Preparatory and Professional Review Enhancement

Corporation 8. Because the immobile client slides down in bed, the

Fundamentals of Nursing nurse is correct to assess which type of injury?
Direction: Choose the best answer. a. An injury resulting from continuous pressure
b. An injury resulting from shearing force
Situation 1 c. A superficial skin injury from friction
A 22-year-old nursing student came in at emergency room d. A secondary injury from agitation in bed
because she sustained a chemical injury on both eyes while
forming a laboratory works in their chemistry class. 9. The client receives TPN temporarily. While in TPN he
complains of nausea, excessive thirst, and increased
1. When irrigating the client’s eyes, which technique is frequency in voiding. The nurse next assesses which
the best way to direct the flow of irrigating solution? of the following client’s data?
a. Directly onto the corneal surface a. Serum BUN and creatinine
b. Away from the inner canthus b. Capillary blood glucose
c. Within the anterior chamber c. Last serum potassium
d. Toward the nasolacrimal duct d. Rectal temperature

The client initially had total loss of vision. Eye patches were Situation 3
done on both eyes after irrigation. The nurse observes a nursing A 65 year old male with BPH was admitted because of
assistant ambulating a blind client. occasional altered mental status. Accidentally he was found out
to have UTI. Based in the history, he had passed out stones
2. Which instruction to the nursing assistant is best for before but he ignored it. He is also a type II DM patient.
maintaining the client’s safety and security?
a. Let the client take your arm while walking 10. The patient is scheduled for creatinine clearance.
b. Take the client’s arm Which of the following statement is correct with
c. Position the client in front regards to this procedure?
d. Have the client walk independently to achieve self- a. A dye will be injected in the venous system to note the
reliance kidney anatomically?
b. Collection of a 24-hour urine specimen is required
The client was discharged after 1 week. She was prescribed with c. Monitoring some signs of urinary obstruction after
some eye drops. The nurse is educating the client. procedure is necessary
d. Collect an early-morning clean catch midstream urine
3. The nurse will teach the client to instill the eye drops specimen
into which part of the client’s eye?
a. Into the cornea 11. A retention catheter is placed since patient had
b. At the inner canthus occasional difficulty in passing out his urine. Urine C
c. At the outer canthus and S was requested subsequently. The preferred
d. In the lower conjuctival sac method of obtaining urine specimen in patient with
indwelling catheter is to:
a. Use a bulb syringe to withdraw urine from catheter.
Situation 2 b. Use a sterile syringe and a needle to withdraw urine
In the ER department that a 45 year-old 55 kg-burn victim, has from catheter port.
deep partial and full-thickness burns on the right anterior lower c. Disconnect the tubing and drain the tube between the
extremity and on the right lower and upper quadrant of the catheter and drainage bag, using sterile technique
abdomen. d. Using sterile technique, drain 30 ml of urine from
catheter collection bag.
4. The nurse who documents the burn injury is accurate
in identifying the full-thickness burns as those that are: Situation 4
a. White and leathery The patient was discharged then in a good condition. After 4
b. Pink and blistered months she came back due to fall injury sustaining fracture of
c. Red and painful right fibula.
d. Blanches on pressure 12. A plaster cast is applied and she was given discharged
instructions. Which of the following statements if
5. How much IV fluids should possibly be infused to the made by the patient indicates a need for further
patient for the first 8 hours? education?
a. 1 liters a. “I am expecting a warm feeling as the cast dries”.
b. 2 liters b. “If the cast becomes wet, I can use a blow drier set on
c. 3 liters the cool setting to dry the cast”.
d. 4 liters c. “I just called up my mother to buy a handy scratching
device that I can use under the cast”
The physician orders the application of Mafenide Acetate d. “I should not use lotion or powder to relieve itching in
(Sulfamylon) to the burn wound as well as wet to dry dressing. the cast edge”.

