FUNDAMENTALS OF NURSING

A. Faye Abdellah
(INTEGRATED CONCEPTS) B. Hildegard Peplau
Mr. Melmarl C.David R.N. C. Virginia Henderson
1. The goal of nursing is to reduce stress D. Florence Nightingale
for faster recovery. Which nursing
theory supports this statement? 5. According to Maslow’s hierarchy of
needs, which of the following is the next
A. Johnson’s Theory basic physiologic need after oxygen?
B. Levine’s Theory
C. Orem’s Theory A. Defecation
D. Rogers’ Theory B. Food
C. Sleep
2. What nursing theory focuses on D. Water
identifying the types of demands placed
on client, assessing the adaptation to 6. Which of the following statements
demands, and helping the client to about health is true?
adapt?
A. Health is a state in which the
A. Leininger’s Theory level of functioning is altered.
B. Neuman’s Theory B. Health is not influenced by a
C. Roy’s Theory person’s belief and behaviors.
D. Watson’s Theory C. Health is a state of complete
physical, mental and social well-
3. Which of the following concepts being.
describes the “Health-Illness D. Health is the totality of a
Continuum? person’s characteristics and well-
being.
A. The preventive health behavior
of an individual When a nurse like CoCo learns the
B. The interaction between agent, physiological variables influencing vital
host, and environment signs and recognizes the relationship of vital
C. The interaction between the sign changes to other physical assessment
condition of the environment, findings, precise determinations of the
and health and illness client’s health problems can be made.
D. All of the above
7. When monitoring body temperature for a
4. Jenny, a private nurse, gives proper client with cardiac disorder, which of the
medications regularly to her 75-year-old following routes should Nurse CoCo
female client with cancer. Cleaning the avoid?
room, changing the bedding, checking A. Axillary
proper ventilation, and providing proper B. Oral
foods are part of her routine, too. Who C. Rectal
among the following has presented the D. Tympanic
theory that emphasizes this kind of
nursing practice?
8. Nurse CoCo is caring for a male client 11. What are the changes in the client’s
with peripheral vascular disease. While health status which is the result of the
assessing the client’s pulses, she finds it nursing intervention?
difficult to palpate for the right pedal A. Healthy lifestyle
pulses. Which of the following actions B. Modified behavior
should be undertaken? C. Desired outcome
A. Call the physician D. Compliance with regimen
immediately.
B. Inspect the left lower 12. Bed bath is one of the most common
extremity. comfort measures wanted by patients but
C. Obtain a Doppler which is not often done by nurses. For
ultrasound device. quality care, Nurse Sabio should provide
D. Auscultate the pulses not only the therapeutic bath but
with a stethoscope. facilitate daily cleansing bath as well.
9. Nurse CoCo is preparing a teaching plan Which of the following should she
for a group of hypertensive patients. AVOID doing in providing baths to
The first step she does is to formulate the clients?
learning objectives. Which of the A. Maintain safety.
following steps in the nursing process is B. Provide privacy.
Therese applying? C. Promote client
A. Assessment independence.
B. Evaluation D. Provide dependency
C. Planning needs of client.
D. Implementation
13. Nurse Sabio is performing
10. Nurse CoCo has become the new oropharyngeal suctioning in an
community health nurse of a local unconscious client. Which of the
baranggay. She identifies the needs, following actions is safe?
problems and concerns of each family A. Gently rotate the catheter
that can be modified by nursing while applying suction.
interventions. Which of the following B. Insert the catheter
steps in the nursing process is initiated? approximately 20 cm.
A. Assessment while applying suction.
B. Planning C. Allow 20 to 30 second
C. Implementation intervals between each
D. Evaluation suction, and limit
suctioning to 15 minutes.
Evaluation of care is an integral part of the D. Apply suction for 5
application of the nursing process. The seconds while inserting
nurse applies all that is known about the the catheter and continue
client’s condition, as well as experience with for another 5 seconds
previous clients, to evaluate whether nursing before withdrawing.
care was effective.
Good health depends in part on a safe
environment. Nurse Angel knows that
practices that control transmission of
infection help to protect clients and health 14. Nurse Angel obtains the temperature of a
workers from disease. febrile client with a glass thermometer
using the axillary method. Which of the
10. Using the principles of standard following nursing actions should she
precautions, Nurse Angel would wear AVOID doing?
gloves when performing which of the A. Patting the axilla dry to
following nursing interventions? avoid friction
A. Feeding a client B. Lubricating the
B. Providing hair care thermometer about 1 inch
C. Providing oral hygiene from the mercury bulb
D. Providing a back massage C. Leaving the thermometer
in place for 5-10 minutes
11. Nurse Angel wears a mask in before reading
preparation for the evaluation of a client D. Placing the thermometer
in isolation. Which of the following in the hollow of the axilla
isolation categories would force her to with the bulb directed
use a mask? towards the patient’s arm
A. Strict isolation close to his body.
B. Contact precaution
C. Protective isolation 15. Nurse Angel is assessing several clients
D. Respiratory isolation with different types of injuries. She
knows that the client LEAST likely to
12. Nurse Angel has been assigned to care develop a wound infection would be the
for four clients who are stable. Using the one with which of the following?
principle of medical sepsis, which client A. A contusion
should she assess first? B. A septic wound
A. A child with measles C. A wound with purulent
B. A child with chicken pox exudate
