SITUATION 1

Nurse Kim cares for a 40-year-old male with electrolyte imbalance. On assessment, the nurse observes
the client to be confused, restless and lethargic.
 
1.    Nurse Kim carries out the order for the client to have a diagnostic test. Which of the
following values indicate hyponatremia? A sodium level _____
*
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A. Below 8.5 to 10.5 mg/dL
B. Between 3.5 and 5.5 mEgL
C. Above 145 mEg/L
D. Below 135 mEg/L
 
 
2. Nurse Kim is aware that the MOST common electrolyte abnormality in hospitalized patient is
______
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A. Hyperkalemia
B. Hyponatremia
 
C. Hypernatremia
D. Hypokalemia
 
3. Nurse Kim writes a nursing diagnosis. Which of the following diagnoses is MOST appropriate
for the client?
*
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A. Excess Fluid Volume
B. Ineffective Breathing Pattern
C. Deficient Fluid Volume
D. Disturbed Thought Processes
 
 
4. The physician prescribes intravenous solutions for the client. Which of the following solutions
is appropriate?
*
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A. 0.9 % Sodium Chloride
 
B. Dextran 6 % in sterile water
C. 0.3 % Sodium Chloride
D. Dextrose 5 % in water
 
5. An appropriate nursing intervention for the client is for Nurse Kim to________
*
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A. Maintain body alignment and assist with movement
B. Monitor level of consciousness
 
C. Administer oral hygiene
D. Monitor laboratory findings
SITUATION 2
The nurse cares for a group of clients with allergies.
 
6. The nurse assesses the client who says he is highly allergic to many food items and
medications. Which of the following hypersensitivity reactions would be responsible for this
type of clinical manifestation?
*
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A. Type 4, delayed sensitivity
B. Type 1, IgE mediated hypersensitivity
 
C. Type 2, cytotoxic hypersensitivity
D. Type 3, immune complex-mediated hypersensitivity
 
7. The nurse assesses an atopic client who had serious Type 1 hypersensitivity reactions. The
nurse is aware that the most severe form of a Type 1 hypersensitivity reaction is which of the
following conditions?
*
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A. Cell-mediated sensitivity
B. Dermatitis
C. Anaphylaxis
 
D. Bronchial asthma
 
8. A client is experiencing anaphylaxis. Which of the following actions by the nurse takes
HIGHEST priority?
*
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A. Administer epinephrine injection
 
B. Place the client in Trendelenburg position
C. Maintain an open airway
D. Administer emergency oxygen
 
9. The nurse develops a care plan for a client with a past history of anaphylaxis. Which drug
should the nurse instruct the client to always have it readily available to treat possible allergic
reaction?
*
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A. Diphenhydramine
B. Acetaminophen
C. Epinephrine
 
D. Acetyl Salicylic Acid
 
10. A client with a history of Type 1 hypersensitivity reaction is receiving immunotherapy. The
nurse administers the allergen injection and asks the client to wait for how many minutes so that
the immediate reactions can be treated?
*
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A. 5 – 15 minutes
 
B. 30 – 40 minutes
C. 60 minutes
D. 15 – 25 minutes
SITUATION 3
Nurse Em cares for a 30 year old male who suffered a spinal cord injury sustained in a sporting accident
which resulted in paraplegia. The following questions relate to the care of a client with a paraplegia.
 
11.The client is fortunate that the level of his injury did not affect his respiratory function. The
nurse understands that the cord segments involved in maintaining respiratory function are:
*
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A. C1-2
B. C3-4
 
C. C5
D. C6
 
12. Nurse Em understands that the LEAST effective method of preventing contractures of the
joints of the lower extremities would be to:
*
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A. Passively move the extremities through range of motion exercises.
B. Provide the client with active exercise instructions.
 
C. Maintain proper alignment in bed.
D. Change the client’s position every two hours.
 
13. Nurse Em plans care for the client which includes turning the client every two hours. This
nursing measure is necessary to:
*
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A. Improve circulation in the lower extremities.
B. Keep the client comfortable.
C. Prevent occurrence of pressure sores.
 
D. Prevent flexion contractures in the lower extremities.
 
14.  Nurse Em recognizes that an early major problem of the client with paraplegia is:
*
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A. Client education.
B. Bladder control.
 
C. Use of mechanical aids for ambulation.
D. Quadriceps setting
 
15. Nurse Em is aware that a complication the client with paraplegia may experience is
formation of urinary calculi. The factor that contributes to this condition is:
*
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A. High fluid intake
B. Increases loss of calcium for the skeletal system.
 
C. Inadequate kidney functioning.
D. Increased calcium intake.
SITUATION 4
A 63-year-old male arrives at the Out-Patient Department complaining of numbness and tingling
sensation of the lower extremities and pain in the legs upon exercising. The nurse suspects the client may
have Peripheral Arterial Disease (PAD).
 
