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FON Practice Exam for Nursing Process, Physical and Health Assessment and Routine Procedures (PM)
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Question 1
In a routine sputum analysis, Which of the following indicates proper nursing action before sputum collection?
A
Rinse the client’s mouth with Listerine after collection
B
Discard the container if the outside becomes contaminated with the sputum
C
Secure a clean container
D
Tell the client that 4 tablespoon of sputum is needed for each specimen for a routine sputum analysis
Question 2
Measure the leg circumference of a client with bipedal edema is best done in what position?
A
Sitting
B
Standing
C
Supine
D
Dorsal recumbent
Question 3
Refers to the pressure when the ventricles are at rest
A
Diastole
B
Systole
C
Pulse pressure
D
Preload
Question 4
The following are social data about the client except
A
Family home situation
B
Usual health status
C
Patient’s lifestyle
D
Religious practices
Question 5
Which is a preferable arm for BP taking?
A
The right arm
B
An arm with the most contraptions
C
The left arm
D
The left arm of the client with a CVA affecting the right brain
Question 6
Which of the following is the correct interpretation of the ERROR OF PARALLAX
A
If the eye level is equal to that of the level of the upper meniscus, the reading is accurate
B
If the eye level is higher than the level of the meniscus, it will cause a false low reading
C
If the eye level is lower than the level of the meniscus, it will cause a false low reading
D
If the eye level is higher than the level of the meniscus, it will cause a false high reading
Question 7
Which of the following is responsible for the rhythm and quality of breathing?
A
Carotid bodies
B
Medulla oblongata
C
Pons
D
Aortic bodies
Question 8
Nurse Angela diagnosed Mrs. Delgado, who have undergone a BKA. Her diagnosis is SELF ESTEEM DISTURBANCE R/T CHANGE IN BODY IMAGE. Although the client has not yet seen her lost leg, Angela already anticipated the diagnosis. This is what type of Diagnosis?
A
Possible
B
Actual
C
Risk
D
Probable
Question 9
+++ Positive result after Benedicts test is depicted by what color?
A
Yellow
B
Orange
C
Green
D
Blue
Question 10
In cleaning the thermometer after use, The direction of the cleaning to follow Medical Asepsis is :
A
From bulb to bulb
B
From stem to stem
C
From bulb to stem
D
From stem to bulb
Question 11
Contains the pneumotaxic and the apneutic centers
A
Pons
B
Carotid bodies
C
Medulla oblongata
D
Aortic bodies
Question 12
How long should the Rectal Thermometer be inserted to the clients anus?
A
2 to 3 inches
B
3 to 5 inches
C
.5 to 1.5 inches
D
1 to 2 inches
Question 13
How long should the thermometer stay in the Client’s Axilla?
A
3 minutes
B
4 minutes
C
7 minutes
D
10 minutes
Question 14
John has a fever of 39.5 degrees 2 days ago, But yesterday, he has a normal temperature of 36.5 degrees. Today, his temperature surges to 40 degrees. What type of fever is John having?
A
Relapsing
B
Intermittent
C
Constant
D
Remittent
Question 15
Rectal examination is done with a client in what position?
A
Sims position
B
Dorsal recumbent
C
Lithotomy
D
Supine
Question 16
She is the first one to coin the term “NURSING PROCESS” She introduced 3 steps of nursing process which are Observation, Ministration and Validation.
A
Johnson
B
Nightingale
C
Rogers
D
Hall
Question 17
A framework for health assessment that evaluates the effects of stressors to the mind, body and environment in relation with the ability of the client to perform ADL.
A
Body system framework
B
Cephalocaudal framework
C
Functional health framework
D
Head to toe framework
Question 18
Which of the following is a contraindication in taking RECTAL temperature?
A
Neutropenic
B
Unconscious
C
NPO
D
Very young children
Question 19
Considered as Safest and most non invasive method of temperature taking
A
Oral
B
Axillary
C
Tympanic
D
Rectal
Question 20
When John has been given paracetamol, his fever was brought down dramatically from 40 degrees Celsius to 36.7 degrees in a matter of 10 minutes. The nurse would assess this event as:
A
The goal is not completely met
B
The goal of reducing john’s fever has been met with full satisfaction of the outcome criteria
C
The goal has been met but not with the desired outcome criteria
D
The desired goal has been partially met
Question 21
Among the following statements, which should be given the HIGHEST priority?
A
Client’s blood pressure is 60/40
B
Client’s temperature is 40 deg. Centigrade
C
Client is cyanotic
D
Client is in extreme pain
Question 22
Which of the following is INCORRECT in assessing client’s BP?
A
If the BP is taken on the left leg using the popliteal artery pressure, a BP of 160/80 is normal.
B
The sound heard during taking BP is known as KOROTKOFF sound
C
Inflate and deflate slowly, 2-3 mmHg at a time
D
Read the mercury at the upper meniscus, preferably at the eye level to prevent error of parallax
Question 23
Which of the following is a primary factor that affects the BP?
A
Stress
B
Obesity
C
Age
D
Gender
Question 24
If the client is female, and the doctor is a male and the patient is about to undergo a vaginal and cervical examination, why is it necessary to have a female nurse in attendance?
A
To ensure that the procedure is done in an ethical manner
B
To assist the doctor
C
To assess the client’s response to examination
D
To ensure that the doctor performs the procedure safely
Question 25
David, 68 year old male client is scheduled for Serum Lipid analysis. Which of the following health teaching is important to ensure accurate reading?
A
Tell the patient to eat fatty meals 3 days prior to the procedure
B
Ask the client to drink 1 glass of water 1 hour prior to the procedure
C
Tell the client that the normal serum lipase level is 50 to 140 U/L
D
NPO for 12 hours pre procedure
Question 26
When should the client test his blood sugar levels for greater accuracy?
A
Before meals
B
During meals
C
In between meals
D
2 Hours after meals
Question 27
Dr. Fabian De Las Santas, is about to conduct an ophthalmoscope examination. Which of the following, if done by a nurse, is a Correct preparation before the procedure?
A
Open the windows, curtains and light to allow better illumination
B
Pour warm water over the ophthalmoscope to ensure comfort
C
Provide the necessary draping to ensure privacy
D
Darken the room to provide better illumination
Question 28
John’s temperature 10 hours ago is a normal 36.5 degrees. 4 hours ago, He has a fever with a temperature of 38.9 Degrees. Right now, his temperature is back to normal. Which of the following best describe the fever john is having?
A
Intermittent
B
Remittent
C
Relapsing
D
Constant
Question 29
Nurse Angela knew that Stephen Lee Mu Chin, has just undergone an operation with an incision near the diaphragm. She knew that this will contribute to some complications later on. She then should develop what type of Nursing diagnosis?
A
Risk
B
Possible
C
Actual
D
Probable
Question 30
Which of the following is TRUE about the blood pressure determinants?
A
HCT of 70% might decrease or increase BP
B
Hypervolemia lowers BP
C
Epinephrine decreases BP
D
Hypervolemia increases GFR
Question 31
A characteristic of the nursing process that is essential to promote client satisfaction and progress. The care should also be relevant with the client’s needs.
A
Efficient
B
Humanistic
C
Organized and Systematic
D
Effective
Question 32
Which of the following is responsible for deep and prolonged inspiration
A
Aortic bodies
B
Carotid bodies
C
Pons
D
Medulla oblongata
Question 33
When is the best time to collect urine specimen for routine urinalysis and C/S?
A
Early morning
B
Later afternoon
C
Midnight
D
Before breakfast
Question 34
Which of the following is TRUE about the auscultation of blood pressure?
A
Sound produced by BP is considered as HIGH frequency sound
B
Pulse + 4 is considered as FULL
C
The bell of the stethoscope is use in auscultating BP
D
Pulse +1 is considered as NORMAL
Question 35
Too narrow cuff will cause what change in the Client’s BP?
A
False low reading
B
False high reading
C
True low reading
D
True high reading
Question 36
Which of the following need is given a higher priority among others?
A
The client is depressed because her boyfriend left her all alone
B
The client has disturbance in his body image because of the recent operation
C
The client is thirsty and dehydrated
D
The client has attempted suicide and safety precaution is needed
Question 37
Which of the following do not correctly correlates the increase BP of Ms. Aida, a 70 year old diabetic?
A
BP is highest in the morning, and lowest during the night
B
Females, after the age 65 tends to have lower BP than males
C
Disease process like Diabetes increase BP
D
Africans, have a greater risk of hypertension than Caucasian and Asians.
Question 38
When does the heart receives blood from the coronary artery?
A
Diastole
B
When the valves opens
C
When the valves closes
D
Systole
Question 39
Which of the following is among an ideal way of collecting a urine specimen for culture and sensitivity?
