This is a 40-item sample questions with rationales in preparation for the 2014 Philippine Nurse Licensure Exam
1. A 72 year-old client is scheduled to have a cardioversion. A nurse reviews the client’s medication administration record. The nurse should notify the health care provider if the client received which medication during the preceding 24 hours?
A) digoxin (Lanoxin)
B) diltiazam (Cardizem)
C) nitroglycerine ointment
D) metoprolol (Toprol XL)
The correct answer is A: digoxin (Lanoxin) Digoxin increases ventricular irritability and increases the risk of ventricular fibrillation following cardioversion. The other medications do not increase ventricular irritability
2. Which of these clients, who all have the findings of a board-like abdomen, would the nurse suggest that the health care provider examine first?
A) An elderly client who stated that "My awful pain in my right side suddenly stopped about 3 hours ago."
B) A pregnant woman of 8 weeks newly diagnosed with an ectopic pregnancy
C) A middle-aged client admitted with diverticulitis and has taken only clear liquids for the past week
D) A teenager with a history of falling off a bicycle and did not hit the handle bars
The correct answer is A: An elderly client who stated that "My awful pain in my right side suddenly stopped about 3 hours ago." This client has the highest risk for hypovolemic and septic shock since the appendix has most likely ruptured as based on the history of the pain suddenly stopping over three hours ago. Being elderly there, is less reserve for the body to cope with shock and infection over long periods. The others are at risk for shock also. However, given that they fall in younger age groups, they would more likely be able to tolerate an inbalance in circulation. A common complication of falling off a bicycle is hitting the handle bars in the upper abdomen often on the left, resulting in a ruptured spleen.
3. The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of
The correct answer is D: Autonomy Individuals must be free to make independent decisions about participation in research without coercion from others.
4. Which statement made by a nurse about the goal of total quality management or continuous quality improvement in a health care setting is correct?
A) “It is to observe reactive service and product problem solving."
B) Improvement of the processes in a proactive, preventive mode is paramount.
C) A chart audits to finds common errors in practice and outcomes associated with goals.
D) A flow chart to organize daily tasks is critical to the initial stages.
The correct answer is B: Improvement of the processes in a proactive, preventive mode is paramount. Total quality management and continuous quality improvement have a major goal of identifying ways to do the right thing at the right time in the right way by proactive problem-solving.
5. A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving Aminophylline, 25mg/hour. Which one of the following findings by the nurse would require immediate intervention?
A) Decreased blood pressure and respirations.
B) Flushing and headache.
C) Restlessness and palpitations.
D) Increased heart rate and blood pressure.
The correct answer is C: Restlessness and palpitations. Side effects of Aminophylline include restlessness and palpitations
6. When teaching a client about the side effects of fluoxetine (Prozac), which of the following will be included?
A) Tachycardia blurred vision, hypotension, anorexia
B) Orthostatic hypotension, vertigo, reactions to tyramine rich foods
C) Diarrhea, dry mouth, weight loss, reduced libido
D) Photosensitivity, seizures, edema, hyperglycemia
The correct answer is C: Diarrhea, dry mouth, weight loss, reduced libido Commonly reported side effects for fluoxetine (Prozac) are diarrhea, dry mouth, weight loss and reduced libido
7. The nurse is preparing to administer a tube feeding to a post-operative client. To accurately assess for agastostomy tube placement, the priority is to
A) Auscultate the abdomen while instilling 10 cc of air into the tube
B) Place the end of the tube in water to check for air bubbles
C) Retract the tube several inches to check for resistance
D) Measure the length of tubing from nose to epigastrium
The correct answer is A: Auscultate the abdomen while instilling 10 cc of air into the tube If a swoosh of air is heard over the abdominal cavity while instilling air into the gastric tube, this indicates that it is accurately placed in the stomach. The feeding can begin after assessing the client for bowel sounds
8.Which of these questions is priority when assessing a client with hypertension?
A) "What over-the-counter medications do you take?"
B) "Describe your usual exercise and activity patterns."
C) "Tell me about your usual diet."
D) "Describe your family's cardiovascular history."
