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PEAK

EXCELLENCE REVIEW CENTER


Fundamentals of Nursing
POST-TEST
By: Raymundo III D. Doce

i. This is a 150-item examination (120 items paper-based exam plus 30-item powerpoint-
based exam). Choose best answer and shade the corresponding letter on the answer sheet
provided.
ii. You are only given 2 hours to answer your paper-based exam. No extension of time shall be
given. Powerpoint-based exam will follow. Rationalization will be conducted thereafter.
iii. Be honest and mind your own paper, as you are soon to be a professional nurse. Any form
of cheating will never be tolerated and is strictly prohibited. Use of calculator is allowed.
Cellphones can only be used (in calculation) only when you are told to do so.

1. The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary
teaching focusing on foods high in which vitamin that may be lacking in a vegan diet?
a. Vitamin A c. Vitamin C
b. Vitamin B12 d. Vitamin E
2. The nurse is inserting an intravenous line into a client’s vein. After the initial stick, the nurse continues to advance
the catheter if:
a. The catheter advances easily c. The client does not complain of discomfort
b. The vein is distended under the needle d. Blood return shows in the backflash chamber of the catheter
3. The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the
distal end of the IV tubing to a needleless device, the exposed tubing drops and hits the top of the medication cart.
Which of the following is the appropriate action by the nurse?
a. Obtain the new IV tubing c. Wipe the distal end of the tubing with Betadine
b. Attach a new needleless device d. Scrub the needleless device with an alcohol swab
4. A client has just undergone insertion of a central venous catheter at the bedside. The nurse would be sure to check
the results of which of the following before initiating the flow rate of the client’s intravenous (IV) solution at 100
mL/hour?
a. Serum osmolality c. Portable chest x-ray film
b. Serum electrolyte levels d. Intake and output record
5. The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period
of time. Which of the following items is important to check regarding the age of blood cells before the transfusion is
begun?
a. Expiration date c. Blood group and type
b. Presence of clots d. Blood identification number
6. A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure.
The nurse suggests to the client to do which of the following to reduce the risk of possible transfusion
complications?
a. Give an autologous blood donation before the surgery
b. Ask a friend or family member to donate blood ahead of time
c. Take iron supplements before surgery to boost hemoglobin levels
d. Request that any donated blood be screened twice by blood bank
7. After surgery from general anesthesia, how should the nurse instruct the client to deep breath and cough?
1. “Assume a sitting position”
2. “Lie on your back”
3. “Hold your breath and exhale slowly”
4. “Splint the surgical incision to minimize pain”
a. 1, 2, 3 c. 1, 3, 4
b. 2, 3, 4 d. 2, 3
8. The doctor prescribes Spironolactone (Aldactone) to a client for the treatment of hypertension. Which dietary
choice of the client reflects a need for further instruction from the nurse?
a. Apple c. Wheat bread
b. Yogurt d. Fresh oranges
9. Which of the following behavior of the nurse reflects her sensitivity to the client’s cultural beliefs?
a. Providing immediate post-mortem care to the body of a Muslim client
b. Discussing the possibility of organ donation with the family of a Jehovah’s Witness who died from a motor
vehicular accident
c. Joining the family of a Baptist client in singing hymn to the dying client
d. Accepting the anger of the Catholic client’s family as the part of the grieving process
10. After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the
nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the
bottom of the now-opened wound. Which corrective intervention should the nurse do first?
a. Allow the area to be exposed to air until all drainage has stopped
b. Place several cold packs over the area, protecting the skin around the wound
c. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely
to indicate a wound evisceration
d. Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30
minutes because this is a minor opening in the surgical wound and should reseal quickly
11. Immobilized patients are at risk for impaired skin integrity. Which of the following interventions would
reduce this risk? (Select all that apply)
1. Repositioning patient every 1 to 2 hours while awake
2. Using an objective, valid scale to assess patient’s risk for pressure ulcer development
3. Using a device to relieve pressure when patient is seated in chair
4. Teaching patient how to shift weight at regular intervals while sitting in a chair
5. A good rule is: the higher the risk for skin breakdown, the shorter the interval between position
changes
a. 1, 2, 3, 4 c. 1, 2, 3, 4, 5
b. 2, 3, 4, 5 d. 2, 3, 5
12. A male patient returned from the operating room 6 hours ago with a cast on his right arm. He has not yet
voided. Which action would be the most beneficial in assisting the patient to void?
a. Suggest he stand at the bedside c. Give him the urinal to use in bed
b. Stay with the client d. Tell him that, if he doesn’t urinate, he will be catheterized
13. An older male patient states that he is having problems starting and stopping his stream of urine and he
feels the urgency to void. The best way to assist this patient is to:
a. Help him stand to void c. Have him practice Credé’s method
b. Place a condom catheter d. Initiate Kegel exercises
14. Since removal of the patient’s Foley catheter, the patient has voided 50 to 100 mL every 2 to 3 hours. Which
action should the nurse take first?
a. Check for bladder distention c. Obtain an order to recatheterize the patient
b. Encourage fluid intake d. Document the amount of each voiding for 24 hours
15. The nurse assesses that the patient has a full bladder, and the patient states that he or she is having
difficulty voiding. The nurse would teach the patient to:
a. Use the double-voiding technique c. Use Credé’s method
b. Perform Kegel exercises d. Keep a voiding diary
1. A physician’s prescription reads Clindamycin Phosphate (Cleocin Phosphate) 0.3 g in 50 ml normal
saline solution to be administered intravenously over 30 minutes. The medication label reads
Clindamycin Phosphate (Cleocin Phosphate) 900 mg in 6 ml. A nurse prepares how many millilitres of
the medication to administer the correct dose?
Ans: _____ ml
2. The doctor ordered Nafcillin 500 mg PO PC. Stock on hand is Nafcillin 1 gram tab. How many tablet/s
will you administer per day?
Ans: _____ tablet/s
3. Which of the following is an example of data that should be validated?
a. The urinalysis report indicates there are white blood cells in the urine
b. The client states she feels feverish; you measure the oral temperature at 98 degree Fahrenheit
c. The client has clear breath sounds; you count a respiratory rate of 18
d. The chest x-ray report indicates the client has pneumonia in the right lower lobe
4. A nurse has received the client assignment for the day. Which client should the nurse assess first?
a. The client who has a nasogastric tube attached to intermittent suction
b. The client who needs to receive subcutaneous insulin before breakfast
c. The client who is 2 days postoperative and is complaining of incisional pain
d. The client who has a blood glucose level of 50 mg/dL and complains of blurred vision
5. A nurse is monitoring the function of a client’s chest tube drainage system. The nurse notes that the
fluid in the water seal chamber is below 2-cm mark. The nurse interprets that:
a. There is a leak in the system
b. The client has a pneumothorax
c. Suction should be added to the system
d. Water should be added to the chamber

