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EVAL EXAM - Funda 1- (KEY)

Fundamental of Nursing (Our Lady of Fatima University)

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* NLE * NCLEX * HAAD * PROMETRICS * DHA * MIDWIFERY * LET * RAD TECH * CRIMINOLOGY * DENTISTRY * PHARMACY *
MED TECH

REFRESHER PHASE
EVALUATIVE EXAM
FUNDAMENTALS OF NURSING
MAY 2024 Philippine Nurse Licensure Examination Review
1. Which of the following is most likely to yield accurate
information about the quality of patient’s pain?
A. “Tell me, what your pain feels like.”
B. “Would you describe your pain as radiating? Acute or
sharp?”
C. Tell, how would you rate your pain in a scale to 1 to
5”
D. “What events seemed to increase your pain?”
2. The nurse is caring for a group of adult patients who require
pain management. It is most important for the nurse to
remember:
A. to use medication only as a last resort after trying to
distract the patient
B. that medicating a patient with chronic pain is a lower
priority than medicating a patient with acute pain.
C. that medication should be given based on the
patient’s perception of pain.
D. to wait for 15 minutes after a patient’s request for pain
medication to be sure the pain is real.
3. Which of the following most appropriately describe pain
sensations that has periods of remission and exacerbation?
A. Acute
B. Chronic
C. Intractable
D. Neuropathic
4. You are obtaining a history of Jessie D. who is admitted with
acute chest pain. Which question will be most helpful for you to
ask?
A. Why do you think you had a heart attack?
B. Do you need anything now?
C. What were you doing when the pain started?
D. Has anyone in your family been sick lately?
5. Which of the following techniques is considered the best way
to determine whether a nasogastric tube is positioned in the
stomach?
A. Aspirating with a syringe and checking pH of
gastric contents
B. Irrigating with normal saline and observing for the
return of the solution
C. Placing the tube’s free end in water and observing for
air bubbles
D. Instilling air and auscultating over the epigastric area
for the presence of the tube
6. The health care provider order reads "aspirate nasogastric
feeding (NG) tubes every 4 hours and check pH of aspirate."
The pH of the aspirate is 10. Which action should the nurse
take?
A. Apply intermittent suction to the feeding tube
B. Hold the tube feeding and notify the provider
C. Administer the tube feeding as scheduled
D. Irrigate the tube with diet cola soda
7. What position will the nurse recommend to the patient
during NGT insertion?
A. Semi-Fowler’s Position
B. Trendelenberg
C. High Fowler’s position
D. Left sims lateral
8. An appropriate technique for nasogastric tube insertion is
for the nurse to:
A. Position the client supine
B. Ice the plastic tube
C. Advance the tube while the client swallows
D. Measure the tube length from the nose to the
sternum
9. The physician orders nasogastric tube insertion to irrigate a
client’s stomach. Which of the following insertion techniques
would most likely make it more difficult for the nurse to insert
the tube?
A. Lubricating the tube with water-soluble lubricant
B. Asking the client to swallow while the tube is advanced
to the stomach
C. Sitting the client upright in a Fowler’s position
D. Having the client tilt the head toward the chest
while inserting the tube into the nose.
10. What position will the nurse recommend to the patient
during TPN administration?
A. High Fowler’s position
B. Trendelenberg
C. Semi-Fowler’s Position
D. Left sims lateral
11. 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
12. . 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
13. 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
14. The most concentrated source of energy in the body is:
A. Protein
B. Carbohydrates
C. Fat
D. Macro minerals
15. 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
D. Place the equivalent of 30 ml of food on the fork
16. 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
17. You attached a pulse oximeter to the client. You know that
the purpose is to:
A. Determine if the client’s hemoglobin is low and if he
needs blood transfusion
B. Check level of client’s tissue perfusion

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C. Measure the efficacy of the client’s anti-hypertensive
medications
D. Detect oxygen saturation of arterial blood
before a symptoms of hypoxemia develops
18. 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:
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
19. A nurse informs a client that the alarm on the pulse
oximeter will not sound when:
A. The client moves the probe
B. The probe falls off
C. The SpO2 falls below the set limit
D. The display reaches full strength during each
cardiac cycle
20. For a client with CAL, a nurse anticipates the use of oxygen
equipment?
A. Face tent
B. Face mask
C. Nasal cannula
D. Nonbreathing mask
21. Assessment of the proper functioning of an oxygen device
includes:
A. No mist in the face tent
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
22. 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.
23. Complications associated with a tracheostomy tube include:
A. Decreased cardiac output
B. Damage to the laryngeal nerve
C. Pneumothorax
D. Respiratory distress syndrome
24. 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
25. 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
26. 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
27. 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?
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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.
28. 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
29. 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
catheter and allow urine to flow from catheter into
the specimen container.
D. Disconnect the drainage the from the collecting bag and allow
the urine to flow from the catheter into the specimen container.
30. The nurse is reviewing with a client how to collect a clean
catch urine specimen. Which sequence is appropriate
teaching?
A. void a little, clean the meatus, then collect specimen
B. clean the meatus, begin voiding, then catch
urine stream
C. clean the meatus, then urinate into container
D. void continuously and catch some of the urine
31. A nurse has an order to obtain 24-hour urine collection on
a client with renal disorder. The nurse avoids which of the
following to ensure proper collection of the 24-hour urine
specimen?
A. have the client void at the start time, and place
he specimen in the container
B. discard the first voiding, and save all subsequent
voiding during 24-hour time period
C. place the container on ice or refrigerator
D. have the client void at the end time, and place the
specimen in a container
32. A nurse is to collect a sputum specimen for culture and
sensitivity from a client. Which action should the nurse take
first?
A. Assist with oral hygiene
B. Ask client to cough sputum into container
C. Have the client take several deep breaths
D. Provide an appropriate specimen container
33. 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
34. The nurse collects a urine specimen for routine urinalysis
from a client. She is aware that:
A. A sterile specimen is required
B. Standing at room temperature for a prolonged
period may alter the urine chemistry
C. The external meatus should be cleaned with
antiseptic soap and water before voiding.
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D. A clean-catch, midstream specimen is required D. Hyperoxygenate before suctioning the client

