C. Bradycardia and Hypertension
D. Fever and Hypertension
Medical Surgical Nursing Exam 1
SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of
SITUATION : Arthur, A registered nurse, witnessed an old woman OLFU Lagro is admitted due to pain in his weight bearing joint. The
hit by a motorcycle while crossing a train railway. The old woman diagnosis was Osteoarthritis.
fell at the railway. Arthur rushed at the scene.
6. As a nurse, you instructed Mr. Rojas how to use a cane. Mr. Rojas
1. As a registered nurse, Arthur knew that the first thing that he will do has a weakness on his right leg due to self immobilization and
at the scene is guarding. You plan to teach Mr. Rojas to hold the cane
A. Stay with the person, Encourage her to remain still and A. On his left hand, because his right side is weak.
Immobilize the leg while While waiting for the
ambulance.
B. On his left hand, because of reciprocal motion.
B. Leave the person for a few moments to call for help.
C. On his right hand, to support the right leg.
C. Reduce the fracture manually.
D. On his right hand, because only his right leg is weak.
D. Move the person to a safer place.
7. You also told Mr. Rojas to hold the cane
2. Arthur suspects a hip fracture when he noticed that the old woman’s
A. 1 Inches in front of the foot.
leg is
B. 3 Inches at the lateral side of the foot.
A. A. Lengthened, Abducted and Internally Rotated.
C. 6 Inches at the lateral side of the foot.
B. Shortened, Abducted and Externally Rotated.
D. 12 Inches at the lateral side of the foot.
C. Shortened, Adducted and Internally Rotated.
8. Mr. Rojas was discharged and 6 months later, he came back to the
D. Shortened, Adducted and Externally Rotated.
emergency room of the hospital because he suffered a mild stroke. The
right side of the brain was affected. At the rehabilitative phase of your
3. The old woman complains of pain. John noticed that the knee is nursing care, you observe Mr. Rojas use a cane and you intervene if
reddened, warm to touch and swollen. John interprets that this signs you see him
and symptoms are likely related to
A. Moves the cane when the right leg is moved.
A. Infection
B. Leans on the cane when the right leg swings through.
B. Thrombophlebitis
C. keeps the cane 6 Inches out to the side of the right foot.
C. Inflammation
D. Holds the cane on the right side.
D. Degenerative disease
SITUATION: Alfred, a 40 year old construction worker developed
4. The old woman told John that she has osteoporosis; Arthur knew cough, night sweats and fever. He was brought to the nursing unit
that all of the following factors would contribute to osteoporosis except for diagnostic studies. He told the nurse he did not receive a BCG
vaccine during childhood
A. Hypothyroidism
9. The nurse performs a Mantoux Test. The nurse knows that Mantoux
B. End stage renal disease Test is also known as
C. Cushing’s Disease A. PPD
D. Taking Furosemide and Phenytoin. B. PDP
5. Martha, The old woman was now Immobilized and brought to the C. PDD
emergency room. The X-ray shows a fractured femur and pelvis. The
ER Nurse would carefully monitor Martha for which of the following D. DPP
sign and symptoms?
10. The nurse would inject the solution in what route?
A. Tachycardia and Hypotension
A. IM
B. Fever and Bradycardia
B. IV
, C. ID B. 3 months
D. SC C. 4 months
11. The nurse notes that a positive result for Alfred is D. 5 months
A. 5 mm wheal 17. Which of the following drugs is UNLIKELY given to Mang Alfred
during the maintenance phase?
B. 5 mm Induration
A. Rifampicin
C. 10 mm Wheal
B. Isoniazid
D. 10 mm Induration
C. Ethambutol
12. The nurse told Alfred to come back after
D. Pyridoxine
A. a week
18. According to the DOH, the most hazardous period for development
B. 48 hours of clinical disease is during the first
C. 1 day A. 6-12 months after
D. 4 days B. 3-6 months after
13. Mang Alfred returns after the Mantoux Test. The test result read C. 1-2 months after
POSITIVE. What should be the nurse’s next action?
