Title RECALLS 6 (NP5) - STUDENT COPY ✅

RECALLS EXAMINATION 6 NURSING PRACTICE V CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS (PART C) MAY 2025 Philippine Nurse Licensure Examination Review GENERAL INSTRUCTIONS: 1. This test questionnaire contains 100 test questions 2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalid your answer. 3. AVOID ERASURES. 4. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set. 5. Write the subject title “NURSING PRACTICE V” on the box provided Abdominal Aortic Aneurysm Situation: In a busy public hospital specializing in cardiac care, Nurse Sheekip is assigned to monitor and care for Mr. Thompson, a 72-year-old male with a history of hypertension and atherosclerosis. He was admitted after complaining of a pulsating sensation in his abdomen and intermittent back pain. A physical examination revealed a pulsatile mass in the mid-abdomen, and a subsequent duplex ultrasound confirmed an abdominal aortic aneurysm (AAA) measuring 5.8 cm. 1.While assessing Mr. Thompson, Nurse Sheekip is most concerned when which finding is noted? A. A systolic bruit over the abdominal mass B. Complaints of feeling a pulsating sensation in the abdomen C. Reports of severe, persistent lower back pain with a sudden drop in blood pressure D. Cyanotic and mottled toes with intact pedal pulses 2. Based on the patient’s presentation, which nursing diagnosis is the highest priority? A. Acute Pain related to pressure from the aneurysm on surrounding structures B. Risk for Ineffective Peripheral Tissue Perfusion related to thromboembolism C. Risk for Deficient Fluid Volume related to potential rupture of the aneurysm D. Anxiety related to fear of an unpredictable health outcome 3. Nurse Sheekip receives new orders for Mr. Thompson. Which prescription should be implemented first? A. Administer an IV antihypertensive medication B. Draw blood for laboratory tests C. Apply a noninvasive blood pressure cuff every 15 minutes D. Educate the patient on signs of rupture 4. What is the most appropriate positioning for Mr. Thompson after undergoing endovascular repair? A. Supine for 6 hours with head of bed elevated to 45° after 2 hours B. High Fowler’s position to reduce pressure on the graft site C. Side-lying with knees flexed to relieve abdominal tension D. Sitting upright to promote lung expansion 5. A nurse researcher is conducting a study on post-operative outcomes in patients who have undergone endovascular repair for an abdominal aortic aneurysm. Which sampling method would ensure the most representative sample of the target population? A. Convenience sampling by selecting patients available during clinic follow-ups B. Snowball sampling by asking participants to refer other patients who had the procedure C. Purposive sampling by selecting only patients with complications for in-depth analysis D. Simple random sampling from a hospital registry of all patients who had the procedure Dialysis Situation: Nurse Mary Grace Piattos is a dedicated hemodialysis nurse working in a busy outpatient dialysis unit. She is responsible for managing the care of patients with end-stage kidney disease (ESKD) who require regular hemodialysis treatments. Today, she is caring for Mrs. Santos, a 58-year-old woman who recently started dialysis due to advanced chronic kidney disease (CKD). 6. Mrs. Santos tells Nurse Mary Grace, “I feel so weak and tired all the time. I don’t think I can keep doing this.” Which nursing diagnosis should Nurse Mary Grace prioritize for Mrs. Santos? A. Risk for infection related to vascular access. B. Activity intolerance related to anemia and fatigue. C. Imbalanced nutrition: less than body requirements related to dietary restrictions. D. Ineffective coping related to chronic illness. 7. During Mrs. Santos’ hemodialysis treatment, Nurse Mary Grace notices that his blood pressure drops to 85/50 mmHg, and he complains of dizziness and nausea. What is the first action Nurse Mary Grace should take? A. Administer a bolus of normal saline as ordered. B. Stop the ultrafiltration and lower the head of the bed. C. Notify the physician immediately. D. Increase the dialysate sodium concentration. 