DECEMBER 2013 BOARD QUESTIONS

Situation 1 You are assigned to a group of toddlers. You reviewed the childrens stage of growth
and development and considered this in providing health education to parents regarding child care.
1. The BEST way for parents to aid a toddler in achieving his developmental task would be to
A. Help him learn to count
C. Urge him to dress up completely by
B. Give him small household chores to do
himself
D. Allow him to make simple decisions
E.
F. 2. The mother of a 2-year old boy tells you that she constantly scolds him for having wet
pants. She says her son was trained at 12 month, but since he started to walk, he wets all
the time. Which nursing diagnosis would be most applicable?
A. Ineffective coping related to lack of self-control of 2 year old
B. Excess fluid volume related to inability to control urination
C. Deficient parental knowledge related to inappropriate method for toilet training
D. Total urinary incontinence related to delayed toilet training
G.
H. 3. A mother of a toddler verbalized concern because her child takes her blanket everywhere.
Which advice would be MOST appropriate for her regarding this?
A. Have her daughter evaluated by child psychologist
B. Destroy the blanket by cutting off a strip from it to carry everyday
C. Make subtle efforts to remove the blanket
D. Understand that this is probably a normal event
I.
J. 4. You plan to conduct health teaching focusing on toilet training. Which of the following is
the MOST important factor for successful toilet training?
A. Age of the child
B. Toilet training at scheduled time
C. Primary caregivers flexibility
D. Developmental readiness of the child
K.
L. 5. As a nurse you would advise a toddlers mother to handle temper tantrums by:
A. Appearing to ignore them
B. Promising him a special activity if he will stop
C. Distracting him with a toy when he begins to hold his breath
D. Mimicking his behavior by also holding her breath
M.
N. Situation 2 Assigned to care for mothers on Labor and Delivery, varied conditions by
birthing mothers are always a continuing challenge. The following conditions apply.
O. 6.
Dyna, G3P2, was admitted at 32 weeks gestation contracting every 7-10 minutes. Her
cervix is 2cm dilated and 70% effaced. For Dynas care what should you have to include in
your nursing care plan?
P. A.
Monitor Dyna and her fetus for response to impending delivery
Q. B.
Start oral terbutaline to stop contraction
R. C.
Assess Dynas past pregnancy history to determine if she has experienced preterm
labor in the past
S. D.
Discuss and agree with Dyna the need to stop working after her discharge from the
hospital
T.
U. 7.
Dimple was admitted in premature labor contracting every 5 minutes. Her cervix is
3cm dilated and 100% effaced, IV MgSO4 at 1g per hour is infusing. You will know that the
drug is providing the desired effect on Dimple when:
V. A.
Contraction diminish in frequency and finally disappear
W. B.
She is able to sleep through her contractions
X. C.
Contraction increase in frequency to every 3 minutes, while there wont be any further
cervical changes
Y. D.
Dimple will experience diminished deep tendon reflexes as well as decline in blood
pressure
Z.
AA.
8.
Andrea just received an epidural for anesthesia during her labor. What should
you include in the plan of care considering the type of anesthesia used.
AB.
A.
Offering a back rub for Andrea to reduce her discomfort during contractions
AC.
B.
Placement of a foley catheter as soon as the anesthesia has been administered
AD.
C.
Assisting Andrea in her position changes while observing for signs of labor
progress
AE.
D.
Intravenous administration of 500- 1000 ml of sugar- free crystalloid solution
AF.
AG.
9.
Celeste delivered her infant son 3 hours ago. She had an episiotomy to facilitate
delivery. Which of the following nursing actions would be the MOST appropriate?

AH.
A.
Take Celeste to a Sitz bath
AI. B.
Administer analgesic medications as ordered
AJ. C.
Place an ice pack on Celestes perineum
AK.
D.
Apply a heat lam to Celestes perineum
AL.
AM.
10.
Lorna is scheduled for a cesarean section delivery due to a transverse fetal lie.
How do you evaluate Lornas level of understanding of the procedure she will undergo?
AN.
A.
Ask Lorna to tell you what she knows about the scheduled surgery
AO.
B.
Draw a diagram of the human body then test Lorna by asking her to draw the
procedure for you
AP. C.
Provide Lorna with the materials for her to read which explains cesarean deliveries
upon her arrival to the hospital
AQ.
D.
Inquire about the help Lorna would have at home after her delivery
AR.
AS.
Situation 3 You are a newly licensed RN and you were accepted in a Government
District Hospital in your native province. Your nursing assignments revolve around the care of
infants and children. The following conditions apply.
AT. 11. You are caring for a 2-month old infant. A pH probe test indicates that the infant has
reflux. Which nursing intervention is MOST appropriate?
A. Teach the mother CPR
B. Elevate the head of the bed
C. Maintain a normal feeding schedule
D. Hold the next feeding
AU.
AV. 12. A 3 month old is placed in Bryants traction for development dysplasia of the hips. Which
of the following toys would be appropriate for you to offer the infant during institutional care?
A. A stuffed animal
C. A tape playing nursery rhymes
B. Colorful blocks
D. A rattle
E.
F. 13. Which of the following nursing approaches would be MOST appropriate to use while
administering oral medication to a 4-month old?
A. Place the medication in a full bottle of formula
B. Place the medication in 45 ml of formula
C. Administer the medication using a plastic syringe, with the infant in reclining position
D. Place the medication in an empty nipple and allow the infant to suck
G.
H. 14. Which of the following nursing actions has the HIGHEST priority for a teenager admitted
with burns to 50% of his body?
A. Health counseling regarding problems of body image
B. Encourage peers to visit on a regular basis
C. Maintain airborne precautions
D. Maintain aseptic technique during procedures
I.
J. 15. A nursing team in the ordinary Philippine Health Care Delivery set-up may consist of one
RN with one or two Nursing Assistants depending on the acuity of case assigned. The nurse
should consider the assignments appropriate if the nursing assistant is assigned to care for a
client with
A. Cancer who has Cheyne- stokes respirations
B. Alzheimers disease requiring assistance with feeding
C. Scleroderma receiving a tube feeding
D. Osteoporosis complaining of burning sensation on urination
K.
L. Situation 4 A generalist nurse needs the necessary competencies to attend to birthing
mothers normal or at risk and most especially those considered high-risk and in varied
settings. The following conditions apply
M. 16.
Nurse Marie is a Community Health Nurse conducting prenatal care at the Rural Health
Unit in one of the communities in Cotabato. Nurse Marie is aware that recent developments
in Maternal Care strongly place emphasis on quality antepartal care. The strength of this
advocacy and health measure is on:
N. A.
Consistent conduct of vaginal examination preferably on every prenatal visit
O. B.
Doing monthly antenatal care during the first 7 months, every two weeks on the 8th
month, and weekly on the 9th month
P. C.
Spending more time with every pregnant woman especially the high risk ones
Q. D.
Proper care to every pregnant woman strongly focusing on the provision of support to
normal pregnancy and the early detection and management of complications
R.
S. 17.
On one occasion Jenna, primigravida mother came for check-up. This was May 12,
2013 and her EDC happens to be May 21, 2013. What can she expect to find during
assessment?