16. The nurse asks the client the following questions. Which of the questions would determine
the risk factors of PAD?

1. “Do you smoke cigarettes?”

2. “Are you diabetic?”

3. “Are you hypertensive?”

4. “Do you exercise?”

5. “Do you drink alcohol?”
*
1/1
A. 2, 3, & 4
B. 1, 2, 3, 4, & 5
C. 1, 4, & 5
D. 1, 2, & 3
 
 
17. The client asks the nurse what the doctor meant when he heard him say that the client has
intermittent claudication. The nurses’ BEST response is, Intermittent claudication is_______
*
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A. Pain that can occur in the body with exercise
B. Pain in the leg when exercising
 
C. Pain in the leg that occurs when at rest
D. A tingling feeling of sensation in the hands
 
18. The nurse writes a nursing diagnosis of Ineffective Tissue Perfusion for the client. Which of
the following interventions is MOST appropriate for this nursing diagnosis?
*
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A. Keep his legs in dependent position
 
B. Elevate his legs
C. Take hot bath
D. Limit his daily activities.
 
19. The nurse writes another nursing diagnosis of Risk for Impaired Skin Integrity related to
decreased peripheral circulation. Which of the following interventions is MOST appropriate for
the nurse to instruct the client?
*
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A. Monitor the extremities for color, motion and sensation, and pulses.
B. Maintain an appropriate level of activity to promote circulation.
 
C. Avoid risk factors that may increase problems with Peripheral Arterial Disease.
D. Protect the legs from injury because the tissues are fragile.
 
20. Which of the following outcomes indicate that there is increased arterial blood supply to the
extremity of the client with peripheral arterial disease?
*
1/1
A. Reduced sensation to touch
B. Reduced muscle pain
 
C. Increased rubor
D. Decreased hair on the extremity
SITUATION 5
Nurse Rose is a newly registered nurse. She is assigned to the surgical unit of X hospital. She is aware of
the legal responsibilities when performing patient care. The following are situations she encountered in
the surgical unit with legal significance.
 
21. A patient is scheduled for abdominal surgery. Which of the following statements is a
responsibility of Nurse Rose in obtaining a consent form?

1. Ensure that the consent form has been signed and is attached to the chart of the patient before
the operation.

2. Witness the signing of the consent before the operation is performed.

3. Provide a detailed description of the operation before asking the patient to sign the consent
form

4. Answer questions that the patient may ask before the patient signs the consent form.
*
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A. 3 & 4
B. 1, 2 & 3
C. 1, 2 & 4
 
D. 1 & 3
 
22. Which of the following health care professionals is legally responsible for obtaining
informed consent for an invasive procedure? The ____
*
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A. Surgeon
 
B. Nurse Supervisor of the unit
C. Medical director
D. Registered nurse on duty
 
23. Nurse Rose documents her observation on a patient for abdominal surgery. Which of the
following statements is legally appropriate notation?
*
1/1
A. “The charge nurse spoke with the patient about the surgery”
B. “The surgeon committed an error in the medication dose to be given”
C. “Patient says he will sue the surgeon and the hospital if the operation turns out to be a failure.”
D. “Patient says he feels sharp and stabbing pain in the abdominal area.”
 
 
24. The attending physician writes an order of Do Not Resuscitate (DNR) on a patient who is
seriously ill. Which of the following is a responsibility of Nurse Rose? Nurse Rose should
________

1)  Carry out the order in the event the patient experiences sudden need for CPR

2)  Determine if there is a living will on the medical record of the patient

3)  Consult the policies and procedures of the Institution if she feels such DNR order is contrary
to the patient’s or family’s wishes.

4)  Refer to the Ethics Committee of the Institution the DNR order to determine appropriateness
of the order.
*
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A. 2 & 3
 
B. 1 & 3
C. 3 & 4
D. 1 & 2
 
25. The physician orders a dose of medication to be given to a patient before undergoing surgery.
Nurse Rose is aware that the dose is too high for the patient. She tries to locate the physician to
check the order but the physician is not available. Which of the following is the MOST
appropriate action Nurse Rose will take to ensure the safety of the patient?
*
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A. Notify the nurse supervisor immediately
B. Administer half of the dose of the medication ordered.
C. Administer the medication as ordered.
D. Withhold the medication.
 
SITUATION 6
The charge nurse in the Emergency Department calls for a crisis meeting to review principles in mass
casualty to enhance preparedness and improve emergency quality care.
 
26. Which of the following statements is NOT TRUE about emergency preparedness?
*
1/1
A. Hospitals should have an emergency preparedness plan that is tested through drills or actual
participation.
B. Generally, hospital employees participate seriously in emergency drills.
 
