Foundation of Nursing - d.

Rectal
6. A client who is unconscious needs
Comprehensive Test Part 1 frequent mouth care. When
performing a mouth care, the best
1. Using the principles of standard
position of a client is:
precautions, the nurse would
a. Fowler’s position
wear gloves in what nursing
b. Side lying
interventions?
c. Supine
a. Providing a back massage
d. Trendelenburg
b. Feeding a client
7. A client is hospitalized for the first
c. Providing hair care
time, which of the following
d. Providing oral hygiene
actions ensure the safety of the
2. The nurse is preparing to take
client?
vital sign in an alert client
a. Keep unnecessary furniture
admitted to the hospital with
out of the way
dehydration secondary to
b. Keep the lights on at all
vomiting and diarrhea. What is
time
the best method used to assess
c. Keep side rails up at all time
the client’s temperature?
d. Keep all equipment out of
a. Oral
view
b. Axillary
8. A walk-in client enters into the
c. Radial
clinic with a chief complaint of
d. Heat sensitive tape
abdominal pain and diarrhea. The
3. A nurse obtained a client’s pulse
nurse takes the client’s vital sign
and found the rate to be above
hereafter. What phrase of nursing
normal. The nurse document this
process is being implemented
findings as:
here by the nurse?
a. Tachypnea
a. Assessment
b. Hyper pyrexia
b. Diagnosis
c. Arrythmia
c. Planning
d. Tachycardia
d. Implementation
4. Which of the following actions
9. It is best describe as a
should the nurse take to use a
systematic, rational method of
wide base support when assisting
planning and providing nursing
a client to get up in a chair?
care for individual, families, group
a. Bend at the waist and place
and community
arms under the client’s
a. Assessment
arms and lift
b. Nursing Process
b. Face the client, bend knees
c. Diagnosis
and place hands on client’s
d. Implementation
forearm and lift
10.Exchange of gases takes place in
c. Spread his or her feet apart
which of the following organ?
d. Tighten his or her pelvic
a. Kidney
muscles
b. Lungs
5. A client had oral surgery following
c. Liver
a motor vehicle accident. The
d. Heart
nurse assessing the client finds
11.The Chamber of the heart that
the skin flushed and warm. Which
receives oxygenated blood from
of the following would be the best
the lungs is the?
method to take the client’s body
a. Left atrium
temperature?
b. Right atrium
a. Oral
c. Left ventricle
b. Axillary
d. Right ventricle
c. Arterial line
12.A muscular enlarge pouch or sac 20.It is describe as a collection of
that lies slightly to the left which people who share some attributes
is used for temporary storage of of their lives.
food… a. Family
a. Gallbladder b. Illness
b. Urinary bladder c. Community
c. Stomach d. Nursing
d. Lungs 21.Five teaspoon is equivalent to
13.The ability of the body to defend how many milliliters (ml)?
itself against scientific invading a. 30 ml
agent such as baceria, toxin, b. 25 ml
viruses and foreign body c. 12 ml
a. Hormones d. 22 ml
b. Secretion 22.1800 ml is equal to how many
c. Immunity liters?
d. Glands a. 1.8
14.Hormones secreted by Islets of b. 18000
Langerhans c. 180
a. Progesterone d. 2800
b. Testosterone 23.Which of the following is the
c. Insulin abbreviation of drops?
d. Hemoglobin a. Gtt.
15.It is a transparent membrane that b. Gtts.
focuses the light that enters the c. Dp.
eyes to the retina. d. Dr.
a. Lens 24.The abbreviation for micro drop
b. Sclera is…
c. Cornea a. µgtt
d. Pupils b. gtt
16.Which of the following is included c. mdr
in Orem’s theory? d. mgts
a. Maintenance of a sufficient 25.Which of the following is the
intake of air meaning of PRN?
b. Self perception a. When advice
c. Love and belonging b. Immediately
d. Physiologic needs c. When necessary
17.Which of the following cluster of d. Now
data belong to Maslow’s hierarchy 26.Which of the following is the
of needs appropriate meaning of CBR?
a. Love and belonging a. Cardiac Board Room
b. Physiologic needs b. Complete Bathroom
c. Self actualization c. Complete Bed Rest
d. All of the above d. Complete Board Room
18.This is characterized by severe 27.1 tsp is equals to how many
symptoms relatively of short drops?
duration. a. 15
a. Chronic Illness b. 60
b. Acute Illness c. 10
c. Pain d. 30
d. Syndrome 28.20 cc is equal to how many ml?
