NURSING PRACTICE I: FOUNDATION OF NURSING PRACTICE

1. This evaluation may be limited to the performance of one nurse or by the whole agency. This is done by
looking into the structure, process and outcome of care provided. This process of evaluation is called:
a. process evaluation
b. quality insurance
c. nursing audit
d. quality assurance
2. A client is confined in your unit. He says that he has difficulty sleeping because of the ambience in the unit.
When evaluating the effect the setting has on the quality of care provided to the client the evaluation being
done is called:
a. quality assurance
b. structure evaluation
c. nursing audit
d. quality assurance
3. The client is given a sponge bath, vital signs are checked, and medications are given on time. The evaluation
of the care provided to him by the nurse is referred to as:
a. nursing audit
b. outcome evaluation
c. process evaluation
d. quality improvement
4. As a result of the comfort measure done and medications administered to the client, some demonstrable
changes are observed. These changes in the clients condition when evaluated is referred to as:
a. outcome identification
b. quality improvement
c. nursing evaluation
d. outcome evaluation
5. The head nurse wants to evaluate the time it takes for the nurse to respond to clients call. This type of quality
evaluation is called:
a. quality improvement
b. structure evaluation
c. nursing audit
d. process evaluation
6. Accuracy in recording of the vital signs is of utmost importance in the management of patient care. Special
considerations to be observed when taking vital signs include the following EXCEPT:
a. frequent measurement done n the ICUexpose clients to more pathogens
b. wait at least 30 minutes after excercising, eating or smoking before taking vital signs
c. clients with acute neurologic deficits must be checked frequently
d. use of games and stories to decrease anxiety in infants to assess vital signs
7. The nurse considers which of these to be CORRECT as when taking vital signs?
a. Standard and uniform equipment are used to measure vital signs for all clients in the ward.
b. Measurement and interpretation of vital signs can be delegated to nursing aides who have been well
trained
c. BP reading is routinely assessed in young infants and children to assess cardiac functioning.
d. Baseline data of the clients physiologic functioning are established through accurate measurement
of vital signs.
8. The nurse obtained a BP reading of 120/ 80 when the client was in supine position. After an hour, the nurse
rechecked it and obtained a reading of 132/ 78 in supine position and 110/ 60 in a sitting position. The most
appropriate action by the nurse is to:
a. get the clients BP reading in the other arm
b. report the readings to the supervisor for appropriate nursing actions
c. assist the client to return to a supine position
d. conduct a physical assessment of the client
9. The nurse has to take the clients thigh blood pressure. You will assist the client assume which correct
position
a. side- lying
b. fowlers
c. slims
d. supine, knees flexed
10. The nurse obtained a prior blood pressure reading of 70/ 40 mmHg from a male client. This time she could
not obtain a reading by auscultation. The most appropriate nursing action would be to:
a. leave the BP cuff on the client so as not to disturb when checking the BP again
b. take the clients BP by palpation reporting to the physician any 20 mm Hg change in reading
c. report to the physician immediately for proper intervention
d. ask a nursing assistant to take blood pressure by auscultation.
11. While the nurse changes the patients gown, the infusion pump alarm turned on. The nurses priority should
be to check first the:
a. intravenous site for occlusion
b. presence of air in the tubing
c. container if empty
d. tubing for kinks
12. The nurse discusses with the clients wife health promoting activities that can help the client with cirrhosis of
the liver in his ADL at home. Which among the following is the most appropriate measure the nurse can
suggest?
a. good nutrition, avoid infection and abstain from alcohol
b. take a glass of milk at bedtime
c. avoid crowded areas
d. ensure adequate rest, sleep and exercise

