FUNDA Q & A
) The nurse should assess the activity
Concepts of Man and His Basic Human Needs
1.) The theory on man as a Biopsychosocial and
Spiritual being by Sister Callista Roy
conceptualizes the following EXCEPT:
A.) Man, as a biologic being is like all other men
B.) Man, as a psychologic being is like no other
man
C.) Man, as a social being is like some other
men
D.) Man, is a spiritual being only when he
professes that he believes in God
Ans: D
>According to the theory on Man as
Biopsychosocial and Spiritual Being, all men are
spiritual by nature. This is because of the will
and intellect; virtues of faith, hope, and charity,
and the belief of existence of supreme power
who guides man’s faith and destiny
2.) Which of the following is NOT a characteristic
of an open system?
A.) It is self-sufficient and is totally isolated from
other systems
B.) It exchanges matter, energy or information
with the environment
C.) It allows sustaining elements to enter the
system to nourish it
D.) It is easily affected by changes in other
systems
Ans: A
>An open system needs to exchange matter,
energy and information. It is interrelated and
interdependent with other systems
3.) Which aspect of man’s nature is
demonstrated by making a choice therapeutic
regimen reluctantly?
A.) Limited and unlimited nature
B.) Mature nature with core of immaturity
C.) A creature of indecisiveness
D.) Rational and logical, yet irrational at times
Ans: C
> Man is a creature of indecisiveness. He is
always at the crossroad of choosing
4.) Body image is:
A.) The way a person appears and his style of
grooming
B.) The way the person looks at a certain age
C.) The way a person pictures/perceives his
appearance and function and how he compares
himself with others.
D.) A body with complete parts and functions
Ans: C
>Body image is the way a person perceives his
appearance and function
5.) The nursing diagnosis Body Image
Disturbance is most likely to be written for which
of the following persons?
A.) A patient with above the knee amputation
B.) A patient with second degree burns
C.) A quadriplegic patient
D.) A person entering the health care system
after moving from wellness to illness
Ans: D
>A person entering a health care system most
likely would experience alteration in body image
6.
tolerance of the patient with which of the
following conditions?
A.) Diabetes mellitus
B.) Diarrhea
C.) Anemia
D.) Kidney stones
Ans: C
>Activity intolerance is an appropriate nursing
diagnosis for a client with anemia. IN anemia,
there is low oxygen-carrying capacity of the
blood, so the client experiences weakness and
fatigue
7.) According to Maslow’s hierarchy of needs,
which of the following is a basic physiologic
need after oxygen?
A.) Water
B.) Freedom from infection
C.) Love and belongingness
D.) Self-esteem
Ans: A
>Water is next to oxygen in the hierarchy of
physiologic needs for survival
8.) Mrs. Sy, diagnosed with cancer of the breast,
is scheduled to undergo chemotherapy. How
should the nurse deal with the topic of hair loss
with client?
A.)Discuss about hair loss as it occurs
B.)Provide reading material about chemotherapy
C.)Acknowledge that hair loss may be a difficult
side effect and explore the patient’s feeling
about this
D.) Give the patient information about head
scarf, hats or wigs
Ans: C
>Focusing on the feelings of the client regarding
hair loss is therapeutic. Discussing about wigs,
headscarf, and hats will be dealt with later
9.) The following are characteristics of basic
human needs EXCEPT:
A.) Priorities are uniform to all individuals
B.) Needs may be met in different ways
C.) Needs are interrelated
D.) Needs may be deferred
Ans: A
>Priorities vary from individual to individual,
according to stage of growth and development,
life situations and other factors
10.) Which of the following needs is considered
by the nurse when she implements reverse
isolation for the client with leukemia?
A.) Physiologic need
B.) Safety and security
C.) Love and belongingness
D.) Self esteem
Ans: B
>The client with leukemia has low resistance to
infections. Protecting him from infection by
implementing reverse or protective isolation
technique meets his need for safety and security
11.) Who among the following clients should be
attended first by the nurse?
A) The client with cough and colds
B.) The client with pain on the chest
C.) The client with fever due to infection
D.) The client who is for discharge
Ans: B
>The client with pain on the chest should be
attended first by the nurse because he needs to
be assessed and managed immediately before
severe problem occurs. The clients with signs
and symptoms of infections may be dealt with
after those without infections to prevent
contamination. The client for discharge would
require longer nursing time for health teachings,
and may be dealt with later
Concepts of Health and Illness
12.) The following are concepts of health:
1...) Health is a state of complete physical,
mental, and social well being and not merely the
absence of disease or infirmity
2.) Health is the ability to maintain balance
3.) Health is the ability to maintain the internal
environment
4.) Health is the integration of all parts and
subparts of an individual
A.) 1,2,3
B.) 1,3,4
C.) 2,3,4
D.) 1,2,3,4
Ans D
1-WHO concept of health
2-Walter Cannon’s concept of health on
homeostasis
3-Claude Bernard’s concept of health on internal
milieu
4- Neuman’s concept of health on integration of
parts and subparts of an individual
13.) The theorist who advocates that health is
the ability to maintain dynamic equilibrium is:
A.) Claude Bernard
B.) Walter Cannon
C.) Hans Selye
D.) Martha Rogers
ANS: B
> Walter Cannon advocates that health is the
ability to maintain dynamic equilibrium
(homeostasis)
14.) The “Health-Illness Continuum Theory”
describes which of the following:
1.) The effect of environment to well-being and
illness
2.) High level wellness is achieved if a person is
able to function independently
3.) Precursor of illness may be hereditary,
environmental and behavioral factors
4.) The relationship between agent, host and
environment
A.) 1,2,3,4
B.) 1,3,4
C.) 1,2,3
D.) 2,3,4
ANS: C
> 1,2,3 Dunn’s “Health-illness Continuum
Theory” describes the following:
1.) The effect of environment to well-being and
illness
2.) High level wellness is achieved if a person is
able to function independently
3.) Precursor of illness may be hereditary,
environmental and behavioral factors
15.) Which of the following statements is not true
is high-level wellness?
A.) It is applicable only to healthy individuals
B.) It is the ability to perform activities of daily
living
C.) It connotes maximizing one’s potentialities
D.) It is the ability to perform self-care
ANS: A
> The statement which is NOT TRUE in high
level wellness is that, it is applicable only to
healthy individuals. High level wellness is
applicable to both the well and the ill, as long as
one maximizes his potentialities and functions
independently
16.) Mrs. De Guzman had been diagnosed to
have hypertension since 15 years ago. Since
then, she had maintained low sodium diet, to
control her blood pressure. This practice is
viewed as:
A.) Her superstitious belief
B.) Her cultural belief
C.) Her personal
D.) Her health belief
ANS: D
> Health belief of an individual influences his/her
preventive health behavior. Health beliefs may
be influenced by individual perceptions,
modifying factors, perceived benefits of
preventive actions and perceived barriers to
preventive actions
17.) The “Role Performance Model” of health
views that:
A.) Health is the absence of signs and
symptoms of disease
B.) Health is successful adaptation
C.) Health is the ability to perform one’s work or
job
D.) Health is realization of one’s potential
ANS: C
> The “Role Performance Model” of health by
Smith views that health is the ability to perform
one’s societal roles such as one’s work or job
18.) Mr. Salvador practices excessive alcohol
intake. This is considered as which type of
precursor to illness?
A.) Behavioral factor
B.) Environmental factor
C.) Hereditary factor
D.) Genetic factor
ANS: A
> Taking alcohol excessively is a behavioral
precursor of illness. Other behavioral factors that
may lead to illness are as follows: cigarette
smoking, poor diet, sedentary lifestyle, poor
hygiene, inadequate rest and sleep, excessive
worry and tension,etc
19.) A person who may or may not be affected
by disease is:
A.) Agent
B.) Carrier
C.) Victim
D.) Host
ANS: D
> A host is an individual who may or may not be
affected by disease
20.) Health promotion activities are directed to
achieve the following:
1. Increasing level of wellness
2. Improving quality of life
3. Relying on health care personnel to maintain
health
4. Promoting healthful lifestyle
A.) 1,2,4
B.) 2,3,4
C.) 1,2,3
D.) 1,2,3,4
ANS: A
> 1,2,4 Health promotion activities are directed
to achieve the following:
1.) Increasing level of wellness
2.) Improving quality of life
3.) Promoting healthful lifestyle
Furthermore, health promotion involves the
principles of self responsibility for one’s health
21.) Which of the following behaviors is not
expected when a client assumes the sick role?
