RECALLS 4: EXAM NP2 notification to the physician?

Situation – This is the first postoperative A. Moderate amount of lochia rubra

day for patient Emma who delivered by B. Fundus is firm at umbilicus
cesarean section (CS). Nurse Ivy a newly C. Pulse rate of 61 beats/minute taken in 24
hired staff was assigned to her. hours
D. Five voidings totaling 240 cc in 12 hours
1. Emma asks the nurse why she has to get
up and walk the day after surgery. Which of 5. On the third postpartum day, Emma
the following is the BEST response of the reports that she has voided five times that
nurse? Walking hastens _________. morning. What should the nurse INITIALLY
do?
A. Hastens lactation
A. Insert a Foley catheter
B. Relieves pain
B. Collect the next voiding and measure the
C. Heals wounds
urine amount
D. Fast recovery from anesthesia
C. Catheterize the client to check for
residual urine
2. Which laboratory finding should the
D. Call the physician
nurse assess on the patient 24 hours after
caesarian section delivery upon doctor’s
request? Situation – Nurses Fatima and Imelda are
doing research on, “The common errors
A. Trace 1+ proteinuria regarding Standard of Nursing
B. Hematocrit 35% Documentation in the Obstetrics Ward of
C. White blood cell count 20,000/cu.mm Medical Center.”
D. Hemoglobin 7.0 g/dL
6. Which could be the MAJOR Purpose of
3. Emma complains of “afterpains”. What the study? To __________.
should be the nurse IMMEDIATE action?
A. Improve the clarity of documentation
A. Advise her to stop breast-feeding for a B. Duplicate the study in other hospitals
day C. Reduce, if not eliminate, errors in
B. Encourage her to drink more water documentation
C. Assess vital signs and pain level D. Protect the hospital and staff from being
D. Administer an analgesic STAT sued

4. Emma is to be discharge 3 days after CS 7. Which of the following could be the BEST
delivery. Which of the following Method to gather the research data?
observations of the nurse would cause the
delay of her discharge and would warrant A. Nursing Audit
B. Focus Group Discussion her first trimester of pregnancy. Because it
C. Phenomenological is her first pregnancy, she went for her
D. Survey prenatal check-up with her mother. She
asked a lot of questions which she expects
8. What is the term used to describe the the nurse to answer her.
arrangement of statistical data that
exhibits the number of times the values of a 11. The nurse asked for the personal data of
variable occurs? the patient which, to some, Carlita did not
like to answer. And so she asked: “Why do
A. Frequency distribution you need to know if I am married?” what
B. Frequency should be a good response of the nurse? “I
C. Skewness asked your marital status because
D. Survey _________.
A. If you do not have a husband, then that
9. In statistics, what is the definition of can pose a big problem for you.”
percentage? It is __________. B. If you are married then your husband will
also suffer from discomforts like you.”
C. You need your husband to accompany
A. Whole population
you every prenatal check-up.”
B. A value on a scale of 100
D. Your husband is your best support
C. A share of profits
system during your pregnancy.”
D. Part of a whole expressed in hundredths
12. The patient asked what is the term for
signs such as breast changes, urinary
10. Based from the study’s findings, to
frequency, fatigue, morning sickness and
whom are the study’s recommendations
amenorrhea?
generally addressed? Using the situation a
forecited, the recommendation should be
A. Probable signs
addressed to _________.
B. Presumptive signs
C. Possible signs
I.Nursing educators
D. Positive signs
II.Staff nurses
III. Nursing Service Administrators
IV. Hospital Administrators

A. I, II, III
B. I, III, IV
C. I, II, III, IV
D. II, III, IV

Situation – Patient Carlita, 19 years old, is in

 A. Heart burn
B. Estrogen
C. heart rate
D. Progesterone

15. The nurse advised patient Carlita to

report to her physician which of the
following MOST important sign, if ever she
will suffer from it?

