COMPREHENSIVE PHASE - POST TEST - FUNDAMENTALS OF 9.

Which of the following behaviors by Nurse Jane Robles

NURSING demonstrates that she understands well the elements of
1. Jessie is complaining of shortness of breath. The nurse effecting charting?
assesses his respiratory rate to be 30 breaths per minute and A. She writes in the chart using a no. 2 pencil.
documents that Jessie is tachypneic. The nurse understands B. She noted: appetite is good this afternoon.
that tachypnea means: C. She signs on the medication sheet after administering the
A. Pulse rate greater than 100 beats per minute medication.
B. Blood pressure of 140/90 D. She signs her charting as follow: J.R
C. Respiratory rate greater than 20 breaths per minute
D. Frequent bowel sounds 10. What is the disadvantage of computerized documentation
of the nursing process?
2. The nurse listens to Mrs. Santo’s lungs and notes a hissing A. Accuracy
sound or musical sound. The nurse documents this as: B. Legibility
A. Wheezes C. Concern for privacy
B. Rhonchi D. Rapid communication
C. Gurgles
D. Vesicular 11. The theorist who believes that adaptation and manipulation
of stressors are related to foster change is:
3. The nurse in charge measures a patient’s temperature at 101 A. Dorothea Orem
degrees F. What is the equivalent centigrade temperature? B. Sister Callista Roy
A. 36.3 degrees C C. Imogene King
B. 37.95 degrees C D. Virginia Henderson
C. 40.03 degrees C
D. 38.01 degrees C 12. Formulating a nursing diagnosis is a joint function of:
A. Patient and relatives
4. Which approach to problem solving tests any number of B. Nurse and patient
solutions until one is found that works for that particular C. Doctor and family
problem? D. Nurse and doctor
A. Intuition
B. Routine 13. Mrs. Caperlac has been diagnosed to have hypertension
C. Scientific method since 10 years ago. Since then, she had maintained low
D. Trial and error sodium, low fat diet, to control her blood pressure. This
practice is viewed as:
5. What is the order of the nursing process? A. Cultural belief
A. Assessing, diagnosing, implementing, evaluating, planning B. Personal belief
B. Diagnosing, assessing, planning, implementing, evaluating C. Health belief
C. Assessing, diagnosing, planning, implementing, evaluating D. Superstitious belief
D. Planning, evaluating, diagnosing, assessing, implementing
14. Becky is on NPO since midnight as preparation for blood
6. During the planning phase of the nursing process, which of test. Adreno-cortical response is activated. Which of the
the following is the outcome? following is an expected response?
A. Nursing history
B. Nursing notes A. Low blood pressure
C. Nursing care plan B. Warm, dry skin
D. Nursing diagnosis C. Decreased serum sodium levels
D. Decreased urine output
7. What is an example of a subjective data?
15. What nursing action is appropriate when obtaining a sterile
A. Heart rate of 68 beats per minute urine specimen from an indwelling catheter to prevent
B. Yellowish sputum infection?
C. Client verbalized, “I feel pain when urinating.” A. Use sterile gloves when obtaining urine.
D. Noisy breathing B. Open the drainage bag and pour out the urine.
C. Disconnect the catheter from the tubing and get urine.
8. Which expected outcome is correctly written? D. Aspirate urine from the tubing port using a sterile syringe.
A. “The patient will feel less nauseated in 24 hours.”
B. “The patient will eat the right amount of food daily.” 16. A client is receiving 115 ml/hr of continuous IVF. The nurse
C. “The patient will identify all the high-salt food from a notices that the venipuncture site is red and swollen. Which of
prepared list by discharge.” the following interventions would the nurse perform first?
D. “The patient will have enough sleep.” A. Stop the infusion
B. Call the attending physician
C. Slow that infusion to 20 ml/hr 23. Which of the following is the most important purpose of
D. Place a clod towel on the site planning care with this patient?
A. Development of a standardized NCP.
17. The nurse enters the room to give a prescribed medication B. Expansion of the current taxonomy of nursing diagnosis
but the patient is inside the bathroom. What should the nurse C. Making of individualized patient care
do? D. Incorporation of both nursing and medical diagnoses in
A. Leave the medication at the bedside and leave the room. patient care
B. After few minutes, return to that patient’s room and do not
leave until the patient takes the medication. 24. Using Maslow’s hierarchy of basic human needs, which of
C. Instruct the patient to take the medication and leave it at the the following nursing diagnoses has the highest priority?
bedside. A. Ineffective breathing pattern related to pain, as evidenced by
D. Wait for the patient to return to bed and just leave the shortness of breath.
medication at the bedside. B. Anxiety related to impending surgery, as evidenced by
insomnia.
18. Which of the following is inappropriate nursing action when C. Risk of injury related to autoimmune dysfunction
administering NGT feeding? D. Impaired verbal communication related to tracheostomy, as
A. Place the feeding 20 inches above the pint if insertion of evidenced by inability to speak.
NGT.
B. Introduce the feeding slowly. 25. When performing an abdominal examination, the patient
C. Instill 60ml of water into the NGT after feeding. should be in a supine position with the head of the bed at what
D. Assist the patient in fowler’s position. position?

