Introduction A.

Fecal oral
B. Droplet
Various questions about Medical-Surgical Nursing that are C. Airborne
perfect for reviewing the wide nursing concept. This 100- D. Sexual contact
item examination will help you practice for your upcoming
NCLEX or NLE exams! 2. Which of the following is concurrent disinfection in the
case of Leo?
Topics
A. Investigation of contact
 Thoracentesis
B. Sanitary disposal of feces, urine and blood
 Seizure
C. Quarantine of the sick individual
 Choledocholithotomy
D. Remove all detachable objects in the room.
 Pain Management
 Diabetes Mellitus
3. Which of the following must be emphasized during
 Perioperative Nursing
mother’s class to Leo’s mother?
 Sterile Technique
 Autoclaving
A. Administration of immunoglobulin to families
 Perioperative Nursing
B. Thorough hand washing before and after eating and
 IV Care
toileting
C. Use of attenuated vaccines
Guidelines D. Boiling of food especially meat

 Read each question carefully and choose the

4. Disaster control should be undertaken when there are 3
best answer.
or more hepatitis A cases. Which of these measures is a
 You are given one minute per question. Spend
priority?
your time wisely!
 Answers and rationales (if any) are given
A. Eliminate fecal contamination from foods
below. Be sure to read them.
B. Mass vaccination of uninfected individuals
 If you need more clarifications, please direct
C. Health promotion and education to families and
them to the comments section.
communities about the disease it’s cause and transmission.
D. Mass administration of immunoglobulin
Situation 1: Leo lives in the squatter area. He goes to
nearby school. He helps his mother gather molasses after
5. What is the average incubation period of Hepatitis A?
school. One day, he was absent because of fever, malaise,
anorexia and abdominal discomfort.
A. 30 days
B. 60 days
1. Upon assessment, Leo was diagnosed to have hepatitis
C. 50 days
A. Which mode of transmission has the infection agent
D. 14 days
taken?
Situation 2: As a nurse researcher you must have a very 10. The use of another persons ideas or wordings giving
good understanding of the common terms of concept used appropriate credit results from inaccurate attribution of
in research. materials to its sources. Which of the following is referred
to when another persons idea is inappropriate credited as
6. The information that an investigator collects from the one’s own?
subjects or participants in a research study is usually
called: A. Plagiarism
B. Quotation
A. Hypothesis C. Assumption
B. Data D. Paraphrase
C. Variable
D. Concept Situation 3: Mrs. Pichay is admitted to your ward. The MD
ordered “Prepare for thoracentesis this pm to remove
7. Which of the following usually refers to the excess air from the pleural cavity.”
independent variables in doing research?
11. Which of the following nursing responsibilities is
A. Result essential in Mrs. Pichay who will undergo thoracentesis?
B. Cause
C. Output A. Support and reassure client during the procedure
D. Effect B. Ensure that informed consent has been signed
C. Determine if client has allergic reaction to local
8. The recipients of experimental treatment is an anesthesia
experimental design or the individuals to be observed in a D. Ascertain if chest x-rays and other tests have been
non experimental design are called: prescribed and completed

A. Setting 12. Mrs. Pichay who is for thoracentesis is assigned by the

B. Subjects nurse to which of the following positions?
C. Treatment
D. Sample A. Trendelenburg position
B. Supine position
9. The device or techniques an investigator employs to C. Dorsal Recumbent position
collect data is called? D. Orthopneic position

