41.

A
FUNDAMENTALS MT2 NOV. 42. D
43. C
44. B
2023 45. A
NLE INTENSIVE 46. C
47. D
ANSWERS: 48. B
1. B 49. D
2. C 50. C
3. B 51. C
4. B 52. A
5. B 53. B
6. B 54. A
7. C 55. C
8. B 56. C
9. A 57. A
10. C 58. D
11. D 59. D
12. D 60. A
13. C 61. D
14. B 62. D
15. A 63. D
16. D 64. D
17. B 65. D
18. D 66. C
19. B 67. D
20. B 68. D
21. C 69. A
22. C 70. A
23. C 71. B
24. C 72. A
25. B 73. A
26. C 74. A
27. B 75. B
28. C 76. D
29. B 77. B
30. B 78. B
31. C 79. A
32. A 80. D
33. A 81. D
34. D 82. A
35. B 83. C
36. D 84. A
37. A 85. B
38. C 86. A
39. A 87. A
40. D 88. D
 89. D 4. A nurse is preparing to remove a nasogastric tube
90. B from a client. The nurse would instruct the client to
91. A do which of the following just before the nurse
92. B removes the tube?
93. A
94. A a. To perform a Valsalva’s maneuver.
95. A
b. To take and hold a deep breath
96. C
97. B c. To exhale.
98. A
99. B d. To inhale and exhale quickly
100. D
1.  Before the insertion of nasogastric tube, the Clear selection
physician should be notified of: 5. A client with severe inflammatory bowel disease
a. Patent nares is receiving total parenteral nutrition (TPN). When
administering TPN, the nurse must take care to
b. Absent bowel sounds maintain the prescribed flow rate because stopping
the TPN abruptly may cause:
c. Evident gag reflex
a. hypotension
d. Impaired swallowing
b. hypoglycemia
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c. hyperglycemia
2. An appropriate technique for nasogastric tube
insertion is for the nurse to: d. air embolism
a. Position the client supine Clear selection
b. Ice the plastic tube 6. What position will the nurse recommend to the
patient during TPN insertion?
c. Advance the tube while the client swallows
a. High Fowler’s position
d. Measure the tube length from the nose to the
sternum b. Trendelenburg
Clear selection c. Semi-Fowler’s Position
3. An appropriate technique for the nurse to d. Left sims lateral
implement during nasogastric tube insertion is to:
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a. Use sterile gloves
7. What position will the nurse recommend to the
b. Have the client mouth-breathe patient during TPN administration?
c. Advance the tube quickly when the client cough a. High Fowler’s position
d. Bend the client’s head backward after the tube is b. Trendelenberg
through the nasopharynx
c. Semi-Fowler’s Position
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d. Left sims lateral
Clear selection d. Make a referral to Meals-on-Wheels

8. A client who requires a central vein access for Clear selection

parenteral nutrition is to receive a solution with:
11. Ms. F.X. has been admitted with right upper
a. Fat emulsion quadrant pain and has been placed on a low fat
diet. Which of the following trays would be
b. 5% dextrose
acceptable for her?
c. Amino acids
A. Liver, fried potatoes and avocado.
d. 10% dextrose
B. Ham, mashed potatoes, cream peas.
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C. Whole milk, rice and pastry.
9. A client with severe inflammatory bowel disease
D. Skim milk, lean fish, tapioca pudding.
is receiving total parenteral nutrition (TPN). When
administering TPN, the nurse must take care to Clear selection
maintain the prescribed flow rate because giving
12.The preoperative nurse is assessing a client for
TPN too rapidly may cause:
risk for latex allergies if they are allergic to all the
a. hyperglycemia following except:

