FUNDAMENTALS OF NURSING

SET B

1. Nurse Carmen patterns her nursing care

depending on the needs of the client. By
doing this, Nurse Carmen applies the
theory of:
A. Jean Watson
B. Faye Abdellah
C. Joyce Travelbee
D. Callista Roy

2. Nurse Cita always makes sure that she

applies Madeleine Leiningers theory into
practice in providing care to her clients by:
A. Providing culturally competent care
B. Formulating client goals to be achieved
during provision of care
C. Altering the clients environment to
promote healing
D. Encouraging self-care among clients

3. Nurse Ava delivers holistic care to all her

clients across the lifespan. In doing this,
Nurse Ava is putting into practice the
theory of:
A. Martha Rogers
B. Myra Levine
C. Nola Pender
D. Virginia Henderson

4. Nurse Queen is taking the blood pressure

of her client with a bladder cuff that is too
narrow. The results would yield:
A. False low results
B. False high results
C. Inaccurate readings
D. False high diastolic

5. Which of the following clients meets the criteria

for the selection of the apical site for assessment
of the pulse instead of the radial pulse?
A. Carmen, a 2-year-old child who is undergoing
routine checkup
B. Cita, who is 36 hours post-appendectomy
C. Ava, a client in shock
D. Queen, whose blood pressure is to be checked
for the first time

6. Nurse Marco knows that which of the following

is not true with regards to temperature taking?
A. Rectal thermometer should be lubricated
before insertion
B. The axillary route is used for infants and
confused clients
C. Oral temperature should be taken for 5-7
minutes
D. A tympanic thermometer will measure
temperature quickly and easily for clients who
cannot easily hold a thermometer orally

7. Antonio, a 35-year-old client, is to undergo thoracentesis and the

nurse assists him to assume a position that is indicated for the
procedure. Which of these can be his position during the
procedure?
1. Sitting position with the arms above the head
2. Sitting position with the arm elevated and stretched
forward
3. Sitting position in which the client leans over a pillow or
overbed table
4. Sitting position with both arms crossed in front of the
chest
A. 1, 2, and 3
B. 2, 3, and 4
C. 3 and 4
D. 2 and 3

8. Mr. Sto. Tomas is ordered to have a liver biopsy

performed. Which of the following should be included in
Nurse Bettys plan of care?
A. Before the procedure, position the patient on his left side
to allow maximum exposure of area where the needle is
to be inserted
B. Instruct the patient to inhale and hold breath up to 20
seconds as the biopsy needle is inserted
C. Ensure that the client is NPO for at least 12 hours before
the procedure
D. After the procedure, assist the client to a right side-lying
position with a small pillow under the biopsy site

9. Which of the following statements made by

Perla who is to undergo MRI needs further
instruction from the nurse?
A. A loud clicking noise during the procedure is
normal.
B. I am afraid because I will be exposed to strong
radiation while inside the machine.
C. I will be able to talk with the technician during
the procedure.
D. I must lie very still while I go into the machine.

10. Mrs. Po, a client with hemiplegia, was instructed to use

crutches to help her in ambulation. Which of the
following statements made by Mrs. Po indicate further
teaching from the nurse regarding the use of crutches
when using the stairs?
A. Going down, the weaker leg goes first with both
crutches, then the strong leg.
B. Going up, the strong leg goes first, then the weaker leg
with both crutches.
C. The weaker leg always goes first with both crutches.
D. A single crutch may be used instead of both crutches if I
held on the weaker side.

11. The attending physician of a client has ordered

the removal of the clients nasogastric tube. After
explaining the procedure to the client, the nurse
positions the client in a semi-fowlers position,
places a towel across the chest, clears the tube
with normal saline, clamps the tube, and
removes the tube:
A. As the client inhales
B. As the client exhales
C. After the client takes a deep breath and holds it
D. After expiration but before inspiration

12. Nurse Luz Barbara is about to administer tube

feeding to Araceli, her 28-year-old client. Which
of the following would indicate that Nurse Luz
Barbara should withhold her feeding?
A. More than half of the last feeding is aspirated
B. The gastric aspirate has a pH of 3
C. 90ml of the last feeding is aspirated
D. There is presence of gurgling sounds over the
epigastric area after injecting air in the tube

