Philippine Nursing Licensure Examination 100 Items
1. A 10 year old who has sustained a head injury is brought to the emergency
department by his mother. A diagnosis of a mild concussion is made. At the
time of discharge, nurse Ron should instruct the mother to:
A. Withhold food and fluids for 24 hours.
B. Allow him to play outdoors with his friends.
C. Arrange for a follow up visit with the child’s primary care provider in
one week.
D. Check for any change in responsiveness every two hours until the
follow-up visit.
2. A male client has suffered a motor accident and is now suffering from
hypovolemic shock. Nurse Helen should frequency assess the client’s vital
signs during the compensatory stage of shock, because:
A. Arteriolar constriction occurs
B. The cardiac workload decreases
C. Decreased contractility of the heart occurs
D. The parasympathetic nervous system is triggered
3. A paranoid male client with schizophrenia is losing weight, reluctant to eat,
and voicing concerns about being poisoned. The best intervention by nurse
Dina would be to:
A. Allow the client to open canned or pre-packaged food
B. Restrict the client to his room until 2 lbs are gained
C. Have a staff member personally taste all of the client’s food
D. Tell the client the food has been x-rayed by the staff and is safe
4. One day the mother of a young adult confides to nurse Frida that she is very
troubled by he child’s emotional illness. The nurse’s most therapeutic initial
response would be:
A. “You may be able to lessen your feelings of guilt by seeking
counseling”
B. “It would be helpful if you become involved in volunteer work at this
time”
C. “I recognize it’s hard to deal with this, but try to remember that this
too shall pass”
, D. “Joining a support group of parents who are coping with this
problem can be quite helpful.
5. To check for wound hemorrhage after a client has had a surgery for the
removal of a tumor in the neck, nurse grace should:
A. Loosen an edge of the dressing and lift it to see the wound
B. Observe the dressing at the back of the neck for the presence of
blood
C. Outline the blood as it appears on the dressing to observe any
progression
D. Press gently around the incision to express accumulated blood from
the wound
6. A 16-year-old primigravida arrives at the labor and birthing unit in her 38th
week of gestation and states that she is labor. To verify that the client is in
true labor nurse Trina should:
A. Obtain sides for a fern test
B. Time any uterine contractions
C. Prepare her for a pelvic examination
D. Apply nitrazine paper to moist vaginal tissue
7. As part of the diagnostic workup for pulmonic stenosis, a child has cardiac
catheterization. Nurse Julius is aware that children with pulmonic stenosis
have increased pressure:
A. In the pulmonary vein
B. In the pulmonary artery
C. On the left side of the heart
D. On the right side of the heart
8. An obese client asks nurse Julius how to lose weight. Before answering, the
nurse should remember that long-term weight loss occurs best when:
A. Eating patterns are altered
B. Fats are limited in the diet
C. Carbohydrates are regulated
D. Exercise is a major component
9. As a very anxious female client is talking to the nurse May, she starts
crying. She appears to be upset that she cannot control her crying. The most
appropriate response by the nurse would be:
A. “Is talking about your problem upsetting you?”
B. “It is Ok to cry; I’ll just stay with you for now”
, C. “You look upset; lets talk about why you are crying.”
D. “Sometimes it helps to get it out of your system.”
10. A patient has partial-thickness burns to both legs and portions of his trunk.
Which of the following I.V. fluids is given first?
A. Albumin
B. D5W
C. Lactated Ringer’s solution
D. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml
11. During the first 48 hours after a severe burn of 40% of the clients body
surface, the nurse’s assessment should include observations for water
intoxication. Associated adaptations include:
A. Sooty-colored sputum
B. Frothy pink-tinged sputum
C. Twitching and disorientation
D. Urine output below 30ml per hour
12. After a muscle biopsy, nurse Willy should teach the client to:
A. Change the dressing as needed
B. Resume the usual diet as soon as desired
C. Bathe or shower according to preference
D. Expect a rise in body temperature for 48 hours
13. Before a client whose left hand has been amputated can be fitted for a
prosthesis, nurse Joy is aware that:
A. Arm and shoulder muscles must be developed
B. Shrinkage of the residual limb must be completed
C. Dexterity in the other extremity must be achieved
D. Full adjustment to the altered body image must have occurred
14. Nurse Cathy applies a fetal monitor to the abdomen of a client in active
labor. When the client has contractions, the nurse notes a 15 beat per minute
deceleration of the fetal heart rate below the baseline lasting 15 seconds.
