FUNDAMENTALS OF NURSING (100 Items)
FUNDAMENTALS OF NURSING (100 Items)
FUNDAMENTALS OF NURSING (100 Items)
COMPREHENSIVE EXAMINATION
FUNDAMENTALS OF NURSING
2nd Semester AY 2010 - 2011
DIRECTION: Shade the letter of the best answer on the answer sheet provided.
STRICTLY NO ERASURES.
1. She is the first one to coin the term “NURSING PROCESS” She introduced 3 steps of
nursing process which are Observation, Ministration and Validation.
A. Nightingale C. Rogers
B. Johnson D. Hall
3. They are the first one to suggest 4 step nursing processes which are: APIE, or assessment,
planning, implementation and evaluation.
1. Yura 3. Roy
2. Walsh 4. Knowles
A. 1,2 C. 3,4
B. 1,3 D. 2,3
6. A characteristic of the nursing process that is essential to promote client satisfaction and
progress. The care should also be relevant with the client’s needs.
A. Organized and Systematic C. Efficient
B. Humanistic D. Effective
7. Rhina, who has Meniere’s disease, said that her environment is moving. Which of the
following is a valid assessment?
1. Rhina is giving an objective data
2. Rhina is giving a subjective data
3. The source of the data is primary
4. The source of the data is secondary
A. 1, 3 C. 2, 4
B. 2, 3 D. 1, 4
8. Nurse Angela, observe Joel who is very apprehensive over the impending operation. The
client is experiencing dyspnea, diaphoresis and asks lots of questions. Angela made a
diagnosis of ANXIETY R/T INTRUSIVE PROCEDURE. This is what type of Nursing
Diagnosis?
A. Actual C. Possible
B. Probable D. Risk
9. Nurse Angela diagnosed Mrs. Delgado, who has undergone a BKA. Her diagnosis is
SELF ESTEEM DISTURBANCE R/T CHANGE IN BODY IMAGE. Although the client
has not yet seen her lost leg, Angela already anticipated the diagnosis. This is what type of
Diagnosis?
A. Actual C. Possible
B. Probable D. Risk
10. Nurse Angela is about to make a diagnosis but very unsure because the S/S the client is
experiencing is not specific with her diagnosis of POWERLESSNESS R/T DIFFICULTY
ACCEPTING LOSS OF LOVED ONE. She then focuses on gathering data to refute or
prove her diagnosis but her plans and interventions are already ongoing for the diagnosis.
Which type of Diagnosis is this?
A. Actual C. Possible
B. Probable D. Risk
11. Nurse Angela knew that Stephen Lee Mu Chin has just undergone an operation with an
incision near the diaphragm. She knew that this will contribute to some complications later
on. She then should develop what type of nursing diagnosis?
A. Actual C. Possible
B. Probable D. Risk
13. Among the following statements, which should be given the highest priority?
A. Client is in extreme pain
B. Client’s blood pressure is 60/40
C. Client’s temperature is 40 deg. Centigrade
D. Client is cyanotic
14. Which of the following need is given a higher priority among others?
A. The client has attempted suicide and safety precaution is needed
B. The client has disturbance in his body image because of the recent operation
C. The client is depressed because her boyfriend left her all alone
D. The client is thirsty and dehydrated
19. All of the following are characteristic of the nursing process except:
A. Dynamic C. Universal
B. Cyclical D. Intrapersonal
20. Which of the following is true about the NURSING CARE PLAN?
A. It is nursing centered
B. Rationales are supported by interventions
C. Verbal
D. At least 2 goals are needed for every nursing diagnosis
21. A framework for health assessment that evaluates the effects of stressors to the mind,
body and environment in relation with the ability of the client to perform ADL.
A. Functional health framework
B. Head to toe framework
C. Body system framework
D. Cephalocaudal framework
22. Client has undergone Upper GI and Lower GI series. Which type of health assessment
framework is used in this situation?
A. Functional health framework C. Body system framework
B. Head to toe framework D. Cephalocaudal framework
24. A type of heat loss that occurs when the heat is dissipated by air current
A. Convection C. Radiation
B. Conduction D. Evaporation
27. Tympanic temperature is taken from John, A client who was brought recently into the
ER due to frequent barking cough. The temperature reads 37.9 Degrees Celsius. As a nurse,
you conclude that this temperature is
A. High
B. Low
C. At the low end of the normal range
D. At the high end of the normal range
28. John has a fever of 38.5 deg. Celsius. It surges at around 40 degrees and go back to 38.5
degrees 6 times today in a typical pattern. What kind of fever is John having?
