygiene measures
pressure injuries are Situation: Elmer has been diagnosed with ESRD and
A. Scapula and elbows is set to go undergo hemodialysis while awaiting for
availability of functioning kidney transplant. Nurse
B. Sacrum and heels Mocha assist him during his stay in the Hospital.
C. Occiput and ears 61. Nurse Moca knows that the most sensitive
indicator of renal function is
D. All of the above
A. Blood urea nitrogen – urea nitrogen: from protein
58. Nurse Llyana stages the pressure injury of one of the
metabolism = protein intake, DHN, GI Bleeding
patients who was admitted to the ICU with existing
community acquired pressure injury. She is aware that B. Serum Creatinine – fairly consistent rate = based on
partial thickness skin loss with exposed epidermis is muscle mass
considered as
C. Glomerular Filtration Rate – how fast/slow waste
A. Stage 1 pressure injury products are being excreted
B. Stage 2 pressure injury D. ABG – acid base balance
C. Stage 3 pressure injury 62. Nurse Mocha interprets the Arterial Blood Gas of
the patient. Result shows a ph 7.28 HCo3 10 and
Paco2 55?
 C. Act as interpreter when medical jargon is not clearly
understood by patient and family

D. All of the above

67. Which of the following pertains to a legal document

through which the patient appoints and authorizes
another person to make medical decision on their
behalf?

A. Advance Directive – general document > decision

maker, living will, end of life care

B. Living will – type of A.D > end of life care

C. Durable power of Attorney – type of A.D > decision

maker

D. Physician Orders for life sustaining treatment

A. Respiratory Acidosis
68. Hope is a multidimensional construct that provides
B. Respiratory Alkalosis comfost as a person ensures life threats and personal
challenges, nurse regine will promote the following hope
C. Metabolic Acidosis
fostering activities for a terminally ill patient except?
D. Metabolic Alkalosis
A. Humor
63. Nephrologist require strict monitoring of intake and
B. Love of family and friends
output among patients with renal disorders. Nurse
Mocha can effectively assess for fluid status by doing all C. Uplifting memories
of the following except?
D. Devaluation of personhood – disrespect or loss of the
A. Assess skin turgor and presence of edema patient sense of identity and self-worth

B. Assess patient’s food preferences 69. The family unconsciously prepares for what might
happen when they were informed of the patient’s
C. Weight the patient daily
terminal illness. Nurse Regine will interpret this as:
D. Check for neck distention
A. Anticipatory grief – before a loss occurs > stage 1
64. Elmer is scheduled for surgical AVF creation on his cancer
right forearm. Nurse Mocha will interpret the following as
B. Uncomplicated grief – normal response > ADLs not
abnormal when it comes to the vascular access for
affected
dialysis except?
C. Complicated grief – prolonged intense grief? ADLs
A. Distal Pain of the right extremity
affected
B. Poor capillary refill
D. Disenfranchised grief – down > undervalue > loss of a
C. Numbness and Tingling pet

D. Presence of a thrill and bruit 70. Which illness trajectory is described when a person
follows a slow decline after a diagnosis, with episodic
65. Nurse Mocha understands that all but one are illness, exacerbation and difficulty returning back to the
inappropriate intervention when it comes to the patient functional baseline.
with an arteriovenous fistula?
A. Sudden death – unexpected = cardiac arrest/accident
A. Check the BP in the right and left extremities
B. Terminal illness – steady and irreversible + clear end
B. Perform blood culture and sensitivity on two sites point + advanced cancer
C. Insert a large bore access in the right arm for blood C. Organ failure – chronic illness in w/c specific organ
transfusion fails > periods of stability and exacerbation
D. Place an arm precaution sign on the bedside. D. Frailty – multisystem declined - age
Situation: Patients approaching the end-of-life Situation: Marlon, A 63-year-old businessman
experience can benefit from palliative care. As a reported an onset of headache and dizziness while
nurse, Nurse Regine is knowledge about palliative he was driving to work, he has been feeling fatigued
and end of life principles of care and the ability to for the past few days and he experiences itching and
recognize the unique response of each patient and excessive sweating at night. The Physician suspects
family to a given illness. The following questions the patient has polycythemia vera upon evaluation
apply. of his laboratory result
66. Nurse Regine’s role in a family meeting for 71. Laboratory finding for the patient with polycythemia
advanced care planning of a terminally ill patient vera will show?
with pancreatic cancer should be to?

A. Advocate for patient based on values shared by

patient and family
A. Elevated erythrocyte and hematocrit count
B. Share clinical nursing updates
B. Thrombocytosis less sensitive to DHT > promotes growth of prostate
cells
C. Leukocytosis
B. Estrogen level is elevated – directly promote prostate
D. All of the above
cell growth
72. Patients with polycythemia vera are at great risk for
C. Testicular androgen stays normal – decline as men
stroke and MI due to which reason
age
A. Increased risk for thrombosis – Inc. blood viscosity >
D. Prostatic lobes atrophies due to elevated DHT -
thick blood > turbulent blood flow > damage inner lining
hyperthrophy
blood vessels > activate platelets > perfect storm for
blood clots (thrombus) > dislodge (embolus) 77. In order to reduce the risk of UTI – which dietary
regimen is advisable for the patient?
B. Uric acid elevation
A. Eggs, cranberries and tomatoes
C. Increased number of basophils – type of wbc >
chronic myeloid leukemia B. Milk, meat products and poultry – milk is slightly acidic

D. Increase in blood cell mass - inc. blood viscosity C. Pulms, legumes and whole grains - alkalinity

73. The purpose of phlebotomy as therapy for the patient D. Tomatoes, prunes and milk products
is to
78. Placement of a urinary catheter for the patient was
A. Prevent vascular thrombosis – secondary purpose ordered. The main purpose of performing open
intermittent irrigation for the patient would be to
B. Maintain hematocrit level at less than 45% - dec.
blood cells A. Free a blockage in a urinary catheter or tubing

C. Suppress bone marrow function – chemo agent B. Maintain the patency of urinary catheter and tubing
hydroxyurea
C. Minimize the risk for developing urinary tract infection
D. Reduce splenomegaly and pruritus
D. To reduce the risk of injury to bladder mucosa and
74. Marlon has developed splenomegaly due to his risk of bladder spasm
disorder being unresponsive to to initial treatment. The
79. The benchmark surgical treatment for BPH which
physician prescribed interferon alfa to counteract this.
involves the insertion of an endoscope through the
The nurse helps the patient alleviate its comfort side
urethra to remove the inner portion of the prostate is
effect which are
called:
> interferon alfa: type of biologic therapy common in
A. Suprapubic prostatectomy – more invasive, incision
hema d/o > modifies the immune system
above the pubic bone, for v. large prostate > 100 grams
A. Nausea and vomiting
B. Retropubic prostatectomy – more invasive, incision
B. Myelosuppression – desired therapeutic effect behind the pubic bone, avoiding bladder > 100 grams
prostate
C. Pruritis – caused by pv
C. TURP – less invasive
D. Flulike symptoms
D. Brachytherapy – brachy = braso > inside prostate
75. Which instruction is appropriate for the nurse to give
cancer radioactive seed placed into the prostate
for a patient with polycythemia vera?
80. Immediate postoperative instruction in terms of
A. Advice the patient to wear tight stockings – higher risk
nutrition and hydration was given to Mr. Rez. Nurse Yuri
for thrombosis
would be incorrect if he states which of the following
B. Take a high dose aspirin regularly – high dose > statements? (-)
bleeding
A. Avoid sweet foods
C. Avoid iron supplements – stimulate production of rbc
B. Thin liquids will be used first – high risk for aspiration:
> further erythropoesis
thick +gag reflex
D. Allow alcohol intake to no more than 2 bottles a day –
C. Taste sensation will be altered temporarily
DHN blood viscosity > higher risk for thrombosis
D. Patient may not be permitted to drink or eat for 7 days
Situation: Carlos, 48 years of age reports problems
with urinating as evidenced by frequent urination at 81. To prevent aspiration for Mr. Re who was placed
night and dribbling of urine. He is also anorexic and with a nasogastric tube for temporary feeding. Nurse
fatigue and he deals with the discomfort in the pelvic Yuri will initiate the following interventions. Except?
area. DRE Digital rectal exam reveals an enlarged
A. Keep a suction setup available bedside – emergency!
rubbery and non-tender prostate gland consistent
with the diagnosis of benign prostatic hyperplasia. B. Keep head of the bed elevated for 30 minutes after
tube feedings – prevent aspiration
76. The pathophysiologic mechanism behind the
occurrence of BPH have been implicated by the C. Instill feedings after aspirating 50% residual volume of
hormonal changes that play a role in its causation which previous intake – 200 – 500 ml > hold the feeding >
of the following is correct regarding this. overdistention + aspiration
A. Prostatic tissue becomes more sensitive to D. Administer antiemetic medication as ordered
dihydrotestosterone – men age > prostate tx becomes
82. Following a laryngectomy, what assessment should You emphasized to the dietitian that he should be served
Nurse Yuri prioritize? foods that is _________.

A. Swallowing ability

B. Airway patency

C. Carotid pulse A. High carbohydrate and low sodium

D. Signs of bleeding B. High calorie and high carbohydrate

Situation: Mr. GI Joe is 55-year-old, married, a car C. Low protein and high fat
dealer has consulted the ER because of on and
D. High protein and high fat
fever, indigestion, weight loss, right abdominal pain,
body malaise, and itchiness of the skin. Based on 87. Mr. GI Joe started to develop ascites and
the health history the patient has been a chain complained of heaviness of the lower extremities to the
smoker and drinks alcoholic beverages almost every physician. An order of Spironolactone (Aldactone) 25
day especially when he has clients to entertain. His mg. /day. What adverse effect of the drug should you
physical examination showed he has suspected liver monitor?
cirrhosis. He was advised for admission for further
work-up and treatment > Spironolactone – potassium diuretic

83. You are the nurse on duty when Mr. GI Joe was A. Hyperkalemia
admitted in the pay floor. In your observational data what B. Palpitation
additional EARLY SIGN of liver cirrhosis do you expect
patient to manifest? C. Irregular pulse rate

A. Gonadal Atrophy D. Hypokalemia

88. When doing an assessment which ONE of the

following conditions is not present based on the Jones
B. Hypotension Criteria:

C. Splenomegaly

D. Ankle Edema

84. Which of the following statements is TRUE of liver

cirrhosis?

