NURSING.CRIMINOLOGY.LET.CSE.NAPOLCOM.

FOE REVIEW
4th Floor Insular Life Bldg, Rizal St., Camia Corner, Legazpi City, Albay 4500
Tel. No: 09175002996 / 09171141434
NOVEMBER 2025 NLE SEASON - ENHANCEMENT REVIEW PHASE
INTEGRATED EXAMINATION 01
Prepared by: Jake Roger B. Coprade, RN, MANc
Instructions:
1. Choose the best answer and shade the corresponding letter on the answer sheet.
2. Avoid erasures or any form of alteration.
3. Use a pencil to shade your answers.
4. You may write, encircle, or underline words on your questionnaire.
1. A 6-year-old boy who was struck by a car while he was riding his bicycle is unresponsive and has pale, cool skin. Assessment

reveals abrasions to his left shoulder and back and a swollen, deformed left thigh. He has a blood pressure of 74/62 mm Hg, a pulse of 152
beats/min, and respirations of 44 breaths/min. without increased work of breathing. What do these findings tell you about the patient s condition?
a. He is unresponsive and his skin is cool because of a low body temperature from being outside
b. His heart rate is fast because of pain in his shoulder and leg
c. His respirations are fast because the impact affected the respiratory center in his brain
d. His blood pressure is low because compensatory mechanisms for blood loss are failing
2. A 10-year-old girl is unresponsive when she surfaces after diving into a lake. Bystanders report that she was shaking all over as they pulled her out
of the water. The first step in caring for this patient is to:
a. Stabilize her cervical spine to reduce the risk of further spinal injury.
b. Elevate her head to reduce the risk of aspiration.
c. Turn her on her side to allow any water to drain from her mouth.
d. Open her mouth and insert an oropharyngeal airway to maintain a patent airway.
Situation: An 8-year-old boy fell 7 feet out of a tree, landing on his right arm and falling to his right side. He is crying and appears agitated. Assessment
reveals that he has pale, warm skin, multiple abrasions on his right shoulder and hip, and a deformed right forearm. He has a blood pressure of 92/74 mm Hg,
a pulse of 128 beats/min, and respirations of 32 breaths/min.
3. What is the best approach to conducting the assessment of this patient?
a. Telling him he must lie still or he may become paralyzed
b. Exposing only those areas currently being assessed and then covering them
c. Asking him if it is okay to listen to his lungs and touch his chest and stomach
d. Asking him what hurts the most and begin by assessing that area of the body
4. After completing your initial assessment, the first step in caring for this patient is to:
a. Manually stabilize the cervical spine to reduce the risk of spinal injury.
b. Initiate hyperventilation to reduce the accumulation of acids in the body
c. Cover him with blankets to prevent heat loss.
d. Place him in a position of comfort to decrease anxiety.
5. A 6-month-old infant who is being cared for by a babysitter is unresponsive and has warm, pink skin and respirations without increased work of
breathing. The babysitter appears anxious and frustrated and explains that the infant had been crying for hours and would not stop. The babysitter
states, "I couldn t get her to stop crying. I tried everything. All of a sudden she got really quiet, and I couldn't wake her up. Please help her. I can't
take her crying anymore." The babysitter states that she does not think that the infant has been sick recently. The infant s altered level of
consciousness is most likely due to:

a. Toxic exposure
b. Shaken baby syndrome
c. Seizures
d. Respiratory failure

6. An 18-month-old boy who reportedly fell down the stairs earlier in the day just isn’t acting right, according to his caregivers. Assessment reveals
multiple bruises on his thighs and back and a deformity of his right thigh. He is alert and crying. What is the best way to interact with the
caregivers?
a. Confront them by telling them you know that this injury could not have occurred from a fall; therefore, you are obligated to take him to the
hospital
b. Ask them why they waited so long to call for help; the delay has made the child very sick; therefore, you will need to administer oxygen and
establish an IV.
c. Contact the local law enforcement agency to request that the caregiver be arrested while you transport the child.
d. Explain that you are very concerned about the child’s condition and that he needs to be examined at the hospital for a possible a broken leg

7. The nurse prepares IM injection that is irritating to the subcutaneous tissue. Which of the following is the best action in order to prevent tracking of
the medication

a. Use a small gauge needle

b. Apply ice on the injection site
c. Administer at a 45° angle
d. Use the Z-track technique