13. The staff nurses in the medical unit are planning total parenteral nutrition to prevent complication when
administered through a central line. Which of the following interventions are most appropriate?
i. follow strict clean technique for all dressing change
ii. promote adequate rest and limited activities
iii. observe strict aseptic technique
iv. cover insertion site with air occlusive dressing
v. cover the insertion site with moisture- proof dressing
a. 2 & 3
b. 3& 4
c. 2, 4, 5
d. 1, 3, 5
14. The nurse is assigned to a client with a diagnosis of cancer of the bladder, with attachment to an appliance for
a standard urine collection at night. The nurse discusses with the wife the reason for the attachment. The best
explanation should be to:
a. prevent urine leakage
b. prevent urine drainage
c. restrict fluid intake
d. prevent urine reflux into the stoma and ureters
15. The nurses in the renal unit are reviewing the laboratory result of the clients. Which of the following laboratory
results will NOT improve by dialysis treatment?
a. low hemoglobin
b. elevated serum potassium level
c. elevated sodium level
d. elevated BUN and Creatinine
16. The incoming nurses in the renal unit are discussing the assessment findings of a 66 y/o client, male with
chronic renal failure and hypertension. He has crackles in the lungs and weight gain from 145 lbs to 160 lbs.
The nursing diagnosis that is appropriate for the above findings is:
a. fluid volume excess related to malfunctioning kidneys
b. increase fluid intake related to chronic renal failure
c. fluid volume deficit related to renal failure
d. fluid volume excess related to inability of the kidney to maintain fluid balance
17. A 16 year old female client got pregnant and was abandoned by her boyfriend. She visited a doctors clinic and
asked the nurse if she could have an abortion. What should be the initial response of the nurse?
a. Why not think it over then decide after careful assessment of the situation.
b. You should not feel that way.
c. What are your feelings about abortion?
d. You seek advise from your parents.
18. A 45 year old female client is admitted to a semi- private room for elective surgery. She tells the nurse that
her prayer group will be coming to pray for her. The group arrived, starting chanting inside the room. What
should be the appropriate action of the nurse?
a. Arrange for the group to go to the prayer room or chapel if available
b. Ask the clients roommate for their understanding and respect the other clients wish
c. Ignore the prayer group and allow their chanting
d. Call the attention of the group and pray quietly
19. A 40 year old male client has been confined in a semi- private room for 2 days until another client came. He
asks the nurse what the condition of the client is. Which of the following should be the nurses response?
a. advise him that all clients condition are held in confidence
b. tell him to ask the new client himself
c. explain in laymans term the condition of the new client
d. ask the client what he wants to know
20. A nurse who functions from an ethic of care is best illustrated when she/ he:
a. uses touch to provide comfort
b. provides a person- to- person encounter
c. listens to clients
d. shows sensivity to unequal relationship
21. The nurse has a responsibility to perform nursing care activities based upon standards of practice. This means
that:
a. minimum level of performance is accepted to ensure high quality care
b. nursing action performed by the nurse is based on scientific knowledge
c. nursing activities performed by the nurse to an acceptable level
d. practices observed by nurses ensure quality care
22. An elderly client in the Medical unit tells the nurse that he is tired of the treatment and sees no improvement
and he would rather take all his medication to end his sufferings. Which of the following should be the initial
action of the nurse?
a. assess the client and make appropriate referrals
b. call the attention of the wife and watch the client closely
c. recommend to the client to seek advocacy support
d. communicate the clients wishes to his family
23. A middle age client is frantic and upright. The client has an order of Benadryl 25 mg p.o. prn for itching. The
nurse administered Benadryl. The best description for the nurses action is:
a. negligence
b. appropriate
c. battery
d. malpractice
24. A female client has an order of repositioning every 2 hours. The nurse failed to change the position of the
client as specified in plan of care. The nurses action constitutes a violation of:

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a. Medical Practice Act

b. Standardized Nursing Care Plan
c. Standards of Practice
d. Nurse Practice Act
The nurse is taking care of an elderly client who is restless and tense. To protect the nurse from being sued
for unlawful restraints which of the following should be her appropriate action?
a. tell the client that a restraint is to be applied for his own protection.
b. Contact the physician for orders and document the reason for using restraints
c. Explain to the family that a restraint is needed for the protection of the client
d. Ask the family to be on the alert to protect the client from harming self
The nurse calls the physician to report a change in the condition of the client. The nurse is unable to reach the
attending physician but left the message to his secretary. The secretary called back and relayed the verbal
order of the physician. Which of the following is the MOST appropriate action of the nurse?
a. refuse to take the order from the secretary
b. accept the verbal order as it comes from the physician and record appropriately
c. insist on talking to the physician
d. take a message and ask for the signature of the physician during the visit
A client is admitted with IV fluid due to severe diarrhea. While monitoring the flow rate of the clients IV fluid,
you assess his response to the treatment. The most important assessment that will show expected outcome
for his client is:
a. daily weight
b. presence of edema
c. skin turgor
d. hourly urine output
You are administering 3 % Sodium Chloride solution to a client who has a diagnosis of Hyponatremia.
Continous assessment is done to ensure that the client is safe from serious side effect of fluid volume excess.
Your assessment will focus on the clients:
a. pedal edema
b. peripheral pulses
c. lung sounds
d. urinary output
The nurse is taking care of a 45 year oldmale client with COPD. The client has difficulty raising respiratory
secretions. Which of the following actions should the nurse perform to reduce the tenacity of the secretions?
a. encourage fluid intake from 2- 3 liters/ day
b. maintain client semi- fowlers position
c. serve low salt, low fat diet
d. administer O2 inhalation
The client asks the nurse why postural drainage is ordered by the physician. The nurse informs the client that
this procedure is done to:
a. facilitate drainage after percussion has loosened the secretions
b. move secretions from lower to the upper segment of the lungs
c. improve respiration by clearing the alveoli
d. help decongest the lungs through drainage of all lung segments.
The nurse kn ows that the principle used in postural drainage, cause the secretions to move through:
a. force of gravity
b. anterior to posterior lung segment
c. pleural space to the apical lung segment
d. sweeping motion during respiration
Oxygen administration at 2 L/ min through nasal cannula is prescribed for this client. When the client asks
why he needs O2 therapy, your most appropriate response is that in his condition low oxygen level serves to:
a. balance CO2 content
b. act a stimulus for breathing
c. restore normal breathing pattern
d. eliminate respiratory drive
The nurse teaches the client how to conserve energy. To meet this goal the nurse instructs the client to:
a. blow slowly through purse lips when lifting objects
b. exhale then inhale with pursed lips when lifting objects
c. inhale then exhale with pursed lips when lifting objects
d. draw a deep breath through pursed lips when lifting objects
When he enters the room, he finds the client in bed. She says that she is afraid to choke on her medications
because sometimes she has hard time swallowing. Which nursing action is most appropriate?
a. mix the medication in the clients soup
b. put the client in supine position
c. ask the client to assume sitting position
d. mix the capsule in a banana for her to chew
The nurse is going to instill otic drops to the client. He instructs the client to lie on his side opposite the ear to
be medicated. To administer the otic medication the nurse will straighten the ear canal by pulling the pinna:
a. upward & forward
b. from side to side
c. upward and backward
d. downward and backward
When giving SQ injection to an obese client, the nurse should pinched the skin at site and inject medication at
which angle?
a. 50
b. 45
c. 20
d. 90
The nurse will next administer an IM injection preparation to another client. The nurse safely administers the
drug using the Z track technique of injection for the following reasons EXCEPT:

a.
b.
c.
d.

this skin method leaves a zigzag path to seal the needle track
the skin is pulled sideways and the needle is injected at 45 angle
this technique is best when medication for IM injection is irritating to tissue
this technique requires that the medication be injected slowly to allow it to disperse evenly in muscle
tissue