C. A client with draining D. Would healing by
wound secondary intention
D. A client who is severely
neutropenic 16. A client is running a 38.5 C
temperature. When Nurse Angel
13. Nurse Angel has been monitoring the performs tepid sponge bath, she/he
temperature of a febrile client once in should be aware that she has to monitor
every 6 hours for two days. She notes which of the following?
that the patient’s fever spikes and falls A. Pulse and temperature
without return to normal body immediately before and
temperature levels. She observes that the after the procedure
client is exhibiting what type of fever B. Pulse and temperature
pattern? every 30 minutes for one
A. Intermittent hour after the procedure
B. Relapsing C. Pulse and temperature
C. Remittent before the procedure and
D. Sustained one hour after the
procedure
 D. Pulse and temperature D. The nurse reminds the
immediately before and doctor to sign the order
every 15 minutes during within 24 hours.
the procedure
20. Ms. Chiefy is admitted to the hospital
Nurse Misagh knows that as a member of with a bleeding ulcer. She is to receive 4
the health care team, she needs to units of packed cells. Which nursing
communicate information about clients intervention is of primary importance in
accurately and in a timely, effective manner. the administration of blood?
The quality of client care depends on the
caregivers’ ability to communicate with one A. Identifying the client.
another. B. Checking of flow rate.
C. Monitoring Vital Signs
17. Nurse Misagh wants to eliminate the D. Checking Blood Temperature
need for repeated referral to the chart for
routine information throughout the day, 21. What would be the most important
so she fills out a form of documentation nursing intervention in caring for the client’s
containing her client’s demographic residual limb during the first 24 hours after
data, primary medical diagnosis, and amputation of the left leg?
recent nursing and medical orders for
safety precautions to be used in A. Applying traction to the residual limb
rendering care. B. Elevating the residual limb on a pillow
C. Keeping the residual limb flat on the
18. Which of the following documents is bed
Misagh accomplishing? D.Abducting the residual limb on a
scheduled basis
A. Kardex
22. When helping the client who had a
B. Nurse’s notes cerebrovascular accident (CVA) learn self-
C. Flow sheets care skills, the nurse should use which of the
D. Charting by exception following interventions to help him learn
how to dress himself?
19. Nurse Misagh is receiving a telephone
order from one of her client’s doctor. A. Encourage the client to ask his
Which of the following should she wife for help when dressing.
AVOID doing in this situation? B. Teach the client to put on
clothing on the affected side first.
A. She reads back the order C. Dress the client, explaining each
to the doctor. step of the process as it is
B. She signs the order in completed.
behalf of the doctor. D. Encourage the client to wear
C. She asks the resident clothing designed especially for
doctor to countersign the people who have had CVA.
order.
23. Bed bath may also be used in which of
the following?
 A. Assessment D. 2 and 4
B. ROM exercises
C. Building rapport 28. A post-operative client is sent to the
D. All of the above x-ray room for some special tests and
will be brought back to his room by a
24. Thumb is not used in taking the pulse stretcher. What type of bed is
rate due to which of the following? appropriate for the nurse to prepare?
A. It has a pulse of its own. A. Open bed
B. It cannot sense pulsation. B. Closed bed
C. It is less sensitive than the three C. Surgical bed
other fingers. D. Occupied bed
D. All of the above
29. Which of the following is not a
25. Which of the following is the most guideline in transferring patients?
appropriate action of the nurse if the patient A. Use proper body mechanics.
has fever? B. Ensure that environment is
A. Perform alcohol bath. free from obstacles.
B. Administer paracetamol. C. Place transfer board under the
C. Perform tepid sponge bath. client before the transfer.
D. Place ice pack over the D. Ask for assistance only if
forehead. patient's weight is 35% or
more of your weight.
26. Which of the following is the most
important thing to remember when taking 30. In order to prevent injury, a nurse
the respiratory rate? must instruct patients not to lift weights
A. Stethoscope must be over the
more than how many percentage of their
patient’s chest. body weight?
B. The nurse must not let the patient
A. 15%
know that he is getting it. B. 25%
C. The patient must be lying down
C. 35%
for good expansion of the lungs. D. 45%
D. All of the above
31. What do you call the difference between
27. In which of the following situations is the apical pulse rate and the radial pulse
the sterile technique needed? rate?
1. Changing a colostomy bag
A. Pulse deficit
2. Changing a dressing over s surgical
B. Pulse median
wound
C. Pulse pressure
3. Changing a warm pack over an
D. Pulse gradient
inflamed joint
4. Changing a dressing over an open
32. The sheet on the head part of the bed is
decubitus ulcer
folded under the mattress and the corner is
mitered. What is the purpose of this?
A. 1 and 2
A. To protect the mattress
B. 1 and 3
B. To prevent wrinkling of the linen
C. 2 and 3
 C. To prevent the linen from being A. The client applies cotton-filled
dislodged gauze squares as the sterile
D. All of the above dressing after cleaning the
incision site.
33. What is the rationale for making a B. The client cleans around the
mitt out of a washcloth? incision site using gauze squares
and full-strength hydrogen
A. Provides warmth and comfort peroxide.
B. Prevents transfer of C. The client rinses the incision site
microorganisms using gauze squares moistened
C. Retains heat and water and with tap water.
protects from the fingernails of D. The client rinses the incision site
the care provider using gauze squares moistened
D. Both A and B are correct with normal saline.

