funda exam

Name: _____________________ Date: __________________ Score: ___________

Direction:Write the letter of the appropriate answer on the space provided before the number.

Strictly NO ERASURES/SUPER IMPOSITIONS allowed.

_______1. Nurse Brenda is teaching a patient about a newly prescribed drug. What could cause a

geriatric patient to have difficulty retaining knowledge about prescribed medications?

a. Decreased plasma drug levels

b. Sensory deficits

c. Lack of family support

d. History of Tourette syndrome

Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed

medications. Decreased plasma drug levels do not alter the patient’s knowledge about the drug. A lack of

family support may affect compliance, not knowledge retention. Tourette syndrome is unrelated to

knowledge retention.

2. When examining a patient with abdominal pain the nurse in charge should assess:

Any quadrant first

The symptomatic quadrant first

The symptomatic quadrant last

The symptomatic quadrant either second or third

Question was not answered

The nurse should systematically assess all areas of the abdomen, if time and the patient’s condition

permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic

area, causing the muscles in other areas to tighten. This would interfere with further assessment.

3. The nurse is assessing a postoperative adult patient. Which of the following should the nurse

document as subjective data?

Vital signs

Laboratory test result

Patient’s description of pain

Electrocardiographic (ECG) waveforms


Subjective data come directly from the patient and usually are recorded as direct quotations that reflect

the patient’s opinions or feelings about a situation. Vital signs, laboratory test result, and ECG waveforms

are examples of objective data.

4. A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider

abnormal?

A palpable radial pulse

A palpable ulnar pulse

Cool, pale fingers

Pink nail beds


A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore,

the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A

palpable radial or lunar pulse and pink nail beds are normal findings.

5. Which of the following planes divides the body longitudinally into anterior and posterior regions?

Frontal plane

Sagittal plane

Midsagittal plane

Transverse plane


Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior

and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left regions; if

exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the

vertical axis, dividing the structure into superior and inferior regions.

6. A female patient with a terminal illness is in denial. Indicators of denial include:

Shock dismay

Numbness

Stoicism

Preparatory grief


Shock and dismay are early signs of denial-the first stage of grief. The other options are associated with

depression—a later stage of grief.

7. The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse

take during this patient transfer?

Position the head of the bed flat

Helps the patient dangle the legs

Stands behind the patient

Places the chair facing away from the bed


After placing the patient in high Fowler’s position and moving the patient to the side of the bed, the nurse

helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and

places the chair next to and facing the head of the bed.

8. A female patient who speaks a little English has emergency gallbladder surgery, during discharge

preparation, which nursing action would best help this patient understand wound care instruction?

Asking frequently if the patient understands the instruction

Asking an interpreter to replay the instructions to the patient.

Writing out the instructions and having a family member read them to the patient

Demonstrating the procedure and having the patient return the demonstration


Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can

perform wound care correctly. Patients may claim to understand discharge instruction when they do not.

An interpreter of family member may communicate verbal or written instructions inaccurately.

9. Before administering the evening dose of a prescribed medication, the nurse on the evening shift

finds an unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge do?

Discard the syringe to avoid a medication error

Obtain a label for the syringe from the pharmacy

Use the syringe because it looks like it contains the same medication the nurse was prepared to give

Call the day nurse to verify the contents of the syringe


As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other

options are considered unsafe because they promote error.

10. When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for

adverse effects. Which factor makes geriatric patients to adverse drug effects?

Faster drug clearance

Aging-related physiological changes

Increased amount of neurons

Enhanced blood flow to the GI tract


Aging-related physiological changes account for the increased frequency of adverse drug reactions in

geriatric patients. Renal and hepatic changes cause drugs to clear more slowly in these patients. With

increasing age, neurons are lost and blood flow to the GI tract decreases.

11. A female patient is being discharged after cataract surgery. After providing medication teaching, the

nurse asks the patient to repeat the instructions. The nurse is performing which professional role?

Manager

Educator

Caregiver

Patient advocate


When teaching a patient about medications before discharge, the nurse is acting as an educator. The

nurse acts as a manager when performing such activities as scheduling and making patient care

assignments. The nurse performs the care giving role when providing direct care, including bathing

patients and administering medications and prescribed treatments. The nurse acts as a patient advocate

when making the patient’s wishes known to the doctor.

12. A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to

reduce the patient’s anxiety?

“Everything will be fine. Don’t worry.”

“Read this manual and then ask me any questions you may have.”

“Why don’t you listen to the radio?”

“Let’s talk about what’s bothering you.”


Anxiety may result from feeling of helplessness, isolation, or insecurity. This response helps reduce

anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop goals

together with the patient to give the patient some control over an anxiety-inducing situation. Because the

other options ignore the patient’s feeling and block communication, they would not reduce anxiety.

