41.

A
FUNDAMENTALS MT2 NOV. 42. D
43. C
44. B
2023 45. A
NLE INTENSIVE 46. C
47. D
ANSWERS: 48. B
1. B 49. D
2. C 50. C
3. B 51. C
4. B 52. A
5. B 53. B
6. B 54. A
7. C 55. C
8. B 56. C
9. A 57. A
10. C 58. D
11. D 59. D
12. D 60. A
13. C 61. D
14. B 62. D
15. A 63. D
16. D 64. D
17. B 65. D
18. D 66. C
19. B 67. D
20. B 68. D
21. C 69. A
22. C 70. A
23. C 71. B
24. C 72. A
25. B 73. A
26. C 74. A
27. B 75. B
28. C 76. D
29. B 77. B
30. B 78. B
31. C 79. A
32. A 80. D
33. A 81. D
34. D 82. A
35. B 83. C
36. D 84. A
37. A 85. B
38. C 86. A
39. A 87. A
40. D 88. D
 89. D 4. A nurse is preparing to remove a nasogastric tube
90. B from a client. The nurse would instruct the client to
91. A do which of the following just before the nurse
92. B removes the tube?
93. A
94. A a. To perform a Valsalva’s maneuver.
95. A
b. To take and hold a deep breath
96. C
97. B c. To exhale.
98. A
99. B d. To inhale and exhale quickly
100. D
1.  Before the insertion of nasogastric tube, the Clear selection
physician should be notified of: 5. A client with severe inflammatory bowel disease
a. Patent nares is receiving total parenteral nutrition (TPN). When
administering TPN, the nurse must take care to
b. Absent bowel sounds maintain the prescribed flow rate because stopping
the TPN abruptly may cause:
c. Evident gag reflex
a. hypotension
d. Impaired swallowing
b. hypoglycemia
Clear selection
c. hyperglycemia
2. An appropriate technique for nasogastric tube
insertion is for the nurse to: d. air embolism
a. Position the client supine Clear selection
b. Ice the plastic tube 6. What position will the nurse recommend to the
patient during TPN insertion?
c. Advance the tube while the client swallows
a. High Fowler’s position
d. Measure the tube length from the nose to the
sternum b. Trendelenburg
Clear selection c. Semi-Fowler’s Position
3. An appropriate technique for the nurse to d. Left sims lateral
implement during nasogastric tube insertion is to:
Clear selection
a. Use sterile gloves
7. What position will the nurse recommend to the
b. Have the client mouth-breathe patient during TPN administration?
c. Advance the tube quickly when the client cough a. High Fowler’s position
d. Bend the client’s head backward after the tube is b. Trendelenberg
through the nasopharynx
c. Semi-Fowler’s Position
Clear selection
d. Left sims lateral
Clear selection
8. A client who requires a central vein access for
parenteral nutrition is to receive a solution with:
a. Fat emulsion
b. 5% dextrose
c. Amino acids
d. 10% dextrose
Clear selection
9. A client with severe inflammatory bowel disease
is receiving total parenteral nutrition (TPN). When
administering TPN, the nurse must take care to
maintain the prescribed flow rate because giving
TPN too rapidly may cause:
a. hyperglycemia
b. air embolism
c. constipation
d. dumping syndrome
Clear selection
SITUATION: Nutrition is an input to and foundation
for health and development. Interaction and
infection and malnutrition are well-documented.
Better nutrition means stronger immune systems,
less illness and better health.
10. A client with congestive heart failure is newly
admitted to home health care. The nurse discovers
that the client has not been following the
prescribed diet. What would be the most
appropriate nursing action?
a. Discharge the client from home health care
related to noncompliance
b. Notify the health care provider of the client's
failure to follow prescribed diet
c. Discuss diet with the client to learn the reasons
for not following the diet