A. Sample 13. During thoracentesis, which of the following nursing

B. Instrument intervention will be most crucial?
C. Hypothesis
D. Concept A. Place patient in a quiet and cool room
B. Maintain strict aseptic technique
C. Advice patient to sit perfectly still during needle insertion
until it has been withdrawn from the chest A. Shampoo hair thoroughly to remove oil and dirt
D. Apply pressure over the puncture site as soon as the B. No special preparation is needed. Instruct the patient to
needle is withdrawn keep his head still and stead.
C. Give a cleansing enema and give until 8 AM
14. To prevent leakage of fluid in the thoracic cavity, how D. Shave scalp and securely attach electrodes to it
will you position the client after thoracentesis?
18. Mr. Santos is placed on seizure precaution. Which of
A. Place flat in bed the following would be contraindicated?
B. Turn on the unaffected side
C. Turn on the affected side A. Obtain his oral temperature
D. On bed rest B. Encourage to perform his own personal hygiene
C. Allow him to wear his own clothing
15. Chest x-ray was ordered after thoracentesis. When D. Encourage him to be out of bed.
your client asks what is the reason for another chest x-ray,
you will explain: 19. Usually, how does the patient behave after
his seizure has subsided?
A. to rule out pneumothorax
B. to rule out any possible perforation A. Most comfortable walking and moving about.
C. to decongest B. Becomes restless and agitated.
D. to rule out any foreign body C. Sleeps for a period of time
D. Say he is thirsty and hungry.
Situation 4: A computer analyst, Mr. Ricardo J. Santos, 25
was brought to the hospital for diagnostic workup after he 20. Before, during and after seizure. The nurse knows that
had experienced seizure in his office. the patient is ALWAYS placed in what position?

16.Just as nurse was entering the room, the patient who A. Low fowler’s
was sitting on his chair begins to have a seizure. Which of B. Modified trendelenburg
the following must the nurse do first? C. Side Lying
D. Supine
A. Ease the patient to the floor
B. Lift the patient and put him on the bed Situation 5: Mrs. Damian an immediate post
C. Insert a padded tongue depressor between his jaws op cholecystectomy and choledocholithotomy patient,
D. Restrain patient’s body movement complained of severe pain at the wound site.

17. Mr. Santos is scheduled for CT SCAN for the next day, 21. Choledocholithotomy is:
noon time. Which of the following is the correct
preparation as instructed by the nurse?
A. The removal of the gallbladder 26. A one-day postoperative abdominal surgery client has
B. The removal of the stones in the gallbladder been complaining of severe throbbing abdominal pain
C. The removal of the stones in the common bile duct described as 9 in 1 – 10 pain rating. Your assessment
D. The removal of the stones in the kidney reveals bowel sounds on all quadrants and the dressing is
dry and intact. What nursing intervention would you take?
22. The simplest pain relieving technique is:
A. Medicate client as prescribed
A. Distraction B. Encourage client to do-imagery
B. Taking aspirin C. Encourage deep breathing exercise
C. Deep breathing exercise D. Call surgeon stat
D. Positioning
27. Pentoxide 5 mg IV every 8 hours was prescribed for
23. Which of the following statement on pain is true? post abdominal pain, which will be your priority nursing
action?
A. Culture and pain are not associated
B. Pain accomplished acute illness A. Check abdominal dressing for possible swelling
C. Patient’s reaction to pain varies B. Explain the proper use of PCA to alleviate anxiety
D. Pain produces the same reaction such as groaning and C. Avoid overdosing to prevent dependence/tolerance
moaning D. Monitor VS, more importantly RR

24. In a pain assessment, which of the following condition 28. The client complained of abdominal distention and
is a more reliable indicator? pain. Your nursing intervention that can alleviate pain is:

A. Pain rating scale of 1 – 10 A. Instruct client to go to sleep and relax

B. Facial expression and gestures B. Advice the client to close the lips and avoid deep
C. Physiological responses breathing and talking
D. Patients description of the pain sensation C. Offer hot and clear soup
D. Turn to sides frequently and avoid too much talking
25. When a client complains of pain, your initial response
is: 29. Surgical pain might be minimized by which nursing
action in the O.R.
A. Record the description of pain
B. Verbally acknowledge the pain A. Skill of surgical team and lesser manipulation
C. Refer the complaint to the doctor B. Appropriate preparation for the scheduled procedure
D. Change to a more comfortable position C. Use of modern technology in closing the wound
D. Proper positioning and draping of client.
Situation 6: You are assigned at the surgical ward and
clients have been complaining of post pain at varying 30. Inadequate anesthesia is said to be one of the
degrees. Pain as you know is very subjective. common cause of pain both in intra and post-op patients.
If general anesthesia is desired, it will involve loss of C. Identifying the absence and presence of pain
consciousness. Which of the following are the 2 general D. Ask the client to point to the painful are by just one
types of GA? finger.

