Tiêu đề PRE-INTENSIVE - NP3 - SC ✅

PRE-INTENSIVE EXAMINATION NURSING PRACTICE III CARE OF THE CLIENT WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS (PART A) NOV 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 III” on the box provided Situation: Nurse Jade is in charge of a client who was admitted for management of acute episodes of cholecystitis. 1. Nurse Jade did her admission assessment. She understands that the pain is characterized as: A. Tenderness that is generalized in the upper epigastric area B. Tenderness and rigidity at the left epigastric area radiating to the back C. Tenderness and rigidity of the upper right abdomen radiating to the midsternal area D. Pain of the left upper quadrant radiating to the left shoulder 2. To confirm the diagnosis of cholecystitis, the attending physician ordered the procedure that can detect gallstones as small as 1 to 2 cm and inflammation. Nurse Jade would prepare the client for which specific diagnostic procedure? A. cholangiography B. gall bladder series C. oral cholecystogram D. ultrasonography 3. The diagnosis was confirmed as cholecystitis with gallstones. The doctor prepared the client for the removal of his gallbladder. The client asks the nurse: “How will this procedure affect my digestion?” The nurse’s most correct response would be: A. “Your body system will adjust in due time.” B. “The removal of the gallbladder usually interferes with digestion but can be remedied by dietary modifications.” C. “The removal of the gallbladder would significantly interfere only with the digestion of fatty food.” D. “The removal of gallbladder does not usually interfere with digestion.” 4. While reviewing the laboratory findings of the client, Nurse Jade found out that which findings are elevated? 1. white blood cell count 2. total serum bilirubin 3. alkaline phosphate 4. red blood cell count 5. cholesterol 6. serum amylase A. 3,5,6 B. 1,2,6 C. 1,2,3 D. 2,3,4 5. A T-tube was inserted and the doctor ordered: “Monitor the amount, color, consistency and odor of drainage.” Which of the following procedures can the nurse perform without the doctor’s order? A. clamping B. emptying C. aspirating D. irrigating Situation: Alfonsus sought hospital confinement for pleuritic pain, fever, and cough. The attending physician had a chest x-ray taken STAT. Result revealed presence of lung infiltrates. The client was assigned to Kianne the staff nurse. 6. When Kikay performed chest auscultation, she observed short discreet bubbling sounds over the lower region of the right lung. Which of the following abnormal findings will Kikay consider? A. Friction rub B. Murmur C. Wheezes D. Crackles 7. Kikay put her priority nursing diagnosis as “Ineffective airway clearance related to increased secretions and ineffective coughing.” Which nursing intervention would be considered to facilitate coughing with the LEAST discomfort? A. Splinting chest wall with pillow when coughing B. Putting the client in semi-Fowler’s position all the time C. Taking cough med q4 hours round the clock D. Utilizing the purse-lip technique of breathing 8. The physician prescribes oral penicillin 500 mg every six hours for seven days. On the fifth day, before Kikay administers the first dose for the day, she computed for the total amount in the milligrams of the oral penicillin that has been received by the client. Which of the following is the correct amount? A. 2,500 mg B. 15,000 mg C. 10,000 mg D. 8,000 mg 9. Standard precaution dictates that the nurse observes which of the following when caring for a client with streptococcal pneumonia? A. Use of face mask B. Use of sterile gloves C. Observe two-feet distance when giving care D. Use clean gloves 10. Sputum cultures are to be obtained to establish the client’s specific antibiotic treatment. Kikay would BEST collect the specimen: A. Early in the morning B. Early morning after an antiseptic gargle C. After brushing the client’s teeth D. Anytime of the day after a warm salt solution gargle Situation: Different communicable diseases spike up in today’s trends. It is important for the nurse to understand the background of different emerging diseases, its presentation, diagnosis and interventions associated to the diseases. The following questions apply to emerging communicable diseases. 11. Ebola virus was discovered in 1978 in Congo and re-appeared last 2014 in Guinea with case fatality rate of 50%. It has several different causative agents and is transmitted through direct or indirect contact to affected primates such as 1 | Page
