NP3

Situation: Upon discharge, the patient with b. Complete bed rest

Chronic Obstructive Pulmonary Disease (COPD) c. Effective coughing
requires considerable patient and family d. Measure fluid intake
teaching;
 
 
Situation: Sandy a flower shop owner admitted
1. A nurse instructs a client diagnosed with
in medical ward has been resuscitated and was
COPD to use purse-lip breathing. The client
transferred to the ICU. The Physician inserted a
inquires the nurse about the advantage of this
CVP line. She was diagnosed of having
kind of breathing. The nurse answers that the
Congestive Heart Failure (CHF).
main purpose of purse-lip is to:
 
a. Prevent bronchial collapse
6. CVP monitoring could provide the following
b. Strengthen the intercostals muscle information, but one:
c. Achieve maximum inhalation a. Vascular tone
d. Allows air trapping b. Blood volume
  c. Ability of the heart to receive and pump blood
2. Nurse Albert teaches a patient about the use d. Glomerular filtration rate
of respiratory inhaler. Arrange the steps in using
 
an inhaler chronologically. 1. Press the canister
down with your fingers as you breathe in 2. Wait 7. The normal CVP reading is:
one minute between puffs if more than one puff a. 8 – 12 cm of H2O
is prescribed 3. Inhale the mist, hold your breath b. 13 – 17 cm of H2O
at least 5 to 10 seconds before exhaling 4. c. 18 – 25 cm of H2O
Remove the cap and shake the inhaler d. 4 – 10 cm of H2O
a. 4, 1, 2, 3  
b. 4, 1, 3, 2 8. In taking the CVP reading, the nurse knows
c. 3, 4, 2, 1 that the stopcock shall be manipulated in a
d. 1, 2, 3, 4 manner that:
  a. There is a communication between the client
3. The physician prescribed monitoring closely of and the manometer
clients oxygen saturation of the blood. Which of b. There is a communication between the
the following will you prepare? manometer and the client and closed to the IV
a. Electrocardiogram machine c. There is a communication between the IV and
b. Spirometer the client and closed to the manometer
c. Pulse oximeter d. There is a communication between the IV and
d. Blood Pressure apparatus manometer and closed to the client
   
4. Patients suffering from COPD are taught to 9. The patient is having volume ventilator. Which
avoid shifts to temperature and humidity. It of the following does not indicate that the client
should be emphasized that heat increases body is adequately ventilated?
temperature and thereby raising the: a. Absence of hyper – and hypoventilations
a. Risk for infection
b. Skin is normal in color
b. Anxiety level
c. Blood pressure is normal
c. The oxygen requirements
d. Presence of neurologic signs
d. Fluid intake
 
  10. Possible means of verifying proper
5. COPD patients may be taught the following placement of Lanie’s catheter (CVP line)?
pulmonary hygiene measures to improve a. Palpation
clearance of airway secretion, except:
b. Auscultation
a. Postural drainage
c. Chest X-ray years are nothing if these are not parallel with
d. Cystoscopy one’s personal-professional growth and maturity.
This implies:
Situation: Enrolling as nursing students taught
you what the nursing profession has in store for a. Simply earning years of job-related service
you and to recognize that each one came from until we retire from service.
different environs, different influences, different b. Extending assistance to our less-fortunate
past and present. As you journey through fellow nurses.
nursing, you saw yourselves transform “from the c. Progressive upgrading of competencies in
person you were” to the “aspiring nurse” you
terms of knowledge, skills, attitudes, and values
have become. Now that you have graduated and
now taking your Nurse Licensure Examination as professional nurse.
(NLE) there is only the “YOU, who is the nurse.” d. Volunteering our services wherever needed.
   
