Professional Documents
Culture Documents
Fundamentals Mt1 Nov 2023
Fundamentals Mt1 Nov 2023
NLE INTENSIVE
Email *
Your email
LAST NAME *
Your answer
FIRST NAME *
Your answer
MIDDLE NAME *
Your answer
SCHOOL *
UC BANILAD
UCLM
UB
CNU
WALK-IN
UCPT
CCMC
a.Hemothorax
b. Tuberculosis
c. Hydrothorax
d. Empyema
2. A client is scheduled for a paracentesis for ascites. Which statement by the
client would indicate to the nurse that the preprocedure teaching has been
successful?
C. “I need to drink two glasses of water right before the procedure to maintain a full
bladder.”
D.“The doctor will slowly remove fluid from my abdomen to relieve the swelling.”
3. Which of the following psychological preparation is not relevant for the patient
before paracentesis?
a. Telling him that the gauge of the needle and anesthesia to be used
b. Telling him to keep still during the procedure to facilitate the insertion of the
needle in the correct place.
d. Physician’s explanation on the purpose of the procedure and how it will be done
4. Which of the following assessments is essential for the nurse to make when
caring for a client who has just had an esophagogastroduodenoscopy (EGD)?
b. Monitor salivary pH
a. Anxiolytic
b. Xylocaine Spray
d. Cholinergic medication
7. The nurse is planning care for the client scheduled for gastroduodenoscopy and
a barium swallows. What will the nursing plan include?
a. Anticipating the client will receive a low-residue diet in the evening and then
receive nothing by mouth (NPO status) 6 to 12 hours before the test.
b. Discussing with the client the nasogastric tube and the importance of gastric
drainage of 24 hours the test.
c. Explaining to the client that he will receive nothing by mouth (NPO status) for 24
hours after the test to make sure his stomach can tolerate his food.
d. Discussing the general anesthesia and explaining that he will wake up in the
recovery room.
8. A nurse assists a physician in performing a liver biopsy. After the biopsy the
nurse plans to place the client which of the following positions?
a. Prone
b. Supine
c. A right side-lying position with a small pillow or folded towel under the puncture
site.
d. A left side-lying position with a small pillow folded towel under the puncture site.
9. A client who is scheduled for a bone marrow aspiration asks the nurse about the
site that will be used for the procedure. The nurse tells the client that in addition to
the iliac crest, bone marrow may be aspirated in which of the following locations?
a. Femur
b. Ribs
c. Sternum
d. Hyoid
10. The correct procedure for auscultating a client’s abdomen for bowel sounds
would include:
B. Encouraging the client to cough to stimulate movement of fluid and air through
the abdomen
a. Give laxatives
d. Encourage ambulation
13. A nurse is reviewing the laboratory test results for a client with a diagnosis of
severe dehydration. The nurse would expect the hematocrit level for this client to
be whish of the following?
a. 60%
b. 47%
c. 45%
d. 32%
14. Which of the following guidelines should be followed when administering an
enema to children?
a. 1 only
b. 1, 2 and 3
d. 2,3 and 4
18. During the first post operative week, the nurse can BEST help the patient with a
colostomy to accept the change in body image by:
a. Cutting the colon and bringing the proximal end through the abdominal wall
21. The nurse evaluates the client’s stoma during the initial postoperative period.
Which of the following signs would indicate inadequate blood supply to the stoma
and should be reported immediately to the physician? A stoma that:
a. Is slightly edematous
22. Colostomy irrigation is ordered for the client on her 5th postoperative day. The
primary purpose of this irrigation is to:
d. Stimulate peristalsis
23. If the client complains of abdominal cramping after receiving approximately
150 ml of solution during colostomy irrigation, the nurse should temporarily:
24. Which of the following should be removed from the client in preparation for an
MRI procedure?
a. Urinary catheter
d. Foam slippers
25. When evaluating the client’s temperature level, the nurse expects the client’s
temperature to be lower:
a. In the morning
b. After exercising
A. LMCL, 5thICS
B. LMCL, 4thICS
C. LMCL, 3rdICS
D. RMCL, 2ndICS
27. Which of the following is most likely to yield accurate information about the
quality of patient’s pain?
