FUNDAMENTALS OF NURSING

NAME:

SCORE:

/ 100

INSTRUCTIONS: Select the correct answer for the following questions. Mark only one answer for each
item by encircling the letter of your choice. STRICTLY NO ERASURES ALLOWED.

1. Upon administering the feeding to patient via

NGT the nurse should prevent aspiration; to
prevent aspiration and regurgitation of the food
the nurse should;

A. Put pressure in the asepto syringe while

administering the feeding
B. Flush the tubing after the feeding
C. Aspirate gastric content

4. As the nurse insert the catheter he noticed that

there is already urine, the nurse should;

A. Inject 10cc of sterile water to the port to

secure the catheter
B. Withdraw the catheter at least 5 inches
C. Advance the catheter another 5cmadvance 2 more inches (5cms) after initial
flow of urine to make sure that end is at the
bladder

D. Maintain the head of the bed elevated for

at least 30-60 minutes

D. Obtain a urine sample immediately

2. The following are the purpose of performing a

catheterization EXCEPT:

5. The proper way on securing the catheter to a

male patient is;

A. To relieve acute or chronic retention

A. Tape the catheter within the patients

abdomen

B. Elevate the head of the bed for at least

1hr

B. Tape the catheter within the outer aspect of

the thigh

C. To instill medication into the bladder

C. Tape the catheter on the gown
D. None of the Above
D. All of the above

3. In performing catheterization procedure the

nurse should;

6. In inserting the catheter to the patient the

nurse should position the patient properly; the
nurse should position a female patient in;

A. Wear a clean gloves during the procedure

B. Observe sterile technique

A. Semi Fowlers

C. Wear gown when inserting the catheter

B. Supine

D. All of the above

C. Dorsal Recumbent

D. Sims

7. A client is receiving nutrition by means of TPN.

A nurse monitors the client for complications of
the therapy and assesses the client for which of
the following signs of hyperglycemia?

A. Nausea, Vomiting and Oliguria

10. Nurse Aileen is about to examine the patient

with suspected gastrointestinal problem. She
would begin her assessment by which of the
following sequence:

1. Inspection

3. Palpation

2. Percussion

4. Auscultation

B. Sweating, chills and abdominal cramps

C. Fever, weak pulse and thirst

A. 1, 2, 4, 3

D. Weakness, Thirst and increased urine

output

B. 1, 2, 3, 4
C. 1, 4, 2, 3
D. 1, 3, 2, 4

8. The purpose of your initial nursing interview is

to:
11. Which of the following may be examined with
palpation?
A. Record pertinent information in the clients
chart for health team to read
B. Assist the client find solutions to her health
concerns

A. Headache
B. Thyroid glands

C. Gait and balance

D. Bowel sounds

C. Understand her her lifestyle, health needs and

possible problems to develop a plan of care
D. Make nursing diagnoses for identified
problems

12. An old man appears to be unkempt has an

initial diagnosis of Pulmonary Tuberculosis. Which
of the following manifestations that can be assess
through auscultation could confirm this case?

9. Which of the following is the least nursing

activity in performing assessment of patient?

A. Blood in the sputum collection

B. Result of Crackles during evaluation
C. Intermittent fever for several days

A. Laboratory test
D. X-ray result reveals tissue scarring
B. Physical Examination
C. Health History
D. Systems review

13. Among the five major cardinal signs of

inflammation, which cardinal sign is a best
assessment done by palpation?

i. Calor

iii. Tumor

ii. Rubor

iv. Dolor

A. i and ii

C. ii and iii

B. i and iii

D. ii and iv

14. Which of the following manifestations

gathered upon auscultation predisposes the
patient the risk to impaired tissue oxygenation?

A. Cyanosis

C. Wheezing sound

B. Hyperventilation

D. Tympanic Sound

15. Patient Uscar is placed on restraint. The

patients capillary refill is normal. However the
patient is agitated and is having facial grimacing.
Which vital sign are you going to check?