11. As an aspirant, a beginning nurse 14. We often give our best in caring but despite
practitioner after your basic nursing education, all efforts, the reality of facing death is inevitable.
the “YOU, who is a professional nurse” means: Our brand and core values of nursing will always
A. I have simply fine-tuned myself, my needs, my extend beyond the ordinary levels of promotive,
wants, my idiosyncrasies, to fit in the profession preventive, curative, and rehabilitative care. This
culturally-bound, Filipino values of nursing
of nursing.
likewise needs to be nurtured:
B. The I in me and the nurse in me are two
A. Psychological care
distinct identities that even my patients have to
B. Emotional care
learn to respect.
C. Spiritual care
C. I have simply retained my former self but
D. Relational care
acquired the knowledge, skills, attitudes, and
 
values expected of a nurse. 15. It is important to not only enrich one’s mind
D. The person I am and the professional nurse I with progressive technical upgrades but equip
aspire to be have now developed into one one’s self with holistic personal and professional
Filipino Nurse. We are one and the same development believing that:
identity. A. we are also God’s angels of mercy on earth
  B. we may also find real holism in the service we
12. As you progress in developing your nursing render
competencies, you have to thread a career-path C. we and the beneficiaries of our care are
according to the culture and design of Philippine made up of body, soul, and spirit and each
Nursing. This means: component do have health needs intertwined
a. Serving in other countries and learning new
D. should we encounter terminal patients, we
and modern ways of doing nursing and sharing
may understand how to support them to their
these back in the Philippines.
dying stage
b. Progressing as nurse-generalist in a multitude
of choice-practice settings to that of expert Situation: Aneleise, 55, was admitted to the
nurse-practitioner also in choice-practice- medical ward for acute myocardial infarction
settings (AMI) management.
c. Avoiding personal and professional  
stagnation by updating and upgrading one’s self 16. The patient called for the nurse and
d. Constantly upgrading one’s self through complains of unrelieved chest pain. She
advanced technological means and strategies verbalized, “I followed your instructions carefully.
I already took 3 NTG SL tablets at 5-minute
 
intervals from my pillbox. But the pain is still
13. It is important to remember that while RNs there.” The nurse’s best action would be:
value “job tenure” because the years in service
A. Oxygenate the patient immediately
spell variety of experiences in nursing practice, it
is far more valuable to consider that tenure- B. c. Get NGT SL tab from the E-cart and give to
patient
C. Call the doctor and report infarction
D. Administer Morphine stat as ordered
 
17. Aneleise’s admission assessment was done
by Nurse Faye. Which of the following
descriptions would the nurse consider as a
classical pain of acute myocardial infarction? a. 1,2,3,6
a. pain radiates to the jaw, back, and left arm b. 1,3,5,6
b. crushing mediastinal pain c. 1,2,3,4
c. sudden chest pain associated with activity d. 1,2,4,5
d. gnawing pain unrelieved by rest
  22. After a thorough assessment and based on
18. Oxygen at 2-4 L/min via nasal cannula was the laboratory findings, the diagnosis of iron
prescribed. Nurse Faye understands that the deficiency anemia is confirmed. The client asks
primary purpose of this order is to: the nurse what is the role of iron in the body?
a. increase myocardial oxygen supply The correct response of the nurse is:
b. decrease cardiac workload a. iron prevents bleeding
c. reduce pain due to ischemia b. iron gives the red color of our blood
d. relieve difficulty of breathing c. the body cannot synthesize hemoglobin
  without iron
19. Morphine sulfate was administered in d. iron helps in the conduction of nutrients to the
intravenous bolus to reduce pain and anxiety. body
Which of the following vital signs should Nurse
 
Faye monitor carefully to specifically determine
23. Which of the following food enhance
cardiac responses?
absorption of iron?
a. temperature
a. cereals
b. pulse rate
b. citrus fruits
c. blood pressure
c. dairy products
d. respiratory rate
d. green leafy vegetables
 
 
20. Nurses must be aware that pain in MI may
24. The client was prescribed Ferrous sulfate as
occur without cause primarily during what time of
iron supplement. For better absorption, the
the day?
nurse would instruct the client to take this
a. anytime of the day supplement:
b. usually after a day’s work a. with meals.
c. early at night before retiring b. 1 hour before meals.
d. early in the morning c. after breakfast
  d. before going to bed
Situation: A nurse admitted a female, 19-year
 
old college student. Her chief complaints are
25. Intramuscular supplementation of Iron
fatigue, weakness, and sometimes dizziness.
causes local pain and can cause stain in the
The patient is plae. The admitting diagnosis is
skin. If you are the nurse, what the best
iron deficiency anemia.
technique of administration will you use?
 