34. In cleansing the perineum of the 36. While examining a client’s leg, the
female patient, the health worker nurse notes an open ulceration with
first cleans the area between the legs visible granulation tissue on the
and the labia using a clean washcloth wound. Which of the following types
with downward strokes, then follows of dressings is MOST appropriate to
the urethral orifice. Which of the apply?
following principles is being
applied? A. Dry sterile dressing
B. Sterile petroleum gauze
I. Moving from clean to dirty C. Moist sterile saline gauze
II. Minimizing vaginal irritation D. Povidone-iodine-soaked gauze
III. Minimizing the transfer of
microorganisms 37. A nurse is preparing a plan of care
IV. Conserving the number of times for a client with an internal radiation
of strokes implant. Which of the following
components is INAPPROPRIATE to
A. I and III include in the plan of care?
B. II and IV
C. I, II and III A. Wear gloves when emptying the
D. I, II, III and IV client’s bedpan.
B. Keep all linens in the room until
35. During a teaching session, the nurse the implant is removed.
demonstrates how to change a C. Wear a lead apron when
tracheostomy dressing and watches providing direct care to the
as the client returns the client.
demonstration. Which of the D. Place the client in a semi-private
following client’s actions indicates room at the end of the hallway.
an accurate understanding of the
procedure? 38. The nurse received an order to
administer Iron Dextran, 50 mg IM
injection. Which of the following is
 CORRECT when carrying out this B. Notify the Cancer Society of the
order? Philippines of the client’s
diagnosis.
A. Insert the needle at 450 C. Request for a dietician to provide
B. Use the Z track technique adequate nutritional intake.
C. Wipe the needle immediately D. Refer the client to a home health
after injection nurse for follow-up visits to
D. Pull the skin laterally toward the provide colostomy care.
injection site
42. You just transferred out a post-out
39. A client who has AIDS is admitted client to her room. What would your
to the in-patient psychiatric unit instruction to the family include to
because of a suicide attempt. His prevent accidents?
close friend recently died of AIDS.
He begins to talk about his feelings A. Report when the IV infusion
related to his illness and the loss of is almost finished
his friend. The client then cried. B. Test the call system if
Which of the following nursing functioning
actions is the MOST appropriate? C. Keep the room lights on for
24 hours
A. Change the subject. D. Make sure the side rails are
B. Sort the client’s mail to distract up
the client.
C. Give the client tissue and tell him 43. One of your post-op patients has a
it is okay to cry. temperature of 37.9 C and was
D. Tell the client to stop crying and shivering. You covered him with a
that everything will be all right. blanket and later took his
temperature again and it is now 38.9
40. When should the nurse introduce C. The nursing student asked you to
information about the end of the explain the absence of shivering
nurse-client relationship? even if the temperature was higher.

