FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

1. Your patient is prescribed to use crutches for ambulation. The 4. A patient needs to go up the stairs while using crutches. What
patient can bear partial weight and needs to be taught how to finding by the nurse demonstrates the patient understands how
use the two-point gait while using crutches. Which description to ambulate upstairs with crutches?
below best describes this type of gait with crutches? A. The patient moves the crutches forward up the step, then
A. The patient moves both crutches forward and then moves the injured and non-injured leg.
both legs forward to the same point as the crutches. - swing- B. The patient moves the non-injured leg forward onto the
to step and then moves the injured leg and crutches up.
B. The patient moves the right crutch (injured side), then C. The patient moves the injured leg forward onto the steps,
moves the left foot (non-injured side), then moves the left then moves the crutches, and then moves the non-injured
crutch (non-injured side), and then moves the right foot leg.
(injured side). - 4-point gait D. The patient moves the crutches and non-injured leg forward
C. The patient moves both the right crutch (injured side) to the step together, and then the non-injured leg.
and left foot (non-injured side) forward together, and
then moves the left crutch (non-injured side) and right 5. Which demonstration by the patient below shows that the
foot (injured side) forward together. patient knows how to properly ambulate a cane?
D. The patient moves both crutches and injured leg forward A. The patient holds the cane on the strong side and moves
together, and then moves the non-injured leg forward. - 3- the cane and weak side forward together, and then moves
point gait the strong side. - patient who needs minimum support
B. The patient holds the cane on the strong side and moves
the cane forward, then moves the weak side, and then
Rationale:
moves the strong side. - patient who needs maximum
4-point gait: 4 steps
support; safer
→ Does not depend on the unaffected side. You can start
C. The patient holds the cane on the weak side and moves the
with left or right unaffected/affected leg
cane forward, then moves the weak side, and then moves
1. Right crutch
the strong side.
2. Left leg
D. The patient holds the cane on the weak side and moves the
3. Left crutch
cane and weak side forward together, and then moves the
4. Right leg
strong side.
3-point gait: 2 steps
1. Crutches + bad leg Rationale: Cane (COAL) - Cane Opposite Affected Leg
2. Good leg → Standard cane: 36 inches (3 ft); cannot be adjusted; not
applicable to all
2-point gait: 2 steps → Aluminum cane: 22-38 inches; can be adjusted
→ Shortcut of 4-point gait → Distance of cane: 6 inches in front and side
1. Right crutch + Left leg → How to walk with the cane?
2. Left crutch + Right leg • People who needs MAX support (first time)
1. Cane
Swing-to: 2 steps 2. Bad leg
1. Both crutches forward 3. Good leg
2. Swing body @ level of crutches • People who needs MIN support (sanay na gumamit)
1. Cane + bad leg
Swing-through-gait: 2 steps 2. Good leg
1. Both crutches forward • Going up
2. Swing body past/beyond crutches 1. Good leg
2. Cane + bad leg
Going up: • Down
1. Good leg 1. Cane + bad leg
2. Crutches + bad leg 2. Good leg

Going down:
1. Crutches + bad leg
2. Good leg

Take note: AND, THEN words to know if it moves together or

not

To measure the size of the crutch: Supine (Anterior fold of

axilla to the heel) + 1 inch
→ Bear weight: on the hands to prevent crutch paralysis

2. While your patient is ambulating with crutches, he moves both

crutches forward along with the injured leg and then moves the
non-injured forward. When you document you will note that the
patient used what type of gait while ambulating with crutches?
A. Two-point gait
B. Three-point gait
C. Four-point gait
D. Swing-to-gait → How to use a walker?
• People who needs MAX support (first time)
3. While using crutches the patient moves both crutches forward 1. Walker
and then moves both legs forward past the placement of the 2. Bad leg
crutches. This is known as the: 3. Good leg
A. Two-point gait • People who needs MIN support (sanay na gumamit)
B. Swing-to-gait 1. Walker + bad leg
C. Swing-through-gait 2. Good leg
D. Three-point gait
Additional note:
→ Walker/Crutches: Not used when both upper extremity
have weakness
• Because it is used by both hands
→ Cane: Used when there’s only one upper extremity
 FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

weakness → Elevator:
• When entering, large wheel goes first
o Nurse should enter the elevator first
6. As a nurse, you instructed Mr. Roxas how to use a cane. Mr.
(nakatalikod)
Roxas has a weakness on his right leg due to self-immobilization
• When exiting, large wheel goes first (iikot yung
and guarding. You plan to teach Mr. Roxas to hold the cane
wheelchair)
A. On his left hand, because his right side is weak - situation
o Nurse still comes first
only indicated that the right leg is weak
▪ Avoid pushing the patient first when
B. On his left hand, because of reciprocal motion.
exiting, the nurse cannot see the view
C. On his right hand, to support the right leg.
outside because there may be obstacles
D. On his right hand, because only his right leg is weak.
along the way
→ Incline:
7. Mr. Roxas was discharged and 6 months later, he came back
• When going up, small wheel goes first
to the emergency room of the hospital because he suffered a
• When going down, large wheel goes first
mild stroke. The right side of the brain was affected. At the
rehabilitative phase of your nursing care, you observed that Mr.
→ 2 wheels - on stationary
Roxas uses a cane and you intervene if you see him
A. moves the cane when the right leg is moved. • Movement is forward and backward
B. leans on the cane when the right leg swings through. (+) • Where is head of the patient placed
C. keeps the cane 6 inches out to the side of the right foot. (+) • Nurse stays on this side (beh isipin mo nasa grey’s
D. holds the cane on the right side. (+) anatomy ka)
o To protect the head of the patient, especially in
case of collision, head part will not be affected
Rationale: o E.g., Anesthesiologist bringing the patient to the
→ Left leg is affected PACU
→ Holds cane at right hands → 2 wheels - on swivel
→ Elevator:
• When entering the elevator, head part first
8. When teaching a client with a long leg cast how to use the
• When exiting the elevator, still head part first
crutches properly when descending down the stairs. The nurse
o Turn the bed around inside the elevator or;
should tell the client to:
o If the bed is not fitted and cannot be turned
A. Advances both legs first
around, use an elevator with a double door
B. Advance the affected leg first
C. Advance the unaffected leg first
Test taking strategy: Always think that all questions in the
D. Advance both crutches
board exam are perfect and ideal.

Test taking strategy: 2 contradicting choices (e.g., options Patient Transfer: from bed to wheelchair
BC) → Patient seated at the side of the bed, nurse stand in front
of the patient, wheelchair parallel to the bed w/ wheels
locked and foot plate in place
9. When teaching a client with hemiparesis to ambulate with a
→ Feet of the nurse should mirror the feet of the patient
cane, the nurse should instruct the client to:
→ Lift the patient: More ideal if the patient can hold the
A. Shorten the stride of the unaffected extremity
nurse’s shoulder or transfer belt can be used to in lifting
B. Lean the body toward the cane when ambulating
C. Advance the cane and the affected extremity
simultaneously
D. Hold it in hand on the same side as the affected lower
extremity

10. Nurse Oliver is caring for a client with impaired mobility that
occurred as a result of a stroke. The client has right sided arm
and leg weakness. The nurse would suggest that the client use
which of the following assistive devices that would provide the
best stability for ambulating?
A. Crutches
B. Single straight-legged cane
C. Quad cane
D. Walker - more stable

Rationale: walker is not used d/t arm, weakness

• Hoyer’s lift
11. The nurse knows that the cane should be at least how many
inches at the top and side of the foot?
A. 4 inches
B. 6 inches
C. 10 inches
D. 12 inches

12. The nurse successfully moved the client from bed to the
wheelchair. After unlocking the breaks of the chair and lowering
the foot plates. The nurse can now move the wheelchair freely.
Upon entering the elevator, the nurse should remember that:
A. The small Patient leaves the wheelchair before entering the 13. When climbing an incline the nurse should remember:
elevator A. The nurse should be at the bottom of the incline pushing
B. wheels should enter the elevator first the client small wheel first
C. Rear large wheels enter the elevator first B. Rear large wheel first against an incline
D. Patient will enter the elevator first C. The nurse should be above the incline and the client below
the incline
D. The nurse should pull the client instead of pushing against
Rationale: the incline
→ Rear - large wheel
→ Front - small wheel
 FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

19. The client is ambulating for the first time after surgery. The
Rationale: Nurse - bottom
client tells the nurse, "I feel faint." The best action by the nurse
includes which of the following?
14. Excessive heavy lifting could cause back injury as well as A. Find another nurse for help.
muscle strain for the nurse. The nurse knows that she should not B. Return the client to her room as quickly as possible.
lift more than how many pounds of her weight? C. Tell the client to take rapid, shallow breaths.
A. 20 lbs D. Assist the client to a nearby chair. - prioritize client safety
B. 30 lbs
C. 50 lbs 20. In pushing the stretcher, which of the following guidelines
D. 10 lbs should be observed to protect the client’s head in the event of
collision?
a. lock wheels of the bed - paano mo mapupush yung stretcher
Rationale: b. push from the end where head is positioned
→ Old: 50 lbs c. fasten safety straps across the client
Test taking strategy: Number system method d. raise the side rails on both sides
→ Eliminate the lowest and highest
→ Should be accurate 21. Because the client weighs 250 pounds, the nurse should
• The principle in creating a question in exam the provide the unlicensed assistive personnel (UAP) with
highest and lowest choices in the questions should instructions that reflect an awareness of workplace injury. Which
be incorrect of the following is most appropriate?
→ Applied in: Volume, length, distance, duration A. "Using proper body mechanics will prevent you from
→ Not applied in: Laws injuring yourself." - not a guarantee
→ If the patient is hundred pounds and you are 120: yes - B. "You are physically fit and at lesser risk for injury when
lift (less than 50 lbs of your weight) transferring the client." -
→ If the patient is 150 lbs and you are 100 lbs: no - lift incorrect
C. "Use the mechanical lift
15. Which of the following devices prevents the external rotation and another person to
of the leg? transfer the client from
A. Sandbags the bed to the chair." -
B. Firm mattress best answer!
C. Pillow D. "Use the back belt to avoid
D. High footboard hurting your back." - not a
guarantee