A.) The client seeks for sick leave
B.) The client consults a physician because of
headache and perceived fever
C.) The client takes medications as prescribed
by the physician
D.) The client ignores his dizziness, with the
hope that it will be relieved spontaneously
ANS: D
> Ignoring signs and symptoms of a disease is
not a sick role behavior. Sick role emphasizes
that the person: is not held responsible for his
condition ; is excused from social roles; is
obliged to get well as soon as possible; is
obliged to seek for competent help, i.e. seeking
advice of health professionals for validation of
real illness, explanation of symptoms and
reassurance or prediction of outcome
Health and Illness- Asepsis and Infection Control
22.) Which of the following situations may cause
droplet transmission of microorganisms?
A.) Facing a clients who is coughing and
sneezing within a distance of 3 feet
B.) Eating contaminated shell fish
C.) Puncture from intravenous needle removed
from a client with hepatitis B
D.) Exposure to flood water
Ans: A
> Facing client who is coughing and sneezing
most likely would cause droplet transmission of
microorganisms
23.) Which of the following is most effective
practice by caregivers and family, when caring
for a client with low resistance to infection due to
cancer.
A.) Allow two visitors only, at a time
B.) Wash hands frequently
C.) Wear masks in the client’s room at all times
D.) Meticulous cleaning of the client’s room
ANS: B
> Handwashing is the most effective practice to
prevent transfer of microorganisms
24.) The primary why the faucet is considered as
contaminated is:
A.) It is located in unsterile area
B.) Many people are using it
C.) It is frequently used
D.) It is opened by dirty hands
ANS: D
> The faucet is considered contaminated
primarily because it is opened by dirty hands
25.) The nurse enters the room of the client on
airborne precautions due to tuberculosis. Which
of the following are appropriate actions by the
nurse?
1. She wears the mask, covering the nose and
mouth
2. She washes her hands before and after
removing gloves, after suctioning the client’s
secretions
3. She removes gloves and mask before leaving
the client’s room
4. She discards contaminated suction catheter
tip in a trash can found in the client’s room
A.) 1 and 2
B.) 1 and 3
C.) 1,2 and 3
D.) 1,2,3, and 4
ANS: D
> 1,2,3, and 4 the mask should cover the nose
and mouth snugly. The hands should be washed
before and after removing gloves. Gloves and
mask should be removed before leaving the
client’s room, to contain the microorganism
within the client’s unit. Contaminated articles like
suction catheter should be discarded in a trash
can found in the client’s room to prevent
contamination of the outside environment.
26.) A 14-yar old male is to be admitted to the
unit due to high fever related to influenza. With
whom among the following clients should be
placed together in the room?
A.) The 12-year old male client who had
undergone appendectomy
B.) The 12-year old female with flu
C.) The 12-year old boy with flu
D.) The 12- year old boy with leukemia
ANS: C
> Clients infected with the same type of
microorganism may cohabitate . The gender and
the age of the clients should also be considered.
Clients of the same gender and approximately of
the same age group will stay together well
27.) After caring for a client with extensive body
burns, the nurse performs which of the following
actions when removing protective wear?
A.) Remove, mask, gown, gloves, cap and shoe
cover
B.) Remove gloves, mask, gown, cap and shoe
cover
C.) Remove gown, mask, gloves, cap and shoe
cover
D.) Remove cap and shoe cover, mask, gloves,
gown
ANS: B
> To remove protective wear, peel off gloves
first, then the mask, gown cap and shoe cover.
This is to prevent contamination of skin by the
contaminated gloves
28.) When discarding used needle and syringes,
which of the following is appropriate nursing
action?
A.) Remove needle from the syringe and discard
them in separate containers
B.) Recap needle, then discard the needle still
attached to the syringe into a container
C.) Discard the uncapped needle and syringe
into a container
D.) Break the needle, then discard syringe into a
container
ANS: C
> Discard the uncapped needle and syringe into B.) A single stress does not cause a disease
a leak-proof, puncture-proof container. This is to C.) Stress in inherent to life
prevent needle puncture of self. Universal D.) Stress may be protective but at times
precaution: NEVER RECAP NEEDLE problematic
29.) When performing surgical hand scrub, ANS: A
which of the following nursing actions ensure > This is an incorrect statement because stress
prevention of contamination? is not a nervous strategy; it is a
1. Keep fingernails short, clean, without nail psychophysiologic response
polish 33.) Adaptive responses of man to stressors are
2. Open faucet with knee or foot control characterized by the following:
3. Keep hands above elbows when washing and 1. They are attempts to maintain equilibrium
rinsing 2. They are fairly uniform in all individuals
4. Wear cap, mask, and shoe cover after hand 3. They are limitless
scrub 4. They are always adequate to overcome
A.) 1,3,4 stressors
B.) 1,2,3 A.) 1 and 2
C.) 1,2,4 B.) 1 and 3
D.) 2,3,4 C.) 1 and 4
ANS: B D.) 2 and 4
> 1,2 and 3- Surgical hand scrub involves the ANS: B
following actions: Keep fingernails short, clean, > 1 and 3 adaptive responses are attempts to
without nail polish, open faucets with knee or maintain equilibrium and they are not limitless
foot control; keep hands above elbows when 34.) The first manifestation of inflammation is:
washing and rinsing. Cap, mask, shoe cover A.) Heat
should be worn before hand scrub, to prevent B.) Redness
contamination of the scrubbed hand C.) Swelling
30.) When removing gloves, which of the D.) Pain
following is inappropriate nursing action? ANS: B
A.) Wash gloved hands first > The first manifestation of inflammation is
B.) Peel off gloves inside out redness. This is due to increased blood flow to
C.) Use glove-to-glove, skin-to-skin technique the area affected
D.) Remove mask and gown before removing 35.) The primary cause of pain at the site of
gloves inflammation is:
ANS: D A.) Release of bradykinin
> When removing gloves, it is inappropriate to B.) Injury to nerve endings
remove mask and gown first before gloves. C.) Compression of local nerve endings by
Appropriate nursing actions are: wash gloved edema fluids
hands first, peel off gloves inside out; use glove- D.) Impaired circulations
to-glove, skin-to-skin techniques. Remove ANS: C
gloves first, followed by the mask, gown, cap, > The primary cause of pain at the site of
and shoe cover inflammation is the compression of local nerve
31.) When pouring sterile solution, the nurse endings by edema fluids
performs which of the following actions 36.) The client is in stress because he was told
correctly? by the physician that he needs to undergo
A.) Hold bottle 6 inches above receptacle on the surgery for removal of tumor in his stomach.
sterile field Which of the following are effects of activation of
B.) Remove cap of bottle and place it with the the sympatho-adreno-medullary response in the
underside lid down on a flat surface client?
C.) Return excess solution from sterile 1. Constipation
receptacle to the bottle 2. Urinary frequency
D.) Place the bottle of sterile solution within the 3. Hypoglycemia
sterile field 4. Increased BP
ANS: A A.) 1 and 2
> When pouring sterile solution, hold bottle 6 B.) 1 and 3
inches above receptacle on the sterile field. Cap C.) 2 and 3
of the bottle should be placed with underside lip D.) 1 and 4
up, on a flat surface. Excess solution should not ANS: D
be returned to the bottle because this is >1 and 4- Effects of SAMR are due to release of
considered contaminated. The bottle of the norepinephrine and epinephrine. These include
sterile solution should be placed outside the constipation and increase BP
sterile field because the outside part of the bottle 37.) The client is on NPO since midnight, as
is nonsterile. Remember, sterile field/object preparation for blood test. Adreno-cortical
should come in contact with sterile objects only, response is activated. Which of the following is
to maintain sterility. an expected response?
STRESS, ADAPTATION,HOMEOSTASIS A.) Low BP
32.) Which of the following does not characterize B.) Decrease urine output
stress? C.) Warm, flushed, dry skin
A.) Stress is a nervous energy D.) Low serum Na levels
ANS: B
> Adreno-cortical response involves release of
aldosterone that leads to retention of sodium
and water. This results to decreased urine output
38.) The client fell from the stairs, and had
twisted her ankle. The injury caused
inflammation of the ankle. The nursing
interventions for the inflamed ankle would least
likely include which of the following?
A.) Elevate the ankle with pillow support
B.) Apply warm compress over the ankle for the
first seventy-two hours
C.) Apply compression bandage over the ankle
D.) Administer anti-inflammatory drug as ordered
by the M.D.
