Practice 4

FUNDAMENTALS OF NURSING
1. Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths
per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means:
A. Pulse rate greater than 100 beats per minute
B. Blood pressure of 140/90
C. Respiratory rate greater than 20 breaths per minute
D. Frequent bowel sounds
2. The nurse listens to Mrs. Sullen’s lungs and notes a hissing sound or musical sound. The nurse
documents this as:
A. Wheezes
B. Rhonchi
C. Gurgles
D. Vesicular
3. The nurse in charge measures a patient’s temperature at 101 degrees F. What is the equivalent
centigrade temperature?
A. 36.3 degrees C
B. 37.95 degrees C
C. 40.03 degrees C
D. 38.01 degrees C
4. Which approach to problem solving tests any number of solutions until one is found that works for
that particular problem?
A. Intuition
B. Routine
C. Scientific method
D. Trial and error
5. What is the order of the nursing process?
A. Assessing, diagnosing, implementing, evaluating, planning
B. Diagnosing, assessing, planning, implementing, evaluating
C. Assessing, diagnosing, planning, implementing, evaluating
D. Planning, evaluating, diagnosing, assessing, implementing
6. During the planning phase of the nursing process, which of the following is the outcome?
A. Nursing history
B. Nursing notes
C. Nursing care plan
D. Nursing diagnosis
7. What is an example of a subjective data?
A. Heart rate of 68 beats per minute
B. Yellowish sputum
C. Client verbalized, “I feel pain when urinating.”
D. Noisy breathing
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8. Which expected outcome is correctly written?
A. “The patient will feel less nauseated in 24 hours.”
B. “The patient will eat the right amount of food daily.”
C. “The patient will identify all the high-salt food from a prepared list by discharge.”
D. “The patient will have enough sleep.”
9. Which of the following behaviors by Nurse Jane Robles demonstrates that she understands well th
elements of effecting charting?
A. She writes in the chart using a no. 2 pencil.
B. She noted: appetite is good this afternoon.
C. She signs on the medication sheet after administering the medication.
D. She signs her charting as follow: J.R
10. What is the disadvantage of computerized documentation of the nursing process?
A. Accuracy
B. Legibility
C. Concern for privacy
D. Rapid communication
11. The theorist who believes that adaptation and manipulation of stressors are related to foster change
is:
A. Dorothea Orem
B. Sister Callista Roy
C. Imogene King
D. Virginia Henderson
12. Formulating a nursing diagnosis is a joint function of:
A. Patient and relatives
B. Nurse and patient
C. Doctor and family
D. Nurse and doctor
13. Mrs. Caperlac has been diagnosed to have hypertension since 10 years ago. Since then, she had
maintained low sodium, low fat diet, to control her blood pressure. This practice is viewed as:
A. Cultural belief
B. Personal belief
C. Health belief
D. Superstitious belief
14. Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated.
Which of the following is an expected response?
A. Low blood pressure
B. Warm, dry skin
C. Decreased serum sodium levels
D. Decreased urine output
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15. What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling
catheter to prevent infection?
A. Use sterile gloves when obtaining urine.
B. Open the drainage bag and pour out the urine.
C. Disconnect the catheter from the tubing and get urine.
D. Aspirate urine from the tubing port using a sterile syringe.