SITUATION 1: Nursing process is a systematic, rational method of planning and providing nursing care. Its
purpose is to identify a client’s health care status, and actual or potential health problems, to establish plans
to meet the identified needs, and to deliver specific nursing interventions to address those needs.

6. In the nursing process, every phase is interrelated to meet the best possible outcome of care for the client.
Which statement best expresses the association between assessment and implementation?
a. Assessment is performed by the physician, but implementation is a nursing process
b. Implementation and assessment can be performed simultaneously
c. Implementation of care does not depend on assessment
d. Data obtained during assessment helps the nurse to plan the individualized care provided during the
implementation phase
7. In the nursing process, all the steps are interrelated. Once the assessment brings inaccurate data, all the steps
will follow. Even the evaluation phase is very crucial because it is the key in:
a. Facilitating collaboration between members of the healthcare team
b. Modifying interventions and enhancing care
c. Improving accurate diagnosis of the needs of the client
d. Assisting the selection of realistic, client-centered outcomes
8. A primary nurse is developing a plan of care for the client where she is assigned. Supposed the nurse poorly
writes the desired outcome statement, what will be its affectation with the care of the client?
a. Additional assessment may be necessary
b. The planned interventions may be incorrect
c. The diagnosis will have to be written
d. None, because the nurse can rewrite the outcome
9. Which of the following is the greatest value of written nursing care plan in nursing practice?
a. Promote individualized care
b. Ensure proper documentation
c. Facilitate review of information
d. Enhance communication of staff members
10. Problem-oriented medical records focus on the client’s problem. The four components are: data base,
problem list, plan of care and progress notes. The progress note sometimes takes the SOAPIER format. The
“R” in this format refers to:
a. Rationale
b. Revision
c. Reports
d. Review

SITUATION 2: Documentation is an important responsibility of the registered nurse. It is said that care that is
not documented is considered not done at all.

11. A post-partum mother died while receiving blood transfusion. The nurse who is assigned to the mother
testifies that the vital signs are taken at the first 15 minute of the transfusion, yet she forgot to plot it in the
chart. The court interpret this as:
a. The nurse is allowed to plot the vital signs while in the courtroom
b. The nurse is allowed to verbally state the vital signs gathered.
c. The nurse is not responsible for the missing data.
d. The nurse did not really took the vital signs
12. Mrs. Rizal 60 years old, is being transferred to the surgical unit from the recovery room following extensive
surgery as the result of trauma from an automobile accident. As the nurse assigned to complete her care, you
know that an important principle to remember when admitting, transferring or discharging a patient is that:
a. The patient is ill and is unable to make decisions or giving accurate information
b. Families get in the way and encouraged not to get involved in the patient’s care
c. The patient is a human being deserving of dignity, courtesy and respect
d. The nurse knows best and should tell the patient what to do
13. After performing the shift’s assessment on one of the clients, the nurse made an error on the documentation
of the findings. The acceptable way in correcting the entry into the nurses note is:
a. Using a whiteout in layering the errors and writing in the correct data
b. Documenting a late entry into the client’s record
c. Trying to erase the error to provide space to write in the correct data
d. Drawing one line through the error, writing the initials and date, and enter the correct information
14. Lolo Andres, age 80, has been hospitalized for 1 week with a diagnosis of stroke. When planning for the
dismissal for Lolo Andres, the nurse should begin to:
a. On his admission to the hospital
b. When his family asks for information
c. When his condition his stabilized
d. When he begins to ask questions
15. The physician is not aware of the decision of a male 60 year old client to leave the hospital. It is not yet the
best time for the patient to leave. Nurse Martha recalls that when a patient chooses to leave a health care
facility without a physician’s written order, Martha needs to:
a. Make clear to the patient the risk of leaving and ask a patient to sign a waiver that states that he
accepts the responsibility for problems that may occur
b. Alert the security because there might be physician’s order before a patient may leave
c. Permit the patient to leave because no one can be held against his or her will
d. Call the family so that they can expect the patient at home

SITUATION 3: Assessing a client’s health status is a major component of nursing care and has two aspects: (1)
the nursing health history, and (2) physical assessment.
16. What is the best way in eliciting rebound tenderness on a client with a rigid board-like abdomen due to
suspected peritonitis?
a. Using light palpation, noting any tenderness over an area
b. Pressing firmly with one hand, releasing pressure while maintaining fingertip contact with the skin, and
noting tenderness on release
c. Pressing the affected area firmly with one hand, releasing pressure quickly and noting any tenderness
when release
d. Using deep ballottement, noting tenderness over an area
17. In conducting physical assessment to a pediatric client, why is inspection followed by auscultation done
initially?
a. Because the child may cry as the assessment proceeds, making auscultation difficult
b. Because the nurse’s hand or stethoscope may feel cold, making the client recoil
c. Because the nurse’s touch may frighten the child
d. Because the nurse’s touch my calm the child
18. After being on bed rest, before ambulation in hall, the proper steps are first is to set in bed, dangle feet,
stand beside bed, and then walk around the bed. If the client after surgery encouraged to ambulate, after
sitting and dangling feet, the next nursing action is?
a. Measure blood pressure
b. Assess temperature
c. Remove anti-embolism stockings
d. Check oxygen saturation
19. Which of the following statements about breathing sounds is true?
a. Adventitious breathing sounds are normal
b. It is best to auscultate for breathing sounds using the bell of the stethoscope
c. Bronchial sounds are normal when heard just above clavicles on each side of the sternum and
abnormal when heard over the lobes
d. Bronchovesicular sounds heard over the scapula are normal sounds
20. When conducting a physical examination, which of the following technique should the nurse employ first?
a. Inspection
b. Palpation
c. Percussion
d. Auscultation

SITUATION 4: Vital signs are significant indicators of the client’s condition on admission. Nursing care of clients
is best carried out when the appropriate method of nursing modality is implemented.