13. A urine culture has been ordered for a female client

suspected of having UTI. The client has a Foley
catheter. How will the nurse collect the specimen?
A. Drain the catheter bag first and collect the first
voided specimen after drainage
B. Collect the specimen from the catheters aspiration
port
C. Collect the specimen from the drainage bag using a
sterile syringe
D. Change the Foley catheter and collect the first
voided specimen in the new catheter

14. Nurse Teresita is to insert an indwelling

catheter to Carmelita, an adult female client.
Which of the following guidelines should not be
observed?
A. Maintain sterility throughout the procedure
B. Use a 14 or 16 Fr urinary catheter
C. The catheters length should be at least 40 cm
D. Only saline water can be used in inflating the
balloon of the catheter

15. Mr. Santos, a client with benign prostatic

hyperplasia, underwent TURP. The nurse orders
from the pharmacy, which of the following
solutions to be used for the clients postoperative continuous bladder irrigation?
A. Sterile 0.9% normal saline
B. Sterile Lugols solution
C. Sterile Dakins solution
D. Sterile normal saline with 5% dextrose

16. Both barium swallow and barium enema are

scheduled to be done to a client. Which of the
following does Nurse Letty knows to be
appropriate for the client?
A. Barium swallow should be done before barium
enema
B. Barium enema should be done before barium
swallow
C. Any of the procedures can be done first
D. Which procedure to be done first depends on
the clients condition

17. The following statements are true about the

guaiac test or fecal occult blood test except
A. It can be done in the home or in the home or in
the clients bedside
B. NSAIDs may cause false-negative results
C. It can help in the diagnosis of colon cancer
D. Clients with ulcer should be regularly checked
for fecal occult blood

18. An enema is the installation of a solution into

the rectum and sigmoid colon. A client is ordered
to have a cleansing enema. The nurse
understands that the purpose of this kind of
enema is to:
A. Stimulate peristalsis through infusion of a large
volume of solution
B. Provide relief from gaseous distention
C. Lubricate the colon and rectum
D. Let the feces absorb oil to become softer and
easier to pass

19. Amelia, a 45-year-old client with a colostomy, is

already for discharge. Which of the following should not
be included in the nurses teachings regarding
colostomy irrigation?
A. Hang the solution at least 18 inches above the stoma
site
B. Insert the irrigation catheter no more than 5 inches into
the stoma
C. After irrigation, the area should be cleansed with mild
soap and water
D. If the catheter does not advance easily into the stoma,
allow water to flow slowly advancing the catheter

20. Nurse Eufemia is about to suction the

secretions from the tracheostomy of an
adult client. Which of the following is
unnecessary when performing suctioning?
A.The nurse sets the pressure at 120 mmHg
B. The nurse uses a Fr 10 suction catheter
C. After the insertion, the nurse retracts the
catheter by 1 cm before exerting suction
D. Apply suction for 10 seconds only

21. A client with COPD is in constant need

of oxygen. The nurse uses which of the
following to administer oxygen to this
patient?
A. Venturi mask
B. Nasal cannula
C. Nonrebreather mask
D. Partial rebreather mask

22. Chest physiotherapy is a group of therapies used in

combination to mobilize pulmonary secretions. The nurse is
planning to perform percussion and postural drainage on a
client with pneumonia. Which of the following aspect of
planning the clients care?
A. Hyperoxygenation of the patient with 100% oxygen should
be done 10 minutes before percussion and postural
drainage
B. A good time to perform percussion and postural drainage is
in the morning after breakfast when the client is well rested
C. The order should be coughing, percussion, positioning,
and then suctioning
D. Percussion and postural drainage should be done before
lunch

23. The nurse should be fully knowledgeable about

transfusion reactions and the management of
these reactions. During blood transfusion, the
nurse observes the following guidelines, except:
A. Using a gauge 18 needle
B. For the first 15 minutes of infusion, monitoring
and the clients vital signs every 5 minutes
C. Slowing down the infusion if the client
experiences chilling, headache or flank pain
D. Blood should be transfused within 4 hours from
receiving it from the laboratory

