Fundamental of Nursing-nle

FUNDAMENTAL OF NURSING 1. The nurse knows which of the following indicates protein deficiency?

b. Patient must be competent c. Knowledgeable information should be provided d. It must be signed right after administration of pre-ops meds. meds. 9. The following concepts of liability negligence are true,except true, except? ?

a. Hypoalbuminemia and pot belly  b. Koionychia (spoon-shaped nails) c. Beefy red tongued. d. Bleeding gums 2. Before administering administering a tube feeding the nurse knows to perform which of the following assessments? a. The GI tract including bowel sound, last BM and distention b. The clients neurologic status, especially gag reflex c. The amount of air in the stomach d. The formula used directly from the refrigerator 3. An adult is being taught about a healthy diet. The nurse can offer: a. Milk b. Jello b.  Jello c. Freshly squeezed orange juice d. Ice cream 5. An adult has received an injection of immunoglobulin of immunoglobulin . The nurse knows that the client will develop which of the following types of  immunity: a. Active natural immunity b. Active artificial immunity c. Passive natural immunity d. Passive artificial immunity  6. BON Resolution No 432 S 2003 is: a. Guidelines for the implementation of Board Resolution No. 14 S 1999 b. Implementing Rules and Regulations of RA 9173 c. Special training on intravenous injection for nurses d. Adoption of a Guide to Evaluate Compliance with Standard for Safe Nursing Practice. 7. Its a type of non-probability sampling wherein the researcher researcher identifies population strata and determines how many participants are needed for each stratum a. Quota Sampling b. Purposive Sampling c. Convenience sampling d. Simple stratified sampling 8. All but one are concepts of informed consent. a. It must be voluntary-without coercion or force

a. Deviation from standard of care is established. b. Duty is owed to the nurse c. Financial, physical and emotional harm is establish d. Direct cause for failure to meet standard of care clearly established. 10. The nurse is caring for a client whose arterial blood gases indicate metabolic acidosis. The nurse knows that of the following, the least likely to cause metabolic acidosis is: a. cardiac arrest b. Diabetic ketoacidosis c. decreased serum potassium level  d. renal failure 11. The nurse is caring for a client who is receiving IV fluids, Which observation the nurse makes best indicates that the IV has infiltrated? a. Pain at the site b. A change in flow rate c. Coldness around the insertion site d. Redness around the insertion site 12. A 27 y.o adult is admitted for treatment of Crohn's disease. Which information is most significant when the nurse assesses nurtritional health? a. Anthropometric measureme a.  measurements nts b. bleeding gums c. dry skin d. facial rubor 13. ASA (aspirin) is being administered to a client. The nurse understands that the most common mechanism of action for nonnarcotic analgesic is their ability to: a. Inhibit prostaglandin systhesis b. After pain perception in the cerebellum c. Directly affect the central nervous system d. Target the pain-producing effect of kinins 14. The nurse caring for an adult client who is receiving TPN will need to be monitored for which of the following metabolic complications? a. Hypoglycemia and Hypercalcemia b. Hyperglycemia and Hypokalemia c. Hyperglycemia and Kyperkalemia d. Hyperkalemia and Hypercalcemia

15. Total parenteral nutrition is ordered for an adult. Which nutrient is not likely to be in the solution? a. Dextrose 10% b. Trace minerals c. Amino acids d. Non of the above 16. A man has sprained his ankle. The physician would order cold applied to the injured area to. a. Reduce the body's temperature b. Increase circulation to the area c. Aid in absorbing the edema d. Relieve pain and control bleeding. 17. An adult is to have a tepid sponge bath to lower his fever. What temperature should the nurse make the water? a. 65 F b. 90 F  c. 110 F d. 105 F 18. An adult has chronic lower back pain and receives hot pack three times a week. The nurse knows that the treatment is given for which of the following reasons? a. To help remove debris from the wound b. To keep the client warm and raise his temperature c. To improve the client's general circulation d. To relieve muscle spasm and promote muscle relaxation 19. An insane man got hold of a knife and stabbed a pregnant woman. His liability will be determined by virtue of : a. Justifying circumstances b. Exempting circumstances c. Mitigating circumstances d. Aggravating circumstances 20. A crime in which all the elements necessary for its execution and accomplishment are present. a. Heinous crime b. frustrated crime c. consummated crime d. attempted crime 21. Once criterion to assess the quality of a study is triangulation. This means. a. accuracy and consistency of information b. soundness of evidence