28. Chronic pain is most effectively relieved when analgesics are administered:
b. Conservatively
d. Intramuscularly
29. The nurse is caring for a group of adult patients who require pain
management. It is most important for the nurse to remember:
a. to use medication only as a last resort after trying to distract the patient
b. that medicating a patient with chronic pain is a lower priority than medicating a
patient with acute pain.
d. to wait for 15 minutes after a patient’s request for pain medication to be sure the
pain is real.
30. Which of the following most appropriately describe pain sensations that has
periods of remission and exacerbation?
a. Acute
c. Chronic
b. Intractable
d. Neuropathic
31. You are obtaining a history of Jessie D. who is admitted with acute chest pain.
Which question will be most helpful for you to ask?
a. relaxation techniques
b. massage
d. body movement
33. The amount of medication that could be given through a deltoid muscle is:
A. 0.5 mL or less
B. 1.0 mL or less
C. 1.5 mL or less
D. 2.0 mL or less
34. Which of the following landmarks should a nurse identify when planning to
inject an IM medication at the ventrogluteal site?
A. Greater trochanter
B. Acromion process
C. Coccyx
D. Antecubital fossa
35. The nurse is preparing to administer an iron injection to a client. The nurse will
give the medication in the:
36. The nurse is preparing the client’s medication which is available for injection in
an ampule. Which of the following should the nurse do when drawing up this
medication?
b. Break the top of the ampule so that it opens toward the nurse
c. Wipe the neck of the ampule with gauze after snapping it open
A. 2 cm.
B. 5 cm.
C. 2.5 cm.
D. 4 cm.
38. Which exam technique is being used when the nurse touches the client’s
abdomen to examine the size of the liver?
a. Inspection
b. Palpation
c. Percussion
d. Auscultation
39. In performing a caloric test in a client with Meniere’s disease, warm instillation
at the left ear will result to:
40. A nurse has prepared a client for an intravenous pyelogram. The nurse
determines that the client understands the procedure if the client states to expect
which sensation during the procedure?
a. nausea
b. Difficulty of breathing
a. Between L1 and L2
b. Between S1 and S2
c. Between L3 and L4
d. Between L4 and L5
A. Curative
B. Primary
C. Secondary
D. Tertiary
43. The nurse is teaching a diabetic patient how to inject insulin and the dosages
necessary for optimal control. This would be an example of what level of health
care.
A. Curative
B. Primary
C. Secondary
D. Tertiary
44. Which of the following is an example of a primary preventive measure?
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
d. Passive prevention
46. The nurse has organized an immunization clinic for healthy babies and
preschool children. This would be an example of what level of preventative health
care?
A. Curative
B. Primary
C. Secondary
D. Tertiary
47. Nurse Mian is assessing a client. Which data is considered a primary source?
a. The client’s husband tells Nurse Mian that the Client seems upset.
48. Nurse Daclis is going to use a theory from another discipline. Which of the
following would the nurse select?
49. Which statement made by the client indicates an internal locus of control?
a. “I have found that when I eat a high-fiber, low-fat diet my diabetes is easier to
regulate.”
b. “My wife fixes all my meals. You’ll have to talk to her about that diet you want me
to be on.”
c. “I can’t exercise the way the doctor told me to because I don’t make enough
money to join a health club.”
d. “My mother and my father both had heart disease. I guess I can expect it, too.”
50. The physician orders nasogastric tube insertion to irrigate a client’s stomach.
Which of the following insertion techniques would most likely make it more difficult
for the nurse to insert the tube?
b. Asking the client to swallow while the tube is advanced to the stomach
d. Having the client tilt the head toward the chest while inserting the tube into the
nose.
51. Which of the following techniques is considered the best way to determine
whether a nasogastric tube is positioned in the stomach?
b. Irrigating with normal saline and observing for the return of the solution
c. Placing the tube’s free end in water and observing for air bubbles
d. Instilling air and auscultating over the epigastric area for the presence of the tube
a. When confirming tube placement, place the tube’s end in a container of water.
b. Use a tongue blade and penlight to examine mouth and throat for signs of a coiled
section of tubing.
c. Stop advancing tube when tape mark reaches the client’s nostril.
d. Inject 10cc of air into tube. At same time, auscultate for air sounds with
stethoscope placed over the epigastric region.
