Fundamental of nursing exam for 2nd year HO students.

Name-------------------------------------------------- IDNO ---------------- Time allowed 1 hrs.

Part I; Give short answer (10 point for each)

1. Sister Hermela is a nurse in the surgical ward and the doctor ordered to insert NG Tube and
give feeding (gavage) for a patient with head injury, she gives milk 200ml for breakfast as
ordered, at the end she record the nursing intervention.
From the above what should be RECORD in the NG Tube feeding procedure list at least 5?
2. Write at least 5 ways of oxygen administration?
3. Write the purpose of NG Tube insertion?
4. Write the INDICATIONS of oxygen administration?
5. Write the definition of urinary catheterization?
6. A. Write at least 3 indication of a urinary catheterization. (3 point)
B. Write the select appropriate balloon size (the amount of fluid or air to be inflated the
catheter in ml or cc) for Adult and Child. (2 point)
C. Write the Catheter size depends on the size of the urethral canal for Adult male, Adult
female and Children. (3 point)
D. Write the 2 types of catheter. (2 point)
7. A. Write at least 2 solutions used for enema. (5 point)
B. Write rectal tube appropriate size measured in French scale for adult and infant/
small child. (5 point)
8. A. Write at least 5 contraindication of enema. (5 point)
B. Write the purpose of enema. (5 point)
9. A. List at least 5 convenient time to assess vital sign. (5 point)

B. Write the difference b/n systolic blood pressure and diastolic blood pressure. (5
point)
10. A. Write the correct in placing temperature site measurement from most accurate to the least
accurate. (5 point)
B. List the 9 Sites for taking pulse rate. (5 point)

Prepared by
Teklewoini Marye (Msc. Assistant professor)
 Answers
1. Time of giving the NG Tube feeding
 Amount of the milk
 Temperature of the milk
 Reaction of patient during and after procedure
 V/S taken before and after the procedure
 Size of the NG Tube
 Length of NG Tube that was inserted
2. *By mask
*Nasal catheter
*Tent
*Ambu bag
*Nasal cannula
6- To administer medications to clients unable to eat by mouth.
- To give tube feedings or lavage.
- For stomach washout (lavage) in case of poisoning or overdose of medication.
- To remove stomach contents for laboratory analysis.
- To perform decompression in case of abdominal distention with air or fluid.
8- Intra/post-operative patients
- patients who have hypoxemia and hypoxia
- Hypoxemic (sao2) < 90%, Pao2< 6o%
- Hypercapenic PCO2>50 mmHg, pH<7.35
- Critical patients
- COPD
- Pneumonia
9. Definition of catheterization: Is the introduction of a tube (catheter) through the urethra into
the urinary bladder
4. A. - For bladder irrigation or decompression
- To measure the amount of post void residual urine for monitoring
- To urine specimen collection for Lab analysis.
-To relieve urinary retention or incontinence
-To obtain sterile urine specimen
-To empty the bladder before, during and after surgery.
-In case of bladder obstruction
B. - For adults = 5-10ml
- For children =3-5ml
C. For adult male = 18fr
For adult female =14-16fr
For children = 8-10fr

Prepared by
Teklewoini Marye (Msc. Assistant professor)
 D. 1. Straight or plain or Robinson
2. Retention or Foleys, indwelling
7.A. Normal saline, Soap solution, Tape water & Epsom salts.

B. Adult = 22-30fr and infant/ small child =10-12fr

3. A. Rectal surgery, Rectal /anal/ cancer, Rectal infection, for a patient with appendicitis and
Rectal /Anal/ fissure
B. To relieve gas, constipation or fecal impaction.
To cleanse the bowel prior to surgery.
To cleanse the bowel prior to diagnostic examination.
To evacuate/empty/ the bowel in patients with neurologic dysfunction.
Evacuates feces in clients with hemiplegia, quadriplegia or paraplegia.
For introducing drug/substance.

10.A. -On admission

-When client has a change in health status

-According to nursing or medical order
-Before & after surgery or invasive diagnostic procedures
-Before & after any nursing intervention that could affect V/S such as ambulation
-According to hospital or other health institution policy.
-Before & after administrating of certain medication that will affect V/S (respiratory and
cardiovascular system)

B. Systolic pressure:-is the first sound heard through stethoscope

Diastolic pressure:-is the cessation of the load sounds or disappearance of the heart sound.

5. A. Rectal → Tympanic → Oral → Axillary

B. Radial artery, Temporal artery, Carotid artery, Brachial artery, Apical artery,
Femoral artery, Popliteal artery, Posterior tibial, Pedal artery (dorsalis pedis).

Prepared by
Teklewoini Marye (Msc. Assistant professor)