MEDICAL

SURGICAL 1
JOHDEL CABALUNA
 CHOOSE ME
P I L I I N M O ‘ Y U N G TA M A PA R A D I
K A M A S A K TA N .
 SITUATION

Lydia is a staff nurse working in

medical unit with several patients
suffering from cardiovascular and
peripheral disorders.
1. There are several factors contributory to the
development of these conditions. Which of the
following are the PRIORITY causative factors that
should be emphasized by Nurse Lydia in her health
teaching?
A.Cigarette smoking and hyperlipidemia
B. Aging process and alcohol intake
C.Stress and overacidity
D.Sedentary life and obesity
1. There are several factors contributory to the
development of these conditions. Which of the
following are the PRIORITY causative factors that
should be emphasized by Nurse Lydia in her health
teaching?
A.Cigarette smoking and hyperlipidemia
B. Aging process and alcohol intake
C.Stress and overacidity
D.Sedentary life and obesity
2. Mr. Jacob is admitted due to congestive heart
failure. Nurse Lydia would expect that if the
failure is on the right side of the heart, the
patient will manifest which of the following?

A.Jugular vein distention

B. Crackles on auscultation
C.Dry protective cough
D.Orthopnea
2. Mr. Jacob is admitted due to congestive heart
failure. Nurse Lydia would expect that if the
failure is on the right side of the heart, the
patient will manifest which of the following?

A.Jugular vein distention

B. Crackles on auscultation
C.Dry protective cough
D.Orthopnea
3. The patient has been receiving Digoxin 0.25 mg
per day to regulate his heart rate. Which of the
following outcomes would indicate that this
medication is achieving its desired effect?

A.Improved appetite
B. Increased pedal edema
C.Increased urine elimination
D.Improved bowel elimination
3. The patient has been receiving Digoxin 0.25 mg
per day to regulate his heart rate. Which of the
following outcomes would indicate that this
medication is achieving its desired effect?

A.Improved appetite
B. Increased pedal edema
C.Increased urine elimination
D.Improved bowel elimination
4. The other patient of Ms. Lydia is suffering from
Buerger’s disease. He has been complaining of intermittent
claudication of the lower extremities which has been giving
him so much discomfort. What is the BEST nursing action
she should perform to address the patient’s complaint?

A.Allow the patient to lie flat on bed

B. Teach him foot care and leg exercises
C.Place affected extremities in a dependent position
D.Apply hot water bag to the affected extremities
4. The other patient of Ms. Lydia is suffering from
Buerger’s disease. He has been complaining of intermittent
claudication of the lower extremities which has been giving
him so much discomfort. What is the BEST nursing action
she should perform to address the patient’s complaint?

A.Allow the patient to lie flat on bed

B. Teach him foot care and leg exercises
C.Place affected extremities in a dependent position
D.Apply hot water bag to the affected extremities
5. Which of the following information is NOT true of
Buerger’s disease?

A.Small and medium arteries and veins are mostly

affected
B. Smoking is a major cause of Buerger’s
disease
C.Incidence of Buerger’s disease is high in men
than women
D.A strong relationship exists between
diabetes and Buerger disease
5. Which of the following information is NOT true of
Buerger’s disease?

A.Small and medium arteries and veins are mostly

affected
B. Smoking is a major cause of Buerger’s
disease
C.Incidence of Buerger’s disease is high in men
than women
D.A strong relationship exists between
diabetes and Buerger disease
 SITUATION
Rowena is a student nurse who has been suspected to
have a mitral valve prolapse (MVP) during the
annual physical examination of students enrolled in
X University. She was referred to a cardiologist for
further work-up. You are assigned to take care of her.
6. As a nurse, which of the following do you expect to be
manifested by Rowena as an early sign of Mitral Valve prolapse
during your physical assessment? A ________.

A. Diastolic click of the valve leaflet as a result of the

ballooning of the right atrium.
B. Diastolic click of the valve leaflet as a result of the
ballooning of the left atrium.
C. Systolic click of the valve leaflet as a result of the
ballooning of the left atrium.
D. Systolic click of the valve leaflet as a result of the
ballooning of the right atrium.
6. As a nurse, which of the following do you expect to be
manifested by Rowena as an early sign of Mitral Valve prolapse
during your physical assessment? A ________.

A. Diastolic click of the valve leaflet as a result of the

ballooning of the right atrium.
B. Diastolic click of the valve leaflet as a result of the
ballooning of the left atrium.
C. Systolic click of the valve leaflet as a result of the
ballooning of the left atrium.
D. Systolic click of the valve leaflet as a result of the
ballooning of the right atrium.
7. The patient remains to be asymptomatic for six months
and was very carefree in complying with the preventive
measures instructed by the health team. Choose from the
following the signs and symptoms that you further expect
from Rowena to manifest.

1. Fatigue 4. Anxiety
2. Dizziness 5. Shortness of breath
3. Palpitation

A.3, 4, & 5 C. 3 & 4

B. 1 & 2 D. 1, 2, 3, 4 & 5
7. The patient remains to be asymptomatic for six months
and was very carefree in complying with the preventive
measures instructed by the health team. Choose from the
following the signs and symptoms that you further expect
from Rowena to manifest.

1. Fatigue 4. Anxiety
2. Dizziness 5. Shortness of breath
3. Palpitation

A.3, 4, & 5 C. 3 & 4

B. 1 & 2 D. 1, 2, 3, 4 & 5
8. The BEST approach in assessing the EARLY
sign of Mitral valve prolapse is through
__________.

A. Percussion
B. Palpation
C. Inspection
D. Auscultation
8. The BEST approach in assessing the EARLY
sign of Mitral valve prolapse is through
__________.

A. Percussion
B. Palpation
C. Inspection
D. Auscultation
9. When an individual is suffering from MVP like
Rowena you should emphasize to her to AVOID the
following EXCEPT _______________.

A. Smoking
B. Alcoholic Beverages
C. Caffeine
D. Light Exercises
9. When an individual is suffering from MVP like
Rowena you should emphasize to her to AVOID the
following EXCEPT _______________.

A. Smoking
B. Alcoholic Beverages
C. Caffeine
D. Light Exercises
10. One of the nursing diagnoses that you have included in
your care plan for Ms. Rowena is “Excess volume R/T
decreased Cardiac output secondary to valvular disease”.
Which of the following is the POTENTIAL outcome if medical
and nursing interventions have been effectively implemented?
1. Adequate fluid volume is maintained.
2. Vital signs within normal limits.
3. Clear lung sounds.
4. Pulmonary congestion absent.

A. 1, 2 & 3 C. 1 & 2
B. 2 & 3 D. 1, 2, 3 & 4
10. One of the nursing diagnoses that you have included in
your care plan for Ms. Rowena is “Excess volume R/T
decreased Cardiac output secondary to valvular disease”.
Which of the following is the POTENTIAL outcome if medical
and nursing interventions have been effectively implemented?
1. Adequate fluid volume is maintained.
2. Vital signs within normal limits.
3. Clear lung sounds.
4. Pulmonary congestion absent.

A. 1, 2 & 3 C. 1 & 2
B. 2 & 3 D. 1, 2, 3 & 4
 SITUATION
Mr. Alba, 62 years old, an executive of a
construction firm was admitted in a nearby tertiary
hospital because of sudden severe abdominal pain.
After completing the physical examination he was
advised to be admitted for a suspected abdominal
aneurysm.
11. When a patient is suffering from abdominal
aortic aneurysm the clinical manifestation likely to
be present are the following EXCEPT __________.

A.Severe mid-abdominal and lumbar back pain

B.Pulsating abdominal mass
C.Ischemic pain not relieved by rest
D.Cool cyanotic extremities in the iliac arteries
11. When a patient is suffering from abdominal
aortic aneurysm the clinical manifestation likely to
be present are the following EXCEPT __________.

A.Severe mid-abdominal and lumbar back pain

B.Pulsating abdominal mass
C.Ischemic pain not relieved by rest
D.Cool cyanotic extremities in the iliac arteries
12. In order to confirm the diagnosis, an abdominal
ultrasonography was ordered which revealed rupture
of the blood vessels. To decrease the amount of gas
in the bowel, the patient has to fast for how long
PRIOR to the procedure?

A.5 – 7 hours
B. 13 – 24 hours
C.4 – 6 hours
D.8 – 12 hours
12. In order to confirm the diagnosis, an abdominal
ultrasonography was ordered which revealed rupture
of the blood vessels. To decrease the amount of gas
in the bowel, the patient has to fast for how long
PRIOR to the procedure?