1. Nutritional deficiency with decreased protein intake

A. Erythema Marginatum
attributes to liver damage.
B. Subcutaneous Nodules
2. Cirrhosis can happen to people with alcohol intake
C. Chorea
3. Women are at greater risk for the development of
alcohol-induced liver disease D. Bronchopneumonia

4. Most patients affected by liver cirrhosis are between 89. In rheumatic fever, the factor contributory to the
40 to 60 years of age. development of this disease process is brought about
by
A. 1,2,3,4

B. 1,2

C. 1,2,3

D. 2 and 3

85. During Mr. GI Joe’s confinement he developed

further itchiness of the skin and jaundice. Which of
the following nursing actions is NOT recommended
as this will induce skin breakdown? (-)

A. Add baking soda when bathing the patient - alkaline

B. Massage the skin with emollients every 2 hours

C. Use commercial soaps and alcohol-based lotion

D. Rub the itchy skin with knuckles instead of using the

nails

86. At early stage of Mr. GI Joe’s disease process, the

physician ordered this SPECIFIC diet for Mr. GI Joe,
 D. Before any pre-op medications are administered

92. Which of the following nursing goals are achieved

when early ambulation is done by post-surgery
patients?

1. Improved circulation

2. Improved respiratory functions

3. Prevent venous stasis

4. Prevent emboli formation

A. 3 and 4

B. 1, 2, 3,4

C. 1, 3, 4

D. 1 and 2

93. Which of the following patient is MOST at risk

during the induction of Anesthesia ?

A. 6-year-old with history of allergy

B. 65-year-old diabetic woman – age elderly

C. 35-year-old TB case

D. 25-year-old polio case

94. As a circulating nurse, which of the following is your

PRIORITY nursing action to promote safety of your
patient?
A. Auto-immune reaction to streptococcal infection

B. Auto-immune reaction to collagen disease

A. Prevent peri-operative position injury
C. Parents had rheumatic heart disease
B. Provide adequate lighting during the procedure
D. Exposure to colds and droplet infection
C. Optimize surgeon’s access to surgical site
90. Marimar, 6 years old, is receiving digitals for
having Patent Ductus Arteriosus with heart failure D. Maintain a surgical aseptic technique during the
with heart failure. Prior to the administration of the procedure
medicines, which of the following nursing actions 95. Being the nurse in the Post Anesthesia Care Unit.
should be done by nurse Rica? Which of the following is your PRIORITY concern after
the surgery?

A. Monitor vital signs – immediate reflection of the

condition

A. Take the carotid pulse rate for one full minute. B. Observe surgical site for bleeding

B. Take the heart rate for one full minute C. Validate doctor’s order

C. Take the respiratory rate D. Check level of consciousness

D. Take the blood pressure 96. Mr. Jesse is admitted due to congestive heart
failure. Nurse Brilliantina would expect that if the failure
Mr. Gaudencio Suarez is a surgical nurse in a is on the right side of the heart, the patient will
medical center and he had been practicing for manifest which of the following.
almost five years in this unit. The staffs go on shift
rotation. For that shift, he had two patients for
operation. One is for Lobectomy and another is for
Nephrectomy
A. Jugular vein distention
91. When is the BEST time for the operative consent is
be signed by his: B. Crackles on auscultation

C. Dry productive cough

D. Improved bowel elimination

A. As soon as the surgical procedure is explained to the 97. The patient has been receiving Digoxin 0.25 mg
patient per day to regulate his heart rate. Which of the
B. On admission when the relatives are around following outcomes would indicate that his medication
is achieving its desired effect
C. A Day before the surgery
A. Improved appetite
B. Increased pedal edema probable and wants to collect more data is a/an
_________
C. Increased urine elimination
A. Risk nursing diagnosis
D. Improved bowel elimination
B. Possible nursing diagnosis
98. The other patient of Nurse Brillantina is suffering
from Buerger’s disease. He has been complaining of C. Actual nursing diagnosis
intermittent claudication of the lower extremities which
D. Wellness nursing diagnosis
has been giving him so much discomfort. What is the
best nursing action (long term) so she should perform 2. Which of the following statements is
to address the patients complain? a POSSIBLE nursing diagnosis?

A. Constipation related to decreased activity and fluid

intake

B. Potential for Enhanced Spiritual Well Being

A. Allow the patient to lie flat on bed – eliminate gravity >
decrease blood flow to limbs C. Possible Self Care Deficit – grooming related to
fatigue and muscular weakness
B. Teach him foot care and leg exercises – collateral
circulation > additional blood pathways + long term D. Risk for Activity Intolerance related to prolonged bed
rest
C. Place affected extremities in dependent position –
short term 3. Which of the following is a RISK nursing diagnosis?
D. Apply hot water bag to the affected extremities A. Potential for Enhanced Spiritual Well Being
99. Which of the following information is NOT true about B. Possible Self-Care Deficit; grooming related to fatigue
Buerger’s Disease? and muscular weakness
A. Small and medium arteries and veins are mostly C. Risk for activity intolerance related to prolonged bed
affected. rest
B. Smoking is a major cause of Buerger’s disease. D. Constipation related to decreased activity and fluid
intake
C. Incidence of Buerger’s disease is high in men than
women. Situation: The nurse provides health education to a
group of adolescents about pelvic inflammatory
D. A strong relationship between Diabetes and Buerger’s
disease (PID). – severe inflammation of reproductive
Disease
tract
Situation: Gloria, 58 years old, beautician has
undergone bowel obstruction surgery. During his
first day post-op. she vomited clear liquids about
three times during your shift. Her vital signs include:
temp-37.9-degree C. 138/84 PR-78/min and RR-
4. The nurse explains that prevention of PID in
26/min. her surgical incision is intact, slight
adolescents is important due to which of the following
bleeding, swilling and tenderness with slight pain.
reasons. PID ________:
100. Which of the following manifestations would
A. can have devastating effects on the reproductive tract
indicate the development of wound infection?
of affected adolescents.
A. Presence of elevated red blood cells count. – DHN,
B. is easily prevented by compliance to any form of
PV
contraception
B. Profuse and increasing perspiration. – anxiety, pain,
C. can cause life-threating defects in infants born to
systemic infection
affected adolescents.
C. Increased blood pressure, rr and pulse rate –
D. Is easily prevented by proper personal hygiene.
bleeding, pain, anxiety, systemic infx
5. The nurse explains to the group of adolescents that
D. Increasing pain on the surgical incision.
the most common cause of PID is _______:

A. Tuberculosis bacilli

B. Gonorrhea – chlamydia also

C. Staphylococcus
RECALLS 6 NP4 D. Streptococcus
Situation: The charge nurse in the medical unit 6. The nurse further explains that PID presents the
updates her knowledge on nursing diagnosis. She following signs and symptoms, which the adolescent
reviews the terms used to describe clinical should be aware of:10.
adjustment.

1. A nursing diagnosis formulated when there is

insufficient evidence to support the presence of the
problem but the nurse believes the problem is highly
 B. Pulse and blood pressure

C. Respiratory rate and depth

D. Ability to move extremities

12. The Nurse anticipates detecting the occurrence of

what common complication of head injury.
A. A hard painless, red and defined lesion on the genital
area. – primary syphilis A. Intracranial hemorrhage

B. Small vesicles on the genital area with itching. – B. Diabetes insipidus

herpes simplex virus

C. lower abdominal pain and urinary tract infection

D. Cervical discharge with redness and edema - C. Diabetes mellitus

cervicitis.
D. Basilar Skull Fracture – type of head injury
7. Which of the following statements is true when
teaching adolescents about gonorrhea? 13. The nurse is aware that she should monitor Ysha’s

A. Gonorrhea may be contracted through contact with a A. Pulse rate

contaminated toilet seat. B. Temperature
B. The infectious agent for gonorrhea is Neisseria C. Urine output
gonorrhea
D. Oxygen saturation
C. Gonorrhea is most often treated by multidose of
administration of penicillin. – ceftriaxone + doxycycline + 14. Ysha is ordered to receive desmopressin (DDAVP)/
metronidazole synthetic vasopressin (ADH) anti ihi, for management of
her condition. The nurse should check which of the
D. Treatment of sexual partners is the priority of following measurement to determine the effectiveness of
treatment. this medication?
8. The nurse further explains to the adolescents A. Daily Weight
that gonorrhea is highly infectious and it ____:
B. Temperature
A. Is limited to the external genitalia.
C. Apical heart rate
B. Can lead to sterility – scar tissue > occlude tubes >
fertilized egg cannot pass through > sterility > D. Pupillary response
hysterectomy
15. The nurse knows that which of the following
C. Is easily treated. conditions may alter the effectiveness of DDAVP?

D. Occurs rarely among adolescents A. Increased oral secretion

9. Which of the following signs and symptoms should the B. Arterial Obstruction
nurse correlate with a diagnosis of osteoarthritis?
C. Nasal Congestion
A. Erythema and edema over the affected joints
D. Obesity
B. Joint stiffness that decreases with activity
16. Matilda, with hyperthyroidism is to receive
C. Anorexia and weight loss Lugol’s iodine solution before a subtotal
thyroidectomy is performed. The nurse is aware that
D. Fever and malaise this medication is given to:
10. Which of the following factors would most likely > Lugol’s solution – preparation for thyroid surgery
increase the joints symptoms of osteoarthritis?
> High doses > decreasing size and vascularity of the
A. Emotional stress – perception of pain thyroid gland > highly vascular > reduce risk for
B. Obesity – inc. pressure on joints hemorrhage

C. History of Smoking – rheumatoid arthritis A. Decrease the total basal metabolic rate. –
methimazole and propylthiouracil
D. Alcohol Abuse
B. Maintain the function of the parathyroid glands.
Situation: Ysha is an autistic child who loves to bang
her head, one day while head banging, she C. Block the formation of thyroxine by the thyroid gland.
unintentionally hit the wall and briefly loses D. Decrease the size and vascularity of the thyroid
consciousness gland.

