PINES CITY COLLEGE

COLLEGE OF NURSING
BSN I
Comprehensive exam RLE
Second Semester, SY 2020 – 2021

DIRECTION: Read and analyze each question carefully. Select the best answer and click the letter of your
choice. (100 points)

1. Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions? 

A. Providing a back massage  C. Providing hair care 

B. Feeding a client  D. Providing oral hygiene 
 
2. Nurse Jane obtained a client’s pulse and found the rate to be above normal. The nurse document this
finding as which of the following? 

A. Tachypnea  C. Arrythmia 
B. Hyper pyrexia  D. Tachycardia 

3. Which of the following actions should Nurse Clefferson take to use a wide base support when assisting a client
to get up in a chair? 

A. Bend at the waist and place arms under the client’s arms and lift 
B. Face the client, bend knees and place hands on client’s forearm and lift 
C. Spread his or her feet apart 
D. Tighten his or her pelvic muscles 

4. A client at the ICU, who is unconscious needs frequent mouth care. When performing a mouth care, what
should be the best position of a client? 

A. Fowler’s position  C. Supine 

B. Side lying  D. Trendelenburg 
 
5. A client in the medical ward is hospitalized for the first time, which of the following actions ensure the safety
of the client? 

A. Keep unnecessary furniture out of the way 

B. Keep the lights on at all time 
C. Keep side rails up at all time 
D. Keep all equipment out of view 
 
6. A walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea. Nurse Glaselle takes
the client’s vital signs hereafter. What phrase of nursing process is being implemented here by the nurse? 

A. Assessment  C. Planning 
B. Diagnosis  D. Implementation 
 
7. Which of the following is best describe as a systematic, rational method of planning and providing nursing care
for individual, families, group, and community? 

A. Assessment  C. Diagnosis 
B. Nursing Process  D. Implementation 
 

8. Exchange of gases takes place in which of the following organ? 

A.
B. Kidney  D. Liver 
C. Lungs  E. Heart 
 
1|Page Comprhensive exam RLE
9. Which chamber of the heart that receives oxygenated blood from the lungs is the? 

A. Left atrium  C. Left ventricle 
B. Right atrium  D. Right ventricle
 

10. Which of the following organ is a muscular enlarge pouch or sac that lies slightly to the left which is used for
temporary storage of food? 

A. Gallbladder  C. Stomach 
B. Urinary bladder  D. Lungs 
 
11. Which of the following is a transparent membrane that focuses the light that enters the eyes to the retina? 

A. Lens  C. Cornea 
B. Sclera  D. Pupils 
 
12. Which of the following cluster of data belong to Maslow’s hierarchy of needs? 

A. Love and belonging  C. Self-actualization 

B. Physiologic needs  D. All of the above 

13. What is the psychosocial stage of a toddler?

A. Trust vs. mistrust

B. Autonomy vs. shame and doubt
C. Initiative vs. guilt
D. Identity vs. role confusion

14. What is the teaching strategy to a 6-year-old who is more realistic and objective?

A. Be honest and allay her fears

B. Encourage independence and active participation
C. Allow time to ask question
D. Use play therapy

15. Which of the following are the general characteristic of an infant?

A. Egocentric C. Motivated by curiosity

B. Limited sense of time D. Dependent on environmenT

16. Which of the following has the characteristic of natural curiosity?

A. Child C. Adult
B. Toddler D. Elderly

17. What are the three mechanisms to determine learning style?

A. Observation, documentation, feedback

B. Observation, interview, administration of learning style instruments
C. Observation, history taking and nursing diagnosis
D. Observation, documentation, feedback

18. Before using any learning style instrument, what are the things necessary thing to determine beforehand?

A. Determine the learner

B. Determine the reliability and the validity of the tool
C. Determine the effective of the tools
D. Determine the needs of the teacher
 
2|Page Comprhensive exam RLE
19. Which of the following is the nurse’s role in the health promotion? 