b. air embolism A. Avocados

c. constipation B. orange

d. dumping syndrome C. kiwi

Clear selection D. Banana

SITUATION: Nutrition is an input to and foundation Clear selection

for health and development. Interaction and
13. A client complains that low- salt food is very
infection and malnutrition are well-documented.
tasteless. The nurse best response would be
Better nutrition means stronger immune systems,
less illness and better health. a. “I know how it’s difficult for you”
10. A client with congestive heart failure is newly b. “You miss your ham and cabbage?”
admitted to home health care. The nurse discovers
that the client has not been following the c. “Salt can be harmful to your health”
prescribed diet. What would be the most d. “Ask the doctor if you can splurge occasionally”
appropriate nursing action?
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a. Discharge the client from home health care
related to noncompliance 14.Clients with hepatitis have a regular diet
ordered, unless they become increasingly
b. Notify the health care provider of the client's symptomatic. The diet then will be modified to
failure to follow prescribed diet decrease the amount of 
c. Discuss diet with the client to learn the reasons a. Carbohydrates
for not following the diet
b. Fats
c. Fluids b. Calorie counts

d. Protein c. Skinfold measurements

Clear selection d. Daily weights

15.A client recovering from an infected abdominal Clear selection

wound. Which of the following foods should the
19.The most concentrated source of energy in the
nurse encourage the client to eat to support wound
body is:
healing and recovery from infection?
a. Protein
a. Chicken and orange slices
b. Carbohydrates
b. Cheese omelet and bacon
c. Fat
c. Cheeseburger and French fries
d. Macro minerals
d. Gelatin salad and tea
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20.A nurse is preparing to feed the client with mild
16.The nurse teaches the client with iron deficiency
dysphagia. The nurse would do which of the
anemia that food sources with high iron content
following to assist the client with swallowing?
include
a. Place the food on the tip of the client’s tongue
a. Cheese
b. Provide foods that have a soft consistency
b. Eggs
c. Use water to help the client swallow food in the
c. Squash
mouth
d. Beef
Place the equivalent of 30 ml of food on the fork
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Clear selection
17.A 45-year-old client has a permanent colostomy.
21. A postoperative client is on a clear liquid diet,
Which of the following foods should be avoided?
what of the following are allowed on a clear liquid
a. Peanut butter and jelly sandwich and milk diet?

b. Corn beef and cabbage and boiled potatoes a. Ice cream, butter, yoghurt, vegetable juices

c. Oatmeal, whole-wheat toast, and milk b. Mashed potatoes, fish, bananas, vegetable juices

d. Tuna on whole wheat bread and iced tea c. Gelatin, hard candy, tea, popsicles

Clear selection d. Milk, gelatin, canned fruits, bread

18. The nurse is caring for a client who has been Clear selection
admitted to the hospital with a diagnosis of
22. Oral ferrous sulfate is prescribed for the client to
malnutrition. The nurse most effectively monitors
take at home. The nurse would teach the client to
the client’s status by which measure?
take orange juice with the iron preparation,
a. Intake measurement because orange juice:
a. Decreased the toxicity of the medication d. Detect oxygen saturation of arterial blood before
a symptoms of hypoxemia develops
b. Helps prevent mouth ulcers
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c. Masks the bitter taste of the enteric-coated tablet
26.While the client has pulse oximeter on his
d. Acts as a reducing agent to increase medication
fingertip, you notice that the sunlight is shinning on
absorption
the area where the oximeter is : Your action will be
Clear selection to:

23. The nurse’s teaching plan would also include A. Set and turn on the alarm of the oximeter
telling the client to expect which of the following
B. Do nothing since there is no identified problem
side effects of oral ferrous sulfate?
C. Cover the fingertip sensor with a towel or
a. Bright orange urine
bedsheet
b. Excessive perspiration
D. Change the location of the sensor every four
c. Dark red or black stool hours

d. Yellow or light-green sputum Clear selection

Clear selection 27.A nurse informs a client  that the alarm on the
pulse oximeter will not sound when:
24. Which of the following menu is appropriate for
one with low sodium diet? a. The client moves the probe

a. instant noodles, fresh fruits and ice tea b. The probe falls off

b. ham and cheese sandwich, fresh fruits and c. The SpO2 falls below the set limit
vegetables
d. The display reaches full strength during each
c. white chicken sandwich, vegetables salad and tea cardiac cycle