8. Nurse Mary Grace Piattos cares for Mr. Antonio Rivera, a 58-year-old man with diabetic nephropathy and fluid overload, has been placed on continuous venovenous hemodialysis (CVVHD) due to hemodynamic instability. Mr. Rivera’s family asks why CVVHD is used instead of traditional hemodialysis. The nurse explains that CVVHD is preferred for: A. Patients with chronic kidney disease who need long-term dialysis B. Patients who are hemodynamically unstable and cannot tolerate rapid fluid shifts C. Patients with a history of peritoneal dialysis failure D. Patients who prefer shorter treatment sessions 9. Nurse Mary Grace Piattos is assessing Mr. Joel Ramirez, a 58-year-old patient receiving peritoneal dialysis (PD). He reports mild abdominal discomfort and nausea. Which assessment finding would most strongly support a diagnosis of peritonitis? A. Clear, straw-colored effluent with intermittent mild cramping B. Red-tinged drainage fluid and mild discomfort around the catheter site C. Cloudy dialysate effluent, diffuse abdominal pain, and rebound tenderness D. Increased blood pressure and dry mucous membranes 10. Nurse Mary Grace Piattos is caring for Ms. Ana Lopez, a 62-year-old patient who had a peritoneal dialysis (PD) catheter inserted two days ago. Ms. Lopez reports noticing small 1 | Page
amounts of dialysate leaking around the catheter site. Which nursing intervention is most appropriate? A. Instructing the patient to temporarily stop PD exchanges to allow healing B. Increasing dialysate volume to promote tissue expansion around the catheter C. Encouraging the patient to perform more frequent exchanges to prevent fluid buildup D. Applying pressure at the catheter insertion site to stop the leakage Autism Spectrum Disorder Situation: Nurse Shimenet is a compassionate and skilled pediatric nurse working in a busy pediatric clinic. She is responsible for providing care to children with a variety of developmental and behavioral conditions, including autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD). Today, she is caring for 6-year-old Liam, who has been recently diagnosed with ASD, and 8-year-old Emma, who has ADHD and struggles with impulsivity and inattention at school. 11. Nurse Shimenet is assessing Liam, a 6-year-old with ASD. His mother reports that he avoids eye contact, repeats phrases from his favorite TV show, and becomes upset when his daily routine is disrupted. Which finding is most characteristic of ASD? A. Hyperactivity and impulsivity. B. Frequent tantrums and aggression. C. Difficulty with fine motor skills. D. Delayed speech and repetitive behaviors. 12. Nurse Shimenet is planning care for Liam, who has ASD and struggles with transitions. Which intervention is most appropriate to help him cope with changes in routine? A. Provide a visual schedule to prepare him for upcoming activities. B. Encourage him to engage in imaginative play with peers. C. Use time-out as a consequence for disruptive behavior. D. Administer a stimulant medication to improve focus. 13. Nurse Shimenet is preparing to administer methylphenidate (Ritalin) to Emma, who has ADHD. Which action is most important before administering the medication? A. Assess Emma’s height and weight to monitor for growth delays. B. Verify the medication dose with Emma’s parents. C. Administer the medication with food to reduce nausea. D. Teach Emma about the long-term side effects of the medication. 14. Liam’s parents refuse to vaccinate him due to concerns about a link between vaccines and ASD. How should Nurse Shimenet respond? A. Respect their decision and document their refusal. B. Educate them about the lack of evidence linking vaccines to ASD. C. Report their refusal to child protective services. D. Provide them a list of vaccines that have no direct link to the development of ASD. 15. Emma, who has ADHD, becomes agitated and starts throwing objects in the clinic. What is the priority action Nurse Shimenet should take? A. Administer a PRN dose of methylphenidate to calm her. B. Use a calm voice to redirect her to a safe activity. C. Restrain Emma to prevent injury to herself or others. D. Notify her parents and send her home immediately. Suicidal Patient Situation: Nurse Feishang, a psychiatric nurse at a busy outpatient mental health clinic, is assigned to care for a 28-year-old patient, Blingblong, who has a history of major depressive disorder and recent suicidal ideation. Blingblong, a graphic designer, has been struggling with overwhelming feelings of hopelessness after a recent job loss and the end of a long-term relationship. He was brought