OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING
2ND SEMESTER 2023-2024
FUNDAMENTALS OF NURSING POST-TEST
ANTHONY M. NOTARIO, LPT, RN, MAN

Situation 1 A 65 year old male with BPH was admitted because of

A 22-year-old nursing student came in at emergency room occasional altered mental status. Accidentally he was found out
because she sustained a chemical injury on both eyes while to have UTI. Based in the history, he had passed out stones
forming a laboratory works in their chemistry class. before but he ignored it. He is also a type II DM patient.
1. When irrigating the client’s eyes, which technique is the best 10. The patient is scheduled for creatinine clearance. Which of
way to direct the flow of irrigating solution? the following statement is correct with regards to this
a. Directly onto the corneal surface procedure?
b. Away from the inner canthus a. A dye will be injected in the venous system to note the
c. Within the anterior chamber kidney anatomically.
d. Toward the nasolacrimal duct b. Collection of a 24-hour urine specimen is required
The client initially had total loss of vision. Eye patches were c. Monitoring some signs of urinary obstruction after
done on both eyes after irrigation. The nurse observes a procedure is necessary
nursing assistant ambulating a blind client. d. Collect an early-morning clean catch midstream urine
2. Which instruction to the nursing assistant is best for specimen
maintaining the client’s safety and security? 11. A retention catheter is placed since patient had occasional
a. Let the client take your arm while walking difficulty in passing out his urine. Urine C and S was
b. Take the client’s arm requested subsequently. The preferred method of obtaining
c. Position the client in front urine specimen in patient with indwelling catheter is to:
d. Have the client walk independently to achieve self- a. Use a bulb syringe to withdraw urine from catheter.
reliance b. Use a sterile syringe and a needle to withdraw urine
The client was discharged after 1 week. She was prescribed from catheter port.
with some eye drops. The nurse is educating the client. c. Disconnect the tubing and drain the tube between the
3. The nurse will teach the client to instill the eye drops into catheter and drainage bag, using sterile technique
which part of the client’s eye? d. Using sterile technique, drain 30 ml of urine from
a. Into the cornea catheter collection bag.
b. At the inner canthus Situation 4
c. At the outer canthus The patient was discharged then in a good condition. After 4
d. In the lower conjunctival sac months she came back due to fall injury sustaining fracture of
Situation 2 right fibula.
In the ER department that a 45 year-old 55 kg-burn victim, has 12. A plaster cast is applied and she was given discharged
deep partial and full-thickness burns on the right anterior lower instructions. Which of the following statements if made by
extremity and on the right lower and upper quadrant of the the patient indicates a need for further education?
abdomen. a. “I am expecting a warm feeling as the cast dries”.
b. “If the cast becomes wet, I can use a blow drier set on
4. The nurse who documents the burn injury is accurate in
the cool setting to dry the cast”.
identifying the full-thickness burns as those that are:
c. “I just called up my mother to buy a handy scratching
a. White and leathery c. Red and painful
device that I can use under the cast”
b. Pink and blistered d. Blanches on pressure
d. “I should not use lotion or powder to relieve itching in
5. How much IV fluids should possibly be infused to the
the cast edge”.
patient for the first 8 hours?
13. She was taught how to use crutches temporarily in three-
a. 1 liters c. 3 liters
point gait. The patients understand the instructions
b. 2 liters d. 4 liters
correctly if she states that?
The physician orders the application of Mafenide Acetate
a. “I should straight my elbow holding the hand bar”.