A. Cough
B. Vaginal bleeding
C. Headache
D. strong fetal movement

Situation – As a newly-hired staff nurse of

the hospital, Erlyn learned that the hospitals
have an in-service training for its staff. The
in-service trainings conducted are based on
13. The patient asked what causes newborn hospital and staff’s needs. One of the
babies with total absence of extremities. identified needs was on knowledge deficit
The nurse answered that the cause for of Mother and Baby Friendly Hospital
Amelia is intake of which of the following Initiative (MBFHI).
medications during pregnancy
___________. 16. What is the FIRST step among the ten
steps for successful breastfeeding?
A. Anti-emetics
B. Antibiotics A. Have a written breastfeeding policy that
C. analgesics is routinely communicated to all staff.
D. anti-bacterial B. Inform all pregnant women about the
benefits and management of breastfeeding.
Phocomelia 🡪 The upper or lower limbs of
C. Foster the establishment of breastfeeding
the child to be underdeveloped or missing
support groups.
D. Train all health care staff in skills
14. The patient complained that every
necessary to implement the policy.
morning, she becomes nauseated and
oftentimes, she would vomit excessively.
“What could be the cause of this,” she
asked? The nurse’s answer is: “It is due to
17. When practicing rooming-in, how long
increase level of ________.”
should the baby stay with the mother? Situation – Jade is 23 years old. She and her
______ hours. boyfriend, Kevin, are planning to get
married in a couple of months. Thereafter,
1/1 they plan to have three babies. For this
A. 8 reason they sought reproductive health
B. 24 counseling for their benefit and the proper
C. 12 growth and development of their future
D. 10 children. Nurse Nilda was there to help
them.
18. What is the CORRECT time for which the
mother should initiate breastfeeding? It
should be _______ hours after birth. 21. Jade asks what she must do in order to
be healthy in case she becomes pregnant.
A. ½ Which among the answers of Nurse Nilda
B. 1 should NOT be followed by Jade?
C. 3
D. 2 A. Get support from husband and family.
B. May have a massage from a lay midwife.
19. Erlyn learned that newborn infants C. To readily accept her pregnancy.
should ONLY be given, which of the D. Early prenatal check-up
following?
22. Kevin asks what possible contribution
A. Fruit juice he could give for the normal development
B. Breastmilk of the baby. Nurse Jade agreed that his
C. water BEST contribution would be the following
D. cow’s milk EXCEPT __________.

20. Which is the LAST part of the initiative, A. Stroke Jade’s abdomen and talk to baby
as recommended by WHO and UNICEF, for B. Provide Jade nutritious food and drinks
the MBFHI external team to do before its C. Join wife during prenatal check-up
final designation as MBFHI Hospital? D. May smoke once in a while

