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Ans: A>Water is next to oxygen in the hierarchy of physiologic needs for survival
8.) Mrs. Sy, diagnosed with cancer of the breast,is scheduled to undergo
chemotherapy. Howshould the nurse deal with the topic of hair losswith client?
A.)Discuss about hair loss as it occurs
B.)Provide reading material about chemotherapy
C.)Acknowledge that hair loss may be a difficultside effect and explore the patients
feelingabout this
D.) Give the patient information about headscarf, hats or wigs
Ans: C>Focusing on the feelings of the client regardinghair loss is therapeutic.
Discussing about wigs,headscarf, and hats will be dealt with later
9.) The following are characteristics of basichuman needs EXCEPT:
A.) Priorities are uniform to all individuals
B.) Needs may be met in different ways
C.) Needs are interrelated
D.) Needs may be deferred
Ans: A>Priorities vary from individual to individual,according to stage of growth and
development,life situations and other factors
10.) Which of the following needs is consideredby the nurse when she implements
reverseisolation for the client with leukemia?
A.) Physiologic need
B.) Safety and security
C.) Love and belongingness
D.) Self esteem
Ans: B>The client with leukemia has low resistance toinfections. Protecting him
from infection byimplementing reverse or protective isolationtechnique meets his
need for safety and security
11.) Who among the following clients should beattended first by the nurse?
A) The client with cough and colds
B.) The client with pain on the chest
23.) Which of the following is most effectivepractice by caregivers and family, when
caringfor a client with low resistance to infection due tocancer.
A.) Allow two visitors only, at a time
B.) Wash hands frequently
C.) Wear masks in the clients room at all times
D.) Meticulous cleaning of the clients room
ANS: B> Handwashing is the most effective practice toprevent transfer of
microorganisms
24.) The primary why the faucet is considered ascontaminated is:
A.) It is located in unsterile area
B.) Many people are using it
C.) It is frequently used
D.) It is opened by dirty hands
ANS: D> The faucet is considered contaminatedprimarily because it is opened by
dirty hands
25.) The nurse enters the room of the client onairborne precautions due to
tuberculosis. Whichof the following are appropriate actions by thenurse?
1. She wears the mask, covering the nose andmouth
2. She washes her hands before and after removing gloves, after suctioning the
clientssecretions
3. She removes gloves and mask before leavingthe clients room
4. She discards contaminated suction catheter tip in a trash can found in the clients
room
A.) 1 and 2
B.) 1 and 3
C.) 1,2 and 3
D.) 1,2,3, and 4
ANS: D> 1,2,3, and 4 the mask should cover the noseand mouth snugly. The hands
should be washedbefore and after removing gloves. Gloves andmask should be
ANS: C > Discard the uncapped needle and syringe intoa leak-proof, puncture-proof
container. This is toprevent needle puncture of self. Universalprecaution: NEVER
RECAP NEEDLE
29.) When performing surgical hand scrub,which of the following nursing actions
ensureprevention of contamination?
1. Keep fingernails short, clean, without nailpolish
2. Open faucet with knee or foot contro
l3. Keep hands above elbows when washing andrinsing
4. Wear cap, mask, and shoe cover after handscrub
A.) 1,3,4
B.) 1,2,3
C.) 1,2,4
D.) 2,3,4
ANS: B> 1,2 and 3- Surgical hand scrub involves thefollowing actions: Keep
fingernails short, clean,without nail polish, open faucets with knee or foot control;
keep hands above elbows whenwashing and rinsing. Cap, mask, shoe cover should
be worn before hand scrub, to preventcontamination of the scrubbed hand
30.) When removing gloves, which of thefollowing is inappropriate nursing action?
A.) Wash gloved hands first
B.) Peel off gloves inside out
C.) Use glove-to-glove, skin-to-skin technique
D.) Remove mask and gown before removing gloves
ANS: D> When removing gloves, it is inappropriate to remove mask and gown first
before gloves. Appropriate nursing actions are: wash gloved hands first, peel off
gloves inside out; use glove-to-glove, skin-to-skin techniques. Remove gloves first,
followed by the mask, gown, cap, and shoe cover
31.) When pouring sterile solution, the nurse performs which of the following actions
correctly?