A. Health risk appraisal 

B. Teach client to be effective health consumer 
C. Worksite wellness 
D. None of the above 
 
20. Which of the following refers to the preparation of the bed with a new set of linens? 

A. Bed bath  C. Bed shampoo 

B. Bed making  D. Bed lining 
 
21. Which of the following is the most important purpose of handwashing? 

A. To promote hand circulation 

B. To prevent the transfer of microorganism 
C. To avoid touching the client with a dirty hand 
D. To provide comfort 
 
22. What should be done to prevent contaminating of the environment in bed making? 

A. Avoid funning soiled linens  C. Finished both sides at the time 

B. Strip all linens at the same time  D. Embrace soiled linen 

23. The most important purpose of cleansing bed bath is which of the following?

A. To cleanse, refresh and give comfort to the client who must remain in bed 
B. To expose the necessary parts of the body 
C. To develop skills in bed bath 
D. To check the body temperature of the client in bed 
 
24. Which of the following technique involves the sense of sight? 

A. Inspection  C. Percussion 
B. Palpation  D. Auscultation 

25. Which of the following is the first technique used in assessing the abdomen of a client? 

A. Palpation  C. Percussion 
B. Auscultation  D. Inspection 
 
26. Which of the following is a technique in physical examination that is use to assess the movement of air through
the tracheobronchial tree? 

A. Palpation  C. Inspection 
B. Auscultation  D. Percussion 

27. Which among the following is an instrument used for auscultation?

 
A. Percussion-hammer  C. Stethoscope 
B. Audiometer  D. Sphygmomanometer 
 
28. Resonance is best described as which of the following choices? 

A. Sounds created by air filled lungs 

B. Short, high pitch and thudding 
C. Moderately loud with musical quality 
D. Drum-like 
 
29. The best position for examining the rectum is which of the following? 
B. Sim’s 
A. Prone 

3|Page Comprhensive exam RLE

 C. Knee-chest  D. Lithotomy 
 
30. Which of the following refers to the manner of walking? 

A. Gait  C. Flexion and extension 

B. Range of motion  D. Hopping 

31. Nurse Justine observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of
the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as
which of the following?
 
A. Tachypnea  C. Orthopnea 
B. Eupnca  D. Hyperventilation 
 
32. Mr. Kurdapyo is about to undergo abdominal inspection, nurse Lara Flyn should place him in which of the
following positions? 

A. Prone  C. Supine 
B. Trendelenburg  D. Side-lying 
 
33. During a Romberg test, nurse Lhevenie should ask the patient to assume which position? 

A. Sitting  C. Genupectoral 
B. Standing  D. Trendelenburg 
 
34. Which of the following parameters should be checked when assessing respirations? 

A. Rate  C. Symmetry 
B. Rhythm  D. All of the above 
 
35. Which of the following patients is at greatest risk for developing pressure ulcers? 

A. An alert, chronic arthritic patient treated with steroids and aspirin 

B. An 88-year old incontinent patient with gastric cancer who is confined to his bed at home 
C. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula 
D. A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of
bed. 
 
36. An additional Vitamin C is required during all of the following periods except in which of the following? 

A. Infancy  C. Childhood 
B. Young adulthood  D. Pregnancy 
 
37. Which of the following nursing interventions promotes patient safety? 

A. Asses the patient’s ability to ambulate and transfer from a bed to a chair 
B. Demonstrate the signal system to the patient 
C. Check to see that the patient is wearing his identification band 
D. All of the above 
 
38. Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which
of the following conclusions? 

A. Side rails are ineffective 

B. Side rails should not be used 
C. Side rails are a deterrent that prevent a patient from falling out of bed. 
D. Side rails are a reminder to a patient not to get out of bed 
 
39. The most common injury among elderly persons is which of the following?

A. Atheroscleotic changes in the blood vessels 

B. Increased incidence of gallbladder disease 
C. Urinary Tract Infection 
D. Hip fracture 

4|Page Comprhensive exam RLE

  
40.The very first thing a nurse will assess when doing a head to toe examination is which of the following? 
 