A
Use a clean container
B
Add preservatives, refrigerate the specimen or add ice according to the agency’s protocol
C
Collect around 30-50 ml of urine
D
Discard the first flow of urine to ensure that the urine is not contaminated
Question 40
All of the following factors correctly influence respiration except one. Which of the following is incorrect?
A
Increase altitude, Increase RR
B
Hydrocodone decreases RR
C
Increase temperature of the environment, Increase RR
D
Stress increases RR
Question 41
Hyperpyrexia is a condition in which the temperature is greater than
A
100 degree Fahrenheit
B
40 degree Celsius
C
39 degree Celsius
D
105.8 degree Fahrenheit
Question 42
Considered as the most accessible and convenient method for temperature taking
A
Rectal
B
Tympanic
C
Axillary
D
Oral
Question 43
All of the following are characteristic of the Nursing process except
A
Cyclical
B
Intrapersonal
C
Dynamic
D
Universal
Question 44
A process of heat loss which involves the transfer of heat from one surface to another is
A
Radiation
B
Conduction
C
Convection
D
Evaporation
Question 45
In palpating the client’s breast, Which of the following position is necessary for the patient to assume before the start of the procedure?
A
Dorsal recumbent
B
Lithotomy
C
Sitting
D
Supine
Question 46
The best position for any procedure that involves vaginal and cervical examination is
A
Side lying
B
Supine
C
Dorsal recumbent
D
Lithotomy
Question 47
Which of the following completely describes PULSUS PARADOXICUS?
A
Pulse is paradoxically low when client is in standing position and high when supine.
B
A greater-than-normal increase in systolic blood pressure with inspiration
C
A greater-than-normal decrease in systolic blood pressure with inspiration
D
Pulse is paradoxically high when client is in standing position and low when supine.
Question 48
The sequence in examining the quadrants of the abdomen is:
A
RUQ,RLQ,LUQ,LLQ
B
RLQ,RUQ,LLQ,LUQ
C
RLQ,RUQ,LUQ,LLQ
D
RUQ,RLQ,LLQ,LUQ
Question 49
Client has undergone Upper GI and Lower GI series. Which type of health assessment framework is used in this situation?
A
Body system framework
B
Cephalocaudal framework
C
Functional health framework
D
Head to toe framework
Question 50
Which of the following is a correct nursing action when collecting urine specimen from a client with an Indwelling catheter?
A
Detach catheter from the connecting tube and draw the specimen from the port
B
Use sterile syringe to aspirate urine specimen from the drainage port
C
Insert the syringe straight to the port to allow self sealing of the port
D
Collect urine specimen from the drainage bag
Question 51
Which of the following statement is TRUE about pulse?
A
Males have higher pulse rate than females after puberty
B
Digitalis has a positive chronotropic effect
C
In lying position, Pulse rate is higher
D
Young person have higher pulse than older persons
Question 52
Which of the following is TRUE about temperature?
A
Thyroxin decreases body temperature
B
The highest temperature usually occurs later in a day, around 8 P.M to 12 M.N
C
The lowest temperature is usually in the Afternoon, Around 12 P.M
D
Elderly people are risk for hyperthermia due to the absence of fats, Decreased thermoregulatory control and sedentary lifestyle.
Question 53
In assessing the abdomen, Which of the following is the correct sequence of the physical assessment?
A
Inspection, Auscultation, Palpation, Percussion
B
Palpation, Auscultation, Percussion, Inspection
C
Inspection, Palpation, Auscultation, Percussion
D
Inspection, Auscultation, Percussion, Palpation
Question 54
Which of the following is TRUE about respiration?
A
I:E 1:1
B
I:E 2:1
C
I:E 1:2
D
I:E : 4:3
Question 55
In collecting a urine from a catheterized patient, Which of the following statement indicates an accurate performance of the procedure?
A
Clamp above the port for 30 to 60 minutes before drawing the urine from the port
B
Clamp above the port for 5 to 10 minutes before drawing the urine from the port
C
Clamp below the port for 30 to 60 minutes before drawing the urine from the port
D
Clamp below the port for 5 to 10 minutes before drawing the urine from the port
Question 56
Which of the following nursing intervention is important for a client scheduled to have a Guaiac Test?
A
Avoid turnips, radish and horseradish 3 days before procedure
B
Encourage caffeine and dark colored foods to produce accurate results
C
Do not eat read meat 12 hours before procedure
D
Continue iron preparation to prevent further loss of Iron
Question 57
Tympanic temperature is taken from John, A client who was brought recently into the ER due to frequent barking cough. The temperature reads 37.9 Degrees Celsius. As a nurse, you conclude that this temperature is
A
At the low end of the normal range
B
High
C
At the high end of the normal range
D
Low
Question 58
The difference between the systolic and diastolic pressure is termed as
A
Pulse deficit
B
Apical rate
C
Cardiac rate
D
Pulse pressure
Question 59
Nurse Angela, observe Joel who is very apprehensive over the impending operation. The client is experiencing dyspnea, diaphoresis and asks lots of questions. Angela made a diagnosis of ANXIETY R/T INTRUSIVE PROCEDURE. This is what type of Nursing Diagnosis?
A
Possible
B
Risk
C
Probable
D
Actual
Question 60
John has a fever of 38.5 Deg. Celsius. It surges at around 40 Degrees and go back to 38.5 degrees 6 times today in a typical pattern. What kind of fever is John having?
A
Constant
B
Intermittent
C
Remittent
D
Relapsing
Question 61
Which of the following statement is true regarding temperature?
A
The bulb used in Rectal temperature reading is pear shaped or round
B
When the client is swimming, BMR Decreases
C
The older the person, the higher his BMR
D
Oral temperature is more accurate than rectal temperature
Question 62
Which of the following Nursing diagnosis is INCORRECT?
A
Possible ineffective coping R/T Loss of loved one
B
High risk for injury R/T Absence of side rails
C
Self esteem disturbance R/T Effects of surgical removal of the leg
D
Fluid volume deficit R/T Diarrhea
Question 63
Which of the following is more life threatening?
A
BP = 80/50
B
BP = 160/120
C
BP = 180/100
D
BP = 90/60
Question 64
This specimen is required to assess glucose levels and for the presence of albumin the the urine
A
24 hours urine collection
B
Midstream clean catch urine
C
Second voided urine
D
Postprandial urine collection
Question 65
The primary respiratory center
A
Pons
B
Carotid bodies
C
Aortic bodies
D
Medulla oblongata
Question 66
A community health nurse should be resourceful and meet the needs of the client. A villager ask him, Can you test my urine for glucose? Which of the following technique allows the nurse to test a client’s urine for glucose without the need for intricate instruments.
A
Nitrazine paper test
B
Litmus paper test
C
Benedict’s test
D
Acetic Acid test
Question 67
A type of heat loss that occurs when the heat is dissipated by air current
A
Conduction
B
Evaporation
C
Radiation
D
Convection
Question 68
Which of the following is inappropriate in collecting mid stream clean catch urine specimen for urine analysis?
A
Do perineal care before specimen collection
B
Discard the first flow of the urine
C
Collect 5 to 10 ml for urine
D
Collect early in the morning, First voided specimen
Question 69
A patient’s chart is what type of data source?
A
Secondary
B
Primary
C
Tertiary
D
Can be A and B
Question 70
Which of the following is a OBJECTIVE data?
A
Anxiety
B
Dizziness
C
Chest pain
D
Blue nails
Question 71
Which characteristic of nursing process is responsible for proper utilization of human resources, time and cost resources?
A
Organized and Systematic
B
Humanistic
C
Effective
D
Efficient
Question 72
In inspecting the abdomen, which of the following is NOT DONE?
A
The best position in assessing the abdomen is Dorsal recumbent
B
Ask the client to void first
C
Knees and legs are straighten to relax the abdomen
D
The knees and legs are externally rotated
Question 73
In collecting a routine specimen for fecalysis, Which of the following, if done by a nurse, indicates inadequate knowledge and skills about the procedure?
A
The nurse scoop the specimen specifically at the site with blood and mucus
B
Ask the client to call her for the specimen after the client wiped off his anus with a tissue
C
She took around 1 inch of specimen or a teaspoonful
D
Ask the client to defecate in a bedpan, Secure a sterile container
Question 74
How many minute/s is/are allowed to pass before making a re-reading after the first one?
A
5
B
1
C
15
D
30
Question 75
What can you expect from Marianne, who is currently at the ONSET stage of fever?
A
Convulsion
B
Pale,cold skin
C
Hot, flushed skin
D
Increase thirst
Question 76
Which of the following is the best position for the client to assume if the back is to be examined by the nurse?
A
Prone
B
Side lying
C
Standing
D
Sitting
Question 77
The primary factor responsible for body heat production is the
A
Metabolism
B
Release of thyroxin
C
Muscle activity
D
Stress
Question 78
A community health nurse is assessing client’s urine using the Acetic Acid solution. Which of the following, if done by a nurse, indicates lack of correct knowledge with the procedure?