21. The following chart entries were found on the client’s chart: client complained of chest pain. Pain relief
occurred after 1/150 g nitroglycerin sublingual was administered. Vital signs 110, 110/70, Dionesia Pacquiao,
nurse. Which aspect of the chart entry is INCORRECT?
a. The nurse’s name
b. The client’s complaint
c. The intervention
d. The client’s vital signs
22. In a post-operative client, which of the following sets of vital signs need to be reported to the physician
immediately?
a. Temperature 36.4 °C; pulse rate 121; respiratory rate 26; blood pressure 90/55 mmHg
b. Temperature 37.5 °C; pulse rate 99; respiratory rate 18; blood pressure 110/70 mmHg
c. Temperature 37.8 °C; pulse rate 101; respiratory rate 21; blood pressure 120/80 mmHg
d. Temperature 37.2 °C; pulse rate 90; respiratory rate 18; blood pressure 110/80 mmHg
23. The korotkoff sound of blood pressure deflation has 5 phases. The sound of the third phase is?
a. Soft, muffling sounds
b. Disappearance of sounds
c. More intense tapping
d. A murmur or swishing sounds
24. Which of the following statements about monitoring a client’s temperature is NOT true?
a. The least accurate method for obtaining the temperature is the axillary method
b. The most accessible method for obtaining the temperature is the oral method
c. The safest and most non-invasive method for obtaining the client’s temperature is the rectal method
d. The dorsal surface of the hands is the best to palpate for the client’s temperature
25. Which of the following clients can the nurse delegate to the nursing assistant?
a. A 40-year-old client, scheduled for catheter insertion
b. A 50-year-old client with CVA, eating his/her meal for the first time
c. A 60-year-old client who has just had tracheostomy suctioning
d. A 35-year-old client scheduled for routine urinalysis

SITUATION 5: A diagnostic procedure essentially helps the health care team to rule out any possible
problem/s or diseases of a patient.

26. A 4 month old baby boy is suspected to have intussusception based on the complaint during the infant’s
feeding. Barium swallow is scheduled in the morning. The night before the procedure, the nurse instructs the
mother to:
a. Maintain NPO for 6 hours
b. Offer the infants only clear liquids
c. Feed the infant regular formula
d. Make the infant NPO for 3 hours
27. Mrs. Everdeen is suspected with liver CA. A liver biopsy is performed to obtain a liver specimen for
malignancy testing. After the procedure the priority action of the nurse is to:
a. Encouraged ambulation based on client’s tolerance
b. Inform about NPO status for 24 hours
c. Frequently monitor the vital signs, specifically the heart rate and blood pressure
d. Request for urinalysis to get urine specific gravity
28. The lateral side of the fingertip is the preferred site to prick and get a blood specimen for glucose monitoring.
The scientific rationale behind this is:
a. It leaves more room for other site selection
b. The side of the finger is less responsive to pain
c. It is easier for self-determination method
d. The blood supply is greater in this area
29. Mrs. Labelle verbalizes her concern to the nurse that she is having a hard time getting a drop of blood from
her fingertip for blood sugar test. The nurse should teach her to:
a. Use the puncture site several times for a row for best results
b. Asks the physician to order a different type of blood glucose monitoring system
c. Reminds the patient that it is acceptable to skip blood glucose monitoring once in a while
d. Suggest that the patient use a warm water on a finger just before using the blood lancet
30. Nurse Ray is taking care of Apple, who was admitted with flu-like symptoms, nausea, and vomiting. Apple has
ongoing intravenous infusion. While Nurse Ray is reviewing the latest laboratory results of his patient, he
noted that the BUN is 32, creatinine is 1.3, and hematocrit of 49%. The priority nursing action of Nurse Ray is:
a. Do nothing because the results are within normal limits
b. Evaluate urine output for amount and specific gravity
c. Decrease IV rate and notify the physician, as lab results indicate overhydration
d. Notify the physician STAT

SITUATION 6: Oxygenation is a vital part of a patient’s total recovery.


31. The relative of a client with chest tube inserted is rushing towards the nurses’ station and says that the
client’s chest tube was disconnected. The most appropriate nursing action is to:
a. Cover the end of the chest tube with sterile gauze
b. Put the end of chest tube into a bottle of sterile water
c. Assist the client to his bed and place him on his affected side
d. Reconnect the tube in the chest tube system
32. A chest tube drainage system is inserted in a client with hemothorax. After 4 hours, the nursing assessment
will most likely expected that in the water-seal chamber, there is:
a. Vigorous bubbling
b. Negative fluid fluctuation
c. Fluctuation with inspiration and expiration
d. Bloody drainage
33. The nurse is developing a nursing care plan following lobectomy. During suctioning, deep tracheal suction
should be done w/ extreme caution based on the understanding that:
a. Suctioning may traumatize the bronchial suture line
b. The tracheobronchial tree are dry
c. Coughing reflex may not be easily triggered
d. The remaining normal lung needs normal stimulant
34. The ideal technique when removing the inner cannula of the tracheostomy tube is by:
a. Clockwise rotation of the inner cannula
b. Using sterile gloves in picking up the inner cannula
c. Rinsing the tube’s neck plate then in line with its curvature pull the inner cannula gently
d. Counterclockwise unlocking of the inner cannula and gently withdrawing based on its curvature
35. The relative of the client, who is receiving 3 LPM oxygen via nasal cannula, asks nurse Krizzy why the oxygen
needs to be bubbled through a humidifier. The most accurate comment should be based on:
a. Hinder the development of the chemic reaction between oxygen and tubings
b. Diminish burning sensation brought by direct oxygen delivery
c. Block environmental gases from contaminating the oxygen gas
d. Avoid dryness of the nasal passages

SITUATION 7: Florence Nightingale has established the relationship between health and adequate nutrition in
her book “Notes on Nursing”.