24. Nurse Leonila is taking care of a patient who is to

undergo blood transfusion. As she was checking the
unit of blood received from the blood bank, she
noticed that there is the presence of gas bubbles in
the bag. Which of the following will be Nurse
Leonilas most immediate action?
A. Add 10 ml of normal saline to the bag
B. Shake the bag gently to mix the contents
C. Warm the bag for 10 minutes and reassess if there
is still presence of bubbles
D. Return the bag to blood bank

25. Before transferring a client from the bed

to a wheelchair, the initial action of the
nurse is to:
A. Identify the client
B. Secure the wheelchair lock
C. Position the wheelchair parallel to the
bed
D. Check the clients room number

26. Which of the following statements about TPN

is incorrect?
A. The nurse is responsible for mixing the TPN
solution
B. The subclavian and jugular veins are more
commonly used for TPN administration
C. The trendelenburg position is the appropriate
position during the TPN tube insertion
D. The TPN infusion line cannot be used for other
solutions

27. When a chest tube is being removed,

the nurse should instruct the client to:
A. Cough vigorously
B. Deep breathe
C. Inhale and hold breath
D. Exhale deeply

28. To promote continuous and proper chest

tubes attached to a client, the nurse
should keep the collection device:
A. Above the clients chest
B. Beside the client
C. Below the level of the clients chest
D. At floor level

29. The nurse is providing care to a client

with a tracheostomy tube in place. The
nurse notes that his/her breathing has
become noisy. Which intervention is a
nursing priority?
A. Adjust the cuff pressure
B. Reposition the client
C. Suction the tracheostomy
D. Notify the physician

30. A client with fractured leg asks the nurse,

What is the difference between a plaster cast
and a fiber glasss cast? while his cast is being
prepared. Which statement is the correct
response?
A. Plaster casts dry up faster.
B. Plaster casts need to be replaced every
month.
C. Fiber glass cast is heavier than a plaster cast.
D. Fiber glass cast can cause skin irritation.

31. Nurse Maria Linda utilizes therapeutic

communication techniques when talking to
her clients. Applying Lydia Halls theory of
care, core, and cure, this intervention
belongs to which element of Halls theory?
A. The Body
B. The Pathology
C. The Person
D. The Intervention

32. Nurse Anesia recalled that the increasing need

in terms of amount of food as a child grows is
part of Dorothea Orems Theory of Self-Care. To
which form of self-care requisite does this
belong to?
A. Universal self-care requisite
B. Developmental self-care requisite
C. Health deviation self-care requisite
D. Personal self-care requisite

33. Nurse Salud is to administer 0.5ml of

medication subcutaneously in the upper arm of a
200-pound client. She can grasp approximately
two inches of the clients tissue at the upper arm.
Which among the following will nurse Salud
use?
A. 2-ml syringe, Gauge 25, 5/8-inch needle
B. 2-ml syringe, Gauge 22, 1-inch needle
C. 1-ml syringe, Gauge 26, 1/4-inch needle
D. 3-ml syringe, Gauge 23, 1 1/2-inch needle

34. Nurse Remedios is to administer 0.5ml medication

by IM to a 75-year-old emaciated patient. Which
among the following should she use?
A. 2-ml syringe, Gauge 25, 5/8-inch needle, deltoid
site
B. 2-ml syringe, Gauge 22, 1-inch needle,
ventrogluteal site
C. 1-ml syringe, Gauge 26, 1/4-inch needle, inner
forearm
D. 3-ml syringe, Gauge 23, 1 1/2-inch needle, vastus
lateralis

35. Araceli recalled one of her clients who had to

have rectal suppositories. All of the following are
client considerations when administering
suppositories except:
A. Client should be positioned in the left lateral or
left Sims position, with the upper leg flexed
B. Sterile technique should be used
C. Suppositories should be inserted beyond the
internal sphincter (i.e., 4 inches)
D. Client should remain in the left lateral position
for at least 5 minutes to retain the suppository

36. When percussing over the stomach, the

nurse notes a loud, drumlike sound. The
term to document this percussion tone is:
A. Dullness
B. Flatness
C. Tympany
D. Resonance

