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RECALLS 2 EXAM
July 2021 Philippine Nurse Licensure Examination Review

NAME: ZAMORA, MARIA KARINA D.

Nursing Practice II
Situation 1 – Patient Norma, who is in the third trimester, arrives at the hospital
with vaginal bleeding. She states that she snorted cocaine approximately 2 hours
ago.
1. Which defined complication is MOST likely causing the client’s vaginal bleeding?
a) Premature separation of normally implanted placenta – BASTA NAG COCOCAINE NA PREG
b) Pregnancy outside the uterus
c) Termination of pregnancy before the age of viability
d) Abnormal lower implantation of the placenta
2. The abdominal pain associated with abruption placentae may be INITIALLY caused by which of
the following?
a) Disseminated intravascular coagulation
b) Blood in the myometrium
c) Hemorrhagic shock
d) Concealed haemorrhage
3. The bleeding following severe abruption placentae is usually caused by which of the following
condition?
a) Thrombocytopenia
b) Hyperglobulinemia
c) polycythemia
d) hypofibrinogenemia
4. What should the nurse prepare for the POSSIBLE order of the physician?
a) The administration of the oxytocin
b) A high- forceps birth
c) An immediate caesarean birth
d) The insertion of a fetal monitor
 5. Abruption Placenta can cause hemorrhagic disorder which can lead to hypovolemic shock. What
is the LATE sign of hypovolemic shock that the nurse should watch for?
a) Hypertension
b) Tachycardia
c) hypotension – initially/early: normotension tachy tachy
d) tachypnea

Situation 2- A nurse is performing an admission assessment on Carlo, a 4-year-old,

who has been diagnosed with nephrotic syndrome.

6. What sign will BEST support the medical diagnosis of nephrosis?

a) Gross hematuria, tea-colored, scanty urine
b) History of a streptococcal infection
c) Periorbitaledema
d) Anasarca – generalized edema
7. Carlo receives prednisone as the major treatment for his nephrosis. Which of the following
actions should be observed by the nurse in the administration of prednisone?
a) All of the options.
b) Administer the drug on a full stomach.
c) Monitor Carlo’s temperature.
d) Protect Carlo from infection.
8. Which side effect of prednisone will be MOST prominent on Carlo and for which he should be
prepared before its administration?
a) Hypotension
b) Decreased weight
c) mooning of face – seen in Cushing’s syndrome
d) vomiting
9. What is the nursing diagnosis for a child with severe edema caused from nephrotic syndrome? It
is risk for_________.
a) Impaired skin integrity
b) Constipation
c) Ineffective thermoregulation
d) Imbalanced nutrition more than body
requirements

10. What will be the APPROPRIATE recommend diet for Carlo?

a) High iron, no protein
b) High calorie, high protein
c) High sodium, high protein
d) Low sodium, moderate protein
Situation 3- Nurse Jayjay works in the research unit of the prinsesa Urduja
Women’s Clinic. In the close monitoring of their patients using oral contraceptives
(OC), she noted several cases of myocardial infarction (MI).

11. To establish the relationship between MI and OC, Nurse Jayjay should make a research proposal
for which of the following STUDY design?
a) Retrospective
b) Prospective cohort
c) incidence
d) cross- sectional
*A and D – same method of gathering data
12. Since OCs are categorized into 1st, 2nd and 3rd generations, Nurse Jayjay decided to study not
only the relationship of MI and OC but also which of the three generations of OCs will have the
highest risk for MI. Hence, which of the following groups will she include in her study?
a) Those who do not take OC, and those who take OC from 1st, 2nd, ad 3rd OCs.
b) All those who take OC and those who do not.
c) Those who take 1st OC 2nd OC and 3rd OC.
d) Those with MI and those with no MI.
13. Statistical analyses revealed odds ratio for MI among women who used any type of OC, as
compared with non-users, was .99. What does this mean?
a) Reject the null hypothesis; there is no significant relationship between MI and OC. –
ACCEPT talaga yan ; halos walang relationship kasi malapit na sa 1 ; null hypothesis – means
no relationship

b) The study focused on the three groups: 1st OC users with MI, 2nd OC users with MI and 3rd OC
users with MI.
c) There is a relationship between MI and OC and the risk of MI among users of any type of
oral contraceptive is twice that of non users.
d) The odds of getting MI among OC users and those who are not users is 1:2
14. Which of the following is the independent variable of the study?
a) Highest risk
b) Three generation of OC
c) OC
 d) MI
15. Identify the groups in the study that will validate the occurrence of the MI among OC users.
a) Old cases of MI c) old and new cases of MI
b) Prevalence of MI d) incidence of MI

Situation 4- Maureen, G2 P3, is a Type I diabetes mellitus (DM) since she was 10
years old. She is in her first trimester of pregnancy. Lorella is her nurse.