to the clinic by his sister Hugis Mangga, who found a note suggesting suicidal intent. During the assessment, Blingblong reports passive suicidal ideation but denies an active plan. 16. Nurse Feishang is conducting a suicide risk assessment for Blingblong. Which of the following statements by Blingblong would indicate the highest risk for suicide? A. "I just don’t see the point of anything anymore, but I don’t have the energy to do anything about it." B. "I wish I could just go to sleep and never wake up, but I’d never do that to my sister." C. "I’ve been organizing my things and making sure my sister knows how to access my bank account." D. "Sometimes I think about how things would be easier if I weren’t around, but it’s just a passing thought." 17. Nurse Feishang is reviewing a study on suicide prevention. The study used random selection of participants. What type of sampling method was used? A. Convenience sampling B. Purposive sampling C. Non-probability sampling D. Probability sampling 18. Blingblong expresses feelings of guilt, saying, “I’m a burden to my family.” Which of the following is the most therapeutic response? A. “Your family would be devastated if you died.” B. “It sounds like you’re feeling really hopeless right now.” C. “You should focus on the positive things in your life.” D. “You’re not a burden. Your family loves you.” 19. Nurse Feishang is providing medication education to Blingblong about fluoxetine. Which statement by Blingblong indicates a need for further teaching? A. "I’ll take my fluoxetine in the morning to avoid insomnia." B. "If I miss a dose, I can take it later in the day as long as it’s within 8 hours." C. "Since I’m on fluoxetine, I can take St. John’s Wort to help with my depression." D. "I may have some nausea at first, but taking the medication with food might help." 20. Nurse Feishang is educating Blingblong, who is prescribed phenelzine, a monoamine oxidase inhibitor (MAOI), about dietary restrictions. Which Filipino meal choice by Blingblong indicates he understands the dietary precautions? A. Sinigang na baboy with plain rice and fresh mango slices B. Tokwa’t baboy with soy sauce and sukang tuba (coconut vinegar) dip C. Dinuguan with puto and a glass of tapuy D. Longganisa with fried rice, itlog na maalat Benign Prostatic Hyperplasia Situation: Nurse Ga Linda is working the evening shift on a busy medical-surgical unit when she receives a new admission, Mr. Robert Tan, a 72-year-old male with a history of hypertension and type 2 diabetes mellitus. He was admitted due to increasing difficulty with urination, including nocturia, hesitancy, weak urinary stream, and incomplete bladder emptying. Earlier today, Mr. Tan experienced acute urinary retention at home, prompting a visit to the emergency department, where a urinary catheter was placed. A diagnosis of benign prostatic hyperplasia (BPH) was confirmed, and he is now admitted for further evaluation and management. 21. Which nursing intervention is the most appropriate for Mr. Tan while managing his BPH symptoms? A. Encouraging a high-protein diet to strengthen bladder muscles B. Advising him to drink large amounts of fluids at night to promote urination C. Teaching him to avoid caffeine and alcohol to reduce bladder irritation D. Recommending the use of diuretics in the evening to improve urine flow 22. Mr. Tan’s provider prescribes tamsulosin (Flomax) for BPH. Which instruction should Nurse Ga Linda prioritize when educating the patient about this medication? A. “Take this medication on an empty stomach to enhance absorption.” 2 | Page
B. “Stand up slowly from a sitting or lying position to prevent dizziness.” C. “Report any increased urination or dribbling to your provider immediately.” D. “You may stop taking the medication once your symptoms improve.” 