6. The nurse who applies Sulfamylon understands that 13. She was taught how to use crutches temporarily in
which of the following is the main disadvantage of three-point gait. The patients understand the
this drug? instructions correctly if she states that?
a. Skin discoloration a. “I should straight my elbow holding the hand bar”.
b. Pain on application b. “My weight should be born by my axilla”.
c. Fluid volume deficit c. “When I will go down stairs, I will use my crutches
d. Contact dermatitis and leukopenia with my unaffected lower extremity”.
d. “I will use these crutches for a non-weight bearing
7. When the client asks why that kind of dressings are gaits”.
being applied, which explanation by the nurse is most
accurate? 14. While the nurse assisting her in ambulation. The
a. The dressing will prevent wound infections patient tells the nurse that her father is a diagnosed
b. The dressing removes dead cells and tissues AIDS victim. The patient noted raised dark purplish
c. The dressings absorb blood and drainage lesions on the trunk of her father’s body. She asks the
d. The dressing will protect the skin and injury nurse what test could identify and confirm these
lesions. The nurse has the best knowledge if he states
The patient became bedridden and frequently found at the that?
bottom of the bed with feet hanging on the footboard. The a. ELISA
nurses typically pull him up in bed and reposition him for b. Western Blot
comfort. c. Skin biopsy
d. Lung biopsy
Situation 5: Diagnostics and Treatments
15. In assessing the laboratory findings for a client, the
nurse should be aware that a decrease in the serum
level of which laboratory value might cause digitalis
toxicity?
a. Potassium
b. Sodium
c. Phosphorous
d. Calcium
16. Nurse Gina is preparing the client for an ultrasound of
the gallbladder. Which of the following statements would
be the most important to prepare the client for the test?
a. “You will have food and fluids restricted for 4 to 8 hours
prior to the test”.
b. “Stool in the bowel may cause reporting of inaccurate
findings”.
c. “You may drink and eat as much as you can”.
d. “You will not eat 24 hours prior to exam”
24. The nurse is assisting Mrs. Jane Mario to collect a
midstream urine specimen. The nurse uses the principles of
aseptic technique by:
a. Cleansing the meatus with upward strokes
b. Irrigate with sterile water
c. Making sure the fingers will not touch the inner surface
of the collection container
d. Collect urine for 24 hours
25. The nursing student is assigned to an adult who is
scheduled for bone marrow aspiration. The co-assigned
nurse asks the nursing student about the possible sites that
could be used to perform the procedure. The student nurse
correctly states:
a. Femur
b. Iliac crest
c. Scapula
d. Ribs
Situation 6: Maslow's Hierarchy of Needs

17. Following a bronchoscopy, the client requests for 26. According to Maslow’s hierarchy of needs, which of
water. The most important consideration to note is which of the following is a basic physiologic need after oxygen?
the following? a. Fluids
a. The client is ambulatory b. Freedom from infection or any disease
b. The client is in bed with rails up c. Love and belongingness
c. The client received local anesthetic prior to procedure d. Self-esteem
d. The client is coherent
27. Which of the following needs does the nurse consider
18. Martha Agoncillo is experiencing shortness of breath when she implements reverse isolation for the client
after oxygen that was being delivered by nasal cannula was with
decreased to 2L/min. Pulse oximetry revels an O2 leukemia?
saturation reading of 71 %. Which of the following would a. Physiologic need
be the most appropriate immediate nursing action? b. Safety and security
a. Increase the O2 concentration to 15 L/min c. Love and belongings
b. Place client to semi fowler's position. d. Self-esteem
c. Do nothing. It is expected. Compensation follows with
this case anyway. Situation 7: Concept of Bowel Elimination
d. Place the client upright position. Assess for the status
and notify the physician immediately 28. Constipation is a common problem for immobilized
patients because of:
19. The laboratory report shows WBC differential for a. Decreased peristalsis and positional
your client who is experiencing an allergic reaction. Which discount
type of cell would you expect to be elevated? b. Increased defecating reflex
a. Neutrophils c. Decreased tightening of the anal
b. Eosinophils sphincter
c. Monocytes d. Increased colon motility
d. Lymphocytes :
29. The following are correct nursing actions when
20. Your client has recently completed chemotherapy and administering enema, Except:
has developed bone marrow suppression. Which of the a. Provide privacy
following reports will you closely monitor? b. Introduce solution slowly
a. ESR c. Alternate NSS with tap water soap suds.