Rationale: 22. A 75-year-old client, hospitalized with a cerebral vascular

→ Trochanter rolls - BEST in preventing external rotation accident (stroke), becomes disoriented at times and tries to get
→ There is no trochanter rolls in the choices, choose out of bed, but is unable to ambulate without help. What is the
sandbags most appropriate safety measure?
A. Restrain the client in bed.
16. Nurse Ron is assisting with transferring a client from the B. Ask a family member to stay with the
operating room table to a stretcher. To provide safety to the client. - incorrect; passing the task
client, the nurse should: C. Check the client every 15 minutes.
a. Moves the client rapidly from the table to the stretcher. - hahahhaha apir patient
incorrect D. Use a bed exit safety monitoring
b. Uncovers the client completely before transferring to the device. - best answer! ; can be
stretcher. - incorrect placed on the bed or wheelchair
c. Secures the client safety belts after transferring to the
stretcher. 23. A nurse must perform a catheterization on a male client.
d. Instructs the client to move self from the table to the Which of the zones of proximity would be most appropriate?
stretcher. - incorrect A. Personal distance - 1.5-4 ft; during health teaching; you are
not touching the patient
B. Public distance - 12-15 ft
Rationale: When transferring a client to the bed there should C. Intimate distance - 0-1.5 ft; it involves touch not sex
be: nubayan!; almost done in all nursing care
→ Higher: occupied bed D. Social distance - 4-12 ft
→ Lower: unoccupied bed
• Easier to pull pag pababa via gravity 24. A client has jaundice. Which of the following comfort
measures would be appropriate for the nurse to implement?
A. Offer hot beverages frequently
17. In a client 1 day post MI, which of the following will meet the
B. Encourage taking a hot bath or shower
client’s need for elimination?
C. Keep the air temperature at approximately 68 to 70°F
A. Bedpan
D. Suggest the use of alcohol-based skin lotion
B. Call bell
C. Bedside commode
D. Enema/rectal suppositories (stool softeners) - enema is not Rationale: Jaundice
really needed but rectal suppositories are needed by the → Bile is in circulation
patient to prevent straining → Bile has salt content → yellowish discoloration and
pruritus (itchiness) d/t deposits of bile salts to the skin
Rationale: You cannot use the other choices if without the → Management for Pruritus
call bell because the patient is still on 1-day post-op and • Also indicated for patient who have pancreatitis,
needs assistance cholelithiasis, hepatic problems
• Nursing considerations:
Test taking strategy: Umbrella technique o All interventions should be cold (cold packs,
→ If 3 out of 4 questions is correct cold drinks, cold environment)
o Heat can aggravate the itchiness
o Avoid commercially prepared lotion
18. To increase stability during dient transfer, the nurse
increases the base of support by performing which of the
following?
A. Leaning slightly backward
B. Spacing the feet farther apart
C. Tensing the abdominal muscles
D. Bending the knees
 FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

25. The nurse is about to obtain the temperature of a five-year-

Six Cardinal Gaze - tests the extraocular muscle function,
old patient through the tympanic route. The nurse should:
cranial nerves
a. Pull the pinna of the ear backward and downward
→ Moving the object to 6 sides/location, the patient should
b. Pull the pinna of the ear sidewards and upwards
properly follow the object with no extra eye movements
c. Pull the pinna of the ear downwards and backwards
d. Pull the pinna of the ear upwards and backwards

Rationale:
→ <3 years old - down and back
→ >/= 3 years old - up and back
→ Considered in taking temperature, during otoscopic
exam, administration of medications

26. Mrs. Posadas has an eye infection with a moderate amount

of discharge. To clean her eyes, the nurse should:
A. Use hydrogen peroxide
B. Wipe from the outer canthus to the inner canthus - should
be from inner to outer
C. Position on the same side as the eye to be cleansed
D. Use only one cotton ball per eye - wrong because it means
that even if the cotton is already dirty, you are still using the
same/only one cotton ball; in reality, you can use many
cotton balls as necessary

27. A client is diagnosed with conduction hearing loss. What 29. When applying eye ointment, the following guidelines apply
might the nurse indicate to the client could be a reason for this EXCEPT:
loss? A. squeeze about 5 cm of ointment and gently close but not
A. There has been damage to the inner ear - sensorineural squeeze eye - should be 2 cm
hearing loss B. apply ointment from the inner canthus going outward of the
B. Something has happened to the hearing center of the brain affected eye
- sensorineural hearing loss C. discard the first bead of the eye ointment before
C. An ear infection has torn the tympanic membrane application because the tube likely to expel more than
D. The auditory nerve is not functioning - sensorineural desired amount of ointment - discard first bead because
hearing loss it is contaminated, not because it is more likely to expel the
more than the desired amount
28. The client's vision is tested with a Snellen's chart. The results D. hold the tube above the conjunctival sac do not let tip touch
of the tests are documented as 20/60. The nurse interprets this the conjunctiva
as
a. The client can read at a distance of 60 feet what a client with Rationale:
normal vision can read at 20 feet. How to apply eye ointment:
b. The client is legally blind. 1. Discard the first bead (unang labas) because its
c. The client's vision is normal. contaminated, even though it is brand new,
d. The client can read at a distance of 20 feet what a client contaminated by teh cap
with normal vision can read at 60 feet. 2. Hold the tube above the conjunctival sac
3. Apply ointment INNER to OUTER
Additional Notes: Different ways of checking eye function 4. Instruct the patient to close eyelids but do not squeeze,
medication may leak or goes to systemic circulation
Snellen’s Chart - measures visual
acuity Steps in applying eye drops:
→ Perfect vision: 20/20 1. Instruct the patient to look up (less blinking)
→ 20/10 - hyperopia (far- 2. Using the non-dominant hand, expose the lower
sightedness) conjunctival sac (medication will be held at the dominant
→ 20/40 - myopia (near- hand)
sightedness) 3. Position the eye drops/medication 1-2 cm above the sac
→ 20/200 - legal blindness using the dominant hand
(considered a disability) 4. Instill the medication
5. Press firmly the nasolacrimal duct (to prevent systemic
Ishihara Test - measures color absorption) for at least 30 seconds
vision/blindness with use of primary
colors Note:
→ 3 types of color blindness: → You cannot give eye ointment and eye drops at the same
1. Deuteranomaly - green → red time, there should be an interval (hours)
2. Protanomaly - red → green → Prevent systemic absorption because the eye
3. Pratanopia - not able to tell the difference between ointment/drops are indicated ONLY for the eyes
red and green
4. Deuteranopia - not able to tell the difference 30. Hard contact lenses are worn for no greater than?
between red and green A. 3 Hours
B. 6 Hours
C. 12 Hours
D. 24 Hours

Rationale:

Contact lens: Advantages

1. Cannot be seen (cosmetic value)
Tonometry - measures the IOP
2. Highly effective in correcting Astigmatism
→ Commonly used in patients with Glaucoma
3. Safer when it comes to physical activities
→ Normal IOP: 10-21 mmHg
4. (X) fog
5. Provides better vision, no blind spots
 FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

Hard contact lens: Rationale: Ulcerative colitis

→ Rigid, unwettable (cannot absorb water), airtight plastic → An inflammatory bowel disease
→ Worn for 12-14 hours → Same diet as Cronh’s disease
→ Not recommended for first timer users → If there is severe inflammation/exacerbation in UC:
• Place the client in NPO
Soft contact lens: • Start TPN
→ It covers the entire cornea - molds the eye
→ Lasts for 1-30 days or more depending on the brand
34. Mr. D. is a 26-year-old recently diagnosed with ulcerative
→ Recommended for first timers
colitis. The nurse has been giving dietary instructions to Mr. D.
→ Should be cleaned once a week (recommended)
to help prevent exacerbation of his inflammatory bowel disease.
Which dietary choice indicates that Mr. D. understands the
dietary instructions?
A. apple - high fiber
B. celery - high fiber
C. refined cereals - high fiber
D. hard cheeses - low fiber

35. A client was sent home with a prescription of Mineral Oil as

Laxative. Mineral oil as Laxatives will include which health
instructions
1. Swallow
2. Do not take with meals
Note: Do not sleep with contact lens, causes dryness and 3. Take with meals
irritation d/t not blinking 4. Action is expected in 2 to 4 hours
A. All except 2
Test taking strategy: Use again the number system B. 1,3, and 4
technique (eliminate highest and lowest) C. 1,2, and 4
D 1 and 2 only

31. The nurse is checking the client’s overall oxygenation. In

assessment of the presence of central cyanosis, the nurse will Test-taking strategies:
inspect the client’s: → Two contradicting/opposing actions (options 2 and 3)
a. Palms and soles of the feet → Options A and B are the same (when 2 options are the
b. Nail beds same, they are wrong)
c. Earlobes
d. Tongue 36. The decrease of absorption of certain vitamins is affected
when taking mineral oil. Which of the following is affected?
Rationale: options ABC are peripheral 1. A
2. B
3. C
32. Which foods should the nurse encourage a client with 4. D
diverticulosis to incorporate into his diet? Select all that apply. 5. E
1. Mango A. 1,2,3,4,5
2. Broccoli. B. 1,4 and 5
3. Tomatoes - have seeds C. 2 and 3
4. Monggo - does not have a seed because mongo is D. 1,4 and 3
already the seed
5. Popcorn - have seeds
A. 2, 5 Rationale: When taking mineral oil, fat-soluble vitamins are
B. 1 only affected (Vitamin A, D, E, K)
C. 1, 2, 4
D. All of the above 37. When discussing the Food Guide Pyramid with a 75-year-old
client, the nurse should remember that the guide has been
Rationale: Diverticulosis modified for older people. Unlike the standard Food Guide
→ Outpouching in the intestinal wall Pyramid, the version for elderly individuals.
→ Most common site: sigmoid colon A. Include 8-oz glasses of water at the base of the pyramid.
• One: diverticulum B. Set upper limits on serving of most food and water.
• Many: diverticulosis C. Increases the amounts of recommended milk and dairy
→ Inflamed: Diverticulitis products.
→ Diverticulosis: high fiber D. Eliminates the portion of the pyramid for fats, oils, and
• High fiber = high residue sweets.
• Because we don’t want the patient to be constipated
o More poop = poop in the pouches Rationale: Food pyramid for Older Adults
→ Diverticulitis: low fiber diet
• Same as ulcerative colitis
• Low fiber = low residue
→ Avoid seeds that may go into the pouches

