A. “I take my water pill every morning.
”
Medical-Surgical
Nursing COMPREHENSIVE EXAM
LOCAL NURSING LICENSURE EXAM
Warning: This material is protected by Copyright
Laws. Unauthorized use shall be prosecuted in the full
extent of the Philippine Laws. For exclusive use of
CBRC reviewees only.
Situation 1 – You are the nurse on duty on the coronary care
unit of a tertiary hospital. All of the following questions apply.
1. Five minutes after administration of the first dose of
nitroglycerin, the client still complains of chest pain. Which of the
following interventions must not be performed?
A. Administration of the 2nd dose of nitroglycerin
B. Assessment of the client’s BP
C. Pain assessment
D. None of the above
2. Which of the following is the most effective method in relieving
chest pain of patients who have myocardial infarction?
A. Administration of Morphine Sulphate
B. Administration of Nitrates SL
C. Provision of oxygen therapy via nasal cannula
D. Sufficient rest and exercise
3. Mr. Young is admitted after suffering from acute myocardial
infarction. Alteplase therapy is ordered for him. The following is
the priority intervention for him:
A. Being alert for signs of hemorrhage
B. Monitoring for signs of infection
C. Assessment for musculoskeletal functions
D. Assessment of neurological status
4. The most common cause of Cardiogenic shock is damage to the
heart muscle for a severe heart attack. Which treatments would
the nurse anticipate for a patient who is experiencing
Cardiogenic shock?
A. Corticosteroids, epinephrine and oxygen
B. Oxygen, fluids and O negative blood
C. IV nitroglycerine, diuretics and intra-aortic balloon pump
D. Oxygen, dopamine and lidocaine
5. A client with myocardial infarction and cardiogenic shock is
placed on an intra-aortic balloon pump (ABP). If the device is
functioning properly, the balloon inflates when the:
A. Tricuspid valve is close C. Aortic valve is closed
B. Pulmonic valve is open D. Mitral valve is closed
Situation 2 – Congestive heart failure and inflammation of
certain layers of the heart are some of the most common
causes of heart-related deaths in the world.
6. The nurse is caring for a client diagnosed with congestive heart
failure (CHF) who is complaining of shortness of breath and
dyspnea. Which intervention should the nurse implement first?
A. Assess the client’s lung sounds
B. Elevate the client’s head of the bed
C. Administer oxygen via nasal canula
D. Check the client’s pulse oximeter reading
Situation 4 – A nurse is assigned to care for patients who
7. The home health care nurse is visiting a client diagnosed with have certain types of anemia. The following queries apply.
CHF. Which comment by the client would warrant intervention
by the nurse?
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098/735-0740
B. “I have to sleep on two pillows at night.”
C. “I have some leg cramps every now and then.”
D. “I must rest after I walk around the block.”
8. The client is diagnosed with pericarditis. Which signs and
symptoms should the nurse expect in this client?
A. The client has pulsus paradoxus and night sweats
B. Complain of fatigue and arthralgias
C. Constant chest pain and friction rub
D. Increased chest pain when ambulating but not at rest
9. During the shift assessment, the nurse notes muffled heart
sounds in a patient with acute pericarditis. During the shift
assessment, the nurse notes muffled heart sounds. Which
intervention should the nurse implement?
A. Notify the health care provider
B. Continue to monitor the client
C. Get an order to place the client on telemetry
D. Recheck the client in 4 hours
10. The nurse is assessing the client diagnosed with subacute
bacterial endocarditis. Which question should the nurse ask the
client during the admission interview to support this diagnosis?
A. “Have you had a sore throat in the last month?”
B. “Did you have frequent sore throats as a child or young
adult?”
C. “Do you have a family history of heart disease?”
D. “What prescription medication do you take?”
Situation 3 – Blood is a bodily fluid in humans that deliver
necessary substances such as nutrients and oxygen to the
cells and transports metabolic waste products away from
those same cells.
11. Which of the following is true of red blood cell?
A. It is nucleated
B. It has a lifespan of 100 days
C. Its production and formation depends on the action of the
kidney
D. It is produced in the yellow marrow
12. Which organ is responsible for stimulating the production of red
blood cells?
A. Yellow marrow C. Spleen
B. Red marrow D. Kidney
13. What is the life span of normal platelets?
A. 3-4 months C. 1-3 months
B. 1-2 months D. 7-10 days
14. An adult diagnosed with Disseminated Intravascular
Coagulation (DIC). The nurse should identify that the client is at
risk for which of the following nursing diagnosis?
A. Risk for increased cardiac output related to fluid volume
excess
B. Disturbed sensory perception related to bleeding into tissue
C. Alteration in tissue perfusion related to bleeding and
diminished blood flow
D. Risk for aspiration related to constriction of respiratory
musculature
15. A client is diagnosed with Polycythemia vera and asks the nurse
about the disorder. The nurse plans to base the response on
which characteristic of the condition?