ANS: B
> Application of warm compress over an
inflamed body part for the first 72hours of injury
is not included in the nursing interventions for
inflammation. Cold compress is preferably
applied during the first 72hours to cause
vasoconstriction and prevent/reduce swelling.
39.) Which of the following events characterize
the GAS stage of Alarm?
A.) Fight-or-flight response is activated
B.) The person regains homeostasis
C.) Adaptive mechanisms fail
D.) Levels of resistance are increased
ANS: A
> During the GAS stage of Alarm, fight-or-flight
response is activated
40.) The client is a 57 year old male who works
as a traffic officer. He is exposed to sunlight from
morning until afternoon. Which of the following is
considered as a physiologic adaptive mode of
the client?
A.) He learns to interpret different traffic signs
B.) He sees to it that he wears his uniform as
dignified as a policeman does
C.) He develops dark skin
D.) He learns the skill of giving traffic directions
to drivers and pedestrian
ANS: C
> Development of dark skin due to prolonged
exposure to sunlight, is an example of
physiologic adaptive mode
41.) The first protective cells launched at the site
of tissue injury are the:
A.) Basophils
B.) Eosinophils
C.) Monocytes
D.) Neutrophils
ANS: D
> Neutrophils are the first protective cells
launched at the site of injury to perform
phagocytosis
Therapeutic Communication
42.) Therapeutic nurse-patient relationship is
described as follows:
1. It is based on friendship and mutual interest
2. It is a professional relationship
3. It is focused on helping the patient solve
problems and achieve health-related goals
4. It is maintained only as long as the patient
requires professional help
A.) 1,2,3
B.) 1,2,4
C.) 2,3,4
D.) 1,3,4
ANS: C
> 2,3,4- Nurse-patient relationship is a
professional relationship, it is a helping
relationship; it is maintained only as long as the
patient requires professional help. It is not based
on friendship and mutual interest.
43.) During the working phase of therapeutic
relationship, the nurse performs the following
activities EXCEPT:
A.) Reviews the client’s medical record
B.) Establishes a contract with the client
regarding expectations and responsibilities
C.) Decides with the client on mutually agreed
upon goals
D.) Discusses with the client on time frame of
the relationship
ANS: A
> Reviewing the client’s medical record is an
activity done during the pre-interaction phase of
the therapeutic nurse-patient relationship. All the
other choices are performed during the working
phase
44.) The client has been scheduled to undergo
surgery for removal of tumor in her right breast.
Which of the following manifestations indicate
that she is experiencing mild anxiety?
A.) She has increased awareness of the
environment details
B.) She focuses on selected aspect of her illness
C.) She experiences incongruence of thoughts,
feelings and actions
D.) She experiences random motor activity
ANS: A
> Increased awareness of the environment
details is a manifestation of mild anxiety
45.) Which of the following nursing interventions
would least likely be effective when dealing with
a client with aggressive behavior?
A.) Approach in calm, direct manner
B.) Provide opportunities to express feelings
C.) Maintain eye contact with the client
D.) Isolate the client from other clients
ANS: D
> Isolating the client who manifests aggressive
behavior would be ineffective intervention. This
may further agitate him. Providing outlets, like
physical activities will be more effective, to divert
the client’s energy
46.) The client express fear that God will not be
supportive and might be punitive. He is
experiencing which of the following responses?
A.) Spiritual pain
B.) Spiritual anger
C.) Spiritual anxiety
D.) Spiritual loss
ANS: C
>Spiritual anxiety is expression of fear that God
will not be supportive and might be punitive
47.) The client verbalizes, “I’m nothing.” Which
of the following is the most appropriate response
by the nurse?
A.) “Are you suggesting that you feel worthless?”
B.) “Of course, you’re everything.”
C.) “That’s not true.”
D.) “You should not feel that way.”
ANS: A
> Attempts to translate into feelings is a
therapeutic technique of communication. Using
denial (B), disagreeing (C), and advising (D), are
non-therapeutic techniques of communication.
48.) The client verbalizes that he is very anxious
that the diagnostic tests he had undergone
might reveal he has cancer. Which of the
following is most appropriate nursing
intervention?
A.) Tell the client not to worry unnecessarily, until
the results are in.
B.) Ask the client to express feelings and
concerns with regards to outcome of the tests
C.) Reassure the client that everything will be
alright
D.) Advise the client to divert his attention by
watching television or reading newspaper
ANS: B
> Exploring the client’s feelings and encouraging
evaluation encourage verbalization by the client
and therefore promote therapeutic nurse-client
relationship. Reassuring (A and C), advising (D),
are non-therapeutic techniques of
communication
49.) Which of the following statements clearly
defines therapeutic communication?
A.) Therapeutic communication is an
interactional process which is primarily directed
by the nurse
B.) Therapeutic communication is conveys
feelings of warmth, acceptance and empathy
from the nurse to a patient in a relaxed
atmosphere
C.) Therapeutic communication is a reciprocal
interaction based on trust and aimed at
identifying patient needs and developing mutual
goals
D.) Therapeutic communication is the
assessment component of the nursing process
ANS; C
> Therapeutic communication is a reciprocal
interaction based on trust and aimed at
identifying patient needs and developing mutual
goals.
50.) Which of the following concepts is most
important in establishing therapeutic nurse-
patient relationship?
A.) The nurse must fully understand the patient’s
feelings, perceptions and reactions before goals
can be established
B.) The nurse must be a role model for health-
fostering behaviors
C.) The nurse must recognize that the patient
may manifest maladaptive behavior during
illness
D.) The nurse needs to understand that the
patient may test her before he can accept and
trust her
ANS: D
> In establishing therapeutic nurse-patient
relationship, the nurse needs to understand that
the patient may test her before he can accept
and trust her
51.) Which communication skill is most effective
in dealing with covert communication?
A.) validation
B.) Listening
C.) Evaluation
D.) Clarification
ANS: A
> Validation is required for covert
communication. Only the patient can describe
what he wants to convey through covert
communication.
52.) Which of the following are qualities of good
recording?
1. Brevity
2. Completeness and chronology
3. Appropriateness
4. Accuracy
A.) 1,2
B.) 3,4
C.) 1,2,3
D.) 1,2,3,4
ANS: D
> 1,2,3 4- Good recording is characterized by
brevity, completeness and chronology,
appropriateness and accuracy.
53.) All of the following chart entries are correct
EXCEPT:
A.) Complained of chest pain
B.) Chest pain relieved after administration of
NTG sublingually
C.) Able to ambulate to the bathroom without
assistance
D.) Vital signs 120/84 82, 18
ANS: D
> Recording of vital signs should be
T,PR,RR,BP. So the recording of vital signs letter
D is incorrect. The rest are correct chart entries.
54.) The accepted method for signing a nurse’s
note is:
A.) J.C./R.N.
B.) Juan Cruz, Clinical Instructor
C.) Juan Cruz
D.) Juan D. Cruz, R.N.
ANS: D
> The accepted method of signing a nurse’s
notes is writing one’s full name n script and
affixing R.N. to signify one’s status as a
registered nurse
55.) Which of the following teachings methods is
most appropriate for teaching a diabetic client on
self-injection of insulin?
A.) Detailed explanations
B.) Demonstration
C.) Use of pamphlets
D.) Filmstrip
ANS: B
> Demonstration is the best teaching strategy for
psychomotor skills like self-injection of insulin.
56.) the most important characteristic of effective
nurse-patient relationship is that:
A.) It is growth-facilitating
B.) It is base on mutual understanding
C.) It fosters hope and confidence
D.) It involves primarily emotional bond
ANS: A
> The most important characteristic of effective
nurse-patient relationship is that, it is growth-
facilitating for the nurse and the patient
57.) Which of the following statements is most
likely to promote a client’s compliance in
performing post-operative deep breathing,
coughing and turning exercises?
A.) “You will be given adequate medication is
these exercises will cause you pain.”
B.) “Deep breathing, coughing and turning
exercises will promote good breathing, body
circulation. This will prevent complications.”
C.) “These exercises will promote maximum
respiratory ventilation, prevent thrombophlebitis
and atelectasis.”
D.) “Your cooperation during these exercises will
determine the rate of your recovery.”
ANS: B
> Giving information is a therapeutic technique
of communication, like giving explanation on the
benefits that a client will experience from deep
breathing, coughing and turning exercises
during the postop period
58.) When using printed material to teach
diabetic patient about foot care, the nurse
should:
A.) Read the material to the patient
B.) Allow the patient to read the material
C.) Give the material to a family member to read
the patient
D.) Read the material to evaluate its clarity,
accuracy and effectiveness
ANS: D
> Reading materials to be distributed to clients
should be evaluated by the nurse, for clarity,
accuracy and effectiveness
59.) The patient asks the nurse, “ Do you think, I
have the cancer?” The most appropriate
response of the nurse is:
A.) “I will refer you to your doctor.”
