1. Which of the following is most likely to yield accurate information about the quality of
patient’s pain?
A.“Tell me, what your pain feels like.” CORRECT ANSWER
B. “Would you describe your pain as radiating? Acute or sharp?” WRONG KASI NAG
SASUGGEST
C. Tell, how would you rate your pain in a scale to 1 to 5” SEVERITY
D. “What events seemed to increase your pain?” PROVOKED

 
2.  The nurse is caring for a group of adult patients who require pain management. It is
most important for the nurse to remember:

A. to use medication only as a last resort after trying to distract the patient
B. that medicating a patient with chronic pain is a lower priority than medicating a patient with
acute pain.
C. that medication should be given based on the patient’s perception of pain.
D. to wait for 15 minutes after a patient’s request for pain medication to be sure the pain is real.

 
3.  Which of the following most appropriately describe pain sensations that has periods
of remission and exacerbation?
a. Acute
c. Chronic
b. Intractable
d. Neuropathic

 
4. You are obtaining a history of  Jessie D. who is admitted with  acute chest pain.
Which question will be most helpful for you to ask?

a. Why do you think you had a heart attack?

b. Do you need anything now?
c. What were you doing when the pain started?
d. Has anyone in your family been sick lately?

 
5. Which of the following techniques is considered the best way to determine whether a
nasogastric tube is positioned in the stomach?

A. Aspirating with a syringe and checking pH of gastric contents 

B. Irrigating with normal saline and observing for the return of the solution
C. Placing the tube’s free end in water and observing for air bubbles
D. Instilling air and auscultating over the epigastric area for the presence of the tube
 
6. The health care provider order reads "aspirate nasogastric feeding (NG) tubes every
4 hours and check pH of aspirate." The pH of the aspirate is 10 (mataas). Which action
should the nurse take?

a. Apply intermittent suction to the feeding tube

b. Hold the tube feeding and notify the provider
c. Administer the tube feeding as scheduled
d. Irrigate the tube with diet cola soda

 
7. What position will the nurse recommend to the patient during NGT insertion?

a. Semi-Fowler’s Position
b. Trendelenberg
c. High Fowler’s position
d. Left sims lateral

 
8. An appropriate technique for nasogastric tube insertion is for the nurse to:
A. Position the client supine
B. Ice the plastic tube
C. Advance the tube while the client swallows
D. Measure the tube length from the nose to the sternum
 
 
9. The physician orders nasogastric tube insertion to irrigate a client’s stomach. Which
of the following insertion techniques would most likely make it more difficult for the
nurse to insert the tube?

A. Lubricating the tube with water-soluble lubricant

B. Asking the client to swallow while the tube is advanced to the stomach
C. Sitting the client upright in a Fowler’s position
D. Having the client tilt the head toward the chest while inserting the tube into the nose.
 
 
10. What position will the nurse recommend to the patient during TPN administration?

a. High Fowler’s position

b. Trendelenberg
c. Semi-Fowler’s Position
d. Left sims lateral
 
11. A client who requires a central vein access for parenteral nutrition is to receive a
solution with:

A. Fat emulsion
B. 5% dextrose
 C. Amino acids
D. 10% dextrose

 
12. . A client with congestive heart failure is newly admitted to home health care. The
nurse discovers that the client has not been following the prescribed diet. What would
be the most appropriate nursing action?

a. Discharge the client from home health care related to noncompliance

b. Notify the health care provider of the client's failure to follow prescribed diet
c. Discuss diet with the client to learn the reasons for not following the diet
 d. Make a referral to Meals-on-Wheels
 
13. The nurse is caring for a client who has been admitted to the hospital with a
diagnosis of malnutrition. The nurse most effectively monitors the client’s status by
which measure?