a. Z-track
21. The nurse prepared the client for complete
blood count (CBC) testing. The complete blood b. IV bolus
count is normal if the result is: c. vigorous rubbing of the injection site after
injection
d. use the gluteus maximus muscle
Situation: Nurse Jade is in charge of a client who
was admitted for management of acute episodes
of cholecystitis.
  and odor of drainage.” Which of the following
26. Nurse Jade did her admission assessment. procedures can the nurse perform without the
She understands that the pain is characterized doctor’s order?
as: A. clamping
A. Tenderness that is generalized in the upper B. emptying
epigastric area C. aspirating
B. Tenderness and rigidity at the left epigastric D. irrigating
area radiating to the back
C. Tenderness and rigidity of the upper right Situation: A nursing student was assigned to
abdomen radiating to the midsternal area take care of a client who was diagnosed of
D. Pain of the left upper quadrant radiating to polycythemia vera (^ RBC).
 
the left shoulder
31. You planned the nursing care of the client
 
together with the nursing student. You asked the
27. To confirm the diagnosis of cholecystitis, the nursing student to enumerate the clinical
attending physician ordered the procedure that manifestations of a client with polycythemia
can detect gallstones as small as 1 to 2 cm and vera. You expected the nursing student to
inflammation. Nurse Jade would prepare the enumerate the following manifestations, except:
client for which specific diagnostic procedure?
a. splenomegaly
A. cholangiography
b. ruddy complexion
B. gall bladder series
c. generalized pruritus
C. oral cholecystogram
d. hepatomegaly
D. ultrasonography
 
 
32. The nursing student reviews laboratory
28. The diagnosis was confirmed as cholecystitis findings and finds which blood results are
with gallstones. The doctor prepared the client elevated?
for the removal of his gallbladder. The client
a. RBC, WBC, platelet count
asks the nurse: “How will this procedure affect
my digestion?” The nurse’s most correct b. WBC, platelet and cholesterol
response would be: c. bilirubin, RBC and platelet
A. c. “Your body system will adjust in due time.” d. BP, WBC, and hematocrit
B. “The removal of the gallbladder usually  
interferes with digestion but can be remedied 33. Phlebotomy was ordered as part of the
by dietary modifications.” therapy. You instructed the client and
emphasized that the procedure can be repeated.
C. “The removal of the gallbladder would
The client inquired, “What is the primary aim of
significantly interfere only with the digestion of the procedure?” Your appropriate response is:
fatty food.” a. “Remove the excess blood and donate to
D. “The removal of gallbladder does not usually patients of the same blood type.”
interfere with digestion.” b. “Prevent headache and dizziness.”
  c. “Keep the BP reading within normal range.”
29. While reviewing the laboratory findings of the d. “Keep the hematocrit within normal range.”
client, Nurse Jade found out that which findings
 
are elevated? 1. white blood cell count 2. total
34. The companion asks why the client was
serum bilirubin 3. alkaline phosphate 4. red
advised to avoid iron supplements or vitamins.
blood cell count 5. cholesterol 6. serum amylase
The correct response of the nurse would be:
A. 3,5,6
a. “These supplements enhance the production
B. 1,2,6
of RBC.”
C. 1,2,3
b. “The vitamins and iron can suppress bone
D. 2,3,4
marrow function.”
 