A.5 – 7 hours
B. 13 – 24 hours
C.4 – 6 hours
D.8 – 12 hours
13. The anesthesiologist visited the patient and informed
him that a moderate sedation will used during surgery. Which
of the following are the responsibilities of the health team
with this type of anesthesia? Continual assessment of
__________.
1. Vital signs 2. Level of consciousness
3. Cardiac function 4. Respiratory function

A. 1 & 2
B. 2 & 3
C. 1, 2, 3 & 4
D. 1, 2 & 3
13. The anesthesiologist visited the patient and informed
him that a moderate sedation will used during surgery. Which
of the following are the responsibilities of the health team
with this type of anesthesia? Continual assessment of
__________.
1. Vital signs 2. Level of consciousness
3. Cardiac function 4. Respiratory function

A. 1 & 2
B. 2 & 3
C. 1, 2, 3 & 4
D. 1, 2 & 3
14. During surgery, what is the ideal position to be
assumed by Mr. Alba?

A.Sims
B.Trendelenburg
C.Dorsal recumbent
D.Lithotomy
14. During surgery, what is the ideal position to be
assumed by Mr. Alba?

A.Sims
B.Trendelenburg
C.Dorsal recumbent
D.Lithotomy
15. Immediately after surgery, the PRIORITY
complication that has to be watched by the nurse is
____________.

A.Renal failure
B.Impotence
C.Infection
D.Hemorrhage
15. Immediately after surgery, the PRIORITY
complication that has to be watched by the nurse is
____________.

A.Renal failure
B.Impotence
C.Infection
D.Hemorrhage
 SITUATION
An adult male is wheeled in the Emergency
Department with complaints of nausea and
vomiting, abdominal pain and lower back pain. The
physician writes a medical diagnosis of abdominal
aortic aneurysm (AAA).
16. The nurse assesses the patient with AAA. Which of
the following assessment findings is related to the
aneurysm?

1. Pulsatile abdominal mass

2. Hyperactive bowel sounds
3. Systolic bruit over the area of the mass
4. Subjective sensation of “heart beating” in the abdomen

A.1, 3, 4 C.2, 3, 4
B. 1, 2, 3, 4 D.1, 2, 3
16. The nurse assesses the patient with AAA. Which of
the following assessment findings is related to the
aneurysm?

1. Pulsatile abdominial mass

2. Hyperactive bowel sounds
3. Systolic bruit over the area of the mass
4. Subjective sensation of “heart beating” in the abdomen

A.1, 3, 4 C.2, 3, 4
B. 1, 2, 3, 4 D.1, 2, 3
17. The nurse auscultates the abdominal area of the
patient with AAA. Which of the following sounds
can be DISTINCTLY heard over the area?

A.Dullness
B. Bruit
C.Friction rubs
D.Crackles
17. The nurse auscultates the abdominal area of the
patient with AAA. Which of the following sounds
can be DISTINCTLY heard over the area?

A.Dullness
B. Bruit
C.Friction rubs
D.Crackles
18. The nurse recalls specific anatomic sites for
aneurysm. The most common sites are the aortic
arch, thoracic aorta and abdominal aorta. Which of
the following areas is an AAA most commonly
located?

A.Proximal to the renal arteries

B. Distal to the iliac arteries
C.Distal to the renal arteries
D.Adjacent to the aortic arch
18. The nurse recalls specific anatomic sites for
aneurysm. The most common sites are the aortic
arch, thoracic aorta and abdominal aorta. Which of
the following areas is an AAA most commonly
located?

A.Proximal to the renal arteries

B. Distal to the iliac arteries
C.Distal to the renal arteries
D.Adjacent to the aortic arch
19. The patient complains of severe lower back
pain. Which of the following is the PRIORITY
action by the nurse?

A.Take the vital signs and document results

B. Administer pain medication as prescribed
C.Notify the physician
D.Observe for signs of abdominal distention
19. The patient complains of severe lower back
pain. Which of the following is the PRIORITY
action by the nurse?

A.Take the vital signs and document results

B. Administer pain medication as prescribed
C.Notify the physician
D.Observe for signs of abdominal distention
20.The nurse is aware that rupture of the aneurysm is a life-
threatening emergency. Which of the following groups of
symptoms indicates a ruptured AAA?

A. Intermittent lower back pain, decreased blood pressure,

decreased RBC count, increased WBC count
B. Severe lower back pain, decreased blood pressure, decreased
RBC count, decreased WBC count
C. Lower back pain, increased blood pressure, decreased RBC
count, increased WBC count
D. Severe lower back pain, decreasedblood pressure, decreased
RBC count, increased WBC count.
20.The nurse is aware that rupture of the aneurysm is a life-
threatening emergency. Which of the following groups of
symptoms indicates a ruptured AAA?

A. Intermittent lower back pain, decreased blood pressure,

decreased RBC count, increased WBC count
B. Severe lower back pain, decreased blood pressure, decreased
RBC count, decreased WBC count
C. Lower back pain, increased blood pressure, decreased RBC
count, increased WBC count
D. Severe lower back pain, decreasedblood pressure, decreased
RBC count, increased WBC count.
 SITUATION
Mr. Ping, 58-year-old, 5’4”, 180 lbs. a former
employee in an auditing firm consulted the OPD
because of an on and off headache, pain on the neck
and sometimes dizziness when walking. Based on
the health history and physical examination, he was
having hypertension (HTN).
21. When planning for a teaching program for Mr. Ping
and the family members, your PRIMARY concern as a
nurse is for them to __________.

A.Learn to know how to monitor blood pressure of the

patient
B. Learn to know hot to perform stress management
C.Understand why strenuous activities has to be avoided
D.Know and understand about the disease process
21. When planning for a teaching program for Mr. Ping
and the family members, your PRIMARY concern as a
nurse is for them to __________.

A.Learn to know how to monitor blood pressure of the

patient
B. Learn to know hot to perform stress management
C.Understand why strenuous activities has to be avoided
D.Know and understand about the disease process
22. Considering the patient’s rights, the physician
explained to the patient that classification of blood
pressure (BP) for adults and its category. Since Mr.
Ping’s BP ranges from 145/159 (systolic) 92/98
(diastolic) and was consistent for almost 3 months
he was classified to be in ________.

A.Stage 2 HPN C. Stage 1 HPN

B. Stage 3 HPN D. Prehypertension
STAGES OF HPN

PRE HPN:___________________
STAGE 1:___________
STAGE 2:__________
22. Considering the patient’s rights, the physician
explained to the patient that classification of blood
pressure (BP) for adults and its category. Since Mr.
Ping’s BP ranges from 145/159 (systolic) 92/98
(diastolic) and was consistent for almost 3 months
he was classified to be in ________.

A.Stage 2 HPN C. Stage 1 HPN

B. Stage 3 HPN D. Prehypertension
23. When teaching Mr. Ping about lifestyle
modifications, the tole of exercise is highly essential
because of his weight. The nurse should emphasize to
the patient to engage in aerobic exercise INITIALLY for
__________.

A.60 minutes 2x a week

B. 45 minutes 3x a week
C.25 to 35 minutes 4x a week
D.30 minutes everyday
23. When teaching Mr. Ping about lifestyle
modifications, the tole of exercise is highly essential
because of his weight. The nurse should emphasize to
the patient to engage in aerobic exercise INITIALLY for
__________.

A.60 minutes 2x a week

B. 45 minutes 3x a week
C.25 to 35 minutes 4x a week
D.30 minutes everyday
24. The DASH diet has been prescribed to Mr. Ping by
his physician. Which the following is NOT included in the
Dietary Approach to Stop Hypertension?

A.Meats leans, poultry without skin and fish

B. Vegetables like squash, spinach, carrot and potatoes.
C.Fruits like bananas, oranges, melons and mangoes
D.Dairy products, high in fats, non-skim mozzarella
cheese.
24. The DASH diet has been prescribed to Mr. Ping by
his physician. Which the following is NOT included in the
Dietary Approach to Stop Hypertension?

