A – THE NURSING PROCESS 9.

A type of heat loss that occurs when the heat is

dissipated by air current
1. Nurse Angela, observe Joel who is very apprehensive A. Convection
over the impending operation. The client is experiencing B. Conduction
dyspnea, diaphoresis and asks lots of questions. Angela C. Radiation
made a diagnosis of ANXIETY R/T INTRUSIVE D. Evaporation
PROCEDURE. This is what type of Nursing Diagnosis?
A. Actual 10. John has a fever of 38.5 Deg. Celsius. It surges at
B. Probable around 40 Degrees and go back to 38.5 degrees 6 times
C. Possible today in a typical pattern. What kind of fever is John
D. Risk having?
A. Relapsing
2. Nurse Angela diagnosed Mrs. Delgado, who have B. Intermittent
undergone a BKA. Her diagnosis is SELF ESTEEM C. Remittent
DISTURBANCE R/T CHANGE IN BODY IMAGE. D. Constant
Although the client has not yet seen her lost leg, Angela
already anticipated the diagnosis. This is what type of 11. John has a fever of 39.5 degrees 2 days ago, But
Diagnosis? yesterday, he has a normal temperature of 36.5 degrees.
A. Actual Today, his temperature surges to 40 degrees. What type of
B. Probable fever is John having?
C. Possible A. Relapsing
D. Risk B. Intermittent
C. Remittent
3. Nurse Angela is about to make a diagnosis but very D. Constant
unsure because the S/S the client is experiencing is not
specific with her diagnosis of POWERLESSNESS R/T 12. John’s temperature 10 hours ago is a normal 36.5
DIFFICULTY ACCEPTING LOSS OF LOVED ONE. She degrees. 4 hours ago, He has a fever with a temperature of
then focus on gathering data to refute or prove her 38.9 Degrees. Right now, his temperature is back to
diagnosis but her plans and interventions are already normal. Which of the following best describe the fever john
ongoing for the diagnosis. Which type of Diagnosis is is having?
this? A. Relapsing
A. Actual B. Intermittent
B. Probable C. Remittent
C. Possible D. Constant
D. Risk
13. Marianne is now at the Defervescence stage of the
4. Nurse Angela knew that Stephen Lee Mu Chin, has
fever, which of the following is expected?
just undergone an operation with an incision near the
A. Delirium
diaphragm. She knew that this will contribute to some
B. Goose flesh
complications later on. She then should develop what
C. Cyanotic nail beds
type of Nursing diagnosis?
D. Sweating
A. Actual
B. Probable
14. Considered as the most accessible and convenient
C. Possible
method for temperature taking
D. Risk
A. Oral
B. Rectal
B – HEALTH ASSESSMENT
C. Tympanic
D. Axillary
5. Among the following statements, which should be
given the HIGHEST priority?
15. Considered as Safest and most non invasive method of
A. Client is in extreme pain
temperature taking
B. Client’s blood pressure is 60/40
A. Oral
C. Client’s temperature is 40 deg. Centigrade
B. Rectal
D. Client is cyanotic
C. Tympanic
D. Axillary
6. Which of the following need is given a higher priority
among others?
16. Which of the following is NOT a contraindication in
A. The client has attempted suicide and safety
taking ORAL temperature?
precaution is needed
A. Quadriplegic
B. The client has disturbance in his body image because
B. Presence of NGT
of the recent operation
C. Dyspnea
C. The client is depressed because her boyfriend left
D. Nausea and Vomitting
her all alone
D. The client is thirsty and dehydrated
17. In cleaning the thermometer after use, The direction of
the cleaning to follow Medical Asepsis is :
7. Which of the following is a OBJECTIVE data?
A. From bulb to stem
A. Dizziness
B. From stem to bulb
B. Chest pain
C. From stem to stem
C. Anxiety
D. From bulb to bulb
D. Blue nails