T.
U.
V.
W.

A.
B.
C.
D.
pubis

FH at least at the level of the xyphoid process, engaged

FH- 2 fingers below xyphoid process, engaged
Cervix open, FH- 2 fingers below xyphoid process, floating
Cervix closed, uneffaced, fundal height midway between the umbilicus and symphisis

X.
Y. 18.
On a Monday morning, following nurse Maries community nursing assignment, she
goes on duty in their RHU-attached district hospital. She attends to Lanie who just had her
second vaginal examination and in labor. Nurse Marie determines that the fetus is in the right
occiput anterior position (ROA) and at (-) 1 station. This is based on her findings from her
examination of the fetal presenting part which is:
Z. A.
1 cm below the ischial spines
AB.
C.
Directly in line with the
AA.
B.
1 cm above the ischial
ischial spines
spines
AC.
D.
In no relationship to the
ischial spines
AD.
AE.
19.
By 12:00 noon same Monday, another patient attended to by Nurse Marie in the
RHU, Evelyn, was admitted in active labor. Nurse Marie locates the fetal heart sounds in the
upper right quadrant of the mothers abdomen. Here Nurse Marie recognizes which of the
following?
AF. A.
The fetus is in the most common anterior fetal position
AG.
B.
This position is referred to as being left- antero pelvic
AH.
C.
This indicates that Evelyn will probably have breach delivery
AI. D.
Evelyn will probably deliver quickly without problems
AJ.
AK.
20.
By 3:00PM, when Nurse Marie was done with her endorsements, another
mother, Abbie was rolled in already in active labor. She suddenly trembles, becomes very
tense with contractions and is quite irritable. She would frequently say , hindikona kaya ito!
(I can no longer bear this!) This kind of behavior may be indicative that the client
AL.A.
Is already entering the transition phase of labor
AM.
B.
Is developing some abnormality in terms of uterine contractions
AN.
C.
Needs immediate administration of an analgesic or anesthetic
AO.
D.
Has been poorly prepared for labor in the parents classes
AP.
AQ.
Situation 5 Personal and professional development is as much the responsibility of
the nurse as it is for nursing services handling nurses in any healthcare setting. The following
situations apply.
AR.
21.
After starting a new job at a nurse-managed long term healthcare facility, nurse
Paulo took time to evaluate his job assignments. Which of the following job assignments
deserves appropriate PRIORITY questioning?
AS.
A.
A licensed nurse assigned to perform uncomplicated wound care
AT. B.
A non- licensed nurse graduate giving medications to all patients in the unit
AU.
C.
An unlicensed nurse graduate assigned to assist clients with activities of daily
living
AV. D.
A licensed nurse assigned to admit clients to the facility
AW.
AX.
22.
Nurse Jackie is conducting the orientation of new nurses in the same health
facility particularly assigned to the assisted living healthcare unit. Which of the following
should nurse Jackie include in the orientation?
AY. A.
Procedures for caring for client- residents with intravenous therapy or wound care
AZ.
B.
Client- residents who are all independent in daily care and medication
BA.
C.
Skilled nursing care is provided 24 hours a day
BB.
D.
Socialization is encourage and small group outings are offered twice per week
BC.
BD.
23.
Nurse Ronna is caring for four clients in a medical- surgical unit from a nearby
government hospital, each with orders to be transferred to the nurse-managed long term
healthcare facility. Which of the following transfer orders would appropriate for nurse Ronna
to question?
BE.
A.
A 62- year old client who has diabetes mellitus and recently had a below- theknee amputation and is receiving wound care to a sub- acute care unit
BF. B.
A 28 year old client who recently experienced a severe head trauma and is in coma to
a rehabilitation unit
BG.
C.
A 3 year old client with a permanent physical disability to a special care unit
BH.
D.
An 85 year old client who has mild dementia and a history of frequently
misplacing things and forgetting to take medications to an assisted living facility
BI.
BJ. 24.
Which of the following activities performed while on the job would appropriately result
in a reprimand?
BK.
1.
A registered nurse going out of the facility to smoke a cigarette