C. Emergency preparedness training and drills are standard functions of emergency departments of
hospitals.
D. Drills must involve the participation and collaboration of the community.
 
27. The charge nurse explains that mass casualty incidents are due to events such as the
following EXCEPT:
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A. Earthquakes
B. Severe weather phenomena.
C. Lightning strikes.
 
D. Transportation disasters.
 
28. The charge nurse reiterates the importance of using a disaster triage tag system. Clients that
have been “green-tagged” are those ________.
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A. With injuries of closed fracture, sprains, contusions and abrasions.
 
B. Who are expected to die or are dead already.
C. With major injuries such as open fractures and large wounds.
D. Experiencing hemorrhagic shock that requires immediate treatment.
 
29. The term NBC means nuclear, biological and chemical weapons of mass destruction. Which
of the following is an example of biologic terrorism agents?
*
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A. Vaccine
B. Nerve agent antidotes
C. Anthrax
 
D. Neoplastic agents
 
30. The charge nurse emphasizes the overall goal in a disaster situation which is ___.
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A. Saving as many lives as possible
B. Using a disaster triage system that categorizes triage priority by color and number.
C. Calling all emergency medical service providers from the hospital to attend the needs of the victims.
D. Doing the greatest good for the greatest number of people.
 
SITUATION 7
The nurse in the emergency department performs initial assessment on clients brought to the department.
The following questions pertain to assessment and nursing interventions
 
31. The nurse assesses a trauma client in pain who refuses pain medication. Which of the
following alternative methods to manage pain can the nurse use or recommend?

1)  Positioning/Splinting

2)  Application of heat and cold

3)  Non-therapeutic touch

4)  Guided imagery

5)  Humor
*
1/1
A. 1, 2, 3 & 5
B. 2, 4 & 5
 
C. 1, 2, 3, 4 & 5
D. 1, 2 & 5
 
32. The nurse assesses circulation of an adult trauma victim by palpating a central pulse. Which
of the arteries will the nurse palpate?
*
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A. Apical artery
 
B. Brachial artery
C. Femoral artery
D. Popliteal artery
 
33. The nurse performs complete spinal immobilization. The procedure includes the following
actions EXCEPT _____.
*
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A. Placing the client on the backboard
B. Placing a small pillow on the head.
 
C. Application of a rigid cervical collar.
D. Immobilization of the head and neck.
 
34. In inspecting a client’s airway, the nurse should observe the following, EXCEPT:
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A. Tongue obstructing the airway
 
B. Foreign objects that may have been lodged.
C. Loose teeth or dentures.
D. Condition of the tonsils.
 
35. The correct sequence of the primary assessment of trauma clients is ____.

1)  Open and inspect the client's airway while initiating or maintaining cervical spine protection.

2)  Palpate a central pulse for strength and rate.

3)  Conduct a brief neurologic assessment to determine the degree of disability as measured by
the client’s level of consciousness.

4)  Remove clothing so that all injuries can be quickly identified.

5)  Assess for spontaneous breathing.

*
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A. 2, 5, 1, 3 & 4
B. 1, 2, 3, 4 & 5
C. 1, 3, 2 & 5
D. 1, 5, 2, 3 & 4
 
SITUATION 8
A 38 year old female trauma victim is brought to the emergency department of X hospital.
 
36. The trauma client has a blood type of AB+. Which type of blood will the client need?
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A. AB-
B. AB+
C. Any type
 
D. O+ only
 
37. Nurse Pau continues to monitor the condition of the trauma client. The client is in
hypovolemic shock. Which of the following types of blood products should Nurse Pau prepare?
*
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A. Platelets
B. Packed red blood cells
C. Plasma
D. Whole blood
 
 
38.  Nurse Pau admits the client. What factors will assist the nurse in determining the
classification of a trauma client?

1)  Site the injury

2)  Speed of the vehicle

3)  Height of fall

4)  Mechanism of injury

*
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A. 2 & 4
B. 1, 2, 3, & 4
 
C. 1 & 3
D. 1, 2 & 4
 
39. The trauma client manifests a deviated trachea, jugular vein distention, and cyanosis. Nurse
Pau realizes that the trauma client is MOST likely demonstrating?
*
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A. Tension pneumothorax
 
B. Cervical spine injury
C. Blunt trauma to the chest
D. Acceleration-deceleration injury
 
40. The physician assesses the trauma client using the Champion Revised Scoring System. Nurse
Pau understands that the elements of this scoring system are which of the following: 

1)  Diastolic Blood Pressure

2)  Systolic Blood Pressure

3)  Heart Rate

4)  Glasgow Coma Scale

5)  Respiratory Rate

*
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A. 2, 4 & 5
 
B. 2, 3, 4 & 5
C. 1, 3 & 5
D. 1, 2, 3, 4 & 5
SITUATION 9
The nurse assists in the care of a 20-year old male client needing blood transfusion. The attending
physician writes an order of blood transfusion of 250 cc of packed red cells after blood cross matching.
 