A
The nurse determines abnormal result if she noticed that the test tube becomes cloudy
B
The nurse heats the test tube after adding 1/3 part acetic acid
C
The nurse heats the test tube after adding 2/3 part of Urine
D
The nurse added the Urine as the 2/3 part of the solution
Question 79
The following are correct actions when taking radial pulse except:
A
Use two or three fingers to palpate the pulse at the inner wrist
B
Put the palms downward
C
Use the thumb to palpate the artery
D
Assess the pulse rate, rhythm, volume and bilateral quality
Question 80
In assessing the client’s chest, which position best show chest expansion as well as its movements?
A
Sidelying
B
Supine
C
Prone
D
Sitting
Question 81
The characteristic fever in Dengue Virus is characterized as:
A
Biphasic
B
Triphasic
C
Tricyclic
D
Bicyclic
Question 82
Who collects Blood specimen?
A
Physician
B
Medical technologist
C
Physical therapist
D
The nurse
Question 83
In palpating the client’s abdomen, Which of the following is the best position for the client to assume?
A
Supine
B
Lithotomy
C
Dorsal recumbent
D
Side lying
Question 84
Which of the following is TRUE about the mechanism of action of the Aortic and Carotid bodies?
A
If the BP is elevated, the RR increases
B
Elevated BP leads to Metabolic alkalosis
C
If the BP is elevated, the RR decreases
D
Low BP leads to Metabolic acidosis
Question 85
How many minutes are allowed to pass if the client had engaged in strenuous activities, smoked or ingested caffeine before taking his/her BP?
A
10
B
15
C
5
D
30
Question 86
Which of the following is true about the NURSING CARE PLAN?
A
Rationales are supported by interventions
B
Verbal
C
It is nursing centered
D
At least 2 goals are needed for every nursing diagnosis
Question 87
They are the first one to suggest a 4 step nursing process which are : APIE , or assessment, planning, implementation and evaluation.
Yura
Walsh
Roy
Knowles
A
1,3
B
1,2
C
3,4
D
2,3
Question 88
Which of the following is incorrect with regards to proper urine testing using Benedict’s Solution?
A
If the color remains BLUE, the result is POSITIVE
B
Heat the Benedict’s solution without the urine to check if the solution is contaminated
C
Add 8 to 10 drops of urine
D
Heat around 5ml of Benedict’s solution together with the urine in a test tube
Question 89
Which characteristic of nursing process addresses the INDIVIDUALIZED care a client must receive?
A
Effective
B
Humanistic
C
Efficient
D
Organized and Systematic
Question 90
Rhina, who has Menieres disease, said that her environment is moving. Which of the following is a valid assessment?
Rhina is giving an objective data
Rhina is giving a subjective data
The source of the data is primary
The source of the data is secondary
A
1,3
B
2.4
C
1,4
D
2,3
Question 91
The American Nurses association formulated an innovation of the Nursing process. Today, how many distinct steps are there in the nursing process?
A
ADPIE – 5
B
APIE – 4
C
ADOPIER – 7
D
ADOPIE – 6
Question 92
Marianne is now at the Defervescence stage of the fever, which of the following is expected?
A
Sweating
B
Delirium
C
Cyanotic nail beds
D
Goose flesh
Question 93
The heat regulating center is found in the
A
Medulla oblongata
B
Thalamus
C
Pons
D
Hypothalamus
Question 94
Nurse Angela is about to make a diagnosis but very unsure because the S/S the client is experiencing is not specific with her diagnosis of POWERLESSNESS R/T DIFFICULTY ACCEPTING LOSS OF LOVED ONE. She then focus on gathering data to refute or prove her diagnosis but her plans and interventions are already ongoing for the diagnosis. Which type of Diagnosis is this?
A
Probable
B
Possible
C
Risk
D
Actual
Question 95
Which of the following is a NOT a correct statement of an Outcome criteria?
A
Reestablishes a normal pattern of elimination
B
Discusses fears and concerns regarding the surgical procedure
C
Demonstrates proper coughing and breathing technique after a teaching session
D
Ambulates 30 feet with a cane before discharge
Question 96
When palpating the client’s neck for lymphadenopathy, where should the nurse position himself?
A
At the client’s left side
B
At the client’s back
C
At the client’s right side
D
In front of a sitting client
Question 97
In a 24 hour urine specimen started Friday, 9:00 A.M, which of the following if done by a Nurse indicate a NEED for further procedural debriefing?
A
The nurse discards the Friday 9:00 A M urine of the client
B
The nurse added preservatives as per protocol and refrigerates the specimen
C
The nurse included the Saturday 9:00 A.M urine of the client to the specimen collection
D
The nurse ask the client to urinate at 9:00 A.M, Friday and she included the urine in the 24 hour urine specimen
Question 98
Clinitest is used in testing the urine of a client for glucose. Which of the following, If committed by a nurse indicates error?
A
The nurse puts 1 clinitest tablet into a test tube
B
She added 5 drops of urine and 10 drops of water
C
Specimen is collected after meals
D
She added 5 drops of urine and 10 drops of water
Question 99
Which of the following is NOT a contraindication in taking ORAL temperature?
A
Quadriplegic
B
Dyspnea
C
Presence of NGT
D
Nausea and Vomitting
Question 100
Which of the following is TRUE with regards to Client Goals?
A
They should answer for WHO, WHAT ACTIONS, WHAT CIRCUMSTANCES, HOW WELL and WHEN.
B
Example is : After discharge planning, Client demonstrated the proper psychomotor skills for insulin injection.
C
They are general and broadly stated
D
They are specific, measurable, attainable and time bounded
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FON Practice Exam for Nursing Process, Physical and Health Assessment and Routine Procedures (EM)
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Question 1
Which of the following is TRUE about the mechanism of action of the Aortic and Carotid bodies?
A
Low BP leads to Metabolic acidosis
B
If the BP is elevated, the RR increases
C
Elevated BP leads to Metabolic alkalosis
D
If the BP is elevated, the RR decreases
Question 2
Which of the following is true about the NURSING CARE PLAN?
A
It is nursing centered
B
At least 2 goals are needed for every nursing diagnosis
C
Verbal
D
Rationales are supported by interventions
Question 3
Which of the following is a primary factor that affects the BP?
A
Gender
B
Stress
C
Age
D
Obesity
Question 4
Nurse Angela knew that Stephen Lee Mu Chin, has just undergone an operation with an incision near the diaphragm. She knew that this will contribute to some complications later on. She then should develop what type of Nursing diagnosis?
A
Possible
B
Probable
C
Actual
D
Risk
Question 5
Marianne is now at the Defervescence stage of the fever, which of the following is expected?
A
Delirium
B
Cyanotic nail beds
C
Sweating
D
Goose flesh
Question 6
Which of the following is a OBJECTIVE data?
A
Chest pain
B
Blue nails
C
Dizziness
D
Anxiety
Question 7
Which characteristic of nursing process is responsible for proper utilization of human resources, time and cost resources?
A
Efficient
B
Organized and Systematic
C
Effective
D
Humanistic
Question 8
Nurse Angela is about to make a diagnosis but very unsure because the S/S the client is experiencing is not specific with her diagnosis of POWERLESSNESS R/T DIFFICULTY ACCEPTING LOSS OF LOVED ONE. She then focus on gathering data to refute or prove her diagnosis but her plans and interventions are already ongoing for the diagnosis. Which type of Diagnosis is this?
A
Possible
B
Actual
C
Risk
D
Probable
Question 9
Hyperpyrexia is a condition in which the temperature is greater than
A
39 degree Celsius
B
40 degree Celsius
C
105.8 degree Fahrenheit
D
100 degree Fahrenheit
Question 10
When does the heart receives blood from the coronary artery?
A
Systole
B
When the valves closes
C
Diastole
D
When the valves opens
Question 11
Which of the following is responsible for the rhythm and quality of breathing?
A
Aortic bodies
B
Pons
C
Carotid bodies
D
Medulla oblongata
Question 12
Clinitest is used in testing the urine of a client for glucose. Which of the following, If committed by a nurse indicates error?
A
She added 5 drops of urine and 10 drops of water
B
Specimen is collected after meals
C
The nurse puts 1 clinitest tablet into a test tube
D
She added 5 drops of urine and 10 drops of water
Question 13
How many minute/s is/are allowed to pass before making a re-reading after the first one?
A
30
B
15
C
1
D
5
Question 14
How long should the thermometer stay in the Client’s Axilla?
A
3 minutes
B
7 minutes
C
4 minutes
D
10 minutes
Question 15
Which of the following is the best position for the client to assume if the back is to be examined by the nurse?