A.) Hold bottle 6 inches above receptacle on thesterile field
B.) Remove cap of bottle and place it with theunderside lid down on a flat surface
B.) Redness
C.) Swelling
D.) Pain
ANS: B> The first manifestation of inflammation isredness. This is due to increased
blood flow tothe area affected
35.) The primary cause of pain at the site of inflammation is:
A.) Release of bradykinin
B.) Injury to nerve endings
C.) Compression of local nerve endings byedema fluids
D.) Impaired circulations
ANS: C> The primary cause of pain at the site of inflammation is the compression of
local nerveendings by edema fluids
36.) The client is in stress because he was toldby the physician that he needs to
undergosurgery for removal of tumor in his stomach.Which of the following are
effects of activation of the sympatho-adreno-medullary response in theclient?
1. Constipation
2. Urinary frequency
3. Hypoglycemia
4. Increased BP
A.) 1 and 2
B.) 1 and 3
C.) 2 and 3
D.) 1 and 4
ANS: D>1 and 4- Effects of SAMR are due to release of norepinephrine and
epinephrine. These includeconstipation and increase BP
37.) The client is on NPO since midnight, aspreparation for blood test. Adrenocorticalresponse is activated. Which of the following isan expected response?A.) Low
BPB.) Decrease urine outputC.) Warm, flushed, dry skinD.) Low serum Na levels
ANS: B> Adreno-cortical response involves release of aldosterone that leads to
retention of sodiumand water. This results to decreased urineoutput38.) The client
fell from the stairs, and hadtwisted her ankle. The injury causedinflammation of the
ankle. The nursinginterventions for the inflamed ankle would leastlikely include
which of the following?A.) Elevate the ankle with pillow supportB.) Apply warm
compress over the ankle for thefirst seventy-two hoursC.) Apply compression
bandage over the ankleD.) Administer anti-inflammatory drug asordered by the
M.D.ANS: B> Application of warm compress over aninflamed body part for the first
72hours of injuryis not included in the nursing interventions for inflammation. Cold
compress is preferablyapplied during the first 72hours to causevasoconstriction and
prevent/reduce swelling.39.) Which of the following events characterizethe GAS
stage of Alarm?A.) Fight-or-flight response is activatedB.) The person regains
homeostasisC.) Adaptive mechanisms failD.) Levels of resistance are increasedANS:
A> During the GAS stage of Alarm, fight-or-flightresponse is activated40.) The client
is a 57 year old male who worksas a traffic officer. He is exposed to sunlightfrom
morning until afternoon. Which of thefollowing is considered as a physiologic
adaptivemode of the client?A.) He learns to interpret different traffic signsB.) He
sees to it that he wears his uniform asdignified as a policeman doesC.) He develops
dark skinD.) He learns the skill of giving traffic directionsto drivers and
pedestrianANS: C> Development of dark skin due to prolongedexposure to sunlight,
is an example of physiologic adaptive mode41.) The first protective cells launched
at the siteof tissue injury are the:A.) BasophilsB.) EosinophilsC.) MonocytesD.)
NeutrophilsANS: D> Neutrophils are the first protective cellslaunched at the site of
injury to performphagocytosisTherapeutic Communication42.) Therapeutic nursepatient relationship isdescribed as follows:1. It is based on friendship and mutual
interest2. It is a professional relationship3. It is focused on helping the patient
solveproblems and achieve health-related goals4. It is maintained only as long as
the patientrequires professional helpA.) 1,2,3B.) 1,2,4C.) 2,3,4D.) 1,3,4ANS: C>
2,3,4- Nurse-patient relationship is aprofessional relationship, it is a
helpingrelationship; it is maintained only as long as thepatient requires professional
help. It is not basedon friendship and mutual interest.43.) During the working phase
of therapeuticrelationship, the nurse performs the followingactivities EXCEPT:A.)