(Sulfamylon) to the burn wound as well as wet to dry
b. “My weight should be born by my axilla”.
dressing. c. “When I will go down stairs, I will use my crutches with
6. The nurse who applies Sulfamylon understands that which my unaffected lower extremity”.
of the following is the main disadvantage of this drug? d. “I will use these crutches for a non-weight bearing
a. Skin discoloration gaits”.
b. Pain on application 14. While the nurse assisting her in ambulation. The patient
c. Fluid volume deficit tells the nurse that her father is a diagnosed AIDS victim.
d. Contact dermatitis and leukopenia The patient noted raised dark purplish lesions on the trunk
7. When the client asks why that kind of dressings are being of her father’s body. She asks the nurse what test could
applied, which explanation by the nurse is most accurate? identify and confirm these lesions. The nurse has the best
a. The dressing will prevent wound infections knowledge if he states that?
b. The dressing removes dead cells and tissues a. ELISA c. Skin biopsy
c. The dressings absorb blood and drainage b. Western Blot d. Lung biopsy
d. The dressing will protect the skin and injury Situation 5: Diagnostics and Treatments
The patient became bedridden and frequently found at the 15. In assessing the laboratory findings for a client, the nurse
bottom of the bed with feet hanging on the footboard. The should be aware that a decrease in the serum level of which
nurses typically pull him up in bed and reposition him for laboratory value might cause digitalis toxicity?
comfort. a. Potassium c. Phosphorous
8. Because the immobile client slides down in bed, the nurse b. Sodium d. Calcium
is correct to assess which type of injury?
16. Nurse Gina is preparing the client for an ultrasound of the
a. An injury resulting from continuous pressure
gallbladder. Which of the following statements would be the
b. An injury resulting from shearing force
c. A superficial skin injury from friction most important to prepare the client for the test?
d. A secondary injury from agitation in bed a. “You will have food and fluids restricted for 4 to 8 hours
9. The client receives TPN temporarily. While in TPN he prior to the test”.
complains of nausea, excessive thirst, and increased b. “Stool in the bowel may cause reporting of inaccurate
frequency in voiding. The nurse next assesses which of the findings”.
following client’s data? c. “You may drink and eat as much as you can”.
d. “You will not eat 24 hours prior to exam”
a. Serum BUN and creatinine 17. Following a bronchoscopy, the client requests for water.
b. Capillary blood glucose The most important consideration to note is which of the
c. Last serum potassium following?
d. Rectal temperature a. The client is ambulatory
Situation 3 b. The client is in bed with rails up
 c. The client received local anesthetic prior to procedure 30. The patient is scheduled for proctosigmoidoscopy. She says
d. The client is coherent she is nervous. The most appropriate response to made by
18. Martha Agoncillo is experiencing shortness of breath after the nurse is:
oxygen that was being delivered by nasal cannula was a. “You need not worry. You have the best Doctor in the
decreased to 2L/min. Pulse oximetry revels an O2 hospital”
saturation reading of 71 %. Which of the following would b. “I don’t blame you for feeling that way, if I were in your
be the most appropriate immediate nursing action? position, I would feel the same”
a. Increase the O2 concentration to 15 L/min c. Why do you feel that way? Don’t you trust god
b. Place client to semi fowler's position. d. You should be really upset. Would you like to sit and talk
c. Do nothing. It is expected. Compensation follows with about it?
this case anyway. 31. From your admission interview of a patient, you obtained a
history of allergies. You can best communicate this
d. Place the client upright position. Assess for the status
information by:
and notify the physician immediately
a. Placing allergy alert in Kardex
19. The laboratory report shows WBC differential for your client b. Writing in the patients Chart
who is experiencing an allergic reaction. Which type of cell c. Informing his attending physician
would you expect to be elevated? d. Taking note when giving medications
a. Neutrophils c. Monocytes
Situation 8: Concept of Feeding and Bowel Elimination
b. Eosinophils d. Lymphocytes 32. When inserting NGT, the neck should be:
20. Your client has recently completed chemotherapy and has a. Flexed c. Tilted to the left
developed bone marrow suppression. Which of the following b. Extended d. In neutral position
reports will you closely monitor? 33. Which of the following is inappropriate nursing action when
a. ESR c. Hemoglobin administering NGT feeding?
