C.

A 5-day post-op hysterectomy client sharing

her surgical experience
D. A known alcoholic client who denies he is
CLASSIFIED EXAMINATION intoxicated to alcohol
FOR CRITICAL TEST ANALYSIS
4. To implement the care plan successfully, nurses
Basic Concepts of Nursing Practice need cognitive, interpersonal, and technical skills.
Philippine Nurses Licensure Examination All BUT one are activities to be done in the
Warning: This material is protected by Copyright Laws.
process of implementation:
Unauthorized use shall be prosecuted in the full extent of the A. Supervising the delegated care
Philippine Laws. For exclusive use of CBRC reviewees only. B. Reassessing the client
C. Documenting nursing activities
SITUATION 1 – The nursing practice is a form of D. Setting prioritized problems
scientific reasoning and requires the nurse’s
critical thinking to provide the best care possible 5. Evaluating is a planned, ongoing, purposeful
to the client. The following questions relate to activity in which clients and health care
this. professionals determine the client’s progress and
effectiveness of nursing care. Which of the
1. In problem-solving, the nurse obtains information following statements reflects outcome
that clarifies the nature of the problem and evaluation?
suggests possible solutions. The client who is A. Client Lorenzo’s temperature decreased
short of breath benefits from the head of the bed from 38 degrees Celsius to 37.4 degrees
elevated. However, extended use of this position Celsius after Nurse Celso provides cool bath
can cause skin breakdown in the sacral area. In and compress
solving this problem, the nurse determines that B. Nurse Celso noted that client Mariana,
the best approach would be to study the amount admitted in the charity ward, has difficulty
of sacral pressure found in various other voiding using the bedpan because other
positions. This approach is an example of: clients can see her.
A. Scientific method C. Nurse Anita always checks the client’s
B. Trial and Error method identification band before administration of
C. Intuition medications.
D. Nursing Process D. Three clients were still admitted in the
emergency ward for 5 days as the charity
2. The nursing process has distinctive wards, already full, cannot accommodate
characteristics that enable the nurse to respond them.
to the changing health status of the client. Which
of the following statements does NOT describe SITUATION 2 - Alexa is on her fourth year on BS
the nursing process? Nursing and her clinical instructor asked her to
A. The nursing process is designed to be discuss about the basic concepts of nursing.
responsive to the continually changing needs
of a client 6. During the vital sign taking of patient June, Nurse
B. The nursing process applies to the care of all Kaila is checking the BP cuff and noticed that it is
client systems including individuals, families, too narrow for the arm of her patient. If Nurse
groups or communities Kaila proceeded to take the blood pressure of
C. Critical thinking, not decision-making, is patient June what is EXPECTED of the result?
involved in every phase of the nursing A. A BP cuff that is too narrow can result to a
process false elevated blood pressure reading.
D. The nursing process is client-centered and B. The blood pressure reading of patient June
the plan of care is organized based on the is expected to be within normal limits.
client’s problems rather than nursing goals C. Since the BP cuff is too narrow, the result
would be false low blood pressure.
3. Sources of data are primary or secondary. The D. Not enough information to conclude that the
client is the primary source of data. On the other blood pressure of June would be false high
hand, all sources other than the client are or low.
considered secondary sources. Which of the
following options may be concluded as the MOST 7. Surgical asepsis is a set of practices that render
accurate source of information? and keep objects and areas free from
A. A 68-year-old Alzheimer client being microorganism. It is also known as sterile
interviewed for the past medical history technique. All of the following are principles of
B. A pre-school child asked about the surgical asepsis, EXCEPT:
medication she’s taking to manage asthma