19.Which of the following is the a. 2
nurse’s role in the health b. 20
promotion c. 2000
a. Health risk appraisal d. 20000
b. Teach client to be effective
health consumer
c. Worksite wellness
d. None of the above
29.1 cup is equals to how many a. Three times a day orally
ounces? b. Three times a day after
a. 8 meals
b. 80 c. Two time a day by mouth
c. 800 d. Two times a day before
d. 8000 meals
30. The nurse must verify the client’s 36.Back Care is best describe as:
identity before administration of a. Caring for the back by
medication. Which of the following means of massage
is the safest way to identify the b. Washing of the back
client? c. Application of cold compress
a. Ask the client his name at the back
b. Check the client’s d. Application of hot compress
identification band at the back
c. State the client’s name 37.It refers to the preparation of the
aloud and have the client bed with a new set of linens
repeat it a. Bed bath
d. Check the room number b. Bed making
31. The nurse prepares to administer c. Bed shampoo
buccal medication. The medicine d. Bed lining
should be placed… 38.Which of the following is the most
a. On the client’s skin important purpose of
b. Between the client’s cheeks handwashing
and gums a. To promote hand circulation
c. Under the client’s tongue b. To prevent the transfer of
d. On the client’s conjuctiva microorganism
32. The nurse administers cleansing c. To avoid touching the client
enema. The common position for with a dirty hand
this procedure is… d. To provide comfort
a. Sims left lateral 39.What should be done in order to
b. Dorsal Recumbent prevent contaminating of the
c. Supine environment in bed making?
d. Prone a. Avoid funning soiled linens
33. A client complains of difficulty of b. Strip all linens at the same
swallowing, when the nurse try to time
administer capsule medication. c. Finished both sides at the
Which of the following measures time
the nurse should do? d. Embrace soiled linen
a. Dissolve the capsule in a 40.The most important purpose of
glass of water cleansing bed bath is:
b. Break the capsule and give a. To cleanse, refresh and give
the content with an comfort to the client who
applesauce must remain in bed
c. Check the availability of a b. To expose the necessary
liquid preparation parts of the body
d. Crash the capsule and place c. To develop skills in bed bath
it under the tongue d. To check the body
34.Which of the following is the temperature of the client in
appropriate route of bed
administration for insulin? 41.Which of the following technique
a. Intramuscular involves the sense of sight?
b. Intradermal a. Inspection
c. Subcutaneous b. Palpation
d. Intravenous c. Percussion
35. The nurse is ordered to d. Auscultation
administer ampicillin capsule TIP 42.The first techniques used
p.o. The nurse shoud give the examining the abdomen of a
medication… client is:
 a. Palpation c. Knee-chest
b. Auscultation d. Lithotomy
c. Percussion 47.It refers to the manner of walking
d. Inspection a. Gait
43. A technique in physical b. Range of motion
examination that is use to assess c. Flexion and extension
the movement of air through the d. Hopping
tracheobronchial tree: 48.The nurse asked the client to read
a. Palpation the Snellen chart. Which of the
b. Auscultation following is tested:
c. Inspection a. Optic
d. Percussion b. Olfactory
44.An instrument used for c. Oculomotor
auscultation is: d. Troclear
a. Percussion-hammer 49.Another name for knee-chest
b. Audiometer position is:
c. Stethoscope a. Genu-dorsal
d. Sphygmomanometer b. Genu-pectoral
45.Resonance is best describe as: c. Lithotomy
a. Sounds created by air filled d. Sim’s
lungs 50.The nurse prepare IM injection
b. Short, high pitch and that is irritating to the
thudding subcutaneous tissue. Which of the
c. Moderately loud with following is the best action in
musical quality order to prevent tracking of the
d. Drum-like medication
46.The best position for examining a. Use a small gauge needle
the rectum is: b. Apply ice on the injection
a. Prone site
b. Sim’s c. Administer at a 45° angle
d. Use the Z-track technique

1.d 11.a 21.b 31.b 41.a

2.b 12.c 22.a 32.a 42.d
3.d 13.c 23.b 33.c 43.b
4b 14.c 24.a 34.c 44.c
5.b 15.c 25.c 35.a 45.a
6.b 16.a 26.c 36.a 46.vc
7.c 17.d 27.b 37.b 47.a
8.a 18.b 28.b 38.b 48.a
9.b 19.b 29.a 39.a 49.b
10.b 20.c 30.a 40.a 50.d
Foundation of Nursing - responsibilities for Mrs. Mitchell
now include:
Comprehensive Test Part 2 a. Reviewing daily activated
partial thromboplastin time
(APTT) and prothrombin
1. The most appropriate nursing
time.