c. use of multiple sources for conclusions d. consistency and stability of evidence over time 22. It is thought to be the most recent method or system in providing nursing care a. Case System method b. primary nursing method  c. functional nursing method d. team nursing method 23. A patient classification system where patients minimal theraphy and less frequent observation a. minimal care (category 1) b. moderate care (category 2) c. maximum care (category 3) d. intensive care (category 4) 24. The nurse is to apply a dressing to a stage II pressure ulcer. Which of the following dressing is best? a. Dry gauze dressing b. wet gauze dressing c. wet to dry dressing d. moisture vapor permeable dressing 25. The client has been placed in the trendelenburg position. The nurse knows the effects of this position to the client include which of the following. a. increase blood flow to the feet b. decrease blood pressure c. increase pressure on the diaphragm d. decrease intracranial pressure 26. A man who has been in an MVA is going into shock. Before placing the client in a modified trendelenburg position, the nurse should assess the client for: a. long bone fracture b. air embolus c. head injury  d. thrombophlebitis 27. The nurse enter a room and finds a fire. Which is the best initial action? a. Evacuate any people in the room, beginning with the most ambultory  and ending with the least mobile b. activating the fire alarm or call the operator, depending on the institutions system c. get a fire extinguisher and put out the fire d. close all the windows and doors and turn off any oxygen or electricity appliance.

28. A member of the board of nursing may be removed and/or suspended on the following grounds except: a. Toleration of irregularities in the licensure examination b Violation of the Philippine Nursing Act  c. Neglect of duty or incompetence d. Immoral unprofessional or dishonorable conduct 29. A tendency of the evaluator to inaacurately rate a group because of the belief that he/she has a very good cooperative group.

b. go to the bahtroom and void saving a sample c. assume a lithotomy position on the exam table d. assemble all the equipments needed for the examination 35. An adult is supine. Which of the ff. can the nurse to to prevent external rotation of the legs? a. put a pillow under the clients lower legs b. place a pillow directly under the client knee c. use a trochanter rool alongside the client's upper thighs d. lower the client's legs so that they ae below hips. 36. The following are elements of felony except?

a. hawthorne effect b. sunflower effect  c. horn's effect d. halo effect

a. There must be an act of ommision b. such act or omission must be done voluntarily c. such act maybe done with or without intent  d. such act or omission is punisable by law

30. A type of probability sampling where the researcher selects random samples, successively from a larger to smaller units by either simple or stratified methods.

37. To qualify as a dean of the college of nursing the applicants must have?

a. Multi-stage sampling b. Systematic sampling c. purposive sampling d. snowballing sampling

a. At least 5 years of teaching and supervision b. At least 10 years of clinical practive c. At least 3 years of being a clinical coordinator d. At least 2 years management units.

31. The nurse is to open a sterile package from central supply. Which is the correct direction to open the first lap?

38. A research design where there is manipulation of independent variable but no random or control group

a. Toward the nurse b. Away from the nurse c. To the nurse's left or right hand d. It does not matter as long as the nurse touches only the outside edge

a. longitudinal design b. quasi-experimental  c. experimental d. cross-sectional

32. The nurse knows which of the following is the proper technique for medical asepsis?

39. Four clients have signaled with the call bells for the nurse. Who should you see first?

a. gloving for all the client contact b. changing hospital linens weekly c. using your hands to turn off the faucet after handwashing d. gowning to care for a 1 year old child w/ infections diarrhea

a. A client who needs to use the toilet b. A client who does not have his glasses or hearing aide c. A client who has just been given morphine d. A client in a chair with a restraint vest on.