A. During the orientation phase A. The patient is no longer

B. When the client can tolerate it febrile thus he is no longer
C. As the goals of the relationship chilling.
are reached B. Shivering normally
D. At least one or two sessions disappears as temperature
before the last meeting become higher.
C. The body has reached its new
41. A client was discharged after her set point thus the absence of
abdominal surgery and colostomy shivering.
formation. Which of the following D. The patient is feeling better.
nursing actions is MOST likely to
promote continuity of care? 44. The chest tube drainage of
Mr.Weiss, has continuous bubbling
A. Ask an occupational therapist to in the water seal drainage. After an
evaluate the client at home.
 hour you noticed that the bubbling B. Guage
stops. Which of the following D. Inches
condition is the possible cause of the
malfunctioning sealed drainage? 48. When transporting clients with chest
tube, the system should be:
A. A suction being too high
C. A tube being too small A. disconnected
B. An air leak B. closed
D. A tension pneumothorax C. placed lower than the patients
chest
45. While you are making your D. placed between the legs of
endorsement, you found out the chest the client to prevent breakage
tube of a client was disconnected.
What would be your appropriate 49. Ms. Jackie, the PACU nurse,
action? discovered that Budoy, who weighs
110 lbs prior to surgery, is in severe
A. Assist the client back to his pain 3 hrs after cholecystectomy.
bed and place him on the Upon checking the chart, Budoy
affected side found out that she has an order of
B. Cover the end of the chest Demerol 100 mg I.M. prn for pain.
tube with sterile gauze Nurse Jackie should verify the order
C. Reconnect the tube to the with:
chest tube system
D. Put the end of the chest tube A. Nurse supervisor
onto a cup of sterile normal C. Surgeon
saline B. Anesthesiologist
D. Intern
46. Dr. Santi asked you to assist him the
removal of Mr. Weiss’s chest tube. 50. Ms. Katerina, 57, who is a diabetic
You would instruct the client to: is for debridement of incision
wound. When the circulating nurse
A. Continuously breathe checked the present IV fluid, she
normally of the chest tube found out that there is no insulin
B. Take a deep breath, exhale incorporated as ordered. What
and bear down should the circulating nurse do?
C. Exhale upon actual removal
of the tube A. Double check the doctors
D. Hold breath until the chest is order and call the attending
pulled out MD
B. Communicate with the ward
47. Chest tube diameter is measured or and call the attending M.D.
expressed in: C. Communicate with the client
to verify if insulin was
A. French incorporated or not
C. Milliliters D. Incorporate insulin as ordered
51. The current insulin pumps available B. unstable diabetes
in the market have the following D. abdominal renal glucose
capability EXCEPT: threshold