13. A scrub nurse in the operating room has which responsibility?

Positioning the patient

Assisting with gowning and gloving

Handling surgical instruments to the surgeon

Applying surgical drapes


The scrub nurse assist the surgeon by providing appropriate surgical instruments and supplies,

maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges,

needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the

patient, applies appropriate equipment and surgical drapes, assists with gowning and gloving, and

provides the surgeon and scrub nurse with supplies.

14. A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the

nurse in charge do?

Leave the medication at the patient’s bedside

Tell the patient to be sure to take the medication. And then leave it at the bedside

Return shortly to the patient’s room and remain there until the patient takes the medication

Wait for the patient to return to bed, and then leave the medication at the bedside


The nurse should return shortly to the patient’s room and remain there until the patient takes the

medication to verify that it was taken as directed. The nurse should never leave medication at the

patient’s bedside unless specifically requested to do so.

15. The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The

vial reads 10,000 units per millilitre. The nurse should anticipate giving how much heparin for each dose?

¼ ml

½ ml

¾ ml

1 ¼ ml


The nurse solves the problem as follows: 10,000 units/7,500 units = 1 ml/X 10,000 X = 7,500 X=

7,500/10,000 or ¾ ml

16. The nurse in charge measures a patient’s temperature at 102 degrees F. what is the equivalent

Centigrade temperature?

39 degrees C

47 degrees C

38.9 degrees C

40.1 degrees C


To convert Fahrenheit degrees to centigrade, use this formula: C degrees = (F degrees – 32) x 5/9 C

degrees = (102 – 32) 5/9 + 70 x 5/9 38.9 degrees C

17. To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test?

Red blood cell count

Sputum culture

Total hemoglobin

Arterial blood gas (ABG) analysis


All of these test help evaluate a patient with respiratory problems. However, ABG analysis is the only test

evaluates gas exchange in the lungs, providing information about patient’s oxygenation status.

18. The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a

stethoscope with a bell and diaphragm is true?

The bell detects high-pitched sounds best

The diaphragm detects high-pitched sounds best

The bell detects thrills best

The diaphragm detects low-pitched sounds best


The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds

best. Palpation detects thrills best.

19. A male patient is to be discharged with a prescription for an analgesic that is a controlled substance.

During discharge teaching, the nurse should explain that the patient must fill this prescription how soon

after the date on which it was written?

Within 1 month

Within 3 months

Within 6 months

Within 12 months


In most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the date

on which the prescription was written.

20. Which human element considered by the nurse in charge during assessment can affect drug

administration?

The patient’s ability to recover

The patient’s occupational hazards

The patient’s socioeconomic status

The patient’s cognitive abilities


The nurse must consider the patient’s cognitive abilities to understand drug instructions. If not, the nurse

must find a family member or significant other to take on the responsibility of administering medications in

the home setting. The patient’s ability to recover, occupational hazards, and socioeconomic status do not

affect drug administration.

21. When explaining the initiation of I.V. therapy to a 2-year-old child, the nurse should:

Ask the child, “Do you want me to start the I.V. now?”

Give simple directions shortly before the I.V. therapy is to start

Tell the child, “This treatment is for your own good”

Inform the child that the needle will be in place for 10 days


Because a 2-year-old child has limited understanding, the nurse should give simple directions and

explanations of what will occur shortly before the procedure. She should try to avoid frightening the child

with the explanation and allow the child to make simple choices, such as choosing the I.V. insertion site, if

possible. However, she shouldn’t ask the child if he wants the therapy, because the answer may be “No!”

Telling the child that the treatment is for his own good is ineffective because a 2-year-old perceives pain

as a negative sensation and cannot understand that a painful procedure can have position results. Telling

the child how long the therapy will last is ineffective because the 2-year-old doesn’t have a good

understanding of time.

22. All of the following parts of the syringe are sterile except the:

Barrel

Inside of the plunger

Needle tip

Barrel tip


All syringes have three parts: a tip, which connects the needle to the syringe; a barrel, the outer part on

which the measurement scales are printed; and a plunger, which fits inside the barrel to expel the

medication. The external part of the barrel and the plunger and (flange) must be handled during the

preparation and administration of the injection. However, the inside and trip of the barrel, the inside (shaft)

of the plunger, and the needle tip must remain sterile until after the injection.

23. The best way to instill eye drops is to:

Instruct the patient to lock upward, and drop the medication into the center of the lower lid

Instruct the patient to look ahead, and drop the medication into the center of the lower lid

Drop the medication into the inner canthus regardless of eye position

Drop the medication into the center of the canthus regardless of eye position


Having the patient look upward reduces blinking and protects the cornea. Instilling drops in the center of

the lower lid promotes absorption because the drops are less likely to run into the nasolacrimal duct or out

of the eye.

