NURSING PRACTICE I - COMMUNITY HEALTH NURSING

For questions 1-5

Situation: Public Health Nurse Jesusa has several elderly clients in her caseload.
1.​ Which of the following clients is MOST likely to be a victim of elder abuse?
a.​ 65-year-old female with hip replacement
b.​ 70-year-old male with diabetes mellitus
c.​ 76-year-old male with Parkinson's disease
d.​ 80-year-old female with Alzheimer's dementia
Rationale: Elderly individuals with cognitive impairments, such as Alzheimer’s dementia, are at a
higher risk of being victims of elder abuse due to their vulnerability and potential inability to
communicate or report abuse.

2.​ To prevent deformities of the knee joint in an elderly client with exacerbation of
rheumatoid arthritis, which of the following instructions should Nurse Jesusa
provide?
a.​ Tell the client she will need joint immobilization for three weeks.
b.​ Discourage passive range of motion because it will cause further swelling.
c.​ Encourage range of motion of the joint within the limits of pain.
d.​ Tell the client to remain on bed rest until swelling subsides.
Rationale: Encouraging range of motion within the limits of pain helps maintain joint function and
flexibility, which is crucial in preventing deformities in clients with rheumatoid arthritis.

3.​ Nurse Jesusa is visiting a client with Paget's disease. Which is an important part of
preventive care for the client with Paget's disease?
a.​ Keep the environment free of clutter.
b.​ Tell the client to take a multivitamin daily.
c.​ Encourage the client to take the influenza vaccine.
d.​ Advise the client to see the dentist regularly.
Rationale: Keeping the environment free from clutter is crucial for clients with Piaget’s disease as
it helps prevent falls and injuries, which are significant due to potential bone deformities and
weakness associated with the condition.

4.​ Mrs. Andrea is taking prescribed aspirin, 325 mg daily, for her transient ischemic
attacks. Nurse Jesusa explains that aspirin was prescribed to:
a.​ prevent headaches
 b.​ boost coagulation
c.​ decrease platelet aggregation
d.​ prevent cerebral anoxia
Rationale: Aspirin is an antiplatelet medication that works by decreasing platelet aggregation,
which helps prevent blood clots that can lead to transient ischemic attacks and strokes.

5.​ Nurse Jesusa is visiting a client with Stage III Alzheimer's disease. Which of the
following is a characteristic of this stage?
a.​ Wandering at night
b.​ Dementia
c.​ Failure to recognize familiar objects
d.​ Irritability
Rationale: Stage III Alzheimer’s disease is characterized by significant cognitive decline,
including dementia, which affects memory, thinking, and social abilities.

For questions 6-10

Situation: The public health nurse must have an understanding of demography, which
should support the health care plan.
6.​ Demography is concerned with the study of population. Which of the following is
included in a demographic profile?
a.​ Change in population, distribution, and health status.
b.​ Size, distribution, composition, and change in population.
c.​ Size, composition, health status, and environment.
d.​ Size, distribution, and composition.
Rationale: A demographic profile includes the size, distribution, composition, and change in
population, which are essential for understanding the dynamics of a population and planning
appropriate health care services.

7.​ Based on the 2017 Demographic Report (July 2016 estimate), the Philippine
population has reached:
a.​ 102 million
b.​ 120 million
c.​ 85 million
d.​ 140 million
Rationale: According to the 2017 Demographic Report, the estimated population of the
Philippines was approximately 102 million, making option A the correct answer.
 8.​ There are three demographic variables in population growth. Which one is NOT
included?
a.​ Mortality
b.​ Migration
c.​ Morbidity
d.​ Fertility
Rationale: Morbidity refers to the presence of disease or health conditions in a population, while
mortality, migration, and fertility are key demographic variables that directly influence
population growth.

9.​ Population structure is a diagram of the population typically presented in a

pyramid-like style format based on _____________.
a.​ age and civil status
b.​ sex and educational attainment
c.​ age and sex
d.​ age and fertility
Rationale: Population structure is typically represented in a pyramid format based on age and
sex, illustrating the distribution of various age groups and the proportion of males to females
within a population.

10.​An aging population refers to a phenomenon in which the median age of the
population in a country rises significantly compared to the total population. This is
caused by any combination of the following:
1. a declining birth rate
2. rising life expectancy
3. decreased fertility
4. increased child survival
5. better health
a.​ 1, 2, 4, and 5
b.​ 1, 2, and 3
c.​ 1, 2, 3, and 4
d.​ 1, 2, 3, 4, and 5
Rationale: All listed factors contribute to an aging population: a declining birth rate and
decreased fertility lead to fewer young people, while rising life expectancy, increased child
survival, and better health contribute to a larger elderly population.
For questions 11-15
Situation: You will start working as a field nurse at the Philippine Red Cross. You are
reviewing RA 7719 or the Blood Services Act of 1994. This law ensures a safe and
accessible blood supply by promoting voluntary blood donation.
11.​The following are characteristics of a donor donating blood.
1. Be in good health condition
2. Weigh at least 110 lbs
3. Be 17 years of age and older
4. Carry a valid identification card
5. Be at least 5 feet tall
6. Never had an accident
To ensure the safety of the blood supply, donors must meet which of the following
BEFORE donating?
a.​ 1, 2, 3, 4
b.​ 1, 3, 4, 5
c.​ 1, 4, 5, 6
d.​ 1, 2, 5, 6
Rationale: To ensure the safety of the blood supply, donors must be in good health, weigh at
least 110 lbs, be 17 years of age or older, and carry a valid identification card. These criteria are
essential for assessing donor eligibility and ensuring the safety of the blood supply.

12.​You are aware that a person is STILL ELIGIBLE to donate blood under which of the
following conditions?
a.​ Taking antibiotics or maintenance medications
b.​ Having used self-injected, non-prescribed drugs
c.​ Having high or low blood cholesterol
d.​ Pregnancy and recent childbirth
Rationale: Individuals taking antibiotics or maintenance medications may still be eligible to
donate blood, provided they are not experiencing any active infections or symptoms that would
contraindicate donation. The other options typically disqualify a person from donating blood
due to health risks or safety concerns.

13.​You keep a list of "Walking Blood Donors." You mobilize the community to register
in this list with their blood types. Some instructions for blood donors are the
following:
1. Go to any hospital or clinic and register as a potential blood donor.
2. Register at any Blood Center Unit in a government hospital.
3. Your complete health history will be taken.
4. You will be given an honorarium upon registration.
5. A physical examination and your vital signs will be taken.
6. A blood test will be taken to determine your blood type.
Which of these will you include in your instructions?
a.​ 1, 4, 5, 6
b.​ 2, 3, 4, 5
c.​ 2, 4, 5, 6
d.​ 1, 3, 5, 6
Rationale: The correct instructions for blood donors include registering at a Blood Center Unit,
providing health history, undergoing a physical examination, and having a blood test to
determine blood type. Option 1 and 4 are not standard practices for blood donation, as
honorarium is not typically given for registration.

14.​After donating blood, you advise the donor to do the following, EXCEPT:
a.​ Increase fluid intake following blood donation.
b.​ Skip the next meal to allow the body system to rest.
c.​ Avoid carrying or lifting heavy objects using the donating arm.
d.​ Leave the adhesive dressing on for 3-6 hours.
Rationale: Skipping the next meal is not advisable after donating blood, as it is important for
donors to replenish their energy and nutrients to aid recovery.

15.​Which of the following statements is NOT true about the benefits of blood
donation? It _____________.
a.​ reduces cancer risk
b.​ burns calories
c.​ enhances production of new blood cells
d.​ is a good prevention against infection
Rationale: While blood donation can have various health benefits, it is not specifically
recognized as a good prevention against infection. The other options highlight more direct
benefits associated with blood donation.

For questions 16-20

Situation: Field Health Services and Information System (FHSIS) provides a summary of
data on health service delivery and selected programs from the barangay level up to
the national level. As a nurse, you should know the process of how this information is
processed and consolidated.
16.​All of the following are objectives of FHSIS, EXCEPT:
a.​ Minimizing recording and reporting burden, allowing more time for patient care
and promotive activities
b.​ Completing the clinical picture of chronic disease and describing their natural
history
c.​ Providing a standardized, facility-level database which can be accessed for
more in-depth studies
d.​ Ensuring that data reported are useful and accurate and are disseminated in a
timely and easy-to-use fashion
Rationale: The objective of FHSIS is not to complete the clinical picture of chronic diseases, as it
primarily focuses on health service delivery data rather than clinical details or disease history.