A. prevent unexpected saving in 55. It is necessary for a diabetic client to

blood glucose measurements exercise regularly. What is the effect
B. detects signs and symptoms of regular exercise to a diabetic
of hypoglycemia and client?
hyperglycemia
C. deliver a pre-meal bolus dose A. It burns excess glucose
of insulin before each meal B. It improves insulin utilization
D. Deliver a continuous basal and lowers blood glucose
rate of insulin at 0.5 units to C. It lowers glucose, improves
2.0 units per hour insulin utilization: decrease
total trigyceride levels
52. Discharge plan of a diabetic clients D. It will make you fit and
include injection site rotation. You energized
should emphasize that the space
between sites should be: 56. There is an order of Central Venous
Pressure (CVP) reading. As a nurse,
A. 6cm you should know that this is a
C. 2.5cm measure of observing signs of:
B. 5cm
D. 4cm A. hypoxia
B. hypovolemia
53. It is critical also that a diabetic client C. hypothermia
should be educated in the possible D. hypoxemia
sites if regular insulin injection. The
fastest absorption rate happens at the 57. The nurse is performing wound care.
tissue areas of: Which of the following practices
violates surgical asepsis?
A. gluteal area
C. anterior area A. Holding sterile objects above the
B. deltoid area waist
D. abdominal area B. Pouring a solution onto a sterile
field cloth
54. Self-monitoring of blood glucose C. Considering a 1” edge around the
(SMBG) is recommended for sterile field as being
patients use. You will recommend contaminated
this technology in the following D. Opening the outermost flap of a
diabetic patients, EXCEPT: sterile package away from the
body
A. client with proliferative
retinopathy C. 58. Which of the following should the
hypoglycemia without nurse document after tracheostomy?
warning
 A. Type of anesthesia used C. Assess the equipment.
B. Size and type of D. Check the oxygen tank.
tracheostomy tube used
C. Size and length of 63. The nurse observes a constant
tracheostomy tube used bubbling in the water-seal chamber
D. Permit for tracheostomy of a closed chest drainage system.
signed by patient or relatives What does this imply?

59. What is the importance of the low A. The system has an air leak.
pressure of the tracheostomy tube? B. The chest tube is obstructed.
C. The client has a
A. To prevent asphyxiation pneumothorax.
B. To allow more air to enter D. The system is functioning
C. To prevent tracheal mucosa normally.
damage 64. Sputum examination for culture and
D. To make tracheostomy tube sensitivity test was ordered. Which
weaning easier of the following interventions BEST
addresses this condition?
60. Normally, which of these will you
use to inflate the tracheostomy tube A. Proper positioning when
cuff? coughing
B. Administration of analgesics
A. 2 cc air in a syringe to minimize chest pain when
B. 2 cc NSS in a syringe breathing
C. 5 cc air in a syringe C. Prescription of an antibiotic
D. 5 cc NSS in a syringe to destroy the disease-causing
bacteria
61. What is the importance of deflating D. Forcing increased fluid intake
the tracheostomy tube cuff? to enhance expectoration of
the secretion
A. To limit phonation
B. To prevent phonation 65. You included postural drainage as
C. To avoid blowing of part of your plan of care for the
secretions above the cuff into client. Which of the following
the oropharynx techniques is NOT appropriate for
D. To obtain opportunity to the client?
blow secretions above the
cuff into the oropharynx A. Percuss only in areas where
there is no pain.
62. When the high-pressure alarm on the B. Perform the procedure an
mechanical ventilator sounds, what hour after her meal.
is the MOST appropriate initial C. Include apical secretion
action of the nurse? drainage, if several areas
require drainage.
A. Call for help.
B. Assess the patient.
 D. Allow the patient to continue
with the session despite of 69. A routine urinalysis is ordered for
chest discomfort. Mr. James Myhusband . The
specimen, however, cannot be sent
66. After postural drainage, which of the immediately to the laboratory. What
following nursing interventions should the nurse do?
should the nurse perform?
A. Take no special action.
A. Serving the breakfast B. Refrigerate the specimen.
B. Providing oral hygiene C. Store on ‘dirty’ side of the stock
C. Suctioning the secretion room
D. Allowing the client to have a D. Discharge and collect a new
warm shower specimen later.

Mr. Jay Sean, An 82-year-old male aphasic 70. The nurse understands that the
client has an indwelling catheter inserted to structure encircling the male urethra
closely monitor hourly urine output. is:

67. The family of the client complains A. Epididymis

that the attending nurse failed to B. Prostate gland
obtain a signed consent prior to C. Seminal vesicle
insertion of the indwelling catheter. D. Bulbo-urethral gland
What does this situation imply?
71. Which of the following procedures
A. The catheter was inserted for the can BEST prevent contamination
client’s benefit. from Mr. Imortal’s retention
B. A treatment does not need a catheter?
separate consent form.
C. The consent was not obtained A. Cleaning the perineum
because the client is aphasic. B. Encouraging intake of fluids
D. Treatment without the client’s C. Irrigating the catheter
consent is a violation of the D. Cleaning the area around the
client’s rights. meatus periodically

68. Which of the following nursing 72. The client calls the nurse and
interventions is appropriate for a complains of discomfort in the
client with continuous bladder bladder and urethra. What should the
irrigation? nurse do initially?