d. canned soup, potato salad, and diet soda Clear selection

Clear selection 28.For a client with CAL, a nurse anticipates the use
of oxygen equipment?
SITUATION: I n today’s critical care environment the
assessment of oxygenation is crucial, especially for a. Face tent
patients’ delivery, it is often difficult to get a true
b. Face mask
assessment of the patient’s oxygenation status.
c. Nasal cannula
25.You attached a pulse oximeter to the client. You
know that the purpose is to: d. Nonbreathing mask

a. Determine if the client’s hemoglobin is low and if Clear selection

he needs blood transfusion
29. Assessment of the proper functioning of an
b. Check level of client’s tissue perfusion oxygen device includes:

c. Measure the efficacy of the client’s anti- a. No mist in the face tent
hypertensive medications
b. The reservoir of the rebreathing mask collapsing c. Holding the spirometer above the head, seal the
on inhalation mouthpiece, and exhaling slowly for 3 seconds

c. A flow rate between 1 and 6L/min for the nasal d. Holding the spirometer above the head, seal the
cannula mouthpiece around the lips, and holding breath for
a while.
d. The nasal cannula positioned below the nares
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Clear selection
33 The following nursing interventions are
30.An unexpected outcome of oxygen use is:
appropriate for a nursing diagnosis of Ineffective
a. Decrease anxiety Airway Clearance related to obesity EXCEPT?

b. An increased pulse rate a. Diversional Activity

c. A decreased respiratory rate b. Start weight reduction

d. An increased level of consciousness c. Place patient in high Fowler’s position

Clear selection d. Have client cough & deep breathe every 2 hours
while wake
31.The proper technique to use for administering
oxygen to a client with an artificial airway is: Clear selection

a. Applying sterile gloves 34. The primary reason in teaching pursed-lip

breathing to persons with emphysema is to help:
b. Leaving fluid in the tubing
A. Promote oxygen intake
c. Attaching the T tube to the humidified oxygen
source B. Strengthen the diaphragm

d. Monitoring the response to the oxygen with C. Strengthen the intercostals muscles
hourly arterial blood gas levels
D. Promote carbon dioxide elimination
Clear selection
Clear selection
32. Nurse Nikka is teaching a client on how to
35.Complications associated with a tracheostomy
properly use an incentive spirometry to a client.
tube include:
Teaching is effective if which of the following
sequence is observed; a. Decreased cardiac output

a. The client holds the spirometry in upright b. Damage to the laryngeal nerve
position, exhales normally, seal the lips tightly
c. Pneumothorax
around the mouthpiece, takes a slow deep breath
and hold breath for 2 seconds to keep the balls d. Respiratory distress syndrome
elevated.
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b. Exhales normally, hold the spirometer upright,
seals the mouthpiece, takes a fast shallow breath 36. A priority goal for the hospitalized client with a
and holds breath for 5 seconds to keep the balls new tracheostomy would be to:
elevated. a. Decrease secretions
b. Instruct the client in caring for the tracheostomy d. A guide for easy removal of the tracheostomy
tube
c. Relieve anxiety related to the device
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d. Maintain patent airway
40. Which of the following statements contains one
Clear selection
of the basic rules to follow when caring for a client
37. A client has a tracheostomy tube. The nurse with a chest tube and water-seal drainage system?
knows that the obturator is kept at the client’s
a. Ensure that the air vent on the water-seal
bedside because:
drainage system is capped when the suction is off
a. The obturator is kept at the client’s bedside in
b. Strip the chest and drainage tubes at least every
case the tube becomes dislodged and needs to be
4 hours if excessive bleeding occurs
reinserted.
c. Ensure that the collection and suction bottles are
b. The obturator is a guide in inserting the tube.
at the client’s chest level at all times
c. The obturator, after insertion, will be kept by the
d. Ensure that the collection and suction bottles are
client.
below the client’s chest level at all times
d. The obturator will be used to make an opening
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for the tube
41 In an underwater-seal drainage system,
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cessation of fluid fluctuation in the chest and
38. The nurse is cleaning the incision site and tube drainage tubes generally means that the:
flange of a client with tracheostomy. A sterile
a. Lung has fully expanded
applicator soaked in what solution is used in
removing crusty secretions? b. Lung has collapsed