A. Assess business facilities if they follow 23. For the normal developmental of the
the 10 steps for successful breastfeeding. fetus, Nurse Nilda taught the couple that
B. Develop a research on the benefits of Jade should prevent Folic Acid Deficiency
breastfeeding within the institution. anemia by good diet, correct way of cooking
C. Disseminate the benefits of breastfeeding vegetables and taking Folic Acid
to communities. supplements. Which of the following is NOT
D. Follow up mothers if they are exclusively included among the outcomes of folic acid
breastfeeding. deficiency to the baby?
A. Cleft lip B. Altered family processes related to
B. Cleft palate chronic illness.
C. Neural tube defect C. High risk for infection related to vomiting.
D. Fractures of all types D. Risk for aspiration related to loss of
consciousness.
24. Jade asks the nurse what possible
diseases should she avoid that would 27. Which of the following would be the
guarantee health for the baby? These are: LEAST PRIORITY nursing care for a child
with seizure disorder?
1. Rubella – risk for miscarriage or still
birth A. Observation and recording all seizures.
2. Rheumatic fever - increased maternal B. Ensuring safety and protection from
and fetal risks injury.
3. Anemia C. Teaching the family about anticonvulsant
4. Chronic hypertension drug therapy: indication, dosage, route and
effects.
A. 1, 2, 3 D. Assessing for signs and symptoms of
B. 1, 2, 3, 4 Increased Intracranial Pressure.
C. 1, 2, 4
D. 2, 3, 4 28. Robbie will be taking phenytoin
(Dilantin) regularly for seizure control.
25. Nurse Nilda advised the couple that Which of the following will be the MOST
the BEST way to check the condition of the important teaching to Robbie’s family?
mother and the baby is to have _________.
A. Administer acetaminophen to promote
A. Regular well-selected exercise sleep.
B. Regular prenatal check-up B. Serve a diet that is high in iron
C. Music therapy C. Maintain good oral hygiene and dental
D. Good food care
D. Omit medication if the child is seizure
Situation – A hospitalized adolescent Robbie
free.
suddenly has a seizure while his family is
visiting. Nurse Karen notes whole body
29. After teaching the parents about their
rigidity followed by general jerking
child’s unique psychological needs related
movements. Robbie vomits immediately
to a seizures disorder and possible
after seizure.
stressors, which of the following concerns
voiced by them would indicate the need for
26. Which of the following would be the
additional teaching? The child’s
PRIORITY nursing diagnosis for Robbie?
___________.
A. Fluid volume deficit related to vomiting.
A. Feeling different from peers
B. Cognitive delays urination.
C. Poor self-image C. Pain at the lower quadrant and increased
D. Dependency pulse rate. – fundus at the back
D. Sharp fundal pain and discomfort
30. Which of the following is NOT a focus between contractions. – abruptio placenta
for teaching plan for an adolescent with a
seizure disorder?
Abruptio placenta 🡪 premature separation
of placenta after 20th week. If below 20
A. Obtaining a driver’s license
wks., abortion
B. Increase risk for infections
C. Peer pressure
D. Drug and alcohol use 33. A woman 2 ½ months pregnant calls you
by telephone because she passed out some
“berry-like” blood clots and now has
Situation – Any pregnancy may pose a risk.
continued dark brown vaginal bleeding.
A pregnant woman must therefore submit
Which of the following is the BEST
herself for regular pre-natal consultation in
instruction you should give her?
any health facility near her place of abode.
A nurse can play an important role in
A. “Continue normal activity but take your
making these pregnant women aware of
pulse and respiratory rate every 4 hours.”
these risks in all stages of pregnancy.
B. “Come to the health facility if uterine
contractions start.”
C. “Come to the health facility with any
31. What CHIEF ingredient of the prenatal
vaginal material passed out.”
vitamin for pregnancy nutrition that the
D. “Maintain bedrest and count the number
patient should look for?
of perineal pads used every hour.”
A. Vitamin B12 H mole 🡪 passage of clear fluid grape like
B. Potassium sized vesicles and dark brown vaginal
C. Vitamin C discharge
D. Folic Acid.
34. A woman, 33 weeks pregnant, with
32. A woman in labor is at risk for abruptio preterm rupture of membranes had blood
placenta. Which of the following work ordered daily. Which laboratory
assessments would MOST convince you and report would be MOST important to read
the pregnant woman to believe that this daily?
has happened?
A. Serum creatinine
A. Painless vaginal bleeding and downward B. Red blood cell count
trend of BP. – placenta Previa C. Sodium and potassium levels
B. And increased blood pressure and scanty D. White blood cell count
 II.Have a clear and accurate record of what
PROM 🡪 rupture of the amniotic sac before was done to the patient.
labor begins. III.Have an evidence of the health care
member’s accountability in giving care
IV.Detect patients who are clinically
35. An 18 –year –old delivers to an 8 –
deteriorating
pound – baby after 10 hours of labor. In the
post-partal period, which of the following
A. II, III, IV
would be a PRIORITY concern to assess for
B. I, II, III, IV
by the nurse?
C. I, II, III
D. I, III, IV
A. Endometritis
B. Thrombophlebitis 38. Which of the following is the CORRECT
C. Bleeding definition of focus charting?
D. Amniotic embolus -
A. It is an electronically form of
documentation of nursing care done to a
Situation – Patient Fe, 15 years old, G0P1,
patient by a registered nurse.
AOG 39 weeks, has been admitted at 6:30 in
B. It is a note, written or electronically
the morning for lumbo-sacral pains and
generated, to provide documentation
strong uterine contractions every 10
related to a specific focus.
minutes. Nurse Jocele was there to admit
C. It is a nurse-centered way of
her. She uses Focus, Data, Action and
documentation that describes the patient
Response (FDAR) as the form of charting.
status and nursing care rendered.
D. It is a nurse-centered approach to
36 In any type of charting or
documentation.
documentation, which of the following
should the nurse refer to and use to
39. In the given situation, which is the
generate and describe the status of patient
FOCUS?
Fe? Nursing __________.
A. Jocele as the admitting nurse
A. Assessment
B. Lumbo-sacral pains and strong uterine
B. Process
contractions
C. actions
C. 15 years old, G0P1, AOG of 36 weeks
D. diagnosis
D. Admission at 6:30 in the morning