19. A female patient is being discharged after thyroidectomy. A. 30 degrees

After providing the medication teaching. The nurse asks the B. 90 degrees
patient to repeat the instructions. The nurse is performing C. 45 degrees
which professional role? D. 0 degree
A. Manager
B. Caregiver 26. A male client undergone a colon resection. While turning
C. Patient advocate him, wound dehiscence with evisceration occurs. Nurse Trish
D. Educator first response is to:
A. Call the physician
B. Place a saline-soaked sterile dressing on the wound.
20. Which data would be of greatest concern to the nurse when C. Take a blood pressure and pulse.
completing the nursing assessment of a 68-year-old woman D. Pull the dehiscence closed.
hospitalized due to Pneumonia?
A. Oriented to date, time and place 27. Nurse Audrey is caring for a client who has suffered a
B. Clear breath sounds severe cerebrovascular accident. During routine assessment,
C. Capillary refill greater than 3 seconds and buccal cyanosis the nurse notices Cheyne- Strokes respirations. Cheyne-
D. Hemoglobin of 13 g/dl strokes respirations are:
A. A progressively deeper breaths followed by shallower
21. During a change-of-shift report, it would be important for breaths with apneic periods.
the nurse relinquishing responsibility for care of the patient to B. Rapid, deep breathing with abrupt pauses between each
communicate. Which of the following facts to the nurse breath.
assuming responsibility for care of the patient? C. Rapid, deep breathing and irregular breathing without
A. That the patient verbalized, “My headache is gone.” pauses.
B. That the patient’s barium enema performed 3 days ago was D. Shallow breathing with an increased respiratory rate.
negative
C. Patient’s NGT was removed 2 hours ago 28. Nurse Bea is assessing a male client with heart failure. The
D. Patient’s family came for a visit this morning. breath sounds commonly auscultated in clients with heart
failure are:
22. Which statement is the most appropriate goal for a nursing A. Tracheal
diagnosis of diarrhea? B. Fine crackles
A. “The patient will experience decreased frequency of bowel C. Coarse crackles
elimination.” D. Friction rubs
B. “The patient will take anti-diarrheal medication.”
C. “The patient will give a stool specimen for laboratory 29. The nurse is caring for Kenneth experiencing an acute
examinations.” asthma attack. The client stops wheezing and breath sounds
D. “The patient will save urine for inspection by the nurse. aren’t audible. The reason for this change is that:
A. The attack is over.
B. The airways are so swollen that no air can get through.
C. The swelling has decreased. D. Tuberculosis
D. Crackles have replaced wheezes.
36. Nurse Oliver is working in a out patient clinic. He has been
30. Mike with epilepsy is having a seizure. During the active alerted that there is an outbreak of tuberculosis (TB). Which of
seizure phase, the nurse should: the following clients entering the clinic today most likely to
A. Place the client on his back remove dangerous objects, and have TB?
insert a bite block.
B. Place the client on his side, remove dangerous objects, and A. A 16-year-old female high school student
insert a bite block. B. A 33-year-old day-care worker
C. Place the client o his back, remove dangerous objects, and C. A 43-yesr-old homeless man with a history of alcoholism
hold down his arms. D. A 54-year-old businessman
D. Place the client on his side, remove dangerous objects, and
protect his head. 37. Virgie with a positive Mantoux test result will be sent for a
chest X-ray. The nurse is aware that which of the following
reasons this is done?
31. After insertion of a cheat tube for a pneumothorax, a client A. To confirm the diagnosis
becomes hypotensive with neck vein distention, tracheal shift, B. To determine if a repeat skin test is needed
absent breath sounds, and diaphoresis. Nurse Amanda C. To determine the extent of lesions
suspects a tension pneumothorax has occurred. What cause D. To determine if this is a primary or secondary infection
of tension pneumothorax should the nurse check for?
A. Infection of the lung. 38. Kennedy with acute asthma showing inspiratory and
B. Kinked or obstructed chest tube expiratory wheezes and a decreased forced expiratory volume
C. Excessive water in the water-seal chamber should be treated with which of the following classes of
D. Excessive chest tube drainage medication right away?
A. Beta-adrenergic blockers
32. Nurse Maureen is talking to a male client, the client begins B. Bronchodilators
choking on his lunch. He’s coughing forcefully. The nurse C. Inhaled steroids
should:A. Stand him up and perform the abdominal thrust D. Oral steroids
maneuver from behind.
B. Lay him down, straddle him, and perform the abdominal 39. Mr. Vasquez 56-year-old client with a 40-year history of
thrust maneuver. smoking one to two packs of cigarettes per day has a chronic
C. Leave him to get assistance cough producing thick sputum, peripheral edema and cyanotic
D. Stay with him but not intervene at this time. nail beds. Based on this information, he most likely has which
of the following conditions?
33. Nurse Ron is taking a health history of an 84 year old client. A. Adult respiratory distress syndrome (ARDS)
Which information will be most useful to the nurse for planning B. Asthma
care? C. Chronic obstructive bronchitis
A. General health for the last 10 years. D. Emphysema
B. Current health promotion activities.
C. Family history of diseases. Situation: Francis, age 46 is admitted to the hospital with
D. Marital status. diagnosis of Chronic Lymphocytic Leukemia.

