Situation 1 - Because of the serious consequences of severe burns management requires a multi disciplinary approach.

You have important responsibilities as a nurse.

1. While Sergio was lighting a barbecue grill with a lighter fluid, his shirt burst into flames. The most effective way
to extinguish the flames with as little further damage as possible is to:
a. log roll on the grass/ground
b. slap the flames with his hands
c. remove the burning clothes
d. pour cold liquid over the flames

CORRECT ANSWER: A
RATIONALE: Stop, drop and roll is a simple fire safety technique taught to children, emergency services
personnel and industrial workers as a component of health and safety training. Primarily, it is a method to
extinguish a fire on a person's clothes or hair without, or in addition to, the use of conventional firefighting
equipment.
In addition to extinguishing the fire, stop, drop and roll is an effective psychological tool, providing those in a fire
situation, particularly children, with a routine that can be used to focus on in order to avoid panic.
Stop, drop and roll consists of three components.
 Stop - The fire victim must stop still. Ceasing any movement which may fan the flames or hamper those
attempting to put the fire out.
 Drop - The fire victim must 'drop' to the ground, lying down if possible.
 Roll - The fire victim must roll on the ground in an effort to extinguish the fire by depriving it of oxygen. If
the victim is on a rug or one is nearby, they can roll the rug around themselves to further extinguish the
flame.
The effectiveness of stop, drop and roll may be further enhanced by combining it with other firefighting
techniques,including the use of a fire extinguisher, dousing with water, or fire beating.

2. Once the flames are extinguished, it is most important to:

a. cover Sergio with a warm blanket
b. give him sips of water
c. calculate the extent of his burns
d. assess Sergio's breathing

CORRECT ANSWER: D
RATIONALE: Thermal burns are caused by exposure to flames, hot liquids, steam or hot objects. Like this one, 1 st
priority should go to the assessment of breathing if there are no airway problems, possibility of inhalation of the
smoke from the flames may cause smoke poisoning from by products of combustion. A localized inflammatory
reaction may occur, causing a decrease in bronchial ciliary action and a decrease in surfactant. A compromised
breathing may later on lead to respiratory complications. Assess for mucosal edema in the airways, after several
hours, sloughing of the tracheobronchial epithelium may occur, and hemorrhagic bronchitis may develop, ARDS
can result.(Source: Saunders Comprehensive Review for the NCLEX-RN exam 3rd Edition, p. 545)
OPTION A: covering Sergio with a warm blanket will not benefit the situation since it can only increase heat and
compromise comfort that should be provided for Sergio.
OPTION B: Although giving sips of water may help in the drying of the mucosa of the patient, it is first essential to
assess the airway and breathing of the patient as mucosal edema may be present and sips of water may result to
aspiration.
OPTION C: Calculating the extent of the burn may be done after assessment of the ABC’s which is very essential
in providing care to the patient.

3. Sergio is brought to the Emergency Room after the barbecue grill accident. Based on the assessment of the
physician, Sergio sustained superficial partial thickness bums on his trunk, right upper extremities ad right
lower extremities. His wife asks what that means. Your most accurate response would be:
a. Structures beneath the skin are damaged
b. Dermis is partially damaged
c. Epidermis and dermis are both damaged
d. Epidermis is damaged

CORRECT ANSWER: D
RATIONALE: Superficial partial thickness: These burns are superficial with injury to the epidermis. These are first-
degree burns and are characterized by erythema, edema, and pain; slight fluid loss, especially if less than 15% of
the body is involved. Superficial partial-thickness burns heal spontaneously within 2-3 weeks, usually without
scarring. Injured area is sensitive to cold air. Grafts may be used if healing process is prolonged.
SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 rd edition,p. 544)
OPTION A: is true for Deep Full-thickness burns as it involves injury to the muscle and bone.
OPTION B: is true for Deep Partial-thickness burns as it involves the epidermis and superficial dermis causing
erythema, pain, vesicles with oozing; fluid loss slight to moderate.
OPTION C: is true for Full-thickness (3rd Degree) burn affects the epidermis, entire dermis and at times the
subcutaneous tissue, resulting in charred or pearly white, dry skin and absence of pain; fluid loss usually severe,
especially if more than 2% of body surface is involved.
(SOURCE: Mosby Comprehensive Review of Nursing for the NCLEX-RN exam 18 th edition, p. 169.)

4. During the first 24 hours after thermal injury, you should assess Sergio for
a. hypokalemia and hypernatremia
b. hypokalemia and hyponatremia
 c. hyperkalemia and hyponatremia
d. hyperkalemia and Hypernatremia

CORRECT ANSWER: C
RATIONALE: Hyperkalemia can also result from injury to muscle or other tissues. Since most of the potassium in
the body is contained in muscle, a severe trauma that crushes muscle cells results in an immediate increase in
the concentration of potassium in the blood. Hyperkalemia result from severe burns for the 1 st 24 hours.
Hyponatremia in burns occur due to low plasma osmolarity.
(SOURCE: Silvestri Saunders Online Review Course,Fluid and Electrolyte Imbalance, p. 18)

5. Teddy, 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 Teddy is developing:
a. Cerebral hypoxia
b. Hypervolemia
c. Metabolic acidosis
d. Renal failure .

CORRECT ANSWER: A
RATIONALE: Rarely do burn-injured clients suffer neurologic damage. The client with a major burn injury is most
often awake and alert on admission to the hospital. If alteration in level of consciousness manifests, the client may
be suffering from hypoxemia or hypovolemia and needs further assessment for identifying the origin of these
changes. It is most often related to impaired perfusion to the brain, hypoxia/hypoxemia (as in a closed space fire),
inhalation injury (as from exposure to asphyxiate or other toxic materials from the fire). Major burn injuries that
may cause severe fluid loss can lead to a decrease in blood pressure, causing decreased cerebral perfusion,
followed by impaired oxygenation to the brain. Neurologic manifestations may include headache, dizziness,
memory loss, confusion or loss of consciousness, disorientation, visual changes, hallucinations, combativeness
and coma.
(SOURCE: Med.-Surg. Nsg. By Black and Hawk 7th edition, vol.2, p.1441

Situation 2 - You are now working as a staff nurse in a general hospital. You have to be prepared to handle situations with
ethico-legal and moral implications.

6. You are on night duty in the surgical ward. One of our patients Martin is prisoner who sustained an
abdominal gunshot wound. He is being guarded by policemen from the local police unit. During your rounds
you heard a commotion. You saw the policeman trying to hit Martin. You asked why he was trying to hurt Martin.
He denied the matter. Which among the following activities will you do first?
a. Write an incident report
b. Call security officer and report the incident
c. Call your nurse supervisor and report the incident:
d. Call the physician on duty

CORRECT ANSWER: A
RATIONALE: The incident report is used as a means of identifying risk situations and improving client care.
Specific documentation guidelines are followed in completion of the incident report. The criteria’s to formulating an
incident report are as follows:
 Accidental omission of ordered therapies
 Circumstances that led to injury or a risk for client injury
 Client falls
 Medication administration errors
 Needlestick injuries
 Procedure-related or equipment-related accidents
 A visitor having symptoms of an illness
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 rd edition, p. 57)

7. The nurse gives an inaccurate dose of a medication to a client. Following assessment of the client, the
nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls
the physician to report the occurrence. The nurse who administered the inaccurate medication dose
understands that the:
a. error will result in suspension
b. incident report is a method of promoting quality care and risk management
c. incident will be reported to the board of nursing
d. incident will be documented in the personnel file.

CORRECT ANSWER: B
RATIONALE: Documentation of unusual occurrences, incidents, and accidents and the nursing actions taken as a
result of the occurrence is internal to the institution or agency and allows the nurse and administration to review
the quality of care and determine any potential risks present. Based on the information provided in the question,
the nurse’s error will not result in suspension nor will it be documented in the personnel file. The situation and the
error presented in the question are not a reason for notifying the board of nursing.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 rd edition, p. 62)

8. The nurse hears a client call for help. The nurse hurries down the hallway to the client’s room and finds the client
lying on the floor. The nurse performs a thorough assessment and assists the client back to bed. The nurse
 notifies the physician of the incident and completes an incident report. Which of the following would the nurse
document on the incident report?
a. the client was found lying on the floor
b. the client climbed over the side rails
c. the client fell out of bed
d. the client became restless and tired to get out of bed

CORRECT ANSWER: A
RATIONALE: The incident report should contain the client’s name, age, and diagnosis. The report should contain
a factual description of the incident, any injury experienced by those involved, and the outcome of the situation.
Option A is the only option that describes the facts as observed by the nurse. Options B, C, and D are
interpretations of the situation and not factual data as observed by the nurse.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 rd edition, p. 63)

9. You are on duty in the medical ward. The mother of your patient who is also a nurse came running to the
nurse station and informed you that Fiolo went into cardiopulmonary arrest. Which among the following will you do
first?
a. Start basic life support measures
b. Call for the Code
c. Bring the crash cart to the room
d. Go to see Fiolo and assess for airway patency and breathing problems

CORRECT ANSWER: D
RATIONALE: The purpose of primary assessment in cardiopulmonary arrest is to immediately identify any client
problem that poses a threat, what could have caused the arrest. Airway clearance and breathing should be
assured before anything else after which, immediate interventions such as CPR and advanced life support must
be instituted to aid in preserving the client’s life.
OPTIONS A-C: these are the following interventions that are done after a primary assessment of the ABC’s had
been made.
(SOURCE: Med.-Surg. Nursing by Black and Hawk, 7th edition, vol.2, p.2485)

10. A client is brought to the emergency medical services after being hit by a car. The name of the client is
not known. The client has sustained a severe head injury, multiple fractures, and is unconscious. An emergency
craniotomy is required. Regarding informed consent for the surgical procedure, which of the following is the best
action?
a. call the police to identify the client and locate the family
b. obtain a court order for the surgical procedure.
c. ask the emergency medical services team to sign the informed consent
d. transport the victim to the operating room for surgery

CORRECT ANSWER: D
RATIONALE: Generally, in only 2 instances is an informed consent of an adult client not needed. One instance is
when an emergency is present and delaying treatment for the purpose of obtaining an informed consent would
result in injury or death o the client. The 2 nd instance is when the client waives the right to give informed consent.
OPTION 2, will delay emergency treatment and option 3 is inappropriate. Although option 1 may be pursued, it is
not the best action.

Situation 3 - Colorectal cancer can affect old and younger people. Surgical procedures and other modes of treatment are
done to ensure quality of life. You are assigned in the Cancer institute to care of patients with this type of cancer.

11. Larry, 55 years old, who is suspected of having colorectal cancer, is admitted to the CI. After taking the history
and vital signs the physician does which test as a screening test for colorectal cancer.
a. Barium enema
b. Carcinoembryonic antigen
c. Annual digital rectal examination
d. Proctosigmoidoscopy

CORRECT ANSWER: C
RATIONALE: Early detection through routine screening is the key to decreasing mortality. It is recommended that
people with an average risk for colon cancer be screened annually for digital rectal examinations and Fecal occult
blood tests begin at 40 years of age withy sigmoidoscopy every 3-5 years beginning at 50 years of age.