A. Monitor urine specific gravity A. Notify the physician.

B. Record urinary output every hour B. Milk the tubing gently.
C. Include irrigation solution in any C. Check the patency of the catheter
24-hour urine test order D. Irrigate the catheter with
D. Subtract volume of irrigant from prescribed solution
urine output to determine urine 73. The client experiences difficulty in
volume voiding after his indwelling catheter
 is removed. The nurse notes this the following nursing instructions is
finding as related to which of the appropriate?
following factors?
A. “Eat a large meal 1 hour
A. Fluid imbalances before bedtime.”
B. Recent sedentary lifestyle B. “Eat spinach and yugurt to
C. Nervous tension following the reduce drainage odor.”
procedure C. “Monitor ileostomy output
D. An interruption in the normal daily, 800 mL/day is
voiding habits normal.”
D. “Avoid shaving hair around
74. Ms. Etheridge, a female client is the stoma to prevent
requested to undergo urinalysis. folliculitis.”
Which of the following methods
used to collect a specimen for urine 77. Which of the following diagnostic
culture should the nurse teach a tests should be performed annually
client? after age 40 to screen for colon
cancer?
A. Void in a clean container.
B. Void into a urinal then pour the A. Colonoscopy
urine into the specimen B. Abdominal X-ray
container. C. CT scan of the abdomen
C. Clean the foreskin of the penis of D. Digital rectal examination
uncircumcised men before
voiding. 78. The nurse is assessing a client with
D. Begin the stream of urine in the suspected gastric cancer. Which of
toilet and catch the midstream the following diagnostic modalities
urine in a sterile container. is appropriate for this case?

