SDCA TEST BANK #1 9.

Arman states that he is well since he feels no signs

1. Nursing has been focused on health and caring. and symptoms of his disease. Which of the 4 health
Traditionally, nursing was concerned with: models by Smith best explains Armans behavior?
A. Attending to the poor A. Eudaemonistic
B. Keeping people health and well B. Clinical
C. Caring for the sick and infirmed C. Adaptive
D. Working with dregs of society D. Role performance

2. Nursing has evolved for a subservient role to one that 10. Stress in endemic to every persons daily life. The
is: following are physiologic responses to stress
A. People oriented EXCEPT:
B. Handmaid of doctor A. Urine output of 2fluid ounce in 3 hours
C. Coordinative role B. Bronchodilation
D. Self-regulatory C. Mydriasis
D. Increased salivation
3. A key element of Florence Nightingales nursing
practice was: 11. In times of stress, BP increases because of:
A. Maintaining a maximum level of wellness A. Increase in sodium and water retention due to
B. Promoting the patients self care needs release of mineralocorticoids which results in
C. Recognizing nutrition as an important part of increased in blood volume
nursing care B. Decrease cardiac output and peripheral resistance
D. Addressing the patients adaptation to health C. Increase in secretion of renin because of the
problems effect of epinephrine
D. Increase in renal perfusion secondary to
4. The nurse theorist whose theory focused on the epinephrine
phases of nursing client relationship is:
A. Dorothy Johnson 12. The following increase blood pressure EXCEPT one:
B. Hildegard Peplau A. Exercise
C. Martha Rogers B. Fear and anxiety
D. Myra Levine C. Renal disease
D. Sympatholytic response
5. The nurse theorist whose major assumption is
Caring promotes health more than curing is the of: 13. What is the ideal inhalation to exhalation ratio?
A. Dorothy Johnson A. 1:2
B. Jean Watson B. 2:1
C. Sister Callista Roy C. 1:1
D. Virginia Henderson D. Any of the above

6. The nurses understanding of human needs is
essential to effective nursing care. Which statement
about Maslows need theory is TRUE?
A. Unmet needs causes illness
B. Priorities on human needs do not vary
C. Self-actualization is achieved on retirement
D. Risk factors are safety needs
14. Aside from body temperature, the PR and the RR will
be likewise taken. Which of the following instances
can the nurse take the patients RR?
A. While taking the pulse
B. While taking the temperature
C. While conversing the client
D. While moving the patient

7. Maslows need theory is ranked according to: 15. All but one causes tachycardia:
A. Priority needs of man A. Fasting
B. Identified problems in health assessment B. Cigarette smoking
C. How critical need is to survival C. Severe pain
D. Physiologic needs of man D. Anxiety

8. A Muslim client is in traction and confined to bed.
He needs assistance with his evening meal of
chicken, rice, beans, a roll and a glass of fruit juice.
Choose the nursing approach that is most
representative of the concept of holism.
A. Nurse removes the items from the overbed table
to make room for the dinner trey
B. Nurse pushes the overbed table towards the bed
so that it will be within the patients reach when
the dinner arrives
C. Nurse asks a family member to assist the patient
with the tray and the overbed table while she
straightens the area in an attempt to provide a
pleasant atmosphere for eating
D. Nurse prepares the environment and the
overbed table and inspects the contents of the
dinner tray. She asks the patient if he would
like to make any substitutions in the food and
fluids he has received
16. Which of the following influences heat production
most?
A. Alcoholic drinks
B. Active exercise
C. Food intake
D. Body metabolism
17. The BP of your patient Paula, 42, a known
hypertensive is 130/80mmHg on admission. Will you
give the standing order of Plendil 2.5mg tab OD?
A. Yes, because her anxiety might make her BP
rise
B. Yes, because her BP is variable
C. No, because it is her normal range
D. No, because fasting may be required later
18. Before taking the patients blood pressure, which of
the following must the nurse do first?
A. Cleanse the patients antecubital fossa with an
alcohol sponge