38. The nurse prepares Penicillin for skin test. He uses tuberculin syringe with gauge 25 needle and performs the
procedure correctly by:
a. withdrawing needle quickly to minimize bleeding
b. stretching skin over site and inserting needle at 10- 15 angle sample
c. massaging the injection site
d. pinching the skin over site and injecting medication slowly
39. A client is scheduled for surgery and the nurse infers from his body language that he is anxious. The nurses
most therapeutic response would be:
a. Think about healthy you could be after surgery
b. I know how you feel. I had surgery before.
c. If you are worried about the surgery, you shouldnt. We have the best surgical team in the hospital.
d. You seem worried. Would you like to talk about it?
40. While talking to a 73 y/ o female client, the nurse notices that she does not have her hearing aid on. To ensure
that the client can hear her, the nurse should:
a. speak aloud to clients good ear
b. talk in high pitch voice slowly
c. enunciate and exaggerate her lip movements
d. speak slowly and distinctly and directly face the client
41. Which of the following steps should be included in reporting an incident?
a. Record, investigate, notification, action
b. Notification, investigation, action and record
c. Investigate, report, action and record.
d. Discovery, notification, investigation, consultation, action & record
42. Technology is an essential tool for all health service professionals. A computer based information system
serves several purposes EXCEPT:
a. Build strategic resources for timely and relevant data
b. Promotes organizational innovation
c. Improve operational efficiency
d. Use for decision making and communication
43. Of the following types of medication error, which error may reach the patient?
a.
dispensed wrong drug
b.
inability to administer right dose
c.
documented wrong dose
d.
prepared wrong dose
44. Which of the following is an organizational practice which may result to medication error?
a.
illegible hand writing of the physician
b.
manufacturers labelling and packaging
c.
excessive workload for the staff nurses
d.
drug name confusion
45. The hospital set a patient safety goal to improve effectiveness of communication among the nurses. Which of the following strategies
is related to this goal?
a.
inform nurse of look-alike and sound-alike drugs
b.
use at least two patient identifiers
c.
provide preference guide to verify generic and brand names of drugs
d.
standardize abbreviations
46. Illegible handwriting of prescriber is a source medication error. Which of the following is a preventive measure related to this?
a.
have a pharmacist review medication orders
b.
clarify order with the prescriber
c.
utilize medication administration schedule
d.
administer only fully labelled medications
47. The nurse found out that the medication she supposed to administer is not available in the patients cubicle. Which of the following is
a safety practice to be followed by the nurse?
a.
adjust schedule of drug administration
b.
wait for the pharmacy to dispense
c.
skip the current dose
d.
borrow medication from another patients medication cubicle
48. In the hospital where you work, increased incidence of medication error was identified as the number one problem in the unit. During
the brainstorming session of t the nursing service department, probable causes were identified. Which of the following is process
related
a.
Interruptions
b.
use of unofficial abbreviations
c.
lack of knowledge
d.
failure to identify client
49. Miscommunication of drug orders was identified as a probable cause of medication error. Which of the following is a safe medication
practice related to this?
a.
maintain medication in its unit dose package until point of actual administration
b.
note both generic and brand name of the medication in the Medication Administration Record
c.
only officially approved abbreviations maybe used in the prescription orders
d.
encourage client to ask question about their medications
50. An order for a client was given and the nurse in charge of the client reports that she has no experience of doing the procedure before.
Which of the following is the most appropriate action of the nursing supervisor?
a.
assign another nurse to perform the procedure
b.
ask the nurse to find a way to learn the procedure
c.
tell the nurse to read the procedure manual
d.
do the procedure with the nurse
51. Mr. Joses chart contains all information about his health care. The functions of records include all the following EXCEPT:
a.
means of communication that health team members use to communicate their contributions to the clients health care
b.
the clients record also shows a document of how much health care agencies will be reimbursed for their services

c.
d.

