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POST TEST
FUNDAMENTALS OF NURSING
Philippine Nursing Licensure Examination
NAME:
4. An 85 year old client has had a stroke
1. The client’s temperature at 8am using an resulting in right sided facial drooping,
oral electronic thermometer is 36.1 degree C difficulty swallowing and the inability to move
(97.2 F). If the respiration, pulse and blood self or maintain position unaided. The nurse
pressure were within normal range. What determines that which site are most
would the nurse do next? appropriate for taking the temperature? SATA
A. Wait 15 minutes and retake it 1. Oral
B. Check what the client’s 2. Rectal
temperature was the last time it 3. Axillary
was taken. 4. Tympanic
C. Retake it using a different thermometer 5. Temporal Artery
D. Chart the temperature as it is normal A. 1,2,3,4
B. 3,4
2. When the nurse enters a client’s room to C. 3,4,5
measure routine vital signs, the client is on the D. 2,3,4
phone. What technique should the nurse use
to determine the respiratory rate? 5. When auscultating the blood pressure, the
A. Count the respirations during nurse hears: From 200 to 180 mmhg:
conversational pauses. silence; then a thumping sound continuing
B. Ask the client to end the phone call now down to 150 mmHg;muffled sounds
and resume it at a later time. continuing down to 130 mmHg; soft
C. Wait at the client’s bedside until the thumping sounds continuing down to 105
phone call is completed and then count mmHg; muffled sounds continuing down to
respirations. 95mmHg; then silence. The nurse recods
D. Since there is no evidence of the blood pressure as :
distress or urgency, postpone the A. 180/95
measurement until later. B. 150/95
C. 180/105
3. For a client with a previous blood pressure D. 150/105
of 138/74 mmHg and a pulse of 64bpm,
approximately how long should the nurse take 6. Which is a normal finding on auscultation of
to release the blood pressure cuff in order to the lungs?
obtain an accurate reading? A. tympany over the right upper lobe.
A. 10-20 seconds B. Resonance over the left upper lobe.
B. 30 -45 seconds C. hyperresonance over the left lower lobe
C. 1-1.5minutes D. dullness above the left 10th intercostal
D. 3-3.5 minutes space.
7. After auscultating the abdomen, the nurse 11.Lipoproteins carry cholesterol in the
should report which finding to the primary care bloodstream. For this reason, primary
provider? caregivers are interested in monitoring lipid
A. bruit over the aorta density profiles. Which of the following is of
B. absence of bowel sounds for 60 seconds. primary interest to the primary caregiver in
C. continuous bowel sounds over the relationship to the patient’s risk for
ileocecal valve. cardiovascular disease?
D. a completely irregular pattern of bowel A. VLDL and Hct
sounds. B. VLDL and HDL
C. LDLs and Hgb
8. If unable to locate the client’s poplitel pulse D. LDLs and HDLs
during a routine examination. what should the
nurse do next? 12. The nurse is instructing a patient about a
A. check for pedal pulse TENS unit, how it is used, and how it works.
B. check for femoral pulse Appropriate information for this patient would
C. take the client’s blood pressure on the be:
thigh A. “The stimulation of the skin seeks to
D. ask another nurse to try to locate the localize the acute pain and will last for
pulse several minutes after the unit is
applied.”
9. A 78 year old male needs a 24 hour urine B. “This unit stimulates both the skin
specimen. In planning his care, the nurse and the underlying tissues to
realizes that which measure is most important? decrease the intensity of the pain.”
A. A.Instruct the client to empty his C. “The mechanism for use of this unit is
bladder and save this voiding to start well known and can be read about.”
the collection. D. “During those days when using the
B. Instruct the client to use sterile TENS unit, no analgesic can be given.”
individual containers to collect the urine.