33. An adult ha a left, above the knee amputation two weeks ago. The nurse places him in a prone position tree times a day because

40. Which of the ff. should the nurse observe first?

a. Prevents pressure ulcer on the sacrum b. helps the prosthesis to fit correctly c. prevents flexion constractures d. allow better blood flow to the heart

a. A client who has just returned from the OR b. A client whose call light is not working c. A client with Alzheimer's disease d. A clietn who is receiving a heating pad treatment 41. Which of the ff. should the nurse deal first?

34. A woman is to have a pelvic exam. Which of the following should the nurse have the client do first? a. Remove all her clothes and her socks and shoes

a. A client who need her dressing changed b. A client who needs to be suctioned  c. A client needs to be medicated for postoperative pain

d. A client who is incontinent and needs to be cleaned 42. One of the major ethical princles in research is beneficence that includes:

a. apply a cold compress to decrease swelling b. apply a warm compress to dilate the blood vessels c. Massage the area to promote absorption of the drug d. Instruct the client to tighten his gluteal muscles to enhance absorption of the drug

a. Right to protection of protection from physical and psychological harm b. Right to full-disclosure c. Right to performance of sources good d. Right to protection of participants form explotation.

55. These are mitigating circumstances that lessen the penalty, except:

43. He described humans as "wanting organism" that satisfly their basic needs in a specific sequence?

a. Under 18 and over 70 b. No intention to commit so grave c. There wa sufficent provocation d. in contempt of authority 

a. Frederick Herzberg b. Abraham Maslow  c. BF Skinner d. Victor Vroom 50. A client has been receiving an I V solution. What is an appropriate expected outcome for this client? a. Monitor fluid intake and output every 4 hours b. The client remains free of signs and symptoms of phelibits c. edema and warmth over the IV site d. Excess fluid volumn evidenced by weight gain 51. This theorist of management developed the 14 principles of  management based on his experience. a. Mary Follett b. Max Weber c. Henry Fayol  d. Kurt Lewin 52. The nurse prepares to palpate a clients maxillary sinues. For this procedure, where should the nurse place the hands? a. On the bridge of the nose b. below the eyebrows c. below the cheekbones d. over the t emporal area 53. A client who receives general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? a. Pain related to the surgery b. Fluid volume deficit related to fluid and blood loss from surgery c. Impared physical mobility related to surgery d. Risk for aspiration related to anesthesia 54. After a client receives an IM injection, he complains of a burning pain in the injection site. Which nursing action whould be best to take at this time?

56. The nurse is monitoring options of effectiveness of drug theraphy, when should the nurse obtain a measurement of the blood sample through level. a. 1 hour before administering the next dose b. immediately before administering the next dose c. immediately after administering the next dose d. 30 mins. after administering the next dose 57. Which od the following options servers a framework for nursing education and clinical practice? a. Scientific breakthrough b. technological advances c. theoretical models d. medical practices 58. Nursing care for a client includes removing elastic stocking once per day. What is the rationale for this interventions? a. TO increase blood flow to the heart b. to observe the lower extremities c. to allow the leg muscles to stretch and relax d. To permit veins in the legs to fill with blood. 59. Hyperactive bowel sounds can result from all the following except. a. Paralytic ileus b. hunger c. intestinal obstruction d. diarrhea 60. The following characteristics speak of a leader except: a. Do the right thing b. focus on people c. develops visions and strategies d. have a short-term views 61. This theory of management suggest that an employees work