Reviews the clients medical recordB.) Establishes a contract with the
clientregarding expectations and responsibilitiesC.) Decides with the client on
mutually agreedupon goalsD.) Discusses with the client on time frame of the
relationshipANS: A> Reviewing the clients medical record is anactivity done during
the pre-interaction phase of the therapeutic nurse-patient relationship. All theother
choices are performed during the workingphase44.) The client has been scheduled
to undergosurgery for removal of tumor in her right breast.Which of the following
manifestations indicatethat she is experiencing mild anxiety?A.) She has increased
awareness of theenvironment detailsB.) She focuses on selected aspect of her
illnessC.) She experiences incongruence of thoughts,feelings and actionsD.) She
experiences random motor activityANS: A> Increased awareness of the
environmentdetails is a manifestation of mild anxiety45.) Which of the following
nursing interventionswould least likely be effective when dealing witha client with
aggressive behavior?A.) Approach in calm, direct manner B.) Provide opportunities
to express feelingsC.) Maintain eye contact with the clientD.) Isolate the client from
other clientsANS: D> Isolating the client who manifests aggressivebehavior would
be ineffective intervention. Thismay further agitate him. Providing outlets,
likephysical activities will be more effective, to divertthe clients energy46.) The
client express fear that God will not besupportive and might be punitive. He
isexperiencing which of the following responses?A.) Spiritual painB.) Spiritual anger
C.) Spiritual anxietyD.) Spiritual lossANS: C>Spiritual anxiety is expression of fear
that Godwill not be supportive and might be punitive47.) The client verbalizes, Im
nothing. Whichof the following is the most appropriate responseby the nurse?A.)
Are you suggesting that you feel worthless?B.) Of course, youre everything.C.)
Thats not true.D.) You should not feel that way.ANS: A
> Vit K is necessary for blood clotting. Prolongeddeficiency of this vitamin leads to
bleeding65.) The following are signs and symptoms of dehydration EXCEPT:A.)
Weight lossB.) Decreased urine outputC.) Elevated body temperatureD.) Elevated
BPANS: D> Elevated BP is not a sign of dehydration.A,B,C are signs and symptoms
of dehydration.66.) The client is experiencing hypokalemia.Which of the following
should be included in hisdiet?A.) BananaB.) MilkC.) CheeseD.) FishANS: A>
Hypokalemia is low serum potassium level.Providing potassium-rich foods like
banana andother fresh fruits is effective nursing interventionfor this condition67.)
During insertion of NGT, which position isbest assumed by the client?A.) LowFowlersB.) Semi-FowlersC.) High-FowlersD.) LateralANS: C> During insertion of
NGT, the patient is bestplaced in high-Fowlers position with neckhyperextended
until the tube is in theoropharynx. Once the NGT is in the oropharynx,the client is
instructed to flex the neck andswallow, as the tube is advanced.68.) The length of
NGT to be inserted iscorrectly measured;A.) From the tip of the nose to the
umbilicusB.) From the tip of the nose to the xiphoidprocessC.) From the tip of the
nose to the earlobe to theumbilicusD.) From the tip of the nose to the earlobe to
thexiphoid process.ANS: D> The length of NGT to be inserted is measuredfrom the
tip of the nose, to the earlobe, to thexiphoid process (N-E-X) which is
approximately50cm69.) When inserting NGT, the neck should:A.) FlexedB.)
HyperextendC.) Tilted to the leftD.) In neutral positionANS: B> When inserting NGT,
the neck is initiallyhyperextended70.) The most accurate method of
assessingmethod of placement of NGT is:A.) AspirationB.) Testing the pH of gastric
aspirationC.) X-ray studyD.) Introduction of air into NGT and auscultate atthe
epigastric area.ANS: C> The most accurate method of assessingplacement of NGT is
through X-ray.71.) Which of the following is inappropriatenursing action when
administering NGTfeeding?A.) Assist the client in Fowlers positionB.) Introduce
feeding slowlyC.) Place the feeding 24 inches above the pointof insertion of NGTD.)
