Situation 1: After an abdominal surgery, the circulating and scrub nurses have
critical responsibility about sponges and instrument count.
2. The layer of the abdomen is divided into 5. Arrange the following from the
first layer going to the deepest layer.
1. Fascia
2. Muscle
3. Peritoneum
4. Subcutaneous/fat
5. Skin
a. 5,4,3,2,1
b. 5,4,2,1,3
c. 5,4,1,3,2
d. 5,4,1,2,3
7. To obtain specimen for sputum culture and sensitivity, which of the following
instruction is best?
a. Upon waking up, cough deeply and expectorate into container
b. Cough after pursed lip breathing
c. Save sputum for two days in covered container
d. After respiratory treatment, expectorate into a container
8. The best time for collecting the sputum specimen for culture is
a. Before retiring at night
b. Upon waking up in the morning
c. Anytime of the day
d. Before meals
11. You are the nurse in charge of Mr. Santos. When asked what are the organs
to be examined during cystoscopy, you will enumerate as follows:
a. Urethra, kidney, bladder, urethra
b. Urethra, bladder wall, trigone, ureteral opening
c. Bladder wall, uterine wall, and urethral opening
d. Urethral opening, ureteral opening bladder
12. In the OR, you will position Mr. Santos who is undergoing cystoscopy in:
a. Supine
b. Lithotomy
c. Semi-fowler
d. Trendelenburg
13. After cystoscopy, Mr. Santos asked you to explain why there is no incision of
any kind. What do you tell him?
a. “Cystoscopy is direct visualization and examination by urologist.”
b. “cystoscopy is done by x-ray visualization of the urinary tract.”
c. “Cystoscopy is done by using lasers on the urinary tract.”
d. “Cystoscopy is an endoscopic procedure of the urinary tract.”
14. Withing 24-48 hours post cystoscopy, it is normal to observe one of the
following:
a. Pink-tinged urine
b. Distended bladder
c. Signs of infection
d. Prolonged hematuria
Situation 4: Mang Felix, a 79 year old man who is brought to the surgical unit
form PACU after a transurethral resection. You are assigned to receive him. You
noted that he has a 3 way indwelling urinary catheter for continuous fast drip
bladder irritation which is connected to a straight drainage.
16. Immediately after surgery, what would you expect his urine to be?
a. Light yellow
b. Amber
c. Bright red
d. Pinkish to red
17. The purpose of the continuous bladder irrigation is to:
a. Allow continuous monitoring of the fluid output status
b. Provide continuous flushing of clots and debris from the bladder
c. Allow for proper exchange of electrolytes and fluid
d. Ensure accurate monitoring of intake and output
18. Mang Felix informs you that he feels some discomfort on the hypogastric
area and he has to void. What will be your most appropriate action?
a. Remove his catheter then allow him to void on his own
b. Irrigate his catheter
c. Tell him to “go ahead and void. You have an indwelling catheter.”
d. Assess color and rate of outflow if there is a change, refer to urologist for
possible irrigation
19. You decided to check on Mang Felix’s IV fluid infusion. You noticed a change
in flow rae, pallor and coldness around the insertion site. What is your
assessment finding?
a. Phlebitis
b. Infiltration to subcutaneous tissue
c. Pyrogenic rection
d. Air embolism
21. Melamine is a synthetic resin used for whiteboards, hard plastics and jewelry
box covers due to its fire retardant properties. Milk and food manufacturers add
melamine in order to:
a. It has a bacteriostatic property leading to increase food and milk life as a way
of preserving the foods
b. Gives a glazy and more edible look on foods
c. Make milks tasty and creamy
d. Create an illusion of a high protein content on their product
22. Most of the milks contaminated by Melamine came from which country?
a. India
b. China
c. Philippines
d. Korea
23. Which government agency is responsible for testing the melamine content of
foods and food products?
a. DOH
b. MMDA
c. NBI
d. BFAD
24. Infants are the most vulnerable to melamine poisoning. Which of the
following is NOT a sign of melamine poisoning?
a. Irritability, back ache, urolithiasis
b. High blood pressure, fever
c. Anuria, oliguria or hematuria
d. Fever, irritability and large output of diluted urine
28. The three main consequence of leukemia that causes the most danger is:
a. Neutropenia causing infection, anemia causing impaired oxygenation, and
thrombocytopenia leading to bleeding tendencies
b. Central nervous system infiltration, anemia causing impaired oxygenation and
thrombocytopenia leading to bleeding tendencies
c. Splenomegaly, hepatomegaly, fractures
d. Invasion by the leukemia cells to the bone causing severe bone pain
Situation 7: Breast cancer is the 2nd most common type of cancer after lung
cancer and 99% of which, occurs in woman. Survival rate is 98% if this is
detected early and treated promptly. Carmen is a 53 year old patient in the high
risk group for breast cancer was recently diagnosed with Breast Cancer.