motivation is controlled by conditions in the external environment rather than by internal needs and desires. a. vroom's expectancy theory b. skinner's operant theory  c. adam's equity theory d. white competence theory 62. In Lydia Hall's theory, which of the ff. represents "core"? a. Nurturance and factors that are exclusive to nursing b. Therapeutic use of self  c. Focuses on nursing related to physicians order d. All of the above. 63. A research that seeks to describe an existing problem situation and examine the underlying factors that contributes to the emergence of the problem: a. Explanatory research b. Quantitative research c. Exploratory research d. Quantitative research 64. During blood transfusion, the patient manifest tacycardia, distended neck vein and increase CVP reading, the nurse should a. Obtain vital signs b. Call the physician c. Stop the infusion d. Decrease the rate of infusion. 65. A nurse who is maintainin a private clinic in the community and renders service on materials and child health amont the neighborhood for a fee is a. primary care nurse b. an independent nurse practioner  c. n urse-midwife d. a nurse specialist 66. A client comes to the clinic for a diagnostic allergy testing. Why is intradermal injections used for such tsting. a. intradermal injection is less painful b. intradermal drugs are easier to administer c. intradermal drug diffuse more rapidly d. intradermal drugs diffuse more slowly  67. A client is placed in isolation. Client isolation techniques attempt to break the chain of infection by interfering with the a. Agent b. susceptible host

c. transmission mode d. portal of entry 68. A research hypothesis that proposes that there is association or significant relationship between variables is called. a. null hypothesis b. directional hypothesis c. alternative hypothesis d. non-directional hypothesis 69. Which of the ff. laboratory test results is themost impt. indicator of malnutrition in a client with a wound? a. serum potassium level b. albumin level  c. lymphocyte count d. differential count 70. Which detail of a clients drug theraphy is the nurse legally responsible for documenting? a. Peak concentration time of drug b. Safe ranges of the drug c. Clients socioeconomic data d. client's reaction to the drug 71. Which of the ff. statements about these nursing practice acts are true? a. These acts are not effective in the supervision or revocation of licensure of erring nurses b. These acts have been authorized by the accredited national nurses organization c. These acts usually define the scope of nursing practice d. These acts describe the diffences between a registered nurse and a practice nurse 72. The following are true on a manager except? a. Are interested in efficiency b. emphasize tactics, structure and system c. motivate people to comply with standards d. use person to person influence 73. The nurse is assessing tactile fremitus in a client with pneumonia. For this examination, the nurse hould use the: a. fingertips b. ulnar surface of the hand  c. dorsal surface of the hand d. finger pads 74. The ff. activities belong to the design phase in the research process, except? a. developing a time table b. selecting the study design c. determining sampling plan d. conducting a pilot study 75. When inspecting a client's skin, the nurse finds a vesicle on the client's arm. Which description appliest to a vesicle? a. flat, nonpalpable and colored b. solid, elevated and cicumscribed c. circumscribed, elevated, and filled with serous fluid  d. elevated, pus-filled and circumscribed 76. Which nursing action is essential when providing continuous enteral feeding?

a. elevating the head of the bed  b. positioning the client on the left side c. warming the formula before administering it d. hanging a full day's worth of formula at one time 77. After initial assessment of a client, findings reveals a body temp of 38.5 C, Consequently the clients blood pressure can be expected to a. Fluctuates b. Remain the Same c. Increase d. Decrease 78. The nurse assesses the skin turgor of an elderly client. When evaluating skin turgon, the nurse should remember that:

b. 47.2 C c. 38.9 C  d. 40.1 C

a. Over hydration causes the skin to tent b. Dehydration causes the skin to appear edematous and spongy c. Inelastic turgor is a normal part of aging d. Normal skin turgon is moist and boggy.

85. Why should an infant be quiet and seated upright when the nurse assess his fontaanels?

79. Which of the ff. does not govern the practice of nursing? a. RA 7164 b. RA 9173 c. BON Resolution for Code of Ethics d. Board Resolution Scope of Nursing Practice 80. A client with sever chest pain is brought to the emergency department. He tells the nurse, "I just have a little indigestion." Which of the following mechanisms is the client exhibiting? a. Denial  b. Anxiety c. Repression d. Confusion 81. These are "in-between factors" present in research environment that threaten the internal and external validity of a research study. a. Dependent variable b. Independent variables c. Intervening variables d. Criterion variable 82. The ff. are motivational factors according to Herzberg, except: a. Challenging aspects of the work itself  b. Added responsibility c. Oppurtunities for personal growth d. Quality of supervision 83. The nurse measures the client's temperature at 102 F. What is the equivalent centigrade temp? a. 39.1 C