Page 1 of 6
 B. Note the patients age and explain the
procedure
C. Wipe the cuff and the valve with dry cloth
D. Palpate the brachial pulse
19. Which statement best describes the purpose of
nursing diagnosis?
A. Identification of problem areas
B. Specification of patients health care needs
C. Organization of the assessment data gathered
D. Preparation of a clinical abstract
20. When the nurse makes a nursing diagnosis, she
should NOT include which of the following in her
statement?
A. Actual and potential health problems amenable
to nursing actions
B. Patients nursing problem
C. Disease condition and pathology
D. Clinical judgement about individual, family or
community
21. Matt Murdock, 18, reports to having loose liquid
light brown stool every 2 days. Passage of stools is
associated with cramping abdominal pain. Bowel
sounds are increased and temperature is 38C. He has
not taken any medicine but reports a feeling of
general malaise. He stated that he ate at a fast food
restaurant 2 nights ago. Which is an appropriate
nursing diagnosis?
A. Alteration in bowel elimination: diarrhea of
unknown etiology possibly related to spoiled
food
B. Disturbance in elimination: bowel related to
possible gastroenteritis
C. Alteration in body temperature related to
dehydration
D. Pain: abdominal pain related to diarrhea
22. Your nursing diagnosis reads: High risk for
impaired skin integrity. Which of the following
objectives is inappropriate?
A. Demonstrate optimal nutritional intake
B. Maintain optimal circulation to all body areas
C. Consult the dietitian as needed for a
nutritional assessment
D. Promote and maintain intact skin tissue
23. Tim, a dyspneic patient asks the nurse if she can be
bathed sitting on a chair. The nurses response should
be:
A. Im sorry, Im allowed to bathe you in bed.
B. Since you are more comfortable on the chair,
I will be happy to assist you there.
C. My supervisor would be upset if she sees me
bathing you on the chair.
D. This is against hospital policy and how I have
been thought.
24. Lionel Fusco, 20 is diagnosed to have epilepsy. The
nurse noticed that he is wearing a rosary bead around
his neck. The nurse should:
A. Remove the rosary beads and give this to the
family member for safe keeping
B. Respect the patients right to wear the beads
C. Place the beads in an envelope and store them in
the agencys safe
D. Place the beads on the bedside table or chair
instead
25. On assessment, you noticed that the nail of your
client is spoon shaped. Your client has iron
deficiency anemia. This condition is called:
A. Clubbing
B. Koilonychias
C. Paronychia
D. Beaus line
26. The following are objective data gathered by the
nurse EXCEPT:
A. Blood loss approximately 250ml
B. Gurgles appreciated
C. Dyspnea
D. Fever
27. What are the 3 important elements in a good hand
washing?
A. Water, soap and friction
B. Water, soap and time
C. Soap time and friction
D. Water time and friction
28. Mrs. Smith, your patient is unable to sleep in her
first night of hospitalization. She appears restless and
anxious. The structure of the nervous system that
controls sleep is the:
A. Hypothalamus
B. Reticular activating system
C. Medulla oblongata
D. Cerebral cortex
29. Which of the following statement about rest and
sleep is true?
A. Regular bedtime promotes sleep
B. Ill persons sleep more than normal
C. Sedatives reduce sleepless nights
D. A low protein diet promotes sleep
30. Carol, a college student was brought by her mother in
the ER because of fever and cough. Which of the
following actions would you do first on admission?
A. Orient mother on hospital policy deposit policy
B. Determine the patients most immediate needs
C. Take patient to her bed
D. Take the patients vital sign
31. The following are sounds due to turbulent blood flow
secondary to arterial obstruction
A. Bruit
B. Thrill
C. Fremitus
D. A and B
32. In physical examination, less tender body areas are
palpated first to:
A. Reduce patient apprehension
B. Ensure patients cooperation
C. Properly position patient
D. Obtain accurate findings
33. You are going to assess your patients abdomen.
Which of the following sequence of physical
assessment will you use?
A. Percussion and auscultation
B. Inspection, palpation, percussion, auscultation
C. Inspection, auscultation, percussion, palpation
D. Auscultation, percussion, palpation
34. Your client is for urinalysis and the nurse teaches the
client how to collect the specimen correctly. Which
of the following instructions should the nurse
include?
Page 2 of 6
 A. Save the first voided urine C. 4-8 inches
B. Voided directly into the sterile specimen D. 6-8 inches
container
C. Cleanse the urethral meatus after obtaining the 44. Which of the following statement is TRUE about
specimen rectal tube insertion?
D. Stop collecting the urine after the bladder is A. The rectal tube may remain in the colon for 2-3
empty hours to achieve the desirable effect
B. The rectal tube should remain in the colon not
35. You received the routine fecalysis result of your longer than 30minutes and reinserted 2-
client. Which of the following results would not be 3hours after
normal? C. The rectal tube should remain in the colon only
A. Odor-foul smelling for 5-10minutes to prevent rectal damage
B. Amorphous phosphate (+) D. The rectal tube may remain in the colon for 24
C. (+) dead bacteria hours or until the effect has been achieved
D. (+) mucus
45. Because of constipation, the AMD ordered the client
36. Results of the laboratory test of your patient Melissa to take 60ml of castor oil PO. The castor oil
shows that her total serum calcium is 6mg/dl. The facilitates cleansing by:
normal serum calcium level in an adult is: A. Lubricating the feces
A. 8-10mg/dl B. Increasing the volume of intestinal contents
B. 6-8mg/dl C. Softening the stools
C. 3-5mg/dl D. Irritating the nerve endings in the intestinal
D. 10-12mg/dl mucosa

