Saint Gabriel College

Old Buswang, Kalibo, Aklan

FINAL EXAM in N-103 FUNDAMENTALS in NURSING - SKILLS

CHRISTINE R. ELISERIO, RN, MN

Instructor

Name:_____________________________ Year Level ______________Date:___________

Test 1. Multiple Choice.

INSTRUCTIONS:
1. Use short coupon bond for your answer sheet.
2. All answers must be in CAPITAL letters.
3. Avoid erasure or any unnecessary marks on your answer sheet
4. Utilize front page only of your answer sheet.
5. Make your handwriting readable, with bigger strokes.
6. Use dark black ink pen.
7. Picture the entire answer sheet at once using portrait mode and submit it on
time through messenger or GC.
8. Picture must be clear, no shadow
9. BE HONEST

1. The nurse is preparing to make an occupied bed for a patient who is on aspiration
precautions. What will the nurse do to ensure the safety of this patient during the bed
change?

A. Fold a pillow in half and place it under the patient's head.

B. Lower the bed to a flat position and place two pillows beneath the patient's head.
C. Keep the head of the bed no lower than a 30-degree angle.
D. Ask another caregiver to hold the patient's head during the bed change.

2. The nurse is directing a nursing attendant to make an occupied bed. What will the
nurse say to minimize the risk of disease transmission to staff and patient during the bed
change?
A. "Soiled linen should be rolled toward your uniform."
B. "Soiled linen should be kept away from your uniform."
C. "You'll need to apply Standard Precautions during this task."
D. "Keep the linen bag at the foot of the bed."

3. Which action ensures that a patient will not have unnecessary pain during a linen
change?
A. Discontinue the bed change if the patient expresses or displays physical signs
of pain.
B. Explain the procedure to the patient before beginning the linen change.
C. Administer a prescribed analgesic 30 to 60 minutes before the bed change if
needed.
D. Postpone the bed change if the patient reports having physical pain before you
begin.

4. The nurse is changing the bed linen of a patient on bed rest. When the nurse is ready to
make the other side of the bed, what will the nurse do before having the patient turn onto
the side that has already been made?
A. Raise the side rails
B. Lower the head of the bed
C. Apply the top sheet
D. Discard the soiled linen in the linen bag
5. What will the nurse do, right after placing a clean top sheet on the patient?
A. Make a cuff with the top of the sheet.
B. Make a horizontal toe pleat.
C. Tuck the remaining portion of the sheet under the foot of the mattress.
D. Remove the bath blanket.

6. The nurse who is preparing to make an unoccupied bed should do what to ensure his or
her personal safety?
A. Put on sterile gloves.
B. Place the bed at a comfortable working height.
C. Place the call light within the nurse's reach.
D. Place a laundry bag on the bedside chair.

7. The nurse is preparing to change the soiled linen of a patient's unoccupied bed. Which
precaution minimizes the risk of transmitting microorganisms?
A. Perform hand hygiene and apply clean gloves.
B. Place fresh linen on a clean bedside table or chair.
C. Put soiled linen in a pillow case before placing in a hamper.
D. Roll soiled linen together with the dirty sides toward the center.

8. A patient on bed rest needs a complete change of linen. What should the nurse plan to do?
A. Make an occupied bed.
B. Change the draw sheet and top sheet
C. Use a mechanical lift to raise the patient
D. Transfer the patient to a chair during the linen change.
9. Which action VIOLATES medical asepsis when the nurse makes an occupied bed?
A. Returning unused linnet to a linen closet
B. Wearing gloves when changing the linen
C. Tucking clean linen against the frame of the bed
D. Using the old top sheet for a new bottom sheet

10. Which of the following will cause the spread of microorganisms?

A. Placing dirty linens in a laundry bag
B. Rolling dirty linens away from you
C. Performing hand hygiene before handling clean linen
D. Shaking and tossing the dirty linen

11. Which of the following goes on the bed first?

A Top sheet C. Bottom sheet
B. Blanket D. Rubber draw

12. A client is not feeling well and will spend most of the day in bed. What kind of bed
should the nurse make after the client's bath?
A. Closed bed C. Occupied bed
B. Open bed D. Hospital bed

13. The nurse is caring for a client who has a deep wound and whose saline-
wound dressing has been changed every 12 hours. While removing the old dressing,
the nurse notes that the packing material is dry and adheres to the wound bed. Which
of the following modifications is most appropriate?
A. Reduce the time interval between dressing changes
B. Discontinue application of saline-moistened packing and apply hydrocolloid
dressing
C. Assure that the packing material is completely saturated when placed in wound
D. Use less packing material
14. The nurse prepares to irrigate the client's wound. The primary reason for performing
this procedure is to:
A. Remove debris from the wound
B. Decrease scar formation
C. Improve circulation from the wound
D. Decrease irritation from wound drainage

15. When turning a client, the nurse notices a reddened area on the coccyx. What skin
care interventions should the nurse use on this area?
A. Clean the area with mild soap, dry, and add a protective moisturizer.
B. Apply a dilute hydrogen peroxide and water mixture and use a heat lamp to the
area.
C. Soak the area in normal saline solution.
D. Wash the area with an astringent and paint it with povidone-iodine (Betadine).

