FUNDAMENTALS OF NURSING – POST TEST

TEST PREP FOR NOVEMBER, 2022 NLE

1. The physician’s order reads, “Take orthostatic blood pressure measurement once daily.” The nurse would
measure the blood pressure on which of the following position?
a. Lying, standing, and then sitting c. Sitting, standing, and then lying
b. Lying, sitting, and then standing d. Standing, sitting, and then lying
2. Which of the following occurs when an adult has a pulse rate of 100 to 180 beats/ minute
a. Bradycardia c. Pulse applitude
b. Arrhythmia d. Tachycardia
3. Which of the following statements concerning respiratory rates is accurate
a. Infants and young children have a lower respiratory rate than adults
b. Healthy adults breathe about 12 to 20 times per minute
c. The respiratory rate decreases in response to the increase in metabolic rate during pyrexia
d. An increase in intracranial pressure stimulates the respiratory center and increase the respiratory rate
4. Which of the following statistics regarding blood pressure is accurate?
a. Blood pressure tends to be lower in prone or supine position than in seated or standing
b. Men are usually have a lower blood pressure than woman of the same age
c. Blood pressure decreases after eating
d. Blood pressure is usually higher on arising in the morning
5. Which of the following conditions tends to lower blood pressure?
a. High viscosity of the blood d. Strong pumping action of blood into the
b. Low blood volume arteries
c. Decrease elasticity of walls of arterioles
6. A weak and thread pulse found after the nurse palpates peripheral pulse may indicate which of the
following conditions?
a. Hypertension and circulatory overload
b. Decrease cardiac output
c. Impaired circulation
d. Inflammation of the vein
7. The most important and basic practice to prevent nosocomial infections is to:
a. Check that providers are up-to-date for their immunizations.
b. Ensure that providers wash their hands before and after giving a client care.
c. Mandate prophylactic antibiotics pre- operatively for clients.
d. Place all clients with inflammatory conditions in private rooms with negative pressure airflow.
8. A client has been admitted with symptoms of urinary burning and urgency. Which of the following
diagnostic test can the nurse anticipate will be ordered to diagnose the possibility of UTI?
a. Clean-catch midstream urine c. Intravenous pyelography (IVP)
b. Catheterized urine d. Random urines specimen
9. Random urines specimen. The nurse is assessing a postoperative patient for signs of haemorrhage.
Which adaptation is most
indicative of shock?
a. Hyperemia c. Irregular pulse
b. Hypotension d. Slow respiration
10. The nurse concludes that a patient is experiencing hyperthermia. Which assessment precipitated this
conclusion?
a. Mental confusion c. Decrease heart rate
b. Increase appetite d. Rectal temperature of 38.8 ◦C
11. The nurse is obtaining a patient’s blood pressure. Which information is most important for the nurse to
document?
a. Staff member who took the blood pressure
b. Patient’s tolerance to having the blood pressure taken
c. Position of the patient if the patient is not in a sitting position
d. Difference between the palpated and auscultated systolic readings
12. The nurse is assessing a patient’s bilateral pulses for symmetry. However the nurse should not assess
which pulse sites on both sides of the body at the same time?
a. Radial c. Femoral
b. Carotid d. Brachial
13. The nurse in the clinic must obtain the vital signs of each patient before each patient is assessed by the
practitioner. The nurse should obtain a temperature via the rectal route for a patient:
a. Who is a mouth breather d. Who cannot tolerate a semi-Fowler’s
b. With a history of vomiting position
c. With an intelligence of a seven-year-
old child
14. A patient with hypertension is given discharge instructions to take the blood pressure every day. The
nurse is evaluating a family member taking the patient’s blood pressure as part of the patient’s discharge
teaching plan. The nurse identifies that further teaching is necessary when the family member:
a. Place then diaphragm of the stethoscope over the brachial artery
b. Applies the center of the bladder of the cuff directly over an artery
c. Releases the valve on the manometer so that the gauge drops 10 mm Hg per heartbeat
d. Inserts the 2 earpieces of the stethoscope into the ears so that they tilt slightly forward