16. What could be the MOST possible effect of DM to Maureen? She can have ______.
a) Ketoacidosis
b) Hyperinsulinism
c) Hyperglycemia
d) Hypoglycemia – d/t organogenesis
17. Which of the following would require an increased dose of medication once Maureen is in the
second half of pregnancy?
a) Insulin
b) Pancreatic enzymes
c) estrogenic hormone
d) antihypertensives
18. What is the route of administration for insulin during pregnancy?
a) Intravenous
b) Subcutaneous
c) oral
d) shot with flex pen
*bago maging placenta, corpus luteum muna – doon kukuha si baby ng nutrients ; 2nd tri rin ang
placenta – kaya ang start ng hypergly ay 2nd tri rin
19. Considering Maureen’s condition, Nurse Lorella will anticipate what effect to the fetus? The
condition will be_______.
a) Large for gestational age – in percentage ; sa isang daan na baby, pang-ilan siya sa
pinakamabigat
b) Macrosomia – based on weight
c) Intrauterine growth retardation (IUGR)
d) meningomyelocele
20. On the first postpartum day, which of the following requirements for insulin will be anticipated
by the nurse to be ordered by the physician?
a) Remain unchanged
b) Decrease sharply and suddenly – bababa rin ang HPL, sasabay siya HAHAAHAHAHA
c) Increase rapidly
d) Decrease slowly and steady
Situation 5- Mrs.Alim, gravida 3 para 3003, is admitted to the postpartal unit after
an uncomplicated labor and vaginal delivery. She opted to breastfeed her baby.
Nurse Imee is around to take care of her.

21. The first day after delivery, Mr. Alim tells the nurse that his wife has been talking constantly
about her recent delivery experience. He asks if this is a sign of postpartal blues. What should be
the BEST response of the nurse?
a) “Do you feel uncomfortable about her talking on her delivery experience?”
b) “Yes, it’s clear sign of post partum blues. She may need a psychiatric evalution.”
c) “This is a normal reaction. It allows her to accept the reality of the birth of your baby.” –
taking in
d) “No, you should divert her attention away from her delivery.”
22. Later that day, Mrs. Alim tells Nurse Imee that she has urinated four times within the last hour
but only in small amounts. What should be the INITIAL ACTION of the nurse?
a) Explain that this is normal during the first 24 hours after delivery.
b) Palpate Mrs.Alim’s fundus to assess uterine consistency and location. – straight cath na
pag ayaw talaga maihi
c) Catheterize Mrs.Alim immediately to expel any retained urine.
d) Begin measuring and recording and recording Mrs.Alim’s intake and output.
23. Which assessment finding is MOST indicative that Mrs.Alim is developing puerperal infection?
a) Increased pulse rate
b) Foul- smelling lochia
c) Elevated body temperature
d) A white blood cell count of 25,000/mcg
24. Mrs.Alim asks Nurse Imee when her menstrual period will return. The nurse answers that a
breastfeeding patient typically resumes menstruating in about____________.
a) 8 to 12 weeks
b) 3 to 6 months
c) 4 to 6 months
d) 4 to 6 weeks
25. Mrs. Alim complains of pain due to breast engorgement. What will the nurse do to encourage
her to continue breastfeeding?
a) Let her continue breastfeeding on schedule.
b) Put hot compress over the breast for 15 minutes before breastfeeding.
c) Put cold compress over the breast for 15 minutes before breastfeeding.
d) Let her continue breastfeeding on demand. – the more na stimulated, the more na lalabas
ang mailk ; positive feedback mech

Situation 6- Nurse Janice attends to patient Aude who is three months pregnant
when a pelvic sonogram was conducted on her revealing the fetus’ weak cardiac
pulsation. Nurse Janice advised the patient to have a follow up visit o their clinic
after a week but it was only after two weeks that the patient returned when she
started to suffer from severe abdominal pains. Upon examination, the doctor found
out that there was a dead fetus in her womb. The patient underwent hysterectomy
and as a result, she had no more chance to bear a child.

