Fundamentals in Nursing A.
Nursing history
B. Nursing notes
Fundamentals in Nursing Set A C. Nursing care plan
D. Nursing diagnosis
7. What is an example of a subjective data?
1. Jake is complaining of shortness of breath.
The nurse assesses his respiratory rate to be 30
breaths per minute and documents that Jake is A. Heart rate of 68 beats per minute
tachypneic. The nurse understands that B. Yellowish sputum
tachypnea means: C. Client verbalized, “I feel pain when
urinating.”
D. Noisy breathing
A. Pulse rate greater than 100 beats
8. Which expected outcome is correctly written?
per minute
B. Blood pressure of 140/90
C. Respiratory rate greater than 20 A. “The patient will feel less nauseated
breaths per minute in 24 hours.”
D. Frequent bowel sounds B. “The patient will eat the right
2. The nurse listens to Mrs. Sullen’s lungs and amount of food daily.”
notes a hissing sound or musical sound. The C. “The patient will identify all the high-
nurse documents this as: salt food from a prepared list by
discharge.”
D. “The patient will have enough
A. Wheezes
sleep.”
B. Rhonchi
9. Which of the following behaviors by Nurse
C. Gurgles
Jane Robles demonstrates that she understands
D. Vesicular
well th elements of effecting charting?
3. The nurse in charge measures a patient’s
temperature at 101 degrees F. What is the
equivalent centigrade temperature? A. She writes in the chart using a no. 2
pencil.
B. She noted: appetite is good this
A. 36.3 degrees C
afternoon.
B. 37.95 degrees C
C. She signs on the medication sheet
C. 40.03 degrees C
after administering the medication.
D. 38.01 degrees C
D. She signs her charting as follow: J.R
4. Which approach to problem solving tests any
10. What is the disadvantage of computerized
number of solutions until one is found that works
documentation of the nursing process?
for that particular problem?
A. Accuracy
A. Intuition
B. Legibility
B. Routine
C. Concern for privacy
C. Scientific method
D. Rapid communication
D. Trial and error
11. The theorist who believes that adaptation and
5. What is the order of the nursing process?
manipulation of stressors are related to foster
change is:
A. Assessing, diagnosing,
implementing, evaluating, planning
A. Dorothea Orem
B. Diagnosing, assessing, planning,
B. Sister Callista Roy
implementing, evaluating
C. Imogene King
C. Assessing, diagnosing, planning,
D. Virginia Henderson
implementing, evaluating
12. Formulating a nursing diagnosis is a joint
D. Planning, evaluating, diagnosing,
function of:
assessing, implementing
6. During the planning phase of the nursing
process, which of the following is the outcome? A. Patient and relatives
B. Nurse and patient until the patient takes the
C. Doctor and family medication.
D. Nurse and doctor C. Instruct the patient to take the
13. Mrs. Caperlac has been diagnosed to have medication and leave it at the
hypertension since 10 years ago. Since then, she bedside.
had maintained low sodium, low fat diet, to D. Wait for the patient to return to bed
control her blood pressure. This practice is and just leave the medication at the
viewed as: bedside.
18. Which of the following is inappropriate
A. Cultural belief nursing action when administering NGT feeding?
B. Personal belief
C. Health belief A. Place the feeding 20 inches above
D. Superstitious belief the pint if insertion of NGT.
14. Becky is on NPO since midnight as B. Introduce the feeding slowly.
preparation for blood test. Adreno-cortical C. Instill 60ml of water into the NGT
response is activated. Which of the following is after feeding.
an expected response? D. Assist the patient in fowler’s
position.
A. Low blood pressure 19. A female patient is being discharged after
B. Warm, dry skin thyroidectomy. After providing the medication
C. Decreased serum sodium levels teaching. The nurse asks the patient to repeat the
D. Decreased urine output instructions. The nurse is performing which
15. What nursing action is appropriate when professional role?
obtaining a sterile urine specimen from an
indwelling catheter to prevent infection? A. Manager
B. Caregiver
A. Use sterile gloves when obtaining C. Patient advocate
urine. D. Educator
B. Open the drainage bag and pour out 20. Which data would be of greatest concern to
the urine. the nurse when completing the nursing
C. Disconnect the catheter from the assessment of a 68-year-old woman hospitalized
tubing and get urine. due to Pneumonia?