A. Intake measurement
B. Calorie counts
C. Skinfold measurements
D. Daily weights
14. The most concentrated source of energy in the body is:

a. Protein
b. Carbohydrates
c. Fat
d. Macro minerals

15. A nurse is preparing to feed the client with mild dysphagia. The nurse would do
which of the following to assist the client with swallowing?

a. Place the food on the tip of the client’s tongue

b. Provide foods that have a soft consistency 
c. Use water to help the client swallow food in the mouth
Place the equivalent of 30 ml of food on the fork

 
16. A postoperative client is on a clear liquid diet, what of the following are allowed on a
clear liquid diet?

A. Ice cream, butter, yoghurt, vegetable juices 

B. Mashed potatoes, fish, bananas, vegetable juices
C. Gelatin, hard candy, tea, popsicles
D. Milk, gelatin, canned fruits, bread

 
17. You attached a pulse oximeter to the client. You know that the purpose is to:

A. Determine if the client’s hemoglobin is low and if he needs blood transfusion

B. Check level of client’s tissue perfusion
C. Measure the efficacy of the client’s anti-hypertensive medications
D. Detect oxygen saturation of arterial blood before a symptoms of hypoxemia develops  
18. While the client has pulse oximeter on his fingertip, you notice that the sunlight is
shinning on the area where the oximeter is : Your action will be to:

A. Set and turn on the alarm of the oximeter

B. Do nothing since there is no identified problem
C. Cover the fingertip sensor with a towel or bedsheet
D. Change the location of the sensor every four hours

 19. A nurse informs a client that the alarm on the pulse oximeter will not sound when:

A. The client moves the probe

B. The probe falls off –mag aalarm
C. The SpO2 falls below the set limit- mag aalarm
D. The display reaches full strength during each cardiac cycle

 
20. For a client with CAL, a nurse anticipates the use of oxygen equipment?

A. Face tent
B. Face mask
C. Nasal cannula
D. Nonbreathing mask
 
21. Assessment of the proper functioning of an oxygen device includes:

A. No mist in the face tent

B. The reservoir of the rebreathing mask collapsing on inhalation
C. A flow rate between 1 and 6L/min for the nasal cannula
 D. The nasal cannula positioned below the nares
 
22. Nurse Nikka is teaching a client on how to properly use an incentive spirometry to a
client. Teaching is effective if which of the following sequence is observed;

A. The client holds the spirometry in upright position, exhales normally, seal the lips
tightly around the mouthpiece, takes a slow deep breath and hold breath for 2 seconds to
keep the balls elevated.
B. Exhales normally, hold the spirometer upright, seals the mouthpiece, takes a fast shallow
breath and holds breath for 5 seconds to keep the balls elevated.
C. Holding the spirometer above the head, seal the mouthpiece, and exhaling slowly for 3
seconds
 D. Holding the spirometer above the head, seal the mouthpiece around the lips, and holding
breath for a while.
 
23. Complications associated with a tracheostomy tube include:

A. Decreased cardiac output

B. Damage to the laryngeal nerve
C. Pneumothorax
D. Respiratory distress syndrome

24. After suctioning a client’s tracheostomy tube (2-3 mins interval), the nurse waits a
few minutes before suctioning again. The nurse would use intermittent suction primarily
to help prevent:

A. Stimulating the client’s cough reflex

B. Depriving the client of sufficient oxygen supply
 C. Dislocating the tracheostomy rube
D. Obstructing the suctioning catheter with secretions

25. The following nursing interventions are appropriate for a nursing diagnosis of
Ineffective Airway Clearance related to obesity EXCEPT?
A. Diversional Activity
B. Start weight reduction
C. Place patient in high Fowler’s position
D. Have client cough & deep breathe every 2 hours while wake

26. The primary reason in teaching pursed-lip breathing to persons with emphysema is
to help:
A. Promote oxygen intake
B. Strengthen the diaphragm
C. Strengthen the intercostals muscles
D. Promote carbon dioxide elimination
 
 
27. The nurse doing the health teaching to a client for testing feces for occult blood
informs the client about what can produce false positive results: What should the nurse
emphasize?

a. If you have eaten red meat or raw radishes and melons, in the last couple of days, the
test may be positive and it may be inaccurate.
 b. If you have taken more then 250 mg of vitamin C, it may produce a reading that is too high
but is inaccurate.
c. If you have recently eaten any colored vegetables, it may color the stool and produce an
inaccurate test result.
d. If you have been drinking tea, the result might be elevated.