c. “Actually, the patient does not need these
30. A T-tube was inserted and the doctor
ordered: “Monitor the amount, color, consistency supplements.”
d. “It is best that the client gets these D. peanut butter
supplements from natural sources.”  
  39. The nurse is discharging a client with
35. The client complained of generalized urethritis. Which of the following would be most
pruritus. The following are appropriate nursing important for the nurse to include in this client’s
interventions, except: discharge instructions?
a. administer routine antihistamine round the A. warm sitz bath with bath salts
clock B. eliminate phosphorous-rich food
b. regulate room temperature to 25 degrees or C. daily application of a vaginal deodorant spray
lower D. avoid sexual intercourse until symptoms
c. bathe in tepid or cool water followed by coca- subside
based lotion application  
d. wearing light material, loose-fitting camisa 40. A nurse caring for a patient who has an ileal
conduit (ileal loop) following a cystectomy for
bladder cancer should teach the patient that the
Situation: Nurse Carolina is assigned to care for
type of drainage expected from the stoma is:
clients in the medical ward for clients suffering
from renal and urinary concerns. A. urine and mucus shreds
  B. clear urine
36. An adolescent is hospitalized with acute C. urine streaked with blood
glomerulonephritis (AGN). Which aspect of the D. both urine and feces
client’s history is most significant to her
diagnosis? (GAHBS: Group A Beta Hemolytic Situation: The nurse cares for patients with
Streptococcus) problems of the urinary tract.
A. Sitting next to a student with mononucleosis  
B. Immunization with VZIG after exposure to 41. The client with chronic renal failure is on a
varicella restricted protein diet and is taught about high-
C. Experiencing a bout of cystitis within the past biologic-value protein foods. An understanding
year of the rationale for this diet is demonstrated
when the client states that high-biologic-value
D. Having an untreated sore throat two weeks
protein foods are:
ago A. Necessary to prevent muscle wasting
  B. Used to increase urea blood products
37. A client with renal calculi has just returned
C. Needed to promote weight gain
from having extracorporeal shock wave
lithotripsy (ESWL) to the right kidney. Following D. Responsible for controlling hypertension
the procedure, the nurse should:  
A. limit the client’s fluid intake for the next eight 42. The home health care nurse visits a 40-year-
hours old housewife who has been placed on
hemodialysis. When receiving the diet with the
B. monitor the nephrostomy tube for kinking or
client, the nurse encourages her to include:
occlusion A. Rice
C. strain the urine to detect any stone B. Baked salmon
fragments C. Potatoes
D. apply anesthetic cream over the client’s right D. Barbecued beef
flank  
  43. The nurse notes that the latest potassium
38. The nurse is providing dietary teaching for a level for a client in renal failure is 6.2 mEq. The
client with a history of uric acid kidney stones. first action by the nurse should be to:
Which food should be avoided by the client on a A. Call the laboratory and repeat the test
purine-restricted diet?
B. Alert the cardiac arrest team
A. liver
C. Obtain an ECG strip and have lidocaine
B. tapioca
available
C. milk
D. Take the vital signs and notify the physician
  49. Lanthanum carbonate is given to the patient
44. A client with acute renal failure moves into to address which electrolyte imbalance:
the diuretic phase after one week of therapy. a. Hypocalcemia
During this phase the client must be assessed b. Hypernatremia
for sign of developing: c. Hyperkalemia
A. Renal failure d. Hyperphosphatemia
B. Hyperkalemia  
C. Hypovolemia 50. Low-dose dopamine was ordered for a
D. Metabolic acidosis patient with Acute Kidney Injury. Which of these
  would you monitor to measure its effectiveness?
45. A client with a transplanted kidney is taught
the signs of rejection. The nurse would know a. Heart rate
that the teaching was effective when the client b. Urine output
says that a sign of rejection would be: c. Capillary time refill
A. An increased urinary output
d. Respiratory rate
B. A subnormal temperature
C. An elevated blood pressure Situation: You are a school nurse in the public
D. Weight loss school of Municipality of Cavite. As part of your
Nutrition Program you will give a talk on
Situation: Mrs. Jones, 45 years old, is a patient "Nutritional problems affective Highschool
under your care in the Pay Ward. She is a Students."
known hypertensive with poor compliance to her  
pharmacologic treatment. During your rounds, 51. As a school nurse, part of your responsibility
your VS of Mrs. Jones are as follows: T 37.3C, is as a/an:
HR 97bpm, RR 15 breaths/min, and BP 140/95. A. Health educator
Your physical assessment also showed that she B. Event coordinator
has pitting edema on her lower extremities.
C. Researcher
 