bats. It is also commonly known as the hemorrhagic fever. Given its signs and symptoms of myalgia, high fever, malaise, internal bleeding and shock, the nurse should anticipate all of the following management except: A. Intensive fluid replacement B. Contact tracing C. Isolation D. Close-door home care 12. Zika virus is another emerging disease which was discovered in Uganda in 1947. It is known to be transmitted through mosquito bites specifically of Aedesaegypti and albopictus. Aside from a known complication of microcephaly to infants born to a mother who had a history of Zika virus, which complication is known to develop among adults who have had a history of the disease? A. Guillain-Barre Syndrome B. Alzheimer’s disease C. Degenerative spondylosis D. Hunter’s syndrome 13. In caring for a client with AIDS and is currently on HAART therapy, which of the following statements indicates a need for further teaching regarding the management of the disease? A. “I should take my HAART medications with meals” B. “I should regularly check my liver function.” C. “I should immediately consult my physician if I experience abdominal pain which radiates to the back” D. “I could go swimming in a public resort with my family and friends” 14. Nurse Pau is teaching a group of student nurses about Dengue. Which of the following statements if said by the student indicates correct understanding of the topic being discussed? A. “The confirmatory test for Dengue virus is the complete blood count test” B. “20 or more petechial spots inside a 2.5 cm2 box may indicate presence of bleeding according to the principle of the Rumpel lead test” C. “The drug of choice for the client’s fever is acetylsalicylic acid” D. “There is a need to restrict the client’s fluid during Grade III Dengue Fever” 15. SARS and MERS-COV almost have the same presenting signs and symptoms. Although they both have the same causative agent which beta-coronavirus, MERS-COV has a higher case fatality rate of 30% compared to the 10% CFR of SARS. The difference between the statistics of the two diseases can be attributed to: A. The extent of respiratory complications in MERS-COV B. The presence of renal involvement in MERS-COV C. The easier diagnosis of SARS D. The self-limiting nature of SARS Situation: Verbal communication is extremely important especially when the Nurse is exploring problems and disorders with the clients in any age group. Nurse Dante is assigned to different clients in the ward. 16. A client is hospitalized with a diagnosis of possible Cancer of the pancreas. On admission the client asks the nurse, “Do you think I have anything serious like cancer?”What is the nurse’s best reply? A. “What makes you think you have cancer? B. “I don’t know if you do, but let’s talk about it.” C. “Why don’t you discuss this with your doctor?” D. “Don’t worry, we won’t know until all the test result are back.” 17. Nurse Dante approaches a male client and asks how he is feeling. The client states “I’m feeling a bit nervous today.” Which of the following is the Nurse’s best reply? 1. Please explain what you mean by the word nervous 2. What is making you feel nervous? 3. Would a backrub ease your nervousness? 4. You do look like you’re nervous 18. When assessing a client what statement would indicate negative self-talk? A. Everyone has to learn something new sometime B. I am looking forward to making home visits , but I am also nervous C. This is going to be difficult, but I know I can do it D. Who can ever have enough experience to prepare for that job? 19. While receiving a preoperative enema a client starts to cry and says. “I’m sorry you have to do this messy thing me,” what is the best response by the nurse? A. “I don’t mind it.” B. “You seem to be upset.” C. “This is part of my job.” D. “Nurses get used to this.” 20. “But you don’t understand” is a common statement associated with adolescent. The best response by the nurse when communicating with an adolescent is to say: A. “I don’t understand.” B. “I would like to understand, let’s talk.” C. “I don’t understand. I was a teenager once too.” D. “I’m not sure have to I believe it’s you who has to understand.” Situation: Knowledge of the physiologic and pathologic changes in pregnant women is necessary in order to determine which situations require management and possible referral. 21. Nurse Dianne is observing a client in the labor room. Which of the following changes in the cardiovascular system shows a pathologic response? A. Increase in total cardiac volume by 40-50%. B. Anasarca C. Varicosities of the lower extremities D. Heart is elevated slightly upward and to the left. 22. The gastrointestinal system is also one of the systems most affected by the pregnancy. Which of the following is true? A. Nausea and vomiting as a result of the secretion of the HCG, subsiding by the 6 th month. B. Poor appetite caused by increased gastric motility. C. Flatulence and heartburn due to decreased gastrointestinal motility and slowed emptying of the stomach caused by a decrease in progesterone production. D. Ptyalism as a result of increasing levels of estrogen. 