BL.2.
A registered nurse leaving unlicensed facility personnel to transfer patients from their
beds to wheelchairs
BM.
3.
A registered nurse on duty leaving her post to attend t a physician appointment
in the same hospital
BN.
4.
A registered nurse leaving the admission of new clients to the facility to
unclicensed health personnel
BO.
A.
1, 2, and 4
BQ.
C.
Only 3
BP. B.
3, 4, 1
BR.
D.
2,3,4
BS.
BT. 25.
Nurse Mickah is caring for a client who had a mild cerebrovascular accident (CVA) on a
rehabilitation unit. In order to maximize goal of rehabilitation, which of the following should
be included in the clients plan of care?
BU.
A.
Inform the client of the limitations as a result of the CVA
BV. B.
Administer all of the clients medication on time
BW.
C.
Encourage the client to participate in all physical and speech therapies
BX.
D.
Offer the client a high- protein and caloric diet
BY.
BZ.
Situation 6 Caring for mothers during the antepartal period also involves conditions
which place them at risk. Here are some of those conditions which require safe nursing care
interventions.
CA.
26.
Andrea, a pregnant mother, is admitted with a diagnosis of ectopic pregnancy.
Your priority nursing intervention is to:
CB.
A.
Allow Andrea and her
CD.
C.
Monitor Andreas vital
family to grieve for the lost pregnancy signs
later
CE.
D.
As Andrea about her blood
CC.
B.
Obtain surgical consent
type
CF. 27.
After being hospitalized for pregnancy-induced hypertension (PIH), Honey (the client)
asks you her baby is in danger from her high blood pressure. You will base your response on
which of the following?
CG.
A.
Placental perfusion is already at risk
CH.
B.
Honeys hypertension early in pregnancy has already damaged the fetus
CI. C.
Her fetus blood pressure will also be elevated
CJ. D.
Honeys headache will prevent her from taking in adequate nutrition
CK.
CL.28.
You used Nitrazine paper to test the vaginal fluid from Joan a pregnant client, who
feels her membranes have already ruptured. If the membranes have already ruptured you
would expect that the Nitrazine paper will:
CM.
A.
Not change color
CO.
C.
To dark green
CN.
B.
Turn blue
CP. D.
Be bright yellow
CQ.
CR.
29.
In one prenatal appointment, you evaluated the record of a 41-year old client
and entertained that she is at risk for delivering a child with what possible chromosomal
abnormality?
CS.
A.
Hemophilia
CU.
C.
Turners syndrome
CT. B.
Downs syndrome (trisomy 21)
CV.D.
Cystic fibrosis
CW.
CX.
30.
In planning the care of Bheng, a pregnant mother who has diabetes mellitus and
is taking insulin, which of the following should you entertain as possible medical intervention
from her attending obstetrician?
CY. A.
Increase in the dosage of her
DA.
C.
Discontinuance of the
insulin
insulin
-eliminate
CZ.
B.
Decrease in the dosage of
DB.
D.
Continuance of the same
her insulin
dose of insulin
DC.
DD.
Situation 7 Providing health education to clients seem inherent among most Filipino
Nurses. This is an important practice and is a responsibility towards pregnant mothers. The
following questions apply.
DE.
31.
Maru, a client who is pregnant for the first time attends the prenatal clinic. Maru
tells you Im worried about gaining too much weight because I have heard that it is bad for
me The nurses best response would be,
DF. A.
A 25 pound weight gain is recommended however, the pattern of your weight gain
will be more important than the total count
DG.
B.
Yes weight gain causes complication during pregnancy
DH.
C.
Dont worry about gaining weight. We are more concerned if you dont gain
enough weight to ensure proper growth of the baby
DI. D.
If you gain over 15 pounds, you will have to follow a low- calorie diet
DJ.
DK.
32.
Mrs. Puruganan is a patient you meet in a prenatal clinic. As the nurse in
charge, you are fully aware that the client understands your instructions when to refer to her

obstetrician the danger signs of pregnancy, when she states that, I will see my doctor when
I develop
DL.
A.
Leg cramps
DO.
D.
Nausea and vomiting
DM.
B.
Heartburn
during first trimester
DN.
C.
Tight finger rings and puffy
eyelids
DP.
DQ.
33.
A client, 28 weeks of gestation, experiences constant low back pain and asks
you to teach her exercises that will provide some relief. As a nurse, you would consider the
teaching effective if the client performs
DR.
A.
Abdominal contractions
DT.C.
Tailor sitting
DS.
B.
Kegels exercise
DU.
D.
Pelivic rocking
DV.
DW.
34.
When assessing a woman who is six days postpartum following vaginal delivery,
you are expected to describe lochia as:
DX.
A.
Pink in color with the
DZ.
C.
Red in color with
occasional small clots
occasional small dots
DY. B.
Brown in color with red clots
EA.D.
White in color without clots
EB.
EC.
35.
Which of the following physiologic responses would you consider normal in early
postpartum period among clients you handle?
ED.
A.
Decrease in blood pressure
EF. C.
Urinary urgency and dysuria
EE.B.
Increase motility of the GI system
EG.
D.
Rapid diuresis
EH.
EI. Situation 8 As community organizer, the nurse encounters a lots of challenges just to get
things accomplished in meeting the health and development needs of the community.
EJ.
EK.36. You are faced with realities of seeking data and analyzing these data for purposes of
coming up with rational community diagnosis. You are aware that all these efforts are
intended to:
A. Serve as data base of information for any and all socio economic and even political ends of
LGU management
B. Facilitate the identification of community problems
C. Answer the problems of the community
D. Establish trends and pattern in terms of health needs and problems of the community
EL.
EM.
37. In planning for community health nursing programs and services, priority goals are
set based on:
A. Availability of the resources
C. Priority agenda of the local health
B. The nature of the problem encountered
officials
D. Existing health policies and legislations
E.
F. 38. When community leaders dominate the decision making for community health services
and programs in organization, this is
A. Consensus decision making
B. Unilateral action of one dominating other members decision
C. Leadership and decision making monopoly by community health leaders
D. Democratic vote dominance decision making
G.
H. 39.
To motivate and mobilize people in an organization a good facilitator must possess the
following competencies, EXCEPT
I. A.
A demonstration of professionalism, self confidence and genuine concern for people
J. B.
The ability to adapt to the changing situation
K. C.
Be more interested in achieving objectives toward building ones own credentials and
credibility
L. D.
The ability to share responsibility in a group/ organizations journey in achieving set
goals
M.
N. 40.
The purpose of evaluation in the planning cycle is to determine the following, EXCEPT
O. A.
Determine specific gains from the program based on set criteria and standards
P. B.
Determine whether the program is relevant and effective
Q. C.
Learning the level obtained in terms of personal contribution to the programs and
projects
R. D.
Estimate the resources needed for the implementation activity
S.
T. Situation 9 Caring for mothers during the INTRAPARTAL period gets any nurse into a lot of
seeming routine undertakings but in all these are meaningful tasks in bringing about a new
life. Here are some of those conditions which require safe nursing care interventions.

