Fundamentals, HA, Hygiene, Perioperative

1. Estelle, student nurse was reviewing the objectives of Nursing Health

Assessment. Which of the following should not be included?
A. Utilize concepts, principles, techniques, and appropriate assessment
tools in the assessment of individual client with varying age group and
development
B. Observe bioethical concepts/ principles and core values and nursing
standards in the care of clients
C. To build rapport with patient and family
D. Establish a data base for the family normal abilities risk factors,
and current alternations in functions

2. Which of the following is the most important nursing objectives for

nurse doing a health assessment?
A. Identify and document the abnormal and normal findings
B. Discuss with obese patient the Body Mass Index (BMI) and healthy
lifestyle
C. To organize the collected information
D. To identify the health problems

3. Which of the following is an example of focus or ongoing assessment?

A. nursing admission assessment
B. hourly assessment of client's fluid intake and output chart
C. assessment of person airway, breathing and circulation during cardiac
arrest
D. Reassessment of client’s functional health patterns in home visit

4. Which question would best assess the quality of Mr. Connors pain?
A. Is the pain sharp?
B. What does the pain feel like?
C. Does anything make the pain worse?
D. When did the pain first start?

5. Which one of the following is NOT a function of the Upper airway?

A. For clearance mechanism such as coughing
B. Transport gases to the lower airways
C. Warming, Filtration and Humidification of inspired air
D. Protect the lower airway from foreign mater

6. It is the hair the lines the vestibule which function as a filtering

mechanism for foreign objects
A. Cilia
B. Nares
C. Carina
D. Vibrissae

7. All of the following chart entries are correct except

A. V/S 36.8 C,80,16,120/80
B. Complained of chest pain
C. Seems agitated
D. Able to ambulate without assistance

8. An adult client is on extreme pain. He is moaning and grimacing. What is

the best way to assess the client’s pain?
A. Perform physical assessment
B. Have the client rate his pain on the smiley pain rating scale
C. Active listening on what the patient says
D. Observe the client’s behavior

9. Excessive alcohol intake is what type of risk factor?

A. Genetics
B. Age
C. Environment
D. Lifestyle

10. Which area of the skin is best for assessing skin turgor?
A. Hand
B. Face
C. Neck
D. Below the clavicle

11. Considered as the first line of defense of the body against infection
A. Skin
B. WBC
C. Leukocytes
D. Immunization

12. The nursing diagnosis Body Image Disturbance is most likely to be

written for which of the following persons?
A. A patient with above the knee amputation
B. A patient with second degree burns
C. A quadriplegic patient
D. A person entering the health care system after moving from
wellness to illness

13. A nursing assistant reports that a patient is “blue.” What area is

best for assessing central cyanosis?
A. Oral mucosa
B. Nails
C. Ear lobes
D. Lips

14. All of the following chart entries are correct EXCEPT:

A. Complained of chest pain
B. Chest pain relieved after administration of NTG sublingually
C. Able to ambulate to the bathroom without assistance
D. Vital signs 120/84 82, 18

15. The following are appropriate nursing actions for the elderly with
hearing impairment EXCEPT:
A. Speak clearly, in well-enunciated words
B. Use normal tone of voice
C. Repeat instructions as needed
D. Increase loudness of voice when speaking

16. This is the paranasal sinus found between the eyes and the nose
that extends backward into the skull
A. Ethmoid
B. Sphenoid
C. Maxillary
D. Frontal

17. Gina wants to change her surname to something shorter, the court
denied her request which depresses her and find herself binge eating.
She accidentally aspirates a large piece of nut, and it passes the carina.
Probability wise, where will the nut go?
A. For clearance mechanism such as coughing
B. Transport gases to the lower airways
C. Warming, Filtration and Humidification of inspired air
D. Protect the lower airway from foreign mater

18. Casssandra, A 22 year old grade Agnostic, Asked you, how many
spikes of bones are there in my ribs? Your best response is which of the
following?
 A. We have 13 pairs of ribs Cassandra
B. We have 12 pairs of ribs Cassandra
C. Humans have 16 pairs of ribs, and that was noted by Vesalius in 1543
D. Humans have 8 pairs of ribs. 4 of which are floating