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 A. Microorganisms travel to moist surfaces 12. Luisa, who gave birth two months ago, is
faster than with dry surfaces. breastfeeding her baby when she asks their RHU
B. When in doubt about the sterility of an object, nurse if she can undergo mammography since
consider it unsterile. her two cousins were recently diagnosed with
C. Once the skin has been sterilized, consider it stage 1 breast cancer. What is the nurse’s BEST
sterile. response?
D. If you can reach the object by overreaching, A. “It is better if you do a mammogram after 6
just move around the sterile field to pick it months because mammograms interfere
rather than reaching for it. with breastfeeding and might decrease the
milk production.”
8. The nurse is caring for Mr. Nuñez, a client in the B. “Breastfeeding mothers can have
medical-surgical unit. He has right sided mammograms.”
weakness of the extremities and mild slurring of C. “Mammograms of lactating breasts are
speech due to the cerebrovascular accident. How impossible to read, so it is better to wait
should the nurse assist Mr. Nuñez to ambulate? after4 months. After that, it is more beneficial
A. The nurse must stand at the client’s right side to do the procedure.”
and hold the client’s arm D. “Mammograms do not interfere with
B. The nurse must stand at the client’s right side breastfeeding although it is advisable to
and put his arm around the client’s waist breastfeed immediately prior to the
C. The nurse must stand on the client’s left side procedure.”
and hold the client’s arm
D. The nurse must stand at the client’s left side 13. MRI is the procedure of choice over CT scan for
and put his arm around the client’s waist most neurologic disorders because of which
advantage?
9. When learning how to implement the nursing A. MRI has low ionizing radiation
process into a plan of care for a client, the student B. MRI may detect presence of subarachnoid
nurse realizes that part of the purpose of the hemorrhage
nursing process is to do which of the following? C. MRI is sensitive to blood flow
A. Deliver care to a client in an organized way D. MRI is able to distinguish water, iron, fats,
B. Implement a plan that is close to the medical and blood.
model
C. Identify client needs and deliver care to meet 14. A CT scan is ordered for a client with
those needs astrocytoma. Before the procedure, the nurse
D. Make sure that standardized care is available should:
to clients A. Tell the client to lie perfectly still during the
procedure.
10. Which of the following elements is BEST B. Tell the client to do deep breathing exercises
categorized as secondary subjective data? if she feels any discomfort during the
A. The nurse measures a weight loss of 10 procedure.
pounds since the last clinic visit. C. Instruct the client of sensations to be felt as
B. Spouse states the client has lost all appetite. the contrast medium is being injected in the
C. The nurse palpates edema in lower vessels.
extremities. D. Assess the client for any discomforts or fears
D. Client states severe pain when walking up regarding closed spaces.
stairs.
15. Mr. Soriano, a 50-year-old client, is suspected to
SITUATION 3 – Nurses are collaborators in the have polycythemia vera. Bone marrow biopsy
diagnostic process. They have critical roles in and aspiration is ordered by the physician. Which
ensuring communication, care coordination, and of the following should NOT be included in the
patient education; monitoring a patient’s nurse’s health teaching regarding this procedure?
condition; and identifying and preventing A. The biopsy sample will be taken from the
potential diagnostic errors. posterior iliac crest.
B. Bone marrow aspiration is done before bone
11. Francisco, a 40-year-old businessman, is marrow biopsy.
admitted to your ward due to diabetic neuropathy C. Mr. Soriano should feel a pressure sensation
of his right foot leading to gangrene. He has been but should not feel actual pain when the
a diabetic for 8 years. The doctor wants to know sample is being acquired.
if Francisco has blocked vessels and arterioles in D. After the sample is obtained, pressure is
his lower extremities. You anticipate him to order applied to the site for 5 to 15 minutes.
which diagnostic procedure?
A. Doppler Ultrasound SITUATION 14 – Mr. Solano is a clinical
B. Electromyography instructor and he wants to assess the knowledge
C. Angioplasty of his student nurses regarding the nursing
D. Nerve conduction studies
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 process, body mechanism, and assistive 21. Research shows that handwashing is perceived
devices. to be the single most important infection control
measure that can be adopted, with the high
16. In the validating activity of the assessing phase of infection rates generally attributed to poor hand
the nursing process, the nurse performs which of hygiene compliance. Handwashing is a
the following? requirement when caring for clients. Which is
A. Collects subjective data. TRUE about hand washing?
B. Applies a framework to the collected data. A. Hand washing twice per shift reduces
C. Confirms data are complete and accurate. transmission of pathogens from one client to
D. Records data in the client record. another
B. If the nurse is in a rush, he/she can wear
17. In the diagnostic statement “Excess Fluid Volume medical gloves instead of hand washing
related to decreased venous return as manifested C. Bar soap should be used for hand washing
by lower extremity edema (swelling),” the etiology and prevents transmission of pathogens
of the problem is which of the following? D. Alcohol based products can be used in
A. Excess fluid volume situations where running water is not
B. Decreased venous return available
C. Edema
D. Unknown 22. Standard precautions are used in the care of all
hospitalized persons regardless of their diagnosis
18. A client who has been in a wheelchair for several or possible infection status. They apply to blood,
years is currently experiencing problems with skin all body fluids, secretions, and excretions except
breakdown and urinary retention in addition to sweat, non-intact skin, and mucous membranes.
depression. When formulating a nursing As regards to asepsis and illness control, when
diagnosis, an APPROPRIATE selection would be discarding used needles and syringes, which of
which of the following? the following is an APPROPRIATE nursing
A. Syndrome diagnosis action?
B. Risk nursing diagnosis A. Remove needles from the syringe and
C. Actual diagnosis discard them in separate container.
D. Wellness diagnosis B. Recap needle, then discard the needle still
attached to the syringe into a container.
19. The nurse is working on a hospital committee C. Discard the uncapped needle and syringe
focused on preventing back injury in nurses. into a container.
Which recommendation by this committee is D. Break the needle, then discard syringe into a
MOST likely to result in a decrease in back container.
injuries if followed?
A. Nurses must wear back belts when lifting 23. Isaac, 15 years old, was hospitalized for MRSA
clients. infection. You then found out that he is ordered
B. All nursing personnel must attend annual for isolation by the physician. To prevent sensory
body mechanics education. deprivation, you as his nurse should:
C. In order to prevent injury, nurses must strive A. Provide a telephone inside the room so the
to become physically fit. client can talk with family members
D. No solo lifting of clients is permitted in the B. Let the client talk with family members to
facility. avoid expression of disgust
C. Provide the client all his personal items
20. Which statement from a client with one weak leg inside the room
regarding use of crutches when using stairs D. Maintain a clean and pleasant environment
indicates a need for increased teaching? and allow recreational activities for the client
A. “Going up, the strong leg goes first, then the
weaker leg with both crutches.” 24. All healthcare providers must apply clean or
B. “Going down, the weaker leg goes first with sterile gloves, gowns, masks, and protective
both crutches, then the strong leg.” eyewear according to the risk of exposure to
C. “The weaker leg always goes first with both potentially infective materials. Before a surgical
crutches.” procedure, the following protective items must be
D. “A cane or single crutch may be used instead put on in what sequence?
of both crutches if held on the weaker side.” i. Eyewear or goggle iv. Gloves
ii. Cap v. Gown
SITUATION 5 – Preventing infection requires iii. Mask
engagement of the patient, their families and
caregivers, as well as other healthcare A. iii – ii – i – v – iv
personnel. B. iii – ii – i – iv – v
C. ii – iii – i – v – iv
D. ii – iii – i – iv – v