D. Advocate for a healthy lifestyle
46. Because of the inability of the kidneys to
filter properly, accumulation of wastes occurs.  
Which of these manifestations is not related to 52. A female student asked you if she is
the electrolyte imbalances occurring in CKD? overweight or not. What information would you
a. Trousseau’s sign solicit from her for you to be able to answer her
b. Calcification of major blood vessels question?*
c. Tremors A. her age
d. U-wave B. her height and age
  C. her height and weight
47. The patient may exhibit impaired secretion of D. her weight and age
aldosterone, which eventually may be  
manifested in: 53. She told you that she is 16 years old, weighs
a. Anorexia 176 lbs and she stands 5 ft. and 4 inches. Your
b. Jugular vein distention answer to her would be:*
c. Vomiting A. "You are on the verge of being classified as
d. Sunken eyeballs obese"
  B. "You are overweight"
48. Which of these drugs would cause an C. "You are underweight"
interaction and serious effect with loop diuretics? D. "You are within the normal range"
a. Atorvastatin  
b. Digoxin 54. Another student asked you on the risk factor
c. Clopidogrel for Obesity. Using a psycho-biologic theory your
d. Tramadol answer would be:
  A. Peer pressure and low self-confidence
B. Eating disorder as the results of living in a b. Delusions
diet-conscious society c. Thirst
C. Eating disorder as a generic trait d. Peripheral edema
D. Eating disorder as a fixation at the oral stage  
  59. A bipolar patient develops hyponatremia due
55. You were asked if Meridia, an appetite to excessive vomiting. Which of these
suppressant, is safe to take. Your response was: medications of the patient could cause toxicity
A. "I will refer you to the dietician so she can induced by hyponatremia?
incorporate the drug in the diet plan for obese a. Valproate
client" b. Clozapine
B. "What information have you gathered c. Lithum
regarding the drug?" d. Risperidone
C. "there are known adverse side effects of the  
drug, headache being the most common 60. Calcium gluconate is ordered for a patient
whose serum calcium falls under 8.6mg/dL.
complaint"
Which of the following actions would necessitate
D. "I will refer you to the pharmacist so he can intervention?
discuss further the action of the drug" a. Incorporating the calcium gluconate in
sodium bicarbonate
Situation: Electrolyte and fluid imbalances b. Administering calcium gluconate via slow IV
normally occur in patients with renal and
bolus
metabolic disorders. As a nurse, it is your
responsibility to be able to differentiate normal c. Monitoring the patient for postural
from abnormal laboratory values, findings, and hypotension
patient responses. This way, you will be able to d. Using D5W as a diluent for calcium gluconate
address efficiently and properly the electrolyte
imbalance(s) the patient is presenting. Situation: Alfonsus sought hospital confinement
  for pleuritic pain, fever, and cough. The
56. How does insulin work in treating attending physician had a chest x-ray taken
hyperkalemia? STAT. Result revealed presence of lung
a. Insulin binds with potassium for excretion in infiltrates. The client was assigned to Kianne the
the urine staff nurse.
 