D. 2-4 weeks after
A. Call the Physician
19. This is the name of the program of the DOH to control TB in the
B. Notify the radiology dept. for CXR evaluation country
C. Isolate the patient A. DOTS
D. Order for a sputum exam B. National Tuberculosis Control Program
14. Why is Mantoux test not routinely done in the Philippines? C. Short Coursed Chemotherapy
A. It requires a highly skilled nurse to perform a Mantoux D. Expanded Program for Immunization
test
20. Susceptibility for the disease [ TB ] is increased markedly in those
B. The sputum culture is the gold standard of PTB with the following condition except
Diagnosis and it will definitively determine the extent
of the cavitary lesions A. 23 Year old athlete with diabetes insipidus
C. Chest X Ray Can diagnose the specific B. 23 Year old athlete taking long term Decadron therapy
microorganism responsible for the lesions and anabolic steroids
D. Almost all Filipinos will test positive for Mantoux C. 23 Year old athlete taking illegal drugs and abusing
Test substances
15. Mang Alfred is now a new TB patient with an active disease. What D. Undernourished and Underweight individual who
is his category according to the DOH? undergone gastrectomy
A. I 21. Direct sputum examination and Chest X ray of TB symptomatic is
in what level of prevention?
B. II
A. Primary
C. III
B. Secondary
D. IV
C. Tertiary
16. How long is the duration of the maintenance phase of his
treatment? D. Quarterly
A. 2 months
,SITUATION: Michiel, A male patient diagnosed with colon cancer B. Slow down the irrigation
was newly put in colostomy.
C. Tell the client that cramping will subside and is
22. Michiel shows the BEST adaptation with the new colostomy if he normal
shows which of the following?
D. Notify the physician
A. Look at the ostomy site
28. The next day, the nurse will assess Michiel’s stoma. The nurse
B. Participate with the nurse in his daily ostomy care noticed that a prolapsed stoma is evident if she sees which of the
following?
C. Ask for leaflets and contact numbers of ostomy
support groups A. A sunken and hidden stoma
D. Talk about his ostomy openly to the nurse and friends B. A dusky and bluish stoma
23. The nurse plans to teach Michiel about colostomy irrigation. As the C. A narrow and flattened stoma
nurse prepares the materials needed, which of the following item
indicates that the nurse needs further instruction? D. Protruding stoma with swollen appearance
A. Plain NSS / Normal Saline 29. Michiel asked the nurse, what foods will help lessen the odor of his
colostomy. The nurse best response would be
B. K-Y Jelly
A. Eat eggs
C. Tap water
B. Eat cucumbers
D. Irrigation sleeve
C. Eat beet greens and parsley
24. The nurse should insert the colostomy tube for irrigation at
approximately D. Eat broccoli and spinach
A. 1-2 inches 30. The nurse will start to teach Michiel about the techniques for
colostomy irrigation. Which of the following should be included in the
B. 3-4 inches nurse’s teaching plan?
C. 6-8 inches A. Use 500 ml to 1,000 ml NSS
D. 12-18 inches B. Suspend the irrigant 45 cm above the stoma
25. The maximum height of irrigation solution for colostomy is C. Insert the cone 4 cm in the stoma
A. 5 inches D. If cramping occurs, slow the irrigation
B. 12 inches 31. The nurse knew that the normal color of Michiel’s stoma should be
C. 18 inches A. Brick Red
D. 24 inches B. Gray
26. Which of the following behavior of the client indicates the best C. Blue
initial step in learning to care for his colostomy?
D. Pale Pink
A. Ask to defer colostomy care to another individual
SITUATION: James, A 27 basketball player sustained inhalation
B. Promises he will begin to listen the next day burn that required him to have tracheostomy due to massive upper
airway edema.
C. Agrees to look at the colostomy
32. Wilma, His sister and a nurse is suctioning the tracheostomy tube
D. States that colostomy care is the function of the nurse of James. Which of the following, if made by Wilma indicates that she
while he is in the hospital is committing an error?
27. While irrigating the client’s colostomy, Michiel suddenly A. Hyperventilating James with 100% oxygen before and
complains of severe cramping. Initially, the nurse would after suctioning
A. Stop the irrigation by clamping the tube B. Instilling 3 to 5 ml normal saline to loosen up
secretion
, C. Applying suction during catheter withdrawal A. James’ respiratory rate is 18
D. Suction the client every hour B. James’ Oxygen saturation is 91%
33. What size of suction catheter would Wilma use for James, who is C. There are frank blood suction from the tube
6 feet 5 inches in height and weighing approximately 145 lbs?
D. There are moderate amount of tracheobronchial
A. Fr. 5 secretions
B. Fr. 10 39. Wilma knew that the maximum time when suctioning James is
C. Fr. 12 A. 10 seconds
D. Fr. 18 B. 20 seconds
34. Wilma is using a portable suction unit at home, What is the amount C. 30 seconds
of suction required by James using this unit?