A. Relapsing C. Remittent
B. Intermittent D. Constant
29. John has a fever of 39.5 degrees 2 days ago, but yesterday, he has a normal temperature
of 36.5 degrees. Today, his temperature surges to 40 degrees. What type of fever is John
having?
A. Relapsing C. Remittent
B. Intermittent D. Constant
30. John’s temperature 10 hours ago is a normal 36.5 degrees. 4 hours ago, He has a fever
with a temperature of 38.9 Degrees. Right now, his temperature is back to normal. Which of
the following best describe the fever john is having?
A. Relapsing C. Remittent
B. Intermittent D. Constant
32. When John has been given paracetamol, his fever was brought down dramatically from
40 degrees Celsius to 36.7 degrees in a matter of 10 minutes. The nurse would assess this
event as:
A. The goal of reducing john’s fever has been met with full satisfaction of the
outcome criteria
B. The desired goal has been partially met
C. The goal is not completely met
D. The goal has been met but not with the desired outcome criteria
33. What can you expect from Marianne, who is currently at the onset stage of fever?
A. Hot, flushed skin C. Convulsion
B. Increase thirst D. Pale, cold skin
34. Marianne is now at the defervescence stage of the fever, which of the following is
expected?
A. Delirium C. Cyanotic nail beds
B. Goose flesh D. Sweating
35. Considered as the most accessible and convenient method for temperature taking
A. Oral C. Tympanic
B. Rectal D. Axillary
36. Considered as Safest and most non invasive method of temperature taking
A. Oral C. Tympanic
B. Rectal D. Axillary
39. How long should the rectal thermometer be inserted to the clients anus?
A. 1 to 2 inches C. 3 to 5 inches
B. .5 to 1.5 inches D. 2 to 3 inches
40. In cleaning the thermometer after use, The direction of the cleaning to follow Medical
Asepsis is:
A. From bulb to stem C. From stem to stem
B. From stem to bulb D. From bulb to bulb
41. How long should the thermometer stay in the client’s axilla?
A. 3 minutes C. 7 minutes
B. 4 minutes D. 10 minutes
43. The following are correct actions when taking radial pulse except:
A. Put the palms downward
B. Use the thumb to palpate the artery
C. Use two or three fingers to palpate the pulse at the inner wrist
D. Assess the pulse rate, rhythm, volume and bilateral quality
44. The difference between the systolic and diastolic pressure is termed as
A. Apical rate C. Pulse deficit
B. Cardiac rate D. Pulse pressure
48. Which of the following is responsible for deep and prolonged inspiration?
A. Medulla oblongata C. Carotid bodies
B. Pons D. Aortic bodies
49. Which of the following is responsible for the rhythm and quality of breathing?
A. Medulla oblongata C. Carotid bodies
B. Pons D. Aortic bodies
51. Which of the following is true about the mechanism of action of the Aortic and Carotid
bodies?
A. If the BP is elevated, the RR increases
B. If the BP is elevated, the RR decreases
C. Elevated BP leads to metabolic alkalosis
D. Low BP leads to metabolic acidosis
52. All of the following factors correctly influence respiration except one. Which of the
following is incorrect?
A. Hydrocodone decreases RR
B. Stress increases RR
C. Increase temperature of the environment, Increase RR
D. Increase altitude, Increase RR
53. When does the heart receive blood from the coronary artery?
A. Systole C. When the valves opens
B. Diastole D. When the valves closes
56. Which of the following is true about the blood pressure determinants?
A. Hypervolemia lowers BP
B. Hypervolemia increases GFR
C. HCT of 70% might decrease or increase BP
D. Epinephrine decreases BP
57. Which of the following do not correctly correlates the increase BP of Ms. Aida, a 70
year old diabetic?
A. Females, after the age 65 tends to have lower BP than males
B. Disease process like Diabetes increase BP
C. BP is highest in the morning and lowest during the night
D. Africans, have a greater risk of hypertension than Caucasian and Asians.
58. How many minutes are allowed to pass if the client had engaged in strenuous activities,
smoked or ingested caffeine before taking his/her BP?