C. post a sign stating “Save All urine” 13. A patient admitted with the diagnosis of
in the bathroom. possible myocardial infarction complains of
D. keep the urine specimen in room pain and tingling in his left arm says, “How in
temperature. the world could I be having a heart attack
when it’s just my arm that is giving me
10. The physician orders a urine culture and trouble?”The nurse explains that the patient is
sensitivity for a 36 year old patient with an experiencing:
indwelling Foley catheter. Which of the A. referred pain.
following actions by the nurse is best? B. psychogenic pain.
A. The nurse clamps the catheter C. neuromuscular pain.
tubing below the level o f the port D. muscle spasms of shoulder.
for 10 minute.
B. The nurse removes 20 ml from the 14. To perform postural drainage on a patient,
catheter bag and place it in a sterile the nurse should:
container. A. Encourage the patient to drink 8 oz of
C. The nurse separates the catheter from water 30 minutes before the procedure.
the tubing and allows 30 ml of urine to B. Suction the patient before performing
drain into a sterile cup. the procedure.
D. The nurse clamps the catheter just C. Ask the patient which position he finds
below the insertion site for 20 minutes. most comfortable.
 D. Perform the procedure before the
client takes his meal. 19. For which of the following client’s would
you take an apical pulse rather than radial
15. Which finding would the nurse identify as pulse?
interfering with the effective functioning of the A. A client in shock
chest tube? B. To check a client’s response to changing
A. 15 cm water suction on chest tube from a lying to a sitting position
system. C. A client with an arrhythmia
B. An air leak in water seal chamber D. A client less than 24 hours postoperative
C. Leaking blood around chest tube site.
D. Clots of blood in the chest tube. 20. The nurse is assisting a female client to
collect a midstream urine specimen. The nurse
16. There is a continuous bubbling in the water uses the principles of aseptic technique by
sealed drainage system with suction. And A. Cleansing the meatus with antiseptic pads
oscillation is observed. As a nurse, what should using upward strokes.
you do? B. Letting go of the labia once they are
A. Consider this as normal findings cleansed to allow the client to urinate.
B. Notify the physician C. Making sure that the fingers avoid
C. Check for tube leak touching the inside of the collection
D. Prepare a petrolatum gauze dressing container.
D. Instructing the client to urinate in the
17. Which of the following if done by a nurse container after the labia has been
indicates deviation from the standards of NGT cleansed.
feeding?
A. Do not give the feeding and notify the 21. When discarding used needles and
doctor of residual of the last feeding is syringes, which of the following is appropriate
greater than or equal to 400 ml nursing action?
B. Height of the feeding should be 12 A. Remove needle from syringe and discard
inches about the tube point of insertion them in separate containers.
to allow slow introduction of feeding B. Recap needle, then discard the needle
C. Ask the client to position in supine still attached to the syringe into a
position immediately after feeding container.
to prevent dumping syndrome C. Discard the uncapped needle and
D. Clamp the NGT before all of the water is syringe into a container
instilled to prevent air entry in the D. Break the needle, then discard syringe
stomach into a container

18. To ensure a good fit of the appliance to 22. Which of the following if done by a nurse
avoid leakage, which of the following should indicates deviation from the standards of NGT
the nurse consider for pouch placement? feeding?
A. Place the pouch only when the patient is
A. Give the feeding and notify the
lying down.
doctor of residual of the last
B. The pouch placement should be
feeding is greater than or equal to
checked for sitting comfort,
400 ml
standing comfort, and ambulation.
B. Height of the feeding should be 12
C. The pouch should fit very snugly to
inches about the tube point of insertion
edges of stoma.
to allow slow introduction of feeding
D. The pouch must cover the entire
C. Ask the client to position in Fowler’s
abdomen.
position immediately after feeding
 D. Clamp the NGT before all of the water is B. Discontinuing the enema and notifying
instilled to prevent air entry in the the primary health care provider
stomach C. Raising the enema bag so that the
solution can be introduced quickly
23. Which of the following statements made by D. Clamping the tubing for 30 seconds
a patient who is scheduled for a mammogram and restarting the flow at a slower
indicates a need for further teaching? rate
A. I will not use underarm antiperspirant
before the procedure. 28. The nurse caring for an immunosuppressed
B. A dye will be injected into my vein patient is diligent about protecting the patient
prior to the procedure. from infection.When visitors come in, in
C. I may experience discomfort during the addition to having them put on isolation garb,
procedure. the nurse would prohibit them bringing:
D. My Breasts will be compressed while the A. a battery-operated DVD player.
X rays are taken B. books.