12. To confirm his impression of colorectal cancer, Larry will require which diagnostic study?
a. carcinoembryonic antigen
b. incisional biopsy of the colon
c. stool hematologic test
d. abdominal computed tomography (CT) test

CORRECT ANSWER: B
Rationale: Incisional biopsy; a selected part of the lesion is removed. This form of biopsy is commonly completed
During endoscopic examination. The Frozen Method procedure is used to assess for malignant cells from tissue
samples. Frozen sections are used for rapid microscopic diagnosis. A thin slice of tissue is cut from the frozen
specimen and examined. The procedure requires 10-15 minutes. The pathologist can determine whether
malignancy is present and whether the entire tumor has been removed by looking for a margin of tumor-free
tissue.
 SOURCE: Med.-Surg. Nsg. By Black and Hawk 7th edition, Vol.1, p. 106)

13. The following are risk factors for colorectal cancer, EXCEPT:
a. inflammatory bowels
b. low fat, high fiber diet
c. smoking
d. genetic factors-familial adenomatous polyposis

CORRECT ANSWER: B
RATIONALE: Epidemiologic studies indicate that diet may be a major factor in the development of cancer of the
large bowel. Studies on bulk in stool and the rate of transit of fecal matter have so far given mixed results. Some
researchers propose that metabolic and bacterial end products are carcinogenic and that constipation allows a
longer contact with the bowel wall, thus raising the probability that cancer will develop. Increasing fiber in the diet
may reduce exposure to carcinogens by speeding stool transit through the intestines.
(SOURCE: Med-Surg. Nsg Black and Hawk 7th edition, Vol.1 p. 831)

14. Symptoms associated with cancer of the colon include:

a. constipation, ascites and mucus in the stool
b. diarrhea, heartburn and eructation
c. blood in the stools, anemia, and pencil-shaped, stools
d. anorexia, hematemesis, and increased peristalsis

CORRECT ANSWER: C
RATIONALE: Symptoms include the following: Blood in stools, anorexia, vomiting, and weight loss, malaise,
Anemia, abnormal stools. Ascending colon tumor: Diarrhea, Descending Colon tumor: constipation or some
diarrhea, or flat, ribbon-like stool resulting from a partial obstruction. Rectal Tumor: alternating constipation and
diarrhea, guarding or abdominal distention, abdominal mass (a late sign), Cachexia (a late sign). (source:
Saunders Comprehensive Review for the NCLEX-RN exam, 3rd Edition, p.592)

15. Several days prior to bowel surgery, Larry may be given sulfasuxidine and neomycin primarily to:
a. promote rest of the bowel by minimizing peristalsis
b. reduce the bacterial content of the colon
c. empty the bowel of solid waste
d. soften the stool by retaining water in the colon

CORRECT ANSWER: B
RATIONALE: Sulfasuxidine/sulfadiazine is a type of Sulfa drug, primarily for the treatment of asymptomatic
mengococcal carrier, can be used as alternative for penicillin in rheumatic fever. Neomycin, kanamycin sulfate,
erythromycin, & succinylsulfathiazole (Sulfasuxidine) are used pre-operatively to reduce bacterial number in the
GI tract. (Source: Nursing Drug Handbook 2006, 26 th Edition, p. 131) Sulfasuxidine and other antiseptics and
antibiotics, as prescribed to decrease the bacterial content of the colon to reduce the risk of infection from the
surgical procedure.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 rd edition, p. 592)

Situation 4 - ENTEROSTOMAL THERAPY is now considered especially in nursing. You are participating in the OSTOMY
CARE CLASS.

16. You plan to teach Fermin how to irrigate the colostomy when:
a. The perineal wound heals and Fermin can sit comfortably on the commode
b. Fermin can lie on the side comfortably, about the 3rd postoperative day
c. The abdominal incision is close and contamination is no longer a danger
d. The stool starts to become formed, around the 7th postoperative day

CORRECT ANSWER: C
RATIONALE: Carefully assess the client’s physical condition, emotional and mental attitudes toward the
colostomy before attempting to teach ostomy self-care. Pace the teaching to the client’s level of acceptance of the
colostomy and ability to manage it. Teach the client how to apply the pouch to the stoma correctly. The client first
should be taught how to examine the stoma. A healthy stoma and abdominal incision is a very good indicator that
client is now ready for ostomy care teaching.
(SOURCE: Med-Surg. Nsg. by Black and Hawk, 7th edition, vol.1, p. 837)

17. When preparing to teach Fermin how to irrigate his 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. After breakfast
d. After Fermin accepts alteration in body image

CORRECT ANSWER: C
RATIONALE: A suitable time for the irrigation is selected that is compatible with the patient’s posthospital pattern
of activity (preferably after a meal). Irrigation should be performed at the same time each day.
(SOURCE: Brunner and Suddarth’s Med. Surg. Nursing, 10 th Edition Vol. 1, p. 1064)

18. When observing a rectum demonstration of colostomy irrigation, you know that more teaching is
required if Fermin:
a. Lubricates the tip of the catheter prior to inserting into the stoma
 b. Hands the irrigating bag on the bathroom door doth hook during fluid insertion
c. Discontinues the insertion of fluid after only 500 ml of fluid had been insertion
d. Clamps off the flow of fluid when feeling uncomfortable

CORRECT ANSWER: C
RATIONALE: Although 300 mL of fluid may be all that is needed to stimulate evacuation, Volume may be
increased with subsequent irrigations to 500, 1000, up to 1, 500 mL as needed by the patient for effective results.
Allow tepid fluid to enter the colon slowly. If cramping occurs, clamp off the tubing and allow the patient to rest
before progressing. Water should flow in over 5 to 10 minute period.
(SOURCE: Brunner and Suddarth’s Med. Surg. Nursing, 10 th Edition Vol. 1, p. 1064)

19. 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 notice 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 irrigation."

CORRECT ANSWER: A
Rationale: Any difficulty in the insertion of the irrigating tube into the stoma may mean an obstruction to the
system.

20. You would know after teaching. Fermin that dietary instruction for him is effective when he states, "It is
important that I eat:
a. Soft foods that are easily digested and absorbed by my large intestine."
b. Bland food so that my intestines do not become irritated."
c. Food low in fiber so that there is less stool."
d. Everything that I ate before the operation, while avoiding foods that cause gas."

CORRECT ANSWER: A
RATIONALE: As such there is no specific diet plan for Ostomy patients. The main point is that you should be able
to tolerate the food you are eating. Still certain foods you need to avoid or include in your diet so as to maintain a
good health after Ostomy. Below is the list of food you need to keep in consideration:
 Food resulting in thickened stools (Low-Fiber): Applesauce, Peanut butter, boiled milk, Tapioca, Rice,
Cheese, Bananas, and Pretzels.
 Food resulting in soft stools (High Fiber): Red wine, Beer, Coffee, Prune juice, Fresh vegetables,
Fruits and Food with high fiber content.
 Foods resulting in incomplete digestion: Broccoli, Cabbage, Raw carrots, Raw onions, Pineapple,
Beans, Spinach, Potato skins, Corn, Coconut, Celery, Whole grains, Nuts, Raisins, Popcorn, Raw fruits,
Chinese vegetables, Seeds and Skins.
 Foods causing odor: Cabbage, Beans, Asparagus, Onions, Garlic, Eggs, Fish, Alcohol and Vitamins.
 Foods causing gas: Raw apple, Cabbage, Broccoli, Onions, Turnip, Corn, Nuts, Milk, Beer, Carbonated
beverages, iced beverages and Chewing gums.
 Foods causing diarrhea: Fried foods, highly spicy food, Legumes, Grape juice, Apple juice, Prune juice,
Green beans, Spinach, Raw fruits, Cabbage and Milk.
SOURCE: Ostomy Nutrition Guide booklet page 1-5

Situation 5 - Ensuring safety is one of your most important responsibilities. You will need to provide instructions and
information to your clients to prevent complications.

21. Randy has chest tubes attached to a pleural drainage system. When caring for him you should:
a. empty the drainage system at the end of the shift
b. clamp the chest tube when suctioning
c. palpate the surrounding areas for crepitus
d. change the dressing daily using aseptic techniques

CORRECT ANSWER: C
RATIONALE: Assessment actions to check for signs of extended pneumothorax or hemothorax should be
performed such as palpating surrounding areas for crepitus. It may also be an indication for a chest tube
complication known as subcutaneous emphysema. Subcutaneous emphysema occurs when air gets into tissues
under the skin covering the chest wall or neck. This can happen due to stabbing, gun shot wounds, other
penetrations, or blunt trauma. Air can also be found in between skin layers on the arms and legs during certain
infections, including gas gangrene. Subcutaneous emphysema can often be seen as a smooth bulging of the skin.
When a health care provider feels (palpates) the skin, it produces an unusual crackling sensation as the gas is
pushed through the tissue.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN, 3 rd edition, p. 242)

22. Fanny came in from PACK after pelvic surgery. As Fanny's nurse you know that the sign that would be
indicative of a developing thrombophlebitis would be:
a. a tender, painful area on the leg
b. a pitting edema of the ankle
c. a reddened area at the ankle
d. pruritus on the calf and ankle
 CORRECT ANSWER: A
RATIONALE: Thrombophlebitis is a condition in which a clot forms in a vessel wall as a result of the inflammation
of the vessel wall. It has 3 Types: Superficial, Femoral, and Pelvic. Assessment findings for a developing
Superficial Thrombophlebitis are tenderness and pain in the affected lower extremity. Also includes the following
symptoms: warm and pinkish red color over the thrombus area, palpable thrombus that feels bumpy and hard.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 rd Edition, p.329)

23. To prevent recurrent attacks on Terry who has acute glomerulonephritis, you should instruct her to:
a. seek early treatment for respiratory infections
b. take showers instead of tub bath
c. continue to take the same restrictions on fluid intake
d. avoid situations that involve physical activity

CORRECT ANSWER: A
RATIONALE: One of the causes of Glomerulonephritis is a history of pharyngitis or tonsillitis 2 – 3 weeks before
symptoms. Usually a streptococcal infection may precede it. It is very important to seek treatment for respiratory
infections existing to stop the progress of the disease. And it is usually with untreated respiratory infections (Group
A β-hemolytic streptococcus) that this sequelae develop.
OPTION B: Taking showers instead of tub baths is a measure to prevent bacteria from entering the urethra,
however is indicated for UTI.
OPTION C: Some fluid restrictions are observed for Glomerulonephritis but it is more of an intervention rather
than a preventive measure for recurrence.
OPTION D: Avoiding physical activity is also an intervention for Glomerulonephritis.

24. Herbert has a laryngectomy and he is now for discharge. He verbalized his concern regarding his
laryngectomy tube being dislodged, what should you teach him first?
a. Recognize that prompt closure of the tracheal opening may occur
b. Keep calm because there is no immediate emergency
c. Reinsert another tubing immediately
d. Notify the physician at once

CORRECT ANSWER: D
RATIONALE: If the patient verbalizes his concerns regarding dislodgement it would mean then that the patient
has not been well educated about the process of having a laryngectomy. It is stated that the patient is now for
discharge and it is expected that by this time the patient should be having all the information he has to know
regarding the laryngectomy. Preoperative teaching is done so that patient will be able to correct misconceptions
and fears about the reason for having the surgery, nature of the surgical procedure. Postoperatively, the nurse
reviews equipment and treatments for care with the patient, patients’ family. It means that after essential
information and teaching had been offered, patient still lack the knowledge and confidence to carry out self care
and important procedure considerations.
(SOURCE: Brunner and Suddarth’s Textbook of Medical Surgical Nursing 10 th Edition, p. 510-511)

25. When caring for Larry after an exploratory chest surgery and pneumonectomy, your priority would be to maintain:
a. supplementary oxygen
b. ventilation exchange
c. chest tube drainage
d. blood replacement

CORRECT ANSWER: A
RATIONALE: After surgery, the vital signs are checked frequently. Oxygen is administered via a mechanical
ventilator, nasal cannula, or mask for as long as necessary. A reduction in lung capacity requires a period of
physiologic adjustment, and fluids may be given at a low hourly rate to prevent fluid overload and pulmonary
edema.
OPTION B and C: ventilation exchange may also be important as it is the goal of the surgery to promote a better
gas exchange and oxygenation. Chest Tube drainage is already a precursor of the surgery as it is needed to
facilitate recuperation of lung expansion functions and avoid further complications such as pneumothorax and
hemothorax.
OPTION D: Blood replacement is a standing order in cases that bleeding problem may arise within the surgical
procedure.
(SOURCE: Brunner and Suddarth’s Textbook of Med.-Surg. Nursing 10 th edition, vol.1 p. 628)

Situation 6 - Infection can cause debilitating consequences when host resistance is compromised and virulence of
microorganisms and environmental factors are favorable. Infection control is one important responsibility of the nurse to
ensure quality of care.