Nurse Cathy should:
A. Change the maternal position
B. Prepare for an immediate birth
C. Call the physician immediately
D. Obtain the client’s blood pressure
1. A 10 year old who has sustained a head injury is brought to the emergency
department by his mother. A diagnosis of a mild concussion is made. At the
time of discharge, nurse Ron should instruct the mother to:
A. Withhold food and fluids for 24 hours.
B. Allow him to play outdoors with his friends.
C. Arrange for a follow up visit with the child’s primary care provider in
one week.
D. Check for any change in responsiveness every two hours until the
follow-up visit.
2. A male client has suffered a motor accident and is now suffering from
hypovolemic shock. Nurse Helen should frequency assess the client’s vital
signs during the compensatory stage of shock, because:
A. Arteriolar constriction occurs
B. The cardiac workload decreases
C. Decreased contractility of the heart occurs
D. The parasympathetic nervous system is triggered
3. A paranoid male client with schizophrenia is losing weight, reluctant to eat,
and voicing concerns about being poisoned. The best intervention by nurse
Dina would be to:
A. Allow the client to open canned or pre-packaged food
B. Restrict the client to his room until 2 lbs are gained
C. Have a staff member personally taste all of the client’s food
D. Tell the client the food has been x-rayed by the staff and is safe
4. One day the mother of a young adult confides to nurse Frida that she is very
troubled by he child’s emotional illness. The nurse’s most therapeutic initial
response would be:
A. “You may be able to lessen your feelings of guilt by seeking
counseling”
B. “It would be helpful if you become involved in volunteer work at this
time”
C. “I recognize it’s hard to deal with this, but try to remember that this
too shall pass”
, D. “Joining a support group of parents who are coping with this
problem can be quite helpful.
5. To check for wound hemorrhage after a client has had a surgery for the
removal of a tumor in the neck, nurse grace should:
A. Loosen an edge of the dressing and lift it to see the wound
B. Observe the dressing at the back of the neck for the presence of
blood
C. Outline the blood as it appears on the dressing to observe any
progression
D. Press gently around the incision to express accumulated blood from
the wound
6. A 16-year-old primigravida arrives at the labor and birthing unit in her 38th
week of gestation and states that she is labor. To verify that the client is in
true labor nurse Trina should:
A. Obtain sides for a fern test
B. Time any uterine contractions
C. Prepare her for a pelvic examination
D. Apply nitrazine paper to moist vaginal tissue
7. As part of the diagnostic workup for pulmonic stenosis, a child has cardiac
catheterization. Nurse Julius is aware that children with pulmonic stenosis
have increased pressure:
A. In the pulmonary vein
B. In the pulmonary artery
C. On the left side of the heart
D. On the right side of the heart
8. An obese client asks nurse Julius how to lose weight. Before answering, the
nurse should remember that long-term weight loss occurs best when:
A. Eating patterns are altered
B. Fats are limited in the diet
C. Carbohydrates are regulated
D. Exercise is a major component
9. As a very anxious female client is talking to the nurse May, she starts
crying. She appears to be upset that she cannot control her crying. The most
appropriate response by the nurse would be:
A. “Is talking about your problem upsetting you?”
B. “It is Ok to cry; I’ll just stay with you for now”
, C. “You look upset; lets talk about why you are crying.”
D. “Sometimes it helps to get it out of your system.”
10. A patient has partial-thickness burns to both legs and portions of his trunk.
Which of the following I.V. fluids is given first?
A. Albumin
B. D5W
C. Lactated Ringer’s solution
D. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml
11. During the first 48 hours after a severe burn of 40% of the clients body
surface, the nurse’s assessment should include observations for water
intoxication. Associated adaptations include:
A. Sooty-colored sputum
B. Frothy pink-tinged sputum
C. Twitching and disorientation
D. Urine output below 30ml per hour
12. After a muscle biopsy, nurse Willy should teach the client to:
A. Change the dressing as needed
B. Resume the usual diet as soon as desired
C. Bathe or shower according to preference
D. Expect a rise in body temperature for 48 hours
13. Before a client whose left hand has been amputated can be fitted for a
prosthesis, nurse Joy is aware that:
A. Arm and shoulder muscles must be developed
B. Shrinkage of the residual limb must be completed
C. Dexterity in the other extremity must be achieved
D. Full adjustment to the altered body image must have occurred
14. Nurse Cathy applies a fetal monitor to the abdomen of a client in active
labor. When the client has contractions, the nurse notes a 15 beat per minute
deceleration of the fetal heart rate below the baseline lasting 15 seconds.
Nurse Cathy should:
A. Change the maternal position
B. Prepare for an immediate birth
C. Call the physician immediately
D. Obtain the client’s blood pressure
