Nursing Review Exam Questions FUNDA

 

COMPREHENSIVE COMPREHENSI VE NURSING REVIEW by R. C. REÑA | 12

FUNDAMENTALS OF NURSING PART 1

1. Using the the principles principles of standard precautions, precautions, the nurse would would wear gloves in in what nursing interventions? interventions? a. Pro Provi vidi ding ng a back back ma mass ssag agee  b. Feeding a client c. Pr Prov ovid idin ing g hai hairr ccar aree d. Pro Provi vidi ding ng or oral al hy hygi gien enee 2. The nurse nurse is prepar preparing ing to take vital vital sign in an alert alert client client admitt admitted ed to the hos hospi pital tal wit with h dehydrat dehydration ion secondary to vomiting and diarrhea. What is the best method used to assess the client’s temperature?

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a. Axillary Oral  b. c. Radial d. Heat Heat sen sensi siti tive ve tap tapee A nurse obtained obtained a client’s client’s pulse pulse and found found the rate to be above above nor normal. mal. The nur nurse se document document this this findings findings as: a. Tachypnea  b. Hyper pyrexia c. Arrythmia d. Ta Tach chyc ycaard rdia ia Which of of the following following action actionss should should the nurse nurse take to use a wide wide base support support when assist assisting ing a client client to get up in a chair? a. Bend aatt the waist waist and and pla place ce arms under under the client client’s ’s arms and lift lift  b. Face the client, bend knees and place hands hands on client’s forearm and li lift ft c. Spre Spread ad his his or or her her feet feet apa apart rt d. Tighte Tighten n his his or her pelvic pelvic mus muscle cless A client had oral oral surgery surgery following following a motor vehicle vehicle accident accident.. The nurse assessin assessing g the client client finds the skin skin flu flushe shed d and warm. Which of the follo followin wing g would would be the best metho method d to take take the client’s client’s body temperature? a. Oral  b. Axillary c. Ar Arte teri riaal lin inee d. Rectal A client who who is unconscious unconscious needs needs frequent frequent mouth mouth care. When When performing performing a mout mouth h care, the bes bestt position position of a client is: a. Fo Fowl wler er’s ’s posi positi tion on  b. Side lying c. Supine d. Tr Tren end dele lenb nbur urg g A client is hospita hospitalized lized for the the first time, which which of the following following actions actions ens ensure ure the safety safety of the client? client? a. Kee Keep p un unnec necess essary ary ffurn urnitu iture re out out of the the wa way y  b. Keep the lights on at all time time c. Ke Keep ep sid sidee rail railss up at aall ll ttim imee

d. Keep Keep aall ll equipm equipment ent out of view view 8. A walk-in walk-in client client enters into into the clinic clinic with a chief chief complaint complaint of abdominal abdominal pa pain in and diarrhea. diarrhea. The nu nurse rse takes the client’s vital sign hereafter. What phrase of nursing process is being implemented here by the nurse? a. Assessment  b. Diagnosis c. Planning d. Impl Implem emen enta tati tion on 9. It is best describe describe as a systematic, systematic, rational rational method method of planning planning and providing providing nu nursing rsing ca care re for individual individual,, families, group and community a. Assessment  b. Nursing Process c. Diagnosis d. Impl Implem emen enta tati tion on 10. Exchange of gases takes place in which which of the following following organ? a. Kidney  b. Lungs c. Liver d. Heart 11. The Chamber of the heart that receives oxygenated blood blood from the lungs lungs is the? a. Left atrium

 

COMPREHENSIVE COMPREHENSI VE NURSING REVIEW by R. C. REÑA | 13

12.