D. Aspirate urine from the tubing port
using a sterile syringe. A. Oriented to date, time and place
16. A client is receiving 115 ml/hr of continuous B. Clear breath sounds
IVF. The nurse notices that the venipuncture site C. Capillary refill greater than 3
is red and swollen. Which of the following seconds and buccal cyanosis
interventions would the nurse perform first? D. Hemoglobin of 13 g/dl
21. During a change-of-shift report, it would be
A. Stop the infusion important for the nurse relinquishing
B. Call the attending physician responsibility for care of the patient to
C. Slow that infusion to 20 ml/hr communicate. Which of the following facts to the
D. Place a clod towel on the site nurse assuming responsibility for care of the
17. The nurse enters the room to give a patient?
prescribed medication but the patient is inside
the bathroom. What should the nurse do? A. That the patient verbalized, “My
headache is gone.”
A. Leave the medication at the B. That the patient’s barium enema
bedside and leave the room. performed 3 days ago was negative
B. After few minutes, return to that C. Patient’s NGT was removed 2 hours
patient’s room and do not leave ago
D. Patient’s family came for a visit this minute is tachypnea. A blood
morning. pressure of 140/90 is considered
22. Which statement is the most appropriate goal hypertension. Pulse greater than
for a nursing diagnosis of diarrhea? 100 beats per minute is
tachycardia. Frequent bowel
A. “The patient will experience sounds refer to hyper-active bowel
decreased frequency of bowel sounds.
elimination.” 2. (A) Wheezes. Wheezes are
B. “The patient will take anti-diarrheal indicated by continuous, lengthy,
medication.” musical; heard during inspiration or
C. “The patient will give a stool expiration. Rhonchi are usually
specimen for laboratory coarse breath sounds. Gurgles are
examinations.” loud gurgling, bubbling sound.
D. “The patient will save urine for Vesicular breath sounds are low
inspection by the nurse. pitch, soft intensity on expiration.
23. Which of the following is the most important
purpose of planning care with this patient? 3. (B) 37.95 degrees C. To convert °F
to °C use this formula, ( °F – 32 )
(0.55). While when converting °C to
A. Development of a standardized
°F use this formula, ( °C x 1.8) + 32.
NCP.
Note that 0.55 is 5/9 and 1.8 is 9/5.
B. Expansion of the current taxonomy
of nursing diagnosis
4. (D) Trial and error. The trial and
C. Making of individualized patient
error method of problem solving
care
isn’t systematic (as in the scientific
D. Incorporation of both nursing and
method of problem solving) routine,
medical diagnoses in patient care
or based on inner prompting (as in
24. Using Maslow’s hierarchy of basic human
the intuitive method of problem
needs, which of the following nursing diagnoses
solving).
has the highest priority?
5. (C) Assessing, diagnosing,
planning, implementing,
A. Ineffective breathing pattern related evaluating. The correct order of the
to pain, as evidenced by shortness nursing process is assessing,
of breath. diagnosing, planning,
B. Anxiety related to impending implementing, evaluating.
surgery, as evidenced by insomnia. 6. (C) Nursing care plan. The
C. Risk of injury related to outcome, or the product of the
autoimmune dysfunction planning phase of the nursing
D. Impaired verbal communication process is a Nursing care plan.
related to tracheostomy, as 7. (C) Client verbalized, “I feel pain
evidenced by inability to speak. when urinating.”. Subjective data
25. When performing an abdominal examination, are those that can be described only
the patient should be in a supine position with the by the person experiencing it.
head of the bed at what position? Therefore, only the patient can
describe or verify whether he is
A. 30 degrees experiencing pain or not.
B. 90 degrees 8. (C) “The patient will identify all the
C. 45 degrees high-salt food from a prepared list
D. 0 degree by discharge.”. Expected outcomes
Answers and Rationales are specific, measurable, realistic
statements of goal attainment. The
1. 1. (C) Respiratory rate greater than phrases “right amount”, “less
20 breaths per minute. A respiratory
rate of greater than 20 breaths per
nauseated” and “enough sleep” are nurse should aspirate the urine
vague and not measurable. from the port using a sterile syringe
9. (C) She signs on the medication to obtain a urine specimen. Opening
sheet after administering the a closed drainage system increase
medication.A nurse should record a the risk of urinary tract infection.
nursing intervention (ex. Giving 16. (A) Stop the infusion. The sign and
medications) after performing the symptoms indicate extravasation
nursing intervention (not before). so the IVF should be stopped
Recording should also be done immediately and put warm not cold
using a pen, be complete, and towel on the affected site.
