P1 FUNDAMENTALS RLE

CHECK FOR UNDERSTANDING

RATIONALIZATION ACTIVITY 1
S1 - Environmental Cleaning

[Link] can a clean patient environment contribute?

A. Reduction in environmental contamination including removal of
pathogens.
B. Prevention of healthcare-associated infection.
C. A & B
D. None of the above
Answer: C – Cleaning results in reductions in environmental
contamination, including the removal of many pathogens. A clean patient
environment contributes to prevention of healthcare-associated infection.

2. A nurse is knowledgeable that a patient under her care in the

isolation room will be discharged during her shift. What type of
cleaning will be performed?
A. Regular cleaning
B. Intensive cleaning
C. Routine cleaning
D. Terminal cleaning

Answer: D – Terminal cleaning is performed when a patient with a

transmissible illness is discharged (usually for isolation rooms), e.g. MRSA
and other drug-resistant bacteria, tuberculosis, Clostridium difficile.

3. This type of cleaning includes mopping of floors and damp dusting

of surfaces with detergent.
A. Regular cleaning
B. Intensive cleaning
C. Routine cleaning
D. Terminal cleaning

Answer: C – Routine cleaning is the standard, everyday procedure for

cleaning of clinical areas, including mopping of floors, damp dusting of
surfaces with detergent, etc.

4. This is a method of dusting is employed in the care of hospital

furnishings which are not upholstered, and for the removal of dust
from all surfaces above the floor.
A. Dump dusting
B. Damp dusting
C. Low dusting
D. High dusting

Answer: B – is a method of dusting is employed in the care of hospital

furnishings which are not upholstered, and for the removal of dust from all
surfaces above the floor.

5. This refers to dusting those areas over windows, pipes, wall and
ceiling.
A. Dump dusting
B. Damp dusting
C. Low dusting
D. High dusting

Answer: D – refers to dusting those areas over windows, pipes, wall and
ceiling.

6. This type of dusting is done to all places easily reached by

standing on the floor; done daily.
1. Dump dusting
2. Damp dusting
3. Low dusting
4. High dusting

Answer: C – refers to dusting done to all places easily reached by standing on the
floor; done daily.

7. Why is it necessary for someone to wear appropriate PPEs even

when cleaning?
A. PPEs are not necessary for cleaning as long as you are healthy.
B. To protect if there are any spills of blood/body fluids.
C. To prevent from being infected if the patient is on transmission-based
precautions
D. B & C
Answer: D – To protect oneself if there are any spills of blood/body fluids
or if the patient is on transmission-based precautions.

8. As you clean a patient’s bed side table, what rationale would you
keep in mind as you perform the cleaner-to-dirtier method?

A. Minimize spread of microorganisms.

B. To save time
C. To save cleaning cloth
D. B & C
Answer: A – Cleaner-to-dirtier method is performed to minimize spread of
dirt and microorganisms.

9. To prevent microorganisms from dripping and contaminating clean

areas, what strategy should you observe?

A. Dirtier to cleaner strategy

B. High to low strategy
C. Bottom to top strategy
D. Methodical strategy
Answer: B – this strategy prevents microorganisms to drip or fall and
contaminate cleaned areas.

10. You observe a colleague cleaning a patient’s room where she

jumps from one area to another. What errors could unfortunately
happen?

A. None, since she is still cleaning the room.

B. She will easily get tired.
C. She is spreading the pathogens
D. She may miss some areas of the room.
Answer: D – She may miss areas if systematic manner is not practiced.
RATIONALIZATION ACTIVITY 2
S2 - Body Mechanics, Moving and Positioning - Basic Body Mechanics

1. It is described as the coordinated efforts of the musculoskeletal

and nervous systems.
A. Body balance
B. Body alignment
C. Body posture
D. Body mechanics

Answer: D – is described as the coordinated efforts of the musculoskeletal

and nervous systems.

2. This refers to the positioning of the joints, tendons, ligaments, and

muscles while standing, sitting, and lying.
A. Body alignment
B. Posture
C. A & B
D. None of the above

Answer: A/B/C – The terms body alignment and posture are similar and
refer to the positioning of the joints, tendons, ligaments, and muscles while
standing, sitting, and lying.

3. These are white, shiny, flexible bands of fibrous tissue that bind
joints together, connect bones and cartilages, and aid joint flexibility
and support.
A. Joints
B. Ligaments
C. Tendons
D. Cartilage

Answer: B – Ligaments are white, shiny, flexible bands of fibrous tissue that bind
joints together, connect bones and cartilages, and aid joint flexibility and support.

4. These are nonvascular (without blood vessels) supporting

connective tissue located chiefly in the joints and thorax, trachea,
larynx, nose, and ear.
A. Joints
B. Ligaments
C. Tendons
D. Cartilage
Answer: D – nonvascular (without blood vessels) supporting connective
tissue located chiefly in the joints and thorax, trachea, larynx, nose, and
ear.

5. What postural abnormality is described as the lateral S- or C-

shaped spinal column with vertebral rotation, unequal heights of hips
and shoulders
A. Toticollis
B. Lordosis
C. Kyphosis
D. Scoliosis

Answer: D – is the lateral S- or C-shaped spinal column with vertebral

rotation, unequal heights of hips and shoulders

6. How does the principle of enlarging the base of support increases

the stability of the body work?

A. In assisting the patient to move, your feet should be close together to be

more stable.
B. In assisting the patient to move, your feet should be apart to be more
stable.
C. In assisting the patient to move, your feet should be widely apart to be
more stable.
D. None of the above
Answer: B – The feet act as the base and in assisting the patient to move,
your feet should be apart to be more stable.

7. This principle is applied when picking an object up from the floor

by bending at the knees and keeping your back straight rather than by
bending forward at the waist.

A. Enlarging the base of support increases the stability of the body.

B. Weight is balanced best when the center of gravity is directly above the
base of support.
C. A person or an object is more stable if the center of gravity is close to
the base of support.
D. None of the above
Answer: C – A person or an object is more stable if the center of gravity is
close to the base of support; prevents strain.
8. If a nurse is to push a patient’s bed forward, where should he place
his foot to observe proper body mechanics?

A. Forward
B. Spread sideways
C. Maintain feet close together
D. Opposite the direction of the bed.
Answer: A – By enlarging the base of support in the direction of the force
to be applied increases the amount of force that can be applied.

9. Which of the following describes a nurse who does not observe

proper body mechanics?

A. Picking up an object by bending at the knees and keeping your back

straight.
B. Keeping feet apart when assisting a patient.
C. Twisting your body from the waist.
D. Working on a smooth surface to reduce friction.
Answer: C – By twisting your waist this will strain muscles at the back

10. By adjusting the level of the bed of a patient as the nurse is at the
bedside, what is the rationale?

A. Adjust the height of the client’s bed to avoid back strain.

B. Adjust the height of the client’s bed to avoid patient fall.
C. Adjust the height of the client’s bed to promote patient comfort.
D. Adjust the height of the client’s bed to provide privacy.
Answer: A – Adjust the height of the client’s bed to avoid back strain and work at a
comfortable height.

RATIONALIZATION ACTIVITY 3

S3 - Body Mechanics, Moving and Positioning - Mobility

1. It is the maximum amount of movement available at a joint in one of

the three planes of the body.
A. Mobility
B. Range of motion
C. Gait
D. Exercise and activity
Answer: B – is described as the maximum amount of movement available
at a joint in one of the three planes of the body.

2. What type of joint is fits this description oval head of one bone fits
into a shallow cavity of another bone; flexion–extension and
abduction–adduction can occur.
A. Ball-and-socket
B. Condyloid
C. Gliding
D. Hinge

Answer: B – is described as oval head of one bone fits into a shallow

cavity of another bone; flexion–extension and abduction–adduction can
occur.

3. Which of the following does NOT describe adduction?

A. Move leg laterally away from body.
B. Lower arm sideways and across body as far as possible.
C. Place hand with palm down and extend wrist medially toward thumb.
D. Move leg back toward medial position and beyond if possible.

Answer: A – is the only movement among the choices that is describes

ABDUCTION.

4. What should be assessed when planning patient activities such as

walking, ROM exercises or ADLs?
A. Exercise
B. Activity tolerance
C. Activity intolerance
D. Disability

Answer: B – Assessment of activity tolerance is necessary when planning

activity such as walking, ROM exercises, or ADLs.

5. If a patient is observed laterally while standing, how should the

spinal curves be aligned?
A. Aligned straight
B. Aligned in an S pattern
C. Aligned in a reveresedS pattern
D. None of the above.
Answer: C – When observed laterally, the head is erect, and the spinal
curves are aligned in a reversed S pattern.

6. A characteristic of correct alignment when one sits is observed

when

A. The body weight is distributed evenly on the buttocks and thighs.

B. The body weight is distributed the buttocks only.
C. The body weight is distributed on the thighs only.
D. None of the above
Answer: A – The body weight is distributed evenly on the buttocks and
thighs.

7. How should you assess a bedridden patient’s body alignment?

A. Prone position
B. Lateral position
C. Supine position
D. Assist the patient standing to measure accurately

Answer: B – Assess body alignment for a patient who is immobilized or

bedridden with the patient in the lateral position. Removing all positioning
supports from the bed except for the pillow under the head and support the
body with an adequate mattress.

8. Which of the following abnormal findings would be the result if

inspection is utilized during assessment?

A. Generalized edema
B. Increased respiratory rate
C. Joint contracture
D. Distended bladder or abdomen
Answer: B – is the only abnormal finding that could be noted utilizing
inspection during assessment, the rest are observed when palpation is
utilized.
9. Which of the following abnormal findings is NOT a part of the
musculoskeletal system?

A. Decreased range of motion

B. Joint contracture
C. Activity intolerance
D. Asymmetrical chest wall movement
Answer: D - Asymmetrical chest wall movement is an abnormal finding
under the respiratory system.

10. Which abnormal finding is NOT found under the cardiovascular

system?

A. Peripheral edema
B. Generalized edema
C. Orthostatic hypotension
D. Weak peripheral pulses
Answer: B – All except generalized edema are found under the
cardiovascular system.

RATIONALIZATION ACTIVITY 4

1. When reading a medical record, you notice the following documentation: Patient states, “I have
had low back pain and burning sensation every time that I urinate in the past days and is
worsening, and now I am having fever and chills.” This is an example of:
a. Past history
b. A Review of systems
c. A functional assessment
d. A reason for seeking care / chief complaint
Answer: D.
RATIONALE: The statement indicates a reason for seeking care.
2. Which of the following actions is most appropriate to verify the reliability of the information
provided by the patient during the interview?
a. Provide the patient with a printed history to complete and then compare the data provided
b. Rephrase the same questions later in the interview
c. Review the patient’s previous medical records.
d. Call the nearest relative to verify the data provided.

Answer: B
RATIONALE: Consistency in the client’s answer to questions indicates reliability.
3. During an interview for health history, the student nurse asks, “Mrs Cassandra O’Connor, what
do you do when you experience chest pain?” the student nurse is seeking which of the following
information?
a. The client’s perception of the problem.
b. Aggravating or relieving factors
c. The frequency of the problem
d. The severity of the problem

Answer: B
RATIONALE: The statement seeks to assess relieving factors to the problem.
4. Which of the following statements is an appropriate documentation of the client’s reason for
seeking health care or the chief complaint?
a. Acute episode of Meniere’s disease, duration 2 hours
b. Dizziness with nausea and vomiting, 2-hour duration
c. “Spinning” sensation of the body for 2 hours
d. Abnormal hearing test results.