order for a patient who develops
b. Reporting an APTT above 45
dyspnea and shortness of breath
seconds to the physician
would be…
c. Assessing the patient for
a. Maintain the patient on
signs and symptoms of
strict bed rest at all times
frank and occult bleeding
b. Maintain the patient in an
d. All of the above
orthopneic position as
6. The four main concepts common
needed
to nursing that appear in each of
c. Administer oxygen by
the current conceptual models
Venturi mask at 24%, as
are:
needed
a. Person, nursing,
d. Allow a 1 hour rest period
environment, medicine
between activities
b. Person, health, nursing,
2. The nurse observes that Mr.
support systems
Adams begins to have increased
c. Person, health, psychology,
difficulty breathing. She elevates
nursing
the head of the bed to the high
d. Person, environment,
Fowler position, which decreases
health, nursing
his respiratory distress. The nurse
7. In Maslow’s hierarchy of
documents this breathing as:
physiologic needs, the human
a. Tachypnea
need of greatest priority is:
b. Eupnca
a. Love
c. Orthopnea
b. Elimination
d. Hyperventilation
c. Nutrition
3. The physician orders a platelet
d. Oxygen
count to be performed on Mrs.
8. The family of an accident victim
Smith after breakfast. The nurse
who has been declared brain-dead
is responsible for:
seems amenable to organ
a. Instructing the patient
donation. What should the nurse
about this diagnostic test
do?
b. Writing the order for this
a. Discourage them from
test
making a decision until their
c. Giving the patient breakfast
grief has eased
d. All of the above
b. Listen to their concerns and
4. Mrs. Mitchell has been given a
answer their questions
copy of her diet. The nurse
honestly
discusses the foods allowed on a
c. Encourage them to sign the
500-mg low sodium diet. These
consent form right away
include:
d. Tell them the body will not
a. A ham and Swiss cheese
be available for a wake or
sandwich on whole wheat
funeral
bread
9. A new head nurse on a unit is
b. Mashed potatoes and
distressed about the poor staffing
broiled chicken
on the 11 p.m. to 7 a.m. shift.
c. A tossed salad with oil and
What should she do?
vinegar and olives
a. Complain to her fellow
d. Chicken bouillon
nurses
5. The physician orders a
b. Wait until she knows more
maintenance dose of 5,000 units
about the unit
of subcutaneous heparin (an
c. Discuss the problem with
anticoagulant) daily. Nursing
her supervisor
 d. Inform the staff that they cerebral damage resulting
must volunteer to rotate from anoxia.
10.Which of the following principles b. The nurse applies a hot
of primary nursing has proven the water bottle or a heating
most satisfying to the patient and pad to the abdomen of a
nurse? patient with abdominal
a. Continuity of patient care cramping.
promotes efficient, cost- c. The nurse assists a patient
effective nursing care out of bed with the bed
b. Autonomy and authority for locked in position; the
planning are best delegated patient slips and fractures
to a nurse who knows the his right humerus.
patient well d. The nurse administers the
c. Accountability is clearest wrong medication to a
when one nurse is patient and the patient
responsible for the overall vomits. This information is
plan and its documented and reported
implementation. to the physician and the
d. The holistic approach nursing supervisor.
provides for a therapeutic 15. Which of the following signs and
relationship, continuity, and symptoms would the nurse expect
efficient nursing care. to find when assessing an Asian
11.If nurse administers an injection patient for postoperative pain
to a patient who refuses that following abdominal surgery?
injection, she has committed: a. Decreased blood pressure
a. Assault and battery and heart rate and shallow
b. Negligence respirations
c. Malpractice b. Quiet crying
d. None of the above c. Immobility, diaphoresis, and
12. If patient asks the nurse her avoidance of deep breathing
opinion about a particular or coughing
physicians and the nurse replies d. Changing position every 2
that the physician is incompetent, hours
the nurse could be held liable for: 16. A patient is admitted to the
a. Slander hospital with complaints of
b. Libel nausea, vomiting, diarrhea, and
c. Assault severe abdominal pain. Which of
d. Respondent superior the following would immediately
13. A registered nurse reaches to alert the nurse that the patient
answer the telephone on a busy has bleeding from the GI tract?