36. Which electrolyte imbalance occurs in a client with burns?


a. Hypernatermia and hypokalemia
b. Hypernatremia and hyperkalemia
c. Hyponatremia and hypokalemia
d. Hyponatremia and hyperkalemia
37. Which of the following statements about TPN is INCORRECT?
a. The nurse is responsible for mixing the TPN solution
b. The subclavian and jugular veins are most commonly used for TPN administration
c. The trendelenburg position is the most appropriate position during TPN tube insertion
d. The TPN infusion line cannot be used for other solution
38. The most common deficiency seen in alcoholics is:
a. Vitamin B6 (Pyridoxine)
b. Vitamin B5 (Pantothenic Acid)
c. Vitamin B2 (Riboflavin)
d. Vitamin B1 (Thiamin)
39. Nurse Kate is a newly hired nurse and assigned to the medical unit. The first patient assigned to her is for NGT
feeding. During the evaluation of the supervisor in the unit, which of the following is an inappropriate action
of the nurse:
a. She introduced the feeding slowly
b. She assisted the patient in assuming a fowler’s position
c. She placed the feeding 20 inches above the point of insertion of NGT
d. She instilled 60 ml of water into the NGT after feeding
40. One of the clients in the medical unit is a Muslim. The nurse who is assigned to the client will be giving dietary
instructions related to the client’s diagnosis. The nurse most consider the religious practices and beliefs of the
client when he remembers that Muslims are NOT ALLOWED to eat:
1. Fishes with scales 3. Porkchop, ham, and bacon 5. Wine and alcoholic beverages
2. Crabs and lobsters 4. Soda and coffee
a. 1, 3, and 5
b. 2, 4, and 5
c. 3, 4, and 5
d. 2, 3, 4, and 5

SITUATION 8: Appropriate management of client’s condition requires critical thinking.

41. Which of the following is considered as one of the most important responsibilities of the nurse when a client
undergoes diagnostic testing?
a. Report the result to the physician
b. Inform the client of the result
c. Analyze the result
d. Obtain the results directly from the laboratory
42. Nurse Vent is assigned to a 65-year old patient, who is being weaned from a ventilator. Prior to extubation,
the latest arterial blood gases are analyzed from the following results: pH of 7.33, PaO2 of 74mmHg, PaCO2
of 51mmHg, and HCO3 of 25 mEqs/L. Immediate physician notifications is necessary because the client is in a
state of:
a. Respiratory alkalosis
b. Respiratory acidosis
c. Metabolic alkalosis
d. Metabolic acidosis
43. One of the morning shift nurses is assigned to four patients in the ward. Which of the following patients
handled by the nurse will most likely progress to metabolic alkalosis?
a. A 12-year old boy receiving isotonic sodium chloride IV solution
b. A 61-year old with who is unable to access water freely
c. A 36-year old post-surgical patient who has continuous nasogastric suction
d. A 58-year old who just experienced a stroke
44. A male client’s findings on arterial blood gas analysis are pH 7.50, PaCO2 of 37, and HCO3 of 28 mEqs/L.
Based on the stated values, the nurse notifies the MD since the client manifests:
a. Partially Compensated Metabolic Alkalosis
b. Uncompensated Metabolic Alkalosis
c. Partially Compensated Metabolic Acidosis
d. Uncompensated Metabolic Acidosis
45. The patient presents to the unit and is hooked to mechanical ventilator on SIMV mode. The physician
ordered for stat arterial blood gases which yielded the following: pH of 7.44, PaCO2 of 34, and HCO3 of 23
mEqs/L. Based on these findings, the nurse notes that the patient is having:
a. Uncompensated Respiratory Acidosis
b. Compensated Respiratory Alkalosis
c. Uncompensated Respiratory Alkalosis
d. Compensated Respiratory Acidosis

SITUATION 9: Nursing theory is an organized and systematic articulation of a set of statements related to
questions in the discipline of nursing.

46. The four major concepts in nursing theory are the:


a) Person, Environment, Nurse, Health
b) Nurse, Person, Environment, Cure
c) Promotive, Preventive, Curative, Rehabilitative
d) Person, Environment, Nursing, Health
47. According to her, Nursing is a helping or assistive profession to persons who are wholly or partly dependent
or when those who are supposedly caring for them are no longer able to give care.
a) Henderson
b) Levine
c) Orem
d) Neuman
48. The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities
contributing to health that he would perform unaided if he has the necessary strength, will and knowledge,
and do this in such a way as to help him gain independence as rapidly as possible.
a) Henderson
b) Abdellah
c) Levine
d) Peplau
49. Caring is the essence, a dominant domain that distinguishes nursing from other health disciplines. Care is an
essential human need. This is under:
a) Benner
b) Watson
c) Leininger
d) Swanson
50. A depressed client just had undergone electroconvulsive therapy. Following the theory/principle of
prioritization, which is the highest priority in the post-therapy care?
a) Document the client’s response to treatment
b) Reorient to time, place and person
c) Monitor respiratory status
d) Observe for confusion

SITUATION 10: Professional nurses are responsible for managing and providing care to clients receiving
Intravenous Therapy.