d. Make a referral to Meals-on-Wheels
Clear selection
11. Ms. F.X. has been admitted with right upper
quadrant pain and has been placed on a low fat
diet. Which of the following trays would be
acceptable for her?
A. Liver, fried potatoes and avocado.
B. Ham, mashed potatoes, cream peas.
C. Whole milk, rice and pastry.
D. Skim milk, lean fish, tapioca pudding.
Clear selection
12.The preoperative nurse is assessing a client for
risk for latex allergies if they are allergic to all the
following except:
A. Avocados
B. orange
C. kiwi
D. Banana
Clear selection
13. A client complains that low- salt food is very
tasteless. The nurse best response would be
a. “I know how it’s difficult for you”
b. “You miss your ham and cabbage?”
c. “Salt can be harmful to your health”
d. “Ask the doctor if you can splurge occasionally”
Clear selection
14.Clients with hepatitis have a regular diet
ordered, unless they become increasingly
symptomatic. The diet then will be modified to
decrease the amount of 
a. Carbohydrates
b. Fats
c. Fluids
d. Protein
Clear selection
15.A client recovering from an infected abdominal
wound. Which of the following foods should the
nurse encourage the client to eat to support wound
healing and recovery from infection?
a. Chicken and orange slices
b. Cheese omelet and bacon
c. Cheeseburger and French fries
d. Gelatin salad and tea
Clear selection
16.The nurse teaches the client with iron deficiency
anemia that food sources with high iron content
include
a. Cheese
b. Eggs
c. Squash
d. Beef
Clear selection
17.A 45-year-old client has a permanent colostomy.
Which of the following foods should be avoided?
a. Peanut butter and jelly sandwich and milk
b. Corn beef and cabbage and boiled potatoes
c. Oatmeal, whole-wheat toast, and milk
d. Tuna on whole wheat bread and iced tea
Clear selection
18. The nurse is caring for a client who has been
admitted to the hospital with a diagnosis of
malnutrition. The nurse most effectively monitors
the client’s status by which measure?
a. Intake measurement
b. Calorie counts
c. Skinfold measurements
d. Daily weights
Clear selection
19.The most concentrated source of energy in the
body is:
a. Protein
b. Carbohydrates
c. Fat
d. Macro minerals
Clear selection
20.A nurse is preparing to feed the client with mild
dysphagia. The nurse would do which of the
following to assist the client with swallowing?
a. Place the food on the tip of the client’s tongue
b. Provide foods that have a soft consistency
c. Use water to help the client swallow food in the
mouth
Place the equivalent of 30 ml of food on the fork
Clear selection
21. A postoperative client is on a clear liquid diet,
what of the following are allowed on a clear liquid
diet?
a. Ice cream, butter, yoghurt, vegetable juices
b. Mashed potatoes, fish, bananas, vegetable juices
c. Gelatin, hard candy, tea, popsicles
d. Milk, gelatin, canned fruits, bread
Clear selection
22. Oral ferrous sulfate is prescribed for the client to
take at home. The nurse would teach the client to
take orange juice with the iron preparation,
because orange juice:
a. Decreased the toxicity of the medication
b. Helps prevent mouth ulcers
c. Masks the bitter taste of the enteric-coated tablet
d. Acts as a reducing agent to increase medication
absorption
Clear selection
d. Detect oxygen saturation of arterial blood before
a symptoms of hypoxemia develops
Clear selection
26.While the client has pulse oximeter on his
fingertip, you notice that the sunlight is shinning on
the area where the oximeter is : Your action will be
to:

23. The nurse’s teaching plan would also include
telling the client to expect which of the following
side effects of oral ferrous sulfate?
a. Bright orange urine
b. Excessive perspiration
c. Dark red or black stool
A. Set and turn on the alarm of the oximeter
B. Do nothing since there is no identified problem
C. Cover the fingertip sensor with a towel or
bedsheet
D. Change the location of the sensor every four
hours

d. Yellow or light-green sputum Clear selection

Clear selection 27.A nurse informs a client  that the alarm on the
pulse oximeter will not sound when:
24. Which of the following menu is appropriate for
one with low sodium diet? a. The client moves the probe

a. instant noodles, fresh fruits and ice tea b. The probe falls off

b. ham and cheese sandwich, fresh fruits and c. The SpO2 falls below the set limit
vegetables
d. The display reaches full strength during each
c. white chicken sandwich, vegetables salad and tea cardiac cycle

d. canned soup, potato salad, and diet soda Clear selection

Clear selection 28.For a client with CAL, a nurse anticipates the use
of oxygen equipment?
SITUATION: I n today’s critical care environment the
assessment of oxygenation is crucial, especially for a. Face tent
patients’ delivery, it is often difficult to get a true
b. Face mask
assessment of the patient’s oxygenation status.
c. Nasal cannula
25.You attached a pulse oximeter to the client. You
know that the purpose is to: d. Nonbreathing mask

a. Determine if the client’s hemoglobin is low and if Clear selection

he needs blood transfusion
29. Assessment of the proper functioning of an
b. Check level of client’s tissue perfusion oxygen device includes:

c. Measure the efficacy of the client’s anti- a. No mist in the face tent
hypertensive medications
b. The reservoir of the rebreathing mask collapsing
on inhalation
c. A flow rate between 1 and 6L/min for the nasal
cannula
d. The nasal cannula positioned below the nares
Clear selection
30.An unexpected outcome of oxygen use is:
a. Decrease anxiety
b. An increased pulse rate
c. A decreased respiratory rate
d. An increased level of consciousness
Clear selection
31.The proper technique to use for administering
oxygen to a client with an artificial airway is:
a. Applying sterile gloves
b. Leaving fluid in the tubing
c. Attaching the T tube to the humidified oxygen
source
d. Monitoring the response to the oxygen with
hourly arterial blood gas levels
Clear selection
32. Nurse Nikka is teaching a client on how to
properly use an incentive spirometry to a client.
Teaching is effective if which of the following
sequence is observed;
a. The client holds the spirometry in upright
position, exhales normally, seal the lips tightly
around the mouthpiece, takes a slow deep breath
and hold breath for 2 seconds to keep the balls
elevated.
b. Exhales normally, hold the spirometer upright,
seals the mouthpiece, takes a fast shallow breath
and holds breath for 5 seconds to keep the balls
elevated.
c. Holding the spirometer above the head, seal the
mouthpiece, and exhaling slowly for 3 seconds
d. Holding the spirometer above the head, seal the
mouthpiece around the lips, and holding breath for
a while.
Clear selection
33 The following nursing interventions are
appropriate for a nursing diagnosis of Ineffective
Airway Clearance related to obesity EXCEPT?
a. Diversional Activity
b. Start weight reduction
c. Place patient in high Fowler’s position
d. Have client cough & deep breathe every 2 hours
while wake
Clear selection
34. The primary reason in teaching pursed-lip
breathing to persons with emphysema is to help:
A. Promote oxygen intake
B. Strengthen the diaphragm
C. Strengthen the intercostals muscles
D. Promote carbon dioxide elimination
Clear selection
35.Complications associated with a tracheostomy
tube include:
a. Decreased cardiac output
b. Damage to the laryngeal nerve
c. Pneumothorax
d. Respiratory distress syndrome
Clear selection
36. A priority goal for the hospitalized client with a
new tracheostomy would be to:
a. Decrease secretions
b. Instruct the client in caring for the tracheostomy d. A guide for easy removal of the tracheostomy
tube
c. Relieve anxiety related to the device
Clear selection
d. Maintain patent airway
40. Which of the following statements contains one
Clear selection
of the basic rules to follow when caring for a client
37. A client has a tracheostomy tube. The nurse with a chest tube and water-seal drainage system?
knows that the obturator is kept at the client’s
a. Ensure that the air vent on the water-seal
bedside because:
drainage system is capped when the suction is off
a. The obturator is kept at the client’s bedside in
b. Strip the chest and drainage tubes at least every
case the tube becomes dislodged and needs to be
4 hours if excessive bleeding occurs
reinserted.
c. Ensure that the collection and suction bottles are
b. The obturator is a guide in inserting the tube.
at the client’s chest level at all times
c. The obturator, after insertion, will be kept by the
d. Ensure that the collection and suction bottles are
client.
below the client’s chest level at all times
d. The obturator will be used to make an opening
Clear selection
for the tube
41 In an underwater-seal drainage system,
Clear selection
cessation of fluid fluctuation in the chest and
38. The nurse is cleaning the incision site and tube drainage tubes generally means that the:
flange of a client with tracheostomy. A sterile
a. Lung has fully expanded
applicator soaked in what solution is used in
removing crusty secretions? b. Lung has collapsed