A.Meats leans, poultry without skin and fish

B. Vegetables like squash, spinach, carrot and potatoes.
C.Fruits like bananas, oranges, melons and mangoes
D.Dairy products, high in fats, non-skim mozzarella
cheese.
25. Beta-adrenergic blocker Propranolol 80mg. BID has
been ordered to Ping. As a nurse what adverse effects
should be included in you teaching plan when a patient is
taking this drug?
1. Dizziness & Fatigue
2. Insomnia & nightmares
3. Fatigue & bradycardia
4. Sexual dysfunction

A.1, 2, 3 & 4 C. 1 & 2

B. 3 & 4 D. 1, 2 & 3
25. Beta-adrenergic blocker Propranolol 80mg. BID has
been ordered to Ping. As a nurse what adverse effects
should be included in you teaching plan when a patient is
taking this drug?
1. Dizziness & Fatigue
2. Insomnia & nightmares
3. Fatigue & bradycardia
4. Sexual dysfunction

A.1, 2, 3 & 4 C. 1 & 2

B. 3 & 4 D. 1, 2 & 3
 SITUATION
The role of the health professionals in the care
delivery system has been very challenging especially
with the contemporary approach to practice where
teamwork and collaboration is highly needed.
26. Nurse Josie is a graduate nurse assigned in the cardiac
rehabilitation unit after she has undergone a special training program in
rehabilitation nursing. She is aware that working in this unit needs
collaborative practice. Which of the following is NOT an acceptable
behavior in teamwork?

A. Actively engaging in care planning and management including audit

B. Contributing to decision making regarding patient’s needs and
concerns
C. Respecting the role of the members of the health team in care
management
D. Questioning therapeutic intervention by the health team despite
evidences
26. Nurse Josie is a graduate nurse assigned in the cardiac
rehabilitation unit after she has undergone a special training program in
rehabilitation nursing. She is aware that working in this unit needs
collaborative practice. Which of the following is NOT an acceptable
behavior in teamwork?

A. Actively engaging in care planning and management including audit

B. Contributing to decision making regarding patient’s needs and
concerns
C. Respecting the role of the members of the health team in care
management
D. Questioning therapeutic intervention by the health team despite
evidences
27. In the Cardiac rehabilitation program, the team
members emphasize to the patient and family the
importance of education and lifestyle changes.
In which phase of the cardiac rehabilitation includes low
level exercise, physical activity and changes for the
resumption of an active lifestyle?

A.Phase 2 C. Phase 3
B. Phase 1.5 D. Phase 1
CARDIAC REHAB PROGRAM

• PHASE 1-IN-PATIENT
• LOW LEVEL EXERCISE
• EDUCATION FOR FAMILY MEMBERS
• MAY GO HOME
• PHASE 2
• OPD
• 2 WEEKS DISCHARGE
• MONITORED EXERCISE
• LIFESTYLE MANAGEMENT
• PHASE 3
• COMMUNITY BASED
• ON GOING EXERCISE
• MAINTENANCE PROGRAM
• PHASE 4
• LONG TERM LIFESTYLE CHANGE
• CAN BE DONE AT HOME OR
COMMUNITY
27. In the Cardiac rehabilitation program, the team
members emphasize to the patient and family the
importance of education and lifestyle changes.
In which phase of the cardiac rehabilitation includes low
level exercise, physical activity and changes for the
resumption of an active lifestyle?

A.Phase 2 C. Phase 3
B. Phase 1.5 D. Phase 1
28. The implementation of course of action from several alternatives
are usually done by the team when designing a program for the
rehabilitation of cardiac patients. The steps for an EFFECTIVE
decision-making include which of the following____________?
1. Determine the foal of the outcome
2. Identify the need for the decision
3. Evaluate the alternative action/s chosen, if it was achieved
4. identify alternative actions, with each benefits and consequences
5. choose an alternative action/s

A. 2, 1, 4, 5 & 3 C. 3, 2, 1, 4 & 5
B. 1, 3, 2, 4 & 5 D. 4, 1, 3, 2 & 5
28. The implementation of course of action from several alternatives
are usually done by the team when designing a program for the
rehabilitation of cardiac patients. The steps for an EFFECTIVE
decision-making include which of the following____________?
1. Determine the foal of the outcome
2. Identify the need for the decision
3. Evaluate the alternative action/s chosen, if it was achieved
4. identify alternative actions, with each benefits and consequences
5. choose an alternative action/s

A. 2, 1, 4, 5 & 3 C. 3, 2, 1, 4 & 5
B. 1, 3, 2, 4 & 5 D. 4, 1, 3, 2 & 5
29. The interdisciplinary team of cardiac rehabilitation
professionals work with each patient to help attain mutually
established goals. Which of the following is NOT included in the
Short-term goals _________?

A. Limiting the physiological and psychological effects of the

heart disease.
B. Reconditioning the patient to assume activities of the daily
living.
C. Reversing completely the atherosclerotic disease process.
D. Decreasing the risk and symptoms of cardiac disease.
29. The interdisciplinary team of cardiac rehabilitation
professionals work with each patient to help attain mutually
established goals. Which of the following is NOT included in the
Short-term goals _________?

A. Limiting the physiological and psychological effects of the

heart disease.
B. Reconditioning the patient to assume activities of the daily
living.
C. Reversing completely the atherosclerotic disease process.
D. Decreasing the risk and symptoms of cardiac disease.
30. Nurse Josie, as a member of the rehabilitation team
promote wellness and help cardiovascular patients and
those at risk alter their lifestyles through which of the
following EXCEPT ________

A.Smoking cessation
B.Stress management
C.Vigorous exercise
D.Low-fat, low-cholesterol diet
30. Nurse Josie, as a member of the rehabilitation team
promote wellness and help cardiovascular patients and
those at risk alter their lifestyles through which of the
following EXCEPT ________

A.Smoking cessation
B.Stress management
C.Vigorous exercise
D.Low-fat, low-cholesterol diet
 SITUATION
Nurse Roger is assigned in a disaster-prone province
in the Visayas. He is aware that with the increase
frequency of disaster happening, he has to respond
quickly and efficiently to assist the population
affected by calamities.
31. Which of the following BEST defines a disaster?

A.Any event that results in multiple deaths.

B. Devastation that covers a broad geographical area.
C.Devastation that cannot be relieved without assistance.
D.The event results in multiple injuries, deaths, and
property damage.
31. Which of the following BEST defines a disaster?

A.Any event that results in multiple deaths.

B. Devastation that covers a broad geographical area.
C.Devastation that cannot be relieved without assistance.
D.The event results in multiple injuries, deaths, and
property damage.
32. Nurse Roger is guided by the ICN framework of
disaster nursing competencies. This framework consists of
four areas in the continuum of disaster management that c
that corresponds to the 4 stages of disaster. What consists
of the FIRST STAGE?

A.Response
B. Preparedness
C.Prevention
D.Recovery
32. Nurse Roger is guided by the ICN framework of
disaster nursing competencies. This framework consists of
four areas in the continuum of disaster management that c
that corresponds to the 4 stages of disaster. What consists
of the FIRST STAGE?

A.Response
B. Preparedness
C.Prevention
D.Recovery
33. Nurse Roger has invited several agencies in the
community to a meeting to discuss the disaster plan for
the community. Which of the following BEST describes
the purpose of this meeting? To_______.

A.Enhance communication among agencies in the

community
B. Increase stability in the community
C.Manage response to disasters in the community
D.Improve overall community functioning
33. Nurse Roger has invited several agencies in the
community to a meeting to discuss the disaster plan for
the community. Which of the following BEST describes
the purpose of this meeting? To_______.

A.Enhance communication among agencies in the

community
B. Increase stability in the community
C.Manage response to disasters in the community
D.Improve overall community functioning
34. Nurse Roger has adapts professional nursing skills in
recognizing and meeting the physical and emotional needs resulting
from a disaster. For people who are willing to talk ensuing a disaster,
which of the following is the MOST appropriate approach?

A. “I am with you. It is good you are trying to release your distress

by crying. It will make you feel better.”
B. “What you need to do now is to wait for instructions and services
to be provided.”
C. “Don’t feel bad. Others are in the same situation as yours.”
D. “You need not cry. You need to move on and build you life
again.”
34. Nurse Roger has adapts professional nursing skills in
recognizing and meeting the physical and emotional needs resulting
from a disaster. For people who are willing to talk ensuing a disaster,
which of the following is the MOST appropriate approach?

A. “I am with you. It is good you are trying to release your distress

by crying. It will make you feel better.”
B. “What you need to do now is to wait for instructions and services
to be provided.”
C. “Don’t feel bad. Others are in the same situation as yours.”
D. “You need not cry. You need to move on and build you life
again.”
35. As he passed by a road going to an evacuation
center, Nurse Roger encountered a flash flood. A
flash flood_________.