A. It occurs as a result of a hereditary factor
B. It is classified as a myeloproliferative disorder
C. It occurs as a result of lack of the intrinsic factor
D. It is an anemia that occurs as a result of poor iron intake
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16. Which of the following is considered as the most common type
of anemia in the world?
A. Iron deficiency anemia C. Pernicious anemia
B. Aplastic anemia D. Megaloblastic anemia
17. Which of the following clients is most likely to have Iron
Deficiency Anemia?
A. Vanessa, 45 year old, who changes her regular pad twice a
day during 28 days.
B. Debbie, 24 year old, who changes her regular pad twice a
day during 28 days menstrual cycle.
C. Nerry, 33 year old, with peptic ulcer who had surgery 65
weeks ago.
D. Prince, 27 year old, who have intestinal hookworm.
18. Which of the following lab value should the nurse know to be
consistent with hemolytic anemia?
A. Increase RBC, decrease bilirubin, decrease hemoglobin
and hematocrit, increase reticulocytes
B. Decrease RBC, increase bilirubin, decrease hemoglobin
and hematocrit, increase reticulocytes
C. Decrease RBC, decrease bilirubin, increase hemoglobin
and hematocrit, decrease reticulocytes
D. Increase RBC, increase bilirubin, increase hemoglobin and
hematocrit, decrease reticulocytes
19. Which clinical manifestation noted in the client with pernicious
anemia, would indicate that the client had been noncompliant
with B12 injections?
A. Hyperactivity in the evening hours
B. Weight gain of 5 lbs in one week
C. Paresthesia of hands and feet
D. Diarrhea stools several times a day
20. A client is to receive epoetin (Epogen) injections. What
laboratory value should the nurse assess before giving the
injection?
A. Hematocrit
B. Partial thromboplastin time
C. Hemoglobin concentration
D. Prothrombin time
Situation 5 – In COPD, the airflow limitation is progressive
and is associated with an abnormal inflammatory response of
the lungs to noxious particles or gases. Mr. Del Rosario has
just been admitted to the unit with a diagnosis of acute
exacerbation of end-stage COPD.
21. You conducted a physical assessment on the client and noted
the following: respiratory rate of 37 breaths per minute, dyspneic
and dusky color of the skin. Which of the following should you
perform initially?
A. Monitor the client’s ECG reading
B. Attach Mr. Del Rosario to an oxygen source via nasal
cannula regulated at 10 Lpm
C. Assist client into a High Fowler’s position
D. Contact the physician immediately
22. Which assessment finding by the staff nurse in a client with
COPD would require the supervisor to intervene?
A. Presence of barrel chest and dyspnea
B. Use of accessory muscles during inspiration
C. Oxygen flow meter set at 3 Lpm while the client is
ambulating
D. Rust-colored sputum collected early in the morning
23. Mr. Sandler, a 42 year old client is currently prescribed with
Propranolol for his hypertension. As you browse through the
chart of the client, you found out that he has a history of
bronchial asthma. Because of this knowledge, which of the 30. The nurse is caring for a client diagnosed with an acute
following should you take first before giving Propranolol?
A. Monitor the apical pulse rate for a full minute
B. Instruct the client to change position slowly
C. Give the drug with food
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098/735-0740
D. Contact the physician and verify the order
24. Upon receiving a client with status asthmaticus in the
Emergency Department, priority intervention should include:
A. Give the client a short acting beta adrenergic agonist
B. Administer Solu-medrol, a glucocorticoid intravenously
C. Start infusion of Theophylline via IV
D. Monitoring of breath sounds every 5-10 minutes
25. Nurse Vangie is completing the admission assessment of a
client diagnosed with Reactive Airway Disease. Which
manifestation would indicate to Nurse Vangie that there is an
acute exacerbation of the condition?
A. Complaints of chest tightness and difficulty of breathing
B. Temperature reading of 37.8°C and feelings of nausea
C. Crackles heard upon auscultation of the lung fields and
presence of red raised areas on the chest
D. Symmetrical expansion of the thoracic cavity noted during
inspiration
Situation 6 – An individual’s nutritional status depends not
only on the type and amount of intake but also on the
functioning of the gastric and intestinal portions of the
gastrointestinal (GI) system. A nurse is assigned in the
Medical-Surgical Unit and is taking care of patients with
gastrointestinal conditions. The following questions apply.
26. Mr. Logan, your patient diagnosed with Acute Inflammatory
Bowel Disease is ready for discharge. You reviewed with the
patient home instructions in order to prevent exacerbation of the
disease. Which of the following statements made by Mr. Logan
warrants further reinforcement?
A. “When I quit taking prednisone, I will taper it off slowly.”
B. “Support groups are made available for people affected
with this condition.”