24. The difference between an 18G needle and a 25G needle is the needle’s:

Length

Bevel angle

Thickness

Sharpness


Gauge is a measure of the needle’s thickness: The higher the number the thinner the shaft. Therefore, an

18G needle is considerably thicker than a 25G needle.

25. A patient receiving an anticoagulant should be assessed for signs of:

Hypotension

Hypertension

An elevated hemoglobin count

An increased number of erythrocytes


A major side effect of anticoagulant therapy is bleeding, which can be identified by hypotension (a systolic

blood pressure under 100 mm Hg). Anticoagulants do not result in the other three conditions.

1. A patient is wearing a soft wrist-safety device. Which of the following nursing assessment is

considered abnormal?

a. Palpable radial pulse

b. Palpable ulnar pulse

c. Capillary refill within 3 seconds

d. Bluish fingernails, cool and pale fingers


A safety device on the wrist may impair blood circulation. Therefore, the nurse should assess the patient

for signs of impaired circulation such as bluish fingernails, cool and pale fingers. Palpable radial and ulnar

pulses, capillary refill within 3 seconds are all normal findings.

2. Pia’s serum sodium level is 150 mEq/L. Which of the following food items does the nurse instruct Pia

to avoid?

a. broccoli

b. sardines

c. cabbage

d. tomatoes


The normal serum sodium level is 135 to 145 mEq/L, the client is having hypernatremia. Pia should avoid

food high in sodium like processed food. Broccoli, cabbage and tomatoes are good source of Vitamin C.

3. Jason, 3 years old vomited. His mom stated, “He vomited 6 ounces of his formula this morning.” This

statement is an example of:

a. objective data from a secondary source

b. objective data from a primary source

c. subjective data from a primary source

d. subjective data from a secondary source


Jason is the primary source; his mother is a secondary source. The data is objective because it can be

perceived by the senses, verified by another person observing the same patient, and tested against

accepted standards or norms.

4. Which of the following is a nursing diagnosis?

a. Hypethermia

b. Diabetes Mellitus

c. Angina

d. Chronic Renal Failure


Hyperthermia is a NANDA-approved nursing diagnosis. Diabetes Mellitus, Angina and Chronic Renal

Failure are medical diagnoses.

5. What is the characteristic of the nursing process?

a. stagnant

b. inflexible

c. asystematic

d. goal-oriented


The nursing process is goal-oriented. It is also systematic, patient-centered, and dynamic.

6. A skin lesion which is fluid-filled, less than 1 cm in size is called:

a. papule

b. vesicle

c. bulla

d. macule


Vesicle is a circumscribed circulation containing serous fluid or blood and less than 1 cm (ex. Blister,

chicken pox).

7. During application of medication into the ear, which of the following is inappropriate nursing action?

a. In an adult, pull the pinna upward.

b. Instill the medication directly into the tympanic membrane.

c. Warm the medication at room or body temperature.

d. Press the tragus of the ear a few times to assist flow of medication into the ear canal.


During the application of medication it is inappropriate to instill the medication directly into the tympanic

membrane. The right thing to do is instill the medication along the lateral wall of the auditory canal.

8. Which of the following is appropriate nursing intervention for a client who is grieving over the death of

her child?

a. Tell her not to cry and it will be better.

b. Provide opportunity to the client to tell their story.

c. Encourage her to accept or to replace the lost person.

d. Discourage the client in expressing her emotions.


Providing a grieving person an opportunity to tell their story allows the person to express feelings. This is

therapeutic in assisting the client resolve grief.

9. It is the gradual decrease of the body’s temperature after death.

a. livor mortis

b. rigor mortis

c. algor mortis

d. none of the above


Algor mortis is the decrease of the body’s temperature after death. Livor mortis is the discoloration of the

skin after death. Rigor mortis is the stiffening of the body that occurs about 2-4 hours after death.

10. When performing an admission assessment on a newly admitted patient, the nurse percusses

resonance. The nurse knows that resonance heard on percussion is most commonly heard over which

organ?

a. thigh

b. liver

c. intestine

d. lung


Resonance is loud, low-pitched and long duration that’s heard most commonly over an air-filled tissue

such as a normal lung.

11. The nurse is aware that Bell’s palsy affects which cranial nerve?

a. 2nd CN (Optic)

b. 3rd CN (Occulomotor)

c. 4th CN (Trochlear)

d. 7th CN (Facial)


Bells’ palsy is the paralysis of the motor component of the 7th caranial nerve, resulting in facial sag,

inability to close the eyelid or the mouth, drooling, flat nasolabial fold and loss of taste on the affected side

of the face.

12. Prolonged deficiency of Vitamin B9 leads to:

a. scurvy

b. pellagra

c. megaloblastic anemia

d. pernicious anemia


Prolonged Vitamin B9 deficiency will lead to megaloblastic anemia while pernicious anemia results in

deficiency in Vitamin B12. Prolonged deficiency of Vitamin C leads to scurvy and Pellagra results in

deficiency in Vitamin B3.