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16.

 b. Right atrium c. Le Left ft ventr entric iclle d. Righ Rightt vent ventri ricl clee A mus muscul cular ar enlarge enlarge pouch or sac that lies slightl slightly y to the left left which which is used used for tempora temporary ry stora storage ge of food… a. Gallbladder  b. Urinary bladder c. Stomach d. Lungs The ability of the body to defend itself itself against scientific invadin invading g agent such as baceria, toxin, viruses and foreign body a. Hormones  b. Secretion c. Immunity d. Glands Hormones Hormones secreted secreted by Islets of Langerhans Langerhans a. Pr Pro oges geste tero rone ne  b. Testosterone c. Insulin d. Hemoglobin It is a transparent transparent membrane that focuses focuses the light that enters the eyes to the retina. a. Lens  b. Sclera c. Cornea d. Pupils Which of the following following is included included in Orem’s theory? a. Main Mainten tenanc ancee of a suff suffici icient ent inta intake ke of of air air  b. Self perception

c. Lo Love ve and and bel belon ongi ging ng d. Ph Phys ysio iolo logi gicc need needss 17. Which of the following following cluster cluster of data belong to Maslow’s hierarchy hierarchy of needs a. Lo Love ve and and bel belon ongi ging ng  b. Physiologic needs c. Se Self lf act actua uali liza zati tion on d. All All of th thee abov abovee 18. This is characterized characterized by severe symptoms symptoms relatively of of short duration. duration. a. Ch Chro ron nic Il Illn lnes esss  b. Acute Illness c. Pain d. Syndrome 19. Which of the following following is the nurse’s role in the health promotion promotion a. He Heal alth th ri risk sk ap appr prai aisa sall  b. Teach client to be effective health health consumer c. Wo Work rksi site te well wellne ness ss None Noneas ofath the e abo above ve of people 20. It is d. describe collection people who share share some attributes of their lives. a. Family  b. Illness c. Community d. Nursing 21. Five teaspoon is equivalent equivalent to how many milliliters milliliters (ml)? a. 30 ml  b. 25 ml c. 12 ml d. 75 ml 22. 1800 ml is equal equal to how many many liters? liters? a. 1.8  b. 18000 c. 180 d. 2800 23. Which of the following following is the abbreviation of drops? a. Gtt.  b. Gtts. c. Dp. d. Dr.

 

COMPREHENSIVE COMPREHENSI VE NURSING REVIEW by R. C. REÑA | 14

24. The abbrevia abbreviation tion for micro micro drop is… is… a. µgtt  b. gtt c. mdr d. mgts 25. Which of the follow following ing is the meaning meaning of PRN? a. When advice  b. Immediately c. Wh When en nece necesssar ary y d. Now 26. Which of the following following is the appropriate meani meaning ng of CBR? a. Card Cardia iacc Boa Board rd Ro Room om  b. Complete Bathroom c. Co Comp mple lete te Bed Bed Re Rest st d. Comp Comple lete te Boa Board rd Roo Room m 27. 1 tsp is equals equals to to how many many drops? drops? a. 15  b. 60 c. 10 d. 30 28. 20 cc is is equal equal to how how many ml? a. 2  b. 20 c. 2000 d. 20000 29. 1 cup is equal to how many ounces? a. 8  b. 80 c. 800 d. 8000 30. The nurse must verify the client’s client’s identity before ad administration ministration of medication. medication. Which of the following following is the safest way to identify the client? a. Ask Ask the the cl clie ient nt hi hiss nam namee  b. Check the client’s identification identification band c. State the client client’s ’s name name aloud aloud and have the client client repeat it d. Chec Check k th thee roo room m nu numb mber er 31. The nurse prepares to administer buccal buccal medication. The The medicine should be placed… a. On th thee cli clien ent’ t’ss sski kin n  b. Between the client’s cheeks and gums gums c. Un Unde derr the the cl clie ient nt’s ’s ton tongu guee d. On th thee clie client nt’s ’s conj conjuc ucti tiva va 32. The nurse administers administers cleansing enema. enema. The common position position for this procedure is… a. Si Sims ms le left ft late latera rall  b. Dorsal Recumbent