37. As the nurse prepares to assist Mrs.

Cawaon with her newly created ileostomy,
she is aware that:
A. An appliance will not be required on a
continual basis
B. The size of the stoma stabilizes within 2
weeks
C. Irrigation is necessary for regulation
D. Fecal drainage will be liquid

38. While helping the client out of the bed, his

chest tube becomes dislodged and falls to the
floor. The most appropriate action of the nurse
is:
A. Reinsert the tube
B. Seal off the insertion site
C. Ask the patient to perform Valsalva maneuver
D. Position the client on the side where the chest
tube is placed

39. Nurse Paquiz took the blood pressure of Mila, a 66-year-old client.
Upon auscultation, she noted the following:
- From 180 to 160 mmHg: silence
- From 160 mmHg: a thumping sound continuing down to 140 mmHg
- From 140 mmHg: muffled, swooshing sounds continuing to
110
mmHg
- From 110 mmHg: soft, thumping sounds continuing to 100
mmHg
- From 100 mmHg: muffled sounds that fade at 90 mmHg
- Then, silence
Nurse Paquiz will record this as:
A. BP = 160/100 mmHg
B. BP = 160/90 mmHg
C. BP = 160/110/100 mmHg
D. BP = 160/100/90 mmHg

40. The doctor has ordered nasogastric feedings

for a client following a stroke. Prior to
administering a tube feeding, the nurse should
A. Discard any aspirant and begin the tube feeding
B. Check for tube placement by checking the pH of
the aspirant
C. Attach the feeding tube to low suction 30
minutes before feeding
D. Mix the feeding with 200 ml of water

41. The nurse is suctioning the

tracheostomy of an adult client. The
recommended pressure setting is
A. 40 60 mmHg
B. 60 80 mmHg
C. 80 120 mmHg
D. 120 140 mmHg

42. When performing tracheostomy suction,

the nurse should stop suctioning if the
clients heart rate falls below
A. 80 beats per minute
B. 70 beats per minute
C. 60 beats per minute
D. 50 beats per minute

43. A client with cancer of the bladder has had a

cystectomy with the formation of an ileal conduit.
Which of the following describes an ileal
conduit?
A. The urine drains into the small intestine
B. The urine is eliminated with stool
C. The urine is emptied from a reservoir using a
catheter
D. The urine is drained from an abdominal opening

44. The nurse is about to bathe a female patient who

has an intravenous line in place, and needs to
remove her gown. The nurse should:
A. Temporarily disconnect the IV tubing at a point
close to the patient and thread it through the gown
B. Cut the gown with scissors to allow arm movement
C. Thread the bag and tubing through the gown
sleeve, keeping the line intact
D. Temporarily disconnect the tubing from intravenous
container, threading it through the gown

45. When using a cane for maximal support,

the nurse is aware that the patient should:
A. Hold the cane on the weaker side
B. Distribute weight evenly between the feet
and the cane
C. Keep the elbow that is holding the can
straight and stiff
D. Advance the weaker foot ahead of the
cane

46. After an initial assessment, the nurse

documents the presence of reddened area
that has blistered. According to recognized
staging systems, this ulcer is classified as
A. Stage I
B. Stage II
C. Stage III
D. Stage IV

47. Who is the founder of the Philippine

Nurses Association?
A. Loreta Tupaz
B. Julita Sotejo
C. Socorro Diaz
D. Anastacia Giron Tupaz

48. The client is in surgery and will be

returning to his bed via a stretcher. The
nurse plans ahead by making which type
of bed and placing the bed in which
position?
A. An open bed in low position
B. An occupied bed in low position
C. A closed bed in high position
D. A surgical bed in high position

49. JCAHO guidelines regarding the use of

restraints recommend that:
A. Vest restraints be used, because they are the
least restrictive type
B. Restraints should be used only for 48 hours in
nonpyschiatric patients
C. Restraints should be applied to prevent
wandering behavior
D. Alternative measures must be attempted first

50. All of the following are examples of good chart

entries, except:
A. Client reports 4 on the 10-point rating scale and
states, Pain is much better.
B. Client reports that he is unable to have bowel
movement in 3 days. Client is belching and
passing flatus, with (+) bowel sounds in all 4
quadrants
C. Client given fleet enema at 10:20am
D. Client consumed 1 piece of banana and 2 slices
of bread for breakfast and anorexia for lunch