37. Of the following hematologic test result, which is 46. As part of the clients outpatient teaching plan, the
normal? nurse should instruct him to take care of the
A. PTT 30-40seconds following medication after LGIS?
B. Neutrophils 20% A. Laxative
C. HDL 60% B. Antacid
D. Total serum bilirubin 1.2mg/dl C. Emetic
D. Digestant
38. Richard has an oxygen therapy given via face mask.
The primary effect of oxygen therapy is to: 47. Pain is one of the patients major problems. Which of
A. Increase oxygen in the tissues and cells the following statements is NOT true?
B. Increase oxygen carrying capacity of the blood A. Utilize various type of pain relief measures if
C. Increase respiratory rate necessary
D. Increase oxygen pressure in the alveolar sac B. Utilize measures that the nurse believes to be
effective
39. To promote lung expansion, what measures can the C. If therapy proves to be ineffective at first, change
nurse employ? with another relief measure
A. Oxygen inhalation D. Pain tolerance varies greatly among individuals
B. Chest cupping and vibration
C. Steam inhalation 48. To remove matting of hair, which of the following
D. Deep breathing and coughing exercise method is most effective?
A. Moisten the affected part with a small amount
40. The following are early manifestations of hypoxemia, of oil
EXCEPT: B. Comb the hair by strand
A. Tachycardia C. Perform bed shampoo
B. Restlessness D. Apply a hair gel thoroughly on the scalp
C. Tachypnea
D. Cyanosis 49. The most dangerous complication of vomiting is:
A. Aspiration
41. Diabetic Donna, 38 years old is readmitted to the B. Dehydration
hospital for evaluation of her condition. Which of C. Hypokalemia
these could be used to test for the presence of sugar D. Fever
in the blood?
A. Clinitest 50. The following are appropriate nursing interventions
B. Benedicts test to relieve anorexia nervosa, EXCEPT:
C. GTT A. Provide fastidious hygienic measures
D. Test-tape B. Offer small frequent feedings
C. Serve food at proper temperature
42. All but one blood exams do NOT require fasting: D. Adminster vitamin substitutes for food
A. CPK
B. Calcium determination 51. One of the following goals of the nurse is to prevent
C. A/G ratio contractures and deformities especially in clients who
D. Total bilirubin are immobile. Thus, the nurse should change the
clients position in bed at least:
43. Mang Tomas, 68 complains of a gassy abdomen. His A. When told to do so
AMD ordered rectal tube insertion. The nurse should B. Every 2 hours
insert the tube: C. As often as necessary
A. 3-4 inches D. Every 2-3 hours
B. 8-10 inches