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c. Supine d. Prone A client complains complains of difficulty difficulty of swallowing, swallowing, when the nurse try to administer administer capsu capsule le medication. medication. Which of the following measures the nurse should do? a. Dis Dissol solve ve the the ca capsu psule le in a glass glass of of water water  b. Break the capsule and give the content content with an applesauce applesauce c. Check the avai availabil lability ity of a liqui liquid d prepara preparation tion d. Crash the capsu capsule le and and place place it it under under the the tongu tonguee Which of the following following is the appropriate route route of administration administration for insulin? insulin? a. In Inttramu ramusc scu ula larr  b. Intradermal c. Su Sub bcuta cutane neo ous d. In Inttrav raveno enous The nurse is ordered to administer administer ampicillin capsule TIP TIP p.o. The nurse shoud give the medication… medication… a. Th Three ree ti time mess a da day y ora orall lly y  b. Three times a day after meals c. Tw Two o tim timee a day day by mout mouth h d. Tw Two o ti times mes a day day befo before re mea meals ls Back Care Care is best descri describe be as: a. Cari Caring ng ffor or the the b back ack by m mean eanss of massag massagee  b. Washing of the back

 

COMPREHENSIVE COMPREHENSI VE NURSING REVIEW by R. C. REÑA | 15

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43 43..

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c. App Applic licati ation on of of cold cold compr compress ess at th thee bac back k d. Applic Applicati ation on of of hot comp compres resss at the the back back It refers to the preparation of the the bed with a new new set of linens linens a. Bed bath  b. Bed making c. Bed shampoo d. Bed lining Which of the following following is the most important purpose of handwashing handwashing a. To p pro romo mote te han hand d circ circul ulat atio ion n  b. To prevent the transfer of microorganism microorganism c. To av avoi oid d touchi touching ng the the cli client ent with with a dirt dirty y hand hand d. To pr prov ovid idee comf comfor ortt What should be done in order order to prevent contaminat contaminating ing of the environment in bed bed making? a. Av Avoi oid d funn funnin ing g soil soiled ed lin linen enss  b. Strip all linens at the same time c. Fin Finish ished ed bot both h sside idess at at the the tim timee d. Em Embr brac acee soi soile led d li line nen n The most important purpose purpose of cleansing cleansing bed bath bath is: a. To cle cleanse, anse, refres refresh h and give give comfort comfort to to the clien clientt who m must ust re remain main in in bed  b. To expose the necessary parts of the body c. To develo develop p ski skills lls in bed bath bath d. To ch check eck the b body ody tempe temperatur raturee of the clien clientt in bed Which of the following following technique technique involves the the sense of sight? sight? a. In Insspection  b. Palpation c. Percu rcussion d. Au Ausc scu ult ltat atio ion n The first techniques techniques used examining examining the abdomen of a client is: a. Palpation  b. Auscultation c. Percu rcussion d. In Insspection A te tech chni niqu quee in phys physic ical al exam examin inat atio ion n th that at is us usee to as asse sess ss the the move moveme men nt of air air thro throug ugh h the the tracheobronchial tree: a. Palpation  b. Auscultation c. In Insspection d. Percu rcussion An instrument instrument used for ausculta auscultation tion is: a. Pe Perc rcus ussi sion on-h -ham amme merr  b. Audiometer c. Stethoscope d. Sp Sphy hygm gmom oman anom omet eter er Resonance Resonance is best best describe describe as: as: a. Sou Sounds nds create created d by air fil filled led lu lungs ngs  b. Short, high pitch and thudding thudding c. Mod Modera eratel tely y loud loud with with music musical al qual quality ity d. Drumm-llike The best position position for examining the rectum is: a. Prone  b. Sim’s c. Knee-c -ch hest d. Lithotomy It refers refers to the manner manner of walkin walking g a. Gait  b. Range of motion c. Flex Flexio ion n and and ex exte tens nsio ion n d. Hopping The nurse asked the client to read read the Snellen chart. Which of th thee following is tested: a. Optic  b. Olfactory c. Oculomotor d. Troclear Another Another name for knee-chest knee-chest position position is: a. Genu-dorsal

 

COMPREHENSIVE COMPREHENSI VE NURSING REVIEW by R. C. REÑA | 16

 b. Genu-pectoral c. Lithotomy d. Sim’s 50. The nurse prepare IM injection injection that is irritating to the subcutaneous subcutaneous tissue. Which of the following is the  best action in order to prevent prevent tracking of the medication a. Use Use a smal smalll gau gauge ge ne need edle le  b. Apply ice on the injection injection site c. Ad Admi mini nist ster er at a 45° 45° aang ngle le d. Use Use th thee ZZ-tr track ack te tech chni niqu quee