19. Cassandra asked you: How many air is there in the oxygen and
how many does human requires? Which of the following is the best
response:
A. God is good, Man requires 21% of oxygen and we have 21% available in
our air
B. Man requires 16% of oxygen and we have 35% available in our air
C. Man requires 10% of oxygen and we have 50% available in our air
D. Human requires 21% of oxygen and we have 21% available in our
air

20. All but one of the following is a purpose of steam inhalation

A. Mucolytic
B. Warm and humidify air
C. Administer medications
D. Promote bronchoconstriction

21. Which method of oxygenation least likely produces anxiety and

apprehension?
A. Nasal Cannula
B. Simple Face mask
C. Non-Rebreather mask
D. Partial Rebreather mask

22. Which of the following oxygen delivery method can deliver 100%
Oxygen at 15 LPM?
A. Nasal Cannula
B. Simple Face mask
C. Non Rebreather mask
D. Partial Rebreather mask

23. Roberto San Andres, A new nurse in the hospital is about to

administer oxygen on patient with Respiratory distress. As his senior
nurse, you should intervene if Roberto will:
A. Uses venture mask in oxygen administration
B. Put a non rebreather mask in the patient before opening the
oxygen source
C. Use a partial rebreather mask to deliver oxygen
D. Check for the doctor’s order for Oxygen administration

24. When assessing skin, the appearance of dusky blue fingers, lips, or
mucous membranes is called:
A. Jaundice
B. Cyanosis
C. Xanthoma
D. Rubor

25. Red-purple pinpoint skin discolorations less than 0.5 cm in

diameter usually seen in patients with Dengue Fever are called:
A. Ecchymosis
B. Hemangiomas
C. petechiae
D. nevus flammeus

26. Which of the following is the first sign of dehydration?

A. Tachycardia
B. Restlessness
C. Thirst
D. Poor skin turgor

27. Which of the following statement by a client with prolonged

vomiting indicates the initial onset of hypokalemia?
A. My arm feels so weak
B. I felt my heart beat just right now
C. My face muscle is twitching
D. Nurse, help! My legs are cramping

28. A nurse is assessing a client who is experiencing shortness of

breath. The client exhibits nasal flaring, use of accessory muscles, a
respiratory rate of 36 breaths per minute, and an oxygen saturation of
89% on 2 Liters of oxygen via nasal cannula. After listening to the
client's breath sounds, which of these interventions is appropriate based
on the assessment data?
A. Get the client back to bed
B. Notify the client's Physician
C. Ask the respiratory therapist to give a breathing treatment
D. Check the position of the nasal cannula

29. A client states " I never feel as though I'm getting enough air” The
client has a 20 year history of COPD  and is hospitalized with
pneumonia. His respiratory rate is 40 breaths per minute and shallow.
Bilateral course crackles in the upper lung lobes are auscultated by the
nurse. The client has a dry cough and is restless. Which of these nursing
diagnoses would the nurse choose to plan care for the client?
A. Impaired gas exchange
B. Insufficient airway clearance
C. Ineffective breathing pattern
D. Risk for aspiration
30. A client presents to the emergency room with fever, malaise and a
productive cough. During the physical examination, the nurse palpates
the chest from one side to other while the client says "99". This
technique will assist in detecting which of these physical findings?
A. Ecophony
B. Bronchophony
C. Pectoriloquy
D. Fremitus

31. When obtaining a health history, what would be the appropriate

distance between you and the patient?
A. 0–18 inches
B. 1–2 feet
C. 3–4 feet
D. 5–12 feet

32. When assessing the skin, which part of the hand is best for
detecting temperature changes?
A. Palmar aspect
B. Ulnar aspect
C. Dorsal aspect
D. Finger tips

33. Which part of your hand is best for detecting vibratory

sensations?
A. Heel of your hand
B. Dorsal surface of your hand
C. Ulnar surface of your hand
D. Palmar surface of your hand
34. Which part of your hand is the most discriminatory, able to detect
fine sensations?
A. Dorsal surface
B. Finger pads
C. Ulnar surface
D. Palmar surface