51. Nurse Gigi committed a mistake in her chart

entry. She recalled that the rules in correcting
mistakes in a chart entry include the following
except:
A. Correct documentation of errors promptly
B. Erase the wrong entry
C. Draw a single line through the incorrect entry,
write error above the words, and sign it
D. Write the correct entry beside the incorrect one

52. Alvin recalled that one of his clients had a Nitroglycerin

patch. All of the following statements are correct about a
transdermal Nitroglycerin patch except:
A. Applied to hairless, clean area of the skin that is not subject
to excessive movement or wrinkling like the abdomen
B. Should not be applied to areas with cuts, burns, or
abrasions or on distal parts of the extremities
C. If a client with transdermal patch develops a fever, the
medication will be absorbed and metabolized at a faster
rate than normal, thus monitoring for changes in the effects
of the medication should be done
D. When removed, the patch should be folded with the
medication side to the inside, placed in a closed container
and kept away from children and pets

53. A colostomy is a surgical procedure that brings

the end of the large intestine through the
abdominal wall. A nurse is demonstrating
colostomy care to a client with a newly-created
colostomy. The nurse demonstrates correct
cutting of the appliance by making the opening
how much larger than that of the clients stoma?
A. 1/2 inch
B. 1/4 inch
C. 1/8 inch
D. 1/16 inch

54. A client is admitted to the hospital after

sustaining a fall from a roof. The client has
plaster cast due to multiple lacerations and a
right leg fracture. As the clients nurse, you will
position the clients leg in which manner to
promote optimal circulation?
A. Neutral position
B. Flat for 3 hours and elevated for 1 hour
C. Elevated on pillows continuously for 24-48
hours
D. Elevated for 3 hours, and then flat for 1 hour

55. Which of the following represents

correct condom catheter nursing care?
A. Ensure that the tip of the penis fits snugly
against the end of the condom
B. Check the penis for adequate circulation
30 minutes after applying
C. Change the condom every 8 hours
D. Tape the collecting tubing to the lower
abdomen

56. During the straight catheterization of a female

client, if the catheter slips into the vagina, the
nurse should:
A. Leave the catheter in place and get a new
sterile catheter
B. Leave the catheter in place and ask another
nurse to attempt the procedure
C. Remove the catheter and redirect it to the
urinary meatus
D. Remove the catheter, wipe it with a sterile
gauze, and redirect it to the urinary meatus

57. Which of the following demonstrates proper

transfer technique in moving a client from sitting
on the side of the bed to a chair?
A. Have the client grasp the nurse around the neck
for stability while standing
B. The nurse rocks from the rear foot to the front
foot while standing the client
C. Place the chair perpendicular to the bed
D. Have the client sit first on the edge of the chair
and then push back fully

58. To increase stability during patient

transfer, the nurse increases the base of
support by:
A. Leaning slightly backward
B. Spacing the feet further apart
C. Tensing the abdominal muscles
D. Bending the knees

59. When implementing the plan of care for a

patient receiving IV therapy, which intervention
would be most appropriate?
A. Changing the IV catheter and entry site daily
B. Changing the tubing every 8 hours
C. Increasing the rate to catch up if the correct
amount has not been infused at the end of the
shift
D. Monitoring the flow rate at least every hour

60. Mrs. Dones, who is experiencing

flatulence, would be helped if she were
placed in which of the following positions?
A. Trendelenburg position
B. Knee-chest position
C. Modified trendelenburg position
D. Fowlers position

61. Under Presidential Proclamation No.

539, the Nurses Week is held every
A. First week of September every year
B. Last week of October every year
C. Last week of September every year
D. Third week of October every year

62. The correct method for determining the vastus

lateralis site for IM injection is to:
A. Locate the upper aspect of the upper outer quadrant
of the buttock about 5 to 8 cm below the iliac crest
B. Palpate the lower edge of the acromion process and
the midpoint lateral aspect of the arm
C. Palpate a 1 circular area anterior to the umbilicus
D. Divide the area between the greater femoral
trochanter and the lateral femoral condyle into thirds,
and select the middle third on the anterior of the
thigh