U. 41.
You are performing an admission assessment on Chell in early labor at 40 weeks of
gestation and evaluates the normal fundal height to be
V. A.
48 cm
X. C.
35 cm
W. B.
38 cm
Y. D.
40 cm
Z.
AA.
42.
After performing Leopolds maneuver on Chell, you should prepare her for a
vaginal delivery after determining the fetus in which of the following positions?
AB.
A.
Longitudinal, cephalic lie,
AD.
C.
Transverse lie
vertex presentation
AE.
D.
Oblique lie
AC.
B.
Longitudinal, cephalic lie,
face presentation
AF.
AG.
43.
You are caring for Chie, a client who is 5cm dilated. You should follow the
protocol for care of the client in
AH.
A.
Second stage of labor
AK.
D.
Transition, first stage of
AI. B.
Latent phase, first stage of labor
labor
AJ. C.
Active phase, first stage of labor
AL.
AM.
44.It is a priority when caring for Cristina, a newly delivered mother to monitor fundal
height and tone, lochia, and vital signs especially when her uterus is boggy and fails to
contract. She is most likely having:
AN.
A.
Fever
AQ.
D.
Disseminated
AO.
B.
Postpartum hemorrhage
intravascular coagulation
AP. C.
Hematoma
AR.
AS.
45.
Ezzer, a client 38 weeks of gestation complains of pain in the public bone
when walking. You informed the client that this is laxity of the symphysis pubis due to which
of the following hormones?
AT. A.
Relaxin
AV. C.
Melantrophin
AU.
B.
Progesterone
AW.
D.
Estrogen
AX.
AY. Situation 10 Caring for mothers during the Antepartal and Intrapartal period challenges
every nurse considering the complex tasks that need to be performed, the same is true
during the POSTPARTAL PERIOD. The following situations apply.
AZ.
46.Which of the following clinical manifestations would you assess as indicative of
pregnancy induced hypertension (PIH) for Mae, 2 days after vaginal delivery?
BA.
1.
ringing of the ears
BD.
4.
headache
BB.
2.
chest pain
BE.
5.
edema
BC.
3.
epigastric pain
BF. 6.
visual changes
BG.
BH.
A.
2,3,4,5
BJ. C.
4,5,6,1
BI. B.
1,2,3,4
BK.
D.
3,4,5,6
BL.
BM.
47.
Barbie, a postpartum client who delivered 24 hours ago, informs you of having
night sweats but denies other complaints. Her vital signs are as follows: Temp 37.3 degree
Celsius (99.2 F) PR 68 RR 18 breaths/ min and BP 120/68. Which is your most
APPROPIATE intervention?
BN.
A.
Assure the client that findings are all normal and monitoring shall continue
BO.
B.
Tell the client that she might have some infections
BP. C.
Notify the physician
BQ.
D.
Just proceed with regular monitoring
BR.
BS.48.
Methylergonovine maleate (Methergine) has been ordered for Joyce. You should
withhold this medication if which of the following would be present?
BT. A.
PR of 68
BW.
D.
Reduction in the amount of
BU.
B.
Breasts- tender
uterine blood flow
BV. C.
Blood pressure of 145/96
BX.
BY. 49.
Which among the following instructions should you include about the use of narcotic
pain medications following delivery?
BZ.
A.
Pain medications must be
CB.
C.
Pain medications can be
used only when pain is unbearable
constipating
CC.
D.
Driving is allowed while
CA.
B.
Pain medications will not
taking this medication
be addicting
CD.
CE.
50.
How much insulin should you administer to Margarita who has gestational
diabetes mellitus 6 hours after her delivery?

CF. A.
Same amount as given while she
was pregnant
CG.
B.
Insulin is not needed

CH.
C.
Best to shift to oral
diabetic medications
CI. D.
Should be increase from before
delivery