Note:
→ -losis: high fiber
→ -litis: low fiber

33. Which of the following diets would be most appropriate for

the client with ulcerative colitis?
A. High-calorie, low-protein.
B. High-protein, low-residue. - high protein to promote
healing; low residue prevent too much gastric motility
C. Low-fat, high fiber.
D. Low-sodium, high-carbohydrate.
 FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

38. Ms. F.X. has been admitted with right upper quadrant pain 43. A client who has been diagnosed with gastroesophageal
and has been placed on a low-fat diet. Which of the following reflux disease (GERD) complains of heartburn. To decrease the
trays would be acceptable for her? heartburn, the nurse should instruct the client to eliminate which
A. Liver, fried potatoes and avocado. of the following items from the diet?
B. Ham, mashed potatoes, cream peas. A. Lean beef.
C. Whole milk, rice and pastry. B. Air-popped popcorn.
D. Skim milk, lean fish, tapioca pudding. C. Hot chocolate. - GI irritant
D. Raw vegetables.
Rationale: Eliminate foods high in fat:
44. A nurse is caring for a patient diagnosed with esophageal
● Dairy product except for low-fat milk
reflux disorder. The patient should be advised to:
● Fried
a. Keep the head of the bed lowered
b. Drink a cup of hot tea before bedtime.
39. The patient is diagnosed with anemia. Which vitamin is c. Avoid food containing peppermint
needed for supplementation? d. Drink a carbonated drink after meals.
A. Vit. C
B. Ferrous Sulfate
Rationale: Menthols weakens the lower esophageal
C. Vit. D
sphincter
D. Magnesium

45. The cooked food most likely to remain contaminated by the

Rationale: Eliminate those that are not vitamins (ferrous
virus that causes hepatitis Type A is:
sulfate and magnesium are minerals)
A. Canned tuna - already undergone process; no virus anymore
B. Broiled shrimp
40. Which of the following menu is appropriate for one with a low C. Baked haddock - a fish
sodium diet? D. Steamed lobster - not enough what to kill the virus
a. instant noodles, fresh fruits and ice tea
b. ham and cheese sandwich, fresh fruits and vegetables 46. A client is taking digoxin (Lanoxin) and furosemide (Lasix)
c. white chicken sandwich, vegetables salad and tea for heart failure. Which of the following would be the best menu
d. canned soup, potato salad, and diet soda choices for this client?
a. Chicken with baked potato and cantaloupe - both are high
in potassium
Rationale: Low sodium diet - remove all processed food such b. Eggs and ham
as noodles, ham, canned c. Grilled cheese sandwich and French-fried potatoes
d. Pizza with pepperoni
41. Mr. Williams would demonstrate that he was aware of dietary
influences in the prevention of the dumping syndrome if he Rationale: diet should be high in potassium; lasix is a
adjusted his intake by: potassium wasting diuretic
A. Decreasing fats
B. Decreasing proteins
C. Increasing fluids at mealtimes 47. Which of the following if done by a nurse indicates deviation
D. Decreasing carbohydrates from the standards of NGT feeding?
A. Do not give the feeding and notify the doctor of residual of
the last feeding is greater than or equal to 50 ml
Rationale: Dumping syndrome B. Height of the feeding should be 12 inches about the tube
→ Complication of billroth 1 & 2 (can be also in pernicious point of insertion to allow slow introduction of feeding
anemia) C. Ask the client to position in supine position immediately
→ Diet: after feeding to prevent dumping syndrome
• No fluids during meals; in between meals or 30 D. Clamp the NGT before all of the water is instilled to prevent
minutes after meals air entry in the stomach.
• Decrease fiber and carbohydrate
• Increase protein and fats - to slow down the
movement Rationale: Position in: NGT
• Small frequent feedings → Insertion - high fowler's/sitting/upright with behad
→ Ds in dumping syndrome: extended
• Diarrhea → Feeding - semi-fowler's, after - maintain semi-fowler’s for
• Diaphoresis 30 minutes
• Dizziness → Removal - semi-fowler’s
• DHN
→ Position: lay down after meals 48. Which of the following if done by a nurse indicates deviation
from the standards of NGT feeding?
42. Ryan, 38 years old, is diagnosed with peptic ulcer and asks A. Do not give the feeding and notify the doctor of residual of
you what food is best to add to his diet so as not to exacerbate the last feeding is greater than or equal to 50 ml
his symptoms. Your BEST response would be for him to take: B. Height of the feeding should be 12 inches about the tube
A. Citrus fruit juices or shakes point of insertion to allow slow introduction of feeding
C. Leafy green vegetable dishes C. Ask the client to position in supine position immediately
B. Mocha, café latte and other similar drinks after feeding to prevent dumping syndrome
D. Milk regularly 3-4 times daily D. Clamp the NGT before all of the water is instilled to prevent
air entry in the stomach

Rationale: Peptic ulcer

→ Diet: Diet As Tolerated (DAT) - avoid irritants only! Additional Note:
• Bland diet is not considered because peptic ulcer is → >250 cc feeding - 100 cc residual volume
a long-term condition (beh ano ka kakain ng walang → <250 cc feeding - 50 cc residual volume
lasa for a year?)
 FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

49. A client is scheduled for NGT Feeding. Checking the residual 55. The physician in charge made an order to monitor for signs
volume, you determined that he has 40 cc residual from the last of insensible fluid loss. The nurse is correct if she mentioned that
feeding. You reinstill the 40 cc of residual volume and added the insensible fluid loss occurs on:
250 cc of feeding ordered by the doctor. You then instill 60 cc A. Fecal elimination
of water to clear the lumen and the tube. How much will you put B. Perspiration
in the client’s chart as input? C. Diaphoresis - not measured; process of sweating
A. 250 cc D. Micturition
B. 290 cc
C. 350 cc 56. Before a procedure, Give the sequence on applying the
D. 310 cc protective items listed below:
1. Eye wear or goggles
2. Mask
Rationale: Do not add the residual volume
3. Gloves
→ 250 cc + 60 cc = 310
4. Gown
A. 4,1,2,3
Test taking strategy: number system method
B. 4,2,1,3
C. 3,4,2,1
50. The preoperative nurse is assessing the client at risk for latex D. 4,2,3,1
allergies. Clients are at risk for latex allergies if they are allergic
to all of the following, except: 57. In removing protective devices, which should be the exact
a. avocados sequence?
b. apples 1. Eye wear or goggles
c. tomatoes 2. Mask
d. bananas 3. Gloves
4. Gown
A. 3,2,1,4
Rationale: B. 3,4,1,2
→ Gloves: use poly vinyl or nitrile C. 3,1,2,4
→ Condom: lamb-skin condom D. 3,1,4,2 - according to CDC

51. The home care nurse is ordering dressing supplies for a 58. The client is a tailor who was admitted for eye surgery.
client who has an allergy to latex. The nurse asks the medical Assuming that all of the following are realistic, a long-term goal
supply personnel to deliver which of the following? for this client should include:
a. Adhesive bandages a. Returning to sewing
b. Elastic bandages b. Preventing ocular infection
c. Cotton pads and silk tape c. Performing independent hygienic care in hospital
d. Brown Ace bandages d. Administering eye drops on time in the hospital

Rationale: options ABD are made of latex Rationale: work/home setting - long term goals

52. A nurse is developing a plan of care for a preoperative client 59. A client who has been hospitalized for a period of time is now
who has a latex allergy. Which intervention would be included in being transferred to a rehabilitation center for more long-term
the plan? care. As he is preparing to be discharged, the client asks the
a. Avoid using medication form glass ampules. - incorrect nurse if he can take his chart with them, since it’s his record. The
b. Avoid using IV tubing that is made of polyvinyl chloride. - nurse responds correctly by saying:
incorrect a. “There’s a new law that protects your records, so you’re not
c. Use medications that are from ampules with rubber stopper. going to be able to have access to them.”
- incorrect b. “We’ll make sure that all of your records are sent ahead to
d. Apply a cloth barrier to the client’s arm under a blood the rehab hospital, so you don’t really have to worry about
pressure cuff when taking the blood pressure. those details.”
c. “You’ll have to ask your doctor for permission to do that.”
53. Mr. Regalado’s condition, a diabetic patient, improves and d. “Actually, the original record is the property of the
discharge planning is initiated. This includes planning his hospital, but you are welcome to have copies of your
nutritional regimen to encourage compliance. The client will records.”
MOST likely be referred to:
A. Nutritionist Rationale:
B. Cardiologist → Record - owned by hospital/institution
C. Endocrinologist → Information - owned by the patient
D. Dietitian