63. A client has a three-chamber chest

drainage system. The nurse knows that
the third chamber provides for
A. An air seal
B. Drainage collection
C. Suction control
D. Water seal

64. A patient has returned to his room after femoral

arteriography. All of the following are appropriate
interventions except:
A. Assess femoral, popliteal, and pedal pulses
every 15 minutes for 2 hours
B. Check the pressure dressing for sanguineous
drainage
C. Assess a vital signs every 15 minutes for 2
hours
D. Order a hemoglobin and hematocrit count in 1
hour after the arteriography

65. Which of the following is known as the

First True Nursing Law?
A. RA 9173
B. Act 2808
C. RA 877
D. RA 7164

66. Nursing education in the Philippines

became a baccalaureate degree thru the
initiative of:
A. Rosario Diamante
B. Julita Sotejo
C. Anastacia Giron Tupaz
D. Annie Sand

67. Which of the following statement about

the term Nursing Process is true?
A. It is used only in the US
B. It originated with Florence Nightingale
C. It was first used by Lydia Hall in 1955
D. It was initiated by the National League for
Nursing in 1983

68. Which of the following is the federation

of national nurses associations founded in
1899 which includes the Philippine Nurses
Association?
A. American Nurses Association
B. Sigma Theta Tau
C. International Council of Nurses
D. National League for Nursing

69. You are to administer a medication to Mr.

Brown. In addition to checking his identification
bracelet, you can correctly verify his identity by:
A. Asking the patient his name
B. Reading the patients name on the sign over the
bed
C. Asking the patients roommate to verify his
name
D. Asking, Are you Mr. Brown?

70. The doctor orders an enteric-coated

medication for a client on gastrostomy tube.
What should the nurse do?
A. Crush the medication and administer it through
the gastrostomy tube
B. Dissolve it in water before giving the medication
C. Call the pharmacy to request for a change in
form
D. Administer it orally

71. Which of the following actions is not

appropriate when using the z-track
method of drug injection?
A. Use a needle that is at least 1 long
B. Allow the needle to remain in the muscles
for 10s when injecting the medication
C. Stretch the skin laterally
D. Massage the injection site to promote
absorption of the drug

72. Which of the following is considered as

one of the most important responsibilities
of the nurse when a client undergoes
diagnostic testing?
A. Report the result to the physician
B. Inform the client of the result
C. Analyze the result
D. Obtain the results directly from the
laboratory

73. The nurse utilizes the focus problem charting. The three
main components of this method are summarized by the
letters D.A.R. which stands for?
I. Data
II. Activity
III. Response
IV. Action
V. Revision
A. I, II, III
B. II, III, IV
C. I, III, IV
D. I, II, V

74. The following chart entries were found on the

clients chart: client complained of chest pain.
Pain relief occurred after 1/150g nitroglycerin
sublingual was administered. Vital signs 110,
110/70, John Lopez, nurse. Which aspect of the
chart entry is INCORRECT?
A. The nurses name
B. The clients complaint
C. The intervention
D. The clients vital signs

75. Which of the following statements about

monitoring a clients temperature is not true?
A. The least accurate method for obtaining the
temperature is the axillary method
B. The most accessible method for obtaining the
temperature is the oral method
C. The safest and most non-invasive method for
obtaining the clients temperature is the rectal
method
D. The dorsal surface of the hands is the best to
palpate for the clients temperature

76. When assessing the abdomen, the nurse

performs inspection first, followed by
auscultation, and palpation. The main reason
why auscultation is done before palpation is to:
A. Let the client relax and be more comfortable
B. Prevent alteration of bowel sounds
C. Prevent alteration of vascular sounds
D. Determine any areas of tenderness in the
abdomen

77. Nurse Delia admitted to the unit a 56-year-old male

client who has an AV fistula on his left arm for
hemodialysis. Which of the following would be Nurse
Delias most appropriate action to prevent injury to the
client?
A. Telling client to inform all members of the health team
entering his room to about the presence of the AV fistula.
B. Mentioning that the client has an AV fistula during the
end-of-shift report
C. Placing a sign on the clients bedside that says: No
blood pressure measurements or venipunctures in the left
arm.
D. Putting a large note about the AV fistula in front of the
clients medical chart