A. head  C. ears  
B. eyes  D. general appearance 
 
41. When assessing a client’s physical appearance, a nurse will note which of the following? (select all that apply) 

A. clients age  C. client’s speech 

B. client’s gender  D. Palpate maxillary and facial sinuses 
 
42. When it comes to assessing the client’s physical appearance which of the following lists what a nurse would
look for? 

A. gender,age, ethnicity, dress, speech, level of conciousness 

B. religion,age, ethnicity, dress, speech, level of conciousness 
C. age, gender, ethnicity, dress, diet, speech, level of conciousness 
D. gender,age, ethnicity, marital status, dress, speech, level of consciousness 

43. Nurse Elizabeth has her client come in and looks at the way he is dressed what is she looking for? 

A. that her client has a good fashion sense 

B. that her client feels comfortable with her 
C. that her client’s dress is appropriate for his gender, age, and time of the year 
D. that her client’s dress is appropriate for his gender, societal status, and marital status 
 
44. What could the nurse assess based solely on the way the client walks into the room? 

A. gender and age  C. signs of illness, well nourished 

B. dress and signs of illness  D. gait and posture 
 
45. Nurse Dave has his client come in and proceeds to ask him his name, his date of birth, if he knows where he is,
and what day of the week it is. In doing this Dave is testing which of the following?
 
A. intelligence coeffient  C. social and cognitive skills 
B. level of conciousness  D. physical and mental development 
 
46. A nurse should assess a client’s level of consciousness to ensure they are oriented how? (select all that apply) 

A. oriented to time 
B. oriented to place 
C. oriented to person 
D. understands and responds to questions appropriately 
E. all of the above 
 
47. Which of the following would be considered normal observations regarding a client’s speech? Select all that
applies

A. that it is rushed and garbbled 

B. it is articulate and easy to understand 
C. it is articulate but spoken in a language other than English 
D. it is hapazard and sing-song like 
 
48. Nurse George has just assessed his client’s articulation, language, and other aspects of his speech. In doing this
which cranial nerve has he just assessed? 

A. cranial nerves 4 and 5  C. cranial nerves 9 and 12 

B. cranial nerves 6 and 12  D. cranial nerves 10 and 12 
 
49. What is the very first thing a nurse should do at the beginning of a head to toe assessment? 

A. state the clients name and age 

B. introduce yourself to the client 
C. have the client walk in and take a seat 

5|Page Comprhensive exam RLE

 D. state the client’s gender and ethnicity 
 
50. Which of the following would be considered normal nursing observations regarding general appearance? 

A. client is well groomed 
B. dress is appropriate for the season 
C. no visible signs of illness noted 
D. client appears well-nourished 
E. all of the above 
 

51. Which of the following would a nurse include in the general appearance portion of the assessment as normal
observations regarding the client’s greeting? 

A. client greets with a smile, not a frown 

B. client frowns brows and blinks erratically 
C. client is making eye contact 
D. client does not appear to be in distress 
E. facial expression cannot be identified 
 
52. Which to things would a nurse state they are going to do at the end of the general appearance portion of
the head-to-toe assessment? 

A. record vitals and emotions 

B. record vision and pain level 
C. record vitals and pain level 
D. record level of consciousness and general appearance 

 
53. If a client reports they are in pain what would a nurse do first? 

A. call the doctor immediately  C. assess client’s pain on scale 0 to 10 

B. document it immediately  D. assess client’s pain on scale 0 to 20 
 
54. A nurse conducting an assessment on a clients head would do what first? 

A. inspect and palpate hair 

B. inspect and palpate scalp 
C. look at patient’s prior medical history 
D. inspect and palpate sinuses to control spread of germs 
 
55. Before a nurse palpates a person’s scalp what is the very first action they should take? 

A. preform hand hygiene 
B. ask the client how their hair feels 
C. go ahead and inspect the client’s scalp 
D. go right ahead and palpate client’s scalp with bare hands. 
 