b. Insulin causes the pituitary gland to produce
61. When Kikay performed chest auscultation,
aldosterone to increase sodium and water
she observed short discreet bubbling sounds
absorption and potassium excretion over the lower region of the right lung. Which of
c. Insulin causes potassium ions to be the following abnormal findings will Kikay
transported into the cell consider?
d. Insulin increases the affinity of glucose to A. Friction rub
potassium B. Murmur
  C. Wheezes
57. In caring for Lucy who has fluid volume D. Crackles
deficit, which among these evaluations would  
indicate that the patient is recovering from the 62. Kikay put her priority nursing diagnosis as
fluid imbalance? “Ineffective airway clearance related to
a. Urine specific gravity 1.05 increased secretions and ineffective coughing.”
b. CVP 5 mmHg Which nursing intervention would be considered
c. Urine output 10mL/hr to facilitate coughing with the LEAST
d. Hematocrit 55% discomfort?
  A. Splinting chest wall with pillow when
58. What is the primary and initial manifestation coughing
of hypernatremia? B. Putting the client in semi-Fowler’s position all
a. Increased DTRs the time
C. Taking cough med q4 hours round the clock setting in the care plan is CORRECT. The goal
D. Utilizing the purse-lip technique of breathing should be:
  A. Client focused, realistic and measurable
63. The physician prescribes oral penicillin 500 B. Nurse focused, time-limited, realistic and
mg every six hours for seven days. On the fifth measurable
day, before Kikay administers the first dose for C. Nurse focused flexible, measurable and
the day, she computed for the total amount in realistic
the milligrams of the oral penicillin that has been D. Client focused, measurable and allowing the
received by the client. Which of the following is
client to understand what needs to be done
the correct amount?
A. 2,500 mg  
68. The new nurse is asked to review the
B. 15,000 mg
medication list for a client who will undergo
C. 10,000 mg pulmonary function test. The nurse manager
D. 8,000 mg asks: “Which of the following drug class should
  be withheld prior to the test”. The CORRECT
64. Standard precaution dictates that the nurse answer of the new nurse is:
observes which of the following when caring for A. Antiussives
a client with streptococcal pneumonia? B. Bronchodilators
A. Use of face mask C. Antiemetics
B. Use of sterile gloves D. d. Antibiotics
C. Observe two-feet distance when giving care  
D. Use clean gloves 69. A physician orders a urine specimen for
  culture and sensitivity STAT for Pedro in room
65. Sputum cultures are to be obtained to 102. The nurse manager delegated the function
establish the client’s specific antibiotic treatment. to the new nurse. Which of the following
Kikay would BEST collect the specimen: statements is the MOST appropriate for the
A. Early in the morning nurse manager to say to initiate delegation of
B. Early morning after an antiseptic gargle task?
C. After brushing the client’s teeth A. “We need urine for culture STAT for Pedro in
D. Anytime of the day after a warm salt solution room 102. Tell me when you send it to the
gargle laboratory.”
B. “A STAT urine culture was ordered for client in
Situation: A new licensed nurse is assigned to room 102. Would you get it please.”
the medical unit. The nurse manager assesses C. “We need a STAT urine culture for Pedro in
that nurses skill is deficient. The following room 102.”
questions apply. D. “Please get the urine sample for culture and
  sensitivity in room 102 client.”
66. Which action is MOST appropriate for the  
nurse manager to undertake/plan for this new
70. Towards the end of the shift, the nurse
nurse in her unit?
manager noted increasing unrest among the
A. Discuss with the new nurse her alternatives staff due to the tardiness of the new nurse in
B. Counsel the new nurse that if her finishing her charting. Which action is BEST for
performance doesn’t improve in 2 months, she the nurse manager to take?
will be replaced. A. Dismiss the problem as nothing as it is not
C. Refer the new nurse to the Human Resource interfering with the ward activity
department for re-evaluation B. Ignore the observation and proceeds to her
D. Plan with the new nurse to work on how to office
improve her skills C. Discuss the observation with the staff
  D. Report to the nurse supervisor
67. The nurse manager wants to assess
improvement of the new nurse. She asks which
of the following characteristics of client goal
Situation: In COPD, the airflow limitation is a. Complaints of chest tightness and difficulty
progressive and is associated with response of of breathing
the lungs to noxious particles or gases. Mr. De b. Crackles head upon auscultation of the lung
Leon has just been admitted to the unit with a
fields, and presence of red raised areas on the
diagnosis of acute exacerbation of end-stage
COPD. chest
  c. Symmetrical expansion of the thoracic cavity
71. Upon physical assessment, you noted the during inspiration
following: RR 37breaths per minute, dyspneic, d. Temperature reading of 37.8C with feelings of
and dusky-colored skin. Which of the following nausea
should you perform initially?
a. Monitor the client’s ECG tracing Situation: Anne Grace. 45 years old post-
b. Attach Mr. De Leon to an oxygen source via menopausal, consulted the physician in the OPD
nasal cannula regulated at 10lpm for abdominal pain. She has been stressed,
c. Position the patient to High-Fowler’s irritable lately. She is more relaxed when she
d. Contact the doctor immediately smokes and drinks alcoholic beverages. She
was advised by the doctor to be admitted for a
 
suspected duodenal ulcer.
72. Which assessment finding by the staff nurse
 
in a client with COPD would require the
supervisor to intervene? 76. Upon admission, the nurse obtained further
history of the patient. Which of the following is a
a. Presence of barrel chest and dyspnea
typical pain pattern of a patient with duodenal
b. Oxygen flow meter set at 2lpm while the client ulcer?
is ambulating A. Pain is felt after 1-2 hours after meals
c. Rust-colored specimen collected early in the B. Burning, cramping pressure like pain
morning C. Pain is not relieved with antacids
d. Use of accessory muscles during inspiration D. Burning in the high left epigastrium, back and
  upper abdomen
73. Mr. Basilio, a 43-year-old client, is currently  
prescribed with Propanolol for his hypertension.
77. Ms. Anne was ordered to have blood typing.
As you browsed through this patient’s chart, you
The nurse is aware that the higher incidence of
noted history of bronchial z take first before
duodenal ulcer belongs to what blood type?
administering Propanolol?
A. A
a. Measure the apical pulse rate for a full minute
B. 0
b. Instruct the patient to change position slowly
C. B
c. Contact the physician to verify order
D. AB
d. Give drug with meals 
 