23. After prostatectomy, Nurse Ga Linda notes that Mr. Thompson's intake is 2500 mL, but his urinary output is only 800 mL, and he shows signs of increasing blood pressure and confusion. What is the priority nursing action? A. Document the findings and continue monitoring B. Encourage the patient to drink more fluids C. Notify the surgeon immediately and assess for fluid retention D. Increase the IV fluid rate to promote urine output 24. Nurse Ga Linda is monitoring Mr. Thompson's urinary drainage 6 hours after surgery. Which finding is most concerning and requires immediate action? A. Pink-tinged urine with a few small clots B. Dark red urine with large clots C. Light pink urine transitioning to amber D. Blood-tinged urine after ambulation 25. Nurse Ga Linda is caring for a postoperative patient who has undergone a TURP procedure for benign prostatic hyperplasia (BPH). The patient has a three-way catheter in place, connected to a closed sterile drainage system with continuous irrigation. The nurse is monitoring for potential catheter problems and signs of complications. Which of the following interventions should the nurse implement to ensure proper management of the drainage system? A. Monitor for signs of bladder distention and assess the abdomen for a rounded swelling above the pubis, indicating overdistension. B. Use a portable bladder scanner to assess for urinary retention only if the patient complains of severe pain. C. Apply gentle pressure to the catheter tubing to remove any obstructing clots if the patient reports discomfort. D. Secure the catheter tubing to the catheter itself to prevent any tension on the bladder during movement Snake bite Situation: Nurse El Phaba is an experienced emergency department (ED) nurse working in a rural hospital. One evening, a 12-year-old boy, Fiyero is brought to the ED by his parents after being bitten by a snake while playing in the woods. Fiyero is anxious, complaining of severe pain and swelling at the bite site on his left forearm. 26. Nurse El Phaba is preparing to administer Crotalidae polyvalent immune Fab antivenin (CroFab) to Fiyero. Which action is most important before starting the infusion? A. Administer diphenhydramine to prevent an allergic reaction. B. Measure the circumference of Ethan’s forearm for baseline data. C. Start the infusion at a rapid rate to ensure quick delivery. D. Obtain a blood sample for coagulation studies. 27. Fiyero develops hypotension and tachycardia during the antivenin infusion. What is Nurse El Phaba’s priority action? A. Stop the infusion and administer IV diphenhydramine. B. Increase the infusion rate to deliver the antivenin faster. C. Notify the physician and prepare vasopressors. D. Document the reaction and continue monitoring. 28. Nurse El Phaba is preparing to measure Fiyero’s forearm circumference to monitor for compartment syndrome. Which action is most important? A. Use a paper tape measure for accuracy. B. Measure both forearms at the same locations for comparison. C. Mark the measurement sites with a pen for consistency. D. Measure the circumference every 2 hours. 29. The physician orders the administration of Crotalidae polyvalent immune Fab antivenom (CroFab) to treat the envenomation. Nurse El Phaba is preparing the medication for infusion. Which of the following actions should the nurse take to ensure the proper administration of the antivenin? A. Administer the antivenin as a rapid IV bolus over 10 minutes to reduce the risk of shock. B. Dilute the antivenin in 500 to 1000 mL of normal saline and begin the infusion slowly, increasing the rate after 10 minutes if no reaction occurs. C. Administer the antivenin intramuscularly for faster absorption and to minimize tissue damage at the site of the bite. D. Measure the circumference of the affected limb after the administering the antivenin, to assess the severity of the bite. 30. Nurse El Phaba is reviewing recent research on snakebite management. Which finding is most relevant to her practice? A. Ice application reduces swelling and pain at the bite site. B. Tourniquets are effective in preventing venom spread. C. Antivenin is most effective when administered within 4 hours. D. Corticosteroids should be given immediately to reduce inflammation. Anxiety Situation: Nurse Cynthia Akina Lotemo is a compassionate and skilled psychiatric nurse working in a busy outpatient mental health clinic in the Philippines. She specializes in managing patients with anxiety disorders and provides holistic care that integrates cultural sensitivity and evidence-based practices. Today, she is caring for two patients: Maria, a 28-year-old woman with generalized anxiety disorder (GAD) who struggles with excessive worry and insomnia, and Juan, a 35-year-old man with panic disorder who experiences frequent panic attacks. 