CJ.
CK.
Situation 11 Barangay Pag-asa is located at the foot of Sierra Madre Mountain. Main
livelihood here is farming and they have a total population of 9,000. Last year, there were 23
recorded pregnancies and two (2) maternal deaths. Three (3) cases of neonatal deaths were
likewise recorded. Four farmers also died of PTB while two died of accidents. The following
questions apply.
CL.51. What is the maternal death rate of the barangay?
CM.
86.95
CO.
87.96
CN.
95.86
CP. 87.95
CQ.
CR.
Situation 11 Barangay Pag-asa is located at the foot of Sierra Madre Mountain. Main
livelihood here is farming and they have a total population of 9,000. Last year, there were 23
recorded pregnancies and two (2) maternal deaths. Three (3) cases of neonatal deaths were
likewise recorded. Four farmers also died of PTB while two died of accidents. The following
questions apply.
CS.
52. The crude death rate is:
A. 1.22
C. 2.22
B. 1.32
D. 2.32
E.
F. 53. One of the farmers, Mang Leo who died of PTB underwent Standard Clinical Classification
(SCC) three times. He maybe classified under:
A. Category IV
C. Category III
B. Category II
D. Category I
E.
F. 54. Another farmer named Mang Juan has hypopigmented anesthethic skin lesions. Using the
Madrid classification, the lesion can be regarded as:
A. Borderline leprosy
C. Lepromatous
B. Polar tuberculoid
D. Tuberculoid
E.
F. 55. Mang Juans best treatment is:
A. PB, 19 blister packs
C. MB, 24 blister packs
B. MB, 18 blister packs
D. PB, 6 blister packs
E.
F. Situation 12 Documentation is an important aspect of every nurses activities. This is a
major area of responsibility which helps facilitate continuity of work within a 24 hour cycle.
G. 56.
A 26 year old mother was admitted for hyperemesis gravidarum. While taking the
history of this client it would be most important to report which of the following?
H. A.
Cool lower extremities bilaterally
J. C.
Anxiety about the effect of her
I. B.
Diminished palpable peripheral
condition to the baby
pulses
K. D.
Allergy to shellfish
L.
M. 57.
You are on duty and you received report from the previous shift. You will prioritize the
client who is:
N. A.
A scheduled to receive heparin and the PTT is 70 seconds
O. B.
Receiving blood transfusion and complains of a dry mouth
P. C.
Receiving ciprofloxacin (Cipro) and complains of a fine macular ras
Q. D.
IV potassium and complains of burning at the IV site
R. 58.
You are reviewing the nurses notes in your clients chart. You would be most
concerned by which of the following entries?
S. A.
Vital signs are within normal limits
T. B.
Foley catheter draining clear urine and the pH is 6.5
U. C.
The clients skin is blanched over the scapular areas
V. D.
The client drinks 3 glasses of orange juice everyday
W.
X. 59.
You are attending to clients in your clinic. As you return to your desk you find 4 phone
messages. Which of the messages from the client would you prioritize?
Y. A.
Mario who is nauseated and has vomited 6 times in the pervious 24 hours
Z. B.
Mario who complains of leg pain after walking half a mile
AA.
C.
Aling Dora who has stage II decubitus ulcer at home reports that the dressing
has come off
AB.
D.
Mercy who has cold symptoms has an oral temperature of 39.4 C
AC.
AD.
60.
At approximately 6 pm, nurses on duty in an affiliate hospital begin to read the
nurses notes for the evening shift. The last entry is noted for 1 PM and there is no signature.
The most appropriate nursing response is to

AE.

A.
Leave approximately 3 or 4 lines for the day nurse to enter the day information
and sign the chart
AF. B.
Do not enter anything until the day nurse has been notified of the problem and returns
to the unit to complete charting
AG.
C.
Review with the client the activities after 1 pm and enter what are determined
to be the activities after 1 pm
AH.
D.
Begin charting on the next line below the last entry, and make a note for the
day nurse to make a late entry to complete the chart
AI.
AJ. Situation 13 You are participating in the health promotion program of DOH. Your team has
planned to incorporate various lifestyle related activities.
AK.
61. The W.H.O. principle of health promotion serves as your guide. Which of the
following statements is not PART of the principles of health promotion of W.H.O.?
A. Combines diverse but complementary methods or approached including communication,
education, legislation and fiscal development
B. Involves the population as a whole but focuses on people at risk from specific diseases
C. Is directed towards action on the determinants of health and requires close cooperation
between sectors beyond healthcare
D. Is primarily a societal and political venture and not a medical service although health
professionals have an important role in advocating and enabling health promotion
AL.
AM.
62. In order to motivate people to participate in physical activities for health
promotion, the nurse should consider the following EXCEPT:
A. Provide options for age- based physical activities
B. Brisk walking as the best form of exercise for all age groups
C. Once a week of intense physical activities can compensate for the desired exercise
three times a week
D. Help clients to determine physical activities that can easily be integrated into their
daily activities
AN.
AO.
63. RE-orienting focus of health care delivery from cure to health promotion or
wellness is achieved by enhancing the skills of health workers in which of the following?
1. Screening
2. Case finding
3. Prevention of risk factors that contribute to development of major noncommunicable diseases (NCD) primordial prevention.
4. Prevention and management of NCD
A. 1 and 2
C. All except 4
B. 3 and 4
D. 1,2,3,4
E.
F. 64. Primary level of prevention is illustrated in which of the following activities?
A. Conducting operation timbang
B. Teaching a patient post- mastectomy exercises
C. Isolation of the child with TB
D. Teaching the mother of the child with diarrhea on how to use Oresol
G.
H. 65. Raising public awareness to ensure full community participation in health
promotion initiatives can be done through:
1. Producing and disseminating information through mass media, health campaigns, public
information system and school education (IEC)
2. Adopt and support policies and programs focused on health i.e. anti smoking (advocacy)
political
3. Initiating health promotion initiative such as Healthy Cities, Healthy Schools, Healthy
Worksites (advocacy)
4. Posting of community bulletin boards in places where people converge such as for mothers
class, barangay assemblies etc. - IEC
A. All except 2
C. 1,2,3,4
B. 1 and 2
D. 3 and 4
E.
F. Situation 14 Nursing students who are having their clinical and community experiences
(RLE) are on their way towards personal and professional development. These experiences
run far beyond building skills and applying knowledge but more so with building the
character of a professional nurse and her expected relationship within the profession. The
following situations apply.
G. 66.
You are the professional nurse supervising a student giving health teaching to a client.
Your intervention is required when you observe the student nurse:
H. A.
Keeps glancing at her wrist watch while instructing the client
I. B.
Chooses a time for teaching when there are no visitors
J. C.
Begins instructions to the client discussing information that concerns the client