60. After classroom discussion regarding confidentiality policies

Rationale: special DIETS are done by dieticians and laws protecting client records, a student asks why it’s OK
→ Diabetes: for them to review and have access to client records in the
• Diet: Regular, well-balanced diet clinical area. The nurse educator responds correctly by stating
o Problem: hypoglycemia that’s why diet should that:
be regular (schedules) a. “Confidentiality and privacy laws don’t apply to students.”
• Food exchanged list will be done b. “Records are used in educational settings and for
o Beef - replaced by fish (same amount of learning purposes, but the student is bound to hold all
protein) information in strict confidence.”
o White rice - replaced by adlai rice/other source c. “Most students review so many records and charts that they
of carbohydrates could not possibly remember details from any one of them.”
d. “As long as the clinical instructor is in the area, accessing
54. All of the following are good sources of vitamin A except: client records is part of the education process.”
A. Sweet potatoes
B. Carrots 61. A student nurse is reviewing an assigned client’s chart. When
C. Apricots - good source of potassium trying to locate recent lab results, the student notices that each
D. Egg yolks department has a separate section in the chart. This type of
documentation system is called which of the following?
a. Case management
b. Source-oriented record
c. Focus charting - FDAR
d. Problem-oriented record
 FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

Rationale: Rationale:
→ Universal Donor: Type O
Source Oriented Medical Record (SOMR) → Universal Recipient: Type AB
→ Each person/department has SEPARATE SECTION in → AB (-) - cannot receive OB (+)
the CHART: e.g.,
• ER - admission sheet
• Doctor - physician’s order sheet
• Nurses - nurse's notes
• Dietary department - diet sheet
• Physical therapist - progress notes
→ Advantage: information are easily located

Problem Oriented Medical Record (POMR)

→ Composed of:
• Database
• Problem list: e.g.,
o Pneumonia - written by doctor
o Activity intolerance - written by nurse
o Laboratory values: ph: 7.3, HCO3: 24 - written
by medtech
o Ineffective airway clearance - written by nurse
• Plan of care
• Progress notes
→ Disadvantage: difficult to find the information
→ Advantage: it enhances communication and
collaboration between the members of the healthcare
team
67. A client with a peripheral IV line is about to receive a blood
62. A 74-year-old female is brought to the emergency transfusion of packed red blood cells due to anemia. The nurse
department c/o right hip pain. The right hip is shorter than the administering the transfusion will:
left and is externally rotated. During inspection, the nurse A. infuse the blood slowly over a period of 5 to 6 hours - up to
observes what appears to be cigarette burns on the right inner 4 hours only
thighs. Which of the following is the most appropriate B. initially infuse at a rapid rate and check pulse frequently -
documentation? slower rate
A. Multiple lesions on inner thighs possibly related to elder C. obtain the client’s vital signs prior to the transfusion
abuse. D. prime the tubing with a D5W solution prior to infusing blood
B. Six round skin lesions partially healed, on inner thighs - should be PNSS
bilaterally.
C. Several burn areas on both of the client’s inner thighs. 68. As AP’s nurse, what will you do AFTER the transfusion has
D. Several lesions on inner thighs similar to cigarette burns. started?
A. Add the total amount of blood to be transfused to the intake
and output
Rationale: Documentation should be specific B. Discontinue the primary IV of Dextrose 5% Water
→ Avoid: several or multiple, cannot be counted no specific C. Check the vital signs every 15 minutes
numbers D. Stay with AP for 15 minutes to note for any possible BT
reactions
63. These are data that are monitored by using graphic charts
or graphs that indicate the progression or fluctuation of a client's Rationale: nurse can also stay for the first 50 ml/ first 15-30
Temperature and Blood pressure. mins after BT has started, because BT reactions usually
A. Progress notes happens at this time
B. Kardex
C. Flow chart
D. Flow sheet 69. An order is written to start an IV on a 75-year-old client who
is getting ready to go to the operating room for total hip
64. The client has an allergy to Iodine-based dye. Where should replacement. What gauge of catheter would best meet the needs
you put this vital information in the client’s chart? of this client?
A. In the first page of the client’s chart a. 18
B. At the last page of the client’s chart b. 20
C. At the front metal plate of the chart c. 24
D. In the Kardex - “in the chart” is being asked; but placed in d. 25
the kardex as well
Rationale: the patient is an older adult, either BT or for OR
65. Which of the following is NOT TRUE about the Kardex purposes, a smaller gauge of catheter would be used.
A. It provides readily available information - correct → For pedia clients, gauge 22-24 is used for BT
B. It is a tool of end of shift reports - correct
C. The primary basis of endorsement
D. Where Allergies information are written - correct

Rationale: chart is the primary basis of endorsement

66. A pregnant client is rushed to the hospital with massive blood

loss. Replacement fluids are initiated, but the blood loss is so
severe that blood transfusion is necessary. Which blood type is
safe to administer during a resuscitation situation?
a. Type O negative
b. Type O positive
c. Type AB positive
d. Type AB negative
 FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

73. Which of the following laboratory tests is considered the

most reliable indicator of renal function?
A. Blood urea nitrogen - least indicator; because it is affected by
patient’s diet (problem yung diet, not kidney)
B. Urinalysis
C. Creatinine Clearance - priority indicator
D. Serum creatinine - second indicator

Rationale: tested using 24-hour urine collection; Options AD

are from blood tests
→ Hierarchy in testing: creatinine clearance → serum
creatinine → BUN

74. Which of the following guidelines pertaining to changing

intravenous (IV) containers, tubings, or dressings must be
followed?
A. All IV bags should be changed every 24 hours,
regardless of how much solution remains.
B. When IV infusion is no longer needed, the catheter should
be removed immediately.
C. All IV tubing and dressings must be changed every 24
hours.
D. IV bags should only be changed when a small amount of
fluid remains in the neck of the container.

Rationale: Intravenous
→ Solution: changed q 24 hours (regardless of the
remaining or volume of solution)
→ Tubings: changed q 72-96 hours
70. The nurse reads that 50% of a particular drug’s original dose → Site:
will be in a client’s bloodstream 4 hours after administration. This • Gauze dressing - changed q 2 days together with
means that the half-life of the drug would be: assessment
A. 1 hour • Transparent dressing - changed q 5-7 days (longer
B. 2 hours since it is easily visible = easy assessment)
C. 4 hours
D. 8 hours
75. Which type of colostomy can allow a patient to have bowel
continence?
71. An appropriate technique for the nurse to use when
A. Descending or Sigmoid Colostomy
preparing a liquid medication is to:
B. Ascending or Transverse Colostomy
A. Measure the level of the medication at the meniscus
C. Transverse or Descending Colostomy
B. Draw up small amounts with a needle and a syringe - we
D. Ascending or Descending Colostomy
don’t use syringe
C. Pour from the same side as the medication label on the
bottle - label cannot be seen; label should also be checked Rationale:
D. Place the cup on a counter and pour and measure from → Continence - control in bowel
above - level of the medication will not accurate if measured Different Types of Colostomy:
from above → Ileostomy - watery/liquid stools
→ Ascending - watery/liquid stool
→ Transverse - mushy stool (like mashed potato with gravy
Rationale: “it’s the pout for me ”
yumyum)
→ Descending - semi-formed stool (like mashed potato w/o
gravy)
→ Sigmoid - well-formed (french fries na daw )

Double Barreled Colostomy

→ There’s 2 stoma (depending on location)
• Both in transverse colon
o Proximal stoma → where feces exits
o Distal stoma → drains mucus
→ Purpose: To rest the inflamed portion
→ Common on ulcerative colitis (sigmoid ang location)
• Presence of inflammation
• Needs to rest the inflamed side of colon

72. In preparing two different medications from two vials, the

nurse must:
A. Inject fluid from one vial into the other - fluid is not injected,
only air
B. Uncap the syringe and wipe the needle with an alcohol
preparation before inserting into either vial
C. Discard the medication from vial number two if
medication from vial number one is pushed into it
D. Insert air into the first vial, but not the second vial - incorrect

Additional Notes: Insulin: inject air to N → inject air R →

withdraw insulin R → withdraw insulin N
 FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

76. On assessment of a patient with a colostomy, you note the

o To prevent hypovolemic shock (too much fluid
stoma is located on the right area of the abdomen. Due to its
aspirated → shock)
location, this is known as what type of colostomy?
→ Post-test:
A. Descending Colostomy
B. Transverse • Position: POC
C. Ileostomy • Site: - Important NR
D. Ascending Colostomy o Checking site for drainage, pressure dressing
is used to prevent leakage
77. During the first postoperative week, the nurse can BEST help • Vital signs q 15 for 1 hr
the patient with a colostomy to accept the change in body o WOF: tachycardia and dyspnea
image by:
A. Changing the dressing just prior to meals THORACENTESIS
B. Encouraging the patient to observe the stoma and its
care
C. Deodorizing the room periodically with a spray can
D. Applying a large bulky dressing over the stoma to decrease
odors

78. A patient has a double-barrel colostomy of the transverse

colon. You note on assessment two stomas, a proximal and
distal stoma. What type of stool do you expect to drain from the
proximal and distal stomas?
A. Proximal: lose to partly formed stool; Distal: mucous → Pre-test: void (for comfort purposes)
B. Proximal: liquid stool; Distal: mucous → Intra-test: sitting while leaning forward (orthopneic
C. Proximal: mucous; Distal: lose to partly formed stool position); sitting at the edge of the bed while leaning on
D. Proximal & Distal: lose to partly formed stool the table
• Alternative position: Lateral position or side lying on
79. A client is recovering from an ileostomy that was performed the unaffected side to expose the affected side (for
to treat inflammatory bowel disease. During discharge teaching, those who cannot seat or unconscious)
the nurse should stress the importance of: • Maximum amount to aspirate: 1L
A. Increasing fluid intake to prevent dehydration. o To prevent hypovolemic shock (too much fluid
B. Wearing an appliance pouch only at bedtime. - should aspirated → shock)
always wear all the time → Post-test:
C. Consuming a low-protein, high fiber diet - should be low • Position: lateral position on UNAFFECTED side for
fiber the affected lung to expand
D. Taking only enteric-coated medications • Site: - Important NR
o Checking site for drainage, pressure dressing
Rationale: d/t diarrhea is used to prevent leakage
• Vital signs q 15 for 1 hr
o WOF: tachycardia and dyspnea
79. Because a bronchoscopy was ordered, the nurse knows
that the suspected lesion was not in the: LUMBAR PUNCTURE
A. Bronchus
B. Pharynx
C. Larynx
D. Trachea