b. WBC d. Increased the flow rate of the enema
c. Hemoglobin solution if abdominal cramps occur.
d. Hematocrit

21. You would anticipate that a client with liver failure 30. The patient is scheduled for proctosigmoidoscopy. She
would have elevated serum blood level of which of the says she is nervous. The most appropriate response to made by
following? the nurse is:
a. Ammonia a. “You need not worry. You have the best Doctor
b. Glucose in the hospital”
c. ESR b. “I don’t blame you for feeling that way, if I
d. Platelet count were in your position, I would feel the
same”
22. In MRI procedure, which of the following will be c. Why do you feel that way? Don’t you trust
removed? god
a. Plastic bracelet d. You should be really upset. Would you like to
b. Teeth braces sit and talk about it?
c. Catheters
d. Slippers 31. From your admission interview of a patient, you
obtained a history of allergies. You can best communicate this
23. Mr. Bert Lambino is scheduled for a colonoscopy. He information by:
asks you regarding the procedure. Your best answer would a. Placing allergy alert in Kardex
be: b. Writing in the patients Chart
a. Evaluate whether there is tumor or other problem on the c. Informing his attending physician
large intestines d. Taking note when giving medications
b. Determine the presence of blood in the abdominal cavity
c. Evaluate presence of impaction of stool
d. Evaluate peptic ulcer
 Situation 8: Concept of Feeding and Bowel Elimination c. Hypotension
32.When inserting NGT, the neck should be: d. Hypokalemia
a. Flexed
b. Extended SITUATION 10: Ms Tony Gabriel was admitted to the hospital
c. Tilted to the left for gastric bleeding, physician ordered a blood transfusion.
d. In neutral position
42. Before blood transfusion, the nurse must
33.Which of the following is inappropriate nursing action assess Mr. Tony for which of the following
when administering NGT feeding? a. Clotting Time and History for bleeding
a. Assist the client in Fowler’s position b. Vital Signs
b. Introduce feeding slowly c. Dextrose 5% in water
c. Place the feeding 24 inches above the d. Plasma and CBC
point of insertion NGT
d. Instill 60 ml of water into the NGT 43. Before administering the transfusion, the
after feeding nurse must start an IV Infusion with which
of the following?
34. Refers to the passage of stool with bright red blood due a. Sterile water solution
to lower gastrointestinal bleeding b. Normal Saline solution
a. Melena c. Dextrose 5% in water
b. Hematochezia d. Plasma combined with D5LR
c. Steatorrhea
d. Hematoma 44. Which of the following is the appropriate
needle for blood transfusion?
35. The following are solutions used as non-retention enema a. butterfly needle
EXCEPT: b. 18 G needle
a. Tap water c. 19 G needle
b. Carminative enema d. 20 G needle
c. Normal saline
d. Fleet enema 45. Which of the following is NOT expected to be done
by the nurse in case of whole blood
36. When leaving an isolation room, the nurse correctly transfusion?
removes her equipment: a. Assess the venipuncture for evidence of
hematoma
a. gown, gloves and mask b. Prepare the blood transfusion
b. gloves, mask and gown c. Assess the patient closely for any reaction
c. mask, gown and gloves d. Ensuring correctness of serial code of the
d. gown and mask inside the room and gloves blood product, blood type, and name of donor