35. Which of the following are appropriate nursing actions when

rendering hair shampoo to a patient?
A. plug the ears with cotton balls
B. place Kelly pad under the head d. all of the above
C. use warm water
D. all of the above

36. Which factor in a patient's history is most likely related to the

development of Pediculus humanus capitis?
A. Lower socioeconomic status
B. Sharing of hairbrushes and hats
C Multiple sexual partners
D Contact with infested pets

37. A nurse assesses an adult patient who has all of these

manifestations. Which one should the nurse associate with scabies
infestation?
A Reddened scalp with hair loss
B Skin ulcerations around the ankles
C Irritation of the skin at the wrists and elbows
D Visible nits (ie, eggs) on hair shafts
38. A nurse should provide which instruction about the application of
the medication permethrin 5% [Elimite] to a patient who has scabies?
A "Apply the medication to the entire body surface in one
 application."
B "Rub the medication into your palms and apply it to the area of
infestation."
C "Discard any infested bedding and clothing."
D "Do not bathe for 48 hours after applying the medication topically."
39. A parent of a child with head lice asks the nurse when the child
may return to school after treatment with permethrin 1% [Nix]. Which
response should the nurse make?
A "When the hair has been cut off 2 inches so that the ova can't hatch."
B "Two treatments usually are needed within 48 hours, so after that."
C "After the one-time application and the nits have been removed
with a comb."
D "When family members who have had close contact have been
treated."
40. Infestation of the scalp with lice is:
A. pediculosis humanis
B. pediculosis capitis
C. pediculosis pubis
D. pediculosis corporis

41. During a bath, the nurse observes that a client has a dry skin. The
nurse best action is to:
A. bath the client frequently
B. use an emollient on dry skin
C. massage skin with alcohol
D. discourage fluid intake

42. Which of the following is NOT a purpose of a cleansing bath and

skin care?
A. To reduce local inflammation
B. To promote comfort
C. To provide exercise
D. To stimulate circulation
43. Which of the following is the correct temperature of the water for
tepid sponge bath?
A. 38⁰C (warm water)
B. 37⁰C (tap water)
C. 35⁰C (Iced water)
D. 37.5⁰C (lukewarm water)

44. Which of the following positions of the client and the hospital bed
is MOST appropriate in doing a bed bath for him?
A. Move the client away from you and adjust the bed in high position
B. Move the client towards you and adjust the bed in low position
C. Move the client towards you and adjust the bed in high position
D. Move the client away from you and adjust the bed in low position

45. A patient is now in the recovery room after having vaginal surgery.
Due to the positioning of the procedure, you would want to assess for
what while the patient is in recovery?
A. Bowel Sounds
B. Dysrhythmia
C. Homan’s sign
D. Hemoglobin level

46. After surgery your patient is semi-comatose with vital signs

within normal limits. As the nurse, what position would be best for this
patient?
A. Semi-Fowlers
B. Prone
C. Low-Fowlers
D. Side positioning preferably on the left side
47. After surgery your patient starts to shiver uncontrollably. What
nursing intervention would you do FIRST?
A. Apply warm blankets & continue oxygen as prescribed
B. Take the patient's rectal temperature
C. Page the doctor for further orders
D. Adjust the thermostat in the room

48. The nurse is monitoring the patient who is 24 hours post-opt from
surgery. Which finding requires intervention?
A. BP 100/80
B. 24-hour urine output of 300 Ml
C. Pain rating of 4 on 1-10 scale
D. Temperature of 99.3' F

49. A patient is 6 days post-opt from abdominal surgery. The patient

is to be discharged later today. The patient uses the call light and asks
you to come to his room and look at his surgical site. On arrival, you see
that approximately 2 inches of internal organs are protruding through
the incision. What intervention would you NOT do?
A. Put the patient in prone position with knees extended to put
pressure on the site
B. Cover the wound with sterile normal saline dressing
C. Monitor for signs of shock
D. Notify the MD and administer as prescribed antiemetic to prevent
vomiting