A. Epidural and Spinal 34. What symptom more distressing than pain, should the
B. Subarachnoid block and intravenous nurse monitor when giving opioids especially among
C. Inhalation and Regional elderly clients who are in pain?
D. Intravenous and inhalation
A. Forgetfulness
Situation 7: Nurse’s attitudes toward the pain influence the B. Constipation
way they perceive and interact with clients in pain. C. Drowsiness
D. Allergic reactions like pruritus
31. Nurses should be aware of that older adults are at risk
of underrated pain. Nursing assessment and management 35. Physical dependence occurs in anyone who takes
of pain should address the following beliefs EXCEPT: opiods over a period of time. What do you tell a mother of
a ‘dependent’ when asked for advice?
A. Older patients seldom tend to report pain than the
younger ones A. Start another drug and slowly lessen the opioid dosage
B. Pain is a sign of weakness B. Indulge in recreational outdoor activities
C. Older patients do not believe in analgesics, they are C. Isolate opioid dependent to a restful resort
tolerant. D. Instruct slow tapering of the drug dosage and alleviate
D. Complaining of pain will lead to being labelled a bad physical withdrawal symptoms.
patient
Situation 8: The nurse is performing health education
32. Nurses should understand that when a client responds activities for Jane Segovia, a 30 years old Dentist with
favourably to a placebo, it is known as the placebo effect. Insulin dependent diabetes Mellitus.
Placebos do not indicate whether or not a client has:
36. Jane is preparing a mixed dose of insulin. The nurse is
A. Conscience satisfied with her performance when she:
B. Real pain
C. Disease A. Draw insulin from the vial of clear insulin first
D. Drug tolerance B. Draw insulin from the vial of the intermediate acting
insulin first
33. You are the nurse in the pain clinic where you have C. Fill both syringes with the prescribed insulin dosage then
client who has difficulty specify the location of pain. How shake the bottle vigorously
can you assist such client? D. Withdraw the intermediate acting insulin first before
withdrawing the short acting insulin first.
A. The pain is vague
B. By charting-it hurts all over
37. Jane complains of nausea, vomiting, diaphoresis and A. Soak feet in hot water
headache. Which of the following nursing intervention are B. Avoid using mild soap on the feet
you going to carry first? C. Apply a moisturizing lotion to dry feet but not between
the toes
A. Withhold the client’s next insulin injection D. Always have a podiatrist to cut your toe nails; never cut
B. Test the client’s blood glucose level them yourself
C. Administer Tylenol as ordered
D. Offer fruit juice, gelatine and chicken bouillon 42. Another patient was brought to the emergency room
in an unresponsive state and a diagnosis of
38. Jane administered regular insulin at 7 A.M. and the hyperglycaemic hyperosmolar nonketotic syndrome is
nurse should instruct Jane to avoid exercising at around: made. The nurse immediately prepare to initiate which of
the following anticipated physician’s order?
A. 9 to 11 A.M.
B. After 8 hours A. Endotracheal intubation
C. Between 8 A.M. to 9 A.M. B. 100 units of insulin
D. In the afternoon, after taking lunch. C. Intravenous infusion of normal saline
D. Intravenous infusion of sodium bicarbonate
39. Jane was brought at the emergency room after four
month because she fainted in her clinic. The nurse should 43. Jane eventually developed DKA and is being treated in
monitor which of the following test to evaluate the overall the emergency room. Which finding would the nurse
therapeutic compliance of a diabetic patient? expect to note as confirming this diagnosis?