A
Side lying
B
Prone
C
Sitting
D
Standing
Question 16
Which of the following is TRUE about temperature?
A
Elderly people are risk for hyperthermia due to the absence of fats, Decreased thermoregulatory control and sedentary lifestyle.
B
The lowest temperature is usually in the Afternoon, Around 12 P.M
C
Thyroxin decreases body temperature
D
The highest temperature usually occurs later in a day, around 8 P.M to 12 M.N
Question 17
A community health nurse should be resourceful and meet the needs of the client. A villager ask him, Can you test my urine for glucose? Which of the following technique allows the nurse to test a client’s urine for glucose without the need for intricate instruments.
A
Litmus paper test
B
Benedict’s test
C
Nitrazine paper test
D
Acetic Acid test
Question 18
Which of the following do not correctly correlates the increase BP of Ms. Aida, a 70 year old diabetic?
A
Africans, have a greater risk of hypertension than Caucasian and Asians.
B
Females, after the age 65 tends to have lower BP than males
C
Disease process like Diabetes increase BP
D
BP is highest in the morning, and lowest during the night
Question 19
Too narrow cuff will cause what change in the Client’s BP?
A
False high reading
B
True low reading
C
True high reading
D
False low reading
Question 20
This specimen is required to assess glucose levels and for the presence of albumin the the urine
A
Second voided urine
B
Midstream clean catch urine
C
24 hours urine collection
D
Postprandial urine collection
Question 21
Considered as the most accessible and convenient method for temperature taking
A
Oral
B
Axillary
C
Tympanic
D
Rectal
Question 22
In collecting a routine specimen for fecalysis, Which of the following, if done by a nurse, indicates inadequate knowledge and skills about the procedure?
A
The nurse scoop the specimen specifically at the site with blood and mucus
B
Ask the client to call her for the specimen after the client wiped off his anus with a tissue
C
Ask the client to defecate in a bedpan, Secure a sterile container
D
She took around 1 inch of specimen or a teaspoonful
Question 23
A patient’s chart is what type of data source?
A
Primary
B
Can be A and B
C
Secondary
D
Tertiary
Question 24
Nurse Angela, observe Joel who is very apprehensive over the impending operation. The client is experiencing dyspnea, diaphoresis and asks lots of questions. Angela made a diagnosis of ANXIETY R/T INTRUSIVE PROCEDURE. This is what type of Nursing Diagnosis?
A
Risk
B
Probable
C
Actual
D
Possible
Question 25
What can you expect from Marianne, who is currently at the ONSET stage of fever?
A
Convulsion
B
Pale,cold skin
C
Increase thirst
D
Hot, flushed skin
Question 26
Which of the following nursing intervention is important for a client scheduled to have a Guaiac Test?
A
Avoid turnips, radish and horseradish 3 days before procedure
B
Do not eat read meat 12 hours before procedure
C
Encourage caffeine and dark colored foods to produce accurate results
D
Continue iron preparation to prevent further loss of Iron
Question 27
Which of the following is among an ideal way of collecting a urine specimen for culture and sensitivity?
A
Collect around 30-50 ml of urine
B
Discard the first flow of urine to ensure that the urine is not contaminated
C
Use a clean container
D
Add preservatives, refrigerate the specimen or add ice according to the agency’s protocol
Question 28
Which characteristic of nursing process addresses the INDIVIDUALIZED care a client must receive?
A
Efficient
B
Effective
C
Organized and Systematic
D
Humanistic
Question 29
Considered as Safest and most non invasive method of temperature taking
A
Axillary
B
Oral
C
Tympanic
D
Rectal
Question 30
Which of the following need is given a higher priority among others?
A
The client has attempted suicide and safety precaution is needed
B
The client is thirsty and dehydrated
C
The client has disturbance in his body image because of the recent operation
D
The client is depressed because her boyfriend left her all alone
Question 31
Which of the following statement is true regarding temperature?
A
The older the person, the higher his BMR
B
When the client is swimming, BMR Decreases
C
The bulb used in Rectal temperature reading is pear shaped or round
D
Oral temperature is more accurate than rectal temperature
Question 32
Which of the following is TRUE about respiration?
A
I:E 1:2
B
I:E 2:1
C
I:E 1:1
D
I:E : 4:3
Question 33
All of the following are characteristic of the Nursing process except
A
Universal
B
Cyclical
C
Dynamic
D
Intrapersonal
Question 34
The difference between the systolic and diastolic pressure is termed as
A
Pulse deficit
B
Pulse pressure
C
Apical rate
D
Cardiac rate
Question 35
Which of the following is TRUE about the auscultation of blood pressure?
A
The bell of the stethoscope is use in auscultating BP
B
Sound produced by BP is considered as HIGH frequency sound
C
Pulse + 4 is considered as FULL
D
Pulse +1 is considered as NORMAL
Question 36
Client has undergone Upper GI and Lower GI series. Which type of health assessment framework is used in this situation?
A
Cephalocaudal framework
B
Body system framework
C
Functional health framework
D
Head to toe framework
Question 37
The best position for any procedure that involves vaginal and cervical examination is
A
Side lying
B
Dorsal recumbent
C
Lithotomy
D
Supine
Question 38
Among the following statements, which should be given the HIGHEST priority?
A
Client is in extreme pain
B
Client’s blood pressure is 60/40
C
Client’s temperature is 40 deg. Centigrade
D
Client is cyanotic
Question 39
In assessing the client’s chest, which position best show chest expansion as well as its movements?
A
Sidelying
B
Supine
C
Prone
D
Sitting
Question 40
The following are correct actions when taking radial pulse except:
A
Use the thumb to palpate the artery
B
Put the palms downward
C
Assess the pulse rate, rhythm, volume and bilateral quality
D
Use two or three fingers to palpate the pulse at the inner wrist
Question 41
Dr. Fabian De Las Santas, is about to conduct an ophthalmoscope examination. Which of the following, if done by a nurse, is a Correct preparation before the procedure?
A
Darken the room to provide better illumination
B
Pour warm water over the ophthalmoscope to ensure comfort
C
Open the windows, curtains and light to allow better illumination
D
Provide the necessary draping to ensure privacy
Question 42
David, 68 year old male client is scheduled for Serum Lipid analysis. Which of the following health teaching is important to ensure accurate reading?
A
Tell the client that the normal serum lipase level is 50 to 140 U/L
B
NPO for 12 hours pre procedure
C
Ask the client to drink 1 glass of water 1 hour prior to the procedure
D
Tell the patient to eat fatty meals 3 days prior to the procedure
Question 43
The primary respiratory center
A
Aortic bodies
B
Carotid bodies
C
Medulla oblongata
D
Pons
Question 44
When palpating the client’s neck for lymphadenopathy, where should the nurse position himself?
A
At the client’s back
B
At the client’s left side
C
At the client’s right side
D
In front of a sitting client
Question 45
A process of heat loss which involves the transfer of heat from one surface to another is
A
Conduction
B
Radiation
C
Evaporation
D
Convection
Question 46
In palpating the client’s abdomen, Which of the following is the best position for the client to assume?
A
Supine
B
Lithotomy
C
Side lying
D
Dorsal recumbent
Question 47
When John has been given paracetamol, his fever was brought down dramatically from 40 degrees Celsius to 36.7 degrees in a matter of 10 minutes. The nurse would assess this event as:
A
The goal has been met but not with the desired outcome criteria
B
The goal is not completely met
C
The goal of reducing john’s fever has been met with full satisfaction of the outcome criteria
D
The desired goal has been partially met
Question 48
A community health nurse is assessing client’s urine using the Acetic Acid solution. Which of the following, if done by a nurse, indicates lack of correct knowledge with the procedure?
A
The nurse determines abnormal result if she noticed that the test tube becomes cloudy
B
The nurse heats the test tube after adding 2/3 part of Urine
C
The nurse heats the test tube after adding 1/3 part acetic acid
D
The nurse added the Urine as the 2/3 part of the solution
Question 49
Which of the following is a contraindication in taking RECTAL temperature?
A
Unconscious
B
NPO
C
Very young children
D
Neutropenic
Question 50
A characteristic of the nursing process that is essential to promote client satisfaction and progress. The care should also be relevant with the client’s needs.
A
Organized and Systematic
B
Efficient
C
Effective
D
Humanistic
Question 51
In a routine sputum analysis, Which of the following indicates proper nursing action before sputum collection?
A
Discard the container if the outside becomes contaminated with the sputum
B
Tell the client that 4 tablespoon of sputum is needed for each specimen for a routine sputum analysis
C
Rinse the client’s mouth with Listerine after collection
D
Secure a clean container
Question 52
Which is a preferable arm for BP taking?