8. Resonance is best describe as:

a. Sounds created by air filled lungs

b. Short, high pitch and thudding
c. Moderately loud with musical quality
d. Drum-like low pitched sound

9. Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions?

a. Providing a back massage

b. Feeding a client

COMMITMENT.EXCELLENCE.QUALITY 1
 c. Providing hair care
d. Providing oral hygiene

10. The nurse is preparing to take vital sign in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the
best method used to assess the client’s temperature?

a. Oral
b. Axillary
c. Radial
d. Heat sensitive tape

11. Which of the following actions should the nurse take to use a wide base support when assisting a client to get up in a chair?
a. Bend at the waist and place arms under the client’s arms and lift
b. Face the client, bend knees and place hands on client’s forearm and lift
c. Spread his or her feet apart
d. Tighten his or her pelvic muscles
12. A client who is unconscious needs frequent mouth care. When performing a mouth care, the best position of a client is:

a. Fowler’s position
b. Side lying
c. Supine
d. Trendelenburg

13. Which of the following cluster of data belong to Maslow’s hierarchy of needs

a. Love and belonging

b. Physiologic needs
c. Self actualization
d. All of the above

14. Five teaspoon is equivalent to how many milliliters (ml)?

a. 30 ml
b. 25 ml
c. 12 ml
d. 22 ml

15. 5 grains is equal to how many mg?

a. 50mg
b. 150mg
c. 300mg
d. 450mg

16. 20 cc is equal to how many ml?

a. 2
b. 20
c. 2000
d. 20000

17. The nurse must verify the client’s identity before administration of medication. Which of the following is the safest way to identify the client?
a. Ask the client his name
b. Check the client’s identification band
c. State the client’s name aloud and have the client repeat it
d. Check the room number
18. The nurse prepares to administer buccal medication. The medicine should be placed…

a. On the client’s skin

b. Between the client’s cheeks and gums
c. Under the client’s tongue
d. On the client’s conjuctiva

19. The nurse is ordered to administer ampicillin capsule TID p.o. The nurse shoud give the medication…

a. Three times a day orally

b. Three times a day after meals
c. Two time a day by mouth
d. Two times a day before meals

20. When administering medications labelled TID, the nurse understands that she should give this medication at

a. 8am- 1pm- 8pm

b. 8am- 12pm- 4pm
c. 8am- 1pm- 6pm
d. 8am- 1pm- 4pm

21. The most appropriate independent nursing intervention for a patient who develops dyspnea and shortness of breath would be…
a. Maintain the patient on strict bed rest at all times
b. Maintain the patient in an orthopneic position as needed
c. Administer oxygen by Venturi mask at 24%, as needed
d. Allow a 1 hour rest period between activities
22. The family of an accident victim who has been declared brain-dead seems amenable to organ donation. What should the nurse do?
a. Discourage them from making a decision until their grief has eased
b. Listen to their concerns and answer their questions honestly
c. Encourage them to sign the consent form right away
d. Tell them the body will not be available for a wake or funeral
23. If nurse administers an injection to a patient who refuses that injection, she has committed:

COMMITMENT.EXCELLENCE.QUALITY 2
 a. Assault and battery
b. Negligence
c. Malpractice
d. None of the above

24. If patient asks the nurse her opinion about a particular physicians and the nurse replies that the physician is incompetent, the nurse could be held
liable for:

a. Slander
b. Libel
c. Assault
d. Respondent superior

25. A registered nurse reaches to answer the telephone on a busy pediatric unit, momentarily turning away from a 3 month-old infant she has been
weighing. The infant falls off the scale, suffering a skull fracture. The nurse could be charged with:

a. Defamation
b. Assault
c. Battery
d. Malpractice and negligence

26. Which of the following is an example of nursing malpractice?

a. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and
has cerebral damage resulting from anoxia.
b. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping.
c. The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus.
d. The nurse administers the wrong medication to a patient and the patient vomits. This information is documented and reported to the
physician and the nursing supervisor.
27. During a Romberg test, the nurse asks the patient to assume which position?