Answer: C
RATIONALE: Documentation should be subjective, objective, factual and concise.
5. A review of systems (ROS) provides which of the following information?
a. An evaluation of the past and present health state of each body system
b. A documentation of the objective findings of the nurse.
c. A documentation of the current health problems of the patient.
d. A statement that describes the overall health state of the patient.
Answer: A
RATIONALE: A review of systems (ROS) is an evaluation of the past and present health state of each
body system
6. You are collecting data for a comprehensive health history on a patient new to your clinic.
Under what component of the health history would you place data on a chronic childhood illness?
a. Past history
b. Health maintenance
c. General information
d. Risk factors

Answer: A
RATIONALE: Past History—Childhood illnesses, such as measles, rubella, mumps, whooping cough,
chickenpox, rheumatic fever, scarlet fever, and polio, are included in the Past History. Also included are
any chronic childhood illnesses.
7. A nurse is evaluating a young adult patient who has presented to the emergency department
with the chief complaint of abdominal pain. If the nurse is using the PQRSTU method of pain
assessment, which of the following questions should be asked for the “S” portion of the
assessment?
a. “How did your pain start?” and “Is there anything that you can do that stops your pain?”
b. “Have you ever had these same symptoms previously?” and “Do you have a history of a previous
abdominal surgery?”
c. “How severe is your pain on scale of 1 to 10, where 1 is minimal pain and 10 is the most intense pain?”
and “Are you experiencing any other symptoms in addition to your pain?”
d. “Tell me more about your pain: is it sharp, stabbing, superficial, or does it start and stop?”

Answer: C
RATIONALE: The “S” portion of the PQRSTU method of pain assessment should include questions
related to the patient’s severity of pain (via a pain scale) and associated symptoms occurring with the
pain.
8. You are a nurse working in an ambulatory clinic and conducting medication reconciliation to a
client. Which statement would be best when conducting this kind of health history?
a. "Medications prescribed by other providers do not need to be included on the record."
b. "Natural products may interact with other drugs."
c. "Over-the-counter products and herbal supplements are not considered medications."
d. "Holistic products do not need to be included on the record."

Answer: B
RATIONALE: Prescribed medications may have adverse interactions with OTC medication and herbal
medications.
9. A patient comes into the clinic for a routine annual physical. Where would you document this
information?
a. Initial information
b. History of present illness
c. Health maintenance
d. Chief complaint

Answer: D
RATIONALE: Chief Complaint(s)—sometimes patients have no specific complaints. Report their goals
instead. For example, “I have come for my regular check-up” or “I’ve been admitted for a thorough
evaluation of my heart.”
10. While gathering data for the family history portion of the health history, what would you ask
about?
a. Suicide
b. Number of siblings
c. Family ethnicity
d. Religion

Answer: A
RATIONALE: Review each of the following conditions and record whether they are present or absent in
the family: hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or
renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental ill- ness,
suicide, substance abuse, and allergies, as well as symptoms reported by the patient.

RATIONALIZATION ACTIVITY 5
In this position the patient rests on the side with the major portion of
bodyweight on the dependent hip and shoulder.
A. Fowler’s position
B. Prone position
C. Side-Lying position
D. Sims’ position
Answer: C – In the side-lying (or lateral) position the patient rests on the
side with the major portion of bodyweight on the dependent hip and
shoulder.
2. In this position the patient lies face or chest down.
A. Fowler’s position
B. Prone position
C. Side-Lying position
D. Sims’ position
Answer: B – The patient in the prone position lays face or chest down.
3. How does Sims’ position differentiate from lateral position?
A. The patient places the weight on the anterior ileum, humerus, and
clavicle.
B. The face is turned to the side with a pillow under the head.
C. The face is not turned to the patient’ side.
D. Sims’ position is also the same with side-lying position.

Answer: A – In Sims' position the patient places the weight on the anterior
ileum, humerus, and clavicle.
4. What is the goal for logrolling a patient?
A. To keep the body in straight alignment when turning the patient.
B. Not to twist the patient’s head, spine, shoulders, knees, or hips
C. Repositioning 2 hours to avoid pressure ulcers.
D. All of the above

Answer: D – All the given choices are the goals of logrolling a patient.
5. How will you prevent footdrop for a patient in a prone position?
A. Move the patient down in bed so that the feet are over the mattress
B. Support the feet with a pillow just high enough to keep the toes from
touching the bed
C. A & B
D. None of the above

Answer: A – To prevent footdrop for a patient in prone position, move the patient
down in bed so that the feet are over the mattress, or support the lower legs on a
pillow just high enough to keep the toes from touching the bed.

6. For what reason should you place a patient’s arms flexed at

shoulder level when in prone position?
A. Maintains proper body alignment.
B. Support reduces risk of joint dislocation.
C. Because the patient cannot move.
D. A & B
Answer: D – Patients in prone position should have their arms support in a
flexed position level at shoulders to maintain proper body alignment and
support reduces risk of joint dislocation.
7. Ensuring that both shoulders are aligned with the hips when
assuming a lateral position prevents which complication?

A. Twisting of the spine

B. Lateral flexion of the neck
C. Internal shoulder rotation and adduction
D. Internal rotation and adduction of the hip; lumbar lordosis
Answer: A – Placing a pillow at the patient’s lower back supports lumbar
vertebrae & decreases flexion of vertebrae.
8. A colleague of yours placed a pillow under semiflexed upper leg
level at hip from groin to foot of the patient. Based on your
colleague’s action, what is his rationale?

A. Flexion prevents hyperextension of leg.

B. Maintains leg in correct alignment.
C. Prevents pressure on bony prominences.
D. All of the above
Answer: D – All are correct rationales for placing a pillow under semiflexed
upper leg level at hip from groin to foot of the patient.
9. A colleague has placed a patient on a Sims’ position, she has not
placed a small pillow under her head. What will you do?

A. Ignore her as it is not your patient.

B. Place a small pillow secretly.
C. Inform the nurse supervisor at once.
D. Check for oral drainage orders as this position is optimal for draining oral
secretions.
Answer: D - Check for oral drainage orders as this position is optimal for
draining oral secretions.

10. As a patient is rolled as one unit, the nurse on opposite side of

bed places pillows along length of patient. What is the rationale for
the nurse’s action?

A. Pillows keep patient safe.

B. Pillows keep patient aligned.
C. Pillows keep patient comfortable.
D. Pillows keep patient company.
Answer: B – Placing pillows keep patient aligned.
RATIONALIZATION ACTIVITY 6
1. This position facilitates respiration by allowing maximum chest
expansion.
A. Orthopneic position
B. Jack knife position
C. Trendelenburg position
D. Genupectural position
Answer: A –Facilitates respiration by allowing maximum chest expansion.

2. This position obtains better exposure of the vagina, cervix and

rectum.
A. Genupectoral position
B. Lithotomy position
C. Trendelenburg position
D. Jack knife position

Answer: A – Obtains better exposure of the vagina, cervix and rectum.

3. Which position is indicated for operations on the rectum and

coccyx?
A. Trendelenburg position
B. Knee chest position
C. Bozeman position
D. Genupectoral position

Answer: C – Place client in a prone position with the hip directly over the
break in the table and is indicated for operations on the rectum and coccyx.
4. Which position is used for postural drainage of the lungs?
A. Fowler’s position
B. Bozeman position
C. Orthopneic position
D. Trendelenburg position

Answer: D – Used for postural drainage of the lungs.

5. Assisting a patient to sit in his bed, what should you do to assess

his body alignment continually?

A. Raise bed to waist level. Place patient in prone position.

B. Raise bed to lowest level possible. Place patient in supine position.
C. Raise bed to waist level. Place patient in supine position.
D. Let the patient stand erect for accurate assessment.
Answer: C – By raising bed to waist level and placing patient in supine
position it will enable you to assess patient’s body alignment continually.

6. You are to assist a patient in positioning in bed. Which action will

improve your balance?
A. Place feet in wide base of support, with foot away from the bed.
B. Place feet in wide base of support, with foot farther to bed.
C. Place feet in wide base of support, with foot closer to bed in front of
other foot.
D. Place feet in narrow base of support, with foot closer to bed in front of
other foot.

Answer: C – Place feet in wide base of support, with foot closer to bed in
front of other foot this improves balance and allows transfer of body weight
as you move patient to sitting position.

7. A patient who can partially bear weight should have the head of his
bed raised at 30 degrees, for which rationale?

A. Facilitates raising patient to sitting position.

B. Because the patient cannot move.
C. Protects him or her from falling.
D. A & C
Answer: D – The head of the patient’s bed raised at 30 degrees facilitates
raising patient to sitting position and protects him or her from falling.

8. To maintain the alignment of the patient’s head and cervical

vertebrae, where should a nurse place her arm that’s nearer to the
head of the bed?

A. Under the patient’s chest.

B. At the patient’s nape.
C. Under the patient’s shoulder.
D. Under the patient’s head.
Answer: C – Place arm nearer head of bed under patient's shoulders,
supporting head and cervical vertebrae.

9. A nurse rocks a patient up to standing position on count of 3 while

straightening hips and legs and keeping knees slightly flexed. What is
the rationale for the nurse’s actions?

A. For the patient to feel at ease.

B. To get the rhythm of the patient.
C. Rocking motion gives patient’s less body momentum and requires more
muscular effort to lift him or her.
D. Rocking motion gives patient’s body momentum and requires less
muscular effort to lift him or her.
Answer: D – Rocking motion gives patient’s body momentum and requires
less muscular effort to lift him or her..

10. As a nurse lowers the patient down into the chair, what should he
demonstrate to observe proper body mechanics?

A. Flex arms and show his biceps while lowering patient into chair.
B. Flex hips and knees while lowering patient into chair.
C. Flex fingers and wrist while lowering patient into chair.
D. Flex neck and legs while lowering patient into chair.
Answer: B – The nurse should flex hips and knees while lowering patient into
chair.

RATIONALIZATION ACTIVIT Y 7

1. It is the invasion of a susceptible host by microorganisms which results in disease.

A. Pathogens
B. Infection
C. Colonization
D. Communicable disease
Answer: B – is the invasion of a susceptible host (e.g., human being) by pathogens or microorganisms

2. This is where microorganisms survive and multiply.

A. Infectious agent
B. Portal of Exit
C. Reservoir
D. Portal of entry.

Answer: C – a place where microorganisms survive, multiply, and await transfer to a susceptible host
such as humans & animals.

3. It is a mode of transmission where evaporated droplets suspend in air during coughing or

sneezing.
A. Direct
B. Indirect
C. Droplet
D. Airborne

Answer: D – Droplet nuclei or residue or evaporated droplets suspended in air during coughing or
sneezing or carried on dust particles.

4. To cut the link between Mode of Transmission and Portal of Entry, which of the following
should be observed?
A. Hand hygiene
B. Immunization
C. Screening health care staff
D. A & B

Answer: A – Hand hygiene cuts the link between the Mode of Transmission and Portal of Entry; B & C
are interventions to cut the link between hosts and infectious agents.

5. It is the interval from onset of nonspecific signs and symptoms to more specific symptoms and
the patient may be capable of spreading the disease to others.

A. Incubation period
B. Prodromal stage
C. Illness stage
D. Convalescence
Answer: B – Is the interval from onset of nonspecific signs and symptoms to more specific symptoms
and the patient may be capable of spreading the disease to others.

6. It is the interval when acute symptoms of infection disappear.

A. Incubation period
B. Prodromal stage
C. Illness stage
D. Convalescence

Answer: D – Is the interval when acute symptoms of infection disappear.

7. Which among the following statements regarding inflammation is true?

A. Acute inflammation is an immediate response to cellular injury.

B. The decrease in local blood flow causes the redness and localized warmth at the site of inflammation.
C. Damaged cells are permanent. D. None of the above
Answer: A – Acute inflammation is an immediate response to cellular injury.

8. This type of infection is a result from the rendered health services in a health care institution.

A. Health care-associated infection

B. Exogenous infection
C. Endogenous infection
D. Diseases
Answer: A – Is a type of infection that results from the delivery of health services in a health care facility.

9. Which of the following HAIs is not associated with the urinary tract?

A. Unsterile insertion of urinary catheter

B. Improper positioning of the drainage tubing
C. Improper disposal of secretions
D. Obstructing or interfering with urinary drainage
Answer: C – is an HAI related to the respiratory tract.