37. Which of the following are the

40. What is the term used to describe the
purposes of documentation? To ________.
patient’s data or assessment, the action
done based on the assessment and
I.Ensure the development of organized
response based on the action made:
comprehensive care plan
A. Progress Note
B. Flow sheets 43. Which SIGNIFICANT statement of the
C. Standard of Care mother predisposes her son to cleft lip or
palate?
D. Focus Format
Situation – Head nurse Carmen supervises A. “On my 6 months of pregnancy, I saw a
Nurse Donna who is assigned to take care of rabbit with the same case of my son.”
a newborn baby boy named Henrich with a B. “I am asthmatic and I usually take
cleft palate. steroids.”
C. “My mother- in- law doesn’t like me,
that’s why she cursed me.”
41. The mother asks the head nurse why D. “I believe my enemy did some forms of
the pediatrician recommended that closure witchcraft on me.”
of the palate should be done before he is 6
months old. She asked Nurse Donna to 44. For an infant born with a unilateral
answer her. Which of the following is Nurse cleft lip and palate, which of the following
Donna’s APPROPRIATE response? type of feeding will be BEST to use?

A. “After age 2, surgery is very frightening A. Rubber-tipped syringe or medicine

and should be avoided if possible.” dropper.
B. “The eruption of the 2-year molars often B. Full breast feeding.
complicates the surgical procedure.” C. IV fluids on limited number of ounces.
C. “Surgery should be performed before the D. Cross-cut rubber nipple.
child starts to use faulty speech patterns.”
D. “As he gets older the palate gets wider 45. Which of the following is the number
and more difficult to repair.” ONE consideration in the care of an infant
after the surgical repair of a cleft lip?
42. The head nurse continued to ask Nurse
Donna, “A cleft lip predispose an infant to A. Preventing the infant from crying
infections PRIMARILY because of which of B. Feeding the infant with a spoon for 2
the following reasons?” days after surgery
C. Placing the infant in a semi-sitting
position
A. Waste products that accumulate along
D. Keeping the infant NPO for 1 say after
the defect.
surgery.
B. Inadequate circulation in the defective
area.
C. Deficient nutrition from ineffective Situation – Miel, on her 35 weeks of
feeding. gestation, is admitted because of
D. Mouth breathing that dries the hypertension, BP of 185/110, severe
oropharyngeal mucous membranes. headache and blurred vision. She was
placed on imposed bedrest without toilet technique on buttocks.
privileges. The physician orders MgSo4.
Erika is the nurse assigned to her. 49. The nurse must be alert to MgSo4
toxicity. Which of the following in NOT
included?
46. Which of the following would Nurse
Erika anticipate in then patient’s maternal A. Fetal bradycardia
history? B. Urine output of <30 ml per hour
C. Respiration of <12 per min
A. On and off vaginal spotting D. Increase in maternal pulse rate
B. Esophageal discomfort is experienced
after a heavy meal. 50. Which of the following hospital
C. Weight gain of 20lbs in the 1st and 2nd environment will be MOST conducive to
Trimester Miel’s condition? A room that is / with
D. Fetus moves very frequently ____________.

47. When a patient is on an imposed A. Bright and well-ventilated

bedrest, which of the following can help the B. 2 or three other patients
patient cope? These are the following, C. Quiet and non-stimulating
EXCEPT __________. D. A call button for watcher’s use.