35. What is the priority of care after the urinary catheter is 45. Which method is the best for the nurse to evaluate the
removed? effectiveness of tracheal suctioning?
A. Encourage the client to eliminate fluid intake. A. Note subjective data such as, “My breathing is much
B. Document size of catheter and client’s tolerance of improved now.”
procedure. B. Note objective findings such as decreased respiratory
C. Evaluate the client for normal voiding. rate and pulse.
D. Documentation of client’s teaching C. Consult with respiratory therapist to determine
36. During an assessment, the nurse expects that the average effectiveness.
daily urinary output for the adult client will be: D. Auscultate the chest for change or clearing in
A. 500 to 1000ml adventitious breath sounds.
B. 700 to 1500ml 46. Organize the following steps of suctioning in chronological
C. 1200 to 1500ml order:
D. 2000 to 3000ml 1. Put on sterile glove.
37. Nurse Jane evaluates a client with diagnosis of dehydration 2. Lubricate catheter with normal saline
to have which of the following specific gravity reading? 3. Apply suction for 5-10sec.
A. 1.000 4. Explain procedure to client.
B. 1.017 5. Wash hands thoroughly.
C. 1.023
D. 1.035 A. 54132
38. A client has a tracheostomy tube. The nurse knows that the B. 45213
obturator is kept at the client’s bedside because: C. 54123
A. The obturator is kept at the client’s bedside in D. 45132
case the tube becomes dislodged and needs to 47. A nurse is performing oropharyngeal suctioning on the
be reinserted. unconscious client. Which of the following actions is safe?
B. The obturator is a guide in inserting the tube. A. Insert the catheter approximately 20 cm while applying
C. The obturator, after insertion, will be kept by the client. suction.
D. The obturator will be used to make an opening for the B. Allow 20 to 30 second intervals between each suction,
tube and limit suctioning to a total of 15 minutes.
39. The nurse is cleaning the incision site and tube flange of a C. Gently rotate the catheter while applying
client with tracheostomy. A sterile applicator soaked in what suction.
solution is used in removing crusty secretions? D. Apply suction for 5 minutes while inserting and
A. Isopropyl alcohol continue for another 5 seconds before withdrawing.
B. Hydrogen peroxide (Full strength) 48. Applying suction in the nasopharynx for too long may cause
C. Hydrogen peroxide ( half-strength solution secretions to increase or decrease, therefore the nurse should:
mixed with sterile normal saline) A. Allow 20 to 30 second intervals between each
D. Ammonia suction, limit suctioning to 5 minutes in total
40. Tracheostomy tubes used among adults often have cuffs. B. Allow 2 to 3 minutes between suction when possible
This inflatable cuff functions by: C. Allow 5 minutes between each suction
A. Producing an airtight seal to prevent aspiration D. Allow 1 to 2 minutes between each suction
of oropharyngeal secretions and air leakage 49. The correct pressure of the wall suction unit when
B. Anchoring the tube in place suctioning a child patient is?
C. Distributing a low even pressure over the trachea A. 95 – 100mg M Hg
D. A guide for easy removal of the tracheostomy tube B. 50 – 95 mm Hg
41. Which of the following statements contains one of the basic C. 100 – 120mm Hg
rules to follow when caring for a client with a chest tube and D. 10 – 15mm Hg
water-seal drainage system? 50. A nurse suctioning a client through a tracheotomy tube.
A. Ensure that the air vent on the water-seal drainage The nurse plans to apply suction during the withdrawal of the
system is capped when the suction is off catheter for a period of time no greater than?
B. Strip the chest and drainage tubes at least every 4 A. 10 seconds
hours if excessive bleeding occurs B. 15 seconds
C. Ensure that the collection and suction bottles are at the C. 20 seconds
client’s chest level at all times D. 30 seconds
D. Ensure that the collection and suction bottles
are below the client’s chest level at all times
42. 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
43. 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
44. 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

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