15. Which method of examination is being used to assess the temperature of a patient’s skin?
a. Palpation c. Percussion
b. Inspection d. Observation
16. Which assessment requires the nurse to assess the patient further?
a. 18-year-old woman with a pulse rate of 140 after riding 2 miles on an exercise bike
b. 50-year-old man with a BP of 112/60 upon awakening in the morning
c. 65-year-old man with a respiratory rate of 10
d. 40-year-old woman with a pulse of 88
17. The nurse must collect the following specimens. Which specimen collection does not require the use
of surgical aseptic
technique?
a. Stool for ova and parasite
b. Specimen for throat culture
c. Urine from a retention catheter
d. Exudate from a wound for culture and
sensitivite
 18. A client with possible diagnosis of colon cancer is scheduled for barium enema. The client’s teaching
includes:
a. Cleansing the intestines before the test
b. Drinking the barium solution 24 hours before the test
c. Drinking the barium solution in radiology just before the test
d. Eating a high protein meal 2 hours before the test
19. When assessing the client for pain, the nurse knows that the most accurate indicator of pain is the:
a. Client’s vital signs
b. Client’s diagnosis and type of surgery
c. Nurse’s observation of the client’s body language
d. Client’s own report of pain
20. Nurse Cassie is currently assigned in male medical ward. The following lab report concludes the
client’s fasting serum glucose level
are if the results are:
a. take the BP again in 2 minutes in the same arm
b. retake the BP again immediately in the same arm
c. use an electronic BP cuff on the other arm
d. check to see if the stethoscope is plugged
21. An elderly client with tuberculosis has difficulty coughing up secretions for a sputum specimen. Which
nursing action is
appropriate?
a. Spray the oropharynx with saline
b. Ask the client to drink a warm liquid
c. Force fluids for the next 8 hours
d. Raise the head of the bed to at least 45 degrees
22. A patient returns to his room following a lower GI series. When he is assessed by the nurse, he
complains of weakness.
Which of the following nursing diagnoses should receive priority in planning his care?
a. alteration in sensation-perception, gustatory
b. constipation, colonic
c. high risk for fluid-volume deficit
d. nutrition, less than body requirements
23. A client in a long term care facility complains of pain. The nurse collects data about the client’s pain.
The first step in pain assessment is
for the nurse to
a. have the client identify coping methods
b. get the description of the location and intensity of the pain
c. accept the client’s report of pain
d. determine the client’s status of pain
24. An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse
should be
a. Assess the severity and location of the pain
b. Obtain an order for an analgesic
c. Reassure him that this is not unusual for his age
d. Encourage him to increase his activity
25. An immobile patient experiences multiple urinary tract infections. Urinary bacteria are more likely to
grow when the urine is:
a. Alkaline b. Dilute
 c. Aromatic d. Acidic
26. Mr. Natan is experiencing some difficulty breathing. The nurse most appropriately assists him into the:
a. Dorsal recumbent position c. Fowler’s position
b. Lateral position d. Sim’s position
27. A 35-year-old female has been experiencing periods of gastric pain for 6 months. She is admitted to the
hospital for complete diagnostic
evaluation. She is to have a gastrointestinal series. The patient asks the nurse whether she will
experience pain during the gastrointestinal
series. Which of these statements by the nurse would be an accurate and appropriate answer to the
patient’s question?
A. “There will be no pain.”
B. “Don’t worry about the sensation you will have.”
C. “You may be uncomfortable during the procedure, but you should not experience pain.”
D. “Most patients state that they do not have pain.”
28. When a person has a fever or diaphoresis, the urine output will be which of the following?
a. decreased and highly concentrated
b. decreased and highly diluted
c. increased and concentrated
d. increased and diluted
29. Mr. Lorenzo, a hospitalized patient with diabetes mellitus, has developed a UTI. He is 80 years old and
has an indwelling catheter in place. Which factor is most likely to cause of his UTI?