50. A patient reports he hasn't had a bowel movement or passed gas

since surgery. On assessment, you note the abdomen is distended and no
bowel sounds are noted in the four quadrants. You notify the MD. What
non-invasive nursing interventions can you perform without a MD
order?
A. Insert a nasogastric attached to intermittent suction
B. Administer IV fluids
C. Encourage ambulation, maintain NPO status, and monitor intake &
output
D. Encourage at least 3000 ml of fluids per day

51. What is a potential postoperative concern regarding a patient who

has already resumed a solid diet?
A. Failure to pass stool within 12 hours of eating solid foods
B. Failure to pass stool within 48 hours of eating solid foods
C. Passage of excessive flatus
D. Patient reports a decreased appetite

52. A nurse is developing a care plan for a patient who is at risk for
developing pneumonia after surgery. Which of the following is not an
appropriate nursing intervention?
A. Encourage patient intake of 3000 ml/day of fluids if not contraindicated
B. Encourage patient to use the incentive spirometer device 10 times every
1-2 hours while awake
C. Encourage early ambulation and patient to eat meals in beside chair
D. Repositioning every 3-4 hours

53. When assessing your patient who is post-opt, you notice that the
patient's right calf vein feels hard, cord-like, and is tender to the touch.
The patient reports it is aching and painful. What would NOT be an
appropriate nursing intervention for this patient?
A. Allow the patient to dangle the legs to help increase circulation and
alleviate pain
B. Instruct the patient to not sit in one position for a long period of time
C. Elevate the extremity 30 degrees without allowing any pressure on
affected are
D. Administer anticoagulants as ordered by MD
54. A patient is recovering from surgery. The patient is very restless,
heart rate is 120 bpm and blood pressure is 70/53, skin is cool/clammy.
As the nurse you would?
A. Continue to monitor the patient
B. Notify the MD
C. Obtain an EKG
D. Check the patient's blood glucose

55. A patient is taking Aspirin 325 mg PO by mouth daily. The patient

is scheduled for surgery in a week. What education do you provide the
patient with before surgery?
A. Educate the patient to take the scheduled dose of Aspirin the day of
surgery to help prevent blood clots
B. To hold his morning dose of Aspirin because the nurse will give it to him
before surgery
C. None of the above are correct
D. The medication should be discontinued for 48 hours prior to the
scheduled surgery date

56. You are observing your patient use the incentive spirometry. What
demonstration by the patient lets you know the patient understands
how to use the device properly?
A. The patient inhales slowly on the device and maintains the flow
indicator between 600 to 900 level
B. The patient blows on the mouthpiece rapidly
C. The patient uses the incentive spirometry once a day
D. The patient rapidly inhales on the devices and exhales
57. As the nurse you are getting the patient ready for surgery. You are
completing the preoperative checklist. Which of the following is not part
of the preoperative checklist?

A. Assess for allergies

B. Conducting the Time Out
C. Informed consent is signed
D. Ensuring that the history and physical examination has been completed

58. You are completing the history on a patient who is scheduled to

have surgery. What health history increases the risk for surgery for the
patient?
A. Urinary Tract infections
B. History of Premature Ventricle Beats
C. Abuse of street drugs
D. Hyperthyroidism

59. As a nurse, which statement is incorrect regarding an informed

consent signed by a patient?
A. The nurse is responsible for obtaining the consent for surgery
B. Patients under 18 years of age may need a parent or legal guardian to
sign a consent form
C. The nurse can witness the client signing the consent form
D. It is the nurse's responsibility to ensure the patient has been educated
by the physician about the procedure before informed consent is
obtained

60. The nurse has just reassessed the condition of a postoperative

client who was admitted 1 hour ago to the surgical unit. The nurse plans
to monitor which parameter most carefully during the next hour?

A. Urine output of 20ml/hour

B. Temperature of 37.6 ‘C
C. Blood pressure of 114/70
D. Serous drainage on the surgical dressing