A. Glycosylated Hemoglobin A. Comatose state

B. Fasting blood glucose B. Decreased urine output
C. Ketone levels C. Increased respiration and increase in pH
D. Uirne glucose level D. Elevated blood glucose level and plasma bicarbonate
level
40. Upon the assessment of HbA1C of Mrs. Segovia. The
nurse has been informed of a 9 % HbA1C result. In this 44. The nurse teaches Jane to know the difference
case, she will teach the patient to: between hypoglycaemia and ketoacidosis. Jane
demonstrates understanding of the teaching by stating
A. Avoid infection that glucose will be taken of which of the following
B. Take adequate food and nutrition symptoms develops?
C. Prevent and recognize hypoglycaemia
D. Prevent and recognize hypoglycaemia A. Heavy breathing
B. Shakiness
41. The nurse is teaching plan of care for Jane with regards C. Blurred vision
to proper foot care. Which of the following should be D. Foul breath odor
included in the plan?
45. Jane has been scheduled to have a FBS taken in the 48. Merle, age 86, is complaining of dizziness when she
morning. The nurse tells Jane to eat or drink after stands up. This may indicate:
midnight. Prior to taking the blood specimen, the nurse
noticed that Jane is holding a bottle of distilled water. The A. dementia
nurse asked Jane if she drink any, and she said yes. Which B. a visual problem
of the following is the best nursing action? C. functional decline
D. drug toxicity
A. Administer syrup of ipecac to remove the distilled water
from the stomach. 49. Cardiac ischemia in an older patient usually produces:
B. Suction the stomach content using NGT prior to
specimen collection A. ST-T wave changes
C. Advice to physician to reschedule to diagnostic B. Very high creatinine kinase level
examination next day C. Chest pain radiating to the left arm
D. Continue as usual and have the FBS analysis performed D. Acute confusion
and specimen be taken.
50. The most dependable sign of infection in the older
Situation 9: Elderly clients usually produce unusual signs patient is:
when it comes to different diseases. The ageing process is a
complicated process and the nurse should understand that A. change in mental status
it is an inevitable fact and she must be prepared to care for B. fever
the growing elderly population. C. pain
D. decreased breath sounds with crackles
46. Hypoxia may occur in the older patients because of
which of the following physiologic changes associated Situation 10 – In the OR, there are safety protocols that
with aging. should be followed. The OR nurse should be well versed
with all these to safeguard the safety and quality of
A. Ineffective airway clearance patient delivery outcome.
B. Decreased alveolar surfaced area
C. Decreased anterior-posterior chest diameter 51. Which of the following should be given highest priority
D. Hyperventilation when receiving patient in the OR?

47. The older patient is at higher risk A. Assess level of consciousness

for incontinence because of: B. Verify patient identification and informed consent
C. Assess vital signs
A. dilated urethra D. Check for jewelry, gown, manicure, and dentures
B. increased glomerular filtration rate
C. diuretic use 52. Surgeries like I and D (incision and drainage) and
D. decreased bladder capacity debridement are relatively short procedures but
considered ‘dirty cases’. When are these procedures best Situation 11: Sterilization is the process of removing ALL
scheduled? living microorganism. To be free of ALL living
microorganism is sterility.
A. Last case
B. In between cases 56. There are 3 general types of sterilization use in the
C. According to availability of anaesthesiologist hospital which one is not included?
D. According to the surgeon’s preference
A. Steam sterilization
53. OR nurses should be aware that maintaining the B. Chemical sterilization
client’s safety is the overall goal of nursing care during the C. Autoclaving
intraoperative phase. As the circulating nurse, you make D. Sterilization by boiling
certain that throughout the procedure:
57. Autoclave or steam steam under pressure is the most
A. the surgeon greets his client before induction of common method of sterilization in the hospital. The nurse
anesthesia knows that the temperature and time is set to the
B. the surgeon and anesthesiologist are in tandem optimum level to destroy not only the microorganism, but
C. strap made of strong non-abrasive materials are fastened also the spores. Which of the following is the ideal setting
securely around the joints of the knees and ankles and of the autoclave machine?
around the 2 hands around an arm board.
D. Client is monitored throughout the surgery by the A. 10,000 degree Celsius for 1 hour
assistant anaesthesiologist B. 5,000 degree Celsius for 30 minutes
C. 37 degree Celsius for 15 minutes
54. Another nursing check that should not be missed D. 121 degree Celsius for 15 minutes
before the induction of general anesthesia is:
58. It is important that before a nurse prepares the
A. check for presence underwear material to be sterilized. A chemical indicator strip should
B. check for presence dentures be placed above the package, preferably, Muslin sheet.
C. check patient’s ID What is the color of the striped produced after
D. check baseline vital signs autoclaving?