26. Honrad, who has been complaining of anorexia and feeling tired, develops jaundice. After a workup he
is diagnosed of having Hepatitis A. His wife asks you about gamma globulin for herself and her household
help. Your most appropriate response would be:
a. "Don't worry your husband's type of hepatitis is no longer communicable"
b. "Gamma globulin provides passive immunity for Hepatitis B"
c. "You should contact your physician immediately about getting gamma globulin."
d. "A vaccine has been developed for this type of hepatitis"

CORRECT ANSWER: D
 RATIONALE: Gamma Globulins contain the antibody immunoglobulins IgM, IgG, IgA, IgD, and IgE, which are
essential in the body’s defense against microorganisms. Household and personal contacts of clients with HAV
should be given immune globulin (gamma globulin [Gammar] passive) is helpful prophylaxis both before and after
exposure. However a specific vaccine had been developed for Hepatitis A which is the inactivated hepatitis A
vaccine (active), which is given two doses of at least 6 months apart for persons who reside in a community that
has a high rate of hepatitis A virus infection, who are at risk because of foreign travel, or who have chronic liver
disease. (SOURCE: Med.-Surg. Nsg. By Black and Hawk, 7th edition, vol.1, p. 427, Vol.2 p. 2241)

27. Voltaire develops a nosocomial respiratory tract infection. He asks you what that means.
a. "You acquired the infection after you have been admitted to the hospital."
b. "This is a highly contagious infection requiring complete isolation."
c. "The infection you had prior to hospitalization flared up."
d. "As a result of medical treatment, you have acquired a secondary infection."

CORRECT ANSWER: A
RATIONALE: Nosocomial Infections also are referred to as hospital-acquired infections. Such infections are
infections acquired in a hospital or other health care facility that were not present or incubating at the time of a
client’s admission. The hospital environment provides exposure to a variety of virulent organisms that the client
has not been exposed to in the past; therefore the client has not developed resistance to these organisms.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 rd edition, p. 180)

28. As a nurse you know that one of the complications that you have to watch out for when caring for Omar
who is receiving total parenteral nutrition is:
a. stomatitis
b. hepatitis
c. dysrhythmia
d. infection

CORRECT ANSWER: D
RATIONALE: It is most important to watch out for signs of infection because a patient in TPN is most prone to
infection because of an open venous access that can be easily contaminated; furthermore, microorganisms can
easily find its way to enter the body through the bloodstream. A strict aseptic technique must be used because the
TPN solution has a high concentration of glucose, which is a medium for bacterial growth. Signs of an infection
are as follows: Chills, elevated WBC count, erythema or drainage at the insertion site, and fever. Assess IV site for
redness, swelling, tenderness, or drainage. Change IV tubing every 24 hours or according to agency protocol. If
signs of infection occur at the site, the following must be done:

 IV line must be removed and restarted at a different site

 Remove the tip of the IV catheter and send it to the laboratory for culture
 Prepare the client for blood cultures

29. A solution used to treat Pseudomonas wound infection is:

a.Dakin's solution
b.Half-strength hydrogen peroxide
c. Acetic acid
d.Betadine

CORRECT ANSWER: C
RATIONALE: Acetic Acid is effective for irrigating, cleansing, and packing wounds infected by Pseudomonas
Aeruginosa. Healthy skin surrounding the wound must be protected with a petroleum barrier because acetic acid
excoriates the skin. (Source: Saunders Comprehensive Review for the NCLEX-RN exam, 3 rd edition, p. 566)The
use of acetic acid to treat Pseudomonas aeruginosa in superficial wounds dates back to 1916 when it was
discovered that a 1% solution applied to war wounds led to elimination of this organism then called Bacillus
pyocyaneas. In 1992 a prospective study involving the use of 5% acetic acid was undertaken in 9 patients. No
patients complained of discomfort after the soaks which were applied daily. Two wounds lost Pseudomonas
species within 2 days and a further four within one week. Only one patient remained contaminated after three
weeks. Following eradication of the organism, healing occurred rapidly. Milner-S;Acetic acid to treat
Pseudomonas aeruginosa in superficial wounds and burns - (letter);The Lancet;Vol 340 (1992):61. It is possible
the application of acetic acid may confer other benefits to the healing process as well as the removal of bacteria.
Acidification of a wound would also increase the pO2 and reduces the histotoxicity of ammonia which may be
present (Ammonia is less toxic in an acid environment).
OPTION A: Dakin’s Solution or more commonly known as Bleach is a chloride solution that loosens, dissolves,
and deodorizes necrotic tissue and blood clots. The solution must not be in contact with healing or normal tissue.
OPTION B: Half strength hydrogen peroxide is a 3% solution has effervescent action that releases gas and
breaks up necrotic tissue. However, it is not used to pack wounds because it decomposes too rapidly.
OPTION D: Betadine is a brand name of povidone-iodine which is a water-soluble complex of iodine with
polyvinylpyrrolidone (PVP), with from 9.0% to 12.0% available iodine, calculated on a dry basis [1].It is used in
hospitals for cleansing and disinfecting the skin, preparing the skin preoperatively and treating infections
susceptible to iodine.It works through disruption of pathogen cell walls.

30. Which of the following is most reliable in diagnosing a wound infection?

a. Culture and sensitivity
b. Purulent drainage from a wound
c. WBC count of 20,000/pL
 d. Gram stain testing

CORRECT ANSWER: D
RATIONALE: The Gram-Stain is the most important of all bacteriologic differential stains to diagnose a wound
infection. It divides bacteria into two physiologic groups: Gram – and Gram + organisms, thus determining the
type of medication to be given to the patient. Infectious diseases or processes can be diagnosed by detection of
an immunologic response specific to an infecting agent in a patient’s serum. Normal humans produce both IgM
( first-response antibodies) and IgG (antibodies that may persist long after an infection) to most pathogens.
(Frances Fischbach’s A manual of Laboratory and Diagnostic Tests 7 th edition, p. 500)

Situation 7 - As a nurse you need to anticipate the occurrence of complications of stroke so that life threatening situations
can be prevented.

31. Wendy is admitted to the hospital with signs and symptoms of stroke. Her Glasgow Coma Scale is 6
on admission. A central venous catheter was inserted and an I.V. infusion was started. As a nurse assigned
to Wendy what will he your priority goal?
a. Prevent skin breakdown
b. Preserve muscle function
c. Promote urinary elimination
d. Maintain a patent airway

CORRECT ANSWER: D
RATIONALE: In a pt. that has a GCS of 6, it is very essential that airway must be maintained since deficient O2
delivery to the brain can cause irreversible brain damage in only 6 minutes. Taking into consideration the ABC’s of
emergency and medical management Airway must be established first followed by Breathing, and last is
circulation. If patient have already manifestations of brain injury, patient may fail to initiate his own breathing and
thus airway patency can be compromised resulting to a more severe condition.
(SOURCE: Brunner and Suddarth’s Textbook of Medical Surgical Nursing Vol.1 10 th Edition, p. 201-202)

32. Knowing that for a comatose patient hearing is the best last sense to be lost, as Judy's nurse, what should
you do?
a. Tell her family that probably she can't hear them
b. Talk loudly so that Wendy can hear you
c. Tell her family who are in the room not to talk
d. Speak softly then hold her hands gently

CORRECT ANSWER: D
RATIONALE: It is important to get the attention of the client before beginning to speak despite it’s inability to
respond or to react, nurse must move close to the client and speak slowly and clearly, talking in lower tones is
advised as shouting may not help and may only disturb other clients inside the unit. Source: Saunders
Comprehensive Review for the NCLEX-RN exam, 3rd Edition, p. 910-911)

33. Which among the following interventions should you consider as the highest priority when caring for June
who has hemiparersis secondary to stroke?
a. Place June on an upright lateral position
b. Perform range of motion exercises
c. Apply antiembolic stocking
d. Use hand rolls or pillows for support

CORRECT ANSWER: B
RATIONALE: Hemiparesis is the partial paralysis of one side of the body. It is generally caused by lesions of the
corticospinal tract, which runs down from the cortical neurons of the frontal lobe to the motor neurons of the spinal
cord) and is responsible for the movements of the muscles of the body and its limbs. ROM exercises are the
highest priority of all the interventions because for a patient with hemiparesis, rehabilitation and restoration of
functional capability is very important. ROM exercises may be done with assistance or guidance of a physical
therapist and a rehabilitation nurse. Exercise when performed correctly assists in maintaining and building muscle
strength, maintaining joint function, preventing deformity, stimulating circulation, developing endurance and
promoting relaxation. Some disabilites, such as spinal cord injury, acute brain injury, and other conditions that
cause muscle weakness or hemiparesis require extended periods in the recumbent position, thus may be assisted
to an alternative 90-degree position such as a reclining wheelchair with elevated leg rests.
(SOURCE: Brunner and Suddarths textbook for Medical Surgical Nursing Vol.1, 10 th edition, p.163)

34. Ivy, age 40, was admitted to the hospital with a severe headache, stiff neck and photophobia. She was diagnosed
with a subarachnoid hemorrhage secondary to ruptured aneurysm. While waiting for surgery, you can provide a
therapeutic by doing which of the following?
a. honoring her request for a television
b. placing her bed near the window
c. dimming the light in her room
d. allowing the family unrestricted visiting privileges

CORRECT ANSWER: C
RATIONALE: Prior to surgery it is important that medical management be maintained, includes: maintaining
cerebral perfusion pressure, controlling ICP, minimizing effects of vasospasm. The client with intracranial
aneurysm is at great risk for the development of increased ICP. (Normal ICP 0-15mmHg). A therapeutic nursing
management is to decrease environmental stimuli which can increase ICP.
  Dim all lights
 Speak softly
 Touch gently and only when needed
 Space all interventions
 Limit noxious stimuli such as suctioning to only as needed

OPTIONS A, B and D are distractive and are examples of environmental stimuli that may aggravate the condition
of the patient.(Source: Med.-Surg. Nsg. By Black and Hawk 7 th edition Vol.2, p.2095)

35. When performing a neurological assessment on Walter, you find that his pupils are fixed and dilated.
This indicated that he:
a. probably has meningitis
b. is going to be blind because of trauma
c. is permanently paralyzed
d. has received a significant brain injury

CORRECT ANSWER: D
RATIONALE: Fixed, Dilated pupils (unilateral or bilateral) or midposition fixed pupils indicate an upper midbrain
involvement of brain injury. .
(SOURCE: Med.-Surg. Nsg. By Black and Hawk 7th edition Vol.2,p. 2055)

Situation 8 - With the improvement in life expectancies and the emphasis in the quality of life it is important to provide
quality care to our older patients. There are frequently encountered situations and issues relevant to the older, patients.

36. Hypoxia may occur in the older patients because of which of the following physiologic changes associated
with aging.
a Ineffective airway clearance
b. Decreased alveolar surface area
c. Decreased anterior-posterior chest diameter
d. Hyperventilation

CORRECT ANSWER: B
RATIONALE: A 70-year-old expends 70% of the total elastic work of breathing on the chest wall compared with
40% for a 20-year-old. While there is great variation between individual and genders, there are age-related
decrements of respiratory muscle strength and endurance of approximately 20% by the age of 70 years.
Beginning in early adulthood, there is a progressive enlargement of the alveolar ducts and respiratory bronchioles.
The effect of the enlargement of the terminal respiratory units is a decrease of functional alveolar surface area by
15% by the age of 70 years. The decrease in alveolar surface area reduces alveolar surface tension with
consequential negative effect on alveolar gas exchange and forced expiratory flow.

