FUNDA Q & A B.

)Provide reading material about chemotherapy

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.) The nurse should assess the activity 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
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 a leak-proof,
puncture-proof container. This is to prevent needle puncture of
self. Universal precaution: NEVER RECAP NEEDLE
29.) When performing surgical hand scrub, which of the
following nursing actions ensure prevention of contamination?
1. Keep fingernails short, clean, without nail polish
2. Open faucet with knee or foot control
3. Keep hands above elbows when washing and rinsing
4. Wear cap, mask, and shoe cover after hand scrub
A.) 1,3,4
B.) 1,2,3
C.) 1,2,4
D.) 2,3,4
ANS: B
> 1,2 and 3- Surgical hand scrub involves the following actions:
Keep fingernails short, clean, without nail polish, open faucets
with knee or foot control; keep hands above elbows when
washing and rinsing. Cap, mask, shoe cover should be worn
before hand scrub, to prevent contamination of the scrubbed
hand
30.) When removing gloves, which of the following is
inappropriate nursing action?
A.) Wash gloved hands first
B.) Peel off gloves inside out
C.) Use glove-to-glove, skin-to-skin technique
D.) Remove mask and gown before removing gloves
ANS: D
> When removing gloves, it is inappropriate to remove mask
and gown first before gloves. Appropriate nursing actions are:
wash gloved hands first, peel off gloves inside out; use glove-
to-glove, skin-to-skin techniques. Remove gloves first, followed
by the mask, gown, cap, and shoe cover
31.) When pouring sterile solution, the nurse performs which of
the following actions correctly?
A.) Hold bottle 6 inches above receptacle on the sterile field
B.) Remove cap of bottle and place it with the underside lid
down on a flat surface
C.) Return excess solution from sterile receptacle to the bottle
D.) Place the bottle of sterile solution within the sterile field
ANS: A
> When pouring sterile solution, hold bottle 6 inches above
receptacle on the sterile field. Cap of the bottle should be
placed with underside lip up, on a flat surface. Excess solution
should not be returned to the bottle because this is considered
contaminated. The bottle of the sterile solution should be
placed outside the sterile field because the outside part of the
bottle is nonsterile. Remember, sterile field/object should come
in contact with sterile objects only, to maintain sterility.
STRESS, ADAPTATION,HOMEOSTASIS
32.) Which of the following does not characterize stress?
A.) Stress is a nervous energy
B.) A single stress does not cause a disease
C.) Stress in inherent to life
D.) Stress may be protective but at times problematic
ANS: A
> This is an incorrect statement because stress is not a
nervous strategy; it is a psychophysiologic response
33.) Adaptive responses of man to stressors are characterized
by the following:
1. They are attempts to maintain equilibrium
2. They are fairly uniform in all individuals
3. They are limitless
4. They are always adequate to overcome stressors
A.) 1 and 2
B.) 1 and 3
C.) 1 and 4
D.) 2 and 4
ANS: B
> 1 and 3 adaptive responses are attempts to maintain
equilibrium and they are not limitless
34.) The first manifestation of inflammation is:
A.) Heat
B.) Redness
C.) Swelling
D.) Pain
ANS: B
> The first manifestation of inflammation is redness. This is due
to increased blood flow to the area affected
35.) The primary cause of pain at the site of inflammation is:
A.) Release of bradykinin
B.) Injury to nerve endings
C.) Compression of local nerve endings by edema fluids
D.) Impaired circulations
ANS: C
> The primary cause of pain at the site of inflammation is the
compression of local nerve endings by edema fluids
36.) 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
B.) 1 and 3
C.) 2 and 3
D.) 1 and 4
ANS: D
>1 and 4- Effects of SAMR are due to release of
norepinephrine and epinephrine. These include constipation
and increase BP
37.) The client is on NPO since midnight, as preparation for
blood test. Adreno-cortical response is activated. Which of the
following is an expected response?
A.) Low BP
B.) Decrease urine output
C.) Warm, flushed, dry skin
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 A.) Provide health teachings in several brief sessions
D.) Ego Integrity vs. Despair B.) Provide recreational activities like needleworks
C.) Make decisions for the client
Ans: B D.) Use audio-visual aids when providing health teachings

70.) The following are characteristics of a middle—aged adult Ans: A

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
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

71.) The aging process which is characterized by severe mental Ans: B

deterioration is:
A.) Senility 80.) The following are true in the human sexuality of the elderly
B.) Senescence EXCEPT:
C.) Gerontology A.) There is minimal change in amount of sexual response
D.) Geriatrics B.) There is cessation of sexual activity among elderly
C.) There is increased refractory periods in male
Ans: A D.) There is reduced vaginal lubrication

72.) The rate of Living Theory of Aging conceptualizes that: Ans: B

A.) Changes in replication of DNA –RNA are the causes of aging
B.) Aging is caused by a change in the immune system 81.) The following are characteristics of an elderly who has
C.) The body is like a machine, parts wear out and the machine achieved ego integrity EXCEPT:
breaks down A.) Views life with sense of wholeness and satisfaction from past
D.) The faster one lives, the sooner one ages and dies accomplishments
B.) Accepts death as completion of life
Ans: D C.) Experiences serenity and shares wisdom
D.) He wishes to live life longer to correct past mistakes
73.) The Disengagement Theory of aging believes that:
A.) Human beings are mortal and must eventually leave their Ans: D
place and role in society
B.) One must constantly struggle to remain functional 82.) According to Kohlberg’s theory on moral development,
C.) Persons will remain the same unless external and internal relationships are based on:
factors stimulate change A.) Mutual trust
D.) NOTA B.) Mutual satisfaction of needs
C.) Mutual approval of each other
Ans: A D.) Mutual beliefs