C. “From now on, I have to avoid sodas and alcohol.”
D. “I feel relieved because the physician told me that I can
still eat anything I want.”
27. A client was rushed in the Emergency Department with
complaints of abdominal pain. You suspect that he may be
suffering from Peptic Ulcer Disease. Which of the following
client statements support the diagnosis of Gastric Ulcer?
A. “There are bright red spots in my stool.”
B. “I experience a burning sensation in my chest if I lie down
after having a meal.”
C. “After eating a heavy meal, I feel severe pain on the right
side of my abdomen.”
D. “Lately, I don’t eat that much because I get stomach pain
minutes after I eat.”
28. Bella, a client with a history of diverticulosis, complains of
abdominal pain and bowel irregularity for the past few weeks. An
abdominal ultrasound confirms diverticulitis. On assessment, the
nurse would expect which of the following?
A. Left upper quadrant pain, fever, vomiting and a flat
abdomen
B. Right upper quadrant abdominal pain, flatulence and fever
C. Epigastric pain, flatulence and abdominal pain
D. Left lower quadrant pain, tenderness and nausea
29. Who among the following clients is most likely to be diagnosed
of Regional Enteritis?
A. Nerry, who experiences abdominal pain when eating
B. Vanessa, who is passing 10-20 loose stools a day
C. Prince, who complains of left lower quadrant pain and low
grade fever
D. Debbie, who has in increasing abdominal girth
exacerbation of ulcerative colitis. Which assessment finding
would warrant immediate intervention by the nurse?
A. ABG reveals pH of 7.32; PaO2 of 95 mmHg; PaCO2 of 38
and HCO3 of 20
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 B. Serum potassium of 4.3 mEq/L
C. Serum sodium of 137 mEq/L
D. Hgb of 12 and Hct of 40%
Situation 7 – An understanding of the structure and function of
the biliary tract and pancreas is essential, along with an
understanding of the close link of biliary tract disorders with
liver disease.
31. Ms. Santibanez, a client admitted 4hours ago, presents with low
grade fever and vague pain in the abdominal region. The
physician suspects that she has appendicitis. The major
complication of appendicitis is the perforation of the appendix
which generally occurs 24 hours after the onset of pain. The
nurse knows that the following symptom suggests a possible
perforation:
A. Jaundice
B. Fever and increasing abdominal distention
C. Fatigue
D. Malaise and pallor
32. Which signs and symptoms would the nurse expect in a client
diagnosed with cholelithiasis?
A. Rigid, board-like abdomen
B. Fever and elevated white blood cell count
C. Jaundice and clay-colored stools
D. Elevated amylase and lipase
33. A client diagnosed with acute pancreatitis has been complaining
of mid-epigastric pain unrelieved by narcotics administered an
hour ago. The drug is prescribed every 4 hours PRN. Which
intervention should the nurse implement next?
A. Instruct the client to lie in the prone position with legs
extended
B. Explain to the client that she cannot administer more
medication for 3 hours
C. Notify the physician and ask to increase the dose of the
narcotic pain medication
D. Place the client in side-lying position with knees flexed
34. Elsa was rushed in the facility due to severe abdominal pain
radiating at the back after attending a birthday celebration. The
physician suspects pancreatitis. Which laboratory value should
the nurse monitor?
A. Serum bilirubin and calcium
B. Serum SGOT and serum SGPT
C. Serum amylase and lipase
D. Hemoglobin and Hematocrit
35. After conducting several tests on Elsa, the physician now
confirmed the diagnosis of acute pancreatitis. Which laboratory
data would indicate that the client’s pancreatitis is deteriorating?
A. The blood urea nitrogen (BUN) serum level is decreased
B. The amylase and lipase serum levels are below the normal
limits
C. Decreasing white blood cell count
D. The hematocrit has decreased by 5% in a 24 hour period
Situation 8 – Renal failure is a systemic disease and is a final
common pathway of many different kidney and urinary tract
diseases. You were assigned to care for various clients
diagnosed with diseases affecting their renal functioning. The
following questions pertain to this topic.
36. The oliguric phase of Acute Renal Failure may be manifested by
which of the following?
A. A drop in the serum creatinine and BUN levels
B. Urine output of more than 1L for 24 hours
C. Urine output of less than 40 mL for 24 hours
D. Return to normal functioning of the renal tubules
37. Upon reading the chart of a client with acute renal failure, you
43. Nurse Alex is conducting an assessment of a client suspected to
noticed that the physician made an order for insulin. Which of
have Type I Diabetes Mellitus. Which assessment finding
supports the diagnosis of Type I DM?
