Sultan Kudarat Educational Institution College of Nursing Tacurong City BSN IV RELATED LEARNING EXPOSURE PRE-TEST Name: _________________________________________

Score:_________ Multiple Choice: Read each statement carefully and select the best answer by encircling the letter of your choice. ERASURES are strictly prohibited. The item/s that ERASURES are apparent will automatically considered void. Think critically and answer carefully. 1. Which of the following statements is not true in 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 ones potentialities. d. It is the ability to perform self-care. 1. 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. 1. According to Maslows 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 1. Who among the following clients should be attended to 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. 1. A person who may or may not be affected by disease is: a. Agent b. Carrier c. Victim d. Host 1. Health promotion activities are directed to achieve the following

i. Increasing level of wellness ii. Improving quality of life iii. Relying on health care personnel to maintain health iv. Promoting healthful lifestyle a. i, ii, iv b. ii, iii, iv c. i, ii, iii d. i, iii, iv 1. 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 1. Which of the following situations may cause droplet transmission of microorganisms? a. Facing a client 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 1. 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. The nurse enters a patient's room and assesses that the patient is exhibiting signs of dyspnea. The nurse will place the patient in which of the following positions? a. Supine c. Trendelenburg b. High-Fowler's d. Lithotomy

1.

1. It is a microsopic study of stool for presence of bleeding in the gastrointestinal tract. a. Stool cultures and sensitivity test b. Guaiac stool exam c. Routine fecalysis d. None of the above

1.

The nurse notices a sputum specimen sitting on the bedside table in a patient's room. After asking the patient when he produced the sputum specimen, he learns the specimen is about 4 hours old. Knowing this information, the nurse:

a. Immediately takes the sputum specimen to the laboratory b. Discards the specimen and assists the patient in obtaining another specimen c. Refrigerates the sputum specimen d. Waits an additional 2 hours before sending the specimen to the laboratory 13. It is a graphical recording of the hearts electrical activities. a. Echocardiography b. Electrocardiography c. Cardiac stress test d. Phonocardiography 13. During the health history, the patient informs the midwife/nurse that her mother has diabetes. What is the significance of this information? a. The patient may be at risk for developing diabetes. b. The patient may need teaching on preventing diabetes. c. The patient may need to attend a support group for diabetes. d. This may affect the patient's diet during hospitalization. 13. During the spiritual assessment, the patient indicates that he or she does not eat meat. This would be considered a: a. Personal choice c. Risk for malnutrition b. Religious practice d. Lifestyle choice 13. The most effective assessment technique for the nurse assessing the lymph nodes of a patient's neck is: a. Inspection c. Palpation b. Auscultation d. Percussion 13. Which of the following is not an appropriate nursing action when collecting a 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 ml of urine d. Discard the first flow of urine 13. In the diagnostic statement, Excess fluid volume related to decreased venous return as manifested by lower extremity edema (swelling), the etiology of the problem is which of the following? a. Excess fluid volume b. Decreased venous return c. Edema d. Unknown

13. When initiating the implementation phase of the nursing process, the nurse performs which of the following steps first? a. Carrying out nursing interventions b. Determining the need for assistance c. Reassessing the client d. Documenting interventions 13. Which of the following is the primary purpose of the evaluating phase of the careplanning process to determine whether: a. Desired outcomes have been met. b. Nursing activities were carried out. c. Nursing activities were effective. d. Clients condition has changed. 13. The following are specific activities during evaluation except; a. Collecting data b. Performing nursing intervention c. Measuring goal attainment d. Revising or modifying the care plan 13. 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 given highest priority d. Clients with unstable conditions should be given priority over those with stable conditions 13. Which of the following is incorrect statement of nursing diagnosis? a. High risk for ineffective airway clearance r/t pneumonia b. High risk for injury r/t dizziness c. Constipation r/t decreased activity and fluids as manifested by small, hard, formed stool every 3 days d. Anxiety r/t insufficient knowledge regarding surgical experience 13. Which of the following is an incorrect statement of outcome criteria? a. Ambulates 30 feet with cane before discharge b. Discusses fears and concerns regarding the surgical procedure during the preoperative teaching. c. Demonstrates proper coughing technique after the teaching session. d. Reestablishes normal pattern of bowel elimination

13.