34. When performing oral care on a comatose client, Nurse 40. The treatment for patients with leukemia is bone marrow
Krina should: transplantation. Which statement about bone marrow
A. Apply lemon glycerin to the client’s lips at least every 2 transplantation is not correct?
hours. A. The patient is under local anesthesia during the procedure
B. Brush the teeth with client lying supine. B. The aspirated bone marrow is mixed with heparin.
C. Place the client in a side lying position, with the head of the C. The aspiration site is the posterior or anterior iliac crest.
bed lowered. D. The recipient receives cyclophosphamide (Cytoxan) for 4
D. Clean the client’s mouth with hydrogen peroxide. consecutive days before the procedure.

35. A 77-year-old male client is admitted with a diagnosis of 41. After several days of admission, Francis becomes
dehydration and change in mental status. He’s being hydrated disoriented and complains of frequent headaches. The nurse
with L.V. fluids. When the nurse takes his vital signs, she notes in-charge first action would be:
he has a fever of 103°F (39.4°C) a cough producing yellow A. Call the physician
sputum and pleuritic chest pain. The nurse suspects this client B. Document the patient’s status in his charts.
may have which of the following conditions? C. Prepare oxygen treatment
A. Adult respiratory distress syndrome (ARDS) D. Raise the side rails
B. Myocardial infarction (MI)
C. Pneumonia
42. During routine care, Francis asks the nurse, “How can I be cough. The nurse assesses the patient with understanding that
anemic if this disease causes increased my white blood cell an infection that is acquired during hospitalization is known as:
production?” The nurse in-charge best response would be that A. community acquired infection
the increased number of white blood cells (WBC) is: B. an iatrogenic infection
A. Crowd red blood cells C. a nosocomial infection
B. Are not responsible for the anemia. D. an opportunistic infection
C. Uses nutrients from other cells
D. Have an abnormally short life span of cells. 48. A client with anemia has a hemoglobin of 6.5 g/dL. The
client is experiencing symptoms of cerebral tissue hypoxia.
43. Diagnostic assessment of Francis would probably not Which of the following nursing interventions would be most
reveal: important in providing care?
A. Predominance of lymhoblasts A. Providing rest periods throughout the day
B. Leukocytosis B. Instituting energy conservation techniques
C. Abnormal blast cells in the bone marrow C. Assisting in ambulation to the bathroom
D. Elevated thrombocyte counts D. Checking temperature of water prior to bathing