8. A patient’s chart is what type of data source? 18. Which of the following completely describes PULSUS
A. Primary PARADOXICUS?
B. Secondary
C. Tertiary A. A greater-than-normal increase in systolic blood
D. Can be A and B pressure with inspiration
B. A greater-than-normal decrease in systolic blood
pressure with inspiration
C. Pulse is paradoxically low when client is in standing
position and high when supine.
D. Pulse is paradoxically high when client is in standing
position and low when supine.
19. How many minutes are allowed to pass if the client
had engaged in strenuous activities, smoked or ingested
caffeine before taking his/her BP?
A. 5
B. 10
C. 15
D. 30
20. Too narrow cuff will cause what change in the
Client’s BP?
A. True high reading
B. True low reading
C. False high reading
D. False low reading
21. Which of the following is the correct interpretation of
the ERROR OF PARALLAX
A. If the eye level is higher than the level of the
meniscus, it will cause a false high reading
B. If the eye level is higher than the level of the
meniscus, it will cause a false low reading
C. If the eye level is lower than the level of the
meniscus, it will cause a false low reading
D. If the eye level is equal to that of the level of the
upper meniscus, the reading is accurate
22. In assessing the abdomen, Which of the following is
the correct sequence of the physical assessment?
A. Inspection, Auscultation, Percussion, Palpation
B. Palpation, Auscultation, Percussion, Inspection
C. Inspection, Palpation, Auscultation, Percussion
D. Inspection, Auscultation, Palpation, Percussion
23. Dr. Fabian De Las Santas, is about to conduct an
ophthalmoscope examination. Which of the following, if
done by a nurse, is a Correct preparation before the
procedure?
A. Provide the necessary draping to ensure privacy
B. Open the windows, curtains and light to allow better
illumination
C. Pour warm water over the ophthalmoscope to ensure
comfort
D. Darken the room to provide better illumination
24. If the client is female, and the doctor is a male and
the patient is about to undergo a vaginal and cervical
examination, why is it necessary to have a female nurse
in attendance?
A. To ensure that the doctor performs the procedure
safely
B. To assist the doctor
C. To assess the client’s response to examination
D. To ensure that the procedure is done in an ethical
manner
25. In palpating the client’s breast, Which of the
following position is necessary for the patient to assume
before the start of the procedure?
A. Supine
B. Dorsal recumbent
C. Sitting
D. Lithotomy
C – NURSING PROCEDURES
26. When is the best time to collect urine specimen for
routine urinalysis and C/S?
A. Early morning
B. Later afternoon
C. Midnight
D. Before breakfast
27. Which of the following is among an ideal way of
collecting a urine specimen for culture and sensitivity?
A. Use a clean container
B. Discard the first flow of urine to ensure that the
urine is not contaminated
C. Collect around 30-50 ml of urine
D. Add preservatives, refrigerate the specimen or add ice
according to the agency’s protocol
28. In a 24 hour urine specimen started Friday, 9:00 A.M,
which of the following if done by a Nurse indicate a NEED
for further procedural debriefing?
A. The nurse ask the client to urinate at 9:00 A.M,
Friday and she included the urine in the 24 hour urine
specimen
B. The nurse discards the Friday 9:00 A M urine of the
client
C. The nurse included the Saturday 9:00 A.M urine of the
client to the specimen collection
D. The nurse added preservatives as per protocol and
refrigerates the specimen
29. When should the client test his blood sugar levels for
greater accuracy?
A. During meals
B. In between meals
C. Before meals
D. 2 Hours after meals
30. A community health nurse should be resourceful and
meet the needs of the client. A villager ask him, Can you
test my urine for glucose? Which of the following technique
allows the nurse to test a client’s urine for glucose without
the need for intricate instruments.
A. Acetic Acid test
B. Nitrazine paper test
C. Benedict’s test
D. Litmus paper test
31. In a routine sputum analysis, Which of the following
indicates proper nursing action before sputum collection?
A. Secure a clean container
B. Discard the container if the outside becomes
contaminated with the sputum
C. Rinse the client’s mouth with Listerine after
collection
D. Tell the client that 4 tablespoon of sputum is needed for
each specimen for a routine sputum analysis
32. Who collects Blood specimen?
A. The nurse
B. Medical technologist
C. Physician
D. Physical therapist
33. A process of heat loss which involves the transfer of
heat from one surface to another without direct contact is
A. Radiation
B. Conduction
C. Convection
D. Evaporation
34. The best position for any procedure that involves
vaginal and cervical examination is
A. Dorsal recumbent
B. Side lying
C. Supine
D. Lithotomy
35. In palpating the client’s abdomen, Which of the
following is the best position for the client to assume?
A. Dorsal recumbent
B. Side lying
C. Supine
D. Lithotomy
36. Rectal examination is done with a client in what
position?
A. Dorsal recumbent 45. Roger has been seen agitated, shouting and running.
B. Sims position As Nurse Aida approaches, he shouts and swear, calling
C. Supine Aida names. Nurse Aida told Roger “That is an
D. Lithotomy unacceptable behavior Roger, Stop and go to your room
now.” The situation is most likely in what phase of NPR?

