Fundamentals of Nursing

1. Nurse Margarito has transfused a unit of packed RBCs which has a 250-ml bag of 0.9 %
sodium chloride (normal saline) attached. The follow up IV order is to hang a 1000ml bag of
5% dextrose in water. Which of the following steps would the nurse take in the process of
discontinuing the completed transfusion?
a. Aspirate the IV line before connecting the IV solution tubing
b. Disconnect the tubing while there is blood in the line and attach the IV solution tubing
c. Infuse the rest of the normal saline before changing from the blood tubing to the IV
tubing
d. Flush the blood tubing with normal saline before changing to the IV tubing
2. Jesse a patient with AIDS is obese. When administering a subcutaneous injection to an
obese patient, it is best for Nurse De Silva to:
a Inject needle at a 15 degree angle' over the stretched skin of the client
b. Pinch skin at the Injection site and use airlock technique
c. Pull skin of patient down to administer the drug in a Z track
d. Spread skin or pinch at the injection site and inject needle at a 45-90 degree
angle

3. The rationale for giving medications through the subcutaneous route is;
a. It is richly supplied with blood
b. Absorption time of the medicine is slower
c. There are less pain receptors in this area
d. The medication can be injected in any site
4. Nurse De Silva knows he can perform chest physiotherapy:
a. Immediately before meals
b. One hour after meals
c. During meals
d. Before bedtime
5. While doing nasopharyngeal suctioning on the client, the nurse can avoid trauma to the
area by:
a. Apply suction for at least 60 seconds each time to ensure that all secretions are removed
b. Using clean gloves to prevent introduction of pathogens to the respiratory system
c. Applying no suction while inserting the catheter
d. Rotating catheter as it is inserted with gentle suction
6. Emerald has difficulty breathing when on her back and must sit upright in bed to breathe
effectively and comfortably. The nurse documents this condition as:
a. Apnea
b. Orthopnea

c. Dyspnea
d. Tachypnea
7. When taking blood pressure reading the following are incorrect, except:
a. The nurse should make sure that the cuff be deflated fully then immediately start second
reading for same client
b. The nurse should release the valve carefully so that the pressure decreases at
the rate of 2-3 mmHg per second
c. Large enough to wrap around upper arm of the adult client 1 cm above the brachial artery
d. Inflated to 30 mmHg above the estimated systolic BP based on palpation of radial or
bronchial artery

8. The nurse, while taking the blood pressure of the client, deflated the cuff too quickly. The
reading would be:
a. Erroneously high systolic and low diastolic reading
b. Erroneously low systolic and high diastolic reading
c. Inconsistent
d. None of the above
9. A female client is admitted to the hospital. Before performing a venipuncture to the client
to initiate continuous intravenous (IV) therapy, Nurse Corazon should initially:
a. Place a cool compress over the vein
b. Apply a tourniquet below the chosen vein site
c. Inspect the IV solution for particles or contamination
d. Secure an arm board to the joint located above the IV site
10. Tracheostomy tubes used among adults often have cuffs. What is the main function of
this inflatable cuff?
a. Anchoring the tube in place
b. Distributing a low even pressure over the trachea
c. A guide for easy removal of the tracheostomy tube
d. Producing an airtight seal to prevent aspiration of oropharyngeal secretions and
air
leakage
11. Blood pressure is the measurement of:
a. The flow of blood through the heart
b. The flow of blood through the circulation
c. The force of blood against the arterial walls
d. The force of blood against the venous walls
12. Nurse Marco finished assessing the blood pressure of her client and is not sure of the
measurement that she has just obtained. Which of the following is correct when
repeating BP measurements?
a. Repeat BP assessment immediately after the first attempt
b. Wait for 30 seconds minutes before making another measurement
c. Wait for 1-2 minutes before making another measurement
d. Wait for 30 minutes before making another measurement