78. Who among the following nurses withdraw medication in an

ampule correctly?
A. Nurse Carmencita who places the ampule on a flat surface,
inserts the needle into the middle of the ampule, holds the
ampule upside down, and then aspirates the medication.
B. Nurse Betty who holds the ampule on eye level, inserts the
needle into the middle of the ampule, holds the ampule
upside down, and then aspirates the medication.
C. Nurse Yolanda who holds the ampule slightly to its side,
inserts the needle into the middle of the ampule, and then
aspirates the medication.
D. Nurse Perla who places the ampule on a flat surface, inserts
the needle into the middle of the ampule, and then aspirates
the medication.

79. A nurse is preparing to administer a skin test to a

client to determine if the client is allergic to the
prescribed antibiotic. The nurse determines that
which area is most appropriate for injection of the
medication?
A. Inner aspect of the forearm that is close to a burn
scar.
B. Dorsal aspect of the upper arm that has a small
amount of hair.
C. Dorsal aspect of the upper arm near a mole.
D. Inner aspect of the forearm that is not heavily
pigmented.

80. The Z-track method used during an intramuscular (IM) injection has
been found to be less painful than the traditional injection technique
and decreases
A. Push the skin approximately 3 cm to the side, pierce the skin quickly
and smoothly using a 90-degree angle, aspirate for 5 to 10 seconds,
and if there is no blood administer the medication steadily and slowly
B. Pull the skin approximately 2.5 cm to the side, pierce the skin slowly
and smoothly using a 90-degree angle, aspirate for 5 to 10 seconds,
and if there is no blood administer the medication steadily and slowly
C. Pull the skin approximately an inch to the side, pierce the skin
quickly and smoothly using a 90-degree angle, aspirate for 5 to 10
seconds, and if there is no blood administer the medication steadily
and slowly
D. Pull the skin approximately an inch to the side, pierce the skin slowly
and smoothly using a 90-degree angle, aspirate for 5 to 10 seconds,
and if there is no blood administer the medication quickly

81. Different kinds of nasogastric tubes are available and

serve different purposes. A client post-abdominal
surgery was admitted in the unit. Endorsements from
the OR nurse included the client having a Salem sump
tube. The nurse in the unit understands that the
purpose of this tube is to:
A. Apply internal pressure to the abdomen by means of
inflated balloon to prevent bleeding
B. Prevent abdominal distention
C. Instill feedings into the stomach for the post-op patient
D. Help in the elimination of urine

82. Dialysis is used when the kidneys are not able to perform
its function of removing fluid and waste products. Usually,
patients on dialysis are hospitalized for this treatment as well
as the management of other existing co-morbidities resulting
from kidney failure. Handling some patients for dialysis, the
nurse implements which of the following interventions when
caring for hospitalized patients on hemodialysis?
A. Withhold all antihypertensive agents before dialysis
B. Blood transfusion is contraindicated while patient is on
dialysis
C. Immediately report presence of thrill over the vascular
access
D. A low protein, low sodium, high potassium diet is strictly
followed

83. A chest tube is a flexible plastic tube that is

inserted through the side of the chest into the
pleural space to remove air, fluid or pus. You
know that the clients lung has completely
expanded when:
A. Pleuritic pain decreased
B. Drainage of fluid into the collection bottle
ceases and the fluctuations in the water seal
chamber ceases
C. Oxygen saturation is 96%
D. Breathing pattern is normal

84. Mrs. Bueno complained of dizziness upon arising in

bed every morning. Nurse Elvie, provided her with
client teaching on preventing orthostatic
hypotension. This includes all of the following except:
A. Rest with the head of the bed elevated at 8 to 12
inches
B. Sit up in bed for 3 minutes before ambulating
C. Sit on the side of the bed with legs dangling for 1
minute
D. Stand with care, holding on to edge of the bed or
another nonmovable object for 1 minute

85. In another hospital, the PIE method of

charting is used. This system of charting
includes assessment flow sheets, nurses
progress notes and an integrated plan of
care. The P in this method refers to:
A. Progress update
B. Practical guide of the nurse
C. Plan of care
D. Problem