PEDIATRIC NURSING
Situation 1: Agata, 2 years old is rushed to the ER due to cyanosis precipitated by crying. Her mother observed
that after playing she gets tired. She was diagnosed with Tetralogy of Fallot.
1. The goal of nursing care fro Agata is to:
A. Prevent infection
B. Promote normal growth and development
C. Decrease hypoxic spells
D. Hydrate adequately
2. The immediate nursing intervention for cyanosis of Agata is:
A. Call up the pediatrician
B. Place her in knee chest position
C. Administer oxygen inhalation
D. Transfer her to the PICU
3. Agata was scheduled for a palliative surgery, which creates anastomosis of the subclavian artery to
the pulmonary artery. This procedure is:
A. Waterston-Cooley
B. Raskkind Procedure
C. Coronary artery bypass
D. Blalock-Taussig
4. Which of the following is not an indicator that Agata experiences separation anxiety brought about
her hospitalization?
A. Friendly with the nurse
B. Prolonged loud crying, consoled only by mother
C. Occasional temper tantrums and always says NO
D. Repeatedly verbalizes desire to go home
5. When Agata was brought to the OR, her parents where crying. What would be the most appropriate
nursing diagnosis?
A. Infective family coping r/t situational crisis
B. Anxiety r/t powerlessness
C. Fear r/t uncertain prognosis
D. Anticipatory grieving r/t gravity of child’s physical status
6. Which of the following respiratory condition is always considered a medical emergency?
A. Laryngeotracheobronchitis (LTB)
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B. Epiglottitis
C. Asthma
D. Cystic Fibrosis
7. Which of the following statements by the family of a child with asthma indicates a need for additional
teaching?
A. “We need to identify what things triggers his attacks”
B. “He is to use bronchodilator inhaler before steroid inhaler”
C. “We’ll make sure he avoids exercise to prevent asthma attacks”
D. “he should increase his fluid intake regularly to thin secretions”
8. Which of the following would require careful monitoring in the child with ADHD who is receiving
Methylphenidate (Ritalin)?
A. Dental health
B. Mouth dryness
C. Height and weight
D. Excessive appetite
Situation 2: Laura is assigned as the Team Leader during the immunization day at the RHU
9. What program for the DOH is launched at 1976 in cooperation with WHO and UNICEF to reduce
morbidity and mortality among infants caused by immunizable disease?
A. Patak day
B. Immunization day on Wednesday
C. Expanded program on immunization
D. Bakuna ng kabtaan
10. One important principle of the immunization program is based on?
A. Statistical occurrence
B. Epidemiologic situation
C. Cold chain management
D. Surveillance study
11. The main element of immunization program is one of the following?
A. Information, education and communication
B. Assessment and evaluation of the program
C. Research studies
D. Target setting
12. What does herd immunity means?
A. Interruption of transmission
B. All to be vaccinated
C. Selected group for vaccination
D. Shorter incubation
13. Measles vaccine can be given simultaneously. What is the combined vaccine to be given to children
starting at 15 months?
A. MCG
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B. MMR
C. BCG
D. BBR

