CHECK FOR UNDERSTANDING (25 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct answer
and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You are given 25
minutes for this activity:

Multiple Choice

1. Nurse Edberg is about to perform physical assessment of the abdomen. Which order of assessment must Nurse
Edberg do?
a. Inspection, palpation, percussion, and auscultation
b. Auscultation, percussion, palpation, and inspection
c. Inspection, auscultation, percussion, and palpation
d. Any order that the nurse desires

ANSWER: C
RATIO: Letter C is the correct order that must be done in order to avoid any alterations in the bowel sounds. Letter A
is done for the rest of the body

2. Nurse Ann is going to assess a newly admitted client who is suspected to have Dengue Hemorrhagic Fever. Which
of the following should she record as subjective data?
a. Body temperature of 38.8 degrees Celsius
b. Complete blood count result
c. Patient’s complaint about abdominal pain
d. Client’s blood pressure of 110/78

ANSWER: C
RATIO: Complaints about pain are considered subjective data. Subjective data are information from the client's point
of view (“symptoms”), including feelings, perceptions, and concerns obtained through interviews. 

3. Which of the following is the purpose of physical examination?

a. To obtain subjective data from the patient
b. To know about the patient’s chief complaint
c. To determine changes in a patient’s health status and how to respond to a problem as well as promote healthy
lifestyles and wellbeing
d. To evaluate the outcome of the nursing interventions

ANSWER: C
RATIO: Physical examination helps determine the general status of the patient’s health. The exam also gives the health
provider a chance to talk to the patient about any ongoing pain or symptoms that they’re experiencing or any
other health concerns that they might have.

4. A student nurse is instructed to perform an intramuscular injection by using the Z-track method. The student nurse must
know that the purpose of doing the Z-track method is
a. To enhance blood flow to the injection site
b. To allow faster absorption of the drug into the muscle
c. To prevent drug leakage into the subcutaneous tissue, helps seal the drug in the muscle, and minimizes skin
irritation.
d. To allow faster drug clearance.

ANSWER: C
RATIO: The Z-track method is a type of IM injection technique used to prevent tracking (leakage) of the medication into
the subcutaneous tissue (underneath the skin).
 5. Nurse Aladdin Abdulrahman is reviewing the patient’s blood pressure after administering an oral antihypertensive 30
minutes before. The nurse is employing which stage of the nursing process?
a. Nursing diagnosis
b. Planning
c. Implementation
d. Evaluation

ANSWER: D
RATIO: The nurse conducts evaluation measures to determine if expected outcomes are met, not
the nursing interventions.

6. A patient named Jasmine Allamudin is in the bathroom when Nurse Belle enters to give a prescribed medication. What
should the nurse in charge do?
a. Wait for the patient to return to her bed then leave the medication at her bedside.
b. Return shortly to the patient’s room and remain there until the patient takes her medication.
c. Tell the patient to be sure to take the medication and then leave it at her bedside.
d. Leave the medication at her patient’s bedside.

ANSWER: B
RATIO: The nurse should return shortly to the patient’s room and remain there until the patient takes the medication to
verify that it was taken as directed. The nurse should never leave medication at the patient’s bedside unless
specifically requested to do so.

7. Dr. Rodrigo Robredo orders heparin, 7500 units, to be administered subcutaneously every 6 hours. The vial reads 10000
units per milliliter. Nurse Leni should anticipate giving how much heparin for each dose?

a. 0.25 ml
b. 0.5 ml
c. 0.75 ml
d. 1.25 ml

ANSWER: C
RATIO: 0.75ml

8. A patient named Panfilo dela Rosa is suffering from hypoxia. The physician is most likely to order which of the
following tests?
a. Arterial blood gas analysis
b. Total hemoglobin and hematocrit
c. Chest X-ray
d. Complete blood count

ANSWER: A
RATIO: AN ARTERIAL BLOOD GAS (ABG) analysis can tell you about the patient's oxygenation (via PaO2 and SaO2),
acid-base balance, pulmonary function (through the PaCO2), and metabolic status