D. 45 seconds
A. 2-5 mmHg
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was
B. 5-10 mmHg diagnosed with Acute Close Angle Glaucoma. He is being seen by
Nurse Jet.
C. 10-15 mmHg
40. What specific manifestation would nurse Jet see in Acute close
D. 20-25 mmHg angle glaucoma that she would not see in an open angle glaucoma?
35. If a Wall unit is used, What should be the suctioning pressure A. Loss of peripheral vision
required by James?
B. Irreversible vision loss
A. 50-95 mmHg
C. There is an increase in IOP
B. 95-110 mmHg
D. Pain
C. 100-120 mmHg
41. Nurse jet knew that Acute close angle glaucoma is caused by
D. 155-175 mmHg
A. Sudden blockage of the anterior angle by the base of
36. Wilma was shocked to see that the Tracheostomy was dislodged. the iris
Both the inner and outer cannulas was removed and left hanging on
James’ neck. What are the 2 equipment’s at james’ bedside that could B. Obstruction in trabecular meshwork
help Wilma deal with this situation?
C. Gradual increase of IOP
A. New set of tracheostomy tubes and Oxygen tank
D. An abrupt rise in IOP from 8 to 15 mmHg
B. Theophylline and Epinephrine
42. Nurse jet performed a TONOMETRY test to Mr. Batumbakal.
C. Obturator and Kelly clamp What does this test measures
D. Sterile saline dressing A. It measures the peripheral vision remaining on the
client
37. Which of the following method if used by Wilma will best assure
that the tracheostomy ties are not too tightly placed? B. Measures the Intra Ocular Pressure
A. Wilma places 2 fingers between the tie and neck C. Measures the Client’s Visual Acuity
B. The tracheotomy can be pulled slightly away from the D. Determines the Tone of the eye in response to the
neck sudden increase in IOP.
C. James’ neck veins are not engorged 43. The Nurse notices that Mr. Batumbakal cannot anymore determine
RED from BLUE. The nurse knew that which part of the eye is affected
D. Wilma measures the tie from the nose to the tip of the by this change?
earlobe and to the xiphoid process.
A. IRIS
38. Wilma knew that James have an adequate respiratory condition if
she notices that B. PUPIL
D. Fever and Hypertension
Medical Surgical Nursing Exam 1
SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of
SITUATION : Arthur, A registered nurse, witnessed an old woman OLFU Lagro is admitted due to pain in his weight bearing joint. The
hit by a motorcycle while crossing a train railway. The old woman diagnosis was Osteoarthritis.
fell at the railway. Arthur rushed at the scene.
6. As a nurse, you instructed Mr. Rojas how to use a cane. Mr. Rojas
1. As a registered nurse, Arthur knew that the first thing that he will do has a weakness on his right leg due to self immobilization and
at the scene is guarding. You plan to teach Mr. Rojas to hold the cane
A. Stay with the person, Encourage her to remain still and A. On his left hand, because his right side is weak.
Immobilize the leg while While waiting for the
ambulance.
B. On his left hand, because of reciprocal motion.
B. Leave the person for a few moments to call for help.
C. On his right hand, to support the right leg.
C. Reduce the fracture manually.
D. On his right hand, because only his right leg is weak.
D. Move the person to a safer place.
7. You also told Mr. Rojas to hold the cane
2. Arthur suspects a hip fracture when he noticed that the old woman’s
A. 1 Inches in front of the foot.
leg is
B. 3 Inches at the lateral side of the foot.
A. A. Lengthened, Abducted and Internally Rotated.
C. 6 Inches at the lateral side of the foot.
B. Shortened, Abducted and Externally Rotated.
D. 12 Inches at the lateral side of the foot.
C. Shortened, Adducted and Internally Rotated.
8. Mr. Rojas was discharged and 6 months later, he came back to the
D. Shortened, Adducted and Externally Rotated.
emergency room of the hospital because he suffered a mild stroke. The
right side of the brain was affected. At the rehabilitative phase of your
3. The old woman complains of pain. John noticed that the knee is nursing care, you observe Mr. Rojas use a cane and you intervene if