pediatric unit, momentarily a. Complete blood count
turning away from a 3 month-old b. Guaiac test
infant she has been weighing. The c. Vital signs
infant falls off the scale, suffering d. Abdominal girth
a skull fracture. The nurse could 17.The correct sequence for
be charged with: assessing the abdomen is:
a. Defamation a. Tympanic percussion,
b. Assault measurement of abdominal
c. Battery girth, and inspection
d. Malpractice b. Assessment for distention,
14.Which of the following is an tenderness, and
example of nursing malpractice? discoloration around the
a. The nurse administers umbilicus.
penicillin to a patient with a c. Percussions, palpation, and
documented history of auscultation
allergy to the drug. The d. Auscultation, percussion,
patient experiences an and palpation
allergic reaction and has
18.High-pitched gurgles head over a. Respiratory rate only
the right lower quadrant are: b. Temperature only
a. A sign of increased bowel c. Pulse rate and temperature
motility d. Temperature and respiratory
b. A sign of decreased bowel rate
motility 26.All of the following can cause
c. Normal bowel sounds tachycardia except:
d. A sign of abdominal a. Fever
cramping b. Exercise
19.A patient about to undergo c. Sympathetic nervous
abdominal inspection is best system stimulation
placed in which of the following d. Parasympathetic nervous
positions? system stimulation
a. Prone 27.Palpating the midclavicular line is
b. Trendelenburg the correct technique for
c. Supine assessing
d. Side-lying a. Baseline vital signs
20.For a rectal examination, the b. Systolic blood pressure
patient can be directed to assume c. Respiratory rate
which of the following positions? d. Apical pulse
a. Genupecterol 28.The absence of which pulse may
b. Sims not be a significant finding when a
c. Horizontal recumbent patient is admitted to the
d. All of the above hospital?
21. During a Romberg test, the nurse a. Apical
asks the patient to assume which b. Radial
position? c. Pedal
a. Sitting d. Femoral
b. Standing 29.Which of the following patients is
c. Genupectoral at greatest risk for developing
d. Trendelenburg pressure ulcers?
22.If a patient’s blood pressure is a. An alert, chronic arthritic
150/96, his pulse pressure is: patient treated with steroids
a. 54 and aspirin
b. 96 b. An 88-year old incontinent
c. 150 patient with gastric cancer
d. 246 who is confined to his bed
23.A patient is kept off food and at home
fluids for 10 hours before surgery. c. An apathetic 63-year old
His oral temperature at 8 a.m. is COPD patient receiving
99.8 F (37.7 C) This temperature nasal oxygen via cannula
reading probably indicates: d. A confused 78-year old
a. Infection patient with congestive
b. Hypothermia heart failure (CHF) who
c. Anxiety requires assistance to get
d. Dehydration out of bed.
24.Which of the following parameters 30. The physician orders the
should be checked when administration of high-humidity
assessing respirations? oxygen by face mask and
a. Rate placement of the patient in a high
b. Rhythm Fowler’s position. After assessing
c. Symmetry Mrs. Paul, the nurse writes the
d. All of the above following nursing diagnosis:
25.A 38-year old patient’s vital signs Impaired gas exchange related to
at 8 a.m. are axillary temperature increased secretions. Which of the
99.6 F (37.6 C); pulse rate, 88; following nursing interventions
respiratory rate, 30. Which has the greatest potential for
findings should be reported? improving this situation?
 a. Encourage the patient to surgery. Which of the following
increase her fluid intake to nursing interventions would be
200 ml every 2 hours appropriate?
b. Place a humidifier in the a. Encourage the patient to
patient’s room. walk in the hall alone
c. Continue administering b. Discourage the patient from
oxygen by high humidity walking in the hall for a few
face mask more days
d. Perform chest c. Accompany the patient for
physiotheraphy on a regular his walk.
schedule d. Consuit a physical therapist
31.The most common deficiency before allowing the patient
seen in alcoholics is: to ambulate
a. Thiamine 36.A patient has exacerbation of
b. Riboflavin chronic obstructive pulmonary
c. Pyridoxine disease (COPD) manifested by
d. Pantothenic acid shortness of breath; orthopnea:
32.Which of the following statement thick, tenacious secretions; and a
is incorrect about a patient with dry hacking cough. An
dysphagia? appropriate nursing diagnosis
a. The patient will find pureed would be:
or soft foods, such as a. Ineffective airway clearance
custards, easier to swallow related to thick, tenacious
than water secretions.
b. Fowler’s or semi Fowler’s b. Ineffective airway clearance
position reduces the risk of related to dry, hacking
aspiration during swallowing cough.
c. The patient should always c. Ineffective individual coping
feed himself to COPD.
d. The nurse should perform d. Pain related to
oral hygiene before immobilization of affected
assisting with feeding. leg.
