Post Test Funda Key

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POST TEST FUNDAMENTALS OF NURSING Philippine Nursing Licensure Examination NAME:

1. The client’s temperature at 8am using an oral electronic thermometer is 36.1 degree C (97.2 F). If the respiration, pulse and blood pressure were within normal range. What would the nurse do next? A. Wait 15 minutes and retake it B. Check what the client’s temperature was the last time it was taken. C. Retake it using a different thermometer D. Chart the temperature as it is normal 2. When the nurse enters a client’s room to measure routine vital signs, the client is on the phone. What technique should the nurse use to determine the respiratory rate? A. Count the respirations during conversational pauses. B. Ask the client to end the phone call now and resume it at a later time. C. Wait at the client’s bedside until the phone call is completed and then count respirations. D. Since there is no evidence of distress or urgency, postpone the measurement until later. 3. For a client with a previous blood pressure of 138/74 mmHg and a pulse of 64bpm, approximately how long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading? A. 10-20 seconds B. 30 -45 seconds C. 1-1.5minutes D. 3-3.5 minutes

4. An 85 year old client has had a stroke resulting in right sided facial drooping, difficulty swallowing and the inability to move self or maintain position unaided. The nurse determines that which site are most appropriate for taking the temperature? SATA 1. Oral 2. Rectal 3. Axillary 4. Tympanic 5. Temporal Artery A. 1,2,3,4 B. 3,4 C. 3,4,5 D. 2,3,4 5. When auscultating the blood pressure, the nurse hears: From 200 to 180 mmhg: silence; then a thumping sound continuing down to 150 mmHg;muffled sounds continuing down to 130 mmHg; soft thumping sounds continuing down to 105 mmHg; muffled sounds continuing down to 95mmHg; then silence. The nurse recods the blood pressure as : A. 180/95 B. 150/95 C. 180/105 D. 150/105 6. Which is a normal finding on auscultation of the lungs? A. tympany over the right upper lobe. B. Resonance over the left upper lobe. C. hyperresonance over the left lower lobe D. dullness above the left 10th intercostal space.

7. After auscultating the abdomen, the nurse should report which finding to the primary care provider? A. bruit over the aorta B. absence of bowel sounds for 60 seconds. C. continuous bowel sounds over the ileocecal valve. D. a completely irregular pattern of bowel sounds. 8. If unable to locate the client’s poplitel pulse during a routine examination. what should the nurse do next? A. check for pedal pulse B. check for femoral pulse C. take the client’s blood pressure on the thigh D. ask another nurse to try to locate the pulse 9. A 78 year old male needs a 24 hour urine specimen. In planning his care, the nurse realizes that which measure is most important? A. A.Instruct the client to empty his bladder and save this voiding to start the collection. B. Instruct the client to use sterile individual containers to collect the urine. C. post a sign stating “Save All urine” in the bathroom. D. keep the urine specimen in room temperature. 10. The physician orders a urine culture and sensitivity for a 36 year old patient with an indwelling Foley catheter. Which of the following actions by the nurse is best? A. The nurse clamps the catheter tubing below the level o f the port for 10 minute. B. The nurse removes 20 ml from the catheter bag and place it in a sterile container. C. The nurse separates the catheter from the tubing and allows 30 ml of urine to drain into a sterile cup. D. The nurse clamps the catheter just below the insertion site for 20 minutes.