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educational resource for student of nursing and medicine

recording of actions in advance to save time

An advantage of automated or computerized client care system is:

a.
the nursing diagnoses for clients data can be accurately determined
b.
cost of confinement will be reduced
c.
information concerning the client can be easily updated
d.
the number of people to take care of the client will be reduced
Information in the patients chart is inadmissible in court as evidence when?
a.
the clients family refuses to have it used
b.
the clients objects to its use
c.
the handwriting is not legible
d.
it has too many abbreviations that are unofficial
Nursing audit aims to:
a.
provide research data to hospital personnel
b.
study clients illness and treatment regimen closely
c.
compare actual nursing done to established standards
d.
provide information to health-care provider
A telephone order is given for a client in your ward. What is your most appropriate action?
a.
copy the order on the chart and sign the physicians name as close to his original signature as possible
b.
repeat the order back to the physicians , cop onto the order sheet and indicate that it is telephone order
c.
write the order on the clients chart and have the head nurse co- sign it
d.
tell the physician that you cannot take the order but you will care the nurse supervisor
Which of the following client conditions should be Miss Rogues priority in the pediatric unit?
a.
the baby whose fontanelle is bulging and firm while asleep
b.
the infant who is brought in for upper respiratory tract infection whose temperature is slightly elevated
c.
a baby who is wailing after being awakened by the banging of the door
d.
a baby boy whose circumcision has yellowish exudates
When suctioning the endoctracheal tube, the nurse should:
a.
explain procedure to patient, insert catheter gently applying suction, withdrawn using twisting motion
b.
insert catheter unit resistance is met, then withdrawn slightly, applying suction intermittently as catheter is withdrawn
c.
hyper oxygenate client then insert catheter using back and forth motion
d.
insert suction catheter four inches into the tube, suction 30 seconds using twirling motion as catheter is withdrawn
As a nurse you were taught how to evaluate arterial blood gas (ABG) values. Which of the following do first?
a.
evaluate HCO3
b.
evaluate pH
c.
determine acid base status
d.
evaluate PaCO2
For clients with diabetic ketoacidosis, their body compensate for the acidosis in many ways. When caring for these clients, which of
the following manifestations will you anticipate to observe?
i. Nausea and vomiting
ii. Oliguria
iii. Kussmaul breathing
iv. Polyuria
a.
1 and 2
b.
3 and 4
c.
1,3 and 4
d.
all of the above
Brenda, 30 years old, was brought to the Emergency Department (ED) with nausea, confusion, dehydration and oliguria. Her mother
informs you that Brenda has been depressed after loosing her jobs as a bank executive. An empty bottle of Aspirin was found in her
bathroom sink. Her laboratory values revealed the following: pH=7.35, PaCO2=66,mmHg, PaO2=130 mmHg and HCO3=26mEq/L.
What is the correct acid-base interpretation of her ABG?
a.
Compensated respiratory acidosis
b.
Uncompensated metabolic acidosis
c.
Compensated metabolic acidosis
d.
Compensated metabolic acidosis
From the record of a client whose pulmonary artery pressure is being monitored through a pulmonary artery catheter, she encountered
a report regarding right arterial pressure. Which of the following is an appropriate interpretation of right atrial pressure?
a.
right ventricular end-systolic pressure
b.
indirectly reflects ventricular contraction
c.
reflects atrial filling from superior vena cava
d.
pressure in the atrium during ventricular filing
Which of the following symbols are used to document arterial oxygen saturation as measured by pulse oximeter?
a.
pO2
b.
paO2
c.
SpO2
d.
SO2
The ICU nurse orientee observed the following arterial blood gases results in one of the patients record: ph-7 46;paO2-97
mmHq;paCO2-40mmHg and HCO3-30meq/L. Which of the following is the interpretation of theses results?
a.
respiratory alkalosis
b.
metabolic acidosis
c.
metabolic alkalosis
d.
respiratory acidosis
The ICU nurse orientee further observed that a liver biopsy which was scheduled for a patient was postponed. When she received the
CBC and prothrombin time results of the patient, which of the following did she identify as the probable cause of the postponement of
the liver biopsy?
a.
Prothrombin time 15 seconds
b.
plateletcount- 100,000/mm3
c.
Hemoglobin- 12gm/dl
d.
Hematocrit 39%
A patient was admitted because of severe complication related to Stevens-Johnson Syndrome. The patient has red purplish lesions on
the face, torso and mucous membrane. Which of the following is CORRECT about Stevens- Johnson Syndrome?
a.
hypersensitivity reaction
b.
skin malignancy
c.
bacterial infection
d.
viral infection

