FUNDAMENTALS OF NURSING 8.

A walk-in patient visits the clinic,

complaining of abdominal pain and
PRELIM diarrhea. After taking the patient’s vital
1. When a nurse is preparing to measure signs, which phase of the nursing
the temperature of an alert patient process is the nurse implementing?
admitted to the hospital due to A. Implementation
dehydration caused by vomiting and B. Diagnosis
diarrhea, which is most appropriate? C. Planning
a. Axillary method D. Assessment
b. Oral method 9. Which medical examination technique
c. Radial method primarily utilizes the sense of vision?
d. Rectal method a. Auscultation
b. Inspection
2. Which tool is commonly utilized for the c. Percussion
auscultation technique during physical d. Palpation
examination? 10. In which organ does the exchange of
a. Stethoscope gasses primarily occur?
b. Otoscope a. Lungs
c. Sphygmomanometer b. Kidney
d. Reflex hammer c. Intestines
d. Heart
3. A nurse measures a patient’s pulse rate 11. Which of the following is component of
and discovers that it is higher than Orem’s self-care deficit nursing theory?
normal. The nurse should document a. Physiologic needs
this finding as: b. Love and belonging
a. Hypotension c. Maintenance of a sufficient intake
b. Tachycardia of air.
c. Tachypnea d. Self-actualization
d. Arrythmia 12. What is the safest method for a nurse to
verify a client’s identity before
4. What is the correct meaning of the administering medication?
abbreviation CBR? a. Ask the client their name.
a. Complete Bet Rest b. Check the client’s identification
b. Comprehensive Bed Rest band.
c. Cardiac Board Room c. Verify the client’s social security
d. Complete Bathroom number.
5. The following term is best describe as a d. State the client’s name aloud and
systematic, rational method of planning have the client repeat it.
and providing nurse care for individuals, 13. A patient has undergone oral surgery
families, groups, and communities. after a motor vehicle accident. The
A. Nursing process nurse assessing the patient notices
B. Diagnosis flushed and warm skin. Which of the
C. Assessment following methods would be most
D. Evaluation appropriate to measure the client’s
6. Which of the following clusters of data body temperature?
are part of Maslow’s hierarchy of A. Axillary method
needs? B. Rectal method
a. Physiological needs C. Oral method
b. Safety and security D. Arterial line method
c. Sex 14. Which of the following positions is most
d. All of the above suitable for performing rectal
7. What is the body’s ability to protect examination?
itself against harmful invading agents a. Knee-chest position
such as bacteria, toxins, viruses, and b. Fowler’s position
foreign bodies called? c. Prone ( face down)
a. Hormones d. Sims position
b. Glands 15. Which technique is typically utilized first
c. Immunity when examining a client’s abdomen?
d. Inflammation a. Auscultation
 b. Inspection B. Clear breath sounds.
c. Percussion
C. Capillary refill greater than 3 seconds and
d. Palpation
buccal cyanosis.
16. Which physical examination technique
is employed to evaluate airflow within D. Hemoglobin of 13 g/dl
the tracheobronchial tree?
a. Auscultation
b. Percussion 23. When performing an abdominal
c. Inspection examination, the patient should be in a supine
d. Palpation position with the head of the bed at what
17. During the planning phase of the position?
nursing process, which of the following
is outcome? A. 30 degrees
a. Nursing history B. 90 degrees
b. Nursing notes
c. Nursing care plan C. 45 degrees
d. Nursing diagnosis
D. 0 degree
18. What is example of subjective data?
a. Heart rate of 69 beats per minute
b. Yellowish skin
24. Jake is complaining of shortness of breath.
c. Client verbalized, “nasaktan ako
The nurse assesses his respiratory rate to be 30
nung iniwan niya ako.”
breaths per minute and documents that Jake is
d. Adventitious breath sound
tachypneic. The nurse understands that
19. The theorist who believes that
tachypnea means:
adaptation and manipulation of
stressors are related to fostering change A. Pulse rate greater than 100 beats per minute
is:
a. Dorothea Orem B. Blood pressure of 140/90
b. Sister Calista Roy C. Respiratory rate greater than 20 breaths per
c. Imogene King minute
d. Florence Nightingale
20. Which of the following is the most D. Frequent bowel sounds
important purpose of planning care
with patient?
a. Development of a standardized NCP. 25. Formulating a nursing diagnosis is a joint
b. Expansion of the current taxonomy function of:
of nursing diagnosis.
A. Patient and relatives
c. Making of individualized patient
care. B. Nurse and patient
d. Incorporation of both nursing and
C. Doctor and family
medical diagnosis in patient care.
21. Which of the following behaviors by D. Nurse and doctor
nurse Jane Robles demonstrates that
she understands well the elements of
effective charting? 26. Using Maslow's hierarchy of basic human
a. She signs her charting as follows: J.R needs, which of the following nursing diagnoses
B. She writes in the chart using a no. 2 has the highest priority?
pencils.
C. She noted: appetite is good this A. Ineffective breathing pattern related to pain,
afternoon. as evidenced by shortness of breath.
D. She signs on the medication sheet B. Anxiety related to impending surgery, as
after administering the medication evidenced by insomnia.

C. Risk of injury related to autoimmune

22. Which data would be of greatest concern to dysfunction.
the nurse when completing the nursing
assessment of a 68-year-old woman D. Impaired verbal communication related to
hospitalized due to Pneumonia? tracheostomy, as evidenced by the inability to
speak
A. Oriented to date, time and place.
 B. Call the attending physician

27. What nursing action is appropriate when C. Slow that infusion to 20 ml/hr
obtaining a sterile urine specimen from an
D. Place a clod towel on the site
indwelling catheter to prevent infection?