11.Lipoproteins carry cholesterol in the bloodstream. For this reason, primary caregivers are interested in monitoring lipid density profiles. Which of the following is of primary interest to the primary caregiver in relationship to the patient’s risk for cardiovascular disease? A. VLDL and Hct B. VLDL and HDL C. LDLs and Hgb D. LDLs and HDLs 12. The nurse is instructing a patient about a TENS unit, how it is used, and how it works. Appropriate information for this patient would be: A. “The stimulation of the skin seeks to localize the acute pain and will last for several minutes after the unit is applied.” B. “This unit stimulates both the skin and the underlying tissues to decrease the intensity of the pain.” C. “The mechanism for use of this unit is well known and can be read about.” D. “During those days when using the TENS unit, no analgesic can be given.” 13. A patient admitted with the diagnosis of possible myocardial infarction complains of pain and tingling in his left arm says, “How in the world could I be having a heart attack when it’s just my arm that is giving me trouble?”The nurse explains that the patient is experiencing: A. referred pain. B. psychogenic pain. C. neuromuscular pain. D. muscle spasms of shoulder. 14. To perform postural drainage on a patient, the nurse should: A. Encourage the patient to drink 8 oz of water 30 minutes before the procedure. B. Suction the patient before performing the procedure. C. Ask the patient which position he finds most comfortable.

D. Perform the procedure before the client takes his meal. 15. Which finding would the nurse identify as interfering with the effective functioning of the chest tube? A. 15 cm water suction on chest tube system. B. An air leak in water seal chamber C. Leaking blood around chest tube site. D. Clots of blood in the chest tube. 16. There is a continuous bubbling in the water sealed drainage system with suction. And oscillation is observed. As a nurse, what should you do? A. Consider this as normal findings B. Notify the physician C. Check for tube leak D. Prepare a petrolatum gauze dressing 17. Which of the following if done by a nurse indicates deviation from the standards of NGT feeding? A. Do not give the feeding and notify the doctor of residual of the last feeding is greater than or equal to 400 ml B. Height of the feeding should be 12 inches about the tube point of insertion to allow slow introduction of feeding C. Ask the client to position in supine position immediately after feeding to prevent dumping syndrome D. Clamp the NGT before all of the water is instilled to prevent air entry in the stomach 18. To ensure a good fit of the appliance to avoid leakage, which of the following should the nurse consider for pouch placement? A. Place the pouch only when the patient is lying down. B. The pouch placement should be checked for sitting comfort, standing comfort, and ambulation. C. The pouch should fit very snugly to edges of stoma. D. The pouch must cover the entire abdomen.

19. For which of the following client’s would you take an apical pulse rather than radial pulse? A. A client in shock B. To check a client’s response to changing from a lying to a sitting position C. A client with an arrhythmia D. A client less than 24 hours postoperative 20. The nurse is assisting a female client to collect a midstream urine specimen. The nurse uses the principles of aseptic technique by A. Cleansing the meatus with antiseptic pads using upward strokes. B. Letting go of the labia once they are cleansed to allow the client to urinate. C. Making sure that the fingers avoid touching the inside of the collection container. D. Instructing the client to urinate in the container after the labia has been cleansed. 21. When discarding used needles and syringes, which of the following is appropriate nursing action? A. Remove needle from syringe and discard them in separate containers. B. Recap needle, then discard the needle still attached to the syringe into a container. C. Discard the uncapped needle and syringe into a container D. Break the needle, then discard syringe into a container 22. Which of the following if done by a nurse indicates deviation from the standards of NGT feeding? A. Give the feeding and notify the doctor of residual of the last feeding is greater than or equal to 400 ml B. Height of the feeding should be 12 inches about the tube point of insertion to allow slow introduction of feeding C. Ask the client to position in Fowler’s position immediately after feeding

D. Clamp the NGT before all of the water is instilled to prevent air entry in the stomach 23. Which of the following statements made by a patient who is scheduled for a mammogram indicates a need for further teaching? A. I will not use underarm antiperspirant before the procedure. B. A dye will be injected into my vein prior to the procedure. C. I may experience discomfort during the procedure. D. My Breasts will be compressed while the X rays are taken 24. Which of the following conditions, reported to a nurse by a 20 year old male patient, would indicate a risk for development of testicular cancer? A. Genital herpes B. Undescended Testicle C. Measles D. Hydrocele 25. The patient with cirrhosis would have which of the following laboratory results? A. Increased serum albumin B. Elevated serum transaminase C. Normal Prothrombin time D. Increased serum magnesium 26. The nurse is scheduling a client for a series of diagnostic studies of the gastrointestinal (GI) system. Which of these studies should the nurse schedule last to avoid altering the results of the remaining tests? A. Ultrasound B. Colonoscopy C. Barium enema D. Computed tomography 27. The nurse has administered approximately half of a high-cleansing enema when the client reports pain and cramping. Which nursing action is appropriate? A. Reassuring the client that those sensations will subside