A. Blood Pressure

C. Pain

B. Pulse

D. Respirations

16. When removing the clients gown with IVF on

his left arm, the nurse should:
A. Remove the side of the gown without
the contraption first
B. Remove the side of the gown with
contraption first
C. Remove either sides of the gown
D. Remove the IVF then just reinsert it
17. It is a glass container usually designed to hold
a single dose of a drug.
A. Vial
C. container
B. Ampule
D. Glass
18.PPD is administered through what type of
injection?
A. Subcutaneous
C. Z track
B. Intradermal
D. intramuscular

19. Its purpose is to allow slower absorption of a

medication compared with either intramuscular
or intravenous route.
A. Oral
C. subcutaneous
B. Intradermal
D. Intramuscular
20. What will you do to the needles and syringes
that were used?
A. Wash and reserve for the next injection
B. Discard the needle
C. Put it inside the refrigerator
D. Separate the needle and syringe then
discard into appropriate container.
21. It is essential to ___________________ after
administration of medication.
A. Explain the purpose to the client
B. Ask permission to the client
C. Discard the unused drug
D. Document/chart
22. This type of assessment is use to provide
information about location, size and condition of
the underlying structures.
A. Inspection
C. auscultation
B. Palpation
D. Percussion
23. It is a systematic method of observation and
palpation which provide information about the
number of fetuses, the identity of presenting part,
the fetal line and attitude.
A. Massage
C.
auscultation
B. Leopolds maneuver
D.
Internal
examination
24.This is the installation of a solution into the
rectum and sigmoid colon.
A. Bladder irrigation
C. both
B. Enema
D. none of the
above
25.The amount of enema to be administered to
an adult should be:
A. 250-500ml
C. 750-1000ml
B. 500-750ml
D. 250
* A preschool, B school age
26. In Benedicts Test, if the result is Blue, what is
the interpretation?
A. Slight trace
C. trace
B. No sugar present
D. moderate
amount
* A green, C yellow, D orange
27 It should be used in cleaning for the mothers
breast.
A. Alcohol
C. petroleum jelly
B. Soap and water
D.
baby
powder
28.This is the normal head circumference of a
newborn.
A. 30-33cm
C. 31-34cm
B. 33-35cm
D. 43-48cm
* A chest, D - anthropometric
29.While inspecting the umbilical cord, Nurse RJ
noticed 2 veins and one artery. What is the best
thing for him to do?
A. Do nothing
B. Report to the physician

C. Soak to povidone iodine

D. Assess carefully then report to the
physician
30.This site is commonly used for Vit. K
administration for newborn.
A. Rectus femoralis
C.
Gluteus
maximus
B. Vastus lateralis
D. Deltoid
31.How many identification tags will the nurse
use during post mortem care?
A. 7
C. 2
B. 3
D. 5
32.What kind of solution is used during Blood
Transfusion?
A. 0.9 % NaCl
C. PLR
B. D5LR
D. D5NSS
33.It is the removal of airway secretions using
negative pressure.
A. Suctioning
C. gurgling
B. Swallowing
D. all of the above
34.In tracheostomy care, what is the best position
for the patient?
A. Supine
C. Trendelenburg
B. Dorsal
D. Semi-Fowlers
35.It is the aspiration of gastric contents and the
washing out of the stomach by means of gastric
tube.
A. Enema
C. Gastric enema
B. Barium swallow
D.
Blood
glucose monitoring
36.While inserting a straight catheter to a male
adult client nurse Bhelle will advance it in:
A. 2-3 inches
C. 5-6 inches
B. 7-9 inches
D.
9-12
inches
37.In female client, nurse Leah will tape the
catheter:
A. Below the abdomen C. Inner thigh
B. Above symphysis pubis
D.
On the
knee
38.While cleaning the eyes of patient during
bedbath, Nurse AJ must begin from:
A. Inner canthus to outer canthus
B. From far side to near side
C. From outer cantus to inner canthus
D. From near side to far side
39.In body mechanics base of support should be:
A. Wide
C. Lower
B. Narrow
D. Higher
40.A body temperature above normal/ usual
range is called:
A. Pyrexia
C. Fever
B. Hyperthermia
D.
All of the
above
41.The difference between the diastolic and
systolic pressure is called:
A. Cardiac output
C.
Peripheral
resistance
B. Pulse pressure
D.
Arterial
blood pressure
* Cardiac output = heart rate x stroke
volume
42.A bluish tinge, most evident in nail beds, lips
and buccal mucosa.