A
The right arm
B
The left arm
C
An arm with the most contraptions
D
The left arm of the client with a CVA affecting the right brain
Question 53
Rhina, who has Menieres disease, said that her environment is moving. Which of the following is a valid assessment?
Rhina is giving an objective data
Rhina is giving a subjective data
The source of the data is primary
The source of the data is secondary
A
2.4
B
2,3
C
1,4
D
1,3
Question 54
Which of the following statement is TRUE about pulse?
A
Young person have higher pulse than older persons
B
In lying position, Pulse rate is higher
C
Digitalis has a positive chronotropic effect
D
Males have higher pulse rate than females after puberty
Question 55
In collecting a urine from a catheterized patient, Which of the following statement indicates an accurate performance of the procedure?
A
Clamp above the port for 30 to 60 minutes before drawing the urine from the port
B
Clamp above the port for 5 to 10 minutes before drawing the urine from the port
C
Clamp below the port for 30 to 60 minutes before drawing the urine from the port
D
Clamp below the port for 5 to 10 minutes before drawing the urine from the port
Question 56
Which of the following is TRUE about the blood pressure determinants?
A
Hypervolemia increases GFR
B
Epinephrine decreases BP
C
HCT of 70% might decrease or increase BP
D
Hypervolemia lowers BP
Question 57
When is the best time to collect urine specimen for routine urinalysis and C/S?
A
Midnight
B
Before breakfast
C
Early morning
D
Later afternoon
Question 58
All of the following factors correctly influence respiration except one. Which of the following is incorrect?
A
Increase altitude, Increase RR
B
Increase temperature of the environment, Increase RR
C
Hydrocodone decreases RR
D
Stress increases RR
Question 59
Which of the following is TRUE with regards to Client Goals?
A
They are general and broadly stated
B
They are specific, measurable, attainable and time bounded
C
Example is : After discharge planning, Client demonstrated the proper psychomotor skills for insulin injection.
D
They should answer for WHO, WHAT ACTIONS, WHAT CIRCUMSTANCES, HOW WELL and WHEN.
Question 60
How many minutes are allowed to pass if the client had engaged in strenuous activities, smoked or ingested caffeine before taking his/her BP?
A
5
B
30
C
15
D
10
Question 61
In assessing the abdomen, Which of the following is the correct sequence of the physical assessment?
A
Inspection, Palpation, Auscultation, Percussion
B
Palpation, Auscultation, Percussion, Inspection
C
Inspection, Auscultation, Percussion, Palpation
D
Inspection, Auscultation, Palpation, Percussion
Question 62
John has a fever of 39.5 degrees 2 days ago, But yesterday, he has a normal temperature of 36.5 degrees. Today, his temperature surges to 40 degrees. What type of fever is John having?
A
Intermittent
B
Remittent
C
Relapsing
D
Constant
Question 63
Which of the following is more life threatening?
A
BP = 180/100
B
BP = 80/50
C
BP = 160/120
D
BP = 90/60
Question 64
Rectal examination is done with a client in what position?
A
Dorsal recumbent
B
Sims position
C
Supine
D
Lithotomy
Question 65
If the client is female, and the doctor is a male and the patient is about to undergo a vaginal and cervical examination, why is it necessary to have a female nurse in attendance?
A
To ensure that the procedure is done in an ethical manner
B
To assess the client’s response to examination
C
To assist the doctor
D
To ensure that the doctor performs the procedure safely
Question 66
A type of heat loss that occurs when the heat is dissipated by air current
A
Convection
B
Radiation
C
Conduction
D
Evaporation
Question 67
Which of the following is responsible for deep and prolonged inspiration
A
Carotid bodies
B
Pons
C
Medulla oblongata
D
Aortic bodies
Question 68
They are the first one to suggest a 4 step nursing process which are : APIE , or assessment, planning, implementation and evaluation.
Yura
Walsh
Roy
Knowles
A
1,3
B
3,4
C
1,2
D
2,3
Question 69
The following are social data about the client except
A
Patient’s lifestyle
B
Religious practices
C
Usual health status
D
Family home situation
Question 70
Which of the following completely describes PULSUS PARADOXICUS?
A
A greater-than-normal decrease in systolic blood pressure with inspiration
B
Pulse is paradoxically high when client is in standing position and low when supine.
C
A greater-than-normal increase in systolic blood pressure with inspiration
D
Pulse is paradoxically low when client is in standing position and high when supine.
Question 71
John’s temperature 10 hours ago is a normal 36.5 degrees. 4 hours ago, He has a fever with a temperature of 38.9 Degrees. Right now, his temperature is back to normal. Which of the following best describe the fever john is having?
A
Intermittent
B
Constant
C
Remittent
D
Relapsing
Question 72
Which of the following is a correct nursing action when collecting urine specimen from a client with an Indwelling catheter?
A
Detach catheter from the connecting tube and draw the specimen from the port
B
Insert the syringe straight to the port to allow self sealing of the port
C
Use sterile syringe to aspirate urine specimen from the drainage port
D
Collect urine specimen from the drainage bag
Question 73
Which of the following is inappropriate in collecting mid stream clean catch urine specimen for urine analysis?
A
Discard the first flow of the urine
B
Collect early in the morning, First voided specimen
C
Collect 5 to 10 ml for urine
D
Do perineal care before specimen collection
Question 74
The characteristic fever in Dengue Virus is characterized as:
A
Tricyclic
B
Biphasic
C
Triphasic
D
Bicyclic
Question 75
+++ Positive result after Benedicts test is depicted by what color?
A
Blue
B
Green
C
Orange
D
Yellow
Question 76
She is the first one to coin the term “NURSING PROCESS” She introduced 3 steps of nursing process which are Observation, Ministration and Validation.
A
Johnson
B
Rogers
C
Hall
D
Nightingale
Question 77
Which of the following is the correct interpretation of the ERROR OF PARALLAX
A
If the eye level is higher than the level of the meniscus, it will cause a false high reading
B
If the eye level is equal to that of the level of the upper meniscus, the reading is accurate
C
If the eye level is lower than the level of the meniscus, it will cause a false low reading
D
If the eye level is higher than the level of the meniscus, it will cause a false low reading
Question 78
In cleaning the thermometer after use, The direction of the cleaning to follow Medical Asepsis is :
A
From bulb to stem
B
From stem to stem
C
From bulb to bulb
D
From stem to bulb
Question 79
Contains the pneumotaxic and the apneutic centers
A
Aortic bodies
B
Carotid bodies
C
Pons
D
Medulla oblongata
Question 80
The American Nurses association formulated an innovation of the Nursing process. Today, how many distinct steps are there in the nursing process?
A
APIE – 4
B
ADOPIE – 6
C
ADPIE – 5
D
ADOPIER – 7
Question 81
The heat regulating center is found in the
A
Thalamus
B
Medulla oblongata
C
Hypothalamus
D
Pons
Question 82
Nurse Angela diagnosed Mrs. Delgado, who have undergone a BKA. Her diagnosis is SELF ESTEEM DISTURBANCE R/T CHANGE IN BODY IMAGE. Although the client has not yet seen her lost leg, Angela already anticipated the diagnosis. This is what type of Diagnosis?
A
Probable
B
Risk
C
Actual
D
Possible
Question 83
Who collects Blood specimen?
A
Physician
B
Medical technologist
C
Physical therapist
D
The nurse
Question 84
John has a fever of 38.5 Deg. Celsius. It surges at around 40 Degrees and go back to 38.5 degrees 6 times today in a typical pattern. What kind of fever is John having?
A
Remittent
B
Relapsing
C
Constant
D
Intermittent
Question 85
Tympanic temperature is taken from John, A client who was brought recently into the ER due to frequent barking cough. The temperature reads 37.9 Degrees Celsius. As a nurse, you conclude that this temperature is
A
At the high end of the normal range
B
At the low end of the normal range
C
Low
D
High
Question 86
The primary factor responsible for body heat production is the
A
Stress
B
Metabolism
C
Muscle activity
D
Release of thyroxin
Question 87
In inspecting the abdomen, which of the following is NOT DONE?
A
Ask the client to void first
B
The best position in assessing the abdomen is Dorsal recumbent
C
The knees and legs are externally rotated
D
Knees and legs are straighten to relax the abdomen
Question 88
In a 24 hour urine specimen started Friday, 9:00 A.M, which of the following if done by a Nurse indicate a NEED for further procedural debriefing?
A
The nurse ask the client to urinate at 9:00 A.M, Friday and she included the urine in the 24 hour urine specimen
B
The nurse discards the Friday 9:00 A M urine of the client
C
The nurse added preservatives as per protocol and refrigerates the specimen
D
The nurse included the Saturday 9:00 A.M urine of the client to the specimen collection
Question 89
Which of the following is incorrect with regards to proper urine testing using Benedict’s Solution?