41. Before infusing the blood, the nurse assesses the client’s ________.
*
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A. Vital signs
 
B. Mental state
C. Skin color
D. Hemoglobin and hematocrit levels
 
 42. The nurse takes the temperature of the client. The temperature registers 39⁰C. Based on this
finding, the nurse should:
*
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A. Administer an antihistamine and transfuse the blood.
B. Start the blood transfusion as ordered.
C. Withhold the blood transfusion and notify the physician.
 
D. Give tepid sponge bath and wait for the temperature to go down then transfuse the blood.
 
43. Which of the following nursing interventions should have the HIGHEST priority when
caring for a client receiving blood transfusion?
*
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A. Regulate the drops accurately.
B. Instruct the client to notify the nurse if the client experiences itchiness, headache or difficulty of
breathing.
 
C. Document the blood type, time transfusion started, and vital signs taken.
D. Inform the client that the transfusion may last for one and a half to two hours.
 
44. The nurse administers the blood and starts the transfusion at 20 – 25 drops per minute. The
nurse observes for a transfusion reaction which usually occurs during the _____ minutes after
transfusion.
*
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A. 15 minutes
 
B. 45 minutes
C. 5 minutes
D. 30 minutes
 
45. The client receiving blood transfusion begins to wheeze on respiration, itch and observes that
his skin becomes flushed with hives. The nurse recognizes these signs as characteristic of what
type of reaction?
*
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A. Bacterial
B. Hemolytic
C. Allergic
 
D. Systemic
SITUATION 10
Nurse Olan works the day shift in the female medical unit. Nurse Olan is aware that when caring for
clients, the nursing process can be an effective tool for communication.
 
46. Nurse Olan understands that the MOST important aspect of communication is to_____
*
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A. Observe the facial expressions of your patients.
B. Clarify the statements made.
C. Listen to what is being said.
 
D. Restate the words you hear from the client.
 
47. Which of the following activities will Olan consider to validate effectiveness of a nurse-
client communication?
*
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A. Assessment of the physician.
B. Feedback from the client.
 
C. Adaptation of the client to physiologic changes.
D. Conference with the members of the health team.
 
48. Nurse Olan formulates nursing diagnoses for her clients. She knows that a nursing diagnosis
represents the:
*
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A. Prepared plan of care.
B. Actual nursing interventions carried out.
C. Nursing judgments about the health of her patients.
D. Actual or potential health problems of her patients.
 
 
49. Nurse Olan collects data and begins to develop a trust relationship with her clients. This
activity is what aspect of the nursing process?
*
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A. Evaluation
B. Implementation
C. Planning
D. Assessment
 
 
50. Nurse Olan understands that the nursing process is a scientific method and a proven form for:
*
1/1
A. Problem solving
 
B. Health education
C. Oral communication
D. Cost containment
SITUATION 11
Mr. M. E, 37 year old was accompanied by his wife and teen age daughter to the out patient department
for complaints of fever, fatiuge, malaise and painful swollen joints. The physician ordered that the Mr.
M.E be admitted to the hospital for observation and treatment. You are the admitting nurse in the OPD.
You found out during the interview that Mr. M. E does not have a regular job. His wife works as laundry
woman. 
 
51. Before admitting the client, you should FIRST make sure that: 
*
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a. The consent for admission is signed by the client.
 
b. The consenr for admission is signed by the wife and witnessed by the daughter.
c. The client can pay his hospital bills.
d. The consent form is signed by the social worker.
 
52. Mr. M.E id brough to the medical ward. The next day, he wants to know about his illness.
The nurse on duty replied, “You don’t need to know your diagnosis”. Which of following rights
of the patient is violated? Right to ______. 
*
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a. Obtain from his physician complete current information concerning his diagnosis, treatment and
prognosis.
 
b. Receive from his physician information necessary to give informed consent.
c. Expect reasonable continuity of care.
d. Considerate and respectful care, irrespective of one’s socio- economic status.
 
53. After five days of hospitalization, the physician said Mr. M.E can be discharged. He ordered
medications to be taken at home. The client is still weak and symptomatic. Which of the
following rights could be violated in this case? Right to ____. 
*
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a. Know hospital rules and regaulation
b. Privacy
c. Refuse treatment
d. Continuity of care
 
 
54. Because Mr. M.E cannot pay for his medical bills, he is referred to the social worker. Which
of the following rights is applicable on this case? The right to ___. 
*
1/1
a. Considerate and respectful care irrespective of his socio-economics status.
 
b. Expect reasonable continuity of care
c. Examine and receive an explanation of his medical bills regardless of the source of payment
d. Know what hospital rules and regulation apply to his conduct as a client.
 
