FUNDAMENTALS IN NURSING

1. The nurse manager has requested that a

nurse perform a self-assessment prior to an annual
performance evaluation. Using Maslow’s model of
self-actualization, the nurse understands that self-
actualization is at the top of the pyramid and refers
to:
A. Becoming the person you would like to be by
making the most of your physical, mental, and
spiritual competencies
B. Needing recognition, usefulness,
independence, dignity and freedom
C. Needing safety, security, and protection
D. Needing to belong to a group
2. The nurse is evaluating a patient
complaining of shortness of breath. The nurse
assesses the patient’s respiratory rate to be 26
breaths/minute and documents that the patient
is tachypneic. The nurse understands that
tachypnea means:
A. Frequent bowel sounds
B. Heart rate greater than 100 beats/minute
C. Hyperventilation
D. Respiratory rate greater than 20
breaths/minute
3. The nurse assesses a patient complaining
of frequent episode of epistaxis. The nurse
knows the patient has:
A. An enlarged spleen
B. A tendency to bruise easily
C. Nosebleeds
D. Seizures
4. The doctor order intra-arterial monitoring
to obtain continuous blood pressure in a
critically ill patient. Collateral circulation should
be assessed prior to selection of an arterial site.
The test used to assess the patency of the radial
and ulnar arteries is the:
A. Allen’s test
B. Homans’ sign
C. Trendelenburg’s test
D. Weber’s test
5. The four major concepts in nursing theory
are the
A. Person, Environment, Nurse, Health
B. Nurse, Person, Environment, Cure
C. Promotive, Preventive, Curative,
Rehabilitative
D. Person, Environment, Nursing, Health
6. The act of utilizing the environment of the
patient to assist him in his recovery is theorized
by
A. Nightingale
B. Benner
C. Swanson
D. King
7. The most unique characteristic of nursing
as a profession is
A. Education
B. Theory
C. Caring
D. Autonomy
8. To administer nitroglycerin sublingually,
the nurse:
A. Insert it rectally
B. Places it in the buccal area
C. Places it on the chest wall
D. Places it under the tongue
SITUATION: Sheila Reyes has a history of
hypertension and complains of shortness of breath
when she lies flat. The nurse assesses her blood
pressure to have a diastolic reading of 200 mmHg.
(Questions 10 and 11 relate to this situation)