51. A client had a 1000 mL bag of 5% dextrose in 0.9% sodium chloride hung at 3 PM. The nurse making rounds at
around 3:45 PM finds that the client is complaining of a pounding headache and is dyspneic, is experiencing
chills, and is apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 ml remaining. The
nurse should take which action first?
a) Call the physician
b) Slow the IV infusion
c) Sit the client up in bed
d) Remove the IV catheter
52. The nurse has a prescription to hang an intravenous (IV) bag of 1000 mL 5% dextrose in water with 20 mEq
potassium chloride. The nurse should plan to do which of the following immediately after injecting the
potassium chloride into the port of the IV bag?
a) Rotate the bag gently
b) Attach the tubing to the client
c) Prime the tubing with the Iv solution
d) Check the solution for yellowish discoloration
53. A client with the recent diagnosis of myocardial infarction and impaired renal function is recuperating on the
step-down cardiac unit. The client’s blood pressure has been borderline low and intravenous (IV) fluids have
been infusing at 100mL/hour via a central line catheter in the right internal jugular for approximately 24
hours to increase renal output and maintain the blood pressure. Upon entering the client’s room, the nurse
notes that the client is breathing rapidly and is coughing. The nurse determines that the client is most likely
experiencing which complication of IV therapy?
a) Hematoma
b) Air embolism
c) Systemic infection
d) Circulatory overload
54. The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse
notes that the client’s IV site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes
that which of the following complication has occurred?
a) Infection
b) Phlebitis
c) Infiltration
d) Thrombosis
55. A client involved in a motor vehicle crash presents to the emergency department with severe internal
bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous
(IV) solution will most likely be prescribed to increase intravascular volume, replace immediate blood loss
volume, and increase blood pressure?
a) 5 % dextrose in Lactate Ringer’s
b) 0.33% sodium chloride (1/3 normal saline)
c) 0.225% sodium chloride (1/4 normal saline)
d) 0.45% sodium chloride (1/2 normal saline)

SITUATION 11: Nurses are indeed responsible for the safe administration of blood products, managing and
providing care related to the procedure for administering blood components, and monitoring for
complications or transfusion reactions.

56. Packed red blood cells have been prescribed for client with low hemoglobin and hematocrit levels. The nurse
takes the client’s temperature before hanging the blood transfusion and records 100.6° F orally. Which of the
following is the appropriate nursing action?
a) Begin the transfusion as prescribed
b) Delay hanging the blood and notify the physician
c) Administer an antihistamine and begin the transfusion
d) Administer two tablets of acetaminophen (Tylenol) and begin the transfusion
57. The staff nurse is done on her entry for the graveyard shift at 4 am when she recalls that she forgot to
document the blood transfusion done at 12 am. The standard way to manage this scenario is to:
a) Wait until the next day to chart the missing information
b) Add a late entry note about the blood transfusion before leaving the unit
c) Omit the information, since charting for that day is already completed
d) Report the blood transfusion to the nursing supervisor
58. The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion,
which action should immediately be taken first?
a) Remove the IV line
b) Run a solution of 5% dextrose in water
c) Run normal saline at a keep-vein-open rate
d) Obtain a culture of the tip of the catheter device removed from the client
59. A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit levels.
The nurse notifies the blood bank of the prescription, and a blood specimen is drawn from the client for
typing and crossmatching. The nurse receives a telephone call from the blood bank and is informed that the
unit of blood is ready for administration. Enumerate the actions in order of priority that the nurse should take
to administer the blood.
1. Hang the bag of blood
2. Obtain the unit of blood from the blood bank
3. Ensure that an informed consent has been signed
4. Insert an 18- or 19- gauge intravenous catheter into the client
5. Verify the physician’s prescription for the blood transfusion
6. Ask a licensed nurse to assist in confirming blood compatibility and verifying client identity
a. 3-5-4-2-6-1 c. 3-5-2-4-6-1
b. 5-3-4-2-6-1 d. 5-3-2-4-6-1
60. A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which of the
following IV solutions from the IV storage area to hang with the blood product at the client’s bedside?
a) Lactated Ringer’s
b) 0.9% sodium chloride
c) 5% dextrose in 0.9% sodium chloride
d) 5% dextrose in 0.45% sodium chloride

SITUATION 12: When a nurse is being confronted with medication or intravenous calculation, he/she must be
extra careful for the safety of the patient.
61. A physician’s prescription reads 1000 mL of normal saline (NS) to infuse over 12 hours. The drop factor is 15
drops (gtts)/ 1 mL. A nurse prepares to set the flow rate at how many drops per minute? (round answer to
the nearest whole number)

Answer: _____ drops per minute


62. A physician’s prescription reads potassium chloride 30 mEq to be added to 1000 mL normal saline and to be
administered over a 10 hour period. The label of the medication bottle reads 40 mEq/ 20 mL. A nurse
prepares how many milliliters of potassium chloride to administer the correct dose of medication?

Answer: _____ mL

63. A physician prescribes 3000 mL of D5W to be administered over a 24- hour period. A nurse determines that
how many milliliters per hours will be administered to the client?

Answer: ______mL per hour

64. Gentamicin sulfate, 80 mg in 100 mL normal saline, is to be administered over 30 minutes. The drop factor
is 10 drops (gtt)/mL. A nurse sets the the flow rate at how many drops per minutes? (round answer to the
nearest whole number.)

Answer: _____mL

65. A physician’s prescription reads morphine sulfate, 8 mg stat. the medication ampule reads morphine
sulfate, 10 mg/ mL. A nurse prepares how many milliliters to administer the correct dose?

Answer: _____mL

SITUATION 13: Nursing responsibility includes positioning clients safely and appropriately to provide safety
and comfort. Knowledge regarding the client position required for a certain procedure or condition is
expected.