Situation: A 30-year-old client named Kiana is

11. Ysha is brought into the emergency department of LA admitted to the Philippine Lung Center due to
Medical Center after suffering a head injury, The first sudden onset of chest pain and dyspnea. He has no
action by the nurse is to determine the Ysha’s history of respiratory disease but had a complete
femur fracture. 3 days ago, the following questions
A. Level of consciousness apply
17. He is diagnosed with pulmonary embolism (fat D. Systolic blood pressure decreases from 122 – 98
embolism) the nurse immediately implements which mmhg
expected prescription for this client?
Option 5
A. HIGH FOWLER’S, OXYGEN, MORPHINE
SITUATION: Janice is a 50-year-old obese patient.
B. Supine position, oxygen, and meperidine She admits that her self-esteem has been
hydrochloride (Demerol) [IM] progressively becoming low as her body size
increases. She also claimed that her performance in
C. High Fowler’s position, oxygen, and meperidine
her work has already been impaired. She electively
hydrochloride (Demerol) [IV]
subjects herself to a bariatric surgery.
D. High Fowler’s position, oxygen, and two tablets of
21. Rapid emptying of gastric contents into the small
acetaminophen with codeine (Tylenol #3)
intestine may occur postoperatively due to gastric
18. The doctor ordered ABG analysis for Chandler resection. Dina is at risk for developing dumping
Bing. The nurse is now sending the ABG specimen to syndrome. The nurse monitors her for:
the laboratory for analysis. Which of the following pieces
of information should the nurse write on the laboratory
requisition?

1 Ventilator settings – fraction of inspired oxygen (FiO2)

A. Dizziness
2 A list of client allergies
3 The client’s temperature B. Bradycardia – tachycardia dapat

4 The date and time the specimen was drawn C. Constipation – diarrhea dapat

5 Any supplemental oxygen the client is receiving D. Extreme thirst – late sign
6 Extremity from which the specimen was obtained
22. The nurse places Janice in which best position to
A. 1,3,5,6 prevent occurrence of dumping syndrome?

B. 1,2,4,5 A. Supine – 10 to 20 degrees fowler

C. 1,2,3,4 B. Trendelenburg

D. 1,3,4,5 C. Fowler’s

19. The nurse is now inserting an oropharyngeal D. Prone

airway to Kianna the nurse plans to use which correct
23. Janice now ready to resume diet since she now has
insertion procedure?
normal bowel sounds. To minimize complications from
A. Flex the client’s neck – gently hyperextend eating, the nurse teaches her to do which of the
following?
B. Leave any dentures in place
1. Lying down after eating
C. Suction the client’s mouth once per shift
2. Eating a diet high in protein – slow osmotic effect
D. Insert the airway with tip pointed upward
3. Eating a diet low in protein
4. Eating six small meals per day

5. Eating concentrated sweet between meals

A. 1,3,5

B. 1,2,5

C. 1,2,4

D. 1,3,4

24. In preventing dumping syndrome which additional

instruction should be provided to Janice:
20. Chandler Bing is now intubated and receiving
mechanical ventilation. The physician has added 7 cm of A. Ambulate following a meal
positive end expiratory pressure (PEEP) to the ventilator B. Eat high carbohydrate foods
settings of the client. The nurse assesses for which of
the following expected but adverse effects of PEEP? C. Limit the fluids taken with meals

> PEEP – to keep the alveoli open > atelectasis D. Sit in a high fowler position during meals
(collapse)
Situation: Patients with varying diseases always
> Increased thoracic pressure > compressed vena cava receive medications for them to recuperate. As part
> reduced venous return (preload) > decreased cardiac of the dependent functions of a nurse, knowledge in
output > low bp pharmacology is one of the most essential
competencies that should possess to be aware
A. Decreased peak pressure on the ventilator when to verify a doctor’s medication order and to
B. Increased temperature from 98OF to 100OF rectally know the side effect, adverse effect therapeutic level
and nursing consideration for each drug
C. Decreased heart rate from 78 to 64 beats per minute
 25. A. nurse in the new ward is reviewing the result of a C. Pulse oximeter
client Richard’s Phenytoin Dilantin level that was drawn
D. Intra-arterial catheter – INVASIVE
that morning the nurse determines that he had a
therapeutic drug level if the result was Phenytoin 31. According to the standards of AHA (2017),
(Dilantin) Anticonvulsant normal – 10 – 20 mcg hypertension stage 1 is described as:
>Phenytoin – anticonvulsant: 10-20 mcg/ml A. Systolic BP of 120-139mmHg, diastolic BP of 80-
89mmHg
A. 3 mcg/mL
B. Systolic BP of 120-149mmHg, diastolic BP of 90-
B. 8 mcg / ml
99mmHg
C. 15 mcg / ml
C. Systolic BP of 130 – 139 mmHgm diastolic BP of 80 –
D. 24 mcg/ ml 89 mmHG

26. Client Mark has begun medication therapy with D. Systolic Bp of 140-149, diastolic BP of 100-
Betaxolol (Kerlone) The nurse determines he is 110mmHg
experiencing the intended effect of therapy which of the
following is noted?

> betaxolol is negative inotropic , chrono

A. Edema present at

B. Weight loss of 5 pounds

C. Pulse rate increased from 58 to 74 beats/ min

D. Blood pressure decreased from 142/94 to 128/82

mmHg

27. The nurse has taught another client named Darl with 32. A patient was ordered to have his EKG reading
asthma, who is taking a xanthine done. As the nurse you know that the EKG is performed
bronchodilator about beverages to avoid. The nurse to assess:
determines that the client understands the information if
A. Heart chambers and heart valves – use 2D echo
the client chooses which of the following beverages from
the dietary menu? B. Hypertrophy, infarction, axis deviation
> xanthine bronchodilator – CNS stimulant C. Dysrhythmias, mitral stenosis, electrical conduction –
2D echo (MS) + EKG
> no cs and t with phylline > cola, coffee, chocolate
D. Coronary vessels and artery disease – angiogram
A. Cola
(DYE IV + xray femoral
B. Coffee
33. During a disaster which principle is integral in
C. Chocolate milk decision making and providing health care to those
who are victims?
D. Cranberry juice
A. Beneficence – do good + majority benefit
28. Client Argie is ordered to start on Glipizide once
daily. The nurse observes for which of the following B. Non maleficence – do no harm + diff. decisions
intended effect of this medication?
C. Utilitarianism – do good for the greatest number of
A. Weight loss people

B. Resolution of infection D. Paternalism

C. Decreased blood glucose 34. A patient admitted to the hospital with myocardial
infarction develops severe pulmonary edema. Which
D. Decreased blood pressure of the following symptoms should the nurse expect
29. Client Donna, a toddler is hospitalized the patient to exhibit?
for acetaminophen (Tylenol) overdose. The nurse A. Slow, deep respirations – rapid and shallow
prepares to administer which specific antidote for this
medication overdose? B. Stridor – airway obstruction

A. Vitamin K – warfarin – oral C. Bradycardia - tachycardia

B. Protamine sulphate – heparin overdose > IV D. Air hunger

C. Acetylcysteine (Mucomyst) 35. A child is seen in the emergency department

for scarlet fever. Which of the following descriptions of
D. Naloxone hydrochloride (Narcan) - opiods scarlet fever is NOT correct?
30. Which of the following is the best indirect method of A. Scarlet fever is caused by infection with group A
measuring blood pressure? Streptococcus bacteria
A. Palpatory blood pressure – systolic bp B. “Strawberry tongue” is a characteristic sign.
B. Aneroid sphygmomanometer
C. Petechiae occur on the soft palate. – forscheimer 40. Mr. Joe tested positive for HIV. Which of the
spots > german measles (rubella) following explanation can you give him?

D. The pharynx is red and swollen. > less than 20 pag check antibodies

Situation: You are a staff nurse in a psychiatric unit. A. Antibodies to the AIDS virus are present in the blood –
You are taking care of Mr. Joe. who is suffering from aids CD4 < 200 cells/mm3 or + infection
heroin-addiction with suspected complications of
B. “This means that you will not develop AIDS in the
HIV.
future.”
36. Macy asked you what HIV seropositivity means.
C. “You have been diagnosed with AIDS.”
Your answer will be:
D. “At this point, AIDS virus is not active in your blood.” -
A. An infected person with HIV is capable of transmitting
<20 copies
the virus to sexual partner
Situation: A 60-year-old male is admitted to the
B. An infected person can donate blood after five years. -
oncology unit. According to the client, he felt a
parenteral
growth during a routine digital prostate examination.
C. The person tested is not infectious. He complains of pain on urination and frequent
urination.
D. With appropriate medication, the infected person will
be no longer infectious after two months. - lifelong 41. The nurse understands that the function of the
antiretroviral prostate gland is primarily to ______;

37. In your morning rounds, you noticed in Mr. Joe A. Regulate the acidity and alkalinity environment for
the presence of cough, shortness of breath and proper sperm development. – seminal vesicles/cowper
tachypnea (respiratory sx). Which of the opportunistic gland
infection is probably causing these manifestations?
B. Produce a secretion that aids the nourishment and
A. Toxoplasmgondii – common cause for encephalitis > passage of sperm
neuro
C. Secrete a hormone that stimulates the production and
B. Cytomegalo virus – retinitis. Gi, neuro maturation of sperm. – FSH/LH > pituitary > testes >

C. Cryptococcus neoformans – meningitis > neuro D. Store undeveloped sperm before ejaculation. -
epidydimis
D. Pneumocystis jirovecii
42. The nurse analyzes the laboratory values and
notes that the serum phosphate level is elevated.
This finding indicates which of the following:

A. It confirms the diagnosis of prostate cancer.

B. The progression or regression of prostate cancer.

C. The likelihood of metastasis to the bones.

D. There are complications associated with cancer.

43. The nurse knows that hormone therapy is the mode

of treatment for a client with prostate cancer. The goal
of this form of treatment is to ______:

A. Limit the amount of circulating androgens

38. Which of the following are the most possible cause B. Increase prostaglandin level.
of HIV in Mr. Joe’s case?
C. Increase the amount of circulating androgens.
A. Unprotected sex with his fiancée
D. Increase testosterone level.
B. Exposure to infected body fluid.
Situation: The nurse cares for a female client who is
C. Unprotected anal intercourse. terminally ill and is experiencing pain.
D. His heroin addiction 44. The nurse prepares a care plan for the client. The
overall goal for the client is ________. The client will:
39. Another day, Mr. Joe. was visited by her girlfriend
Macy, who admitted she had been having sex with him. A. Achieve control of pain and discomfort.
In describing risky sexual practices, which of the
following you will tell Macy is not a risk factor? B. Receive adequate cerebral oxygenation and
perfusion.
A. Mucosal exposure such as splashing the eyes or
mouth – low risk but can still cause C. Be free from infection.