56. When it comes to hand hygiene and your client you should always do what? 

A. inform client you have washed your hands  C. wash hands in patient’s presence 

B. wear gloves so they do not worry  D. wash hands outside patient’s room

57. Nurse Rain is assessing his client’s scalp after putting on clean gloves he begins to palpate the hair which of the
following things would he be looking for? (select all that apply) 

A. hair color 
B. hair texture 
C. hair distribution 
D. Lice, alopecia 
E. carcinomas of the skin 
 
58. Which of the following would not be considered normal findings when assessing the scalp and hair of a middle-
aged man? Select all that applies 

6|Page Comprhensive exam RLE

 A. thinning hair 
B. receding hair line 
C. alopecia 
D. Lice 
 

59. Nurse Joan asks her client Freedy to clench his jaw as she continues to palpate his head. When she asks him to
do this what is Nurse Joan most likely trying to palpate? 

A. Freedy’s temporal artery  C. Freedy’s submandibular joint 

B. Freedy’s temporomandibular joint  D. Freedy’s submental joint 

60. A nurse palpates a client’s temporomandibular joint, then asks him to clench his teeth. In doing this the nurse is
assessing which cranial nerve?
 
A. cranial nerve 5  C. cranial nerve 3 
B. cranial nerve 7  D. cranial nerve 4 

61. A nurse doing her assessment proceeds to palpate a client’s frontal and maxillary sinuses. What should she
make sure she checks for? 

A. swelling  C. tenderness 
B. lesions  D. tactile signs of carcinoma 

62. Nurse Bill when doing his head-to-toe assessment on his client asks him to smile, frown, wrinkle forehead, puff
cheeks, raise eyebrows, close eye lids In doing this the nurse is assessing which cranial nerve? 

A. cranial nerve 5  C. cranial nerve 3 

B. cranial nerve 7  D. cranial nerve 4 

63. When doing an assessment on a client’s eyes the very first thing that a nurse should look at is? 

A. eyes internal structures  C. the pupil’s reactivity to light 

B. color of the iris  D. eyes external structures 

64. The three things a nurse needs to check for when doing an examination on the eyes regarding the external
structures is which of the following?

A. eyelash distribution, coloring, drainage 

B. eyelash texture, shape of eyes, redness 
C. Shape of eyes, pupil’s reactivity, iris’s color 
D. drainage, possible tumors, irritatin

65. Nurse Fred when examining his client’s eyes takes a light cotton ball and gently brushes it across his client’s
eyes to elicit a blink this is known as which of the following?

A. consensual light reflex test  C. red light reflex 

B. corneal reflex test  D. PERRLA 

66. When a nurse preforms a corneal reflex test which cranial nerve are they assessing?
 
A. cranial nerve 5  C. cranial nerve 3 
B. cranial nerve 7  D. cranial nerve 4 
 
67. When preforming an assessment on a patient’s eyes what might the nurse use the ophthalmoscope for? 

A. consensual light reflex test  C. red light reflex 

B. corneal reflex test  D. PERRLA 

68. Which of the following would be considered a normal observation regarding a client’s red-light reflex? 

A. red light reflex is displaced  C. drainage is visible 

B. red light reflex is intact  D. red light reflex is absent 

7|Page Comprhensive exam RLE

  
69. A nurse would use a Snellen chart to assess which of the following?

A. hearing  C. vision 
B. consensual light reflex  D. bone conduction 
 
70. A nurse doing a head-to-toe assessment has his client stand 20 feet away from a chart and while blocking one
eye asks him to read the smallest line, he can then do the same thing in the other eye. The nurse is most likely
assessing his client’s what? 

A. hearing  C. vision 
B. consensual light reflex  D. bone conduction 
 
71. When a nurse does an assessment on a client’s vision using either the Snelling chart or newspaper finger-wiggle
test which cranial nerve are they assessing? 

