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UNIVERSITY OF PERPETUAL HELP SYSTEM – DALTA

BRGY. PACIANO – RIZAL, CALAMBA CITY, LAGUNA


COLLEGE OF NURSING

TERMINAL COMPETENCY EXAMINATION


RLE (MIDTERM) - BSN LEVEL - III
1st SEMESTER, SY 2010-2011

GENERAL DIRECTIONS:

1. Read and understand each item carefully


2. Select and mark the answer by shading the box that corresponds to the letter of the
correct answer on the separate sheet
3. Avoid unnecessary marks and erasures
4. Use BLACK ink pen only.

1. Which of the following would be an example of an objective data? The patient:

a. Is anorexic
b. Feels warm
c. Ate half of lunch
d. Has the urge to void

2. Which of the following is an example of a subjective data? The patient states:

a. I just went in the urinal and it needs to be emptied


b. My pain feels like a “5” on a scale of 1 to 5
c. The doctor said I can go home today
d. I only ate half my breakfast

3. During which of the five steps in the Nursing Process are outcomes of care determined to
be achieved?

a. Implementation
b. Evaluation
c. Diagnosis
d. Planning

4. When considering the Nursing Process, “observe” is to “assess” as “determine” is to?

a. Plan
b. Analyze
c. Diagnose
d. Implement

5. An essential concept related to understanding the Nursing Process is that it?

a. Is dynamic rather than static


b. Focuses on the role of the nurse
c. Moves from the simple to the complex
d. Is based on the patient’s medical problem
6. Which of the following is the most accurately stated goal? The patient will:

a. Be taught how to use a urinal when on bed rest


b. Experience fewer incontinence episodes at night
c. Be assisted to the toilet every 2 hours and whenever necessary
d. Transfer independently and safely to a commode before discharge

7. Which word best describes the role of the nurse when identifying and meeting the needs
of the patient holistically?

a. Teacher
b. Advocate
c. Counsellor
d. Surrogate

8. The word most closely associated with scientific principle is?

a. Data
b. Problem
c. Rationale
d. Evaluation

9. Which part of the Nursing Diagnosis is most directly related to the concept of a pebble
dropped into a pond causing ripples on the surface of the water?

a. Defining characteristics
b. Outcome criteria
c. Etiology
d. Goal

10. Which of the following would be an example of a subjective data?

a. Jaundice
b. Dizziness
c. Diaphoresis
d. Hypotention

11. The patient comes to the ER complaining of chest pain and dyspnea. When taking the
patient’s VS the nurse is?

a. Assessing
b. Evaluating
c. Diagnosis
d. Implementing

12. Which of the following statements by the nurse is an example of inference? The patient
is?

a. Hypotensive
b. Withdrawn
c. Jaundiced
d. Oliguric

13. What step of the Nursing Process is being used when the nurse teaches a patient the use
of visualization to cope with chronic pain?

a. Planning
b. Diagnosis
c. Evaluation
d. Implementation
14. Where in the patient’s chart would the nurse find documentation of the current medical
diagnosis?

a. Physician’s History
b. Social Service Record
c. Admission Sheet
d. Progress Notes

15. During which of the 5 steps in the Nursing Process are data analysed critically?

a. Diagnosis
b. Clustering
c. Collection
d. Assessment

16. Which of the following is a well-designed goal? The patient will:

a. Have a lower temperature


b. Be given Aspirin 80 mgs. every 8 hours prn
c. Be taught how to take an accurate temperature
d. Maintain fluid intake sufficient to prevent dehydration

17. During the evaluation step of the Nursing process the nurse must?

a. Establish outcomes
b. Determine priorities
c. Take corrective actions
d. Set the time frame for goals

18. Determining what nursing actions will be employed occurs in which step of the Nursing
Process?

a. Implementation
b. Assessment
c. Diagnosis
d. Planning

19. When considering the Nursing process the words “present” is to “future” as “plan” is to?

a. Diagnosis
b. Implement
c. Evaluation
d. Assessment

20. The appropriateness of a Nursing Diagnosis is supported by its?

a. Defining characteristics
b. Planned interventions
c. Diagnostic statements
d. Related risk factors

21. The VS that would change first indicating that a post-op patient had internal bleeding
would be the?

a. Body temperature
b. Blood pressure
c. Pulse pressure
d. Heart rate
22. When assessing a patient’s strength in preparation for getting out of bed the nurse
should?

a. Ask if the patient is dizzy


b. Determine if the patient has dependent edema
c. Instruct the patient to push against leg resistance
d. Inquire if the patient feels strong enough to get out of bed