A
Add 8 to 10 drops of urine
B
Heat the Benedict’s solution without the urine to check if the solution is contaminated
C
If the color remains BLUE, the result is POSITIVE
D
Heat around 5ml of Benedict’s solution together with the urine in a test tube
Question 90
How long should the Rectal Thermometer be inserted to the clients anus?
A
1 to 2 inches
B
2 to 3 inches
C
.5 to 1.5 inches
D
3 to 5 inches
Question 91
Which of the following is INCORRECT in assessing client’s BP?
A
The sound heard during taking BP is known as KOROTKOFF sound
B
Read the mercury at the upper meniscus, preferably at the eye level to prevent error of parallax
C
Inflate and deflate slowly, 2-3 mmHg at a time
D
If the BP is taken on the left leg using the popliteal artery pressure, a BP of 160/80 is normal.
Question 92
A framework for health assessment that evaluates the effects of stressors to the mind, body and environment in relation with the ability of the client to perform ADL.
A
Head to toe framework
B
Cephalocaudal framework
C
Body system framework
D
Functional health framework
Question 93
When should the client test his blood sugar levels for greater accuracy?
A
2 Hours after meals
B
Before meals
C
During meals
D
In between meals
Question 94
Which of the following Nursing diagnosis is INCORRECT?
A
Possible ineffective coping R/T Loss of loved one
B
High risk for injury R/T Absence of side rails
C
Self esteem disturbance R/T Effects of surgical removal of the leg
D
Fluid volume deficit R/T Diarrhea
Question 95
Refers to the pressure when the ventricles are at rest
A
Systole
B
Preload
C
Pulse pressure
D
Diastole
Question 96
In palpating the client’s breast, Which of the following position is necessary for the patient to assume before the start of the procedure?
A
Sitting
B
Dorsal recumbent
C
Supine
D
Lithotomy
Question 97
Which of the following is NOT a contraindication in taking ORAL temperature?
A
Nausea and Vomitting
B
Presence of NGT
C
Dyspnea
D
Quadriplegic
Question 98
Measure the leg circumference of a client with bipedal edema is best done in what position?
A
Sitting
B
Standing
C
Dorsal recumbent
D
Supine
Question 99
The sequence in examining the quadrants of the abdomen is:
A
RLQ,RUQ,LLQ,LUQ
B
RUQ,RLQ,LLQ,LUQ
C
RUQ,RLQ,LUQ,LLQ
D
RLQ,RUQ,LUQ,LLQ
Question 100
Which of the following is a NOT a correct statement of an Outcome criteria?
A
Discusses fears and concerns regarding the surgical procedure
B
Reestablishes a normal pattern of elimination
C
Ambulates 30 feet with a cane before discharge
D
Demonstrates proper coughing and breathing technique after a teaching session
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1. She is the first one to coin the term “NURSING PROCESS” She introduced 3 steps of nursing process which are Observation, Ministration and Validation.
Nightingale
Johnson
Rogers
Hall
2. The American Nurses association formulated an innovation of the Nursing process. Today, how many distinct steps are there in the nursing process?
APIE – 4
ADPIE – 5
ADOPIE – 6
ADOPIER – 7
3. They are the first one to suggest a 4 step nursing process which are : APIE , or assessment, planning, implementation and evaluation.
Yura
Walsh
Roy
Knowles
1,2
1,3
3,4
2,3
4. Which characteristic of nursing process is responsible for proper utilization of human resources, time and cost resources?
Organized and Systematic
Humanistic
Efficient
Effective
5. Which characteristic of nursing process addresses the INDIVIDUALIZED care a client must receive?
Organized and Systematic
Humanistic
Efficient
Effective
6. A characteristic of the nursing process that is essential to promote client satisfaction and progress. The care should also be relevant with the client’s needs.
Organized and Systematic
Humanistic
Efficient
Effective
7. Rhina, who has Menieres disease, said that her environment is moving. Which of the following is a valid assessment?
Rhina is giving an objective data
Rhina is giving a subjective data
The source of the data is primary
The source of the data is secondary
1,3
2,3
2.4
1,4
8. Nurse Angela, observe Joel who is very apprehensive over the impending operation. The client is experiencing dyspnea, diaphoresis and asks lots of questions. Angela made a diagnosis of ANXIETY R/T INTRUSIVE PROCEDURE. This is what type of Nursing Diagnosis?
Actual
Probable
Possible
Risk
9. Nurse Angela diagnosed Mrs. Delgado, who have undergone a BKA. Her diagnosis is SELF ESTEEM DISTURBANCE R/T CHANGE IN BODY IMAGE. Although the client has not yet seen her lost leg, Angela already anticipated the diagnosis. This is what type of Diagnosis?
Actual
Probable
Possible
Risk
10. Nurse Angela is about to make a diagnosis but very unsure because the S/S the client is experiencing is not specific with her diagnosis of POWERLESSNESS R/T DIFFICULTY ACCEPTING LOSS OF LOVED ONE. She then focus on gathering data to refute or prove her diagnosis but her plans and interventions are already ongoing for the diagnosis. Which type of Diagnosis is this?
Actual
Probable
Possible
Risk
11. Nurse Angela knew that Stephen Lee Mu Chin, has just undergone an operation with an incision near the diaphragm. She knew that this will contribute to some complications later on. She then should develop what type of Nursing diagnosis?
Actual
Probable
Possible
Risk
12. Which of the following Nursing diagnosis is INCORRECT?
Fluid volume deficit R/T Diarrhea
High risk for injury R/T Absence of side rails
Possible ineffective coping R/T Loss of loved one
Self esteem disturbance R/T Effects of surgical removal of the leg
13. Among the following statements, which should be given the HIGHEST priority?
Client is in extreme pain
Client’s blood pressure is 60/40
Client’s temperature is 40 deg. Centigrade
Client is cyanotic
14. Which of the following need is given a higher priority among others?
The client has attempted suicide and safety precaution is needed
The client has disturbance in his body image because of the recent operation
The client is depressed because her boyfriend left her all alone
The client is thirsty and dehydrated
15. Which of the following is TRUE with regards to Client Goals?
They are specific, measurable, attainable and time bounded
They are general and broadly stated
They should answer for WHO, WHAT ACTIONS, WHAT CIRCUMSTANCES, HOW WELL and WHEN.
Example is : After discharge planning, Client demonstrated the proper psychomotor skills for insulin injection.
16. Which of the following is a NOT a correct statement of an Outcome criteria?
Ambulates 30 feet with a cane before discharge
Discusses fears and concerns regarding the surgical procedure
Demonstrates proper coughing and breathing technique after a teaching session
Reestablishes a normal pattern of elimination
17. Which of the following is a OBJECTIVE data?
Dizziness
Chest pain
Anxiety
Blue nails
18. A patient’s chart is what type of data source?
Primary
Secondary
Tertiary
Can be A and B
19. All of the following are characteristic of the Nursing process except
Dynamic
Cyclical
Universal
Intrapersonal
20. Which of the following is true about the NURSING CARE PLAN?
It is nursing centered
Rationales are supported by interventions
Verbal
Atleast 2 goals are needed for every nursing diagnosis
21. A framework for health assessment that evaluates the effects of stressors to the mind, body and environment in relation with the ability of the client to perform ADL.
Functional health framework
Head to toe framework
Body system framework
Cephalocaudal framework
22. Client has undergone Upper GI and Lower GI series. Which type of health assessment framework is used in this situation?
Functional health framework
Head to toe framework
Body system framework
Cephalocaudal framework
23. Which of the following statement is true regarding temperature?
Oral temperature is more accurate than rectal temperature
The bulb used in Rectal temperature reading is pear shaped or round
The older the person, the higher his BMR
When the client is swimming, BMR Decreases
24. A type of heat loss that occurs when the heat is dissipated by air current
Convection
Conduction
Radiation
Evaporation
25. Which of the following is TRUE about temperature?
The highest temperature usually occurs later in a day, around 8 P.M to 12 M.N
The lowest temperature is usually in the Afternoon, Around 12 P.M
Thyroxin decreases body temperature
Elderly people are risk for hyperthermia due to the absence of fats, Decreased thermoregulatory control and sedentary lifestyle.
26. Hyperpyrexia is a condition in which the temperature is greater than
40 degree Celsius
39 degree Celsius
100 degree Fahrenheit
105.8 degree Fahrenheit
27. Tympanic temperature is taken from John, A client who was brought recently into the ER due to frequent barking cough. The temperature reads 37.9 Degrees Celsius. As a nurse, you conclude that this temperature is
High
Low
At the low end of the normal range
At the high end of the normal range
28. John has a fever of 38.5 Deg. Celsius. It surges at around 40 Degrees and go back to 38.5 degrees 6 times today in a typical pattern. What kind of fever is John having?