86. Problem-oriented medical records focus on the

clients problem. The four components are: data
base, problem list, plan of care and progress
notes. The progress note sometimes takes the
SOAPIER format. The R in this format refers
to:
A. Rationale
B. Revision
C. Reports
D. Review

87. Which of the following statements about

charting is NOT true?
A. If an error is made on the chart, the nurse
should draw a line and initial it
B. The original copy of the chart is owned by the
hospital
C. When using the SOAPIER method, R stands
for research
D. The purpose of auditing the nurses notes is to
assess the quality of client care

88. The nurse is to assist the client with coughing

and deep breathing exercises to prevent
postoperative complications. This is best
accomplished by planning:
A. Coughing exercises 1 hour before meals and
deep breathing 1 hour after meals
B. Forceful coughing as many times as tolerated
C. Huff coughing every 2 hours and as needed
D. Diaphragmatic and purse-lip breathing 5 to 10
times four times a day

89. A client with a chronic lung disorder

requires some supplemental oxygen. The
nurse anticipates that safe delivery would
be oxygen:
A. 2 L/min per nasal cannula
B. 6 L/min per face mask
C. 8 L/min per partial rebreathing mask
D. 10 L/min per nonrebreathing mask

90. A client will be undergoing a

sigmoidoscopy requiring visualization of
the anus, rectum, and sigmoid colon. The
nurse expects the preparation to include
which type of enema?
A. Oil retention
B. Return flow
C. High, large volume
D. Low, small volume

91. While assessing an established colostomy, the

nurse reports it as an unusual finding if:
A. The stoma extends 1/2 inch above the
abdomen
B. The skin under the appliance looks red briefly
after removing the appliance
C. The stoma color is a deep red-purple
D. An ascending colostomy delivers liquid feces

92. When you return to your client to remove the heating

pad 30 minutes after application, the client requests that
you leave it in place. You explain to the client that:
A. Heat application for longer than 30 minutes can actually
cause the opposite effect of the one desired
B. It will be acceptable to leave the pad in place if the
temperature is reduced to between 40.6 46C
C. It will be acceptable to leave the pad in place for another
30 minutes if the site appears satisfactory when
assessed
D. It will be acceptable to leave the pad in place as long as
it is moist heat

93. The client has a pressure ulcer with a

shallow, partial skin thickness, eroded
area but no necrotic areas. The nurse
would treat the area with which of the
following dressings?
A. Alginate
B. Dry gauze
C. Hydrocolloid
D. No dressing is indicated

94. When a fire occurs in a clients room, the

nurses priority is to:
A. Run for help
B. Protect the client
C. Put out the fire
D. Report the fire

95. As a part of preparing a client for a test, you are to take

vital signs. However, the client is on the phone. How
would you handle taking the clients respiratory rate?
A. Count the respirations during the time that the client is
listening (rather than talking) on the phone
B. Tell the client that it is important to end the phone call
now and resume it at a later time
C. Wait at the clients bedside until the phone call is
completed and then count respirations
D. Record the measurement as deferred since the talking
client is clearly not in respiratory distress and take it later

96. For which of the following clients would

you take an apical pulse rather than a
radial pulse?
A. A client in shock
B. To check a clients response to changing
from a lying to a sitting position
C. A client with an arrhythmia
D. A client less than 24 hours postoperative

97. During removal of fecal impaction, which

of the following could occur because of
vagal stimulation?
A. Bradycardia
B. Atelectasis
C. Tachycardia
D. Cardiac tamponade

98. When explaining parenteral nutrition, the

nurse would describe this method as
providing nutrients to the patient by way of
which of the following?
A. Gastrostomy tube
B. Intravenous route
C. Nasointestinal route
D. Jejunostomy tube

99. When using the swing-through crutch

gait, the patient should:
A. Bear weight on the unaffected foot
B. Bear weight on both feet
C. Stimulate normal walking as closely as
possible
D. Move the right crutch and left foot forward
at the same time

100. Mr. Brown is experiencing some

difficulty breathing. The nurse most
appropriately assists him into the:
A. Dorsal recumbent position
B. Lateral position
C. Fowlers position
D. Sims position