13. Which of the following pulse sites is used to assess the pulse of Baby Jacob, an 11month-old infant?
a. Carotid
b. Popliteal
c. Radial
d. Apical
14. Which of the following is a correct statement about pulse oximetry measurement?
a. A range of 95-98% is considered normal oxygen saturation
b. Oximetry measurement measures oxygen saturation of the venous blood
c. Fasting is required 12 hours before the measurement
d. Pulse oximetry is a replacement for arterial blood gas analysis
15. Nurse Joedel is using an otoscope to assess the tympanic membrane of her client
Marie, 15 years of age. To straighten Maries ear canal, Nurse Rosalie should pull the
pinna:
a. Up and back
b. Downward and forward
c. Down and back
d. Left and right
16. The nurse is determining the breath sounds of the client. Upon performing
auscultation, the nurse hears a superficial grating or creaking sound heard during
inspiration and expiration. This sound is a characteristic of?
a. Vesicular breath sound
b. Gurgles
c. Friction rub
d. Crackles

17. To prepare a patient for a paracentesis, it is essential for the nurse to:
a. Administer a cleansing enema
b. Pre-medicate the patient with a narcotic analgesic
c. Restrict the patients intake of fluids
d. Have the patient empty his bladder
18. Which of the following is a primary consideration in determining the priorities in meeting
clients unmet needs according to Maslow?
a.
b.
c.
d.

Physiological needs
Security needs
Self-esteem needs
Spiritual needs

19. The nurse is assessing the client who has edema. The skin remains indented or pitted at
6mm. The nurse describes the degree of edema as:
a. 1+

b. 2+

c. 3+

d. 4+

20. The patient smokes and drinks coffee. When taking the temperature of a client who
recently drank coffee, how long should the nurse wait before taking the clients oral
temperature for accurate reading?
a. 20 minutes
b. Quarter of an hour
c. 60 minutes
d. Half an hour

21. In assessing oral temperature, how long should the nurse wait prior to reading the
thermometer?
a. 1 minute
b. 2-3 minutes
c. 5 minutes
d. 10 minutes

22. When obtaining the temperature rectally, the nurse should insert the thermometer:
a. 1 cm into the rectum
b. 2.5 cm into the rectum
c. 2 inches into the rectum
d. 3 inches into the rectum

23. Continuous high pitched musical or whistling sound from a client is:
a. Orthopnea
b. Stridor
c. Stertor
d. Wheeze

24. The nurse cleans the clients beside and attends to the personal hygiene of the patient
as well as washing her hands before and after procedure and in between patients. The nurse
is applying whose nursing theory in her actions?
a
b
c
d

Dorothea Orem
Florence Nightingale
Hildegard Peplau
Virginia Henderson

25. All of the following nursing considerations correspond with the underlying condition,
except:
a. A client with CHF placed by Nurse Gerry on High Fowlers position
b. A client post cataract surgery place by Nurse Ronald on Semi Fowlers position
c. Nurse Joel placing a client post liver biopsy on right lateral position
d. Nurse Ritchie placing a client with autonomic dysreflexia on supine position
26. The physician orders codeine sulphate, gr PO q4H PRN. The medication bottle reads
codein sulphate, 15mg/tablet. How many tablet(s) will the nurse administer to the client?
A. 0.5 tablet
B. 1 tablet
C. 1.5 tablets
D. 2 tablets
gr is 30 mg so give 2 tabs
27. This refers to the stiffening of the body that occurs 2 4 hours after death.
a. Algor mortis
b. Rigor mortis
c. Livor mortis
d. Manor mortis

28. After circulation has ceased, discoloration appears in the lowermost or dependent areas
of the body of the deceased. This is known as:
a. Algor mortis
b. Rigor mortis
c. Livor mortis

d. Manor mortis
29. To administer a soap-suds enema to an adult before abdominal surgery, the nurse should:
a.
b.
c.
d.

Fill the container with cold water to soothe the intestinal mucosa.
Insert the tip of the rectal tube 1-2 inches into the rectum
Raise the fluid container 12-18 inches above the patients anus
Remove and place the rectal tube several times during the procedure
30. The nurse is reviewing the report of a client's routine urinalysis. Which value should the
nurse consider abnormal?
a. Specific gravity of 1.03
b. Urine pH of 3.0
c. Absence of protein
d. Absence of glucose
31. In nursing history in the Philippines, when was the first nurse licensure examination
held?
a. 1944
b. 1919
c. 1920
d. 1957
32. All of the following is not included in the complications of hyperalimentation, except:
a. air embolism
b. hypoglycemia
c. decrease urine output
d. color blindness
33. When preparing drug injection from an ampule, Nurse De Silva initially:
a. Taps the ampule at the top to allow fluid to flow to the base of the ampule
b. Checks expiration date of the medication ampule
c. Removes needle cap of syringe and pulls plunger to expel air
d. Breaks the neck of the ampule with a gauze wrapped around it
34. After a lumbar puncture, the nurse should place the client in:
a. Supine position with pillow
b. Supine with neck hyperextended
c. Prone for 4-12 hours
d. Prone for 2-3 hours