A.occurs suddenly for a short duration

B.is caused by the blocking of drains
C.is caused by heavy rains
D.occurs in urban areas
35. As he passed by a road going to an evacuation
center, Nurse Roger encountered a flash flood. A
flash flood_________.

A.occurs suddenly for a short duration

B.is caused by the blocking of drains
C.is caused by heavy rains
D.occurs in urban areas
 SITUATION
Ms. Lontok, a Public Health Nurse Supervisor, is
preparing a supervisory plan for midwives under her
charge, a supervisory plan is a written document on
how to organize and systematizes supervisory
activities.
36. The need for supervision may arise from the
following:
1. Lack of staff motivation
2. Conflict between personal and organizational goals
3. Lack of knowledge and skills
4. Desire for promotion and job permanency
5. Achieve health goals for the agency

A.2,3,4 C.3,4,5
B.1,4, 5 D.1,2,3
36. The need for supervision may arise from the
following:
1. Lack of staff motivation
2. Conflict between personal and organizational goals
3. Lack of knowledge and skills
4. Desire for promotion and job permanency
5. Achieve health goals for the agency

A.2,3,4 C.3,4,5
B.1,4, 5 D.1,2,3
37. Ms. Lontok would require information regarding the
supervisory needs of the midwives which can be taken
from which of the following?
1. Review of records and reports
2. Interview of the midwives
3. Review of literature
4. Observation of the midwives at work
5. Results of survey among the staff

A.2,3,5 C.1,2,4
B . 1,3,4 D.2,4,5
37. Ms. Lontok would require information regarding the
supervisory needs of the midwives which can be taken
from which of the following?
1. Review of records and reports
2. Interview of the midwives
3. Review of literature
4. Observation of the midwives at work
5. Results of survey among the staff

A.2,3,5 C.1,2,4
B . 1,3,4 D.2,4,5
38. Ms. Lontok prioritizes supervisory needs and
problems based on the following criteria,
EXCEPT__________.

A.Convenience to both parties to address needs

B. Degree of importance of the identifies need
C.Availability of resources needed
D.Activities needed to meet the identified need
38. Ms. Lontok prioritizes supervisory needs and
problems based on the following criteria,
EXCEPT__________.

A.Convenience to both parties to address needs

B. Degree of importance of the identifies need
C.Availability of resources needed
D.Activities needed to meet the identified need
39. During the actual supervisory visit, which of the
following is NOT expected of Ms. Lontok? She
________.

A.Discusses the objectives of the visit

B. Expresses appreciation and support given for
the visit
C.Conveys a formal, strict approach to the midwives
D.Explains the process and outcomes of the visit
39. During the actual supervisory visit, which of the
following is NOT expected of Ms. Lontok? She
________.

A.Discusses the objectives of the visit

B. Expresses appreciation and support given for
the visit
C.Conveys a formal, strict approach to the midwives
D.Explains the process and outcomes of the visit
40. After setting the objectives and selecting the
activities, Ms. Lontok would need to identify the
indicators for evaluation. Which one is not included?

A.Needs met
B. Performance increased
C.Promotion achieved
D.Quality of service improved
40. After setting the objectives and selecting the
activities, Ms. Lontok would need to identify the
indicators for evaluation. Which one is not included?

A.Needs met
B. Performance increased
C.Promotion achieved
D.Quality of service improved
 SITUATION
As a public health nurse, Ms. Isay intends to focus
on special population to focus on a specific
population to advocate, educate, and collaborate with
members from a community to improve health of the
people.
41. Nurse Isay collects data and monitors the health
status of the population. Which of the following core
public health functions is being implemented?

A.Assurance
B. Policy development
C.Assessment
D.Prevention
41. Nurse Isay collects data and monitors the health
status of the population. Which of the following core
public health functions is being implemented?

A.Assurance -guarantee
B. Policy development -supervision
C.Assessment
D.Prevention -avoidance
42. Nurse Isay included in her data collection the
number and proportion of persons aged 25 or older
with less than high school education. Which of the
following BEST describes this data?

A.Health status data

B. Health care resource data
C.Health risk factors
D.Socio-demographic data
42. Nurse Isay included in her data collection the
number and proportion of persons aged 25 or older
with less than high school education. Which of the
following BEST describes this data?

A.Health status data-overall status, inicidence

B. Health care resource data-materials
C.Health risk factors-exposure
D.Socio-demographic data
43. Working in the community with an
aggregate/population, who does MS. Isay MOST
likely to interact with?

A.Students in the local high school

B. Patients at the local hospital
C.Residents who play basketball
D.Christians in the community
43. Working in the community with an
aggregate/population, who does MS. Isay MOST
likely to interact with?

A.Students in the local high school

B. Patients at the local hospital
C.Residents who play basketball
D.Christians in the community
44. Ms. Isay has a clear understanding of
population-focused practice. Which of the following
characteristics would she MOST likely to display?

A.Improving the effectiveness of care provided

B. Sponsoring a fund-raising project
C.Volunteering for a community action
D.Providing health interventions for individuals
44. Ms. Isay has a clear understanding of
population-focused practice. Which of the following
characteristics would she MOST likely to display?

A.Improving the effectiveness of care provided-

management
B. Sponsoring a fund-raising project
C.Volunteering for a community action
D.Providing health interventions for individuals
45. Ms. Isay is working to improve population-
focused care in the community. Which of the
following BEST describes a key opportunity for
nurses like her to accomplish this goal?

A.Assuming traditional nursing roles

B. Conducting community assessments
C.Specializing in community health practice
D.Influence public health policy
45. Ms. Isay is working to improve population-
focused care in the community. Which of the
following BEST describes a key opportunity for
nurses like her to accomplish this goal?

A.Assuming traditional nursing roles

B. Conducting community assessments
C.Specializing in community health practice
D.Influence public health policy
 SITUATION
A male teenager was wheeled in the Emergency
Department (ED) for stab wound. The ED nurse
suspects the kidneys may have been injured.
46. The nurse assesses the patient for complications.
Which are the MOST COMMON complications?
1. Urinary leakage
2. Delayed bleeding from the damage
3. Abscess formation
4. Paralytic ileus
5. Renal failure

A.4 and 5 C.1 and 2

B. 3 and 4 D.2 and 3
46. The nurse assesses the patient for complications.
Which are the MOST COMMON complications?
1. Urinary leakage
2. Delayed bleeding from the damage
3. Abscess formation
4. Paralytic ileus
5. Renal failure

A.4 and 5 C.1 and 2

B. 3 and 4 D.2 and 3
47. The nurse knows that with renal trauma further
complications may occur such as:
1. Secondary hemorrhage usually due to infection
2. Renal artery stenosis
3. Renal atrophy
4. Hypotension
5. Hydronephrosis

Which are the POSSIBLE complications?

A.2, 3, 4, 5 C.1, 2, 3, 5
B.1, 2, 3, 4, 5 D.1, 3, 4, 5
47. The nurse knows that with renal trauma further
complications may occur such as:
1. Secondary hemorrhage usually due to infection
2. Renal artery stenosis-atherosclerosis
3. Renal atrophy
4. Hypotension
5. Hydronephrosis

Which are the POSSIBLE complications?

A.2, 3, 4, 5 C.1, 2, 3, 5
B.1, 2, 3, 4, 5 D.1, 3, 4, 5
48. The nurse assesses the patient to detemine the
extent of injury. Which of the following signs is a
cardinal sign of renal trauma?

A.Shock
B. Lumbar pain
C.Abdominal pain
D.Hematuria
48. The nurse assesses the patient to detemine the
extent of injury. Which of the following signs is a
cardinal sign of renal trauma?

A.Shock
B. Lumbar pain
C.Abdominal pain
D.Hematuria
49. The nurse writes a nursing diagnosis for the patient with
stab wound. The MOST appropriate nursing diagnosis is
_____________.

A. Nutrition imbalance, less than body requirements,

related to nausea from renal trauma
B. Deficient fluid volume related to blood in the urine
C. Acute pain in the abdominal area related to renal trauma
D. Acute pain in the lumbar area related to renal trauma
49. The nurse writes a nursing diagnosis for the patient with
stab wound. The MOST appropriate nursing diagnosis is
_____________.