A. The proximity of the male genitalia to C. A high glucose level
the rectum D. The indwelling urinary catheter
B. Decreased immunity
 30. The client is in respiratory distress. The doctor’s orders oxygen per mask and the client to be placed on
Fowler’s position. Which of the following is the most important for this client?
a. support and align the hands with the forearms
b. raise the head of the bed to allow for greater lung expansion
c. use handrolls
d. support the feet at right angles to the lower legs
31.The nurse has an order to obtain a urinalysis sample from a client with an indwelling urinary catheter.
The nurse would plan to avoid which of the following, which could contaminate the specimen?
a. Obtaining the specimen from the urinary drainage bag.
b. Clamping the tubing of the drainage bag.
c. Aspirating a sample from the port on the drainage bag.
d. Wiping the port with an alcohol swab before inserting the syringe.
32. The nurse describes the procedure for collecting a clean-catch urine for culture and sensitively to a male
patient. Which of the
following explanations, if made by the nurse, would be the MOST accurate?
a. "The urinary meatus is cleansed with an iodine solution and then a urinary drainage catheter is
inserted to obtain urine."
b. "You will be asked to empty your bladder one half hour before the test; you will then be asked to
void into a container."
c. "Before voiding, the urinary meatus is cleansed with an iodine solution and urine is voided into a
sterile container; the container must not touch the penis."
d. "You must void a few drops of urine, then stop; then void the remaining urine into a clean container
that should be immediately covered.”
33. A urine specimen for ketones should be removed from the client’s retention catheter by:
a. Disconnecting the catheter and draining it into a clean container
b. Cleansing the drainage valve and removing it from the catheter bag
c. Wiping the catheter with alcohol and draining into a sterile test tube
d. Using a sterile syringe to remove it from a clamped, cleaned catheter
34. The nurse instructs a female client to obtain a clean-catch urine sample for culture and sensitivity. Which
statement by the client indicates that the client understands the procedure for collecting the specimen?
a. "I should empty my bladder into a container so that the full amount of urine can be determined."
b. "A urine specimen will be obtained from a catheter."
c. "I need to cleanse the labia using cleansing towels, void into the toilet, and then void into the sterile
specimen container."
d. "I need to clean the labia with toilet paper and void into the sterile specimen container."
35. To collect a clean-catch midstream urine specimen from a female client, the nurse instructs her to clean
the area as the external urinary meatus with an antiseptic. How should the client do this?
a. By swabbing the labia minora from front to back
b. By cleaning the labia minora from back to front
c. By cleaning the labia majora from back to front
d. By swabbing the entire perineal area
36. The nurse is preparing to collect a 24-hour urine specimen from the client. Which of the following is an
inaccurate action when
collecting the specimen?
a. Asking the client to void, saving the specimen, and noting the start time.
b. To allow drainage to occur.
c. To allow the urine to collect in the tubing.
d. To have the client check the tubing for urine.
37. A client has an order for a stool culture. The nurse avoids doing which of the following when carrying out
this order?
a. Wearing sterile gloves
b. Using a sterile container
c. Refrigerating the specimen
 d. Sending specimen directly to the laboratory
38. When caring for a client after a cardiac catheterization, it is most important that the nurse:
a. Help client to ambulate
b. Administer oxygen
c. Check the ECG every 30 minutes
d. Check the pulse distal to the insertion site
39. A 44-year-old man returns to his room following a cardiac catheterization. Which of the following
assessments, if made by the nurse,
would justify calling the physician?
a. Pain at the site of the catheter insertion
b. Absence of the pulse distal to the catheter insertion site
c. Drainage on the dressing covering the catheter insertion site
d. Redness at the catheter insertion site
40. Which of the following techniques is considered a non-invasive diagnostic method to evaluate cardiac
changes?
a. Cardiac biopsy c. Magnetic resonance imaging (MRI)
b. Cardiac catheterization d. Pericardiocentesis
41. Before a transesophageal echocardiogram (TEE), a client is given an oral topical anesthetic spray. Upon
return from the procedure, the
nurse observes that the client has no active gag reflex. In response, the nurse should:
a. Insert an oral airway. c. Position the client on his side.
b. Withhold food and fluids. d. Introduce a nasogastric (NG) tube.