a. Isopropyl alcohol c. Chest tube is in the pleural space

b. Hydrogen peroxide (Full strength) d. Mediastinal space has decreased

c. Hydrogen peroxide ( half-strength solution mixed Clear selection

with sterile normal saline)
42 The chest tube drainage of  aileen’s has
d. Ammonia continuous bubbling in the water seal drainage.
After an hour you noticed that the bubbling stops.
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Which of the following condition is the possible
39. Tracheostomy tubes used among adults often cause of the malfunctioning sealed drainage?
have cuffs. This inflatable cuff functions by:
A. A suction being too high
a. Producing an airtight seal to prevent aspiration of
B. An air leak
oropharyngeal secretions and air leakage
C. A tube being too small
b. Anchoring the tube in place
D. A tension pneumothorax
c. Distributing a low even pressure over the trachea
Clear selection
43. While you were making endorsement, you D. placed between the legs of the client to prevent
found out the chest tube of a client was breakage.
disconnected. What would be your appropriate
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action?
47. Which of the following measures should the
A. Assit the client back to his bed and place him on
nurse perform in relation to suctioning a
the affected side
tracheostomy tube?
B. Cover the end of the chest tube with sterile gauze
a. Apply suction while inserting the suction catheter
C. Reconnect the tube to the chest tube system into the tube

D. Put the end of the chest tube into a cup of sterile b. Change the tracheostomy tube after suctioning
normal saline the client

Clear selection c. Select a suction catheter that approximates the

diameter of the tracheostomy tube
44. Dr. Black Daclis asked you to assist him with the
removal of jeld’s chest tube. You would instruct the d. Hyperoxygenate before suctioning the client
client to:
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A. A continuously breathe normally during the
48. After suctioning a client’s tracheostomy tube,
normal of the chest tube
the nurse waits a few minutes before suctioning
B. Take a deep breath, exhale, and bear down again. The nurse would use intermittent suction
primarily to help prevent:
C. Exhale upon the actual removal of the tube
a. Stimulating the client’s cough reflex
D. Hold breath until the chest tube is pulled out
b. Depriving the client of sufficient oxygen supply
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c. Dislocating the tracheostomy rube
45 Chest tube diameter is measured or expressed
in: d. Obstructing the suctioning catheter with
secretions
A. French
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B. Gauge
49. Which method is the best for the nurse to
C. Millilitres
evaluate the effectiveness of tracheal suctioning?
D. Inches
a. Note subjective data such as, “My breathing is
Clear selection much improved now.”

46. When transporting clients with chest tube, the b. Note objective findings such as decreased
system should be respiratory rate and pulse.

A. disconnected c. Consult with respiratory therapist to determine

effectiveness.
B. closed
d. Auscultate the chest for change or clearing in
C. placed lower than the patient’s chest adventitious breath sounds.
Clear selection d. Allow 1 to 2 minutes between each suction

50. Organize the following steps of suctioning in Clear selection

chronological order:
53. The correct pressure of the wall suction unit
1. Put on sterile glove. when suctioning a child patient is?

2. Lubricate catheter with normal saline a. 95 – 100mg Hg

3. Apply suction for 5-10sec. b. 50 – 95 mm Hg

4. Explain procedure to client. c. 100 – 120mm Hg

5. Wash hands thoroughly. d. 10 – 15mm Hg

a. 54132 Clear selection

b. 45213 54. A nurse suctioning a client through a

tracheotomy tube. The nurse plans to apply suction
c. 54123
during the withdrawal of the catheter for a period
d. 45132 of time no greater than? 