23. How often should a patient’s temperature be taken who has had a temperature of 101
degree F for the last 24 hours?

a. Every 2 hours
b. Every 4 hours
c. Every 6 hours
d. Every 8 hours

24. When a brachial pulse is unable to be palpated, which pulse would indicate adequate
brachial blood flow?

a. Radial
b. Carotid
c. Femoral
d. Popliteal

25. Which is the first action implemented by the nurse when obtaining a 24 hour urine
specimen?

a. Ensure that a basin with ice is ready to hold the collection container
b. Have the patient empty the bladder before beginning the test
c. Teach the patient to cleanse the meatus before each voiding
d. Prepare an I and O sheet to be used to document each voiding

26. Which of the following can cause the urine to appear red in color?

a. Beets
b. Strawberries
c. Cherry Jell-O
d. Red food dye

27. What is the most important thing the nurse should do when assessing a carotid artery?

a. Monitor for a full minute


b. Palpate just below the ear
c. Press gently when palpating the site
d. Massage the site before assessing for rate

28. Which of the following would result in an accurate BP reading for an average size adult
male patient?

a. Wrapping the lower edge of the cuff over the antecubital space
b. Positioning the BP apparatus above the level of the heart
c. Pumping the cuff about 60 mmHg above the points where the brachial pulse is
lost
d. Releasing the valve on the cuff so that the pressure decreases at the rate of 2-3
mmHg/second

29. In an adult, what blood pressure result would cause a concern about hypertension?

a. 120/80 mmHg
b. 130/60 mmHg
c. 140/90 mmhg
d. 130/90 mmHg
30. When planning to care for a patient who has an intolerance for activity, what is the first
assessment that should be made by the nurse?

a. Influence on the other family members


b. Impact on functional health patterns
c. Pattern of VS
d. Range of motion exercises

31. Which of the following is an adaptation to inadequate nutrition?

a. Presence of surface papillae on the tongue


b. Reddish-pink mucous membranes
c. Cachectic appearance
d. Shiny eyes

32. When taking a rectal temperature the nurse should?

a. Take the temperature for 5 minutes


b. Wear gloves throughout the procedure
c. Place the patient in the R-lateral position
d. Insert the thermometer 2 inches into the rectum

33. Which is usually unrelated to a nursing physical assessment?

a. Posture and gait


b. Balance and strength
c. Hygiene and grooming
d. Blood and urine values

34. The patient has a temperature of 102 degree F and complains of feeling thirsty.Which
additional adaptation should the nurse expect during this febrile stage of a fever?

a. Restlessness with confusion


b. Decreased RR
c. Profuse perspiration
d. Pale and cold skin

35. Which of the following is the most common site for assessing the heart rate?

a. Radial
b. Apical
c. Carotid
d. Temporal

36. Which of the following characteristic of a blood pressure would indicate shock?

a. Rising diastolic
b. Decreasing systolic
c. Korotkoff’s sounds
d. Widening pulse pressure

37. Which of the following assessment is a subtle indicator of depression?

a. Unkempt appearance
b. Anxious behaviour
c. Tense posture
d. Crying
38. Which of the following conditions would place a person at risk for hypothermia?

a. Heat stroke
b. Inability to sweat
c. Excessive exercise
d. High alcohol intake

39. Which adaptation would be expected in a patient who has lost 2 units of blood?

a. Rapid and shallow breathing


b. Increased urine output
c. Hypertension
d. Bradypnea

40. A concern that is common to the collection of specimens, regardless of their source for
culture and sensitivity test is?

a. The specimen should be suspended in a preservative media


b. The specimen should be collected in the morning
c. Surgical asepsis must be maintained
d. Two specimens should be obtained

41. The nurse recognizes the need for an increase in caloric intake above the average
requirements for the patient who has?

a. Nausea
b. Dysphagia
c. Pneumonia
d. Depression

42. The person with the greatest risk for developing an infection is?

a. A 2 months old who is breastfeeding


b. A 20 y.o. who works in a movie theatre
c. A 40 y.o. who is receiving cancer chemotherapy
d. A 60 y.o. who is taking antibiotics while having dental surgery

43. Healing by primary intention is most likely to occur with?

a. Cuts in the skin from a kitchen knife


b. Excoriated perianal areas
c. Abrasions of the skin
d. Pressure ulcers

44. The primary reason why the nurse should avoid glued-on artificial nails is because?

a. It interferes with the dexterity of the fingers


b. It could fall off in a patient’s bed
c. It harbor microorganisms
d. It can scratch a patient