NURSES LICENSURE EXAMINATION (NLE)

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 25. The nurse encourages her client with injuries in 30. After performing back massage for a patient
lower extremities to perform isometric exercises experiencing pain, what is the primary reason the
by: nurse asks her to rate her current level of pain?
A. Squeezing a towel or pillow between the A. To facilitate the use of analgesia that would
knees while at the same time tightening the further help alleviate pain
muscles in the fronts of the thighs by B. To evaluate the effectiveness of the
pressing the knees backwards, and holding massage to patient’s pain.
for several seconds. C. To be able to report to the primary healthcare
B. Lifting the buttocks off the bed by pushing provider the duration of the massage of the
with the hands against the mattress, and patient.
pushing the body to a sitting position. D. To help ease patient’s anxiety and would
C. Lifting weights further reduce pain reception.
D. All of the mentioned exercises

SITUATION 6 – Ensuring client comfort is of

paramount importance for the patient’s well-
“No matter where you’re from,
being. your dreams are valid.”
-Lupita Nyong’o-
26. In performing catheterization of patient Jena, the
nurse would position her in which of the
following?
A. Dorsal recumbent position
B. Supine position
C. Side-lying position
D. Modified trendelenburg position

27. This occurs when the client’s opioid dose, over

time, leads to a decreased sensitivity of the drug’s
analgesic effect.
A. Physical dependence
B. Addiction
C. Tolerance
D. Pseudoaddiction

28. Which interventions, when implemented by the

nurse, would apply the gate control theory of
pain? Select all that apply.
1. Oral analgesics around the clock
2. Massage
3. Patient-controlled analgesia
4. Heat or cold application
5. Acupressure

A. 2, 3, 5 C. 2, 5
B. 2, 1, 5 D. 2, 4, 5

29. A nurse is caring for an 82-year-old woman in a

long-term care facility who has had two urinary
tract infections in the past year related to
immobility. Which finding would the nurse
EXPECT in this patient?
A. Improved renal blood supply to the kidneys
B. Urinary stasis
C. Decreased urinary calcium
D. Acidic urine formation

NURSES LICENSURE EXAMINATION (NLE)

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