a. Isopropyl alcohol c. Chest tube is in the pleural space

b. Hydrogen peroxide (Full strength) d. Mediastinal space has decreased

c. Hydrogen peroxide ( half-strength solution mixed Clear selection

with sterile normal saline)
42 The chest tube drainage of  aileen’s has
d. Ammonia continuous bubbling in the water seal drainage.
After an hour you noticed that the bubbling stops.
Clear selection
Which of the following condition is the possible
39. Tracheostomy tubes used among adults often cause of the malfunctioning sealed drainage?
have cuffs. This inflatable cuff functions by:
A. A suction being too high
a. Producing an airtight seal to prevent aspiration of
B. An air leak
oropharyngeal secretions and air leakage
C. A tube being too small
b. Anchoring the tube in place
D. A tension pneumothorax
c. Distributing a low even pressure over the trachea
Clear selection
43. While you were making endorsement, you
found out the chest tube of a client was
disconnected. What would be your appropriate
action?
A. Assit the client back to his bed and place him on
the affected side
B. Cover the end of the chest tube with sterile gauze
C. Reconnect the tube to the chest tube system
D. Put the end of the chest tube into a cup of sterile
normal saline
Clear selection
44. Dr. Black Daclis asked you to assist him with the
removal of jeld’s chest tube. You would instruct the
client to:
A. A continuously breathe normally during the
normal of the chest tube
B. Take a deep breath, exhale, and bear down
C. Exhale upon the actual removal of the tube
D. Hold breath until the chest tube is pulled out
Clear selection
45 Chest tube diameter is measured or expressed
in:
A. French
B. Gauge
C. Millilitres
D. Inches
Clear selection
46. When transporting clients with chest tube, the
system should be
A. disconnected
B. closed
C. placed lower than the patient’s chest
D. placed between the legs of the client to prevent
breakage.
Clear selection
47. Which of the following measures should the
nurse perform in relation to suctioning a
tracheostomy tube?
a. Apply suction while inserting the suction catheter
into the tube
b. Change the tracheostomy tube after suctioning
the client
c. Select a suction catheter that approximates the
diameter of the tracheostomy tube
d. Hyperoxygenate before suctioning the client
Clear selection
48. After suctioning a client’s tracheostomy tube,
the nurse waits a few minutes before suctioning
again. The nurse would use intermittent suction
primarily to help prevent:
a. Stimulating the client’s cough reflex
b. Depriving the client of sufficient oxygen supply
c. Dislocating the tracheostomy rube
d. Obstructing the suctioning catheter with
secretions
Clear selection
49. Which method is the best for the nurse to
evaluate the effectiveness of tracheal suctioning?
a. Note subjective data such as, “My breathing is
much improved now.”
b. Note objective findings such as decreased
respiratory rate and pulse.
c. Consult with respiratory therapist to determine
effectiveness.
d. Auscultate the chest for change or clearing in
adventitious breath sounds.
Clear selection d. Allow 1 to 2 minutes between each suction

50. Organize the following steps of suctioning in Clear selection

chronological order:
53. The correct pressure of the wall suction unit
1. Put on sterile glove. when suctioning a child patient is?

2. Lubricate catheter with normal saline a. 95 – 100mg Hg

3. Apply suction for 5-10sec. b. 50 – 95 mm Hg

4. Explain procedure to client. c. 100 – 120mm Hg

5. Wash hands thoroughly. d. 10 – 15mm Hg

a. 54132 Clear selection

b. 45213 54. A nurse suctioning a client through a

tracheotomy tube. The nurse plans to apply suction
c. 54123
during the withdrawal of the catheter for a period
d. 45132 of time no greater than? 