44. Robert, a 57-year-old client with acute arterial occlusion of 49. A client was involved in a motor vehicular accident in which
the left leg undergoes an emergency embolectomy. Six hours the seat belt was not worn. The client is exhibiting crepitus,
later, the nurse isn’t able to obtain pulses in his left foot using decrease breath sounds on the left, complains of shortness of
Doppler ultrasound. The nurse immediately notifies the breath, and has a respiratory rate of 34 breaths per minute.
physician, and asks her to prepare the client for surgery. As the Which of the following assessment findings would concern the
nurse enters the client’s room to prepare him, he states that he nurse most?
won’t have any more surgery. Which of the following is the best A. Temperature of 102 degrees F and productive cough
initial response by the nurse? B. ABG with PaO2 of 92 and PaCO2 of 40 mmHg
A. Explain the risks of not having the surgery C. Trachea deviating to the right
B. Notifying the physician immediately D. Barrel-chested appearance
C. Notifying the nursing supervisor
D. Recording the client’s refusal in the nurses’ notes 50. The proper way to open an envelop-wrapped sterile
package after removing the outer package or tape is to open
45. During the endorsement, which of the following clients the first position of the wrapper:
should the on-duty nurse assess first? A. away from the body
A. The 58-year-old client who was admitted 2 days ago with B. to the left of the body
heart failure, blood pressure of 126/76 mm Hg, and a C. to the right of the body
respiratory rate of 22 breaths/minute. D. toward the body
B. The 89-year-old client with end-stage right-sided heart
failure, blood pressure of 78/50 mm Hg, and a “do not 51. Nurse Clementine was assessing a patient’s priority nursing
resuscitate” order needs. She has been employed in Toprank Medical Center for 4
C. The 62-year-old client who was admitted 1 day ago with years now. Under Patricia Benner’s Ladder of Clinical
thrombophlebitis and is receiving L.V. heparin Proficiency, At which stage does nurse Clementine belong?
D. The 75-year-old client who was admitted 1 hour ago with A. Advance Beginner
new-onset atrial fibrillation and is receiving L.V. dilitiazem B. Proficient
(Cardizem) C. Competent