A. Let the patient lie on her side to allow

Situation - a 13-year-old- girl named Zelda
more blood to the uterus.
tells the nurse at the pediatric clinic that
B. Increase fluid intake to 8 glasses a day to
she took a pregnancy test and it was
prevent constipation.
positive. She tells the nurse that her
C. Discourage participation of family in
grandfather, with whom she, her younger
patient care to prevent further anxiety.
siblings, and her mother live, has repeatedly
D. Use relaxation techniques to help cope
molested her for the past 3 years. When the
with stress such as music and books.
nurse asks the girl if she has told this to
anyone, she replies: “Yes, my mother.”
48. MgSo4 injections are painful to the
patient. Which of the following is the BEST
51. As the nurse’s legal responsibility, which
route for injection to prevent such negative
is the APPROPRIATE agency should she
experience for patient Miel?
notify FIRST?

A. Intravenous injection at the main IV line.

a) City Health Office to do a vaginal
B. Intravenous injection given through
examination to confirm the pregnancy
“piggy back”.
b) DSWD for notifying the girl’s mother
C. Intramuscular on each of the deltoid
about the pregnancy test positive result.
muscle.
c) Board members of Child Protective
D. Deep intramuscular using z-track
Services for proper intervention sexual abuse
d) Philippine National Police concerning a
possible sex crime a) Recurrent UTI
b) Fracture and bruises
52. If Zelda is really a victim of incest and c) Enuresis
the agency opts that she be admitted in the d) Failure to thrive syndrome
hospital, where should she be placed?
Situation - Nurse Von is assigned at the
a) With an older friendly child
Under Five Clinic. Mostly of her patients are
b) In a room near the nurse’s station
infants, so she took the opportunity to have
a mother’s class on the care of infants.
c) With another 5 year old
d) In a private room
56. Which of the following will Nurse Von
EMPHASIZE regarding the importance of
53. The abusive parent usually manifests
play during infancy? Play enhances _______
one of the following characteristics
development.
EXCEPT________
a) Cognitive
a) History of severe mental illness
b) Emotional
b) History of drug abuse
c) Physical
c) Belongs to low-income group
d) Social
d) Low tolerance for frustration
57. Which among the infants would show
54. When a patient, who allegedly has been
signs that he/she is experiencing maternal
sexually abused, the nurse should be aware
deprivation?
that legal proceedings may be necessary.
Because of this possibility, which of the
a) Hyperactive
following actions is MOST important to be
b) Overweight
done by the nurse?
c) prone to illness
d) responsive to stimuli
a) Determining if there are other injuries
such as bruises and hematomas.
58. What should Nurse Von include in the
b) Asking the parents for their approval for
accident prevention teaching plan for a
diagnostic examinations for the child.
mother with 4-month-old infant?
c) Assessing the child’s physical, intellectual
and emotional developmental levels.
a) Keep crib rails up to the highest position.
d) Documenting physical findings and
b) Cover electric outlets with safety plugs.
interactions during admission.
c) Remove poisonous substances from low
areas.
55. What typical assessment findings are
d) Remove small objects from the floor.
observed to a patient who is a victim of
59. When teaching a mother how to 62. Nurse Karl charted an IMPORTANT plan
prevent accidents while caring for her 6- of care for Mrs. Lim. He indicated in her
month-old infant, Nurse Von should charting that the patient should report
emphasize that at this age, the infant can immediately signs and symptoms of a virus-
already do which of the following causing- disease which may affect the
developmental milestone? cardiovascular system of the fetus during
which of the period of pregnancy?
a) Stand while holding on to furniture.
b) Crawl short distances. a) First month
c) Roll over from back to abdomen.
d) Sit up without assistance. b) Third month
c) Second Month
60. Nurse Von assesses the oral cavity of a d) Fourth Month
6-month-old child and finds out that the