55. Some lifetime habits and hobbies affect postoperative A. Black

respiratory function. If your client smokes 3 packs of B. Blue
cigarettes a day for the past 10 years, you will anticipate C. Gray
increased risk for: D. Purple

A. perioperative anxiety and stress 59. Chemical indicators communicate that:

B. delayed coagulation time
C. delayed wound healing A. The items are sterile
D. postoperative respiratory function B. That the items had undergone sterilization process but
not necessarily sterile operative site is not shaved, what should be done to make
C. The items are disinfected suturing easy and lessen chance of incision infection?
D. That the items had undergone disinfection process but
not necessarily disinfected A. Draped
B. Pulled
60. If a nurse will sterilize a heat and moisture labile C. Clipped
instruments, it is according to AORN recommendation to D. Shampooed
use which of the following method of sterilization?
64. It is also the nurse’s function to determine when
A. Ethylene oxide gas infection is developing in the surgical incision. The
B. Autoclaving perioperative nurse should observe for what signs of
C. Flash sterilizer impending infection?
D. Alcohol immersion
A. Localized heat and redness
Situation 12 – Nurses hold a variety of roles when providing B. Serosanguinous exudates and skin blanching
care to a perioperative patient. C. Separation of the incision
D. Blood clots and scar tissue are visible
61. Which of the following role would be the responsibility
of the scrub nurse? 65. Which of the following nursing interventions is done
when examining the incision wound and changing the
A. Assess the readiness of the client prior to surgery dressing?
B. Ensure that the airway is adequate
C. Account for the number of sponges, needles, supplies, A. Observe the dressing and type and odor of drainage if
used during the surgical procedure. any
D. Evaluate the type of anesthesia appropriate for the B. Get patient’s consent
surgical client C. Wash hands
D. Request the client to expose the incision wound
62. As a perioperative nurse, how can you best meet the
safety need of the client after administering preoperative Situation 13: The preoperative nurse collaborates with the
narcotic? client significant others, and healthcare providers.

A. Put side rails up and ask the client not to get out of bed 66. To control environmental hazards in the OR, the nurse
B. Send the client to OR with the family collaborates with the following departments EXCEPT:
C. Allow client to get up to go to the comfort room
D. Obtain consent form A. Biomedical division
B. Chaplaincy services
63. It is the responsibility of the pre-op nurse to do skin C. Infection control committee
prep for patients undergoing surgery. If hair at the D. Pathology department
67. An air crash occurred near the hospital leading to a 70. The documentation of all nursing activities performed
surge of trauma patient. One of the last patients will need is legally and professionally vital. Which of the following
surgical amputation but there are no sterile surgical should NOT be included in the patients chart?
equipments. In this case, which of the following will the
nurse expect? A. Presence of prosthetic devices such as dentures, artificial
limbs hearing aid, etc.
A. Equipments needed for surgery need not be sterilized if B. Baseline physical, emotional, and psychosocial data
this is an emergency necessitating life saving measures C. Arguments between nurses and residents regarding
B. Forwarding the trauma client to the nearest hospital that treatment
has available sterile equipment is appropriate D. Observed untoward signs and symptoms and
C. The nurse will need to sterilize the item before using it to interventions including contaminant intervening factors.
the client using the regular sterilization setting at 121
degree Celsius in 15 minutes. Situation 14 – Team efforts is best demonstrated in the OR.
D. In such cases, flash sterilizer will be use at 132 degree
Celsius in 3 minutes. 71. If you are the nurse in charge for scheduling surgical
cases, what important information do you need to ask the
68. Tess, the PACU nurse discovered that Malou, who surgeon?
weighs 110 lbs prior to surgery, is in severe pain 8 hours
after cholecystectomy. Upon checking the chart, Malou A. Who is your internist?
found out that she has an order of Demerol 100 mg I.M. B. Who is your assistant and anesthesiologist, and what is
prn for pain. Tess should verify the order with: your preferred time and type of surgery?
C. Who are your anesthesiologist, internist, and assistant?
A. Nurse supervisor D. Who is your anesthesiologist?
B. Anesthesiologist
C. Surgeon 72. In the OR, the nursing tandem for every surgery is:
D. Intern on duty
A. Instrument technician and circulating nurse
69. Rosie, 57, who is diabetic is for debridement if incision B. Nurse anesthetist, nurse assistant, and instrument
wound. When the circulating nurse checked the present IV technician
fluid, she found out that there is no insulin incorporated C. Scrub nurse and nurse anesthetist
as ordered. What should the circulating nurse do? D. Scrub and circulating nurses