b. WBC d. Hematocrit a. Assist the client in Fowler’s position
21. You would anticipate that a client with liver failure would b. Introduce feeding slowly
have elevated serum blood level of which of the following? c. Place the feeding 24 inches above the point Of insertion
a. Ammonia c. ESR NGT
b. Glucose d. Platelet count d. Instill 60 ml of water into the NGT after feeding
22. In MRI procedure, which of the following will be removed? 34. Refers to the passage of stool with bright red blood due to
a. Plastic bracelet c. Catheters lower gastrointestinal bleeding
b. Teeth braces d. Slippers a. Melena c. Steatorrhea
23. Mr. Bert Lambino is scheduled for a colonoscopy. He asks b. Hematochezia d. Hematoma
you regarding the procedure. Your best answer would be: 35. The following are solutions used as non-retention enema
a. Evaluate whether there is tumor or other problem on the EXCEPT:
a. Tap water c. Normal saline
large intestines
b. Carminative enema d. Fleet enema
b. Determine the presence of blood in the abdominal cavity
36. When leaving an isolation room, the nurse correctly removes
c. Evaluate presence of impaction of stool
her equipment:
d. Evaluate peptic ulcer a. gown, gloves and mask
24. The nurse is assisting Mrs. Jane Mario to collect a b. gloves, mask and gown
midstream urine specimen. The nurse uses the principles of c. mask, gown and gloves
aseptic technique by: d. gown and mask inside the room and gloves outside the
a. Cleansing the meatus with upward strokes room
b. Irrigate with sterile water 37. During the surgical procedure of explore laparotomy the
c. Making sure the fingers will not touch the inner surface of nurse having a hard time to count the towel pads and later
the collection container finds out that one was missing. What will be the nursing
d. Collect urine for 24 hours responsibility here?
25. The nursing student is assigned to an adult who is a. Let the towel pad be lost since it’s disposable
scheduled for bone marrow aspiration. The co-assigned b. Inform the physician that the first counting was a
nurse asks the nursing student about the possible sites that mistake
could be used to perform the procedure. The student nurse c. Tell the team to pack-up since sterility was broken
correctly states: d. Inform the surgeon that one towel pad was missing and
a. Femur c. Scapula a possibility for another exploration is done to find the
b. Iliac crest d. Ribs towel pad
Situation 6: Maslow's Hierarchy of Needs Situation 9: Mrs. Antoine de Falcon, businesswoman, is
26. According to Maslow’s hierarchy of needs, which of the experiencing Dyspnea. He is admitted in ICU after the diagnosis
following is a basic physiologic need after oxygen? of CHF.
a. Fluids 38. In increasing the condition which of the following is the
b. Freedom from infection or any disease symptom he would likely exhibits:
c. Love and belongingness a. Dyspnea and spleenomegaly
b. Dyspnea and ederma of extremity
d. Self-esteem
c. Orthopnea, moist rales and cough
27. Which of the following needs does the nurse consider when
d. None of the above
she implements reverse isolation for the client with
39. Which of the following would be the best indicator for this
leukemia?
condition?
a. Physiologic need
b. Safety and security a. Characteristic of pulse c. Temperature
c. Love and belongings b. Blood Pressure d. Breathing pattern
d. Self-esteem 40. Which of the following position would be comfortable for him?
Situation 7: Concept of Bowel Elimination a. Dorsal recumbent c. Low Fowlers
28. Constipation is a common problem for immobilized patients b. High Fowlers d. Supine
because of: 41. Phenetoin (Dilantin) is ordered by the doctor to manage Mrs.
a. Decreased peristalsis and positional discount De Falcon's seizure. The nurse knows that she might expect
b. Increased defecating reflex side effect on the patient:
c. Decreased tightening of the anal sphincter a. Decrease Cardiac Rate c. Hypotension
d. Increased colon motility b. Gingival Hyperplasia d. Hypokalemia
29. The following are correct nursing actions when administering Situation 10: Ms Tony Gabriel was admitted to the hospital for
enema, Except: gastric bleeding, physician ordered a blood transfusion.