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098/735-0740
the following is the appropriate rationale behind this order for
clients with acute renal failure:
A. Insulin will reduce the toxins in the client’s body by lowering
the metabolic rate
B. Insulin can help manage the increased level of potassium
in the client’s body
C. The client probably had an elevated blood glucose level
D. Insulin administration can increase client’s tolerance to
activities
38. A client diagnosed with chronic renal failure is being managed
with peritoneal dialysis. Which assessment finding required
immediate reporting to the physician?
A. Complaints of nausea and abdominal pain by the client
B. Amount of dialysate return is less than what is instilled
C. Weight loss of approximately 1 Kg within the last week
D. Colorless appearance of dialysate return
39. Mr. Clarence has been inserted with an arteriovenous (AV)
fistula in the right upper extremity for hemodialysis treatments.
When planning care for Mr. Clarence, which of the following
measures should you implement to ensure safety of the client?
A. Assess the fistula for the presence of a bruit and thrill every
four hours.
B. Use the fistula as a port for all venipunctures and
intravenous infusions.
C. Use the right arm when taking the blood pressure to ensure
accuracy.
D. Ensure that small clamps are attached to the AV fistula
dressing.
40. A client has been admitted in the facility due to renal calculi
formation. Blood analysis results reveal a calcium level of 9
mg/dL and elevated purine level. You expect that the stones of
the client is composed of:
A. Magnesium ammonium phosphate
B. Cysteine
C. Calcium oxalate
D. Uric acid
Situation 9– Diabetes Mellitus is a group of metabolic
diseases characterized by elevated levels of glucose in the
blood (hyperglycemia) resulting from defects in insulin
secretion, insulin action, or both. A 56-year old obese female
sought admission to the hospital for chief complaints of
muscle weakness and frequent urination. The admitting
impression is DM type 2.
41. You are giving health instructions to the patient during your
rounds. Which of the following statements made by the patient
indicates the need for further teaching?
A. “I may need to reduce my weight to help lower down my
blood glucose level.”
B. “I must start checking the food labels for the carbohydrate
content to help control my diabetes.”
C. “I need not to be worried because my children won’t inherit
my diabetes.”
D. “If I get any types of cuts on my feet, I need to watch them
closely”
42. You are to give the prescribed Metformin (Glucophage) to the
patient. She asked you what the drug is for. You accurately
answered the query of the patient if you stated:
A. This drug prevents the breakdown of glucose in the liver.
B. This drug slows down the absorption of carbohydrates in
the intestines.
C. This will increase the production of insulin in the beta cells
and eventually will lower down you sugar.
D. Metformin causes the muscle cells to be more open to
circulating insulin.
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 A. Weight gain of approximately 15 kg in the last few years
B. Family history reveals gestational diabetes of the client’s
granddaughter
C. Urinary frequency
D. An unhealed sore on the right toe
44. Nurse Natalia administered the prescribed regular insulin of her
patient at 0800 H. She should expect that the drug will reach its
peak at approximately:
A. 2000 H C. 1100 H
B. 1400 H D. 0900 H
45. Nurse Jacq is assigned to care for Mr. Samuel, a client
diagnosed with Hyperglycemic Hyperosmolar Nonketotic Coma.
Which finding warrants immediate intervention by Nurse Jacq?
A. ABG results reveal metabolic acidosis
B. +4 ketones on urinalysis
C. Skin turgor is tented
D. Bilateral crackles heard upon auscultation of the lungs
Situation 10 – The hormones secreted by the endocrine
system are affected in large part by structures in the central
nervous system, such as the hypothalamus. The nurse
reviewed the medical records of the clients assigned to him
and found out that his clients are suffering from Endocrine
disorders. The following questions apply.
46. Immediately during the post-operative period after surgical
hypophysectomy, it is vital for the nurse to check the client’s:
A. Serum calcium levels C. Breath sounds
B. Blood pressure D. Bowel sounds
47. Following the removal of the parathyroid glands, which of the
following order should the nurse anticipate?
A. Ensure that intravenous calcium preparations are available
at the bedside
B. Position the client flat on bed with the head and neck
immobilized
C. Endotracheal tube must be maintained for 36 hours
D. Obtain rectal temperatures only until discharge
48. A patient is prescribed with levothyroxine (Synthroid) to control
her hypothyroidism. Which statement by the patient warrants
further discussion of the nurse?
A. “My thyroid levels should be monitored on a daily basis.”
B. “I need to avoid iodine rich foods from now on.”
C. “I will monitor my weight monthly.”
D. “I may experience chest pain while I’m on this drug.”
49. In providing health instructions to a patient diagnosed with
Hyperthyroidism, the nurse should include which of the
following?
A. Maintain a calm, restful environment
B. Eat a low-calorie, low-protein diet
C. Take the thyroid hormone on a full stomach
D. Wear a thick weaved cloth while under the sun
50. The client had a bilateral adrenalectomy for Cushing’s disease.
He is for discharge with home prescription of Hydrocortisone.