17.​The fundamental block or foundation of the FHSIS is the _____________.

a.​ output record
b.​ target client list
c.​ reporting forms
d.​ family treatment record
Rationale: The fundamental block or foundation of the FHSIS is the reporting forms, as they are
essential for collecting and standardizing data from various health service delivery points,
enabling effective consolidation and analysis.

18.​The primary advantage of having a target client list is it _____________.

a.​ lets nurses save time and effort in monitoring treatment and services to
beneficiaries
b.​ helps nurses monitor services rendered to clients in general
c.​ facilitates monitoring and supervision of services
d.​ facilitates easier reporting for the nurses
Rationale: Having a target client list allows nurses to focus their efforts on specific individuals who
require monitoring, thereby saving time and effort in delivering treatment and services
effectively.

19.​The nurse uses the FHSIS record system incorrectly when she:
a.​ goes to the individual or FTR for entry confirmation in the Tally/Report
Summary
 b.​ refers to other sources for completing monthly and quarterly reports
c.​ records diarrhea in the Tally sheet/Report form with a code FHSIS/M-1
d.​ records a child who has frequent diarrhea in TCL: Under Five
Rationale: Referring to other sources for completing monthly and quarterly reports is incorrect as
it undermines the integrity of the FHSIS data, which should be based solely on the information
collected from the designated health service delivery points.

20.​In assessing a patient, the _____________ is used by the nurse to record his/her
address, full name, age, symptoms, and diagnosis.
a.​ output record
b.​ target client list
c.​ individual treatment record
d.​ reporting forms
Rationale: The individual treatment record is specifically designed to document a patient’s
personal information, symptoms, and diagnosis, making it the correct choice for recording such
details during an assessment.

For questions 21-25

Situation: Public health nurses participate in health screenings which help in the early
detection of a disease or identify those who are at risk for a particular disease or
condition. Early detection, followed by treatment and management of the condition,
can result in better outcomes and lower the risk of serious complications.
21.​Nurse Susana organized a health fair in one of the communities she covers,
which was well attended, with several screening tests being given
simultaneously. What would Nurse Susana consider the purpose of the health
fair?
a.​ Case finding
b.​ Multiphasic screening
c.​ Community bonding
d.​ Community service
Rationale: Nurse Susana organized a health fair with several screening tests being given
simultaneously, which aligns with the concept of multiphasic screening, where multiple tests are
conducted to identify various health issues in a community setting.

22.​As nursing students were setting up a health screening at a local community

center, they reviewed the need to screen for heart disease and cancer. One
 student asked, "But colon cancer is prevalent; why aren't we setting up for
sigmoidoscopy?" How would Nurse Susana reply?
a.​ "Would you like to perform that test for the screening?"
b.​ "Can you find adequate privacy for a sigmoidoscopy?"
c.​ "A sigmoidoscopy is expensive to perform and invasive."
d.​ "What a great idea. Would you like to help arrange it?"
Rationale: A sigmoidoscopy is expensive to perform and invasive, making it less practical for a
community health screening compared to other screening methods that are less invasive and
more cost-effective.

23.​Sensitivity is the ability of a screening test to accurately identify what aspect of

the screening?
a.​ Persons who now have a diagnosis of the disease.
b.​ Persons who have the disease.
c.​ Persons with symptoms of the disease.
d.​ Persons who do not have the disease.
Rationale: Sensitivity refers to the ability of a screening test to correctly identify individuals who
have the disease, thus minimizing false negatives and ensuring those affected receive timely
intervention.

24.​The ability of a screening test to distinguish correctly between persons with and
without a disease is known as _____________.
a.​ sensitivity
b.​ validity
c.​ reliability
d.​ specificity
Rationale: Validity refers to the ability of a screening test to accurately measure what it is
intended to measure, which includes distinguishing between those with and without a disease.

25.​Some common examples of screening tests are the following, EXCEPT:

a.​ Urinalysis for male and female clients
b.​ Cholesterol levels in heart disease screening
c.​ PSA levels for prostate cancer in men
d.​ Pap smears for cervical cancer screening in women
Rationale: Urinalysis is not typically categorized as a screening test for a specific disease but
rather as a general diagnostic tool, making it the exception among the listed options.
NURSING PRACTICE II - CARE OF HEALTHY MOTHER/CHILD

For questions 26-30

Situation: Aira, a student, 18 years old, primigravida, delivered a baby boy forty hours
ago. The transition from being single to being a mother entails strengths and courage.
The response to change may be different for every person.
26.​The patient has been seen crying and irritable. As her nurse, you know that Aira is
experiencing "baby blues." Which is the BEST description of her condition? It is a
condition in which the patient experiences some feelings of:
a.​ Excitement
b.​ Euphoria
c.​ Sadness
d.​ Anxiety
Rationale: "Baby blues" is characterized by feelings of sadness, irritability, and emotional
fluctuations that many new mothers experience shortly after childbirth.

27.​Which of the following is TRUE about baby blues? It is:

a.​ a condition that begins 6 to 12 months postpartum
b.​ related to childhood poverty
c.​ a serious condition that would warrant antidepressant therapy
d.​ related to hormonal changes
Rationale: Baby blues are typically related to hormonal changes that occur after childbirth,
leading to mood swings and emotional fluctuations in the early postpartum period.

28.​In planning to help Aira, the nurse has explained to her the cause of baby blues.
Which ONE of these is correct?
a.​ Status quo in estrogen and progesterone.
b.​ Total decrease in estrogen and progesterone.
c.​ Total increase in estrogen and progesterone.
d.​ Increase or decrease in the levels of estrogen and progesterone.
Rationale: The baby blues are thought to be caused by fluctuations in hormone levels,
particularly estrogen and progesterone, which can increase or decrease after childbirth, leading
to emotional changes.
 29.​As a nurse, you should know the manifestations that Aira may present at any
time. These are the following:
1. Crying
2. Anorexia
3. Feeling of inadequacy
4. Isolation
5. Disturbed sleep
6. Mood swings
a.​ 1, 2, 3, 5, 6
b.​ 3, 4, 5, 6
c.​ 2, 3, 4, 5
d.​ 2, 3, 4, 5, 6
Rationale: The manifestations listed in option A (Crying, Anorexia, Feeling of inadequacy,
Disturbed sleep, Mood swings) are common indicators of postpartum emotional changes,
including potential postpartum depression, which Aira may experience as she transitions into
motherhood.

30.​Which of the following nursing measures can help Aira in her condition?
a.​ Psychotherapy
b.​ Support
c.​ Counseling
d.​ Mild antidepressant
Rationale: Support is crucial for new mothers as it helps them adjust to the significant changes in
their lives, providing emotional and practical assistance during the transition to motherhood.

For questions 31-35

Situation: Cel is a beginning nurse. She still has to be mentored when it comes to
charting.
31.​Cel must know that in narrative charting, documentation of client care should be
_____________. Choose the BEST answer.
a.​ Descriptive
b.​ Chronologic
c.​ Extensive
d.​ Formatted
Rationale: In narrative charting, documentation of client care should be descriptive to provide a
clear and detailed account of the patient's condition and the care provided.
 32.​Which statement is not TRUE about medical records that Cel must understand?
Charts _____________.
a.​ Can be borrowed by any nursing student.
b.​ Can be accessed by researchers.
c.​ Contents must be kept confidential.
d.​ Can be given out only with the client's written consent.
Rationale: Medical records are confidential and should not be borrowed by anyone, including
nursing students, as they contain sensitive patient information.

33.​The following are methods of charting, EXCEPT:

a.​ Focus
b.​ POMR
c.​ Narrative
d.​ Sequential
Rationale: Sequential is not a recognized method of charting in nursing; the other options are
established methods used for documenting patient care.

34.​In the PIE method of charting, the meaning of P is _____________.

a.​ Problem
b.​ Plan
c.​ Procedure
d.​ Progress
Rationale: In the PIE method of charting, "P" stands for "Problem," which refers to the patient's
identified issues or diagnoses that need to be addressed in the care plan.