a. Provide privacy 42. Before blood transfusion, the nurse must assess Mr. Tony for
b. Introduce solution slowly which of the following
c. Alternate NSS with tap water soap suds. a. Clotting Time and History for bleeding
d. Increased the flow rate of the enema solution if b. Vital Signs
abdominal cramps occur. c. Dextrose 5% in water
d. Plasma and CBC
43. Before administering the transfusion, the nurse must start 56. Karl should be informed that the Urine C and S studies are
an IV Infusion with which of the following? required for which of these purposes?
a. Sterile water solution a. to analyze the elements, present in the urine
b. Normal Saline solution b. to determine if the urine contains evidence of malignant
c. Dextrose 5% in water cells
d. Plasma combined with D5LR c. to identify the organism causing the infection in the
44. Which of the following is the appropriate needle for blood urinary tract
transfusion? d. to localize the site of the inflammatory process in the
a. butterfly needle c. 19 G needle urinary test
b. 18 G needle d. 20 G needle 57. The specimen required for Urinary Albumin Determination
45. Which of the following is NOT expected to be done by the is:
nurse in case of whole blood transfusion? a. fractional urine collection
a. Assess the venipuncture for evidence of hematoma b. midstream urine sample
b. Prepare the blood transfusion c. 24-hour urine
c. Assess the patient closely for any reaction d. early morning midstream urine
d. Ensuring correctness of serial code of the blood product, 58. The following are normal characteristics found in the urine
blood type, and name of donor EXCEPT:
46. Which of the following is recommended initial rate of flow the a. specific gravity= 1.020 c. uric acid = traces
first 30 minutes in case of blood transfusion? b. ph = 6 d. RBC
a. 60 gtts c. 40 gtts 59. To obtain a 24 hour urine sample, which of these
b. 10 gtts d. 20 gtts instructions should be given to Karl?
Situation 11: NGT/NIT Concepts a. “Collect each voiding in separate containers for the next
47. Nurse Joan is caring for patient with nasogastric tube. The 24 hours”
doctor orders 100-ml flush through the tube every 4 hrs. b. “Keep a record of the time and amount of each voiding
When it’s necessary to flush a nasogastric tube, the solution for 24 hours”
to use is: c. “Collect all the urine voided starting from the time
a. Distilled water c. Sterile saline indicated by doctor”
b. Sterile water d. Clean water d. “Discard the first voiding in the morning and then
48. During insertion of nasogastric tube, which position is best collect the total volume of each voiding for 24 hours”
assumed by the client? 60. The most dangerous and life threatening of the
a. Low fowlers c. High-fowlers complication of IV therapy is:
b. Supine Position d. Lateral a. Pyrogenic reaction c. Circulatory overload
Situation 12: Post Mortem Concepts (49,50) b. Air embolism d. Thrombophlebitis
49. As a nurse, when is the right time to conduct a post- 61. All but one are reasons why IV injection is preferred:
mortem care? a. when large volume must be given
a. The physician left the client after CPR b. when rapid onset of action is desired
b. The physician had talked to relatives of the client c. when drugs are highly irritating to the tissue
c. The physician pronounced that the client is dead d. when drug incompatibility is a major problem
d. After relative leaves the client 62. A widely used method of organizing and recording data
50. How many identification tags are prepared after death to about a client which is quickly accessible usually used
ensure identity? during endorsement procedure in the Philippines?
a. 2 c. 5 a. Kardex c. Admission form
b. 3 d. 4 b. Chart d. computer
51. Mang Tomas, 68, complains of a “gassy” abdomen, His AMD 63. Which of the following in NOT caused by prolonged
ordered rectal tube insertion. The nurse should insert the immobility?