A. Nutrition imbalance, less than body requirements,

related to nausea from renal trauma
B. Deficient fluid volume related to blood in the urine
C. Acute pain in the abdominal area related to renal trauma
D. Acute pain in the lumbar area related to renal trauma
50. The physician prescribes Magnetic Resonance Imaging
(MRI) of both kidneys to confirm clinical suspicion and
determine the severity of the injury. Which of the following
activities is a PRIMARY nursing consideration in preparing the
patient for MRI?
A. Administer all medications scheduled before the test.
B. Report findings of metal screening; sedate the patient before
sending him for MRI
C. Coordinate the MRI with other patient care activities and
inform the patient about the test
D. Ensure the patient is on NPO and hold all medications until
test is completed
50. The physician prescribes Magnetic Resonance Imaging
(MRI) of both kidneys to confirm clinical suspicion and
determine the severity of the injury. Which of the following
activities is a PRIMARY nursing consideration in preparing the
patient for MRI?
A. Administer all medications scheduled before the test.
B. Report findings of metal screening; sedate the patient before
sending him for MRI
C. Coordinate the MRI with other patient care activities and
inform the patient about the test
D. Ensure the patient is on NPO and hold all medications until
test is completed
 SITUATION
Nurse Rolly, a triage nurse admits clients in the
Emergency Department (ED) of X hospital. The
following are situations in the ED nurse Rolly
encounters.
51. Four victims are brought to the ED after a motor
vehicle crash. Who among the following victims require the
HIGHEST priority for treatment?

A.21-year old male with fracture of the face jaw

B. 20-year old female with a misaligned right leg
C.35-year old male complaining of abdominal pain
D.62-year old female with palpation and chest pain
51. Four victims are brought to the ED after a motor
vehicle crash. Who among the following victims require the
HIGHEST priority for treatment?

A.21-year old male with fracture of the face jaw

B. 20-year old female with a misaligned right leg
C.35-year old male complaining of abdominal pain
D.62-year old female with palpation and chest pain
52. Four victims of a car crash are brought to the
ED. Nurse Rolly assesses the victims. Select who
among the following has the HIGHEST priority for
treatment.

A.Absence of peripheral pulses

B. A sucking chest wound
C.Severe bleeding of facial and head lacerations
D.An open femur fracture with profuse bleeding
PRIMARY ASSESSMENT

AIRWAY
BREATHING
CIRCULATION
DISABILITY (LOC)
EXPOSURE (PHYSICAL EXAM)
SECONDARY ASSESSMENT
• S/SX
• ALLERGIES
• MEDICATIONS
• PAST MEDICAL HX
• LAST MEAL
• EVENTS
52. Four victims of a car crash are brought to the
ED. Nurse Rolly assesses the victims. Select who
among the following has the HIGHEST priority for
treatment.

A.Absence of peripheral pulses

B. A sucking chest wound
C.Severe bleeding of facial and head lacerations
D.An open femur fracture with profuse bleeding
53. Nurse Rolly performs primary assessment on one of
the trauma victims, and determines that the client has a
patent airway. The NEXT assessment by Nurse Rolly
should be to __________.
A.Palpate for the presence of peripheral pulses
B. Check the level of consciousness
C.Examine the client for any external bleeding
D.Observe/assess client’s breathing or respiratory effort
53. Nurse Rolly performs primary assessment on one of
the trauma victims, and determines that the client has a
patent airway. The NEXT assessment by Nurse Rolly
should be to __________.
A.Palpate for the presence of peripheral pulses
B. Check the level of consciousness
C.Examine the client for any external bleeding
D.Observe/assess client’s breathing or respiratory effort
54. A 45-year old male client was brought in the ED
with head and neck trauma sustained in a motorcycle
accident. The FIRST action of Nurse Rolly is to
__________.

A.Suction of the mouth and oropharynx

B. Obtain venous access
C.Immbolize the cervical spine
D.Administer supplemental oxygen
54. A 45-year old male client was brought in the ED
with head and neck trauma sustained in a motorcycle
accident. The FIRST action of Nurse Rolly is to
__________.

A.Suction of the mouth and oropharynx

B. Obtain venous access
C.Immbolize the cervical spine
D.Administer supplemental oxygen
55. Jerome, 65 years old who works as a carpenter fell
off from a ladder while fixing the roof of a neighbor. He
was brought to the ED by family members. He is
unconscious. Nurse Rolly does a primary assessment on
client Jerome which is to:

A.Ask the family about Jerome’s medical conditions

B. Assess the vital signs
C.Attach a cardiac ECG monitor
D.Obtain a Glasgow coma scale score
55. Jerome, 65 years old who works as a carpenter fell
off from a ladder while fixing the roof of a neighbor. He
was brought to the ED by family members. He is
unconscious. Nurse Rolly does a primary assessment on
client Jerome which is to:

A.Ask the family about Jerome’s medical conditions

B. Assess the vital signs
C.Attach a cardiac ECG monitor
D.Obtain a Glasgow coma scale score
 SITUATION
You are a staff nurse at the Emergency Room. Renato, a
32-year old employee in a Business Processing
Outsourcing company was brought in, in a company car
with the chief complaints of severe headache, inability to
move his eyes upward, and restlessness. Vital signs upon
admission: BP = 160/100; Cheyne-strokes respiration was
noted. Water manometer test revealed increased
intracranial pressure (IICP).
56. Renato was started on Mannitol therapy. What
is the rationale for this treatment?

A.To prevent seizures

B. To prevent dehydration
C.To prevent serious fluid and electrolye imbalance
D.To increase the osmolality of the blood
56. Renato was started on Mannitol therapy. What
is the rationale for this treatment?

A.To prevent seizures

B. To prevent dehydration
C.To prevent serious fluid and electrolye imbalance
D.To increase the osmolality of the blood –
MEASURE OF SOLUTES
57. Select the PRIORITY nursing responsibility for
taking care of patient on Mannitol therapy like
Renato. Monitoring of _________.

A.Respiratory rate
B. Urine output
C.Renal function
D.Muscle function
57. Select the PRIORITY nursing responsibility for
taking care of patient on Mannitol therapy like
Renato. Monitoring of _________.

A.Respiratory rate
B. Urine output
C.Renal function
D.Muscle function
58. Decreased level of consciousness is one of the
results of IICP. Which of the following is NOT an early
manifestation of decreased LOC?

A.Lethargy
B. Comatose with no response to painful stimuli
C.Restlessness
D.Disorientation
58. Decreased level of consciousness is one of the
results of IICP. Which of the following is NOT an early
manifestation of decreased LOC?

A.Lethargy
B. Comatose with no response to painful stimuli
C.Restlessness
D.Disorientation
59. Renato has been observed to manifest signs of
disorientation. Which of the following occurs FIRST
in the state of disorientaion. Disorientation to
_________.

A.Place
B. Environment
C.People
D.Time
59. Renato has been observed to manifest signs of
disorientation. Which of the following occurs FIRST
in the state of disorientaion. Disorientation to
_________.

A.Place
B. Environment
C.People
D.Time
60. On admission to the ER, a variety of laboratory
tests, for diagnostic purposes, were done to Renato
who has been assessed to have decreased LOC.
What test was NOT done at this point?

A.Urinalysis for WBC

B. Blood and urine toxicology
C.Blood glucose
D.Serum electrolytes
60. On admission to the ER, a variety of laboratory
tests, for diagnostic purposes, were done to Renato
who has been assessed to have decreased LOC.
What test was NOT done at this point?

A.Urinalysis for WBC

B. Blood and urine toxicology
C.Blood glucose
D.Serum electrolytes
 SITUATION
Norilee, an accountant, 29 years old was rushed by
her husband in the ER because of body weakness,
palpitation, confusion and diaphoresis. Her blood
glucose is 450mg. / dl with fruity acetone smell on
her breath. She was diagnosed to be suffering from
type 1 diabetes mellitus 6 months ago.
61. Which of the following are the clinical
characteristics of type 1 diabetes mellitus EXCEPT
________.

A.Often have islet cell antibodies

B. Ketosis prone when insulin is absent
C.Onset any age, above 30 years old, usually obese
D.Onset any age, below 30 year old, usually thin
61. Which of the following are the clinical
characteristics of type 1 diabetes mellitus EXCEPT
________.

A.Often have islet cell antibodies

B. Ketosis prone when insulin is absent
C.Onset any age, above 30 years old, usually obese
D.Onset any age, below 30 year old, usually thin
62. Patient Norilee upon admission has a breath
characteristic of fruity acetone, this is brought about
by the presence of __________.