B. Anal intercourse is the primary way in spreading HIV D. Receive life sustaining food and liquids.
– vaginal intercourse-hetero 45. The nurse is aware of the document that expresses
C. HIV can be transmitted during sexual intercourse from a client’s wish for life sustaining treatment in the event
an infected partner. of terminal illness or permanent unconsciousness. This
document is the ______;
D. Oral sex is considered risky
A. No-code order 50. The nurse added that in B-Thalassemia, which family
history may be present in the development of the
B. Durable power of attorney – decision maker
condition?
C. Living will – end of life care

D. Last will and testament – property, possession

46. The client nears death and requests that no

medication be given that would cause a loss of
consciousness, including pain medication. The nurse
A. Autosomal dominant disorder
would promote the best end-of-life care for the client
by which of the following? B. Autosomal recessive disorder
A. Discuss the request of the dying client with family C. Y-linked genetic disorder
members and respect their wishes.
D. X-linked genetic disorder
B. Comfort is the highest priority in this situation so give
medications as ordered. 51. The nurse presented assessment data she gathered
from her patient. She emphasized that her patient
C. Respect the client’s wishes and withhold pain has greenish-yellow skin tone and severe
medications and other medications ordered anemia requiring transfusion support to sustain life. She
identifies this type of B-Thalassemia as:
D. Be compassionate and give half of dose of the
medication ordered.

47. Which of the following statement

is TRUE about terminally ill clients?

A. Terminally ill clients require minimum physical care. A. Thalassemia major

B. Health care personnel do not understand their own B. Thalassemia intermedia

feelings about death and dying therefore they avoid
C. Thalassemia trait
caring for terminally clients.
D. Thalassemia minor
C. Terminally ill clients have the right to die with dignity
52. Based from the patient’s manifestations, severe
D. Terminally ill client’s experiences pain most of the
anemia in B-Thalassemia is also known as:
time.
A. Kleihauer-Betke’s anemia
48. The dying clients wishes to donate her eyes after
she dies. Which of the following statements is NOT B. Charcot’s anemia
TRUE about organ donation?
C. Coombs’s anemia
> R.A 7170 organ donation Act of 1991
D. Cooley’s anemia
A. Any individual, at least 15 years old of age and of a
sound mind may donate a part of his body to take the 53. The patient is receiving long-term blood transfusion
effect after transplantation needed by the recipient – at therapy for the treatment of his disorder. Chelation
least 18 years old therapy (removal of toxic substances) is prescribed to
prevent organ damage from the presence of too much
B. Sharing of human organs or tissues shall be made iron in the body as a result of the transfusions. The
only through an exchange program duly approved by the nurse correctly anticipates the medication used for
Department of Health chelation therapy for the patient which is:
C. The choice to donate an organ must be a written A. Naloxone – opioid antagonist
document
B. Calcium Disodium Edetate – lead poisoning
D. Laws that do not require the consent of a family
members to retrieve organs if the donor has expressed C. Deferoxamine – bind to iron > feces/urine
his last wish to donate
D. Protamine sulfate – heparin overdose
SITUATION: A nurse working in the hema ward of
54. The nurse is caring for another patient with a
Bloody hospital for 3 years is assigned to care for
hereditary bleeding disorder. The nurse noted that
pediatric patients with hereditary condition. One of
the patient has increased tendency to bleed from
her patients is named Ryan, diagnosed with B-
mucous membranes. Most probably, the physician’s
Thalassemia.
medical diagnosis for this patient would be:
49. The nurse is presenting a clinical conference and
discusses the cause of B- Thalassemia. The nurse
informs her audience that the child at greatest risk of
developing this disorder is:
A. Christmas disease
A. A child of Mexican descent

B. A child of Mediterranean descent – African at risk

B. Classic hemophilia
C. A child of Asian descent – alpha thalassemia

D. A child of American descent

C. Von Willebrand disease

D. B-Thalassemia

Situation: Mrs. Tina, a 47-year-old married woman

with four children, went to the hospital because of
joint pain. Upon reviewing her medical history, the
nurse discovers that she was diagnosed with
osteoarthritis.

55. Nurse Madie was assigned to care for this patient.

She is aware that osteoarthritis is not associated with
the following signs and symptoms:

a. Edema over the affected joints – RHEUMATOID

ARTHRITIS

b. Stiffness is decreased with movement.

c. Pain

d. Limitations in range-of-motion

56. A comprehensive physical assessment and health

history was taken by Nurse Madie. She was able to
take note of various risk factors present from the
patient's lifestyle. Nurse Madie knows that among the
following, the factor that most likely aggravates Mrs.
Lima's symptoms is:

58. Nurse Madie is aware that osteoarthritis is a

"wear-and-tear" disease. She expects that the joints
most likely affected in this condition are the:

A. Hips and knees

B. Tibia and fibula

C. Humerus and radius

D. Thoracic spine

59. As part of health teaching, Nurse Madie instructs

A. Recent leg fracture – temporary pain or mobility issue
Mrs. Tina that to effectively decrease joint pain and
B. Working as a corporate president for 10 years stiffness before starting her daily activities, she
should not do the following excluding:
C. Weight of 75kg and height of 165cm – OBESE 1 –
BMI = KG/M2 + pre-obese = extra weight = extra stress A. Decrease carbohydrates and protein, and increase
in joints more fat in diet.

D. Dehydration B. Perform range of motion exercises and apply liniment

to the affected joints
57. Nurse Sugar is assessing a client with Cushing’s
syndrome. Which observation should the nurse report C. Administer codeine when pain is exceedingly high.
to the physician immediately?
D. Apply cold compress to affected joints.

60. Being the patient's primary nurse, Nurse Madie

collaborates with the healthcare team, especially with
the physical therapist. The physical therapist
recommended that Mrs. Lima undergo a regimen of
rest, exercise and physical therapy. Nurse Madie
explains to the patient that this regimen will:

A. Pitting edema of the legs – expected; fluid retention

due to NA+

B. An irregular apical pulse – aldosterone = NA++ H20

retention > K+ excrete > heart A. Help patient cures the disease

C. Dry mucous membranes B. To reduce the inflammation due to the disease

process.
D. Frequent urination
C. To restore her abilities she had when she was
younger
D. Prevent the crippling effect of osteoarthritis D. Seek a new order after 2 doses that do not achieve a
tolerable level of pain relief
Situation: EJ has been wearing eyeglasses since he
was 5 years old. When he turned 18, he wanted to 66. One of the clients experience severe, intractable
dispose of the eyeglasses and started wearing long- pain (UNRELIEVED PAIN) and complains that the pain
wearing contact lenses. Before his 24th birthday, he medication is not working for him. Which of the following
was rushed into the emergency department because actions is MOST appropriate for Nurse Alfie?
of severe eye pain. After assessment, he was
A. Suggest to the client to try deep breathing to cope
diagnosed to have corneal ulcer.
with the pain.
61. Which of the following affects the ability of the eye
B. Explore the nature of the pain and encourage the
to clearly focus? A change in the_______.
client to perceive it in a different way.
A. Stroma – thick middle layer of cornea > keeps it clear
C. Support the client emotionally and tell him he will
and strong
receive the next dose of medication as soon as possible.
B. Sensory cells of the retina – convert light into
D. refer the client to the attending physician immediately
electrical signals brain > rods and cones (color
and report that the pain medication is not providing
C. curvature of the cornea – helps bend (refract) > focus adequate pain
light on retina
67. Nurse Andi assesses a client complaining of acute
D. epithelium – thin outermost layer of cornea = protect pain. The most appropriate nursing assessment would
and absorbs nutrients include which of the following?

62. Which of the following is the predisposing factor for A. The nurse impression of client’s pain
EJ’s condition?
B. The client’s pain rating
A. Bacterial infection
C. Nonverbal cues from the client
B. Prolonged misuse of contact lenses
D. Pain relief after appropriate nursing interventions
C. Malnutrition
Situation: Nurse Margot is working as a staff in the
D. Viral infection neurosciences ward the following questions apply

63. Corneal ulcers are considered medical 68. A patient who suffered from the vehicular accident
emergencies. Which of the following nursing actions will was intubated due to respoiratory arrest. At which level
be your PRIORITY? of the spinal cord does the nurse suspect to be
affected?
A. Remove the contact lens
A. C1 – C2
B. Prompt referral to the ophthalmologist for treatment

C. Administer eyedrops

D. Pressure dressing applied to both eyes for comfort B. C3 – C4

Situation: Nurse Andi works in the oncology unit.

She takes care of cancer patients in pain. She is
aware that cancer pain management is one of her C. C5
responsibilities.
D. C6
64. Nurse Andi collaborates with the physician in the
development of a drug regimen for the clients. Which of
the following medications is least preferred in the
treatment of cancer pain?