ANSWERS for FUNDAMENTALS OF NURSING PART 1

1.d

11.a

21.b

31.b

41.a

2.b

12.c

22.a

32.a

42.d

3.d

13.c

23.b

33.c

43.b

4b

14.c

24.a

34.c

44.c

5.b

15.c

25.c

35.a

45.a

6.b

16.a

26.c

36.a

46.c

7.c

17.d

27.b

37.b

47.a

8.a

18.b

28.b

38.b

48.a

9.b

19.b

29.a

39.a

49.b

10.b

20.c

30.a

40.a

50.d

 

COMPREHENSIVE COMPREHENSI VE NURSING REVIEW by R. C. REÑA | 17

FUNDAMENTALS OF NURSING PART 2

1. The most most appropriate appropriate nursing nursing order order for a patient patient who develop developss dyspn dyspnea ea and shor shortness tness of of breath would would  be… a. Maint Maintain ain the the p patien atientt on strict strict bed rest at all all ti times mes  b. Maintain the patient in an orthopneic orthopneic position as needed c. Admin Administer ister oxygen oxygen by by Venturi Venturi mask at 24%, 24%, as needed needed d. Allow a 1 hour rest period period between between activitie activitiess 2. The nurse nursto e observes observe Mr. position, Adams begins bewhich gins todecreases hav havee increased increas difficulty difficultydistress. br breathi eathing. ng. She elevates elevates the head headthis of the bed the highs that Fowler his ed respiratory The nurse documents  breathing as: a. Tachypnea  b. Eupnca c. Orthopnea d. Hype Hyperv rven enti tila lati tion on 3. The physic physician ian orders orders a pla platel telet et count count to be perf perform ormed ed on Mrs. Smit Smith h after breakfa breakfast. st. The nurse nurse is responsible for: a. Instr Instructin ucting g the the patient patient about this diagnosti diagnosticc test test  b. Writing the order for this test test c. Givi Giving ng tthe he pat patie ient nt bre break akfa fast st d. All All of th thee abov abovee 4. Mrs. Mitchell Mitchell has has been given given a copy of her diet. diet. The nurse nurse discusse discussess the foods foods allowed allowed on a 500-mg 500-mg low sodium diet. These include: a. A ham and Swiss cheese cheese sandwich sandwich on whole whole wheat bread  b. Mashed potatoes and broiled broiled chicken c. A tos tossed sed salad salad with with oil and vine vinegar gar and and olive olivess d. Chic Chicke ken n bou bouil illo lon n 5. The physician physician orders orders a maintenance maintenance dose of 5,000 units units of subcutaneous subcutaneous heparin heparin (an antico anticoagul agulant) ant) daily. daily.  Nursing responsibilities responsibilities for Mrs. Mitchell now include: include: a. Review Reviewing ing daily daily activated activated partial partial th thrombo romboplast plastin in time (AP (APTT) TT) and prothro prothrombin mbin tim time. e.  b. Reporting an APTT above 45 seconds seconds to the physician c. Asses Assessing sing the the patient patient for for signs and symptom symptomss of frank and occult occult bleedin bleeding g d. All All of th thee abov abovee 6. The four four main concepts concepts common common to nursing nursing that that appear appear in each of the the current current conceptual conceptual models models are: a. Pers Person, on, n nurs ursing ing,, enviro environme nment, nt, medi medicin cinee  b. Person, health, nursing, support support systems c. Pers Person, on, hea health lth,, psych psycholo ology, gy, nur nursin sing g d. Person, Person, eenv nviro ironme nment, nt, heal health, th, nurs nursing ing 7. In Maslow’s Maslow’s hierarch hierarchy y of physiolog physiologic ic needs, needs, the huma human n need of greatest greatest pr priori iority ty is: a. Love  b. Elimination c. Nutrition d. Oxygen 8. The family family of an accident accident victim victim who has been declared declared brain-de brain-dead ad seems amen amenable able to organ organ donation. donation. What should the nurse do? a. Disco Discourag uragee them from from making making a decisi decision on until until their their grief grief has eased  b. Listen to their concerns and and answer their questions honestly c. Encou Encourage rage them to sign sign the the consent consent form right right away away d. Tell tthem hem the the body body will not be be avail available able for for a wake wake or funeral funeral 9. A new head nurse nurse on a unit is distres distressed sed about about the the poor staffi staffing ng on the 11 p.m p.m.. to 7 a.m. a.m. shift shift.. What should she do? a. Comp Compla lain in to to her her fello fellow w nurs nurses es  b. Wait until she knows more more about the unit c. Dis Discus cusss th thee probl problem em with with her her super supervi visor sor d. Infor Inform m the staff that they must volunteer volunteer to ro rotate tate 10. Which of the following following principles principles of primary nursing nursing has proven the most satisfy satisfying ing to the patient and nurse? a. Conti Continuit nuity y of patient patient care promotes promotes efficien efficient, t, cost-effec cost-effective tive nu nursin rsing g care  b. Autonomy and authority authority for planning are best delegated delegated to a nurse who knows the patient well c. Ac Acco coun unta tabi bili lity ty is clea cleare rest st when when on onee nurs nursee is resp respon onsi sibl blee for for the the over overal alll plan plan and and it itss implementation.

