Professional Documents
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Diagnostic Examination
Instructions:
Select the best answer for each of the following questions. Read the questions well.
STRICTLY NO ERASURES.
3. 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
4. According to Maslow’s hierarchy of needs, which of the following is a basic physiologic need after oxygen?
A. Water C. Love and belongingness
B. Freedom from infection D. Self-esteem
A. 1,2,4 C. 1,2,3
B. 2,3,4 D. 1,2,3,4
7. 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
9. 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
10. 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
A. 1 and 2 C. 1 and 4
B. 1 and 3 D. 2 and 4
15. The client is in stress because he was told by the physician that he needs to undergo surgery for removal of tumor in his stomach.
Which of the following are effects of activation of the sympatho-adreno-medullary response in the client?
1) Constipation
2) Urinary frequency
3) Hypoglycemia
4) Increased BP
A. 1 and 2 C. 2 and 3
B. 1 and 3 D. 1 and 4
16. 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.
17. 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
18. The first protective cells launched at the site of tissue injury are the:
A. Basophils
B. Eosinophils
C. Monocytes
D. Neutrophils
A. 1,2,3
B. 1,2,4
C. 2,3,4
D. 1,3,4
20. 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
21. 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
22. 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
C. Purple D. Blue
25. 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
26. 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
27. The four concepts common to nursing that appear in each of the current conceptual models:
A. Person, Nursing, Environment, Medicine
B. Person, Health, Nursing, Support System
C. Person, Environment, Health, Nursing
D. Person, Environment, Psychology, Nursing
29. 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.
31. The primary factor responsible for body heat production is:
A. Metabolism
B. Release of thyroxine
C. Thyroxine output
D. Muscle activity
33. The difference between the systolic pressure and the diastolic pressure is:
A. Apical rate
B. Cardiac rate
C. Pulse deficit
D. Pulse pressure
34. 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
35. The process involved in the exchange of gases in the lungs is:
A. Diffusion
B. Osmosis
C. Hydrostatic pressure
D. Oncotic pressure
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FUNDAMENTALS OF NURSING PRACTICE
Diagnostic Examination
37. A client has just entered the post anesthesia care unit (PACU) from surgery. The postoperative client's immediate needs include
initial monitoring of which of the following items?
A. Vital signs, level of consciousness, and presence of pain
B. Skin coloring, surgical incision, limb movements
C. Skin temperature, blood pressure, mental status
D. Temperature, emotional status, social support
38. The nurse examines the ocular motility of a client who recently experienced a cerebrovascular accident. Follow-up documentation
would describe the function of which of the following cranial nerves?
A. Cranial nerves I, III, and IV
B. Cranial nerves II and V
C. Cranial nerves III, IV, and VI
D. Cranial nerves IV and VII
39. In which of the following positions would it be best to place the client so the nurse can inspect and palpate the Bartholin glands?
A. Semi-Fowler's
B. Sim's
C. Lithotomy
D. Prone
40. A client comes to the walk-in clinic with complaints of abdominal pain and diarrhea. The nurse takes the client's vital signs. The
nurse is implementing which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
43. The correct site at which to verify a radial pulse measurement is the:
A. Brachial artery
B. Apex of the heart
C. Temporal artery
D. Inguinal site
52. The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data?
A. Vital signs
B. Laboratory test result
C. Patient’s description of pain
D. Electrocardiographic (ECG) waveforms
54. The nurse in charge measures a patient’s temperature at 102 degrees F. what is the equivalent Centigrade temperature?
A. 39 degrees C C. 38.9 degrees C
B. 47 degrees C D. 40.1 degrees C
55. To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test?
A. Red blood cell count
B. Sputum culture
C. Total hemoglobin
D. Arterial blood gas (ABG) analysis
56. The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a bell and diaphragm
is true?