C. potted plants.
24. Which of the following conditions, reported D. boxed candy.
to a nurse by a 20 year old male patient, would
indicate a risk for development of testicular 29. A nurse caring for a patient who has been
cancer? on bed rest for a week notices a reddened area
A. Genital herpes on the patient’s left hip. The skin is intact but,
B. Undescended Testicle when the nurse presses on the area, the
C. Measles redness does not fade. The nurse recognizes
D. Hydrocele this pressure ulcer as a:
A. Stage I ulcer
25. The patient with cirrhosis would have B. Stage II ulcer
which of the following laboratory results? C. Stage III ulcer
A. Increased serum albumin D. Stage IV ulcer
B. Elevated serum transaminase
C. Normal Prothrombin time 30. A client diagnosed with left pleural effusion
D. Increased serum magnesium has just been admitted for
treatment. The nurse should plan to have
which procedure tray available for
26. The nurse is scheduling a client for a
use at the bedside?
series of diagnostic studies of the
A. Intubation
gastrointestinal (GI) system. Which of these
B. Paracentesis
studies should the nurse schedule last to
C. Thoracentesis
avoid altering the results of the remaining
D. Central venous line insertion
tests?
A. Ultrasound
31. Organize the following steps of suctioning
B. Colonoscopy
in chronological order: ‘
C. Barium enema
1. Put on sterile gloves
D. Computed tomography
2. Lubricate catheter with normal saline
3. Apply suction for 5-10 seconds
27. The nurse has administered approximately
4. Explain procedure to the patient
half of a high-cleansing enema when the client
5. Wash hands thoroughly
reports pain and cramping. Which nursing
A. 4,5,1,2,3
action is appropriate?
B. 5,4,1,2,3
A. Reassuring the client that those
C. 5,1,2,1,3
sensations will subside
 D. 4,5,2,1,3 colostomy care at home. Which statement by
the parents indicates their understanding of
32. A nurse is teaching a client with left leg the instructions?
weakness to walk with a cane. The nurse A. “We will give antidiarrheal medications.”
should include which nursing points about safe B. “We will report signs of skin
cane use in the client teaching?SATA breakdown.”
1. Place the cane 8”-10” from the base of the C. “We will give saline water enemas if my
little toe. child doesn’t pass stool.”
2. Hold the cane on the uninvolved side of the D. “We will apply a heat lamp to any moist
body red tissue around the stoma.”
3. Adjust the cane so that the handle is level
with the hip bone 36. In caring for client on contact precaution
4. Walk by moving the involved leg,then the for a draining infected foot ulcer, correct
cane, and then the uninvolved leg technique include
5. Shorten the stride length on the involved A. Wearing a mask during dressing
side changes.
A. 1,2,3,4 B. Providing disposable meal trays and
B. 2,3 silverwares
C. 2,3,5 C. Following standards precaution in
D. 1,3,4 all interaction with the client
D. Using surgical aseptic technique for all
33. Which of the following, if done by the direct contact with the client.
nurse, indicates incompetence during
suctioning an unconscious client? 37. An early finding that would indicate that a
A. Measure the length of the suction client is hypertensive is:
catheter to be inserted by A. An extended Korotkoffs sound
measuring from the tip of the B. A regular pulse of 92 beats per minute
nose, to the earlobe, to the xiphoid C. A diastolic blood pressure that
process remains greater than 90 mm Hg
B. Use KY Jelly if suctioning D. An achy, throbbing headache over the
nasopharyngeal secretion left eye when arising in the morning
C. The maximum time of suctioning
should not exceed 15 seconds 38. A client has an order for an injection to be
D. Allow 30 seconds interval between administered intradermally. The nurse avoids
suctioning which of the following actions when
administering this medication?