10. Which among the following statements is true?

A. Defenses against infection change with aging.

B. A patient's nutritional health indirectly influences susceptibility to infection.
C. The body responds to emotional or physical stress by the general adaptation syndrome.
D. Patients with diseases of the immune system are at particular risk for infection.
Answer: B – A patient's nutritional health DIRECTLY influences susceptibility to infection.
RATIONALIZATION ACTIVIT Y 8

1. It i refers to the practices or procedures that help reduce the risk for infection.
A. Aseptic technique
B. Surgical asepsis
C. Medical asepsis
D. Hand hygiene
Answer: A – refers to the practices or procedures that help reduce the risk for infection

2. You are informed by your senior nurse that you’ll scrub-in an operation later today. What
technique should you observe during the operation?
A. Aseptic technique
B. Surgical asepsis
C. Medical asepsis
D. Hand hygiene

Answer: B – in the operating room set-up, surgical asepsis ism observed to isolate an operative area
from the unsterile environment, and maintains a sterile field for surgery.

3. What technique should you observe in caring for a patient who is admitted due to asthma
exacerbation?
A. Aseptic technique
B. Surgical asepsis
C. Medical asepsis
D. Hand hygiene

Answer: C – break the chain of infection and is observed for all patients, even when no infection is
diagnosed.

4. In controlling and eliminating of infectious agents in reusable supplies,w hat process should be
done first?
A. Hand hygiene
B. Rinsing
C. Cleaning
D. Sterilization

Answer: C – occurs before disinfection and sterilization procedures.

5. Ensuring efficacy whenever disinfecting and sterilizing all of the following are observed except:

A. Concentration of solution and duration of contact

B. Type and number of pathogens
C. Temperature of the environment
D. All of the above
Answer: D – all of these should be observed in disinfecting and sterilizing.
6. You have noticed a colleague soaking a not fully rinsed instrument in an sterilizing agent. What
will you do?
A. None as soap helps disinfect the instrument.
B. Let your colleague proceed with her work.
C. Inform your colleague that instruments should be properly rinsed next time.
D. Inform your colleague that instruments should be properly rinsed and let her repeat the process.

Answer: D – To correct the process, the nurse must repeat rinsing the instrument as soap causes certain
disinfectants to be ineffective. Thorough rinsing of an object isnecessary before disinfecting.

7. In protecting the susceptible host, all of the following should be observed except:

A. Lubrication helps keep the skin hydrated and intact.

B. Flossing adds tartar and plaque which causes germ infection.
C. Maintenance of adequate fluid intake promotes normal urine formation
D. None of the above
Answer: B – Flossing REMOVES tartar and plaque that cause germ infection.

8. To reduce reservoirs of infection, which of the following one must observe:

A. Place tissues, soiled dressings, or soiled linen in fluid absorbent bags for proper disposal.
B. Date bottles when opened and discard in 48 hours.
C. Wearing of gloves and protective eyewear should be avoided if the incident has not yet happened.
D. Never raise a drainage system (e.g., urinary drainage bag) above the level of the site being drained
unless it is clamped off.
Answer: D – This would prevent urine flowing back to your system which may cause infection.

9. To reduce reservoirs of infection, which of the following one must NOT observe:

A. Place tissues, soiled dressings, or soiled linen in fluid resistant bags for proper disposal.
B. Date bottles when opened and discard in 24 hours.
C. Wearing of gloves and protective eyewear should be avoided if the incident has not yet happened.
D. Never raise a drainage system (e.g., urinary drainage bag) above the level of the site being drained
unless it is clamped off.
Answer: C – Wear gloves and protective eyewear if splashing or spraying with contaminated blood or
body fluids is anticipated.

10. Which among the following statements is true.

A. Sharing bedpans, urinals, bath basins, and eating utensils among patients is allowed if they have the
same disease.
B. When using a stethoscope, always wipe off the bell, diaphragm, and ear tips with water before
proceeding to the next patient.
C. When diarrhea occurs, electronic thermometers are recommended for rectal temperatures.
D. Do not use electronic thermometers for patients on contact isolation.
Answer: B – Do not use electronic thermometers for patients on contact isolation to avoid contact and
spreading of microorganisms.
RATIONALIZATION ACTIVIT Y 9

1. These category of precaution is designed to be used for the care of all patients, in all settings,
regardless of risk or presumed infection status.
A. Isolation precaution
B. Regular precaution
C. Standard precaution
D. Transmission-based precaution
Answer: C – is designed to be used for the care of all patients, in all settings, regardless of risk or
presumed infection status.

2. Theis set of precaution is designed for the care of patients who are known or suspected to be
infected or colonized with microorganisms transmitted by droplet, airborne, or contact routes.
A. Regular precaution
B. Standard precaution
C. Transmission-based precaution
D. Specified-type precaution

Answer: C – designed for the care of patients who are known or suspected to be infected or colonized
with microorganisms transmitted by droplet, airborne, or contact routes.

3. You are taking care of a patient who is diagnosed to have chickenpox. Which type of precaution
should you observe?
A. Direct contact
B. Contact precaution
C. Droplet precautions
D. Airborne precautions

Answer: D – diseases, like chickenpox, are transmitted by smaller droplets, which remain in the air for
longer periods of time.

4. When a patient is diagnosed to have influenza, which practice, when observed, will protect the
nurse from being infected?
A. Cloth mask, proper hand hygiene and dedicated-care equipment.
B. Surgical mask, proper hand hygiene and dedicated-care equipment.
C. N95 mask, proper hand hygiene and dedicated-care equipment.
D. None since influenza is not serious and is caused by a virus

Answer: B – Droplet precautions (e.g. influenza) is observed by wearing surgical mask when within 3 feet
of the patient, proper hand hygiene, and some dedicated-care equipment.

5. For a patient who has been diagnosed with active pulmonary tuberculosis, which room should
he occupy?
A. Negative-air flow room
B. Positive-air flow room
C. Respiratory ward
D. Infectious diseases ward
Answer: A – patients under airborne precaution are placed in this room as air is not returned to the inside
ventilation system but is filtered through a high-efficiency particulate air (HEPA) filter and exhausted
directly to the outside.

6. You are aware that standard precautions apply to the following except:
A. Blood and blood products
B. Bodily fluids, secretions, excretions including sweat
C. Bodily fluids, secretions, excretions excluding sweat
D. Non-intact skin, and mucous membranes

Answer: C – sweat is included in applying the standard precautions.

7. When wearing a disposable mask, one must know to follow the following except:

A. Keep talking to a minimum while wearing a mask to reduce respiratory airflow.

B. A mask that has become moist does not provide a barrier to microorganisms and is ineffective and is
discarded.
C. A mask that has become moist does not provide a barrier to microorganisms and should be air dried to
reuse.
D. A properly applied mask fits snugly over the mouth and nose so pathogens and body fluids cannot
enter or escape through the sides.
Answer: C – B is the correct statement as masks that are moist are inffective and should be discarded.

8. When should masks (surgical/respirator) be worn?

A. In caring for a PTB patient.
B. When transporting patient on droplet precautions.
C. At time needed by immunocompromised patients.
D. All of the above.
Answer: D – All the given statements are moments where wearing masks is a must.

9. When taking care of a patient who is suspected to have PTB, you should wear which PPE?

A. Surgical masks
B. Respirator masks
C. Gloves
D. Gown
Answer: B – Specially fitted respiratory protective devices (N95 respirator masks) are required when
caring for patients on airborne precautions such as patients with known or suspected TB (CDC, 2005a).

10. Which of the following is observed when using gloves as PPE?

A. Change gloves and perform hand hygiene between tasks on the same patient after contact with
material that contains a high concentration of microorganisms.
B. Change gloves and perform hand hygiene after all tasks are done on the same patient after contact
with material that contains a high concentration of microorganisms.
C. Opt to wear clean gloves when touching blood, body fluid, secretions.
D. B & C
Answer: A – Changing of gloves and performing hand hygiene should be observed every after
completion of a task regardless if the same patient is being taken care of.

RATIONALIZATION ACTIVIT Y 10

1. How is inherent hygiene defined as per the World Health Organization?

A. Hand cleansing practices are likely established in the first 10 years of a person's life.
B. This imprinting affects an individual's attitudes about hand cleansing throughout life.
C. Hand cleansing practices are likely established in the first 10 years of a person's life; this imprinting
affects an individual's attitudes about hand cleansing throughout life.
D. Hand cleansing practices are likely established in the first 10 years of a person's life; this imprinting
cannot affect an individual's attitudes about hand cleansing throughout life.
Answer: A – The cleansing practices in the first 10 years of life is called inherent hand hygiene as per the
WHO.

2. It is the most effective basic technique in preventing and controlling the transmission of
infection.
A. Hand washing
B. Hand rub
C. Hand hygiene
D. Hand shake

Answer: C – is thehe most effective basic technique in preventing and controlling the transmission of
infection.

3. Which of the following is true about hand hygiene:

A. Hand washing kills microorganisms.
B. Hand washing does not kill microorganisms.
C. Hand washing and hand rub are the same.
D. None of the above.

Answer: B – The fundamental principle behind handwashing is removing microorganisms mechanically

from the hands and rinsing with water.

4. When should you NOT perform handhygiene?

A. After giving an intravenous medication.
B. Before draining a urine bag.
C. After measuring the blood pressure.
D. Before inserting an NGT.

Answer: B – Handhygiene should be observed after draining a urine bag or any body fluid exposure.
5. When should you observe handhygiene?

A. After talking to a patient.

B. During an aseptic procedure.
C. Before taking the vital signs.
D. None of the above
Answer: C – Before touching a patient; one must observe handhygiene in order not to spread
microorganisms.

6. After assisting a physician in wound suturing, you have noticed a speck of blood on your right
arm. Which handhygiene practice should you observe?
A. Hand rub
B. Hand washing
C. Hand washing then hand rub
D. Hand rub then hand washing

Answer: B – For visibly soiled hands, one must perform hand washing.

7. A colleague asks you to wash your uniform’s sleeve as there are speck of blood, which among
the responses is appropriate?

A. I’ll just iron them for the microorganisms to die.

B. I’ll splash my sleeve with later during my break.

C. Splashing water against my uniform willallo microorganisms to spread.

D. None of the above
Answer: C – Microorganisms travel and grow in moisture.

8. What is the rationale for interlacing one’s hand during handwashing?

A. Interlacing fingers and thumbs ensures that all surfaces are cleansed.
B. Interlacing fingers and thumbs creates more lather.
C. Friction and rubbing mechanically loosen and remove dirt and transient bacteria.
D. A & C
Answer: D – Both statement are correct rationales as to why interlacing hands during handwashing is
observed.

9. After hand washing, in what motion will you dry your hands?
A. Drying from least clean (forearms) to cleanest (fingertips).
B. Drying from least clean (fingertips) to cleanest (forearms).

C. Drying from cleanest (fingertips) to least clean (forearms).

D. Drying from cleanest (forearms) to least clean (fingertips).
Answer: C – Drying from cleanest (fingertips) to least clean (forearms) area avoids contamination.
10. Keeping hands and forearms lower than elbows during washing prevents:

A. Joint pain
B. Cramps
C. Venous blood flow
D. Contamination
Answer: D – Water flows from least to most contaminated area, rinsing microorganisms into the sink.

CHECK FOR UNDERSTANDING P2  

RATIONALIZATION ACTIVITY 11 

1. A patient’s room should be maintained at which

temperature  range?  
A. 20° and 24° C (68° and 73.8° F)  
B. 20° and 23° C (68° and 73.4° F)  
C. 19° and 22° C (66° and 73.4° F)  
D. 20° and 23° C (68° and 73.4° F)  

Answer: B – Depending on age and physical condition,

maintain the  room temperature between 20° and 23° C
(68° and 73.4° F).  

2. After making the bed of a patient, which of the

following  should you do? Select all that apply.  
A. Return it to the lowest horizontal position  
B. Return it to the lowest vertical position  
C. Verify that the wheels are not unlocked  
D. Verify that the wheels are unlocked  

Answer: A, C – After making a bed, return it to the lowest

horizontal  position and verify that the wheels are locked to
prevent accidental  falls when the patient gets in and out
alone.  
3. To avoid bending and stretching over the
mattress, what  should a nurse do?  
A. Perform stretching exercises  
B. Raise the bed to the appropriate height  
C. Ask the patient to get out of the bed  
D. Assist the patient out of bed  
Answer: B – Always raise the bed to the appropriate
height before  changing linen so you do not have to bend
or stretch over the  mattress. 
4. A nursing attendant is removing the used linens from
a room  that has just been vacated, all of the following
are correct should  be done except:  
A. Shake the linen.  
B. Do not place the soiled linen on the floor  
C. Place the soiled linen on linen bags  
D. None of the above  

Answer: A – To avoid air currents that spread

microorganisms, never  shake the linen.  