66. You were asked to attend a seminar on basic infection control where standard to clients call. This type of
quality evaluation is called. Your nursing action which indicates your observance of standard precautions
would be when you:
a. dispose needles, scalpel blades, sharp instrument in double bags
b. protect yourself from infections through contact with blood or body fluid borne viruses
c. protect yourself from contact with blood, open wounds and body fluids
d. practice frequent hand washing including washing of contaminated gloves
67. You have mild cough, runny nose and low fever but you still reported to work. Which of the following actions
is NOT an effective way to control infection?
a. do frequent hand washing
b. cover your mouth and nose when you sneeze or cough
c. Minimize working with clients highly susceptible to infections
d. Use mask, gloves and gown while working.
68. Understanding the risks of infection, who among the clients listed below should receive immediate attention
and care?
a. Adult female with Vit. B deficiency due to chronic alcohol intake
b. Adult male with fresh second degree burns on arms and chest
c. A teenager who is bleeding due to a cut on the finger
d. An elderly male with diabetes mellitus and toe infection
69. During the seminar the nurses are informed that ICU patients have a high risk of contracting hospital acquired
infections. Which of the following explanations is TRUE?
a. Many procedures done in the ICU expose clients to more pathogens
b. ICU is never empty so disinfection of this special area is difficult to accomplish
c. Clients are critically ill and highly susceptible to infection
d. ICU personnel are less strict with asepsis since clients are on antibiotics all the time.
70. While taking care of clients, the nurse practices basic personal hygiene when she:
a. Wears ornate jewelry to look pleasant to her clients and colleagues
b. Uses perfume to smell clean and fresh and avoid unpleasant body odor
c. Uses light colored nail polish to protect her nails from infectious material
d. Fixes her hair so that does not fall to her face
SITUATION: The nurse in the Pediatric Unit is preparing medications for a child for surgery. His weight is 22. 9 kg. The
physician ordered Atropine Sulfate 0.2 mg to be administered subcutaneously. An IV infusion of 0.9% Normal Saline
solution 500 ml was stated to run for 24 hours.
71. In determining volume for subcutaneous injection for infants and small children, the nurse should be guided
that the maximum amount is:
a. 1.5 mL
b. 1 mL
c. 0.5 mL
d. 0.1 mL
72. The safe dose of Atropine Sulfate for children is 0. 01 mg/ kg. The nurse computed the safe dose for the
prescribed Atropine Sulfate. She computed the correct dose if she obtained:
a. 0.4 mg
b. 0.2 mg
c. 0.1 mg
d. 0.3 mg
73. After arriving at the safe dose of Atropine Sulafate, the nurse analyzes the desired dose ordered. Which of the
following conclusions should guide the nurse in administering the drug?
a. desired dose is within safe dose range
b. weight of child is not proportional to the desired dose
c. desired dose is more or less adequate for the childs weight
d. computed dose is more than the desired dose