The correct answer is A: "What over-the-counter medications do you take?" Over-the-counter medications, especially those that contain cold preparations can increase the blood pressure to the point of hypertension.
9. The nurse is teaching parents of a 7 month-old about adding table foods. Which of the following is anappropriate finger food?
A) Hot dog pieces
B) Sliced bananas
C) Whole grapes
The correct answer is B: Sliced bananas Finger foods should be bite-size pieces of soft food such as bananas. Hot dogs and grapes can accidentally be swallowed whole and can occlude the airway. Popcorn is too difficult to chew at this age and can irritate the airway if swallowed
10 client is ordered warfarin sodium (Coumadin) to be continued at home. Which focus is critical to be included in the nurse’s discharge instruction?
A) Maintain a consistent intake of green leafy foods
B) Report any nose or gum bleeds
C) Take Tylenol for minor pains
D) Use a soft toothbrush
The correct answer is B: Report any nose or gum bleeds The client should notify the health care provider if blood is noted in their stools or urine, or any other signs of bleeding occ
11. The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse?
A) Decreased breath sounds in right lower lobe
B) Aspiration of a residual of 100cc of formula
C) Decrease in bowel sounds
D) Urine output of 250 cc in past 8 hours
The correct answer is A: Decreased breath sounds in right lower lobe
The most common problem associated with enteral feedings is atelectasis. Maintain client at 30 degrees during feedings and monitor for signs of aspiration. Check for tube placement prior to each feeding or every 4 to 8 hours if continuous feeding
12. The nurse is talking with the family of an 18 months-old newly diagnosed with retinoblastoma. A priority in communicating with the parents is
A) Discuss the need for genetic counseling
B) Inform them that combined therapy is seldom effective
C) Prepare for the child's permanent disfigurement
D) Suggest that total blindness may follow surgery
The correct answer is A: Discussing the need for genetic counseling The hereditary aspects of this disease are well documented. While the parents focus on the needs of this child, they should be aware that the risk is high for future offspring
Question Number 13 of 40
The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5. Which of the following would the nurse anticipate?
A) Additional potassium will be given IV
B) Blood for coagulation studies will be drawn
C) Total parenteral nutrition (TPN) will be started
D) Serum lipase levels will be evaluated
The correct answer is C: Total parenteral nutrition (TPN) will be started The client is not absorbing nutrients adequately as evidenced by the cachexia and low protein levels. (A normal total serum protein level is 6.0-8.0.) TPN will maintain a positive nitrogen balance in the client who is unable to digest and absorb nutrients adequately.
Question Number 14 of 40
The nurse is teaching about nonsteroidal anti-inflammatory drugs to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions?
A) Reporting joint stiffness in the morning
B) Taking the medication 1 hour before or 2 hours after meals
C) Using alcohol in moderation unless driving
D) Continuing to take aspirin for short term relief
The correct answer is B: Taking the medication 1 hour before or 2 hours after meals Taking the medication 1 hour before or 2 hours after meals will result in a more rapid effect.
Question Number 15 of 40
Which approach is a priority for the nurse who works with clients from many different cultures?
A) Speak at least 2 other languages of clients in the neighborhood
B) Learn about the cultures of clients who are most often encountered
C) Have a list of persons for referral when interaction with these clients occur
D) Recognize personal attitudes about cultural differences and real or expected biases
The correct answer is D: Recognize personal attitudes about cultural differences and real or expected biases The nurse must discover personal attitudes, prejudices and biases specific to different cultures. Sensitivity to these will affect interactions with clients and families across cultures.
Question Number 16 of 40
A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states “I refuse both radiation and chemotherapy because they are 'hot.'” The next action for the nurse to take is to
A) Document the situation in the notes
B) Report the situation to the health care provider
C) Talk with the client's family about the situation
D) Ask the client to talk about the concerns about the "hot" treatments
The correct answer is D: Ask the client to talk about the concerns about the "hot" treatments The "hot-cold" system is found among Mexican-Americans, Puerto Ricans, and other Hispanic-Latinos. Most foods, beverages, herbs, and medicines are categorized as hot or cold, which are symbolic designations and do not necessarily indicate temperature or spiciness. Care and treatment regimens can be negotiated with clients within this framework.