a. Sitting
b. Standing
c. Genupectoral
d. Trendelenburg

28. If a patient’s blood pressure is 150/96, his pulse pressure is:

a. 54
b. 96
c. 150
d. 246

29. A patient is kept off food and fluids for 10 hours before surgery. His oral temperature after surgery is 99.8 F (37.7 C) This temperature reading
probably indicates:

a. Infection
b. Hypothermia
c. Anxiety
d. Dehydration

30. Which of the following statement is incorrect about a patient with dysphagia?
a. The patient will find pureed or soft foods, such as custards, easier to swallow than water
b. Fowler’s or semi Fowler’s position reduces the risk of aspiration during swallowing
c. The patient should always feed himself
d. The nurse should perform oral hygiene before assisting with feeding.
31. A prescribed amount of oxygen s needed for a patient with COPD to prevent:
a. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2)
b. Circulatory overload due to hypervolemia
c. Respiratory excitement
d. Inhibition of the respiratory hypoxic stimulus
32. Mrs. Chua a 78 year old client is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear when listening to client’s lungs
indicative of chronic heart failure would be:

a. Stridor
b. Crackles
c. Wheezes
d. Friction rubs

33. Which of the following should the nurse teach the client about the signs of digitalis toxicity?

a. Increased appetite
b. Elevated blood pressure
c. Skin rash over the chest and back
d. Visual disturbances such as seeing yellow spots

34. Nurse Roger teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help

a. Retard rapid drug absorption

b. Excrete excessive fluids accumulated at night
c. Prevents sleep disturbances during night
d. Prevention of electrolyte imbalance

35. What would be the primary goal of therapy for a client with pulmonary edema and heart failure?

a. Enhance comfort
b. Increase cardiac output
c. Improve body image disturbance
d. Peripheral edema decreased

COMMITMENT.EXCELLENCE.QUALITY 3
 36. A female client is taking Cascara Sagrada. Nurse Betty informs the client that the following maybe experienced as side effects of this medication:

a. GI bleeding
b. Peptic ulcer disease
c. Abdominal cramps
d. Partial bowel obstruction

37. Nurse Jamie should explain to male client with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing because…

a. More accurate
b. Can be done by the client
c. It is easy to perform
d. It is not influenced by drugs

38. Jessie weighed 210 pounds on admission to the hospital. After 2 days of diuretic therapy, Jessie weighs 205.5 pounds. The nurse could estimate the
amount of fluid Jessie has lost…

a. 0.3 L
b. 1.5 L
c. 2.0 L
d. 3.5 L

39. Nurse Donna is aware that the shift of body fluids associated with Intravenous administration of albumin occurs in the process of:

a. Osmosis
b. Diffusion
c. Active transport
d. Filtration

40. What do you call the area on the right side of the epigastric region?

a. Right iliac region

b. Right umbilical region
c. Right lumbar region
d. Right hypochondriac region

41. The nurse should be fully aware about transfusion reactions and the management of these reactions. During blood transfusion, the nurse observes
the following guidelines except:
a. Using a gauge 18 needle
b. For the first 15 minutes of the procedure, monitor the clients vital signs every 5 minutes
c. Slowing down the infusion if the client experiences chilling, headache or flank pain.
d. Blood should be transfused within 4 hours from receiving it from the laboratory
42. A client suddenly manifested fever and headache 10 minutes after the start of blood transfusion, as the nurse on duty, what will you do?
a. Stop the procedure and call the doctor
b. Slow down the infusion rate
c. Do nothing for this is a normal occurrence during blood transfusion
d. Stop the procedure, get the patient’s vital signs, change the BT line with PNSS at KVO rate, and call the physician
43. A client is rushed to the emergency ward after being involved in a car accident. The client was bleeding profusely and the physician ordered
immediate blood transfusion. The nurse found out that the clients blood type was AB. The laboratory notified the nurse that there is no available
blood type AB at the moment. In this case, the nurse knows that besides from blood type AB, which other blood type can be given to the patient?

a. Type O
b. Type A
c. Type B
d. All of the above

44. This blood type is also called “The universal donor”

a. Type O
b. Type A
c. Type B
d. Type AB

45. This blood type is also called “The universal recipient”

a. Type O
b. Type A
c. Type B
d. Type AB

46. Polycythemia vera is characterized by too many blood cells. Kel is admitted with polycythemia. As his nurse, which should you include in your
interventions for Kel?

a. Monitoring the client for stroke symptoms

b. Preparing for administration of a blood transfusion
c. Assesing patients for signs of hypokalemia
d. Restricting fluids to prevent excess fluid volume