A.Lactic acids
B. Uric acid
C.Nitric acid
D.Ketoacids
62. Patient Norilee upon admission has a breath
characteristic of fruity acetone, this is brought about
by the presence of __________.

A.Lactic acids
B. Uric acid
C.Nitric acid
D.Ketoacids
63. Based on the presenting manifestations of
patient Norilee, you expect that the physician will
likely order which of the following treatment?

A.50% dextrose
B. 5% lactated ringers
C.Dextrose 10% in water
D.Normal saline solution
63. Based on the presenting manifestations of
patient Norilee, you expect that the physician will
likely order which of the following treatment?

A.50% dextrose
B. 5% lactated ringers
C.Dextrose 10% in water
D.Normal saline solution
64. When caring for patient Norilee, which of the
following should be included in your teaching plan?
1. Signs and symptom of hypoglycemia
2. Self-glucose monitoring
3. Administration of insulin
4. Meal planning and exercise

A.2, 3 & 4 C.1 & 2

B.2 & 3 D.1, 2, 3 & 4
64. When caring for patient Norilee, which of the
following should be included in your teaching plan?
1. Signs and symptom of hypoglycemia
2. Self-glucose monitoring
3. Administration of insulin
4. Meal planning and exercise

A.2, 3 & 4 C.1 & 2

B.2 & 3 D.1, 2, 3 & 4
65. When formulating a Nursing diagnosis for Ms.
Norilee who is suffering from type 1 diabetes mellitus
with ketoacidosis, which of the following will be the top
PRIORITY?

A.Impaired tissue integrity

B. Deficient fluid volume
C.Imbalanced nutrition
D.Risk for infection
65. When formulating a Nursing diagnosis for Ms.
Norilee who is suffering from type 1 diabetes mellitus
with ketoacidosis, which of the following will be the top
PRIORITY?

A.Impaired tissue integrity

B. Deficient fluid volume
C.Imbalanced nutrition
D.Risk for infection
 SITUATION
Mr. Joe is 55-year old, married, a car dealer has consulted
the ER because of on and off fever, indigestion, weight
loss, right abdominal pain, body malaise, and itchiness of
the skin. Based on the health history the patient has been a
chain smoker and drinks alcoholic beverages almost every
day especially when he has clients to entertain. His
physical examination showed he has a suspected liver
cirrhosis. He was advised for admission for further work-
up and treatment.
66. You are the nurse on duty when Mr. Joe was
admitted in the pay floor. In your observational data
what additional EARLY SIGN of liver cirrhosis do
you expect patient to manifest?

A.Gonadal atrophy
B. Hypotension
C.Splenomegaly
D.Ankle edema
66. You are the nurse on duty when Mr. Joe was
admitted in the pay floor. In your observational data
what additional EARLY SIGN of liver cirrhosis do
you expect patient to manifest?

A.Gonadal atrophy
B. Hypotension
C.Splenomegaly
D.Ankle edema
67. Which of the following statements is TRUE of liver
cirrhosis?
1. Nutritional deficiency with decreased protein intake
contributes to liver damage
2. Cirrhosis can happen to people with alcohol intake
3. Women are at greater risk for the development of alcohol-
induced liver disease
4. Most patients affected by liver cirrhosis are between 40 to
60 years of age

A. 1, 2, 3, and 4 C. 1, 2, and 3
B. 1, 2 D. 2, 3
67. Which of the following statements is TRUE of liver
cirrhosis?
1. Nutritional deficiency with decreased protein intake
contributes to liver damage
2. Cirrhosis can happen to people with alcohol intake
3. Women are at greater risk for the development of alcohol-
induced liver disease
4. Most patients affected by liver cirrhosis are between 40 to
60 years of age -30-40

A. 1, 2, 3, and 4 C. 1, 2, and 3
B. 1, 2 D. 2, 3
68. During Mr. 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

B. Massage the skin with emollients every 2 hours
C. Use of commercial soaps and alcohol-based lotions
D.Rub the itchy skin with knuckles instead of using the
nails
68. During Mr. 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

B. Massage the skin with emollients every 2 hours
C. Use of commercial soaps and alcohol-based lotions
D.Rub the itchy skin with knuckles instead of using the
nails
69. At early stage of Mr. Joe’s disease process, the
physician ordered this SPECIFIC diet for Mr. Joe.
You emphasized to the dietitian that he should be
served foods that is __________.

A.High carbohydrate and low sodium

B. High calorie and high carbohydrate
C.Low protein and high fat
D.High protein and high fat
69. At early stage of Mr. Joe’s disease process, the
physician ordered this SPECIFIC diet for Mr. Joe.
You emphasized to the dietitian that he should be
served foods that is __________.

A.High carbohydrate and low sodium

B. High calorie and high carbohydrate
C.Low protein and high fat
D.High protein and high fat
70. Mr. Joe started to develop ascites and
complained of heaviness of the lower extremities to
the physician. An order of Spironolactone
(Aldactone) 25 mg/day. What adverse effect of the
drug should you monitor?

A.Hyperkalemia
B.Palpitation
C.Irregular pulse rate
D.Hypokalemia
70. Mr. Joe started to develop ascites and
complained of heaviness of the lower extremities to
the physician. An order of Spironolactone
(Aldactone) 25 mg/day. What adverse effect of the
drug should you monitor?

A.Hyperkalemia
B.Palpitation
C.Irregular pulse rate
D.Hypokalemia
 SITUATION
Mr. Bang 62 year old, an executive of a shoe company
was brought to the hospital after having vomited bright
red blood immediately after supper. He claimed he had
drinking session with his former classmates in college.
He was already advised by their family physician not to
drink alcohol due to a suspected fatty liver. You are the
nurse-on-duty when he was admitted.
71. Based on your assessment and history taking
for Mr. Bang which PRIORITY findings should you
document and report to the physician?

A.Use of anti-inflammatory drugs

B.Vital signs BP-140/90, PR- 88/min., RR-24/min.
C.Abdominal pain (3 in a scale of 10)
D.Tense, rigid abdomen
71. Based on your assessment and history taking
for Mr. Bang which PRIORITY findings should you
document and report to the physician?

A.Use of anti-inflammatory drugs

B.Vital signs BP-140/90, PR- 88/min., RR-24/min.
C.Abdominal pain (3 in a scale of 10)
D.Tense, rigid abdomen
72. You have formulated your Nursing Diagnosis for the
patient and wrote in the nursing care plan which ONE
of the following?

A.Deficient Fluid Volume R/T vomiting of blood and

gastric secretion.
B. Non-compliance R/T alcohol and medication intake.
C.Fear of death R/T unknown cause of bleeding.
D.Risk of Aspiration R/T active bleeding.
72. You have formulated your Nursing Diagnosis for the
patient and wrote in the nursing care plan which ONE
of the following?

A.Deficient Fluid Volume R/T vomiting of blood and

gastric secretion.
B. Non-compliance R/T alcohol and medication intake.
C.Fear of death R/T unknown cause of bleeding.
D.Risk of Aspiration R/T active bleeding.
73. The physician orders insertion of nasogastric
tube with lavage to Mr.Bang. What kind of solution
will you expect to be written in the doctor’s order
when a patient will undergo a lavage.

A.Normal Saline solution

B.Distilled water
C.Tap warm water
D.Dextrose 5% in water
73. The physician orders insertion of nasogastric
tube with lavage to Mr.Bang. What kind of solution
will you expect to be written in the doctor’s order
when a patient will undergo a lavage.

A.Normal Saline solution

B.Distilled water
C.Tap warm water
D.Dextrose 5% in water
74. When a patient has a gastro-intestinal bleeding and
there is the presence of hematemesis, how should you
describe this in your documentation?
A.Bloody vomitus appearing as fresh, bright red blood or
“coffee-ground” in appearance.
B. Brownish vomitus appearing as “chocolate” in
appearance from previous food intake.
C.Black, tarry stools in appearance often foul smelling,
from a previous food intake.
D.Small amounts of fresh blood observed either through
gastric secretions or stools
74. When a patient has a gastro-intestinal bleeding and
there is the presence of hematemesis, how should you
describe this in your documentation?
A.Bloody vomitus appearing as fresh, bright red blood or
“coffee-ground” in appearance.
B. Brownish vomitus appearing as “chocolate” in
appearance from previous food intake.
C.Black, tarry stools in appearance often foul smelling,
from a previous food intake.
D.Small amounts of fresh blood observed either through
gastric secretions or stools
75. The following are the practice guidelines in
documentation. Which ONE of these is NOT
recommended to be written in your charting?