9. The nurse documents that Mrs. Killian has:

A. Dyspnea
B. Exertional dyspnea
C. Orthopnea
D. Paroxysmal nocturnal dyspnea
10. Diastole is defined as:
A. A measure of contractility
B. The amount of blood ejected from the
ventricles with each contraction of the heart
C. The period when the heart contracts and
the muscles fibers are tight and short
D. The period when the muscle fibers are
stretched and the heart’s cavities fill with blood
11. What is a characteristic of the nursing
process?
A. Asystematic
B. Goal-oriented
C. Inflexible
D. Stagnant
12. What is the order of the nursing process?
A. Assessing, diagnosing, implementing,
evaluating, planning
B. Assessing, diagnosing, planning,
implementing, evaluating
C. Diagnosing, assessing, planning,
implementing, evaluating
D. Planning, diagnosing, implementing,
assessing, evaluating
13. During the planning phase of the nursing
process, which of the following is the “product’
developed?
A. Nursing care plan
B. Nursing diagnosis
C. Nursing history
D. Nursing notes
14. Objective data are also known as:
A. Covert data
B. Inferences
C. Overt data
D. Symptoms
15. The primary source of data collection in
the assessment phase of the nursing process is
the:
A. Chart
B. Patient
C. Doctor
D. Family
16. What is an example of subjective data?
A. Color of wound drainage
B. Odor of breath
C. Respirations of 14 breaths/minute
D. The patient’s statement of “I feel sick to
my stomach”
17. This is the best patient care model when
there are many nurses but few patients.
A. Functional nursing
B. Team nursing
C. Primary nursing
D. Total patient care
18. This patient care model works best when
there are plenty of patient but few nurses
A. Functional nursing
B. Team nursing
C. Primary nursing
D. Total patient care
19. Who developed the first theory of nursing?
A. Hammurabi
B. Alexander
C. Fabiola
D. Nightingale
20. She described the four conservation
principle.
A. Levin
B. Leininger
C. Orlando
D. Parse
21. Established in 1906 by the Baptist foreign
mission society of America. Miss rose nicolet,
was it’s first superintendent.
A. St. Paul Hospital School of nursing
B. Iloilo Mission Hospital School of nursing
C. Philippine General Hospital School of
nursing
D. St. Luke’s Hospital School of nursing
22. Anastacia Giron-Tupas was the first Filipino
nurse to occupy the position of chief nurse in
this hospital.
A. St. Paul Hospital
B. Iloilo Mission Hospital
C. Philippine General Hospital
D. St. Luke’s Hospital
23. Period of nursing where religious Christian
orders emerged to take care of the sick
A. Apprentice period
B. Dark period
C. Contemporary period
D. Educative period
24. This period marked the religious upheaval
of Luther, Who questions the Christian faith.
A. Apprentice period
B. Dark period
C. Contemporary period
D. Educative period
25. She conceptualized that man, as an Open
system is in constant interaction and transaction
with a changing environment.
A. Roy
B. Levin
C. Neuman
D. Newman
26. Two-year-old Jason’s mother states, “Jason
vomited 8 ounces of his formula this morning.”
This statement is an example of:
A. Objective data from a primary source
B. Objective data from a secondary source
C. Subjective data from a primary source
D. Subjective data from a secondary source
27. The nurse performs a neurologic exam on
a patient. After the exam, which of the following
should be recorded as objective data?
A. +4 patellar reflexes in both of the patient’s
legs
B. Patient’s description of ringing in his ears
C. Patient’s sensations of numbness in his
right arm
D. Patient’s statement, “The room is
spinning”
28. It is most important to identify the etiology
(risk factors) of a nursing diagnosis because
doing so:
A. Assists in organizing nursing care of
patients with a similar diagnosis
B. Describes that patient’s health problem or
response in a few words
C. Gives direction to the required nursing
interventions for the patient
D. Indicates the presence of a particular
health problem in a patient
29. When should discharge planning
commence?
A. 24 hours after discharge
B. The day before discharge
C. Upon admission
D. When the patient desires
30. The scientific reason for selecting a specific
nursing intervention supported by clinical
research is called a:
A. Criterion
B. Rationale
C. Strategy
D. Theory
31. An expected outcome on a patient’s nursing care
plan reads. “patient will be able to transfer from the bed
to a wheelchair without assistance by the end of the
week.” When the nurse evaluated the patient’s progress,
the patient was able to transfer from the bed to a
wheelchair to go to the physical therapy department
without any help from the nurse. Which of the following
would be an appropriate evaluative statement for the
nurse to place on the patient’s nursing care plan?
A. “Patient was able to transfer from the bed to a
wheelchair without assistance.”
B. “Goal impossible to measure.”
C. “Goal met; patient was able to transfer from the
bed to a wheelchair without assistance.”
D. “Goal not met.”
32. The goal or expected outcome “Patient will
maintain current weight of 165 pounds” can
best be evaluated by which of the following
measures?
A. Determining the patient’s food preferences
B. Monitoring dietary intake for each meal