PROFESSIONAL NURSING PRACTICE

1. Asking the questions to determine if the person understands the health teaching provided by the
nurse would be included during which step of the nursing process?
A. Assessment
B. Evaluation
C. Implementation
D. Planning and goals
2. Which of the following item is considered the single most important factor in assisting the health
professional in arriving at a diagnosis or determining the person’s needs?
A. Diagnostic test results
B. Biographical date
C. History of present illness
D. Physical examination
3. In preventing the development of an external rotation deformity of the hip in a client who must
remain in bed for any period of time, the most appropriate nursing action would be to use:
A. Trochanter roll extending from the crest of the ileum to the midthigh.
B. Pillows under the lower legs.
C. Footboard
D. Hip-abductor pillow
4. Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
5. When the method of wound healing is one in which wound edges are not surgically approximated
and integumentary continuity is restored by granulations, the wound healing is termed
A. Second intention healing
B. Primary intention healing
C. Third intention healing
D. First intention healing
6. An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver
learns that the client lives alone and hasn’t been eating or drinking. When assessing him for
dehydration, nurse Oliver would expect to find:
A. Hypothermia
B. Hypertension
C. Distended neck veins
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D. Tachycardia
7. The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as needed, to control a
client’s postoperative pain. The package insert is “Meperidine, 100 mg/ml.” How many milliliters of
meperidine should the client receive?
A. 0.75
B. 0.6
C. 0.5
D. 0.25
8. A male client with diabetes mellitus is receiving insulin. Which statement correctly describes an
insulin unit?
A. It’s a common measurement in the metric system.
B. It’s the basis for solids in the avoirdupois system.
C. It’s the smallest measurement in the apothecary system.
D. It’s a measure of effect, not a standard measure of weight or quantity.
9.Nurse Oliver measures a client’s temperature at 102° F. What is the equivalent Centigrade
temperature?
A. 40.1 °C
B. 38.9 °C
C. 48 °C
D. 38 °C
10.The nurse is assessing a 48-year-old client who has come to the physician’s office for his annual
physical exam. One of the first physical signs of aging is:
A. Accepting limitations while developing assets.
B. Increasing loss of muscle tone.
C. Failing eyesight, especially close vision.
D. Having more frequent aches and pains.
11.The physician inserts a chest tube into a female client to treat a pneumothorax. The tube is connected
to water-seal drainage. The nurse in-charge can prevent chest tube air leaks by:
A. Checking and taping all connections.
B. Checking patency of the chest tube.
C. Keeping the head of the bed slightly elevated.
D. Keeping the chest drainage system below the level of the chest.
12.Nurse Trish must verify the client’s identity before administering medication. She is aware that the
safest way to verify identity is to:
A. Check the client’s identification band.
B. Ask the client to state his name.
C. State the client’s name out loud and wait a client to repeat it.
D. Check the room number and the client’s name on the bed.
13.The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8 hours. The I.V. tubing
delivers 15 drops/ml. Nurse John should run the I.V. infusion at a rate of:
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A. 30 drops/minute
B. 32 drops/minute
C. 20 drops/minute
D. 18 drops/minute
14.If a central venous catheter becomes disconnected accidentally, what should the nurse in-charge do
immediately?
A. Clamp the catheter
B. Call another nurse
C. Call the physician
D. Apply a dry sterile dressing to the site.
15.A female client was recently admitted. She has fever, weight loss, and watery diarrhea is being
admitted to the facility. While assessing the client, Nurse Hazel inspects the client’s abdomen and notice
that it is slightly concave. Additional assessment should proceed in which order:
A. Palpation, auscultation, and percussion.
B. Percussion, palpation, and auscultation.
C. Palpation, percussion, and auscultation.
D. Auscultation, percussion, and palpation.

MEDSURGE
1. Marco who was diagnosed with brain tumor was scheduled for craniotomy. In preventing the
development of cerebral edema after surgery, the nurse should expect the use of:
A. Diuretics
B. Antihypertensive
C. Steroids
D. Anticonvulsants
2. Halfway through the administration of blood, the female client complains of lumbar pain. After
stopping the infusion Nurse Hazel should:
A. Increase the flow of normal saline
B. Assess the pain further
C. Notify the blood bank
D. Obtain vital signs.
3. Nurse Maureen knows that the positive diagnosis for HIV infection is made based on which of the
following:
A. A history of high risk sexual behaviors.
B. Positive ELISA and western blot tests
C. Identification of an associated opportunistic infection
D. Evidence of extreme weight loss and high fever
4. Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure recognizes
an adequate amount of high-biologic-value protein when the food the client selected from the menu was:
A. Raw carrots
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B. Apple juice
C. Whole wheat bread
D. Cottage cheese
5. Kenneth who has diagnosed with uremic syndrome has the potential to develop complications. Which
among the following complications should the nurse anticipates:
A. Flapping hand tremors
B. An elevated hematocrit level
C. Hypotension
D. Hypokalemia
6. A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant
assessment would be:
A. Flank pain radiating in the groin
B. Distention of the lower abdomen
C. Perineal edema
D. Urethral discharge
7. A client has undergone with penile implant. After 24 hrs of surgery, the client’s scrotum was
edematous and painful. The nurse should:
A. Assist the client with sitz bath
B. Apply war soaks in the scrotum
C. Elevate the scrotum using a soft support
D. Prepare for a possible incision and drainage.
8. Nurse hazel receives emergency laboratory results for a client with chest pain and immediately
informs the physician. An increased myoglobin level suggests which of the following?
A. Liver disease
B. Myocardial damage
C. Hypertension
D. Cancer
9. Nurse Maureen would expect the a client with mitral stenosis would demonstrate symptoms associated
with congestion in the:
A. Right atrium
B. Superior vena cava
C. Aorta
D. Pulmonary
10. A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be:
A. Ineffective health maintenance
B. Impaired skin integrity
C. Deficient fluid volume
D. Pain
11. Nurse Hazel teaches the client with angina about common expected side effects of nitroglycerin
including:
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A. high blood pressure
B. stomach cramps
C. headache
D. shortness of breath
12. The following are lipid abnormalities. Which of the following is a risk factor for the development of
atherosclerosis and PVD?
A. High levels of low density lipid (LDL) cholesterol
B. High levels of high density lipid (HDL) cholesterol
C. Low concentration triglycerides
D. Low levels of LDL cholesterol.
13. Which of the following represents a significant risk immediately after surgery for repair of aortic
aneurysm?
A. Potential wound infection
B. Potential ineffective coping
C. Potential electrolyte balance
D. Potential alteration in renal perfusion
14. Nurse Josie should instruct the client to eat which of the following foods to obtain the best supply of
Vitamin B12?
A. dairy products
B. vegetables
C. Grains
D. Broccoli
15. Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the
following physiologic functions?
A. Bowel function
B. Peripheral sensation
C. Bleeding tendencies
D. Intake and out put

CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATION

1. Nurse Michelle should know that the drainage is normal 4 days after a sigmoid colostomy when the
stool is:
A. Green liquid
B. Solid formed
C. Loose, bloody
D. Semiformed
2. Where would nurse Kristine place the call light for a male client with a right-sided brain attack and
left homonymous hemianopsia?
A. On the client’s right side
B. On the client’s left side
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C. Directly in front of the client
D. Where the client like
3. A male client is admitted to the emergency department following an accident. What are the first
nursing actions of the nurse?
A. Check respiration, circulation, neurological response.
B. Align the spine, check pupils, and check for hemorrhage.
C. Check respirations, stabilize spine, and check circulation.
D. Assess level of consciousness and circulation.
4. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and
relieves angina by:
A. Increasing contractility and slowing heart rate.
B. Increasing AV conduction and heart rate.
C. Decreasing contractility and oxygen consumption.
D. Decreasing venous return through vasodilation.
5. Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails
of the bed and unresponsive to shaking or shouting. Which is the nurse next action?
A. Call for help and note the time.
B. Clear the airway
C. Give two sharp thumps to the precordium, and check the pulse.
D. Administer two quick blows.
6. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should:
A. Plan care so the client can receive 8 hours of uninterrupted sleep each night.
B. Monitor vital signs every 2 hours.
C. Make sure that the client takes food and medications at prescribed intervals.
D. Provide milk every 2 to 3 hours.
7. A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for
2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?
A. Stop the I.V. infusion of heparin and notify the physician.
B. Continue treatment as ordered.
C. Expect the warfarin to increase the PTT.
D. Increase the dosage, because the level is lower than normal.
8. A client undergone ileostomy, when should the drainage appliance be applied to the stoma?
A. 24 hours later, when edema has subsided.
B. In the operating room.
C. After the ileostomy begin to function.
D. When the client is able to begin self-care procedures.
9. A client undergone spinal anesthetic, it will be important that the nurse immediately position the client
in:
A. On the side, to prevent obstruction of airway by tongue.
B. Flat on back.
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C. On the back, with knees flexed 15 degrees.
D. Flat on the stomach, with the head turned to the side.
10.While monitoring a male client several hours after a motor vehicle accident, which assessment data
suggest increasing intracranial pressure?
A. Blood pressure is decreased from 160/90 to 110/70.
B. Pulse is increased from 87 to 95, with an occasional skipped beat.
C. The client is oriented when aroused from sleep, and goes back to sleep immediately.
D. The client refuses dinner because of anorexia.
11.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear
first?
A. Altered mental status and dehydration
B. Fever and chills
C. Hemoptysis and Dyspnea
D. Pleuritic chest pain and cough
12. A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit?
A. Chest and lower back pain
B. Chills, fever, night sweats, and hemoptysis
C. Fever of more than 104°F (40°C) and nausea
D. Headache and photophobia