outside the room
46. Which of the following is recommended initial rate
37. During the surgical procedure of explore laparotomy of flow the first 30 minutes in case of blood transfusion?
the nurse having a hard time to count the towel pads and a. 60 gtts
later finds out that one was missing. What will be the b. 10 gtts
nursing responsibility here? c. 40 gtts
a. Let the towel pad be lost since it’s d. 20 gtts
disposable
b. Inform the physician that the first counting Situation 11: NGT/NIT Concepts
was a mistake
c. Tell the team to pack-up since sterility was 47. Nurse Joan is caring for patient with nasogastric tube. The
broken doctor orders 100-ml flush through the tube every 4 hrs. When
d. Inform the surgeon that one towel pad was it’s necessary to flush a nasogastric tube, the solution to use is:
missing and a possibility for another exploration is done to a. Distilled water
find the towel pad b. Sterile water
c. Sterile saline
SITUATION 9: Mrs. Antoine de Falcon, businesswoman, is d. Clean water
experiencing Dyspnea. He is admitted in 48. During insertion of nasogastric tube, which position is best
ICU after the diagnosis of CHF. assumed by the client?
a. Low fowlers
38. In increasing the condition which of the b. Supine Position
following is the symptom he would likely exhibits: c. High-fowlers
a. Dyspnea and spleenomegaly d. Lateral
b. Dyspnea and ederma of extremity
c. Orthopnea, moist rales and cough Situation 12: Post Mortem Concepts (49,50)
d. None of the above
49. As a nurse, when is the right time to conduct a post-mortem
39. Which of the following would be the best indicator care?
for this condition?
a. Characteristic of pulse a. The physician left the client after CPR
b. Blood Pressure b. The physician had talked to relatives of the client
c. Temperature c. The physician pronounced that the client is dead
d. Breathing pattern d. After relative leaves the client

40. Which of the following position would be 50. How many identification tags are prepared after death to
comfortable for him? ensure identity?
a. Dorsal recumbent
b. High Fowlers a. 2
c. Low Fowlers b. 3
d. Supine c. 5
d. 4
41. Phenetoin (Dilantin) is ordered by the doctor to
manage Mrs. De Falcon's seizure. The nurse knows 51. Mang Tomas, 68, complains of a “gassy” abdomen, His
that she might expect side effect on the patient: AMD ordered rectal tube insertion. The
a. Decrease Cardiac Rate nurse should insert the tube:
b. Gingival Hyperplasia a. 2-5 inches
 b. 2-3 inches 60. The most dangerous and life threatening of the complication
c. 4-8 inches of IV therapy is:
d. 6- 8 inches A. Pyrogenic reaction
B. Air embolism
52. Because of constipation, the AMD ordered the client to C. Circulatory overload
take 60 ml of castor oil. Castor oil facilitates D. Thrombophlebitis
a. Lubricating the feces
b. Increasing the volume of intestinal contents 61. All but one are reasons why IV injection is preferred:
c. Softening the stools A. when large volume must be given
d. Irritating the nerve endings in the intestinal B. when rapid onset of action is desired
mucosa C. when drugs are highly irritating to the tissue
D. when drug incompatibility is a major problem
53. One of the important goals of the nurse is to prevent
contractures and deformities especially in clients who are 62. A widely used method of organizing and recording data
immobile. Thus, the nurse should change the client’s positions about a client which is quickly accessible usually used during
in bed at least: endorsement procedure in the Philippines?
a. when told to do so A. Kardex B. Chart C. Admission
b. every 2 hours form D. computer
c. as often as necessary
d. every 2 – 3 hours daily 63. Which of the following in NOT caused by prolonged
immobility?
A. contractures B. thrombosis
54. Which of the measures when taking by the nurse explains C. pneumonia D. Hyperpyrexia
the precaution to be taken undergoing oxygen therapy.