37. The older patient is at higher risk for in incontinence because of:
a. dilated urethra
b. increased glomerular filtration rate
c. diuretic use
d. decreased bladder capacity

CORRECT ANSWER: D
RATIONALE: Aging causes a number of changes in urinary tract physiology, all of which can affect continence.
These changes include:
 A decrease in bladder elasticity, which decreases bladder capacity and requires the older adult to void
more frequently
 A decrease in the strength of the detrusor muscle, resulting in incomplete bladder emptying
 An increase in spontaneous detrusor muscle contractions
 A decrease in the ability to postpone urination
 A decrease in urethral closing pressure

38. Merle, age 86, is complaining of dizziness when she stands up. This may indicate:
a. dementia
b. a visual problem
c. functional decline
d. drug toxicity

CORRECT ANSWER: B
RATIONALE : Visual information is of particular importance to maintaining balance. The visual systems most
involved are the optokinetic and pursuit systems. The optokinetic system is the motor impulse responsible for
moving the eyes when the head moves, so that the field of vision remains clear. The pursuit system allows a
person to focus on a moving object while the head remains stationary. Both of these systems feed information
about the person's position relative to the surroundings to the brainstem. A specific type of eye movement called
nystagmus, which is repetitive jerky movements of the eye, most often in the horizontal direction, may cause
dizziness. Nystagmus may indicate that neurologic signals from the optokinetic or pursuit systems are not in
agreement with the other balance information received by the brain. If the eyes do not move in parallel or if the
upper eyelid covers more than a tiny portion of the iris, note the conditions as abnormal findings.
(SOURCE: Med.-Surg. Nsg. by Black and Hawk 7th edition, vol.2, p. 1924)
 39. Cardiac ischemia in an older patient usually produces:
a. ST-T wave changes
b. Very high creatinine kinase level
c. chest pain radiating to the left arm
d. acute confusion

CORRECT ANSWER: C
RATIONALE: A classical manifestation of Myocardial ischemia is angina that can develop quickly or slowly. Some
ignore the chest pain, thinking that it will go away or that it is indigestion. Its location is usually retrosternal or
slightly to the left of the sternum, as reported by 90% of incidents. The pain usually radiates to the left shoulder
and upper arm and may then travel down the inner aspect of the left arm to the elbow, wrist, and 4 th-5th finger.
(SOURCE: Med.-Surg. Nsg. By Black and Hawk 7th edition, vol.2, p.1703)

40. The nurse is providing medication instructions to an older adult who is taking digoxin (Lanoxin) daily.
The nurse bears in mind that which age-related body changes could place the client at risk for digoxin toxicity?
a. decreased cough efficiency and decreased vital capacity
b. decreased lean body mass and decreased glomerular filtration rate
c. decreased salivation and decreased gastrointestinal motility
d. decreased muscle strength and loss of bone density

CORRECT ANSWER: B
RATIONALE: The older client is at risk for medication toxicity because of decreased lean body mass and age-
associated decreased glomerular filtration rate. Although options A, C and D identify age-related changes that
occur in the older client, they are not associated specifically with this risk.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 rd edition, p. 394)

Situation 9 - A "disaster" is a large-scale emergency—even a small emergency left unmanaged may turn into a disaster.
Disaster preparedness is crucial and is everybody's business. There are agencies that are in charge of ensuring prompt
response. Comprehensive Emergency Management (CEM) is an integrated approach to the management of emergency
program and activities for all four emergency phases (mitigation, preparedness, response, and recovery), for all type of
emergencies and disasters (natural, man-made, and attack) and for all levels of government and the private sector.

41. Which of the four phases of emergency management is defined as "sustained action that reduces or eliminates
long-term risk to people and properly from natural hazards and the effect"?
a. Recovery
b. Mitigation
c. Response
d. Preparedness

CORRECT ANSWER: B
RATIONALE: Mitigation - actions or measures that can prevent the occurrence of a disaster or reduce the
damaging effects of one
 Involves determining community hazards and risks (actual and potential threats) for the occurrence of a
disaster
 Involves identifying available community resources and community-health personnel
 Involves determining the resources available for care of infants, older clients, the disabled, and those with
chronic health problems

Recovery: Includes actions taken to return to normal after the disaster. Includes prevention of debilitating effects
and restoration of personal, economic, and environmental health and stability to the community

Response: Involves putting disaster-planning services into action and enumerating the actions needed to save
lives and prevent further damage. Primary concerns include the safety and physical and mental health of both the
victims and the members of the disaster-response team

Preparedness: Includes plans for rescue, evacuation, and care of disaster victims

 Includes plans for training disaster personnel and gathering resources, equipment, and other materials
needed for dealing with the disaster
 Includes identification of specific responsibilities for various disaster-response personnel
 Establishes a community disaster plan and an effective public-communication system
 Involves setting up an emergency medical system and a plan for its activation
 Includes checking proper functioning of emergency equipment
 Involves making anticipatory provisions and setting up a location for distribution of food, water, clothing,
shelter, other supplies, and medicine
 Includes checking supplies on a regular basis and replenishing those that have become outdated
 Includes practicing community disaster plans (mock-disaster drills)

SOURCE: Saunders Comprehensive Review for the NCLEX-RN Exam, 3 rd Edition, p. 73-74)

42. You are a community health nurse collaborating with the Red Cross and working with disaster relief following a
 typhoon which flooded and devastated the whole province. Finding safe housing for survivors, organizing support
for the family, organizing counseling debriefing sessions and securing physical care are the services you are
involved with. To which type of prevention are these activities included.
a. Tertiary prevention
b. Primary prevention
c. Aggregate care prevention
d. Secondary prevention

CORRECT ANSWER: A
RATIONALE: Tertiary prevention combats the complications of disaster.
Primary prevention of disaster is possible through technical, organizational and judicial means
Secondary prevention implies the optimal management of disaster itself.
Aggregate care prevention:

43. During the disaster you see a victim with a green tag, you know that the person:
a. has injuries that are significant and require medical care but can wait hours will threat to life or limb
b. has injuries that are life threatening but survival is good with minimal intervention
c. indicates injuries that are extensive and chances of survival are unlikely even with definitive care
d. has injuries that are minor and treatment can be delayed from hours to days

CORRECT ANSWER: D
RATIONALE: Green Tag: are reserved for the "walking wounded" who will need medical care at some point, after
more critical injuries have been treated. They will require a doctor's care in several hours or days but not
immediately, may wait for a number of hours or be told to go home and come back the next day (examples:
broken bones without compound fractures, many soft tissue injuries). Option A:Yellow Tag: Their condition is
stable for the moment but requires watching by trained persons and frequent re-triage, will need hospital care
(and would receive immediate priority care under "normal" circumstances).
OPTION B: Red Tag: They require immediate surgery or other life-saving intervention, and have first priority for
surgical teams or transport to advanced facilities; they "cannot wait" but are likely to survive with immediate
treatment.
OPTION C: Black Tag: They are so severely injured that they will die of their injuries, possibly in hours or days
(large-body burns, severe trauma, lethal radiation dose), or in life-threatening medical crisis that they are unlikely
to survive given the care available (cardiac arrest, septic shock, severe head or chest wounds); they should be
taken to a holding area and given painkillers as required to reduce suffering.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 rd Edition p.75)

44. The term given to a category of triage that refers to life threatening or potentially life threatening injury or illness
requiring immediate treatment:
a. Immediate
b. Emergent
c. Non-acute
d. Urgent

CORRECT ANSWER: D
RATIONALE: Urgent Category are conditions that could potentially progress to a serious problem requiring
emergency intervention. May be associated with significant discomfort or affecting ability to function at work or
activities of daily living. Usually victim must be treated within 30-60 minutes. These are patients who have a
trauma score of 10 or 11 and can wait for a short time before transport to definitive medical attention. Some
examples of conditions that can be treated at urgent care include: accidents and falls, broken bones, breathing
difficulties, severe abdominal pain, bleeding/cuts, high fever and vomiting/diarrhea/dehydration.

Immediate - are used to label those who cannot survive without immediate treatment but who have a chance of
survival. patients who have a trauma score of 3 to 10 (RTS) and need immediate attention. they need advanced
medical care at once or within 1 hour. These people are in critical condition and would die without immediate
assistance. They require immediate surgery or other life-saving intervention, and have first priority for surgical
teams or transport to advanced facilities; they "cannot wait" but are likely to survive with immediate treatment.
Examples: Talking, not walking (severe distress with dyspnea, twitching, and/or nausea and vomiting);moderate-
to-severe effects in two or more systems (eg, respiratory, gastrointestinal, muscular);circulation intact

Emergent – Clients with life-threatening injuries, who need immediate attention and continuous evaluation, yet
have a high probability of survival once their condition is stabilized. Examples: clients with trauma, chest pain,
severe respiratory distress or cardiac arrest, limb amputation, or acute neurological deficits and those who have
sustained chemical splashes to the eye.

Non-acute – Clients with local injuries who do not have immediate complications and who can wait several hours
for medical treatment; these clients require evaluation every 1 to 2 hours thereafter. Examples: clients with minor
lacerations, sprains, or cold symptom
(SOURCE:Saunders Comprehensive Review for the NCLEX-RN exam 3rd edition, p.74-75)

45. Which of the following terms refer to a process by which the individual receives education about recognition
of stress reactions and management strategies for handling stress which may be instituted after a disaster?
a. Critical incident stress management
b. Follow-up
c. Debriefing
 d. Defusion

CORRECT ANSWER: A
RATIONALE: It is an adaptive short term helping process that focuses solely on an immediate and identifiable
problem to enable the individual/s affected to return to their daily routine(s) more quickly and with a lessened
likelihood of experiencing post-traumatic stress disorder. Critical Incident Stress Management is designed to help
people deal with their trauma one incident at a time by allowing the individual to talk about the incident when it
happens without judgment or criticism. Follow-up can be held weeks or months later if needed to address any
unresolved issues Debriefings are usually the second level of intervention for those directly affected by the
incident and often the first for those not directly involved. Defusings are limited only to individuals directly
involved in the incident and are often done informally, sometimes at the scene. They are designed to assist
individuals in coping in the short term and address immediate needs

Situation 10 - As a member of the health and nursing team you have a crucial role to play in ensuring that all the
members participate actively is the various tasks agreed upon,

46. While eating his meal, Matthew accidentally dislodges his IV line and bleeds. Blood oozes on the surface of the
over-bed table. It is most appropriate that you instruct the housekeeper to clean the table with:
a. Acetone
b. Alcohol
c. Ammonia
d. Bleach

CORRECT ANSWER: D
RATIONALE: Blood or bodily fluids emanating from ANY person shall be treated cautiously. Gloves shall be worn
when cleaning up blood spills or other bodily fluid spills. These spills shall be disinfected with a ten percent bleach
solution or an approved cleansing solution. Bleach primarily is used to disinfect blood spills on various surfaces,
they are composed of various chemical components one of which is Sodium Hypochlorite. A 1 in 5 dilution of
household bleach with water (1 part bleach to 4 parts water) is effective against many bacteria and some viruses,
and is often the disinfectant of choice in cleaning surfaces in hospitals. The solution is corrosive, and needs to be
thoroughly removed afterwards, so the bleach disinfection is sometimes followed by an ethanol disinfection.

47. The nurse manager has implemented a change in the method of the nursing delivery system from functional team
nursing. A nursing assistant is resistant to the change and is not taking an active part in facilitating the process of
change. Which of the following would be the best approach in dealing with the nursing assistant?
a. ignore the resistance
b. exert coercion with the nursing assistant.
c. provide a positive reward system for the nursing assistant
d. confront the nursing assistant to encourage verbalization of feelings regarding the change.

CORRECT ANSWER: D
RATIONALE: Confrontation is an important strategy to meet resistance head-on. Face-to-face meetings to
confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and
development of strategies to solve the problem. Option A will not address the problem. Option B may produce
additional resistance. Option C may provide problem solving measures.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 rd edition, p.78)

48. Part of your responsibility as a member of the diabetes core group is to get referrals from the various wards
regarding diabetic patients needing diabetes education. Prior to discharge today 4 patients are referred to you.
How would you start prioritizing your activities?
a. Bring your diabetes teaching kit and start your session taking into consideration their distance from your office
b. Contact the nurse-in-charge and find out from her the reason for the referral
c. Determine their learning needs then prioritize
d. involve the whole family in the teaching class

CORRECT ANSWER: C
RATIONALE: Learning need is a desire or a requirement to know something that is presently unknown to the
learner. A comprehensive assessment of learning needs incorporates data from the nursing history and physical
assessment and addresses the client’s support system. It also considers client characteristics that may influence
the learning process: readiness to learn, motivation to learn, and reading or comprehension level, for example.
Assessment of learning need is done first before developing a teaching plan.
OPTION D may be done at later part of learning.