35.​In charting neurologic assessment, Cel must understand that the following should
be indicated, EXCEPT:
a.​ Skin elasticity
b.​ Facial symmetry
c.​ Movement of extremities
d.​ Level of consciousness
Rationale: Skin elasticity is not a direct indicator of neurologic function and is more related to
hydration and skin health, rather than neurological assessment.
For questions 36-40
Situation: Patient Haydee, 23 years old, G2 P1 and is in her 9th month of pregnancy. First,
she calls the hospital to receive validation that it is alright for her to come for evaluation
or admission.
36.​During the first contact of the patient with the nurse, the latter should demonstrate
the following behavior, with the EXCEPTION of:
a.​ Encouraging
b.​ Caring
c.​ Compelling
d.​ Comforting
Rationale: In this situation, the nurse should focus on encouraging, caring, and comforting the
patient. Compelling implies pressure or force, which is not appropriate in a supportive
healthcare interaction.

37.​Patient Haydee asks how she could distinguish between true and false labor.
Which is NOT INCLUDED among the factors on which the nurse should base her
answers?
a.​ Engagement of fetus
b.​ Vital signs
c.​ Contractions
d.​ Cervix by vaginal examination
Rationale: Vital signs are not a direct factor in distinguishing between true and false labor; the
other options focus on specific signs related to labor progression.

38.​Patient Haydee comes to the perinatal unit of Hospital Dee. Nurse Arcez
conducts a thorough screening assessment. Which is the least appropriate
screening assessment to be used by the nurse?
a.​ Physical examination
b.​ Laboratory review
c.​ Radiologic procedures
d.​ Interview
Rationale: Radiologic procedures are typically not used as a routine screening assessment in
pregnancy due to potential risks to the fetus, making it the least appropriate choice in this
context.
 39.​During admission, the nurse needs to take the patient's obstetrical data. Which of
the following is the MOST important?
a.​ Prenatal check-up records
b.​ Diagnostic test results
c.​ Previous pregnancy experience
d.​ Laboratory results
Rationale: Prenatal check-up records are crucial as they provide a comprehensive overview of
the patient's health and the progress of the current pregnancy, which is essential for making
informed decisions during admission.

40.​Every pregnant woman preparing for labor and delivery has a birth plan. What is
the PRIMARY objective of a birth plan? It describes:
a.​ her psychosocial data that is necessary for her hospitalization.
b.​ the cultural and religious requirements related to the care of the mother
and newborn.
c.​ the repertoire of comfort and relaxation measures.
d.​ options on her wishes and preferences about her labor, delivery, and
puerperium.
Rationale: The primary objective of a birth plan is to outline the patient's wishes and preferences
regarding her labor, delivery, and postpartum care, ensuring that her desires are communicated
and respected during the birthing process.

For questions 41-45

Situation: Baby Sharon, a newly delivered baby girl, was delivered normally in the
maternity clinic. Nurse Juvy is performing her initial routine assessment.
41.​Nurse Juvy's assessment reveals the following: Heart rate is 110 beats per minute,
she has a vigorous cry, moves actively with good flexion, has a normal skin
color, and bluish extremities. What would be the APGAR score of Baby Sharon?
a.​ 9 points
b.​ 7 points
c.​ 5 points
d.​ 10 points
Rationale: The APGAR score is calculated based on five criteria: Appearance, Pulse, Grimace
response, Activity, and Respiration. Baby Sharon has a heart rate of 110 (2 points), a vigorous cry
(2 points), active movement with good flexion (2 points), normal skin color (2 points), and bluish
extremities (0 points). This totals to 9 points.
 42.​Baby Sharon was placed on phototherapy. What precautions should Nurse Juvy
observe?
a.​ Be certain that the newborn's intake is adequate
b.​ Assess the newborn for symptoms of headache
c.​ Keep the newborn wrapped to prevent sunburn
d.​ Put sunglasses on the newborn to protect his/her eyes
Rationale: Putting sunglasses on the newborn is crucial during phototherapy to protect the eyes
from the intense light, which can cause damage. This precaution helps ensure the safety and
well-being of the baby during treatment.

43.​Physiologic jaundice among newborn babies usually occurs on which of the

following? It occurs:
a.​ within 24 hours from birth
b.​ 7 days after birth
c.​ upon birth
d.​ between the 2nd and the 3rd day after birth
Rationale: Physiologic jaundice typically appears between the 2nd and 3rd day after birth due
to the immature liver's inability to process bilirubin efficiently, which is a normal physiological
response in newborns.

44.​If transient discoloration of Baby Sharon's skin is noted while under phototherapy,
what is this phenomenon called?
a.​ Hyperbilirubinemia
b.​ Cyanosis
c.​ Jaundice
d.​ Bronze baby syndrome
Rationale: The transient discoloration of Baby Sharon's skin under phototherapy is likely due to
jaundice, which is a common condition in newborns caused by elevated bilirubin levels.

45.​If Baby Sharon develops dehydration, what is the FIRST sign to look for by Nurse
Juvy?
a.​ Soft and depressed eyeballs
b.​ Oliguria
c.​ Non-elastic skin/poor skin turgor on thighs and abdomen
d.​ Sunken fontanels
Rationale: Soft and depressed eyeballs are often one of the earliest signs of dehydration in
infants, indicating a decrease in fluid volume and the need for further assessment.

For questions 46-50

Situation: A young mother brings her 4-year-old son, Richard, to a Pediatric Clinic where
you are assigned.
46.​The young mother wanted to know about the motor development that is
APPROPRIATE for a preschooler. Which of the following statements is NOT true?
a.​ "He can alternate feet when climbing."
b.​ "He can tie his shoelaces."
c.​ "He has not developed good posture."
d.​ "He can hop two or more times."
Rationale: Tying shoelaces typically develops around age 5 to 6, making it an inappropriate
motor skill for a 4- year-old preschooler.

47.​Healthy physical development is dependent upon nutrition, brain development,

muscle, and bone. Which of the following is NOT APPROPRIATE for the physical
development of a preschooler?
a.​ Gains 5 pounds per year
b.​ Assists in brushing and flossing teeth
c.​ Sleeps 6 to 8 hours each day
d.​ Eruption of the primary teeth
Rationale: Preschoolers typically require more sleep than 6 to 8 hours; they generally need about
10 to 12 hours of sleep per night for optimal physical and cognitive development.

48.​Her son starts asking you many questions about the things inside the Pediatric
Clinic. You should inform the mother of which of the following statements?
a.​ Impolite, so the mother should discipline her son to stay quiet in public
places.
b.​ Not normal in a preschooler, so the mother may need to consult a child
psychiatrist.
c.​ Expected in a preschooler, as they tend to ask many questions during this
age.
d.​ Expected in toddlers only, so he may have a delayed development.
Rationale: It is expected for preschoolers to be curious and ask many questions as part of their
developmental stage, indicating healthy cognitive and social development.
 49.​You informed the mother about the normal psychosocial development of
preschoolers. She correctly understands your health teaching if she verbalizes
that:
a.​ her son is more active with his parents and tends to be a bit selfish with his
toys
b.​ he may tend to exaggerate, boast, and tattle on others
c.​ he continues to react to separation from his parents
d.​ he may have temper tantrums resulting from his frustration in wanting to
do everything for himself
Rationale: Preschoolers often exhibit behaviors such as exaggerating, boasting, and tattling as
part of their social development, reflecting their growing understanding of social interactions
and the desire for attention.

50.​Before finishing the check-up, which of the following principles is NOT included
among the principles of guidance in handling Richard?
a.​ Basing her expectations within the child's limitations
b.​ Controlling temper tantrums
c.​ Reinforcing the correct use of language
d.​ Acceptance of masturbation as a normal phenomenon to be
discouraged in public
Rationale: Acceptance of masturbation as a normal phenomenon to be discouraged in public
is not a principle of guidance in handling a child, as it does not align with the developmental
understanding and acceptance of children's natural behaviors in a supportive manner.

NURSING PRACTICE III - CARE OF CLIENTS (PART A)

For questions 51-55

Situation: Ms. Simon is a nurse manager of a medical unit in a tertiary hospital. She is
responsible for the supervision of the staff nurses assigned to the unit and other health
care personnel.
51.​Ms. Simon reminds the nursing staff to safeguard and improve the quality of care
given to the patients. Which of the following activities is a PRIORITY to safeguard
nursing practice? Nurses should _____________.
a.​ know their strengths and weaknesses
 b.​ understand their professional, legal, and ethical obligations and
responsibilities
c.​ document care accurately
d.​ practice nursing competently
Rationale: Understanding professional, legal, and ethical obligations is fundamental to
safeguarding nursing practice, as it ensures that nurses are aware of the standards and
regulations that govern their actions and responsibilities in patient care.