66. A client is being prepared for a thoracentesis. A nurse assists a client to which position for the procedure?
a) Lying in bed on the affected side
b) Lying in bed on the unaffected side
c) Sims’ position with the head of the bed flat
d) Prone with the head turned to the side and supported by a pillow
67. A nurse is preparing to insert a nasogastric tube into a client. The nurse places the client in which position
for insertion?
a) Right side
b) Low Fowler’s
c) High Fowler’s
d) Supine with the head flat
68. A nurse develops a plan of care for a client with deep vein thrombosis. Which client position or activity in
the plan will be included?
a) Out-of-bed activities as desired
b) Bed rest with the affected extremities kept flat
c) Bed rest with elevation of the affected extremity
d) Bed rest with the affected extremity in a dependent position
69. A nurse is providing instructions to a client and the family regarding home care after right eye cataract
removal. Which statement by the client would indicate an understanding of the instructions?
a) “I should not sleep on my left side”
b) “I should not sleep on my right side”
c) “ I should not sleep with my head elevated”
d) “I should not wear my glasses at any time”
70. A nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the
enema, the nurse places the client in which position?
a) Left sims’ position
b) Right sims’ position
c) On the left side of the body, with the head of the bed elevated 45 degrees
d) On the right side of the body, with the head of the bed elevated 45 degrees

SITUATION 14: As a client advocate, the nurse should ensure protection of the client’s rights and promotion of
safety and comfort.

71. Which of the following signs taped on the door of clients in the unit violates the client’s rights?
a. “DO NOT PALPATE THE ABDOMEN”, taped on the door of a client with abdominal aortic aneurysm
b. “PROVIDE ASSISTANCE. CLIENT IS BLIND”, taped on the door of a client with severe glaucoma
c. “NPO”, taped on the door of a client scheduled for surgery
d. “NO VISITORS ALLOWED”, taped on the door of a client undergoing radiation therapy
72. The health care provider’s order is 1000 mL 0.9% NaCl with 20 mEq K+ intravenously over 8 hours. Which
assessment finding causes you to clarify the order with the health care provider before hanging this fluid?
a. Flat neck veins c. Hypotension
b. Tachycardia d. Oliguria
73. You assess four patients. Which patient is at greatest risk for the development of hypocalcemia?
a. 56-year-old with acute kidney renal failure
b. 40-year-old with appendicitis
c. 28-year-old who has acute pancreatitis
d. 65-year-old with hypertension and asthma
74. Immobilized patients are at risk for impaired skin integrity. Which of the following interventions would
reduce this risk? (Select all that apply)
6. Repositioning patient every 1 to 2 hours while awake
7. Using an objective, valid scale to assess patient’s risk for pressure ulcer development
8. Using a device to relieve pressure when patient is seated in chair
9. Teaching patient how to shift weight at regular intervals while sitting in a chair
10. A good rule is: the higher the risk for skin breakdown, the shorter the interval between
position changes
c. 1, 2, 3, 4 c. 1, 2, 3, 4, 5
d. 2, 3, 4, 5 d. 2, 3, 5
75. The nurse assesses that the patient has a full bladder, and the patient states that he or she is having
difficulty voiding. The nurse would teach the patient to:
a. Use the double-voiding technique c. Use Credé’s method
b. Perform Kegel exercises d. Keep a voiding diary
SITUATION 15: Acid-base imbalances are common disturbances that affected many patients. Nurses are
expected to know the interpretation of the results.