31. All of the following are factors that said to contribute to the development of
breast cancer except:
a. Prolonged exposure to estrogen such as an early menarche or late
menopause, nulliparity, and childbirth after age 30.
b. Genetics
c. Increasing age
d. Prolonged intake of tamoxifen (Nolvadex)
32. Protective factors for the development of breast cancer includes which of the
following except:
a. Exercise
b. Prophylactic tamoxifen
c. Breast feeding
d. Alcohol intake
33. A patient diagnosed with breast cancer has been offered the treatment
choices of breast conservation surgery with radiation or a modified radical
mastectomy. When questioned by the patient about these options, the nurse
informs the patient that the lumpectomy with radiation
a. Reduces the fear and anxiety that accompanies the diagnosis and treatment of
cancer
b. Has about the same 10-year survival rate as the modified radical mastectomy
c. Provides a shorter treatment period with a fewer long term complications
d. Preserves the normal appearance and sensitivity of the breast
34. Carmen, who is asking the nurse the most appropriate time of the month to
do her self-examination of the breast. The MOST appropriate reply by the nurse
would be:
a. The 26th days of the menstrual cycle
b. 7 to 8 days after conclusion of the menstrual period
c. During her menstruation
d. The same day each month
35. Carmen being treated with radiation therapy. What should be included in the
plan of care to minimize skin damage from the radiation therapy?
a. Cover the areas with thick clothing materials
b. Apply a heating pad to the site
c. Wash skin with water after the therapy
d. Avoid applying creams and powders to the area
36. Based on DOH and World Health Organization (WHO) guidelines, the
mainstay for early protection method for breast cancer that is recommended for
developing countries is
a. a monthly breast self examination (BSE) and an annual health worker breast
examination (HWBE)
b. an annual hormone receptor assay
c. an annual mammogram
d. a physician conduct a breast clinical examination every 2 years
37. the purpose of performing the breast self examination (BSE) regularly is to
discover
a. fibrocystic masses
b. cancerous lungs
c. areas of thickness or fullness
d. changes from previous BSE
38. If you are to instruct a post-menopausal woman about BSE, when would you
tell her to do BSE?
a. On the same day of each month
b. Right after the menstrual period
c. On the first day of her menstruation
d. On the last day of her menstruation
39. During breast self-examination, the purpose of standing in front of the mirror
is to observe the breast for
a. Thickening of the tissue
b. Axillary lymphnodes
c. Lumps in the breast tissue
d. Change in size and contour
40. When preparing to examine the left breast in a reclining position, the
purpose of placing a small folded towel under the client’s left shoulder is to
a. Bring the breast closer to the examiner’s right hand
b. Tense the pectoral muscle
c. Balance the breast tissue more evenly on the chest wall
d. Facilitate lateral positioning of the breast
41. Albert is receiving external radiation therapy and he complains of fatigue and
malaise. Which of the following nursing interventions would be most helpful for
Albert?
a. Tell him that sometimes these feelings can be psychogenic
b. Refer him to the physician
c. Reassure him that these feelings are normal
d. Help him plan his activities
Situation 9: Burns are caused by transfer of heat source to the body. It can be
thermal, electrical, radiation or chemical.
46. A burn characterized by pale white appearance, charred or with fat exposed
and painlessness is
a. Superficial partial thickness burn
b. Deep partial thickness burn
c. Full thickness burn
d. Deep full thickness burn
47. Which of the following BEST describes superficial partial thickness burn or
first degree burn?
a. Structures beneath the skin are damaged
b. Dermis is partially damaged
c. Epidermis and dermis are both damaged
d. Epidermis is damaged
49. During the acute phase of the burn injury, which of the following is a
priority?