reddened, warm to touch and swollen. John interprets that this signs you see him
and symptoms are likely related to
A. Moves the cane when the right leg is moved.
A. Infection
B. Leans on the cane when the right leg swings through.
B. Thrombophlebitis
C. keeps the cane 6 Inches out to the side of the right foot.
C. Inflammation
D. Holds the cane on the right side.
D. Degenerative disease
SITUATION: Alfred, a 40 year old construction worker developed
4. The old woman told John that she has osteoporosis; Arthur knew cough, night sweats and fever. He was brought to the nursing unit
that all of the following factors would contribute to osteoporosis except for diagnostic studies. He told the nurse he did not receive a BCG
vaccine during childhood
A. Hypothyroidism
9. The nurse performs a Mantoux Test. The nurse knows that Mantoux
B. End stage renal disease Test is also known as
C. Cushing’s Disease A. PPD
D. Taking Furosemide and Phenytoin. B. PDP
5. Martha, The old woman was now Immobilized and brought to the C. PDD
emergency room. The X-ray shows a fractured femur and pelvis. The
ER Nurse would carefully monitor Martha for which of the following D. DPP
sign and symptoms?
10. The nurse would inject the solution in what route?
A. Tachycardia and Hypotension
A. IM
B. Fever and Bradycardia
B. IV
, C. ID B. 3 months
D. SC C. 4 months
11. The nurse notes that a positive result for Alfred is D. 5 months
A. 5 mm wheal 17. Which of the following drugs is UNLIKELY given to Mang Alfred
during the maintenance phase?
B. 5 mm Induration
A. Rifampicin
C. 10 mm Wheal
B. Isoniazid
D. 10 mm Induration
C. Ethambutol
12. The nurse told Alfred to come back after
D. Pyridoxine
A. a week
18. According to the DOH, the most hazardous period for development
B. 48 hours of clinical disease is during the first
C. 1 day A. 6-12 months after
D. 4 days B. 3-6 months after
13. Mang Alfred returns after the Mantoux Test. The test result read C. 1-2 months after
POSITIVE. What should be the nurse’s next action?
D. 2-4 weeks after
A. Call the Physician
19. This is the name of the program of the DOH to control TB in the
B. Notify the radiology dept. for CXR evaluation country
C. Isolate the patient A. DOTS
D. Order for a sputum exam B. National Tuberculosis Control Program
14. Why is Mantoux test not routinely done in the Philippines? C. Short Coursed Chemotherapy
A. It requires a highly skilled nurse to perform a Mantoux D. Expanded Program for Immunization
test
20. Susceptibility for the disease [ TB ] is increased markedly in those
B. The sputum culture is the gold standard of PTB with the following condition except
Diagnosis and it will definitively determine the extent
of the cavitary lesions A. 23 Year old athlete with diabetes insipidus
C. Chest X Ray Can diagnose the specific B. 23 Year old athlete taking long term Decadron therapy
microorganism responsible for the lesions and anabolic steroids
D. Almost all Filipinos will test positive for Mantoux C. 23 Year old athlete taking illegal drugs and abusing
Test substances
15. Mang Alfred is now a new TB patient with an active disease. What D. Undernourished and Underweight individual who
is his category according to the DOH? undergone gastrectomy
A. I 21. Direct sputum examination and Chest X ray of TB symptomatic is
in what level of prevention?
B. II
A. Primary
C. III
B. Secondary
D. IV
C. Tertiary
16. How long is the duration of the maintenance phase of his
treatment? D. Quarterly
A. 2 months
,SITUATION: Michiel, A male patient diagnosed with colon cancer B. Slow down the irrigation
was newly put in colostomy.
C. Tell the client that cramping will subside and is
22. Michiel shows the BEST adaptation with the new colostomy if he normal
shows which of the following?
D. Notify the physician
A. Look at the ostomy site
28. The next day, the nurse will assess Michiel’s stoma. The nurse
B. Participate with the nurse in his daily ostomy care noticed that a prolapsed stoma is evident if she sees which of the
following?
C. Ask for leaflets and contact numbers of ostomy
support groups A. A sunken and hidden stoma
D. Talk about his ostomy openly to the nurse and friends B. A dusky and bluish stoma
23. The nurse plans to teach Michiel about colostomy irrigation. As the C. A narrow and flattened stoma
nurse prepares the materials needed, which of the following item
indicates that the nurse needs further instruction? D. Protruding stoma with swollen appearance
