Nursing Practice I – Foundations of Nursing (Final – C1)

Number of Items: Fifty (50)

Number of Hours: One (1) Hour
ONLY FOR: FINAL DIAGNOSTIC EXAM

Situation 1 – Mr. Ibarra is assigned to the triage area and B. Tuberculin syringe 1 ml with needle gauge 26 or 27
while on duty, he assesses the condition of Mrs. Simon C. Syringe 2 ml and needle gauge 22
who came in with asthma. She has difficulty breathing and D. Syringe 1-3 ml and needle gauge 25 to 27
her respiratory rate is 40 per minute. Mr. Ibarra is asked to 5. The rationale for giving medications through the
inject the client epinephrine 0.3 mg subcutaneously. subcutaneous route is:
A. There are many alternative sites for subcutaneous
1. The indication for epinephrine injection for Mrs. Simon is injection
to: B. Absorption time of the medicine is slower
A. Reduce anaphylaxis C. There are less pain receptors in this area
B. Relieve hypersensitivity to allergen D. The medication can be injected while the client is in any
C. Relieve respiratory distress due to bronchial spasm position
D. Restore client’s cardiac rhythm
Situation 2 – The use of massage and meditation to help
2. When preparing the epinephrine injection from an decrease stress and pain have been strongly
ampule, the nurse initially: recommended based on documented testimonials.
A. Taps the ampule at the top to allow fluid to flow to the 6. Martha wants to do a study on this topic: “Effects of
base of the ampule massage and meditation on stress and pain”. The type of
B. Checks expiration date of the medication ampule research that best suits this topic is:
C. Removes needle cap of syringe and pulls plunger to A. Applied research
expel air B. Qualitative research
D. Breaks the neck of the ampule with a gauze wrapped C. Basic research
around it D. Quantitative research

3. Mrs. Simon is obese. When administering a 7. The type of research design that does not manipulate
subcutaneous injection to an obese patient, it is best for the independent variable is:
nurse to: A. Experimental design
A. Inject needle at a 15 degree angle over the stretched B. Quasi-experimental design
skin of the client C. Non-experimental design
B. Pinch skin at the injection site and use airlock technique D. Quantitative design
C. Pull skin of patient down to administer the drug in a Z
track 8. This research topic has the potential to contribute to
D. Spread skin or pinch at the injection site and inject nursing because it seeks to
needle at a 45-90 degree angle A. Include new modalities of care
B. Resolve a clinical problem
4. When preparing for a subcutaneous injection, the proper C. Clarify an ambiguous modality of care
size of syringe and needle would be: D. Enhance client care
A. Syringe 3-5 ml and needle gauge 21 to 23