 

COMPREHENSIVE COMPREHENSI VE NURSING REVIEW by R. C. REÑA | 18

d. The holis holistic tic approach approach provides provides for a therapeut therapeutic ic relationshi relationship, p, continuity continuity,, and efficient efficient nursing care. 11. If nurse administers an injection injection to a patient who refuses that injection, she has committed: committed: a. Assa Assaul ultt aand nd ba batt tter ery y  b. Negligence c. Ma Mallpra racctice d. None None of th thee abo above ve 12. If patient asks the nurse her opinion opinion about a particular particular physicians and the nurs nursee replies that the physician is incompetent, the nurse could be held liable for: a. Slander  b. Libel cd.. A sauonde ltdent Resp Resspon nt supe superi rior or 13. A registered registered nurse nurse reaches to answer answer the telephone telephone on a busy pediatric pediatric unit, momentarily momentarily turning turning away from a 3 month-old infant she has been weighing. The infant falls off the scale, suffering a skull fracture. The nurse could be charged with: a. Defamation  b. Assault c. Battery d. Ma Malp lpra raccti tice ce 14. Which of the following following is an example of n nursing ursing malpractice? malpractice? a. The nurs nursee administers administers penici penicillin llin to a patient patient with with a documented documented his history tory of allergy allergy to th thee drug. The  patient experiences an allergic allergic reaction and has cerebral damage resulting resulting from anoxia.  b. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping. c. The nur nurse se assists assists a patient patient out out of bed wi with th the bed locked locked in positi position; on; the patie patient nt slips slips and fractures his right humerus. d. The nurse ad adminis ministers ters the wrong wrong medication medication to a patient patient and the patient patient vomits. This This information information is documented and reported to the physician and the nursing supervisor. 15. Which of the following following signs and symptom symptomss would the nurse expect to find when assessing assessing an Asian Asian  patient for postoperative postoperative pain following abdominal abdominal surgery? a. Decrea Decreased sed blood blood pressu pressure re and heart heart rate rate and shallow shallow respirat respirations ions  b. Quiet crying c. Immobi Immobility lity,, diaph diaphoresi oresis, s, and avoida avoidance nce of deep deep breathing breathing or or coughing coughing d. Changi Changing ng positi position on ever every y 2 hou hours rs 16. A patient is admitted to the hospital hospital with complaints complaints of nausea, vomiting, diarrhea, and severe abdo abdominal minal  pain. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract? a. Co Comp mple lete te blo blood od cou count nt  b. Guaiac test c. Vital signs d. Abdo Abdomi mina nall gi girt rth h 17. The correct sequence for assessing the abdom abdomen en is: a. Tympa Tympanic nic percuss percussion, ion, measure measurement ment of of abdominal abdominal girth girth,, and in inspect spection ion