47. Symptoms may not become apparent until later stages of chronic renal failure because:
a. Liver hormones compensate for impaired renal function
b. Adrenal glands compensate for the kidney’s decreased function
c. Kidneys have great function reserve.
d. Other body system take over some of the kidney’s function
48. Dumping syndrome is a term that refers to a constellation of vasomotor symptoms after eating, especially after a Billroth II procedure. A patient
who has undergone a Billroth II operation may prevent experiencing dumping syndromes by:

a. Lying down after meals

b. Drinking water after meals

COMMITMENT.EXCELLENCE.QUALITY 4
 c. Stay in upright position after meals
d. Bend over after meals

49. Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"

a. Stat Order
b. Single Order
c. Standard Written Order
d. Standing Order

50. Nurse Jake is a handsome nurse working in the medical ward. The doctor ordered some medications that nurse Jake would give on his shift. Which
of the following doctor’s order needs questioning?

a. Simvastatin 50mg PO q 4hrs

b. Ceftriaxone 100mg q 8hrs
c. Metoprolol tartrate 25mg IV PRN
d. Fomatidine 20mg by mouth daily

51. When a client asked “what do you mean by otic drops?” the most appropriate thing the nurse would tell the client is that:
a. “It is a medication the will be administered in your eyes”
b. “You will be on your side when this is administered in your ear”
c. “It is an oral medication for hearing impairments”
d. “It is a medication injected directly into your eye”
52. A client is to undergo skin testing, Nurse Pining Garcia is incorrect in administering the medication when she:

a. Used a blue ballpen

b. Administered on the outer portion of the forearm
c. Prepared a 1ml syringe
d. Created a wheel on the client’s skin

53. A newly wed, Mr. Jack Cole and Mrs. Gina Cole, wanted to know what the purpose of using the Z-track method is. As a knowledgeable nurse you
know that Z-track technique is:
a. A technique that is used so that the medication will not flow out of the injection site in subcutaneous injection
b. A method of locking medication in the muscle during injection
c. A method of creating a bleb on the client’s skin
d. A form of intradermal injection that creates a Z-like pattern
54. A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. The nurse in-charge would
take which priority action in the care of this client?

a. Admit the client into a private room

b. Encourage family and friends to visit
c. Place client on reverse isolation
d. Advise the client to take frequent rest periods

55. A newly admitted female client was diagnosed with agranulocytosis. The nurse formulates which priority nursing diagnosis?

a. Deficient knowledge
b. Constipation
c. Diarrhea
d. Risk for infection

56. Rey Piñ oco, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain and swelling. After the nurse applies
ice to the ankle for 30 minutes, which statement by Tony suggests that ice application has been effective?

a. “my ankle feels warm”

b. “I need something stronger to relieve the pain”
c. “My ankle looks redder now”
d. “My ankle looks less swollen now”

57. The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which
electrolyte imbalance?

a. Hypervolemia
b. Hypernatremia
c. Hypokalemia
d. Hyponatremia

58. Nurse Kenna Joth is caring for a female client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/μl. The female client is
dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hr. The client complains of severe bone pain and is scheduled to
receive a dose of morphine sulfate. In administering the medication, Nurse Kenna should avoid which route?

a. Oral
b. IV
c. IM
d. SQ

59. In assisting a female client for immediate surgery, the nurse in charge is aware that she should:
a. Encourage the client to void following preoperative medication.
b. Encourage the client to drink water prior to surgery.

COMMITMENT.EXCELLENCE.QUALITY 5
 c. Obtain informed consent
d. Assist the client in removing dentures and nail polish
60. A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. What is the priority action by
the nurse?

a. Place the client on T-burg position

b. Place client in high-Fowler’s position
c. Stop the TPN
d. Notify Physician

61. Nurse Michelle who is a very competent nurse witnesses a female client sustain a fall and suspects that the leg may be broken. The nurse takes
which priority action?

a.Take a set of baseline V/S

b. Reassure the client that everything will be alright
c. Immobilize the leg before moving the client
d. Call the radiology department for X-Ray