16. Which of the following is a complication of wound healing?

A. Three centimeters of sanguineous fluid on a surgical dressing
B. Hypotension and increased pain at the surgical site
C. Presence of red tissue in the center of a closing wound
D. Low-grade temperature

17. The following are functions of dressings, Except:

A. Promote hemostasis
B. Keep wound bed dry
C. Wound debridement
D. Prevent contamination

18. A physician orders the application of a warm, sterile compress to reduce edema in a
client's wound. Which of the following is a recommended step in this procedure?
A. Place a heating device directly on the dressing.
B. Cover the site with three layers of gauze and with a clean, dry bath towel.
C. Keep the dressing in place for the prescribed amount of time or up to 30 minutes.
D. Apply pressure to the compress to mold it around the wound site.

19. The following are actions that the nurse perform when cleansing a wound prior to the
application of a new dressing, Except
A. Avoid touching the wound bed, whether with gloves or forceps.
B. Use a sterile applicator to apply any ointment that is ordered.
C. Clean from the outside of the wound to the center.
D. Use a new gauze for each wipe of the wound.

20. Which of the following types of wound drainage should alert the nurse to the possibility
of infection?
A. Drainage that appears to be mostly fresh blood.
B. Foul-smelling drainage that is grayish in color.
C. Large amounts of drainage that is clear and watery.
D. Copious wound drainage that is blood-tinged.
TEST 2
CASE SCENARIO:
Yeh Min is a 56 year old male, residing at Poblacion, Kalibo, Aklan, was admitted
at Saint Gabriel Medical Center yesterday June 17,2021 because of on and off nape
pain for 3days. Impression: Essential Hypertension.

Vital Signs taken as follows:

8 am 10 am 12 nn
T - 37.1 ° C per axilla T- 36.5° C per axilla T- 36.7° C per axilla
P - 88 beats/min P- 90 beats/min P- 90 beats/min
R- 20 breaths / min R- 20 breaths / min R- 19 breaths / min
BP- 160/ 100 mmHg BP- 150/ 90 mmHg BP- 140/ 80 mmHg
Pain scale of 7 Pain scale of 6 Pain scale of 4

Doctor’s Order: June 18,2021 9:45 am

1. Catapres 75mcg/ tablet. 1 tablet SL now then prn for BP 140/90mmHg and
above.
2. Amlodipine 10 mg/ tablet, give 1 tablet once a day.
3. Celebrex 200mg/ tablet, 1 tablet BID pc
4. Next IVF to follow- # 3 . PNSS 1 liter for 12 hours.
5. Request for blood Cholesterol tomorrow to include creatinine, fasting
blood sugar, potassium, sodium. Instruct NPO post midnight.
6. Diet: Low salt, low fat
7. Request for ECG
8. Daily monitoring of blood pressure and record.

Dr. Harry S. Melgar

WHAT TO DO?

1. Supposing you are on 7-3 shift. Your CI assigned you to take care of patient
Yeh Min, diagnosed with Essential Hypertension. This is his second day of
hospitalization. Reflect all your data based on the given scenario.
2. Fill out all the needed information on every forms ( Name of patient, age address,
sex, date, time, etc)
3. Reflect all the results of vital signs on the monitoring sheet
4. Graph the vital signs on TPR graphing sheet ( 8am and 12 nn)
5. Carry out the written order made by Dr. H. Melgar during his rounds today.
(Note the date and time)
6. Transcribe all the drugs ordered in the medication sheet. (date, time, signature)
7. Make a medicine card for the drugs using a pre-cut cartolina , follow the
measurement of 4 x 10 cm. If NO color available, may use coupon bond and
write the color on the upper right edge of the medicine card, to indicate that you
know the color coding.
8. Note the 3rd bottle of IVF for the time it started if the second bottle ( PNSS 1
liter presently hooked and dripping at 8 hrs when you received the patient at 7
am) was consumed at 11am today.
9. Make a chronological narrative charting for 7-3 shift.
10. All entries must be handwritten, readable.
11. Submit your Final exam/ activity as soon as you are done or until 6pm today June
18, 2021

GOODLUCK and GODBLESS ! STAY SAFE

Prepared by:

Christine R. Eliserio, RN, MN

Subject Instructor