Instill 60mls of water into the NGT after feedingANS: C> During NGT feeding, the
height of the feedingis 12 inches above the point of NGT insertion,not 24 inches. If
the height of feeding is too high,this results to very rapid introduction of
ANS: D> Fecal impaction is the accumulation of hardened, putty-like fecal mass at
the rectum78.) The following are appropriate nursingmeasures to relieve
constipation EXCEPT:A.) Include fruits and vegetablesB.) Have adequate activity and
exerciseC.) Take laxatives at regular basisD.) Answer immediately to the urge to
defecateANS: C> Regular use of laxative is inappropriatenursing measures to
relieve constipation79.) Castor oil acts as a laxative by:A.) Providing chemical
stimulation of theintestinal mucosaB.) Softening the stoolC.) Increasing the bulk of
the stoolD.) Lubricating the stoolANS: A> Castor oil provides chemical stimulation to
theintestinal mucosa, to increase peristalsis andpromote defecation80.) Which of
the following foods should beavoided by the client prevent flatulence?A.) Fruit
juiceB.) CabbageC.) MeatD.) FishANS: B> To prevent flatulence, avoid gas-forming
foodslike cabbage81.) Which of the following antidiarrhealmedications absorb gas or
toxic substancesfrom the bowel?A.) DemulcentB.) CabbageC.) MeatD.) FishANS: B>
Absorbent anti-diarrheal medications absorbgas or toxic substances from the
bowel82.) The most common-side effect of overuse of laxatives is:A.) DiarrheaB.)
Nausea and vomitingC.) ConstipationD.) FlatulenceANS: C> The most common sideeffect of overuse of laxative is rebound constipation83.) Which of the following
should be included inthe diet of the patient with diarrhea?A.) BananaB.) PapayaC.)
PineappleD.) AvocadoAns: A> Banana should be included in the diet of theclient
with diarrhea. It is rich in potassium and itreplaces potassium losses due to
diarrhea84.) Which of the following fluids may be givento a client with diarrhea?A.)
D.) Increase the flow rate of the enema solutionif abdominal cramps occur ANS: D>
Increasing flow rate of enema solution if abdominal cramps occur is inappropriate
nursingaction. Temporarily stop flow of solution if abdominal cramps occur, until
peristalsisrelaxes.92.) The functional unit of the kidneys is the:A.) GlomerulusB.)
Bowmans capsuleC.) NephronD.) TubulesANS: C> The nephron is the unit of the
kidney93.) Which of the following initiates voiding?A.) Valsalva maneuver B.)
Increased intraabdominal pressureC.) Sympathetic response stimulationD.)
Parasympathetic response stimulationANS: D> The PNS promotes contraction of the
bladder and promotes relaxation of urethral sphincter.Therefore, it initiates
voiding.94.) The following are normal characteristics of urine EXCEPT:A.) Appears
clear B.) pH= 3.5C.) Sp.Gr=1.020D.) Amber ANS: B> Urine pH of 3.5 if too low. This
indicatesacidosis. The normal pH of urine is slightlyacidic, an average of 695.)
Frequent scanty urination is:A.) UrgencyB.) hesitancyC.) PollakuriaD.) PolyuriaANS:
C> Pollakuria is frequent scanty urination96.) The volume of urine in the bladder
thattriggers the urge of an adult patient to void is:A.) 50-100mlsB.) 100-200 mlsC.)
250-450 mlsD.) 500-600 mlsANS: C> 250-450 mls of urine in the bladder makes
anadult client feel the urge to void97.) Which of the following is not as
assessmentfinding in urinary retention?A.) Flat sound over the suprapubic area
onpercussionB.) Smooth, firm ovoid mass at the suprapubicareaC.) Protrusion
arising out the pelvisD.) Frequent passage of small amount of urineANS: A> Flat
sound over the suprapubic area onpercussion does not indicate bladder
distention.Accumulation of urine in the bladder will producedull sound98.) Which of
the following is most effectivenursing measure to relieve urinary retention?A.) Allow
the patient to listen to the sound of running water B.) Dangle fingers in warm water
C.) Provide privacyD.) Pour warm water over perineumANS: C> providing privacy is
the most effective nursingmeasure to relieve urinary retention.99.) The best
position for female during urinarycatheterization is:A.) SupineB.) Dorsal
recumbentC.) LateralD.) Semi-FowlersANS: B> Dorsal recumbent position is the
best positionduring urethral catheter insertion in a femaleclient.100.) The female
urethral meatus is located:A.) Above the clitorisB.) Below the vaginalC.) Between
the clitoris and vaginal orificeD.) Between the vaginal orifice and anusANS: C> The
female urethral meatus is locatedbetween the