K. D.
Uses culturally appropriate language and teaching materials
L.
M. 67.
You are the head nurse reviewing procedures with the health care team and with a
group of nursing students. You emphasized that as Head Nurse you can and will intervene if
and when necessary. You decide to intervene when staff nurse says, it is my responsibility
to:
N. A.
Answer questions that the patient may have before surgery
O. B.
Explain the surgery and ask the patient to sign the consent form
P. C.
Ensure that the consent form has been signed and attached to the patients chart
Q. D.
Uses culturally appropriate language and teaching materials
R.
S. 68.
You are observing a student nurse auscultate the lungs of a client. The student nurse
is correctly auscultating the right middle lobe (RML) if the stethoscope is placed in which of
the following positions?
T. A.
Posterior chest wall, midaxillary, right side
U. B.
Left of the sternum, midclavicular at right fifth intercostals
V. C.
Posterior and anterior base of the right side
W. D.
Right anterior chest between the fourth and sixth intercostals
X.
Y. 69.
A nursing student is assigned to you to mentor. In preparing a patient for a magnetic
resonance imaging (MRI) which of the following outcome-statement proves successful
mentoring?
Z. A.
The dye used in the test will turn my urine green for about 24 hours
AA.
B.
This procedure will take about 90 minutes to complete. There will be no
discomfort
AB.
C.
The wires that will be attached to my head and chest will not cause me any pain
AC.
D.
I will be put to sleep for this procedure. I will return to my room in 2 hours
AD.
AE.
70.
Again, within the mentoring process you observe a student nurse caring for a
client following standard precautions you determine that care is appropriate if the student
nurse performs which of the following activities?
AF. A.
Changes the dressing for a client with draining abscess
AG.
B.
Administers an IM injection to a client with rubella
AH.
C.
Delivers food tray to a client with hepatitis
AI. D.
Gives isoniazid (INH) to a client with tuberculosis
AJ.
AK.
Situation 15 The San Antonio Health Station in Barangay 33-A is about to conduct
community health services and the Community Health nurse is in charge of this activity. The
following questions apply.
AL.71.
Nurse Jenny, and nursing team involved in conducting community surveys, are aware
that to effectively provide appropriate intervention after completing the necessary
Community Survey they must come up with a comprehensive community diagnosis. Which of
the following has the correct step by step process?
AM.
A.
Define study population, determine objective, determine data to be collected,
develop instruments, collect data, actual data gathering, data analysis, community health
nursing problem, priority setting, data presentation, determine data to be collected,
AN.
B.
Determine objective, define study population, actual data gathering, data
presentation, develop instruments, data analysis, data presentation, priority setting, identify
community
AO.
C.
Determine objective, define study population, determine data to be collected,
actual data gathering, data presentation, develop instruments, data analysis, data
presentation, priority setting, identify community
AP. D.
A combination of two approximates the best procedure to be adopted by the
community health nurse
AQ.
Determine objective
Data collation
Define study population
Data presentation
Determine data to be collected
Data analysis
Collecting data
Identifying comm nursing problems
Developing instruments
Priority setting
Actual data gathering

72.
Considering cultural diversities, Nurse Jenny and her team considered which of the
following as NOT included in variables that could potentially make for population groupings
within the community?
A.
Concepts about health and illness
B.
Cultural beliefs and practices that affect health
C.
Ethnicity, social class, religion, race, language, political orientation
D.
Lifestyle, norms and practices


73.
While Nurse Jenny and her team start to deliberate on their approaches to the delivery
of community health services, other nurses want to find out which sex groups need
immediate and continued attention. In this case, which formula is best to be applied?
A.
Sex ratio is equal to population size divided by the number of female plus males
multiplied by 100
B.
Sex ratio is equal to number of females divided by no.of females multiplied by 1000
C.
Sex ratio is equal to population size at later time divided by the number of males
multiplied by 1000
D.
Sex ratio is equal to number of males divided by numbers of females multiplied by 100

74.
After much deliberation, Nurse Jenny and her nursing team identified the priority
community problems. Next step is planning. A threatening view of the concept of planning is
that it is
A.
Change oriented
C.
Futuristic
B.
A continuous and dynamic
D.
A scientific process
process

75.
Nurse Jenny and her team concluded their planning phase in partnership with
significant community resource e.g. the municipal doctor, midwives, the barangay health
workers, barangay nutrition scholars, and other willing community resident volunteers, and
they came up with specific goals. To accomplish these goals it is essential for people to work
together. Which of the following is NOT part of the process?
A.
Cooperation, collaboration
C.
Coalition or collaboration
B.
Networking, coordination
D.
Transportation, communication

Situation 16 Part of the important task faced by community health nurses is COMMUNITY
ORGANIZING (CO). These questions apply.
76. These statements regarding Community Organizing (CO) are true, EXCEPT
A. CO is successful only if the nurse takes action for the people
B. CO is biased towards the poor, deprived and oppressed segments of society
C. The nurse applies CO as strategy to initiate people participation
D. The context of CO is the current situation affecting people and their communities