5. You are removing the soiled linens of a patient which

principle  should be observed:  
A. Sterile technique  
B. Medical asepsis  
C. Surgical asepsis  
D. Concept of asepsis  

Answer: B – When changing bed linen, follow principles

of medical  asepsis by keeping soiled linen away from the
uniform.  

6. As you went to check on your patient, you saw her

significant  other remove the used bedpan from the
overbed table to  facilitate serving meals. What should
you do? Select all that  apply.  

A. Let the significant other do her own thing  

B. Ask if the bedpan has been used, if not it causes no
problem  C. Instruct the significant other not to place the
bedpan or urinal in the  overbed table  
D. Clean the over-bed table with antiseptic cleaner  
Answer: C, D – Do not place the bed pan or urinal on the
over-bed  table. When changing bed linen, follow principles
of medical asepsis  by keeping soiled linen away from the
uniform. 
7. How can a ventilation system be classified as
effective?  A. Effective ventilation systems are
mostly costly.  
B. All effective ventilation systems work in the same
manner and are  all effective.  
C. Stale air and foul odors are not lingering
in a room.  D. All of the above  
Answer: C – An effective ventilation system keeps
stale air and odors from lingering in a room.  

8. After a patient uses a urinal, the nurse-in-charge

discards the  urine and places it inside the toilet. What
would you perform  differently that is in accordance
with the protocols? Select all  that apply.  
A. Measure the urine output even if in not strict I&O
monitoring.  B. Place the urinal at the bedside table to
offer accessibility and  convenience.  
C. Rinse the urinal after each use.  
D. All the actions done by the nurse is in
accordance with the  guidelines.  
Answer: A & C – Always measure urine output
quantitatively to  document accurate data and empty and
rinse commodes, bedpans,  and urinals promptly after
each use.  
 9. Which of the following is incorrect about bed
making?  A. Changing linens are done only in the
morning.  
B. Changing lines is usually done in the morning after the
patient’s  bath.  
C. Changing linens are done as needed (e.g
soiled, wet)  D. B & C  
Answer: A – Both B & C are correct.  

10. A patient has an ongoing Nicardipine drip who is

placed on  an IV infusion pump. The device used emits
a beeping sound as  there is no mute function. What
should you do as a nurse?  A. Stop the device as it
causes anxiety to the patient. 
B. Stop the device and and document the the incident.  C.
Inform the patient that the sound emitted by the device is
normal.  D. None of the above.  
Answer: C – Infusion a pump usually emit beeping sounds and is normal. 

RATIONALIZATION ACTIVITY 12 

 WORD DESCRIPTION/FUNCTION  
DRAWSHEET A drawsheet can aid moving the patient  in bed.  

FLOOR The floor is heavily contaminated.  

GLOVES Hand hygiene and PPE prevent the  

spread of microorganisms.  

AMPER Placing linens directly into the hamper  helps prevent the spread of  
microorganisms.  

OOSENING Loosening linens over the patient’s feet  gives more room for movement.  

MITER This provides for a neat appearance.  

PILLOWCASE Open each pillowcase in the same  

manner as you opened other linens. 
HAKING Opening linens by shaking them causes  organisms to be carried on air currents.  

WRINKLES Wrinkles and creases in the linens are  uncomfortable

to lie on.  

RATIONALIZATION ACTIVITY 13 

1. These are quick and efficient way of monitoring a
patient's  condition or identifying problems and
evaluating his or her  response to intervention.  
A. Vital signs  
B. Body temperature  
C. Respiratory rate  
D. All of the above  
Answer: A – Vital signs are are quick and efficient way of
monitoring  a patient's condition or identifying problems and
evaluating his or her  response to intervention.  

2. This occurs because heat-loss mechanisms are

unable to  keep pace with excessive heat
production.  
A. Heat exhaustion  
B. Heat stroke  
C. Hyperthermia  
D. Fever or pyrexia  

Answer: D – Fever occurs because heat-loss

mechanisms are  unable to keep pace with excessive
heat production.  

3. A patient complains in the ER that her axillary

temperature  rises and falls for the last two days but
has never returned  within the normal range. What is
this pattern called?  A. Sustained  
B. Intermittent  
C. Remittent  
D. Relapsing 
Answer: C – Remittent fever is where the temperature
spikes and  falls without a return to acceptable
temperature levels.  

4. As it was endorsed, the newly admitted patient has

lesions on  her left axilla. How will you measure her
temperature?  A. Do not measure her temperature,
document the reason, inform the  health care provider  
B. Measure her temperature, inform her that it will
be quick  C. Assess the right axillar for lesions, if
none, use that site to  measure the temperature.  
D. Proceed with measuring the temperature orally.  

Answer: C – Check the right axilla; Presence of skin

lesions may  alter local temperature or area may be
painful to touch.  

5. The thermometer measured a patient’s axillary

temperature at  38.9oC. What will you do?  
A. Document at the appropriate log  
B. Document, inform patient & give paracetamol  
C. Document, inform patient & cover the patient with thick
blankets  D. Document, inform patient & offer tepid
sponge bath  

Answer: D – Body temperature regulation; is bathing a

patient with a  cool cloth increases conductive heat loss.  

6. Using this site for measuring the temperature is

prescribed as  it is reliable for stable term and preterm
infants, however, not  recommended for detecting
fever:  

A. Oral  
B. Axillary  
C. Temporal artery  
D. Skin  
Answer: B – Prescribed as it is reliable for stable term
and preterm  infants, however, not recommended for
detecting fever. 
7. This site for measuring temperature is
sensitive to core  temperature changes but
inaccuracies are reported due to  incorrect
positioning of the device:  

A. Temporal Artery  
B. Skin  
C. Rectal  
D. Tympanic membrane  
Answer: D – Sensitive to core temperature changes but
inaccuracies  are reported due to incorrect positioning of the
device. 

8. Refers to a temperature alteration where an

elevated body  temperature is related to the inability
of the body to promote  heat loss or reduce heat
production:  
A. Heat exhaustion  
B. Heat stroke  
C. Hyperthermia  
D. Fever or pyrexia  
Answer: A - Respiratory rate and depth are irregular,
characterized  by alternating periods of apnea and
hyperventilation.  

9. This is described as the involuntary body

response to  temperature differences in the
body:  

A. Basal metabolic regulation  

B. Radiation  
C. Shivering  
D. Diaphoresis  
Answer: C - Shivering is an involuntary body
response to  temperature differences in the
body.  

10. It is a fever pattern that is regarded for

fever spikes  interspersed with usual
temperature levels; returns to  acceptable
value at least once in 24 hours.  

A. Sustained  
B. Intermittent  
C. Remittent 
D. Relapsing  
Answer: B – Fever spikes interspersed with usual
temperature  levels; returns to acceptable value at
least once in 24 hours. 

RATIONALIZATION ACTIVITY 14 

1. It is described as the movement of gases in and

out of the  lungs:  
A. Respiration  
B. Ventilation  
C. Diffusion  
D. Perfusion  
Answer: B – is described as the movement of gases in and
out of the  lungs  

2. A nurse knows not to let the patient know that her

respirations  are being assessed for what rationale?  
A. Patients should be informed of all
procedures done  B. Provide inaccurate
results  
C. Alter rate and depth of breathing  
D. A and B  
Answer: D – An inaccurate result can be obtained as
patients who  are aware of of the assessment can alter
the rate and depth of  breathing.  

3. Which of the following factors result to increased

respiratory  rate and depth? Select all that apply.  
A. Exercise  
B. Acute pain  
C. Anxiety  
D. Smoking 
E. Opioid analgesics  
F. Increased altitude  

Answer: A, C, D, E, F – These factors result to increased

respiratory  rate and depth.  

4. The process of diffusion and perfusion by

measuring which  among the choices:  
A. Respiratory rate  
B. Respiratory depth  
C. Oxygen saturation  
D. A and B  

Answer: C – valuate the respiratory processes of

diffusion and  perfusion by measuring the oxygen
saturation of the blood.  

5. Which among the following statement is

regarded as  incorrect:  
A. Diaphragmatic breathing results from the
contraction and  relaxation of the diaphragm  
B. Observed it best by watching abdominal
movements  C. Healthy men and children usually
demonstrate diaphragmatic  breathing  
D. Women tend to use thoracic muscles to breathe,
assessed by  observing movements in the upper
chest.  
E. All of the above  
F. None of the above  

Answer: E – All of the statements are correct regarding

ventilator  rhythm.  

6. By observing the degree of excursion or

movement in the  chest wall, which of the following
are you assessing?  

A. Respiratory Rate  
B. Ventilatory Depth  
C. Ventilatory Rhythm 
D. None of the above Answer: B – Assessing the
ventilatory depth of  respirations is done by observing the
degree of excursion or  movement in the chest wall.  

7. Which breathing pattern is characterized by increase

in rate &  depth of respirations, where hypocarbia
sometime occur?  

A. Tachypnea  
B. Hyperpnea  
C. Hyperventilation  
D. None of the above  
Answer: C – In hyperventilation, rate and depth of
respirations  increase and hypocarbia sometimes
occur.  

8. What is the expected breathing pattern for

Cheyne-Stokes  respiration?  

A. Respiratory cycle begins with slow, shallow breaths that

gradually  increase to abnormal rate and depth. The pattern
 reverses; breathing  slows and becomes shallow,
concluding as apnea before respiration  resumes.  
B. Respiratory cycle begins with slow, shallow breaths that
gradually  increase to abnormal rate and depth. The pattern
reverses; breathing  catches pace and becomes deep,
concluding as apnea before  respiration resumes.  
C. Respirations are abnormally deep, regular, and
increased in rate.  D. Respirations are abnormally shallow
for two to three breaths,  followed by irregular period of
apnea.  
Answer: A - Respiratory rate and depth are irregular,
characterized  by alternating periods of apnea and
hyperventilation.  

9. A nurse notices irregularities as he measured the

patient’s  respiratory rate. For how long should he
measure?  

A. 15 seconds the multiply by 4  

B. 30 seconds then multiply by 2  
C. Full one minute  
D. 2 minutes to be sure 
Answer: C - Respiratory rate is equivalent to the
number of  respirations/minute. Suspected
irregularities require 1 minute.  

10. You are caring for a patient who is 3 months old,

you have  measured his RR at 48 bpm, at rest. What
should you do?  

A. Document the measured RR at the appropriate log  B.

Document the measured RR & inform the guardian  C.
Document the measured RR & inform the guardian & the
nurse-in charge  
D. Document the measured RR; inform the guardian &
the health  care provider  
Answer: A – The RR measured is with the normal range 
RATIONALIZATION ACTIVITY 15 

1. Typically used in assessing pulse is the radial artery,

for what  reason?  
A. It’s the proper site.  
B. It’s convenient.  
C. It’s the most accurate.  
D. All of the above  

Answer: B – You can assess any artery for pulse rate,

but you  typically use the radial artery because it is easy
to palpate.  2. You are to measure the pulse of patient
with casts over her  upper extremities. What should
you do?  
A. Do not take the pulse since she has casts over
her arms.  B. Do not take the pulse since she has
casts over her arms &  document the reason.  
C. Use the apical pulse in measuring her pulse rate.  D.
Base the pulse rate from the previous shifts since it’s the
same.  

Answer: C – If the radial pulse is abnormal or intermittent

resulting  from dysrhythmias or if it is inaccessible
because of a dressing or  cast, assess the apical pulse.  
3. In auscultating for bowel, lung & heart
sounds, which  particular of the stethoscope
should be used? 
A. Stethoscope  
B. Chest piece  
C. Bell  
D. Diaphragm  

Answer: D – It transmits high-pitched sounds created by

the high velocity movement of air and blood.  
4. In assessing the patient’s pulse, you noticed
that it is  irregular. For long should you assess
his pulse?  A. 15 seconds the multiply by 4  
B. 30 seconds then multiply by 2  
C. Full one minute  
D. 2 minutes to be sure  

Answer: C – Inefficient contraction of heart fails to

transmit pulse  wave, interfering with cardiac output,
resulting in irregular pulse.  Assessing for a full minute
ensures accurate count.  5. Which among the
following data would you refer to a  physician?  
A. Infant, HR 155bpm  
B. Toddler, 140bpm  
C. Preschooler, 130bpm  
D. Adult, 100bpm  

Answer: C – The other choices present a heart rate

acceptable  within their age group.  
6. Among the given pulse sites, which is used
during cardiac  arrest?  