13. Nurse Cherry is teaching a 72 year old patient about a newly prescribed medication. What could

cause a geriatric patient to have difficulty retaining knowledge about the newly prescribed medication?

a. Absence of family support

b. Decreased sensory functions

c. Patient has no interest on learning

d. Decreased plasma drug levels


Decreased in sensory functions could cause a geriatric patient to have difficulty retaining knowledge

about the newly prescribed medications. Absence of family support and no interest on learning may affect

compliance, not knowledge retention. Decreased plasma levels do not alter patient’s knowledge about the

drug.

14. When assessing a patient’s level of consciousness, which type of nursing intervention is the nurse

performing?

a. Independent

b. Dependent

c. Collaborative

d. Professional


Independent nursing interventions involve actions that nurses initiate based on their own knowledge and

skills without the direction or supervision of another member of the health care team.

15. Claire is admitted with a diagnosis of chronic shoulder pain. By definition, the nurse understands

that the patient has had pain for more than:

a. 3 months

b. 6 months

c. 9 months

d. 1 year


Chronic pain s usually defined as pain lasting longer than 6 months.

16. Which of the following statements regarding the nursing process is true?

a. It is useful on outpatient settings.

b. It progresses in separate, unrelated steps.

c. It focuses on the patient, not the nurse.

d. It provides the solution to all patient health problems.


The nursing process is patient-centered, not nurse-centered. It can be use in any setting, and the steps

are related. The nursing process can’t solve all patient health problems.

17. Which of the following is considered significant enough to require immediate communication to

another member of the health care team?

a. Weight loss of 3 lbs in a 120 lb female patient.

b. Diminished breath sounds in patient with previously normal breath sounds

c. Patient stated, “I feel less nauseated.”

d. Change of heart rate from 70 to 83 beats per minute.


Diminished breath sound is a life threatening problem therefore it is highly priority because they pose the

greatest threat to the patient’s well-being.

18. To assess the adequacy of food intake, which of the following assessment parameters is best used?

a. food preferences

b. regularity of meal times

c. 3-day diet recall

d. eating style and habits


3-day diet recall is an example of dietary history. This is used to indicate the adequacy of food intake of

the client.

19. Van Fajardo is a 55 year old who was admitted to the hospital with newly diagnosed hepatitis. The

nurse is doing a patient teaching with Mr. Fajardo. What kind of role does the nurse assume?

a. talker

b. teacher

c. thinker

d. doer


The nurse will assume the role of a teacher in this therapeutic relationship. The other roles are

inappropriate in this situation.

20. When providing a continuous enteral feeding, which of the following action is essential for the nurse

to do?

a. Place the client on the left side of the bed.

b. Attach the feeding bag to the current tubing.

c. Elevate the head of the bed.

d. Cold the formula before administering it.


Elevating the head of the bed during an enteral feeding prevents aspiration. The patient may be placed on

the right side to prevent aspiration. Enteral feedings are given at room temperature to lessen GI distress.

The enteral tubing should be changed every 24 hours to limit microbial growth.

21. Kussmaul’s breathing is;

a. Shallow breaths interrupted by apnea.

b. Prolonged gasping inspiration followed by a very short, usually inefficient expiration.

c. Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and

temporary apnea.

d. Increased rate and depth of respiration.


Kussmaul breathing is also called as hyperventilation. Seen in metabolic acidosis and renal failure. Option

A refers to Biot’s breathing. Option B is apneustic breathing and option C is the Cheyne-stokes breathing.

22. Presty has terminal cancer and she refuses to believe that loss is happening ans she assumes

artificial cheerfulness. What stage of grieving is she in?

a. depression

b. bargaining

c. denial

d. acceptance


The client is in denial stage because she is unready to face the reality that loss is happening and she

assumes artificial cheerfulness.

23. Immunization for healthy babies and preschool children is an example of what level of preventive

health care?

a. Primary

b. Secondary

c. Tertiary

d. Curative

The primary level focuses on health promotion. Secondary level focuses on health maintenance. Tertiary

focuses on rehabilitation. There is n Curative level of preventive health care problems.

24. Which is an example of a subjective data?

a. Temperature of 38 0C

b. Vomiting for 3 days

c. Productive cough

d. Patient stated, “My arms still hurt.”

Subjective data are apparent only to the person affected and can or verified only by that person.

25. The nurse is assessing the endocrine system. Which organ is part of the endocrine system?

a. Heart

b. Sinus

c. Thyroid

d. Thymus

The thyroid is part of the endocrine system. Heart, sinus and thymus are not.