signed with the nurse’s full name 17. (B) After few minutes, return to that
and title. patient’s room and do not leave
10. (C) Concern for privacy. A patient’s until the patient takes the
privacy may be violated if security medication. This is to verify or to
measures aren’t used properly or if make sure that the medication was
policies and procedures aren’t in taken by the patient as directed.
place that determines what type of 18. (A) Place the feeding 20 inches
information can be retrieved, by above the pint if insertion of
whom, and for what purpose. NGT. The height of the feeding is
11. (B) Sister Callista Roy. Sister Roy’s above 12 inches above the point of
theory is called the adaptation insertion, bot 20 inches. If the
theory and she viewed each person height of feeding is too high, this
as a unified biophysical system in results to very rapid introduction of
constant interaction with a feeding. This may trigger nausea
changing environment. Orem’s and vomiting.
theory is called self-care deficit 19. (D) Educator. When teaching a
theory and is based on the belief patient about medications before
that individual has a need for self- discharge, the nurse is acting as an
care actions. King’s theory is the educator. A caregiver provides
Goal attainment theory and direct care to the patient. The nurse
described nursing as a helping acts as s patient advocate when
profession that assists individuals making the patient’s wishes known
and groups in society to attain, to the doctor.
maintain, and restore health. 20. (C) Capillary refill greater than 3
Henderson introduced the nature of seconds and buccal
nursing model and identified the 14 cyanosis. Capillary refill greater
basic needs. than 3 seconds and buccal
12. (B) Nurse and patient. Although cyanosis indicate decreased
diagnosing is basically the nurse’s oxygen to the tissues which
responsibility, input from the requires immediate
patient is essential to formulate the attention/intervention. Oriented to
correct nursing diagnosis. date, time and place, hemoglobin of
13. (C) Health belief. Health belief of 13 g/dl are normal data.
an individual influences his/her 21. (C) Patient’s NGT was removed 2
preventive health behavior. hours ago. The change-of-shift
14. (D) Decreased urine report should indicate significant
output. Adreno-cortical response recent changes in the patient’s
involves release of aldosterone that condition that the nurse assuming
leads to retention of sodium and responsibility for care of the patient
water. This results to decreased will need to monitor. The other
urine output. options are not critical enough to
15. (D) Aspirate urine from the tubing include in the report.
port using a sterile syringe. The
22. (A) “The patient will experience 3. Jason, 3 years old vomited. His mom stated,
decreased frequency of bowel “He vomited 6 ounces of his formula this
elimination.” The goal is the morning.” This statement is an example of:
opposite, healthy response of the
problem statement of the nursing A. objective data from a secondary
diagnosis. In this situation, the source
problem statement is diarrhea. B. objective data from a primary
23. (C) Making of individualized patient source
care. To be effective, the nursing C. subjective data from a primary
care plan developed in the planning source
phase of the nursing process must D. subjective data from a secondary
reflect the individualized needs of source
the patient. 4. Which of the following is a nursing diagnosis?
24. (A) Ineffective breathing pattern
related to pain, as evidenced by
A. Hypethermia
shortness of breath.. Physiologic
B. Diabetes Mellitus
needs (ex. Oxygen, fluids, nutrition)
C. Angina
must be met before lower needs
D. Chronic Renal Failure
(such as safety and security, love
5. What is the characteristic of the nursing
and belongingness, self-esteem
process?
and self-actualization) can be met.
Therefore, physiologic needs have
the highest priority. A. stagnant
25. (D) 0 degree. The patient should be B. inflexible
positioned with the head of the bed C. asystematic
completely flattened to perform an D. goal-oriented
abdominal examination. If the head 6. A skin lesion which is fluid-filled, less than 1 cm
of the bed is elevated, the in size is called:
abdominal muscles and organs can
be bunched up, altering the findings A. papule
B. vesicle
C. bulla
Fundamentals in Nursing Set B D. macule
7. During application of medication into the ear,
1. A patient is wearing a soft wrist-safety device. which of the following is inappropriate nursing
Which of the following nursing assessment is action?
considered abnormal?
A. In an adult, pull the pinna upward.
A. Palpable radial pulse B. Instill the medication directly into
B. Palpable ulnar pulse the tympanic membrane.
C. Capillary refill within 3 seconds C. Warm the medication at room or
D. Bluish fingernails, cool and pale body temperature.
fingers D. Press the tragus of the ear a few
2. Pia’s serum sodium level is 150 mEq/L. Which times to assist flow of medication
of the following food items does the nurse into the ear canal.
instruct Pia to avoid? 8. Which of the following is appropriate nursing
intervention for a client who is grieving over the
A. broccoli death of her child?
B. sardines
C. cabbage A. Tell her not to cry and it will be
D. tomatoes better.
B. Provide opportunity to the client to
tell their story.