26. Aude filed legal charges against all people concerned regarding the outcome of the procedure
done to redress the damages caused by the procedure. Who among the following will be
accountable to the patient?
a) None, all members of the health care team performed their professional duties on the
patient.
b) Only Dr. A but not the nurse because the latter was just following orders from the physician.
c) Dr. A and the nurse because of their failure to perform their perspective duties with
diligence and care.
d) Dr. A and the hospital administrator because of command responsibilities on the treatment
and care to the patient.
27. Under the situation, if the physician and the nurse are liable over the consequence of the
treatment and care of the patient, what applicable legal doctrine will this be?
a) Respondeat Superior
b) Captain of Ship Doctrine
c) Patient’s Proximate Negligence
d) Res Ipsa Loquitor
28. If the nurse is called to testify on the alleged surgical procedure performed to the patient to
determine whether there was lack of necessary care and diligence, the nurse should testify only
on matters which are ________.
a) Within her personal knowledge s
b) Documented in the chart
c) Advised by her lawyer
d) Being asked by the court
29. Medical records have legal implications. In as much as the nurse failed to chart the discharge
instructions, what principle in records management was violated?
a) “If it was not documented, it was not done.”
b) “Completion of chart should be within 48 hours.”
c) “No document, no discharge.”
d) “Not all documented data are true.”
30. Hospital A practices clinical pharmacy. Physician writes the order of medications, pharmacist
prepares it and the nurse administers it. Who then will be liable for any drug overdose
administered intravenously by the nurse?
a) Pharmacist
b) Nurse and Physician
c) Nurse
d) nurse and pharmacist – nurse ang nag-administer, pharma ang taga prepare
Situation 7- Nurse Margie is collecting data from a newly admitted patient, Mrs. De
la Cruz, who is pregnant with twins. She has a healthy 3-year-old child who was
delivered at 38 weeks. She also revealed that she does not have a history of
abortion nor fetal demise. Her last menstrual period began February 7, 2017 and
ended February 12, 2017.

31. What is the GTPAL for Mrs. De la Cruz?

a) G = 1, T = 1 , P = 1, A = 0, L = 1
b) G = 2, T = 0 , P = 0, A = 0, L = 1
c) G = 3, T = 2 , P = 0, A = 0, L = 1
d) G = 2, T = 1 , P = 0, A = 0, L = 1
32. What is the expected change in the hemotologic system that occurs during the END of the first
trimester of pregnancy that Nurse Margie should recognize?
a) An increase in hematocrit
b) A decrease in WBC’s
c) An increase in blood volume
d) A decrease in sedimentation rate
33. Mrs. De la Cruz asks about the functions of placenta. Which of the following items should Nurse
Margie include in the teaching plan?
1) The placenta filters the fetal urine.
2) Fetal and maternal blood mix in the placenta to exchange nutrients.
3) The placenta filters the alcohol from the mother’s blood.
4) Substances are exchanged by the placenta without mixing the maternal and fetal
blood.
5) Fetal respiration, nutrition and excretion are carried out by the placenta.
a) 1, 2, 3 c) 3, 4, 5
b) 4, 5 d) 1, 2
34. Mrs. De la Cruz asks “When will be my expected date of delivery (EDD)?” Based on her
knowledge of Naelgeles’s Rule, which should be the CORRECT answer of Nurse Margie?
a) November 14, 2017
b) October 14, 2017
c) October 19, 2017
d) November 19, 2017
35. Nurse Margie Explained the chronological order of the growth and development of the fetus as
it occurs in pregnancy which is the following __________.
a) Ovum, zygote, morula, embryo, fetus, infant
b) Morula, zygote, ovum, fetus, embryo, infant
c) Morula, ovum, embryo, zygote, fetus, infant
d) Zygote, ovum, morula, embryo, fetus, infant
Situation 8- Patient Myra a gravida 1, para 0. Patient is admitted at the labor room.
Her cervix is 100% effaced, and upon IE, her cervix is 3 cm dilated, the fetus is at +
1 station. Staff Nurse Nina attends to her.