Relapsing
Intermittent
Remittent
Constant
29. John has a fever of 39.5 degrees 2 days ago, But yesterday, he has a normal temperature of 36.5 degrees. Today, his temperature surges to 40 degrees. What type of fever is John having?
Relapsing
Intermittent
Remittent
Constant
30. John’s temperature 10 hours ago is a normal 36.5 degrees. 4 hours ago, He has a fever with a temperature of 38.9 Degrees. Right now, his temperature is back to normal. Which of the following best describe the fever john is having?
Relapsing
Intermittent
Remittent
Constant
31. The characteristic fever in Dengue Virus is characterized as:
Tricyclic
Bicyclic
Biphasic
Triphasic
32. When John has been given paracetamol, his fever was brought down dramatically from 40 degrees Celsius to 36.7 degrees in a matter of 10 minutes. The nurse would assess this event as:
The goal of reducing john’s fever has been met with full satisfaction of the outcome criteria
The desired goal has been partially met
The goal is not completely met
The goal has been met but not with the desired outcome criteria
33. What can you expect from Marianne, who is currently at the ONSET stage of fever?
Hot, flushed skin
Increase thirst
Convulsion
Pale,cold skin
34. Marianne is now at the Defervescence stage of the fever, which of the following is expected?
Delirium
Goose flesh
Cyanotic nail beds
Sweating
35. Considered as the most accessible and convenient method for temperature taking
Oral
Rectal
Tympanic
Axillary
36. Considered as Safest and most non invasive method of temperature taking
Oral
Rectal
Tympanic
Axillary
37. Which of the following is NOT a contraindication in taking ORAL temperature?
Quadriplegic
Presence of NGT
Dyspnea
Nausea and Vomitting
38. Which of the following is a contraindication in taking RECTAL temperature?
Unconscious
Neutropenic
NPO
Very young children
39. How long should the Rectal Thermometer be inserted to the clients anus?
1 to 2 inches
5 to 1.5 inches
3 to 5 inches
2 to 3 inches
40. In cleaning the thermometer after use, The direction of the cleaning to follow Medical Asepsis is :
From bulb to stem
From stem to bulb
From stem to stem
From bulb to bulb
41. How long should the thermometer stay in the Client’s Axilla?
3 minutes
4 minutes
7 minutes
10 minutes
42. Which of the following statement is TRUE about pulse?
Young person have higher pulse than older persons
Males have higher pulse rate than females after puberty
Digitalis has a positive chronotropic effect
In lying position, Pulse rate is higher
43. The following are correct actions when taking radial pulse except:
Put the palms downward
Use the thumb to palpate the artery
Use two or three fingers to palpate the pulse at the inner wrist
Assess the pulse rate, rhythm, volume and bilateral quality
44. The difference between the systolic and diastolic pressure is termed as
Apical rate
Cardiac rate
Pulse deficit
Pulse pressure
45. Which of the following completely describes PULSUS PARADOXICUS?
A greater-than-normal increase in systolic blood pressure with inspiration
A greater-than-normal decrease in systolic blood pressure with inspiration
Pulse is paradoxically low when client is in standing position and high when supine.
Pulse is paradoxically high when client is in standing position and low when supine.
46. Which of the following is TRUE about respiration?
I:E 2:1
I:E : 4:3
I:E 1:1
I:E 1:2
47. Contains the pneumotaxic and the apneutic centers
Medulla oblongata
Pons
Carotid bodies
Aortic bodies
48. Which of the following is responsible for deep and prolonged inspiration
Medulla oblongata
Pons
Carotid bodies
Aortic bodies
49. Which of the following is responsible for the rhythm and quality of breathing?
Medulla oblongata
Pons
Carotid bodies
Aortic bodies
50. The primary respiratory center
Medulla oblongata
Pons
Carotid bodies
Aortic bodies
51. Which of the following is TRUE about the mechanism of action of the Aortic and Carotid bodies?
If the BP is elevated, the RR increases
If the BP is elevated, the RR decreases
Elevated BP leads to Metabolic alkalosis
Low BP leads to Metabolic acidosis
52. All of the following factors correctly influence respiration except one. Which of the following is incorrect?
Hydrocodone decreases RR
Stress increases RR
Increase temperature of the environment, Increase RR
Increase altitude, Increase RR
53. When does the heart receives blood from the coronary artery?
Systole
Diastole
When the valves opens
When the valves closes
54. Which of the following is more life threatening?
BP = 180/100
BP = 160/120
BP = 90/60
BP = 80/50
55. Refers to the pressure when the ventricles are at rest
Diastole
Systole
Preload
Pulse pressure
56. Which of the following is TRUE about the blood pressure determinants?
Hypervolemia lowers BP
Hypervolemia increases GFR
HCT of 70% might decrease or increase BP
Epinephrine decreases BP
57. Which of the following do not correctly correlates the increase BP of Ms. Aida, a 70 year old diabetic?
Females, after the age 65 tends to have lower BP than males
Disease process like Diabetes increase BP
BP is highest in the morning, and lowest during the night
Africans, have a greater risk of hypertension than Caucasian and Asians.
58. How many minutes are allowed to pass if the client had engaged in strenuous activities, smoked or ingested caffeine before taking his/her BP?
5
10
15
30
59. Too narrow cuff will cause what change in the Client’s BP?
True high reading
True low reading
False high reading
False low reading
60. Which is a preferable arm for BP taking?
An arm with the most contraptions
The left arm of the client with a CVA affecting the right brain
The right arm
The left arm
61. Which of the following is INCORRECT in assessing client’s BP?
Read the mercury at the upper meniscus, preferably at the eye level to prevent error of parallax
Inflate and deflate slowly, 2-3 mmHg at a time
The sound heard during taking BP is known as KOROTKOFF sound
If the BP is taken on the left leg using the popliteal artery pressure, a BP of 160/80 is normal.
62. Which of the following is the correct interpretation of the ERROR OF PARALLAX
If the eye level is higher than the level of the meniscus, it will cause a false high reading
If the eye level is higher than the level of the meniscus, it will cause a false low reading
If the eye level is lower than the level of the meniscus, it will cause a false low reading
If the eye level is equal to that of the level of the upper meniscus, the reading is accurate
63. How many minute/s is/are allowed to pass before making a re-reading after the first one?
1
5
15
30
64. Which of the following is TRUE about the auscultation of blood pressure?
Pulse + 4 is considered as FULL
The bell of the stethoscope is use in auscultating BP
Sound produced by BP is considered as HIGH frequency sound
Pulse +1 is considered as NORMAL
65. In assessing the abdomen, Which of the following is the correct sequence of the physical assessment?
Inspection, Auscultation, Percussion, Palpation
Palpation, Auscultation, Percussion, Inspection
Inspection, Palpation, Auscultation, Percussion
Inspection, Auscultation, Palpation, Percussion
66. The sequence in examining the quadrants of the abdomen is:
RUQ,RLQ,LUQ,LLQ
RLQ,RUQ,LLQ,LUQ
RUQ,RLQ,LLQ,LUQ
RLQ,RUQ,LUQ,LLQ
67. In inspecting the abdomen, which of the following is NOT DONE?
Ask the client to void first
Knees and legs are straighten to relax the abdomen
The best position in assessing the abdomen is Dorsal recumbent
The knees and legs are externally rotated
68. Dr. Fabian De Las Santas, is about to conduct an ophthalmoscope examination. Which of the following, if done by a nurse, is a Correct preparation before the procedure?
Provide the necessary draping to ensure privacy
Open the windows, curtains and light to allow better illumination
Pour warm water over the ophthalmoscope to ensure comfort
Darken the room to provide better illumination
69. If the client is female, and the doctor is a male and the patient is about to undergo a vaginal and cervical examination, why is it necessary to have a female nurse in attendance?
To ensure that the doctor performs the procedure safely
To assist the doctor
To assess the client’s response to examination
To ensure that the procedure is done in an ethical manner
70. In palpating the client’s breast, Which of the following position is necessary for the patient to assume before the start of the procedure?
Supine
Dorsal recumbent
Sitting
Lithotomy
71. When is the best time to collect urine specimen for routine urinalysis and C/S?
Early morning
Later afternoon
Midnight
Before breakfast
72. Which of the following is among an ideal way of collecting a urine specimen for culture and sensitivity?
Use a clean container
Discard the first flow of urine to ensure that the urine is not contaminated
Collect around 30-50 ml of urine
Add preservatives, refrigerate the specimen or add ice according to the agency’s protocol
73. In a 24 hour urine specimen started Friday, 9:00 A.M, which of the following if done by a Nurse indicate a NEED for further procedural debriefing?