a. Wound healing
b. Reconstructive surgery
c. Emotional support
d. Fluid resuscitation
50. While in the emergent phase, the nurse knows that the priority is to:
a. prevent infection
b. control pain
c. prevent deformities and contractures
d. return the hemodynamic stability via fluid resuscitation
51. The MOST effective method of delivering pain medication during the
emergent phase is
a. Intramuscularly
b. Subcutaneously
c. Orally
d. Intravenously
52. When a client accidentally splashes chemicals to his eyes, the initial priority
care following the chemical burn is to
a. Irrigate with normal saline for 1 to 15 minutes
b. Transport a physician immediately
c. Irrigate with water for 15 minutes or longer
d. Cover the eyes with a sterile gauze
53. Which of the following can be a fatal complication of upper airway burns?
a. Stress ulcers
b. Hemorrhage
c. Shock
d. Laryngeal spasms and swelling
54. When a client will rush towards you and he has burning clothes on, it is your
priority to do which of the following first?
a. Log roll on the grass/ground
b. Slap the flames with his hands
c. Try to remove the burning clothes
d. Splash the client with 1 bucket of cool water
56. During the first 24 hours after the thermal injury, you should assess Sergio
for
a. Hypokalemia and hypernatremia
b. Hypokalemia and hyponatremia
c. Hyperkalemia and hyponatremia
d. Hyperkalemia and hypernatremia
57. A client who sustained deep partial thickness and full thickness burns of the
face, whole anterior chest and both upper extremities two days ago begins to
exhibit extreme restlessness. You recognize that this most likely indicates that
the client is developing
a. Cerebral hypoxia
b. Hypervolemia
c. Metabolic acidosis
d. Renal failure
58. A 165 lbs trauma client was rushed to the emergency room with full
thickness burns on the whole face, right and left arm, and at the anterior part of
chest sparing the abdominal area. He also has superficial partial thickness burn
at the posterior trunk and at the half upper portion of the left leg. He is in the
emergent phase of burn. Using the parkland’s formula, you know that during the
first 8 hours of burn, the amount of fluid will be given is:
a. 5,400 ml
b. 10,600 ml
c. 9,450 ml
d. 6,750 ml
59. The doctor incorporated insulin on the client’s fluid during the emergent
phase. The nurse knows that insulin is given because
a. Clients with burn also develops metabolic acidosis
b. Clients with burn also develops hyperglycemia
c. Insulin is needed for additional energy and glucose burning after the stressful
incident to hasten wound healing, regain of consciousness and rapid return of
hemodynamic stability
d. For hyperkalemia
61. You plan to teach Fermin how to irrigate the colostomy when
a. The perineal wound heals and Fermin can sit comfortable on the commode
b. Fermin can lie on the side comfortable, about the 3rd post-operative day
c. The abdominal incision is closed and contamination is no longer a danger
d. The stools starts to become formed around the 7th post-operative day
62. When preparing to teach Fermin how to irrigate colostomy, you should plan
to do the procedure:
a. When Fermin would have normal bowel movement
b. At least 2 hours before visiting hours
c. Prior to breakfast and morning care
d. After Fermin accepts alteration in body image
64. You are aware that teaching about colostomy care is understood when
Fermin states, “I will contact my physician and report:
a. If I have any difficulty inserting the irrigating tube into the stoma.”
b. If I noticed a loss of sensation to touch in the stoma tissue.”
c. The expulsion of flatus while the irrigating fluid is running out.”
d. When mucus is passed from the stoma between the irrigation.”
65. You would know after teaching Fermin that dietary instruction for him is
effective when he states, “it is important that I eat:
a. Soft food that is easily digested and absorbed by the large intestines.”
b. Bland food so that my intestines do not become irritated.”
c. Food low in fiber so that there are fewer stools.”
d. Everything that I ate before the operation, while avoiding foods that cause
gas.”
Situation 11: Based on studies of nurses working in special units like the
intensive care unit and coronary care unit, it is important for nurses to gather as
much information to be able to address their needs for nursing care.
66. Critically ill patients frequently complain about which of the following when
hospitalized?
a. Hospital food
b. Lack of blankets
c. Lack of privacy
d. Inadequate nursing staff
68. Which of the following factors may inhibit learning in critically ill patients?
a. Gender
b. Medication
c. Educational level
d. Previous knowledge of illness
69. Which of the following statements does not apply to critically ill patients?
a. Majority need extensive rehabilitation
b. All have been hospitalized previously
c. Are physically unstable
d. Most have chronic illness
70. Families of critically ill patients desire which of the following needs to be met
first by the nurse?
a. Provision of comfortable space
b. Emotional support
c. Updated information on client’s status
d. Spiritual counseling
71. His diagnosis was hyperthyroidism. The following are expected symptoms
except
a. Anorexia
b. Palpitation
c. Fine tremors of the hands
d. Hyperalertness
72. She has to take drugs to treat her hyperthyroidism. Which of the following
will you NOT expect that the doctor will prescribe?