tooth that buds first is the __________. 63. Looking at the medication sheet, the
charge nurse noted that Nurse Karl used the
CORRECT ROUTE in the administration of
a) Upper molars the vaccine, which was_______________.
b) Lower central incisor
c) Canines a) Rectal
d) Lower molars b) Intradermal
c) Subcutaneous
d) Intramuscular
Situation - Nurse Karl is caring for a mother-
infant dyad. The mother has just given birth
64. After administration of the vaccine,
to a baby boy two days ago. Today, the
health teaching was also charted by the
charge nurse us doing a chart audit to
staff nurse. Which of the following is the
determine whether the nursing process was
CORRECT one?
properly done from prenatal to postnatal
periods. The laboratory results of the
a) Immediate follow-up check up
mother and baby boy are shown below.
b) Nothing Per Orem
c) No pregnancy for 3 months
61. Using the chart data, which nursing
d) Avoid exposure to Rubella
intervention was CORRECTLY done by Nurse
Karl for Mrs. Gloria Lim?
65. Nurse Karl should also include in his
charting an additional health education to
a. Rubella vaccination
Mrs. Lim that is: rubella virus can be
b. Rhogam injection
transmitted via the placenta by the process
c. Neonatal 50% glucose infusion
of ______________.
d. Maternal blood transfusion
a) Simple diffusion
b) Pinocytosis a) “If it is difficult on your part, then you can
c) Active Transport use local herbs said to help the production
d) Facilitated Diffusion of the breast milk.”
b) “That’s a big problem ma’am, but you
can still try again.”
Situation- Breastfeeding is one of the major
c) “Just continue breastfeeding. This will
responsibilities of OPD Nurse Pau. Along
stimulate the hypothalamus in the
this line, she gathers pregnant women to
production of breast milk.”
provide them health education about the
d) I empathize with you. I too, do not have
topic.
breast milk.”
66. Nurse Pau explains that exclusive
69. Malou, one of the pregnant women,
breastfeeding is giving the baby_______.
asked Nurse Pau to teach her the proper
positioning of the baby while breastfeeding.
a) Breast milk and introducing solids at one
Among Nurse Pau’s answers, which one is
month
NOT CORRECT?
b) Breast milk with drops of syrup
c) Breast milk alternating with sips of boiled
a) The baby can lie down perpendicularly
water
with the mother to promote better
d) Only breast milk for 6 months
bonding.
b) The baby’s face should be towards the
67. She further explains that the specific
mother’s breast to have an eye to eye
objectives of exclusive and extended
contact.
breastfeeding from 2005 to 2010 are the
c) The baby’s head and body should be
following EXCEPT_________.
aligned to promote better swallowing.
d) The baby’s tummy should be close to the
a) 50% of infants are exclusively
mother’s tummy for better support.
breastfeeding up to 6 months
b) 90% of infants are started on
70. To convince the pregnant mothers to
complementary feeding by 6 months of age.
breastfeed their newborns upon delivery,
c) 70% of newborns are initiated to
the BEST thing that Nurse Pau must do is to
breastfeeding within an hour after birth.
______________
d) Twelve (12) months is the median
duration of breastfeeding.
a) Explain the hospital policy on “No
breastfeeding; No admission”
b) Relate her own experience on
68. A mother questioned Nurse Pau in the
breastfeeding
event that she does not produce milk, what
c) Prepare the mothers physically,
should she do? The BEST answer of Nurse
emotionally and psychologically
Pau would be___________.
d) Ask other mothers to convince them to
breastfeed a) 90
b) 75
c) 85
Situation - Geneva is now 15 years old. She
d) 80
goes to an exclusive school but she seldom
interacts with her classmates nor is
74. How can Geneva be helped to reduce
interested to join school activities. Her
her weight? She can be advised to cut
mother brought her to an adolescent
intake of which of the following?
specialist and was diagnosed of
malnutrition.
a) Salt, protein and fats
b) Carbohydrates, vitamins and salts
71. Which of the following is NOT a
c) Carbohydrates, fats and salts
CORRECT statement about malnutrition?
d) Fats, protein and sweets
Malnutrition is for ____________.