A. cranial nerve 5  C. cranial nerve 3 

B. cranial nerve 7  D. cranial nerve 2 

72. A nurse performing a visual acuity of a patient would most likely have a client read a newspaper or wiggle their
finger out to the side to test which of the following?

A. spatial awareness  C. peripheral vision 

B. vision  D. Farsightedness 
 
73. Which of the following is a recommendation of the World Health Organization (WHO)?  Perform hand
hygiene: 

A. Before and after having direct contact with patients 

B. With alcohol-based hand rub if hands are not visibly soiled 
C. After removing gloves 
D. Before handling an invasive device (regardless of whether or not gloves are used) 
E. All are WHO recommendations 
 
74. You do not need to worry about washing your hands if you wear gloves when you provide care for your client 

A. True  B. False 
 
75. You should wash your hands before & after you wear your gloves.

A. True  B. False 
 
76. When bathing a patient’s extremities, the nurse should use long, firm strokes from the distal to the proximal
areas. This technique does which of the following?

A. Provides an opportunity for skin assessment 

B. Avoids undue strain on the nurse 
C. Increases venous blood return 
D. Causes vasoconstriction and increases circulation 

 
77. Blood pressure measurement is an important part of the patient’s data base. It is which of the following?

A. The basis of the nursing diagnosis 

B. Objective data 
C. An indicator of the patient’s well being 
D. Subjective data 
 
78. Which factor is least significant during assessment when gathering information about cultural practices? 

A.  Language, timing 

8|Page Comprhensive exam RLE

 B. Touch, eye contact 
C. Biocultural needs 
D. Pain perception, management expectations 
 
79. Transcultural nursing implies which of the following? 

A. Using a comparative study of cultures to understand similarities and differences across human
groups to provide specific individualized care that is culturally appropriate 
B. Working in another culture to practice nursing within their limitations 
C. Combining all cultural beliefs into a practice that is a nonthreatening approach to minimize cultural barriers
for all clients’ equality of care 
D. Ignoring all cultural differences to provide the best generalized care to all clients. 
 
80. What should the nurse do when planning nursing care for a client with a different cultural background? The
nurse should do which of the following?

A. Allow the family to provide care during the hospital stay so no rituals or customs are broken 
B. Identify how these cultural variables affect the health problem 
C. Speak slowly and show pictures to make sure the client always understands 
D. Explain how the client must adapt to hospital routines to be effectively cared for while in the hospital 
 
81. Which activity would not be expected by the nurse to meet the cultural needs of the client? 

A. Promote and support attitudes, behaviors, knowledge, and skills to respectfully meet client’s cultural needs
despite the nurse’s own beliefs and practices 
B. Ensure that the interpreter understands not only the language of the client but feelings and attitudes behind
cultural practices to make sure an ethical balance can be achieved 
C. Develop structure and process for meeting cultural needs on a regular basis and means to avoid overlooking
these needs with clients 
D. Expect the family to keep an interpreter present at all times to assist in meeting the communication
needs all day and night while hospitalized.  
 
82. Ethical principles for professional nursing practice in a clinical setting are guided by the principles of conduct
that are written in which of the following?

A. American Nurses Association’s (ANA’s) Code of Ethics 

B. Nurse Practice Act (NPA) written by state legislation. 
C. Standards of care from experts in the practice field 
D. Good Samaritan laws for civil guidelines 
 
83. A client is hospitalized in the end stage of terminal cancer. His family members are sitting at his bedside. What
can the nurse do to best aid the family at this time? 

A. Limit the time visitors may stay so they do not become overwhelmed by the situation. 
B. Avoid telling family members about the client’s actual condition so they will not lose hope. 
C. Discourage spiritual practices because this will have little connection to the client at this time. 
D. Find simple and appropriate care activities for the family to perform. 
 
84. When caring for a terminally ill client, it is important for the nurse maintain the client’s dignity. This can be
facilitated by which of the following?