A. Double check the doctor’s order and call the attending 73. While team effort is needed in the OR for efficient and
MD quality patient care delivery, we should limit the number
B. Communicate with the ward nurse to verify if insulin was of people in the room for infection control. Who comprise
incorporated or not this team?
C. Communicate with the client to verify if insulin was
incorporated A. Surgeon, anesthesiologist, scrub nurse, radiologist,
D. Incorporate insulin as ordered orderly
B. Surgeon, assistants, scrub nurse, circulating nurse, 77. The physician orders the nurse to prepare an isotonic
anesthesiologist solution. Which of the following IV solution would the
C. Surgeon, assistant surgeon, anesthesiologist, scrub nurse expect the intern to prescribe?
nurse, pathologist
D. Surgeon, assistant surgeon, anesthesiologist, intern, A. 5 % dextrose in water
scrub nurse B. 10 % dextrose in water
C. 0.45 % sodium chloride
74. Who usually act as an important part of the OR D. 0.5 % dextrose in 0.9% sodium chloride
personnel by getting the wheelchair or stretcher, and
pushing/pulling them towards the operating room? 78. The nurse is making initial rounds on the nursing unit
to assess the condition or assigned clients. The nurse
A. Orderly/clerk notes that the client’s IV site is cool, pale and swollen and
B. Nurse Supervisor the solution is not infusing. The nurse concludes that
C. Circulating Nurse which of the following complications has been
D. Anesthesiologist experienced by the client?

75. The breakdown in teamwork is often times a failure in: A. Infection

B. Phlebitis
A. Electricity C. Infiltration
B. Inadequate supply D. Thrombophlebitis
C. Leg work
D. Communication 79. A nurse reviews the client’s electrolytes laboratory
report and notes that the potassium level is 3.2 mEq/L.
Situation 15: Basic knowledge on Intravenous solutions is Which of the following would the nurse note on the
necessary for care of clients with problems with fluids and electrocardiogram as a result of the laboratory value?
electrolytes.
A. U waves
76. A client involved in a motor vehicle crash presents to B. P waves
the emergency department with severe internal bleeding. C. Elevated T waves
The client is severely hypotensive and unresponsive. The D. Elevated ST segment
nurse anticipates which of the following intravenous
solutions will most likely be prescribed to increase 80. One patient has a runaway IV of 50 % dextrose. To
intravascular volume, replace immediate blood loss and prevent temporary excess of insulin or transient
increase blood pressure? hyperinsulin reaction what solution you prepare in
anticipation of the doctor’s order?
A. 0.45 % sodium chloride
B. Normal saline solution A. Any IV solution available to KVO
C. o.33% sodium chloride B. Isotonic solution
D. Lactated ringer’s solution
C. Hypertonic solution determines that which client is at risk for deficient fluid
D. Hypotonic solution volume?

81. An informed consent is required for: A. A client with colostomy

B. A client with congestive heart failure
A. Closed reduction of a fracture C. A client with decreased kidney function
B. Insertion of intravenous catheter D. A client receiving frequent wound irrigation
C. Irrigation of the external ear canal
D. Urethral catheterization Situation 16: As a perioperative nurse, you are aware of the
correct processing methods for preparing instruments and
82. Which of the following is not true with regards to the other devices for patient use to prevent infection.
informed consent?
86. As an OR nurse, what are your foremost
A. It should describe different treatment alternatives considerations for selecting chemical agents for
B. It should contain a thorough and detailed explanation of disinfection?
the procedure to be done
C. It should describe the client’s diagnosis A. Material compatibility and efficiency
D. It should given an explanation of the client’s prognosis B. Odor and availability/
C. Cost and duration of disinfection process
83. You know that the hallmark of nursing accountability D. Duration of disinfection and efficiency
is the:
87. Before you used disinfected instrument it is essential
A. Accurate documentation and reporting that you:
B. Admitting your mistakes
C. Filing an incidence report A. Rinse with tap water followed by alcohol
D. Reporting a medication error B. Wipe the instrument with sterile water
C. Dry the instrument thoroughly
84. A nurse is assigned to care for a group of clients. On D. Rinse with sterile water
review of the client’s medical records the nurse
determines that which client is at risk for excess fluid 88. You have a critical heat labile instrument to sterilize
volume? and are considering to use high level of disinfectant. What
should you do?
A. The client taking diuretics
B. The client with renal failure A. Cover the soaking vessel to contain the vapour
C. The client with an ileostomy B. Double the amount of high level of disinfectant
D. The client who requires gastrointestinal suctioning C. Test the potency of the high level of disinfectant
D. Prolong the exposure time according to manufacturer’s
85. A nurse is assigned to care for a group of clients. On direction
review of the client’s medical records, the nurse
89. To achieve sterilization using disinfectants, which of A. 10 ml
the following is used? B. 2 ml
C. 0.5 ml
A. Low level disinfectants immersion in 24 hours D. 5 ml
B. Intermediate level disinfectants immersion in 12 hours
C. High level disinfectants immersion in 1 hour 94. Multiple vial-dose-insulin when in use should be:
D. High level disinfectants immersion in 10 hours
A. Kept at room temperature
90. Bronchoscope, Thermometer, Endoscope, ET tube, B. Kept in the refrigerator
Cystoscope are all BEST sterilized using which of the C. Kept in narcotic cabinet
following? D. Store in the freezer