B. Discontinuing the enema and notifying the primary health care provider C. Raising the enema bag so that the solution can be introduced quickly D. Clamping the tubing for 30 seconds and restarting the flow at a slower rate 28. The nurse caring for an immunosuppressed patient is diligent about protecting the patient from infection.When visitors come in, in addition to having them put on isolation garb, the nurse would prohibit them bringing: A. a battery-operated DVD player. B. books. C. potted plants. D. boxed candy. 29. A nurse caring for a patient who has been on bed rest for a week notices a reddened area on the patient’s left hip. The skin is intact but, when the nurse presses on the area, the redness does not fade. The nurse recognizes this pressure ulcer as a: A. Stage I ulcer B. Stage II ulcer C. Stage III ulcer D. Stage IV ulcer 30. A client diagnosed with left pleural effusion has just been admitted for treatment. The nurse should plan to have which procedure tray available for use at the bedside? A. Intubation B. Paracentesis C. Thoracentesis D. Central venous line insertion 31. Organize the following steps of suctioning in chronological order: ‘ 1. Put on sterile gloves 2. Lubricate catheter with normal saline 3. Apply suction for 5-10 seconds 4. Explain procedure to the patient 5. Wash hands thoroughly A. 4,5,1,2,3 B. 5,4,1,2,3 C. 5,1,2,1,3

D. 4,5,2,1,3 32. A nurse is teaching a client with left leg weakness to walk with a cane. The nurse should include which nursing points about safe cane use in the client teaching?SATA 1. Place the cane 8”-10” from the base of the little toe. 2. Hold the cane on the uninvolved side of the body 3. Adjust the cane so that the handle is level with the hip bone 4. Walk by moving the involved leg,then the cane, and then the uninvolved leg 5. Shorten the stride length on the involved side A. 1,2,3,4 B. 2,3 C. 2,3,5 D. 1,3,4 33. Which of the following, if done by the nurse, indicates incompetence during suctioning an unconscious client? A. Measure the length of the suction catheter to be inserted by measuring from the tip of the nose, to the earlobe, to the xiphoid process B. Use KY Jelly if suctioning nasopharyngeal secretion C. The maximum time of suctioning should not exceed 15 seconds D. Allow 30 seconds interval between suctioning 34. The nurse is demonstrating colostomy care to a client with a newly created colostomy. The nurse demonstrates the correct cutting of the appliance by making the circle how much larger than the client’s stoma? A. 1/8 inch B. 1/4 inch C. 1/2 inch D. 1 inch 35. A child with the diagnosis of Hirschsprung’s disease has a temporary colostomy. The nurse provides instructions to the parents about

colostomy care at home. Which statement by the parents indicates their understanding of the instructions? A. “We will give antidiarrheal medications.” B. “We will report signs of skin breakdown.” C. “We will give saline water enemas if my child doesn’t pass stool.” D. “We will apply a heat lamp to any moist red tissue around the stoma.” 36. In caring for client on contact precaution for a draining infected foot ulcer, correct technique include A. Wearing a mask during dressing changes. B. Providing disposable meal trays and silverwares C. Following standards precaution in all interaction with the client D. Using surgical aseptic technique for all direct contact with the client. 37. An early finding that would indicate that a client is hypertensive is: A. An extended Korotkoffs sound B. A regular pulse of 92 beats per minute C. A diastolic blood pressure that remains greater than 90 mm Hg D. An achy, throbbing headache over the left eye when arising in the morning 38. A client has an order for an injection to be administered intradermally. The nurse avoids which of the following actions when administering this medication? A. Inserting the needle at a 10- to 15-degree angle B. Injecting the medication slowly C. Massaging the area after removing needle D. Making a circular mark around the injection site 39. When teaching how to use a nebulizer, the nurse should instruct the client to: A. Hold the breath while spraying the medication carefully into each nostril