23. Changes in the endocrine system also occur during the pregnancy process. Which of the following are true A. BMR Increases B. Metabolic function Increases C. Anterior lobe of the pituitary gland reduces D. Thyroid gland enlarges slightly E. Thyroid activity decreases F. Parathyroid gland increases G. Aldosterone levels gradually decrease H. Body weight increases I. Water retention decreases A. H, F, D, C, I B. I, F, B, G, C C. B, A, E, H, F D. A, B, D, F, H 24. After the 8-hour shift, Nurse Dianne is asked to go on duty on another 8 hours.She is performing an assessment of a primigravid mother who is being evaluated in a clinic during her second trimester. Which of the following indicates an abnormal finding? A. Quickening B. Braxton Hicks Contractions C. FHR of 180 beats per minute D. Consistent increase in fundal height 25. She explains some of the purposes of the placenta to a client during a prenatal visit. The nurse determines that the client understands some of these purposes when the client states that the placenta: A. Cushions and protects the baby. B. Maintains the temperature of the baby. C. Is the way the baby gets food and oxygen. D. Prevents all antibodies and viruses from passing to the baby. 26. The patient’s ABG result reveals presence of respiratory acidosis. Which among these values would you expect to see? A. pH 7.35, CO2 39 mmHg, HCO3 24 mEq/L B. pH 7.47, CO2 30 mmHg, HCO3 22 mEq/L C. pH 7.32, CO2 49 mmHg, HCO3 29 mEq/L D. pH 7.31, CO2 31 mmHg, HCO3 20 mEq/L 27.During the initial stages of cardiogenic shock, respiratory 2 | Page
rate increases to improve oxygenation. Nurse Froilan expects the patient’s ABG to present: A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis 28. The nurse caring for a client with an ileostomy understands that the client is most at risk for developing which acid-base disorder? A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory alkalosis D. Respiratory acidosis 29. The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse’s findings? A. pH 7.25, PCO2 50 mm Hg B. pH 7.35, PCO2 40 mm Hg C. pH 7.50, PCO2 52 mm Hg D. pH 7.52, PCO2 28 mm Hg 30. The nurse is caring for a client with an IV who is experiencing dyspnea, hypotension, a weak, rapid pulse, a decreased level of consciousness, and who is becoming cyanotic. The priority nursing intervention is to: A. Notify the physician B. Place the client in Trendelenburg position C. Administer oxygen D. Discontinue the IV 31. Mr. Antonio Sanchez, 47 y.o., was diagnosed with chronic renal failure. Which of the following ABG findings would be expected? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis 32. A 60-year-old client is admitted to the hospital presenting shortness of breath, fever, and productive cough. Which ABG finding is most related to the diagnosis of COPD? A. pH 7.33, PaCO2: 48mmHg; HCO3: 24mEq/L B. pH 7.48; PaCO2: 30mmHg; HCO3: 23mEq/L C. pH 7.30; PaCO2: 40mmHg; HCO3: 20mEq/L D. pH 7.49; PaCO2: 38mmHg; HCO3: 29mEq/L 33. A patient is taking furosemide, a potassium-wasting diuretic. Which among these ABG findings would you expect in his long-term use of the diuretic? A. pH 7.48, PaCO2: 46mmHg; HCO3: 28mEq/L B. pH 7.26; PaCO2: 32mmHg; HCO3: 21mEq/L C. pH 7.35; PaCO2: 40mmHg; HCO3: 25mEq/L D. pH 7.30; PaCO2: 33mmHg; HCO3: 20mEq/L 34. A clinical instructor observes SN Tina as she performs ET suctioning to an unconscious client. Which of these indicates that Tina needs further teaching on carrying out the procedure? A. Tina suctioned for 20 seconds on the last suctioning to ensure that the airway is clear. B. Tina pressed the silent button of the mechanical ventilator momentarily prior to suctioning. C. Tina suctioned a small amount of NSS after each suctioning. D. Tina applied suction on the catheter while it was being withdrawn. 35. The nurse is planning to perform percussion and postural drainage. Which is an important aspect of planning the client’s care? A. Percussion and postural drainage should be done before lunch. B. The order should be coughing, percussion, positioning, and then suctioning. C. A good time to perform percussion and postural drainage is in the morning after breakfast when the client is well rested. D. Percussion and postural drainage should always be preceded by 3 minutes of 100% oxygen. Situation: In the OR, there are safety protocols that should be followed. The OR nurse should be well versed with all these to safeguard the safety and quality of patient delivery outcome. 