A. Use sterile gloves when obtaining urine.

32. Mrs. Caperlac has been diagnosed with
B. Open the drainage bag and pour out the
hypertension 10 years ago. Since then, she has
urine.
maintained a low-sodium, low-fat diet to control
C. Disconnect the catheter from the tubing and her blood pressure. This practice is viewed as:
get urine.
A. Cultural belief
D. Aspirate urine from the tubing port using a
B. Personal belief
sterile syringe.
C. Health belief

D. Superstitious belief
28. Which statement is the most appropriate
goal for a nursing diagnosis of diarrhea?

A. “The patient will experience a decreased 33. Which of the following nursing theorists
frequency of bowel elimination.” conceptualizes that all persons strive to achieve
self-care?
B. “The patient will take anti-diarrheal
medication.” [Link] Callista Roy
C. “The patient will give a stool specimen for B. Dorothea Orem
laboratory examinations.”
C. Dorothy Johnson
D. “The patient will save urine for inspection by
the nurse. D. Jean Watson

29. What is the order of the nursing process? 34. Which of the following nursing theorists
introduced Transcultural Nursing Model?
A. Assessing, diagnosing, implementing,
evaluating, and planning A. Imogene King

B. Diagnosing, assessing, planning, [Link] Orem

implementing, and evaluating [Link] Johnson
C. Assessing, diagnosing, planning, [Link] Leininger
implementing, and evaluating

D. Planning, evaluating, diagnosing, assessing,

and implementing 35. The four concepts common to nursing that
appear in each of the current conceptual
models
30. The nurse in charge measures a patient's A.) Person, Nursing, Environment, Medicine
temperature at 101 degrees F. What is the
equivalent centigrade temperature? B. Person, Health, Nursing, Support System

A. 36.3 degrees C [Link], Environment, Health, Nursing

B. 38.3 degrees C [Link], Environment, Psychology, Nursing

C. 40.03 degrees C

D. 38.01 degrees C 36. Which of the following is not a subjective

data?
31. A client is receiving 115 ml/hr of continuous
IVF. The nurse noticed that the venipuncture A. Dizziness
site was red and swollen. Which of the following B. Chest pain
interventions would the nurse perform first?
C. Anxiety
A. Stop the infusion
D. Bluish discoloration
 [Link] heat-regulating center is found in the:

37. The client with fever had been observed to A. Medulla oblongata
experience elevated temperature for few days,
B. Thalamu
followed by 1 to 2 days of normal range of
temperature. The type of fever he is C. Hypothalamus
experiencing is:
D. Pons
A. Intermittent fever
43. The following are appropriate nursing
B. Relapsing fever actions when performing physical health
examination to a client EXCEPT:
C. Remittent fever
[Link] privacy of the client throughout the
D. Constant fever
procedure.

B. Prepare the needed articles and equipment

38. A process of heat loss which involves the before the procedure
transfer of heat from one surface to another is:
C. Assess the abdomen following this sequence:
A. Radiation right lower quadrants

B. Conduction [Link] assessing the chest, it is best to place

the client in side lying
C. Convection
44 . Cheyne-Stokes breathing is:
D. Evaporation
A. Slow, shallow respirations which result to
inadequate alveolar ventilation
39. The systematic manner of collecting data
B. Difficulty of breathing in reclining position
about the client by listening to body sounds
with the use of stethoscope is: C. Marked rhythmic waxing and waning of
respirations from very deep to very shallow
A. Inspection
breathing and temporary apnea
B. Palpation
D. Shallow breaths interrupted by apnea
C. Percussion

D. Auscultation 45. The best position to promote maximum lung

expansion is:
A. Supine
40. The following are correct nursing actions B. Retractions
when taking the radial pulse EXCEPT:
C. Noisy breathing
A. Put the palms downward
D. Semi fowler’s
B. Use the thumb to palpate the artery

C. Use two to three fingertips to palpate the

pulse at the inner wrist [Link]. Salvador practices excessive alcohol
intake. This is considered as which type of
D. Assess the pulse rate, rhythm, volume and precursor to illness?
bilateral equality A.) Behavioral factor
B.) Environmental factor

C.) Hereditary factor

D.) Genetic factor
41. The difference between the systolic pressure
and the diastolic pressure is: 47. Which of the following teachings methods
isnmost appropriate for teaching a diabetic
A. Apical rate client on self-injection of insulin?
[Link] rate A.) Detailed explanations
B.) Demonstration
C. Pulse deficit C.) Use of pamphlets
D.) Filmstrip
D. Pulse pressure
48. The caregiver role of the nurse emphasizes:
A.) Implementing nursing care measures

B.) Providing direct nursing care

C.) Recognition of needs of clients

D.) Observation of the client’s responses to

illness

49. The nurse takes the patient’s advocate role

when she;

A.) Defends the rights of the patient

B.) Intercedes on behalf of the patient

C.) Refers the patient to other services

D.) Works with the significant others

50. The manager role of the nurse is best

demonstrated when she:

A.) Plans nursing care with the patient

B.) Intercedes on behalf of the patient

C.) Refers the patient to other services

D.) Works with the significant of others

51. All of the following are primary

responsibilities of the nurse manager EXCEPT

A.) Performing bedside nursing

B.) Coordinating and delegating patient care

C.) Setting standards of performance

D.) Designating staff schedules

52. The following are specific activities during

evaluation EXCEPT:

A.) Collecting dat

B.) Performing nursing interventions

C.) Measuring goal attainment

D.) Revising or modifying the care plan