46. Honey, a 23-year old client complains of substernal chest D. Expert

pain and states that her heart feels like “it’s racing out of the
chest”. She reports no history of cardiac disorders. The nurse 52. When a client has a retention catheter, the nurse is
attaches her to a cardiac monitor and notes sinus tachycardia expected to:
with a rate of 136beats/minutes. Breath sounds are clear and A. Clean the urinary meatus and adjascent skin periodically.
the respiratory rate is 26 breaths/minutes. Which of the B. Encourage liberal amount of fluid intake.
following drugs should the nurse question the client about C. Flush the catheter as needed.
using? D. Perform perineal flushing as needed.
A. Barbiturates
B. Opioids 53. When considering the safety needs of a client with a urinary
C. Cocaine catheter, which of the following should the nurse observe?
D. Benzodiazepines A. Keep a closed sterile drainage system.
B. Irrigate catheter daily
47. A patient is admitted to the medical surgical unit following C. Keep the bag lower than the bed.
surgery. Four days after surgery, the patient spikes a 38.9 D. Measure intake and output daily.
degrees C oral temperature and exhibits a wet, productive
54. A client practices Islam and his diet must consider his
religious practices and beliefs. You are aware that this client 61. While the nurse is giving a sponge bath to the client, what
would avoid which of the following food? action can facilitate venous blood flow?
A. Rubbing with long smooth strokes from the distal to the
1. Shrimps and crabs proximal parts of the extremities.
2. Wine and alcoholic drinks B. Circular massage strokes from the distal to the proximal
3. Fish with scales. parts of the body.
4. Pork products like bacon
C. Rubbing with short smooth strokes from the proximal to
5. Caffeinated products like cola drinks.
distal parts of the extremities.
A. 2, 4, and 5 D. Smooth long strokes alternating with chopping motions on
B. 3, 4 and 5 the limbs.
C. 1, 4 and 5
D. 1, 2 and 4 62. The client is for occult blood test. Which of the following
statement would indicate to the nurse that the client
55. When the nurse assist the client to identify and cope with understood the instructions for occult blood test preparation.
stressful emotional problems of the nurse is assuming the role A. “I will avoid all types of meat.”
of: B. “I will refrain from eating dark colored foods for a day.”
A. advocate C. I shouldn’t smoke.
B. Teacher D. I will avoid aquamephyton.
C. Counselor
D. Leader 63. A nurse is caring for a client following a bronchoscopy.
Which sign if noted in the client should be reported
56. The expanded role of the nurse acquired after specialized immediately?
training and credentialing is described as: A. Blood streaked sputum
A. Primary care nurse B. Dry cough
B. Private duty nurse C. Hematuria
C. Clinical nurse specialist D. Stridor
D. Visiting nurse
64. All of the following except one are done to assess the
scrotum.
57. When the hospital director gives the nurse a position of A. palpation
authority within a formal organization, she assumes the role of: B. auscultation
A. Manager C. percussion
D. inspection
B. Advocate
C. Leader 65. The nurse inspects a patient’s pupil size and determines a
D. Teacher result of OD = 2mm and OS = 3mm. Unequal pupils are known
as:
58. The nurse uses his interpersonal skills to guide the client in A. Enteric
making decisions about his health care acting the role of: B. Diplopia
A. Leader C. Anecteric
B. Advocate D. Anisocoria
C. Liaison
D. Counselor 66. Using Maslow’s Hierarchy of human needs. Which of the
following nursing diagnoses has the highest priority?
59. In nutrition education, your targeted participants include all A. Anxiety related to impending surgery, as evidenced by
EXCEPT: insomnia.
A. Food handlers B. High risk for impaired tissue perfusion (decrease blood
B. Young children supply) related to hemorrhage
C. Food service people C. Ineffective breathing pattern related to pain, as evidenced by
D. Mothers shortness of breath
D. Ineffective airway clearance related to dyspnea as
60. What kind of dressing and grooming would the nurse do for evidenced by impaired tissue perfussion
a client who is semi-dependent?
A. Client dresses self and nurse supervises. 67. A client who will have mastectomy expresses sadness
B. Nurse dresses client and assist in zipping or buttoning about losing her breast. The most appropriate nursing
clothing. diagnosis is:
C. Nurse combs client’s hair and assists with dressing. A. Ineffective Individual Coping
D. Nurse gathers the items for the client and client dresses self. B. Anticipatory Grieving
Nurse may button, tie, or zip clothing. C. Knowledge deficit
D. Fear
75. Nurse De Silva knows he can perform chest physiotherapy:
68. The nurse performs a neurologic exam on a patient. After A. Immediately before meals
the exam which of the following should be recorded as B. One hour after meals
objective data? C. During meals
A. + 4 Patellar reflexes on both the patient’s legs D. Before bedtime
B. Patient’s description of ringing in his ears
C. Patient’s sensations of numbness in his right arm
D. Patient’s statement, “The room is spinning” 76. A client is discharged home with a prescription for
Coumadin (sodium warfarin). The client should be instructed
69. Which of the following nursing diagnoses is in PES format? to:
A. Fluid volume deficit related to prolonged vomiting A. Have a PTT done monthly
B. Risk for impaired skin integrity as manifested by poor skin B. Avoid green leafy vegetables
turgor and old age C. Drink more liquids
C. Ineffective airway clearance related to retained secretions D. Avoid crowds
as manifested by infectious process
D. Self-esteem disturbance related to rejection by the husband 77. The OR team collaborates from the first to the last surgical
as manifested by crying and isolation. procedure. Who monitors the activities of each OR suite?
A. scrub nurse
70. When the arm is above the heart, what will be the result of B. anesthesiologist
the BP reading? C. circulating nurse
A. False High D. surgeon
B. False Low
C. Undetermind 78. Nurse Rits, a newly registered nurse is going to suction the
D. Slightly increased by 2-3 mmHg secretion of patient Baby Dave Garcia. He should keep in mind
that in hyperventilating Baby Dave, he must:
71. Which nursing role does the nurse performs when she A. give 3 inflations
provides health teaching to effect behavior change w/c focuses B. place the oxygen tank at 10 liters per minute
on acquiring new knowledge or technical skills. C. place the oxygen tank at 100%
A. Caregiver D. give 3 hyperinflations
B. Communicator
C. Teacher 79. Assessment of the aortic valve should be on the patient’s:
D. Change Agent A. 3rd ICS to the left
B. 2nd ICS to the right
72. A client with renal failure is having difficulty with C. 5th ICS to the right
defecation. What is the best nursing action? D. *th ICS to the right
A. Give laxative as ordered
B. Have the client increase oral fluid intake 80. After renal biopsy, patient suddenly complained of severe
C. Have the client increase raw fruits and vegetables as a form pain on the site. What is your most important nursing action?
of fiber intake A. Assess for malingering.
D. Have the client increase his activity and exercise. B. Call the doctor immediately
C. Assess pain scale
73. In pulling the external ear during inspection to a 5 y.o. child D. Give analgesic as ordered.
using an otoscope, one must perform the following, pulling the
pinna: 81. To give a Z-track injection, the nurse measures the correct
A. up and front medication dose and then draws a small amount of air into the
B. down and back syringe. What is the rationale for this action?
C. down and front A. Adding air decreases pain caused by the injection.
D. up and back B. Adding air prevents the drug from flowing back into the
needle track.
74. When taking blood pressure reading the following are C. Adding air prevents the solution from entering a blood
incorrect, except: vessel.
A. The nurse should make sure that the cuff be deflated fully D. Adding air ensures that the client receives the entire dose.
then immediately start second reading for same client
B. The nurse should release the valve carefully so that the
pressure decreases at the rate of 2-3 mmHg per second 82. In a syringe, the following are parts of a needle except
C. Large enough to wrap around upper arm of the adult client 1 A. Hub
cm above the brachial artery B. Shaft
D. Inflated to 30 mmHg above the estimated systolic BP based C. Gauge
on palpation of radial or bronchial artery D. Bevel
 B. Remove dead skin cells and debris
83. The following are guidelines for application of a C. Absorb blood and drainage
transdermal patch except: D. Protect the skin from injury
A. Hairless, clean area skin
B. Applied to areas not subjected to excessive movement or 90. Which of the following statements is true about proper
wrinkling body mechanics?
C. The distal part of the body ex. The forearm A. Adjust the work area to a level that will secure the clients
D. Applied to areas without cuts, burns or abrasions alignment
B. When moving an object, hold them as close as possible to
84. Which of the following guidelines is appropriate in your feet
measuring residual urine? C. When pulling an object, enlarge the base of support by
A. Catheterize the client immediately after voiding and keeping them close
measure both voided and catheterized amount D. Before moving an object, contract your gluteal, abdominal,
B. After the first voiding, have the client void again. Measure leg, and arm muscle
both voiding
C. Catheterize the client upon awakening , measure the 91. Which of the following actions best indicates that the client
amount and compare it with voided amount from the previous needs more practice to combine two insulins, short and
day intermediate-acting, before discharge?
D. Catheterize the client after voiding and measure the amount A. The client rolls the vial of intermediate-acting insulin to mix it
with its additive
85. Before inserting a rectal tube, which of the following B. The client instills air into the short acting and intermediate
nursing measures is most helpful for eliminating intestinal gas? acting insulin vials
A. Ambulate the client on the hall C. The client instills intermediate-acting insulin into the vial of
B. Provide a carbonated beverage short acting insulin
C. Restrict the intake of solid food D. The client inverts each vial prior to withdrawing the specified
D. Administer a narcotic analgesic amount of insulin