B.) “If I were you, I will not worry unnecessarily
C.) “You sound concerned about what the doctor
may find.”
D.) “You will undergo different tests before
cancer can be diagnosed.”
ANS: C
> Focusing on client’s feeling is therapeutic
60.) The patient is scheduled for
proctosigmoidoscopy. She says she is nervous.
The most appropriate response to be made by
the nurse is:
A.) “You need not worry. You have the best
doctor in the hospital.”
B.) “I don’t blame you for feeling that way. If I
were in your position, I would feel the same.”
C.) “Why do you feel that way? Don’t you trust
God?”
D.) “You sound really upset. Would you like to sit
and talk about it?
ANS: D
> Focusing on client’s feeling is therapeutic
61.) Which of the following behavior should the
nurse recognize when caring for elderly
patients?
A.) Most elderly resent being cared for by people
not related to them
B.) Many elderly patients need support in
maintaining their independence
C.) Elderly patients refuse to change old habits
D.) Most elderly are unable to learn new skills
ANS: B
> Maintaining independence among elderly is
essential to maintain their ego integrity
62.) The nurse can best evaluate that the patient
is learning by:
A.) His ability to repeat what was taught
B.) A desired change in his behavior
C.) Verbal acknowledgements that he
understands
D.) His ability to get a good score from a
questionnaire
ANS: B
> The best evidence that learning has taken
place is an observable desired change in the
client’s behavior
63.) Therapeutic communication begins with:
A.) Giving initial care
B.) Showing empathy
C.) Interacting with patient
D.) Knowing your patient
ANS: D
> Therapeutic communication begins with
knowing the client
64.) Which of the following responses is
appropriate when a patient requests to be
discharged at once?
A.) “I will notify the supervisor about your
request.”
B.) “You can only be discharged after the doctor
has given a medical clearance.”
C.) “I will notify your doctor, so I can inform him
about your request.”
D.) “I understand your request but please sign
this special form.”
ANS: C
> Discharge from the hospital requires
physician’s order. Reassuring the client that his
desire to go home will be conveyed to the M.D.
is therapeutic
65.) From your admission interview of a patient,
you obtained a history of allergies. You can best
communicate this information by:
A.) Placing allergy alert in kardex
B.) Writing in the patient’s chart
C.) Informing his attending physician
D.) Observation of the patient’s behavior
ANS: C
> Informing the attending physician about the
client’s allergies is the best way to communicate
the information. Merely placing the information in
the kardex, writing in the patient’s chart, will not
ensure that the physician will be properly
informed about the patient’s allergy
66.) Which of the following techniques can be
most helpful in assessing the degree of distress
and discomfort of a newly admitted patient?
A.) Review the nurse’s notes
B.) Performing physical assessment
C.) Active listening on what the patient says
D.) Observation of the patient’s behavior
ANS: C
> Active listening on what the patient says will be
most helpful in assessing the degree of distress
and discomfort her is expressing. Only the
patient will be able to describe his distress and
discomfort, because these are subjective data.
67.) Which of the following factors will least likely
facilitate learning of a patient?
A.) Motivation to learn
B.) Active participation in the learning activity
C.) Influencing the client to change his health
beliefs
D.) Positively worded corrections
ANS: C
> Influencing the client to change his health
beliefs will least likely facilitate his learning.
Learning takes place more easily if the new
leaning is closely related to previous learning
like health beliefs.
68.) Which of the following principles must be
given consideration by the nurse when giving
patient teaching to an elderly client/
A.) Use audio-visual aids to facilitate learning
B.) Provide opportunity for independence to
learn
C.) Provide lecture for at least 2 hours
D.) Proceed from complex to simple material
ANS: B
> An elderly client learns best if he is given
opportunity for independence to learn. Audio-
visual aids may be ineffective among elderly
because of possible visual and hearing
impairment. Elderly have short attention span,
so providing lecture for at least 2 hours is
ineffective. Proceeding from simple to complex
material facilitates learning; not complex to
simple material.
Stages of Growth and Development: Adulthood
69.) The development task of the young adult
according to Erikson is:
A.) Identity vs. Role confusion
B.) Intimacy vs. Isolation
C.) Generativity vs. Stagnation
D.) Ego Integrity vs. Despair
Ans: B
70.) The following are characteristics of a middle
—aged adult EXCEPT:
A.) There is a sense of stability and
consolidation
B.) The person becomes more oriented and
career-oriented
C.) The person is more family oriented and
career-oriented
D.) The person is more concerned with adhering
to laws that protect the welfare and rights of
others.
Ans: C
71.) The aging process which is characterized
by severe mental deterioration is:
A.) Senility
B.) Senescence
C.) Gerontology
D.) Geriatrics
Ans: A
72.) The rate of Living Theory of Aging
conceptualizes that:
A.) Changes in replication of DNA –RNA are the
causes of aging
B.) Aging is caused by a change in the immune
system
C.) The body is like a machine, parts wear out
and the machine breaks down
D.) The faster one lives, the sooner one ages
and dies
Ans: D
73.) The Disengagement Theory of aging
believes that:
A.) Human beings are mortal and must
eventually leave their place and role in society
B.) One must constantly struggle to remain
functional
C.) Persons will remain the same unless
external and internal factors stimulate change
D.) NOTA
Ans: A
74.) Which of the following is inappropriate
nursing action for the elderly when providing
hygienic practices and skin care?
A.) Provide daily bath
B.) Use mild, superfatted soap
C.) Use body lotion
D.) Change position frequently
Ans: A
75.) The following are appropriate nursing
actions for the elderly with hearing impairment
EXCEPT:
A.) Speak clearly, in well-enunciated words
B.) Use normal tone of voice
C.) Repeat instructions as needed
D.) Increase loudness of voice when speaking
Ans: D
76.) Which of the following colors is difficult to be
distinguished by an elderly?
A.) Red
B.) Green
C.) Purple
D.) Blue
Ans: C
77.) Which of the following enhances drug
toxicity among elderly?
A.) Less acute vision
B.) Decreased renal function
C.) Altered memory
D.) Diminished sense of taste
Ans: B
78.) Which of the following should be include in
the nursing care plan of an elderly?
A.) Provide health teachings in several brief
sessions
B.) Provide recreational activities like
needleworks
C.) Make decisions for the client
D.) Use audio-visual aids when providing health
teachings
Ans: A
79.) Which of the following may be a primary
reason why an elderly finds it difficult to comply
with low sodium diet?
A.) The patient had been used to taking salty
foods in his younger years
B.) The patient experiences diminished sense of
taste
C.) The patient has decreased absorption in the
GI tract
D.) The patient experiences decreased
peristalsis
Ans: B
80.) The following are true in the human
sexuality of the elderly EXCEPT:
A.) There is minimal change in amount of sexual
response
B.) There is cessation of sexual activity among
elderly
C.) There is increased refractory periods in male
D.) There is reduced vaginal lubrication
Ans: B
81.) The following are characteristics of an
elderly who has achieved ego integrity EXCEPT:
A.) Views life with sense of wholeness and
satisfaction from past accomplishments
B.) Accepts death as completion of life
C.) Experiences serenity and shares wisdom
D.) He wishes to live life longer to correct past
mistakes
Ans: D
82.) According to Kohlberg’s theory on moral
development, relationships are based on:
A.) Mutual trust
B.) Mutual satisfaction of needs
C.) Mutual approval of each other
D.) Mutual beliefs
Ans: A
83.) According to Havighurst’s theory on
developmental tasks, the following are tasks of a
65-year old person EXCEPT:
A.) Adjusting to retirement and reduced income
B.) Adjusting to decreasing Physical strength
and health
C.) Establishing an explicit affiliation with one’s
age group
D.) Adjusting to aging parents
Ans: D
84.) Which of the following will help maintain the
self-esteem of an elderly client?
A.) Provide as much independence as possible,
with consideration to safety
B.) Assist the client to accept the need for
seeking help in making decisions and judgments
C.) Do hygiene measures for the elderly to
promote sense of well-being
D.) Plan for routine activities of daily living to be
followed by the client
Ans: A
85.) The following are appropriate nursing
actions to prevent postural hypotension in an
elderly patient EXCEPT:
A.) Advise to get out of bed gradually
B.) Instruct to have a daily fluid intake of 3
glasses a day
C.) Advise to avoid straining at stool
D.) Advise to avoid bending down and suddenly
standing up again
Ans: B
86.) Which of the following is not appropriate
nursing intervention for an elderly with
osteoporosis?