75. A 60-year-old client has a A. Colonoscopy

nasogastric tube in place for 7 days B. Gastroscopy
that has caused dryness of his mouth. C. Barium enema
Which of the following nursing D. Blood chemistry
interventions is appropriate to
stimulate salivation? 79. A 51-year-old female client with
history of hepatitis B is admitted due
A. Assist client in brushing teeth. to liver cirrhosis. Which of the
B. Encourage client to chew following laboratory values does the
anesthetic lozenges. nurse expect to be altered?
C. Provide sour candies or ice chips
for the client to chew. A. Blood pH
D. Lubricate the external nares with B. Prothrombin time
a water-soluble lubricant. C. Carbon dioxide level
76. The nurse is teaching stoma care to a D. White blood cell count
client with an ileostomy. Which of
80. A 36-year-old obese male client, d. “ My family was angry when
who previously refused I told them they could not
cholecystectomy for gallstones, now smoke on my room.”
presents with fever and elevated
WBC count. Which of the following 84. Percussion is usually performed in
tests is usually ordered to confirm if clients with respiratory problems.
this client has developed The primary purpose of this
cholecystitis? procedure is to
a. Relieved bronchial spasm
A. Endoscopy b. Increase depth of respiration
B. Barium swallow c. Loosen pulmonary secretions
C. Abdominal ultrasound d. Expel carbon dioxide from
D. CT scan of the abdomen the lungs
85. The nurse is caring for the client who
81. Clinical indications for total is to have lumbar puncture. How
parenteral nutrition do NOT include should the client be positioned
which of the following conditions? during the procedure?
a. Prone with the head turned
A. Diabetes mellitus type I to the left
B. Severe persistent vomiting b. Trendelenburg
C. Intestinal pseudo-obstruction c. Side lying, fetal position
D. Severe short-bowel syndrome d. Sitting at the edge of the bed
86. A. client receiving total parenteral
82. What is the most appropriate time to nutrition (TPN) complains of nausea,
obtain a sputum specimen for excessive thirst, and increased
culture? frequency of voiding. The nurse
a. After chest physiotherapy initially assesses which of the
b. Early in the morning following client data?
c. After the patient ate a light a. Serum blood urea nitrogen and
breakfast creatinine
d. After aerosol therapy b. Capillary blood glucose
c. Last serum potassium
83. An adult is receiving oxygen by d. Rectal temperature
nasal prongs. Which statement by the
client indicates that the client 87. Mrs. G Younghusband, is receiving
teaching regarding oxygen therapy total parenteral nutrition (TPN),; if
has been effective? you will evaluate her nutritional
a. “ I was feeling fine so I status, which of the following
removed my nasal prongs.” indicators will tell you that TPN was
b. “ I’ve increased my fluid to effective?
six glasses a day.” a. laboratory work up
c. “ Don’t forget to come back b. adequate hydration
quickly when you get me out c. weight gain
of the bed, I don’t like to be d. diminish episode of nausea and
without my oxygen for too vomiting
long.”
88. When transporting clients with chest 92. The purpose of the continuous
tube, the system should be; bladder irrigation is to:
a. disconnected a. allow continuous monitoring of the
b. closed fluid output status
c. placed lower than the patient’s chest b. provide continuous flushing of clots
d. placed between the legs of the client and debris from the bladder
to prevent breakage c. allow for proper exchange of
electrolytes
89. Which of the following observations d. ensure accurate monitoring of intake
indicates that the closed chest and output
drainage is functioning properly?
a. absence of bubbling in the suction 92. Alyboro is receiving external radiation
control bottle therapy and he complains of fatigue and
b. the fluctuating movement of fluid in malaise. Which of the following nursing
the long tube of the water-seal bottle interventions would be most helpful for
during inspiration Alyboro?
c. intermittent bubbling through the a. tell him that sometimes these feelings can
long tube of the suction control be psychogenic
bottle b. refer him to the physician
d. less than 25 ml drainage in the c. reassure him that these feelings are
drainage bottle normal
d. help him plan his activities and rest period
90. A nurse assesses the water seal
chamber of a closed chest drainage
system and notes fluctuations in the 93. Immediately following the radiation
chamber. The nurse determines that therapy, Alyboro is:
this finding indicates that; a. considered radioactive for 24 hrs
a. an air leak is present b. given a complete bath
b. the tubing is kinked c. placed on isolation for 6 hours
c. the lung has re expanded d. free from radiation
d. the system is functioning as expected
94. Alyboro is admitted with radiation
91. The nurse assists the physician with induced thrombocytopenia. As a nurse you
the removal of a chest tube. What should observe the following symptoms:
action would prevent the cause of a. Petechiae, ecchymosis, epistaxis
complication? b. weakness, easy fatigability, pallor
a. gently pulling the tube upon c. Headache, dizziness, blurred vision
exhalation d. severe sore throat, bacteremia,
b. gently pulling the tube upon hepatomegaly
inhalation
c. quickly pulling the tube upon 95. What nursing diagnosis should be of the
exhalation highest priority?
d. quickly pulling the tube upon a. Knowledge deficit regarding
inhalation thrombocytopenia precautions
b. activity intolerance
c. impaired tissue perfusion
d. ineffective tissue perfusion, peripheral, towel under the puncture site
cerebral d. At the left side-lying position
with a small pillow or folded
96. what intervention should you include in towel under the puncture site
your care plan?
a. inspect his skin for petechiae, bruising, GI 99. Ms. Angola comes to the clinic for a
bleeding regularly check up and suspected of having
b. place Albert on strict isolation precaution Tuberculosis. The nurse understands
c. provide rest in between activities the most accurate method for
d. administer antipyretics if his temperature confirming the diagnosis is:
exceeds 38 ◦c
a. obtaining client’s health
97. Anton is being treated with radiation history
therapy. What should be included in the plan b. a positive Purified Protein
of care to minimize skin damage from the Derivative Test (PPD)
radiation therapy? c. a chest X-ray positive for
a. cover the areas with thick clothing lung lesion
materials d. a sputum culture positive for
b. apply a heating pad to the site Mycobacterium Tuberculosis
c. wash akin with water after the therapy
d. avoid applying creams and powders to the 100. Nurse Younghousewyf is assessing
area a client who
had a Miller-Abbott tube in place
98. Nurse Phil is assisting a physician for 24 hours, which assessed finding
performing a liver biopsy. Nurse Phil indicates that the tube is located in
places the client in which of the the intestines?
following most appropriate position
following the procedure? a. bowel sounds are absent
b. the client is nauseous
a. Supine c. aspirate from the tube has a
b. Prone pH of 7
c. At right side-lying position d. abdominal X-ray reveals that
with a small pillow or folded the tube is above the pylorus