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9. Martha does review of related literature for the purpose
of:
A. Determine statistical treatment of data research
B. Gathering data about what is already known or unknown
about the problem
C. To identify if problem can be replicated
D. Answering the research question
10. Client’s rights should be protected when doing research
using human subjects. Martha identifies these rights as
follows EXCEPT:
A. Right of self-determination
B. Right to compensation
C. Right of privacy
D. Right not to be harmed
Situation 3 – Richard has a nursing diagnosis of ineffective
airway clearance related to excessive secretions and is at
risk for infection because of retained secretions. Part of
Nurse Mario’s nursing care plan is to loosen and remove
excessive secretions in the airway.
11. Mario listens to Richard’s bilateral sounds and finds
that congestion is in the upper lobes of the lungs. The
appropriate position to drain the anterior and posterior
apical segments of the lungs when Mario does percussion
would be:
A. Client lying on his back then flat on his abdomen on
Trendelenburg position
B. Client seated upright in bed or on a chair then leaning
forward in sitting position then flat on his back and on his
abdomen
C. Client lying flat on his back and then flat on his abdomen
D. Client lying on his right then left side on Trendelenburg
position
Final Diagnostic Exam III
12. When documenting outcome of Richard’s treatment
Mario should include the following in his recording
EXCEPT:
A. Color, amount and consistency of sputum
B. Character of breath sounds and respiratory rate before
and after procedure
C. Amount of fluid intake of client before and after the
procedure
D. Significant changes in vital signs
13. When assessing Richard for chest percussion or chest
vibration and postural drainage, Mario would focus on the
following EXCEPT:
A. Amount of food and fluid taken during the last meal
before treatment
B. Respiratory rate, breath sounds and location of
congestion
C. Teaching the client’s relatives to perform the procedure
D. Doctor’s order regarding position restrictions and client’s
tolerance for lying flat
14. Mario prepares Richard for postural drainage and
percussion. Which of the following is a special
consideration when doing the procedure?
A. Respiratory rate of 16 to 20 per minute
B. Client can tolerate sitting and lying positions
C. Client has no signs of infection
D. Time of last food and fluid intake of the client
15. The purpose of chest percussion and vibration is to
loosen secretions in the lungs. The difference between the
procedures is:
A. Percussion uses only one hand while vibration uses
both hands
B. Percussion delivers cushioned blows to the chest with
cupped palms while vibration gently shakes secretion loose
on the exhalation cycle
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C. In both percussion and vibration the hands are on top of
each other and hand action is in tune with client’s breath
rhythm
D. Percussion slaps the chest to loosen secretions while
vibration shakes the secretions along with the inhalation of
air
Situation 4 – A 61 year old man, Mr. Regalado, is admitted
to the private ward for observation after complaints of
severe chest pain. You are assigned to take care of the
client.
16. When doing an initial assessment, the best way for you
to identify the client’s priority problem is to:
A. Interview the client for chief complaints and other
symptoms
B. Talk to the relatives to gather data about history of
illness
C. Do auscultation to check for chest congestion
D. Do a physical examination while asking the client
relevant questions
17. Upon establishing Mr. Regalado’s nursing needs, the
next nursing approach would be to:
A. Introduce the client to the ward staff to put the client and
family at ease
B. Give client and relatives a brief tour of the physical set
up the unit
C. Take his vital signs for a baseline assessment
D. Establish priority needs and implement appropriate
interventions
18. Mr. Regalado says he has “trouble going to sleep”. In
order to plan your nursing intervention you will:
A. Observe his sleeping patterns in the next few days
B. Ask him what he means by this statement
C. Check his physical environment to decrease noise level
Final Diagnostic Exam III
D. Take his blood pressure before sleeping and upon
waking up
19. Mr. Regalado’s lower extremities are swollen and
shiny. He has pitting pedal edema. When taking care of Mr.
Regalado, which of the following interventions would be the
most appropriate immediate nursing approach?
A. Moisturize lower extremities to prevent skin irritation
B. Measure fluid intake and output to decrease edema
C. Elevate lower extremities for postural drainage
D. Provide the client a list of food low in sodium
20. Mr. Regalado will be discharged from your unit within
the hour. Nursing actions when preparing a client for
discharge include all EXCEPT:
A. Making a final physical assessment before client leaves
the hospital
B. Giving instructions about his medication regimen
C. Walking the client to the hospital exit to ensure his
safety
D. Proper recording of pertinent data
Situation 5 – Nancy, mother of 2 young kids, 36 years old,
had a mammogram and was told that she has breast cysts
and that she may need surgery. This causes her anxiety as
shown by increase in her pulse and respiratory rate,
sweating and feelings of tension.
21. Considering her level of anxiety, the nurse can best
assist Nancy by:
A. Giving her activities to divert her attention
B. Giving detailed explanations about the treatments she
will undergo
C. Preparing her and her family in case surgery is not
successful
D. Giving her clear but brief information at the level of her
understanding
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22. Nancy blames God for her situation. She is easily
provoked to tears and wants to be left alone, refusing to eat
or talk to her family. A religious person before, she now