C. Restricting high-calorie food
D. Weighing the patient on the same scale
33. The nurse manager evaluates the quality
of the nursing care plans developed for the
patients on the nursing unit. This is an example
of which type of evaluation?
A. Outcome
B. Peer
C. Process
D. Structure
34. In the implementing phase of the nursing
process, the nurse does which of the following
tasks?
A. Determines the patient’s health status
B. Identifies available resources
C. Measures goal achievement
D. Puts the nursing care plan into action
35. Collaborative nursing interventions:
A. Are based on the written instructions of
another professional
B. Are determined solely by the nurse and
patient
C. Reflect the overlapping responsibilities of
health care personnel
D. Require supervision by the doctor
36. When a assessing a patient’s level of pain,
which type of nursing intervention is the nurse
performing?
A. Collaborative
B. Dependent
C. Independent
D. Professional
37. What should the nurse do after making a
charting error in the nurses’ notes?
A. Draw a line through the error and write
“Error” and her initials above it
B. Obliterate the mistaken with a black felt
pen
C. Recopy the page of nurses’ notes and start
over
D. Report the incident immediately to the
head nurse
38. Independent nursing interventions:
A. Are also known as standing orders
B. Are initiated based on the nurse’s own
knowledge and skill
C. Consist primarily of health education
D. Relate directly to the patient’s disease
process
39. The head nurse wants to determine how
the size and location of the nursing station
influences the delivery of nursing care on the
unit. This is an example of which type of
evaluation?
A. Outcome
B. Peer
C. Process
D. Structure
40. Which of the following statements about
the term nursing process is true?
A. It is used only in the United States
B. It originated with Florence Nightingale
C. It was first used by Lydia Hall in 1955
D. It was initiated by the national league for
Nursing in 1983
41. The nurse has organized an immunization
clinic for healthy babies and preschool children.
This would be an example of what level of
preventative health care?
A. Curative
B. Primary
C. Secondary
D. Tertiary
42. The nurse is caring for a patient in the
hospital after the surgical removal of his
gallbladder. This would be an example of what
level of preventative health care?
A. Curative
B. Primary
C. Secondary
D. Tertiary
43. A nurse is a lifelong learner. The most
important reason for this is:
A. Accrediting agencies, such as the National
League for Nursing, require it
B. Employers require it to stay employed
C. Doctors need to be ensured the nurse is
competent in nursing
D. Nurses must remain current in nursing
research, skills, and knowledge
44. Maslow’s hierarchy of basic needs is a
common theory that nursing education
incorporates to explain the basic needs of
people. What need must be met before the
person can focus on safety and security?
A. Love and belonging
B. Physiological
C. Self-actualization
D. Self-esteem
45. The nurse performs many roles in the
practice of nursing. Which role is defined as “the
protection of human or legal rights and the
securing of quality care for each patient”?
A. Advocator
B. Communicator
C. Counselor
D. Leader
46. The nurse is teaching a diabetic patient
how to inject insulin and the dosages necessary
for optimal control. This would be an example of
what level of health care?
A. Curative
B. Primary
C. Secondary
D. Tertiary
47. Founder of the PNA
A. JulitaSotejo
B. Anastacia GironTupas
C. Eufemia Octaviano
D. Anesia Dionisio
48. A woman undergoing radiation therapy
developed redness and burning of the skin
around the best. This is best classified as what
type of disease?
A. Neoplastic
B. Traumatic
C. Nosocomial
D. Iatrogenic
49. The classification of CANCER according to its
etiology Is best described as
1. Nosocomial
2. Idiopathic
3. Neoplastic
4. Traumatic
5. Congenital
6. Degenerative
a. 5 and 2
b. 2 and 3
c. 3 and 4
d. 3 and 5
50. Term to describe the reactiviation and
recurrence of pronounced symptoms of a
disease
A. Remission
B. Emission
C. Exacerbation
D. Sub acute
51. A foley catheter operates by the principle
of
a. Inertia c. diffusion
b. Gravity d. osmosis
52. The client is receiving total parenteral
nutrition (TPN). Which lab test should be taken
daily?
a. Hemoglobin
b. Creatinine
c. Blood glucose
d. White blood cell count
53. Nurse Honeyboy is suctioning a client via a
tracheostomy tube. When suctioning, he must
limit the suctioning to a maximum of :
a. 5 seconds
b. 15 seconds
c. 10 seconds
d. 20 seconds
54. The client with Cirrhosis is scheduled for a
parencentesis. Which instruction should be
given to the client before the exam?
a. “You will need to lay flat during the exam.”
b. “You need to empty your bladder before
the procedure.”
c. “You will be asleep during the procedure.”
d. “The doctor will inject a medication to
treat your illness during the procedure.”
55. After undergoing a liver biopsy, the client
would be placed in which position?
a. Semi- fowler
b. lateral on affected site
c. supine
d. prone
56. Which medication administration situations
should be documented in a healthcare facility's
incident reporting system?