74. The nurse is using an IV infusion device for the intravenous Fluid. A total of 500 ml of 0.9 % NSS is to infuse
over 24 hours. At what hourly rate should the nurse program the IV infusion device?
a. 21 ml/ hr
b. 30 ml/ hr
c. 41 ml/ hr
d. 15 ml/ hr
75. The vital signs sheet of a client reads 104/ 100/ 90. The reading of 100 is interpreted appropriately as the
pressure level when the:
a. 1st thumping sound is heard
b. Sound becomes muffled
c. Last sound is heard
d. Sound has a whooshing quality
76. There is an order to obtain the patients arterial blood oxygen saturation (SaO2). What will you prepare to do
the test?
a. pulse oximeter
b. intravenous pump
c. spirometer
d. ventilator
77. The equipment set an alarm and gave a reading of 69 % SaO2. When ask for initial action in the situation, you
most appropriate response is to:
a. call the physician and report the reading immediately
b. change the position of the client
c. check the connection of the equipment
d. assess the clients vital signs

78. A client reported to have orthostatic hypotension. Which of the following would you consider a sign?
a. Increase in pulse 0f 40 beats/ min and decrease in BP of 30 mm Hg from a sitting to a standing
position
b. A drop of 30 mm Hg from a supine to a standing position with a rise in pulse of 40 beats/ min
c. Decrease in pulse by 20 beats/ min and increase in BP by 20 mm Hg from supine to standing
position
d. A sudden drop in BP of 30 mm Hg systolic and 10 mm Hg diastolic from lying to sitting or sitting to
standing position
79. You demonstrate the correct technique in taking thigh blood pressure. Which of the following should you do
1st?
a. Wrap the cuff around the mid- thigh
b. Help client assume a prone position
c. Expose the thigh
d. Locate the popliteal artery
80. When conducting assessment, the nurse is expected to obtain which of the following significant findings in
pneumonia?
i. cough, fever and chest pain
ii. cough and hypoxia
iii. dyspnea, tachypnea, tachycardia
iv. crackles and wheezes
a. 1 only
b. 1 and 3
c. 3 only
d. 2 and 4
81. With the above data, the nursing diagnosis should be stated as:
a. impaired oxygenation r/ t cough and shortness of breath
b. impaired gas exchange r/ t presence of infectious exudate in the left lobe of the lung
c. impaired oxygenation r/ t pneumonia with infectious exudate in the left lobe of the ling
d. impaired circulation r/ t productive cough and pain in the left chest.
82. The nurse classified the nursing intervention for this client. Which of the following statements refers to this?
a. circulatory status: adequate blood exchange
b. airway management: facilitation of patency of air passages
c. respiratory status: gas exchange
d. demonstrates return of temperature to 37c
83. The nurse formulates plan of care with the client and states the expected outcome as:
a. reports relief of dyspnea
b. expresses comfort of well being
c. speaks comfortably
d. improved breathing
84. The nurse instructs the client how to do effective coughing techniques. The expected outcome of this
technique that will benefit the client is:
a. patent airway
b. increased clearance of exudates
c. adequate tissue perfusion
d. improved breathing
85. Variations in sleep pattern in the different age groups are evident. Which of the following g is TRUE regarding
sleep required among middle- aged group?
a. the satisfaction with the quality of sleep increases as one approaches the middle- age level
b. sleep and rest fluctuates in relation to job- related stress and parenting responsibilities
c. the frequency of nocturnal awakening tends to increase while satisfaction with the quality of sleep
tends to decrease
d. cardian rhythm tends to be prominent with increasing age
86. The goal for the client is that he will:
a. verbalize orientation to night and day
b. sleep more at night and less during the day
c. increase nocturnal sleep
d. gain satisfaction from nocturnal sleep
87. Which of the following is the best time for the client to take a nap?
a. time of day opposite to the midpoint of the nocturnal sleep period
b. time of day near the midpoint of the nocturnal sleep period
c. mid- morning and should be 30 minutes or less
d. mid- afternoon for at least 1 hour.
88. A 68 y/o female client is for discharge. The daughter asks the nurse what she could do to prevent injuries at
home since the client has poor vision. You instruct the daughter to:
a. maintain position of furniture in the house
b. keep the house well lighted at all times
c. put the client on bed rest to prevent possible accidents
d. use wheelchair in the house
89. A 30 year old female client, states that she has frequent UTI and asked the nurse how she could prevent
recurrence. Which of the following is the appropriate instruction of the nurse?
a. regaular intake of 2 glasses of apple juice daily
b. wear cotton underwear with pantyliners all the time
c. drink eight ounce glasses of water daily
d. wipe perineal area after every voiding