9. Nurse Ishbelle uses a stethoscope to auscultate a female patient’s chest. Which statement about the stethoscope with
the bell and the diaphragm is true?
a. The bell detects thrills best
b. The bell detects high-pitched sounds best
c. The diaphragm detects high-pitched sounds best
d. The diaphragm detects low-pitched sounds best

ANSWER: C
RATIO: The diaphragm is best for higher pitched sounds, like breath sounds and normal heart sounds. The bell
is best for detecting lower pitch sounds, like some heart murmurs, and some bowel sounds.

10. Nurse Vincent is teaching the community about the importance of exercise to prevent the occurrence of type II
diabetes mellitus.
a. Primary prevention
 b. Secondary prevention
c. Tertiary prevention
d. Passive prevention

ANSWER: A
RATIO: Primary prevention. A healthy diet, together with regular physical activity, maintenance of a healthy body
weight, consumption of moderate amounts of alcohol, and avoidance of sedentary behaviors and smoking, is likely
to prevent most type 2 diabetes cases.

11. When observing universal precaution, the nurse must always practice which of the following to prevent the
transmission of infection?
a. Having a proper diet
b. Maintain adequate exercise
c. Taking supplemental vitamins and minerals
d. Practice hand hygiene at all times

ANSWER: D
RATIO: Hand hygiene is a major component of standard and universal precautions and one of the most effective
methods to preve nt transmission of pathogens associated with health care.

12. Nurse Jason is going to feed the patient via the nasogastric tube. Which nursing action is essential in performing
enteral feeding?
a. Elevating the head of the bed
b. Positioning the patient to the left side
c. Warming the formula before administering it
d. Hanging a full day’s worth of formula at one time

ANSWER: A
RATIO: Position patient sitting up at 45 to 90 degrees (unless contraindicated by the patient's condition), with a pillow
under the head and shoulders. This allows the NG tube to pass more easily through the nasopharynx and into the
stomach.

13. Nurse Joy is going to administer a tablet via the sublingual route. She should instruct her patient to place the
tablet on the:
a. Inside of the cheek
b. Floor of the mouth
c. Roof of the mouth
d. Top of the tongue

ANSWER: B
RATIO: Sublingual administration of the drug means placement of the drug under the tongue and drug reaches
directly in to the blood stream through the ventral surface of the tongue and floor of the mouth.

14. Which of the following best describes Kussmaul respirations?

a. Increased rate and depth of breathing over a prolonged period of time. In response to metabolic acidosis, the
body's attempt to blow off CO2 to buffer a fixed acid such as ketones.
b. Gradual increase in volume and frequency, followed by a gradual decrease in volume and frequency, with apnea
periods of 10 - 30 seconds between cycle.
c. Short episodes of rapid, deep inspirations followed by 10 - 30 second apneic period.
d. Only able to breathe comfortable in upright position (such as sitting in chair), unable to breath laying down.

ANSWER: A
RATIO: Kussmaul breathing is characterized by a deep, rapid breathing pattern. It is typically an indication that the
body or organs have become too acidic. In an attempt to expel carbon dioxide, which is an acidic compound in blood,
the body starts to breathe faster and deeper.

15. Doctor Rodrigo Robredo has ordered dextrose 5% in water, 1000 ml to be infused over 8 hours. The I.V. tubing is
delivering 15 drops per milliliter. Nurse Bong should run the infusion rate at:
 a. 15 drops per minute
b. 21 drops per minute
c. 31 drops per minute
d. 125 drops per minute

ANSWER: C
RATIO: 31 drops per minute (1,000/ 8 x 60 = 2.08 x 15 = 31.2 or 31)

16. Which of the following is true about the working phase of the nurse-patient relationship?
a. Obtain subjective data
b. Make the patient comfortable
c. Greet the patient
d. Establish rapport