A.) Include milk and dairy products in diet
B.) Take large amounts of protein-rich and salty
foods
C.) Have regular exercise
D.) Wear rubber-soled, low heeled shoes that
grip well
Ans: B
87.) The following are nursing interventions to
minimize confusion among elderly?
A.) Use touch to convey concern
B.) Have clocks or calendars in the environment
C.) Keep a routine of activities of daily living
D.) All of theses
Ans: D
88.) The following nursing interventions are
appropriate in the prevention of pressure sores
among bedridden elderly patient EXCEPT:
A.) Massage bony prominences
B.) Apply alcohol on the skin
C.) Apply cornstarch over the bedlinens
D.) Elevate head of bed at 45 to 90 degree
angle
Ans: B
89.) Florence Nightingale conceptualizes that
nursing is:
A.) The act of utilizing the environment of the
patient to assist him in his recovery
B.) Assisting the individual, sick or well, in the
performance of those activities contributing to
health, preventing illness and rehabilitating the
sick or disabled
C.) A humanistic science dedicated to
compassionate concern with maintaining and
promoting health, preventing illness and
rehabilitating the sick or disabled
D.) A unique profession in that it is concerned
with all the variables affecting an individual’s
response to stressors.
Ans: A
90.) Which of the following nursing theorists
conceptualizes that all persons strive to
achieve self-care?
A.) Sister Callista Roy
B.) Dorothea Orem
C.) Dorothy Johnson
D.) Jean Watson
Ans: B Ans: A

91.) Which of the following nursing theorists 98.) The four concepts common to nursing
introduced Transcultural Nursing Model? that appear in each of the current conceptual
A.) Imogene King models
B.) Dorothea Orem A.) Person, Nursing, Environment, Medicine
C.) Dorothy Johnson B.) Person, Health, Nursing, Support System
D.) Madeleine Leininger C.) Person, Environment, Health, Nursing
D.) Person, Environment, Psychology, Nursing
Ans: D
Ans:C
92.) The most important communication skill 99.) Which of the following is not a subjective
to be developed by the nurse manager data?
except. A.) Dizziness
A.) Performing bedside nursing B.) Chest pain
B.) Assertiveness C.) Anxiety
C.) Questioning D.) Bluish discoloration
D.) Attentive Listening Ans: D
100.) The following are specific activities during
Ans: D evaluation EXCEPT:
A.) Collecting data
93.) Which of the following moral theories is B.) Performing nursing interventions
based on respect for other humans and C.) Measuring goal attainment
belief that relationships are based on mutual D.) Revising or modifying the care plan
trust? Ans: B
A.) Erikson’s Theory
B.) Kolberg’s Theory
C.) Freud’s Theory
D.) Schulman and Mekler’s Theory

Ans: B

94.) 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

Ans: C

95.) 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

Ans: A

96.) 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

Ans: B

97.) 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
Funda Part 2
--Nursing Process--
1.) Which of the following is incorrect statement
of nursing diagnosis?
A.) High risk for ineffective airway clearance
related to pneumonia
B.) High risk for injury related to dizziness
C.) Constipation related to decreased activity
and fluids as manifested by small, hard, formed
stool every three days
D.) Anxiety related to insufficient knowledge
regarding surgical experience
ANS: A
> is incorrect statement of nursing diagnosis
(refer to NANDA, appendix A). B,C and D are
correct statement of nursing diagnosis.
2.) Which of the following would NOT be a basis
for establishing priorities in client care?
A.) Actual problems take precedence over
potential concerns
B.) Attend to equipment and contraptions first,
such as IV fluids, urinary catheter, drainage
tubes, before the client
C.) Airway should always be given highest
priority
D.) Clients with unstable condition should be
given priority over those with stable conditions.
ANS: B
> Attend to client first before equipment. A, C
and D are basis for establishing priorities in
client care
3.) Which of the following is an incorrect
statement of outcome procedure?
A.) Ambulates 30 feet with cane before
discharge
B.) Discusses fears and concerns regarding the
surgical procedure during preoperative teaching
C.) Demonstrates proper coughing technique
after the teaching session
D.) Reestablishes normal pattern of bowel
elimination
ANS: D
> Outcome criteria should be specific,
measurable, attainable, realistic and time-bound.
A, B and C are correct statements of outcome
criteria
--Assessing Health--
4.) The primary factor responsible for body heat
production is:
A.) Metabolism
B.) Release of thyroxine
C.) Thyroxine output
D.) Muscle activity
ANS: A
> The primary factor responsible for body
production is metabolism
5.) The heat-regulating center is found in the:
A.) Medulla oblongata
B.) Thalamus
C.) Hypothalamus
D.) Pons
ANS: C
> The heat-regulating center is found in the
hypothalamus
6.) 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
ANS: B
> Conduction is the process of heat loss which
involves the transfer of heat from one surface to
another
7.) The following statements are true about body
temperature EXCEPT:
A.) Core body temperature measures the
temperature of deep tissues
B.) Highest body temperature is usually reached
between 8:00 P.M. to 12:00 M.N.
C.) Elderly people are at risk of hypothermia due
to decreased thermoregulatory controls and
decreased subcutaneous fats
D.) Sympathetic response stimulation decreases
body heat production
ANS: D
> Is incorrect statement about body temperature.
Sympathetic nervous system releases
norepinephrine which increases metabolic rate,
thereby increases body heat production.
8.) The client with fever had been observed to
experience elevated temperature for few days,
followed by 1 to 2 days of normal range of
temperature. The type of fever he is
experiencing is:
A.) Intermittent fever
B.) Relapsing fever
C.) Remittent fever
D.) Constant fever
ANS: B
> Relapsing fever is “on-and-off” fever
9.) Which of the following is NOT an appropriate
nursing action when taking oral temperature?
A.) Wash the thermometer from the bulb to the
stem before use
B.) Place the thermometer under the tongue
directed towards the side
C.) Take oral temperature for 2-3 minutes
D.) Take oral temperature using a thermometer
with pear-shaped bulb
ANS: D
> Is not appropriate nursing action when taking
oral temperature. Thermometer with pear-
shaped or rounded bulb is used for rectal
temperature-taking
10.) The following are contraindications to oral
temperature taking EXCEPT:
A.) Dyspnea
B.) Diarrhea
C.) Nasal-packing
D.) Nausea and vomiting
ANS: B
> Diarrhea is not a contraindication for oral
temperature-taking
11.) Which of the following nursing actions is
inappropriate when taking the rectal
temperature?
A.) Assist client to assume lateral position
D.) Lubricate thermometer with water-soluble
lubricant before use
C.) Hold the thermometer in place for 2 minutes
D.) Instruct to strain during insertion of the
thermometer
ANS: D
> Instructing client to strain during insertion of
rectal thermometer is inappropriate. This may
cause trauma to the anus.
12.) The following are correct nursing actions
when taking the radial pulse EXCEPT:
A.) Put the palms downward
B.) Use the thumb to palpate the artery
C.) Use two to three fingertips to palpate the
pulse at the inner wrist
D.) Assess the pulse rate, rhythm, volume and
bilateral equality
ANS: B
> Using the thumb when palpating pulse is
incorrect nursing action. The thumb has strong
pulsation and the nurse might be counting her
own pulse, instead of the client’s pulse
13.) The difference between the systolic
pressure and the diastolic pressure is:
A.) Apical rate
B.) Cardiac rate
C.) Pulse deficit
D.) Pulse pressure
ANS: D
> Pulse pressure is the difference between
systolic pressure and diastolic pressure.
14.) When measuring the blood pressure, the
following are nursing considerations EXCEPT:
A.) Ensure that the client is rested
B.) Use appropriate size of BP cuff
C.) Initiate and deflate BP cuff 2-3 mm Hg/sec
D.) Read upper meniscus of mercury
ANS: D
> Reading the upper meniscus of mercury will
yield inaccurate BP reading. BP reading is done
by noting the level of the lower meniscus of the
mercury.
15.) The process involved in the exchange of
gases in the lungs is:
A.) Diffusion
B.) Osmosis
C.) Hydrostatic pressure
D.) Oncotic pressure
ANS: A
> Diffusion is exchange of gases from an area of
higher pressure to an area of lower pressure.