31. Nurse Cynthia is assessing Maria, who reports constant worry, difficulty sleeping, and frequent headaches. Which finding is most indicative of generalized anxiety disorder (GAD)? A. Episodic panic attacks with chest pain and shortness of breath. B. Persistent excessive worry lasting more than 6 months. C. Hallucinations and delusions. D. Sudden mood swings and impulsivity. 32. Maria tells Nurse Cynthia, “I’ve been taking more lorazepam than prescribed because my anxiety is worse.” How should Nurse Cynthia respond? A. Respect her decision and document the increased dose. B. Educate Maria about the risks of benzodiazepine dependence. C. Administer a higher dose to meet her needs. D. Notify the physician to discontinue the medication. 33. Juan experiences a panic attack in the clinic. He is hyperventilating, trembling, and says, “I can’t breathe!” What is Nurse Cynthia’s priority action? A. Administer a PRN dose of lorazepam. B. Encourage Juan to run around to release energy. C. Document the episode in Juan’s medical record. D. Stay with Juan and speak in a calm, reassuring voice. 34. Juan develops signs of benzodiazepine withdrawal, including agitation, tremors, and sweating, after abruptly stopping his clonazepam. What is Nurse Cynthia’s priority action? A. Administer a PRN dose of clonazepam to relieve symptoms. B. Reassure Juan that the symptoms will resolve on their own. C. Notify the physician and prepare for a gradual tapering plan. D. Encourage Juan to drink more water to stay hydrated. 35. Nurse Cynthia is caring for a patient, Ana, who is experiencing anxiety. Ana is pacing around the room, has difficulty concentrating, and says, “I can’t think straight!” Her heart rate is 110 bpm, and her breathing is rapid. Which stage of anxiety is Ana most likely experiencing, and what is the most appropriate nursing intervention? 3 | Page
A. Severe anxiety – Stay with Ana, speak in a calm voice, and encourage deep breathing. B. Mild anxiety – Provide detailed education about anxiety management techniques. C. Panic anxiety – Move Ana to a quiet room and remain with her until the panic subsides. D. Moderate anxiety – Use short, simple sentences to redirect Ana’s focus. Dissociative Identity Disorder Situation: Nurse Leni Totga, a psychiatric nurse working in a mental health clinic, is assigned to care for patients with dissociative disorders. One of her regular patients is Ramon, a 34-year-old man who has been experiencing dissociative amnesia following a traumatic childhood event. Recently, Ramon has had episodes where he suddenly finds himself in unfamiliar places without recollection of how he got there. His wife, Mila, accompanies him to the clinic, concerned about his worsening symptoms and his increasing detachment from reality. 36. Ramon tells Nurse Leni, “Sometimes I wake up in a place I don’t recognize. I don’t remember what happened before, but I find receipts or items I don’t recall buying. My wife says I’ve been acting differently, but I don’t believe her.” Which assessment finding would be most concerning? A. Ramon describes feeling as if he is watching himself from outside his body. B. Ramon has gaps in his memory and finds himself in unknown locations. C. Ramon expresses that his wife is lying and insists he has no issues. D. Ramon is able to recall specific events when asked leading questions. 37. Mila tells Nurse Leni that Ramon disappeared for two days and came back with a new phone and clothes but could not explain where he had been. What is the nurse’s priority intervention? A. Assess Ramon’s risk for self-harm or harm to others. B. Encourage Mila to monitor Ramon’s dissociative episodes. C. Ask Ramon to recall details of his whereabouts to improve memory. D. Advise Mila to provide Ramon with grounding techniques. 38. During a therapy session, Ramon says, “I feel like a stranger in my own life. Sometimes I think I’m a different person.” Which response by Nurse Leni is the most therapeutic? A. “That sounds confusing. Can you describe what that feels like for you?” B. “It must be hard for your wife to deal with this, too.” C. “Maybe if you tried harder, you could remember things more clearly.” D. “That’s just your mind playing tricks on you; you’re still the same person.” 