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 b. Assessment for distention, distention, tenderness, and discolo discoloration ration around the umbilicus. umbilicus. c. Perc Percus ussio sions, ns, palpa palpatio tion, n, and auscu ausculta ltatio tion n d. Auscul Auscultat tation ion,, percuss percussion ion,, and palpati palpation on High-pitched gurgles head over the right lower quadrant are: a. A si sign gn of inc increa reased sed bowel bowel moti motilit lity y  b. A sign of decreased bowel motility motility c. No Norm rmal al bow bowel el sou sound ndss d. A sig sign n of abdo abdomi mina nall cramp crampin ing g A patient about to undergo undergo abdominal inspection inspection is best placed in wh which ich of the following pos positions? itions? a. Prone  b. Trendelenburg c. Supine d. Side-lying For a rectal examination, the patient patient can be directed to assume which o off the following posi positions? tions? a. Ge Gen nupec upecte tero roll  b. Sims c. Ho Hori rizo zont ntal al recum recumbe bent nt d. All All of th thee abov abovee During a Romberg test, test, the nurse asks asks the patient to assume which which position? a. Sitting  b. Standing

 

COMPREHENSIVE COMPREHENSI VE NURSING REVIEW by R. C. REÑA | 19

c. Ge Gen nupec upecto tora rall d. Tr Tren end dele lenb nbur urg g 22. If a patient’s blood blood pressure is 150/96, his pulse pulse pressure is: a. 54  b. 96 c. 150 d. 246 23. A patient is kept kept off food and fluids fluids for 10 hours before surgery. His oral oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates: a. Infection  b. Hypothermia

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29.

cd.. A nhxydra ietrat y tio De Deh yd ion n Which of the following following parameters should be checked checked when assessing assessing respirations? a. Rate  b. Rhythm c. Symmetry d. All All of th thee abov abovee A 38-year old patient’ patient’ss vital signs signs at 8 a.m. are axillary axillary temperature temperature 99.6 F (37.6 C); pulse rate rate,, 88; respiratory rate, 30. Which findings should be reported? a. Resp Respir irat ator ory y ra rate te on only ly  b. Temperature only c. Puls Pulsee rate rate aand nd tem tempe pera ratu ture re d. Temper Temperatu ature re and and respir respirato atory ry rate rate All of the following following can cause tachycardia tachycardia except: a. Fever  b. Exercise c. Sym Sympat pathet hetic ic ne nervo rvous us syste system m stimul stimulati ation on d. Parasy Parasympath mpathetic etic nervous nervous system system stimu stimulatio lation n Palpating the midclavicular midclavicular line is the correct technique technique for assessing a. Base Baseli line ne vit vital al sig signs ns  b. Systolic blood pressure pressure c. Resp Respir irat ator ory y ra rate te d. Ap Apic ical al pul ulse se The absence of which pulse pulse may not be a significant finding finding when a patient is admitt admitted ed to the hospital? a. Apical  b. Radial c. Pedal d. Femoral Which of the following following patients patients is at greatest greatest risk for developing developing pressure ulcers? ulcers? a. An aler alert, t, chronic chronic arthriti arthriticc patient patient treated treated with with steroids steroids and and aspirin aspirin  b. An 88-year old incontinent incontinent patient with gast gastric ric cancer who is confined to his his bed at home c. An apat apatheti heticc 63-year 63-year old COPD COPD patient patient receivin receiving g nasal oxyge oxygen n via can cannula nula d. A confus confused ed 78-year 78-year old patient patient with congest congestive ive heart heart failure (CHF) (CHF) who requires requires assistan assistance ce to get