62. As a nurse you must have a good clinical judgment in prioritizing clients, who among the following clients in the unit needs prioritization?
a. A 63 year old post-operative abdominal hysterectyomy client of three days whose incisional dressing is saturated with serosanguinous fluid.
b. A 44 year old client with chest pain who is complaining of nausea.
c. A 26 year old client admitted for dehydration whose 2 nd IV has infiltrated
d. A 34 year old post-operative appendectomy client of five hours complaining of pain.
63. The nurse assessed a client receiving IVF and noted slight swelling on the insertion site, when assessed further the site looks redder and felt warm
to touch. This common problem in IVF administration indicates:

a. Infiltration of the IV site

b. Phlebitis
c. Attempted removal
d. Docot’s edema

64. A client has a Chest tube attached to him. As you were doing your rounds you observed continuous bubbling on the 3 rd bottle furthest from the
client. You immediately understand that:
a. This is a sign of damage in the tube and air is sipping in the bottle
b. This is normal
c. This is a sign of lung collapse
d. This is an indication of dislodged tube
65. The client is about to have his chest tube removed. One of your basic responsibilities is to assist in the procedure therefore you advise the client to
do which of the following upon removal?

a. Exhale forcefully
b. Avoid doing vasalva maneuver
c. Inhale rapidly
d. Inhale and hold

66. A complication of CCT is tension pneumothorax. What happens in this condition?

a. Air sips out of the thoracic cavity causing negative pressure inside
b. The trachea deviates towards unaffected area
c. Fluid gushes out of the incision site
d. AOTA
67. All of the following are purposes of CTT except:

a. Drainage of blood in the thoracic cavity

b. Drainage of pus in the thoracic cavity
c. For lung expansion promotion
d. Removal of air from the lungs

68. The nurse inspects the 3 chest tube bottles and locates the water seal bottle in which position?

a. Closest to the client

b. In the middle
c. Furthest from the client
d. Besides the 4th bottle

69. When a client dies you will note a sudden deceased body temperature. This is termed as?

a. Livor mortis
b. Rigor mortis
c. Rigiore mortis
d. Algor mortis

70. The most commonly used site of tag placement in deceased patients is on their:

a. Ankle
b. Nose bridge
c. Ear
d. Neck

71. Vivid dreaming occurs in which stage of sleep?

COMMITMENT.EXCELLENCE.QUALITY 6
 a. Stage I NREM
b. REM
c. Stage II NREM
d. Dealta Stage

72. When bathing a patient’s extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique:

a. Provides opportunity for skin assessment

b. Avoids undue strain on the nurse
c. Increase venous blood return
d. Cause vasoconstriction and increase circulation

73. The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:

a. Replenish his supply every 3 months

b. Take one every 15 minutes if pain occurs
c. Leave the medication in the brown bottle
d. Crush the medication and take with water

74. The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:

a. Feet
b. Lungs
c. Hands
d. Sacrum

75. The best method of evaluating the amount of peripheral edema is:

a. Weighing the client daily

b. Measuring the extremity
c. Measuring the intake and output
d. Checking for pitting

76. A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the
nurse to take?
a. Call security for assistance and prepare to sedate the client.
b. Tell the client to calm down and ask him if he would like to play cards.
c. Tell the client that if he continues his behavior he will be punished.
d. Leave the client alone until he calms down.
77. Mrs. Yarina Gustufa a half Filipino half Russian with suspected meningitis is admitted to the unit. The doctor is performing an assessment to
determine meningeal irritation and spinal nerve root inflammation. A positive Kernig’s sign is charted if the nurse notes:

a. Pain on flexion of the hip and knee

b. Nuchal rigidity on flexion of the neck
c. Pain when the head is turned to the left side
d. Dizziness when changing positions

78. One of the major features of liver cirrhosis is the presence of Cullen’s sign. This sign is characterized by:
a. Going out into the sun and the client’s skin shine bright like a diamond
b. A bruise-like appearance around the RUQ of the abdomen
c. A discoloration around the umbilicus
d. Peri-orbital edema on one eye
79. Every good nurse already knows that to treat morning sickness in pregnant women they must give dry crackers before the mother gets out of bed.
The reason behind this is that:
a. The crackers satisfy the hunger thus urge for vomiting is reduced
b. The crackers absorb the undigested contents of the stomach
c. The crackers decrease peristalsis
d. The crackers absorb the some of the gastric juice