Page 3 of 6
52. Turning the sole of the foot outward is called:
A. Abduction
B. Circumduction
C. Eversion
D. Foot drop
53. When caring for artificial dentures of the client, the
most important consideration is:
A. Place a washcloth in a basin or bowl or sink to
prevent damage of dentures if dropped
B. Use soap and water to cleanse the dentures
C. Soak dentures in warm water
D. Place dentures in transparent container
54. The most effective nursing measure to relieve
dryness of the skin is to:
A. Apply powder on the skin
B. Increase fluid intake
C. Bathe the client daily
D. Apply alcohol on the skin
55. The following are purposes of condom
catheterization, except:
A. To collect urine for male incontinence
B. To measure hourly urine output
C. To prevent skin irritation
D. To permit physical activity without fear of
embarrassment
56. Which of the following statements is true regarding
an individuals tolerance to heat and cold?
A. The inner aspect of wrist, neck and forearm are
not temperature sensitive
B. The larger area exposed to heat or cold, the
greater is the tolerance
C. Persons with neurosensory impairments have
high tolerance to heat/cold application
D. Intact skin is more sensitive to temperature
variation than impaied skin areas
57. The primary substance responsible for dilating blood
vessels during inflammatory response is:
A. Histamine
B. Epinephrine
C. Dopamine
D. Bradykinin
58. The infusion site of your client is edematous and
reddened. Your client is complaining of pain along
the vein. What should you do first?
A. Check the IV solution and refer immediately
B. Stop infusion and reinsert the IV immediately
C. Place a warm compress over the IV site
D. Slow down the IV infusion
59. Which of the following is the first sign that decubitus
ulcer might be developing?
A. Papules appear at pressure areas
B. Rash appears at pressure area
C. Local skin area is reddened
D. Local skin area is bluished
60. You are going to take the temperature of Boromir, an
2 year old boy whose right arm has a posterior mold.
Which route will you use?
A. Oral
B. Rectal
C. Axilla avoinding the unaffected side
D. Tymphanic
61. When assessing the pulse of Liza, you noted that it is
jerky will full expansion followed by a sudden
collapse. Her pulse is described to be:
A. Corrigan
B. Dicrotic
C. Collapsing
D. Bigeminal
SITUATION: Kaye is for gastric gavage. An NGT is to be
inserted by the resident on duty.
62. If the tubing does not appear to be in the stomach
when you checked it, your first action should be to:
A. Call the AMD for a decision
B. Withhold the feeding ordered
C. Remove the tube immediately
D. Administer the feeding gradually
63. If a residual amount of more than 150ml is aspirated
before the feeding, the nurse should:
A. Call the AMD for a decision
B. Withhold the feeding
C. Refer to AMD
D. Aspirate again to validate your data
64. All but one of these vitamins if deficient will lead to
anemia:
A. Vitamin B12
B. Folic acid
C. Pyridoxine
D. Vitamin E
65. Which of the following is not a complication of
gastric gavage?
A. Aspiration
B. Dehydration
C. Dumping syndrome
D. Nutritional imbalance
SITUATION: Scott is for urine culture and sensitivity test and
for albumin determination.
66. Scott should be informed that the urine C and S
studies are required for which of these purposes?
A. To analyze the elements present in the urine
B. To determine if the urine contains evidence of
malignant cells
C. To identify the organism causing the infection
in the urinary tract
D. To localize the site of the inflammatory process
in the urinary tract
67. The specimen required for urinary albumin
determination is:
A. Fractional urine collection
B. 24 hour urine
C. Midstream urine sample
D. Early morning midstream urine
68. The following are normal characteristics found in the
urine, EXCEPT:
A. Specific gravity = 1.020
B. pH = 6
C. Uric acid = traces
D. RBC
69. To obtain a 24 hour urine sample, which of these
instructions should be given Scott?
A. Collect each voiding in separate containers for
the next 24 hours.
B. Keep a record of the amount and time of each
voiding for 24 hours.
C. Collect all the urine voided starting from the
time indicated by doctor.
Page 4 of 6
 D. Discard the first voiding in the morning and 79. Which of the following is not recorded as fluid
then collect the total volume of each voiding intake?
for 24 hours. A. Porridge
B. Cream soup
70. Which of the following is the most common site for C. Ice cream
abdominal paracentesis? D. Gelatin
A. Symphysis pubis
B. Umbilical region 80. The best way to individualize patient care is by:
C. Between the umbilicus and symphysis pubis A. Collecting data
D. 2 fingerbreaths above the umbilicus B. Determining the cause of the problems
C. Identifying his medical diagnosis
71. Which of the following statements is true about D. Determining the age of the patient
thoracentesis?
A. NPO is required after the procedure 81. Which of the following baths is administered to
B. The patient should remain immobile during relieve constipation after a rectal examination
the insertion of the needle A. Cleansing
C. The patient should remain flat on bed for at least B. Tepid sponge
4 hours after the procedure C. Hot sitz
D. The procedure is contraindicated for COPD D. Shower
patients
82. Digital extraction of feces is contraindicated in a very
72. For which of the following sings should the nurse weak or elderly patients because of vagal stimulation
monitor the client during thoracentesis? which may cause:
A. Hiccoughs A. Tachycardia
B. Incontinence B. Palpitation
C. Fever C. Bradycardia
D. Syncope D. Hypertension