45. Subclinical infections most commonly occur in?

a. Infants
b. Adolescents
c. Older adults
d. School-aged children
46. Which factor places a patient at the greatest risk for developing an infection?

a. Burns over 20% of the body


b. Implantation of a prosthetic device
c. Presence of an indwelling urinary catheter
d. Multiple puncture sites from laparoscopic surgery

47. Which of the following is a secondary line of defense against infection?

a. Mucous membranes of the respiratory tract


b. Urinary tract environment
c. Integumentary system
d. Immune response

48. When performing a physical assessment before surgery, the nurse identifies that a patient
has pediculosis capities or head lice. What should the nurse do first?

a. Move the patient to a private room


b. Call the physician for a treatment order
c. Wash the patient’s hair with a germicidal shampoo
d. Inform the operating room and postpone the surgery for 24 hours

49. Which of the following is most directly related to the word “nosocomial”?

a. Disease-producing
b. Hospital acquired
c. Endogenous
d. Iatrogenic

50. A common systemic adaptation to infection is?

a. Pain
b. Edema
c. Tachycardia
d. Hypothermia

51. Which statement indicates that further teaching is necessary regarding how to ensure
protection from food contamination?

a. I love juicy rare hamburgers with onions and tomato


b. I prefer chicken salad sandwiches with mayonnaise
c. I know to spit out food that doesn’t taste good
d. I should defrost frozen food in the refrigerator

52. Which nursing action protects the patient as a susceptible host in the chain of infection?

a. Wearing personal protective equipment


b. Administering childhood immunizations
c. Recapping a used needle before discarding
d. Disposing of soiled gloves in a waste container

53. Which of the following is an objective adaptation to an ear infection?

a. Throbbing pain
b. Purulent drainage
c. Dizziness when moving
d. Hearing a buzzing sound
54. What blood component should the nurse monitor when assessing an individual’s ability
to withstand exposure to pathogens?

a. Platelets
b. Neutrophils
c. Erythrocytes
d. Hemoglobin

55. Which patient is at the greatest risk for a urinary tract infection?

a. Male with nocturia


b. Uncircumcised male
c. Premenopausal female
d. Female with a purulent vaginal discharge

56. Which of the following is a primary (Non specific) defense that protects the body from
infection?

a. Tears in the eyes


b. Alkalinity of gastric secretions
c. Bile in the GI system
d. Moist environment of the epidermis
57. When brushing a patient’s hair, the nurse notes white oval particles attached to the hair
behind the ears. The nurse should assess the patient further for signs of?

a. Scabies
b. Dandruff
c. Hirsutism
d. Pediculosis

58. A rise in body temperature is associated with the presence of infection because?

a. Pain activates the SNS


b. Erythema increases the flow of blood throughout the day
c. Leukocyte migration precipitates the inflammatory response
d. Phagocytic cells release pyrogens that stimulate the hypothalamus

59. An example of an iatrogenic infection would be a?

a. Vaginal infection in a post menopausal woman


b. Respiratory infection contracted from a grandchild
c. Urinary tract infection in a patient who is sedentary
d. Wound infection caused by unwashed hands of a caregiver
60. A wound is packed with a wet to damp gauze dressing primarily to?

a. Prevent infection of the wound


b. Promote uptake of Vitamin C
c. Facilitate the healing process
d. Promote uptake of nutrients

61. To apply a hospital gown appropriately to a patient receiving an IV infusion, the nurse
should?

a. Insert the IV bag and tubing through the sleeve from the inside of the gown
first.
b. Disconnect the IV at the insertion site, apply the gown, and then reconnect the
IV
c. Close the clamp on the IV tubing no more than 15 seconds while putting on
the gown
d. Don the gown on the unaffected arm, drape the gown over the other shoulder,
and adjust the closure behind the neck.
62. How often should a restraint be removed, the area massaged and the joints moved
through normal range?

a. Every shift
b. Every hour
c. Every two hours
d. Every four hours

63. The nurse should encourage the patient with difficulty in swallowing to?

a. Tilt the head backward when swallowing


b. Drink fluids along with bites of solid food
c. Keep food in the front of the mouth when chewing
d. Keep environmental stimuli to a minimum when eating

64. Which is the first action the nurse should employ to prevent falls in older adults?

a. Conduct a comprehensive risk assessment


b. Suggest removing all throw and area rugs in the home
c. Encourage installation of adequate lightning throughout the home
d. Discuss with the patient the normal changes of aging that place one at risk