A. Radial  
B. Brachial  
C. Carotid  
D. Apical  
Answer: C – Easily accessible site used during
physiological shock  or cardiac arrest when other sites are
not palpable.  7. Which of the following pulse sites is
best used in assessing  the status of blood circulation
to the foot? Select all that apply.  

A. Femoral  
B. Popliteal  
C. Posterior tibial 
D. Dorsalis pedis 

Answer: C, D – Are the pulse sites used to assess

status of  circulation to foot.  
8. In auscultating the apical pulse, which of the
following should  be assessed? Select all that apply.  

A. Rate  
B. Rhythm  
C. Strength  
D. Equality  
Answer: A, B - Assessment of the radial pulse includes
measuring  the rate, rhythm, strength, and equality. When
auscultating an apical  pulse, assess rate and rhythm
only.  
9. When the regular interval is interrupted by an early
or late  beat or a missed beat this indicates an
alteration or abnormality  in which of the following
parameters:  

A. Rate  
B. Rhythm  
C. Strength  
D. Equality  
Answer: B – An interval interrupted by an early or late
beat or a  missed beat indicates an abnormal rhythm or
dysrhythmia.  10. You are documenting the pulse
strength of a patient who is  having a panic attack.
You have given a score of 4, how is this  score
described?  

A. Absent  
B. Barely palpable  
C. Normal  
D. Strong  
E. Bounding  
Answer: E – Document the pulse strength as bounding
(4); full or  strong (3); normal and expected (2);
diminished or barely palpable  (1); or absent (0).
RATIONALIZATION ACTIVITY 16 

1. It is the difference between the systolic and

diastolic  pressure:  
A. Blood pressure  
B. Systolic pressure  
C. Diastolic pressure  
D. Pulse pressure  
Answer: D – is the difference between the systolic and
diastolic  pressure.  
2. Which among the following statements is not
true about  Cardiac Output:  
A. The BP depends on the cardiac output.  
B. Cardiac output increases as a result of an increase in
HR, greater  heart muscle contractility, or an increase in
blood volume.  C. When volume decreases in an enclosed
space such as a blood  vessel, the pressure in that space
rises.  
D. As cardiac output increases, more blood is pumped
against arterial  walls, causing the BP to rise.  

Answer: C – When volume INCREASES in an enclosed

space such  as a blood vessel, the pressure in that space
rises.  
3. According to James et al. (2014), which of the
following is  defined as hypertension  
A. 120/80 mmHg  
B. 135/85 mmHg  
C. 145/95 mmHg  
D. 130/75 mmHg  

Answer: C – Diastolic readings greater than 90 mm Hg

and systolic  readings greater than 140 mm Hg define
hypertension (James et al.,  2014). 
4. It occurs when a normotensive person develops
symptoms  and a drop in systolic pressure by at
least 20 mmHg:  A. Hypertension  
B. Hypotension  
C. Orthostatic hypertension  
D. Postural hypotension 
Answer: C – occurs when a normotensive person
develops  symptoms and a drop in systolic pressure by at
least 20 mm Hg or a  drop in diastolic pressure by at least
20 mm Hg within 3 minutes of  rising to an upright position
(Shibao et al., 2013).  
5. When can a patient be diagnosed as
hypertensive?  A. A first time reading of 130/80
mmHg  
B. A patient who has familial history of hypertension  
 C. A mother who is angry and shouts  
D. A client with 3 or more consecutive readings of 140/90 mmHg  

Answer: D – A client with 3 or more consecutive readings

of 140/90  mmHg.  
6. It is the minimal pressure exerted against the arterial
walls at  all times.  

A. Blood pressure  
B. Systolic pressure  
C. Diastolic pressure  
D. Pulse pressure  
Answer: C – When the ventricles relax, the blood
remaining in the  arteries exerts a minimum pressure.  
7. A patient suddenly claimed to experience
dizziness as he  immediately got up from the bed.
What could be a reason?  

A. Hypertension  
B. Hypotension  
C. Orthostatic hypotension  
D. Anemia  
Answer: C – occurs when a normotensive person
develops  symptoms and a drop in systolic pressure by at
least 20 mm Hg or a  drop in diastolic pressure by at least
20 mm Hg within 3 minutes of  rising to an upright
position.  
8. You have noticed a student nurse is to measure a
patient’s BP  with loose-fitting cuff. What will you do?  

A. Check if the student documented the reading.  

B. Let the student check his blood pressure.  
C. Call the attention of the student and instruct to tighten
the cuff on  the patient’s arm.  
D. Call the attention of the student and instruct to
place the cuff  snugly on the patient’s arm. 
Answer: D - Loose-fitting cuff causes false-high
readings.  9. A client claims to have hypertension as
he had his BP taken  once at 150/100. How will you
deal with the patient?  
A. Confirm that the patient is hypertensive.  
B. Instruct the patient to observe natural ways such as
taking in  garlic.  
C. Instruct the patient to have his BP checked
regularly & return  within 2 months.  
D. Instruct the patient to come back tomorrow to
have his BP  checked.  
Answer: C – One elevated BP measurement does not
qualify as a  diagnosis of hypertension; if a high reading
during the first BP  measurement is obtained, the patient
is encouraged to return for  another check-up within 2
months.  
10. You are instructed to measure the BP of a 6 y/o
patient and  you only have an adult cuff. What will you
do?  

A. Use the adult cuff as it is needed in patient care.  

B. Inform the physician & document the reason.  
C. Let the patient’s guardian buy a pediatric cuff as it
is for their  patient.  
D. None of the above.  
Answer: B –Properly inform the physician of the
situation then  document; using the adult cuff may
give you inaccurate reading. 

RATIONALIZATION ACTIVITY 17 

1. Measuring the oxygen saturation of the blood

evaluates which  respiratory processes? Select all that
apply.  
A. Respiratory rate  
B. Respiratory depth  
C. Respiratory diffusion  
D. Respiratory perfusion  
Answer: C, D – Evaluate the respiratory processes of
diffusion and  perfusion by measuring the oxygen
saturation of the blood. Blood 
flow through the pulmonary capillaries delivers red
blood cells for  oxygen attachment.  
2. After oxygen diffuses from the alveoli into the
pulmonary  blood, where do most oxygen attach?  
A. Red blood cells  
B. White blood cells  
C. Hemoglobin  
D. Hematocrit  

Answer: C – After oxygen diffuses from the alveoli

into the  pulmonary blood, most of the oxygen
attaches to hemoglobin  molecules in red blood
cells.  

3. What carries the oxygenated hemoglobin molecules

to the left  side of the heart and out to the peripheral
capillaries?  A. Red blood cells  
B. White blood cells  
C. Hemoglobin  
D. Hematocrit  

Answer: A – Red blood cells carry the oxygenated

hemoglobin  molecules through the left side of the heart
and out to the peripheral  capillaries, where the oxygen
detaches, depending on the needs of  the tissues. 

4. All, but one, affect the percent of saturation of

oxygen (SaO2):  A. Respiration  
B. Ventilation  
C. Perfusion  
D. Diffusion  
Answer: A – Percent of saturation of oxygen (SaO2) is
affected by  factors that interfere with ventilation,
perfusion, or diffusion.  
5. Which of the following devices permit the
indirect  measuremen of oxygen
saturation:  

A. Arterial blood gas analysis  

B. Complete blood count  
C. Oxygen rebreather face mask  
D. Pulse oximeter 
Answer: D – A pulse oximeter permits the indirect
measurement of  oxygen saturation.  

6. All, but one, of the following statements about

arterial oxygen  saturation measurement is correct:  
A. A saturation of less than 90% is a clinical
emergency (WHO,  2011).  
B. SpO2 is a reliable estimate of SaO2 when the SaO2 is
over 80%.  C. Values obtained with pulse oximetry are less
accurate at  saturations less than 70%.  
D. All are correct.  

Answer: B – SpO2 is a reliable estimate of SaO2 when the

SaO2 is  over 70%.  

7. All, but one, of the following statements about pulse

oximeter  t is correct:  

A. Digit probes are spring loaded and conform to various

sizes.  B. Earlobe probes have greater accuracy at lower
saturations and are  least affected by peripheral
vasoconstriction.  
C. Oxygen saturation measurement using a forehead probe
is quicker  than finger probes (Yont et al., 2011) and more
accurate in conditions  that decrease blood flow (Nesseler et
al., 2012).  
D. All are correct.  
Answer: D – All statements are true.  
8. All, but one, of the following statements about
interference  with arterial pulsations is correct:  

A. Peripheral vascular disease (atherosclerosis)

reduces pulse  volume.  
B. Hyperthermia at assessment site decreases peripheral
blood flow.  C. Pharmacological vasoconstrictors (e.g.,
epinephrine) decrease  peripheral pulse volume.  
D. All are correct.  
Answer: B – Hypothermia at assessment site decreases
peripheral  blood flow. 
9. All, but one, of the following statements about
interference  with light transmission is correct:  
A. Outside light sources interfere with ability of oximeter
to process  reflected light.  
B. Patient motion does not interferes with ability of
oximeter to  process reflected light.  

C. Jaundice interferes with ability of oximeter to process

reflected  light.  
D. All are incorrect.  
Answer: B – Patient motion does not interferes with
ability of  oximeter to process reflected light.  

10. A patient comes in with a dark blue nail polish on

her nails.  Prior assessing the patient’s oxygen
saturation, what should a  nurse perform first?  

A. Monitor vital signs  

B. Ask permission to connect finger probe  
C. Remove nail polish  
D. Do not assess the oxygen saturation  
Answer: C – Black or brown nail polish or metal studs in
nails and  thickened nails can interfere with light absorption
and the ability of the  oximeter to process reflected light
(Chan et al., 2013). 
 RATIONALIZATION ACTIVITY 18 

1. This layer of the skin is regarded as a relatively

impermeable  membrane that prevents entrance of
microorganism:  A. Epidermis  
B. Dermis  
C. Hyperdermis  
D. Hypodermis 
Answer: A – Epidermis is a relatively impermeable
layer that  prevents entrance of microorganisms.  

2. All of the following skin protection implications

are true  except for one:  
A. Weakening of the epidermis occurs by scraping or
stripping its  surface.  
B. Excessive dryness causes cracks and breaks in skin
and mucosa  that allow bacteria to enter.  
C. Constant exposure of skin to moisture prevents
maceration or  softening and interrupting dermal
integrity.  
D. Misuse of soap, detergents, cosmetics,
deodorant, and  depilatories cause chemical
irritation.  

Answer: C – Constant exposure of skin to moisture

CAUSES  maceration or softening, interrupting
dermal integrity.  

3. Among the following interventions which should be

observed:  A. Minimize friction to avoid loss of stratum
corneum, which results in  development of pressure ulcers.  
B. Smooth linen out to remove sources of mechanical
irritation.  C. Remove rings from fingers to prevent
accidentally injuring patient's  skin.  
D. Make sure that bath water is excessively hot or cold.  
Answer: D – Make sure that bath water is NOT
excessively hot or  cold.  

4. One among the following statements is true

regarding  temperature regulation:  
A. Excess blankets or bed coverings interfere with heat
loss through  radiation and conduction.  
B. Wet bed linen or gowns promote with convection and
conduction.  C. Coverings interfere with heat
conservation.  
D. All of the above 
Answer: A – Excess blankets or bed coverings interfere
with heat  loss through radiation and conduction.  

5. Which among the following is true about sebum:

Select all  that apply.  
A. Sebaceous glands secrete sebum, an oily, odorous
fluid, into the  hair follicles.  
B. Sebum softens and lubricates the skin and slows water
loss from  the skin when the humidity is low.  
C. Sebum has bactericidal action.  
D. None of the above  
Answer: A, B C – All statements provided are correct
regarding  sebum.  