Clear selection a. 10 seconds

51. A nurse is performing oropharyngeal suctioning b. 15 seconds

on the unconscious client. Which of the following
c. 20 seconds
actions is safe?
d. 30 seconds
a. Insert the catheter approximately 20 cm while
applying suction. Clear selection

b. Allow 20 to 30 second intervals between each
suction, and limit suctioning to a total of 15
minutes.
c. Gently rotate the catheter while applying suction.
d. Apply suction for 5 minutes while inserting and
continue for another 5 seconds before withdrawing.
Clear selection
52. Applying suction in the nasopharynx for too long
may cause secretions to increase or decrease,
therefore the nurse should:
a. Allow 20 to 30 second intervals between each
suction, limit suctioning to 5 minutes in total
55. Which of the following should the nurse include
when suctioning a client’s tracheostomy?
a. Instill a sterile saline down the trachea to
stimulate a cough then suction with continuous
suctioning
b. Suction the client’s mouth before entering the
trachea
c. Insert the catheter until a cough reflex is obtained
or until resistance is felt
d. Adjust the wall suction to 150 mmHg for the
procedure
Clear selection

b. Allow 2 to 3 minutes between suction when 56. Tonometry is performed on the client with a
possible suspected diagnosis of glaucoma. The nurse
analyzes the test results as documented in the
c. Allow 5 minutes between each suction
client's chart and understands that normal a. Pull the pinna of the ear backward and downward
intraocular pressure is
b. Pull the pinna of the ear sidewards and upwards
a.2 to 7 mmHg
c. Pull the pinna of the ear downwards and
b.22 to 30 mmHg backwards

c. 10 to 21 mmHg d. Pull the pinna of the ear upwards and backwards

d. 31 to 35 mmHg Clear selection

Clear selection 60. Preoperatively before cataract surgery, the

nurse is to instill several types of eye drops into a
57. The clinic nurse is preparing to test the visual
client’s right eye. The accepted abbreviation for the
acuity of a client using a Snellen's chart. Which of
right eye is:
the following identifies the accurate procedure for
this visual acuity test? a. OD

A. Both eyes are assessed together, followed by the b. OS

assessment of the right and then the left eye
c. OU
B. The right eye is tested followed by the left eye,
d. RE
and then both eyes are tested
Clear selection
C. The client is asked to stand at a distance of 40
feet from the chart and is asked to read the largest 61. The nurse inspects a patient's pupil size and
line on the chart determines a result of OD = 2 mm and OS = 3mm.
Unequal pupils are known as:
D. The client is asked to stand at a distance of 40
feet from the chart and to read the line that can be A. anisocoria
read 200 feet away by an individual with
unimpaired vision B. ataxia

Clear selection C. cataract

58. The nurse is preparing to perform a Weber test D. diplopia

on a client. The nurse obtains which item needed to Clear selection
perform this test?
62. Mrs. Posadas has an eye infection with a
a. A tongue blade moderate amount of discharge. To clean her eyes,
b. A tuning fork the nurse should:

c. A stethoscope a. Use hydrogen peroxide

d. A reflex hammer b. Wipe from the outer canthus to the inner canthus

Clear selection c. Position on the same side as the eye to be

cleansed
59. The nurse is about to obtain the temperature of
a seven-year-old child through the tympanic route. d. Use only one cotton ball per eye
The nurse should: Clear selection
63. A client is diagnosed with a conduction hearing
loss. What might the nurse indicate to the client
could be a reason for this loss?
a. There has been damage to the inner ear
b. Something has happened to the hearing center
nof the brain
c. An ear infection has torn the tympanic membrane
d. The auditory nerve is not functioning
Clear selection
64. The client's vision is tested with a Snellen's
chart. The results of the tests are documented as
20/60. The nurse interprets this as
a.The client can read at a distance of 60 feet what a
client with normal vision can read at 20 feet.
b.The client is legally blind.
c.The client's vision is normal.
d.The client can read only at a distance of 20 feet
what a client with normal vision can read at 60 feet.
Clear selection
65. The clinic nurse notes that following several eye
examinations, the physician has documented a
diagnosis of legal blindness in the client's chart. The
nurse reviews the results of the Snellen's chart test
expecting to note which finding?
a.20/20 vision
b.20/60 vision
c. 20/40 vision
d.20/200 vision
Clear selection
66. A client with a peripheral IV line is about to
receive a blood transfusion of packed red blood
cells due to anemia. The nurse administering the
transfusion will:
A. infuse the blood slowly over a period of 5 to 6
hours
B. initially infuse at a rapid rate and check pulse
frequently
C. obtain the client’s vital signs prior to the
transfusion
D. prime the tubing with a D5W solution prior to
infusing blood
Clear selection
67. A client is to receive 1 unit of packed red blood
cells because he has a hemoglobin level of 8 g/dL
and a diagnosis of gastrointestinal bleeding. Before
initiating the transfusion, the nurse needs to check:
A. if the blood has been warmed especially for CVP
lines
B. that the blood had been typed and cross
matched
C. that the recipient’s blood numbers match the
donor’s blood numbers
D. all of the above
Clear selection
68. As AP’s nurse, what will you do AFTER the
transfusion have started?
A. Add the total amount of blood to be transfused
to the intake and output
B. Discontinue the primary IV of Dextrose 5% Water
C. Check the vital signs every 15 minutes
D. Stay with AP for 15 minutes to note for any
possible BT reactions
Clear selection
69. What should you do FIRST before you
administer blood transfusion?
A. Verify client identity and blood product, serial
number, blood type, cross matching results,
expiration date
B. Verify client identity and blood product serial
number, blood type, cross matching results,
expiration date with another nurse
C. Check IV site and use appropriate BT set and
needle
D. Verify physician’s order
Clear selection
70. Lino, a nurse taking care of an adult client with
constipation, in performing a high cleansing  enema,
Lino must keep in mind that the maximum height is:
a. 18 inches above the bed
b. 16 inches above the rectum
c. 18 inches above the rectum
d. 16 inches above the bed
Clear selection
71. You are assigned to Mrs. Dulay, a client with an
order for cleansing enema. While doing the
procedure, the client groans and complains of
abdominal cramping. Your MOST appropriate initial
nursing action would be to:
A. Reduce the flow of the fluid by clamping the
enema tubing
B. Lower the height of the enema container
C. Instruct the client to relax, inhale and exhale
slowly
D. Push the rectal tube further in by 2 inches.
Clear selection
72. The nurse doing the health teaching to a client
for testing feces for occult blood informs the client
about what can produce false positive results: What
should the nurse emphasize?
a. If you have eaten red meat or raw radishes and
melons, in the last couple of days, the test may be
positive and it may be inaccurate.
b. If you have taken more then 250 mg of vitamin C,
it may produce a reading that is too high but is
inaccurate.
c. If you have recently eaten any colored
vegetables, it may color the stool and produce an
inaccurate test result.
d. If you have been drinking tea, the result might be
elevated.
Clear selection
73. The nurse finds a container with the client’s
urine specimen sitting on a counter in the
bathroom. The client states that the specimen has
been sitting in the bathroom at least 2 hours. What
would be the nurse’s most appropriate action?
a. Discard the urine and obtain a new specimen
b. Send the urine to the laboratory as quickly as
possible
c. Add fresh urine to the collected specimen and
send the specimen to the laboratory
d. Place the specimen in the refrigerator until it can
be transported to the laboratory
Clear selection
74.   After IVP a renal stone was confirmed, a left
nephrectomy was done. Her post operative care
includes daily urine   specimen to be sent to the
laboratory. Imelda has a foley catheter to a urinary
drainage system. How will you collect the urine
specimen?
a. Remove urine from drainage tube with sterile
needle and syringe and empty urine from the
syringe into the specimen container
b. Empty a sample urine from the collecting bag into
the specimen container
c. Disconnect the drainage tube from the indwelling d. cleanse the urethral meatus after obtaining the
catheter and allow urine to flow from catheter into specimen
the specimen container.
Clear selection
d. Disconnect the drainage the from the collecting
77.  The nurse is reviewing with a client how to
bag and allow the urine to flow from the catheter
collect a clean catch urine specimen. Which
into the specimen container.
sequence is appropriate teaching?
Clear selection
a. void a little, clean the meatus, then collect
75. The nurse is preparing to collect a sterile urine specimen
specimen from a client who has an indwelling Foley
b. clean the meatus, begin voiding, then catch urine
catheter. The nurse clamped the catheter and
stream
returns to the client to collect the specimen 30
minutes later. The correct order of priority that the c. clean the meatus, then urinate into container
nurse should take to collect the specimen is:
d. void continuously and catch some of the urine
1. Explain procedure to the client
Clear selection
2. Unclamp the catheter
78. A nurse has an order to obtain 24-hour urine
3. Draw urine into the syringe collection on a client with renal disorder. The nurse
avoids which of the following to ensure proper
4. Insert needle into the port
collection of the 24-hour urine specimen?
5. Place urine into the specimen container
a. have the client void at the start time, and place
6. Cleanse the needle entry port he specimen in the container