A. Medication errors and adverse drug reactions

only

B. Medication errors that cause patient harm

C. Near misses and medication errors only

D.near misses, medication errors, and adverse drug

reactions
57. A nurse is assessing his patients in the morning and finds that a frail a 85
year-old female patient is soiled in bed. The patient reports that she has been asked to
cleaned numerous times and has been ignored. Of the following, which demonstrates
appropriate documentation in the patient's chart.

A. The patient was found soiled in bed by this RN. she reports being left alone all night
by the night shift RN, who did not clean her before the change of shift. She was given
a bed bath and provided skin care. Her skin was reddened on her buttocks; emollient
applied.

B. The patient was found soiled in bed by this RN. She was incontinent of urine and
feces and she said she was "ignored for hours" by the night shift RN. She was given a
bed bath and provided skin care. Her skin was reddened on her buttocks; emollient
applied.

C.The patient was found soiled; incontinent of urine and feces. She was given a bed
bath and provided skin care. Her skin was reddened on the buttocks; Emollient
applied. Incident report made.

D. The patient was found soiled; incontinent of urine and feces. She was given a bed
bath and provided skin care. Her skin was reddened on the buttocks; emollient
applied.
58. A home health nurse makes weekly visits to an 87-year-old client
who lives with her son. When home alone, the client is talkative and friendly,
but when the son is home, the client is observed to be withdrawn and
appears anxious. The client has bruises, which she states is from "bumping
into things" and a weight-loss of 10 pounds in the past month. With these
objective findings, the nurse is required to do which of the following? Select
all that apply.

A. ask the client if she has any concerns about her living situation,
maintaining an objective, non-accusatory role.

B. Confront the son about the abuse, demanding that he turn himself in to
seek help for the abusive pattern of behavior.

C. Question the client's son privately about the suspicions of his mother's
condition and about possible abuse or neglect.

D. Report suspected abuse to adult protective services so investigation into

the clients welfare can be performed.
59. The nurse understands the following about informing
and obtaining consent for an eight-year-old patient who is
undergoing a heart transplant:

Select all that apply.

A. Since the child is a minor, he does not need to be informed

about the surgery
B. The child must be informed about the surgery.
C. The child must sign the informed consent form along with
their parent
D. The child only needs to know the risks of the surgery.
E. The parent/guardian must be informed of the risks and
benefits of the procedure and sign the informed consent on
behalf of the child
60. The patient refuses chemotherapy based
on religious beliefs. The hospital staff must
follow his decision based on which patient right?

A. The right to counsel

B. The right to informed consent
C. The right to refuse treatment
D. The right to suffer
61. The patient was recently admitted to hospice care for
lung cancer. After filling out his advanced directive, the
patient says that he worries his physician will be uninterested
in his care. Which of the following statements made by the
nurse best addresses the patient's concerns?

A. "After you fill out an advance directive, the physician plays

a limited role to allow you space and time to be with your
family."
B."Once you are admitted to hospice, the physician plays a
passive role."
C. "Your physician is required by law to help you, so don't
worry."
D. "Your physician will continue to take care of you. The
advanced directive just states what type of care you want, so
we can provide that care even when you cannot tell us too."
62. A physician involved in the patient's care
asks to see the results of his HbA1c. How should
the nurse respond?

A. "Asked the clerk for that information."

B. "I can't give you that information."
C. "It is 8.5."
D. "You can look it up on the computer"
63. A living will includes which of the following?

Select all that apply:

A. Documentation requirements
B. How and when the Living will takes effect
C. How the patient's valuables are distributed
among the family
D. Immunity from liability for following the living
will
E. Which family member will inherit the patient's
home
64. The circulating nurse in the OR notices a small
laceration on the patients hip while positioning pre-op,
but this was missed and not reported during the pre-op
assessment. Of the following, which is the appropriate
action for the nurse to take?

A. At the laceration to the pre-op nurses documentation

so it won't be confused with a surgical injury
B. Document the laceration along with the surgical sites
in the peri-op note
C. Document the presence of a preexisting skin laceration
in the peri-op now.
D. Report it to the receiving PACU nurse after the
procedure so she can document it.
65. Which of the following should the nurse
delegate to the LPN.

Select all that apply:

A. Administering a piggyback IV medication

B. IM medication administration
C. Initiating a primary IV medication
D. Oral medication administration
E. Urinary catheterization
66. Which of the following tasks can be delegated
to a nursing assistant?

Select all that apply.