6. Which among the following is true about

subcutaneous  tissue: Select all that apply.  
A. The fatty tissue functions as a heat insulator for the
body.  B. Subcutaneous tissue also supports upper skin
layers to withstand  stresses and pressure.  
C. Very little subcutaneous tissue underlies the oral
mucosa.  D. None of the above.  
Answer: A, B C – All statements provided are correct
regarding  subcutaneous tissue.  
 7. The following statements are considered as correct
regarding  the skin: Select all that apply.  

A. The neonate's skin is relatively immature at birth.  B. A

toddler's skin layers become more tightly bound together. 
C. During adolescence the growth and maturation of the
integument  deceases.  
D. The condition of the adult's skin depends on bathing
practices and  exposure to environmental irritants. 
Answer: A, B, D – All statements provided are correct. 
8. All but one of the following statements are
considered as  correct regarding the skin:  

A. When an adult bathes frequently or is exposed to an

environment  with low humidity, it becomes dry and flaky.  
B. With aging the rate of epidermal cell replacement
slows, and the  skin thins and loses resiliency.  
C. Moisture leaves the skin, increasing the risk for bruising
and other  types of injury.  
D. As the production of lubricating substances from
skin glands  increase, the skin becomes dry and
itchy.  
Answer: D – As the production of lubricating substances
from skin  glands decreases, the skin becomes dry and
itchy  

9. Which of the following is NOT observed in

integumentary  maturation during the adolescent
stage:  
A. In girls estrogen secretion causes the skin to become
soft, smooth,  and thicker with increased vascularity.  
B. In boys male hormones produce an decreased
thickness of the  skin with some darkening in color.  

C. Sebaceous glands become more active, predisposing

adolescents  to acne (i.e., active inflammation of the
sebaceous glands  accompanied by pimples).  
 D. Sweat glands become fully functional during
puberty.  Answer: B – In boys male hormones
produce a DECREASED  thickness of the skin with
some darkening in color.  

10. Among the statements regarding Hair which is NOT true:  

A. Males reach adolescence; shaving becomes a part

of routine  grooming.  
B. Young girls who reach puberty often begin to shave their
legs and  axillae.  
C. With aging, as scalp hair becomes thinner and drier,
shampooing  is usually performed less frequently.  
D. None of the above  
Answer: D – All statements provided are correct.
RATIONALIZATION ACTIVITY 19 

1. Which among the following nursing care does not

apply to  Early Morning Care: Select all that apply.  
A. Change a patient's gown or pajamas.  
B. Offering a bedpan or urinal if the patient is not
ambulatory.  C. Provide a full or partial bath or a
shower.  
D. Washing the patient's hands and face.  
Answer: A, C – These nursing care are done in the routine
morning  care.  

2. Among the following nursing care, which will

you render  before bedtime? Select all that apply.  
A. Changing soiled bed linens, gowns, or pajamas;  
B. Helping patients wash the face and hands  
C. Offering the bedpan or urinal to
nonambulatory patients  D. Providing oral
hygiene  
 Answer: A, B, C, D – All the given nursing care are
observed during  Evening/Hour-before-sleep Care.  

3. Which of the following statement best defines a

partial bed  bath:  
A. Bath administered to totally dependent patient in bed.  B.
Patient sits or stands under a continuous stream of water. 
C. Bed bath that consists of bathing only body parts that
would cause  discomfort if left unbathed  
D. Involves bathing from a bath basin or sink with patient
sitting in a  chair.  

Answer: C – This statement best defines a partial bed bath.  

4. This is a type of bath where an antimicrobial wipe is

used to  decrease the frequency of hospital-acquired
infections on skin,  invasive lines, and catheters: 
A. Antimicrobial tub bath  
B. Antimicrobial shower  
C. Chlorhexidine gluconate (CHG) bath 
D. Chlorhexidine gluconate (CHG) wipes  
Answer: C – Chlorhexidine gluconate (CHG) bath: This
antimicrobial  bath wipe is used to decrease the frequency
of hospital-acquired  infections on skin, invasive lines, and
catheters.  

5. A complete bed bath, tub bath, or shower often

exhausts a  patient. What should be assessed to
measure her physical  tolerance?  

A. Range of motion  
B. Blood pressure  
C. Heart rate  
D. Activity tolerance test  
Answer: C – Assessing heart rate before, during, and
after a bath  provides a measure of his her physical
tolerance.  

6. Who among the following patients are candidates for

a partial  bed bath? Select all that apply.  
A. An 84 year old hypertensive patient.  
B. A post-operative patient on her 2nd day.  
C. A bedridden patient.  
D. None of the above  

Answer: A, B, C – All patients are candidates for a partial

bed bath.  Provide a partial bed bath to patients who are
aging, dependent, in  need of only partial hygiene, or
bedridden and unable to reach all  body parts.  

7. The question of whether to use bath basins with

soap and  water is an issue because bath basins
provide a reservoir for  bacteria and are a possible
source of transmission of hospital acquired
infections. To prevent this from occurring, what 
actions should be observed? Select all that apply. 
A. Do not bathe patients.  
B. Use CHG 4% solution and soap together with water.  C.
Use CHG 4% solution instead of soap then water.  D. Air-dry
bath basins and avoid using as storage for bath supplies. 
Answer: C, D – In contrast, the use of CHG 4% solution in
place of  standard soap and water in wash basins has been
shown to  decrease bacterial growth in basins (Powers et
al., 2012) and reduce  critical care unit–acquired methicillin-
resistant Staphylococcus aureus  (MRSA) (Petlin et al.,
2014). It is important to air-dry bath basins  completely and
not to use a basin for storing supplies.  

8. In providing bed bath, what should be used if

there’s a  potential contact with body fluids?  
A. Waterproof apron  
B. Mask  
C. Face shield  
D. Gloves  
Answer: D – Gloves are necessary if there is potential
contact with  blood or body fluids.  

9. In assuring the safety of the client while performing

bed bath,  what should you do?  
A. Ask the significant other to stay at the bedside if
something  happens.  
B. Secure consent to restrain the patient.  
C. Raise the side rails.  
D. All of the above.  
Answer: C – Side rails maintain patient safety.  

10. To promote venous return, what should be

observed in  providing a bed bath?  

A. Use warm water  

B. Use cotton bath towels  
C. Avoid CHG  
D. Use firm stroke from ankle to groin 
Answer: D – Washing from ankle to groin with firm strokes
promotes  venous return. 

RATIONALIZATION ACTIVITY 20 

WORDS:  
SHAMPOO  
BRUSHING  
COMBING  
LICE  
TANGLING  
PATCHES  
CONSENT  
BRAIDING  
WARMWATER  
SALINE
P3 FUNDAMENTALS OF NURSING RLE 
RATIO 21-30 

RATIONALIZATION ACTIVITY 21 

MEDICATION ADMINISTRATION 

1. Which of following is not a part of the

guidelines for Safe  Narcotic Administration
and Control:  
A. Store all narcotics in a locked, secure cabinet or
container (e.g.,  computerized, locked cabinets are
preferred).  
B. Maintain a running count of narcotics by counting
them whenever  dispensing them. If you find a
discrepancy correct and report it  immediately.  
C. Use the record to document the patient's
name, date, time of  medication administration,
name of medication, and dosage.  D. A third
nurse witnesses disposal of the unused part if a
nurse  gives only part of a dose of a controlled
substance.  
Answer: D – 
A second nurse witnesses disposal of the
unused part if a nurse  gives only part of a dose
of a controlled substance.  

2. Which among the following names of

medications does a  nurse rarely use in
clinical practice?  
A. First name  
B. Chemical name  
C. Generic name  
D. Brand name  
Answer: B – Nurses rarely use chemical names in
clinical practice.  An example of a chemical name is
N-acetyl-para-aminophenol, which  is commonly
known as Tylenol.  

3. Among the following what does

medication classification  usually indicate?
Select all that apply.  
A. Effect of a medication on a body system. 
B. The symptoms a medication relieves.  
C. Its desired effect.  
D. All of the above.  

Answer: D – Medication classification indicates the

effect of a  medication on a body system, the
symptoms a medication relieves, or  its desired
effect.  

4. It is a tablet or capsule that contains small

particles of a  medication coated with material
that requires a varying amount  of time to
dissolve:  
A. Caplet  
B. Enteric-coated tablet  
C. Sustained release  
D. Troche  

Answer: C – is a tablet or capsule that contains

small particles of a  medication coated with material
that requires a varying amount of  time to dissolve  

5. Which of the following best describes a

liniment:  A. Semisolid, externally applied
preparation, usually containing one  or more
medications.  
B. Usually contains alcohol, oil, or soapy emollient
applied to skin.  C. Semiliquid suspension that
usually protects, cools, or cleanses  skin.  
D. Thick ointment; absorbed through skin more
slowly than ointment;  often used for skin protection.  

Answer: B – Usually contains alcohol, oil, or soapy

emollient applied  to skin.  

6. These are the expected or predicted

physiological response  caused by a
medication:  
A. Therapeutic effects  
B. Adverse effects 
C. Side effects  
D. Toxic effects  

Answer: A – are the expected or predicted

physiological response  caused by a medication.  

7. These are the are the predictable and

often unavoidable  adverse effect produced
at a usual therapeutic dose:  A. Therapeutic
effects  
B. Adverse effects  
C. Side effects  
D. Toxic effects  

Answer: C – are the predictable and often

unavoidable adverse  effect produced at a usual
therapeutic dose. . Undesired, unintended,  and often
unpredictable responses to medication are referred to
as  adverse effects  
8. It is a known effect when combined
medications produce a  greater effect than
given separately.  
A. Medication interaction  
B. Synergistic effect  
C. Fushiwara effect  
D. None of the above  
Answer: B – When two medications have a
synergistic effect, their  combined effect is greater
than the effect of the medications when  given
separately.  

9. When a medication is administered repeatedly,

its serum level  fluctuates between doses. What is
the highest level is called?  A. Top concentration  
B. Peak concentration  
C. Trough concentration  
D. High concentration 
Answer: B - When a medication is administered
repeatedly, its  serum level fluctuates between
doses. The highest level is called the  peak
concentration, and the lowest level is called the
trough  concentration.  

10. A patient is to receive medication TID.

What does this  abbreviation mean?  
A. Twice a day  
B. Thrice a day  
C. Two tabs, once a day  
D. Three tabs, once a day  
Answer: B – Three times a day is abbreviated as TID. 
RATIONALIZATION ACTIVITY 22 
MEDICATION ADMINISTRATION ROUTES AND
COMPUTATION 

1. It is a route of medication administration

where the drug is  placed under the patient’s
tongue:  
A. Oral administration  
B. Sublingual administration  
C. Buccal administration 
D. Mucuos membrane administration  
Answer: B – Medications placed under the patient’s
tongue are given  sublingually.  

2. It is a parenteral administration where

medication is injected  into tissues just below
the dermis of the skin  
A. Intradermal  
B. Intramuscular 
C. Subcutaneous  
D. Intravenous  
Answer: C - Injection into tissues just below the
dermis of the skin is  given subcutaneously.  

3. Administering medications through a catheter

surgically  placed in the subarachnoid space or
one of the ventricles of the  brain: 
A. Epidural  
B. Intrathecal  
C. Intrapleural  
D. Intraperitoneal  

Answer: B - Physicians and specially educated

nurses administer  intrathecal medications through
a catheter surgically placed in the  subarachnoid
space or one of the ventricles of the brain.  

4. Administering medications directly into the

pleural space.  A. Epidural  
B. Intrathecal  
C. Intrapleural  
D. Intraperitoneal  

Answer: C - A syringe and needle or a chest tube

is used to  administer intrapleural medications
directly into the pleural space.  