Question Number 17 of 40
During a routine check-up, an insulin-dependent diabetic has his glycosylated hemoglobin checked. The results indicate a level of 11%. Based on this result, what teaching should the nurse emphasize?
A) Rotation of injection sites
B) Insulin mixing and preparation
C) Daily blood sugar monitoring
D) Regular high protein diet
The correct answer is C: Daily blood sugar monitoring Normal hemoglobin A1C (glycosylated hemoglobin) level is 7 to 9%. Elevation indicates elevated glucose levels over time.
Question Number 18 of 40
The nurse is assigned to care for 4 clients. Which of the following should be assessed immediately after hearing the report?
A) The client with asthma who is now ready for discharge
B) The client with a peptic ulcer who has been vomiting all night
C) The client with chronic renal failure returning from dialysis
D) The client with pancreatitis who was admitted yesterday
The correct answer is B: The client with a peptic ulcer who has been vomiting all night A perforated peptic ulcer could cause nausea, vomiting and abdominal distention, and may be a life threatening situation. The client should be assessed immediately and findings reported to the health care provider
Question Number 19 of 40
To prevent drug resistance common to tubercle bacilli, the nurse is aware that which of the following agents are usually added to drug therapy?
A) Anti-inflammatory agent
B) High doses of B complex vitamins
C) Aminoglycoside antibiotic
D) Two anti-tuberculosis drugs
The correct answer is D: Two anti-tuberculosis drugs Resistance of the tubercle bacilli often occurs to a single antimicrobial agent. Therefore, therapy with multiple drugs over a long period of time helps to ensure eradication of the organism.
Question Number 20 of 40
While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age?
A) 1 year of age
B) 2 years of age
C) 3 years of age
D) 4 years of age
The correct answer is B: 2 years of age A child should be at least 2 years of age to use the radial pulse to assess heart rate.
Question Number 21 of 40
Which of these clients would the nurse monitor for the complication of C. difficile diarrhea?
A) An adolescent taking medications for acne
B) An elderly client living in a retirement center taking prednisone
C) A young adult at home taking a prescribed aminoglycoside
D) A hospitalized middle aged client receiving clindamycin
The correct answer is D: A hospitalized middle aged client receiving clindamycin Hospitalized patients, especially those receiving antibiotic therapy, are primary targets for C. difficile. Of patients receiving antibiotics, 5-38% experience antibiotic-associated diarrhea; C. difficile causes 15 to 20% of the cases. Several antibiotic agents have been associated with C. difficile. Broad-spectrum agents, such as clindamycin, ampicillin, amoxicillin, and cephalosporins, are the most frequent sources of C. difficile. Also, C. difficile infection has been caused by the administration of agents containing beta-lactamase inhibitors (ie, clavulanic acid, sulbactam, tazobactam) and intravenous agents that achieve substantial colonic intraluminal concentrations (ie, ceftriaxone, nafcillin, oxacillin). Fluoroquinolones, aminoglycosides, vancomycin, and trimethoprim are seldom associated with C. difficile infection or pseudomembranous colitis.
Question Number 22 of 40
The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse do first?
A) Explain that the procedure will help him to get well
B) Show a cartoon character with a blood pressure cuff
C) Explain that the blood pressure checks the heart pump
D) Permit handling the equipment before putting the cuff in place
The correct answer is D: Permit handling the equipment before putting the cuff in place The best way to gain the toddler''s cooperation is to encourage handling the equipment. Detailed explanations are not helpful.
Question Number 23 of 40
The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is
A) A firm touch to the trapezius muscle or arm
B) Pinching any body part
C) Sternal rub
D) Gentle pressure on eye orbit
The correct answer is D: Gentle pressure on eye orbit This is an acceptable stimuli only after progressing from lighter to stimuli to more obnoxious.