a. Colace (Docusate)
b. Cytomel (llothyronine)
c. Tapazole
73. The nurse knows that Tapazole has which of the following side effects that
will warrant immediate withholding of the medication?
a. Death
b. Sore throat
c. Hyperthermia
d. Thrombocytosis
76. Basal metabolic rate is assessed on Johnny to determine his metabolic rate.
In assessing the BMR using the standard procedure, you need to tell Johnny
that:
a. Obstructing his vision
b. Restraining his upper and lower extremities
c. Obstructing his hearing
d. Obstructing his nostrils with a clamp
81. Instruments in the surgical suite for surgery are classified as either
CRITICAL, SEMI-CRITICAL and NON-CRITICAL. If the instrument is introduced
directly into the blood stream or into any normally sterile cavity or area of the
body, it is classified as:
a. Critical
b. Semi critical
c. Non-critical
d. Ultra critical
82. Instruments that do not touch the paitnet or have contact only to intact skin
is classified as:
a. Critical
b. Semi critical
c. Non critical
d. Ultra critical
85. As a nurse, you know that intact skin acts as an effective barrier to most
microorganisms. Therefore, items that come in contact with the intact skin or
mucus membranes should be
a. Disinfected
b. Sterile
c. Clean
d. Alcoholized
86. You are caring for Johnny who is scheduled to undergo total thyroidectomy
because of diagnosis of thyroid cancer. Prior to total thyroidectomy, you should
instruct Johnny to
a. Perform range and motion exercise on the head and neck
b. Apply gentle pressure against the incision when swallowing
c. Cough and deep breath every 2 hours
d. Support head with the hands when changing position
90. After surgery, Johnny develops peripheral numbness, tingling and muscle
twitching, and spasm. What would you anticipate to administer?
a. Magnesium sulfate
b. Calcium gluconate
c. Potassium iodides
d. Potassium chloride
Situation 15: Andrea is admitted to the ER following an assault where she was
hit in the face and head. She was brought to the ER by a policewoman.
Emergency measures were started.
96. Andrea’s respiration is described as waxing and waning. You know that this
rhythm of respiration is defined as
a. Biot’s
b. Kussmaul’s
c. Cheyne stokes
d. Eupnea
97. What do you call the triad of sign and symptoms seen in a client with
increasing ICP?
a. Virchow’s triad
b. The Chinese triad
c. Cushing’s triad
d. Charcot’s triad
98. Which of the following is true with the Triad seed in the head injuries?
a. Narrowing of pulse pressure, cheyne stokes respiration, tachycardia
b. Widening pulse pressure, irregular respiration, bradycardia
c. Hypertension, kussmaul’s respiration, tachycardia
d. Hypotension, irregular respiration, bradycardia
99. In a client with a Cheyne stokes respiration, which of the following is the
most appropriate nursing diagnosis?
a. Ineffective airway clearance
b. Ineffective breathing pattern
c. Impaired gas exchange
d. Activity intolerance
100. You know that apnea is seen in client with Cheyne Stokes respiration,
APNEA is defined as:
a. Inability to breath in a supine position so the patient sits up in bed to breathe
b. The patient is dead, the breathing stops
c. There is an absence of breathing for a period of time, usually 15 seconds or
more
d. A period of hypercapnea and hypoxia due to the cessation of respiratory effort
in spite of normal respiratory functioning
ANSWER KEY:
1. D
2. D
3. B
4. B
5. C
6. D
7. A
8. B
9. B
10. B
11. B
12. B
13. D
14. A
15. B
16. D
17. B
18. D
19. B
20. D
21. D
22. B
23. D
24. D
25. B
26. C
27. B
28. A
29. B
30. D
31. D
32. D
33. D
34. B
35. D
36. A
37.B
38. A
39. A
40. C
41. D
42. D
43. A
44. C
45. A
46. C
47. B
48. B
49. A
50. D
51. D
52. C
53. D
54. A
55. D
56. C
57. A
58. A
59. D
60. D
61. D
62. A
63. B
64. A
65. D
66. C
67. D
68. B
69. B
70. B
71. A
72. A
73. B
74. C
75. A
76. D
77. B
78. A
79. D
80. B
81. A
82. C
83. C
84. C
85. A
86. D
87. B
88. D
89. D
90. B
91. A
92. C
93. B
94. C
95. B
96. C
97. C
98. B
99. B
100. C