Rationale: During bronchoscopy, bronchus, larynx and

trachea (BLT) are the only structures that can be visualized

80. To prepare a client for thoracentesis, the nurse should:

A. Remind the patient to eat or drink nothing for six hours → Pre-test: void (for comfort purposes)
before the procedure. → Intra-test: lateral recumbent position/fetal/c position/
B. Ask the patient to sign a consent form for the procedure - knee chest/shrimp/lobster
nurses do not ask the patient to sign the informed consent • Hold breath while inserting
C. Position the patient on the side of the bed leaning over • Best site: between L4 and L5 (safest site)
the bedside table. o L3 and L4, L4 and L5, L5 and S1
D. Pull the privacy curtain and dim the lights of the room o Spinal nerve ends at L2
o No room for error (L3 to S1)
→ Post-test:
Rationale: • Position:
PARACENTESIS o Dorsal Recumbent for 1-12 hours (Kozier & Erb)
o Prone, Side-lying, Supine (Brunner)
o Patient should be flat on bed to prevent leakage
of CSF (spinal headache - bi-frontal and
occipital headache)
▪ Common in spinal anesthesia
▪ Spinal headache is caused by too much
loss of CSF
o Increase fluid intake

Additional Notes:
→ All of the following are aspiration procedures
→ Emptying the bladder: done several times to ensure
→ Pre-test: emptying the bladder (to prevent puncture of walang ihi
bladder) → Void: done only 1 time
→ Intra-test: sitting/upright position at the edge of the bed
or chair
• Alternative position: supine (for those who cannot
seat or unconscious)
• Maximum amount to aspirate: 1.5 L
 FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

81. Maria will be preparing a patient for thoracentesis. She

• Without experience
should assist the patient to which of the following positions for
• Needs supervision
the procedure?
A. Prone with the turned to the side and supported by a pillow. → Advance Beginner
B. Lying in bed on the affected side with the head of the bed • Enough experience
elevated 45 degrees. • Acceptable independent care (no supervision)
C. Sim’s position with the head of the bed flat. → Competent
D. Lying in bed on the unaffected side with the head of the • 2-3 years
bed elevated 45 degrees. • Complex
→ Proficient
82. Lino, a nurse taking care of an adult client with constipation, • 3-5 years
in performing a high cleansing enema, Lino must keep in mind • Holistic
that the maximum height is: → Expert
A. 18 inches above the bed • More than 5 years
B. 16 inches above the rectum • Intuitive
C. 18 inches above the rectum
D. 12 inches above the bed

Rationale: 12-18 inches from point of insertion (rectum/anus)

83. The nurse is caring for a 3-year-old child admitted to the

pediatric unit with acetaminophen poisoning. The nurse
administers syrup of ipecac followed by acetylcysteine every 4
hours for 72 hours. Which laboratory findings confirm the
effectiveness of the drug therapy?
A. AST - SGOT; is not specific for the liver, could also be raised
in heart problem
B. Creatine kinase-MB - for the heart
C. Blood urea nitrogen and serum creatinine - for kidneys
D. ALT - SGPT; specific only for the liver
88. In order to attain the expert level, Nurse Trish’s experience
Rationale: Acetylcysteine - antidote for acetaminophen level should be:
toxicity (hepatotoxic) A. Innovative
B. State-of-the-art
C. Extensive - longer experience
84. In Dunn’s high-level wellness grid, a person suffering from a D. Varied
cerebrovascular accident and confined in the health care facility
falls under which quadrant? 89. Which of the following nurses is a competent practitioner
A. High-level wellness in a favorable environment according to Benner?
B. Emergent high-level wellness in an unfavorable environment a. The nurse is able to use maxims as a guide for what to
C. Protected poor health in a favorable environment consider in a new situation and views the clients holistically.
D. Poor health in an unfavorable environment - Proficient
b. The nurse who does not require rules or guidelines in
85. The discoloration of the body after death is referred to as: making analysis and decisions in a new situation but instead
a. Rigor Mortis - stiffening of the body after death; happens 2- uses intuitive and analytic skills - Expert
4 hours after death c. The nurse is able to coordinate the complex care
b. Algor Mortis - drop in the body temperature; with a rate of demands of a client who is newly admitted and the other
1 degree celsius/hour until the temperature reaches or clients in the unit.
equates to the room temperature d. The nurse who is able to recognize the meaningful aspects
c. Edgar Mortis of a situation where a client was newly diagnosed with
d. Livor Mortis diabetes.

Rationale: brought about by the breakdown of RBC 90. Benner’s “Proficient” nurse level is different from the other
Nursing Responsibility: levels in nursing expertise in the context of having:
→ Prevent discoloration of the face A. the ability to organize and plan activities
→ Before livor mortis, the nurse should positioned the B. having attained an advanced level of education
deceased with pillow under the head to prevent pooling C. a holistic understanding and perception of the client
of blood in the face D. Intuitive and analytic ability in new situations
• happens almost the same time with Rigor Mortis
91. The following are the general guidelines when recording in
the client’s chart. Which is the correct procedure?
86. The stiffening of body after death is termed as: A. Recording should be done before providing nursing care
A. Algor Mortis B. All entries on the record are made in pencil so that the
B. Rigor Mortis necessary changes can be made
C. Sturdy Mortis C. Each recording on the nurse’s notes is signed by the
D. Livor Mortis nurse making it
D. Leave a blank space for a colleague to chart later
87. Nurse Trish successfully passed the Nurse Licensure
Examination. She is now employed as a staff nurse in a General 92. The nurse committed a mistake when writing an entry in the
hospital. How long will it take approximately for Nurse Trish to client’s record. The nurse should take which action?
achieve the competent level? A. Draw a line through the mistake
A. 6 months B. Draw a line through the mistake and write “mistaken entry”
B. 12 months above it
C. 18 months C. Draw a line through the mistake and write “mistaken
D. 30 months entry” next to the original entry with the nurse’s name
or initials
D. Erase the mistaken entry using the correction fluid, write the
Rationale: NACPE keywords
correct entry then place the name/initials and date
→ Novice
• Student
• Newly-hired Rationale: After drawing a line never put “error”, instead put
“mistaken entry”
 FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

93. A nurse enters a client’s room and finds that the wastebasket
▪ Document activities, hours of sleep
is on fire. The nurses immediately assign the client out of the
o Support patient’s bedtime rituals
room. The next nursing action would be to
▪ Skin care, praying
a. Call for help.
o Warm bath
b. Extinguish the fire. - the fire is still confined in the
o Warm milk → contains L-tryptophan which
wastebasket; do not let everyone know that there is fire
promotes sleep
because it will cause panic to the institution
o Avoid bedtime snacks
c. Activate the fire alarm.
o Avoid daytime naps
d. Confine the fire by closing the room door.
▪ Mas lalong di makakatulog sa gabi
o Exercise (morning or afternoon)
Additional note: ARCE o Environmental factors (lighting, noise,
→ Activate alarm temperature) should be adjusted based on the
• To alert other patients/people level of comfort of the patient
→ Rescue
→ Confine Test taking strategy: avoid answering medications (sleeping
→ Extinguish pills) → causes dependency on the drug

2. Sleep apnea
94. A female client verbalizes she has been having trouble → Breathing stops 5 times of 10 seconds pause/hour
sleeping and feels awake as soon as getting into bed. The nurse → Characterized by very loud snoring
recognizes that there are many interventions that promote sleep. → 2 types:
Select all that apply.
• Obstructive Sleep Apnea (OSA)
1. eat a heavy snack near bedtime - incorrect
o Cause: 3 reasons
2. take melatonin containing pills - incorrect
▪ Nasal polyps
3. avoid taking afternoon naps - correct
▪ Enlarged tonsils (d/t tonsillitis ro naturally
4. drink a cup of warm tea with milk at bedtime - incorrect
large tonsils)
5. exercise in the afternoon rather in the evening - correct
▪ Obesity
6. count backwards from 100 to 0 when your mind is
o Management: Continuous Positive Airway
racing - bedtime ritual/diversional activity
Pressure (CPAP) or Surgery
A. 3, 5, 6
▪ CPAP - keep airway open by applying
B. 2, 3, 6
positive pressure during sleep
C. 2, 4, 6
• Central Sleep Apnea (CSA)
D. 2, 5, 6
o Cause: unknown
3. Hypersomnia
15-minute Discussion with Sir Teddy Wong: → Excessive daytime sleepiness
→ Common on DM (d/t hyperglycemia) and
SLEEP hyperthyroidism
NREM (Non-Rapid Eye Movement) 4. Narcolepsy
→ 75-80% of our sleep → Aka “Sleep attack”
→ 3 Stages: → Characterized by Cataplexy - sudden loss of muscle
• NREM I (VLS: Very Light Sleep) - lasts for a few function (naglalakad/kumakain, then biglang
minutes makakatulong)
o Drowsy and relaxed • Lack of chemical in the brain called Hypocretin
o Eyes roll (from side to side) (Orexin)
o Awaken easily (by someone who enters the • Priority: Safety
room, opening of lights) 5. Parasomnias
o Decrease in HR, RR (slight) → Bruxism (cleansing/grinding of teeth)
o Usually experience jerking reflexes • Lack of sleep stress
• NREM II (LS: Light Sleep) - lasts for 10-15 minutes • Management: mouthpiece/guard if there's presence
o Decrease in HR, RR together with Temp already of erosions
(continuously) → Enuresis (bed wetting)
o Intense stimulus (to be awaken) → Somnambulism (sleep walking)
o Eyes still • Priority: SAFETY
• NREM III (DS: Delta Sleep) - lasts for 30 minutes → Somniloquy (sleep talking)
o Delta waves are seen on ECG • Management: get your own room
o Difficult to awaken → Sleep paralysis
o Diminished reflexes
o Decrease in HR, RR, temp (at lowest point of Additional Notes:
vital signs) → Some people snore immediately when asleep may be d/t:
o Snoring - hallmark • Tiredness
• Obesity
REM (Rapid Eye Movement) • Sleep apnea
→ Happens every 90 minutes (pasulpot supot lang sa tulog) → Wet dreams are common on females (especially those
→ Levels of ACTH and Dopamine increases → dreaming who have no sexual experience yet as part of their
(hallmark sign) curiosity, and those who experience sexual activity)
→ Expect irregular vital signs (d/t iba iba daw theme ng
dream)
95. The said client was further diagnosed with primary
SLEEP DISORDERS insomnia. Before assessing the client, the nurse recalls the
1. Insomnia - difficulty in falling and maintaining sleep numerous the several causes of this disorder that includes the
• Chronic Insomnia - if it happens for >30 days following:
• Risk factors: 1. Chronic stress
o Aging (hormonal) 2. GERD - secondary
o Female d/t hormonal changes 3. generalized pain - secondary
o Stimulants (food, medications, anything 4. excessive caffeine
caffeinated) 5. chronic depression - secondary
▪ E.g., levothyroxine (thyroid prep) - given in 6. environmental noise
the morning; causes insomnia A. 1, 4, 6
o Stress B. 1, 2, 5
• Management: C. 3, 4, 6
o Instruct the patient to make a sleep diary D. 2, 3, 6
 FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