A. Jaundice
C. Pallor
B. Cyanosis
D. Vitiligo
* Jaundice yellow, pallor pale, vitiligo
patches
43.Which of the following personal protective
equipment may be reused by the other nurse
during a single shift caring for a single client?
A. Goggles
C. Surgical mask
B. Gown
D. Clean gloves
44.It is a short procedure, generally performed at
the clients bedside in which a sample of liver
tissue is aspirated for examination.
A. Liver biopsy
C.
Liver aspiration
procedure
B. Liver palpation
D. All of the above
45. Which of the following positions correctly
describes dorsal recumbent position?
A. prone with weight of upper body supported
on flat surface by chest
B. flat on back with legs flexed at hips
and knees
C. sitting upright at 90 degrees
D. flat on abdomen with knees slightly flexed
46. Which of the following is not a purpose of
Range of Motion exercises?
A. to stimulate circulation
B. to improve coordination
C. to increase tolerance for more activities
D. None of the above
47. Which of the following is the best example of
radiation?
A. natural drying after excessive sweating
B. facing a fan for cooling
C. warming through a droplight
D. TSB
* A evaporation, B convection, D
conduction
48. It is a form of heat loss which is the transfer
of heat from one molecule to a molecule of lower
temperature (with contact).
A. Convection
C. Evaporation
B. Conduction
D. Radiation
* A air current, C insensible loss of heat
from skin or lungs, D transfer of heat from
one surface to another without contact
49. Which type of temperature is measured thru
axillary routes, skin patch or temperature
sensitive tape?
A. core temperature
C. Both
B. Surface temperature
D. None of
the above
50. Which of the following is the most reliable
route of assessing temperature?
A. axilla
C. rectal

B. oral
D. all of the above
51. It is a contraindication of tympanic route of
assessing temperature.
A. significant ear drainage C.
patients
with oxygen
B. rectal abnormalities D.
None of the
above
52. This type of pulse point is used to assess
circulation to the legs and to auscultate leg blood
pressure.
A. temporal
C. brachial
B. apical
D. popliteal

73. When Mr. Pineda, who has urinary retention

catheter in place, complaints of discomfort in the
bladder and urethra the nurse should first:
A. Notify the physician
B. Milk the tubing gently
C. Check the patency of the catheter

_H_ 53. Florence Nightingale

A. Care, Core,
Cure
_F_ 54. Hildegard Peplau
B. Theory of
Self-Care
_G_ 55. Virginia Henderson C. Adaptation Model
_A_ 56. Lydia Hall
D. Behavioral System
Model
_B_ 57. Dorothea Orem
E. Science of
Unitary Man
_D_ 58. Dorothy Johnson
F.
Interpersonal
Relationship
_C_ 59. Callista Roy
G. 14 Fundamental
Needs Definition of
Nursing
_E_60. Martha Rogers
H.
Environmental
Theory of Nursing

74 When caring for a client with continuous

bladder irrigation, the nurse should:

70. Its purpose is to identify and develop an

individualized, goal oriented and therapeutic care
plan.

D. Include irrigating solution in any 24 hour

urine tests order

A. planning

C. evaluation

B. diagnosing
implementation

D.

71. It is an expected outcome which describes

what the client will do, when it will be done, and
to what extent.

D.

Irrigate the
solutions

catheter

with

A. Monitor urinary specific gravity

B. Record urinary output every hour
C.

Subtract irrigant from

determine urine volume

B. Slow the flow rate

B. measurable

D. realistic

C. Stop the blood immediately

C.

data

B. interview

D. inspection

to

A. Call the physician

C. attainable

A. physical assessment
collection

output

75. A child is to receive a blood transfusion, if an

allergic reaction to the blood occurs, the nurse's
first intervention should be:

A. specific

72. It is an organized systematic process of

collecting objective data based upon a health
history and head-to-toe or general systems
examination.

prescribed

D. Relieved the symptoms with an ordered

antihistamines

___B___76.
(freckles)

Localized

changes

___A___77. Solid elevated lesion

in

skin

color

___E__78. Elevated mass containing serous fluid

accumulation between the upper layers of the
skin. (chicken pox)

A. Rigor Mortis

C. Livor Mortis

B. Algor Mortis

D. Post Mortem Care

___C__79. Pus filled vesicles or bullae (acne)

* B temperature, C discoloration

___D__80. Thinning of the skin surface and loss of

markings (striae)