78. Gastrointestinal endoscopy was ordered in
74. Upon receiving a client with status
order to have better visualization of the gastric
asthmaticus, your priority intervention should
mucosa. After the procedure, the patient
include:
developed high grade fever of 39.8 degrees
a. Start infusion of Theophylline IV Centigrade with acute abdominal pain. What
b. Monitoring of breath sounds every 5-1o PRIORITY nursing intervention should the nurse
minutes perform?
c. Give the client a short-acting beta adrenergic A. Assess the patient at once for possible
agonist perforation
d. Administer Solu-medrol, a glucocorticoid, IV B. Take vital signs every two hours
  C. Give tepid sponge bath
75. A nurse is completing the admission D. Give relief medication as ordered
assessment of a patient with Reactive Airway  
Disease. Which manifestation would indicate to 79. Which of the following conditions is
the nurse that the patient has such condition? contraindicated for nasogastric tube insertion
and need not be ordered by the physician?
A. With cranio-facial surgery C. " I will try to ambulate after the anesthesia
B. All of the options has worn off'
C. With hypophysectomy D. " I am glad I can rest and be relaxed of my
D. Recovering from gastric surgery office work"
   
80. Which of the following is an EXPECTED 84. Which of the following assessment would be
outcome in a patient with duodenal ulcer? The your indication that Mr. Vergilio has recovered
patient will from anesthesia. A sense of?
A. Join friends for social drinks every weekend A. Feeling hungry
B. Engage self with smoking cessation program B. Feeling of warmth in the room
C. No longer join sports program C. Pin pricks in the toes
D. Use Tylenol for control of pain D. Going to the toilet
   
Situation: Mr. Vergilio, a lawyer has been under 85. After Bilroth II surgery, Mr. Vergilio reported
medical treatment for multiple gastric ulcer for that he was having diarrhea after meals. What
the last 5 years and has been advised surgery should the nurse recommend to prevent this
by his doctor. condition:
  A. Take antacids before mealtime
 81. The patient has to undergo a Bilroth II B. Avoid eating saturated fats
surgical operation. Which of the following is C. Avoid taking fluids
done in this procedure? D. Observe fasting overnight
A. A partial removal of the distal 2/3 of the
 
stomach and anastomosis of gastric stump to Situation: Maxine, 35 years old, consulted the
the jejunum OPD because of pain and abdominal distention.
B. A partial removal of the distal 2/3 of the She also complained of frequent urination in
stomach and anastomosis of the stump to the small amount. Doctor's impression is presence
duodenum of kidney stone.
C. Removal of the large portion of the stomach  
and the pyloric sphincter 86. The client is asked to describe the pain she
is experiencing. Which of the following should
D. Removal of the whole stomach
the Nurse expect?
  1. Intense deep ache in the costo-vertebral
82. Prior to surgery, you were asked by Mr. region
Vergilio why atropine sulfate is ordered, your 2. Pain usually radiates anteriorly and towards
BEST response is: the bladder
A. "Atropine causes your laryngeal spasm and 3. Wavelike pain that radiates down to the thigh
will inhibit relaxation of the muscle" and genitalia
B. "Anesthetic agents can increase mucus 4. Acute excruciating pain, colicky in nature that
secretion and atropine will counteract this radiates to genitalia
effect"
C. "Anesthetic agents can cause bradycardia A. 1 and 2
and atropine will counteract this effect" B. 1 only
D. "Atropine relaxes the spinal cord and will C. 2 and 3
relieve the pain" D. 1,2,3 and4
   