100. A nurse observes a slight increase in a patient's vital

Rationale:
signs while he is sleeping during the night. According to the
● Primary insomnia has no underlying cause
patient's stage of sleep, the nurse expects what conditions to be
● Secondary insomnia has an underlying cause
true?
A. He is aware of his surroundings at this point.
96. The nurse has to take care of a patient who has obstructive B. He is in delta sleep at this time. - NREM
sleep apnea (OSA) and has disrupted sleep. He asks the nurse C. This is most likely an NREM stage.
about the possible causes of OSA. The nurses most appropriate D. This stage constitutes around 20% to 25% of total sleep.
response would be the following EXCEPT - REM
A. Nasal Polyps
B. Lack of sleep
Rationale:
C. Obesity
→ NREM - decrease
D. Enlarged tonsils
→ REM - increase

Rationale: Obstructive Sleep Apnea (OSA)

101. The nurse is preparing 10 units of regular insulin and 5 units
● Cause: 3 reasons
of NPH insulin. Which of the following statements is the most
○ Nasal polyps
accurate?
○ Enlarged tonsils (d/t tonsillitis ro naturally
A. The NPH insulin is the shortest acting form of insulin. - NPH
large tonsils)
is an intermediate acting insulin
○ Obesity
B. Air is injected first into the regular insulin, then into the NPH
- air should be injected in NPH first before regular
97. During the intake interview, a client relates experiencing C. The insulin vial should be discarded if there are any bubbles
strange and extremely vivid sensations such as feeling like in it. - bubbles are normal so the medication should not be
falling, hearing her name being called, and sudden jerks for discarded
no reason. The nurse is correct when she provides teaching on D. This medication order is given via the subcutaneous
the stages of sleep by saying route.
A. Such phenomena is normal and called paradoxical sleep. It
occurs on the last stage of sleep known as REM or deep 102. The doctor orders the client to receive 3 units of Humulin R
sleep. It results from increased brain activity and relaxation and 5 units of Humulin U. How should the nurse draw the
of muscles. medication in the insulin syringe?
B. Such phenomena are abnormal and may signify brain or a. Draw 5 units of the short acting insulin first then draw 3 units
sleep disorder. You should see the doctor for a check-up to of the long-acting insulin.
prevent further sleep disturbances and promote adequate b. Draw 3 units of Humulin U first then draw 5 units of Humulin
rest R.
C. It is common to experience those in the early stages of c. Draw 3 units of the short acting insulin first then draw 5
sleep. Those are called hypnagogic hallucinations and units of the long-acting insulin.
jerks. It only signify that you are still relatively awake d. Draw 5 units of the long-acting insulin first then draw 3 units
and alert of the short acting insulin.
D. It is common and normal in the first stage of sleep known as
NREM or light sleep. It occurs because of increased brain
Rationale: U → R → R → U; Clear first then cloudy
activity. It is on this stage where one can also experience
bedwetting and sleepwalking. So safety is a concern and a
priority. 103. Capillary glucose monitoring is being performed every 4
hours for a client diagnosed with diabetic ketoacidosis. Insulin is
administered using a scale of regular insulin according to
Rationale: hypnagogic hallucinations happens in the early
glucose results. At 2 p.m., the client has a capillary glucose level
stages of sleep
of 250 mg/dl for insulin. The nurse should expect the dose’s:
A. onset to be at 2 p.m. and its peak to be at 3 p.m.
98. The client expressed concern that his sleep pattern, which is B. onset to be at 2:15 p.m. and its peak to be at 3 p.m.
sleeping during the day and staying awake at night, is abnormal C. onset to be at 2:30 p.m. and its peak to be at 4 p.m.
and unhealthy. The nurses most therapeutic response is D. onset to be at 4 p.m. and its peak to be at 6 p.m.
A. Many people who work at call centers have the same health
habits as yours, and they are all right
Rationale:
B. Every individual has a different biological clock. as long as
you sleep in function well, your habit is not abnormal and ONSET PEAK DURATION
unhealthy
C. Would you like to change your sleeping habits at this time? Regular 30 mins - 1
D. What makes you think your habit of sleeping during the 2-4 6
(short acting) hr
day and staying awake at night is unhealthy and
abnormal? N
(intermediate 2-4 6-12 16-20
Rationale: further assess the patient; encourage acting)
verbalization
U
6 12-16 20-30
(long acting)
99. A nurse working the night shift in a pediatric unit observes a
10-year-old male patient walking the hallway in a sleep state. → Peak time - hypoglycemia usually occurs
The child is unaware of his environment and doesn't recall the
incident in the morning. Which sleep disorder would the nurse 104. When is the patient receiving NPH insulin most likely to
expect? have a hypoglycemic reaction, if insulin is given at 8am?
a. Bruxism a. Before lunch (10-11 a.m.)
b. Cataplexy b. Early afternoon (1-3 p.m.)
c. Restless leg syndrome c. Late afternoon (4-7 p.m.)
d. Somnambulism d. After supper (8-10 p.m.)

Rationale: Between 2pm-8pm

 FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

105. A patient is being treated for acute renal failure. The 111. The rationale using the Z-track technique in an
physician orders a specific gravity of urine after each voiding. intramuscular injection is:
The nurse observes that the urine has a fixed specific gravity A. It decreases the leakage or discoloration and irritating
of 1.010. The nurse should recognize that this indicates: medication into the subcutaneous tissues
A. Severe damage to the renal tubules B. It will allow a faster absorption of the medication
B. Destruction to the filtration mechanism of the glomerulus C. The Z-track technique prevent irritation of the muscle
C. That the ability to concentrate and dilute urine is within D. It is much more convenient for the nurse
normal limits
D. That the nephrons are intact but hypertrophied. 112. During the interview with the chief of hospital, what would
be the most appropriate outfit to wear?
A. Formal attire
Test taking strategy: beh walang genyen na fixed, unless
B. Gala uniform
may sira ang kidney (Wong, 2022); BASA MAIGI! C. Any scrub suit
D. White hospital uniform
106. When the Type II diabetic patient says, “Why in the world
are they looking at my hemoglobin? I thought 113. What would be the correct approach when entering the
A. Shows how a high glucose level can cause a significant interview room?
drop in the hemoglobin level. A. Offer your hand for a shake
B. Shows what the glucose level has done for the last 3 B. Enter the room and hand your documents
months. C. Smile and grab the chair
C. Indicates a true picture of the patient’s nutritional state. D. Initiate a conversation by asking, "How are you today?"
D. Reflects the effect of high glucose levels on the ability to
produce red blood cells. 114. Which of the following is the best response to the interview
question, “What are your strengths?”
A. “I have many. Where do you want me to begin?”
Rationale: HBa1C AKA Glycosylated Hemoglobin, which is B. “I have strong communication skills, both written and
checked q 3 months verbal, and I am someone who values completing a
task.”
107. The nurse prepares an IM injection for an adult client using C. “I think I am well liked and get along with everyone”.
Z-Track technique. 4ml of medication is to be administered to D. “Well, I am just a new nurse without many strengths right
the client. Which of the now, but I will be learning with this new job.”
following sites will you
choose? Rationale: Option B is more specific, other options show
A. Deltoid - least negativity
recommended site;
capacity is only up to 1
ml 115. Which of the following components are absolutely
B. Rectus femoris necessary to include in a resume?
C. Ventrogluteal - above A. Identifying information, career objective, employment
1 year old experiences, education, and professional organizations
D. Vastus lateralis - for 1 B. Identifying information, employment experiences,
yr old and below education, professional organizations, and awards and
honors
C. Identifying information, employment experiences,
Rationale: Iron is commonly used with Z track technique education, professional organizations, and references
because it causes irritation D. Identifying information, employment experiences,
→ Z-track Technique education, and professional organizations
→ Pull the skin 1 inch in the side
→ Inject IM 90 degrees (aspiration is not needed)
→ Inject slowly and steadily Rationale: References are not usually indicated in the
• 10 seconds per 1 ml resume (dahil may palakasan)
→ Wait for another 10 seconds and then withdraw
→ NEVER or DO NOT massage the site 116. What is the primary function of a cover letter?
A. To entice the prospective employer to become interested
108. In infants 1 year old and below, which of the following is enough to read the resume
the site of choice for intramuscular injection? B. To have a letter to include with your resume
A. Deltoid C. To include references that are not listed on a resume
B. Rectus femoris D. To reiterate all that is on your resume
c. Ventrogluteal
d. Vastus lateralis 117. Andrea has been admitted at the pedia ward because of
typhoid fever. Assessment findings reveal that 2 days ago she
109. In order to decrease discomfort in Z-track administration, experienced high grade fever and then turned normal after 4
which of the following would you perform? hrs. As a nurse you know that this is a kind of:
A. Pierce the skin quickly and smoothly at 90 degrees A. relapsing fever
angle B. constant fever
B. Inject the medication rapidly at around 10 ml per minute C. fever spike
C. Pull back the plunger and aspirate per 1 minute to make D. remittent fever
sure that the needle did not hit a blood vessel
D. Pierce the skin slowly and carefully at 90 degrees angle - Rationale: relapsing fever has days in interval
painful if slowly Types of Fever
1. Intermittent - fever has ups and downs for 24 hours
110. After injection using the Z-track technique, the nurse should
know that she needs to wait for a few seconds before
withdrawing the needle and this is to allow the medication to
2. Remittent - has ups and downs but consistently above
disperse into the muscle tissue thus decreasing the client’s
the normal temperature; does not normalize within 24
discomfort. How many seconds should the nurse wait before
hours
withdrawing the needle?
A. 2 seconds
B. 5 seconds
C. 10 seconds 3. Relapsing - fever goes away then bumabalik for several
D. 15 seconds days
 FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