A.Had urine output of 600 cc during the whole shift.

B. “Appears to be comfortable with good night rest and
sleep”.
C.Refused to eat her dinner as she feels nauseated at
meal time.
D.Slept from 11 PM to 6 AM after Valium 5 mg. was
given.
75. The following are the practice guidelines in
documentation. Which ONE of these is NOT
recommended to be written in your charting?

A.Had urine output of 600 cc during the whole shift.

B. “Appears to be comfortable with good night rest and
sleep”.
C.Refused to eat her dinner as she feels nauseated at
meal time.
D.Slept from 11 PM to 6 AM after Valium 5 mg. was
given.
 SITUATION
Len, a 35 year old dressmaker has been experiencing
recurrent episodes of abdominal pain, nausea and
vomiting and feels her stomach is bloated. She has
been taking contraceptives pills in the past. She is
married with three children. She consulted the OPD
and was advised by the physician to be admitted for
suspected Pancreatitis.
76. Nurse Gladys started her admission care to Ms.
Len. Which of the following laboratory examinations
do you expect the physician to order for the patient?

A.Serum Lipase and Amylase

B.Creatinine & Phospotase
C.Serum Transaminase
D.Urea Nitrogen substance
76. Nurse Gladys started her admission care to Ms.
Len. Which of the following laboratory examinations
do you expect the physician to order for the patient?

A.Serum Lipase and Amylase

B.Creatinine & Phospotase
C.Serum Transaminase
D.Urea Nitrogen substance
77. As a Nurse, which of the following assessment
data you will MOST likely NOT to find on patient
Len?

A.Abdominal and back pain with tenderness

B. Cramping pains before intake of heavy meals
C.Pain unrelieved by intake of antacids
D.Mid-epigastric pain acute in onset after heavy
meals
77. As a Nurse, which of the following assessment
data you will MOST likely NOT to find on patient
Len?

A.Abdominal and back pain with tenderness

B. Cramping pains before intake of heavy meals
C.Pain unrelieved by intake of antacids
D.Mid-epigastric pain acute in onset after heavy
meals
78. The most useful diagnostic test to validate whether
Ms. Len is suffering from Pancreatitis is for her to
undergo _____________.

A.Endoscopic Retrograde Cholangio Pancreatography

B. Endoscopic Ultrasound
C.Percutaneous Transhepatic Cholangiography
D.Cholesterol Serum Level
78. The most useful diagnostic test to validate whether
Ms. Len is suffering from Pancreatitis is for her to
undergo _____________.

A.Endoscopic Retrograde Cholangio Pancreatography

B. Endoscopic Ultrasound-chest, abdomen, colon
C.Percutaneous Transhepatic Cholangiography-biliary
tract-liver, gallbladder and colon
D.Cholesterol Serum Level
79. When managing a patient with Acute Pancreatitis
the first PRIORITY is to _______.

A.insert urinary catheter for adequate elimination

B. encourage oral fluids to improve elimination
C.insert nasogastric tube to decompress stomach
D.administer IV fluids to replace electrolytes lost
79. When managing a patient with Acute Pancreatitis
the first PRIORITY is to _______.

A.insert urinary catheter for adequate elimination

B. encourage oral fluids to improve elimination
C.insert nasogastric tube to decompress stomach
D.administer IV fluids to replace electrolytes lost
80. One of the SAFETY alerts that the nurse-on-
duty (NOD) will have to watch for patient with
Acute Pancreatitis is __________.

A.Diabetes Insipidus
B.Respiratory Distress
C.Hypercalcemia
D.Pericarditis
80. One of the SAFETY alerts that the nurse-on-
duty (NOD) will have to watch for patient with
Acute Pancreatitis is __________.

A.Diabetes Insipidus
B.Respiratory Distress
C.Hypercalcemia
D.Pericarditis
 SITUATION
The nurse cares for a 30-year old female patient who
is admitted for severe vomiting. The diagnosis of the
patient is hypernatremia.
81. The nurse reads the laboratory results. Which of
the following values indicate that the patient is
experiencing hypernatremia?

A.Potassium level of 5.5 mEq/L

B. Urine specific gravity below 1.0008
C.Serum osmolality below 280 mOsm/Kg
D.Serum osmolality above 295 mOsm/Kg
81. The nurse reads the laboratory results. Which of
the following values indicate that the patient is
experiencing hypernatremia?

A.Potassium level of 5.5 mEq/L (3.5-5)

B. Urine specific gravity below 1.0008 ( 1.010-
1.025)
C.Serum osmolality below 280 mOsm/Kg
D. Serum osmolality above 295 mOsm/Kg
NORMAL-275-295 mOsm/kg
82. The nurse monitors the patient for signs and
symptoms of complications. The nurse knows that
one of the PRIMARY risks when treating
hypernatremia is ___________.

A.Renal shutdown
B. Cerebral edema
C.Cellular dehydration
D.RBC destruction
82. The nurse monitors the patient for signs and
symptoms of complications. The nurse knows that
one of the PRIMARY risks when treating
hypernatremia is ___________.

A.Renal shutdown
B. Cerebral edema
C.Cellular dehydration
D.RBC destruction
83. In planning the care for this patient the nurse
includes the following interventions. Which of the
following actions should the nurse NOT include in the
plan of care?

A.Observe for possible increase in temperature

B. Observe and prepare for possible seizure attack
C.Monitor intake and output
D.Restrict fluids to 1,200 mL per day
83. In planning the care for this patient the nurse
includes the following interventions. Which of the
following actions should the nurse NOT include in the
plan of care?

A.Observe for possible increase in temperature

B. Observe and prepare for possible seizure attack
C.Monitor intake and output
D.Restrict fluids to 1,200 mL per day
84. The nurse understands that a patient with
hypernatremia is at high risk for seizures. Which of
the following safety measures is MOST appropriate?
Use of __________.

A.Pillows placed at the head

B. Padded tongue blades
C.Padded restraints
D.Padded side rails
84. The nurse understands that a patient with
hypernatremia is at high risk for seizures. Which of
the following safety measures is MOST appropriate?
Use of __________.

A.Pillows placed at the head

B. Padded tongue blades
C.Padded restraints
D.Padded side rails
85. The nurse formulates a nursing diagnosis for the patient.
Which of the following nursing diagnoses is NOT appropriate
for this patient?

A.Impaired electrolyte, sodium related to vomiting

B. Imbalanced nutrition, more than body requirements,
related to excess intake of foods rich in sodium
C. Risk for injury, bleeding, related to the interference with
blood coagulation secondary to sodium excess
D.Impaired skin integrity, related to peripheral edema
secondary to sodium and water excess
85. The nurse formulates a nursing diagnosis for the patient.
Which of the following nursing diagnoses is NOT appropriate
for this patient?

A.Impaired electrolyte, sodium related to vomiting

B. Imbalanced nutrition, more than body requirements,
related to excess intake of foods rich in sodium
C. Risk for injury, bleeding, related to the interference with
blood coagulation secondary to sodium excess
D.Impaired skin integrity, related to peripheral edema
secondary to sodium and water excess
 SITUATION
The nurse assists in the care of clients with chronic
obstructive pulmonary disease (COPD).
86. The nurse is aware that clients with COPD are
at risk for ineffective respirations EXCEPT which of
the following?

A.Clients undergoing thoracic or abdominal surgery

B. Clients with rib fractures and kyphosis
C.Clients with neuromuscular disorders such as
Guillain-Barre syndrome
D.Clients with fluid volume deficit
86. The nurse is aware that clients with COPD are
at risk for ineffective respirations EXCEPT which of
the following?