Question Number 24 of 40
The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience
A) High fever
C) Face and neck edema
D) Night sweats
The correct answer is B: Nausea Because the client with Hodgkin''s disease is usually healthy when therapy begins, the nausea is especially troubling
Question Number 25 of 40
A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these mediations would the nurse anticipate the health care provider ordering?
A) Oral Coumadin therapy
B) Heparin 5000 units subcutaneously b.i.d.
C) Heparin infusion to maintain the PTT at 1.5-2.5 times the control value
D) Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value
The correct answer is D: Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value Several studies have been conducted in pregnant women where oral anticoagulation agents are contraindicated. Warfarin (Coumadin) is known to cross the placenta and is therefore reported to be teratogenic.
Question Number 26 of 40
A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home 2 days later and finds the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this weight loss?
A) The newborn needs additional assessments
B) The mother should breast feed more often
C) A change to formula is indicated
D) The loss is within normal limits
The correct answer is D: The loss is within normal limits A newborn is expected to lose 5-10% of the birth weight in the first few days because of changes in elimination and feeding.
Question Number 27 of 40
A client is receiving Total Parenteral Nutrition (TPN) via Hickman catheter. The catheter accidentally becomes dislodged from the site. Which action by the nurse should take priority?
A) Check that the catheter tip is intact
B) Apply a pressure dressing to the site
C) Monitor respiratory status
D) Assess for mental status changes
The correct answer is B: Apply a pressure dressing to the site The client is at risk of bleeding or the development of an air embolus if the catheter exit site is not covered immediately
Question Number 28 of 40
A client with a panic disorder has a new prescription for Xanax (Alpazolam). In teaching the client about the drug's actions and side effects, which of the following should the nurse emphasize?
A) Short-term relief can be expected
B) The medication acts as a stimulant
C) Dosage will be increased as tolerated
D) Initial side effects often continue
The correct answer is A: Short-term relief can be expected Xanax is a short-acting benzodiazepine useful in controlling panic symptoms quickly.
Question Number 29 of 40
A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which changes would require the nurse's immediate attention?
A) Increased restlessness
C) Tracheal deviation
The correct answer is C: Tracheal deviation The deviated trachea is a sign that a mediastinal shift has occurred. This is a medical emergency.
Question Number 30 of 40
A client being discharged from the cardiac step-down unit following a myocardial infarction ( MI), is given a prescription for a beta-blocking drug. A nursing student asks the charge nurse why this drug would be used by a client who is not hypertensive. What is an appropriate response by the charge nurse?
A) "Most people develop hypertension following an MI."
B) "A beta-Blocker will prevent orthostatic hypotension."
C) "This drug will decrease the workload on his heart."
D) "Beta-blockers increase the strength of heart contractions."
The correct answer is C: "This drug will decrease the workload on his heart." One action of beta-blockers is to decrease systemic vascular resistance by dilating arterioles. This is useful for the client with coronary artery disease, and will reduce the risk of another MI or sudden death
Question Number 31 of 40
A client has gastroesophageal reflux. Which recommendation made by the nurse would be most helpful to the client?
A) Avoid liquids unless a thickening agent is used
B) Sit upright for at least 1 hour after eating
C) Maintain a diet of soft foods and cooked vegetables
D) Avoid eating 2 hours before going to sleep
The correct answer is D: Avoid eating2 hours before going to sleep Eating before sleeping enhances the regurgitation of stomach contents which have increased acidity into the esophagus. Maintaining an upright posture should be for about 2 hours after eating to allow for the stomach emptying. The options A and C are interventions for clients with swallowing difficulties
Question Number 32 of 40
As a part of a 9 pound full-term newborn's assessment, the nurse performs a dextro-stick at 1 hour post birth. The serum glucose reading is 45 mg/dl. What action by the nurse is appropriate at this time?
A) Give oral glucose water
B) Notify the pediatrician
C) Repeat the test in 2 hours
D) Check the pulse oximetry reading
The correct answer is C: Repeat the test in two hours This blood sugar is within the normal range for a full-term newborn. Normal values are: Premature infant: 20-60 mg/dl or 1.1-3.3 mmol/L, Neonate: 30-60 mg/dl or 1.7-3.3 mmol/L, Infant: 40-90 mg/dl or 2.2-5.0 mmol/L. Critical values are: Infant: <40 mg/dl and in a Newborn: <30 and >300 mg/dl. Because of the increased birth weight which can be associated with diabetes mellitus, repeated blood sugars will be drawn.
