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

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