A. 5 C. 15
B. 10 D. 30
59. Too narrow cuff will cause what change in the client’s BP?
A. True high reading C. False high reading
B. True low reading D. False low reading
62. Which of the following is the correct interpretation of the ERROR OF PARALLAX?
A. If the eye level is higher than the level of the meniscus, it will cause a false high
reading
B. If the eye level is higher than the level of the meniscus, it will cause a false low
reading
C. If the eye level is lower than the level of the meniscus, it will cause a false low
reading
D. If the eye level is equal to that of the level of the upper meniscus, the reading is
accurate
63. How many minute/s is/are allowed to pass before making a re-reading after the first one?
A. 1 C. 15
B. 5 D. 30
64. Which of the following is true about the auscultation of blood pressure?
A. Pulse + 4 is considered as full
B. The bell of the stethoscope is use in auscultating BP
C. Sound produced by BP is considered as HIGH frequency sound
D. Pulse +1 is considered as normal
65. In assessing the abdomen, which of the following is the correct sequence of the physical
assessment?
A. Inspection, Auscultation, Percussion, Palpation
B. Palpation, Auscultation, Percussion, Inspection
C. Inspection, Palpation, Auscultation, Percussion
D. Inspection, Auscultation, Palpation, Percussion
68. Dr. Fabian De Las Santas, is about to conduct an ophthalmoscope examination. Which
of the following, if done by a nurse, is a correct preparation before the procedure?
A. Provide the necessary draping to ensure privacy
B. Open the windows, curtains and light to allow better illumination
C. Pour warm water over the ophthalmoscope to ensure comfort
D. Darken the room to provide better illumination
69. If the client is female, and the doctor is a male and the patient is about to undergo a
vaginal and cervical examination, why is it necessary to have a female nurse in attendance?
A. To ensure that the doctor performs the procedure safely
B. To assist the doctor
C. To assess the client’s response to examination
D. To ensure that the procedure is done in an ethical manner
70. In palpating the client’s breast, which of the following position is necessary for the
patient to assume before the start of the procedure?
A. Supine C. Sitting
B. Dorsal recumbent D. Lithotomy
71. When is the best time to collect urine specimen for routine urinalysis and C/S?
A. Early morning C. Midnight
B. Later afternoon D. Before breakfast
72. Which of the following is among an ideal way of collecting a urine specimen for culture
and sensitivity?
A. Use a clean container
B. Discard the first flow of urine to ensure that the urine is not contaminated
C. Collect around 30-50 ml of urine
D. Add preservatives, refrigerate the specimen or add ice according to the agency’s
protocol
73. In a 24 hour urine specimen started Friday, 9:00 A.M, which of the following if done by
a nurse indicate a need for further procedural debriefing?
A. The nurse ask the client to urinate at 9:00 A.M, Friday and she included the urine
in the 24 hour urine specimen
B. The nurse discards the Friday 9:00 A M urine of the client
C. The nurse included the Saturday 9:00 A.M urine of the client to the specimen
collection
D. The nurse added preservatives as per protocol and refrigerates the specimen
74. This specimen is required to assess glucose levels and for the presence of albumin the
urine:
A. Midstream clean catch urine C. Postprandial urine collection
B. 24 hours urine collection D. Second voided urine
75. When should the client test his blood sugar levels for greater accuracy?
A. During meals C. Before meals
B. In between meals D. 2 Hours after meals
76. In collecting urine from a catheterized patient, which of the following statement
indicates an accurate performance of the procedure?
A. Clamp above the port for 30 to 60 minutes before drawing the urine from the port
B. Clamp below the port for 30 to 60 minutes before drawing the urine from the port
C. Clamp above the port for 5 to 10 minutes before drawing the urine from the port
D. Clamp below the port for 5 to 10 minutes before drawing the urine from the port
77. A community health nurse should be resourceful and meet the needs of the client. A
villager asks him; can you test my urine for glucose? Which of the following technique
allows the nurse to test a client’s urine for glucose without the need for intricate
instruments?
A. Acetic Acid test C. Benedict’s test
B. Nitrazine paper test D. Litmus paper test
78. A community health nurse is assessing client’s urine using the acetic acid solution.
Which of the following, if done by a nurse, indicates lack of correct knowledge with the
procedure?
A. The nurse added the Urine as the 2/3 part of the solution
B. The nurse heats the test tube after adding 1/3 part acetic acid
C. The nurse heats the test tube after adding 2/3 part of Urine
D. The nurse determines abnormal result if she noticed that the test tube becomes
cloudy
79. Which of the following is incorrect with regards to proper urine testing using Benedict’s
Solution?