84. A client is placed on a low-sodium (500mg/day) diet. Which client statement indicates that the nurse's nutrition teaching plan has been effective? a. "I can eat a ham-and-cheese sandwich w/ potato chips for lunch" b. "I choose broiled chiken whith a baked potato for dinner"  c. "I choose a t ossed salad w/ sardines and oil and vinegar dressing for lunch" d. "Im glad i can still have chicken bouillon soup"

a. The mother will have less trouble holding a quiet upright infant b. Lying down can cause the fontanels to recede, making assessment more difficult. c. The infant can breath more easily when sitting up d. Lying down and crying can cause the fontanels to buldge 86. Communicating and using the research findings is under what phase of the research process? a. Implementation phase b. Dissemination phase c. Analysis and interpretation phase d. Design phase 87. To give a Z-tract injection, the nuse measures the correct medication dose and draws a small amount of air into the syringe. What is the rationale for this action? a. Adding air decreases pain caused by the injection b. Adding air prevents the drug from flowing back into the needle tract c. Adding air prevens the solution from entering a blood vessel d. Adding air ensures that client receives the entire dose. 88. Which of the ff. is true of Care System method? a. Autonomy and authority for the care of four to siz patients on a 24-h basis b. Assigning nurses to give total nursing care to a single patient  c. Divison of labor which nurses are assigned to perform secific tasks d. Assigning a team to give total care to a selected group of clients 89. Which of the ff. best describes the action of the nurse who documents her nursing diagnosis? a. She documents and charts it whenever necessary b. She can be accused of malpractice c. She does it reguarly as an impt. responsibility  d. She starts it only when the pt. is acutely ill

90. To help assess a clients cerabral function, the nurse should ask: a. Have you noticed a change in your memory?  b. Have you noticed a chnge in your muscle strength? c. Have you had any coodination problem? d. Have you had any problems with your eyes? 91. The nurse is evaulating a postoperative client for infection. Which sign of sympton would be most indicative for infection? a. The presence of an indwelling urinary catheter b. Rectal temperature of 100F  c. Red, warm , tender incision d. WVC count of 8,000/UI 92. A patient classification system where patients need close attention and complete care in most activities and requires frequent and complex treatments and medications a. Minimal Care (category 1) b. Moderate Care (category 2) c. Maximum Care (category 3) d. Intensive Care (category 4) 93. What nursing diagnosis is commonly used to develop a plan of  care for managing client's drug regimen? a. Noncomplience b. Altered coping mechanism c. Anxiety d. Altered home maintenance 94. Which of the ff. provides that nurses be members of the national nurse organization? a. RA 877 b. 1987 Code of Ethics approved by the house of delegates PNA c. Board Resolution No 1955 promulgated by the Board of Nursing d. RA 7164 95. The ff. are good sources of research problems except? a. Literature b. Clininal experience c. Daily news reports d. existing theories 96. What is the common goal of discharge planning in all care settings? a. prolonging hospitalization until the client can function independently b. Teaching client how to perform self-care activities c. Providing the financial resources needed to ensure proper care d. Preventing the need for medical follow-up care.

97. The physician prescribe as IV infucion of 1000 ml D5W every 12 hours for a client. The IV setup delivers 15 gtt/ml. Approx. how many drops should be administered each minute? a. 18 b. 21 c. 24 d. 27 98. Which of the following provides the material and human resources and building the structure to care out the activities of the organization? a. Planning b. Organizing c. Command d. Control 99. A client is scheduled to receive a blood transfusion. During the transfusion, the nurse should observer for which sign or symptoms of a transfusion reaction? a. Dizziness b. Chills c. Hypothermia d. Hyperreflexia 100. The client has an abdominal hysterectomy, 10 hours ago. Which position should the nurse teach the client to avoid? a. High Fowlers b. lateral recumbent c. Supine d. Side lying