39. Ramon is prescribed Phenelzine, a monoamine oxidase inhibitor (MAOI), for associated depressive symptoms. Which Filipino dish should Nurse Leni instruct him to avoid? A. Sinigang na Baboy B. Bicol Express C. Tinolang Isda D. Chopseuy 40. Ramon, has been placed in mechanical restraints after exhibiting aggressive behavior and attempting to harm others. After two hours, Nurse Leni Totga assesses him and notes that he is calmer, making eye contact, and following directions. According to proper restraint protocols, which of the following is the most appropriate nursing action? A. Continue full restraints and reassess in four hours to ensure long-term behavior stability. B. Remove one limb at a time every 15 minutes while assessing Ramon’s ability to remain calm. C. Administer sedatives prior to releasing one arm and one leg first, then assess Ramon’s response before releasing the other two restraints. D. Completely discontinue restraints immediately to restore Ramon’s autonomy and dignity. Blood Transfusion Situation: Student Nurse Malu Piton has just started her clinical rotation in the medical-surgical ward under the supervision of Nurse Espina. One of her assigned patients is Mr. Ramon Dela Cruz, a 65-year-old man diagnosed with chronic kidney disease (CKD) and anemia secondary to renal failure. He has been admitted for blood transfusion due to a low hemoglobin level of 7.5 g/dL. While assisting Nurse Espina, Malu must ensure patient safety, follow blood transfusion protocols, and provide patient-centered care. 41. Student Nurse Malu is preparing to administer a unit of packed red blood cells (PRBCs) to Mr. Ramon Dela Cruz. Before starting the transfusion, which action should she take first? A. Check the patient’s vital signs and ensure an IV line with normal saline is ready B. Verify the patient’s blood type and crossmatch result with the blood bank record C. Educate the patient about potential transfusion reactions and obtain informed consent D. Prime the blood administration set with lactated Ringer’s solution to prevent clotting 42. During the transfusion, Mr. Dela Cruz reports chills, flank pain, and reddish urine. His blood pressure drops to 85/60 mmHg, and his heart rate increases to 115 bpm. What is the priority nursing action? A. Administer diphenhydramine (Benadryl) and continue monitoring the patient B. Stop the transfusion immediately and keep the IV line open with normal saline using new tubing C. Lower the patient’s head and administer IV fluids rapidly to treat hypotension D. Slow down the blood transfusion rate and reassess in 15 minutes 43. Mr. Dela Cruz is a Jehovah’s Witness and initially declined a blood transfusion. However, when interviewed privately, he states he wants the transfusion but does not want his family to know. What should Student Nurse Malu do? A. Respect the patient’s confidentiality and proceed with the transfusion as requested B. Inform the family of the patient’s decision to ensure shared decision-making C. Refuse to administer the transfusion because it conflicts with the patient’s religion D. Seek an ethics consultation before proceeding with the transfusion 44. Mrs. Lilia Santiago, who has a history of hypertension and CKD, is receiving a fresh frozen plasma transfusion. Thirty minutes into the transfusion, she reports difficulty breathing and chest tightness. The nurse observes jugular vein distension (JVD), crackles in both lung bases, and a blood pressure of 170/92 mmHg. What is the priority nursing action? A. Slow down the transfusion rate and monitor for further changes B. Place the patient in an upright position and administer oxygen C. Stop the transfusion and administer an antihistamine as ordered D. Continue the transfusion and administer IV furosemide (Lasix) as ordered 45. Student Nurse Malu Piton is assisting in a hospital study evaluating the efficacy of leukocyte-reduced blood products in preventing transfusion-related reactions. The research team has completed the data collection phase, and Malu is now responsible for assisting in data analysis. Which of the following actions is most appropriate at this stage of the research process? A. Conduct a literature review to find supporting studies on leukocyte-reduced transfusions B. Apply statistical tests to identify patterns and trends in the collected data C. Obtain informed consent from additional participants to increase the sample size D. Develop a clinical protocol based on assumed conclusions before finalizing the results Pneumonia Situation: Student Nurse Rhaeneyra is assigned to care for Mr. Ernesto, a 67-year-old male admitted to the ICU with 4 | Page