65. Which action is most important when preparing a bed to receive a newly admitted
patient?

a. Place the patient’s name on the end of the bed


b. Ensure that the bed wheels are locked
c. Position the call bell in reach
d. Make an open bed

66. An appropriately worded goal associated with the Nursing Diagnosis Risk for Injury is,
“The patient will be”?

a. Taught how to call for help to ambulate


b. Kept on bed rest when dizzy
c. Safe and free from trauma
d. Restrained when agitated

67. In the hospital setting, an electrical appliance should have a 3-pronged plug because it?

a. Controls stray electrical currents


b. Promotes efficient use of electricity
c. Shuts off the appliance if there is an electrical surge
d. Divides the electricity among the appliances in the room

68. Which action is most important when using a stretcher?

a. Guiding a stretcher around a turn leading with the end with the patient’s head
b. Positioning the patient’s head at the end with the swivel wheels
c. Pulling the stretcher on the elevator with the patient’s feet first
d. Pushing the stretcher from the end with the patient’s head

69. The most serious risk associated with dysphagia is?

a. Anorexia
b. Aspiration
c. Self-care deficit
d. Inadequate intake
70. The physician writes the order “Patient may shower.”When preparing the patient for the
shower the nurse assesses that the patient lacks the strength to tolerate standing for this
procedure. The nurse should?

a. Give the patient a bed bath


b. Assist the patient into a bathtub
c. Use a commode chair in the shower
d. Place the patient in a chair at the sink

71. Which is the most important action by the nurse to prevent falls in patients who are
confused?

a. Encourage use of the corridor handrails


b. Place in a room near the nurse’s station
c. Reinforce how to use the call bell
d. Maintain close supervision

72. When teaching children about fire safety procedures, they should be taught that if their
clothes catch on fire they should?

a. Yell for help


b. Roll on the ground
c. Take their clothes off
d. Pour water on their clothes

73. What should the nurse do first when applying a vest restraint to a patient?

a. Ensure that the back of the vest is positioned on the patient’s back
b. Permit 4 fingers to slide between the patient and the restraint
c. Inspect the patient’s skin where the restraint is to be placed
d. Secure the restraint to the bed frame using a slip knot

74. Which position would be best for an unconscious patient who is vomiting?

a. Supine
b. Side-lying
c. Orthopneic
d. Low-fowler’s

75. What is most important when assisting a patient with a bedpan?

a. Dusting powder on the rim before placing the bedpan under the patient
b. Positioning the rounded rim of the bedpan toward the front of the patient
c. Ensuring the bedside rails are raised once the patient is on the bedpan
d. Encouraging the patient to help as much as possible when using the bedpan

76. Which of the following is an inappropriate route for a topical medication?

a. Intradermal
b. Bladder
c. Rectum
d. Vagina

77. When administering a rectal suppository, the nurse should teach the patient to?

a. Bear down while the medication is being inserted


b. Remain flat in bed for at least 3 minutes after the procedure
c. Assume the R-side lying position with the upper leg flexed
d. Perform slow thoracic breathing through the nose during insertion
78. What should the nurse do first when drawing up 10 units of Humulin R (regular) insulin
and 30 units of Humulin N (NPH) insulin in the same syringe?

a. Inject 10 units of air into the Humulin R insulin vial


b. Inject 30 units of air into the Humulin N insulin vial
c. Draw up 10 units of Humulin R insulin
d. Draw up 30 units of Humulin N insulin

79. Which action takes priority when medication is to be added to an intravenous fluid bag?

a. Attaching a completed IV additive label to the bag


b. Mixing the medication and solution by rotating the bag
c. Maintaining sterile technique throughout the procedure
d. Ensuring that the drug and the IV solution are compatible

80. The nurse holds a bottle of liquid medication with the albel next to the palm of the hand
when pouring a dose to?

a. Conceal the label from the curiosity of others


b. Prevent the soiling of the label by spilled liquid
c. Ensure the accuracy of the measurement of the dose
d. Guarantee that the label is read before pouring the liquid

81. What should the nurse do when administering a lozenge to a patient’s buccal area of the
mouth?

a. Ensure that the medication is dissolved under the tongue


b. Instruct the patient to take occasional sips of water
c. Administer the lozenge one hour before meals
d. Alternate cheeks from one dose to another