55. The nurse discusses and shares the medical records of Mr. M.E to a group of visiting
members of a medical mission team. Which of the following rights could be violated? The right
to ___: 
*
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a. Expect that all communications and records pertaining to his care should be treated as
confidential.
b. Obtain information regarding any relationship of the hospital to another health care and educational
institution in so far as his care is concerned.
c. Informed consent
d. Privacy
 
SITUATION 12
Ms. Jenny is a charge nurse of an oncology unit. She prepares a unit plan to improve the delivery of
patient care and maximizing all human and material resources of the unit. 
 
56. Ms. Jenny implements a change in the nursing delivery system from functional to team
nursing. This type of nursing model of practice is: 
*
1/1
a. Nursing personnel are led by a registered nurse in providing care to a group of patients.
 
b. A task approach method used to provide care to patients.
c. Managed care concepts and tools are used in providing patient care.
d. A single registered nurse is responsible for providing care to a group of patients.
 
57. In implementing the change, Ms. Jenny has the consensus of the staff and other personnel
involved in the care of patients. The main purpose of achieving a consensus when making a
decision within a group is to ___. 
*
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a. Demonstrate that staff member are flexible
b. Facilitate cooperative effort toward goal achievement
 
c. Explore possible alternate solutions
d. Ensure the use of effective autocratic decision making
 
58. Ms. Jenny is aware that there are nursing and other personnel who may be resistant to the
change and are not taking an active part in facilitating the process of change. To overcome
resistance to change, the MOST important action by Ms. Jenny would be to ___. 
*
1/1
a. Emphasize the positive consequences of the change
b. Identify the reason or reasons for the resistance
 
c. State clearly and concisely the purpose of the change
d. Modify the objectives to appeal to more people holding key positions
 
59. To ensure efficiency when organizing daily workload, Ms. Jenny reminds her staff that they
should do which of the following: 
*
1/1
a. Organize care around legally required activities.
 
b. Plan activities to promote nursing convenience
c. Perform routine bed baths between 8:00 to 10:00 in the morning.
d. Provide care to a patient in isolation first.
 
60. Which of the following is the MOST effective resource in helping a staff nurse identify a
solution to a clinical problem?
*
1/1
a. Other staff nurses in the unit
b. Nursing procedure manual
 
c. Organizational chart of the hospital
d. Nurse manager of the unit
SITUATION 13
 A 55 year old male is admitted for complaints of joint pains, weakness, muscle spasm and stiffness when
waking up in the morning. He was diagnosed with Rheumatoid Arthritis (RA). 
 
61. Nurse Ray is aware that RA is a debilitating chronic auto-immune disease. The patient asks
the nurse why his joints are becoming increasingly painful. Which of the following statements is
TRUE about RA? Rheumatoid Arthritis ____. 
*
1/1
a. Is usually caused by the aging process
b. Results from degenerative joint damages
c. Begins with inflammation of joints synovial tissue
 
d. Affects only the weight bearing joints of the body
 
 62. The patient further complains that he gets tired easily when helping his wife in household
chores. He further complains that whenever he walks, his knee hurts. Based on this information,
Nurse Ray writes a nursing diagnosis. Which of the following nursing diagnoses is MOST
appropriate?
*
1/1
a. Activity intolerance related to fatigue and pain
 
b. Body image disturbance related to fatigue and pain
c. Ineffective individual coping related to chronic pain
d. Self- care deficit related to increasing joint pains
 
63. Nurse Ray develops a care plan for positioning the patient. Nurse Ray instructs the patient to
assume a position that would ___: 
*
0/1
a. Prevent venous stasis
b. Promote maximum support
c. Prevent flexion deformities of the joints
d. Decrease edema around the joints
 
Correct answer
c. Prevent flexion deformities of the joints
 
64. Nurse Ray writes a nursing diagnosis of activity intolerance related to lack of energy
conservation. Which of the following activities would Nurse Ray likely to choose to implement
in response to the diagnosis?
*
1/1
a. Encourage the patient to perform all tasks planned for the day.
b. Instruct the patient not to perform daily hygienic care until activity intolerance improves.
c. Administer narcotics to promote pain relief and rest
d. Encourage the patient to alternate periods of rest and activity throughout the day.
 