 
28. The nurse finds a container with the client’s urine specimen sitting on a counter in
the bathroom. The client states that the specimen has been sitting in the bathroom at
least 2 hours. What would be the nurse’s most appropriate action?

A. Discard the urine and obtain a new specimen

 B. Send the urine to the laboratory as quickly as possible
C. Add fresh urine to the collected specimen and send the specimen to the laboratory
D. Place the specimen in the refrigerator until it can be transported to the laboratory

 
29.   After IVP a renal stone was confirmed, a left nephrectomy was done. Her post
operative care includes daily urine   specimen to be sent to the laboratory. Imelda has a
foley catheter to a urinary drainage system. How will you collect the urine specimen?

a. Remove urine from drainage tube with sterile needle and syringe and empty urine from
the syringe into the specimen container
b. Empty a sample urine from the collecting bag into the specimen container
c. Disconnect the drainage tube from the indwelling catheter and allow urine to flow from
catheter into the specimen container.
d. Disconnect the drainage the from the collecting bag and allow the urine to flow from the
catheter into the specimen container.

30.  The nurse is reviewing with a client how to collect a clean catch urine specimen.
Which sequence is appropriate teaching?

a. void a little, clean the meatus, then collect specimen

b. clean the meatus, begin voiding, then catch urine stream
 
c. clean the meatus, then urinate into container
d. void continuously and catch some of the urine

 
31. A nurse has an order to obtain 24-hour urine collection on a client with renal
disorder. The nurse avoids which of the following to ensure proper collection of the 24-
hour urine specimen?

a. have the client void at the start time, and place he specimen in the container
b. discard the first voiding, and save all subsequent voiding during 24-hour time period
c. place the container on ice or refrigerator
d. have the client void at the end time, and place the specimen in a container

32. A nurse is to collect a sputum specimen for culture and sensitivity from a client.
Which action should the nurse take first?

a. Assist with oral hygiene

b. Ask client to cough sputum into container
c. Have the client take several deep breaths
d. Provide an appropriate specimen container

 
33. The physician orders a urine culture and sensitivity for a 36-year old patient with an
indwelling Foley catheter. Which of the following action by the nurse is best?

A. The nurse clamps the catheter tubing below the level of the port for 1 hour.
B. The nurse removes 20ml from the catheter bag and places it in a sterile container.
C. The nurse separates the catheter from the tubing and allows 30ml of urine to drain into a
sterile cup.
D. The nurse clamps the catheter just below the insertion site for 20 minutes-dapat below the
port

34. The nurse collects a urine specimen for routine urinalysis from a client. She is aware
that:
A. A sterile specimen is required
B. Standing at room temperature for a prolonged period may alter the urine chemistry
C. The external meatus should be cleaned with antiseptic soap and water before voiding.
D. A clean-catch, midstream specimen is required
 
35. What is the priority of care after the urinary catheter is removed?
A. Encourage the client to eliminate fluid intake.
B. Document size of catheter and client’s tolerance of procedure.
C. Evaluate the client for normal voiding.
 D. Documentation of client’s teaching
 
36. During an assessment, the nurse expects that the average daily urinary output for
the adult client will be:

A. 500 to 1000ml
B. 700 to 1500ml
C. 1200 to 1500ml
 D. 2000 to 3000ml
 
37. Nurse Jane evaluates a client with diagnosis of dehydration to have which of the
following specific gravity reading?

A. 1.000
 B. 1.017
C. 1.023
D. 1.035

 38. A client has a tracheostomy tube. The nurse knows that the obturator is kept at the
client’s bedside because:

A. The obturator is kept at the client’s bedside in case the tube becomes dislodged and
needs to be reinserted.
B. The obturator is a guide in inserting the tube.
C. The obturator, after insertion, will be kept by the client.
D. The obturator will be used to make an opening for the tube

 
39.  The nurse is cleaning the incision site and tube flange of a client with tracheostomy.
A sterile applicator soaked in what solution is used in removing crusty secretions?