5-7. A patient under your care is to receive 275mg

of  paracetamol syrup. The available medication
on hand reads  500mg/5ml, what is the amount to
be given? Show your solution.  (3 points)  
A. 2.75 ml  
B. 3.00 ml  
C. 3.30 ml  
D. 5.00 ml 
Answer: A – (275mg/500mg) (5ml)  

8-10. The doctor orders 320mg/tab of aspirin to be

chewed to a  patient who suffers from myocardial
infarction. The available  aspirin at the pharmacy
is at 80mg/tab. How many should you let  the
patient take?Show your solution. (3 points)  
A. 0.25 tab  
B. 4 tabs  
C. Refer the unavailability to the physician  
D. None of the above  

Answer: B – (320mg/80mg) 
RATIONALIZATION ACTIVITY 23 

MEDICATION ADMINISTRATION – 
ORDERS & STANDARDS  

1. An order is read as Tetracycline 500 mg PO

q6h. How is this  order classified:  
A. Now orders  
B. PRN orders  
C. Standing orders  
D. STAT orders  
Answer: C – A standing order is carried out until
the health care  provider cancels it by another order
or a prescribed number of days  elapse.  

2. An order is read as Morphine sulfate 2 mg

IV q2h prn for  incisional pain. How is this
order classified:  
A. Now orders  
B. PRN orders  
C. Single (One-Time ) Orders 
D. Standing orders  

Answer: B - Sometimes the health care provider

orders a medication  to be given only when a patient
requires it. This is a prn order. Use  objective and
subjective assessment (e.g., severity of pain, body 
temperature) and discretion in determining whether or
not the patient  needs the medication.  

3. Sometimes a health care provider orders a

medication to be  given once at a specified
time. Which type of order does this  apply to?  
A. Now orders  
B. PRN orders  
 C. Single (One-Time) Orders  
D. Standing orders  

Answer: C – The definition applies to Single (One-Time)

Orders. 

4. This type of order signifies that a single dose

of a medication  is to be given immediately and
only once.  
A. Now orders  
B. PRN orders  
C. Standing orders  
D. STAT orders  
Answer: D - A STAT order signifies that a
single dose of a  medication is to be given
immediately and only once.  For example:
Apresoline 10 mg IV STAT.  

5. It is a type of order where an order is more

specific than a 1- time order and is used when
a patient needs a medication  quickly but not
right away:  
A. Now orders  
B. PRN orders  
C. Standing orders  
D. STAT orders 
Answer: A – NOW, more specific than a 1-time order
and is used  when a patient needs a medication
quickly but not right away, as in a  STAT order.  

6. Among the following instances are

considered to be  medication errors:
Select all that apply.  
A. Inaccurate prescribing  
 B. Administering the wrong medication  
C. Giving the medication using the wrong route
or time interval  D. Administering extra doses 
E. Failing to administer a medication  

Answer: ABCDE – All these instances are

considered to be  medication errors.  

7. In preventing medication errors, which of the

following should  be done by the nurse? Select all
that apply.  
A. Interpret illegible handwriting then clarify with
health care provider.  B. Prepare medications for only
one patient at a time.  C. Document all medications
as soon as they are given.  D. When you have made
an error, reflect on what went wrong and  ask how
you could have prevented the error. Complete an 
occurrence report per agency policy.  
E. Question unusually large or small doses.  

Answer: All except A –All actions should be

followed to ensure  prevention of medication
error.  
Do not interpret illegible handwriting; clarify with health care
provider  

8. Preparing oral medications in syringes

can be fatal when  administered in a
differently. Which among the 6 rights is 
concerned in this situation?  
A. Right patient  
B. Right time 
C. Right dose  
D. Right route  
Answer: D – Medications should be given via the
route they are  ordered and should not be given
differently as this may result to fatal  consequences.  

9. A patient is ordered Ceftriaxone 750mg

SIVP q8h. Which  among the schedule
should the nurse follow?  
A. 8AM – 1PM – 6PM  
B. 9AM – 2PM – 7PM  
C. 7AM – 3PM – 11PM  
D. 7AM – 11AM – 3PM  

Answer: C – Among the given choices, this has

the only correct  number of hours (interval).  

10. To ensure the right dose, whichamong the

following should  be observed? Select all that
apply.  
A. Have another qualified nurse check the
calculated doses when  performing medication
calculations or conversions.  
B. Prepare medications using standard
measurement devices such  as graduated cups,
syringes, and scaled droppers to measure 
medications accurately.  
C. Charge nurses split the medications, label and
package them, and  then send them to the nurse for
administration.  
D. Completely clean a crushing device before
crushing the tablet.  E. Do not use a patient's
favorite foods or liquids because  medications
alter their taste and decrease the patient's desire
for  them.  
Answer: All except C- All except C are observed
to ensure right  dose. Charge nurses Pharmacists
split the medications, label and  package them, and
then send them to the nurse for administration.
RATIONALIZATION ACTIVITY 24 

MEDICATION  
ADMINISTRATION – ORAL  

1. It is a type of medication route where

drugs are given by  mouth:  
A. Oral route  
B. Sublingual route  
C. Buccal route  
D. All of the above  
Answer: A – Medications taken by mouth are given orally.  

2. Which of the following statements is true

regarding oral  administration:  
A. easiest and most desirable route for
administering medications  B. Food sometimes
affects their absorption  
C. Meals enhances medication absorption  
D. Many medications do interact with
nutritional and herbal  supplements.  

Answer: D – Many medications interact with

nutritional and herbal  supplements.  

3. This occurs when food, fluid, or medication

intended for GI  administration inadvertently
enters the respiratory tract.  A. Inspiration  
B. Expiration  
C. Aspiration  
D. Inhibition 
Answer: C – Aspiratrion occurs when food, fluid,
or medication  intended for GI administration
inadvertently enters the respiratory  tract.  

4. In assessing the patient’s ability to swallow,

which should you  assess:  
A. Dentures  
B. Tonsils  
C. Gag reflex  
D. Respiration  

Answer: C – Assess patient's ability to swallow and

cough by  checking for presence of gag reflex and
then offering 50 mL of water  in 5-mL allotments.
Stop if patient begins to cough.  

5. Which among the following one should

NOT observe in  administering oral
medications:  
A. Administer pills one at a time.  
B. Utilize straws because they increase the control
patient has over  volume intake.  
C. Have patient hold and drink from a cup if possible.  

D. Time medications to coincide with mealtimes or

when patient is  well rested and awake if
possible.  
Answer: B – Avoid straws because they decrease
the control patient  has over volume intake, which
increases the risk of aspiration.  
6. If a patient has unilateral weakness,
where should the  medication be
placed?  
A. Affected or weak side of the mouth  
B. Unaffected or strong side of the mouth  
C. Request for another route of administration  
D. Let the patient normally drink the medication 
Answer: B – If patient has unilateral weakness, place
the medication  in the stronger side of the mouth.
Turning the head toward the  weaker side helps the
medication move down the stronger side of the 
esophagus.  

7. A patient is to take a orally disintegrating

medication. All of  the following staments are
correct except:  
A. Remove medication from blister packet
just before use.  B. Do not push the tablet
through the foil.  
C. Place medication on top of patient's tongue and
caution against  chewing the medication.  
D. Place medication on top of patient's tongue and
instruct to chew  and drink water after.  

Answer: D – Place medication on top of patient's

tongue and caution  against chewing the medication
is the correct statement.  

8. For sublingually administered

medications, which of the  following are
correct: Select all that apply. 

A. Medication is absorbed through blood vessels of

undersurface of  tongue.  
B. If swallowed, gastric juices destroy medication, or
liver detoxifies it  so rapidly that therapeutic blood
levels are not attained.  C. Caution patient against
swallowing tablet.  
D. Have patient place medication under
tongue and allow it to  dissolve completely.  
Answer: ABCD – All statements provided are correct.  

9. Among the following actions, which should

NOT be avoided  when medications are given
per buccal? Select all that apply: 

A. Chewing of the medication.  

B. Dissolving against the mucous membranes of the cheek 
C. Water until the medication is dissolved  
D. None of the above  
Answer: B Have patient place medication in mouth
against mucous  membranes of cheek until it
dissolves. Avoid administering liquids  until buccal
medication has dissolved.  

10. Among the following actions, which should

be avoided for  effervescent medications?
Select all that apply:  

A. Add tablet or powder to glass of liquid.  

B. Give immediately after dissolving.  
C. Let the tablet dissolve on the patient’s tongue  
D. Offer water once dissolve on the patient’s
tongue  Answer: C,D – Effervescent tablets or
powder are added to a glass  of liquid and then
given immediately after dissolving. 
 RATIONALIZATION ACTIVITY 25 

MEDICATION ADMINISTRATION – 
TOPICAL AND INHALATION  

1. In administering topical medications in open

wounds, which  of the following should be
observed?  
A. Medical asepsis  
B. Sterile technique  
C. Clean technique  
D. Hand hygiene  
Answer: B – . Use sterile technique if a patient has an open
wound. 
2. Prior applying medications, which of the
following  interventions should one NOT
observe? Select all that apply.  A. Wash the
area with soap and water.  
B. Soaking the involved site.  
C. Locally debriding the tissue.  
D. None of the above.  

Answer: D – All interventions should be

observed as skin  encrustation and dead tissues
harbor microorganisms and block  contact of
medications with the tissues to be treated.  

3. The most commonly administered form of nasal

instillation is  decongestant spray or drops, used
to relieve symptoms of sinus  congestion and
colds. Overusing leads to which rebound effect: 
A. Increase blood pressure.  
B. Nasal irritation.  
C. Nasal congestion worsens.  
D. All of the above.  
 Answer: D – Medication classification indicates the
effect of a  medication on a body system, the
symptoms a medication relieves, or  its desired
effect.  

4. In instilling eye medications, which of the

following should be  observed: Select all that
apply.  
A. Avoid instilling any form of eye medications
directly onto the  cornea.  
B. Avoid touching the eyelids or other
eye structures with  eyedroppers or
ointment tubes.  
C. Use eye medication for both the patient's affected
and unaffected  eyes.  
D. Never allow a patient to use another patient's eye
medications.  

Answer: ABD – All these interventions are correct

except for C as  one should se eye medication only
for the patient's affected eye. 
5. Among the following statements, which is
true regarding ear  instillation:  
A. Eardrops should be at room temperature.  
B. Non-sterile solutions may be used.  
C. Medications should be forced when the ear canal
as deemed to be  occluded.  
D. All of the above.  

Answer: A – Because internal ear structures are

very sensitive to  temperature extremes, you need
to instill eardrops at room  temperature to prevent
vertigo, dizziness, or nausea. 
6. Which among the following regarding dry
powder inhalers  (DPIs) are true: Select all
that apply.  
A. Some DPIs are unit dosed  
B. Other DPIs hold enough medication for 1 month.  
C. DPIs require less manual dexterity.  
D. Tthe medication inside the DPI can clump if
the patient is in a  humid climate  
Answer: ABCD – All statements regarding DPIs are
correct.  

7. Which among the following illnesses

do not receive  medications through
inhalations:  
A. Chronic asthma  
B. Hypertension  
C. Emphysema  
D. Bronchitis  

Answer: B – Patients who receive medications by

inhalation  frequently suffer chronic respiratory
disease such as chronic asthma,  emphysema, or
bronchitis.  

8-10. A patient is prescribed Seretide, 2 puffs

BID. The inhaler  has a total of 200 puffs. How
long should the  
canister/medication last? Show your solution. (3 points)
A. 20 days  
B. 30 days  
C. 40 days  
D. 50days  
Answer: D – 2 puffs x 2 times a day = 4 puffs per
day; 200 puffs / 4  puffs per day = 50 days 
RATIONALIZATION ACTIVITY 26 

1. Which among the following recommendations

is NOT followed  to prevent needlestick injuries
among nurses:Select all that  apply.  
A. Do not recap any needle after medication
administration.  B. Plan safe handling and
disposal of needles before beginning a 
procedure.  
C. Attend education offerings on bloodborne
pathogens and follow  recommendations for  
infection prevention, including receiving the hepatitis
B vaccine.  D. Utilize needles even when effective
needleless systems or sharps  with engineered
sharps injury protection (SESIP) safety devices are 
available.  

Answer: D – Avoid using needles when effective

needleless  systems or sharps with engineered
sharps injury protection (SESIP)  safety devices are
available.  