 
65. The patient is ready for discharge. He tell Nurse Ray, “I know it is important to exercise my
joints, so I won’t lose mobility. But my joints are so stiff and painful that exercise is difficult.
“Which of the following responses by Nurse Ray is MOST appropriate?
*
1/1
a. “Talk to your physician and tell him how you feel. Maybe he can increase the dosage of your pain
medication”.
b. “Take a warm bath before exercising. This may relieve some of your discomfort.”
 
c. “You are probably exercising too much. Decrease your exercise to every other day”.
d. “Stiffness and pain are part of your ailment. You can learn to cope by focusing on activities you
enjoy”.
SITUATION 14
The nurse cares for several clients with acid- based imbalances. 
 
66. The nurse is aware that a client who has experienced cardiac arrest is MOST at risk for which
of the following imbalances?
*
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a. Metabolic Alkalosis
b. Respiratory Alkalosis
c. Metabolic Acidosis
d. Respiratory Acidosis
 
Correct answer
c. Metabolic Acidosis
 
67. The nurse assists in the care of a 30 year old male post surgical client undergoing nasogastric
suctioning. The nurse understands that clients with nasogastrics suction is MOST at risk with
what imbalances?
*
1/1
a. Respiratory Acidosis
b. Metabolic Alkalosis
 
c. Metabolic Acidosis
d. Respiratory Acidosis
 
68. The nurse assesses a 32 year old female client who appears very anxious, restless and
irritable. The client has marked increase rate and depth of respirations. Based on the information
gathered, the client is experiencing which of the following imbalances?
*
0/1
a. Respiratory Alkalosis
b. Metabolic Acidosis
c. Metabolic Alkalosis
d. Respiratory Acidosis
 
69. The female client who is very anxious and fidgety is blowing off to much carbon dioxide
develops tingling sensation of the lips andfingers and is not able to control her respirations. The
most appropriate nursing intervention for the client is to ___:
*
1/1
a. Instrust the client to blow her nose and take deep breaths
b. Administer oxygen
c. Have the client breathe into a paper bag
 
d. Administer intravenous fluids as ordered
 
70. The nurse obtains a sample of a client’s arterial blood gas (ABGs). Which of the following
statements is NOT true about ABGs?
*
1/1
a. Interpretation of the client’s ABGs involves evaluation of pH, PCO2 and HCO3; components of the
ABGs.
b. ABGs assess the client’s oxygenation status and acid- base status.
c. ABGs provide information on blood parameters.
d. ABGs assess the client’s electrolyte and fluid balance.
 
SITUATION 15
Mila, a 35 year old female was brought in the Emergency Unit complaining of cold, clammy skin,
disorientation, restlessness and confusion. The nurse suspects the patient is developing cardiogenic
shock. 
 
71. Nurse Victor who admitted patient mila is aware that a decrease in cardiac output results in a
decrease in cerebral blood flow. Which of the following symptoms is one of the earliest sign of
cardiogenic shock?
*
1/1
a. Tachycardia
b. Altered level of consciousness
 
c. Presence of fourth heart sound (S4)
d. Decreased urine output
 
72. Nurse Victor assesses patient Mila. Decrease of which of the following factors would help
detect that the patient is at risk in developing cardiogenic shock?
*
1/1
a. Heart Rate
b. Cerebral blood flow
c. Cardiac Index
 
d. Blood Pressure
 
73. Nurse Victor reviews the medical history of patient Mila. Which of the following conditions
is the MOST common cause of cardiogenic shock?
*
1/1
a. Decreased hemoglobin level
b. Hypotension
c. Acute myocardial infarction (MI)
 
d. Coronary Artery Disease
 
74. Which of the following procedure would be most helpful to nurse victor to confirm the
underlying cause of cardiogenic shock?
*
1/1
a. Monitoring pulmonary artery pressure
b. Monitoring cardiac enzymes
c. Monitoring mean arterial pressure using an intra-arterial line.
d. Monitoring central venous pressure
 
 
75. The physician prescribes a treatment plan for patient Mila. Nurse victor understands that the
initial treatment goal is which of the following?
*
0/1
a. Prevent infection
 
b. Correct metabolic acidosis
c. Correct hypoxia
d. Increase myocardial oxygen supply
Correct answer
d. Increase myocardial oxygen supply
SITUATION 16
Ms. Dong-a 35 year old and a mother of two sought consultation at the OPD. She claims that she felt a
lump on her breast while doing a self- breast examination. On further examination, nurse Matilde
confirmed that the lump was felt in the upper outer quadrant of the right breast.
 