Which is not appropriate: 64. To prevent fluid and electrolyte disturbances, the nasogastric
a. reinforces teaching every time a new tube should be irrigated with:
individual visits the client on treatment A.0.9% NaCl B. 0.3% NaCl Solution
b. place a “no smoking” sign on the patient’s C. Clean tap water D. Sterile warm water
chart
c. minimize the use of appliance in the 65. All but one are roentgenogram examinations:
patient’s room A. IVP B. Barium Enema
d. the use of electric razor is not allowed for C. EMG D. Barium swallow
the patient
66. Digital extraction of feces is contraindicated in a very weak
55. Which of the following statements is TRUE about rectal or elderly patient because of vagal stimulation which may cause:
tube insertion? A. tachycardia B. Palpitation
a. the rectal tube may remain in the colon for 2 - 3 C. bradycardia D. Hypertension
hours to achieve the desirable effect
b. the rectal tube should remain in the colon not longer 67. The patient had her indwelling catheter removed. The nurse
that 30 minutes and reinserted 2-3 hours after endorses that her patient should be able void in:
c. the rectal tube should remain in the colon only 5 - A. 2- 4 hours B. 4-6 hours
10 minutes to prevent rectal damage C. 6-8 hours D. 8-10 hours
d. the rectal tube may remain in the colon for 24 hours
or until the effect has been achieved 68. To prevent pressure sores, what should you take priority
action?
A. frequent turning and massage
SITUATION 14 : Emertan is for Urine Culture and Sensitivity B. regular bathing and use of mild antiseptic
Test for Urinary Albumin Determination C. change of position every 3 hours
D. increase fluid intake
56. Karl should be informed that the Urine C and S studies are
required for which of these purposes? 69. In planning nursing care to prevent pressure ulcers in a
A. to analyze the elements present in the urine bedridden client the nurse should include which of the following
B. to determine if the urine contains evidence of interventions?
malignant cells A. Turn and position the client BID
C. to identify the organism causing the infection in the B. Vigourously massage bony prominences
urinary tract C. Hang a turning schedule at the client’s bedside with
D. to localize the site of the inflammatory process in the a sign sheet
urinary test D. Slide the client gently when turning

57. The specimen required for Urinary Albumin Determination 70. The state of health is:
is: A. identical among individuals
A. fractional urine collection B. same at certain ages
B. 24-hour urine C. constant in nature
C. midstream urine sample ` D. Continually changing
D. early morning midstream urine
71. A temperature of 101 0F is equivalent to how many degrees
58. The following are normal characteristics found in the urine centigrade?
EXCEPT: A. 38.3 B 30
A. specific gravity= 1.020 C. 38.50 D. 40
B. ph = 6
C. uric acid = traces 72. The following are herbal plants used to treat / manage
D. RBC dizziness EXCEPT:
A. Kalamansi B. suha
59. To obtain a 24 hour urine sample, which of these C. mangga leaf D. dayap rind
instructions should be given to Karl?
A. “Collect each voiding in separate containers for the 73. The following can be determined by palpation EXCEPT:
next 24 hours” A. temperature B. vibration
B. “Keep a record of the time and amount of each C. size and shape D. murmur
voiding for 24 hours” 74. Which of the ff. principles is FALSE in the care of the client
C. “Collect all the urine voided starting from the time with drainage tubes?
indicated by doctor” A. The patency of the tube must be maintained at all
D. “Discard the first voiding in the morning and then times
collect the total volume of each voiding for 24 hours”
 B. The receptacle for drainage must be below the d. (+) mucus
organ being drained
C. The equipment comprising the drainage system 92. Richard has an O2 therapy given via face mask. The primary
must be clean effect of
D. The receptacle for the output must be changed oxygen therapy is to:
PRN a. increased oxygen in the tissues and cells
b. increased oxygen carrying capacity of blood
75. Which of the following vitamins CANNOT be stored in the c. increased respiratory rate
body? d. increased oxygen pressure in alveolar sac
A. Ascorbic acid B. Aquamephyton
C. Calciferol D. Retinol 93. To promote lung expansion, what measures can the
NURSE employ?