76. A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is
hypoventilating and has a respiratory rate of 10 breaths/min. The electrocardiogram (ECG) monitor displays
tachycardia, with a heart rate of 120 beats/min. Arterial blood gases are drawn and the nurse reviews the
results, expecting to note which of the following?
a. A decreased pH and an increased CO2 c. A decreased pH and a decreased HCO3
b. An increased pH and a decreased CO2 d. An increased pH and an increased HCO3
77. A nurse caring for a client with an ileostomy understands that the client is most at risk for developing which
acid-base disorder?
a. Metabolic Acidosis c. Respiratory Acidosis
b. Metabolic Alkalosis d. Respiratory Alkalosis
78. R.A. 7170, the Organ Donation Act of 1991 legalizes organ donation through the organ donor card. Which of
the following statements about organ donation is NOT true?
a. In the absence of a donor card, consent for donation is obtained from the next of kin
b. Anyone who is at least 18-years old may become an organ donor when he/she dies
c. A minor cannot donate any organ
d. Declaration of brain death is done by the attending physician
79. A client intends to donate blood. He/she weighs 105 lbs. He/she is eligible to donate approximately how
many mL of blood?
a. 500 ml c. 450 ml
b. 250 ml d. 100 ml
80. The nurse utilizes the focus problem charting. The three main components of this method are summarized
by the letters D.A.R. which stands for?
1. Data 4. Action
2. Activity 5. Revision
3. Response
a. 1, 2, 3 c. 1, 3, 4
b. 2, 3, 4 d. 1, 2, 5
SITUATION 16: Vital signs are indices of health. Thus, nurses must keenly assess these measures.
81. Mario has a fever of 38 degree Celsius. It surges at around 40 degrees Celsius and goes back again to 38
degrees Celsius today in a typical pattern. This type of fever is called:
a. Relapsing b. Intermittent c. Remittent d. Constant
82. The cuff bladder should encircle the arm at least:
a. 50 percent b. 20 percent c. 80 percent d. 100 percent
83. A client begins to have Cheyne-Stokes Respirations. This type of breathing pattern is best explained as:
a. Completely irregular breathing pattern with random deep and shallow respirations
b. Prolonged inspirations with inspiratory and/or expiratory pauses
c. Rhythmic waxing and waning of both rate and depth of respiration with brief periods of interspersed
apnea
d. Sustained, regular, rapid respirations of increased depth
84. Compensatory changes occur in vital signs in response to haemorrhage. Which of the following
manifestations is most likely to be assessed?
a. Decreased Temperature c. Increased Temperature
b. Decreased Pulse Rate d. Increased Pulse Rate
85. Among the parenteral route of administration, which has the longest absorption time?
a. Intradermal b. Intramuscular c. Intravenous d. Subcutaneous
86. Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of
the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain?
a. Stage 1 c. Stage 3
b. Stage 2 d. Stage 4
87. When obtaining a wound culture to determine the presence of a wound infection, from where
should the specimen be taken?
a. Necrotic tissue c. Drainage on the dressing
b. Wound drainage d. Wound after it has first been cleaned with normal saline
88. On assessing your patient’s sacral pressure ulcer, you note that the tissue over the sacrum is dark,
hard, and adherent to the wound edge. What is the correct stage for this patient’s pressure ulcer?
a. Stage 2 c. Unstageable
b. Stage 4 d. Suspected deep tissue damage
89. A patient has her call bell on and looks frightened when you enter the room. She has been on bed
rest for 3 days following a fractured femur. She says, “It hurts when I try to breathe, and I can’t
catch my breath.” Your first action is to:
a. Call the health care provider to report this change in condition.
b. Give the patient a paper bag to breathe into to decrease her anxiety.
c. Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen.
d. Explain that this is normal after such trauma and administer the ordered pain medication.
90. After a transurethral prostatectomy a patient returns to his room with a triple-lumen indwelling
catheter and continuous bladder irrigation. The irrigation is normal saline at 150 mL/hr. The nurse
empties the drainage bag for a total of 2520 mL after an 8-hour period. How much of the total is
urine output? Please provide the answer on the answer sheet.
ANSWER: _________
91. The nurse notes that the patient’s Foley catheter bag has been empty for 4 hours. The priority
action would be to:
a. Irrigate the Foley c. Notify the health care provider
b. Check for kinks in the tubing d. Assess the patient’s intake
92. Which of the following defining characteristics is consistent with fluid volume deficit?
a. A 1-lb (0.5 kg) weight loss, pale yellow urine
b. Engorged neck veins when upright, bradycardia
c. Dry mucous membranes, thready pulse, tachycardia
d. Bounding radial pulse, flat neck veins when supine
93. The health care provider’s order is 1000 mL 0.9% NaCl with 20 mEq K+ intravenously over 8 hours.
Which assessment finding causes you to clarify the order with the health care provider before
hanging this fluid?
a. Flat neck veins c. Hypotension
b. Tachycardia d. Oliguria
94. A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical
record indicates tympanic temperatures of 38.7°C (101.6°F) (4 AM), 36.6°C (97.9°F) (8 AM), 36.9°C
(98.4°F) (12 NN), 37.6°C (99.6°F) (4 PM), and 38.3°C (100.9°F) (8 PM). How would you describe this
pattern of temperature measurements?
a. Usual range of circadian rhythm measurements
b. Sustained fever pattern
c. Intermittent fever pattern
d. Resolving fever pattern
95. The nurse’s first action after discovering an electrical fire in a patient’s room is to
a. Activate the fire alarm
b. Confine the fire by closing all doors and windows
c. Remove all patients in immediate danger
d. Extinguish the fire by using the nearest fire extinguisher
96. Fire extinguisher colour codes are present so you can identify a type of extinguisher at a glance. As a
knowledgeable, you know that what color of fire extinguisher is used for Class B fires and all
electrical equipment fires like photocopiers, fax machines, and computers?
a. Red c. Blue
b. Cream d. Black
97. A couple is with their adolescent daughter for a school physical and state they are worried about all
the safety risks affecting this age. What is the greatest risk for injury for an adolescent?
a. Home accidents c. Poisoning and child abduction
b. Physiological changes of aging d. Automobile accidents, suicide, and substance abuse
98. A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your
most important nursing intervention during this situation?
a. Begin cardiopulmonary respiration
b. Restrain the child to prevent injury
c. Place a tongue blade over the tongue to prevent aspiration
d. Clear the area around the child to protect the child from injury
99. The Department of the Health promotes the effective management of health care waste which
considers the basic elements of waste minimization, segregation, and proper identification of the
waste. As a nurse who adheres to this basic advocacy of the DOH, where should you dispose
infectious and pathological waste?
a. Black container c. Yellow with black band
b. Yellow container d. Red
100. Cefuroxime Sodium, 1 g in 50 ml normal saline (NS) is to be administered over 30 mins. The
drop factor is 15 drops (gtt)/ml. A nurse sets the flow rate at how many drops per minute?
Answer: _________ drops per minute
101. A physician prescribes 1000 ml D5W to infuse at a rate of 125 ml/hr. A nurse determines that it
will take how many hours for 1 L to infuse?
Answer: _________ hour(s)
102. A physician prescribes 1 unit of packed red blood cells to infuse over 4 hours. The unit of blood
contains 250 ml. The drop factor is 10 drops (gtt)/1 ml. A nurse prepares to set the flow rate at how
many drops per minute? (Round answer to the nearest whole number)
Answer: _________ drops per minute
103. In press briefing, Health Secretary Janette Garin said a new flavivirus is prompting worldwide