75. Which of the following can Geneva do

a) Both the urban and rural areas
to help her with her obesity problem?
b) Both the poor and the rich
c) The underweight as family income
a) Skip one full meal a day.
increases
b) Drink 6 glasses of water every day.
d) The overweight as family income
c) Take weight reducing pills.
increases
d) Exercise 30 minutes three times a week.
72. Advertisement (ads) on television is
Situation - Baby Boy Christian, 6 months
said to be a contributory factor for obesity.
old, was diagnosed as having
What could be a GOOD advice to
communicating hydrocephalus. Nurse
adolescents like Geneva regarding these ads
Peninah is planning nursing care for this
that can be contributory to malnutrition?
baby who is a candidate for ventriculo-
peritoneal shunting.
a) “Check nutritional contents before
76. When helping the parents understand
buying foods.”
the baby’s problem, which of the following
b) “Follow your desire for food and drinks.”
should be Nurse Peninah’s ACCURATE
c) “What you see is what you get.”
explanation?
d) “There is no truth in advertisements.”

a) “The CSF is prevented from adequate

73. Geneva went to see a nutritionist. She absorption by a blockage in the ventricles of
is overweight for her height. What is the the brain.”
normal weight, in POUNDS, for Geneva who b) “Too much Cerebro Spinal Fluid (CSF) is
is 5 feet tall? produced within the ventricles of the
brains.”
c) “The flow of CSF through the brain cells
does not empty effectively into the spinal
cord.” a) The shunt may need to be revised as the
d) “There is a part of the brain surface that child grows older.
usually absorbs CSF after its production that b) If any brain damage has occurred, it is
is not functioning adequately. reversible during the first year of life.
c) Hydrocephalus usually is self- limiting by
2 years of age and then the shunt is
77. Nurse Peninah understands that removed.
hydrocephalus, if left untreated, can cause d) The prognosis is excellent and the valve is
mental retardation because of which of the permanent.
following rationales?
80. What is the drug that will lessen CSF
a) Hypertonic CSF disturbs normal plasma production that Nurse Peninah will
concentration, depriving nerve cells of vital anticipate the doctor to order?
nutrients.
b) Gradually increasing size of the ventricles a) Spironolactone
presses the brain against the bony cranium; b) Lasix
anoxia and decreased blood supply result. c) Mannitol
c) Increasing head size necessitates more d) Diamox
oxygen and nutrients than normal blood
flow can supply. Situation - Nurse Vincent assists in the in-
d) CSF dilutes blood supply, causing cells to service training of nurses in St. James
atrophy. Hospital. Based from the needs assessment,
the nurses need to be trained on patient’s
78. What is the IMPORTANT nursing care safety. The first lecture was on medication
of an infant with increased intracranial administration. Nurse Vincent gave the
pressure? following problems for the nurse to solve.

a) Check the infant’s reflexes at regular 81. An eight-year-old- patient is to receive

intervals. Aminophylline 3 mg/kg TID. If the girl
b) Monitor the infant’s level of weights 25 kg, how much Aminophylline
consciousness by stimulating frequently. should she receive daily?
c) Weight the infant daily before feeding.
d) Elevate the infant’s head higher than the a) 125 mg
hips. b) 225 mg
c) 200 mg
79. Baby Boy Christian just had a d) 100 mg
ventriculoperitoneal shunt. His parents
were worried about the prognosis. What 82. Mrs. Delos Santos is to receive Digoxin
information should Nurse Peninah give to 0.325 mg p.o. because of her heart ailment.
the parents to allay their worry? The stock is 0.250 mg per tablet. How many
TABLETS should the nurse request for 7 c) Medication given to patient A instead to
days supply for the patient? patient B. Patient advised.
d) Wrong dose of medicine administered to
a) 9 patient. Sorry.
b) 7
c) 10
Situation - one of the responsibilities of a
d) 8
nurse in fertility specialist’s office is to
provide health teaching to the patient in
83. In giving insulin to an OB diabetic
relation to timing of intercourse to achieve
patient, the nurse must use an
pregnancy.
APPROPRIATE needle size and length, which
among the following will this be?
86. Which instruction to patient addresses
a) 23 G, 3/8
the BEST time to achieve a pregnancy?
b) 22 G, 2/8
c) 24 G, 4/8
a) 14 days before the next period is
d) 25 G, 5/8
expected
b) Immediately after menses end
c) Midway between periods
84. Nurse Vincent emphasized that patient
d) 14 days after the beginning of the last
safety is___________.
period