The best statement indicating understanding of the drug
associated risk is:
A. “I am taking this drug to replace the hormones usually
secreted by the adrenal medulla”
B. “I should take this pill every morning before breakfast”
C. “This pill may cause weight gain, so I should exercise more
and eat less”
D. “I should call the doctor if I think I am starting a cold and I
should not take aspirin”
Situation 11 – Client care during the perioperative phase
demands knowledge and skill in perioperative care and also
requires an in-depth understanding of related disease
processes that have brought the client to seek treatment.
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098/735-0740
51. Nurse Allen was assigned in the OR to attend to Mrs. Luis who
is scheduled for exploratory laparotomy. Which statement made
by Mrs. Luis indicates that she needs more information prior to
signing an informed consent for abdominal operation?
A. “I will be glad to get back to my gardening when I get
home.”
B. “I should not lift more than 5 pounds after my surgery.”
C. “I should tell the nurse if I am having pain after my surgery.”
D. “I will have to take deep breaths and cough after I wake
up.”
52. As the nurse assigned to this client due for surgery in an hour,
which intervention is a priority for the nurse?
A. Make sure that the antiseptic bath was given on the
previous shift
B. Label the outside of the chart with allergies
C. Obtain the “on call” antibiotic to send to the operating room
D. Complete the preoperative checklist
53. The nurse is caring for clients on a surgical unit. Which client
should the nurse assess first?
A. The client who is 1 day postoperative mastectomy who has
a Reach to Recovery volunteer coming to see her
B. The client who is 8 hours postoperative splenectomy who
is complaining of abdominal pain of 5 on the scale of 1-10
C. The client who is 12 hours postoperative adrenalectomy
who has vomited 100 mL of dark green bile
D. The client who is 2 days postoperative hiatal hernia repair
who is complaining of chest pain radiating down the left
arm
54. Which information should the holding area nurse report to the
operating room team?
A. The client has a permanent bridge in the back of the mouth
B. The client reports being made to go without water since
last night
C. The client states smoking two packs of cigarettes a day for
years
D. The client has had a chest X-ray showing no infiltrates
55. A nurse is developing a plan of care for a preoperative client
who has a latex allergy. Which intervention should be included
in the plan?
A. Avoid using medication from glass ampules
B. Avoid using IV tubing that is made of polyvinyl chloride
C. Use medication that are from ampules with rubber
droppers
D. Apply cloth barrier to the client’s arm under a blood
pressure cuff when taking blood pressure
Situation 12 – Almost every cancer type has been shown to
run in families. This may be due to genetics, shared
environments, cultural or lifestyle factors or chance alone.
The following questions apply.
56. You are assigned at a nearby senior citizen center. The
facilitators of the program requested you to teach the
participants regarding the warning manifestations of cancer.
Which of the following should you include in your discussion
outline?
A. Limit dietary fat
B. Smoking cessation
C. Breast-self exam performed every month
D. Avoid sun exposure
57. Natalia, 10 years old, is admitted in the Oncology Unit with a
diagnosis of Acute Leukemia. Which of the following is most
important for the nurse to ask the parents of Natalia?
A. “Have Natalia experienced any respiratory infection in the
last 6 months?”
B. “Have you noticed any changes in the sleeping patterns of
Natalia recently?”
C. “Has Natalia lost weight recently?”
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 D. “Have you notice any changes in the alertness of your
daughter?”
58. Which of the following clinical data would the nurse most expect
to find in the history of a client suspected of cervical cancer?
A. Foul smelling vaginal discharge
B. Post-coital vaginal bleeding
C. Nausea and vomiting
D. Elevated body temperature
59. Who among the following clients is most likely to be diagnosed
with Colon cancer?
A. Michael who has one soft brown stool every morning
B. Marie who reports having clay-colored stools
C. Joy who observed blood in her stool
D. Cleofe who described her stool as fatty looking
60. Which of the following factors can contribute to the development
of Bladder cancer?
A. A history of nephrolithiasis
B. Cigarette smoking of two packs per day for almost 24 years
C. Employment in the textile industry
D. Frequent complaints of urinary tract infections
Situation 13 – Nurse Dawson is an oncology nurse in a
special training hospital which caters to a wide variety of
cancer patients. He received special trainings in caring for
patients receiving cancer treatments.
61. Upon reading the chart of a patient, Nurse Dawson noted that
the physician ordered a cell-cycle-specific chemotherapeutic
agent. Which of the following is included in this type of
chemotherapeutic agent?
A. Nitrogen mustard
B. Doxorubicin (Doxil)
C. Methotrexate
D. Cyclophosphamide (Cytoxan)
62. The patient developed neutropenia as a complication of her
chemotherapy. Which intervention would be most appropriate
for Nurse Dawson to include in the patient’s plan of care?