A. Ambulating a stable patient

B. Emptying and measuring a foley catheter
reservoir
C. Intake and output documentation
D. Irrigating a nasogastric tube
E. nasotracheal suctioning of a stable patient
F. Setting up patient controlled analgesia
67. The five-year-old is admitted to the
hospital with pneumonia. The nurse observes
bruises on the child's back and arms. The
Mother is present in the patient's room. What
should the nurse do next?

A. Ask the mother if she is abusing her child

B. Call the police
C. Notify the physician of suspected child abuse
D. When the mother leaves, ask the child if she
feels scared or unsafe at home
68. A nurse on the medical surgical floor is caring for patient who
is confused and combative after abdominal surgery. The patient has
pulled out the nasogastric tube required for gastric rest. The nurse
called the doctor to discuss these issues. The doctor has ordered two
point restraints , so the nurse creates a telephone order read back. The
nurse knows that the restraint order will require which of the
following?

Select all that apply.

A.The doctor must perform an in person assessment of the patient's

need for restraints within one hour
B. The doctor must sign a telephone order and assess the need for
continued restraints every four hours
C. The doctor must sign a telephone order and assess the need for
continued restraints within 24 hours
D. The nurse assesses the patient's need for restraints and obtain
another telephone order each hour
69. Which of the following contributions of
Florence Nightingale had an immediate impact
on improving patient's health?
A. Providing a clean environment
B. Improving nursing education
C. Changing the delivery of care in hospitals
D. establishing nursing as a distinct profession
70. Which of the following is the most important
reason for nurses to be critical thinkers?
A. Nurses need to follow policies and procedures
B. Nurses work with other healthcare
professionals
C. Nurses care for patients with multiple health
issues
D. Nurses have to be flexible and work different
schedules
71. Which of the following includes objective
and subjective data?
A. Patient's BP is 132/68 and HR is 88
B. Patient's cholesterol is elevated, and stated
that he likes fried food
C. Patient states she is having trouble sleeping
and drinks coffee at night
D. Patient states he gets frequent headaches
and takes aspirin for it
72. Which of the following is an example of an
active listening behavior?
A. Taking frequent notes
B. Asking for more details
C. Leaning in, facing the patient
D. Sitting with legs crossed
73. Which of the following explains why it is
important to have the correct etiology for a
nursing diagnosis? The etiology:
A. is the cause of the problem
B. can not always be observed
C.directs nursing care
D. is an inference
74. Who is the primary decision maker when
caring for healthy adult clients?
A. Physician
B. Family
C. Patient
D. Nurse
75. Which of the following nursing
interventions is an indirect-care intervention?
A. Emotional support
B. Teaching
C. Consulting
D. Physical care
76. A patient is having difficulty with feelings
of self-loathing and disgust after being attacked
and raped. According to Maslow, which level is
the patient struggling with?
A. Physiological
B. Safety & Security
C. Love & Belonging
D. Self-esteem
77. The nurse is talking to a class of children
ages 9-12. For this group, it would be most
important for the nurse to discuss______.
A. Safe sex practices
B. Healthy food choices
C. Importance of getting enough sleep
D. Use of seat belts and safety equipment
78. The nurse should encourage a group of
teenagers to eat plenty of _______________?
A. Dairy products
B. Fish
C. Nuts & Legumes
D. High fiber products
79. A patient tells the nurse, "I can't see well
enough to read anymore. I have new glasses but
it is still hard." What should the nurse advise the
patient to do first?
A. Go back to the eye doctor and have the
glasses checked.
B. Buy some audio books and listen to those.
C. Adapt to reading less.
D. Install a bright, but glare-free light near
where you read.
80. When providing postmortem care, why
would the nurse place dentures in the mouth
and close the eyes and mouth of the patient
within 2 to 4 hours after death?
A. To prevent blood from settling in the head,
neck, and shoulders
B. To perform these actions more easily before
rigor mortis develops
C. To set mouth in natural position for viewing
by the family
D. To prevent discoloration caused by blood
settling in the facial area.
81. A client who cannot manage a patient-
controlled analgesia pump is prescribed
morphine 4mg IV q 1 hr PRN for pain. When
should the nurse administer the medication?