36. Which of the following should be given highest priority when receiving patient in the OR? A. Assess level of consciousness B. Verify patient identification and informed consent C. Assess vital signs D. Check for jewelry, gown, manicure and dentures 37. Surgeries like I and D (Incision and Drainage) and debridement are relatively short procedures but considered “dirty cases.” When are these procedures best scheduled? A. Last case B. In between cases C. According to the availability of the anesthesiologist D. According to the surgeon’s preference 38. Katarina, an active cheerleader, complains of flashes of lights appearing and a shadow covering the upper vision of her left eye. You suspect that Katarina sustained a: A. Retinal Detachment B. Glaucoma C. Cataract D. Macular degeneration 39. Based on the situation, you plan to position the client on: * A. Side-lying on the affected eye B. Lateral on the affected eye C. Dependent position on the area affected D. Independent position on the side affected 40. As you prepare the patient for surgery, you noticed that the patient is fidgeting, going in and out of his bed and frequently asks about the procedure. These behaviors of the patient most likely suggest? A. The patient does not have enough sleep last night. B. Client is pressed between financial burden and family responsibilities. C. She drank too much coffee during breakfast D. She is anxious about the surgery. 41.The nurse should expect a patient who has chronic renal failure to be given epoetin alfa (Epogen) to A. elevate the white blood cell count B. enhances the maturation of thrombocytes. C. increases the production of platelets. D. stimulates the synthesis of red blood cells. 42. To which of the following nursing diagnoses would a nurse give priority when caring for a patient who has syndrome of inappropriate secretion of antidiuretic hormone (SIADH)? A. Decreased cardiac output B. Altered nutrition C. Urinary incontinence D. Fluid volume excess 43. A 48- year- old woman, who does not have a family history of breast cancer, asks a nurse in the ambulatory care center whether she should have a mammogram. Which of the following responses by the nurse would be accurate? A. “At your age, a mammogram is recommended every one to two years.” B. “You do not need to begin to get mammograms until you are 50 years old.” C. “A mammogram is not indicated unless you have a family history of breast cancer.” D. “A mammogram would be necessary only if you feel a change in breast tissue.” 44. When planning care for a 14- year- old female who is pregnant, a nurse should recognize that the adolescent is at risk for A. glucose intolerance B. fetal chromosomal abnormalities C. incompetent cervix D. iron deficiency anemia 45. Which of the following statements made by a patient who is scheduled for a mammogram indicates a need for further teaching? A. “I will not use underarm antiperspirant before the procedure.” B. “A dye will be injected into my vein prior to the procedure.” C. ‘I may experience discomfort during the procedure.” D. “My breasts will be compressed while the x –rays are taken.” 46. Which of the following findings in a 13- year- old girl who 3 | Page
has Crohn’s disease would indicate that corticosteroid therapy has been effective? A. Expansion of muscle mass B. Increase in the number of stools C. Moon- like appearance of the face D. Decreased complaints of abdominal pain 47. The teaching plan for a child who is taking long- term corticosteroid therapy would include which of the following instructions? A. Dental check- ups every three months to assess for gingival hyperplasia B. Regular physical therapy sessions to prevent muscular hypertrophy C. Eye examinations yearly to assess for cataract formation D. Regular appointments with a registered dietician to prevent malnutrition 48. A six- year- old child has a short arm cast placed on the right extremity. While assessing the fingers during the immediate period after casting, a nurse would report which of the following findings? A. Mild edema B. Pain on movement C. Slight coolness of the cast when touched D. Capillary refill greater than three seconds 49. A patient who is undergoing detoxification from heroin complains to the nurse of severe muscle cramps and headache and demands additional Methadone. Which of the following actions should the nurse take first? A. Measure vital signs. B. Administer p. r. n. medication. C. Provide support and reassurance. D. Contact the physician. 