Clear selection a. 10 seconds

51. A nurse is performing oropharyngeal suctioning b. 15 seconds

on the unconscious client. Which of the following
c. 20 seconds
actions is safe?
d. 30 seconds
a. Insert the catheter approximately 20 cm while
applying suction. Clear selection

b. Allow 20 to 30 second intervals between each 55. Which of the following should the nurse include
suction, and limit suctioning to a total of 15 when suctioning a client’s tracheostomy?
minutes.
a. Instill a sterile saline down the trachea to
c. Gently rotate the catheter while applying suction. stimulate a cough then suction with continuous
suctioning
d. Apply suction for 5 minutes while inserting and
continue for another 5 seconds before withdrawing. b. Suction the client’s mouth before entering the
trachea
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c. Insert the catheter until a cough reflex is obtained
52. Applying suction in the nasopharynx for too long
or until resistance is felt
may cause secretions to increase or decrease,
therefore the nurse should: d. Adjust the wall suction to 150 mmHg for the
procedure
a. Allow 20 to 30 second intervals between each
suction, limit suctioning to 5 minutes in total Clear selection

b. Allow 2 to 3 minutes between suction when 56. Tonometry is performed on the client with a
possible suspected diagnosis of glaucoma. The nurse
analyzes the test results as documented in the
c. Allow 5 minutes between each suction
client's chart and understands that normal a. Pull the pinna of the ear backward and downward
intraocular pressure is
b. Pull the pinna of the ear sidewards and upwards
a.2 to 7 mmHg
c. Pull the pinna of the ear downwards and
b.22 to 30 mmHg backwards

c. 10 to 21 mmHg d. Pull the pinna of the ear upwards and backwards

d. 31 to 35 mmHg Clear selection

Clear selection 60. Preoperatively before cataract surgery, the

nurse is to instill several types of eye drops into a
57. The clinic nurse is preparing to test the visual
client’s right eye. The accepted abbreviation for the
acuity of a client using a Snellen's chart. Which of
right eye is:
the following identifies the accurate procedure for
this visual acuity test? a. OD

A. Both eyes are assessed together, followed by the b. OS

assessment of the right and then the left eye
c. OU
B. The right eye is tested followed by the left eye,
d. RE
and then both eyes are tested
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C. The client is asked to stand at a distance of 40
feet from the chart and is asked to read the largest 61. The nurse inspects a patient's pupil size and
line on the chart determines a result of OD = 2 mm and OS = 3mm.
Unequal pupils are known as:
D. The client is asked to stand at a distance of 40
feet from the chart and to read the line that can be A. anisocoria
read 200 feet away by an individual with
unimpaired vision B. ataxia

Clear selection C. cataract

58. The nurse is preparing to perform a Weber test D. diplopia

on a client. The nurse obtains which item needed to Clear selection
perform this test?
62. Mrs. Posadas has an eye infection with a
a. A tongue blade moderate amount of discharge. To clean her eyes,
b. A tuning fork the nurse should:

c. A stethoscope a. Use hydrogen peroxide

d. A reflex hammer b. Wipe from the outer canthus to the inner canthus

Clear selection c. Position on the same side as the eye to be

cleansed
59. The nurse is about to obtain the temperature of
a seven-year-old child through the tympanic route. d. Use only one cotton ball per eye
The nurse should: Clear selection
63. A client is diagnosed with a conduction hearing A. infuse the blood slowly over a period of 5 to 6
loss. What might the nurse indicate to the client hours
could be a reason for this loss?
B. initially infuse at a rapid rate and check pulse
a. There has been damage to the inner ear frequently

b. Something has happened to the hearing center C. obtain the client’s vital signs prior to the
nof the brain transfusion