52.​Ms. Simon, in collaboration with maintenance personnel, prepares a safety

program that includes periodic inspections of electrical equipment, conducting
fire drills, and proper disposal of hazardous waste. Which component of a quality
program do these activities illustrate?
a.​ Quality Improvement Program
b.​ Quality Assurance Program
c.​ Total Quality Program
d.​ Risk Management Program
Rationale: The activities described, such as inspections of electrical equipment, fire drills, and
hazardous waste disposal, are focused on minimizing risks and ensuring safety, which aligns with
the objectives of a Risk Management Program.

53.​Ms. Simon reviews a report on the number of patients who fell from their beds and
other fall incidents. Which of the following is an APPROPRIATE approach for Ms.
Simon to manage the situation?
a.​ Apply risk management principles
b.​ Implement a systems approach
c.​ Implement quality assurance measures
d.​ Apply total quality management principles
Rationale: Applying risk management principles is appropriate as it involves identifying, assessing,
and prioritizing risks related to patient falls, allowing Ms. Simon to develop strategies to minimize
these incidents effectively.

54.​A patient is admitted for episodes of seizures. Sometimes during the night, the
patient falls out of bed. The night nurse found the patient on the floor. The nurse
manager instructs the night nurse to explain what happened. Which of the
following BEST describes an incident report? An incident report.
1. serves as a record of facts surrounding the event
2. identifies the people involved, the date, time, and location of the event
3. is a part of the patient's medical record
4. can be used in a court of law
a.​ 2, 3, 4
b.​ 1, 3, 4
c.​ 1, 2, 4
d.​ 1, 2, 3, 4
Rationale: An incident report serves as a record of facts surrounding the event, identifies the
people involved, the date, time, and location of the event, and can be used in a court of law.
However, it is not part of the patient's medical record, as it is a separate document for quality
assurance and risk management purposes.

55.​Ms. Simon receives a report that a nurse administered a drug incorrectly to a

diabetic patient who needs more than one type of insulin. The nurse's action,
however, did not cause a negative effect on the patient. Which is the MOST
appropriate action for the nurse manager to take?
a.​ Instruct the nurse to write an incident report.
b.​ Refer the nurse to the quality assurance committee of the hospital.
c.​ Report the nurse to the attending physician.
d.​ Refer the nurse to the risk management committee of the hospital.
Rationale: Instructing the nurse to write an incident report is the most appropriate action as it
documents the error, promotes accountability, and allows for analysis to prevent future
occurrences, while also ensuring that the incident is formally recorded despite no harm coming
to the patient.

For questions 56-60

Situation: Ms. Lilia, 62 years old, has undergone partial gastrectomy and is ready for
discharge. Nurse Chit provided the patient with oral and written instructions along with
her daughter.
56.​As a post-gastrectomy patient, which of the following is the APPROPRIATE
instruction to be provided to her in relation to wound and incision care?
a.​ Demonstration of proper wound management.
b.​ Suturing of the incision site if found open.
c.​ Apply an anesthetic agent to the incision site if there is pain.
d.​ Inspect for the presence of purulent materials.
Rationale: Demonstration of proper wound management is essential for post-gastrectomy care,
ensuring the patient understands how to care for her incision to prevent infection and promote
healing.

57.​After gastrectomy, dumping syndrome may occur; what warning sign should be
emphasized to the patient and family members to be reported, EXCEPT?
a.​ Dizziness and palpitations
b.​ Vomiting of purulent and red blood
c.​ Cramps and abdominal fullness
d.​ Nausea and vomiting
Rationale: Vomiting of purulent and red blood is a serious sign that indicates potential
complications such as bleeding or infection, which should be reported. However, the other
options are more typical symptoms associated with dumping syndrome and may not require
immediate reporting unless they are severe or persistent.

58.​One of the symptomatic reliefs of dumping syndrome is through diet

management. Which of the following is considered ineffective for the patient to
follow EXCEPT?
a.​ Assume a recumbent position after meals.
b.​ Avoid taking liquids with meals.
c.​ Eat small but frequent feedings.
d.​ Take liquids with meals at all times.
Rationale: Taking liquids with meals at all times is not recommended for managing dumping
syndrome, as it can exacerbate symptoms by increasing gastric volume and accelerating
gastric emptying.

59.​Nurse Chit informed patient Lilia of the possible risks of developing complications
after surgery. Which of these can happen if she is not compliant with her health
instructions?
1. Aspiration pneumonia
2. Electrolyte imbalance
3. Wound infection
4. Atelectasis
a.​ 1 & 2
b.​ 3 & 4
c.​ 1, 2, & 3
 d.​ 1, 2, 3 & 4
Rationale: Non-compliance with health instructions after a partial gastrectomy can lead to
multiple complications, including aspiration pneumonia due to improper eating habits,
electrolyte imbalance from dietary changes, wound infection from poor care, and atelectasis
from inadequate respiratory exercises. Therefore, all listed complications are possible risks.

60.​When a patient undergoes Billroth II surgery of the stomach, it is very important

that the patient and family members are oriented that this operation involves
which of the following?
a.​ Removal of the stomach anastomosed to the ileum.
b.​ Removal of the stomach anastomosed to the duodenum.
c.​ Removal of the stomach with the remaining segment anastomosed to the
jejunum.
d.​ Removal of the stomach anastomosed to the anal sphincter.
Rationale: Billroth II surgery involves the removal of the stomach and anastomosis to the ileum,
which is crucial for the patient and family to understand for post-operative care and dietary
adjustments.

For questions 61-65

Situation: To ensure continuity of care, the nurse should be able to document relevant
baseline information about the patient's condition.
61.​Which assessment findings will the nurse record to be consistent in a client with
respiratory failure?
a.​ Hypoxemia, hypercapnia
b.​ Hypoxia, hypocapnia
c.​ Hyperventilation
d.​ Respiratory alkalosis
Rationale: In respiratory failure, hypoxemia (low oxygen levels in the blood) and hypercapnia
(elevated carbon dioxide levels) are key assessment findings that indicate the severity of the
condition and are essential for documenting the patient's baseline status.

62.​Oxygen therapy is the administration of oxygen at a concentration greater than

that found in the environmental atmosphere. The goal of oxygen therapy is to..
a.​ none of these
b.​ reverse the effects of hypoxemia in a patient
 c.​ provide adequate transport of oxygen in the blood while decreasing the
work of breathing and reducing stress on the myocardium
d.​ deliver a high concentration of oxygen in the blood while decreasing the
work of breathing and reducing hypoxemia on the myocardium
Rationale: The goal of oxygen therapy is to provide adequate transport of oxygen in the blood
while decreasing the work of breathing and reducing stress on the myocardium, ensuring that
tissues receive sufficient oxygen for metabolism and function.

63.​The nurse is aware of the differences between hypoxia and hypoxemia.

Hypoxemia is characterized by:
a.​ a decrease in oxygen supply to the tissues
b.​ a deficiency of oxygen in the biotic environment
c.​ a decrease in the arterial oxygen tension in the blood and is manifested
by changes in mental status (progressing through impaired judgment,
agitation, disorientation, confusion, lethargy, and coma)
d.​ an insufficient amount of oxygen in the body and, if severe enough, can
be life-threatening
Rationale: Hypoxemia specifically refers to a decrease in the arterial oxygen tension in the
blood, which can lead to various neurological changes, including altered mental status, as
described in the answer choice.

64.​A nurse suspects a diabetic patient to have hypokalemia when she observes
which of the following symptoms to be documented?
a.​ Edema, bounding pulse, confusion
b.​ Spasms, hypotension, convulsions
c.​ Sunken eyeballs, Kussmaul breathing, hunger
d.​ Apathy, weakness, abdominal distention
Rationale: Apathy, weakness, and abdominal distention are common symptoms of
hypokalemia, which can lead to muscle weakness and gastrointestinal disturbances.

65.​In the initial presentation of type 1 diabetes mellitus in a patient, which symptoms
would the nurse expect to assess and document?
a.​ Blurred vision and weight gain
b.​ Polydipsia and polyphagia
c.​ Short attention span and hyperactivity
d.​ Weight loss and hypotonic reflexes
Rationale: In type 1 diabetes mellitus, polydipsia (excessive thirst) and polyphagia (excessive
hunger) are classic symptoms due to the body's inability to utilize glucose effectively, leading to
dehydration and increased appetite.