concern because of an alarming connection to a neurological birth disorder and the rapid spread of
the virus across the globe, the ZIKA VIRUS. The Philippines had its first reported case of Zika virus
infection in 2012- a 15 year old boy in Cebu who had no travel history. Which of the following
statements is not true regarding Zika virus?
a. The public can be protected against active infection of Zika virus by strict adherence to
mosquito protection measures
b. The female Aedes Aegypti, is the primary carrier of Zika, Dengue fever, and Chikungunya;
and it is an aggressive biter
c. The complication of Zika virus may be strongly associated with microcephaly
d. Zika virus has the same vector with the dengue fever, and is most active 2 hours before
sunrise and 2 hours after sunset
104. The Department of Health (DOH) confirmed that monkeys held captive in an unnamed facility in
the Philippines have the EBOLA RESTON VIRUS. All but one of the following statements about the
said virus is correct:
a. It is thought that fruit bats of the Pteropodidae family are natural Ebola virus hosts
b. Ebola is introduced into the human population through close contact with the blood,
secretions, organs, or other bodily fluids of infected animals such as chimpanzees, gorillas,
fruit bats, and monkeys
c. Ebola then spreads through human-to-human transmission through droplet when
respiratory droplets generated via coughing, sneezing on another individual from an
infected host
d. Male ebola survivors should be offered semen testing at 3 months after onset of the disease
105. Fact: A 63-year old Saudi national has been announced dead apparently due to the MIDDLE
EAST RESPIRATORY SYNDROME-CORONA VIRUS (MERS-CoV) which showed symptoms such as
coughing, high fever, and occasional chills. A Filipino nurse should be made aware of the key facts of
the MERS-CoV, and believes that which of the following statements is incorrect:
a. No vaccine or specific treatment is currently available
b. Typical MERS symptoms include fever, cough, shortness of breath, and severe acute
respiratory illness
c. MERS-CoV is zoonotic virus that is transmitted more commonly from chimpanzee, and
eventually passed to humans
d. MERS-CoV can spread from ill people to others through close contact, and can affect
anyone
106. The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides
dietary teaching focusing on foods high in which vitamin that may be lacking in a vegan diet?
c. Vitamin A c. Vitamin C
d. Vitamin B12 d. Vitamin E
107. The nurse is inserting an intravenous line into a client’s vein. After the initial stick, the nurse continues to
advance the catheter if:
a. The catheter advances easily c. The client does not complain of discomfort
b. The vein is distended under the needle d. Blood return shows in the backflash chamber of the catheter
108. The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach
the distal end of the IV tubing to a needleless device, the exposed tubing drops and hits the top of the medication
cart. Which of the following is the appropriate action by the nurse?
a. Obtain the new IV tubing c. Wipe the distal end of the tubing with Betadine
b. Attach a new needleless device d. Scrub the needleless device with an alcohol swab
109. A client has just undergone insertion of a central venous catheter at the bedside. The nurse would be sure to
check the results of which of the following before initiating the flow rate of the client’s intravenous (IV) solution at
100 mL/hour?
a. Serum osmolality c. Portable chest x-ray film
b. Serum electrolyte levels d. Intake and output record
110. The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain
period of time. Which of the following items is important to check regarding the age of blood cells before the
transfusion is begun?
a. Expiration date c. Blood group and type
b. Presence of clots d. Blood identification number
111. A client requiring surgery is anxious about the possible need for a blood transfusion during or after the
procedure. The nurse suggests to the client to do which of the following to reduce the risk of possible transfusion
complications?
a. Give an autologous blood donation before the surgery
b. Ask a friend or family member to donate blood ahead of time
c. Take iron supplements before surgery to boost hemoglobin levels
d. Request that any donated blood be screened twice by blood bank
112. After surgery from general anesthesia, how should the nurse instruct the client to deep breath and cough?
5. “Assume a sitting position”
6. “Lie on your back”
7. “Hold your breath and exhale slowly”
8. “Splint the surgical incision to minimize pain”
a. 1, 2, 3 c. 1, 3, 4
b. 2, 3, 4 d. 2, 3
113. The doctor prescribes Spironolactone (Aldactone) to a client for the treatment of hypertension. Which dietary
choice of the client reflects a need for further instruction from the nurse?
a. Apple c. Wheat bread
b. Yogurt d. Fresh oranges
114. Which of the following behavior of the nurse reflects her sensitivity to the client’s cultural beliefs?
a. Providing immediate post-mortem care to the body of a Muslim client
b. Discussing the possibility of organ donation with the family of a Jehovah’s Witness who died from a motor
vehicular accident
c. Joining the family of a Baptist client in singing hymn to the dying client
d. Accepting the anger of the Catholic client’s family as the part of the grieving process
115. After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When
the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the
bottom of the now-opened wound. Which corrective intervention should the nurse do first?
a. Allow the area to be exposed to air until all drainage has stopped
b. Place several cold packs over the area, protecting the skin around the wound
c. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely
to indicate a wound evisceration
d. Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30
minutes because this is a minor opening in the surgical wound and should reseal quickly
116. Immobilized patients are at risk for impaired skin integrity. Which of the following interventions would
reduce this risk? (Select all that apply)
1. Repositioning patient every 1 to 2 hours while awake
2. Using an objective, valid scale to assess patient’s risk for pressure ulcer development
3. Using a device to relieve pressure when patient is seated in chair
4. Teaching patient how to shift weight at regular intervals while sitting in a chair
5. A good rule is: the higher the risk for skin breakdown, the shorter the interval between position
changes
a. 1, 2, 3, 4 c. 1, 2, 3, 4, 5
b. 2, 3, 4, 5 d. 2, 3, 5
117. A male patient returned from the operating room 6 hours ago with a cast on his right arm. He has not
yet voided. Which action would be the most beneficial in assisting the patient to void?
a. Suggest he stand at the bedside c. Give him the urinal to use in bed
b. Stay with the client d. Tell him that, if he doesn’t urinate, he will be catheterized
118. An older male patient states that he is having problems starting and stopping his stream of urine and he
feels the urgency to void. The best way to assist this patient is to:
a. Help him stand to void c. Have him practice Credé’s method
b. Place a condom catheter d. Initiate Kegel exercises
119. Since removal of the patient’s Foley catheter, the patient has voided 50 to 100 mL every 2 to 3 hours.
Which action should the nurse take first?
a. Check for bladder distention c. Obtain an order to recatheterize the patient
b. Encourage fluid intake d. Document the amount of each voiding for 24 hours
120. The nurse assesses that the patient has a full bladder, and the patient states that he or she is having
difficulty voiding. The nurse would teach the patient to:
a. Use the double-voiding technique c. Use Credé’s method
b. Perform Kegel exercises d. Keep a voiding diary

“I’m not telling you that the preparation for the board
examination is going to be easy, but I’m telling you it’s going to
be worth it. Nurses, always believe in yourself, because if you
don’t, then WHO WILL??”