33.To assess the kidney function of a 37.Mrs. Lim begins to cry as the
patient with an indwelling urinary nurse discusses hair loss. The
(Foley) catheter, the nurse best response would be:
measures his hourly urine output. a. “Don’t worry. It’s only
She should notify the physician if temporary”
the urine output is: b. “Why are you crying? I
a. Less than 30 ml/hour didn’t get to the bad news
b. 64 ml in 2 hours yet”
c. 90 ml in 3 hours c. “Your hair is really pretty”
d. 125 ml in 4 hours d. “I know this will be difficult
34.Certain substances increase the for you, but your hair will
amount of urine produced. These grow back after the
include: completion of
a. Caffeine-containing drinks, chemotheraphy”
such as coffee and cola. 38.An additional Vitamin C is
b. Beets required during all of the following
c. Urinary analgesics periods except:
d. Kaolin with pectin a. Infancy
(Kaopectate) b. Young adulthood
35.A male patient who had surgery 2 c. Childhood
days ago for head and neck d. Pregnancy
cancer is about to make his first 39.A prescribed amount of oxygen s
attempt to ambulate outside his needed for a patient with COPD to
room. The nurse notes that he is prevent:
steady on his feet and that his a. Cardiac arrest related to
vision was unaffected by the increased partial pressure of
 carbon dioxide in arterial a. Atheroscleotic changes in
blood (PaCO2) the blood vessels
b. Circulatory overload due to b. Increased incidence of
hypervolemia gallbladder disease
c. Respiratory excitement c. Urinary Tract Infection
d. Inhibition of the respiratory d. Hip fracture
hypoxic stimulus 45.The most common psychogenic
40.After 1 week of hospitalization, disorder among elderly person is:
Mr. Gray develops hypokalemia. a. Depression
Which of the following is the most b. Sleep disturbances (such as
significant symptom of his bizarre dreams)
disorder? c. Inability to concentrate
a. Lethargy d. Decreased appetite
b. Increased pulse rate and 46.Which of the following vascular
blood pressure system changes results from
c. Muscle weakness aging?
d. Muscle irritability a. Increased peripheral
41.Which of the following nursing resistance of the blood
interventions promotes patient vessels
safety? b. Decreased blood flow
a. Asses the patient’s ability to c. Increased work load of the
ambulate and transfer from left ventricle
a bed to a chair d. All of the above
b. Demonstrate the signal 47.Which of the following is the most
system to the patient common cause of dementia
c. Check to see that the among elderly persons?
patient is wearing his a. Parkinson’s disease
identification band b. Multiple sclerosis
d. All of the above c. Amyotrophic lateral
42.Studies have shown that about sclerosis (Lou Gerhig’s
40% of patients fall out of bed disease)
despite the use of side rails; this d. Alzheimer’s disease
has led to which of the following 48.The nurse’s most important legal
conclusions? responsibility after a patient’s
a. Side rails are ineffective death in a hospital is:
b. Side rails should not be a. Obtaining a consent of an
used autopsy
c. Side rails are a deterrent b. Notifying the coroner or
that prevent a patient from medical examiner
falling out of bed. c. Labeling the corpse
d. Side rails are a reminder to appropriately
a patient not to get out of d. Ensuring that the attending
bed physician issues the death
43.Examples of patients suffering certification
from impaired awareness include 49.Before rigor mortis occurs, the
all of the following except: nurse is responsible for:
a. A semiconscious or over a. Providing a complete bath
fatigued patient and dressing change
b. A disoriented or confused b. Placing one pillow under the
patient body’s head and shoulders
c. A patient who cannot care c. Removing the body’s
for himself at home clothing and wrapping the
d. A patient demonstrating body in a shroud
symptoms of drugs or d. Allowing the body to relax
alcohol withdrawal normally
44.The most common injury among 50.When a patient in the terminal
elderly persons is: stages of lung cancer begins to
 exhibit loss of consciousness, a c. A postoperative patient who
major nursing priority is to: has undergone orthopedic
a. Protect the patient from surgery
injury d. A newly diagnosed diabetic
b. Insert an airway patient
c. Elevate the head of the bed 4. Effective hand washing requires
d. Withdraw all pain the use of:
medications a. Soap or detergent to
promote emulsification
1.b 11.a 21.b 31.a 41.d b. Hot water to destroy
bacteria
2.c 12.a 22.a 32.c 42.d
c. A disinfectant to increase
3.c 13.d 23.d 33.a 43.c surface tension
4.b 14.a 24.d 34.a 44.d d. All of the above
5. After routine patient contact,
5.d 15.c 25.d 35.c 45.a
hand washing should last at least:
6.d 16.b 26.d 36.a 46.d a. 30 seconds
7.d 17.d 27.d 37.d 47.d b. 1 minute
c. 2 minute
8.b 18.c 28.c 38.b 48.c d. 3 minutes
9.c 19.c 29.b 39.d 49.b 6. Which of the following procedures
10.d 20.d 30.a 40.c 50.a always requires surgical asepsis?