36. Taken from the assessment data above that the fetus is at + station, how will Nurse Nina
interpret this? That the head of the fetus is _________.
a) Below the ischial spines – 1 cm below
b) Visible at the vaginal opening
c) Not yet engaged
d) Entering the pelvic inlet
37. Nurse Nina monitors the contractions of the patient. She recorded the contractions as follows:
started at 10:00 A.M another began at 10:15 A.M. In MINUTES, what is the frequency of the
constructions?
a) 10 c) 15
b) 9 d) 14
38. Nurse Nina assesses the duration of the patient’s contractions by timing them from ________ to
________.
a) Beginning of one contraction to the beginning of the next contraction
b) End of the contraction to the beginning of the next contraction
c) End of the contraction to the end of the next contraction
d) Beginning of one contraction to the end of the same contraction
39. After doing Leopold’s maneuvers on the patient I labor, the nurse determines that the fetus is in
the ROA position. Where should the nurse place the Doppler to BEST auscultate the fetal heart
tones?
a) Below the umbilicus near the left groin
b) Below the umbilicus on the right side – likod niya nasa right, likod niya nasa harap ; likod ni
baby nasa harap ni mommy at nasa right ni baby
c) Above the umbilicus in the midline
d) Above the umbilicus on the left on the left side
40. Patient Myra was given epidural anesthesia. This indicates late deceleration of the fetus and so
the nurse has to do important nursing interventions. ARRANGE the following nursing
interventions in ORDER or PRIORITY.
1) Increase intravenous fluids 3
2) Change position of the patient to the left side lying 2
3) Reassess fetal heart rate pattern 1
4) Document intervention and maternal/fetal response 4
a) 3 2 1 4 c) 4 2 3 1
b) 3 4 1 2 d) 2 3 4 1
Situation 9- Ella, a 5- year- old child, is admitted to the hospital for abdominal pain.
The mother reports that the child has been pale, tires easily and has hematomas in
the arms and legs. On physical examination, lymphadenopathy and
hepatosplenomegaly are noted. Diagnostic studies are being performed on the child
because acute lymphocytic leukemia is suspected.

41. Which of the following procedures will confirm this diagnosis?

a) A lumbar puncture c) Bone marrow biopsy
b) A platelet count d) White blood cell count
42. Based from the instructions of the nurse, which of the following activities should NOT be done
by the parents in monitoring possible infection on Ella?
a) Taking the rectal temperature daily
b) Inspecting the skin daily for redness
c) Inspecting the mouth daily for lesions
d) Performing proper hand washing techniques
43. What is the PRIMARY effect of leukemia on the bone marrow?
a) a selective reduction in the number of neutrophils
b) Leucopenia, thrombocytopenia, and anemia
c) The crowding out of normal cells on the site
d) Proliferation of cells producing blood components
44. The patient’s parents asked why her child has hematomas and anemia. Which of the following
should be the explanation of Nurse Vida?
a) “Hematomas and anemia are related to the child’s inactivity.”
b) “All blood cells are made in the bone marrow. Hematomas and anemia are due to
decreased RBC and platelet count.”
c) “Hematomas and anemia are indicative that the end is near.”
d) “theanemia is because the child hasn’t been eating well; the hematomas are from the
multiple needle sticks.”
45. Patients Ella is not expected to survive. Ella says to her mother, “Will you take care of me when I
am dead the way you do now?” the child’s mother asks Nurse Vida how to answer her child.
The nurse’s response should be based on which of the following understanding of the child’s
behaviour.
a) “Children of this age do not understand the finality of death.”
b) “The child is denying that he has a terminal illness.”
c) “Most 5-yea-old children have a great fear of mutilation.”
d) “the child may be having visual and auditory hallucinations.”
Situation 10- Nurses are guided by bio-ethical principles as they practice their chosen profession.

46. What bio- ethical principle guides the nurses when taking care and being responsible for
patients?
a) Solidarity c) Totality
 b) Fidelity d) Stewardship
47. Each person has a responsibility to take care of his/her body. In case a part is defective, it can be
removed for the benefit of the remaining parts. What bio- ethical principle is this?
a) Totality – sum of the whole is greater than the sum of its parts c) Solidarity
b) Stewardship d) Fidelity
48. As member of the health team, nurses are expected to collaborate with other health care
professionals for unity and cooperation. What bio- ethical principle is this?
a) Fidelity c) Solidarity – solid alaws gigiba, walang professional turfing
b) Stewardship d) Totality
49. When another person or entity intrudes in the affairs of the patient to promote justice and
welfare, what bio- ethical principle does he/she promotes
a) Welfare c) Justice
b) Stewardship d) Paternalism
50. As a means to solve any crisis or scarcity in any health care systems, providing an equitable
distribution of resources is based on what bio- ethical principle?
a) Paternalism c) Fidelity
b) Justice d) Stewardship

Situation 11- a 13-year-old- girl named Zeny tells the nurse at the pediatric clinic
that she took a pregnancy test and it was positive. She tells the nurse that her
grandfather, with whom she, her younger siblings, and her mother live, has
repeatedly molested her for the past 3 years. When the nurse asks the girl if she has
told this to anyone, she replies: “Yes, my mother.”