A. Autoclaving at 121 degree Celsius in 15 minutes 95. Insulin using insulin syringe are given using how many
B. Flash sterilizer at 132 degree Celsius in 3 minutes degrees of needle insertion?
C. Ethylene Oxide gas aeration for 20 hours
D. 2% Glutaraldehyde immersion for 10 hours A. 45
B. 180
Situation 17: The OR is divided in three zones to control C. 90
traffic flow and contamination. D. 15

91. What OR attires are worn in the restricted area? Situation 18: Maintenance of sterility is an important
function a nurse should perform in any OR setting.
A. Scrub suit, OR shoes, head cap
B. Head cap scrub suit, mask, OR shoes 96. Which of the following is true with regards to sterility?
C. Mask, OR shoes, scrub suit
D. Cap, Mask, gloves, shoes A. Sterility is time related items are not considered sterile
after a period of 30 days of being not in use.
92. Nursing intervention for a patient on low dose IV B. for 9 months sterile items are considered sterile as long
insulin therapy includes the following EXCEPT: as they are covered with sterile muslin cover and stored in
a dust proof covers.
A. Elevation of serum ketones to monitor ketosis C. Sterility is event related, not time related.
B. Vital signs including BP D. For 3 weeks, items double covered with muslin are
C. Estimate serum potassium considered sterile as long as they have undergone the
D. Elevation of blood glucose levels sterilization process

93. The doctor ordered to incorporate 1000 “u” insulin to 97. Two (2) organizations endorsed that sterility are
the remaining ongoing IV. The strength is 500/ml. affected by factors other that the time itself, these are:
How much should you incorporate into the IV solution?
A. The PNA and the PRC disputes, please direct them to the comments section and
B. AORN and JCAHO we’ll be glad to give you an explanation.
C. ORNAP and MCNAP
D. MMDA and DILG 1. A. Fecal oral
2. B. Sanitary disposal of feces, urine and blood
98. All of these factors affect the sterility of the OR 3. B. Thorough hand washing before and after
equipment, these are the following except: eating and toileting
4. C. Health promotion and education to families
A. The material used for packaging and communities about the disease it’s cause
B. The handling of the materials as well as its transport and transmission.
C. Storage 5. A. 30 days
D. The chemical or process used in sterilizing the material 6. B. Data
7. B. Cause
99. When you say sterile, it means: 8. A. Setting
9. B. Instrument
A. The material is clean. 10. A. Plagiarism
B. The material as well as the equipments are sterilized and 11. D. Ascertain if chest x-rays and other tests
had undergone a rigorous sterilization process have been prescribed and completed
C. There is a black stripe on the paper indicator 12. D. Orthopneic position
D. The material has no microorganism nor spores present 13. C.  Advise patient to sit perfectly still during
that might cause an infection needle insertion until it has been withdrawn
from the chest
100. In using liquid sterilizer or autoclave machine, which 14. A. Place flat in bed
of the following is true? 15. A.  to rule out pneumothorax
16. A. Ease the patient to the floor
A. Autoclave is better in sterilizing OR supplies versus liquid 17. B. No special preparation is needed. Instruct
sterilizer the patient to keep his head still and steady.
B. They are both capable of sterilizing the equipments, 18. A. Obtain his oral temperature
however, it is necessary to soak supplies in the liquid 19. C. Sleeps for a period of time
sterilizer for a longer period of time. 20. C. Side Lying
C. Sharps are sterilized using autoclave and not cidex. 21. C. The removal of the stones in the
D. If liquid sterilizer sterilization process is used, rinsing it common bile duct
before using is not necessary. 22. D. Positioning
23. C. Patient’s reaction to pain varies