42. After bronchoscopy, the client must receive nothing by mouth until gag reflex returns. What is the best
way to assess the return of the
gag reflex?
a. Instruct the client to cough c. Tickle the uvula with a tongue blade
b. Ask the client to extend the tongue d. Observe while the swallow sips of water
43. A nurse is caring for a client after a bronchoscopy and biopsy. Which of the following signs if noted in the
client should be reported
immediately to the physician?
a. Blood streaked sputum c. Hematuria
b. Dry cough d. Bronchospasm
44. A client has just undergone bronchoscopy. Which nursing assessment is most important at this time?
a. Level of consciousness (LOC) c. Personality changes
b. Memory d. Intellectual ability
45. A client has just returned to her room following bronchoscopic examination and asks for a cup of tea.
Before complying with the
request the nurse should consider which of the following?
a. Did the client receive an analgesic prior to the procedure?
b. Was the client given a local anesthetic during the procedure?
c. Is the client able to signal for assistance?
d. Should the client be encouraged to drink fluids?
46. A client has a bronchoscopy in ambulatory surgery. To prevent laryngeal edema, the nurse should:
a. Place ice chips in the client’s mouth
b. Offer the client liberal amount of fluid
c. Keep the client in the semi-Fowler’s position
d. Tell the client to suck on medicated lozenges
47. A client is scheduled for chest x-ray to rule our pneumonia. Which of the following is appropriate for this
procedure?
a. fasting for 4 hours prior to procedure
b. consent form for an invasive procedure
c. Benadryl 25 mg IM prior to the procedure
d. no special preparation is required
 48. A client who is human immunodeficiency virus positive has had a Mantoux skin test. The nurse notes a 7
mm area of induration at the
site of the skin test. The nurse interprets the result as:
a. Positive c. Inconclusive
b. Negative d. The need to repeat testing
49. A post-exposure to tubercle bacilli may be determined by carrying out PPD. What result would confirm
this finding?
a. Wheal formation after 30 minutes c. Redness 2 mm in diameter
b. Induration of more than 10 mm d. Rash that develops after one hour
50. A thoracentesis is performed. Following the procedure, it is most important for the nurse to observe the
client for:
a. Periods of confusion
b. Expectoration of blood
c. Increased breath sound
d. Decreased respiratory rate
51. After the nurse explains the procedure for performing an upper GI x-ray, which statement indicates that
the client understands the
test?
a. A flexible tube will be inserted into the stomach.
b. Dye will be infused into my vein before the test.
c. My body will be placed within an imaging chamber.
d. I will have to swallow a large volume of barium.
52. The client has just return from the x-ray department after undergoing an upper GI series. Which of the
following interventions would be
appropriate at the time?
a. keep him NPO until gag reflex return
b. administer a cleansing enema
c. monitor the vital sign every 15 minutes for 1 hour or until stable
d. give him laxative as ordered to facilitate defecation
53. Suspected of intestinal cancer, Mr Jose is scheduled for an upper GI series with use of barium. After the
procedure, what medications
will the nurse expect to be ordered?
a. analgesics c. antispasmodics
b. laxatives d. antihistamines
54. A client asks the nurse if he will feel a lot of pain during a sigmoidoscopy. The best nursing response is:
a. “No, you should only feel a small amount of pain, since the area is anesthetized.”
b. “NO, the test does not cause pain.”
c. “You will feel slightly uncomfortable and will have the urge to defecate since when the instrument is
inserted.”
d. This test is very painful.”