ANSWER: A
RATIO: The working or middle phase of the relationship is where nursing interventions frequently take place. The nurse
assists the client to explore thoughts (e.g. views of self, others, environment, and problem solving), feelings (e.g. grief,
anger, mistrust, sadness), and behaviours (e.g. promiscuity, aggression, withdrawal, hyperactivity)

17. Which of the following interventions is considered as a primary level of prevention?

a. Using physical therapy to help the patient cope with above-the-knee amputation.
b. Obtaining a breast biopsy to detect breast cancer
c. Administering an anti-Hepatitis B immunization to an infant
d. Administering Ceftriaxone (Rocephin) to a patient who has gonorrhea

ANSWER: C
RATIO: Primary prevention includes those preventive measures that come before the onset of illness or injury and
before the disease process begins. Examples include immunization and taking regular exercise to prevent health
problems developing in the future.

18. Nurse JM is tasked to do a nursing care plan in the ward. The identification of actual or potential health problems is
done during which step of the nursing process?
a. Assessment
b. Nursing diagnosis
c. Planning
d. Implementation

ANSWER: B
RATIO: The diagnosing phase involves a nurse making an educated judgment about a potential or actual health
problem with a patient. Multiple diagnoses are sometimes made for a single patient.

19. A female patient named Mikasa Ackerman has been found to be suffering from deep-vein thrombosis. Which
nursing diagnosis should Nurse Eren prioritize at this time?
a. Altered peripheral tissue perfusion related to venous congestion
b. Risk for injury related to edema
c. Fluid volume excess related to peripheral vascular disease
d. Impaired gas exchange related to decreased blood flow

ANSWER: A
RATIO: Altered peripheral tissue perfusion related to venous congestion

20. Nurse Erina has found out that after giving proper interventions to Soma who has fever brought about by
meningitis, the patient’s fever has not subsided yet. She is revising patient Soma’s nursing care plan. During
which step of the nursing process does revision take place?
a. Nursing diagnosis
b. Planning
c. Evaluation
d. Assessment

ANSWER: C
RATIO: During the evaluation step of the nursing process the nurse determines whether the goals
established have been achieved, and evaluates the success of the plan.
 21. A client named Kakashi has been prescribed with diphenhydramine (Benadryl) for his allergies. He then contacts the
nurse and complains of drowsiness after taking the medication making it almost impossible for him to do his work.
This is an example of
a. Drug synergism
b. Side effect
c. First-pass effect

ANSWER: B
RATIO: common side effect of diphenhydramine is drowsiness.

22. Doctor Eren has ordered Nurse Misaka to administer cefuroxime (Ceftin) 500 mg via IV bolus t.i.d to a patient with acute
glumerulonephritis. The nurse would expect to give the drug to be given
a. Twice a day
b. Thrice a day
c. Once a day
d. Four times a day

ANSWER: B
RATIO: Thrice a day

23. A physician orders 250 mg of an antibiotic suspension, the label on the suspension read “500 mg/5 ml” how much
would the nurse administer?
a. 2.5 ml
b. 5 ml
c. 7.5 ml
d. 10 ml
ANSWER: A
RATIO: 10 ml (250mg/500mg x 5ml = 2.5ml)

24. A nurse is to administer 500 mg of a drug intramuscularly. The label on the multidose vial reads 250 mg/ml. how much
of the medication would the nurse prepare on the syringe?
a. 0.5 ml
b. 1 ml
c. 1.5 ml
d. 2 ml

ANSWER: D
RATIO: 2 ml (500/ 250 = 1ml)

25. When assessing for the liver functioning of a patient who is receiving hepatotoxic drugs the nurse must check
which of the following?
a. Blood urea nitrogen (BUN)
b. Creatinine clearance (CLcr)
c. Complete blood count
d. Alanine aminotransferase and aspartame aminotransferase

ANSWER: D
RATIO: The ALT and AST tests measure enzymes that your liver releases in response to damage or disease.