86. During removal of the NGT, the nurse should perform the 92. The nurse must limit the suction attempt to a maximum of:
following procedures except A. 5 seconds
A. Confirm the physicians order to remove the tube B. 15 seconds
B. Ask the client to take deep breath and hold it before C. 30 seconds
removing the tube D. 1 minute
C. Pinch the tube with the gloved hand prior to withdrawing the
tube 93. The nurse is assessing the client who has edema. The skin
D. Ask the client to exhale while removing the tube remains indented or pitted at 6mm. The nurse describes the
degree of edema as:
87. Different kinds of nasogastric tubes are available and serve A. 1+
different purposes. A client who had undergone abdominal B. 2+
surgery was transferred to the surgical unit. Endorsements C. 3+
from the OR nurse included that the client has Salem Sump D. 4+
tube. Nurse Marie explains to Sarah the purpose of this tube is
to: 94. The client admitted to the Intensive Care Unit. When
A. Apply internal pressure to the abdomen by means of inflated planning to give oral care to the client, the nurse would check
balloon to prevent bleeding first for which of the following?
B. Prevent abdominal distention A. Presence of pain
C. Instill the feedings into the stomach for the post-op patient B. Condition of the integumentary
D. Help in the elimination of urine C. Gag reflex
D. Joint mobility
88. What does the nurse instill first before administering
intravenous medication through a peripherally inserted 95. Daniel, 50 yrs old, has urinary incontinence. His urine
intermittent infusion device (medication lock)? output for the past 3 hours is 60ml. What should the nurse do?
A. Sterile bacteriostatic water A. Stimulate the patient to urinate
B. Sterile normal saline B. Inform the head nurse about the condition
C. Sterile isopropyl alcohol C. Position the patient on his left side
D. Sterile hydrogen peroxide D. Palpate the patient’s hypogastrium