16.) The primary respiratory center is:
A.) Medulla oblongata
B.) Pons
C.) Carotid and aortic bodies
D.) Proprioceptors
ANS: A
> The primary respiratory center is the medulla
oblongata. It contains the central
chemoreceptors that are stimulated by high
levels of carbon dioxide in the blood
17.) Which of the following primarily affects BP?
A.) Age
B.) Stress
C.) Gender
D.) Obesity
ANS: B
> Stress is the primary factor that affects BP,
because of release of norepinephrine by the
sympathetic nervous system.
18.) The following are social data about a client
EXCEPT:
A.) Patient’s lifestyle
B.) Religious practices
C.) Family home situation
D.) Usual health status
ANS: A
> Patient’s lifestyle is not a social data
19.) The systematic manner of collecting data
about the client by listening to body sounds with
the use of stethoscope is:
A.) Inspection
B.) Palpation
C.) Percussion
D.) Auscultation
ANS: D
> Auscultation is listening to body sounds with
the use of stethoscope
20.) The following are appropriate nursing
actions when performing physical health
examination to a client EXCEPT:
A.) Ensure privacy of the client throughout the
procedure
B.) Prepare the needed articles and equipment
before the procedure
C.) Assess the abdomen following this
sequence: right lower quadrants
D.) When assessing the chest, it is best to place
the client in side lying
ANS: D
> This is incorrect nursing action. The best
position when assessing the chest is sitting or
upright position. This allows assessment of the
anterior and posterior chest
21.) Which of the following is inappropriate
nursing action when collecting clean-catch
midstream urine specimen for routine urinalysis?
A.) Collect early morning, first voided specimen
B.) Do perineal care before collection of
specimen
C.) Collect 5-10 mls of urine
D.) Discard the first flow of urine
ANS: C
> This is inappropriate nursing action. For
routine urinalysis, 3-50 mls of urine specimen is
required to yield accurate results
22.) Which of the following nursing actions is
incorrect when performing Benedict’s test?
A.) Collect 24-hour urine specimen
B.) Ensure that Benedict’s solution remains
unchanged after heating it
C.) Add 8-10 drops of urine
D.) Interpret that the urine is negative for
glucose when the color remains blue
ANS: A
> This is incorrect nursing action. When
performing Benedict’s test, collect second-
voided urine specimen
23.) Heat and acetic acid test is done to
determine
A.) Presence of albumin in the urine
B.) Presence of glucose in the urine
C.) Presence of ketones in the urine
D.) Presence of RBC in the urine
ANS: A
> Heat and acetic acid test is done to determine
presence of albumin in the urine.
24.) Which of the following is correct nursing
action when collecting urine specimen from a
client with indwelling urethral catheter?
A.) Collect urine specimen from the urinary
drainage bag
B.) Detach the catheter from the connecting tube
C.) Use sterile needle and syringe to aspirate
urine specimen from the drainage port
D.) Flush the catheter with sterile NSS before
collection of urine specimen
ANS: C
> When collecting urine specimen from a client
with indwelling urethral catheter, collect urine
specimen by using sterile needle and syringe to
aspirate urine specimen from the drainage port.
25.) The following are independent nursing
interventions for a febrile client EXCEPT:
A.) Administer paracetamol 500 mg. tab every 4
hours PRN for temperature 38.5 C
B.) Increase fluid intake
C.) Promote bed rest
D.) Keep the client’s clothing clean and dry
ANS: A
> Administration of antipyretic to a febrile client
is dependent nursing intervention, (not
independent nursing intervention)
------Basic Human Needs: Oxygenation----
26.) The common opening between the
respiratory and digestive system is:
A.) Pharynx
B.) Larynx
C.) Trachea
D.) Bronchus
ANS: A
> The common opening between the respiratory
and digestive system is the pharynx
27.) The right lung has:
A.) 2 lobes
B.) 3 lobes
C.) 4 lobes
D.) 5 lobes
ANS: B
> The right lung has 3 lobes
28.) The amount of air that remains in the lungs
after forceful exhalation is:
A.) Functional residual capacity
B.) Residual volume
C.) Tidal volume
D.) Minute volume
ANS: B
> The amount of air that remains in the lungs
after forceful exhalation is residual volume
29.) Cheyne-Stokes breathing is:
A.) Slow, shallow respirations which result to
inadequate alveolar ventilation
B.) Difficulty of breathing in reclining position
C.) Marked rhythmic waxing and waning of
respirations from very deep to very shallow
breathing and temporary apnea
D.) Shallow breaths interrupted by apnea
ANS: C
> Cheyne-stokes breathing is marked waxing
and waning of respirations from very deep to
very shallow breathing and temporary apnea
30.) The best position to promote maximum lung
expansion is:
A.) Supine
B.) Retractions
C.) Noisy breathing
D.) Semi fowler’s
ANS: D
> The best position to promote maximum lung
expansion is Semi-Fowler’s
31.) The characteristic manifestation of airway
obstruction is:
A.) Bradypnea
B.) Retractions
C.) Noisy breathing
D.) Tachypnea
ANS: C
> The characteristic manifestation of airway
obstruction is noisy breathing.
32.) The following are appropriate nursing
interventions to promote normal respiratory
function EXCEPT:
A.) Adequate fluid intake
B.) Minimize cigarette smoking
C.) Deep breathing and coughing exercises
D.) Frequent change of position among
bedridden clients
ANS: B
> This is inappropriate nursing intervention to
promote respiratory function. Appropriate is
avoid or quit cigarette smoking, not just to
minimize it
33.) The initial manifestations of hypoxemia are
A.) Restlessness, tachycardia
B.) Dizziness, faintness
C.) Headache, blurring of vision
D.) Dyspnea, retractions
ANS: A
> The initial manifestations of hypoxemia are
restlessness and tachycardia
34.) The following are appropriate nursing
actions when performing percussion, vibration
and postural drainage, EXCEPT:
A.) Verify doctor’s order
B.) Perform the procedure before meals and at
bedtime
C.) provide good oral hygiene after the
procedure
D.) Each position during postural drainage
should be assumed for 30 minutes
ANS: D
> This is inappropriate nursing action during
chest physiotherapy. Appropriate is to assume
each position during postural drainage for 10 to
15 minutes
35.) Which of the following nursing actions is
inappropriate when providing steam inhalation
therapy?
A.) Check doctor’s order
B.) Cover the eyes with moist washcloth
C.) Place the spout 3-4 inches away from the
patient’s nose
D.) Place the patient in semi-fowler’s position
ANS: C
> This inappropriate nursing action when
providing steam inhalation therapy. Appropriate
is to place the spout at least 12 inches from the
patient’s nose.
36.) To be effective, steam inhalation should be
rendered for at least:
A.) 5-10 minutes
B.) 15-20 minutes
C.) 30-45 minutes
D.) 60-70 minutes
ANS: B
> To be effective, steam inhalation should be
rendered for at least 15-20 minutes
37.) The correct pressure of the wall suction unit B). Effort
when suctioning an adult patient is: C.) Rate
A.) 95-110 mm Hg D.) Depth
B.) 100-120 mm Hg ANS: C
C.) 50-95 mm Hg > When assessing respirations, the nurse should
D.) 10-15 mm Hg count the rate, not simply describe it.
ANS: B 44.) The small hair-like projections that line the
> The correct pressure of the wall suction unit tracheobronchial tree, which sweep out debris
when suctioning an adult patient is 100-120 mm and excessive mucous from the lungs are
Hg called:
38.) Which of the following is inappropriate A.) Cilia
nursing action when performing oropharyngeal B.) Vibrissae
suctioning? C.) Macrophages
A.) Place the client in semi-fowler’s or lateral D.) Goblet cells
position ANS: A
B.) Measure length of catheter from the tip of the > Cilia are small hair-like projections that line the
nose to the earlobe. tracheobronchial tree
C.) Lubricate suction catheter with alcohol 45.) The following are appropriate nursing
D.) Apply suction during withdrawal of the diagnoses for clients with oxygenation problems:
suction catheter tip: A.) Ineffective airway clearance related to
ANS: C tracheobronchial secretions
> When performing oropharyngeal suctioning, it B.) Ineffective breathing pattern related to
is inappropriate to lubricate catheter with decreased energy and fatigue
alcohol. Alcohol may irritate mucous membrane C.) Impaired gas exchange related to altered
of airways. Appropriate is, use sterile water or oxygen-carrying capacity of the blood
sterile NSS. D.) All of these
39.) The maximum time for applying suction is: ANS: D
A.) 5-10 seconds > All of these (A,B, and C) are appropriate
B.) 10-15 seconds nursing diagnoses for clients with oxygenation
C.) 15-20 seconds problems.