A. Plain NSS / Normal Saline 29. Michiel asked the nurse, what foods will help lessen the odor of his
colostomy. The nurse best response would be
B. K-Y Jelly
A. Eat eggs
C. Tap water
B. Eat cucumbers
D. Irrigation sleeve
C. Eat beet greens and parsley
24. The nurse should insert the colostomy tube for irrigation at
approximately D. Eat broccoli and spinach
A. 1-2 inches 30. The nurse will start to teach Michiel about the techniques for
colostomy irrigation. Which of the following should be included in the
B. 3-4 inches nurse’s teaching plan?
C. 6-8 inches A. Use 500 ml to 1,000 ml NSS
D. 12-18 inches B. Suspend the irrigant 45 cm above the stoma
25. The maximum height of irrigation solution for colostomy is C. Insert the cone 4 cm in the stoma
A. 5 inches D. If cramping occurs, slow the irrigation
B. 12 inches 31. The nurse knew that the normal color of Michiel’s stoma should be
C. 18 inches A. Brick Red
D. 24 inches B. Gray
26. Which of the following behavior of the client indicates the best C. Blue
initial step in learning to care for his colostomy?
D. Pale Pink
A. Ask to defer colostomy care to another individual
SITUATION: James, A 27 basketball player sustained inhalation
B. Promises he will begin to listen the next day burn that required him to have tracheostomy due to massive upper
airway edema.
C. Agrees to look at the colostomy
32. Wilma, His sister and a nurse is suctioning the tracheostomy tube
D. States that colostomy care is the function of the nurse of James. Which of the following, if made by Wilma indicates that she
while he is in the hospital is committing an error?
27. While irrigating the client’s colostomy, Michiel suddenly A. Hyperventilating James with 100% oxygen before and
complains of severe cramping. Initially, the nurse would after suctioning
A. Stop the irrigation by clamping the tube B. Instilling 3 to 5 ml normal saline to loosen up
secretion
, C. Applying suction during catheter withdrawal A. James’ respiratory rate is 18
D. Suction the client every hour B. James’ Oxygen saturation is 91%
33. What size of suction catheter would Wilma use for James, who is C. There are frank blood suction from the tube
6 feet 5 inches in height and weighing approximately 145 lbs?
D. There are moderate amount of tracheobronchial
A. Fr. 5 secretions
B. Fr. 10 39. Wilma knew that the maximum time when suctioning James is
C. Fr. 12 A. 10 seconds
D. Fr. 18 B. 20 seconds
34. Wilma is using a portable suction unit at home, What is the amount C. 30 seconds
of suction required by James using this unit?
D. 45 seconds
A. 2-5 mmHg
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was
B. 5-10 mmHg diagnosed with Acute Close Angle Glaucoma. He is being seen by
Nurse Jet.
C. 10-15 mmHg
40. What specific manifestation would nurse Jet see in Acute close
D. 20-25 mmHg angle glaucoma that she would not see in an open angle glaucoma?
35. If a Wall unit is used, What should be the suctioning pressure A. Loss of peripheral vision
required by James?
B. Irreversible vision loss
A. 50-95 mmHg
C. There is an increase in IOP
B. 95-110 mmHg
D. Pain
C. 100-120 mmHg
41. Nurse jet knew that Acute close angle glaucoma is caused by
D. 155-175 mmHg
A. Sudden blockage of the anterior angle by the base of
36. Wilma was shocked to see that the Tracheostomy was dislodged. the iris
Both the inner and outer cannulas was removed and left hanging on
James’ neck. What are the 2 equipment’s at james’ bedside that could B. Obstruction in trabecular meshwork
help Wilma deal with this situation?
C. Gradual increase of IOP
A. New set of tracheostomy tubes and Oxygen tank
D. An abrupt rise in IOP from 8 to 15 mmHg
B. Theophylline and Epinephrine
42. Nurse jet performed a TONOMETRY test to Mr. Batumbakal.
C. Obturator and Kelly clamp What does this test measures
D. Sterile saline dressing A. It measures the peripheral vision remaining on the
client
37. Which of the following method if used by Wilma will best assure
that the tracheostomy ties are not too tightly placed? B. Measures the Intra Ocular Pressure
A. Wilma places 2 fingers between the tie and neck C. Measures the Client’s Visual Acuity
B. The tracheotomy can be pulled slightly away from the D. Determines the Tone of the eye in response to the
neck sudden increase in IOP.
C. James’ neck veins are not engorged 43. The Nurse notices that Mr. Batumbakal cannot anymore determine
RED from BLUE. The nurse knew that which part of the eye is affected
D. Wilma measures the tie from the nose to the tip of the by this change?
earlobe and to the xiphoid process.
A. IRIS
38. Wilma knew that James have an adequate respiratory condition if
she notices that B. PUPIL