a. Vaginal instillation of
conjugated estrogen
b. Urinary catheterization
Foundation of Nursing - c. Nasogastric tube insertion
Comprehensive Test Part 3 d. Colostomy irrigation
7. Sterile technique is used
1. Which element in the circular whenever:
chain of infection can be a. Strict isolation is required
eliminated by preserving skin b. Terminal disinfection is
integrity? performed
a. Host c. Invasive procedures are
b. Reservoir performed
c. Mode of transmission d. Protective isolation is
d. Portal of entry necessary
2. Which of the following will 8. Which of the following constitutes
probably result in a break in a break in sterile technique while
sterile technique for respiratory preparing a sterile field for a
isolation? dressing change?
a. Opening the patient’s a. Using sterile forceps, rather
window to the outside than sterile gloves, to
environment handle a sterile item
b. Turning on the patient’s b. Touching the outside
room ventilator wrapper of sterilized
c. Opening the door of the material without sterile
patient’s room leading into gloves
the hospital corridor c. Placing a sterile object on
d. Failing to wear gloves when the edge of the sterile field
administering a bed bath d. Pouring out a small amount
3. Which of the following patients is of solution (15 to 30 ml)
at greater risk for contracting an before pouring the solution
infection? into a sterile container
a. A patient with leukopenia 9. A natural body defense that plays
b. A patient receiving broad- an active role in preventing
spectrum antibiotics infection is:
a. Yawning
b. Body hair
 c. Hiccupping a. Prothrombin and
d. Rapid eye movements coagulation time
10. All of the following statement are b. Blood typing and cross-
true about donning sterile gloves matching
except: c. Bleeding and clotting time
a. The first glove should be d. Complete blood count (CBC)
picked up by grasping the and electrolyte levels.
inside of the cuff. 15.The primary purpose of a platelet
b. The second glove should be count is to evaluate the:
picked up by inserting the a. Potential for clot formation
gloved fingers under the b. Potential for bleeding
cuff outside the glove. c. Presence of an antigen-
c. The gloves should be antibody response
adjusted by sliding the d. Presence of cardiac
gloved fingers under the enzymes
sterile cuff and pulling the 16.Which of the following white
glove over the wrist blood cell (WBC) counts clearly
d. The inside of the glove is indicates leukocytosis?
considered sterile a. 4,500/mm³
11.When removing a contaminated b. 7,000/mm³
gown, the nurse should be careful c. 10,000/mm³
that the first thing she touches is d. 25,000/mm³
the: 17. After 5 days of diuretic therapy
a. Waist tie and neck tie at the with 20mg of furosemide (Lasix)
back of the gown daily, a patient begins to exhibit
b. Waist tie in front of the fatigue, muscle cramping and
gown muscle weakness. These
c. Cuffs of the gown symptoms probably indicate that
d. Inside of the gown the patient is experiencing:
12.Which of the following nursing a. Hypokalemia
interventions is considered the b. Hyperkalemia
most effective form or universal c. Anorexia
precautions? d. Dysphagia
a. Cap all used needles before 18.Which of the following statements
removing them from their about chest X-ray is false?