54. The health care provider order reads "aspirate nasogastric feeding (NG) tubes
every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action
should the nurse take?
55. Three days after admission for a cerebral vascular accident, a client has a
nasogastric tube inserted and is receiving intermittent feedings. To best evaluate if
a prior feeding has been absorbed the nurse should:
a. Semi-Fowler’s Position
b. Trendelenberg
57. After nasogastric tubes have been inserted, the nurse can most accurately
determine in the tube is in the proper place if which of the following can be
demonstrated?
58. Which of the following best exhibit placement of the NGT tube?
a. Gastric secretions ph of 6
60. A nursing student is learning the application of the nursing process to client
care. When questioned by the student about the reason for implementing a nursing
diagnosis, the nursing professor responds: “The nursing diagnosis statement:
c. “Includes the disease the client has during the treatment of care.”
61. The client is a tailor who was admitted for eye surgery. Assuming that all of the
following are realistic, a long-term goal for this client should include:
a. Returning to sewing
64. While documenting on a client’s medical record, the nurse realizes that it is a
legal document and should include all of the following, except:
a. Be time sequenced.
d. Be typed.
65. A client who has been hospitalized for a period of time is now being transferred
to a rehabilitation center for more long-term care. As he is preparing to be
discharged, the client asks the nurse if he can take his chart with them, since it’s
his record. The nurse responds correctly by saying:
a. “There’s a new law that protects your records, so you’re not going to be able to
have access to them.”
b. “We’ll make sure that all of your records are sent ahead to the rehab hospital, so
you don’t really have to worry about those details.”
d. “Actually, the original record is the property of the hospital, but you are welcome to
copies of your records.”
66. The nurse makes a mistake when charting on the client’s record. To correct this
mistake the nurse should:
b. Blot out the error with ink and make the correct entry.
c. Draw a line through the error, sign, and date the correction.
d. Leave the error intact and chart the correction immediately following the error
67. After classroom discussion regarding confidentiality policies and laws
protecting client records, a student asks why it’s OK for them to review and have
access to client records in the clinical area. The nurse educator responds correctly
by stating that:
b. “Records are used in educational settings and for learning purposes, but the
student is bound to hold all information in strict confidence.”
c. “Most students review so many records and charts that they could not possibly
remember details from any one of them.”
d. “As long as the clinical instructor is in the area, accessing client records is part of
the education process.”
68. A student nurse is reviewing an assigned client’s chart. When trying to locate
recent lab results, the student notices that each department has a separate section
in the chart. This type of documentation system is called which of the following?
a. Case management
b. Source-oriented record
c. Focus charting
d. Problem-oriented record
69. During nasogastric tube feedings, the nurse is safely able to administer:
a. Antibiotics
b. Syrup-based medications
c. Enteric-coated tablets
70. Mr. Ots Daclis. is a 26-year-old recently diagnosed with ulcerative colitis. The
nurse has been giving dietary instructions to Mr. D. to help prevent exacerbation of
his inflammatory bowel disease. Which dietary choice indicates that Mr. D.
understands the dietary instructions?
A. apple
B. celery
C. refined cereals
D. hard cheeses
71. The physician orders nasogastric tube insertion to irrigate a client’s stomach.
Which of the following insertion techniques would most likely make it more difficult
for the nurse to insert the tube?
b. Asking the client to swallow while the tube is advanced to the stomach
d. Having the client tilt the head toward the chest while inserting the tube into the
nose.
72. Organize these steps in chronological order for client who is having a
nasogastric tube removed.
a. 314625
b. 314526
c. 314256
d. 315426
73. The health care provider order reads "aspirate nasogastric feeding (NG) tubes
every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action
should the nurse take?
A. Do not give the feeding and notify the doctor of residual of the last feeding is
greater than or equal to 50 ml
B. Height of the feeding should be 12 inches about the tube point of insertion to
allow slow introduction of feeding
C. Ask the client to position in supine position immediately after feeding to prevent
dumping syndrome
D. Clamp the NGT before all of the water is instilled to prevent air entry in the
stomach
A. Diarrhea
B. Infection
C. Hyperglycemia
D. Vomiting
76. These are data that are monitored by using graphic charts or graphs that
indicated the progression or fluctuation of client’s Temperature and Blood
pressure.