122. The client has to take clear liquids after midnight and
nothing by mouth after 4:00AM. The nurse recognizes that the
client has deficient knowledge when he states that he:
4. Constant - remains constantly high; hindi nagnonormal a. Ate gelatine at 3:30am
b. Brushed his teeth at 4:00am but did not swallow.
c. Used a cold washcloth to hold against his lips.
d. Smoked a cigarette at 6:00am.

118. The physician decides to cover Mr. R.’s facial wounds with 123. Which procedure or practice requires surgical asepsis?
an allograft. Which statement best describes an allograft? a. Hand washing
A. Tissue taken from an animal - xenograft/heterograft; pig b. Nasogastric tube irrigation
skin/tilapia skin c. IV catheter insertion
B. Tissue taken from another area of the patient’s body - d. Colostomy irrigation
autograft; from the self
C. Tissue taken from a person other than the patient
D. Tissue taken from amniotic membrane Rationale: surgical asepsis - sterile technique

Rationale: 124. Spaulding’s classification system is used to determine

→ Allograft AKA homograft; graft is from the same specie the appropriate method to attain the desire level of disinfection
→ Isograft - from monozygotic twin required for patient care items. This system was adopted and
later modified by the Centers for Disease Control and Prevention
(CDC). Gastroscopes, bronchoscopes, colonoscopes are in
what classification?
a. Critical items
b. Semi-critical items
c. Moderate-critical items - no such thing
d. Non-critical items

Rationale:
Critical Items
→ Enters bloodstream or vascular cavities → needs to be
sterile
→ Surgical instruments, needles
→ Cleaning: should be autoclave

Semi-critical Items
→ Not in the bloodstream but invade mucous membrane
→ Scopes
→ Cleaning: High level disinfection (HLD); use of chemicals

Non-critical Items
→ Intact skin
→ BP cuff, thermometer
119. A client with full-thickness burn receives an allograft. → Cleaning: low-level disinfection (LLD), use of alcohol,
Several days later the client points out that the graft is coming soap
off at the edges. The nurse’s best response would be:
A. It’s not a permanent graft. I’ll notify your physician 125. Instruments in the surgical suite for surgery are classified
B. You must have pulled it loose. I’ll notify your physician as CRITICAL, SEMI-CRITICAL and NON-CRITICAL. If the
C. An infection may be starting. Your physician will be here instrument is introduced directly into the bloodstream or into
shortly any normally sterile cavity or area of the body, it is classified as:
D. That was a permanent graft. Your physician probably will a. Critical
replace it b. Semi critical
c. Non-critical
Rationale: allograft, xenograft - natatanggal sila eventually d. Ultra-critical

126. Spaulding categorized instruments according to use.

120. The nurse is aware that a temporary heterograft is used to Where do you classify an endoscopic instrument?
treat burns because this graft will: a. Decontaminated instruments
A. Debride necrotic epithelium b. High level disinfected instruments
B. Be sutured in place for better adherence c. High technology instruments
C. Relieve pain and promote rapid epithelialization d. Sterile instruments
D. Commonly be used concurrently with topical antimicrobials
127. Autoclave of steam under pressure is the most common
Rationale: Option C shows healing method of sterilization in the hospital. The nurse knows that the
temperature and time is set to the optimum level to destroy not
only the microorganism, but also the spores. Which of the
121. A child weighing 10 kg has a deep partial thickness burn to following is the ideal setting of the autoclave machine?
40 % of his body surface area. The nurse will titrate this child’s a. 10,000 degrees Celsius for 1 hour
IV fluids to achieve which of the following hourly urinary outputs? b. 5,000 degrees Celsius for 30 minutes
A. 5 ml c. 37 degrees Celsius for 15 minutes
B. 10 ml d. 121 degrees Celsius for 15 minutes
C. 30 ml
D. 50 ml
Test taking strategy: Number system method

Rationale:
→ Normal urine output per hr: 1ml/kg/hr 128. A client is diagnosed with an inflamed gallbladder
→ Patient is 10 kg (Cholecystitis) and the patient is experiencing severe pain.
→ 10 kg x 1 ml The doctor explains to the client that she will need to undergo
→ = 10 kg/ml what category of surgery based on urgency?
a. Emergent - should be done immediately
b. Urgent - within 24 to 30 hours
 FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

c. Required - for weeks or months of preparation B. Inject 15 U air into regular insulin vial; inject 35 U air into
d. Elective - optional or patient’s decision NPH vial, withdraw 35 U of NPH; withdraw 15 U regular
insulin
129. Miguel has been diagnosed with localized non-small cell C. Inject 15 U air into regular insulin vial, withdraw 15 units of
tumors, hence the doctor explained to him that he will need to regular insulin; inject 35 U air into NPH vial and withdraw 35
undergo pneumonectomy within 24-30 hours since this needs U NPH.
prompt attention, what category of surgery is this based on D. Inject 35 U air into NPH vial; inject 15 U air into regular
urgency? insulin vial; withdraw 35 U NPH; withdraw 15 U regular
a. Emergent insulin
b. Urgent
c. Required
Rationale:
d. Elective
→ R - regular insulin (short acting)
→ N - NPH (intermediate acting)
Rationale: non-small cell tumors - bronchogenic carcinoma, → U - UltraLente (long acting)
most common in lungs → Can combine:
● 40% is adenocarcinoma • N (cloudy) + R (clear)
• U+R
→ Storage of insulin:
130. Surgery may be performed for various purposes. The
physician explains to the patient the need of removing her • New/unopened insulin - refrigerator
gallbladder (Cholecystectomy). The purpose of this surgery is: • Opened insulin - room temperature
a. Diagnostic - for biopsy ○ For the insulin to be readily available all the time
b. Palliative - creation of colostomy (no need to roll/warm the insulin)
c. Constructive - cleft lip surgeries ○ Until 30 days only
d. Ablative - removing a diseased body part (appendectomy,
cholecystectomy) NR: N → R → R → N
1. Inject air to N
131. A patient diagnosed with colon cancer is being prepared 2. Inject air to R
for palliative surgery to correct an intestinal obstruction. The 3. Withdraw insulin to R
nurse understands that palliative surgery: 4. Withdraw insulin to N
a. the removal and study of tissue to make a diagnosis
b. done to relieve symptoms or improve function - no intent UR: U → R → R → U
to cure
c. done to remove diseased tissue or to correct defects
d. done to correct serious defects that only affect appearance

132. A Covid patient was discharged in the hospital. A UV Lamp

was placed in the room where he stayed for a week. What type
of disinfection is this?
A. Concurrent disinfection - for patients who are still admitted
B. Terminal disinfection - for discharged patients
C. Regular disinfection
D. Routine disinfection
136. A client has been diagnosed with type 1 diabetes mellitus.
133. A male patient’s complete blood count results are back When teaching the client and family how diet and exercise affect
from this morning’s lab draw. Select all the NORMAL results: insulin requirements, the nurse should include which guideline?
1. RBC: 4.8 million A. “You’ll need more insulin when you exercise or increase
2. WBC: 10,000 your food intake.” - results to hypoglycemia
3. Platelets: 350,000 B. “You’ll need less insulin when you exercise or reduce
4. Hbg: 12 g/dL - for male 14-18g/dL is normal your food intake.”
5. Hematocrit: 37% - for male 45-52% is normal C. “You’ll need less insulin when you increase your food
A. All of the above intake.” - this would result to hyperglycemia
B. 1 and 3 D. “You’ll need more insulin when you exercise to decrease
C. 1,2,3,4 your food intake.” - results to hypoglycemia
D. 1,2,3
137. A client is admitted after sustaining burns to the chest,
134. A patient’s lipid panel results are back. You’re providing abdomen, right arm and right leg. Using the rule of nines, the
education to the patient on how to improve the results. Which nurse would determine what percentage of the client’s body
results below do the patient need to improve on except: surface has been injured?
A. LDL 210 mg/dL - normal LDL: <100 mg/dL A. 18%
B. HDL 40 mg/dL - normal HDL: >60 mg/dL B. 27%
C. Total Cholesterol 240 mg/dL - normal cholesterol level: C. 45%
<200 mg/dL D. 64%
D. Triglycerides 135 mg/dL
Rationale:
Rationale: normal triglycerides level: <150mg/dL → Chest, abdomen = 18%
→ Right arm = 9%
Test taking strategy: Double negative = positive → Right leg = 18%