out of bed. 30. The physician physician orders the administratio administration n of high high-humi -humidity dity oxygen oxygen by face mask and placement of the  patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis diagn osis:: Impaired Impaired gas exch exchange ange related to increased increased secretions. secretions. Which Which of the following following nursing interventions has the greatest potential for improving this situation? a. Encou Encourage rage the patien patientt to increase increase her her fluid intake intake to to 200 ml every every 2 hours hours  b. Place a humidifier in the patient’s patient’s room. c. Conti Continue nue admini administer stering ing oxygen oxygen by high high humidi humidity ty face face mask mask d. Perfor Perform m chest chest physi physiothe otheraphy raphy on a regular regular schedu schedule le 31. The most common deficiency seen in al alcoholics coholics is: a. Thiamine  b. Riboflavin c. Pyridoxine d. Pa Pant ntot othe heni nicc aaci cid d 32. Which of the following following statement statement is incorrect about about a patient with dysphagia? dysphagia? a. The pati patient ent will will find pureed pureed or soft soft foods, such such as custards, custards, easier easier to swallow swallow than than water  b. Fowler’s or semi Fowler’s position position reduces the risk of aspi aspiration ration during swallowing swallowing c. The p pati atient ent sho shoul uld d always always feed feed him himsel selff d. The nu nurse rse should should perform perform oral oral hygiene hygiene before before assistin assisting g with feedin feeding. g. 33. To assess the kidney kidney function of a patient patient with an indwelling indwelling urinary (Foley) (Foley) catheter, the nurse measures measures his hourly urine output. She should notify the physician if the urine output is:

 

COMPREHENSIVE COMPREHENSI VE NURSING REVIEW by R. C. REÑA | 20

a. Le Less ss th than an 30 ml/h ml/hou ourr  b. 64 ml in 2 hours c. 90 ml in 3 hour hourss d. 12 125 5 ml ml in 4 ho hour urss 34. Certain substances increase the amount of urine produ produced. ced. These include: a. Caffei Caffeine-co ne-contain ntaining ing drinks, drinks, such such as coffee coffee and cola. cola.  b. Beets c. Urin Urinar ary y anal analge gesi sics cs d. Kaolin Kaolin with with pect pectin in (Kao (Kaope pecta ctate) te) 35. A male patient who had surgery 2 days days ago for head and neck cancer is about to make his firs firstt attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected  by the Which thentfollowing fol interventions would be be appropriate? a. surgery. Enc Encour ourage age the the of pa patie tient tolowing walk walk in innursing the h hall allin alon aterventions lonee  b. Discourage the patient from walking walking in the hall for a few more day dayss c. Acc Accomp ompany any the pat patien ientt for for his his walk walk.. d. Consu Consuit it a phy physical sical therap therapist ist before before allowin allowing g the patien patientt to ambu ambulate late 36. A patient has exacerbation exacerbation of chronic obstructive obstructive pulmonary disease (COPD) manifested by shortness shortness of  breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. An appropriate nursing diagnosis would be: a. Ineffe Ineffective ctive airway airway clearance clearance relate related d to th thick, ick, tenaci tenacious ous secreti secretions. ons.  b. Ineffective airway clearance related to dry, dry, hacking cough. c. Ine Ineffe ffecti ctive ve indi individ vidua uall coping coping to to COPD. COPD. d. Pain relat related ed to to im immobil mobilizati ization on of affected affected leg. leg. 37. Mrs. Lim begins to cry as the nurse discusses discusses hair loss. The b best est response would be: a. “Do “Don’t n’t worry worry.. It’s It’s only only tempor temporary ary””  b. “Why are you crying? I didn’t get get to the bad news yet” c. “Y “You ourr hair hair iiss real really ly pre prett tty” y” d. “I know this this will will be di diffic fficult ult for for you, but your your hair wil willl grow back back after after the completi completion on of chemotheraphy” 38. An additional Vitamin C is required required during all all of the following following periods except: except: a. Infancy  b. Young adulthood c. Childhood d. Preg regnancy 39. A prescribed amount amount of oxygen s needed for a patient patient with COPD COPD to prevent: a. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO 2)  b. Circulatory overload due to hypervolemia hypervolemia c. Resp Respir irat ator ory y ex exci cite teme ment nt d. Inhib Inhibition ition of the the respi respiratory ratory hypoxic hypoxic stimu stimulus lus 40. After 1 week of hospitaliza hospitalization, tion, Mr. Gray develops hypokale hypokalemia. mia. Which of the following following is the most significant symptom of his disorder? a. Lethargy  b. Increased pulse rate and blood pressure pressure c. Mu Musc scle le wea weakn knes esss d. Mu Musc scle le ir irri rita tabi bili lity ty 41. Which of the following following nursing nursing interventions promotes patient safety? a. Asses the patien patient’s t’s ability ability to amb ambulate ulate and transfe transferr from a bed to a chai chairr  b. Demonstrate the signal system system to the patient c. Check tto o see that that the the patient patient is wearing wearing his his iden identific tification ation band d. All All of th thee abov abovee 42. Studies have shown that that about 40% of patients fa fall ll out of bed despite the use o off side rails; this has led tto o which of the following conclusions? a. Side Side rai rails ls are are iine neff ffec ecti tive ve  b. Side rails should not be be used c. Side ra rails ils are a deterrent deterrent that preven preventt a patient patient fr from om falling falling out of bed. bed. d. Side rrails ails are a rremind eminder er to a patient patient not not to get out out of of bed 43. Examples of patients patients suffering from impaired impaired awareness include include all of tthe he following except: except: a. A sem semico iconsc nsciou iouss or over over fatig fatigued ued pati patient ent  b. A disoriented or confused patient c. A pat patien ientt who cann cannot ot care care for for himsel himselff at home home d. A patie patient nt demonstr demonstrating ating symptoms symptoms of drugs drugs or alcoho alcoholl withd withdrawal rawal 44. The most common injury among elderly persons is: is: a. Ath Athero eroscl scleot eotic ic cha change ngess in the the blo blood od vesse vessels ls  b. Increased incidence of gallbladder gallbladder disease c. Urin Urinar ary y Tra Tract ct In Infe fect ctio ion n