80. The substance present in the largest amount in a solution is which of the following?

a. Solutes
b. Solvent
c. Solution
d. Interstitial fluid

81. An adolescent has been participating in a competitive sport game. Accidentally, he fell off and complains of pain in his coxal area. The adolescent
has pain on:

a. Posterior knee area

b. Hip area
c. Thigh area
d. Point of shoulder

82. To maintain homeostasis the body function interacts. The homeostatic control mechanism that responds to environmental changes is called:

a. Effector
b. Receptor
c. Control Center

COMMITMENT.EXCELLENCE.QUALITY 7
 d. Stimuli

83. Knowledge on body landmarks is essential to learn about anatomy and physiology. The posterior surface of the lower leg is known as:

a. Sural
b. Olecranal
c. Crural
d. Fibular

84. The plasma membrane in the body allows some substances to pass through it while excluding others. This type of barrier is termed as:

a. Passive transport process

b. Selective permeability
c. Filtration
d. Active transport processes

85. To sustain life an individual must be able to function properly. Survival needs include the following apart from:

a. Atmospheric pressure
b. Oxygen
c. Gravity
d. None of these

86. The knee in relation to the thigh is termed as:

a. Distal
b. Proximal
c. Ventral
d. Dorsal

87. A correct anatomical position is best exemplified by which of the following?

a. Standing up with palms held unnaturally forward with thumbs pointing towards the body.
b. Standing up with palms held backward with thumbs pointing towards the body.
c. Standing up with palms held unnaturally forward with thumbs pointing away from the body.
d. Standing up with palms held unnaturally forward with thumbs pointing towards the body.

88. The dorsal cavity of the body has two subdivisions. Select all dorsal body cavity.

1. Thoracic
2. Cranial
3. Spinal
4. Adbominopelvic

a. A and B
b. B and C
c. C and D
d. B and D

89. A mother verbalized to the community nurse that her child does not eat iron rich foods like green leafy vegetables. She is worried that her child’s
nutrition might be deprived of iron. The nurse would have an acceptable statement when she presents an alternative food that is fortified with iron
when she states that the mother can give:

a. Mr. chips
b. Clover chips
c. Lucky me! Pancit canton
d. Chippy

90. After delivery the placenta should be disposed of properly. Which is the proper way of disposing the placenta?
a. Pouring alcohol on it and placing it on a sealed plastic bag
b. Pouring formalin on it and placing it inside a sealed plastic bag
c. Throwing it in with the sharps
d. Burying it near the banana tree
91. The child has iodine deficiency which of the following foods would you advise the mother to make the child eat?

a. Egg
b. Tilapya
c. Jack and Jill Pretzels
d. Orange

92. Postural drainage to relieve respiratory congestion should take place:

a. Before meals
b. After meals
c. At the nurse's convenience
d. At the patient's convenience

93. S1 is heard best at the:

a. 5th left intercoastal space along the midclavicular line
b. 3rd intercoastal space to the left of the midclavicular line

COMMITMENT.EXCELLENCE.QUALITY 8
 c. Second right intercoastal space at the sternal border
d. Second left intercoastal space at the sternal border
94. Blood pressure measurement is an important part of the patient's data base. It is considered to be:

a. The basis of the nursing diagnosis

b. Objective data
c. An indicator of the patient's well being
d. Subjective data

95. The correct site at which to verify a radial pulse measurement is the:

a. Brachial artery
b. Apex of the heart
c. Temporal artery
d. Inguinal site

96. The usual sequence for assessing the bowel is:

a. Right lower quadrant, right upper quadrant, left upper quadrant. left lower quadrant
b. Right lower lobe, right upper lobe, left upper lobe, left lower lobe
c. Right hypochondriac, left hypochondriac and umbilical regions
d. Rectum, pancreas, stomach and liver
97. A patient is about to undergo bone marrow aspiration and biopsy and expresses fear and anxiety about the procedure. Which of the following is the
most effective nursing response?
a. Warn the patient to stay very still because the smallest movement will increase her pain.
b. Encourage the family to stay in the room for the procedure.
c. Stay with the patient and focus on slow, deep breathing for relaxation.
d. Delay the procedure to allow the patient to deal with her feelings.
98. Which intervention is an example of primary prevention?
a. Administering digoxin (Lanoxicaps) to a patient with heart failure
b. Administering a measles, mumps, and rubella immunization to an infant
c. Obtaining a Papanicolaou smear to screen for cervical cancer
d. Using occupational therapy to help a patient cope with arthritis
99. The nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse use first?