51. As the nurse’s legal responsibility, which is the APPROPRIATE agency should she notify FIRST?
a) City Health Office to do a vaginal examination to confirm the pregnancy
b) DSWD for notifying the girl’s mother about the pregnancy test positive result.
c) Board members of Child Protective Services for proper intervention
d) Philippine National Police concerning a possible sex crime
52. If Zeny is really a victim of incest and the agency opts that she be admitted in the hospital,
where should she be placed?
a) With an older friendly child
b) In a room near the nurse’s station – to promote safety
c) With another 5 year old
d) In a private room
53. The abusive parent usually manifests one of the following characteristics EXCEPT________
a) History of severe mental illness
b) History of drug abuse
c) Belongs to low income group – any socioeconomic class
d) Low tolerance for frustration
 54. When a patient, who allegedly has been sexually abused, the nurse should be aware that legal
proceedings may be necessary. Because of this possibility, which of the following actions is
MOST important to be done by the nurse?
a) Determining if there are other injuries such as bruises and hematomas.
b) Asking the parents for their approval for diagnostic examinations for the child.
c) Assessing the child’s physical, intellectual and emotional developmental levels.
d) Documenting physical findings and interactions during admission.
55. What typical assessment findings are observed to a patient who is a victim of sexual abuse
a) Recurrent UTI
b) Fracture and bruises
c) Enuresis
d) Failure to thrive syndrome

Situation 12- Nurse Sarah is assigned at the Under Five Clinic. Mostly of her patients
are infants. So she took the opportunity to have a mother’s class on the care of
infants.

56. Which of the following will Nurse Sarah EMPHASIZE regarding the importance of play during
infancy? Play enhances _______ development.
a) Cognitive c) Physical
b) Emotional d) Social
57. Which among the infants would show signs that he/she is experiencing maternal deprivation?
a) Hyperactive c) prone to illness
b) Overweight d) responsive to stimuli

58. What should Nurse Sarah include in the accident prevention teaching plan for a mother with
4month-old infant?
a) Keep crib rails up to the highest position.
b) Cover electric outlets with safety plugs.
c) Remove poisonous substances from low areas.
d) Remove small objects from the floor.
59. When teaching a mother how to prevent accidents while caring for her 6-month-old infant,
Nurse Sarah should emphasize that at this age, the infant can already do which of the following
developmental milestone?
a) Stand while holding on to furniture.
b) Crawl short distances.
c) Roll over from back to abdomen.
d) Sit up without assistance.
60. Nurse Sarah assesses the oral cavity of a 6month-old child and finds out that the tooth that buds
first is the __________.
a) Upper molars c) Canines
 b) Lower central incisor d) Lower molars
*lower central incisor > upper central > upper lateral

Situation 13- Nurse May Ann is caring for a mother- infant dyad. The mother has
just given birth to a baby boy two days ago. Today, the charge nurse us doing a
chart audit to determine whether the nursing process was properly done from
prenatal to postnatal periods. The laboratory results of the mother and baby boy are
shown below.
Mrs. Andrea Santiago: Prenatal Laboratory Results

61. Using the chart data, which nursing intervention was CORRECTLY done by Nurse May Ann for
Mrs. Andrea Santiago?
a. Rubella vaccination
b. Rhogam injection
c. Neonatal 50% glucose infusion
d. Maternal blood transfusion
*normal Rubella titer 1:6 ; abn: 1:8 above
62. Nurse May Ann charted an IMPORTANT plan of care for Mrs. Santiago. She indicated in her
charting that the patient should report immediately signs and symptoms of a virus causing-
disease which may affect the cardiovascular system of the fetus during which of the period of
pregnancy?
a. First month – 1st tri: organogenesis c) Second Month
b. Third month d) Fourth Month
63. Looking at the medication sheet, the charge nurse noted that Nurse May Ann used the CORRECT
ROUTE in the administration of the vaccine, which was_______________.
a. Rectal c) Subcutaneous
b. Intradermal d) Intramuscular
64. After administration of the vaccine, health teaching was also charted by the staff nurse.
Which of the following is the CORRECT one?
a) Immediate follow-up check up
b) Nothing Per Orem
 c) No pregnancy for 3 months
d) Avoid exposure to Rubella
65. Nurse May Ann should also include in her charting an additional health education to Mrs.
Santiago that is: rubella virus can be transmitted via the placenta by the process of
______________.
a. Simple diffusion c) Active Transport
b. Pinocytosis d) Facilitated Diffusion

Situation 14- Breastfeeding is one of the major responsibilities of OPD Nurse Nancy.
Along this line, she gathers pregnant women to provide them health education
about the topic.