76. The nurse evaluates Ms. Dong-a for breast cancer. Which of the following is a risk factor for
developing breast cancer?
*
1/1
a. Using foam contraceptives
b. Having an early menarche before the age of 12
 
c. Having an early menopause before the age of 45
d. Giving birth to a first child before the age of 20
 
77. The nurse recalls that there are other known risk factors for breast cancer such as family
history, environmental and dietary factors. Which of the following is a best established dietary
factor breast cancer?
*
0/1
a. Fat- rich foods
b. Alcohol intake
 
c. Carbonated Drink consumption
d. Caffeine Consumption
Correct answer
a. Fat- rich foods
 
78. The nurse is aware that for breast cancer patients, the single and most important predictor of
outcome is the ___: 
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a. Presence of mastitis and an infection process upon diagnosis
b. Presence of nipple discharge at the time of diagnosis
c. Histologic status of the axillary nodes
 
d. Age of the patient
 
79. Ms. Dong-a appears to be worried and anxious. She asks the nurse what the doctor meant
when told that she has stage II cancer. The nurse explains that staging is based on the size of the
primary tumor. In Stage II, the tumor is ____:
*
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a. 3 Cm in diameter and confined to the breast
 
b. Larger than 5 cm with involvement of the internal mammary lymph nodes
c. 2 cm or less in diameter and confined to the breast
d. up to 5 cm or early metastasis to axillary lymph nodes
 
80. Based on further assessment, biopsy result, Ms. Dong-a may have to undergo mastectomy.
The nurse recognizes that mastectomy is the treatment of choice when which of the following
condition apply?

1.    Tumor involves the nipple-areola complex

2.    Tumor is larger than 7 cm

3.    Tumor exhibits extensive intraductal disease involving multiple quadrant of the breast

4.    Patient cannot comply with daily radiation therapy

*
···/1
a. 1,2 and 3
b. 2,3 and 4
c. 1,3 and 4
d. 1,2,3 and 4
 
SITUATION 17
Nurse Carol participated in a study the purpose of the which is to determine the extent to which gender,
age, weight and height predict selected physiologic outcome, namely: forced expiratory volume in one
second, hemoglobin concentration, food intake, serum glucose concentration, total serum cholesterol
concentration and cancer related weigh change. 
 
81. The independent variable of this study are the following, EXCEPT: 
*
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a. Height and weight
b. Age
c. Gender
d. Educational Attainment
 
 
82. The dependent variables of this study are which of the following: 
*
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a. Cancer
b. Physical Charcteristics
c. Amount of serum concentration
d. Physiologic outcomes
 
 
83. Nurse carol formulates the problem statement for the study. She understands that a good
problem has which of the following characteristics: The problem _____. 

1.    Clearly and unambiguously identifies the variables under consideration

2.    Clearly expresses the relationship of the variable to one another. 

3.    Specifies the nature of the population being studied.

4.    Implies the possibility of empirical testing.

*
1/1
a. 1,3 and 4
b. 1 and 3
c. all of the options
 
d. 2 and 4
 
84. Nurse Carol determines the participants in the study. The sample of the study will be every
5th person in the oncology unit. A table of random numbers will be used to select the beginning
of the sampling with in the first sampling interval. This is an example of which sampling
method?
*
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a. Simple random sampling
b. Quota sampling
c. Stratified random sampling
 
d. Systematic sampling
Correct answer
d. Systematic sampling
 
85. Nurse Carol plans to use a method of data collection that use technical instruments to collect
data the client’s physical, chemical, microbiological and anatomical status. Which of the
following is a method appropriate for the study?
*
1/1
a. Psychological
b. Physiological
 
c. Instrumentation
d. Pharmacological
SITUATION 18
You and your friends are enjoying a quiet meal in a restaurant. Suddenly you noticed that an adult male
customer was holding his throat and apparently choking on his food.
 
86. You approach the person who is apparently choking. What should you do first?
*
0/1
a. Sweep the person’s mouth with your finger.
b. Apply sharp upward thrusts over the person’s sternum
c. Determine if the person can make any verbal sounds.
d. Hit the middle of the person’s back firmly.
 
Correct answer
c. Determine if the person can make any verbal sounds.
 
87. You prepare to perform the Heimlich Maneuver on the conscious adult male. What are the
step to be followed? Arrange the procedure in sequence. 

1.    Place the thumb side of the fist just above the umbilicus and well below the xiphoid process.

2.    Make a fist

3.    Stand behind the victim

4.    Place arms around the victim’s waist

5.    Perform five quick in and up thrusts (between the umbilicus and xiphoid process)
*
1/1
a. 2,5,3,4,1
b. 1,2,3,4,5
c. 4,3,1,2,5
d. 3,4,2,1,5
 