A. Morphine

B. Acetaminophen (Tylenol)

C. Meperidine (Demerol)

D. Hydrocodone - opioids

65. When titrating (adjusting a baseline dose) a drug for

the client in pain, which of the following action is MOST
appropriate?

A. Ask the physician to include a medication order for

breakthrough pain.

B. Follow the physician’s order for the first 24 hours.

C. Reassess the client every 8 hours for drug

effectiveness.
 C. It prevents erosion of bones due to consequent
immobility.

D. Turning prevents prolonged reduced blood flow to the

skin

73. Which of the following is not an expected

manifestation from a patient with anterior cord
syndrome?

A. Loss of pain sensation

B. Loss of temperature function

C. Loss of touch sense

69. A paraplegic client (crosswise – from waist down) is
for discharge to home. The nurse correctly includes D. Loss of motor function
which instruction for patient education 74. An infant is brought to the clinic by his mother, who
has noticed that he holds his head in an unusual position
and always faces to one side. Which of the following is
the most likely explanation?

A. Torticollis
A. Follow up to this clinic if he already feels fine

B. Maintain on bed rest for first 48 hours after the further

recovery
B. Craniosynostosis
C. Instruct to borrow crutches from a friend so he does
not need to buy

D. Encouraged home modification based on patient’s C. Plagiocephaly

needs

70. The nurse who care for a patient with SCI Spinal
Cord Injury found out that he also has renal calculi. D. Hydrocephalus
The nurse knows that patients with SCI are predisposed
to developing kidney stones because:

A. Decreased ability to drink water may led to

dehydration thus concentrating urine particles – possible
secondary cause

B. Spinal shock from SCI increases serum uric acid

levels causing uric acid stones – loss of reflex and
sensation below

C. SCI and kidney stones have different separate

etiologies

D. Immobility due to SCI increases calcium resorption

Situation: Avian flu had an epidemic in 2017 in
71. A 5 year old pediatric client was admitted for different parts of Luzon. Nurse RK is instructing
tuberculosis meningitis and ventriculoperitoneal communities about this disease.
shunt VPS was surgically applied. The mother ask the
nurse why it was placed. Which of the following is a 75. Bird’s flu virus (H5N6) had an outbreak in the
correct statement by the nurse? provinces of Nueva Ecija and Pampanga this 2017.
Which of the following is true of the disease?
A. The shunt is applied to drain the bacteria from your
child’s ventricles A. Humans can contract it from infected pigs.

B. It prevents further crossing of bacteria through blood B. Infected birds shed the virus in their saliva, mucous
brain barrier and feces

C. This shunt will provide IV access for the anticipated C. Cats and dogs can be carriers of the virus.
medication to be given for the child
D. H5N6 least commonly infects aquatic birds.
D. It gives passageway for the overflow CSF to exit
76. The nurse instructs the communities in Nueva Ecija
ventricles
about prevention and treatment of bird’s flu. Which of
72. The patient with Spinal cord iunjury ask the primary the following is not part of her teaching?
reason why has to be turned every 2 hours. The nurse
A. A separate isolation facility is provided for those who
best response is
will contract the disease. – handled by higher public
A. Patient’s back is encouraged to be exposed to air so officials
perspiration is minimized
B. The chickens within a specified radius will be culled.
B. Turning is a form of exercise for a patient with
C. Do not transport chickens outside the area of
paralysis from waist down.
outbreak.
D. Wear appropriate personal protective equipment B. clients with hypothyroidism have increased
when working with poultry. susceptibility to all sedative drugs

Situation: You are a nurse giving care to patients in C. Sedatives will have a paradoxical effect on clients
the Emergency Department in Hospital Manila with hypothyroidism.

77. During a disaster, which principle is integral in D. Sedatives would cause fluid retention and
decision-making and providing health care to those hypernatremia.
who are victims?
82. Nausea and vomiting in which client is of greatest
A. Beneficence concern to the nurse?

B. non-maleficence A. Client postoperative ophthalmic surgery – inc, iop

C. Utilitarianism B. Client receiving chemotherapy – ondansentron -

antiemetic
D. Paternalism
C. Client with Ménière disease
78. A self-employed auto mechanic is diagnosed with
carbon monoxide poisoning. Admission vital signs are D. Client with severe gastroenteritis
blood pressure 90/42 mm Hg, pulse 84/min, respirations
Situation: Harold, a 26-year-old construction worker,
24/min, and oxygen saturation 94% on room air. What is
arrives in the Ear Clinic riding a Honda Motorcycle.
the nurse's priority action?
He is wearing a headset with Mp3 player hooked to
his belt. Harold is for hearing assessment.

83. Pure Tone Audiometry is ordered for Harold. Which

A. Administer 5 mg inhaled albuterol nebulizer treatment of the following does this procedure measure?
to decrease inflammatory bronchoconstriction L/min
A. Vestibular portion of the auditory nerve – balance and
B. Administer 100% oxygen using NRM with flow rate of spatial
15 l/min
B. Ear canal volume – tympanometry
C. Administer methylprednisolone to decrease lung
C. Structure of the car - otoscope
inflammation from toxic inhalant
D. Hearing acuity
D. Titrate oxygen to maintain pulse oximeter saturation
of >95% 84. Harold was found to have Mastoiditis. Which of the
following ear structure is affected?
79. A nurse is assisting in the care of a client who is to
be cardioverted. The nurse plans to set the defibrillator A. Tympanic membrane
to which to which of the following starting energy range
B. Pinna
levels, depending on the specific physician order?
C. Eustachian tube
A. 50 to 100 joules
D. Mastoid air cells
B. 150 to 200 joules – defib: shockable: pulseless
85. Which of the following is the most common cause of
C. 250 to 300 joules – vtach, vfib
Mastoiditis?
D. 350 to 400 joules

80. A nurse has applied the patch electrodes of

an automatic external defibrillator (AED) to the chest A. Bone tumor
of a client who is pulseless. The defibrillator has
interpreted the rhythm to be ventricular fibrillation. B. Untreated Otitis Media
The nurse then:
C. Meningitis
A. Orders any personnel away from the client charges
D. Mastoid diseases
the machine and defibrillates through the console
86. Antibiotics have limited use in the actual treatment of
B. Performs cardiopulmonary resuscitation (CPR) for 1
Mastoiditis because________.
minute before defibrillating
A. Tissue destruction is extensive
C. Charges the machine and immediately pushes the
"discharge" buttons on the console B. It is a long-term treatment
D. Administers rescue breathing during the defibrillation C. antibiotics do not easily penetrate the infected bony
structure of the mastoid
81. A woman with hypothyroidism asks the nurse why
the doctor told her she cannot have a sedative. The D. Culture has to be done to identify which antibiotic is
nurse’s response is based on which of the following most effective for the treatment of Mastoiditis
facts?
87. Which of the following is the most common treatment
for Mastoiditis?

A. Mastoidectomy only

B. Mastoidectomy with tympanoplasty

A. Sedatives potentiate thyroid replacement medication.
 complains of pain on the occipital part of his head. Nurse
Rey knows that this patient is classified under:
C. Antibiotics with tympanoplasty

D. Antibiotics

Situation: You are a staff nurse at the Neurology unit

of the Pediatric Ward.

88. You have a patient for admission who has been

diagnosed with Bacterial Meningitis. Which of the
following type of isolation should you implement?

A. Contact precaution – gloves and gown

B. Universal precaution – all patients

A. ES 1
C. Airborne precaution – N95 + negative air pressure =
MTV, measles, tb, varicella B. ES 2

D. Droplet precaution – surgical mask C. ES3

89. The attending physician of Mr V who has Cerebral D. ES4

Palsy and a seizure disorder prescribed Tegretol-XR for
93. Nurses are expected to be competent in prioritizing.
him. Master V has a gastrostomy feeding tube. The
In performing an emergency assessment for the
medication prescribed is on the hospital’s “No crush list”.
injured passengers, Nurse Jake knows that she
Which of the following you should do in order to
should prioritize:
administer the medication?
A. Breathing assistance
A. Ask the pharmacist for oral suspension
B. Stable hemodynamics
B. Contact the attending physician to change the order
C. Airway clearance
C. Dissolve the medication in 30 ml. of orange juice
D. Infection control
D. Cut the medication into small pieces to be places to
be placed in the feeding tube 94. Nurse Jake receives and assesses an injured
patient. He referred to the resident- on-duty that the
90. You have been observed by your nurse manager that
patient is possibly experiencing hypovolemic
when you gave the I.V. medication, you disconnected the
shock. Which of the findings best supports this?
flush syringe first and then clamped the intermittent
infusion device. Which of the following would be the A. PR-112bpm, RR-27cpm, BP-80/60mmHg
most effective way to improve this nursing practice?
B. PR-55bpm, RR-30cpm, BP-130/80mmHg
A. post an evidence-based article on administration of IV
medication in the neurological unit C. PR-53bpm, RR-11cpm, BP-140/90mmHg

B. Send a group e-mail discussing the importance of D. PR-98bpm, RR-18cpm, BP-100/60mmHg

clamping the device first
95. Another patient rushed into the hospital sustained a
C. Create a poster presentation on administration of I.V. concussion during the accident. Nurse Dannica
assesses that he opens his eyes spontaneously and
D. Ask each nurse if they are aware that their practice is obeys commands. After assessment, she gives him a
obsolete GCS score of 14. Given the circumstances, which
among the following is the priority nursing diagnosis?
Situation: Nurse Jake receives a call informing the
ER department of Hospital X that a bus fell off a cliff. A. Acute pain
Several passengers were severely injured and will
be brought to the hospital. Nurse Jake informs her B. Risk for infection
co-staff and starts preparing to cater the injured
C. Impaired physical mobility
passengers.
D. Risk for injury
91. Being an ER nurse, Jake knows that triaging is a skill
that she must master. She is aware that triaging is Situation: A 46-year-old male patient is brought to
performed in order to: the emergency department with chief complaint of
cervical lymphadenopathy which started a week
A. Prioritize those who are capable of paying
prior to consult. The primary impression is
B. Give way to those who can be treated easier, followed Hodgkin’s Lymphoma.
by those critically-ill

C. Sort patients who will likely survive or not.

D. Direct all available resources to the most critically ill

patients

92. ER nurses in Hospital X uses the 5-level of

emergency severity index (ESI). Nurse Jake received
a patient who is conscious but disoriented and
 D. Serum potassium of 5 mE

3-5 – 5.5

100. What will be the most appropriate nursing

diagnosis for patients undergoing chemotherapy?