77. You have engaged 3 barangays in CO and now you are trying to evaluate their level of
awareness as a cohesive group of people responding to issues and concerns affecting them
and their communities in general. The highest level of awareness by these organized groups
of people is manifested when there is proof of their capability in doing
A. Interest aggregation
C. Interest articulation
B. Political socialization
D. Political mobilization
E.
F. 78. Social investigation (SI) is always a part of aligning local issues with those of higher
concerns of society. In doing SI we normally utilize
A. Local records and reports
C. Secondary data
B. Results generated from ocular
D. Registries available from municipal/ city
inspection
government
E.
F. 79. In doing CO, the best entry strategy to the community is
A. Via free clinics
C. Use of an endorsement by known
B. A low key approach
community leaders
D. Entry with the parish priest or pastor
E.
F. 80. In doing CO, we do appropriate social preparation before actual full-scale engagement.
Our main aim here is to
A. Lay the foundation towards the creation of an organization
B. Imbibe a community way of life
C. Establish rapport with the leaders of the community
D. Develop potential leaders
G.
H. Situation 17 Infant care focuses on conditions considered as HIGH RISK. Here are a few of
those situations which places extra challenge to nursing care modalities.
I. 81.
Nurses tasked with newborn and infant care are most always faced with the
determination of clients with physiologic and pathologic jaundice. In differentiating these
which of the following facts is more important?
J. A.
Unconjugated bilirubin level is
L. C.
Mother is 37 years of age
6mg/dL on 3rd day
M. D.
Infant is a term newborn
K. B.
Appears at 12 hours after birth

N.
O. 82.
A newborn is receiving phototherapy. To meet safety needs while he is undergoing
phototherapy, you would
P. A.
Limit fluid intake
R. C.
Keep him clothed to prevent skin
Q. B.
Make sure the light is not closer
burns
than 24 inches
S. D.
Cover the infant eyes while he is
under the light
T.
U.
V. 83.
A diabetic mother has a problem-free prenatal course and delivers a full-term 9lbs 2oz
girl. At 1 hour after birth, the baby exhibits tremors. You performed heel stick and a
Dextrostix test. The result is 40mg/dL. Yopu conclude that these symptoms are most likely
caused by
W. A.
Hypothermia
Y. C.
Hypercalcemia
X. B.
Hypokalemia
Z. D.
Hypoglycemia
AA.
AB.
84.
A premature infant, 6 hours old, has respirations of 64, mild nasal flaring, and
expiratory grunting. She is pink in room air, temperature is 36.5C. The babys mother had a
ruptured membrane 36 hours prior to delivery. Which measures should you include in your
plan of care?
AC.
A.
Have respiratory therapist set up a respirator since respiratory failure is
imminent. Get blood gases every hour.
AD.
B.
Encourage mother infant feeding. Rooming in as soon as stable, monitor
mothers vital sign every 8 hours.
AE.
C.
Observe for signs of sepsis. Cultures if ordered monitor vital signs at least every
2 hours for the first 24 hours. Encourage family interaction with infant.
AF. D.
Radiant women for the first 48 hours. Vital signs every hour, restrict visitation due to
risk of infection
AG.
AH.
85.
During the assessment of a 2-day old infant with bruising and a
cephalhematoma, you noted jaundice of the face and trunk. The baby is also being
breastfed. Bilirubin level is 10 mg/dL. What does your findings mean?
AI. A.
Breast milk jaundice
AJ. B.
Pathologic janundice requiring exchange transfusion
AK.
C.
Hyperbilirubinemia due to bruising and cephalhematoma
AL.D.
Hyperbilirubinemia due to blood incompatibility
AM.
AN.
Situation 18 What makes professionals like nurses different from the ordinary work
forces in many different settings is the very important inclusion of the ethical and moral and
the LEGAL dimensions of practice. The following looks into the area of delegation of functions
to the extent such is warranted.
AO.
86.
You are the head nurse assigned in a 50-bed OB-Gyne Unit of St Catherines
Hospital and you are preparing to delegate nursing tasks for staff in the unit. Which of the
following tasks should you delegate specifically to registered nurse?
AP. A.
Assist in the performance of physical environment on a young woman admitted with
amenorrhea
AQ.
B.
Secure from the laboratory the results of patients admitted in the unit
AR.
C.
Administer the analgesic drug before a cystocele repair.
AS.
D.
Assist by taking the vital signs of patients admitted with gonorrhea.
AT.
AU.
87.
Again, as the head nurse assigned in an OB-Gyne Unit of St Catherines Hospital
you are preparing to delegate nursing tasks for staff to attend to the NEWBORN infants
roomed-in the unit. Which of the following tasks CAN YOU DELEGATE to non-licensed
nursing personnel?
AV. A.
Assess a newborn with phenylketonuria
AW.
B.
Administer an intramuscular injection to a newborn
AX.
C.
Monitor and follow up completion of the laboratory examinations performed on
the newborn infants.
AY. D.
Perform gestational age assessment
AZ.
BA.
88.
Still within the 50-bed OB-Gyne Unit of St Catherines Hospital, which
responsibilities CAN BE DELEGATED to a non-licensed/non-registered nursing personnel in the
unit?
BB.
1.
Provide the care for a client suspected of having hydrops fetalis
BC.
2.
Monitor the fetal tracing of a mother in labor
BD.
3.
Apply the suprapubic pressure in a client with shoulder dystocia
BE.
4.
Provide comfort measures to a client who is 37 weeks of gestation
BF. A.
1 and 3 can be safely delegated
C. 1, 2 and 3 can be safely delegated
BG.
B.
2 and 4 can be safely delegated
D. ONLY 4 can be safely delegated