7. Label the specimen according to agency protocol b. discard the first voiding, and save all subsequent
voiding during 24-hour time period
a. 1,2,6,4,3,5,7
c. place the container on ice or refrigerator
b. 1,6,4,3,5,2,7
d. have the client void at the end time, and place
c. 1,4,6,3,5,2,7
the specimen in a container
d. 1,2,4,6,3,5,7
Clear selection
Clear selection
79. A nurse is to collect a sputum specimen for
76. A midstream urine specimen is ordered, and the culture and sensitivity from a client. Which action
nurse teaches the client how to collect the should the nurse take first?
specimen correctly. Which of the following should
a. Assist with oral hygiene
the nurse include in the instructions?
b. Ask client to cough sputum into container
a. void directly into the sterile specimen container
c. Have the client take several deep breaths
b. save the first voided urine
d. Provide an appropriate specimen container
c. stop collecting urine after the bladder is empty
Clear selection
80. The physician orders a urine culture and
sensitivity for a 36-year old patient with an
indwelling Foley catheter. Which of the following
action by the nurse is best?
a. The nurse clamps the catheter tubing below the
level of the port for 1 hour.
b. The nurse removes 20ml from the catheter bag
and places it in a sterile container.
c. The nurse separates the catheter from the tubing
and allows 30ml of urine to drain into a sterile cup.
d. The nurse clamps the catheter just below the
insertion site for 20 minutes
b. Document size of catheter and client’s tolerance
of procedure.
c. Evaluate the client for normal voiding.
d. Documentation of client’s teaching
Clear selection
84. Which priority is first when inserting an
indwelling urinary catheter?
a. Aseptic technique
b. Instilling water into the balloon.
c. Taping the catheter to the leg

Clear selection d. Inserting the catheter to the point where the

urine
81. The nurse collects a urine specimen for routine
urinalysis from a client. She is aware that: Clear selection

A. A sterile specimen is required 85. During an assessment, the nurse expects that
the average daily urinary output for the adult client
B. Standing at room temperature for a prolonged will be:
period may alter the urine chemistry
a. 500 to 1000ml
C. The external meatus should be cleaned with
antiseptic soap and water before voiding. b. 700 to 1500ml

D. A clean-catch, midstream specimen is required c. 1200 to 1500ml

Clear selection d. 2000 to 3000ml

82. Which assessment finding would be most Clear selection

indicative of obstructed drainage tubing? 86. Nurse Jane evaluates a client with diagnosis of
a. Bladder distention dehydration to have which of the following specific
gravity reading?
b. Concentrated urine
a. 1.000
c. Increased urge to void
b. 1.017
d. Complaint of burning
c. 1.023
Clear selection
d. 1.035
83. What is the priority of care after the urinary
catheter is removed? Clear selection

a. Encourage the client to eliminate fluid intake. 87 Mrs. Ong, 78, reports accidental loss of urine
before she is able to reach the toilet. She is aware
of the urge to void but states, “Because of my
stroke I sometimes can’t get there soon enough.” lung sounds over the periphery of the right and left
Nurse John suspects: lungs fields.