1. Student Nurse Jenna is reviewing about the roles and responsibilities of a nurse. The following

portrays the role of a nurse advocate as an advocate except:

a. Informs the client about the progress of his condition

b. Evaluate the client’s learning needs and his/her readiness to learn

c. Allow the client to actively participate in his/her care

d. Communicate the needs of the client

This is a nurse’s role as an educator or teacher. The rest are promoting advocacy.

2. During the nursing rounds Nurse Cathy is instructing the patient to avoid smoking to prevent the

worsening of respiratory problems. The patient asked about the things that he can do when feelings of

wanting to smoke arises. The nurse enumerates ways of dealing the situation. This is an example of a

nurse’s role as a/an:

a. Advocate

b. Clinician

c. Change agent

d. Caregiver

As a change agent, the nurse assists the client to MODIFY their BEHAVIOR. As an advocate the nurse

intercedes or works on behalf of the client. As a clinician, the nurse would use technical expertise to

administer nursing care. The role of a nurse as caregiver helps client promote, restore and maintain

dignity, health and wellness by viewing a person holistically.

3. During physical assessment, the nurse closes and door and provides drape to promote privacy. The

nurse is performing her role as a/an:

a. Advocate

b. Communicator

c. Change agent

d. Caregiver

The role of a nurse as caregiver helps client promote, restore and maintain dignity, health and wellness

by viewing a person holistically. As an advocate the nurse intercedes or works on behalf of the client.

Identifying the need and problems of the client and communicating it to other members of the health team

is doing the role of a communicator. As a change agent, the nurse assists the client to MODIFY their

BEHAVIOR.

4. One of Nurse Cathy’s co-workers is Annie who is flexible in any given situation. Annie is performing

her duties well without supervision but still needs more experience and practice to develop a consciously

planned nursing care. According to Patricia Benner’s category in specialization in nursing, Annie is a/an:

a. Novice

b. Expert

c. Competent

d. Advanced beginner

A- Novice is governed by rules and usually inflexible. B- Expert nurses have intuitive grasp on the

situation dealt. C- Competent nurses are planning nursing care consciously. D- Advanced beginners

demonstrate acceptable performance.

5. Nurse Cathy on the other hand, knows the case immediately even before a diagnosis is done. Based

on Benner’s theory she is a/an:

a. Novice

b. Expert

c. Competent

d. Advanced beginner

The ability to perceive something without further evidence is the development of intuition and is seen in

Expert nurses. A novice nurse is governed by rules and usually inflexible. Competent nurses are planning

nursing care consciously. Advanced beginners demonstrate acceptable performance.

6. Nursing is called a profession because:

a. It has a code of ethics for practice.

b. Nurses independence in decion-making.

c. Research orientation was established and continuously developing for practice and theory.

d. All of the above

The following are the criteria of a profession: Extended education Has a theoretical body of

knowledge and expertise leading to defined skills, abilities and norms. Provides a specific service.

Members have autonomy in decision making Research orientation for continuous evolution of practice

and theories.Has a code of ethics for practice

7. The nurse’s week falls on:

a. Every last week of October

b. Every last week of September

c. Every first week of September

d. Every first week of October

Every lat week of October is the “Nurse’s week” which is proclaimed by President Carlos P. Garcia

(Presidential Proclamation 539) in October 17, 1958.

8. The “Founder of PNA and Dean of Philippine Nursing” that was awarded by the PNA in 1981 is:

a. Anna Dahlgen

b. Anastacia Giron-Tupas

c. Florence Nightingale

d. Rosario Montenegro

Anastacia Giron-Tupas is also regarded as the “dean and pioneer of Philippine nursing.” Anna Dahlgen

was the first board topnotcher with 93.5%. Florence Nightingale is the “Lady with the Lamp.” Rosario

Montenegro was the first President of FNA.

9. The clinical instructor is discussing about the Nursing Process. She mentioned that when a cluster of

actual or high-risk diagnosis are present because of a certain situation it is called:

a. Wellness nursing diagnosis

b. Actual nursing diagnosis

c. Syndrome nursing diagnosis

d. Risk nursing diagnosis

Presence of both actual and high-risk diagnosis is called a syndrome nursing diagnosis. Wellness nursing

diagnosis focuses on the clinical judgment on an individual from a specific to higher level of wellness.

Actual diagnoses are clinical judgment of the nurse that is validated. A risk diagnosis is based on the

clinical are based on clinical judgment that the client may develop vulnerability to the problem.

10. Nurse Annie observed one of the patients breathing rapidly. The respirations are deep and labored.

On the pattern of respiration this is a/an:

a. Kussmaul’s respiration

b. Biot’s respiration

c. Tachypnea

d. Hyperpnea

Kussmaul’s respiration is rapid, deep and labored breathing pattern. Biot’s respiration is characterized by

an irregular periods of apnea in a disorganized sequence of breaths. Tachypnea is faster than 20 bpm.