Answers 24. D. Patients description of the pain sensation

25. B. Verbally acknowledge the pain
Here are the answers for the exam. Unfortunately, 26. A. Medicate client as prescribed
rationales are not given. If you need clarifications or 27. D. Monitor VS, more importantly RR
28. D. Turn to sides frequently and avoid too much 54. D. check baseline vital signs
talking 55. D. postoperative respiratory function
29. B. Appropriate preparation for the scheduled 56. D. Sterilization by boiling
procedure 57. D. 121 degree Celsius for 15 minutes
30. D. Intravenous and inhalation 58. A. Black
31. C. Older patients do not believe in analgesics, 59. B. That the items had undergone sterilization
they are tolerant. process but not necessarily sterile
32. B. Real pain 60. A. Ethylene oxide gas
33. D. Ask the client to point to the painful are by 61. C. Account for the number of sponges,
just one finger. needles, supplies, used during the surgical
34. D. Allergic reactions like pruritus procedure.
35. D. Instruct slow tapering of the drug dosage 62. A. Put side rails up and ask the client not to get
and alleviate physical withdrawal symptoms. out of bed
36. A. Draw insulin from the vial of clear insulin 63. C. Clipped
first 64. A. Localized heat and redness
37. B. Test the client’s blood glucose level 65. A. Observe the dressing and type and odor of
38. A. 9 to 11 A.M. drainage if any
39. A. Glycosylated Hemoglobin 66. B. Chaplaincy services
40. C. Prevent and recognize hypoglycaemia 67. D. In such cases, flash sterilizer will be use at
41. C. Apply a moisturizing lotion to dry feet but 132 degree Celsius in 3 minutes.
not between the toes 68. C. Surgeon
42. C. Intravenous infusion of normal saline 69. A. Double check the doctor’s order and call the
43. D. Elevated blood glucose level and plasma attending MD
bicarbonate level 70. C. Arguments between nurses and residents
44. B. Shakiness regarding treatment
45. D. Continue as usual and have the FBS analysis 71. B. Who is your assistant and anesthesiologist,
performed and specimen be taken. and what is your preferred time and type
46. B. Decreased alveolar surfaced area of surgery?
47. D. decreased bladder capacity 72. D. Scrub and circulating nurses
48. C. functional decline 73. B. Surgeon, assistants, scrub nurse, circulating
49. D. Acute confusion nurse, anesthesiologist
50. A. change in mental status 74. A. Orderly/clerk
51. B. Verify patient identification and informed 75. D. Communication
consent 76. D. Lactated ringer’s solution
52. A. Last case 77. A. 5 % dextrose in water
53. C. strap made of strong non-abrasive materials 78. C. Infiltration
are fastened securely around the joints of the 79. A. U waves
knees and ankles and around the 2 hands 80. C. Hypertonic solution
around an arm board. 81. A. Closed reduction of a fracture
82. B. It should contain a thorough and detailed
explanation of the procedure to be done
83. A. Accurate documentation and reporting
84. B. The client with renal failure
85. A. A client with colostomy
86. A. Material compatibility and efficiency
87. D. Rinse with sterile water
88. D. Prolong the exposure time according to
manufacturer’s direction
89. D. High level disinfectants immersion in 10
hours
90. D. 2% Glutaraldehyde immersion for 10 hours
91. B. Head cap scrub suit, mask, OR shoes
92. A. Elevation of serum ketones to monitor
ketosis
93. B. 2 ml
94. A. Kept at room temperature
95. A. 45
96. C. Sterility is event related, not time related.
97. B. AORN and JCAHO
98. D.  The chemical or process used in sterilizing
the material
99. D. The material has no microorganism nor
spores present that might cause an infection
100.B. They are both capable of sterilizing the
equipment, however, it is necessary to soak
supplies in the liquid sterilizer for a longer
period of time.