A. Instruct the client to avoid large crowds and people who
have known diseases
B. Encourage patient to use soft-bristled toothbrush when
performing oral care
C. Regularly assess urine of the patient for hematuria
D. Offer assistance to the patient when moving around
63. Nurse Dawson is preparing the client for the insertion of a
cervical-uterine radiation implant. He should not include the
following in the patient’s teaching plan, EXCEPT:
A. Excretions will be considered radioactive so be careful
when flushing the toilet
B. TV or mobile phone use will be prohibited while the implant
is in place
C. Expect a foley catheter to be inserted
D. A high fiber diet is recommended while on this treatment
64. Johana is receiving radiation therapy on her right breast. Nurse
Dawson’s teaching plan related to skin care should include
which of the following measures?
A. Apply ointment on the broken skin before each radiation
treatment
B. Thoroughly clean the skin each day to remove ointments
and markings on the area
C. Protect the breast area from direct sunlight
D. Wear brassiere at all times to support the breasts
65. Nurse Dawson is caring for a client following a radical 72. For a comprehensive AIDS prevention activities, the following
mastectomy. To prevent lymph edema of the affected arm,
Nurse Dawson can perform which of the following interventions?
A. Apply cold compress on the affected arm
B. Avoiding arm exercises in the immediate postoperative
period
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098/735-0740
C. Elevate the affected arm on a pillow higher than the level of
the heart
D. Maintaining an IV site below the antecubital area of the
affected side
Situation 14 – Dysfunctions involving the immune system
occur across the life span. Many are genetically based; others
are acquired. The nurse has been caring for patients with
autoimmune disorders and disorders that involve the
immunologic system. The following questions apply.
66. The nurse cares for a patient diagnosed with autoimmune
thrombocytopenia purpura. Which of the following nursing goals
is a priority when caring for this patient?
A. Risk for Injury
B. Risk for Infection
C. Potential for Fluid volume deficit
D. Risk for Sensory perceptual alterations
67. For a client diagnosed with Idiopathic thrombocytopenic purpura
(ITP), which nursing intervention is appropriate?
A. Teaching coughing and deep breathing techniques to help
prevent infection
B. Administering platelets, as ordered, to maintain an
adequate platelet count
C. Giving aspirin, as prescribed, to control body temperature
D. Administering stool softeners, as ordered, to prevent
straining during defecation
68. Which of the following is an indication that your patient may be
suffering from Systemic Lupus Erythematosus?
A. Dysphagia and hoarseness of the voice
B. A low-grade fever, arthralgia and a facial rash
C. A bronze suntan from a recent trip to Boracay
D. Ascending body weakness
69. Ms. Carreon 36 years old is diagnosed with an Acute
Exacerbation of Systemic Lupus Erythematosus and is
prescribed with high dose steroids. Which of the following client
statement signifies an effective teaching?
A. “I must report to my doctor if my face is becoming round”
B. “I’ll take my medicine on an empty stomach”
C. “I will stop taking my drug if I notice a weight gain of 2-3
pounds”
D. “I must taper off the drug when they are ordered to be
discontinued”
70. The most important goal for clients experiencing Systemic
Lupus Erythematosus is:
A. Prevention of skin breakdown
B. Ability to maintain reproductive ability
C. Verbalization of feelings regarding changes in body image
D. Body organs will remain functioning
Situation 15 – The incidence rate of AIDS cases in the world
has been steadily increasing the past years. This pandemic
has been one of the focuses of various researches.
71. A client with acquired immunodeficiency syndrome (AIDS) is
being admitted to the hospital for treatment of Pneumocystis
jiroveci infection. Which of the following activities does the nurse
plan to include in the care of this client that assists in
maintaining comfort?
A. Monitor vital signs
B. Evaluate arterial blood gas results
C. Keep the head of the bed elevated
D. Assess respiratory rate, rhythm, depth and breath sounds
factors should be included, EXCEPT:
A. Risk-reduction behaviors
B. Education
C. Universal precautions
D. Reverse or protective isolation
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73. The following clusters of body fluids can transmit the highest
percentage of the HIV virus:
A. Blood, serum, saliva
B. Semen, cervical discharges, blood
C. Blood, semen, tears
D. Semen, virus, breastmilk
74. AIDS is characterized by affliction with different opportunistic
infections all in one time. Which of the following groups of
disease does not belong to these infections:
A. Oral hairy Leukoplakia
B. Tuberculosis and PCP
C. Chicken pox
D. Herpes simplex and candidiasis
75. Isolation techniques that are indicated for HIV patients include
the following:
i. Strict isolation
ii. Reverse isolation
iii. Respiratory isolation
iv. Blood and fluids precaution
A. i, iii C. i, iv
B. ii, iv D. ii, iii
Situation 16 – Nursing care associated to neurological
problems is geared towards alleviation of suffering and health
restoration.