B. Instill the medication from the nebulizer while exhaling through the nose C. Seal the lips around the mouthpiece taking rapid, shallow breaths through the mouth D. Loosely place the lips around the mouthpiece taking a slow, deep breath through the mouth 40. A nurse receives a call that a client is being admitted who will undergo implantation of a sealed internal radiation source. The nurse contacts the admission office clerk to ensure that which of the following rooms is selected for the client? A. A single room at the distance end of the hall B. A single room near the nurse’s station C. A semiprivate room between 2 isolation rooms D. A semiprivate room near the nurse’s stations 41. A female client with a diagnosis of cancer of the cervix has a radon seed implanted. Which data would it be important for the nurse to assess every few hours? A. Presence of nausea and vomiting. B. Hydration status. C. Dislodging of radiation source. D. Ability of the client to change position. 42. To adequately inspect the external ear canal of an adult client, the nurse should do which of the following prior to inserting the otoscope? A. Require that all earrings be removed for safety purposes B. Pull the pinna up and back C. Use an applicator to remove cerumen D. Have the client lie down to promote comfort 43. The nurse is instructing a client who had a stroke how to ambulate using a cane. Which of the following instructions would the nurse provide to the client? A. To hold the cane on the affected (weak) side

B. To hold the cane on the unaffected (strong) side C. To move the cane forward first along with the unaffected (strong) leg D. When going down stairs, to move the cane and the unaffected (strong) leg down first 44. A school nurse has conducted a class on testicular self-examination at the local high school. The nurse determines that the information was interpreted correctly if one of the students states to A. Perform the examination after a cold shower. B. Expect the examination to be slightly painful. C. Roll the testicle between the thumb and forefinger. D. Perform the self-examination every other month. 45. A nurse is instructing a client to perform a two-point gait for crutch walking. The nurse tells the client to A. Move the left fool forward and then the left crutch forward, followed by the right crutch and then theright foot. B. Advance the right crutch and the left foot forward, followed by advancing the right foot and the left crutch forward. C. Advance both crutches forward, followed by the left foot and then the right foot. D. Advance the right foot and then the left foot, followed by both crutches. 46. The oxygen administration device preferred for patients with COPD is: A. Nasal canulla B. Oxygen tent C. Venturi mask D. Oxygen hood 47. A nurse has just received an order to transfuse a unit of packed red blood cells for an assigned client. In planning coverage for the client assignment, the nurse asks if another

nurse will be available to check on the other assigned clients for how long when the unit of blood is hung? A. B. C. D.

5 minutes 15 minutes 30 minutes 45 minutes

48. A nurse enters the nursing lounge and discovers that a chair is on fire. She activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. The next appropriate action in the use of the fire extinguisher is to A. Squeeze the handle on the extinguisher. B. Aim at the base of the fire. C. Sweep the fire from side to side with the extinguisher. D. Sweep the fire from top to bottom with the extinguisher. 49. The following are appropriate nursing actions when performing physical health examination to a client EXCEPT: A. Ensure privacy of the client throughout the procedure B. Prepare the needed articles and equipment before the procedure C. Assess the abdomen following this sequence: right lower quadrant, right upper quadrant, left upper quadrant, left lower quadrant D. When assessing the chest, it is best to place the client in side-lying position 50. The nurse provides information to a client about performing a breast selfexamination (BSE). The nurse determines that the client needs additional teaching if the client makes which statements? 1. “The BSE must be done monthly.” 2. “Lumps in my armpit area are normal.” 3. “I can palpate my breasts with soapy water while showering.” 4. “I should perform the examination on the day that I start my period.”

5. “When I squeeze my nipples, I should expect to note some discharge.” 6. “I should stand before a mirror and inspect each breast for anything unusual. A. B. C. D.

2,4,5 1,3,6 2,3,4,5 2,4,5,6