BH.
BI. 89.
You are preparing the clinical assignments for the maternity unit as Head Nurse in St.
Annes Medical Center. Which of the following tasks CAN BE DELEGATED to non-licensed /
non-registered nursing personnel in the unit?
BJ. 1.
Provide the care in the
BL.3.
Instruct a client on the clinical
preeclampsia
signs of place
BK.
2.
Walk a client in her 37th
BM.
4.
Assess a client for Braxton
week of gestation
Hicks contraction
BN.
A.
1 and 4 can be safely delegated
C. 1, 2 and 3 can be safely delegated
BO.
B.
ONLY 2 can be safely delegated
D. 2 and 3 can be safely delegated
BP.
BQ.
90.
Mila, a nursing assistant, on duty with you in the Maternity Unit of St. Annes
Medical Center, was asked by one of the clients with cystocele who received prior
instructions from you a day earlier. She asks, Miss, why again do I need to do Kegel
exercises? I seem to have gotten lost from the many instructions given me by the nurse
yesterday What must Milas expected response be in this scenario? Tell the client that:
BR.
1.
Kegel exercises will help alleviate the pelvic pains she experiences
BS.2.
These experiences will strengthen her abdominal muscles
BT. 3.
She will immediately refer her query back to the nurse
BU.
4.
These exercises tighten her pelvic organs
BV. A.
1,2,3 are correct responses
C. 3 is the ONLY correct response
BW.
B.
1 and 4 are responses
D. ONLY 2 is the correct response
BX.
BY. Situation 19 Nurse Client Interaction (NCI) is a vital component of the whole nursing care
process. The following ANTEPARTAL communication exchanges apply.
BZ.
91.
In one of the 8th week prenatal visit, Cathy makes statements that lead you to
believe she has mixed emotions about this pregnancy. Understanding the developmental
tasks of pregnancy, you assessed that Cathy is working through which task of pregnancy?
CA.
A.
Fetal distinction
C. Role transition
CB.
B.
Fetal embodiment D. Pregnancy validation
CC.
CD.
92.
Mercy, another pregnant client called to say he counted 7 fetal movements
while doing her daily fetal movement count for one hour. Your appropriate response must be
to:
CE.
A.
Get more information about Mercys activities and nutrition for the day
CF. B.
Instruct mercy to come in and have the decreased fetal movement evaluated
CG.
C.
Educate Mercy that 7 fetal movements in one hour is reassuring
CH.
D.
Teach Mercy to learn the babys often sleep for extended periods and inquire
some more if this is the first time decreased fetal movements
CI.
CJ. 93.
Kris, a pregnant mother asks for more information about her screening prenatal
ultrasound. Before responding, you considered which of the following aspects of the
screening ultrasound?
CK.
A.
It requires a small amount radiation, which is considered safe for the fetus
CL.B.
The screening prenatal ultrasound is done to look at the major organ system for
anomalies
CM.
C.
The procedure can be performed either transvaginally for transabdominally
CN.
D.
The screening ultrasound uses sound waves undetected by the human ear.
CO.
CP. 94.
You returned the call of Mercy who asks about her diagnosis of preterm labor. Based
on an understanding of the condition , you appropriately respond saying,
CQ.
A.
You have been having cervical dilation without contractions and you must stay
on bed rest to slow the process.
CR.
B.
You will deliver this baby early.
CS.
C.
Cervical dilation and effacement before your 20th week in this pregnancy is
labor that is starting too soon and is called preterm labor.
CT. D.
The contractions have been changing your cervix and it is too early before you reach
them.
CU.
CV.95.
Andrea, a pregnant client reports abstaining from drinking alcohol for one month, but
she was overwhelmed with stress and began drinking again last week. The best response
you can give is
CW.
A.
Quitting for a month is
CY. C.
Can you quit again
great and must have been difficult
CZ.
D.
Unfortunately, your baby
CX.
B.
A month is better than
is still at risk from your previous
nothing.
drinking.
DA.

DB.
Situation 20 Professional nurses normally work with many significant others in the
care of clients. Collaboration and teamwork (CTW) are truly important elements in obtaining
all too significant outcomes of care. The following situations apply.
DC.
96.
You are a home care nurse and in one of your home visits instructed Heidi, the
wife of the client about how to perform a wet-to-dry abdominal dressing for her husband with
an infected abdominal incision. You should immediately intervene when the wife:
DD.
A.
Wets the old dressing with sterile saline before removing it
DE.
B.
Irrigates the wound with hydrogen peroxide using a bulb syringe
DF. C.
Cover the wound with wet, sterile 4x4 s.
DG.
D.
Uses montogemery straps to secure the dressing
DH.
DI. 97.
Based on endorsements, you are to monitor Carol, 20-year old woman in active labor
who is receiving oxytocin (Pitocin) 1mU/min IV. You should stop the infusion and report
immediately to the head nurse if the contraction occur at:
DJ. A.
2-minute intervals and last more
DL.
C.
2-minute intervals and last
than 60 seconds
more than 90 seconds
DK.
B.
2.5-minute intervals and
DM.
D.
3 minute intervals and last
last more than 90 seconds
more than 60 seconds
DN.
DO.
98.
While a 2-day old infant is in surgery for repair of spina bifida, the infants
mother Reggie expresses to you her concern after their doctor told her that her child would
be confined to a wheelchair. Which of these statementswould you BEST make?
DP. A.
The corrective surgery will not change your childs physical disability.
DQ.
B.
Physical therapy can restore the function to affected muscles.
DR.
C.
Orthopedic devices will allow your child to strengthen lower extremity
muscles.
DS.
D.
Corrective surgery will return the function to affected muscles.
DT.
DU.
99.
You are receiving a bedside report from another nurse. The nurse giving the
report begins to talk about another client. Your MOST appropriate action would be to ask the
nurse to:
DV.A.
Tone down his/her voice.
DX.
C.
Clarify which client she/he
DW.
B.
Move to another part of
is reporting on.
the room
DY. D.
Focus on this client only.
DZ.
EA.100. A family member of a client who has sustained an electrical burn states, I dont
understand why he has been here a week. The burn does not look that bad. The BEST
response of the nurse is that, Electrical burns:
EB.
A.
Are more prone to infection
EC.
B.
Can be deceptive because damaged underlying tissues are not visible to the
naked eye
ED.
C.
Are always much worse than they look on the outside
EE.D.
Affected cardiac functions hence it is important to do cardiac monitoring.
EF.
MR

Behavioral problems
Vision and hearing problems
Extreme nervousness
Heart defects