Ans: A

74.) Which of the following is inappropriate nursing action for the 83.) According to Havighurst’s theory on developmental tasks,
elderly when providing hygienic practices and skin care? the following are tasks of a 65-year old person EXCEPT:
A.) Provide daily bath A.) Adjusting to retirement and reduced income
B.) Use mild, superfatted soap B.) Adjusting to decreasing Physical strength and health
C.) Use body lotion C.) Establishing an explicit affiliation with one’s age group
D.) Change position frequently D.) Adjusting to aging parents

Ans: A Ans: D

75.) The following are appropriate nursing actions for the elderly 84.) Which of the following will help maintain the self-esteem of
with hearing impairment EXCEPT: an elderly client?
A.) Speak clearly, in well-enunciated words A.) Provide as much independence as possible, with
B.) Use normal tone of voice consideration to safety
C.) Repeat instructions as needed B.) Assist the client to accept the need for seeking help in making
D.) Increase loudness of voice when speaking decisions and judgments
C.) Do hygiene measures for the elderly to promote sense of
Ans: D well-being
D.) Plan for routine activities of daily living to be followed by the
76.) Which of the following colors is difficult to be distinguished client
by an elderly?
A.) Red Ans: A
B.) Green
C.) Purple 85.) The following are appropriate nursing actions to prevent
D.) Blue postural hypotension in an elderly patient EXCEPT:
A.) Advise to get out of bed gradually
Ans: C B.) Instruct to have a daily fluid intake of 3 glasses a day
C.) Advise to avoid straining at stool
77.) Which of the following enhances drug toxicity among D.) Advise to avoid bending down and suddenly standing up
elderly? again
A.) Less acute vision
B.) Decreased renal function Ans: B
C.) Altered memory
D.) Diminished sense of taste 86.) Which of the following is not appropriate nursing intervention
for an elderly with osteoporosis?
Ans: B A.) Include milk and dairy products in diet
B.) Take large amounts of protein-rich and salty foods
78.) Which of the following should be include in the nursing care C.) Have regular exercise
plan of an elderly? D.) Wear rubber-soled, low heeled shoes that grip well
 C.) Refers the patient to other services
Ans: B D.) Works with the significant others

87.) The following are nursing interventions to minimize Ans: A

confusion among elderly?
A.) Use touch to convey concern 96.) The manager role of the nurse is best demonstrated
B.) Have clocks or calendars in the environment when she:
C.) Keep a routine of activities of daily living A.) Plans nursing care with the patient
D.) All of theses B.) Intercedes on behalf of the patient
C.) Refers the patient to other services
Ans: D D.) Works with the significant of others

88.) The following nursing interventions are appropriate in the Ans: B

prevention of pressure sores among bedridden elderly patient
EXCEPT: 97.) All of the following are primary responsibilities of the
A.) Massage bony prominences nurse manager EXCEPT
B.) Apply alcohol on the skin A.) Performing bedside nursing
C.) Apply cornstarch over the bedlinens B.) Coordinating and delegating patient care
D.) Elevate head of bed at 45 to 90 degree angle C.) Setting standards of performance
D.) Designating staff schedules
Ans: B
89.) Florence Nightingale conceptualizes that nursing is: Ans: A
A.) The act of utilizing the environment of the patient to assist
him in his recovery 98.) The four concepts common to nursing that appear in
B.) Assisting the individual, sick or well, in the performance of each of the current conceptual models
those activities contributing to health, preventing illness and A.) Person, Nursing, Environment, Medicine
rehabilitating the sick or disabled B.) Person, Health, Nursing, Support System
C.) A humanistic science dedicated to compassionate concern C.) Person, Environment, Health, Nursing
with maintaining and promoting health, preventing illness and D.) Person, Environment, Psychology, Nursing
rehabilitating the sick or disabled
D.) A unique profession in that it is concerned with all the Ans:C
variables affecting an individual’s response to stressors. 99.) Which of the following is not a subjective data?
A.) Dizziness
Ans: A B.) Chest pain
C.) Anxiety
90.) Which of the following nursing theorists D.) Bluish discoloration
conceptualizes that all persons strive to achieve self-care? Ans: D
A.) Sister Callista Roy 100.) The following are specific activities during evaluation
B.) Dorothea Orem EXCEPT:
C.) Dorothy Johnson A.) Collecting data
D.) Jean Watson B.) Performing nursing interventions
C.) Measuring goal attainment
Ans: B D.) Revising or modifying the care plan
Ans: B
91.) Which of the following nursing theorists introduced
Transcultural Nursing Model?
A.) Imogene King
B.) Dorothea Orem
C.) Dorothy Johnson
D.) Madeleine Leininger

Ans: D

92.) The most important communication skill to be

developed by the nurse manager except.
A.) Performing bedside nursing
B.) Assertiveness
C.) Questioning
D.) Attentive Listening

Ans: D

93.) 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

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