tube: a. contractures c. pneumonia
a. 2-5 inches c. 4-8 inches b. thrombosis d. Hyperpyrexia
b. 2-3 inches d. 6- 8 inches 64. To prevent fluid and electrolyte disturbances, the
52. Because of constipation, the AMD ordered the client to take nasogastric tube should be irrigated with:
60 ml of castor oil. Castor oil facilitates a. 0.9% NaCl c. Clean tap water
a. Lubricating the feces b. 0.3% NaCl Solution d. Sterile warm water
b. Increasing the volume of intestinal contents 65. All but one are roentgenogram examinations:
c. Softening the stools a. IVP c. EMG
d. Irritating the nerve endings in the intestinal mucosa
b. Barium Enema d. Barium swallow
53. One of the important goals of the nurse is to prevent
66. Digital extraction of feces is contraindicated in a very weak
contractures and deformities especially in clients who are
or elderly patient because of vagal stimulation which may
immobile. Thus, the nurse should change the client’s
cause:
positions in bed at least:
a. tachycardia c. bradycardia
a. when told to do so c. as often as necessary
b. Palpitation d. Hypertension
b. every 2 hours d. every 2 – 3 hours daily
67. The patient had her indwelling catheter removed. The nurse
54. Which of the measures when taking by the nurse explains
endorses that her patient should be able void in:
the precaution to be taken undergoing oxygen therapy.
a. 2- 4 hours c. 6-8 hours
Which is not appropriate:
b. 4-6 hours d. 8-10 hours
a. reinforces teaching every time a new individual visits
the client on treatment 68. To prevent pressure sores, what should you take priority
b. place a “no smoking” sign on the patient’s chart action?
c. minimize the use of appliance in the patient’s room a. frequent turning and massage
d. the use of electric razor is not allowed for the patient b. regular bathing and use of mild antiseptic
55. Which of the following statements is TRUE about rectal tube c. change of position every 3 hours
insertion? d. increase fluid intake
a. the rectal tube may remain in the colon for 2 - 3 hours 69. In planning nursing care to prevent pressure ulcers in a
to achieve the desirable effect bedridden client the nurse should include which of the
b. b. the rectal tube should remain in the colon not longer following interventions?
that 30 minutes and reinserted 2-3 hours after a. Turn and position the client BID
c. the rectal tube should remain in the colon only 5 - 10 b. Vigourously massage bony prominences
minutes to prevent rectal damage c. Hang a turning schedule at the client’s bedside with a
d. the rectal tube may remain in the colon for 24 hours or sign sheet
until the effect has been achieved d. Slide the client gently when turning
Situation 14: Emertan is for Urine Culture and Sensitivity Test 70. The state of health is:
for Urinary Albumin Determination a. identical among individuals c. constant in nature
 b. same at certain ages d. Continually changing 86. Morphine So4, 4 mg SC is ordered. Morphine So4 is
71. A temperature of 101 0F is equivalent to how many degrees available as 8mg/ml. How much?
centigrade?
a. 38.3 c. 38.50 Therapeutic positions:
b. 30 d. 40 87. Position of patient if he is for Optic drug administration?
72. The following are herbal plants used to treat / manage supine
dizziness EXCEPT: 88. Position of patient if he is for suctioning?
a. Kalamansi c. mangga leaf semi fowler
b. suha d. dayap rind 89. Position of patient if he is for enema procedure?
73. The following can be determined by palpation EXCEPT: sims fowler
a. temperature c. size and shape 90. Position of patient if he is for NGT insertion?
b. vibration d. murmur high fowler
74. Which of the ff. principles is FALSE in the care of the client
with drainage tubes?
a. The patency of the tube must be maintained at all 91. You received the routine fecalysis result of your client.
times Which of the following result would NOT be normal?