66. Nancy explains that exclusive breastfeeding is giving the baby_______.

a. Breast milk and introducing solids at one month
b. Breast milk with drops of syrup
c. Breast milk alternating with sips of boiled water
d. Only breast milk for 6 months + prescribed oral meds if ever
67. She further explains that the specific objectives of exclusive and extended breastfeeding are the
following EXCEPT_________.
a) 60% of infants are exclusively breastfeeding up to 6 months
b) 90% of infants are started on complimentary feeding by 6 months of age.
c) 70% of newborns are initiated to breastfeeding within an hour after birth.
d) Twelve (12) months is the median duration of breastfeeding. – 2 yrs
68. A mother questioned Nurse Nancy in the event that she does not produce milk, what should she
do? The BEST answer of Nurse Nancy would be___________.
a) “If it is difficult on your part, then you can use local herbs said to help the production of the
breast milk.”
b) “That’s a big problem ma’am, but you can still try again.”
c) “Just continue breastfeeding. This will stimulate the hypothalamus in the production of breast
milk.”
d) I empathize with you. I too, do not have breast milk.”
69. Isabel, one of the pregnant women, asked Nurse Nancy to teach her the proper positioning of
the baby while breastfeeding. Among Nurse Nancy’s answers, which one is NOT CORRECT?
a) The baby can lie down perpendicularly with the mother to promote better bonding. – should
be parallel
b) The baby’s face should be towards the mother’s breast to have an eye to eye contact.
c) The baby’s head and body should be aligned to promote better swallowing.
d) The baby’s tummy should be close to the mother’s tummy for better support.
70. To convince the pregnant mothers to breastfeed their newborns upon delivery, the BEST thing
that Nurse Nancy must do ______________
a) Explain the hospital policy on “No
 breastfeeding; No admission”
b) Relate her own experience on breastfeeding
c) Prepare the mothers physically, emotionally and psychologically
d) Ask other mothers to convince them to
breastfeed

Situation 15- Letty is now 15 years old. She goes to an exclusive school but she
seldom interacts with her classmates nor is interested to join school activities. Her
mother brought her to an adolescent specialist and was diagnosed of malnutrition.

71. Which of the following is NOT a CORRECT statement about malnutrition? Malnutrition is for
____________.
a) Both the urban and rural areas
b) Both the poor and the rich
c) The underweight as family income increases
d) The overweight as family income increases
72. Advertisement (ads) on television is said to be a contributory factor for obesity. What could be
a GOOD advice to adolescents like Letty regarding these ads that can be contributory to
malnutrition?
a) “Check nutritional contents before buying foods.”
b) “Follow your desire for food and drinks.”
c) “What you see is what you get.”
d) “There is no truth in advertisements.”
73. Letty went to see a nutritionist. She is overweight for her height. What is the normal weight, in
POUNDS, for Letty who is 5 feet tall?
a) 90 c) 85
b) 75 d) 80
*60 in = 5 ft
ft to cm: multiply to 2.54 cm
60 in (2.54 cm) = 152.4 cm
Ht in cm minus 100
Then minus 10%
74. How can Letty be helped to reduce her weight? She can be advised to cut intake of which of the
following?
a) Salt, protein and fats
b) Carbohydrates, vitamins and salts
c) Carbohydrates, fats and salts
d) Fats, protein and sweets
 75. Which of the following can Letty do to help her with her obesity problem?
a) Skip one full meal a day.
b) Drink 6 glasses of water every day.
c) Take weight reducing pills.
d) Exercise 30 minutes three times a week. – at least 30 mins for most days of the week ;
recommended is 4x/week

Situation 16- Baby Boy Santos, 6 months old, was diagnosed as having
communicating hydrocephalus. Nurse Lorena is planning nursing care for this baby
who is a candidate for ventriculo- peritoneal shunting.