For questions 66-70

Situation: Ms. CD, 15 years old, 100 lbs, 5 ft. tall, admitted to your unit for diagnostic
evaluation and nutritional support. She is moderately dehydrated with a potassium level
of 2.3 mEq/L. She has experienced weight loss of more than 15 percent within the past 3
months.
66.​What is the PRIMARY collaborative goal of treatment for Ms. CD?
a.​ Restore normal nutrition and weight.
b.​ Assist her in increasing feelings of control over eating.
c.​ Increase her strong desire to eat.
d.​ Resolve possible dysfunctional family roles as an adolescent.
Rationale: The primary collaborative goal of treatment for Ms CD is to restore normal nutrition
and weight, as she is moderately dehydrated and has experienced significant weight loss,
indicating a critical need for nutritional support and stabilization.

67.​For Ms. CD, which route for the delivery of nutrition and fluids will the health care
team try FIRST?
a.​ Gastrostomy tube.
b.​ Nasogastric route.
c.​ Intravenous route.
d.​ Oral route.
Rationale: Given Ms. CD's moderate dehydration and critically low potassium level, the
nasogastric route is the most appropriate first choice for delivering nutrition and fluids. It allows
for immediate access to the gastrointestinal tract for feeding and hydration while being less
invasive than a gastrostomy tube and more suitable than intravenous delivery for nutritional
support in this context.

68.​In caring for this patient suffering from anorexia nervosa, which task can be
delegated to the nursing assistant?
a.​ Obtaining special food for the patient when she requests it.
b.​ Observing for and reporting ritualistic behaviors related to food.
c.​ Weighing the patient daily and reinforcing that she is underweight.
d.​ Sitting with the patient during meals and for about an hour after meals.
Rationale: Weighing the patient daily is a task that can be delegated to a nursing assistant, as it
does not require nursing judgment or assessment skills. Reinforcing that she is underweight,
however, should be done by a nurse to ensure appropriate communication and support.

69.​You find Ms. CD in her room running and trotting around for about the last 30
minutes. What is the BEST response to give her at this time?
a.​ "We have talked about exercise and agreed to reach your weight goal
first."
b.​ "Stop running right now, otherwise, we will change your exercise program."
c.​ "If you continue to exercise like this, you are going to need to eat more."
d.​ "Tell me why you are running and trotting around the room?"
Rationale: Asking Ms. CD why she is running and trotting around the room allows for an open
dialogue to understand her motivations and feelings, which is crucial in addressing her health
and nutritional needs effectively.

70.​Ms. CD is at risk for refeeding syndrome that is caused by rapid feeding. What
should be the PRIORITY action of the health care team to prevent complications
associated with this syndrome?
a.​ Monitor for peripheral edema, crackles in the lungs, and jugular vein
distention.
b.​ Assess for signs of pallor of the extremities and sluggish capillary refill.
c.​ Observe for signs of secret purging and ingestion of water to increase
weight.
d.​ Monitor for decreased bowel sounds, nausea, bloating, and abdominal
distention.
Rationale: The priority action to prevent complications associated with refeeding syndrome is to
monitor for peripheral edema, crackles in the lungs, and jugular vein distention, as these signs
indicate fluid overload and potential heart failure, which are critical concerns during refeeding.

For questions 71-75

Situation: Nina, a cashier in a bookstore, consulted the ER because of abdominal
cramps, nausea, vomiting, and a slight fever. She has been experiencing these
symptoms for almost 3 days now. After a complete physical examination, laboratory,
and diagnostic tests, the physician ordered her to be admitted for exploratory
laparotomy. You are the nurse in charge of this patient.
 71.​As a nurse, the responsibility for your pre-operative care for patient Nina includes
which of the following EXCEPT
a.​ providing adequate nutrition and elimination.
b.​ explaining the surgical procedure while admitting the patient.
c.​ preparing the operative site of the abdominal region.
d.​ ensuring the patient is psychologically ready for the surgery.
Rationale: As a nurse, it is not within the scope of responsibility to explain the surgical procedure
in detail; this is typically the role of the surgeon. The nurse's role focuses on pre-operative care,
including nutrition, site preparation, and psychological readiness.

72.​Which of the following pre-operative medications do you expect to be ordered

by the surgeon the night before surgery?
a.​ Valium
b.​ Phenergan
c.​ Morphine sulfate
d.​ Demerol
Rationale: Phenergan is commonly used as an antiemetic to help control nausea and vomiting,
which is relevant for Nina's symptoms before surgery.

73.​The patient is scheduled for surgery at 8 o'clock. In the morning, the

pre-operative medications were administered an hour before the surgery. What
PRIORITY nursing measures should you perform before transferring the patient to
the operating room?
a.​ Check if she is wearing her identification bracelet.
b.​ Assist the patient to urinate.
c.​ Ask her to sign the consent.
d.​ Determine what type of anesthesia will be used.
Rationale: Checking the identification bracelet is crucial to ensure patient safety and prevent
any errors during the surgical process. It confirms the patient's identity and matches her with the
correct procedure, which is a priority before any surgical intervention.

74.​What medicine is ordered by the surgeon to reduce salivation & bronchial

secretions before the operation?
a.​ Benadryl
b.​ Magnesium S04
c.​ Atropine S04
 d.​ Codeine
Rationale: Atropine sulfate is an anticholinergic medication that is commonly used to reduce
salivation and bronchial secretions before surgical procedures, making it the correct choice in
this scenario.

75.​After 36 hours post-exploratory laparotomy, which of the following PRIORITY

physical findings should be reported immediately to the attending physician?
a.​ Nausea & vomiting
b.​ No bowel sounds
c.​ Presence of flatus
d.​ Rigid abdomen
Rationale: A rigid abdomen may indicate peritonitis or internal bleeding, which are serious
complications following surgery. This finding requires immediate attention from the attending
physician.

NURSING PRACTICE IV - CARE OF CLIENTS (PART B)

For questions 76-80

Situation: Nurse Luisa is assigned to the coronary care unit of a tertiary hospital. She
reviews the cardiovascular system before caring for patients with heart diseases.
76.​Given a set of statements regarding the physiology of the cardiovascular system,
which of the following statements is TRUE?
a.​ The QRS interval on the electrocardiogram represents the electrical
impulses passing through the ventricles.
b.​ The heart rate increases when the parasympathetic system is stimulated.
c.​ When there is a decrease in stroke volume, the heart rate decreases.
d.​ When a person has heart muscle disease, the heart muscles stretch as far
as necessary in order to maintain good function.
Rationale: The QRS interval on the electrocardiogram indeed represents the electrical impulses
passing through the ventricles, indicating ventricular depolarization, which is a true statement
about cardiovascular physiology.

77.​Nurse Luisa collects data from a patient with a primary diagnosis of heart failure.
The patient reports that he has experienced the following disorders. Which
disorder does not precipitate heart failure?
 a.​ Thyroid disorders
b.​ Nutritional anemia
c.​ Peptic ulcer disease
d.​ Recent upper respiratory infections
Rationale: Peptic ulcer disease does not directly precipitate heart failure, whereas the other
options can lead to conditions that exacerbate heart failure, such as thyroid disorders affecting
metabolism, nutritional anemia impacting oxygen delivery, and upper respiratory infections
increasing cardiac workload.

78.​Nurse Luisa has a patient admitted for palpitations and mild shortness of breath.
An electrocardiogram (ECG) was taken. The results revealed a normal P wave,
P-R interval, and QRS complex with a regular rhythm and a cardiac rate of 108
beats per minute. Nurse Luisa recognizes this cardiac dysrhythmia as:
a.​ Sinus dysrhythmia
b.​ Sinus tachycardia
c.​ Supraventricular tachycardia
d.​ Ventricular tachycardia
Rationale: The ECG findings indicate a normal P wave, P-R interval, and QRS complex, which are
characteristic of sinus tachycardia. The regular rhythm and elevated heart rate of 108 beats per
minute further support this diagnosis.

79.​The electrical activity of the patient's heart is being continuously monitored.