b. The receptacle for drainage must be below the organ a. odor – foul smelling
being drained b. amorphous phosphates(+)
c. The equipment comprising the drainage system must c. (+)dead bacteria
be clean d. (+) mucus and (+) occult blood test
d. The receptacle for the output must be changed PRN 92. Richard has an O2 therapy given via face mask. The primary
75. Which of the following vitamins CANNOT be stored in the effect of
body? oxygen therapy is to:
a. Ascorbic acid c. Calciferol a. increased oxygen in the tissues and cells
b. Aquamephyton d. Retinol b. increased oxygen carrying capacity of blood
76. An independent nursing action to lower body temperature is c. increased respiratory rate
to: d. increased oxygen pressure in alveolar sac
a. perform bedbath everyday 93. To promote lung expansion, what measures can the NURSE
b. administer antipyretic per doctor’s order employ?
c. TSB a. oxygen inhalation
d. give fluids 1 liter per day b. chest cupping and vibration
77. When the radial pulse of your patient is irregular, the nurse c. steam inhalation
should: d. deep breathing and coughing exercise
a. take the apical pulse 94. The following are early manifestations of hypoxemia,
b. request another nurse to take the pulse. EXCEPT:
c. count the pulse for 30 seconds and record rate a. Tachycardia c. Tachypnea
d. wait for 30 minutes & count radial pulse for one minute b. Restlessness d. Cyanosis
95. Mang Tomas , 68, complains of a “gassy” abdomen, His AMD
78. When the drugs is administered via the spinal canal, the
ordered rectal tube insertion. The nurse should insert the
route use is:
tube:
a. intra-arterial c. intra-synovial
a. 2 – 4 inches c. 4 – 8 inches
b. intrathecal d. intravenous
b. 8 – 10 inches d. 6 – 8 inches
79. A drugs is absorbed most rapidly when:
96. Because of constipation, the AMD ordered the client to take
a. given in an empty stomach
60 ml of castor oil. Castor oil facilitates
b. injected intravenously
a. Lubricating the feces
c. injected intramuscularly b. Increasing the volume of intestinal contents
d. administered with a glass of water c. Softening the stools
80. When mixing medications in one syringe from one vial & d. Irritating the nerve endings in the intestinal mucosa
one ampule, the nurse withdraws the drugs: 97. Pain is one of the patient’s major problems Which of the
a. from the ampule first c. simultaneously following statements is NOT TRUE?
b. from the vial first d. any a. utilize various types of pain relief measures if necessary
81. Several client are being admitted to the hospital unit at b. utilize measures that the nurse believes to be effective
once time. There is only one private room available. Which c. if therapy proves ineffective at first, change with another
of the following clients has highest priority for being relief measure
admitted to this private room? d. pain tolerance varies greatly among individuals
a. A client admitted for surgery 98. To remove matting of hair, which of the ff. methods is most
b. A client under the age twelve effective?
c. A client who has a communicable respiratory infection a. moisten the affected part with a small amount of oil
d. A client with large infected abdominal wound b. comb the hair by strand
c. perform bed shampoo
d. apply a hair gel thoroughly on the scalp
82. Metropolol (Lopressor), 25 mg PO, is ordered. Available in
99. The MOST dangerous complication of vomiting is:
50 mg/tab. How many tablet the nurse will give?
a. Aspiration c. Hypokalemia
b. Dehydration d. Fever
83. Phenytoin (Dilantin), 100 mg PO, is ordered to be given 100. One of the important goals of the nurse is to prevent
NGT. Available 30 mg/5ml. How much the nurse will give? contractures and deformities especially in clients who are
16.5 ml/ 17 ml immobile. Thus, the nurse should change the client’s
84. Captopril (Capoten), 12.5 mg PO, is ordered. Captopril is positions in bed at least:
available in 25mg tablets. How many? a. when told to do so c. as often as necessary
1/2 tablet b. every 2 hours d. every 2 – 3 hours
85. Theophylline elixir , 100 mg PO, is ordered , via PEG.
Available is 80mg/15 ml. How many? God Bless!
1.820ml/ 1.9