73. The most dangerous and life threatening 83. The patient had her indwelling catheter removed. The
complications of IV therapy is: nurse endorses that her patient should be able to void
A. Pyrogenic reaction in:
B. Air embolism A. 2-4 hours
C. Circulatory overload B. 4-6 hours
D. Thrombophlebitis C. 6-8 hours
D. 8-10 hours
74. All but one is a reason why IV injection is preferred:
A. When large volume must be given 84. To prevent pressure sores, what should you take as a
B. When rapid onset of action is desired priority action?
C. When drugs are highly irritating to the tissue A. Frequent turning
D. When drug incompatibility is a major B. Regular bathing and use of mild antiseptic
problem C. Change position every 3 hours
D. Increase fluid intake
75. A widely used method of organzing and recording
data about a client which is quickly accessible to all 85. How do you administer a pre-operative order of
members of the health team, usually used during Demerol 50mg and Atropine gr 1/150
endorsement procedures in the Philippines: intramuscularly?
A. Kardex A. In separate syringes both diluted in saline
B. POR solution
C. SOR B. In one syringe without saline solution
D. Computer C. In one syringe drawing up Atropine then
Demerol
76. Which of the following is not caused by prolonged D. In one syringe drawing up Demerol then
immobility? Atropine
A. Contractures
B. Thrombosis 86. In planning nursing care to prevent pressure ulcers in
C. Pneumonia a bed ridden client, the nurse should include which of
D. Incontinence the following interventions?
A. Turn and position the client BID
77. To prevent fluid and electrolyte disturbances, the B. Vigorously massage bony prominences
NGT should be irrigated with: C. Hang a turning schedule at the clients
A. 0.9% NaCl bedside with a sign sheet
B. 0.3% NaCl solution D. Slide the client gently when turning
C. Clean tap water
D. Sterile warm water 87. The state of health is:
A. Identical among individuals
78. All but one are roentgenogram examination: B. Same at certain ages
A. IVP C. Constant in nature
B. Barium enema D. Continually changing
C. EMG
D. UGIS 88. A temperature of 101F is equivalent to how many
degrees centigrade?
A. 38.3

Page 5 of 6
 B. 30 98. A drug is absorbed most rapidly when:
C. 38.5 A. Given in an empty stomach
D. 40 B. Injected intravenously
C. Injected intramuscularly
89. What route of temperature assessment is best for D. Administered with a glass of water
children less than 3 years old?
A. Oral 99. When mixing medications in one syringe from one
B. Rectal vial and one ampule, the nurse withdraws the drug:
C. Axillary A. From the ampule first
D. Skin B. From the vial first
C. Simultaneously
90. What is the major mechanism by which the body D. Any
regulates fluid intake?
A. Urination 100. Several clients are being admitted to the hospital unit
B. Hormonal secretion at one time. There is only one private room available.
C. Thirst Which of the following clients has the highest
D. Temperature priority for being admitted to this private room?
A. A client admitted for surgery
91. The following are herbal plants used to treat/manage B. A client under the age of 12
dizziness, EXCEPT: C. A client who has a communicable respiratory
A. Kalamansi infection
B. Suha D. A client with large infected abdominal wound
C. Manga leaf
D. Dayap rind

92. The following can be determined by palpation,

EXCEPT:
A. Temperature
B. Vibration
C. Size and shape
D. Murmur

93. Which of the following principles is false in the care

of the client with drainage tubes?
A. The patency of the tube must be maintained at all
times
B. The receptacle for drainage must be below the
organ being drained
C. The equipment comprising the drainage
system must be clean
D. The receptacle for the output must be changed
PRN

94. Which of the following vitamins cannot be stored in

the body?
A. Ascorbic acid
B. Menadione
C. Calciferol
D. Retinol

95. An independent nursing action to lower body

temperature is to:
A. Perform bed bath
B. Administer antipyretic per doctors order
C. Apply cold compress intermittently
D. Give fluids 1 liter per day

96. When the radial pulse of the patient is irregular, the

nurse should:
A. Perform bed bath
B. Request another nurse to take the pulse
C. Count the pulse for 30 seconds and record rate
D. Wait for 30 minutes and count the radial pulse
for one minute

97. When the drug is administered via the spinal canal,

the route used is:
A. Intra-arterial
B. Intrathecal
C. Intrasynovial
D. Intravenous

Page 6 of 6