a. Auscultation
b. Inspection
c. Percussion
d. Palpation

100. Which statement regarding heart sounds is correct?

a. S1 and S2 sound equally loud over the entire cardiac area.
b. S1 and S2 sound fainter at the apex
c. S1 and S2 sound fainter at the base
d. S1 is loudest at the apex, and S2 is loudest at the base
101. A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.d. in the plan of care, the nurse should emphasize teaching the patient about the
importance of consuming:

a. Fresh, green vegetables

b. Bananas and oranges
c. Lean red meat
d. Creamed corn

102. Nurse Margareth is revising a client’s care plan. During which step of the nursing process does such revision take place?

a. Assessment
b. Planning
c. Implementation
d. Evaluation

103. The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a bell and diaphragm is true?
a. The bell detects high-pitched sounds best
b. The diaphragm detects high-pitched sounds best
c. The bell detects thrills best
d. The diaphragm detects low-pitched sounds best
104. A female adult client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, nurse Julia
formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which “related-to” phrase should the
nurse add?
a. Related to bone demineralization resulting in pathologic fractures
b. Related to exhaustion secondary to an accelerated metabolic rate
c. Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces
d. Related to tetany secondary to a decreased serum calcium level
105. When caring for a male client with diabetes insipidus, nurse Juliet expects to administer:
a. vasopressin (Pitressin Synthetic).
b. furosemide (Lasix).
c. regular insulin.
d. 10% dextrose.
106. A male client with type 1 diabetes mellitus has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client,
nurse Sharmaine would be most accurate in stating:
a. “The test needs to be repeated following a 12-hour fast.”
b. “It looks like you aren’t following the prescribed diabetic diet.”

COMMITMENT.EXCELLENCE.QUALITY 9
 c. “It tells us about your sugar control for the last 3 months.”
d. “Your insulin regimen needs to be altered significantly.”
107. A male client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
a. Infusing I.V. fluids rapidly as ordered
b. Encouraging increased oral intake
c. Restricting fluids
d. Administering glucose-containing I.V. fluids as ordered
108. A female client has a serum calcium level of 7.2 mg/dl. During the physical examination, nurse Noah expects to assess:
a. Trousseau’s sign.
b. Homans’ sign.
c. Hegar’s sign.
d. Goodell’s sign.
109. Which outcome indicates that treatment of a male client with diabetes insipidus has been effective?
a. Fluid intake is less than 2,500 ml/day.
b. Urine output measures more than 200 ml/hr.
c. Blood pressure is 90/50 mm Hg.
d. The heart rate is 126 beats/minute.
110. A male client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. Nurse Jack explains that these medications are only
effective if the client:
a. prefers to take insulin orally.
b. has type 2 diabetes.
c. has type 1 diabetes.
d. is pregnant and has type 2 diabetes.
111. Dietary management is one of the most important interventions for endocrine disorders. Which of the following disorders would most likely be
prescribed with increased iodine intake?
a. Hypothyroidism
b. Hyperthyroidism
c. Hypoparathyroidism
d. Hyperparathyroidism
112. Which of the following arteries primarily feeds the anterior wall of the heart?
a. Circumflex artery
b. Internal mammary artery
c. Left anterior descending artery
d. Right coronary artery
113. Which of the following actions is the first priority care for a client exhibiting signs and symptoms of coronary artery disease?
a. Decrease anxiety
b. Enhance myocardial oxygenation
c. Administer sublignual nitroglycerin
d. Educate the client about his symptoms
114. After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs?
a. Left-sided heart failure
b. Pulmonic valve malfunction
c. Right-sided heart failure
d. Tricuspid valve malfunction
115. Which of the following actions is incorrect in handling nitroglycerin tablets?
a. Place nitroglycerine in amber colored bottles
b. After use return the medication to inside the refrigerator
c. Burning sensation under the tongue is a normal response
d. None of the above
116. A 70 years old client went to the eye clinic for a check-up and stated “I have noticed a whitish arc around my cornea.” The best response by the nurse
is:
a. “This is a sign that you are already developing age-related cataract”
b. “There is nothing to worry about; the arc you see is a normal development for the elderly.”
c. “Were you exposed to any strong radiation lately because that may lead to possible corneal problems?”
d. “That is a parasitic problem and needs immediate surgery.”
117. Knowledge of the basic anatomy and physiology of the eyes is one of the major components to effectively care for clients with eye problems. As a
nurse who knows the regulation mechanism of the aqueous humor, you know that the ciliary body is located:
a. Ventral the lens
b. Dorsal the iris
c. Anterior the iris
d. Posterior part of the lens
118. As a nurse working at an airline you encountered a woman who complains of feeling of fullness on the ears as the plane ascends, you know that to
prevent barotrauma you can:
a. Offer sips of fluids as the plane ascends
b. Advise client to slightly and softly blow her nose
c. Offer chewing gum
d. Advise to wear headphones
119. A client asked you what barotrauma is. The best response is:
a. It is the physical damage to tissues due to differences in pressure
b. It is the damage to the eardrums due to increasing speed of the vehicle
c. It is the feeling of fullness in the ear due to sudden drop in atmospheric temperature
d. All of the above
120. Among the 12 cranial nerves which is responsible for constricting the pupils?
a. CN VIII (Vestibulo-Cochlear)
b. CN II (Optic)
c. CN III (Oculomotor)
d. CN VII (Facial)
121. The following are medical treatments for acute glaucoma except:
a. Miotics (Pilocarpine)
b. A-agonist (Epinephrine)
c. b-blockers (Timolol)
d. carbonic anhydrase inhibitor (Acetazolamide)
122. Loss of central vision is the most common manifestation of what eye disorder?
a. Cataract
b. Retinal detachment
c. Macular degeneration
d. Glaucoma