A. Progress notes
B. Kardex
C. Flow chart
D. Flow sheet
77. Provides a concise method of organizing and recording data about the client. It
is a series of flip cards kept in portable file used in change of shift reports.
A. Kardex
B. Progress Notes
C. SOAPIE
78. The client has an allergy to Iodine-based dye. Where should you put this vital
information in the client’s chart?
D. In the Kardex
B. Urinary catheterization
D. Colostomy irrigation
81. Which of the following devices prevents the external rotation of the leg?
a. Sandbags
b. Firm mattress
c. Pillow
82. To prevent plantar flexion and keep the feet in dorsiflexion, the nurse will use:
b. Foot board
c. Boots
d. Bed board
83. The single most important device depending on the need to support or elevate
the back, arms, legs, heels, sacrum or any part of the body of the client needing
support and elevation is:
a. Trapeze bar
b. Mattress
c. Pillow
d. Bed boards
84. The nurse knows that the cane should be at least how many inches at the top
and side of the foot?
a. 4 inches
b. 6 inches
c. 10 inches
d. 12 inches
85. A client was sent home with a prescription of Mineral Oil as Laxative. Mineral
oil as Laxatives will include which health instructions
1) Swallow
a. All except 2
b. 1,3, and 4
c. 1,2,and 4
d. 1 and 2 only
86. The decrease of absorption of certain vitamins is affected when taking mineral
oil. Which of the following is affected?
1) A
2) B
3) C
4) D
5) E
a. 1,2,3,4,5
b. 1,4 and 5
c. 2 and 3
d. 1,4 and 3
87. The nurse successfully moved the client from bed to the wheelchair. After
unlocking the breaks of the chair and lowering the foot plates. The nurse can now
move the wheelchair freely. Upon entering the elevator, the nurse should remember
that:
a. The small Patient leaves the wheelchair before entering the elevator
a. The nurse should be at the bottom of the incline pushing the client small wheel
first
c. The nurse should be above the incline and the client below the incline
d. The nurse should pull the client instead of pushing against the incline
89. When teaching a client with long leg cast how to use the crutches properly
when descending down the stairs. The nurse should tell the client to:
91. The physician incharge made an order to monitor for signs of insensible fluid
loss. The nurse is correct if she mentioned that insensible fluid loss occurs on:
a. Fecal elimination
b. Perspiration
c. Diaphoresis
d. Micturation
92. The nurse is to insert an NG Tube when suddenly, she accidentally dip the end
of the tube in the client’s glass containing distilled drinking water which is definitely
not sterile. As a nurse, what should you do?
a. Personal distance
b. Public distance
c. Intimate distance
d. Social distance
94. The patient is diagnosed with anemia. Which vitamin is needed for
supplementation?
A. Vit. C
B. Ferrous Sulfate
C. Vit. D
D. Magnesium
95. The nurse knows that the cane should be at least how many inches at the top
and side of the foot?
A. 4 inches
B. 6 inches
C. 10 inches
D. 12 inches
96. Nurse Dave reviewed the document of the patient. Upon checking, he noticed
that the amount of fluid left in the bottle was not charted by the outgoing nurse.
Which of the following should he do?
b. Leave it as is
97. The Physician ordered Garamycin 1 gm IV ANST, then 500mg IV q6h. Nurse
Dave noted that the initial dose was given at 8 AM. In the medication card, which
was endorsed to him by another nurse, the next dose will be given at 8 PM. Which
of the following should be done first?
98. The physician incharge made an order to monitor for signs of insensible fluid
loss. The nurse is correct if she mentioned that insensible fluid loss occurs on:
a. Fecal elimination
b. Perspiration
c. Diaphoresis
d. Micturation
99. The nurse uses a stethoscope to auscultate a client’s chest. Which statement
about a stethoscope with a bell and diaphragm is true?
A. 5 minutes
B. 15 minutes
C. 30 minutes
D. 60 minutes
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Forms