49. The nurse is working in a long-term care facility and is administering medications to assigned clients. A client
refuses to take the prescribed medication, and the nurse threatens the client and tells the client that if the
medication is not taken orally, then restraints will be applied and the medication will be given by injection.
This statement by the nurse constitutes which legal tort?
a. invasion of privacy
b. negligence
c. assault
d.battery

CORRECT ANSWER: C
RATIONALE: An assault occurs when a person puts another person in fear of a harmful or offensive contact. For
this intentional tort to be actionable, the victim must be aware of the threat of harmful or offensive contact. Battery
 is the actual contact with one’s body. Negligence involves actions below the standards of care. Invasion of privacy
occurs with unreasonable intrusion into the individual’s private affairs.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 rd edition, p.64)

50. The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which
of the following would indicate the need for further action and analysis?
a. a client’s family attending a diabetic teaching session
b. canceling physical therapy sessions on the weekend
c. normal vital signs and absence of wound infection in a postoperative client
d. a client demonstrating accurate medication administration following teaching

CORRECT ANSWER: B
RATIONALE: Variances are actual deviations or detours from the critical paths. Variances can be positive or
negative, avoidable or unavoidable, and can be caused by a variety of things. Positive variance occurs when the
client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when
untoward events prevent a timely discharge. Variance analysis occurs continually to anticipate and recognize
negative variance early so that appropriate action can be taken.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 rd edition, p.76)

Situation 11 - One of the realities that we are confronted with is mortality. It is important for us nurses to be aware of how
we view suffering, pain, illness, and even our death as well as its meaning. That way we can help our patients cope with
death and dying.

51. Nurse Fay is assigned to client Irma. Irma is terminally ill she speaks to Nurse Fay in confidence. Nurse Fay now
feels that Irma's family could be helpful if they knew what Irma has told her. What should Nurse Fay do first?
a. Tell the physician who in turn could tell the family
b. Obtain Irma's permission to share the information with the family
c. Tell Irma that she has to tell her family what she told you
d. Make an appointment to discuss the situation with the family

CORRECT ANS: C
RATIONALE: The nurse may feel conflict because the nurse wants the client to share important information but is
unsure about making such promise. The information may be important to the health or safety of the client or
others. Let the client decide whether to share the information or not.
(SOURCE: Foundations of Psychiatric Mental Health Nursing, 4th edition; Elizabeth M. Varcarolis; pp.246)
The family is the primary system to which a person belongs, and in most cases, it is the most powerful system to
which a person may ever belong. Birth, puberty, marriage, and death are all considered to be family experiences.
The family can be the source of love or hate, pride or shame, security or insecurity.
OPTIONS:
A – Wrong delegation
B & C – Let the client decide whether to share the information or not.

52. Nurse Nathalie Angie is assigned to client Ruby. Ruby who has been told she has terminal cancer turns away
and refuses to respond to Nurse Nathalie Angie. Nurse Nathalie Angie can best help her by:
a. Coming back periodically and indicating your availability if she would like you to sit with her
b. Insisting that Ruby should talk with you because it is not good to keep everything inside
c. Leaving her alone because she is uncooperative and unpleasant to be with
d. Encouraging her to be physically active as possible

CORRECT ANS: A
RATIONALE: Therapeutic Communication Technique:
Offering Self – making one self available. It is important that this offer is unconditional, that is, the client
doesnot have to respond verbally to get the nurse’s attention. (Source: Psychiatric Mental Health Nursing, 2 nd
edition; Sheila L. Videbeck; pp. 117)
Silence – Absence of verbal communication, which provides time for the client to put thoughts into words,
regain composure, or continue talking. Nurse says nothing but continues to maintain eye contact and conveys
interest. (Source: Psychiatric Mental Health Nursing, 2 nd edition; Sheila L. Videbeck; pp. 118)
OTHER OPTIONS:
B – Non therapeutic communication Technique ( Disapproving )
C – Judgemental
D – Giving advise implies that only the nurse knows what is best for the client.

53. Eddy who is terminally ill and recognizes that he is in the process of losing, everything and everybody he loves, is
depressed. Which of the following would best help him during depression?
a. Arrange for visitors who might cheer him
b. Sit down and talk with him for a while
c. Encourage him to look at the brighter side of things
d. Sit silently with him

CORRECT ANS: D
RATIONALE: Silence often encourages the client to verbalize, provided that it is interested and expectant. Silence
gives the client time to organize thoughts, direct the topic of interaction, or focus on issues that are most
important. Much non verbal behavior takes place during silence, and the nurse needs to be aware of the client
and his or her own nonverbal behavior. (Source: Psychiatric Mental Health Nursing; Shiela L. Videbeck; pp.118)
OPTION A – Not the job of the nurse.
 OPTION B – Must be comfortable sitting with the client in silence. Let the client know you are available to
converse but do not require the client to talk.
OPTION C – Non-therapeutic Communication Technique: Making stereotyped comments – Such comments are of
no value in the nurse client relationship. Any automatic responses will lack the nurse’s consideration or
thoughtfulness.

54. Which of the following statements would best indicate that Chun Lee; who is dying has accepted this
impending death?
a. "I'm ready to die."
b. "I have resigned myself to dying"
c. "What's the use"?
d: "I'm giving up"

CORRECT ANS: A
RATIONALE: Concrete message. Implies acceptance literally. Acceptance occurs when the person shows
evidence of coming to terms with death. ( Source: Psychiatric Mental Health Nursing 2 nd edition; Shiela Videbeck;
pp. 241)
OPTIONS B, C – Implies Denial; Shock and disbelief towards loss and or dying.
OPTION D – Implies Anger; maybe expressed towards God, relative, friends, or health care providers.

55. Piola, 90 years old has planned ahead for her-death-philosophically, socially, financially and emotionally.
This is recognized as:
a. Acceptance that death is inevitable
b Avoidance of the true sedation
c. Denial with planning for continued life
d. Awareness that death will soon occur

CORRECT ANS: D
RATIONALE: In this age the patient is aware that death will soon occur. Look at the statement.
OPTIONS A,B and C – Destructors

Situation 12 - Brain tumor, whether malignant or benign, has serious management implications nurse, you should be able
to understand the consequences of the disease and the treatment.

56. Nurse Farrah Faye is caring for Conrad who has a brain tumor and Increased Intracranial Pressure (ICP).
Which intervention should Nurse Farrah Faye include in her plan to reduce ICP?
a. Administer bowel Softener
b. Position Conrad with his head turned toward the side of the tumor
c. Provide sensory stimulation
d. Encourage coughing and deep breathing

CORRECT ANS: A
RATIONALE: Bowel softener promotes bowel evacuation without straining / Valsalva’s maneuver because it
increases ICP. (Source: Medical Surgical Nursing 7 th Edition; pp 2201). Straining during coughing, movement in
bed or moving bowels increases ICP. ( Source: Medical Surgical Nursing 7 th editon; Black and Hawks; pp. 2089)
OPTION B – Positioning the client with his head towards the side of the tumor increases pressure on the tumor
and increases or produces pain.
OPTION C – Noise and frequent interruptions may decrease needed sleep and alter ability to cope.
OPTION D – Coughing increases ICP.

57. Nurse Glaiza Mae helps in positioning patient Conrad. Keeping Conrad's head and neck in alignment results in:
a. increased intrathoracic pressure
b. increased venous outflow
c. decreased venous outflow
d. increased intra abdominal pressure

CORRECT ANS: B
RATIONALE: Maintaining head and neck in neutral alignment facilitates drainage and reduces edema.
(SOURCE: Medical Surgical Nursing 7th edition; pp. 2089)
OPTION A – Not related.
OPTION C – Opposite of the correct ans.
OPTION D – Increased abdominal pressure could lead to increase ICP.

58. Which of the following activities may increase intracranial pressure (ICP)?
a. Raising the head of the bed
b. Manual hyperventilation
c. Use of osmotic Diuretics
d. Valsava's maneuver

CORRECT ANS: D
RATIONALE: Straining during coughing, movement in bed, moving bowels or Valsalva Maneuver increases ICP.
( SOURCE: Medical Surgical Nursing 7th editon; Black and Hawks; pp. 2089)

OPTION A – Facilitates venous drainage from the brain.

 OPTION B – Hyperventilation had been recommended as the primary treatment of head injured clients because
carbon dioxide causes cerebral blood vessels to dilate. By manually hyperventilating or increasing the ventilator
settings to cause hyperventilation, a hypocarbic (low carbon dioxide) blood level is created. A partial pressure of
C02 (PaC02) level between 30 and 35 mmHg results in vasoconstriction of the cerebral blood vessels, leading to
decreased blood flow thus decreased ICP.
OPTION C – Osmotic diuretics such as Mannitol, is used to expand immediately the volume of plasma that
increases blood flow and oxygen delivery. Mannitol has a delayed effect of creating an osmotic gradient and pulls
fluid out of the cells, creating diuresis over the following hours. Thus reduces cerebral edema.

59. After Nurse Ma. Erma assessed Conrad, she suspected increased ICP.Her most appropriate respiratory
goal is to:
a. maintain partial pressure of arterial 02 (Pa02) above 80 mmHg
b. lower arterial pH
c. prevent respiratory alkalosis
d. promote C02 elimination

CORRECT ANS: D
RATIONALE: Hyperventilation had been recommended as the primary treatment of head injured clients because
carbon dioxide causes cerebral blood vessels to dilate. By manually hyperventilating or increasing the ventilator
settings to cause hyperventilation, a hypocarbic (low carbon dioxide) blood level is created. A partial pressure of
C02 (PaC02) level between 30 and 35 mmHg results in vasoconstriction of the cerebral blood vessels, leading to
decreased blood flow thus decreased ICP. ( Source: Medical Surgical Nursing 7 th editon; Black and Hawks; pp.
2089)
OPTION A - An increased ICP has an increased need for oxygen and glucose because of an increased metabolic
rate. The PaO2 must be kept between 90 and 100mmHg.
OPTION B - Inadequate oxygenation also forces brain cells to produce energy using anaerobic metabolism, which
produces lactic acid and lowers pH, also dilating blood vessels and exacerbating the problem.
OPTION – Respiratory Alkalosis can lead to Decreased intracranial pressure (secondary to cerebral
vasoconstriction), preventing

60. Conrad underwent craniotomy. As his nurse; you know that drainage on a craniotomy dressing must be
measured and marked, which findings should you report immediately to the surgeon?
a. Foul-smelling drainage
b. yellowish drainage
c. Greenish drainage
d. Bloody drainage

CORRECT ANS: A
RATIONALE: Foul smelling and purulent drainage indicates wound infection. The client may also have fever,
malaise, anorexia, and leukocytosis. Notify surgeon of any suspected wound infection. ( Source: Medical Surgical
Nursing 7th editon; Black and Hawks; pp. 307)
OPTIONS B & C – Not common.
OPTION D – Common in the first 24 hrs of post-surgery
When to Call Your Doctor
If you experience any of the following:
 A temperature that exceeds 101º F
 An incision that shows signs of infection, such as redness, swelling, pain, or drainage.
 If you are taking an anticonvulsant, and notice drowsiness, balance problems, or rashes.
 Decreased alertness, increased drowsiness, weakness of arms or legs, increased headaches,
vomiting, or severe neck pain that prevents lowering your chin toward the chest.