83. You just finished your pre-operative teaching 87. Which of the following questions should the
to Mr. Vergilio. Which of the following statements Nurses ask to determine the PREDISPOSING
indicates that further teaching is needed? factor of stone formation?
A. "The pre-operative medications will allay my A. How much water do you drink everyday?
fear of the operation" B. Do you engage in outdoor sports?
B. " The breathing exercises will help expand my C. What kind of medications do you take?
lungs after surgery"
D. Do you have a family history of stone c. Heidegger
formation? d. Glaser and Strauss (grounded theory)
   
88. A 24-hour urine collection was ordered for 93. Which of the following phenomenological
Maxine. This is a measurement of the following, analytic methods require a validation of results
EXCEPT: by returning to the study participants?
A. Calcium A. Van Kaam
B. Creatinine B. Colaizzi
C. Magnesium C. Giorgi
D. Sodium D. Strutfest
   
89. Lithotripsy was ordered for Maxine, She 94. Coombs (2007) explored the phenomenon of
asked the Nurse "What is this procedure all spousal caregiving from the perspective of the
about? The nurse replied, "It: spousal caregivers (the lived experience of
A. Will break up the stones in the calyces of the spousal caregivers). The research question of
kidney" the study was: “What is it like for older
B. Is a procedure to extract renal stones" caregivers to care for a spouse who has
survived a stroke?” What type of research was
C. Will create electrical discharge to break the
done by the author?
stones in the kidney" A. Phenomenology
D. Will visualize the stone and destroy it" B. Ethnographic study
  C. Grounded theory
90. Maxine is preparing to go home. Which of
D. Feminist research
the following is NOT an essential component of
your health instruction?  
A. Engage in outside activity so she can sweat a 95. What is the correct order of preparing
qualitative data before analysis? i. Transcribing
lot
Qualitative Data ii. Managing/ Organizing
B. Drink 8-10 glasses per day Qualitative Data iii. Developing a Category
C. Restrict intake of protein to 60 g/day Scheme iv. Coding Qualitative Data
D. Take non steroid drugs for pain A. III, I, IV, II
  B. I, III, IV, II
Situation: Conrad, a newly-graduated nurse, is C. III, I, II, IV
currently working as a Research Assistant with D. III, II, I, IV
his former professor on a qualitative study
regarding the health education strategies used
Situation: A 56-kg patient is rushed to the ER
by barangay health workers.
due to scald burns. It was noted that he had full-
 
thickness burns on his right arm, right thigh, half
91. A qualitative study is undertaken by the of the right leg; and partial-thickness burns on
research team. If the study focuses on how his chest and abdomen in front. You are
indigenous barangay health workers view their assigned to care for the patient.
work as grass root professionals, the team is
 
using what ethnographic perspective?
96. During the resuscitation phase, which of
a. Etic perspective (insider’s exp)
these do you expect the nurse to do?
b. Emic perspective (outsider’s exp) A. Administer insulin to treat hyperglycemia.
c. Tacit perspective(individual exp) B. Start furosemide therapy to increase
d. Exo perspective(external exp) potassium excretion.
  C. Start clear-liquid diet to increase nutrient
92. Who developed the interpretive
intake.
phenomenology methodologic school of
thought? D. Starting the patient on an isotonic
a. Husserl (school of pheno) crystalloid-infusion for resuscitation. (LR sol)
b. Parse (phenomological hermeneutic method  
97. What should the nurse monitor first to
determine the effectiveness of the fluid
challenge?
A. Skin turgor
B. Urine output
C. Heart rate
D. IV site
 
98. A nurse is about to administer an H2 blocker
(prevent ulcers/curling’s ulcer)for the patient.
She knows that this medication addresses which
complication of burn injury?
A. Pruritus of the affected areas
B. Loss of gastric motility following burn injury
 
C. Severe pain caused by the exposed nerves on
burn areas
D. Gastric mucosal sloughing from loss of
plasma volume
 
99. Which of these manifestations is an early
indication of compartment syndrome?
A. Absent capillary refill
B. Pain with passive ROM
C. Drainage on burnt areas
D. Paralysis
 
100. Over resuscitation is not uncommon during
the first days following burn treatment. Which of
these signs may indicate over resuscitation?
A. Shortness of breath
B. Urine output of 1L/day
C. Temperature of 38.5C
D. Increased lethargy