50. Which of the following measures should a nurse include in the care plan of a patient who has a diagnosis of bipolar disorder, manic type? A. Decrease environmental stimuli B. Involve the patient in competitive activities C. Limit the verbalization of feelings D. Foster independent decision- making 51. A nurse should instruct a pre- menopausal woman to examine her breasts according to which of the following schedules? A. During the week prior to the onset of the monthly period B. During every shower C. Seven days after the menstrual period D. On the same day every month 52. A nurse is taking the history from a patient who is suspected of having Hodgkin’s disease. Which of the following questions should the nurse ask to support the diagnosis? A. “Do you wake up sweating during the night?” B. “Do you urinate more frequently?” C. “Have you noticed recent memory lapses?” D. “Have you experienced visual changes lately?” 53. A nurse is observed taking all of the following actions when suctioning a patient who has a newly- placed tracheostomy tube. Which of the following actions require intervention? A. Applying suction for less than 15 seconds at one time B. Administering 100% oxygen prior to starting suctioning C. Utilizing negative pressure of 120 mm Hg during suctioning D. Deflating the tracheostomy cuff for three minutes before initiating suction 54. Which of the following criteria would be a reliable indicator of improvement in a patient who has a diagnosis of anorexia nervosa? A. Electrolyte balance B. Energy level C. Fluid intake D. Desire to eat 55. A nurse evaluates a three- month- old, developmentally- delayed infant for manifestations of cerebral palsy. Which of the following findings would a nurse report? A. Exaggerated arching of the back B. Absence of the extrusion reflex when fed from a spoon C. Head circumference measurement less than the 50th percentile D. Slight head lag when pulled to a sitting position 56. To which of the following nursing diagnoses should a nurse give priority in the care of a patient who is receiving chemotherapy for treatment of breast cancer? A. Risk for infection B. Stress incontinence C. Altered sexuality patterns D. Impaired physical mobility 57. Which of the following conditions, reported to a nurse by a 20- year- old male patient, would indicate a risk for development of testicular cancer? A. Genital herpes B. Undescended testicle C. Measles D. Hydrocele 58. Which of the following criteria would indicate improvement in an outpatient who has anorexia nervosa? A. The patient identifies the relationship between emotions and eating behaviors. B. The patient develops a plan to control negative feelings. C. The patient reports putting “thin” clothes on display in her room as a reminder to maintain proper weight. D. The patient avoids contact with her dysfunctional family. 59. A 10- year- old boy who is in the terminal stages of Duchenne muscular dystrophy is being cared for at home. When evaluating for a major complication of this disease, a nurse would give priority to assessing which of the following body systems? A. Integumentary B. Neurological C. Respiratory D. Gastrointestinal 60. The parent of a 12- year- old child, who is on acetylsalicylic acid (Aspirin) therapy for juvenile rheumatoid arthritis, tells a nurse, “I just read an article that said Aspirin should not be given to children.” Which of the following responses by the nurse is most appropriate? A. “Stop the Aspirin only if your child is diagnosed with a viral illness.” B. “Your child can take a different anti- inflammatory instead of aspirin.” C. “Because the Aspirin dose your child receives is so small, the risk is minimal.” D. “The benefits of Aspirin for your child outweigh the risks.” Situation: As a community health nurse, you are now in the entry phase of community organizing process, after establishing rapport with the people in Barangay PutingBuhangin. The following questions apply. 61. In the entry phase of community organizing, all but one are the activities a community health nurse shall implement: A. Information campaign on health programs B. Project Management C. Core group formation D. Conduct of deepening social investigation 62. Identification of potential leaders is crucial during the entry phase, this will facilitate the core group formation and start community mobilization. Which of these characteristics may not be necessary to an efficient and effective community leader? A. Responsive and willing to work for change B. Must have relatively good communication skills C. A respected member of the community D. A college graduate who has good management and leadership skills 63. The best way in identifying potential community leader which is proven to be effective is: A. Do a house-to-house survey among the people on who they see as a leader in the community B. During group meetings and other small mobilization, observe people who actively motivates other residents C. Ask volunteers who are willing to become community leaders D. Conduct a review of the family background and wealth as a basis for the community leader’s capacity 4 | Page