61. Which of the following instructions should Nurse Julie Lorraine provide to a patient who has
diabetes and hypertrophic lipodystrophy?
a. Rotate insulin injection sites
b. Inject insulin at the edge of the affected area
c. Withhold injection of insulin until the area heals
d. Use a longer needle to administer the insulin

CORRECT ANS: A
RATIONALE: Hypertrophic lipodystrophy occurs when the same injection sites are used frequently. The patient
should rotate insulin injection sites and avoid using the affected area for six months. This will allow the thickened
subcutaneous tissue to regress. (Source: Medical Surgical Nursing; Novak and Broom)
OPTION B – Injecting at the edge of the affected area could result in erratic absorption of the insulin.
OPTION C – Withholding insulin for any length of time without a specific physician order is illegal. Since the site
could take up to six months to heal, the patient would certainly go into diabetic ketoacidosis and die without
appropriate intervention.
OPTION D – Since insulin is injected into subcutaneous tissue, a longer needle would bypass this tissue and alter
the absorption rate of the insulin. Also, only regular insulin can be given via the intramuscular route. This is done
when immediate action is desired.

62. The registered nurse’s signature as a witness on an informed consent indicates that the patient
a. has been informed regarding the procedure.
b. was medicated for pain before the consent was signed.
c. can describe how the procedure will be done.
 d. voluntarily agreed to having the procedure performed.

CORRECT ANS: A
RATIONALE: In order for an informed consent to be valid, three basic criteria must be met. The patient’s decision
must be voluntary, the patient must be informed, and the patient must be competent to understand the information
and alternatives. The registered nurse’s signature as a witness indicates these criteria were met.
OPTION B – for informed consent to be valid, it must be obtained before the administration of the patient’s
preoperative medication.
OPTION C – The patient needs only to understand the information and alternatives, not describe the procedure.
OPTION D – Making a voluntary decision to have a procedure performed is only part of an informed consent.

63. Nurse Aileen is assessing a patient with hypovolemic shock, which of the following manifestations would
Nurse Aileen most likely see first?
a. Nervousness and apprehension
b. Decreased urinary output
c. Systolic blood pressure below 90 mmHg
d. Hypoventilation and tachycardia

CORRECT ANS: A
RATIONALE: Early hypoxic and hypocapnic changes result in restlessness, confusion, lethargy and mental
cloudiness. (Source: CGFNS guide 5th edition; pp 58)
OPTION B – Decreased urinary output is a clinical manifestation of hypovolemic shock, but occurs later than
nervousness and apprehension.
OPTION C – During the compensatory stage pf shock, the blood pressure is adequate to perfuse the vital organs.
The systolic blood pressure does not drop below 90 mmHg until the progressive stage of shock.
OPTION D – The heart rate is is increased and the depth of ventilation is increased in the early stages of shock to
compensate for the lactic acid produced due to anaerobic metabolism.

64. Staff nurses, Allen and Mary Jane, learn that a patient they have been caring for during the last few weeks
Has just been diagnosed with tuberculosis. When the nurses express concern about contracting tuberculosis
themselves, the charge nurse’s response should be based on which of the following statements?
a. Tuberculosis is not highly infectious when standard precautions are followed.
b. The Mantoux test is used to confirm diagnosis of tuberculosis.
c. Tuberculosis is easily treated with a short course of antibiotics.
d. Vaccination with Bacillus Calmette Guerin (BCG) will be used to immunize the nurses against infection.

CORRECT ANS: A
RATIONALE: The infectious stage of tuberculosis declines immediately after effective chemotherapy. The risk of
infectious tuberculosis is much higher for persons who are immunosuppressed. Patients need to be taught to
cover their mouth when coughing, because tuberculosis is spread by droplets. (SOURCE: CGFNS guide 5 th
edition; pp. 59)
OPTION B – For a definite diagnosis of TB, a positive sputum culture is necessary. A Mantoux test identifies
individuals exposed to Mycobacterium tuberculosis. This test does not differentiate between active and dormant
infection.
OPTION C – Antimycobacterial therapy is usually prescribed for six to nine months. Short term use of antibiotics
is not effective chemotherapy.
OPTION D – BCG strengthens the body’s immune system.

65. To which of the following nursing diagnosis would a nurse manager give priority when an impaired nurse returns
to work?
a.Ineffective individual coping
b.Situational low self-esteem
c. Growth and development; altered
d.Ineffective family coping; compromised

CORRECT ANS: A
RATIONALE: The impaired nurse has difficulty in coping with stress and has abused substances as a means to
reduce stress and anxiety. The nurse manager should closely monitor the recovering nurse’s ability to manage
stress and utilize effective coping methods. Recognizing the use of ineffective coping is a priority concern.
(Source: CGFNS guide 5th edition; pp 77)
OPTION B – Situational low self-esteem is defined as negative self-appraisal in a person with previous positive
self-evaluation. Individuals who abuse substances have experience low self-esteem and a negative self concept.
Over a long period of time, therefore, a recovering nurse’s low self-esteem is not related specifically to returning to
work.
OPTION C – Altered growth and development is identified as a predisposing factor that is associated with
substance abuse disorders but is not relevant diagnosis for the recovering nurse.
OPTION D – The diagnosis of ineffective family coping compromised, is inappropriate in this situation and in
relation to the role of the nurse manager.

66. A woman who is dependent on alcohol is admitted to the detoxification unit. The answer to which of the following
question is essential for the nurse to obtain from the patient immediately?
a. How does her husband react to her problem?
b. When did she have her last drink?
c. How old she was when she began to drink?
d. What did she eat in the past four hours?
 CORRECT ANS: B
RATIONALE: Alcohol withdrawal begins within four to six hours of cessation of, or reduction in, heavy and
prolonged alcohol use. By knowing when the patient had her last drink, the nurse can anticipate withdrawal
symptoms and intervene inappropriately. ( Source: CGFNS guide 5 th edition; pp 165)
OPTION A – This information will be use when the individual begins counseling. If the patient has a husband who
enables her drinking, it will be much more difficult for her to quit.
OPTION C – Knowing how old the patient was when she started drinking provides information on the length of her
addiction. However, it is not a question that needs to be asked immediately.
OPTION D – The nurse should be aware of what the patient has eaten prior to admission since food may slow
down the absorption of alcohol and thereby delay withdrawal. However, the most essential assessment for the
nurse to make is determining when the patient had her last drink.

67. A patient seems unconcerned about the sudden loss of vision in both eyes. Physical examination fails to reveal a
physical cause for this problem. Which of the following terms should the nurse use to describe this phenomenon
when charting the behavior?
a.La belle indifference
b.Malingering
c. Hypochondria
d.Confabulation

CORRECT ANS: A
RATIONALE: An inappropriate lack of concern about difficulties despite their apparent severity is called la belle
indifference. This phenomenon is often seen in patients with conversion disorders and is unconscious in nature.
(SOURCE: CGFNS guide 5th edition; pp 269)
OPTION B – Malingering is a conscious effort to deceive others, often for personal gain, by pretending physical
symptoms.
OPTION C – Hypochondria is an excessive preoccupation with an imaginary illness, even though there are no
signs or organic changes. Although there is no organic cause for blindness, the patient is not excessively
preoccupied with the illness.
OPTION D – Confabulation is the detailed fabrication of a story to make up for memory loss. The purpose of
confabulation is to maintain self esteem. It is often seen in dementias.

68. Nurse May is assigned to patient with PTSD. Which of the following observations would be most definitive when
Nurse May is assessing a patient with posttraumatic stress disorder?
a. Substance abuse
b. Aggression
c. Flashbacks
d. Depression

CORRECT ANS: C
RATIONALE: Criteria for the diagnosis of PTSD include acting or feeling as if the traumatic event were recurring.
This phenomenon is termed “flashback”. (Source: CGFNS Guide 5th edition; pp 175)
OPTIONs A, B & D – Aggression, Substance abuse and depression are commonly seen as concurrent behaviors
in PTSD patients who have limited coping skills for dealing with the anxiety caused by the trauma.

69. Disulfiram (Antabuse) is prescribed for a patient. Which of the following comments, if made by the patient, would
indicate correct understanding of the action of this medication?
a. “ I’ll drink fruit juice at social gatherings”
b. “ I’ll take my pulse four times a day”
c. “ I’ll lie down for half an hour after I take the pill”
d. “ I’ll take an antacid before my antabuse”

CORRECT ANS: A
RATIONALE: The patient needs to be aware that ingesting any substances containing alcohol can trigger the
alcohol disulfiram reaction. This reaction can include hypotension, severe nausea and vomiting, flushing,
throbbing headache and respiratory difficulty. (Source: CGFNS Guide 5 th edition; pp. 263)
OPTIONS B & C – Antabuse, by itself, produces transient effects that usually disappear within two weeks such as,
drowsiness, fatigue, impotence, headache, acne and metallic after taste. It is not necessary to monitor the pulse
rate four times a day or to rest after taking the drug.
OPTION D – Antacids interfere with the absorption of medications and should not be taken with antabuse.

70. Which of the following arterial blood gas levels would nurse expect to observe when monitoring a patient who has
metabolic alkalosis?
a.pH, 7.50; pCO2, 38 mmHg; HC03, 30mEq
b.pH, 7.30; pCO2, 56 mmHg; HCO3, 24 mEq
c. pH, 7.38; pCO2, 42 mmHg; HCO3, 25 mEq
d.pH, 7.26; pCO2, 37 mmHg; HCO3, 18 mEq

CORRECT ANS: A
RATIONALE: Metabolic alkalosis is a clinical disturbance characterized by a high pH and a high plasma
bicarbonate concentration. The normal blood pH is 7.35 – 7.45; the normal pCO2 is 38-42 mmHg; and the normal
bicarbonate level is 24 – 26 mEq /L. (Source: CGFNS guide 5th edition; pp. 362)
OPTION B – This arterial blood gas indicates respiratory acidosis.
OPTION C – This is a normal arterial blood gas
 OPTION D – This arterial blood gas indicates metabolic acidosis.

71. While Jayvee, a burn patient is being transferred by Nurse Vicky from the burn unit to the operating room, the IV
bottle fell on Jayvee’s head. He sustained a laceration on his forehead. Nurse Vicky was proven guilty of
negligence. Which of the following did nurse Vicky fail to do?
a. Hold the IV bottle
b. Check the IV stand
c. Place the IV stand on the foot part of the stretcher
d. Restrain Jayvee

CORRECT ANS: A
RATIONALE: Negligence – the commission of an act that a prudent person would not have done or the omission
of the duty that a prudent person would have fulfilled, resulting in injury or harm to another person. (Source:
Mosby’s pocket Dictionary 4th edition; pp. 844). Appropriate and proper check up of the IV stand prior to
transferring the patient would guarantee security of the IV bottle.
OPTION A – Always support or hold the client rather than the equipment. (Source: Fundamentals of Nursing 7 th
edition, Kozier et al; pp.1091)
OPTION C – Doesn’t guarantee the security of the bottle during transfer.
OPTION D – Improper. Needs doctor’s order and patient’s and or folks approval.