A. Every hour around the clock
B. Immediately after taking off the order
C. As needed, but not more than once per hour
D. 1 hour after the last dose administered.
82. Which of the following nursing activities is
of highest priority for maintaining medical
asepsis?
A Washing hands
B. Donning gloves
C. Wearing a gown
D. Wearing a face mask
83. Which of the following behaviors indicates
the highest potential for spreading infectious
among patients. The nurse
___________________
A. disinfects dirty hands with antibacterial soap.
B. allows alcohol-based rub to dry for 10
seconds
C. washes hands only after leaving patients
room
D. uses cold water for medical asepsis.
84. Alcohol-based solutions for hand hygiene
can be used to combat which types of
organisms? Select all that apply.
A. Virus
B. Bacterial Spores
C. Yeast
D. Mold
85. A patient infected with a virus but who
does not have any outward signs of the disease
is considered a:
A. pathogen
B. fomite
C. vector
D. carrier
86. The nurse is instructing a client how to
appropriately dress an infant in cold weather.
Which of the following instructions would be
most appropriate for the nurse to include?
A. Be sure to put mittens on the baby
B. Layer the infant's clothing
C. Place a cap on the baby's head
D. Put warm booties on the baby
87. Bathing a patient with liver dysfunction,
the nurse notes yellow skin tone. The nurse
should document this finding as:
A. Edema
B. Jaundice
C. Cyanosis
D. Pallor
88. Where should the nurse assess skin color
changes in the dark-skinned patient?
A. Nailbeds
B. Any exposed area
C. Oral mucosa
D. Palm of hands
89. What is the body's first line of defense
against bacteria?
A. intact skin
B. hair
C. immune system
D. lymph glands
90. Before administering medication, the
nurse must verify the rights of medication
administration which include:
A. right patient, right room, right drug, right
route, right time
B. right drug, right dose, right route, right
physician, right time
C. right patient, right drug, right route, right
equipment, right time
D. right patient, right drug, right dose, right
route, right time, right documentation
91. Which action should the nurse take to
relax the vastus lateralis muscle before
administering an IM injection into this site?
A. Apply a warm compress
B. Massage the site in a circular motion
C. Apply a soothing lotion
D. Put the patient in a sitting position
92. When changing a diaper, the nurse
observes that a 2 day old infant has a green,
black, tarry stool. What should the nurse do?
A. notify the physician
B. Do nothing, this is normal
C. Give the baby sterile water
D. Apply a skin barrier
92. When changing a diaper, the nurse
observes that a 2 day old infant has a green,
black, tarry stool. What should the nurse do?
A. notify the physician
B. Do nothing, this is normal
C. Give the baby sterile water
D. Apply a skin barrier
93. A patient suddenly develops right lower
quadrant pain, nausea, vomiting. How should
the nurse classify this patient?
A. Acute
B. Chronic
C. Intralatable
D. neuropathic
94. A patient who underwent a left above the
knee amputation complains of pain in his left
foot. What type of pain is he experiencing?
A. psychogenic
B. phantom
C. reffered
D. radiating
95. A patient has an area of non-blancheable
erythemia on his coccyx. The nurse has
determined this to be a stage I pressure ulcer.
What would be the most important treatment
for this patient?
A. transparent film dressing
B. sheet hydrogel
C. frequent turn schedule
D. debridement
96. Which electrolyte is the primary regulator
of fluid volume?
A. potassium
B. calcium
C. sodium
D. magnesium
97. Which of the following terms refers to the
ethics questions that arise out of nursing
practice?
A. nursing ethics
B. bioethics
C. ethical dillema
D. moral distress
98. Which form of communication is the nurse
using when interviewing the patient during the
admission health history and physical
assessment?
A. small group
B. interpersonal
C. group
D. intrapersonal
99. The patient refuses chemotherapy based
on religious beliefs. The hospital staff must
follow his decision based on which patient right?

A. The right to counsel

B. The right to informed consent
C. The right to refuse treatment
D. The right to suffer
100. A nurse stops to help in an emergency at at
the scene of an accident. The injured party files a
suit and the nurse's employing institution insurance
does not cover the nurse. What would probably
cover the nurse in this situation?
A. The nurse's auto insurance
B. The nurse's homeowner's insurance
C. The Good Samaritan laws, which grant immunity
from suit if there is no gross negligence.
D. The Patient Care Partnership, which may grant
immunity from suit if the injured party contends.