A. Heat around 5ml of Benedict’s solution together with the urine in a test tube
B. Add 8 to 10 drops of urine
C. Heat the Benedict’s solution without the urine to check if the solution is
contaminated
D. If the color remains blue, the result is positive
80. +++ Positive result after Benedicts test is depicted by what color?
A. Blue C. Yellow
B. Green D. Orange
81. Clinitest is used in testing the urine of a client for glucose. Which of the following, if
committed by a nurse indicates error?
A. Specimen is collected after meals
B. The nurse puts 1 clinitest tablet into a test tube
C. She added 5 drops of urine and 10 drops of water
D. If the color becomes orange or red, It is considered positive
82. Which of the following nursing intervention is important for a client scheduled to have a
Guaiac’s Test?
A. Avoid turnips, radish and horseradish 3 days before procedure
B. Continue iron preparation to prevent further loss of Iron
C. Do not eat read meat 12 hours before procedure
D. Encourage caffeine and dark colored foods to produce accurate results
83. In collecting a routine specimen for fecalysis, which of the following, if done by a nurse,
indicates inadequate knowledge and skills about the procedure?
A. The nurse scoop the specimen specifically at the site with blood and mucus
B. She took around 1 inch of specimen or a teaspoonful
C. Ask the client to call her for the specimen after the client wiped off his anus with
a tissue
D. Ask the client to defecate in a bedpan, Secure a sterile container
84. In a routine sputum analysis, which of the following indicates proper nursing action
before sputum collection?
A. Secure a clean container
B. Discard the container if the outside becomes contaminated with the sputum
C. Rinse the client’s mouth with Listerine after collection
D. Tell the client that 4 tablespoon of sputum is needed for each specimen for a
routine sputum analysis
86. David, 68 year old male client is scheduled for Serum Lipid analysis. Which of the
following health teaching is important to ensure accurate reading?
A. Tell the patient to eat fatty meals 3 days prior to the procedure
B. NPO for 12 hours pre procedure
C. Ask the client to drink 1 glass of water 1 hour prior to the procedure
D. Tell the client that the normal serum lipase level is 50 to 140 U/L
87. The primary factor responsible for body heat production is the:
A. Metabolism C. Muscle activity
B. Release of thyroxin D. Stress
89. A process of heat loss which involves the transfer of heat from one surface to another is:
A. Radiation C. Convection
B. Conduction D. Evaporation
90. Which of the following is a primary factor that affects the BP?
A. Obesity C. Stress
B. Age D. Gender
91. The following are social data about the client except:
A. Patient’s lifestyle C. Family home situation
B. Religious practices D. Usual health status
92. The best position for any procedure that involves vaginal and cervical examination is:
A. Dorsal recumbent C. Supine
B. Side lying D. Lithotomy
93. Measure the leg circumference of a client with bipedal edema is best done in what
position?
A. Dorsal recumbent C. Standing
B. Sitting D. Supine
94. In palpating the client’s abdomen, which of the following is the best position for the
client to assume?
A. Dorsal recumbent C. Supine
B. Side lying D. Lithotomy
96. Which of the following is a correct nursing action when collecting urine specimen from
a client with an indwelling catheter?
A. Collect urine specimen from the drainage bag
B. Detach catheter from the connecting tube and draw the specimen from the port
C. Use sterile syringe to aspirate urine specimen from the drainage port
D. Insert the syringe straight to the port to allow self sealing of the port
97. Which of the following is inappropriate in collecting mid stream clean catch urine
specimen for urine analysis?
A. Collect early in the morning, First voided specimen
B. Do perineal care before specimen collection
C. Collect 5 to 10 ml for urine
D. Discard the first flow of the urine
98. When palpating the client’s neck for lymphadenopathy, where should the nurse position
himself?
A. At the client’s back C. At the client’s left side
B. At the client’s right side D. In front of a sitting client
99. Which of the following is the best position for the client to assume if the back is to be
examined by the nurse?
A. Standing C. Side lying
B. Sitting D. Prone
100. In assessing the client’s chest, which position best show chest expansion as well as its
movements?
A. Sitting C. Sidelying
B. Prone D. Supine
“Only as high as I reach can I grow, only as far as I seek can I go, only as
deep as I look can I see, only as much as I dream can I be.”
--Karen Ravn--
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PREPARED BY:
ARCON S. ALVAR, RN
INSTRUCTOR