a. Functional incontinence c. Potential for altered nutrition: less than body

requirements as evidenced by 15 lb- weight loss in 3
b. Stress incontinence
weeks.
c. Reflex incontinence
d. Potential for self – esteem disturbance related to
d. Urge incontinence change in body image

Clear selection Clear selection

88. Nurse Angie monitors an increase incidence of 91.  Health is considered as the fundamental human
stress incontinence in a client during which of the right during this period?
following activities?
A. Contemporary
a. Eating
B. Apprentice
b. Sleeping
C. Intuitive
c. Walking
D. Educated
d. Laughing
Clear selection
Clear selection
92.  He promulgated laws of control on the spread
89. A nurse discusses changes due to aging with a of communicable diseases and the ritual of
group at the senior citizen center. The nurse knows circumcision of the male child?
that which of the following changes in the pattern
A. Loreto Tupas
of urinary elimination normally occur with aging?
B. Moses
a. Decrease frequency
C. Pastor Fliedner
b. Incontinence
D. Hippocrates
c. Residual urine decreases
93.  Which of the following is not true about
d. Formation of bladder stone
Florence Nightingale?
Clear selection
A. Contented with the social custom imposed upon
90.  Which of the following statements is a correctly her as the Victorian Lady
written ACTUAL nursing diagnosis?
B. Recognized as the Mother of Modern Nursing
a. Impaired physical mobility as evidenced by
C. She nursed the wounded soldiers during the
decreased range of motion in left shoulder from 180
Crimean war
to 190 degrees of flexion and extension related to
left shoulder pain. D. Her education was rounded out by a continental
tour
b. Ineffective airway clearance related to thickened
bronchial secretions as evidenced by adventitious 94.  She organized the Filipino Red Cross through
the inspiration of Apolinario Mabini?
A. Dona Hilaria de Aguinaldo c. Pinch skin at the injection site and use airlock
technique
B. Josephine Bracken
d. Inject needle at a 15 degree angle over the
C. Cesaria Tan
stretched skin of the client
D. Dona Maria Agoncillo de Aguinaldo
99.  Anton asks to be assisted to move up on bed.
95.  The first hospital established in the Philippines Which of the following should Nurse Diana do first?
that initially catered to patients with leprosy and
a. Move the patient to the edge of the bed near the
mental disorder was
nurse
A. San Lazaro Hospital
b. Adjust the bed to a flat position
B. Mary Johnston Hospital
c. Lock the wheels of the bed
C. Iloilo Mission Hospital
d. Raise the bed rails opposite the nurse
D. Philippine General Hospital
u100.  Which of the following statements is NOT
96.  She is the first Filipino to receive a degree of true about the Z-track technique of intramuscular
Nursing abroad injection?

A. Melchora Aquino a. This technique is used when medications for

intramuscular injection are irritating to tissue
B. Conchita Ruiz
b. This technique leaves a zigzag path that seals
C. Cesarea Tan needle track
D. Capitan Salome c. The medication is injected slowly in this
97.  When preparing the epinephrine injection from technique to allow medication to disperse evenly in
an ampule, the nurse initially: muscle tissue

a. Taps the ampule at the top to allow fluid to flow d. This technique seals the medication in
to the base of the ampule subcutaneous tissue

b. Checks expiration date of the medication ampule Submit

c. Breaks the neck of the ampule with a gauze

wrapped around it

d. Removes needle cap of syringe and pulls plunger

to expel air

98.  Mrs. Manzano is an obese client. When

administering a subcutaneous injection to an obese
client, it is best for the nurse to:

a. Spread skin or pinch at the injection site and

inject needle at a 45-90 degree angle

b. Pull skin of patient down to administer the drug

in a Z track