35. The client is diagnosed with thrombophlebitis. The appropriate client position/activity by
Nurse Steven is which of the following?
a. Bed rest with the affected extremity in dependent position
b. Bed rest with bathroom privileges
c. Bed rest, keeping the affected extremity flat
d. Bed rest, with elevation of the affected extremity

36. The best position for a client for thoracentesis is:

A. Upright leaning sideward
B. Orthopneic
C. Prone
D. Supine

37. All of the following but one are nursing considerations for bronchoscopy:
a. NPO from midnight prior to the procedure
b. Remove dentures and eyeglasses
c. Prepare suction equipment
d. Sedation post procedure as prescribe

38. Pulse oximeter sensor may be attached on these sites, except:

a. finger
b. nose
c. nipple
d. earlobe

39. A client with Chronic Airflow limitation is having low oxygenation level. What is the best
nursing action?
a. Place the client on nasal prong delivering high dose of O2.

b. Give paper bag

c. Instruct deep breathing and coughing exercise
d. Administer 2-3 lpm of 02

40. Complications of tracheostomy are the following: SELECT ALL THAT APPLY.
1 Tube obstruction

5 Bleeding

2 Tube dislodgement

6 Infection

3 Pneumothorax

7 Tracheal Stenosis

4 Subcutaneous emphysema
a. 1,2,3,4,5,
b. 1,2,3,5,6
b. 1,2,3,4,5,6
d. 1,2,3,4,5,6,7

41. In the care for a client with chest tubes Nurse Warren should keep in mind that which
among the following is not true?
a. Water seal should be established with 2cm of water pressure
b. Bubbling in the suction container indicates that there is suction
c. Keep clamp and sterile occlusive dressing at the bedside at all times
d. Position should be maintained at one side to secure placement of the tube.

42. A nurse must know the proper storage for medications. Nurse Jana King must keep in
mind that in storing unused vials of insulins are placed:
A. at room temperature labelled with its expiration date
B. at room temperature well packed
C. inside the refrigerator
D. inside the freezer

43. All but one are characteristics of a good communication:

A. Simplicity
B. Clarity
C. Credibility
D. Speed

44. .When taking the blood pressure the BP cuff should be placed snugly. If the BP cuff is to
loose, what will be the reading?
A. False high
B. Too low
C. The same
D. Undetermined

45. Colostomy care should be instructed to a patient. The nurses best action is to remind
client that one cue that a change is needed is when the client experiences the sensation of?
A. Smelling a bad odor
B. Bearing down
C. Pain
D. Pressure on the appliance

46. A nurse is giving TPN. She must remember that TPN is not to be incorporated by any
substance except:
A. D5 Water
B. Medications
C. Insulin
D. Heparin

47. A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The
most appropriate intervention for this client is
A. Position client in upright position while eating

B. Place client on a clear liquid diet

C. Tilt head back to facilitate swallowing reflex
D. Offer finger foods such as crackers or pretzels

48. When taking a patients temperature, the nurse should expect the highest temperature
when?
A. 6am-4pm
B. 8pm-12 midnight
C. 4am-6pm
D.4am-6am
49. Mang Ken had undergone bronchoscopy. Which among the following is associated with
vasovagal response?
a. increase heart rate
b. increase BP
c. bronchoconstriction
d. decrease saliva
50. A client has had a cystectomy and ureteroileostomy (ileal conduit). The nurse observes
this client for complications in the postoperative period. Which of the following symptoms
indicates an unexpected outcome and requires priority care?
A.
B.
C.
D.

Edema of the stoma

Mucus in the drainage appliance
Redness of the stoma
Feces in the drainage appliance