76. The nurse is assessing the client experiencing a left-sided
cerebrovascular accident (CVA). Which clinical manifestations
would the nurse expect the client to exhibit?
A. Hemiparesis of the left arm and apraxia
B. Paralysis of the right side of the body and aphasia
C. Inability to recognize and use familiar objects
D. Impulsive behavior and hostility towards family
77. The client with increased intracranial pressure is receiving
Mannitol (Osmitrol), an osmotic diuretic. Which intervention
should the nurse implement?
A. Monitor the client’s complete blood cell count
B. Do not administer the drug if the client’s apical pulse less
than 60bpm
C. Advise patient to consume potassium-rich foods.
D. Use a filter needle when administering the medication
78. The male client with a C6 SCI tells the home health nurse he
has had a severe pounding headache for the last 2 hours.
Which intervention should the clinic nurse implement?
A. Determine when and how much the client last urinated
B. Ask the client if he has taken any medication for the
headache
C. Inquire when the client had his last bowel movement
D. Check the client’s respiratory rate reading immediately
79. The client diagnosed with a seizure disorder is prescribed with
Phenytoin (Dilantin), an anticonvulsant. Which statement
indicates the client needs more teaching concerning this
medication?
A. “I will brush my teeth after every meal.”
B. “I will get my Dilantin level checked regularly.”
C. “My urine will turn orange while on Dilantin.”
D. “This medication will prevent my seizures.”
80. In addition to development over a period of hours or days, the
nurse would assess delirium as distinguishable by which of the
following characteristics?
A. Disturbances in cognition and consciousness that fluctuate
during the day
B. The failure to identify objects despite intact sensory
functions 87. The nurse is assisting the EMT at the scene of a vehicular
accident along EDSA. A young man was injured when his
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098/735-0740
C. Significant impairment in social or occupational functioning
over time
D. Memory impairment to the degree of being called amnesia
Situation 17 – The term emergency management traditionally
refers to care given to patients with urgent and critical needs.
The emergency nurse has had specialized education, training,
experience, and expertise in assessing and identifying
patients’ health care problems in crisis situations. Nurse
Lerman has been assigned in the Emergency Department of
the facility.
81. Considering the conditions of the clients below, who should
Nurse Lerman assess first?
A. Ejay, a 55-year old grade school teacher with hypertension
who has an occipital headache
B. Nerry, 10 years old, who has a compound fracture of the
right arm after falling from a swing
C. Prince, an adolescent, who has a pencil sticking out of his
eye after a fight with his seatmate
D. Vanessa, 35 years old, who accidentally spilled hot grease
on her leg
82. During a swimming competition, a 28-year old male participant
incurred a diving accident. He was rushed into the Emergency
Department by an ambulance, intubated on a backboard with a
cervical collar. Upon arrival on the ED, Nurse Lerman should
prioritize which action?
A. Assessment of the neurologic status using GCS
B. Insert a large bore IV line
C. Monitor vital signs
D. Auscultate lungs for equality of breath sounds
83. A client admitted at the ICU had an arrest. The supervising
nurse called for a code to manage the situation. Which of the
following is considered as the primary responsibility of the
supervising nurse during a code?
A. Accompany family members out of the room
B. Record pertinent data regarding the code
C. Making sure that members of the code team are
performing their roles properly
D. Notify the client’s physician about the situation
84. A nearby six-floor building suddenly collapsed and the
Emergency Department of the facility where you are currently
working received an endorsement of the injured victims. As the
charge nurse of the department, which action should you
implement first?
A. Notify the supervisor of the incident
B. Contact nurses who are off duty to report to work for
additional manpower
C. Inform the blood bank to report the incident
D. Give orders to the staff to check the available supplies in
the department
85. Which assessment data is typical for a client experiencing
neurogenic shock?
A. Urine specific gravity of 1.001
B. Apical pulse of 53 bpm
C. Cold and clammy skin
D. Bilateral wheezing upon auscultation
Situation 18 – Critical care nurses are in a unique position to
participate in all aspects of disaster response including triage,
stabilization, definitive care, and evacuation. The following
situations pertain to disaster nursing.
86. Among the clients, who will receive a black tag?
A. A client with hard and distended abdomen
B. A client complaining of paresthesia in the left lower leg
C. A client exhibiting a decerebrate posturing
D. A client who has a possible L1-L2 spinal cord injury
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 motorcycle was hit by a car. He fell off the motorcycle and it fell
back on his legs. He is bleeding profusely from a 5 inch-wound
on his left thigh. Which of the following is the best approach for
the nurse to take to control the bleeding?
A. Apply direct pressure on the wound
B. Remove the motorcycle off his legs
C. Elevate the affected extremity
D. Place a tourniquet above the wound
88. A Critical Incident Stress Management Session will be required
in which of the following situations?