A. The bell detects high-pitched sounds best
B. The diaphragm detects high-pitched sounds best
C. The bell detects thrills best
D. The diaphragm detects low-pitched sounds best
57. The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops per milliliter. The
nurse in charge should run the I.V. infusion at a rate of:
A. 15 drop per minute
B. 21 drop per minute
C. 32 drop per minute
D. 125 drops per minute
58. Which pulse should the nurse palpate during rapid assessment of an unconscious male adult?
A. Radial C. Femoral
B. Brachial D. Carotid
59. 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
63. The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the nursing process?
A. Assessment
B. Nursing diagnosis
C. Planning
D. Evaluation
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TOPNOTCH NURSING REVIEW CENTER © Copyright
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FUNDAMENTALS OF NURSING PRACTICE
Diagnostic Examination
64. A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this
client would be to:
A. Assess the client’s airway
B. Provide pain relief
C. Encourage deep breathing and coughing
D. Splint the chest wall with a pillow
65. A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit
(HCT), 40%. Which goal would be most important for this client?
A. Promote fluid balance
B. Prevent infection
C. Promote rest
D. Prevent injury
A. 1,2,3
B. 1,3,4
C. 2,3,4
D. 1,2,3,4
A. 1,2,3,4
B. 1,3,4
C. 1,2,3
D. 2,3,4
69. 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
70. 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. Read the material to evaluate its clarity, accuracy and effectiveness
D. Give the material to a family member to read the patient
72. 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
73. 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
75. Which of the following nursing actions is inappropriate when taking the rectal temperature?
A. Assist client to assume lateral position
B. 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
76. 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
77. 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
78. Which of the following nutrients remains in the stomach for the longest period?
A. Fats
B. Proteins
C. Carbohydrates
D. Water
81. To assess the adequacy of food intake, which of the following assessment parameters is best used?
A. Food preferences and dislikes
B. Regularity of meal times
C. 3-day diet recall
D. Eating style and habits
83. The oxygen administration device preferred for patients with COPD is:
A. Nasal cannula
B. Oxygen tent
C. Venturi mask
D. Oxygen hood
85. 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
86. 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
87. Which of the following nursing theorists introduced Transcultural Nursing Model?
A. Imogene King
B. Dorothea Orem
C. Dorothy Johnson
D. Madeleine Leininger
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TOPNOTCH NURSING REVIEW CENTER © Copyright
2nd Floor, Pillars Building, Tapuac District, Dagupan City
Office Telephone No.: 075.523.5415, Email: topnotchreviewcenter@yahoo.com
FUNDAMENTALS OF NURSING PRACTICE
Diagnostic Examination
88. The most important communication skill to be developed by the nurse manager except.
A. Performing bedside nursing
B. Assertiveness
C. Questioning
D. Attentive Listening
89. Which of the following moral theories is based on respect for other humans and belief that relationships are based on mutual trust?
A. Erikson’s Theory
B. Kolberg’s Theory
C. Freud’s Theory
D. Schulman and Mekler’s Theory
91. 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
92. 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
93. 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
94. A nurse providing teaching on weight reduction compliments the client on exercising daily. This action will promote the teaching
plan by providing the client with which of the following?
A. Positive reinforcement
B. Feedback on client behavior
C. Empathy towards the client
D. Reassurance to the client
95. A nurse is preparing to administer intravenous medication through a port in the intravenous infusion line. This technique would
require the nurse to use which of the following infection control measures?
A. Standard precautions
B. Clean technique
C. Sterile technique
D. Contact precautions
96. A client with a colostomy is asking the nurse about the types of foods that may loosen stool and cause leakage into the pouch.
Which of the following foods should the client be told to include in the diet to prevent this problem?
A. Asparagus, beans, eggs, fish, onions
B. Applesauce, bananas, rice, tapioca, yogurt
C. Fried foods, highly spiced foods, raw fruits and vegetables
D. Carbonated drinks, fruit juices, greasy and pureed foods,
97. The nurse has been instructed to obtain informed consent from a client who will be undergoing a surgical procedure. What is the
most essential information to include in the discussion prior to the client signing the permission?
A. The client's diagnosis
B. Treatment proposed and the cost
C. The technical aspects of the procedure
D. Right to withdraw consent
98. To administer 1 mL of a flu vaccine intramuscularly (IM) to an obese adult in the deltoid area you would use what size needle?
A. 5/8 inch.
B. 1 inch.
C. 1-1/2 inch.
D. 2 inch.
D. The faster one lives, the sooner one ages and dies
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TOPNOTCH NURSING REVIEW CENTER © Copyright
2nd Floor, Pillars Building, Tapuac District, Dagupan City
Office Telephone No.: 075.523.5415, Email: topnotchreviewcenter@yahoo.com