syringes a. No contradictions exist for
b. Discard all used uncapped this test
needles and syringes in an b. Before the procedure, the
impenetrable protective patient should remove all
container jewelry, metallic objects,
c. Wear gloves when and buttons above the waist
administering IM injections c. A signed consent is not
d. Follow enteric precautions required
13.All of the following measures are d. Eating, drinking, and
recommended to prevent medications are allowed
pressure ulcers except: before this test
a. Massaging the reddened are 19.The most appropriate time for the
with lotion nurse to obtain a sputum
b. Using a water or air specimen for culture is:
mattress a. Early in the morning
c. Adhering to a schedule for b. After the patient eats a light
positioning and turning breakfast
d. Providing meticulous skin c. After aerosol therapy
care d. After chest physiotherapy
14.Which of the following blood tests 20. A patient with no known allergies
should be performed before a is to receive penicillin every 6
blood transfusion? hours. When administering the
medication, the nurse observes a
 fine rash on the patient’s skin. d. 25G, 5/8” long
The most appropriate nursing 25.The appropriate needle gauge for
action would be to: intradermal injection is:
a. Withhold the moderation a. 20G
and notify the physician b. 22G
b. Administer the medication c. 25G
and notify the physician d. 26G
c. Administer the medication 26.Parenteral penicillin can be
with an antihistamine administered as an:
d. Apply corn starch soaks to a. IM injection or an IV
the rash solution
21.All of the following nursing b. IV or an intradermal
interventions are correct when injection
using the Z-track method of drug c. Intradermal or
injection except: subcutaneous injection
a. Prepare the injection site d. IM or a subcutaneous
with alcohol injection
b. Use a needle that’s a least 27. The physician orders gr 10 of
1” long aspirin for a patient. The
c. Aspirate for blood before equivalent dose in milligrams is:
injection a. 0.6 mg
d. Rub the site vigorously after b. 10 mg
the injection to promote c. 60 mg
absorption d. 600 mg
22.The correct method for 28.The physician orders an IV
determining the vastus lateralis solution of dextrose 5% in water
site for I.M. injection is to: at 100ml/hour. What would the
a. Locate the upper aspect of flow rate be if the drop factor is
the upper outer quadrant of 15 gtt = 1 ml?
the buttock about 5 to 8 cm a. 5 gtt/minute
below the iliac crest b. 13 gtt/minute
b. Palpate the lower edge of c. 25 gtt/minute
the acromion process and d. 50 gtt/minute
the midpoint lateral aspect 29.Which of the following is a sign or
of the arm symptom of a hemolytic reaction
c. Palpate a 1” circular area to blood transfusion?
anterior to the umbilicus a. Hemoglobinuria
d. Divide the area between the b. Chest pain
greater femoral trochanter c. Urticaria
and the lateral femoral d. Distended neck veins
condyle into thirds, and 30.Which of the following conditions
select the middle third on may require fluid restriction?
the anterior of the thigh a. Fever
23.The mid-deltoid injection site is b. Chronic Obstructive
seldom used for I.M. injections Pulmonary Disease
because it: c. Renal Failure
a. Can accommodate only 1 ml d. Dehydration
or less of medication 31.All of the following are common
b. Bruises too easily signs and symptoms of phlebitis
c. Can be used only when the except:
patient is lying down a. Pain or discomfort at the IV
d. Does not readily parenteral insertion site
medication b. Edema and warmth at the
24.The appropriate needle size for IV insertion site
insulin injection is: c. A red streak exiting the IV
a. 18G, 1 ½” long insertion site
b. 22G, 1” long d. Frank bleeding at the
c. 22G, 1 ½” long insertion site
32. The best way of determining c. Is induced by the
whether a patient has learned to administration of an
instill ear medication properly is antitussive drug
for the nurse to: d. Can be inhibited by
a. Ask the patient if he/she “splinting” the abdomen
has used ear drops before 37.An infected patient has chills and
b. Have the patient repeat the begins shivering. The best nursing
nurse’s instructions using intervention is to:
her own words a. Apply iced alcohol sponges
c. Demonstrate the procedure b. Provide increased cool
to the patient and liquids
encourage to ask questions c. Provide additional
d. Ask the patient to bedclothes
demonstrate the procedure d. Provide increased
33.Which of the following types of ventilation
medications can be administered 38.A clinical nurse specialist is a
via gastrostomy tube? nurse who has:
a. Any oral medications a. Been certified by the
b. Capsules whole contents are National League for Nursing
dissolve in water b. Received credentials from
c. Enteric-coated tablets that the Philippine Nurses’
are thoroughly dissolved in Association
water c. Graduated from an
d. Most tablets designed for associate degree program
oral use, except for and is a registered
extended-duration professional nurse
compounds d. Completed a master’s
34. A patient who develops hives degree in the prescribed
after receiving an antibiotic is clinical area and is a
exhibiting drug: registered professional
a. Tolerance nurse.