D.) 20-30 seconds ---Basic Human Needs: Nutrition----
ANS: B 46.) The regulating center for fluid and food
> The maximum time for applying suction is 10 intake are located in their
to 15 seconds. This is to prevent hypoxia A.) Thalamus
40.) To evaluate effectiveness of suctioning, the B.) Hypothalamus
nurse should primarily: C.) Medulla oblongata
A.) Auscultate the chest for clear breath sounds D.) Pons
B.) Assess the respiratory rate ANS: B
C.) Check the skin color > The regulating centers for food and fluid intake
D.) palpate the pulse rate are found in the hypothalamus
ANS: A 47.) The enzyme that initiates digestion of starch
> To evaluate effectiveness of suctioning, the in the mouth is:
nurse should primarily auscultate the chest for A.) Amylase
clear breath sounds B.) Sucrase
41.) The oxygen administration device preferred C.) Maltase
for patients with COPD is: D.) Lactase
A.) Nasal cannula ANS: A
B.) Oxygen tent > The enzyme that initiates digestion of starch in
C.) Venturi mask the mouth is salivary amylase
D.) Oxygen hood 48.) Which of the following structure prevents
ANS: C gastric reflux?
> Venturi mask is the preferred device for A.) Pyloric sphincter
oxygen therapy among clients with COPD. B.) Internal sphincter
42.) Which of the following is not to be included C.) Cardiac sphincter
in the nursing interventions for a client receiving D.) Sphincter of Oddi
oxygen therapy? ANS: C
A.) Place a “Non-smoking” sign at the bedside > The cardiac sphincter also known as lower
B.) Place the client in semi-fowler’s position esophageal sphincter prevents gastric reflux
C.) Place sterile water into the oxygen humidifier 49.) Which of the following nutrients remains in
D.) Lubricate nares with oil to prevent dryness of the stomach for the longest period?
the mucous membrane A.) Fats
ANS: D B.) Proteins
> It is inappropriate to lubricate nares with oil C.) Carbohydrates
when the client is receiving oxygen therapy. Oil D.) Water
ignites when exposed to compressed oxygen ANS; A
43.) When assessing respiration, the nurse > Fats remains in the stomach for 4 to 6 hours;
describes the following EXCEPT: carbohydrates for 1 to 2 hours; protein 3 to 4
A.) Rhythm hours
50.) The pancreatic enzyme which completes B.) Milk
digestion of fats is C.) Cold cola beverage
A.) Amylase D.) Ice chips
B.) Lipase ANS: B
C.) Trypsin > Milk does not relieve nausea and vomiting.
D.) Rennin A,B,C may relieve nausea and vomiting
ANS: B 58.) The most life threatening complication of
> Lipase is the pancreatic enzyme that vomiting is:
completes digestion of fats A.) Aspiration
51.) Kwashiorkor is a condition characterized by: B.) Dehydration
A.) Calorie deficiency C.) Fever
B.) Vitamin Deficiency D.) Malnutrition
C.) Protein deficiency ANS: A
D.) Mineral deficiency > The most life-threatening complication of
ANS: C vomiting is aspiration. It causes airway
> Kwashiorkor is protein deficiency obstruction.
52.) Which of the following is most effective 59.) The vomiting center is found in the
nursing measures to relieve anorexia EXCEPT: ________.
A.) Provide small, frequent feedings A.) Cerebellum
B.) Remove unsightly articles from the patient’s B.) Hypothalamus
unit C.) Medulla Oblongata
C.) Provide three full meals a day D.) Cerebrum
D.) Provide good hygienic measures ANS: C
ANS: A > The vomiting center in the Medulla Oblongata
> Providing small frequent feedings is most 60.) The best indicator of nutritional status of the
effective nursing measure to relieve anorexia individual is:
53.) The following factors increase calorie A.) Weight
requirements EXCEPT: B.) Height
A.) Cold climate C.) Arm muscle circumference
B.) Activity and exercise D.) Adequacy of hair
C.) Fever ANS: A
D.) sleep > The best indicator of nutritional status is the
ANS: D weight
> Sleep reduces calorie requirement by 10 to 61.) To assess the adequacy of food intake,
15% . A,B,and C are factors that increase calorie which of the following assessment parameters is
requirement. best used?
54.) The following are good sources of calcium A.) Food preferences and dislikes
EXCEPT: B.) Regularity of meal times
A.) Cheese C.) 3-day diet recall
B.) Milk D.) Eating style and habits
C.) Soy products ANS: C
D.) Carbonated drinks > Dietary diary e.g. 3-day diet recall, is the best
ANS: D assessment parameter for adequacy of food
> Carbonated drinks are not sources of calcium. intake
A,B and C are good sources of calcium. 62.) Prolonged deficiency of vitamin B12 leads
55.) Which of the following is the richest source to:
of iron? A.) beriberi
A.) Mongo B.) Pernicious anemia
B.) Milk C.) Pellagra
C.) Malunggay leaves D.) Peripheral neuritis
D.) Pechay ANS: B
ANS: A > Prolonged Vit B12 deficiency results to
> Among these choices, mongo (a legume) is pernicious anemia
the richest source of iron. The richest source of 63.) The vitamin necessary for absorption of
iron is liver, next is lean meat, then legumes, calcium is:
then green leafy vegetables A.) Vit D
56.) Which of the following is a good source of B.) Vit A
vitamin A? C.) Vit C
A.) Eggs D.) Vit E
B.) Liver ANS: A
C.) Fish > Vit D promotes absorption of calcium
D.) Peanuts 64.) Vit. K is necessary for:
ANS: B A.) Bone and teeth formation
> Liver is very good source of fat-soluble B.) Integrity of skin and mucous membrane
vitamins (A,D,E,K) C.) Blood coagulation
57.) The following may be given to relieve D.) Formation of RBC
nausea and vomiting EXCEPT: ANS: C
A.) Dry toast
> Vit K is necessary for blood clotting. Prolonged
deficiency of this vitamin leads to bleeding
65.) The following are signs and symptoms of
dehydration EXCEPT:
A.) Weight loss
B.) Decreased urine output
C.) Elevated body temperature
D.) Elevated BP
ANS: D
> Elevated BP is not a sign of dehydration.
A,B,C are signs and symptoms of dehydration.
66.) The client is experiencing hypokalemia.
Which of the following should be included in his
diet?
A.) Banana
B.) Milk
C.) Cheese
D.) Fish
ANS: A
> Hypokalemia is low serum potassium level.
Providing potassium-rich foods like banana and
other fresh fruits is effective nursing intervention
for this condition
67.) During insertion of NGT, which position is
best assumed by the client?
A.) Low-Fowler’s
B.) Semi-Fowler’s
C.) High-Fowler’s
D.) Lateral
ANS: C
> During insertion of NGT, the patient is best
placed in high-Fowler’s position with neck
hyperextended until the tube is in the
oropharynx. Once the NGT is in the oropharynx,
the client is instructed to flex the neck and
swallow, as the tube is advanced.
68.) The length of NGT to be inserted is correctly
measured;
A.) From the tip of the nose to the umbilicus
B.) From the tip of the nose to the xiphoid
process
C.) From the tip of the nose to the earlobe to the
umbilicus
D.) From the tip of the nose to the earlobe to the
xiphoid process.
ANS: D
> The length of NGT to be inserted is measured
from the tip of the nose, to the earlobe, to the
xiphoid process (N-E-X) which is approximately
50cm
69.) When inserting NGT, the neck should:
A.) Flexed
B.) Hyperextend
C.) Tilted to the left
D.) In neutral position
ANS: B
> When inserting NGT, the neck is initially
hyperextended
70.) The most accurate method of assessing
method of placement of NGT is:
A.) Aspiration
B.) Testing the pH of gastric aspiration
C.) X-ray study
D.) Introduction of air into NGT and auscultate at
the epigastric area.
ANS: C
> The most accurate method of assessing
placement of NGT is through X-ray.
71.) Which of the following is inappropriate
nursing action when administering NGT feeding?
A.) Assist the client in Fowler’s position
B.) Introduce feeding slowly
C.) Place the feeding 24 inches above the point
of insertion of NGT
D.) Instill 60mls of water into the NGT after
feeding
ANS: C
> During NGT feeding, the height of the feeding
is 12 inches above the point of NGT insertion,
not 24 inches. If the height of feeding is too high,
this results to very rapid introduction of feeding.