refuses to pray or go to church stating that God has
abandoned her. The nurse understands that Nancy is
grieving for herself and is in the stage of:
A. Bargaining
B. Denial
C. Anger
D. Acceptance
23. The nurse visits Nancy and prods her to eat her food.
Nancy replies “what’s the use? My time is running out.” The
nurse’s best response would be:
A. “The doctor ordered full diet for you so that you will be
strong for surgery”
B. “I understand how you feel but you have to try for your
children’s sake”
C. “Have you told your doctor how you feel? Are you
changing your mind about your surgery?”
D. “You sound like you are giving up.”
24. The nurse feels sad about Nancy’s illness and tells her
head nurse during the end of shift endorsement that “it’s
unfair for Nancy to have cancer when she is still so young
and with two kids”. The best response of the head nurse
would be:
A. Advise the nurse to “be strong and learn to control her
feelings”
B. Assign the nurse to another client to avoid sympathy for
the client
C. Reassure the nurse that the client has hope if she goes
through all treatments prescribed for her
D. Ask the other nurses what they feel about the patient to
find out if they share the same feelings
Final Diagnostic Exam III
25. Realizing that she feels angry about Nancy’s condition,
the nurse learns that being self-aware is a conscious
process that she should do in any situation like this
because:
A. This is a necessary part of the nurse – client relationship
process
B. The nurse is a role model for the client and should be
strong
C. How the nurse thinks and feels affect her actions
towards her client and her work
D. The nurse has to be therapeutic at all times and should
not be affected
Situation 6 – Mrs. Seva, 52 years old, asks you about
possible problems regarding her elimination now that she is
in the menopausal stage.
26. Instruction on health promotion regarding urinary
elimination is important. Which would you include?
A. Hold urine as long as she can before emptying the
bladder to strengthen her sphincter muscles
B. If burning sensation is experienced while voiding, drink
pineapple juice
C. After urination, wipe from anal area up towards the
pubis
D. Tell client to empty the bladder at each voiding
27. Mrs. Seva also tells the nurse that she is often
constipated. Because she is aging, what physical changes
predispose her to constipation?
A. Inhibition of the parasympathetic reflex
B. Weakness of sphincter muscles of anus
C. Loss of tone of the smooth muscles of the colon
D. Decreased ability to absorb fluids in the lower intestines
28. The nurse understands that one of these factors
contributes to constipation:
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A. Excessive exercise
B. High fiber diet
C. No regular time for defecation daily
D. Prolonged use of laxatives
29. Mrs. Seva talks about fear of being incontinent due to a
prior experience of dribbling urine when laughing or
sneezing and when she has a full bladder. Your most
appropriate instruction would be to:
A. Tell client to drink less fluids to avoid accidents
B. Instruct client to start wearing thin adult diapers
C. Ask the client to bring change of underwear “just in
case”
D. Teach client pelvic exercise to strengthen perineal
muscles
30. Mrs. Seva asked for instructions for skin care for her
mother who has urinary incontinence and is almost always
in bed. Your instruction would focus on prevention of skin
irritation and breakdown by:
A. Using thick diapers to absorb urine well
B. Drying the skin with baby powder to prevent or mask the
smell of ammonia
C. Thorough washing, rising and drying of skin area that
gets wet with urine
D. Making sure that linen are smooth and dry at all times
Situation 7 – Using Maslow’s need theory, Airway,
Breathing and Circulation are the physiological needs vital
to life. The nurse’s knowledge and ability to identify and
immediately intervene to meet these needs is important to
save lives.
31. Which of these clients has a problem with the transport
of oxygen from the lungs to the tissues?
A. Carol with tumor in the brain
B. Theresa with anemia
Final Diagnostic Exam III
C. A boy with a fracture in the femur
D. Brigitte with diarrhea
32. You noted from the lab exams in the chart of M. Santos
that he has reduced oxygen in the blood. This condition is
called:
A. Cyanosis
B. Hypoxia
C. Hypoxemia
D. Anemia
33. You will do nasopharyngeal suctioning on Mr. Abad.
Your guide for the length of insertion of the tubing for an
adult would be:
A. Tip of the nose to the base of the neck
B. The distance from the tip of the nose to the middle of the
neck
C. The distance from the tip of the nose to the tip of the ear
lobe
D. Eight to ten inches
34. While doing nasopharyngeal suctioning on Mr. Abad,
the nurse can avoid trauma to the area by:
A. Apply suction for at least 20-30 seconds each time to
ensure that all secretions are removed
B. Using gloves to prevent introduction of pathogens to the
respiratory system
C. Applying no suction while inserting the catheter
D. Rotating catheter as it is inserter with gentle suction
35. Myrna has difficulty breathing when on her back and
must sit upright in bed to breathe effectively and
comfortably. The nurse documents this condition as:
A. Apnea
B. Orthopnea
C. Dyspnea
D. Tachypnea
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Situation 8 – You are assigned to screen for hypertension.
Your task is to take blood pressure readings and you are
informed about avoiding the common mistakes in BP taking
that lead to false or inaccurate blood pressure readings.
36. When taking blood pressure reading the cuff should be:
A. Deflated fully then immediately start second reading for
same client
B. Deflated quickly after inflating up to 180 mmHg
C. Large enough to wrap around upper arm of the adult
client 1 cm above brachial artery
D. Inflated to 30 mmHg above the estimated systolic BP
based on palpation of radial or bronchial artery