90. An 8 y/ o is diagnosed with iron deficiency anemia. When assessing the childs fingernails, the nurse
instructed the mother to look for:
a. spoon nail
b. pale nail beds
c. clubbing
d. presence of Beaus lines

91. A client is a heavy smoker consuming 4 packs daily. He asks the nurse why he cant seem to quit smoking
easily. Your best explanation is that nicotine:
a. is associated with a cool image of a young man
b. affects mood and behaviour and causes tolerance
c. decreases heart rate and respiratory rate
d. is in the body system for a long time and causes relaxation
92. When giving health teachings to people who are experimenting with cigarette smoking, the nurse explains the
following problems caused by smoking EXCEPT:
a. smoking greatly increases risk for ischemic heart disease
b. smoking is a major risk factor for cardiovascular problems
c. pregnant women can smoke without risk to fetus
d. many types of cancer such as lung, oropharyngeal, laryngeal are related to smoking
93. A hospitalized client has an order for NGT feeding. Before starting the feeding you check if the tube is in
place. The best way to do this is to:
a. reinsert a new NGT
b. introduce 10- 15 ml of air and auscultate to listen to the gurgling sound
c. aspirate gastric content and check the pH level
d. lower the tube and allow the secretions to drain then examine secretions
94. A client recovering from breast surgery asks you what type of food would fight free radicals to increase
protection from cancer. Your best response would be:
a. Do you want reading materials in cancer fighting food?
b. Food rich in beta- carotene, vit. A, C, E seem to fight free radicals
c. Eat food that are rich in antioxidants and phytochemicals
d. Have you tried the herbal products in the market?
95. You are taking care of a client who has weakness on the right side of the body. You assess that client has a
high risk for aspiration while feeding. Your most appropriate nursing intervention when feeding the client
would be to:
a. raise the head part of the bed
b. feed clear liquid diet
c. use straw
d. place the food on the unaffected side of the mouth
96. The elderly are more at risk of nutritional deficiency and dehydration. While talking to a client who is for
discharge, he tells you about how his plans to keep himself well nourished and hydrated. Which of the
following statements by the client will indicate that he needs some health instructions from you?
a. I dont drink too much at night so I wont have to wake up to go to the bathroom.
b. I drink water or juice whenever I get thirsty
c. At night, I eat less food and avoid coffee so I wont go to the bathroom frequently
d. I consume at least a glass of water or juice with every meal.
97. The client says being in the hospital makes me nervous. The nurses most appropriate response would be to
say:
a. You feel nervous?
b. Why? What about being in the hospital makes you nervous?
c. It is normal to feel nervous. Is this your 1st time to be in a hospital?
d. Dont worry, nurses are on duty round the clock and they will help you.
98. While talking about the loss of her husband a few months ago, the client becomes teary eyed and soon stops
talking. The nurses most therapeutic response would be to:
a. tell the client that it is normal to be sad under such circumstances
b. leave the client so she can have some privacy
c. change the topic conversation so she wont feel sad
d. remain silent, sit with the client
99. The client is informed that she has malignant breast cancer and has had radical mastectomy as soon as
possible. The nurse finds her sobbing uncontrollably saying I should have gone to the doctor sooner. Now my
kids will grow up without a mother. The nurses best therapeutic response would be:
a. :You feel that if you had been diagnosed earlier things would be different?
b. Dont lose hope. Surgery and radiotherapy work wonders.
c. It is natural to feel that way. Most clients do.
d. Is your husband close to your children?
100.Of the following preliminary tasks, which of the following should the researcher do to obtain available
knowledge in her area of interest?
a. review literature
b. identify the population
c. state the problem
d. select the variables