This may trigger nausea and vomiting.
72.) The primary purpose of gastrostomy is:
A.) For feeding
B.) For drainage
C.) To prevent flatulence
D.) To prevent aspiration of gastric reflex
ANS: A
> The primary purpose of gastrostomy is for
feeding
73.) The most important nursing action before
gastrostomy feeding is:
A.) Check VS
B.) Assess for patency of the tube
C.) Measure residual feeding
D.) Check for placement of the tube
ANS: B
> The most important nursing action before
gastrostomy feeding is to assess for patency of
the tube. This is done by instilling 15-30 mls of
water into the tube.
74.) The primary advantage of gastrostomy
feeding is:
A.) It ensures adequate nutrition
B.) It prevents aspiration
C.) It maintains integrity of gastro-esophageal
sphincter
D.) It minimizes fluid-electrolyte imbalances
ANS: C
> The primary advantage of gastrostomy feeding
is, it maintains the integrity of gastro-esophageal
sphincter ( cardiac sphincter) of the stomach
75.) Vit B3 (Niacin) deficiency leads to:
A.) Pellagra
B.) Beriberi
C.) Scurvy
D.) Rickets
ANS: A
> Vitamin B3 (Niacin) deficiency leads to
pellagra
--Basic Human Needs: Bladder and Bowel &
Elimination—
76.) Constipation is best described as:
A.) Irregular passage of stool
B.) Passage of stool every other day
C.) Passage of hard, dry stool
D.) Seepage of liquid feces
ANS: C
> Constipation is passage of hard, dry stool
77.) The accumulation of hardened, putty-like
fecal mass at the rectum is
A.) Obstipation
B.) Constipation
C.) Tympanities
D.) Fecal impaction
ANS: D
> Fecal impaction is the accumulation of 85.) Which of the following laxative increases
hardened, putty-like fecal mass at the rectum the bulk of the stool?
78.) The following are appropriate nursing A.) Colace
measures to relieve constipation EXCEPT: B.) Metamucil
A.) Include fruits and vegetables D.) Dulcolax
B.) Have adequate activity and exercise D.) Duphalac
C.) Take laxatives at regular basis ANS: B
D.) Answer immediately to the urge to defecate > Metamucil increases bulk of the stool and it
ANS: C provides adequate mechanical stimulation for
> Regular use of laxative is inappropriate peristalsis
nursing measures to relieve constipation 86.) The following are appropriate nursing
79.) Castor oil acts as a laxative by: measures to relieve diarrhea EXCEPT:
A.) Providing chemical stimulation of the A.) Provide high-fiber diet
intestinal mucosa B.) Promote rest
B.) Softening the stool C.) Include banana in the diet
C.) Increasing the bulk of the stool D.) Avoid fatty or fried food
D.) Lubricating the stool ANS: A
ANS: A > High fiber die stimulates peristalsis and
> Castor oil provides chemical stimulation to the therefore inappropriate for a client with diarrhea
intestinal mucosa, to increase peristalsis and 87.) The following are solutions used as non-
promote defecation retention enema EXCEPT:
80.) Which of the following foods should be A.) Tap water
avoided by the client prevent flatulence? B.) Carminative enema
A.) Fruit juice C.) Normal Saline Solution
B.) Cabbage D.) Fleet Enema
C.) Meat ANS: B
D.) Fish > Carminative enema is used for retention
ANS: B enema. A,C, and D are solutions used as non-
> To prevent flatulence, avoid gas-forming foods retention enema
like cabbage 88.) The medication that relieves flatulence is:
81.) Which of the following antidiarrheal A.) Imodium (Loperamide)
medications absorb gas or toxic substances B.) Plasil (Metochlopramide)
from the bowel? C.) Prostigmin (Neostigmine)
A.) Demulcent D.) Colace ( Na Docussate)
B.) Cabbage ANS: C
C.) Meat > Prostigmin is cholinergic, so it stimulates
D.) Fish peristalsis. It is used to relieve flatulence
ANS: B 89.) The best position of the adult client during
> Absorbent anti-diarrheal medications absorb enema administration is:
gas or toxic substances from the bowel A.) Left lateral
82.) The most common-side effect of overuse of B.) Supine
laxatives is: C.) Right lateral
A.) Diarrhea D.) Semi-Fowler’s
B.) Nausea and vomiting ANS: A
C.) Constipation > Left lateral position is the best position for the
D.) Flatulence adult client receiving enema. This position
ANS: C facilitates the flow of the solution into the colon
> The most common side-effect of overuse of by gravity
laxative is rebound constipation 90.) Which of the following is inappropriate
83.) Which of the following should be included in nursing action during rectal tube insertion to
the diet of the patient with diarrhea? relieve flatulence?
A.) Banana A.) Insert rectal tube for 3-4 inches
B.) Papaya B.) Use rectal tube size Fr.22-30
C.) Pineapple C.) Keep rectal tube in place for 45 minutes
D.) Avocado D.) Insert well-lubricated rectal tube in rotating
Ans: A motion
> Banana should be included in the diet of the ANS: C
client with diarrhea. It is rich in potassium and it > Keeping the rectal tube in place for 45 minutes
replaces potassium losses due to diarrhea is inappropriate. Beyond 30 minutes rectal tube
84.) Which of the following fluids may be given causes irritation of the mucous membrane in the
to a client with diarrhea? rectal area.
A.) Milk 91.) The following are correct nursing actions
B.) Coffee when administering enema EXCEPT:
C.) Tea A.) Provide privacy
D.) Gatorade B.) Introduce solution slowly
ANS: D C.) Alternate NSS with tap water and soap suds
> Gatorade may be given to a client with D.) Increase the flow rate of the enema solution
diarrhea because it is rich in potassium if abdominal cramps occur
ANS: D ANS: C
> Increasing flow rate of enema solution if > providing privacy is the most effective nursing
abdominal cramps occur is inappropriate nursing measure to relieve urinary retention.
action. Temporarily stop flow of solution if 99.) The best position for female during urinary
abdominal cramps occur, until peristalsis catheterization is:
relaxes. A.) Supine
92.) The functional unit of the kidneys is the: B.) Dorsal recumbent
A.) Glomerulus C.) Lateral
B.) Bowman’s capsule D.) Semi-Fowler’s
C.) Nephron ANS: B
D.) Tubules > Dorsal recumbent position is the best position
ANS: C during urethral catheter insertion in a female
> The nephron is the unit of the kidney client.
93.) Which of the following initiates voiding? 100.) The female urethral meatus is located:
A.) Valsalva maneuver A.) Above the clitoris
B.) Increased intraabdominal pressure B.) Below the vaginal
C.) Sympathetic response stimulation C.) Between the clitoris and vaginal orifice
D.) Parasympathetic response stimulation D.) Between the vaginal orifice and anus
ANS: D ANS: C
> The PNS promotes contraction of the bladder > The female urethral meatus is located
and promotes relaxation of urethral sphincter. between the
Therefore, it initiates voiding.
94.) The following are normal characteristics of
urine EXCEPT:
A.) Appears clear
B.) pH= 3.5
C.) Sp.Gr=1.020
D.) Amber
ANS: B
> Urine pH of 3.5 if too low. This indicates
acidosis. The normal pH of urine is slightly
acidic, an average of 6
95.) Frequent scanty urination is:
A.) Urgency
B.) hesitancy
C.) Pollakuria
D.) Polyuria
ANS: C
> Pollakuria is frequent scanty urination
96.) The volume of urine in the bladder that
triggers the urge of an adult patient to void is:
A.) 50-100mls
B.) 100-200 mls
C.) 250-450 mls
D.) 500-600 mls
ANS: C
> 250-450 mls of urine in the bladder makes an
adult client feel the urge to void
97.) Which of the following is not as assessment
finding in urinary retention?
A.) Flat sound over the suprapubic area on
percussion
B.) Smooth, firm ovoid mass at the suprapubic
area
C.) Protrusion arising out the pelvis
D.) Frequent passage of small amount of urine
ANS: A
> Flat sound over the suprapubic area on
percussion does not indicate bladder distention.
Accumulation of urine in the bladder will produce
dull sound
98.) Which of the following is most effective
nursing measure to relieve urinary retention?
A.) Allow the patient to listen to the sound of
running water
B.) Dangle fingers in warm water
C.) Provide privacy
D.) Pour warm water over perineum