A. Risk for injury r/t radioactive damage to epidermal and

dermal layers

B. Fatigue r/t decreased oxygen-carrying capacity

C. Risk for infections r/t to immunosuppressive effects of

chemotherapy

D. Impaired tissue integrity r/t decreased tissue

perfusion

RECALLS 6 NP5

96. In the later course of the condition, which of these 1. Mental health is defined as:
are expected manifestations?
A. The ability to distinguish what is real from what is not.

B. A state of well-being where a person can realize his

own abilities can cope with normal stresses of life and
work productively.

C. Is the promotion of mental health, prevention of

mental disorders, nursing care of patients during illness
A. Fever, night sweats, weight loss
and rehabilitation
B. Diarrhea, abdominal pain, hematochezia
D. Absence of mental illness
C. Bleeding tendencies, petechiae, melena
2. Which of the following describes the role of a
D. Ascites, jaundice, anorexia technician?

97. The nurse assigned to the patient notes knowledge - medication/treatment, assessment, documentation
deficit on self-care and risk prevention. What should
A. Administers medications to a schizophrenic patient.
the nurse do to challenge this noted nursing diagnosis?
B. The nurse feeds and bathes a catatonic client –
A. Document the nursing diagnosis with the observed
parent surrogate
cues.
C. Coordinates diverse aspects of care rendered to the
B. Plan a health teaching
patient – ward manager
C. Start a meeting with patient’s SOs
D. Disseminates information about alcohol and its
D. Refer to the physician. effects. - teacher

98.The patient asks the nurse, “Why am I given four 3. Liza says, “Give me 10 minutes to recall the name of
chemotherapeutic drugs all at once over a our college professor who failed many students in our
prolonged duration?” The nurse responds with the anatomy class.” She is operating on her:
correct knowledge that:
A. Subconscious – partly remembered, partly forgotten
A. You may not respond to other drugs. Four drugs
B. Conscious
ensures that the cancer cells are killed.
C. Unconscious
B. If you have resistance to one drug, the other drugs
will do the chemotherapeutic action. D. Ego
C. Development to Stages III and IV is prevented. 4. The superego is that part of the psyche that:
D. the combination drugs have different synergistic A. Uses defensive function for protection – ego, defense
actions mechanism
99. Which laboratory finding of a patient receiving B. Is impulsive and without morals. – iD
chemotherapeutic drug will alert the nurse to contact the
physician? C. Determines the circumstances before making
decisions. - ego moderator
A. RBC count of 5 million/uL
D. The censoring portion of the mind. - conscience

5. Primary level of prevention is exemplified by:

B. WBC count of 1700/uL A. Helping the client resume self-care. – tertiary

B. Ensuring the safety of a suicidal client in the

institution. – secondary
C. Hemoglobin of 14 mg/dL
C. Teaching the client stress management techniques -
D. Case finding and surveillance in the community - 11. The client has which somatoform disorder?
secondary
A. Somatization Disorder - chronic syndrome of somatic
Situation: In a home visit done by the nurse, she symptoms that cannot be explained
suspects that the wife and her child are victims of medically>psychological distress
abuse.
B. Hypochondriasis – illness anxiety disorder, fear of
6. Which of the following is the most appropriate for the having serious illness, hypo = haay ma sakit yata ako
nurse to ask?
C. Conversion Disorder – functional neurological d/o –
- safety, direct!! loss of sensory or motor function = saw a traumatic
event > blind >> psycho distress
A. “Are you being threatened or hurt by your partner?
D. Somatoform Pain Disorder – severe and prolonged
B. “Are you frightened of you partner” - emotions
that cannot be explained medically (under somatization
C. “Is something bothering you?” - indirect d/o)

D. “What happens when you and your partner argue?” - 12. Freud explains anxiety as:
indirect
A. Strives to gratify the needs for satisfaction and
7. The wife admits that she is a victim of abuse and security
opens up about her persistent distaste for
B. Conflict between id and superego – ego, alleviate
sex. This sexual disorder is:
anxiety
A. Sexual desire disorder – little or no desire for sex
C. A hypothalamic-pituitary-adrenal reaction to stress –
B. Sexual arousal Disorder – failure to maintain the biomedical
physiologic requirements for sex
D. A conditioned response to stressors - behavioral
C. Orgasm Disorder – inability to reach peak sexual
13. The following are appropriate nursing diagnosis for
response
the client EXCEPT:
D. Sexual Pain Disorder – dyspareunia, before during,
A. Ineffective individual coping – distress + s/sx
after
symptoms
8. What would be the best approach for a wife who is still
B. Alteration in comfort, pain – pain is real
living with her abusive husband?
C. Altered role performance

D. Impaired social interaction

14. The following statements describe somatoform

A. “Here’s the number of a crisis center that you can call
disorders:
for help.”
A. Physical symptoms are explained by organic causes
B. “It’s best to leave your husband.” – never give an
– unexplained organic cause
opinion
B. It is a voluntary expression of psychological conflicts -
C. “Did you discuss this with your family?”
unconscious
D. “Why do you allow yourself to be treated this way”
C. Expression of conflicts through bodily symptoms
9. Which comment about a 3-year-old child if made by
D. Management entails a specific medical treatment
the parent may indicate child abuse?
15. What would be the best response to the client’s
A. “Once my child is toilet trained; I can still expect her to
repeated complaints of pain:
have some"
> acknowledge + reality
B. “When I tell my child to do something once, I don’t
expect to have to tell" A. “I know the feeling is real tests revealed negative
results.”
C. “My child is expected to try to do things such as,
dress and feed.” B. “I think you’re exaggerating things a little bit.”

D. “My 3-year-old loves to say NO.” C. “Try to forget this feeling and have activities to take it
off your mind”
10. The primary nursing intervention for a victim of child
abuse is: D. “So tell me more about the pain” – undue attention to
the physical symptom
A. Assess the scope of the problem
Situation: A nurse may encounter children with
B. Analyze the family dynamics
mental disorders. Her knowledge of these various
C. Ensure the safety of the victim disorders is vital.

D. Teach the victim coping skills 16. When planning school interventions for a child with a
diagnosis of attention deficit hyperactivity disorder, a
Situation: A 30-year-old male employee frequently guide to remember is to:
complains of low back pain that leads to frequent
absences from work. Consultation and tests reveal A. provide as much structure as possible for the child
negative results.
B. ignore the child’s overactivity.
C. encourage the child to engage in any play activity to A. overprotection of the child – reach their possible
dissipate energy maximum capacity

D. remove the child from the classroom when disruptive B. patience, routine and repetition
behavior occurs
C. assisting the parents set realistic goals
17. The child with conduct disorder will likely
D. giving reasonable compliments
demonstrate:
22. The parents express apprehensions on their ability
A. Easy distractibility to external stimuli. - ADHD
to care for their maladaptive child. The nurse
B. Ritualistic behaviors – autistic identifies what nursing diagnosis:

C. Preference for inanimate objects. A. Hopelessness – inability to mobilize resources

D. Serious violations of age-related norms. – aggression, B. altered parenting role – inability to create an
vandalism, stealing, lying, truancy environment for optimal growth and dev

18. Ritalin is the drug of choice for children with ADHD. C. altered family process – change in family relation and
The side effects of the following may be noted: function

> Ritalin also known as methylphenidate D. ineffective coping – inability to form valid appraisal of
the stressor
A. increased attention span and concentration
23. A 5-year-old boy is diagnosed to have autistic
B. increase in appetite – suppresses hunger and
disorder. Which of the following manifestations may be
prioritize nutrition
noted in a client with autistic disorder?
C. sleepiness and lethargy - insomnia
A. argumentativeness, disobedience, angry outburst –
D. bradycardia and diarrhea oppositional defiant disorder

19. School phobia is usually treated by: B. intolerance to change, disturbed relatedness,
stereotypes
A. Returning the child to the school immediately with
family support. – break the cycle of avoidance C. distractibility, impulsiveness and overactivity - adhd

B. Calmly explaining why attendance in school is D. aggression, truancy, stealing, lying – conduct disorder
necessary - illogical
24. The therapeutic approach in the care of an autistic
C. Allowing the child to enter the school before the other child include the following EXCEPT:
children
A. Engage in diversionary activities when acting -out
D. Allowing the parent to accompany the child in the
B. Provide an atmosphere of acceptance
classroom – part of tactic
C. Provide safety measures
20. A 10-year-old child has very limited vocabulary and
interaction skills. She has an I.Q. of 45. D. Rearrange the environment to activate the child
She is diagnosed to have Mental retardation of this
25. According to Piaget a 5-year-old is in what stage of
classification:
development:
A. Profound
A. Sensory motor stage – 0 to 2 years old >
B. Mild symbols/senses

C. Moderate B. Concrete operations – 6 to 12 years old > inductive

reasoning>conservation
D. Severe
C. pre-operational – 2 to 6 years old > language,
symbols, time

D. Formal operation – 12 years old to adulthood,

abstract, deductive

Situation: The nurse assigned in the detoxification

unit attends to various patients with substance-
related disorders.

