1. Physical Assessment
2. Roles of Nurses
3. Prioritization of Needs (Critical Thinking)
4. Development Assessment
The test set is randomly designed in such a way that it includes easy questions as well as difficult questions. Please choose the best answer
1. A 28-month-old child with severe diarrhea is admitted. Upon assessment, the child is feverish, has dry lips, and irritable. What is your first nursing priority upon admission?
a. Asses the hydration status
b. Assess the skin turgor
c. Obtain the apical-radial cardiac rate
d. Weigh the child
2. You were assigned to a patient. Upon assessment, the patient elicited Homan’s sign. What is the nursing priority using this assessment?
a. Encourage fluid and electrolyte balance
b. Encourage good venous circulation
c. Secure patent airway
d. Promote skincare
3. You were assigned to a patient with a nasogastric tube attached for almost three days. It is time to irrigate it, what is the protocol that you will follow?
a. A 30 mL sterile saline must be forcefully instilled and provide a basin to catch the return flow.
b. A 20 mL sterile saline must be gently instilled and provide a basin to catch the return flow.
c. Instill 30 mL sterile water and then withdraw solution.
d. Gently instill 20 mL normal saline and then withdraw solution.
4. A nurse therapeutically responds to a patient with AIDS when he expressed feelings of depression and facing death with the following phrase: “Are you afraid of dying?” What type of therapeutic technique is she using?
a. Using open-ended question
b. Using a close-ended question
c. Using a leading question
5. What role does a nurse exhibits if she stands to protect the needs and wishes of the patient?
d. Client advocate
6. A post appendectomy patient is assigned to you. You have assessed him that he needs more knowledge about proper wound care. What role should you apply in this situation?
a. Role Model
7. While on your night rounds, you have noticed two nursing aides placing bed sheets that they have taken from the floor. What is the proper nursing action?
a. Confront the two nursing aides about their and actions and call them for private counseling
b. Continue your night rounds, they have their own liabilities on their actions.
c. Remind them the principle of medical asepsis
d. Provide a clothes basket for them
8. In a burn patient, in order to promote adequate fluid within 24 hours, what intravenous fluid is appropriate?
a. D5 Water
b. Lactated Ringer’s Solution
c. 0.9% NaCl Solution
9. Being assigned in a pediatric ward, what is the characteristic sign of a normal psychosocial development of a toddler?
a. Erikson’s stage of initiative vs. guilt
b. Imaginary playmates.
c. Negative behavior
d. Demonstrations of sexual curiosity.
10. Defining stress, all of the following describes its characteristics except:
a. Stress response is natural, productive and adaptive
b. Stress is not always a result of damage to the body
c. Stress always results in a feeling of distress
d. Stress involves the entire body as a whole
11. A one-year-old child is admitted. Looking into the physical development of the child, what will be affected or may have a delay?
12. A mother is concerned about the diet of her child that has noncomplicated acute glomerulonephritis. What is the appropriate diet regimen you must teach as a nurse?
a. Low-protein, low-potassium diet.
b. Regular diet, no added salt.
c. Low-sodium, low-protein diet.
d. Low-sodium, high-protein diet.
13. A patient is on Respiratory Isolation for Tuberculosis (TB). Which of the following would be an indicator for the removal of Isolation Precautions?
a. Sputum Culture is negative for AFB, following a course of INH and PAS
b. Patient has been on Anti-Tubercular Drug Therapy with INH for one month’s time
c. Patient has no infiltrates on chest x-ray
d. Absence of adventitious breath sounds
14.A client is diagnosed to have Congestive Heart Failure. Upon auscultating the client’s lungs the nurse hears crackling sounds bilaterally at the bases. What term should you use in documenting this finding?
15. Which of the following response of a 10-year-old patient with acute appendicitis is an alarming sign?
a. “My pain has gone away.”
b. “I am afraid to have surgery.”
c. “I feel hot and thirsty.”
d. “I feel better with my legs up towards my chest
16. A nurse assigned to a child with Acute Glomerulonephritis is picking up doctor’s orders to put in the Kardex. Which of the orders should the nurse question?
a. Bed rest
b. Daily weights
c. Daily blood pressure
d. Strict I & O
17. Which of the following is an INCORRECT statement regarding diet therapy for a patient in renal failure?
a. Limit dietary protein
b. Provide a diet high in carbohydrates
c. Limit Sodium (NA) intake
d. Provide a diet high in Potassium rich food
18. You are assigned to speak to a group of High School students about HIV and AIDS. In discussing transmission the nurse knows that the highest concentration of the HIV virus in infected patients is in the:
b. Cerebrospinal Fluid
19. In teaching HIV in high school students, what is the appropriate health practice that the nurse should emphasize?
a. Wash with antibacterial soap immediately after intercourse.
b. Use a latex condom and water-soluble during intercourse
c. After oral sex, use anti-bacterial mouth wash to destroy the HIV virus
d. Abstain from intercourse if the female partner is having her menstrual period.
20. Which of the following is appropriate in a depressed patient?
a. Using silence
b. Passive Friendliness
c. Using open-ended questions
d. Giving information
21. In a geriatric unit, you have noticed that one patient seemed to change his behavior. Which of the following symptoms DOES NOT indicate that the patient is going into depression?
a. Being talkative
c. Complains of getting tired easily
d. Change in appetite
22. In admitting an elderly patients, it is a nurse’s goal to orient the patient. What is the effective nursing action in order to prevent disorientation?
a. Secure the side rails up all the time
b. Do routine rounds
c. Leave a night light
d. Orient the patient every night before he or she sleeps
23. What is the proper order in the physical assessment when it comes to the examination of the abdomen?
a. Auscultation, Inspection, Percussion, Palpation
b. Inspection, Auscultation, Percussion, Palpation
c. Palpation, Percussion, Inspection, Auscultation
d. Inspection, Percussion, Palpation, Auscultation
24. In assessing the cranial nerve function, a nurse finds out that a patient has a difficulty in determining the different scents when the eyes is closed. Which of the following cranial nerve had a problem?
a. CN III
b. CN II
c. CN I
d. CN V
25. In examining a patient with asthma in exacerbation, what lung sound is predominant?
b. Pleural rub
Question number 19 should be letter B. It is stated in your rationale, Ms. Ira Hope. Please change the answer so there’d be no confusion.
In question number 4, the answer should be letter B. “ Are you afraid of dying?” Is a close-ended question.