76. An independent nursing action to lower body temperature is a.oxygen inhalation
to: b.chest cupping and vibration
A. perform bedbath everyday c.steam inhalation
B. administer antipyretic per doctor’s order d.deep breathing and coughing exercise
C. TSB
D. give fluids 1 liter per day 94. The following are early manifestations of hypoxemia,
EXCEPT:
77. When the radial pulse of your patient is irregular, the nurse a. tachycardia
should: b. restlessness
A. take the apical pulse c. tachypnea
B. request another nurse to take the pulse. d. cyanosis
C. count the pulse for 30 seconds and record rate
D. wait for 30 minutes & count radial pulse for one 95. Mang Tomas , 68, complains of a “gassy” abdomen, His
minute AMD ordered rectal tube insertion. The nurse should insert
the tube:
78. When the drugs is administered via the spinal canal, the
route use is: a. 2 – 4 inches
A. intra-arterial B. intrathecal b. 8 – 10 inches
C. intra-synovial D. intravenous c. 4 – 8 inches
d. 6 – 8 inches
79. A drugs is absorbed most rapidly when:
A. given in an empty stomach 96. Because of constipation, the AMD ordered the
B. injected intravenously client to take 60 ml of castor oil. Castor oil facilitates
C. injected intramuscularly a. Lubricating the feces
D. administered with a glass of water b. Increasing the volume of intestinal contents
c. Softening the stools
80. When mixing medications in one syringe from one vial & d. Irritating the nerve endings in the intestinal
one ampule, the nurse withdraws the drugs: mucosa
A. from the ampule first B. from the vial first
C. simultaneously D. any 97. Pain is one of the patient’s major problems
Which of the following statements is NOT TRUE?
81. Several client are being admitted to the hospital unit at once a. utilize various types of pain relief measures
time. There is only one private room available. Which of the if necessary
following clients has highest priority for being admitted to this b. utilize measures that the nurse believes to be
private room? effective
A. A client admitted for surgery c. if therapy proves ineffective at first, change
B. A client under the age twelve with another relief measure
C. A client who has a communicable respiratory d. pain tolerance varies greatly among
infection individuals
D. A client with large infected abdominal wound
98. To remove matting of hair, which of the ff.
82. Metropolol (Lopressor), 25 mg PO, is ordered. Available in methods is most effective?
50 mg/tab. How many tablet the nurse will give? a. moisten the affected part with a small
amount of oil
83. Phenytoin (Dilantin), 100 mg PO, is ordered to be given b. comb the hair by strand
NGT. Available 30 mg/5ml. How much the nurse will give? c. perform bed shampoo
d. apply a hair gel thoroughly on the scalp
84. Captopril (Capoten), 12.5 mg PO, is ordered. Captopril is
available in 25mg tablets. How many? 99. The MOST dangerous complication of vomiting
is:
85. Theophylline elixir , 100 mg PO, is ordered , via PEG. a. Aspiration
Available is 80mg/15 ml. How many? b. Dehydration
c. Hypokalemia
86. Morphine So4, 4 mg SC is ordered. Morphine So4 is d. Fever
available as 8mg/ml. How much?
100. One of the important goals of the nurse is to prevent
Therapeutic positions: contractures and deformities especially in clients who are
87. Position of patient if he is for Optic drug administration? immobile. Thus, the nurse should change the client’s
positions in bed at least:
88. Position of patient if he is for suctioning? a. when told to do so
b. every 2 hours
89. Position of patient if he is for enema procedure? c. as often as necessary
d. every 2 – 3 hours
90. Position of patient if he is for NGT insertion?

91.You received the routine fecalysis result of your client .

Which of the following result would NOT be normal?
a.odor – foul smelling
b.amorphous phosphates(+)
c. (+)dead bacteria