Suddenly, the patient has a short burst of ventricular tachycardia followed by
ventricular fibrillation. Nurse Luisa should IMMEDIATELY:
a.​ Call for help and initiate cardiopulmonary resuscitation.
b.​ Administer atropine as ordered.
c.​ Run to the nurse's station quickly and call a code.
d.​ Prepare the patient for surgical placement of a pacemaker.
Rationale: In the event of ventricular tachycardia followed by ventricular fibrillation, immediate
action is crucial. Calling for help and initiating cardiopulmonary resuscitation (CPR) is the priority
to maintain circulation and oxygenation until advanced care can be provided.

80.​Nurse Luisa attends to a patient who has continuous ECG monitoring. She
observes that the monitor shows that the rhythm has changed to ventricular
tachycardia. Which of the following interventions is the FIRST action by the nurse?
a.​ Quickly assess the level of consciousness, blood pressure, and pulse.
 b.​ Quickly obtain a defibrillator and defibrillate the patient.
c.​ Administer a precordial thump.
d.​ Administer intravenous lidocaine following emergency protocol.

Rationale: The first action in response to ventricular tachycardia is to quickly assess the patient's
level of consciousness, blood pressure, and pulse to determine the stability of the patient and
guide further interventions.

For questions 81-85

Situation: A 61-year-old male seeks consultation in the OPD. He complains of blood in
the urine, pain on urination, and frequent urination. The medical diagnosis is bladder
cancer.
81.​The male client is admitted to the oncology unit. A cystostomy is performed, a
tumor is visualized and biopsied. The nurse recognizes that the activity most often
associated with bladder tumors is:
a.​ Drinking three cans of carbonated beverages every day.
b.​ Smoking two packs of cigarettes a day.
c.​ Working with heavy equipment every day.
d.​ Jogging 6 km a day.
Rationale: Smoking is the most significant risk factor associated with bladder cancer, with a
strong correlation between tobacco use and the development of bladder tumors.

82.​The client receives a radiation implant for the treatment of bladder cancer.
Which of the following interventions is appropriate?
a.​ Restrict fluid intake.
b.​ Encourage fluid intake.
c.​ Monitor the client for signs and symptoms of cystitis.
d.​ Place the client in isolation.
Rationale: Encouraging fluid intake is appropriate as it helps dilute the urine, potentially reducing
irritation and discomfort during urination, which is important for a patient undergoing treatment
for bladder cancer.

83.​The physician plans to do a cystectomy and ideal conduit on the male client.
The nurse prepares the client for the procedure. Which of the following is an
appropriate action of the nurse?
a.​ Teach the client muscle-tightening exercises.
 b.​ Perform a cleansing enema and give laxatives as ordered.
c.​ Demonstrate to the client the procedure for irrigating the stoma.
d.​ Limit fluid intake for 24 hours.

Rationale: Performing a cleansing enema and giving laxatives as ordered is appropriate to

ensure the bowel is clear before surgery, which is important for a cystectomy procedure.

84.​The client undergoes a radical cystectomy and has an ideal conduit. Which of
the following postoperative assessment findings should the nurse observe and
report to the physician immediately?
a.​ A dusky-colored stoma.
b.​ A red, moist stoma.
c.​ A urine output of more than 30 mL per hour.
d.​ Slight bleeding from the stoma when changing the appliance.
Rationale: A dusky, colored stoma indicates compromised blood supply and potential necrosis,
which is a surgical emergency that requires immediate attention.

85.​Which of the following instructions should the nurse give to the client regarding
ideal conduit skin care at the stoma site?
a.​ Change the appliance before going to sleep.
b.​ Cut the faceplate or wafer of the appliance no more than 4mm larger
than the stoma.
c.​ Clean the skin around the stoma with mild soap and water and dry the
area thoroughly.
d.​ Leave the stoma open to air while changing the appliance.
Rationale: Cleaning the skin around the stoma with mild soap and water and drying it thoroughly
is essential for preventing skin irritation and infection, making it the best instruction for ideal
conduit skin care.

For questions 86-90

Situation: Nurse Stephanie just finished her emergency and disaster training for one
month in the Disaster and Risk Reduction Management conducted by the Department
of Health.
86.​To Nurse Stephanie's knowledge, the key difference between emergencies and
disasters is that:
a.​ Emergencies can typically be handled by available emergency services.
 b.​ Disasters result from man-made errors.
c.​ Disasters typically involve local emergency services and other agencies.
d.​ Emergencies are controlled.
Rationale: Emergencies are usually manageable by local emergency services, while disasters
often require a coordinated response from multiple agencies and resources beyond local
capabilities.

87.​Nurse Stephanie understands that an emergency is any actual threat to public

safety or public health. Which of the following is NOT applicable?
a.​ "I cannot find my mobile phone."
b.​ "A plane is about to crash."
c.​ "Hostage crisis in Jolo Sulu last December 2018."
d.​ "My son has not come home from school."
Rationale: The statement "I cannot find my mobile phone" does not represent an actual threat to
public safety or public health, unlike the other options which involve significant emergencies.

88.​During an earthquake, the impact is greatest in areas close to the epicenter.

Injuries arise primarily from falling objects and collapsing buildings. Direct impact
on health includes high mortality from severe crash injuries. Stephanie arrives at
the scene as the first responder. Which action is MOST appropriate to assure
safety?
a.​ Stop at each victim and quickly assess their respiration.
b.​ Clear the walking wounded using verbal instructions: "If you can walk,
move over there."
c.​ Give priority to dying victims.
d.​ Tag patients.
Rationale: Clearing the walking wounded is crucial in an emergency situation to ensure that
those who can help themselves are moved to safety, allowing first responders to focus on more
critical cases. This action helps to prevent further injuries and organizes the scene for more
effective triage.

89.​Cardiopulmonary resuscitation may be given to the victims. How many seconds

will Stephanie consider for perfusion to be present?
a.​ Two seconds
b.​ One second
c.​ Five seconds
 d.​ Ten seconds
Rationale: Perfusion is typically assessed by checking for a pulse or capillary refill time, which
should ideally take about two seconds to determine if perfusion is adequate.

90.​A group of passengers enters the emergency room with complaints of cough,
tightness in the throat, and extreme periorbital swelling. There is a strong odor
that exudes from their clothes. They report exposure to a "bomb" that was placed
in the bus terminal. What is the PRIORITY action of the ER nurse?
a.​ Check vital signs and auscultate lung sounds
b.​ Readily transfer patients and visitors from the area
c.​ Direct clients to the clean zone for immediate treatment
d.​ Assist clients in the decontamination area
Rationale: The priority action in this scenario is to assist clients in the decontamination area, as
the symptoms and exposure suggest a potential chemical or biological threat. Decontamination
is crucial to prevent further harm and to ensure the safety of both patients and healthcare
workers.

For questions 91-95

Situation: You are a newly hired registered nurse in a tertiary hospital. You are required
to attend an orientation activity on the legal implications of nurses' actions.
91.​You are aware that you need a license to practice nursing in the Philippines.
Licensure is primarily required to protect which of the following?
a.​ The patients under her/his care.
b.​ The school where the nurse obtained his/her nursing education and
training.
c.​ The hospital where s/he is employed.
d.​ Nurses because they are vulnerable to lawsuits.
Rationale: Licensure is primarily required to protect patients under a nurse's care by ensuring that
only qualified individuals provide healthcare services, thereby promoting safety and quality in
patient care.

92.​The facilitator discusses negligence and malpractice. Which of the following

factors is unique to malpractice?
1. There is a contractual relationship between the nurse and the patient.
2. An inappropriate care is an act of commission.
3. The patient is harmed as a result of care.
4. The action of the nurse did not meet the standards of care.
a.​ 1 & 2
b.​ 3 & 4
c.​ 3 only
d.​ 1 only
Rationale: Malpractice specifically involves a breach of duty that results in harm to the patient,
which is encapsulated in options 3 and 4. While all options relate to negligence, the
combination of harm and failure to meet standards is unique to malpractice.

93.​The facilitator cites a situation: Nurse X used medical equipment improperly,

which harmed the patient. The nurse may be charged with:
a.​ Assault
b.​ Negligence
c.​ Battery
d.​ Malpractice

94.​The facilitator gave an example of a nurse who administered the wrong

medication to a patient, resulting in a severe allergic reaction. The nurse could
be sued for:
a.​ Malpractice
b.​ Negligence
c.​ Battery
d.​ Assault
Rationale: Negligence refers to the failure to take proper care in doing something, which in this
case is the improper use of medical equipment that resulted in harm to the patient. This aligns
with the legal definition of negligence in nursing practice.