72. Nurse Krystel is caring for client Olga. Olga is receiving D5W 1 liter regulated at 30 drops/min to be consumed in
8 hrs. It was started at 8am. At 10 am her relative informed Nurse Krystel that the bottle is empty. Which of the
following will Nurse Krystel do first?
a.Refer to nurse manager
b.Assess Olga and check level of fluid left in the bottle
c. Discontinue IV and assess Olga
d.Replace the IV fluid with prescribed follow-up

CORRECT ANS: B
Assessment is the first step in the nursing process. It involves getting the facts. Collect, organize, validate and
recording the clients data. Before Referring to nurse manager and Replacing prescribed IV fluid, assessment
should be done first.( Kosier, B., Fundamentals of Nursing Concept, Process and Practice)

73. When Nurse Lynchen Jeanne volunteers to work in a hospital setting and she commits a mistake, who is legally
responsible?
a. Volunteer nurse, hospital and the nurse in charge
b. The professional organization which the volunteer nurse represents
c. Hospital
d. Volunteer nurse because there is no employer employee relationship

CORRECT ANSWER: A
RATIONALE: Doctrine of Respondeat Superior
Means “let the master answer for the acts of the subordinate”. Under this doctrine, the liability is expanded to
include the master as well as the employee and not a shift of liability from the subordinate to the master.
Therefore, when a person, through his negligence, injures another, he remains fully responsible. This doctrine
applies only to those acions performed by the employee within the scope of his employment. (Source:
Professional Nursing in the Philippines 10th edition; Venzon & Venzon; pp164)

74. Nurse Mark Lawrence is reviewing the laboratory results of Clare who has rheumatoid arthritis. Which laboratory
result should the nurse expect to find?
a. Increased platelet count
b. Altered blood urea nitrogen (BUN) and creatinine levels
c. Electrolyte imbalance
d. Elevated erythrocyte sedimentation rate (ESR)

CORRECT ANS: D
RATIONALE: Elevated Erythrocyte Sedimentation Rate (ESR) and C-reactive protein (CRP) levels are typical of
active disease, with the CRP being more definitive indicator of inflammation.
OPTION A - Increased platelet counts (thrombocytosis) may be seen in individuals who show no significant
medical problems, while others may have a more significant blood problem called myeloproliferative disorder.
Some, although they have an increased number of platelets, may have a tendency to bleed due to the lack of
stickiness of the platelets; in others, the platelets retain their stickiness but, because they are increased in
number, tend to stick to each other, forming clumps that can block a blood vessel and cause damage, including
death (thromboembolism).
OPTION B - The most common cause of an elevated BUN, azotemia, is poor kidney function, although a serum
creatinine level is a somewhat more specific measure of renal function.
OPTION C - There are many causes for an electrolyte imbalance. Causes for an electrolyte imbalance may
include:
 Loss of body fluids from prolonged vomiting.
 Inadequate diet and lack of vitamins.
 Malabsorption and hormonal or endocrine disorders. Kidney disorders.
 Medications such as; Chemo drugs, Diuretics, Antibiotics and corticosteroids.
 75. Nurse Joseph T. accidentally administer 40 mg of Propanolol (Inderal) to a client instead of 10 mg. Although the
client exhibits no adverse reactions to the larger dose, Nurse Joseph T should:
a. Complete an incident report
b. Call the hospital attorney
c. Inform the clients family
d. Do nothing because the clients condition is stable

CORRECT ANS: A
RATIONALE: An incident report (also called unusual occurrence report) is an agency record of an accident or
unusual occurrence. Incident reports are used to make all facts available to agency personnel, to contribute to
statistical data about accidents or incidents, and to help personnel prevent future incidents or accidents. All
accidents are usually reported on incident forms. The nurse includes the following in an incident report:
 Identify the client by name, initials, and hospital or identification number.
 Give the date, time and place of the incident.
 Describe the facts of the incident. Avoid any conclusions or blame. Describe the incident as you saw it
even if your impressions differ from those of the others.
 Incorporate the client’s account of the incident. State the client’s comments by using direct quotes.
 Identify witnesses to the incident.
 Identify any equipment by number and any medication by name and dosage.

The person who identifies that the incident occurred should complete the incident report. This may not be the
same person actually involved with the incident. When an accident occurs, the nurse should first assess the client
and intervene to prevent injury. If a client is injured, nurses must take steps to protect the client, themselves, and
their employer. (Source: Fundamentals of Nursing 7th edition, Kozier et al; pp.61-62)
OPTIONS B & C – Premature actions.
OPTION D – Guilty of Negligence.

Situation 13 – Nurses Denice and Cynthia are going to participate in a Cancer Consciousness Week. They are assigned
to take charge of the women to make them aware of cancer, most especially cervical cancer. They reviewed their
manifestations and management.

76. The following are risk factors for cervical Cancer EXCEPT:
a. immunosuppressive therapy
b. sex at an early age, multiple partners, exposure to socially transmitted diseases, male partner's sexual
habits
c. viral agents like the Human Papilloma Virus
d. smoking

CORRECT ANS: A
RATIONALE: Not included among the risk factors.
OPTIONS B, C & D – are all risk factors of cervical cancer. Human papilloma virus (HPV) is the leading cause of
cervical cancer. Other factors are Low socioeconomic status, Untreated chronic cervicitis,STD’s and Having a
sexual partner with a history of penile or prostate cancer. ( SOURCE: Medical Surgical Nursing 7 th edition; Black
and Hawks; pp 1072)

77. Late signs and symptoms of cervical cancer include the following EXCEPT:
a. urinary/bowel changes
b. pain in pelvis, leg of flank
c. uterine bleeding
d. lymph edema of lower extremities

CORRECT ANS: D
RATIONALE: Lymphedema develops in clients with missing or impaired lymphatic system. Trauma, neoplasms,
filariasis, inflammation, surgical excisions, or high doses of radiation are factors that develops lymphedema.
( Source: Medical Surgical Nursing 7th edition; Black and Hawks; pp 1543)
OPTION A – Late manifestations. Together with pressure on the bowel, bladder or both. Bladder iiritation, Rectal
discharge manifestation of ureteral obstruction and heavy aching abdominal pain.
OPTION B – Pain is late manifestation. It usually becomes a difficult problem with the onset of cachexia, or
general wasting syndrome.
OPTION C - Vaginal discharges and bleeding especially after intercourse are late manifestations as well.
( SOURCE: Medical Surgical Nursing 7th edition; Black and Hawks; pp 1074)

78. When a total hysterectomy is performed due to cancer of the cervix, which of the following organs are removed?
a. the uterus, cervix, fallopian tubes and one ovary
b. the uterus, cervix, and two-thirds of the vagina
c. the uterus, cervix, tubes and ovaries
d. the uterus and cervix

CORRECT ANS: D
RATIONALE: Removal of the uterus and the cervix. Can be performed either abdominally or vaginally.
( SOURCE: Medical Surgical Nursing 7th edition; Black and Hawks; pp 1074)
OPTION A – Total hysterectomy with unilateral salpingo-oophorectomy. (TAUSO)
OPTION B – Radical Hysterectomy
OPTION C – Total Hysterectomy with bilateral salpingo-oophorectomy (TAHBSO)
 ***Panhysterectomy – Removal uterus, cervix, fallopian tube except the ovary.
79. A client with cervical cancer is being treated with a radioactive cervical implant. The client's husband asks
the nurse if he can spend the night with his wife. The nurse should explain that:
a. Overnight stays by family members is against hospital policy.
b. There is no need for him to stay because staffing is adequate.

c. His wife will rest much better knowing that he is at home.

d. Visitation is limited to 30 minutes when the implant is in place.

CORRECT ANSWER D
RATIONALE:Clients with radium implants should have close contact limited to 30 minutes per visit. The general
rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using
lead to shield against the radium. Teaching the family member these principles is extremely important. Answers A,
B, and C are not empathetic and do not address the question; therefore, they are incorrect.

80. A client with bladder cancer is being treated with iridium seed implants. The nurse's discharge teaching should
include telling the client to:
a.Strain his urine

b.Increase his fluid intake

c. Report urinary frequency

d.Avoid prolonged sitting

CORRECT ANSWER A
RATIONALE: Iridium seeds can be expelled during urination, so the client should be taught to strain his urine and
report to the doctor if any of the seeds are expelled. Increasing fluids, reporting urinary frequency, and avoiding
prolonged sitting are not necessary; therefore, answers B, C, and D are incorrect.

Situation 14 - Mr. Muscle, age 63, is admitted to the hospital with a diagnosis of Congestive Heart Failure (CHF). The
physician’s orders include 500 mg of chlorothiazide (Diuril) P.O. twice daily and 0.25 mg of Digoxin (Lanoxin) P.O. daily.

81. Assessment of Mr. Muscle would most likely reveal:

a. Crushing chest pain unrelieved by rest or nitroglycerin ( Nitro-Bid)
b. Diaphoresis with cool, clammy skin
c. Distended neck veins and dependent pitting edema
d. Fever and elevated white blood cell count.

CORRECT ANS: C
RATIONALE: Congestive Heart Failure (CHF) increases systematic venous pressure, causing distended neck
veins. Increased blood volume in the venous system changes capillary membrane permeability, allowing plasma
to enter interstitial tissues.
OPTIONS A & B – Crushing chest pain unrelieved by rest or nitroglycerin and diaphoresis with cool clammy skin
are common symptoms of MI secondary to coronary artery occlusion.
OPTION D – Fever and elevated WBC count are common signs of pericarditis.

81. Mr. Muscle is in the acute phase of left ventricular heart failure. To alleviate his symptoms, the nurse should
place him in:
a. The dorsal recumbent position with elevated feet to reduce edema.
b. An upright position to promote chest expansion.
c. The low-fowlers position with elevated knees to slow the return of blood to the heart.
d. The left lateral sims position to promote emptying to ride side of the heart.

CORRECT ANS: B
RATIONALE: In left ventricular failure, the left ventricle cannot pump the necessary blood volume of oxygenated
blood coming from the lungs, resulting in lung congestion. An upright position allows full chest expansion, which
help relieves dyspnea.
OPTION A – The dorsal recumbent position decreases ventilation; elevating the feet increases blood flow to the
heart, putting a greater work load on it.
OPTION C – The low fowlers position with elevated knees may cause pooling of blood in the abdominal area,
which may lead to increased ascites and poor diaphragmatic contractions.
OPTION D – The left lateral sims position has not been proven more effective in emptying to the right side of the
heart; besides an increase in the amount of blood pumped from the right ventricle into the pulmonary circulation
would only worsen the patients condition.

83. Nurse Charm administers chlorothiazide. This drug should alleviate Mr. Muscle’s symptoms by:
a. Reducing circulatory volume through dieresis
b. Strengthening the force of ventricular contractions
c. Reducing the rate of metabolism and the body’s need for oxygen
d. Slowing the rate of heart contractions.
 CORRECT ANS: A
RATIONALE: Chlorothiazide (Diuril) is a diuretic that acts on the distal tubules to increase the excretion of water,
sodium, chloride, and potassium; this lowers the circulatory volume and alleviates the patient’s symptoms.
OPTIONS B & D – Digoxin (Lanoxin) strengthens the force of ventricular contractions and slows the heart rate.
OPTION C – Chlorothiazide does not affect the metabolic rate.

84. Mr. Muscle is placed on a strict low-sodium, high potassium diet. Which lunch menu is most appropriate for him?
a. Bologna sandwich on low-sodium bread, carrot sticks, orange, and skim milk.
b. Tuna fish, noodle and vegetable casserole, banana and coffee.
c. Boiled egg sandwich on low-sodium toast; lettuce, tomato, onion salad; banana; skim milk.
d. Chicken sandwich on low sodium bread, celery sticks, apple, and tea with lemon.

CORRECT ANS: C
RATIONALE: This meal is low in sodium, has an item high in potassium (banana) and includes foods from all four
basic groups.
OPTIONS A,B & D – Bologna, Carrot sticks, tuna fish, and celery sticks all have high sodium content; Coffee and
tea provide no nutrition.

85. When assessing Mr. Muscle for sign and symptoms of digoxin toxicity, the nurse should watch for all
of the following except:
a. Bradycardia, tachycardia, begimeny, ectopic beats, and pulse deficits.
b. Anorexia, nausea and vomiting, diarrhea, and abdominal pain.
c. Headache, double or blurred vision, drowsiness, confusion, restlessness, and muscle weakness.
d. Abdominal distention, weakness, paralysis, apathy, depression and hallucinations

CORRECT ANS: D
RATIONALE: Abdominal distention, weakness, paralysis, apathy, depression, and hallucinations are signs of
potassium and calcium overdose, not digoxin toxicity
OPTION A – Cardiovascular symptoms of Digoxin toxicity
OPTION B – GI symptoms of digoxin toxicity
OPTION C – Neurologic symptoms of digoxin toxicity

Situation 15 - Mr.Pakyaw has had a persistent cough for about 4 months. One week ago, he noted blood in his sputum.
He is admitted in the hospital for diagnostic testing. The physician orders a bronchoscopy.