34. The nurse is demonstrating colostomy care A. Inserting the needle at a 10- to 15-degree
to a client with a newly created colostomy. The angle
nurse demonstrates the correct cutting of the B. Injecting the medication slowly
appliance by making the circle how much C. Massaging the area after removing
larger than the client’s stoma? needle
A. 1/8 inch D. Making a circular mark around the
B. 1/4 inch injection site
C. 1/2 inch
D. 1 inch 39. When teaching how to use a nebulizer, the
nurse should instruct the client to:
35. A child with the diagnosis of Hirschsprung’s A. Hold the breath while spraying the
disease has a temporary colostomy. The nurse medication carefully into each nostril
provides instructions to the parents about
 B. Instill the medication from the nebulizer B. To hold the cane on the unaffected
while exhaling through the nose (strong) side
C. Seal the lips around the mouthpiece C. To move the cane forward first along
taking rapid, shallow breaths through the with the unaffected (strong) leg
mouth D. When going down stairs, to move the
D. Loosely place the lips around the cane and the unaffected (strong) leg
mouthpiece taking a slow, deep down first
breath through the mouth
44. A school nurse has conducted a class on
40. A nurse receives a call that a client is being testicular self-examination at the local high
admitted who will undergo implantation of a school. The nurse determines that the
sealed internal radiation source. The nurse information was interpreted correctly if one of
contacts the admission office clerk to ensure the students states to
that which of the following rooms is selected A. Perform the examination after a cold
for the client? shower.
A. A single room at the distance end B. Expect the examination to be slightly
of the hall painful.
B. A single room near the nurse’s station C. Roll the testicle between the
C. A semiprivate room between 2 isolation thumb and forefinger.
rooms D. Perform the self-examination every
D. A semiprivate room near the nurse’s other month.
stations
45. A nurse is instructing a client to perform a
41. A female client with a diagnosis of cancer two-point gait for crutch walking. The nurse
of the cervix has a radon seed implanted. tells the client to
Which data would it be important for the nurse A. Move the left fool forward and then the
to assess every few hours? left crutch forward, followed by the right
A. Presence of nausea and vomiting. crutch and then theright foot.
B. Hydration status. B. Advance the right crutch and the
C. Dislodging of radiation source. left foot forward, followed by
D. Ability of the client to change position. advancing the right foot and the
left crutch forward.
42. To adequately inspect the external ear C. Advance both crutches forward,
canal of an adult client, the nurse should do followed by the left foot and then the
which of the following prior to inserting the right foot.
otoscope? D. Advance the right foot and then the left
A. Require that all earrings be removed for foot, followed by both crutches.
safety purposes
B. Pull the pinna up and back 46. The oxygen administration device preferred
C. Use an applicator to remove cerumen for patients with COPD is:
D. Have the client lie down to promote A. Nasal canulla
comfort B. Oxygen tent
C. Venturi mask
43. The nurse is instructing a client who had a D. Oxygen hood
stroke how to ambulate using a cane. Which of
the following instructions would the nurse 47. A nurse has just received an order to
provide to the client? transfuse a unit of packed red blood cells for
A. To hold the cane on the affected (weak) an assigned client. In planning coverage for
side the client assignment, the nurse asks if another
nurse will be available to check on the other 5. “When I squeeze my nipples, I should
assigned clients for how long when the unit of expect to note some discharge.”
blood is hung? 6. “I should stand before a mirror and inspect
each breast for anything unusual.
A. 5 minutes
B. 15 minutes A. 2,4,5
C. 30 minutes B. 1,3,6
D. 45 minutes C. 2,3,4,5
D. 2,4,5,6
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.”