 

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d. Hi Hip p fra ract ctu ure 45. The most common psychogenic psychogenic disorder among elderly person is: a. Depress ession  b. Sleep disturbances (such as bizarre bizarre dreams) c. In Inab abil ilit ity y to to conc concen entr trat atee d. Decr Decrea ease sed d appet appetit itee 46. Which of the following following vascular vascular system changes results results from aging? aging? a. Increa Increased sed peripheral peripheral resistance resistance of the bloo blood d vessel vesselss  b. Decreased blood flow c. Inc Increa reased sed work work load load of of the lef leftt ventr ventricl iclee d. All All of th thee abov abovee 47. Which the following fo llowing isse the most common cause cause of dementia among among elderly person persons? s? a. of Pa Park rkin inso son’ n’ss disea disease  b. Multiple sclerosis c. Amyot Amyotroph rophic ic latera laterall scleros sclerosis is (Lou Gerhig’s Gerhig’s disease) disease) d. Alzh Alzhei eimer mer’s ’s di dise seas asee 48. The nurse’s most important important legal responsibili responsibility ty after a patient’s death in a hospital hospital is: a. Obt Obtain aining ing a conse consent nt of an an autop autopsy sy  b. Notifying the coroner or medical medical examiner c. Lab Labeli eling ng the the corp corpse se appr appropr opriat iately ely d. Ensur Ensuring ing that that the attendin attending g physician physician issues issues th thee death certifica certification tion 49. Before rigor mortis mortis occurs, the nurse is responsible responsible for: a. Pro Provid viding ing a compl complete ete bath bath aand nd dress dressing ing cchan hange ge  b. Placing one pillow under under the body’s head and shoulders shoulders c. Removi Removing ng the the body’s body’s clothin clothing g and wrappi wrapping ng the the body in a shroud shroud d. Allowi Allowing ng the the body body to rrela elax x norma normally lly 50. When a patient in the terminal terminal stages of lung cancer begin beginss to exhibit exhibit loss of consciou consciousnes sness, s, a major nursing priority is to: a. Pro Protec tectt the the pat patien ientt fro from m inju injury ry  b. Insert an airway c. El Elev evat atee the the head head of th thee bed bed d. Withdr Withdraw aw all pain pain medi medicat cation ionss