A.Clients undergoing thoracic or abdominal surgery

B. Clients with rib fractures and kyphosis
C.Clients with neuromuscular disorders such as
Guillain-Barre syndrome
D.Clients with fluid volume deficit
87. Nursing interventions for clients with respiratory
acidosis include the following EXCEPT to:

A.Monitor arterial blood gases (ABGs), pH, paCO2 and

HCO3
B. Administer oxygen and medication as ordered
C.Monitor hourly vital signs and respiratory status
D.Administer sedation as ordered by the physician to
relax the client
87. Nursing interventions for clients with respiratory
acidosis include the following EXCEPT to:

A.Monitor arterial blood gases (ABGs), pH, paCO2 and

HCO3
B. Administer oxygen and medication as ordered
C.Monitor hourly vital signs and respiratory status
D.Administer sedation as ordered by the physician to
relax the client
88. The nurse understands that excess acid in the body
acts as CNS depressant. Clients with acidosis may exhibit
which of the following symptoms:
1. Reduced level of consciousness
2. Confusion
3. Lethargy
4. Coma

A.All of the options C.1, 2, and 3

B.1, 3 and 4 D.1 and 3
88. The nurse understands that excess acid in the body
acts as CNS depressant. Clients with acidosis may exhibit
which of the following symptoms:
1. Reduced level of consciousness
2. Confusion
3. Lethargy
4. Coma

A.All of the options C.1, 2, and 3

B.1, 3 and 4 D.1 and 3
89. The goal for treatment for respiratory acidosis
is to improve ventilation. Which of the following
measures is appropriate for clients with COPD
experiencing respiratory acidosis?

A.Bronchodilators
B. Administer medications as ordered
C.Ambulation
D.Spirometers
89. The goal for treatment for respiratory acidosis
is to improve ventilation. Which of the following
measures is appropriate for clients with COPD
experiencing respiratory acidosis?

A.Bronchodilators
B. Administer medications as ordered
C.Ambulation
D.Spirometers
90. The nurse understands that respiratory acidosis
occurs when ________.

A.The body retains too much carbon dioxide

B. The client is unable to exhale carbon dioxide
C.The client hyperventilates
D.There is loss of acid or retention of base in the
body
90. The nurse understands that respiratory acidosis
occurs when ________.

A.The body retains too much carbon dioxide

B. The client is unable to exhale carbon dioxide
C.The client hyperventilates
D.There is loss of acid or retention of base in the
body
 SITUATION
A nine-year old male child is hospitalized for burns
on the right arm, right leg and abdomen. The nurse
documents the treatment performed on the child.
91. The nurse determines the extent of burns using
the rule of nines. Which of the following assessment
findings should the nurse document?

A. 18% of the child's body surface is burned.

B. 45% of the child's body surface is burned.
C. 50% of the child's body surface is burned.
D. 25% o£ the child's body surface is burned.
91. The nurse determines the extent of burns using
the rule of nines. Which of the following assessment
findings should the nurse document?

A. 18% of the child's body surface is burned.

B. 45% of the child's body surface is burned.
C. 50% of the child's body surface is burned.
D. 25% o£ the child's body surface is burned.
92. The nurse writes a nursing diagnosis for the
child which is the basis of care for the first 24 hours
of admission. The MOST appropriate nursing
diagnosis would be _______:

A. Fear and Anxiety

B. Disturbed Body Image
C. Risk for Infection
D. Impaired Mobility
92. The nurse writes a nursing diagnosis for the
child which is the basis of care for the first 24 hours
of admission. The MOST appropriate nursing
diagnosis would be _______:

A. Fear and Anxiety

B. Disturbed Body Image
C. Risk for Infection
D. Impaired Mobility
93. The physician writes an order for the client.
Infuse D5 Water 500 cc to run for 8 hours. The
IV micro set delivers 60 drops per mL. How
many drops should the nurse regulate the flow
and record it in the client's chart?

A. 50 drops per minute

B. B. 62 drops per minute
C. 35 drops per minute
D. 30 drops per minute
•500 /8=62.5
•60 x 62.5=3.75/hr
•3750/60 min/hr=62.5
93. The physician writes an order for the client.
Infuse D5 Water 500 cc to run for 8 hours. The
IV micro set delivers 60 drops per mL. How
many drops should the nurse regulate the flow
and record it in the client's chart?

A. 50 drops per minute

B. B. 62 drops per minute
C. 35 drops per minute
D. 30 drops per minute
94.The nurse commits an error in documenting the care of the
burnt child. She consults the charge nurse to find out if the
hospital has an established policy on correcting
documentation errors. Which of the following is an
accepted form for correcting errors?

A. Enclose in parenthesis the erroneous statement, draw a

line across the statement, and make the correct entry above
the line drawn.
B. Correct the error by applying correction fluid or tape
and write the correct entry over it.
94.The nurse commits an error in documenting the care of the
burnt child. She consults the charge nurse to find out if the
hospital has an established policy on correcting
documentation errors. Which of the following is an
accepted form for correcting errors?

A. Enclose in parenthesis the erroneous statement, draw a

line across the statement, and make the correct entry above
the line drawn.
B. Correct the error by applying correction fluid or tape
and write the correct entry over it.
C. Cross through the erroneous word or statement
with a double line, affix your initials, write the
phrase “mistaken entry” then write the correct
information.

D. Use the slide rule method. Cross through the

erroneous word or statement with a single line, affix
your initials,
write the date and time the correction was made,
then write the correct information.
C. Cross through the erroneous word or statement
with a double line, affix your initials, write the
phrase “mistaken entry” then write the correct
information.

D. Use the slide rule method. Cross through the

erroneous word or statement with a single line, affix
your initials,
write the date and time the correction was made,
then write the correct information.
95. The nurse is aware that documentation requires the
following EXCEPT: Documentation should:

A. Be systematic and organized.

B. Comply with policy standards of the health care
facility.
C. Present exact and correct details pertinent to the
event.
D. Include reactions and interpretations of the nurse
on the event.
95. The nurse is aware that documentation requires the
following EXCEPT: Documentation should:

A. Be systematic and organized.

B. Comply with policy standards of the health care
facility.
C. Present exact and correct details pertinent to the
event.
D. Include reactions and interpretations of the nurse
on the event.
 SITUATION
Nurse Elma assists in the care of a 25-year-old male
who is admitted in the emergency department for
burns in the chest, abdomen, right arm and right leg.
96. The physician orders total parenteral nutrition (TPN)
for the burn patient. Which of the following statements is
TRUE in this case? TPN is needed to ___________.

A. Provide supplemental vitamins and minerals

B. correct water and electrolyte imbalances
C. ensure adequate caloric and protein intake
D. allow the gastrointestinal tract to rest
96. The physician orders total parenteral nutrition (TPN)
for the burn patient. Which of the following statements is
TRUE in this case? TPN is needed to ___________.

A. Provide supplemental vitamins and minerals

B. correct water and electrolyte imbalances
C. ensure adequate caloric and protein intake
D. allow the gastrointestinal tract to rest
97. Nurse Elma is aware that fluid shifts occur
during the emergent phase of a burn injury. This
shifting is due to fluid moving from what space?
From _______.

A. intracellular to extracellular space

B. extracellular to intracellular space
C. vascular to interstitial space
D. interstitial to vascular space
97. Nurse Elma is aware that fluid shifts occur
during the emergent phase of a burn injury. This
shifting is due to fluid moving from what space?
From _______.

A. intracellular to extracellular space

B. extracellular to intracellular space
C. vascular to interstitial space
D. interstitial to vascular space
98. Nurse Elma understands that fluid shift results
from an increase of which of the following?

A. total volume of intravascular plasma

B. total volume of circulating whole blood
C. permeability of the kidney tubules
D. permeability of capillary walls
98. Nurse Elma understands that fluid shift results
from an increase of which of the following?

A. total volume of intravascular plasma

B. total volume of circulating whole blood
C. permeability of the kidney tubules
D. permeability of capillary walls
99. Which of the following fluid and electrolyte
imbalance would Nurse Elma anticipate that the
patient would be particularly susceptible to in the
emergent phase of burn care?

A. Hyperkalemia
B. Metabolic alkalosis
C. Hemodilution
D. Hypernatremia
99. Which of the following fluid and electrolyte
imbalance would Nurse Elma anticipate that the
patient would be particularly susceptible to in the
emergent phase of burn care?

A. Hyperkalemia
B. Metabolic alkalosis
C. Hemodilution
D. Hypernatremia
100. The patient is ordered to receive fluid resuscitation
therapy. Nurse Elma adjusts the infusion rate by
evaluating the patient’s:

A. hourly body temperature

B. hourly urine output
C. hourly urine specific gravity
D. daily body weight
100. The patient is ordered to receive fluid resuscitation
therapy. Nurse Elma adjusts the infusion rate by
evaluating the patient’s:

A. hourly body temperature

B. hourly urine output
C. hourly urine specific gravity
D. daily body weight
CONGRATULATIONS