76. When helping the parents understand the baby’s problem, which of the following should be
Nurse Lorena’s ACCURATE explanation?
a) “The CSF is prevented from adequate absorption by a blockage in the ventricles of the
brain.”
b) “Too much Cerebro Spinal Fluid (CSF) is produced within the ventricles of the brains.”
c) “The flow of CSF through the brain cells does not empty effectively into the spinal cord.”
d) “There is a part of the brain surface that usually absorbs CSF after its production that is
not functioning adequately.” – walang CSF drainage na maayos
77. Nurse Lorena understands that hydrocephalus, if left untreated, can cause mental retardation
because of which of the following rationales?
a) Hypertonic CSF disturbs normal plasma concentration, depriving nerve cells of vital nutrients.
b) Gradually increasing size of the ventricles presses the brain against the bony cranium;
anoxia and decreased blood supply result.
c) Increasing head size necessitates more oxygen and nutrients than normal blood flow can
supply.
d) CSF dilutes blood supply, causing cells to atrophy.
78. What is the IMPORTANT nursing care of an infant with increased intracranial pressure?
a) Check the infant’s reflexes at regular intervals.
b) Monitor the infant’s level of consciousness by stimulating frequently.
c) Weight the infant daily before feeding.
d) Elevate the infant’s head higher than the hips.
79. Baby Boy Santos just had a ventriculoperitoneal shunt. His parents were worried about the
prognosis. What information should Nurse Lorena give to the parents to allay their worry?
a) The shunt may need to be revised as the child grows older.
b) If any brain damage has occurred, it is reversible during the first year of life.
c) Hydrocephalus usually is self- limiting by 2 years of age and then the shunt is removed.
d) The prognosis is excellent and the valve is permanent.
80. What is the drug that will lessen CSF production that nurse Lorena will anticipate the doctor to
order?
a) Osmitrol c) Mannitol
 b) Lasix d) Diamox – Acetazolamide

Situation 17- Nurse Shasha assists in the inservice training of nurses in St. James
Hospital. Based from the needs assessment, the nurses need to be trained on
patient’s safety. The first lecture was on medication administration. Nurse Shasha
gave the following problems fro the nurse to solve.

81. An eight-year-old- patient is to receive Aminophylline 3 mg/kg TID. If the girl weights 25 kg, how
much Aminophylline should she receive daily?
a) 125 mg c) 200 mg
b) 225 mg d) 100 mg
3 mg (25 kg) = 75 mg
75 (3) = 225 mg
Multiply to 3 because TID
82. Mrs. Cruz is to receive Digoxin 0.325 mg p.o. because of her heart ailment. The stock is 0.250 mg
per tablet. How many TABLETS should the nurse request for 7 days supply for the patient?
a) 9 c) 10
b) 7 d) 8
Desired / stock x quantity
0.325 mg / 0.250 mg x 1 = 1.3
1.3 (7) = 9.1
Answer 10 kasi saan mo kukunin yung .1? sa pwet? HAHAHAHHAA
83. In giving insulin to an OB diabetic patient, the nurse must use an APPROPRIATE needle size and
length, which among the following will this be?
a) 23 G, 3/8 c) 24 G, 4/8
b) 22 G, 2/8 d) 25 G, 5/8
84. Nurse Shasha emphasized that patient safety is___________.
a) Preventing errors and adverse reactions to patients associated with health care
b) Being careful in caring for patients at all times
c) Providing treatment and care to patients and documenting the same
d) Being mindful of the needs of others at all times
85. Nurse Shasha has provided instructions that all care provided by nurses must be documented,
as one of their legal responsibilities. In case errors occur, which is the correct way of
documenting it?
a) Wrong medicine given to wrong patient. Physician notified. Patient observed
b) Medication inadvertently omitted. Supervisor notified.
c) Medication given to patient A instead to patient B. Patient advised.
d) Wrong dose of medicine administered to patient. Sorry.
Situation 18- one of the responsibilities of a nurse in fertility specialist’s office is to
provide health teaching to the patient in relation to timing of intercourse to achieve
pregnancy.