a) Preventing errors and adverse reactions

87. With regards to sexual functioning, the
to patients associated with health care
nurse explained the ovulation occurs on
b) Being careful in caring for patients at all
which of the following conditions?
times
c) Providing treatment and care to patients
and documenting the same
a) Chorionic gonadotropin level is high
d) Being mindful of the needs of others at
b) Luteinizing hormone level is high
all times
c) Oxytocin level is high
d) Progesterone level is high
85. Nurse Vincent has provided
instructions that all care provided by nurses
88. After ovulation has occurred, the nurse
must be documented, as one of their legal
teaches women in the fertility clinic that the
responsibilities. In case errors occur, which
ovum is through to remain viable for many
is the correct way of documenting it?
HOURS?

a) Wrong medicine given to wrong patient.

a) 24 to 36
Physician notified. Patient observed
b) 12 to 18
b) Medication inadvertently omitted.
c) 48 to 72
Supervisor notified.
d) 1 to 6
a) Number of significant accompanying
89. When teaching clients to determine symptoms
the time of ovulation by taking the basal b) Objective symptom presented
temperature, the nurse explains that the c) Subjective symptom presented
change in the basal temperature during
ovulation is shown in which of the following d) Significant reason for the child’s
observations? The hospitalization
temperature_____________.
92. Using the FDAR (Focus Data Action and
Response) Charting, which of the following
a) Drops markedly and remains lower presenting data would be PRIMARY “Focus”
b) Rises markedly and remains high
c) Drops slightly and then rises again a) Vomiting in small amount
d) Rises suddenly and then falls down b) Watery stools 4x in 30 minutes
c) Generalized abdominal pain
90. In response to a client’s question on d) Temperature of 38.1 centigrade
the chief function of progesterone, which of
the following would be the CORRECT 93. When getting the data on the
answer? It _________________. subjective symptom of the abdominal pain,
which of the following should the nurse
a) Stimulates the follicles for ovulation to RELY on?
occur
b) Establishes the secondary male sex a) Mother’s verbal complaint
characteristics b) Result of the abdominal percussion
c) Prepares the uterus to receive a fertilized c) Patient’s verbal complaint
ovum d) Result of auscultation of the abdomen
d) Develops the female reproductive organs
94. The “response” should be based from
which of the following categories of the
Situation- Janna, 3 years old, was admitted
FDAR?
to Pediatrics Ward because of watery stools
four times in 30 minutes accompanied by
a) Intervention made
vomiting, abdominal pain and temperature
b) Laboratory Findings
of 38.1 degrees centigrade. Nurse Gel was
c) Focus
the one who was the admitting nurse.
d) Assessment
91. Which of the following should be the
95. Which of the following can be the
PRIMARY consideration by the nurse when
LEAST source of data for this case?
charting the Chief Complaint? The
___________.
a) Vital signs
b) Laboratory Findings promote justice and welfare, what bio-
c) Intake and output ethical principle does he/she promotes
d) Immunization record
a) Welfare
Situation - Nurses are guided by bio-ethical b) Stewardship
principles as they practice their chosen c) Justice
profession. d) Paternalism

96. What bio- ethical principle guides the 100. As a means to solve any crisis or
nurses when taking care and being scarcity in any health care systems,
responsible for patients? providing an equitable distribution of
resources is based on what bio- ethical
a) Solidarity principle?
b) Fidelity
c) Totality a) Paternalism
d) Stewardship b) Justice
c) Fidelity
97. Each person has a responsibility to take d) Stewardship
care of his/her body. In case a part is
defective, it can be removed for the benefit
of the remaining parts. What bio- ethical
principle is this?

a) Totality
b) Stewardship
c) Solidarity
d) Fidelity

98. As member of the health team, nurses

are expected to collaborate with other
health care professionals for unity and
cooperation. What bio- ethical principle is
this?

a) Fidelity
b) Stewardship
c) Solidarity
d) Totality

99. When another person or entity

intrudes in the affairs of the patient to