c. An ear infection has torn the tympanic membrane D. prime the tubing with a D5W solution prior to
infusing blood
d. The auditory nerve is not functioning
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Clear selection
67. A client is to receive 1 unit of packed red blood
64. The client's vision is tested with a Snellen's
cells because he has a hemoglobin level of 8 g/dL
chart. The results of the tests are documented as
and a diagnosis of gastrointestinal bleeding. Before
20/60. The nurse interprets this as
initiating the transfusion, the nurse needs to check:
a.The client can read at a distance of 60 feet what a
A. if the blood has been warmed especially for CVP
client with normal vision can read at 20 feet.
lines
b.The client is legally blind.
B. that the blood had been typed and cross
c.The client's vision is normal. matched

d.The client can read only at a distance of 20 feet C. that the recipient’s blood numbers match the
what a client with normal vision can read at 60 feet. donor’s blood numbers

Clear selection D. all of the above

65. The clinic nurse notes that following several eye Clear selection
examinations, the physician has documented a
68. As AP’s nurse, what will you do AFTER the
diagnosis of legal blindness in the client's chart. The
transfusion have started?
nurse reviews the results of the Snellen's chart test
expecting to note which finding? A. Add the total amount of blood to be transfused
to the intake and output
a.20/20 vision
B. Discontinue the primary IV of Dextrose 5% Water
b.20/60 vision
C. Check the vital signs every 15 minutes
c. 20/40 vision
D. Stay with AP for 15 minutes to note for any
d.20/200 vision
possible BT reactions
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Clear selection
66. A client with a peripheral IV line is about to
69. What should you do FIRST before you
receive a blood transfusion of packed red blood
administer blood transfusion?
cells due to anemia. The nurse administering the
transfusion will:
A. Verify client identity and blood product, serial a. If you have eaten red meat or raw radishes and
number, blood type, cross matching results, melons, in the last couple of days, the test may be
expiration date positive and it may be inaccurate.

B. Verify client identity and blood product serial b. If you have taken more then 250 mg of vitamin C,
number, blood type, cross matching results, it may produce a reading that is too high but is
expiration date with another nurse inaccurate.

C. Check IV site and use appropriate BT set and c. If you have recently eaten any colored
needle vegetables, it may color the stool and produce an
inaccurate test result.
D. Verify physician’s order
d. If you have been drinking tea, the result might be
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elevated.
70. Lino, a nurse taking care of an adult client with
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constipation, in performing a high cleansing  enema,
Lino must keep in mind that the maximum height is: 73. The nurse finds a container with the client’s
urine specimen sitting on a counter in the
a. 18 inches above the bed
bathroom. The client states that the specimen has
b. 16 inches above the rectum been sitting in the bathroom at least 2 hours. What
would be the nurse’s most appropriate action?
c. 18 inches above the rectum
a. Discard the urine and obtain a new specimen
d. 16 inches above the bed
b. Send the urine to the laboratory as quickly as
Clear selection possible
71. You are assigned to Mrs. Dulay, a client with an c. Add fresh urine to the collected specimen and
order for cleansing enema. While doing the send the specimen to the laboratory
procedure, the client groans and complains of
abdominal cramping. Your MOST appropriate initial d. Place the specimen in the refrigerator until it can
nursing action would be to: be transported to the laboratory

A. Reduce the flow of the fluid by clamping the Clear selection

enema tubing
74.   After IVP a renal stone was confirmed, a left
B. Lower the height of the enema container nephrectomy was done. Her post operative care
includes daily urine   specimen to be sent to the
C. Instruct the client to relax, inhale and exhale laboratory. Imelda has a foley catheter to a urinary
slowly drainage system. How will you collect the urine
D. Push the rectal tube further in by 2 inches. specimen?