 
88. If the victim is unconscious, the sequence is: 

1.    Place the heel of one hand on top of the bottom the umbilicus and xiphoid process.

2.    Straddle the victim’s thighs

3.    Give five thrusts in and up with heel of the bottom hand.

4.    Make a fist

*
1/1
a. 1,2,3
b. 1,2,3,4
c. 2,1,3
d. 2,4,1,3
 
 
89. When you perform abdominal thrusts during the heimlich maneuver, you are trying to __.
*
1/1
a. Produce a burp to expel the foreign body
b. Pump the heart to push air out of the lungs
c. Produce a rush of air that expels the foreign body
 
d. Put pressure on the stomach to expel the foreigh body
 
90. If the victim is pregnant or obese, which modification of the heimlich maneuver would be
appropriate for this person?
*
1/1
a. Thrust against the middle of the sternum rather than between the umbilicus and xiphoid process.
 
b. Perform thrusts gently, rather than forcefully and discontinue the thrusts after 6 tries, if unsucessful
c. Place the fist with the pinkie finger, rather than the thumb against the person’s body.
d. Perform the thrusts with the person in the supine, rather than standing position.
SITUATION 19
The nurse cares for a 4o year old female admitted with a diagnosis of chronic ulcerative colitis. The nurse
tries to communicate therapeutically with the client.
 
91. The nurse recalls that this client is her third admission in the last 8 months. The client is
familiar with the nurse. Which of the following remarks by the nurse would be most beneficial to
the client?
*
1/1
a. “You are back again. What is wrong this time?”
b. “I don’t have to explain things to you. You have been here before anyway”.
c. “It’s been 3 months since you were last here. How do you feel about being back in the hospital?”
 
d. “It’s nice to see you again. Do you mss the hospital?”
 
92. The physician assessess the client and recommends a partial bowel resection and an
ileostomy. The client tells the nurse, “My doctor likes to play smart. T’m sure the more he
operates, the better he likes it”. Which pf the following responses by the nurse would ne most
appropriate?
*
1/1
a. ” Are you not being hard on your doctors? He is trying to help you”.
b. “What do you mean by that?”
c. “You sound upset. We can talk about it, if you would like to.”
 
d. “Is your remarks in any way have something to do with your operation?”
 
93. The client becomes increasingly irritable thinking about her operation. She is unpleasant to
her visitors and refuses her medication and treatments. Which of the followingnursing
interventions would be therapeutics?
*
1/1
a. Encourage the client to direct her anger to her family members.
b. Continue performing assigned tasks and duties as though nothing has happened.
c. Encourage the client to discuss her feeling and concerns.
 
d. Offer the client positive reinforcement everytime she cooperates with her medications and treatments.
 
94. The client refuses to eat her lunch and angrily tells the nurse to get out of her room. What
would be the nurses’ best respnse?
*
1/1
a. “I’ll get you something to relax you”.
b. “You sound angry. What is upsetting you?”
 
c. “Your anger does not bother me. I’ll aback later”.
d. “I’ll leave, but you need to eat”.
 
95. The nurse made arrangement for a former client who underwent ileostomy to talk with client.
The reason for the which is to ___:
*
1/1
a. Encourage the client and provide realistic information on ileostomy.
 
b. Let the client know that she is not the only one who experienced the operation
c. Provide support for the plan of the physician regarding therapy of the client.
d. Convince the client that she will not be disfigured and can still lead quality life.
SITUATION 20
Ms. Ada is a nurse working in the surgical unit. She is aware of her legal responsibilities as she assists in
the care of post operative pateints. 
 
96. Which principle is applicable in a situation where a sponge was left inside the abdomen of a
patient who had an exploratory laparotomy?
*
1/1
a. Doctrine of Force Majeure (acts of God)
b. Doctrine of Res Ipsa Loquitor (injury speaks for itself)
 
c. Doctrine of Viz major (irresistible forces – manmade)
d. Doctrine of Respondeat Superior
 
97. Under the doctrine of respondeat superior, who among the following is liable if the patient
who had exploratory previously was reopened and a piece of gauze was found in the abdominal
cabity? The ___: 
*
1/1
a. Instrument Nurse
b. Surgeon
 
c. Operating Room Nurse
d. Assistant Surgeon
 
98. The doctrine of respondeat superior hold that: 
*
1/1
a. The employer is responsible for the actions of his/her employee.
 
b. The employer is not responsible for the actions of his/her employee.
c. The employee is not responsible for his/her own actions.
d. Using restraints without the patient’s permission constitue false imprisonment.
 
99. Performing an act which a resonable and prudent nurse would not do or the failure to perform
an act which a reasonble and prudent nurse would have done under similar situations is
construed as___. 
*
1/1
a. Misdemenor
b. Malfeasance
c. Malpratice (professional negligence)
d. Negligence
 
 
100. Ms. Ada learned of a nurse in the orthopedic ward who applied hot water bottle over a
paralyzed leg which consequently go burned. This is an example: 
*
1/1
a. Malfeasance
b. Misdemeanor
c. Malpractice
 
d. Negligence