95.​The nurse could be sued for which of the following if he/she says to a patient, "If
you don't stop complaining, I will not allow you to see your family when they
visit?"
a.​ Battery
b.​ Libel
c.​ Negligence
d.​ Assault
Rationale: The nurse's statement implies a threat to restrict the patient's rights, which constitutes
assault as it creates fear of harm or loss of rights, even if no physical harm is intended.
For questions 96-100
Situation: Nurse Lory is assigned to the oncology unit of X Hospital. She assists in the care
of a 40-year-old female with bone cancer.
96.​The patient complains of pain. Nurse Lory assesses the patient. Which of the
following statements is the MOST important information Nurse Lory gathers during
the initial assessment? The:
a.​ response of the family toward the illness of the patient
b.​ amount of pain medication the patient is taking
c.​ results of the assessment of the physical examination
d.​ patient's self-reporting of her pain experience
Rationale: The patient's self-reporting of her pain experience is the most important information to
gather during the initial assessment, as it provides direct insight into the patient's pain level,
quality, and impact on her daily life, which is crucial for effective pain management.

97.​The patient informs Nurse Lory that she is taking medications to control the pain.
Which of the following statements verbalized by the patient indicates that the
patient needs further teaching about medications to control pain?
a.​ "It is okay to take my pain medication even if I am not having any pain."
b.​ "I should contact the nurse if the pain is not effectively controlled by my
medication."
c.​ "I should take my medications around the clock to control the pain."
d.​ "I should not take my pain medication periodically so I don't get addicted
to the drug."
Rationale: The statement "It is okay to take my pain medication even if I am not having any pain"
indicates a misunderstanding of pain management principles, as pain medications should be
taken as needed based on pain levels, rather than preemptively when not in pain.

98.​The patient receives chemotherapy. Nurse Lory writes a nursing diagnosis for the
patient. Which of the following nursing diagnoses is MOST appropriate?
a.​ Risk for infection
b.​ Impaired physical mobility
c.​ Pain related to treatment
d.​ Altered body image
Rationale: Risk for infection is the most appropriate nursing diagnosis for a patient receiving
chemotherapy, as chemotherapy can lead to immunosuppression, increasing the patient's
susceptibility to infections.
 99.​Nurse Lory is aware that a patient receiving chemotherapy is at risk for more
severe depression. She instructs the patient on how to prevent infection at home
when she is discharged. Which of the following should Nurse Lory communicate
to the patient?
a.​ "Visit the laboratory every week for a WBC analysis."
b.​ "Do not share the bathroom with young children or with any pregnant
members of the family."
c.​ "Avoid physical contact with other people while receiving
chemotherapy."
d.​ "Wash your hands frequently and maintain good hygiene."
Rationale: Washing hands frequently and maintaining good hygiene is crucial for patients
receiving chemotherapy, as it helps prevent infections due to their compromised immune
system.

100.​ Nurse Lory observes that the patient becomes irritable and angry with the
medical/nursing staff whenever a procedure or treatment is performed on her.
Which of the following approaches would be BEST to diffuse the anger of the
patient?
a.​ Request the social worker or psychiatrist in the hospital to talk to the
patient.
b.​ Direct the discussion and allow the patient to express her feelings.
c.​ Arrange a meeting between the patient and another person with bone
cancer.
d.​ Let the patient and family members have time with each other.
Rationale: Allowing the patient to express her feelings directly addresses her emotions and can
help her feel heard and understood, which is crucial in managing anger and irritability in a
healthcare setting.

NURSING PRACTICE V - CARE OF CLIENTS (PART C)

For questions 101-105

Situation: Celestina, a 72-year-old female, was seen wandering around Ayala Park
since early morning. At about noon, she was found unconscious along the sidewalk.
She was brought to the Emergency Room of the nearest hospital. When she regained
consciousness, she was confused and could not provide any information about herself.
She was diagnosed with Delirium.
101.​ Upon admission, Celestina was perspiring profusely with a temperature of
103.2 degrees F and showing signs of severe dehydration. She was placed on I.V.
therapy. In her case, what is the CAUSE of the Delirium?
a.​ Vitamin C deficiency
b.​ Hypoglycemia
c.​ Severe dehydration
d.​ Intoxication
Rationale: Severe dehydration can lead to electrolyte imbalances and reduced cerebral
perfusion, which are known to contribute to the development of delirium, especially in elderly
patients.

102.​ Which of the following is the PRIMARY and often the INITIAL sign of Delirium?
a.​ Aphasia
b.​ Sleep disturbance
c.​ Apraxia
d.​ Altered level of consciousness
Rationale: The primary and often initial sign of Delirium is an altered level of consciousness, which
can manifest as confusion or disorientation, as seen in Celestina's case.

103.​ In managing clients with Delirium, it is important to give realistic reassurance

to them. Which of the following statements is the MOST APPROPRIATE for this
nursing action?
a.​ "Do not worry. Your confusion is normal at your age."
b.​ "I know things are upsetting and confusing right now. Your confusion
should clear if you get better."
c.​ "I know you are confused right now. Just wait for your medication to take
effect."
d.​ "Stop crying, Celestina. It will not make you any better."
Rationale: This statement acknowledges the patient's feelings of confusion and provides realistic
reassurance that her condition is temporary and can improve with treatment, which is essential
in managing delirium.

104.​ Celestina attempted to remove the I.V. tubing from her arm, telling you, "Get
off me! Go away!" She is experiencing which of the following?
 a.​ Delusion
b.​ Auditory hallucination
c.​ Disorientation
d.​ Visual hallucination
Rationale: Celestina's statement "Get off me! Go away!" indicates a belief that someone is trying
to harm her, which aligns with delusions, specifically a persecutory delusion.

105.​ Celestina gets agitated, shouting, "There is a snake! There is a snake!",

pointing to the connecting cord of the electric fan. What would be your MOST
APPROPRIATE response?
a.​ "Celestina, it is just your imagination."
b.​ "Celestina, this is the connecting cord of the electric fan."
c.​ "Celestina, where is it? I do not see any."
d.​ "Celestina, you may hold it. You see, it is just a connecting cord."
Rationale: Responding with "Celestina, this is the connecting cord of the electric fan" provides
clear and factual information, helping to orient her to reality without dismissing her feelings or
causing further agitation.

For questions 106-110

Situation: Nurse Melody takes care of her 80-year-old mother and 85-year-old father.
She noticed her parents forgetting the names of their longtime househelp and
repeatedly asking the same questions several times.
106.​ This condition has difficulty in processing stimuli and new information.
Alzheimer's is the most common form of which of these?
a.​ Fatigue
b.​ Malnutrition
c.​ Psychosis
d.​ Dementia
Rationale: Alzheimer's disease is the most common form of dementia, characterized by memory
loss and cognitive decline, which aligns with the symptoms described in the situation.

107.​ Physiologically, what happens to the brain as Alzheimer's progresses?

a.​ Cells die
b.​ Fluids collect
c.​ Tissues swell
d.​ Brain stem atrophies
Rationale: As Alzheimer's disease progresses, there is a significant loss of neurons and synapses in
the brain, leading to cell death. This is a hallmark of the disease and contributes to the cognitive
decline observed in affected individuals.

108.​ No drugs cure this condition. Emphasis is put on delaying the onset of severe
symptoms. Which of the following does NOT help improve Alzheimer's?
a.​ Eat a balanced diet
b.​ Social connections and mental inactivity
c.​ Exercise
d.​ Smoking
Rationale: Social connections and mental inactivity do not help improve Alzheimer's; in fact,
mental inactivity can worsen cognitive decline, while social connections are beneficial for brain
health.

109.​ Which of these measures will help stabilize the mental health of Nurse
Melody's parents?
a.​ Establish a regular routine
b.​ Move to a small apartment
c.​ Correct bad behaviors gently
d.​ Repaint or buy new furniture
Rationale: Establishing a regular routine can provide structure and familiarity, which is beneficial
for individuals experiencing memory issues, helping to reduce confusion and anxiety.

110.​ Her parents usually become anxious and confused late in the afternoon and
after dark. What do you call this phenomenon?
a.​ Dark retreat
b.​ Dark reaction
c.​ Agitation
d.​ Sundowning
Rationale: Sundowning refers to a phenomenon where individuals, particularly those with
dementia or cognitive impairments, experience increased confusion, anxiety, and agitation
during the late afternoon and evening hours.