86. Immediately after the bronchoscopy, the nurse should withhold food and fluid until Mr. Pakyaw’s
gag reflex returns, to prevent:
a. Aspiration
b. Abdominal distention
c. Dyspnea
d. Dyspepsia

CORRECT ANS: A
RATIONALE: After a bronchoscopy, the gag reflex must be present to prevent aspiration of food or fluid into the
lungs.
OPTIONS A, B & C – are not related to the presence of the gag reflex

87. Mr Pakyaw is diagnosed with lung cancer. The physician orders various pulmonary function tests,
including measurements of forced vital capacity and forced expiratory volume. The test results are used
before surgery to:
a. Evaluate the spread of the disease
b. Estimate the amount of anesthesia needed for surgery
c. Determine the amount of lung tissue to be removed
d. Calculate whether the contemplated surgery will leave enough functioning lung tissue

CORRECT ANS: D
RATIONALE: Pulmonary function tests, which measure lung volume and capacity, help identify the degree of
respiratory disability. The results indicate whether enough functioning lung tissue will be intact after surgery to
compensate for the removal of the diseased tissue.
OPTIONS A, B & C – Pulmonary function tests are not used to evaluate the spread of the disease, estimate the
amount of anesthesia needed for the surgery, or determine how much tissue needs to be removed.

88. After lobectomy, Mr. Pakyaw is returned to the unit with chest tubes in place. The nurse assigns a
nursing diagnosis of Impaired gas exchange related to lung alterations after surgery. With this diagnosis,
the expected outcome is that the patient will:
a. Report less chest pain
b. Assume a semi-fowlers position
c. Request pain medication frequently
d. Exhibit a respiratory rate of less than 20 breaths / minute without dyspnea

CORRECT ANS: D
RATIONALE: A normal respiratory rate (less than 20 breaths / minute) without dyspnea indicates probable lung
expansion and effective chest tube functioning.
 OPTIONS A & C – Reporting chest pain and requesting pain medication frequently would be more appropriate
patient outcomes for a nursing diagnosis of Pain related to lung impairment and chest surgery.
OPTION B – Assuming a semifowlers position, which facilitates breathing, may indicate that gas exchange is still
impaired.

89. Mr. Pakyaw will undergo radiation therapy on an outpatient basis to treat the lung cancer. When teaching
Mr. Pakyaw about skin care, the nurse should encourage him to:
a. Use skin lotions and powders on the irradiated area
b. Avoid washing off the marks placed on his skin to guide radiation therapy
c. Wear constrictive clothing
d. Massage the irradiated area to increase circulation

CORRECT ANS: B
RATIONALE: If the patient washes off the marks placed on the skin to guide radiation therapy, the areas must be
reassessed and remarked – a time consuming tasks.
OPTION A – Skin lotions and powders are contraindicated because they may irritate the skin in the
irradiated area.
OPTION C – The patient should avoid wearing constrictive clothing, which decrease circulatory circulation.
OPTION D – Massaging an area alredy tender fromradiation can cause irritation and pain.

90. Mr. Pakyaw’s wife, Chenny, is concerned about his poor appetite and weight loss. Nurse Erika explains
to her that radiation treatment, anxiety, and the disease itself can cause anorexia in cancer patients.
Nurse Erika should encourage Mr. Pakyaw to:
a. Limit activity before and after meals
b. Force fluids
c. Eat high calorie foods
d. Eat hot meat dishes with special sauces

CORRECT ANS: C
Because Mr. Pakyaw’s loss of appetite causes him to eat less than normal, he should make every mouthful count
by eating high calorie foods.
OPTION A – moderate activity increases persons appetite.
OPTION B – Forcing fluids typically causes a feeling of fullness; this would further reduce the patients appetite
and nutritional intake.
OPTION D – He should avoid hot meat dishes, which commonly cause a metallic taste in the patient receiving
radiation therapy.

Situation 16 - Mrs.Dyangga, age 53, has been experiencing bone pain, recurrent infections and abdominal pain for the
past 5 years. After ordering a battery of tests, including x-ray studies, the physician diagnoses Multiple Myeloma.

91. The physician orders administration of melphalan (Alkeran) for Mrs. Dyangga because this drug
causes pancytopenia, the nurse should assess the patient for:
a. Alopecia
b. Skin pigmentation changes
c. Thrombophlebitis
d. Decreased WBC count

CORRECT ANS: D
RATIONALE: Pancytopenia refers to depression in all the blood’s cellular elements; the patient on Melphalan
(Alkeran) therapy would probably have a reduced WBC count.
OPTIONs A & C – Temporary alopecia and mild thrombophlebitis at the infusion site are adverse effects of
melphalan therapy, but they are not related to pancytopenia.
OPTION B – Skin pigmentation is governed by melanocytes, which are controlled by pituitary gland; because
melphalan affects bone marrow production of blood cells, the drug would cause skin pigmentation changes.

92. Nursing care for Mrs. Dyangga should include:

a. Giving 2,000 ml of fluids daily
b. Giving more than 3,000 ml of fluid daily
c. Restricting fluid intake to equal the patient’s insensible fluid loss
d. Encouraging increased intake of fluids, particularly milk

CORRECT ANS: B
RATIONALE: The daily fluid intake of the patient with multiple myeloma should be 3,000 to 4,000 ml. Multiple
myelomas cause bone destruction and high calcium in bloodstream, and excess plasma cells produce high
globulin levels; a high fluid intake helps dilute the calcium overload and prevent protein from precipitating in the
renal tubules.
OPTION A – Less than advised fluid intake.
OPTION C – restricting fluid intake would increase the risk of renal stones
OPTION D – Milk would increase the patients blood calcium level, possibly contributing to calcium excretion in the
urine.

Situation 17 - Nurse Lucille is caring for Madame L, age 59, in the hospital with tentative diagnosis of stage III B
Hodgkins disease.

93. Which assessment finding strongly indicates Hodgkin’s disease?

 a. Night sweats
b. Enlarged lymph nodes
c. Reed-Sternberg cells
d. Hepatomegaly

CORRECT ANS: C
RATIONALE: Reed- Sternberg cells proliferate in the patient with Hodgkins disease, replacing other cellular
elements found in the lymph nodes.
OPTIONS A & B – Night sweats and enlarged lymph nodes occur with hodgkins disease, but they may be caused
by other diseases.
OPTION – Hepatomegaly occurs with other conditions, such as cirrhosis, but not with Hodgkin’s disease.

94. The usual drug therapy for the patient with stage III B Hodgkin’s disease is called MOPP. The “O” in MOPP
stands for:
a. Prednisone (Orasone)
b. Vincristine (Oncovin)
c. Oxacillin (Bactocill)
d. Oxamniquine (Vansil)

CORRECT ANS: B
RATIONALE: The “O” in MOPP stands for Vincristine (Oncovin). The patient with stage III B Hodgkin’s Disease
receives a cyclic drug combination of mechlorethamine (Mustargen), vincristine (Oncovin), procarbazine
(Matulane), and prednisone (Orasone); these drugs are given for 14 days, with 14 days rest between cycles.

OPTION A – “P” in MOPP therapy

OPTION C – Oxacillin (Bactocil) is an antibiotic
OPTION D – Oamniquine (Vansil) is an antihelmintic

95. Which nursing intervention is most effective in relieving nausea and vomiting associated with MOPP therapy?
a. Administering an antiemetic simultaneously with the drug
b. Encouraging the patient to drink hot liquids, such as coffee or tea
c. Giving an antiemetic 1 to 3 hours before MOPP administration
d. Provide frequent oral hygiene

CORRECT ANS: C
RATIONALE: The best intervention for relieving Nausea and Vomiting from MOPP therapy is to administer an
antiemetic 1 to 3 hours before starting therapy; this gives the antiemetic time to take effect.
OPTION – An antiemetic administered simultaneously with MOPP therapy may not be as effective.
OPTION B – The patient should not drink hot liquids; they appear to contribute to nausea.
OPTION D – Frequent oral hygiene may reduce stomatitis, but it does not relieve nausea

96. A patient who has sustained a fracture of femur is at risk for which of the following complications in the
immediate post-fracture period?
a. Electrolyte imbalance
b. Fat embolus
c. Fluid Volume deficit
d. Disuse Syndrome

CORRECT ANS: B
RATIONALE: Complications of fractures include infection, compartment syndrome, venous thrombosis and fat
embolism. (Source: CGFNS study guide 5th edition; pp 323)
OPTION A & C – Electrolyte imbalance and fluid volume deficit may occur post-surgery but they are not evident in
the immediate post-fracture period.
OPTION – Disuse Syndrome may occur late into the post fracture period but is not seen immediately.

97. A patient who has a long leg cast says to Nurse Hazel, “My thigh is itching under the cast.” To provide relief,
Nurse Hazel should?
a. teach patient guided imagery techniques.
b. apply heat to the cast at the site of the itching.
c. elevate the patients affected leg on pillows
d. encourage the patient to move his/her toes.

CORRECT ANS: A
RATIONALE: Itching under the cast can be extremely uncomfortable. The patient may be tempted to slip an
object under the cast to scratch. This is a dangerous practice because of the possibility of breakage and / or skin
irritation. Guided imagery is a way to help patients distract themselves from their pain and may produce relaxation
response. (Source: CGFNS study guide 5th edition; pp 324)
OPTION B – Heat increases itching due to vasodilation.
OPTION C – Elevation prevents dependent edema.
OPTION D – Inability to move the toes indicates compression. The cast may be too tight if the patient is unable to
move his / her toes.

98. Nurse Cherry is caring for a patient who is receiving litium carbonate (Eskalith). Prior to administration of
the next dose, Nurse Cherry finds that the patient’s lithiumblood level is 1.6 mEq /dL. Which of the
following actions should Nurse Cherry take first?
 a. Call the patient’s physician
b. Withhold the dose
c. Take the patients Vital signs
d. Repeat the blood lithium level

CORRECT ANS: B
RATIONALE: The first step a nurse should take when a blood lithium level is 1.6 mEq/ dL or above is to withhold
the lithium dose. (Source: CGFNS study guide 5th edition; pp 324)
OPTION A – The physician should be called to re-evaluate the dose after the nurse has the results of a redrawn
lithium level.
OPTION C – Vital signs may be helpful in assessing if the patient is dehydrated, which can cause an increase in
lithium levels. However this should be the initial action by the nurse.
OPTION D – The nurse should recheck the lithium level after withholding the dose of lithium.

99. Which of the following goals would be given priority in the care plan of a two year old child who
has acute gastroenteritis?
a. Promote hydration.
b. Reduce lethargy
c. Preserve skin integrity
d. Maintain comfort

CORRECT ANS: A
RATIONALE: Therapeutic management of acute diarrheal disease ( acute gastroenteritis) is directed at correcting
the fluid and electrolyte imbalance and preventing or treating malnutrition. Major goals are assessment of fluid
and electrolyte imbalance, re-hydration, maintenance fluid therapy, and reintroduction of an adequate diet.
(SOURCE: CGFNS study guide 5th edition; pp 384)
OPTION B – Lethargy, defined as abnormal drowsiness or stupor, can be caused by high fevers, dehydration and
electrolyte imbalances. While the child with acute gastroenteritis may become lethargic, the correction of the fluid
and electrolyte imbalance is the priority.
OPTION C – A patient goal should be to promote skin integrity, since frequent stools will cause irritation to the
skin. However this should not be the priority goal.
OPTION D – A patient goal should be to promote comfort and relieve stress; however, the primary goal for patient
is hydration

100. A priority nursing intervention for the care of a terminally ill patient diagnosed with metastatic cancer is
a. Maintaining bowel function
b. Alleviating and relieving pain
c. Preventing respiratory arrest
d. managing chemotherapy.

CORRECT ANS: B
RATIONALE: Individuals with cancer pain have a right to obtain optimal pain relief. Nurse caring for terminally ill
patient with metastatic cancer have an ethical obligation to provide pain relief. A goal is to assist the patient to
achieve as comfortable a death as possible. (Source: CGFNS study guide 5 th edition; pp 89)
OPTION A – While constipation may be a problem secondary to pain medications, it is not the priority intervention
in the terminally ill patient.
OPTION C – A goal in the care of a terminally ill cancer patient is not to prolong life, but to provide comfort.
Preventing respiratory arrest would prolong life.
OPTION D – Many terminally ill patients no longer receive chemotherapy. Managing chemotherapy is the role of
oncologist.