C. Encourage her to accept or to 15. Claire is admitted with a diagnosis of chronic
replace the lost person. shoulder pain. By definition, the nurse
D. Discourage the client in expressing understands that the patient has had pain for
her emotions. more than:
9. It is the gradual decrease of the body’s
temperature after death. A. 3 months
B. 6 months
A. livor mortis C. 9 months
B. rigor mortis D. 1 year
C. algor mortis 16. Which of the following statements regarding
D. none of the above the nursing process is true?
10. When performing an admission assessment
on a newly admitted patient, the nurse percusses A. It is useful on outpatient settings.
resonance. The nurse knows that resonance B. It progresses in separate, unrelated
heard on percussion is most commonly heard steps.
over which organ? C. It focuses on the patient, not the
nurse.
A. thigh D. It provides the solution to all patient
B. liver health problems.
C. intestine 17. Which of the following is considered
D. lung significant enough to require immediate
11. The nurse is aware that Bell’s palsy affects communication to another member of the health
which cranial nerve? care team?
A. 2nd CN (Optic) A. Weight loss of 3 lbs in a 120 lb
B. 3rd CN (Occulomotor) female patient.
C. 4th CN (Trochlear) B. Diminished breath sounds in
D. 7th CN (Facial) patient with previously normal
12. Prolonged deficiency of Vitamin B9 leads to: breath sounds
C. Patient stated, “I feel less
A. scurvy nauseated.”
B. pellagra D. Change of heart rate from 70 to 83
C. megaloblastic anemia beats per minute.
D. pernicious anemia 18. To assess the adequacy of food intake, which
13. Nurse Cherry is teaching a 72 year old patient of the following assessment parameters is best
about a newly prescribed medication. What could used?
cause a geriatric patient to have difficulty
retaining knowledge about the newly prescribed A. food preferences
medication? B. regularity of meal times
C. 3-day diet recall
A. Absence of family support D. eating style and habits
B. Decreased sensory functions 19. Van Fajardo is a 55 year old who was
C. Patient has no interest on learning admitted to the hospital with newly diagnosed
D. Decreased plasma drug levels hepatitis. The nurse is doing a patient teaching
14. When assessing a patient’s level of with Mr. Fajardo. What kind of role does the nurse
consciousness, which type of nursing assume?
intervention is the nurse performing?
A. talker
A. Independent B. teacher
B. Dependent C. thinker
C. Collaborative D. doer
D. Professional
20. When providing a continuous enteral feeding, C. Thyroid
which of the following action is essential for the D. Thymus
nurse to do? Answers and Rationales
1. (D) Bluish fingernails, cool and pale
A. Place the client on the left side of
fingers. A safety device on the wrist
the bed.
may impair blood circulation.
B. Attach the feeding bag to the
Therefore, the nurse should assess
current tubing.
the patient for signs of impaired
C. Elevate the head of the bed.
circulation such as bluish
D. Cold the formula before
fingernails, cool and pale fingers.
administering it.
Palpable radial and ulnar pulses,
21. Kussmaul’s breathing is;
capillary refill within 3 seconds are
all normal findings.
A. Shallow breaths interrupted by 2. (B) sardines. The normal serum
apnea. sodium level is 135 to 145 mEq/L,
B. Prolonged gasping inspiration the client is having hypernatremia.
followed by a very short, usually Pia should avoid food high in
inefficient expiration. sodium like processed food.
C. Marked rhythmic waxing and Broccoli, cabbage and tomatoes
waning of respirations from very are good source of Vitamin C.
deep to very shallow breathing and 3. (A) objective data from a
temporary apnea. secondary source. Jason is the
D. Increased rate and depth of primary source; his mother is a
respiration. secondary source. The data is
22. Presty has terminal cancer and she refuses to objective because it can be
believe that loss is happening ans she assumes perceived by the senses, verified by
artificial cheerfulness. What stage of grieving is another person observing the same
she in? patient, and tested against
accepted standards or norms.