89. When a client asks why the nurse is applying wet to dry 96. To avoid complications associated with urinary
dressings over a skin ulcer, the best explanation is that these elimination, the nurse teaches Daniel to perform certain
dressings help to: actions. Which of the following indicates that the expected
A. Prevent wound infections outcome is achieved?
A. Identifies symptoms of and measures to prevent urinary
tract infections
B. Able to perform perineal care only with assistance
C. Maintains proper disposal of urinary output
D. Takes regular tub baths and appropriate personal hygiene
measures

97. The nurse selects which of the following items to test the
function of the cranial nerve II?
A. Lateral gaze
B. Coffee
C. Reflex hammer
D. Snellen’s chart

SITUATION: Blood test is one of the most commonly used

diagnostic test and can provide valuable information about
hematologic system.

98. Nurse Poh receives the laboratory report of a client: RBC

5M/mm3, WBC 12,000 /mm3, Platelet 200,000 /mm3,
prothrombin 11sec. What would this suggest?
A. Dehydration
B. Polycytemia
C. Leukopenia
D. Infection

99. The nurse have assess that the client’s lab report shows 5
mg/dl bilirubin level, S. Potassium 4, S. Sodium 140. This would
most likely indicate:
A. Hypernatremia
B. Renal failure
C. Biliary obstruction
D. Thrombocytopenia

100. Which of the following is a correct statement about pulse

oximetry measurement?
A. A range of 95-98% is considered normal oxygen saturation
B. Oximetry measurement measures oxygen saturation of the
venous blood
C. Fasting is required 12 hours before the measurement
D. Pulse oximetry is a replacement for arterial blood gas
analysis