37. The last expected process in the stages of A. Pre Orientation

inflammation is characterized by B. Orientation
C. Working
A. There will be sudden redness of the affected part D. Termination
B. Heat will increase on the affected part
C. The affected partwill loss its normal function 46. Provides a concise method of organizing and recording
D. Exudates will flow from the injured site data about the client. It is a series of flip cards kept in
portable file used in change of shift reports.
38. What kind of exudates is expected when there is an
antibody-antigen reaction as a result of microorganism A. Kardex
infection? B. Progress Notes
C. SOAPIE
A. Serous D. Change of shift report
B. Serosanguinous
C. Purulent 47. The client has an allergy to Iodine based dye. Where
D. Sanguinous should you put this vital information in the client’s chart?
39. The first manifestation of inflammation is A. In the first page of the client’s chart
B. At the last page of the client’s chart
A. Redness on the affected area C. At the front metal plate of the chart
B. Swelling of the affected area D. In the Kardex
C. Pain, which causes guarding of the area
D. Increase heat due to transient vasodilation 48. Which of the following is NOT TRUE about the Kardex
40. This type of healing occurs when there is a delayed A. It provides readily available information
surgical closure of infected wound B. It is a tool of end of shift reports
C. The primary basis of endorsement
A. First intention D. Where Allergies information are written
B. Second intention
C. Third intention 49. Which of the following, if seen on the Nurses notes,
D. Fourth intention violates characteristic of good recording?
41. Type of healing when scars are minimal due to A. The client has a blood pressure of 120/80,
careful surgical incision and good healing Temperature of 36.6 C Pulse rate of 120 and
Respiratory rate of 22
A. First intention B. Ate 50% of food served
B. Second intention C. Refused administration of betaxolol
C. Third intention D. Visited and seen By Dr. Santiago
D. Fourth intention
50. The physician ordered : Mannerix a.c , what does a.c
42. Imelda, was slashed and hacked by an unknown means?
suspects. She suffered massive tissue loss and
laceration on her arms and elbow in an attempt to evade A. As desired
the criminal. As a nurse, you know that the type of B. Before meals
healing that will most likely occur to Miss Imelda is C. After meals
D. Before bed time
A. First intention
B. Second intention 51. The physician ordered, Maalox, 2 hours p.c, what does
C. Third intention p.c means?
D. Fourth intention A. As desired
B. Before meals
43. In what phase of Nurse patient relationship does a C. After meals
nurse review the client’s medical records thereby D. Before bed time
learning as much as possible about the client?
52. The physician ordered, Maxitrol, Od. What does Od
A. Pre Orientation means?
B. Orientation
C. Working A. Left eye
D. Termination B. Right eye
C. Both eye
44. Nurse Aida has seen her patient, Roger for the first D. Once a day
time. She establish a contract about the frequency of
meeting and introduce to Roger the expected 53. The physician orderd, Magnesium Hydroxide c
termination. She started taking baseline assessment Aluminum Hydroxide. What does c means?
and set interventions and outcomes. On what phase of
NPR Does Nurse Aida and Roger belong? A. without
B. with
A. Pre Orientation C. one half
B. Orientation D. With one half dose
C. Working
D. Termination
54. Which of the following is TRUE with regards to
learning?

A. Start from complex to simple

B. Goals should be hard to achieve so patient can strive
to attain unrealistic goals
C. Visual learning is the best for every individual
D. Do not teach a client when he is in pain

55. According to Bloom, there are 3 domains in learning.

Which of these domains is responsible for the ability of
Donya Delilah to inject insulin?

A. Cognitive
B. Affective
C. Psychomotor
D. Motivative

56. Which domains of learning is responsible for making

John and Marsha understand the different kinds of
family planning methods?

A. Cognitive
B. Affective
C. Psychomotor
D. Motivative

57.) After caring for a client with extensive

body burns, the nurse performs which of the
following actions when removing protective
wear?
A.) Remove, mask, gown, gloves, cap and
shoe cover
B.) Remove gloves, mask, gown, cap and
shoe cover
C.) Remove gown, mask, gloves, cap and
shoe cover
D.) Remove cap and shoe cover, mask,
gloves, gown