55. A barium enema should be done before an UGIS because which of the following?
a. Retained barium may cloud the colon
b. Barium can cause lower gastrointestinal bleeding
c. The physician’s order are in that sequence
d. Barium absorbed readily in the lower intestine
56. Mr Vargas is nervous about a colonoscopy scheduled for tomorrow. The nurse described the test by
explaining that it allows which of
the following?
a. Visual examination of the large intestine
b. Visual examination of the esophagus and stomach
c. Radiographic examination of the large intestine
d. Fluoroscopic examination of the small bowel
57. A physician orders a body magnetic resonance imaging (MRI) for diagnostic purposes. It would be most
important for the nurse to tell the client that the procedure
 a. Takes 15 to 30 minutes c. Is painless, except for the discomfort of lying
b. Involve injection of a contrast dye still
d. Uses only small amounts of radiation
58. To determine the extent of CVA, Mr Jose underwent cerebral angiography. After this procedure, the most
essential responsibility of the nurse is to
a. administer aspirin for pain c. monitor urine output
b. massage the punctured site d. assess the punctured site for bleeding
59. The priority nursing action for a patient who underwent intravenous pyelography (IVP) is:
a. Increase fluid intake c. NPO 4 hours after procedure
b. Place patient in semi-fowler’s position d. Ambulate as soon as possible
60. Prior to the patient undergoing a scheduled intravenous pyelography (IVP), the nurse reviews the patient’s
health history. It would be
important for the nurse to obtain the answer to which of the following questions?
a. Does the patient have difficulty voiding?
b. Does the patient have any allergies to shellfish or iodine?
c. Does the patient have a history of constipation?
d. Does the patient have frequent headaches?
61. During the immediate postoperative period, the nurse should give the highest priority to:
a. Observing for hemorrhage c. Recording the intake and output
b. Maintaining a patent airway d. Checking the vital signs every 15 minutes
62. When a new procedure is needed the nurse may obtain information from the agency’s:
a. Procedure manual
b. Infection control department
c. In-service director
d. Nursing supervisor
63. Barium salts in GI series and barium enemas serves to:
a. Fluoresce and thus illuminate the alimentary tract
b. Give off visible light and illuminates the alimentary tract
c. Dye the alimentary tract and thus provide for color contrast
d. Absorb x-ray and thus give contrast to the soft tissues of the alimentary tract
64. The client is shot in the chest during a holdup and is transported to the hospital. In the emergency
department chest tubes are inserted, one in
the second intercostals space and one in the base of the lung. The nurse understands that the tube in the
second intercostals space will:
a. Remove the air that is present in the intraplueral space
b. Drain serosnguineous fluid from the intraplueral compartment
c. Provide access for the instillation of medication into the pleural space
d. Permit the development of positive pressure between the layers of the pleura
65. An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver
a precise oxygen concentration.
Which of the following types of oxygen delivery system would the nurse anticipate to be prescribed?
a. Venturi mask
b. Aerosol mask
c. Face tent
d. Tacheostomy collar
66. Which of the following is the primary nursing intervention necessary for all patients with a Foley catheter
in place?
a. Maintain the drainage tubing and collection bag level with the patient’s bladder
b. Irrigate the patient with 1% Neosporin solution three times daily
c. Clamp the catheter for 1 hour to maintain the bladder elasticity
d. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity.
67 . Proving perineal care to a patient requires which of the following?
a. Using clean portion of washcloth for each stroke
b. Moving from most contaminated to least contaminated
c. Using sterile gloves
 d. Leaving the foreskin undisturbed in uncircumcised male
68. The single most important means of preventing the spread of infection is:
a. Wearing disposable gloves
b. Handwashing
c. Avoiding persons with known infections
d. Wearing a face mask
69. The priority nursing diagnosis for a client with impaired skin integrity is which of the following:
a. Risk for infection: Inadequate primary defences
b. Impaired physical mobility
c. Anxiety
d. Risk for infection: inadequate secondary defenses
70. During the removal of a fecal impaction, which of the following could occur because of vagal stimulation?
a. Bradycardia
b. Atelectasis
c. Tachycardia
d. Cardiac tamponade