The nurse ask the client to urinate at 9:00 A.M, Friday and she included the urine in the 24 hour urine specimen
The nurse discards the Friday 9:00 A M urine of the client
The nurse included the Saturday 9:00 A.M urine of the client to the specimen collection
The nurse added preservatives as per protocol and refrigerates the specimen
74. This specimen is required to assess glucose levels and for the presence of albumin the the urine
Midstream clean catch urine
24 hours urine collection
Postprandial urine collection
Second voided urine
75. When should the client test his blood sugar levels for greater accuracy?
During meals
In between meals
Before meals
2 Hours after meals
76. In collecting a urine from a catheterized patient, Which of the following statement indicates an accurate performance of the procedure?
Clamp above the port for 30 to 60 minutes before drawing the urine from the port
Clamp below the port for 30 to 60 minutes before drawing the urine from the port
Clamp above the port for 5 to 10 minutes before drawing the urine from the port
Clamp below the port for 5 to 10 minutes before drawing the urine from the port
77. A community health nurse should be resourceful and meet the needs of the client. A villager ask him, Can you test my urine for glucose? Which of the following technique allows the nurse to test a client’s urine for glucose without the need for intricate instruments.
Acetic Acid test
Nitrazine paper test
Benedict’s test
Litmus paper test
78. A community health nurse is assessing client’s urine using the Acetic Acid solution. Which of the following, if done by a nurse, indicates lack of correct knowledge with the procedure?
The nurse added the Urine as the 2/3 part of the solution
The nurse heats the test tube after adding 1/3 part acetic acid
The nurse heats the test tube after adding 2/3 part of Urine
The nurse determines abnormal result if she noticed that the test tube becomes cloudy
79. Which of the following is incorrect with regards to proper urine testing using Benedict’s Solution?
Heat around 5ml of Benedict’s solution together with the urine in a test tube
Add 8 to 10 drops of urine
Heat the Benedict’s solution without the urine to check if the solution is contaminated
If the color remains BLUE, the result is POSITIVE
80. +++ Positive result after Benedicts test is depicted by what color?
Blue
Green
Yellow
Orange
81. Clinitest is used in testing the urine of a client for glucose. Which of the following, If committed by a nurse indicates error?
Specimen is collected after meals
The nurse puts 1 clinitest tablet into a test tube
She added 5 drops of urine and 10 drops of water
If the color becomes orange or red, It is considered postitive
82. Which of the following nursing intervention is important for a client scheduled to have a Guaiac Test?
Avoid turnips, radish and horseradish 3 days before procedure
Continue iron preparation to prevent further loss of Iron
Do not eat read meat 12 hours before procedure
Encourage caffeine and dark colored foods to produce accurate results
83. In collecting a routine specimen for fecalysis, Which of the following, if done by a nurse, indicates inadequate knowledge and skills about the procedure?
The nurse scoop the specimen specifically at the site with blood and mucus
She took around 1 inch of specimen or a teaspoonful
Ask the client to call her for the specimen after the client wiped off his anus with a tissue
Ask the client to defecate in a bedpan, Secure a sterile container
84. In a routine sputum analysis, Which of the following indicates proper nursing action before sputum collection?
Secure a clean container
Discard the container if the outside becomes contaminated with the sputum
Rinse the client’s mouth with Listerine after collection
Tell the client that 4 tablespoon of sputum is needed for each specimen for a routine sputum analysis
85. Who collects Blood specimen?
The nurse
Medical technologist
Physician
Physical therapist
86. David, 68 year old male client is scheduled for Serum Lipid analysis. Which of the following health teaching is important to ensure accurate reading?
Tell the patient to eat fatty meals 3 days prior to the procedure
NPO for 12 hours pre procedure
Ask the client to drink 1 glass of water 1 hour prior to the procedure
Tell the client that the normal serum lipase level is 50 to 140 U/L
87. The primary factor responsible for body heat production is the
Metabolism
Release of thyroxin
Muscle activity
Stress
88. The heat regulating center is found in the
Medulla oblongata
Thalamus
Hypothalamus
Pons
89. A process of heat loss which involves the transfer of heat from one surface to another is
Radiation
Conduction
Convection
Evaporation
90. Which of the following is a primary factor that affects the BP?
Obesity
Age
Stress
Gender
91. The following are social data about the client except
Patient’s lifestyle
Religious practices
Family home situation
Usual health status
92. The best position for any procedure that involves vaginal and cervical examination is
Dorsal recumbent
Side lying
Supine
Lithotomy
93. Measure the leg circumference of a client with bipedal edema is best done in what position?
Dorsal recumbent
Sitting
Standing
Supine
94. In palpating the client’s abdomen, Which of the following is the best position for the client to assume?
Dorsal recumbent
Side lying
Supine
Lithotomy
95. Rectal examination is done with a client in what position?
Dorsal recumbent
Sims position
Supine
Lithotomy
96. Which of the following is a correct nursing action when collecting urine specimen from a client with an Indwelling catheter?
Collect urine specimen from the drainage bag
Detach catheter from the connecting tube and draw the specimen from the port
Use sterile syringe to aspirate urine specimen from the drainage port
Insert the syringe straight to the port to allow self sealing of the port
97. Which of the following is inappropriate in collecting mid stream clean catch urine specimen for urine analysis?
Collect early in the morning, First voided specimen
Do perineal care before specimen collection
Collect 5 to 10 ml for urine
Discard the first flow of the urine
98. When palpating the client’s neck for lymphadenopathy, where should the nurse position himself?
At the client’s back
At the client’s right side
At the client’s left side
In front of a sitting client
99. Which of the following is the best position for the client to assume if the back is to be examined by the nurse?
Standing
Sitting
Side lying
Prone
100. In assessing the client’s chest, which position best show chest expansion as well as its movements?
Sitting
Prone
Sidelying
Supine
Answers
D. Hall
C. ADOPIE – 6
A. 1,2
C. Efficient
B. Humanistic
D. Effective
B. 2,3
A. Actual
D. Risk
C. Possible
D. Risk
B. High risk for injury R/T Absence of side rails
D. Client is cyanotic
D. The client is thirsty and dehydrated
B. They are general and broadly stated
D. Reestablishes a normal pattern of elimination
D. Blue nails
B. Secondary
D. Intrapersonal
A. It is nursing centered
A. Functional health framework
C. Body system framework
B. The bulb used in Rectal temperature reading is pear shaped or round
A. Convection
A. The highest temperature usually occurs later in a day, around 8 P.M to 12 M.N
D. 105.8 degree Fahrenheit
D. At the high end of the normal range
C. Remittent
A. Relapsing
B. Intermittent
C. Biphasic
D. The goal has been met but not with the desired outcome criteria
D. Pale,cold skin
D. Sweating
A. Oral
D. Axillary
A. Quadriplegic
B. Neutropenic
B. .5 to 1.5 inches
B. From stem to bulb
C. 7 minutes
A. Young person have higher pulse than older persons
B. Use the thumb to palpate the artery
D. Pulse pressure
B. A greater-than-normal decrease in systolic blood pressure with inspiration
D. I:E 1:2
B. Pons
B. Pons
B. Pons
A. Medulla oblongata
B. If the BP is elevated, the RR decreases
C. Increase temperature of the environment, Increase RR
B. Diastole
B. BP = 160/120
A. Diastole
D. Epinephrine decreases BP
A. Females, after the age 65 tends to have lower BP than males
D. 30
C. False high reading
D. The left arm
A. Read the mercury at the upper meniscus, preferably at the eye level to prevent error of parallax
B. If the eye level is higher than the level of the meniscus, it will cause a false low reading
A. 1
B. The bell of the stethoscope is use in auscultating BP
A. Inspection, Auscultation, Percussion, Palpation
D. RLQ,RUQ,LUQ,LLQ
B. Knees and legs are straighten to relax the abdomen
D. Darken the room to provide better illumination
D. To ensure that the procedure is done in an ethical manner
A. Supine
A. Early morning
B. Discard the first flow of urine to ensure that the urine is not contaminated
A. The nurse ask the client to urinate at 9:00 A.M, Friday and she included the urine in the 24 hour urine specimen
D. Second voided urine
C. Before meals
B. Clamp below the port for 30 to 60 minutes before drawing the urine from the port
C. Benedict’s test
B. The nurse heats the test tube after adding 1/3 part acetic acid
D. If the color remains BLUE, the result is POSITIVE
D. Orange
A.Specimen is collected after meals
A. Avoid turnips, radish and horseradish 3 days before procedure
C. Ask the client to call her for the specimen after the client wiped off his anus with a tissue
C. Rinse the client’s mouth with Listerine after collection
B. Medical technologist
B. NPO for 12 hours pre procedure
A. Metabolism
C. Hypothalamus
B. Conduction
C. Stress
A. Patient’s lifestyle
D. Lithotomy
A. Dorsal recumbent
A. Dorsal recumbent
B. Sims position
C. Use sterile syringe to aspirate urine specimen from the drainage port