For questions 111-115

Situation: You are assigned to the Orthopedic Unit of the Surgical Ward. It has been
observed that the incidence of infection is increasing among patients on skeletal
traction. As a basis for improving the care of such patients, you want to find out if the
staff nurses have enough knowledge about their care.
111.​ To reduce the risk of infection in patients on skeletal traction, which of the
following principles must be observed?
a.​ Apply the skeletal traction under sterile conditions
b.​ Start the patient on antibiotics at least 24 hours before the procedure
c.​ The skeletal traction must be applied under general anesthesia
d.​ Apply the counter traction immediately after the application of skeletal
pins
Rationale: Applying skeletal traction under sterile conditions is crucial to minimize the risk of
infection, as it prevents the introduction of pathogens during the procedure.

112.​ A patient on skeletal traction has an increased risk of infection. Which of the
following pin sites are considered to have a greater risk for infection?
a.​ Pins placed through the bones
b.​ Pins placed through the skin
c.​ Areas within the line of pull
d.​ Areas with considerable soft tissue
Rationale: Pins placed through the skin are at greater risk for infection because they penetrate
the skin barrier, which is the body's first line of defense against pathogens. This exposure
increases the likelihood of bacteria entering the body and causing infection.

113.​ Pin site care is the most important nursing intervention for patients on skeletal
traction to reduce the risk of infection. Which of the following is the most effective
cleansing solution for this purpose?
a.​ Soapsuds solution
b.​ Hydrochloric acid solution
c.​ Acetic acid solution
d.​ Chlorhexidine solution
Rationale: Chlorhexidine solution is the most effective cleansing solution for pin site care as it has
broad- spectrum antimicrobial properties and is effective in reducing the risk of infection in
patients on skeletal traction.

114.​ Which of the following signs for a patient on skeletal traction should be
reported to the physician? SELECT ALL THAT APPLY.
1. Redness;
2. Loss of appetite;
3. Drainage;
4. Increased tenderness;
5. Formation of renal calculi;
a.​ 1, 2, 3
b.​ 1, 3, 5
c.​ 1, 3, 4
d.​ 1, 2, 5
Rationale: Signs such as redness, drainage, and increased tenderness are indicative of potential
infection or complications in patients on skeletal traction and should be reported to the
physician for further evaluation and intervention.

115.​ Skeletal traction causes increased anxiety and discomfort. Which of the
following nursing actions would provide indicators for increased anxiety and
discomfort in a patient on skeletal traction?
a.​ Perform pin site care daily
b.​ Conduct neurovascular assessments frequently
c.​ Conduct skin assessments frequently
d.​ Maintain the line of pull
Rationale: Performing neurovascular assessments frequently can help identify signs of increased
anxiety and discomfort in a patient on skeletal traction, as these assessments monitor circulation
and nerve function, which can be affected by anxiety and discomfort.

For questions 116-120

Situation: The practice of nursing requires rules and regulations to ensure patient safety
and a competent level of behavior in the professional role as a nurse. The following
questions are related to this statement.
116.​ A nurse attends a Halloween party dressed in a white nurse's uniform. She
becomes drunk and begins talking about her colleagues in a demeaning
manner. Which of the following will the nurse be considered?
a.​ Not presenting a positive or professional image of a nurse.
b.​ Professional misconduct.
c.​ Someone who has the right to vent regarding her colleagues' behavior.
d.​ Appropriate for the situation if it was a private party anyway.
Rationale: The nurse's behavior of becoming drunk and demeaning her colleagues constitutes
professional misconduct, as it undermines the integrity of the nursing profession and violates
standards of conduct expected from healthcare professionals.

117.​ Two nurses are talking about a specific client in the hospital cafeteria. These
nurses are at risk of being accused of which of the following?
1. Professional misconduct
2. Gross incompetence
3. Behavior unbecoming of the profession
4. Breach of confidentiality
a.​ 1, 2, 3
b.​ 1, 2
c.​ 3, 4
d.​ 1, 3, 4
Rationale: Discussing a specific client in a public setting like a cafeteria can lead to accusations
of professional misconduct, behavior unbecoming of the profession, and breach of
confidentiality, as it violates patient privacy and professional standards.

118.​ If a patient to be discharged suggests to the nurse that she would like to get
together again if she feels depressed, what should the nurse's response be?
a.​ Agree to meet with the patient at her convenience
b.​ Provide the patient with information about a crisis center
c.​ Suggest they go to the gym together to exercise
d.​ It's okay as long as they meet in a public place
Rationale: Providing the patient with information about a crisis center is the most appropriate
response, as it directs the patient to professional resources that can offer support and help in
times of need, ensuring patient safety and maintaining professional boundaries.

119.​ Keeping your promise as a nurse to a patient to return in 30 minutes develops

a.​ closure
b.​ trust
c.​ sympathy
d.​ empathy
Rationale: Keeping your promise as a nurse to a patient to return in 30 minutes develops trust, as
it demonstrates reliability and commitment to the patient's care, fostering a strong nurse-patient
relationship.
 120.​ A nurse observes a patient driving his car. The nurse knows the patient has a
seizure disorder and that his driver's license has been suspended. What should
the nurse do?
a.​ Call the patient and ask whether he has been driving.
b.​ Follow the patient home and call the police.
c.​ Discuss the observation with the doctor.
d.​ Notify the police department of the observation.
Rationale: The nurse has a duty to report unsafe behavior that poses a risk to public safety, such
as a patient with a seizure disorder driving despite having a suspended license. Notifying the
police department is the appropriate action to ensure the safety of the patient and others on
the road.

For questions 121-125

Situation: Nursing has a distinct and vital role in the management of sports injuries. The
prevention of sports injury is key to both sports management and health promotion in
sports.
121.​ Sancho, an eighteen-year-old college student, is into sports. While playing
football, he sustained an injury to his left knee. Nurse Sheila is assessing Sancho.
Which of the following signs and symptoms observed by Sheila reflect positive
signs of soft tissue injuries?
a.​ Sprain, fracture, and severe pain
b.​ Pain, bleeding, and swelling
c.​ Bleeding, dislocation, and pain
d.​ Pain, swelling, redness, and warmth
Rationale: Pain, swelling, redness, and warmth are classic signs of soft tissue injuries, indicating
inflammation and injury to the soft tissues surrounding the joint.

122.​ Nurse Sheila should include which of the following approaches in addressing
the initial injury management?
a.​ Relative rest, protection, elevation, and pain alleviation
b.​ Relative rest, elevation, pain alleviation, and ice
c.​ Relative rest, compression, and elevation
d.​ Relative rest, ice, compression, and elevation
Rationale: The RICE method (Rest, Ice, Compression, Elevation) is a widely accepted approach
for the initial management of sports injuries, making option D the most comprehensive and
appropriate choice for addressing injury management.
 123.​ One of the most commonly quoted acronyms in the sports injury literature for
the initial management is that of "DO NOT HARM." This useful approach helps
Nurse Sheila in advising patients to avoid which of the following approaches: 1)
1.) heat application to the affected area;
2) alcohol intake;
3) rest;
4) massage?
a.​ 3 and 4
b.​ 1, 2, 4
c.​ 1, 2, 3, and 4
d.​ 1 and 2
Rationale: The "DO NOT HARM" acronym advises against heat application, alcohol intake, and
massage, as these can exacerbate injuries. Rest is generally recommended for recovery.

124.​ After the initial injury management, Nurse Sheila's priority in her plan of care
for Sancho includes which of the following?
a.​ Restore optimal functional ability
b.​ Alleviation of pain
c.​ Facilitate Sancho's desire to return to sports
d.​ Administration of oral non-steroidal anti-inflammatory drugs as ordered
Rationale: Restoring optimal functional ability is crucial after initial injury management, as it
ensures that the athlete can return to their pre-injury level of performance and participate safely
in sports.

125.​ Nurse Sheila knows that ice or cold therapy is commonly used during the
acute stage of sports injury. The following methods, when applied correctly,
benefit the patient, EXCEPT.
a.​ one hour application to the injured part at a time continuously
b.​ ten minutes application to the injured part at a time and repeated as
necessary
c.​ melting iced water through a wet towel
d.​ application should be done four to eight times daily
Rationale: One hour application to the injured part at a time continuously is excessive and can
lead to frostbite or tissue damage, making it an incorrect method for cold therapy in acute
sports injuries.