Hyperpnea is faster is 20 bpm associated with deep breathing.

11. “Nursing is assisting the individual to perform activities that contributes to his health or recovery by

helping him gain independence.” This is stated by which nursing theorists?

a. Dorothy Johnson

b. Faye Glenn Abdellag

c. Virginia Henderson

d. Rosemarie Rizzo Parse

Virginia Henderson promotes the principle of gaining patient independence and enumerated the 14 basic

components of basic nursing care. Parse defined nursing as a scientific discipline of performing art.

Dorothy Johnson defined nursing as having the main goal of fostering equilibrium within the individual.

Abdellah is the one who grouped the 21 problem areas as a guide in promoting care to patients.

12. The Interpersonal Relationship Model was established by:

a. Faye Glenn Abdellah

b. Hildegard Peplau

c. Lydia Hall

d. Imogene King

The Nurse-Patient interaction model was developed by Peplau. Abdellah is the one who grouped the 21

problem areas as a guide in promoting care to patients. Lydia Hall created the core, care cure key

concepts and Imogene King devised the Open Systems Model.

13. Goal Attainment theory was established by:

a. Faye Glenn Abdellah

b. Hildegard Peplau

c. Lydia Hall

d. Imogene King

Key concepts of goal attainment were designed by Imogene King. The Nurse-Patient interaction model

was developed by Peplau. Abdellah is the one who grouped the 21 problem areas as a guide in

promoting care to patients. Lydia Hall created the core, care cure key concepts.

14. Newborn screening is done to every newborn in the Philippines. This is an example of:

a. Primary prevention

b. Secondary prevention

c. Tertiary prevention

d. Rehabilitation

promotion of early detection and early treatment of the disease is under secondary prevention. Example,

breast self exam, TB screening, genetic counseling

15. The first primary focus of Rehabilitation is:

a. Improved ADL performance

b. Preventing the actual occurrence of the disease

c. Optimal functioning

d. Early detection of the disease

The main focus in rehabilitation is improving the activities of daily living of a person. Letter B is the goal of

Primary prevention, while optimal functioning (C) is the second primary focus of rehabilitation. Letter D is

goal of secondary prevention.

16. The nurse is conducting a health teaching on safe sex. This is an example of:

a. Primary prevention

b. Secondary prevention

c. Tertiary prevention

d. Rehabilitation

Preventing or delaying the actual occurrence of a specific disease is the main goal of primary prevention.

Examples include, maintaining a healthy diet, health teaching on limiting alcohol intake, safe sex.

17. During a health teaching session the nurse discussed about the importance of exercises. Exercises

that changes the muscle tension but causes no change in the muscle length are called:

a. Isokinetic exercises

b. Isotonic exercises

c. Anaerobic exercises

d. Isometric exercises

Isometric or static exercises cause changes in the muscle tension but cause no change in the muscle

length. Examples are isometric push-up and pushing or pulling against an immovable object.

18. Running, bicycling and weight lifting are examples of:

a. Isokinetic exercises

b. Isotonic exercises

c. Anaerobic exercises

d. Isometric exercises

Isotonic exercises are those that shorten muscle to produce contraction and active movements.

19. Which of the following correctly describes Sim’s position?

a. A position where a client lies on the side with the weight on the hips and shoulders with pillows to

support legs, arm, head and back.

b. A position contraindicated in patients with arthritis and joint deformities.

c. A position commonly used for vaginal examination.

d. A position where the client is placed on a semi-prone position on his side.

This correctly describes Sim’s position. (A) In this option, a side lying position is described. (B) In arthritis

and joint deformities, Knee-chest position is contraindicated. (C) In vaginal examinations dorsal

recumbent and lithotomy is commonly used.

20. In bed making the nurse flexes her knees. This posture allows the nurse to:

a. Create a wider base of support

b. Properly align the body

c. Keep a low center of gravity

d. All of the above

Flexing the knees moves the body near to the gravity thereby, maintaining a stable center of gravity. A

body can be properly aligned through keeping the upper body erect. To create a wider base of support

the nurse should spread the feet apart.

21. Jobs of health care team members require pushing, pulling, carrying and lifting during patient care

activities. To prevent musculoskeletal strain and fatigue in pushing an object the nurse should:

a. Place the weight from the flexor to the extensor portions of the leg.

b. Shift weight from the extensor to the flexor portions of the leg.

c. Assume a squat position facing the object or client.

d. Wash hands after the procedure.

placing the weight on the extensor portions of the leg prevents muscle strain in pushing an object. (B)

This is the correct technique in pulling. (C) This is done when a person lifts/carries an object.

22. What is done to avoid the muscle strain during lifting?

a. Pushing the object rather than lifting it

b. Pulling the object rather than lifting it

c. Turning the object rather than lifting it

d. All of the above.