86. Which instruction to patient addresses the BEST time to achieve a pregnancy?
a) 14 days before the next period is expected
b) Immediately after menses end
c) Midway between periods
d) 14 days after the beginning of the last period
87. With regards to sexual functioning, the nurse explained the ovulation occurs on which of the
following conditions?
a) Chorionic gonadotropin level is high
b) Luteinizing hormone level is high
c) Oxytocin level is high
d) Progesterone level is high
88. After ovulation has occurred, the nurse teaches women in the fertility clinic that the ovum is
through to remain viable for many HOURS?
a) 24 to 36 c) 48 to 72
b) 12 to 18 d) 1 to 6
*12-24 hrs talaga
89. When teaching clients to determine the time of ovulation by taking the basal temperature, the
nurse explains that the change in the basal temperature during ovulation is shown in which of
the following observations? The temperature_____________.
a) Drops markedly and remains lower
b) Rises markedly and remains high
c) Drops slightly and then rises again
d) Rises suddenly and then falls down
*Stratum functionalis – ito yung kumakapal kapag nagbubuntis? At ito rin yung nag-s’shed off kapag
nagmmenstruate yung isang babae?
90. In response to a client’s question on the chief function of progesterone, which of the following
would be the CORRECTanswer? It _________________.
a) Stimulates the follicles for ovulation to occur
b) Establishes the secondary male sex characteristics
c) Prepares the uterus to receive a fertilized ovum
d) Develops the female reproductive organs

Situation 19- Marco, 3 years old, who underwent ventricular septal defect repair, is placed on a
maintenance dosage of digoxin (Lanoxin) elixir. Nurse Rita, complete with the knowledge of the disease,
is assigned to him.
 91. The dosage is 0.07 mg/kg/day, and the client’s weight is 7.2 kg. The physician orders the Digoxin
to be given twice daily. How much Digoxin should Nurse Rita prepare to administer at each
dose?
a) 2.5 mg c) 0.37 mg
b) 0.5 mg d) 0.25 mg
0.07 mg (7.2 kg) = 0.504 mg
0.504 / 2 = 0.252
Divided by 2 because it is given twice daily
92. Nurse Rita provides home care instructions to the parents of Marco regarding the procedure for
the administration of digoxin (Lanoxin). Which statement, if made by the parent, indicated the
need for further instructions?
a) “If the child vomits after medication administration, I will repeat the dose.”
b) “If more than one dose is missed, I will call the physician.”
c) “I will take the child’s pulse before administering the medication.”
d) “I will not mix the medication with any food and drinks.”
93. Which of the following instructions about ORAL pediatric medications is TRUE as these interfere
with milk and milk products or food eaten by young children? Oral medication should be
given_____________.
a) With meals always
b) On an empty stomach
c) ½ hour after meals – can interfere with breastmilk
d) With the night time formula
94. Marco has a blood pressure of 92/78; resting pulse of 60; respirations 28 and a potassium level
of 4.8 mEg/L. He is irritable and has vomited twice since the morning dose of digoxin. Which
finding is most indicative of digoxin toxicity?
a) Vomiting c) Bradycardia
b) Lethargy d) Irritability
95. Considering Marco’s age, which of the following is the BEST approach by the nurse when
administering medication?
a) “You will feel better if you take your medication.”
b) “Would you like to take your medicine from a spoon or a cup?”
c) “Do you want to take this pretty red medicine?”
d) This is your medicine and you must take it all right now.”
Situation 20- Mayumi, 3 years old, was admitted to Pediatrics Ward because of watery stools four times
in 30 minutes accompanied by vomiting, abdominal pain and temperature of 38.1 degrees centigrade.
Nurse Sarah was the one who was the admitting nurse.

96. Which of the following should be the PRIMARY consideration by the nurse when charting the
Chief Complaint? The ___________.
a) Number of significant accompanying symptoms
b) Objective symptom presented
c) Subjective symptom presented
 d) Significant reason for the child’s hospitalization
97. Using the FDAR (Focus Data Action and Response) Charting, which of the following presenting
data would be PRIMARY “Focus”
a) Vomiting in small amount
b) Watery stools 4x in 30 minutes
c) Generalized abdominal pain
d) Temperature of 38.1 centigrade
98. When getting the data on the subjective symptom of the abdominal pain, which of the following
should the nurse RELY on?
a) Mother’s verbal complaint
b) Result of the abdominal percussion
c) Patient’s verbal complaint
d) Result of auscultation of the abdomen
99. The “response” should be based from which of the following categories of the FDAR?
a) Intervention made c) Focus
b) Laboratory Findings d) Assessment
*dapat evaluation talaga, kaso alaws
Para malaman yung response sa intervention kailangan mag re-assess ulit
100. Which of the following can be the LEAST source of data for this case?
a) Vital signs c) Intake and output
b) Laboratory Findings d) Immunization record – F & E problem kasi