COMMITMENT.EXCELLENCE.QUALITY 10
 123. The client complains of visual floaters post cataract surgery, as a nurse working on the eye clinic you know that:
a. This is normal post op and would eventually be gone after 12 hours
b. The client is experiencing a post op complication and needs immediate referral to the doctor
c. This is a common problem and can be corrected by positioning the client with the affected eye on the dependent position
d. The client is having photosensitivity and needs application of eye patch for at least 24 hours
124. The nurse is incorrect in doing the webber’s test if he does the following except:
a. Placing the tuning fork behind the client’s ear on top of the mastoid bone
b. Stating that a normal finding would be that the air conduction is heard louder than bone conduction
c. Stating that a normal finding is that the unaffected ear hears the sound louder than the affected ear
d. Placing the tuning fork above the upper lip of the client
125. Encephalitis is a neurologic problem that can eventually lead to what type of hearing loss?
a. Sensorineural
b. Conductive
c. Both a and b
d. It cannot lead to any hearing loss
126. Client’s with meniere’s disease are prescribed low sodium diet because the main problem is:
a. Accumulation of fluid in the middle ear
b. Loss of balance
c. Accumulation of fluids in the area of the inner ear
d. Hypertension
127. Retinopexy is done to clients with retinal detachment. This is a surgery that:
a. Sutures and repairs the torn retina
b. Injects air bubble inside the eye
c. Aspirates fluids between the retina and choroid
d. Uses a buckle to fasten the detachment
128. A client is about to undergo vitrectomy, knowing that further progression of the client’s condition must be prevented the nurse best positions the
client with the unaffected side:
a. Dependent
b. Independent
c. Pressed against the bed
d. Position does not matter
129. A 2 year old boy was brought to the eye clinic by his mother who states that she noticed that his son’s sclera is slightly bluish. The nurse expects that
the doctor would tell the mother that:
a. A prescription of antifungal drops will be given
b. It is a form of congenital eye problem that is usually corrected with laser surgery
c. It is normal for children to have bluish sclera
d. The child needs to wear sunglasses for 1 week until discoloration subsides
130. As a person ages visual changes is a significant factor that a care provider must note to ensure proper care would be given. A competent care giver
must know that the color of the door’s borders in the geriatric client’s room should be painted with what color?
a. White
b. Red
c. Blue
d. Black
131. The client is being prepared for discharge from an ambulatory
surgical unit following vitrectomy. The statement by the client
that suggests to the nurse that discharge teaching was effective
is:
a. “I’m driving home since I feel so good.”
b. “I can’t wait until I get home to wash my hair.”
c. “I can expect to see bright flashes of light for a while.”
d. “I’ll call the surgeon if the analgesic doesn’t relieve the
pain.”

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