Clear selection a. Remove urine from drainage tube with sterile

needle and syringe and empty urine from the
72. The nurse doing the health teaching to a client syringe into the specimen container
for testing feces for occult blood informs the client
about what can produce false positive results: What b. Empty a sample urine from the collecting bag into
should the nurse emphasize? the specimen container
c. Disconnect the drainage tube from the indwelling d. cleanse the urethral meatus after obtaining the
catheter and allow urine to flow from catheter into specimen
the specimen container.
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d. Disconnect the drainage the from the collecting
77.  The nurse is reviewing with a client how to
bag and allow the urine to flow from the catheter
collect a clean catch urine specimen. Which
into the specimen container.
sequence is appropriate teaching?
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a. void a little, clean the meatus, then collect
75. The nurse is preparing to collect a sterile urine specimen
specimen from a client who has an indwelling Foley
b. clean the meatus, begin voiding, then catch urine
catheter. The nurse clamped the catheter and
stream
returns to the client to collect the specimen 30
minutes later. The correct order of priority that the c. clean the meatus, then urinate into container
nurse should take to collect the specimen is:
d. void continuously and catch some of the urine
1. Explain procedure to the client
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2. Unclamp the catheter
78. A nurse has an order to obtain 24-hour urine
3. Draw urine into the syringe collection on a client with renal disorder. The nurse
avoids which of the following to ensure proper
4. Insert needle into the port
collection of the 24-hour urine specimen?
5. Place urine into the specimen container
a. have the client void at the start time, and place
6. Cleanse the needle entry port he specimen in the container

7. Label the specimen according to agency protocol b. discard the first voiding, and save all subsequent
voiding during 24-hour time period
a. 1,2,6,4,3,5,7
c. place the container on ice or refrigerator
b. 1,6,4,3,5,2,7
d. have the client void at the end time, and place
c. 1,4,6,3,5,2,7
the specimen in a container
d. 1,2,4,6,3,5,7
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Clear selection
79. A nurse is to collect a sputum specimen for
76. A midstream urine specimen is ordered, and the culture and sensitivity from a client. Which action
nurse teaches the client how to collect the should the nurse take first?
specimen correctly. Which of the following should
a. Assist with oral hygiene
the nurse include in the instructions?
b. Ask client to cough sputum into container
a. void directly into the sterile specimen container
c. Have the client take several deep breaths
b. save the first voided urine
d. Provide an appropriate specimen container
c. stop collecting urine after the bladder is empty
Clear selection
80. The physician orders a urine culture and b. Document size of catheter and client’s tolerance
sensitivity for a 36-year old patient with an of procedure.
indwelling Foley catheter. Which of the following
c. Evaluate the client for normal voiding.
action by the nurse is best?
d. Documentation of client’s teaching
a. The nurse clamps the catheter tubing below the
level of the port for 1 hour. Clear selection
b. The nurse removes 20ml from the catheter bag 84. Which priority is first when inserting an
and places it in a sterile container. indwelling urinary catheter?
c. The nurse separates the catheter from the tubing a. Aseptic technique
and allows 30ml of urine to drain into a sterile cup.
b. Instilling water into the balloon.
d. The nurse clamps the catheter just below the
insertion site for 20 minutes c. Taping the catheter to the leg

Clear selection d. Inserting the catheter to the point where the

urine
81. The nurse collects a urine specimen for routine
urinalysis from a client. She is aware that: Clear selection

A. A sterile specimen is required 85. During an assessment, the nurse expects that
the average daily urinary output for the adult client
B. Standing at room temperature for a prolonged will be:
period may alter the urine chemistry
a. 500 to 1000ml
C. The external meatus should be cleaned with
antiseptic soap and water before voiding. b. 700 to 1500ml

D. A clean-catch, midstream specimen is required c. 1200 to 1500ml

Clear selection d. 2000 to 3000ml

82. Which assessment finding would be most Clear selection

indicative of obstructed drainage tubing? 86. Nurse Jane evaluates a client with diagnosis of
a. Bladder distention dehydration to have which of the following specific
gravity reading?
b. Concentrated urine
a. 1.000
c. Increased urge to void
b. 1.017
d. Complaint of burning
c. 1.023
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d. 1.035
83. What is the priority of care after the urinary
catheter is removed? Clear selection

a. Encourage the client to eliminate fluid intake. 87 Mrs. Ong, 78, reports accidental loss of urine
before she is able to reach the toilet. She is aware
of the urge to void but states, “Because of my
stroke I sometimes can’t get there soon enough.” lung sounds over the periphery of the right and left
Nurse John suspects: lungs fields.