Therapeutic nurse-patient relationship is described as follows: i. It is based on friendship and mutual interest. ii. It is a professional relationship. iii. It is focused on helping the patient solve problems and achieve healthrelated goals. iv. It is maintained only as long as the patient requires professional help. a. b. c. d. i, ii, iii i, ii,iv ii, iii, iv i, iii, iv

a. b. c. d.

Adequate fluid intake. Minimize cigarette smoking. Deep breathing and coughing exercises. Frequent change of position among bedridden clients.

13. The

13. 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. 13. 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. 13. 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 c. Remittent fever b. Relapsing fever d. Constant fever 13. 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.

following are appropriate nursing actions when performing percussion, vibration and postural drainage, except: a. Verify doctors order. b. Perform 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.

13. Which of the following structures prevents gastric reflux? a. Pyloric sphincter c. Cardiac sphincter b. Internal sphincter d. Sphincter of Oddi 13. Which of the following nutrients remain in the stomach for the longest period? a. Fats c. Proteins b. Carbohydrates d. Water 13. Which of the following is most effective nursing measure to relieve anorexia? a. Provide small, frequent feedings. b. Remove unsightly articles from the patients unit. c. Provide three full meals a day. d. Provide good hygienic measures. 13. Which of the following is the richest source of iron? a. Mongo c. Malunggay leaves b. Ampalaya d. Pechay 13. The following are good sources of calcium, except: a. Cheese c. Soy products b. Milk d. Carbonated drinks 13. The most life-threatening complication of vomiting is: a. Aspiration c. Fever b. Dehydration d. Malnutrition 13. The best indicator of nutritional status of the individual is a. Weight c. Arm muscle circumference b. Height d. Adequacy of hair

13. The

following are appropriate nursing interventions to promote normal respiratory function, except:

13. The client is experiencing hypokalemia. Which of the following should be included in his diet? a. Banana c. Cheese b. Milk d. Fish

13. The following are signs and symptoms of

dehydration, except: a. Weight loss b. Decreased urine output c. Elevated body temperature d. Elevated BP 13. Vitamin K is necessary for a. Bone and teeth formation b. Integrity of skin and mucous membrane c. Blood coagulation d. Formation of RBC 13. 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

13. 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. 13. The best position for female during urinary catheterization is a. Supine c. Lateral b. Dorsal recumbent d. Semi-Fowlers 14. The rationale for lateral or upward anchoring of the urethral catheter in male is to a. Prevent pressure at the penoscrotal area. b. Promote comfort. c. Secure the catheter well. d. Provide privacy. 15. During one of Nurse Diannes home visit to Family Alonzo, she learned that the clients first child lacks immunization. This situation is a: a. Health deficit c. Foreseeable crisis b. Health threat d. Health problem 52. The youngest sibling of Family Alonzo was coughing and upon assessment has a fever. The mother told Nurse Diane that the child has had two incidents of pneumonia within the year. This is a: a. Health deficit c. Foreseeable crisis b. Health threat d. Health problem 53. The neighbor of Family Alonzo has been grieving due to the death of their mother from pregnancy complications. Nurse Diane understands that this event is a: a. Health deficit c. Foreseeable crisis b. Health threat d. Health problem 54. In the collection of data various methods are employed by a public health nurse. Which is not included in these methods? a. Community surveys b. Individual and family health records c. Developing an operational plan b. Observation of health related behaviors of individuals and family groups 55. An indispensible and essential equipment of a public health nurse during her home visit is: a. Black umbrella c. Bag technique

13. The

following are appropriate nursing measures to relieve constipation, except: a. Includes fruits and vegetables. b. Have adequate activity and exercise. c. Take laxatives at regular basis. d. Answer immediately to the urge to defecate.

13. The most common side-effect of laxative overuse is a. Diarrhea c. Constipation b. Nausea and vomiting d. Flatulence 13. The best position of the adult patient during enema administration is a. Left lateral c. Right lateral b. Supine d. Semi-Fowlers