Situation: Moving a client in good body alignment

and positioning body parts properly and
systematically are essential aspects of nursing
practice.
85. To elicit patients cooperation and promote
sense of well-being, Nurse Kelly must do which of
the following first?
A. Proper handwashing
B. Explain the procedure
C. Greet the client and introduce ones
self
D. Wear a smile
86. Nurse Beyonce ensures that the mattress is
firm. A sagging mattress used over a prolonged
period can contribute to the development of
which of the following?
A. Neck flexion
C. Low back pain
B. Foot drop
D.
Pressure
ulcer
87. In order to prevent pressure ulcers in
immobilized clients; Nurse Erik must plan to do
which of the following?
A. Plan a systematic 24-hour schedule for
position changes
B. Reposition clients every 4 hours throughout
the day
C. Use only supportive devices available
D. Assume clients responsibility

A. Papule

C. pustule

E. vesicle

B. Macule

D. atrophy

F. ulcer

81 The order of assessment of the abdomen:

A. Inspection, Percussion, Auscultation
B. Inspection, Auscultation, Percussion,
Palpation
C.

Percussion,
Palpation

D.

Auscultation,
Percussion

Inspection,

Auscultation,

Inspection,

Palpation,

82. Which of the following is an example of an

invasive procedure?
A. Chest X-ray
ultrasound

C.

Doppler

B. ECG

D. Bronchoscopy

88. Mrs. Smith is for an examination of her

genitalia. Nurse Cassie should assist her to
assume which position?
A. Dorsal recumbent position
Knee-chest position
B. Sims position

83. You will correct the nurse if she performs this

act to your client:
A.

Use aseptic technique while suctioning

B. Open thumb port

C. Hyperoxygenate while suctioning
D. Suction while inserting the catheter

84. It is defined as the stiffening of the body and

starts in the involuntary muscles like heart.

C.

D. Prone position

Situation: Vital signs are determined to monitor

the functions of the body. Nurse Jasmine should
measure VS more often if the clients health
status requires it.
89. Monitoring of clients VS should not be a
routine procedure. The following are times to
assess VS except:
A. On admission to a health care agency
B. Before and after surgery or invasive
procedure

C. According to a nursing or medical order

D.

Only
after
medications

administration

A. Close the door and windows of the patients

room
of
B. Inform the client and explain the
purpose of procedure

90. Nurse Jasmine knows that the best way to

prevent transfer of microorganisms is:

C. Remove the clients gown under the top

sheet

A. Use of hand sanitizer

D. Place the bed in flat position
B. Disinfection of used materials
C. Handwashing
D. Health assessment
91. Which of the following is a non modifiable
factor affecting the blood pressure?
A. Stress

C. Exercise

B. Race

D. Diet

92. After taking the temperature per orem, Nurse

Pido must clean the thermometer in what
manner?
A. From bulb to stem in a back and forth
motion
B. From stem to bulb in a rotating motion
C. From bulb to stem in a rotating motion
D. From center down and upward
93. What is the most effective measure to relief
dryness of the skin?

Administering tube feeding

95.__6__ Do after care of equipment
96.__3__ Assess residual feeding contents
97.__2__ Assess tube placement and patency
98.__1__Assist client to Fowlers position in bed or
sitting position in chair
99.__4__ Introduce feeding slowly
100.__5__ Instill 60 mL of water into the NGT
after feeding
101. __7__ Make pertinent documentation
Urinary catheterization
102. __6__ Anchor the catheter properly
103. __2__ Do perineal care
104. __5__ Insert catheter gently, in rotating
motion
105. __1__ Wear sterile gloves
106. __4__ Locate the urinary meatus properly
107. __3__ Lubricate with water lubricant before
insertion
108. Considered as a caring profession:
A. Architecture
B. Engineering
C. Nursing
D. Military
109. The essence of Nursing:

A. Increase fluid intake

of alcohol

C. Avoid use

A. To earn money
B. To be popular
C. To look good
D. To Care

B. Apply cream/lotion
frequently

D. Bathe less

Whatever you do , do it heartily as to the

Lord and not to men
-Galatians 3:23

94. The initial nursing action when providing bed

bath is:

TOPNOTCHERS arent born, they are RAISED

GOD BLESS FUTURE RNs!!!!