a. Functional incontinence c. Potential for altered nutrition: less than body

requirements as evidenced by 15 lb- weight loss in 3
b. Stress incontinence
weeks.
c. Reflex incontinence
d. Potential for self – esteem disturbance related to
d. Urge incontinence change in body image

Clear selection Clear selection

88. Nurse Angie monitors an increase incidence of 91.  Health is considered as the fundamental human
stress incontinence in a client during which of the right during this period?
following activities?
A. Contemporary
a. Eating
B. Apprentice
b. Sleeping
C. Intuitive
c. Walking
D. Educated
d. Laughing
Clear selection
Clear selection
92.  He promulgated laws of control on the spread
89. A nurse discusses changes due to aging with a of communicable diseases and the ritual of
group at the senior citizen center. The nurse knows circumcision of the male child?
that which of the following changes in the pattern
A. Loreto Tupas
of urinary elimination normally occur with aging?
B. Moses
a. Decrease frequency
C. Pastor Fliedner
b. Incontinence
D. Hippocrates
c. Residual urine decreases
93.  Which of the following is not true about
d. Formation of bladder stone
Florence Nightingale?
Clear selection
A. Contented with the social custom imposed upon
90.  Which of the following statements is a correctly her as the Victorian Lady
written ACTUAL nursing diagnosis?
B. Recognized as the Mother of Modern Nursing
a. Impaired physical mobility as evidenced by
C. She nursed the wounded soldiers during the
decreased range of motion in left shoulder from 180
Crimean war
to 190 degrees of flexion and extension related to
left shoulder pain. D. Her education was rounded out by a continental
tour
b. Ineffective airway clearance related to thickened
bronchial secretions as evidenced by adventitious 94.  She organized the Filipino Red Cross through
the inspiration of Apolinario Mabini?
A. Dona Hilaria de Aguinaldo c. Pinch skin at the injection site and use airlock
technique
B. Josephine Bracken
d. Inject needle at a 15 degree angle over the
C. Cesaria Tan
stretched skin of the client
D. Dona Maria Agoncillo de Aguinaldo
99.  Anton asks to be assisted to move up on bed.
95.  The first hospital established in the Philippines Which of the following should Nurse Diana do first?
that initially catered to patients with leprosy and
a. Move the patient to the edge of the bed near the
mental disorder was
nurse
A. San Lazaro Hospital
b. Adjust the bed to a flat position
B. Mary Johnston Hospital
c. Lock the wheels of the bed
C. Iloilo Mission Hospital
d. Raise the bed rails opposite the nurse
D. Philippine General Hospital
u100.  Which of the following statements is NOT
96.  She is the first Filipino to receive a degree of true about the Z-track technique of intramuscular
Nursing abroad injection?

A. Melchora Aquino a. This technique is used when medications for

intramuscular injection are irritating to tissue
B. Conchita Ruiz
b. This technique leaves a zigzag path that seals
C. Cesarea Tan needle track
D. Capitan Salome c. The medication is injected slowly in this
97.  When preparing the epinephrine injection from technique to allow medication to disperse evenly in
an ampule, the nurse initially: muscle tissue

a. Taps the ampule at the top to allow fluid to flow d. This technique seals the medication in
to the base of the ampule subcutaneous tissue

b. Checks expiration date of the medication ampule Submit

c. Breaks the neck of the ampule with a gauze

wrapped around it

d. Removes needle cap of syringe and pulls plunger

to expel air

98.  Mrs. Manzano is an obese client. When

administering a subcutaneous injection to an obese
client, it is best for the nurse to:

a. Spread skin or pinch at the injection site and

inject needle at a 45-90 degree angle

b. Pull skin of patient down to administer the drug

in a Z track