It is easier to pull, roll, push, turn, lever and pivot that it is to lift something.

23. Which body systems coordinated to promote a correct body mechanics?

a. Reproductive and lymphatic system

b. Musculoskeletal and integumentary system

c. Musculoskeletal and nervous system

d. Lymphatic and Gastrointestinal system

Correct body mechanics is the utilization of proper body movement and a result of the coordination of

musculoskeletal and nervous systems in maintaining balance, posture, body alignment during activity

performance.

24. Heat production is affected by:

a. Parasympathetic stimulation

b. Amylase output

c. Individual’s position

d. Muscular activity

The factors that affect heat production are basal metabolic rate, muscular activity, sympathetic

stimulation, thyroxine output and fever.

25. The client’ body temperature is 109.8 degree Fahrenheit. The equivalent of this value in Celsius is:

a. 40 degree Celsius

b. 38.9 degree celcius

c. 43 degree celcius

d. 42.3 degree celcius


Formula F – 32 / 1.8 = degree Celcius Thus, 109.8 – 32 = 77.8 / 1.8 = 43.2 C or 43 Celcius

1. A sudden redness of the skin is known as:

Flush

Cyanosis

Jaundice

Pallor

Flush is a sudden redness of the skin. Cyanosis is a slightly bluish, grayish skin discoloration caused by abnormal

amounts or reduced hemoglobin in the blood. Jaundice is a yellow discoloration of the skin, mucous membranes and

sclerae caused by excessive amounts of bilirubin in the blood. Pallor is an unnatural paleness or absence of color in

the skin indicating insufficient oxygen and excessive carbon dioxide in the blood.

2. The term gavage indicates:

Administration of a liquid feeding into the stomach

Visual examination of the stomach

Irrigation of the stomach with a solution

A surgical opening through the abdomen to the stomach


Gavage is the administration of a liquid feeding into the stomach

3. A patient states that he has difficulty sleeping in the hospital because of noise. Which of the following would be an

appropriate nursing action?

Administer a sedative at bedtime, as ordered by the physician

Ambulate the patient for 5 minutes before he retires

Give the patient a glass of warm milk before bedtime

Close the patient's door from 9pm to 7am


Warm milk will relax the patient because it contains tryptophan, a natural sedative.

4. Which of the following nursing theorists dveloped a conceptual model based on the belief that all persons strive to

achieve self-care?

Martha Rogers

Dorothea Orem

Florence Nightingale

Cister Callista Roy


Dorothea Orem's conceptual model is based on the premise that all persons need to achieve self-care. She also

views the goal of nursing as helping the patient to develop self-care practices to maintain maximum wellness.

5. Which of the following nursing theorists is credited with developing a conceptual model specific to nursing, with

man as the central focus?

Martha Rogers

Dorothea Orem

Florence Nightingale

Sister Callista Roy

Martha Roger's life process model views man as an evolving creature interacting with the environment in an open,

adaptive manner. According to this model, the purpose of nursing is to help man achieve maximum health in his

environment.

6. Which of the following questions is most appropriate to ask when interviewing a potential candidate fo an RN

position?

What was your last nursing experience?

Are you willing to do overtime on weekends?

How many children do you have?

Do you plan to get pregnant?


An interviewer's question should center on the applicant's qualifications for the position. Questions about the

applicant's personal life are inappropriate and may be illegal.

7. If a patient is injured because a nurse acted in a wrongful manner, which party could be held liable along with the

nurse?

The private attending physician

The nursing supervisor

The hospital

All of the above

Under the master servant rule (also known as the doctrine or respondeat superior), when a person is injured by an

employee as a result of negligence in the course of the employee's work, the employer is responsible to the injured

person.

8. Which of the following may be considered a patient's right?

The right to euthanasia

The right to refuse treatment

The right to ignore hospital regulations

The right to refuse to pay for what the patient considers to be inferior service.


Under the bill of rights law, the patient has the right to refuse treatment/life – giving measures, to the extent permitted

by law, and to be informed of the medical consequences of his action.

9. If a patient sues a nurse for malpractice, the patient must be able to prove:

Error, proximal cause, and lack of concern

Error, injury and proximal cause

Injury, error and assault

Proximal cause, negligence and nurse error


Three criteria must be met to establish malpractice: a nursing error, a patient injury, and a connection between the

two.

10. Which communication skills is most effective in dealing with covert communication?

Validation

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Listening

Evaluation

Clarification

Covert communication reflects inner feelings that a person may be uncomfortable talking about. Such communication

may be revealed through body language, silence, withdrawn behavior, or crying. Validation is an attempt to confirm

the observer's perceptions through feedback, interpretation and clarification.