82. Which route of drug administration is not considered parenteral?

a. Epidural
b. Transdermal
c. Subcutaneous
d. Intramuscular

83. Which is most essential when applying a medicated powder to a patient’s skin?

a. Applying a thin layer in the direction of hair growth


b. Protecting the patient’s face with a towel
c. Dressing the area with dry sterile gauze
d. Ensuring that the skin surface is dry

84. What should the nurse do first to access an ampule?

a. Inject the same amount of air as the fluid to be removed


b. Wipe the constricted neck with an alcohol swab
c. Break the constricted neck using a barrier
d. Insert a needle into the rubber seal

85. To limit discomfort when administering medication into the ear of an adult, the nurse
should?

a. Warm the solution to body temperature


b. Place the patient in a comfortable position
c. Pull the pinna of the ear upward and backward
d. Instill the fluid in the center of the auditory canal
86. A patient is instructed to inhale deeply and hold each breath for a second when using a
hand held nebulizer because this action will?

a. Prolong the treatment


b. Limit hyperventilation
c. Disperse the medication
d. Prevent bronchial spasms

87. Which abbreviation indicates that the physician wants a medication administered twice a
day?

a. P.c.
b. H.s.
c. Q2h
d. B.i.d.
88. When administering an IM injection to a morbidly obese patient, the nurse should use
the?

a. The Z-track method


b. An 18 – gauge needle
c. The dorso gluteal site
d. A needle longer than 1 ½ inches

89. A drug delivered by a suppository is absorbed in the?

a. Ear
b. Nose
c. Mouth
d. Rectum

90. What is the first thing the nurse should do when administering a vaginal suppository?

a. Inspect the vaginal orifice


b. Provide perineal care
c. Remove the wrapper
d. Wear sterile gloves

91. To help a patient with short term memory loss to remember to take multiple drugs
throughout the day, the nurse should?

a. Instruct the patient to put the medication in a weekly organizational pill


container
b. Design a chart of the medications the patient takes each day during the week
c. Ask a family member to call the patient when medications are to be taken
d. Suggest that the patient wear a watch with an alarm
92. What should the nurse do when administering an eye irrigation to the right eye?

a. Direct the flow of solution from the inner to the outer canthus
b. Irrigate with an Asepto syringe 2 inches from the eye
c. Don sterile gloves before beginning the procedure
d. Position the patient in a right lateral position

93. A medication is delivered by the Z-track method when the nurse?

a. Uses a special syringe designed for Z-track injections


b. Pulls laterally and downward on the skin before inserting the needle
c. Administers the injection in the muscle on the anterior lateral aspect of the
thigh
d. Injects the needle in a separate spot for each dose on a Z-shaped grid on the
abdomen
94. When reconstituting a powdered medication the nurse should?

a. Keep the needle below the initial fluid level as the rest of the fluid is injected
b. Instill solvent that is consistent with the manufacturer’s directions
c. Score the neck of the ampule before breaking it
d. Shake the vial to dissolve the powder

95. When preparing to administer a tablet to a patient the nurse should remove the p.o.
medication from its unit dose package?

a. Outside the door to the patient’s room


b. When standing next to the patient
c. In the medication room
d. At the medication cart

96. When titrating a drug for the patient in pain, which nursing action is most appropriate?

a. Follow the physician’s order exactly for the first 24 hours


b. Reassess the patient every 8 hours for the drug effectiveness
c. Ask the physician to include a medication order for breakthrough pain
d. Seek a new order after two doses that do not achieve a tolerable level of relief

97. When the physician orders a troche, the nurse should administer it by placing it in the
patient’s?

a. Ear
b. Eye
c. Mouth
d. Rectum

98. What should the nurse do when identifying the left dorsogluteal site for an IM injection?

a. Locate the lower edge of the acromion and the midpoint of the lateral aspect
of the arm
b. Draw a line from the posterior superior iliac spine to the greater trochanter
c. Place the heel of the left hand on the greater trochanter
d. Palpate the anterior lateral aspect of the thigh

99. What action should the nurse teach the patient who has an order for 2-puffs of a
bronchodilator via a metered dose inhaler?

a. Start breathing in while compressing the canister


b. Hold the inspired breath for 2 to 4 seconds
c. Deliver 2 puffs with each inspiration
d. Inhale slowly for 8 to 10 seconds

100. Which of the following is related to an intradermal injection?

a. 2 ml. Syringe
b. 26-gauge needle
c. 1 inch needle length
d. 30 degree angle of insertion

The most important practical lesson than can be given


to nurses is to teach them what to observe.
Florence Nightingale

Level III – CI’s