13. The following are correct nursing actions

when administering enema, except: a. Provide privacy b. Introduce solution slowly. c. Alternate NSS with tap water and soap suds. d. Increase the flow rate of the enema solution if abdominal cramps occur. 13. The height of solution for non-retention enema above the buttocks is a. 12 inches c. 24 inches b. 18 inches d. 4 inches

b. Public health bag

1441

d. Thermometer 61. A woman who is gravid 1 is in the active phase of stage 1 of labor. The fetal position is LOA. When her membranes rupture, the nurse should expect to see a. A large amount of bloody fluid. b. A moderate amount of clear to strawcolored fluid. c. A small amount of greenish fluid. d. A small segment of the umbilical cord. 61. The nurse is caring for a woman in stage 1 labor. The fetal position is LOA. When her membranes rupture, the nurses first action should be to a. Notify the physician. b. Count the fetal heart rate. c. Measure the amount of fluid. d. Perform a vaginal exam 61. A primigravida presents to the labor room with rupture of membranes at 40 weeks AOG. Her cervix is 2cm dilated and 100% effaced. Contractions are every 10 minutes. What should the nurse include in the plan of care? a. Allow her to ambulate as desired as long as the presenting part is not engaged. b. Assess fetal heart tones and maternal status every five minutes. c. Place her on an electronic fetal monitor for continuous assessment of labor. d. Send her home with instructions to return when contractions are every 5 minutes. 61. The nurse is caring for a woman who is in labor. She is 8 cm dilated. To support her during this phase of labor, the nurse should a. Leave her alone most of the time, b. Offer her a back rub during contractions c. Offer her sips of oral fluids d. Provide her with warm blankets 61. When assessing a client who gave birth 4 hours earlier, the nurse finds the uterus to be firm, 2 fingerbreadths above the umbilicus, and displaced to the right. Lochia rubra is moderate. What would be the first nursing action? a. Encourage the woman to urinate b. Gently massage the fundus c. Insert a foley catheter d. Record these normal findings

5 6. What is the primary reason or rationale of performing bag technique? a. To minimize if not prevent the spread of infection. b. To save time and effort in the performance of nursing procedures. c. To promote ease and dexterity in implementing procedures. d. To render effective nursing care to the client. 57. Home visit allows a public health nurse to assess the home and family situations in order to provide the necessary nursing care. Public Nurse Chedie knows that principles are involves in preparing for a home visit. Which of the following least likely describe the principles in home visit preparation? a. A home visit should have a purpose b. Before a home visit is done a family record should be read c. Delivery of the care involves all the members of the family d. The plan for a home visit should be time bounded 58. Nurses provide care to cases such as prenatals, diabetics or tuberculosis patients they encounter. a. individual level c. family level b. community level 59. A cardinal principle in public health nursing practice states that the family is the unit of service. The following are the reasons why the family is the unit of care, EXCEPT. a. The family as a group generates, prevents, tolerates and corrects health problems b. within its membership. c. The health problems of family members are interlocking. d. The family is the most frequent locus of health decisions and actions in personal care. e. None of the above. 60. The following are the characteristics of the Family as a Patient. a. The family is more than the sum of its individual members. b. The family as a behaving, functioning organization is a product of both time and place.. c. A family, like an individual, passes through a growth cycle. d. None of the above.

61. How should a nurse teach a patient to perform diaphragmatic breathing? a. The patient should take three deep breaths and cough hard 3 times. b. The patient should take three deep breaths and exhale forcefully. c. The patient should take a deep breath in through the mouth hold the breath for 5 seconds and exhale all the air out through the nose and mouth. d. The patient should rapidly inhale, hold for 30 seconds, and exhale slowly. 61. During the preoperative assessment, the patient informs the nurse that he ingests 5 to 10 oz of alcohol each day and has for the last 15 years. What postoperative difficulties can the nurse anticipate for this patient? a. Delirium tremens immediately following surgery b. Delirium tremens within 72 hours after his last alcohol drink c. Delirium tremens upon administration of general anesthesia d. Delirium tremens 1 week after his last alcohol drink 61. The patient wears dentures and is reluctant to remove them for the surgery. What is the nurse's best response? a. Everyone needs to remove his dentures prior to surgery. b. You can have your teeth back right after your surgery. c. You may keep your dentures; I will just notify the operating nurse. d. Your dentures need to be removed as a safety precaution; they could potentially interfere with your airway and breathing during surgery. 61. The circulating nurse is responsible for which of the following tasks? a. Monitoring the patient and documents b. Estimating the patient's blood loss c. Setting up the sterile tables d. Keeping track of drains and sponges 61. The nurse is caring for a patient who just had surgery. What is the nurse's highest priority? a. Assessing for hemorrhage b. Maintaining a patent airway c. Managing the patient's pain d. Assessing vital signs every 15 minutes