A. A police officer who has a gunshot wound in the abdomen
acquired in the line of duty
B. A school bus set for a field trip incurred an accident at a
bridge which resulted in 20 hospital admissions and 21
deaths
C. A preschooler was admitted at the ICU due to an accidental
lead poisoning
D. An adolescent died after ingesting significant amounts of
sleeping pills
89. Milagrosa, 20 years old, is being treated in the Emergency
Department after a rape incident. A short-term goal for this client
would be to:
A. Facilitate social interaction with friends and co-workers
B. Express openly feelings about the incident
C. Verbalize at least two methods of stress management
D. Return to pre-trauma level of functioning
90. The primary goal of the nurse who is caring for a client who has
ingested a poison should be which of the following?
A. To halt action of the poison and maintain organ functioning
B. To implement treatment geared towards elimination of the
poison
C. To determine client’s reason for ingesting the poisonous
substance
D. To document actions taken to manage the client’s condition
Situation 19 – Care for patients who suffered from burn injury
requires technical skill and knowledge, prudence, and
conscientious actions. The following questions pertain to care
for clients with burn.
91. A client is due in hydrotherapy for a burn dressing change. To
ensure that the procedure is most tolerable for the client, the
nurse takes which of the following actions?
A. Ensures that the client has a robe and slippers
B. Administers an analgesic 20 minutes before therapy
C. Sends dressing supplied with the client to hydrotherapy
D. Administers the intravenous antibiotic 30 minutes before
therapy
92. Skin closure with a heterograft is performed on a client with burn
injuries. The client asks the nurse about this type of graft. The
nurse bases the response on the knowledge that a heterograft
can be best described as:
A. Skin from a cadaver
B. Skin from another species
C. Skin from a skin bank
D. Skin from burned client
93. A client with burns is progressing through the emergent/
resuscitative phase of burn care into the acute stage. Which of
the following is a priority for nursing care during the acute phase
of burns?
A. Care for the burn wounds
B. Promote the client coping with altered body image
C. Restore maximal functional ability
D. Prevent hypothermia
94. Mr. T’s burns include the face and neck, whole anterior trunk
and anterior surfaces of both upper arms. Using the rule of nine,
what is the TBSA?
A. 27% C. 31.5%
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098/735-0740
B. 31% D. 27.5%
95. A client has been admitted to the burn unit with extensive full
thickness burns. Which of the following considerations has
priority?
A. Fluid status C. Level of pain
Body image D. Risk for infection
Situation 20 – The health and proper functioning of the
musculoskeletal system is interdependent with that of the
other body systems. You are a newly hired staff nurse at the
Regional Hospital. You are assigned at the Orthopedic Ward
where you meet patients with various musculoskeletal
conditions. The following questions apply.
96. Which of the following is a typical finding for a client diagnosed
with osteoarthritis (OA)?
A. Severe bone deformity in the lower extremities
B. Joint stiffness in the morning
C. Enlarged joint space seen on x-rays
D. Elevated temperature at night
97. The nurse is discussing the importance of an exercise program
for pain control with a client diagnosed with OA. Which
information should the nurse include in the teaching plan?
i. Wear supportive walking shoes with white socks when
walking
ii. Carry a complex carbohydrate to eat while exercising
iii. Alternate walking briskly and jogging when exercising
iv. Be sure to ambulate at least 20-30 minutes everyday
v. Instruct to use a walker when ambulating if unsteady
or weak
A. i, iv, v C. i, iii, v
B. i, ii, v D. i, iii, iv
98. Mr. Heberdens complains of severe pain and edema in the right
foot. The physician diagnosed him of having Gouty arthritis.
When caring for Mr. Heberdens, which of the following should
receive the highest priority when developing a plan of care?
A. Apply hot compress to the affected joints
B. Emphasize the importance of maintaining good posture to
prevent deformities
C. Prepare to administer salicylates to minimize the
inflammatory reaction
D. Ensure an intake of at least 3000 ml of fluid per day
99. The client in balanced suspension traction is transported to the
operating room for closed reduction and internal fixation of his
fractured femur. Which of the following would the nurse perform
when transporting the client to the operating room?
A. Assist the client to the bed with extra help and place him on
a gurney
B. Transfer the client to a gurney with manually suspended
traction
C. Call the surgeon to request an order for a temporary
removal of the traction
D. Remove the traction and place the client on a gurney
100.Mrs. Carmencita has a Pearson attachment on the traction
setup. You know that the purpose of a Pearson attachment is
which of the following?
A. It supports the lower portion of the leg
B. It supports the thigh and the upper leg
C. It prevents flexion deformities in the ankle and foot
D. It allows attachment of the skeletal pin
-END-
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“Believe you Can and
you’re halfway
there.”

DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098/735-0740 -8-