11. Which of the following qualities are relevant in documenting patient care?

Accuracy and conciseness

Thoroughness and currentness

Organization

All of the above


Documentation should leave no room for misinterpretation. Thus, the nurse must ensure that all information pertinent

to patient care is reworded accurately, concisely and thoroughly. The information must be up-to-date and well

organized.

12. The usual sequence for assessing the bowel is:

Right lower quadrant, right upper quadrant, left upper quadrant. left lower quadrant

Right lower lobe, right upper lobe, left upper lobe, left lower lobe

Right hypochondriac, left hypochondriac and umbilical regions

Rectum, pancreas, stomach and liver

This sequence follows the anatomy of the bowel. The lobes are parts of the lung. the right and left hypochondriac and

the umbilical area are three of the nine regions of the abdomen.

13. The nurse should take a rectal temperature of a patient who has:

His arm in a cast

Nasal packing

External hemorrhoids

Gastrostomy feeding tubes


A rectal temperature is usually recommended whenever an oral temperature is contraindicated (e.g. the patient who

have undergone oral or nasal surgery, infants and those who have history of seizures, etc). However, a rectal

temperature is contraindicated in patients having rectal disease, rectal surgery or diarrhea)

14. Blood pressure measurement is an important part of the patient's data base. It is considered to be:

The basis of the nursing diagnosis

Objective data

An indicator of the patient's well being

Subjective data

Objective data are those such as BP, which can be measured or perceived by someone other than the patient.

Subjective data are those such as pain, which only the patient can perceive.

15. Postural drainage to relieve respiratory congestion should take place:

Before meals

After meals

At the nurse's convenience

At the patient's convenience


Postural drainage is best performed before, rather after meals to avoid tiring the patient or inducing vomiting. The

patient's safety supersedes the convenience in scheduling this procedure.

16. The correct site at which to verify a radial pulse measurement is the:

Brachial artery

Apex of the heart

Temporal artery

Inguinal site

The best site for verifying a pulse rate is the apex of the heart, where the heartbeat is measured directly.

17. S1 is heard best at the:

5th left intercoastal space along the midclavicular line

3rd intercoastal space to the left of the midclavicular line

Second right intercoastal space at the sternal border

Second left intercoastal space at the sternal border


The S1 heart sound is best heard at the apex of the heart, at the fifth intercoastal space along the midclavicular line.

(An infant's apex is located at the third or fourth intercoastal space just to the left of the midclavicular line)

18. The nurse's main priority when caring foar a patient with hemiplegia?

Educating the patient

Providing a safe environment

Promoting a positive self-image

Helping the patient accept the illness

A patient with hemiplegia (paralysis of one side of the body) has a high risk of injury because of his altered motor and

sensory function, so safety is the nurse's main priority.

19. Constipation is a common problem for immobilized patients because of:

Decreased peristalsis and positional discomfort

An increased defacation reflex

Decreased tightening of the anal sphincter

Increased colon motility


Increased adrenalin production in the immobile patient results in decrease peristalsis and colon motility and more

tightly constricted sphincters.

20. Antiembolism stockings are used primarily to:

Promote venous circulation

Provide external warmth

Prevent dependent edema

Hold foot dressings


Antiembolism stockings are elastic stockings designed to maintain compression of small veins and capillaries in the

legs.

21. To promote correct anatomic alignment in a supine patient, the nurse should:

Place the patient's feet in dorsiflexion

Place a pillow under the patient's knees

Hyperextend the patient's neck

Adduct the patient's shoulder


Anatomic alignment prevents strain on body parts, maintains balance, and promotes physiologic functioning. To

promote this position, the nurse should place the feet in dorsiflexion (at right angles to the legs)

22. An appropriate interdependent intervention to prevent thrombophebitis would be:

Elevate the knee gatch of the bed

Massage the legs vigorously

Apply antiembolism stockings to both legs.

Encourage the patient to sit with his knees crossed

Antiembolism stockings increase venous return to the heart, which helps prevent thromboplebitis.

23. The average daily amount of urine excreted by an adult is:

500 to 600 ml

800 to 1,400 ml

1,000 to 1,200 ml

1,500 to 2,000 ml

An adult's average urine output ranges between 1,500 and 2,000 ml/day.

24. According to Maslow's hierarchy of needs, which of the following is a basic physiologic need after oxygen?

Activity

Safety

Love

Self esteem

According to Maslow, activity is one of the man's most basic physiologic needs, along with oxygen, shelter, food,

water, erst, sleep and temperature maintenance.

25. Mr. Jose is admitted to the hospitalwith a diagnosis of pneumonia and COPD. The physician orders an oxygen

therapy for him. The most comfortable method of delivering oxygen to Mr. Jose is by:

Croupette

Nasal Cannula

Nasal catheter

Partial rebreathing mask


The nasal cannula is the most comfortable method of delivering oxygen because it allows the patient to talk, eat and

drink.

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