2. It is made of glass with a constricted

neck that must be  snapped off to allow
access to the medication:  
A. Syringes 
B. Vials  
C. Needles  
D. Ampules  

Answer: D - made of glass with a constricted neck

that must be  snapped off to allow access to the
medication. A vial is a single-dose  or multidose
container with a rubber seal at the top  

3. In this type of parenteral medication

administration, it  involves placing medications
into the loose connective tissue  under the
dermis:  
A. Intraveneous injection  
B. Intradermal injection  
C. Subcutaneous injection  
D. Intramuscular injection  
Answer: C – involve placing medications into the
loose connective  tissue under the dermis.  

4. This type of parenteral medication

administration, the needle  passes through
subcutaneous tissue and penetrate deep muscle 
:  
A. Intravenous injection  
B. Intradermal injection  
C. Subcutaneous injection  
D. Intramuscular injection  

Answer: D – 
A longer and heavier-gauge needle is needed
to pass through  subcutaneous tissue and
penetrate deep muscle tissue.  

5. This site of IM injection is the preferred and

safest site for all  adults, children, and infants,
especially for medications that  have larger
volumes and are more viscous and irritating:  A.
Outer posterior aspect of the upper arms  
B. Ventrogluteal  
C. Deltoid  
D. Vastus lateralis 
Answer: B – This site is the preferred and safest site
for all adults,  children, and infants, especially for
medications that have larger  volumes and are more
viscous and irritating. The ventrogluteal site is 
recommended for volumes greater than 2 mL  
6. In permforming IM injections, this technique is
used to  minimize local skin irritation by sealing
the medication in muscle  tissue: 
A. A-Track Method  
B. AZ-Track Method  
C. Z-Track Method  
D. None of the above  

Answer: C – the Z-track method be used to

minimize local skin  irritation by sealing the
medication in muscle tissue  

7-10. Identify the type of parenteral

administration and indicate  the angle of needle
insertion observed.  

A. Intramuscular, 90 degrees  
[Link], 45 degrees  
[Link], 90 degrees  
D. Intradermal, 15 degrees  

RATIONALIZATION ACTIVITY 27
1. This type of order signifies that a single dose
of a medication  is to be given immediately and
only once.  
A. Now orders  
B. PRN orders  
C. Standing orders  
D. STAT orders  
Answer: D - A STAT order signifies that a
single dose of a  medication is to be given
 immediately and only once.  For example:
Apresoline 10 mg IV STAT. 

2. A patient is ordered Ceftriaxone 750mg

SIVP q8h. Which  among the schedule
should the nurse follow?  
A. 8AM – 1PM – 6PM  
B. 9AM – 2PM – 7PM  
C. 7AM – 3PM – 11PM  
D. 7AM – 11AM – 3PM  
Answer: C – Among the given choices, this has
the only correct  number of hours (interval).  

3. Many patients, particularly children, fear

injections. As a  nurse, which of the following
should you observe to minimize  discomfort?
Select all that apply. 
A. Use a sharp-beveled needle in the smallest
suitable length and  gauge.  
B. Hold the syringe steady while the needle
remains in tissues.  C. Select the proper
injection site, disrgearding anatomical 
landmarks.  
D. Insert the needle quickly and smoothly to minimize tissue
pulling.  

Answer: ABD – All should are interventions to

minimize discomfort  except for C - Select the
proper injection site, USING anatomical 
landmarks.  

4. Subcutaneous tissue is sensitive to irritating

solutions and  large volumes of medication.
What is the range of acceptable 
 volumes of water-soluble medcations
subcutaneously given to  adults?  
A. 0.3 to 0.5 mL  
B. 0.5 to 1 mL  
C. 0.5 to 1.5 mL  
D. 1.5 to 2.0 mL  

Answer: C - Only administer small volumes (0.5 to

1.5 mL) of water soluble medications
subcutaneously to adults.  

5. You are to give a SC injection to a pediatric

patient who’s slim  and underweight. How should
you introduce the medication to  ensure thatn it
reaches the required site?  
A. Grasp the skin, 2 inches, 90o, intramuscularly.  
B. Grasp the skin, 2 inches, 90o, subcutaneously.  
C. Grasp the skin, 1 inch, 45o, intradermally.  
D. Grasp the skin, 1 inch, 45o, subcutaneously.  

Answer: D – if you can grasp 2.5 cm (1 inch) of

tissue, insert the  needle at a 45-degree angle.  

6. In giving intramuscular injections, which

among the following  should you NOT practice: 
A. Giving medications 2-5ml intramuscullarly to
well-developed  adults.  
B. Giving medications 2 intramuscullarly to children,
older adults and  thin patients.  
C. Giving more than 1 mL to small children
and older infants.  D. Do not give more than
0.5 mL to smaller infants.  

Answer: C – 
Do not give more than 1 mL to small children and older
infants.  
7-10. Identify the different sites utilized in
intramuscular  injections.  
A. Ventrogluteal muscle  
B. Deltoid muscle 
C. Gluteal muscle, upper outer quadrant  
D. Vastus lateralis muscle  

RATIONALIZATION ACTIVITY 28 

1. These type of catheter are used for

intermittent/straight  catheterization:  
A. Single lumen cathethers  
B. Double lumen cathethers  
C. Triple lumen cathethers  
D. Silicone catheters  
Answer: A – Single-lumen are used for
intermittent/straight  catheterization.  

2. These type of catheter are used for are used

for continuous  bladder irrigation (CBI) or when
it becomes necessary to instill  medications into
the bladder:  
A. Single lumen cathethers  
B. Double lumen cathethers 
C. Triple lumen cathethers  
D. Silicone catheters  
Answer: C – Triple-lumen catheters are used for
continuous bladder  irrigation (CBI) or when it
becomes necessary to instill medications  into the
bladder. One lumen drains the bladder, a second
lumen is  used to inflate the balloon, and a third
lumen delivers irrigation fluid  into the bladder. 
3. These type of catheter are helpful in
patients who require  frequent catheter
changes as a result of encrustation:  A.
Single lumen cathethers  
B. Double lumen cathethers  
C. Triple lumen cathethers  
D. Silicone catheters  
Answer: D – All silicone catheters have a larger
internal diameter  and may be helpful in patients who
require frequent catheter changes  as a result of
encrustation.  

4. Which among the following Frenches is

normally used for  adult patient s needing
indwelling catheters:  
A. French 8 – 12  
B. French12– 14  
C. French 10 – 14  
D. French 14 – 16 

Answer: D – Most adults with an indwelling

catheter should use a  size 14 to 16 Fr to minimize
trauma and risk for infection.  

5. Which among the following interventions

should be observed  to prevent CAUTI: Select all
that apply.  
A. Patients in acute care hospital should have
urinary catheters  inserted using clean technique
with sterile equipment.  B. Secure indwelling
catheters to prevent movement and pulling on  the
catheter.  
C. Maintain a closed urinary drainage system.  
D. Maintain an unobstructed flow of urine
through the catheter,  drainage tubing, and
drainage bag.  

Answer: BCD – All are true except A; Patients in

acute care hospital  should have urinary catheters
inserted using ASEPTIC technique  with sterile
equipment.  
A catheter-associated urinary tract infection (CAUTI) 

6. A patient’s catheter becomes occluded. As his

nurse, which of  the following should you
perform? 
A. Irrigate or flush a catheter with sterile solution.  
B. Change the catheter  
C. Inform the physician  
D. None of the above, this is normal.  
Answer: B – If a catheter becomes occluded, it is
best to change it  rather than risk flushing debris
into the bladder.  

7. Which among the given conditions should not

be considered  in placing a suprapubic
catheter?  

A. Blockage of the urethra  

B. Enlarged prostate  
C. Urethral stricture  
D. Before urological surgery  
Answer: D – Suprapubic catheters are placed
when there is  blockage of the urethra (e.g.,
enlarged prostate, urethral stricture,  AFTER
urological surgery).  
8. Among the following procedures, which is not
considered to  be invasive?  

A. Straight catheter insertion.  

B. IFC insertion.  
C. Suprapubic catheterization.  
D. Use of penile sheath.  
Answer: D - The external catheter, also called a
condom catheter or  penile sheath, is a soft, pliable
condom-like sheath that fits over the  penis,
providing a safe and noninvasive way to contain
urine.  

9. A patient is ordered for discharge and

removal of indwelling  catheter. As his nurse,
when should you remove the catheter?  

A. Once ordered.  
B. As soon as the patient settles his hospital bill.  
C. After verifying doctor’s order.  
D. When the patient is ready. 
Answer: A – Prompt removal of an indwelling
catheter after it is no  longer needed is a key
intervention that has proven to decrease the 
incidence and prevalence of hospital-acquired UTIs
(HAUTIs).  

10. Which among the following interventions

should NOT be  observed in preventing
CAUTI:  

A. Keep the urinary drainage bag below the level of

the bladder at all  times.  
B. Avoid dependent loops in urinary drainage tubing.  
C. Ensure that the urinary drainage bag is low
and touching the  ground/floor.  
D. Before transfers or activity, drain all urine from the
tubing into bag  and empty the drainage bag.  
 Answer: c – Prevent the urinary drainage bag
from touching or  dragging on the floor. 

RATIONALIZATION ACTIVITY 29

CATHETERIZATION 
URINARY MEATUS 
FENESTRATED DRAPE 
ASEPTIC TECHNIQUE 
CONSENT 
INVASIVE PROCEDURE 
URINEBAG 
CATHETER 
UPWARD 
FRONT TO BACK 

RATIONALIZATION ACTIVITY 30 

1. It is the instillation of a solution into the rectum and
sigmoid colon. A. Catheterization  
B. Digital Rectal Exam  
C. Enema  
D. Flushing  
Answer: C – An enema is the instillation of a solution into
the rectum and  sigmoid colon.  

2. Which among the following statements is not true

about enemas:  A. The primary reason for an enema is to
promote defecation by stimulating  peristalsis.  
B. The volume of fluid instilled breaks up the fecal mass,
stretches the rectal  wall, and initiates the defecation reflex.  
C. Enemas are also a vehicle for medications that exert a local
effect on rectal  mucosa.  
D. They are used most commonly for the immediate relief of
diarrhea, emptying  the bowel before diagnostic tests or
surgery, and beginning a program of bowel  training.  

Answer: D – They are used most commonly for the

immediate relief of  CONSTIPATION, emptying the bowel
before diagnostic tests or surgery, and  beginning a program
of bowel training. 
3. Amongb the following types of enema, which
provides relief from  gaseous distention?  
A. Oil Retention  
B. Soapsuds  
C. Normal saline  
D. Carminative enema  

Answer:D – Carminative enemas provide relief from gaseous

distention. They  improve the ability to pass flatus.  

4. Which among the following statements is true

about enemas:  A. Sterile technique is unnecessary
because the colon normally contains  bacteria.  
 B. The volume of fluid instilled forms the fecal mass,
stretches the rectal wall,  and initiates the defecation reflex.  
C. Enemas cannot be used as a vehicle for medications that
exert a local effect  on rectal mucosa.  
D. They are used most commonly for the immediate relief of
diarrhea, emptying  the bowel before diagnostic tests or
surgery, and beginning a program of bowel  training.  

Answer: A – All of the statement, except A, are false regarding

enemas.  

5. Asssisting a patient to deficate on a bedpan, on what

position will you  place the patient?  

A. Bed elevated 15 to 30 degrees  

B. Bed elevated 30 to 45 degrees  
C. Bed elevated 45 to 60 degrees  
D. Ask the patient to sit directly onto the bedpan.  
Answer: B – The proper position for the patient on a bedpan is
with the head of  the bed elevated 30 to 45 degrees. 

Matching Type: Match the  

letter of the correct answer  
to the given  
statement. 

1. E 1. infused into the bowel  exert osmotic pressure that  

pulls fluids out of interstitial  
spaces.  

2.C  
2. hypotonic and exerts an  
osmotic pressure lower  
than fluid in interstitial  
spaces.  

3.B  
3. lubricate the feces in the  
rectum and colon.  

4.D  
4. Added to create the  
effect of intestinal irritation  
to stimulate peristalsis.  

5.A  
5. The safest solution to  
use because it exerts the  
same osmotic pressure as  
fluids in interstitial spaces  
surrounding the bowel.  

A. Normal Saline  B. Oil Retention  

C. Tap Water  

D. Soapsuds  

E. Hypertonic solution