A. Isopropyl alcohol
B. Hydrogen peroxide (Full strength)
C. Hydrogen peroxide ( half-strength solution mixed with sterile normal saline)
 D. Ammonia
 
40. Tracheostomy tubes used among adults often have cuffs. This inflatable cuff
functions by:

A. Producing an airtight seal to prevent aspiration of oropharyngeal secretions and air

leakage
 B. Anchoring the tube in place
C. Distributing a low even pressure over the trachea
D. A guide for easy removal of the tracheostomy tube

 
41. Which of the following statements contains one of the basic rules to follow when
caring for a client with a chest tube and water-seal drainage system?

A. Ensure that the air vent on the water-seal drainage system is capped when the suction is off
B. Strip the chest and drainage tubes at least every 4 hours if excessive bleeding occurs
C. Ensure that the collection and suction bottles are at the client’s chest level at all times
D. Ensure that the collection and suction bottles are below the client’s chest level at all
times
 
 
42. While you were making endorsement, you found out the chest tube of a client was
disconnected. What would be your appropriate action?

A. Assit the client back to his bed and place him on the affected side
B. Cover the end of the chest tube with sterile gauze
C. Reconnect the tube to the chest tube system
D. Put the end of the chest tube into a cup of sterile normal saline

 
43. Dr. Black Daclis asked you to assist him with the removal of jeld’s chest tube. You
would instruct the client to:

A. A continuously breathe normally during the normal of the chest tube

B. Take a deep breath, exhale, and bear down
C. Exhale upon the actual removal of the tube
D. Hold breath until the chest tube is pulled out 
44. Which of the following measures should the nurse perform in relation to suctioning a
tracheostomy tube?
A. Apply suction while inserting the suction catheter into the tube
B. Change the tracheostomy tube after suctioning the client
 C. Select a suction catheter that approximates the diameter of the tracheostomy tube
D. Hyperoxygenate before suctioning the client

 45. Which method is the best for the nurse to evaluate the effectiveness of tracheal
suctioning?

A. Note subjective data such as, “My breathing is much improved now.”
B. Note objective findings such as decreased respiratory rate and pulse.
C. Consult with respiratory therapist to determine effectiveness.
D. Auscultate the chest for change or clearing in adventitious breath sounds.
46. Organize the following steps of suctioning in chronological order:

1. Put on sterile glove.

2. Lubricate catheter with normal saline

3. Apply suction for 5-10sec.

4. Explain procedure to client.

5. Wash hands thoroughly.

a. 54132
b. 45213
c. 54123
d. 45132
  47. A nurse is performing oropharyngeal suctioning on the unconscious client. Which
of the following actions is safe?

a. Insert the catheter approximately 20 cm while applying suction.

b. Allow 20 to 30 second intervals between each suction, and limit suctioning to a total of 15
minutes.
c. Gently rotate the catheter while applying suction.
d. Apply suction for 5 minutes while inserting and continue for another 5 seconds before
withdrawing.

 
48. Applying suction in the nasopharynx for too long may cause secretions to increase
or decrease, therefore the nurse should:

A. Allow 20 to 30 second intervals between each suction, limit suctioning to 5 minutes in

total
 B. Allow 2 to 3 minutes between suction when possible
C. Allow 5 minutes between each suction
D. Allow 1 to 2 minutes between each suction 

49. The correct pressure of the wall suction unit when suctioning a child patient is?

a. 95 – 100mg Hg
b. 50 – 95 mm Hg
c. 100 – 120mm Hg
d. 10 – 15mm Hg

 
50. A nurse suctioning a client through a tracheotomy tube. The nurse plans to apply
suction during the withdrawal of the catheter for a period of time no greater than? 

a. 10 seconds
b. 15 seconds
 
c. 20 seconds
d. 30 seconds