Question Number 33 of 40
An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When the nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The nurse understands that which of the following is true in regards to giving immunizations to this child?
A) Live vaccines are withheld in children with renal chronic illness
B) The MMR vaccine should be given now, prior to the transplant
C) An inactivated form of the vaccine can be given at any time
D) The risk of vaccine side effects precludes giving the vaccine
The correct answer is B: The MMR vaccine should be given now, prior to the transplant MMR is a live virus vaccine, and should be given at this time. Post-transplant, immunosuppressive drugs will be given and the administration of the live vaccine at that time would be contraindicated because of the compromised immune system.
Question Number 34 of 40
A nurse admits a client transferred from the emergency room. The client, diagnosed with a myocardial infarction, is complaining of substernal chest pain, diaphoresis and nausea. The first action by the nurse should be
A) Order an EKG
B) Administer morphine sulphate
C) Start an IV
D) Measure vital signs
The correct answer is B: Administer pain medication as ordered Decreasing the clients pain is the most important priority at this time. As long as pain is present there is danger in extending the infarcted area. Morphine will decrease the oxygen demands of the heart and act as a mild diuretic as well.
Question Number 35 of 40
The clinic nurse is counseling a substance-abusing post partum client on the risks of continued cocaine use. In order to provide continuity of care, which nursing diagnosis is a priority ?
A) Social isolation
B) Ineffective coping
C) Altered parenting
D) Sexual dysfunction
The correct answer is C: Altered parenting The cocaine abusing mother puts her newborn and other children at risk for neglect and abuse. Continuing to use drugs has the potential to impact parenting behaviors. Social service referrals are indicated
Question Number 36 of 40
The nurse admits a 2 year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure?
A) "He has been taking long naps for a week."
B) "He has had an ear infection for the past 2 days."
C) "He has been eating more red meat lately."
D) "He seems to be going to the bathroom more frequently."
The correct answer is B: "He has had an ear infection for the past 2 days." Contributing factors to seizures in children include those such as age (more common in first 2 years), infections (late infancy and early childhood), fatigue, not eating properly and excessive fluid intake or fluid retention
Question Number 37 of 40
Which of the following drugs should the nurse anticipate administering to a client before they are to receive electroconvulsive therapy?
B) Chlorpromazine (Thorazine)
C) Succinylcholine (Anectine)
D) Thiopental sodium (Pentothal Sodium)
The correct answer is C: Succinylcholine (Anectine) Succinylcholine is given intravenously to promote skeletal relaxation
Question Number 38 of 40
A client taking isoniazide (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediatley report which of these?
A) Double vision and visual halos
B) Extremity tingling and numbness
C) Confusion and lightheadedness
D) Sensitivity of sunlight
The correct answer is B: Extremity tingling and numbness Peripheral neuropathy is the most common side effect of INH and should be reported to the health care provider; it can be reversed.
Question Number 39 of 40
The nurse is planning care for an 8 year-old child. Which of the following should be included in the plan of care?
A) Encourage child to engage in activities in the playroom
B) Promote independence in activities of daily living
C) Talk with the child and allow him to express his opinions
D) Provide frequent reassurance and cuddling
The correct answer is A: Encourage child to engage in activities in the playroom According to Erikson, the school age child is in the stage of industry versus inferiority. To help them achieve industry, the nurse should encourage them to carry out tasks and activities in their room or in the playroom
Question Number 40 of 40
During a situation of pain management, which statement is a priority to consider for the ethical guidelines of the nurse?
A) The client's self-report is the most important consideration
B) Cultural sensitivity is fundamental to pain management
C) Clients have the right to have their pain relieved
D) Nurses should not prejudge a client's pain using their own values
The correct answer is A: The client''s self-report is the most important consideration Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is. The other statements are correct but not the priority.