26. A 45 years old male revealed that he experienced a

marked increase in his intake of alcohol to achieve the
desired effect This indicates:

A. Withdrawal – s/sx that occur after ingestion of a

substance

B. Tolerance – increase in the amount of substance to

21. The nurse teaches the parents of a mentally achieve the same effects
retarded child regarding her care. The following C. Intoxication – behavioral changes that occur upon
guidelines may be taught except: ingestion of a substance
D. psychological dependence – intake of substance to 31. The daughter revealed that the client used her
prevent withdrawal toothbrush to comb her hair. She is manifesting:

27. The client admitted for alcohol detoxification A. Apraxia

develops increased tremors, irritability, hypertension and
fever. The nurse should be alert for impending:

B. Aphasia

C. Agnosia

D. amnesia
A. delirium tremens – most extreme CNS irritability d/t
alcohol withdrawal

B. Korsakoff’s syndrome – kronik, deficiency in vit b

thiamine > severe memory loss > confabulation (to fill in
memory gaps)

C. esophageal varices – complication of liver cirrhosis >

emergency; scissors

D. Wernicke’s syndrome – acute def. om vit B thiamine –

ataxia 32. She tearfully tells the nurse “I can’t take it when she
28. The care for the client places priority to which of the accuses me of stealing her things.” Which response by
following: the nurse will be most therapeutic?

A. Monitoring his vital signs every hour A.” Don’t take it personally. Your mother does not mean
it.”
B. Providing a quiet, dim room
B. “Have you tried discussing this with your mother?”
C. Encouraging adequate fluids and nutritious foods
C. “This must be difficult for you and your mother.”
D. Administering Librium as ordered
D. “Next time ask your mother where her things were
29. Another client is brought to the emergency room by last seen.”
friends who state that he took something an hour ago.
He is actively hallucinating, agitated, with irritated nasal 33. The primary nursing intervention in working with a
septum. client with moderate stage dementia is ensuring that the
client:
A. Heroin – euphoria + impairment in judgement +
pupillary constriction A. receives adequate nutrition and hydration

B. Cocaine – CNS stimulant B. will reminisce to decrease isolation

C. LSD – hallucinogen > grandiosity + hallucination + C. remains in a safe and secure environment
synesthesia D. independently performs self-care
D. marijuana – slowed time sensation + conjunctival 34. She says to the nurse who offers her breakfast, “Oh
redness + impaired judgement no, I will wait for my husband. We will eat together” The
30. A client is admitted with needle tracts on his arm, therapeutic response by the nurse is:
stuporous and with pin point pupil will likely be managed A. “Your husband is dead. Let me serve you your
with: breakfast.”
A. Naltrexone (Revia) B. “I’ve told you several times that he is dead. It’s time to
eat.”

C. “You’re going to have to wait a long time.”

B. Narcan (Naloxone)
D. “What made you say that your husband is alive?

35. Dementia unlike delirium is characterized by:

C. Disulfiram (Antabuse) A. slurred speech

B. insidious onset

D. Methadone (Dolophine) C. clouding of consciousness

D. sensory perceptual change

Situation: An old woman was brought for evaluation

due to the hospital for evaluation due to increasing
forgetfulness and limitations in daily function.
 40. A nursing diagnosis for bulimia nervosa is
powerlessness related to feeling not in control of eating
habits. The goal for this problem is:

A. Patient will learn problem solving skills

B. Patient will have decreased symptoms of anxiety.

C. Patient will perform self-care activities daily.

D. Patient will verbalize how to set limits on others.

41. In the management of bulimic patients, the following

Situation: A 17-year-old gymnast is admitted to the
nursing interventions will promote a therapeutic
hospital due to weight loss and dehydration
relationship EXCEPT:
secondary to starvation.
A. Establish an atmosphere of trust
36. Which of the following nursing diagnoses will be
given priority for the client? B. Discuss their eating behavior.
A. altered self-image C. Help patients identify feelings associated with binge-
purge behavior
B. fluid volume deficit
D. Teach patient about bulimia nervosa
C. altered nutrition less than body requirements
Situation: A 35-year-old male has intense fear of
D. altered family process
riding an elevator. He claims “As if I will die inside.”
37. What is the best intervention to teach the client when This has affected his studies.
she feels the need to starve?
42. The client is suffering from:
A. Allow her to starve to relieve her anxiety
A. A agoraphobia
B. Do a short-term exercise until the urge passes

C. Approach the nurse and talk out her feelings

B. social phobia
D. Call her mother on the phone and tell her how she
feels

38. The client with anorexia nervosa is improving if: C. Claustrophobia

A. She eats meals in the dining room. – purging type
anorexia

B. Weight gain – 1 to 2 lbs per week D. xenophobia

C. She attends ward activities.

D. She has a more realistic self-concept. 43. Initial intervention for the client should be to:*
39. The characteristic manifestation that will differentiate 1 point
bulimia nervosa from anorexia nervosa is that bulimic
individuals A. Encourage to verbalize his fears as much as he
wants.
A. have episodic binge eating and purging
B. Assist him to find meaning to his feelings in relation to
B. have repeated attempts to stabilize their weight his past.
C. have peculiar food handling patterns C. Establish trust through a consistent approach.
D. have threatened self-esteem D. Accept her fears without criticizing.

44. The nurse develops a countertransference (nurse to

patient) reaction. This is evidenced by:

A. Revealing personal information to the client

B. Focusing on the feelings of the client.

C. Confronting the client about discrepancies in verbal or

non-verbal behavior

D. The client feels angry towards the nurse who

resembles his mother.

45. Which is the desired outcome in conducting

desensitization (gradual exposure):

A. The client verbalizes his fears about the situation

B. The client will voluntarily attend group therapy in the

social hall.
C. The client will socialize with others willingly 51. Which is the best indicator of success in the long-
term management of the client?
D. The client will be able to overcome his disabling fear.
A. His symptoms are replaced by indifference to his
46. Which of the following should be included in the
feelings
health teachings among clients receiving Valium:
B. He participates in diversionary activities.
> diazepam, under benzodiazepine > depressant
C. He learns to verbalize his feelings and concerns
A. Avoid taking CNS depressants like alcohol.
D. He states that his behavior is irrational.
B. There are no restrictions in activities.
Situation: A young woman is brought to the
emergency room appearing depressed. The nurse
learned that her child died a year ago due to an
C. Limit fluid intake.
accident.
- dry mouth
52. The initial nursing diagnosis is dysfunctional grieving.
D. Any beverage like coffee may be taken The statement of the woman that supports this diagnosis
is:
Situation: A 20-year-old college student is admitted
to the medical ward because of sudden onset of A. “I feel envious of mothers who have toddlers”
paralysis of both legs. Extensive examination
B. “I haven’t been able to open the door and go into my
revealed no physical basis for the complaint.
baby’s room “
47. The nurse plans intervention based on which correct
C. “I watch other toddlers and think about their play
statement about conversion disorder?
activities and I cry.”
A. The symptoms are conscious effort to control anxiety -
D. “I often find myself thinking of how I could have
B. The client will experience high level of anxiety in prevented the death.
response to the paralysis.
53. The client said “I can’t even take care of my baby. I’m
C. The conversion symptom has symbolic meaning to good for nothing.” Which is the appropriate nursing
the client diagnosis?

D. A confrontational approach will be beneficial for the A. Ineffective individual coping related to loss.
client.
B. Impaired verbal communication related to inadequate
48. Nina reveals that the boyfriend has been pressuring social skills.
her to engage in premarital sex. The most therapeutic
C. Low esteem related to failure in role performance
response by the nurse is:
D. Impaired social interaction related to repressed anger.
A. “I can refer you to a spiritual counselor if you like.”
54. The following medications will likely be prescribed for
B. “You shouldn’t allow anyone to pressure you into sex.”
the client EXCEPT:
C. “It sounds like this problem is related to your
A. Prozac
paralysis.”

D. “How do you feel about being pressured into sex by

your boyfriend?”
B. Tofranil
49. Malingering (factitious disorder) is different from
somatoform disorder because the former:

A. Has evidence of an organic basis.

C. Parnate

B. It is a deliberate effort to handle upsetting events D. Zyprexa

C. Gratification from the environment are obtained. 55. Which is the highest priority in the post ECT care?

A. Observe for confusion

B. Monitor respiratory status

D. Stress is expressed through physical symptoms.
C. Reorient to time, place and person
50. Unlike psychophysiologic disorder Linda may be
best managed with: D. Document the client’s response to the treatment

A. medical regimen Situation: A 27-year-old writer is admitted for the

second time accompanied by his wife. He is
B. milieu therapy demanding, arrogant talked fast and hyperactive.
C. stress management techniques 56. Initially the nurse should plan this for a manic client:
D. psychotherapy A. set realistic limits to the client’s behavior
B. repeat verbal instructions as often as needed Situation: A widow age 28, whose husband died one
year ago due to AIDS, has just been told that she has
C. allow the client to get out feelings to relieve tension
AIDS.
D. assign a staff to be with the client at all times to help
61. Pamela says to the nurse, “Why me? How could God
maintain control
do this to me?” This reaction is one of:
57. An activity appropriate for the client is:
A. Depression

B. Denial
A. table tennis C. Anger
B. Painting D. bargaining
C. Chess 62. The nurse’s therapeutic response is:
D. cleaning A. “I will refer you to a clergy who can help you
understand what is happening to you.”
58. The client is arrogant and manipulative. In
ensuring a therapeutic milieu, the nurse does one B. “It isn’t fair that an innocent like you will suffer from
of the following: AIDS.”
> therapeutic milieu – adjusting environment C. “That is a negative attitude.”
A. Agree on a consistent approach among the staff D.” It must really be frustrating for you. How can I best
assigned to the client. help you?”
B. Suggest that the client take a leading role in the social 63. One morning the nurse sees the client in a
activities depressed mood. The nurse asks her “What are you
thinking about?” This communication technique is:
C. Provide the client with extra time for one-on-one
sessions A. Focusing
D. Allow the client to negotiate the plan of care B. Validating
59. The nurse exemplifies awareness of the rights of a C. Reflecting
client whose anger is escalating by:
D. giving broad opening
A. Taking a directive role in verbalizing feelings
64. The client says to the nurse” Pray for me” and
B. Using an authoritarian, confrontational approach entrusts her wedding ring to the nurse. The nurse knows
that this may signal which of the following:
C. Putting the client in a seclusion room
A. Anxiety
D. Applying mechanical restraints
B. suicidal ideation
60. A client on Lithium has diarrhea and vomiting. What
should the nurse do first: C. Major depression
A. Recognize this as a drug interaction D. Hopelessness
B. Give the client Cogentin 65. Which of the following interventions should be
prioritized in the care of the suicidal client?