b. Idiosyncrasy 39.The purpose of increasing urine
c. Synergism acidity through dietary means is
d. Allergy to:
35.A patient has returned to his a. Decrease burning
room after femoral arteriography. sensations
All of the following are b. Change the urine’s color
appropriate nursing interventions c. Change the urine’s
except: concentration
a. Assess femoral, popliteal, d. Inhibit the growth of
and pedal pulses every 15 microorganisms
minutes for 2 hours 40.Clay colored stools indicate:
b. Check the pressure dressing a. Upper GI bleeding
for sanguineous drainage b. Impending constipation
c. Assess a vital signs every c. An effect of medication
15 minutes for 2 hours d. Bile obstruction
d. Order a hemoglobin and 41.In which step of the nursing
hematocrit count 1 hour process would the nurse ask a
after the arteriography patient if the medication she
36.The nurse explains to a patient administered relieved his pain?
that a cough: a. Assessment
a. Is a protective response to b. Analysis
clear the respiratory tract of c. Planning
irritants d. Evaluation
b. Is primarily a voluntary 42.All of the following are good
action sources of vitamin A except:
a. White potatoes
b. Carrots
 c. Apricots 47.When transferring a patient from
d. Egg yolks a bed to a chair, the nurse should
43.Which of the following is a use which muscles to avoid back
primary nursing intervention injury?
necessary for all patients with a a. Abdominal muscles
Foley Catheter in place? b. Back muscles
a. Maintain the drainage c. Leg muscles
tubing and collection bag d. Upper arm muscles
level with the patient’s 48.Thrombophlebitis typically
bladder develops in patients with which of
b. Irrigate the patient with 1% the following conditions?
Neosporin solution three a. Increases partial
times a daily thromboplastin time
c. Clamp the catheter for 1 b. Acute pulsus paradoxus
hour every 4 hours to c. An impaired or traumatized
maintain the bladder’s blood vessel wall
elasticity d. Chronic Obstructive
d. Maintain the drainage Pulmonary Disease (COPD)
tubing and collection bag 49.In a recumbent, immobilized
below bladder level to patient, lung ventilation can
facilitate drainage by gravity become altered, leading to such
44.The ELISA test is used to: respiratory complications as:
a. Screen blood donors for a. Respiratory acidosis,
antibodies to human ateclectasis, and hypostatic
immunodeficiency virus pneumonia
(HIV) b. Appneustic breathing,
b. Test blood to be used for atypical pneumonia and
transfusion for HIV respiratory alkalosis
antibodies c. Cheyne-Strokes respirations
c. Aid in diagnosing a patient and spontaneous
with AIDS pneumothorax
d. All of the above d. Kussmail’s respirations and
45.The two blood vessels most hypoventilation
commonly used for TPN infusion 50.Immobility impairs bladder
are the: elimination, resulting in such
a. Subclavian and jugular disorders as
veins a. Increased urine acidity and
b. Brachial and subclavian relaxation of the perineal
veins muscles, causing
c. Femoral and subclavian incontinence
veins b. Urine retention, bladder
d. Brachial and femoral veins distention, and infection
46.Effective skin disinfection before a c. Diuresis, natriuresis, and
surgical procedure includes which decreased urine specific
of the following methods? gravity
a. Shaving the site on the day d. Decreased calcium and
before surgery phosphate levels in the
b. Applying a topical antiseptic urine
to the skin on the evening
before surgery
.d 11.a 21.d 31.d 41.d
c. Having the patient take a
tub bath on the morning of 2.c 12.b 22.d 32.d 42.a
surgery
d. Having the patient shower 3.a 13.a 23.a 33.d 43.d
with an antiseptic soap on 4.a 14.b 24.d 34.d 44.d
the evening v=before and
the morning of surgery 5.a 15.a 25.d 35.d 45.d
6.b 16.d 26.a 36.a 46.d
7.c 17.a 27.d 37.c 47.c
8.c 18.a 28.c 38.d 48.c
9.b 19.a 29.a 39.d 49.a
10.d 20.a 30.c 40.d 50.b