A. depression 4. (A) Hypethermia. Hyperthermia is a
B. bargaining NANDA-approved nursing
C. denial diagnosis. Diabetes Mellitus,
D. acceptance Angina and Chronic Renal Failure
23. Immunization for healthy babies and are medical diagnoses.
preschool children is an example of what level of 5. (D) goal-oriented. The nursing
preventive health care? process is goal-oriented. It is also
systematic, patient-centered, and
A. Primary dynamic.
B. Secondary 6. (B) vesicle. Vesicle is a
C. Tertiary circumscribed circulation
D. Curative containing serous fluid or blood and
24. Which is an example of a subjective data? less than 1 cm (ex. Blister, chicken
pox).
7. (B) Instill the medication directly
A. Temperature of 38 0C
into the tympanic
B. Vomiting for 3 days
membrane. During the application
C. Productive cough
of medication it is inappropriate to
D. Patient stated, “My arms still hurt.”
instill the medication directly into
25. The nurse is assessing the endocrine system.
the tympanic membrane. The right
Which organ is part of the endocrine system?
thing to do is instill the medication
along the lateral wall of the auditory
A. Heart canal.
B. Sinus
8. (B) Provide opportunity to the client 15. (B) 6 months. Chronic pain s
to tell their story. Providing a usually defined as pain lasting
grieving person an opportunity to longer than 6 months.
tell their story allows the person to 16. (C) It focuses on the patient, not
express feelings. This is therapeutic the nurse. The nursing process is
in assisting the client resolve grief. patient-centered, not nurse-
9. (C) algor mortis. Algor mortis is the centered. It can be use in any
decrease of the body’s temperature setting, and the steps are related.
after death. Livor mortis is the The nursing process can’t solve all
discoloration of the skin after patient health problems.
death. Rigor mortis is the stiffening 17. (B) Diminished breath sounds in
of the body that occurs about 2-4 patient with previously normal
hours after death. breath sounds. Diminished breath
10. (D) lung. Resonance is loud, low- sound is a life threatening problem
pitched and long duration that’s therefore it is highly priority
heard most commonly over an air- because they pose the greatest
filled tissue such as a normal lung. threat to the patient’s well-being.
11. (D) 7th CN (Facial). Bells’ palsy is 18. (C) 3-day diet recall. 3-day diet
the paralysis of the motor recall is an example of dietary
component of the 7th caranial history. This is used to indicate the
nerve, resulting in facial sag, adequacy of food intake of the
inability to close the eyelid or the client.
mouth, drooling, flat nasolabial fold 19. (B) teacher. The nurse will assume
and loss of taste on the affected the role of a teacher in this
side of the face. therapeutic relationship. The other
12. (C) megaloblastic roles are inappropriate in this
anemia. Prolonged Vitamin B9 situation.
deficiency will lead to 20. (C) Elevate the head of the
megaloblastic anemia while bed. Elevating the head of the bed
pernicious anemia results in during an enteral feeding prevents
deficiency in Vitamin B12. aspiration. The patient may be
Prolonged deficiency of Vitamin C placed on the right side to prevent
leads to scurvy and Pellagra results aspiration. Enteral feedings are
in deficiency in Vitamin B3. given at room temperature to
13. (B) Decreased sensory lessen GI distress. The enteral
functions. Decreased in sensory tubing should be changed every 24
functions could cause a geriatric hours to limit microbial growth.
patient to have difficulty retaining 21. (D) Increased rate and depth of
knowledge about the newly respiration. Kussmaul breathing is
prescribed medications. Absence also called as hyperventilation.
of family support and no interest on Seen in metabolic acidosis and
learning may affect compliance, not renal failure. Option A refers to
knowledge retention. Decreased Biot’s breathing. Option B is
plasma levels do not alter patient’s apneustic breathing and option C is
knowledge about the drug. the Cheyne-stokes breathing.
14. (A) Independent. Independent 22. (C) denial. The client is in denial
nursing interventions involve stage because she is unready to
actions that nurses initiate based face the reality that loss is
on their own knowledge and skills happening and she assumes
without the direction or supervision artificial cheerfulness.
of another member of the health 23. (A) Primary. The primary level
care team. focuses on health promotion.
Secondary level focuses on health
maintenance. Tertiary focuses on
rehabilitation. There is n Curative
level of preventive health care
problems.
24. (D) Patient stated, “My arms still
hurt.”. Subjective data are apparent
only to the person affected and can
or verified only by that person.
25. (C) Thyroid. The thyroid is part of
the endocrine system. Heart, sinus
and thymus are not.