A. Spending time to let clients share their life experiences 

B. Decreasing emphasis on attending to the clients’ appearance because it only increases their fatigue 
C. Making decisions for clients so they do not have to make them 
D. Placing the client in a private room to always provide privacy 
 
85. A confused client who fell out of bed because side rails were not used is an example of which type of liability? 

A. Felony  C. Battery 
B. Assault  D. Negligence 
 
86. The nurse puts a restraint jacket on a client without the client’s permission and without the physician’s order.
The nurse may be guilty of which of the following?

9|Page Comprhensive exam RLE

 A. Assault  C. Invasion of privacy 
B. Battery  D. Neglect 
 
87. Which stage of development is most unstable and challenging regarding development of personal identity? 

A. Adolescence  C. Childhood 
B. Toddler hood  D. Infancy 

88. Which age group would have a tendency towards eating disorders?
 
A. Adolescence  C. Childhood 
B. Toddler hood  D. Infancy 
 
89. Who is the theorist who believed both early and later life experiences affect development. He then created the
psychosocial developmental stages - starting with Trust vs Mistrust and ending with Integrity vs. Despair. 

A. Skinner  C. Vygotsky 
B. Pavlov  D. Erikson 

90. Erikson believed new-bons feel conflict between which of the following? 

A. Identity and inferiority  C. Initiative vs guilt 

B. Trust vs mistrust  D. Identity vs role confusion 

91. How many levels are in the Hierarchy of Needs? 

A. 7  C. 9 
B. 5  D. 3 

92. Which of the following did Sigmund Freud develop? 

A. Hierarchy of needs  C. Developmental task of adolescence 

B. Eight stages of development  D. Psychosexual development theory 

93. Jean Piaget identified how many stages of children’s mental growth? 

A. 1  C. 3 
B. 2  D. 4 

94. What is the first stage of Piaget's cognitive development? 

A. Preoperational  C. Sensorimotor 
B. Formal operational  D. Concrete operational 

95. Human Development is the study of which of the following?

A. Bodies and stuff 

B. How and why people change and stay the same over time
C. Children
D. All of the above 

96. How many stages are in Erikson's Theory of Psychosocial Development? 

A. 3  C. 8 
B. 5  D. 50 

97.  Intimacy versus Isolation is best described in which of the following? 

 
A. Erikson’s stage (ages of 18 - 35 years) when people begin to explore relationships, moving to
commitment and long-term relationships; failure brings isolation  
B.  Kohlberg's highest level of moral development; occurs around age 13 or older 
C.  Love between two adults  
D.  Erikson’s stage which speaks to children beginning to have more social interactions and developing a
sense of pride in their accomplishments. 

10 | P a g e Comprhensive exam RLE

 
98. Basic physiological needs is best described in which of the following? 
 
A.  Developed by Glen Elder to study growth and development past childhood, throughout the entire lifetime.  
B.  In Maslow's hierarchy of needs, these are the basics of air, food, water, shelter, clothing, rest
and sleep. 
C. Needs of the mind; ways to stay creative and interested.  
D.  Maslow's third level of human needs 
 
99. Which of the following best describes Self-actualization? 
 
A. A part of Kohlberg's moral development theory; people are moral due to knowledge of punishment and
obedience. Children obey to avoid being caught and punished. 
B.  Learning to be self-involved and aggressive. 
C.   Learning through self-work, such as painting or journaling.  
D.  According to Maslow, this level of human development is achieved by people who are all they can
be; they have fulfilled their potential. 
 
100. Which of the following best defines theories? 
 
A. Promises that certain things will happen in certain ways.  
B.  Can never actually be used to guide our thinking and behavior; they are just for general knowledge.  
C. Answer all our questions about human development.  
D. Ways of thinking that help us understand, give us questions to ask and offer looks with
different views. 

Prepared By:

Heide Basing-a
Instructor

Virginia Helen A. Palome RN, LPT

College Coordinator

Buna B. Racal RN, MAN

Dean, College of Nursing

11 | P a g e Comprhensive exam RLE