A. Remove all potentially harmful items from the client’s

C. Reassure the client that these are common side room.
effects of lithium therapy
B. Allow the client to express feelings of hopelessness.
D. Hold the next dose and obtain an order for a stat
serum lithium level C. Note the client’s capabilities to increase self-esteem.

D. Set a “no suicide” contract with the client.

Situation: A 14-year-old male was admitted to a

medical ward due to bronchial asthma after learning
that his mother was leaving soon for U.K. to work as
nurse.

66. The client has which of the following developmental

focus:

A. Establishing relationship with the opposite sex and

career planning. – adolescent stage

B. Parental and societal responsibilities. – middle

adulthood

C. Establishing one’s sense of competence in school. –

school age

D. Developing initial commitments and collaboration in

work – young adulthood
67. The personality type of Ryan is: 73. The sexual response cycle in which the sexual
interest continues to build:
A. Conforming – non assertive > HTN (repressed rage)
A. Sexual Desire
B. Dependent – low grade state of anxiety and stress =
trigger sns > hyperactive airway > prone spams B. Sexual arousal

C. Perfectionist – migraine > inability to complete tasks C. Orgasm

D. masochistic – rheumatoid arthritis > chronic stress > D. Resolution

trigger immune system
74. The inability to maintain the physiologic requirements
68. The nurse ensures a therapeutic environment for the in sexual intercourse is:
client. Which of the following best describes a
A. Sexual Desire Disorder
therapeutic milieu?
B. Sexual Arousal Disorder
A. A therapy that rewards adaptive behavior
C. Orgasm Disorder
B. A cognitive approach to change behavior
D. Sexual Pain disorder
C. A living, learning or working environment.
75. The nurse asks a client to roll up his sleeves so she
can take his blood pressure. The client replies “If you
want I can go naked for you.” The most therapeutic
D. A permissive and congenial environment response by the nurse is:

69. Included as priority of care for the client will be: A. “You’re attractive but I’m not interested.”

A. Encourage verbalization of concerns instead of B. “You wouldn’t be the first that I will see naked.”
demonstrating them through the body
C. “I will report you to the guard if you don’t control
B. Divert attention to ward activities yourself.”

C. Place in semi-fowlers position and render O2 D. “I only need access to your arm. Putting up your
inhalation as ordered sleeve is fine.”

D. Help her recognize that her physical condition has an Situation: Knowledge and skills in the care of violent
emotional component clients is vital in the psychiatric unit. A nurse
observes that a client with a potential for violence is
70. The client is concerned about his coming discharge, agitated, pacing up and down the hallway and
manifested by being unusually sad. Which is the most making aggressive remarks.
therapeutic approach by the nurse?
76. Which of the following statements is most
A. “You are much better than when you were admitted so appropriate to make to this patient?
there’s no reason to worry.”
A. What is causing you to become agitated?
B. “What would you like to do now that you’re about to
go home?” B. You need to stop that behavior now.

C. “You seem to have concerns about going home.” C. You will need to be restrained if you do not change
your behavior.
D. “Aren’t you glad that you’re going home soon?”
D. You will need to be placed in seclusion.
Situation: The nurse may encounter clients with
concerns on sexuality. 77. The nurse closely observes the client who has been
displaying aggressive behavior. The nurse observes that
71. The most basic factor in the intervention with clients the client’s anger is escalating. Which approach is least
in the area of sexuality is: helpful for the client at this time?
A. Knowledge about sexuality. A. Acknowledge the client’s behavior
B. Experience in dealing with clients with sexual B. Maintain a safe distance from the client
problems
C. Assist the client to an area that is quiet
C. Comfort with one’s sexuality
D. Initiate confinement measures
D. Ability to communicate effectively
78. The charge nurse of a psychiatric unit is planning the
72. Which of the following statements is true for gender client assignment for the day. The most appropriate staff
identity disorder? to be assigned to a client with a potential for violence is
A. It is the sexual pleasure derived from inanimate which of the following:
objects. - fetishism A. A timid nurse
B. It is the pleasure derived from being humiliated and B. A mature experienced nurse
made to suffer - masochism
C. an inexperienced nurse
C. It is the pleasure of shocking the victim with exposure
of the genitalia - exhibitionism D. a soft-spoken nurse

D. It is the desire to live or involve in reactions of the 79. The nurse exemplifies awareness of the rights of a
opposite sex client whose anger is escalating by:
A. Taking a directive role in verbalizing feelings D. Preoccupation with perfectionism, orderliness and
need for control - ocpd
B. Using an authoritarian, confrontational approach
85. The plan of care for clients with borderline
C. Putting the client in a seclusion room
personality should include:
D. Applying mechanical restraints
A. Limit setting and flexibility in schedule
80. The client jumps up and throws a chair out of the
B. Giving medications to prevent acting out
window. He was restrained after his behavior can no
longer be controlled by the staff. Which of these C. Restricting her from other clients
documentations indicates the safeguarding of the
D. Ensuring she adheres to certain restrictions
patient’s rights?
Situation: A 42-year-old male client, is admitted in
A. There was a doctor’s order for restraints/seclusion
the ward because of bizarre behaviors. He s given a
B. The patient’s rights were explained to him. diagnosis of schizophrenia paranoid type.

C. The staff observed confidentiality 86. The client should have achieved the developmental
task of:
D. The staff carried out less restrictive measures but
were unsuccessful. A. Trust vs. mistrust – 0 to 1 y.o

Situation: Clients with personality disorders have B. Industry vs. inferiority – 6 to 12

difficulties in their social and occupational
C. Generativity vs. stagnation – 40 to 65
functions.
D. Ego integrity vs. despair - 65
81. Clients with personality disorder will most likely:
87. Clients who are suspicious primarily use projection
A. recover with therapeutic intervention
for which purpose:
B. responds to antianxiety medication
A. deny reality
C. manifest enduring patterns of inflexible behaviors
B. to deal with feelings and thoughts that are not
D. Seek treatment willingly from some personally acceptable
distressing symptoms
C. to show resentment towards others
82. A client tends to be insensitive to others, engages in
D. manipulate others
abusive behaviors and does not have a sense of
remorse. Which personality disorder is he likely to have? 88. The client says “the NBI is out to get me.” The
nurse’s best response is:
A. Narcissistic
A. “The NBI is not out to catch you.”

B. “I don’t believe that.”

B. Paranoid
C. “I don’t know anything about that. You are afraid of
being harmed.”

C. Histrionic D. “What made you think of that.”

89. The client on Haldol has pill rolling tremors and

muscle rigidity. He is likely manifesting:
D. Antisocial
A. tardive dyskinesia
83. The client joins a support group and frequently
preaches against abuse, is demonstrating the use of:

A. Denial B. Pseudoparkinsonism

B. reaction formation

C. Rationalization C. Akinesia
D. projection

84. A teenage girl is diagnosed to have borderline

D. dystonia
personality disorder. Which manifestations support the
diagnosis?

>manipulative, splitting, good/bad

90. The client is very hostile toward one of the staff for
A. Lack of self-esteem, strong dependency needs and no apparent reason. The client is manifesting:
impulsive behavior
A. Splitting
B. social withdrawal, inadequacy, sensitivity to rejection
B. Transference
and criticism - avoidant
C. Countertransference
C. Suspicious, hypervigilance and coldness - paranoid
D. Resistance
Situation: An 18-year-old female was sexually and inability to focus with what the doctor was
attacked while on her way home from work. She is saying.
brought to the hospital by her mother.
96. The nurse assesses the level of anxiety as:
91. Rape is an example of which type of crisis:
A. Mild
A. Situational
B. Moderate

C. Severe

B. Adventitious D. Panic

C. Developmental

D. Internal

92. During the initial care of rape victims, the following

are to be considered EXCEPT:

A. Assure privacy.

B. Touch the client to show acceptance and empathy 97. Anxiety is caused by:

C. Accompany the client in the examination room. A. an objective threat

D. Maintain a non-judgmental approach. B. a subjectively perceived threat

93. The nurse acts as a patient advocate when she does C. hostility turned to the self
one of the following: D. masked depression
A. She encourages the client to express her feeling 98. It would be most helpful for the nurse to deal with a
regarding her experience. - counselor client with severe anxiety by:
B. She assesses the client for injuries - technician. A. Give specific instructions using speak in concise
C. She postpones the physical assessment until the statements.
client is calm B. Ask the client to identify the cause of her anxiety.
D. Explains to the client that her reactions are normal - C. Explain in detail the plan of care developed
teacher
D. Urge the client to focus on what the nurse is saying
94. Crisis intervention carried out to the client has this
primary goal: 99. Which of the following medications will likely be
ordered for the client?
A. Assist the client to express her feelings
A. Prozac - antidepressant
B. Help her identify her resources
B. Valium – antianxiety
C. Support her adaptive coping skills
C. Risperdal - antipsychotic
D. Help her return to her pre-rape level of function
D. Lithium - antimanic
95. Five months after the incident the client complains of
difficulty to concentrate, poor appetite, inability to sleep 100. Which of the following is included in the health
and guilt. She is likely suffering from: teachings among clients receiving Valium:

A. Adjustment disorder A. Avoid foods rich in tyramine. – MAOI

B. Take the medication after meals. – GI upset

C. It is safe to stop it any time after long term use. -

B. Somatoform Disorder
D. Double up the dose if the client forgets her
medication.

C. Generalized Anxiety Disorder

D. Post traumatic disorder

Situation: A 29-year-old client newly diagnosed with

breast cancer is pacing, with rapid speech headache