135. A client, age 23, is diagnosed with diabetes mellitus. The 138. A 29-year-old male patient has superficial partial thickness
physician prescribes 15 U of U-100 regular insulin and 35 U of burns on the anterior right arm, posterior left leg, and anterior
U-100 isophane insulin suspension (NPH) to be taken before head and neck. The patient weighs 78 kg. Use the Parkland Burn
breakfast. The nurse checks the medication order, assembles Formula to calculate the total amount of Lactated Ringers that
equipment, washes hands, rotates the NPH insulin vial, puts on will be given over the next 24 hours?
disposable gloves, and cleans the stoppers. To draw the two A. 11,232 mL
insulin doses into the single U-100 insulin syringe, which B. 5,616 mL
sequence should the nurse use? C. 2,808 mL
A. Inject 35 U air into NPH vial; inject 15 U air into regular D. 16,848 mL
insulin vial, withdraw 15 U regular insulin; withdraw 35
U NPH. - (N → R → R → N) Rationale: Parkland = 4ml x TBSA x kg
→ Anterior right arm = 4.5%
 FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

142. In this stage of illness, the person accepts or rejects a

→ Posterior left leg = 9%
professional's suggestion. The person also becomes passive
→ Anterior head and neck = 4.5%
and may regress to an earlier stage.
• TBSA = 18% A. Symptom Experience
→ 4ml x 18% x 78kg = 5616 mL/24 hours B. Assumption of sick role
C. Medical care contact
Types of Burns: D. Dependent patient role
→ 1st degree burns - superficial thickness
→ 2nd degree - partial thickness
• Superficial-partial thickness Rationale: Stages of Illness
• Deep-partial thickness I. Symptom Experience
• Note: take note of the word “partial”, basta may II. Assumption of sick role
partial 2nd degree burn III. Medical care contact
→ 3rd degree - full thickness IV. Dependent patient role - passive and regress
→ 4th degree - deep full thickness V. Recovery stage

139. A 45-year-old female patient has superficial partial 143. Which of the following is NOT TRUE in steam inhalation?
thickness burns on the posterior head and neck, front of the left A. It is a dependent nursing action - needs doctor’s order
arm, front and back of the right arm, posterior trunk, front and (heat and cold application)
back of the left leg, and back of right leg. The patient weighs 91 B. Spout is put 12-18 inches away from the nose
kg. Use the Parkland Burn Formula to calculate the total amount C. Render steam inhalation for at least 30 minutes
of Lactated Ringers that will be given over the next 24 hours? D. Cover the client’s eye with wash cloth to prevent irritation
A. 12,238 mL
B. 26,208 mL Rationale: should only be 10-15 minutes
C. 16,380 mL
D. 22,932 mL
144. Advancement in Nursing leads to the development of the
Expanded Career Roles. Which of the following is NOT an
Rationale: expanded career role for a nurse?
→ posterior head and neck = 4.5% A. Nurse practitioner
→ front of the left arm = 4.5 % B. Clinical Nurse Specialist
→ front and back of the right arm = 9% C. Nurse Researcher
→ posterior trunk = 18% D. Nurse anesthesiologist
→ front and back of the left leg = 18%
→ back of right leg = 9%
• TBSA = 63% Rationale: Expanded Career Roles
→ 4 ml x 63% x 91 kg = 22,932 mL/24 hours → Nurse practitioner
→ Clinical nurse specialist
→ Nurse midwife
140. A 30-year-old female patient has deep partial thickness → Nurse educator
burns on the front and back of the right and left leg, front of right → Nurse researcher
arm, and anterior trunk. The patient weighs 63 kg. Use the → Nurse anesthetist
Parkland Burn Formula: What is the flow rate during the FIRST 8
hours (mL/hr) based on the total you calculated?
A. 921 mL/hr 145. The nurse provides instructions to a client who is being
B. 938 mL/hr discharged after undergoing a percutaneous renal biopsy.
C. 158 mL/hr Which statement by the client indicates a need to reinforce the
D. 789 mL/hr instructions?
A. “A fever is normal following this procedure.”
B. “I should not work out at the gym for about 2 weeks.”
Rationale: C. “I need to avoid any strenuous lifting for about 2 weeks.”
→ front and back of the right and left leg = 36% D. “I will call the health care provider if my urine becomes
→ front of right arm = 4.5% bloody.”
→ anterior trunk = 18%
• TBSA = 58.5% 146. Which of the following is inappropriate when performing
→ 4 ml x 58.5% x 63 kg = 14,742 mL/24 hours genital care to male clients?
→ 14,742/2 = 7,371 ml - first 8 hours a. Wear gloves
→ 7,371/8 hours = 921 mL/hr b. Use circular motion from the penile shaft towards the
glans
Note: c. Retract prepuce if uncircumcised
→ 1st 8 hours → 50% of total d. Use moist washcloth with soap
→ 2nd 8 hours → 25% of total
→ 3rd 8 hours → 25% of total
→ Lbs to kg = divide by 2.2 Rationale: should be from glans to penile shaft

141. A client with a head injury is being monitored for increased 147. Mr. Liu is a diabetic client, he asked the nurse on how to
intracranial pressure (ICP). His blood pressure is 90/60 mmHG cut his toenails particularly the corns, the nurse’s best
and the ICP is 18 mm Hg; therefore his cerebral perfusion response would be:
pressure (CPP) is: a. Cut nail straight across
a. 52 mm Hg b. Trim toenails from the edge
b. 88 mm Hg c. Consult a podiatrist
c. 48 mm Hg d. Soak foot to a basin with warm water
d. 68 mm Hg
Rationale: a diabetic patient with corns should be referred to
Rationale: podiatrist d/t poor wound healing
→ MAP (sys + 2[diastolic])/3
• 90 + 2(60)/3 = 70 mmHg 148. The nurse is caring for the client who has been admitted
→ ICP = 18 with Glaucoma, when assisting this client for ambulation, the
→ CPP = MAP - ICP nurse would stand:
• 70 - 18 = 52 mmHg A. Slightly in front of the client, offering an elbow to hold -
freedom of movement for the client
B. Slightly in front of the client, grasping the client’s elbow
 FINAL COACHING: FUNDAMENTALS OF NURSING PRACTICE

C. Next to the client, offering an elbow to hold 154. When restoration of health is no longer the goal of care and
D. Next to the client, holding the client’s elbow end-of-life care is the goal, artificial nutrition and hydration
can be prepared and continued to be administered. The nurse
can administer artificial nutrition through the following avenues
Rationale: glaucoma - no peripheral vision, only tunnel vision
EXCEPT:
A. intravenous (I.V.) infusion
149. When holding the transfer belt, the nurse will make sure B. nasogastric tube
that: C. ileostomy tube
A. Hold the transfer belt with the thumbs facing upward - may D. gastrostomy tube
cause wrist injury
B. Hold the transfer belt with the thumb 155. It is medication time. The nurse is aware that distraction
C. Hold the transfer belt with the thumbs facing downward during any phase of drug administration can cause errors. Select
- more stable even when lifting heavy weight which strategy can give MOST protection while preparing the
D. Hold the transfer belt with the little finger medication?
A. Don a medication vest with visible
warning “Don’t Disturb”
Test taking strategy: all of the options are contradicting B. Put your cell phone on silent mode
C. Inform your co-staff that you are
150. The nurse is about to perform a back rub to the client after going to prepare medications for
a complete bed bath. How should the nurse proceed? your clients
A. Place the client at the middle of the bed - at the side of the D. Prepare medication at the bedside
bed, near the nurse so that the nurse can reach the back
B. Pour the lotion into client’s back - lotion should be pour over 156. The nurse is checking the client’s overall oxygenation. In
the hands assessment of the presence of central cyanosis, the nurse will
C. Rub the back gently especially over the bony inspect the client’s:
prominences a. Palms and soles of the feet
D. Wipe the excess lotion using a rubbing motion b. Nail beds
c. Earlobes
151. The nurse knows that the BEST areas used to assess d. Tongue
pallor that are characteristics of anemia are the:
A. conjunctiva and mucous membrane 157. Following surgery, Mrs. Millado developed abdominal
B. lips and fingernails distention. The physician ordered a rectal tube insertion to
C. palms and fingernails relieve distention. To achieve maximum effectiveness, how long
D. tongue and lips should the rectal tube be left in place?
A. 5 minutes
B. 15 minutes - 15-20 minutes
Rationale: C. 30 minutes
Pallor D. 60 minutes
→ Where to assess:
• Conjunctiva 158. A nurse needs to assess a client’s pulse pressure. What is
• Oral mucous membranes the correct procedure?
• Nail beds a. Subtract apical from radial pulse
• Palms b. Subtract systolic from diastolic blood pressure
• Toes c. Subtract radial from apical pulse
→ Dark skin: Buccal mucosa (gilid ng bibig) d. Subtract diastolic from systolic

Cyanosis
→ Where to assess: Rationale: pulse pressure: systolic - diastolic
• Nail beds
• Lips 159. If the arm is said to be below the heart when taking the
• Tongue blood pressure, it will create a:
• Buccal mucosa A. False high reading
• Palms B. True false reading
• Toes C. False low reading
→ Dark skin: palpebral conjunctiva (lining of the eyelids) D. Indeterminate

Jaundice 160. A nurse has deflated the BP cuff too fast. How will this affect
→ Where to assess: the nurse’s reading?
• Sclera a. Erroneously low systolic and high diastolic reading
• Mucous membrane b. Erroneously high systolic and low diastolic reading
• Skin c. Inconsistent
→ Dark skin: hard palate; not on sclera because their sclera d. None of the above
is normally yellowish
Rationale: deflating of cuff should be at least 2-3
152. The nurse knows that the BEST areas used to assess mmHg/seconds only
jaundice in dark-skinned individual is the:
A. hard palate
B. sclera
C. skin
D. fingernails

153. To establish a diagnosis for anemia, the nurse would expect

the following laboratory tests to be ordered by the physician
EXCEPT:
A. Iron studies
B. Bone marrow aspiration
C. Complete blood count
D. Erythrocyte sedimentation rate

Rationale: for inflammation, not anemia