37. Chronic Obstructive Pulmonary Disease (COPD) in one
of the leading causes of death worldwide and is a
preventable disease. The primary cause of COPD is:
A. Tobacco hack
B. Bronchitis
C. Asthma
D. Cigarette smoking
38. In your health education class for clients with diabetes
you teach them the areas for control of Diabetes which
include all EXCEPT:
A. Regular physical activity
B. Thorough knowledge of foot care
C. Prevention nutrition
D. Proper nutrition
39. You teach your clients the difference between, Type I
(IDDM) and Type II (NDDM) diabetes. Which of the
following is true?
A. Both types diabetes mellitus clients are all prone to
developing ketosis
Final Diagnostic Exam III
B. Type II (NIDDM) is more common and is also
preventable compared to Type I (IDDM) diabetes which is
genetic in etiology
C. Type I (IDDM) is characterized by fasting hyperglycemia
D. Type II (NIDDM) is characterized by abnormal immune
response
40. Lifestyle-related diseases in general share areas
common risk factors. These are the following except:
A. Physical activity
B. Smoking
C. Genetics
D. Nutrition
Situation 9 – Nurse Rivera witnesses a vehicular accident
near the hospital where she works. She decides to get
involved and help the victims of the accident.
41. Her priority nursing action would be to:
A. Assess damage to property
B. Assist in the police investigation since she is a witness
C. Report the incident immediately to the local police
authorities
D. Assess the extent of injuries incurred by the victims of
the accident
42. Priority attention should be given to which of these
clients?
A. Linda who shows severe anxiety due to trauma of the
accident
B. Ryan who has chest injury, is pale and with difficulty
breathing
C. Noel who has lacerations on the arms with mild bleeding
D. Andy whose left ankle swelled and has some abrasions
43. In the emergency room, Nurse Rivera is assigned to
attend to the client with lacerations on the arms. While
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assessing the extent of the wound the nurse observes that
the wound is now starting to bleed profusely. The most
immediate nursing action would be to:
A. Apply antiseptic to prevent infection
B. Clean the wound vigorously of contaminants
C. Control and reduce bleeding of the wound
D. Bandage the wound and elevate the arm
44. The nurse applies dressing on the bleeding site. This
intervention is done to:
A. Reduce the need to change dressing frequently
B. Allow the pus to surface faster
C. Protect the wound from microorganisms in the air
D. Promote homeostasis
45. After the treatment, the client is sent home and asked
to come back for follow-up care. Your responsibilities when
the client is to be discharged include the following
EXCEPT:
A. Encouraging the client to go to the outpatient clinic for
follow up care
B. Accurate recording of treatment done and instructions
given to client
C. Instructing the client to see you after discharge for
further assistance
D. Providing instructions regarding wound care
Situation 10 – While working in the clinic, a new client,
Geline, 35 years old, arrives for her doctor’s appointment.
As the clinic nurse, you are to assist the client fill up forms,
gather data and make an assessment.
46. The purpose of your initial nursing interview is to:
A. Record pertinent information in the client’s chart for
health team to read
B. Assist the client find solutions to her health concerns
Final Diagnostic Exam III
C. Understand her lifestyle, health needs and possible
problems to develop a plan of care
D. Make nursing diagnoses for identified health problems
47. While interviewing Geline, she starts to moan and
doubles up in pain. She tells you that this pain occurs
about an hour after taking black coffee without breakfast for
a few weeks now. You will record this as follows:
A. Claims to have abdominal pains after intake of coffee
unrelieved by analgesics
B. After drinking coffee, the client experienced severe
abdominal pain
C. Client complained of intermittent abdominal pain an hour
after drinking coffee
D. Client reported abdominal pain an hour after drinking
black coffee for three weeks now.
48. Geline tells you that she drinks black coffee frequently
within the day to “have energy and be wide awake” and
she eats nothing for breakfast and eats strictly vegetable
salads for lunch and dinner to lose weight. She has lost
weight during the past two weeks. In planning a healthy
balanced diet with Geline, you will:
A. Start her off with a cleansing diet to free her body of
toxins then change to a vegetarian diet and drink plenty of
fluids
B. Plan a high protein diet, low carbohydrate diet for her
considering her favorite food.
C. Instruct her to attend classes in nutrition to find food rich
in complex carbohydrates to maintain daily high energy
level.
D. Discuss with her the importance of eating a variety of
food from major food groups with plenty of fluids.
49. Geline tells you that she drinks 4-5 cups of black coffee
and diet cola drinks. She also smokes up to a pack of
cigarettes daily. She confesses that she is in her 2nd
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month of pregnancy but does not want to become fat that is
why she limits her food intake. You warn or caution her
about which of the following?
A. Caffeine products affect the central nervous system and
may cause the mother to have a “nervous breakdown”
B. Malnutrition and its possible effects on growth and
development problems in the unborn fetus
C. Caffeine causes a stimulant effect on both mother and
the baby
D. Studies show conclusively that caffeine causes mental
retardation

50. Your health education plan for Geline stresses proper

diet for a pregnant woman and the prevention of non-
communicable diseases that are influenced by her lifestyle.
These include the following EXCEPT:
A. Cardiovascular diseases
B. Cancer
C. Diabetes Mellitus
D. Osteoporosis

***END OF EXAMINATION***

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