FUNDAMENTALS IN NURSING A.

Insert it rectally
B. Places it in the buccal area
C. Places it on the chest wall
D. Places it under the tongue
Direction: Choose the letter of the BEST answer by
shading the corresponding letter of your choice on the SITUATION: Sheila Reyes has a history of hypertension and
answer sheet provided. STRICTLY NO ERASURE! complains of shortness of breath when she lies flat. The nurse
assesses her blood pressure to have a diastolic reading of 200
1. The nurse manager has requested that a nurse mmHg. (Questions 10 and 11 relate to this situation)
perform a self-assessment prior to an annual
performance evaluation. Using Maslow’s model of self- 9. The nurse documents that Mrs. Killian has:
actualization, the nurse understands that self- A. Dyspnea
actualization is at the top of the pyramid and refers to: B. Exertional dyspnea
A. Becoming the person you would like to be by C. Orthopnea
making the most of your physical, mental, and D. Paroxysmal nocturnal dyspnea
spiritual competencies
B. Needing recognition, usefulness, independence, 10. Diastole is defined as:
dignity and freedom A. A measure of contractility
C. Needing safety, security, and protection B. The amount of blood ejected from the ventricles
D. Needing to belong to a group with each contraction of the heart
C. The period when the heart contracts and the
2. The nurse is evaluating a patient complaining of muscles fibers are tight and short
shortness of breath. The nurse assesses the patient’s D. The period when the muscle fibers are stretched
respiratory rate to be 26 breaths/minute and and the heart’s cavities fill with blood
documents that the patient is tachypneic. The nurse
understands that tachypnea means: 11. What is a characteristic of the nursing process?
A. Frequent bowel sounds A. Asystematic C. Inflexible
B. Heart rate greater than 100 beats/minute B. Goal-oriented D. Stagnant
C. Hyperventilation
D. Respiratory rate greater than 20 breaths/minute 12. What is the order of the nursing process?
A. Assessing, diagnosing, implementing, evaluating,
3. The nurse assesses a patient complaining of frequent planning
episode of epistaxis. The nurse knows the patient has: B. Assessing, diagnosing, planning, implementing,
A. An enlarged spleen evaluating
B. A tendency to bruise easily C. Diagnosing, assessing, planning, implementing,
C. Nosebleeds evaluating
D. Seizures D. Planning, diagnosing, implementing, assessing,
evaluating
4. The doctor order intra-arterial monitoring to obtain
continuous blood pressure in a critically ill patient. 13. During the planning phase of the nursing process,
Collateral circulation should be assessed prior to which of the following is the “product’ developed?
selection of an arterial site. The test used to assess the A. Nursing care plan C. Nursing history
patency of the radial and ulnar arteries is the: B. Nursing diagnosis D. Nursing notes
A. Allen’s test C. Trendelenburg’s test
B. Homans’ sign D. Weber’s test 14. Objective data are also known as:
A. Covert data C. Overt data
5. The four major concepts in nursing theory are the B. Inferences D. Symptoms
A. Person, Environment, Nurse, Health
15. The primary source of data collection in the
B. Nurse, Person, Environment, Cure assessment phase of the nursing process is the:
C. Promotive, Preventive, Curative, Rehabilitative A. Chart C. Doctor
D. Person, Environment, Nursing, Health B. Patient D. Family

6. The act of utilizing the environment of the patient to 16. What is an example of subjective data?
assist him in his recovery is theorized by A. Color of wound drainage
B. Odor of breath
A. Nightingale C. Swanson
C. Respirations of 14 breaths/minute
B. Benner D. King D. The patient’s statement of “I feel sick to my
stomach”
7. The most unique characteristic of nursing as a
profession is 17. This is the best patient care model when there are
A. Education C. Caring many nurses but few patients.
B. Theory D. Autonomy A. Functional nursing C. Primary nursing
B. Team nursing D. Total patient care
8. To administer nitroglycerin sublingually, the nurse:
18. This patient care model works best when there are C. Subjective data from a primary source
plenty of patient but few nurses D. Subjective data from a secondary source
A. Functional nursing C. Primary Nursing
27. The nurse performs a neurologic exam on a patient.
B. Team nursing D. Total patient care
After the exam, which of the following should be
recorded as objective data?
19. Who developed the first theory of nursing? A. +4 patellar reflexes in both of the patient’s legs
A. Hammurabi B. Patient’s description of ringing in his ears
B. Alexander C. Patient’s sensations of numbness in his right arm
C. Fabiola D. Patient’s statement, “The room is spinning”
D. Nightingale
28. It is most important to identify the etiology (risk factors)
of a nursing diagnosis because doing so:
20. She described the four conservation principle. A. Assists in organizing nursing care of patients with
A. Levin a similar diagnosis
B. Leininger B. Describes that patient’s health problem or
C. Orlando response in a few words
D. Parse C. Gives direction to the required nursing
interventions for the patient
D. Indicates the presence of a particular health
21. Established in 1906 by the Baptist foreign mission
problem in a patient
society of America. Miss rose nicolet, was it’s first 29. When should discharge planning commence?
superintendent. A. 24 hours after discharge
A. St. Paul Hospital School of nursing B. The day before discharge
B. Iloilo Mission Hospital School of nursing C. Upon admission
C. Philippine General Hospital School of nursing D. When the patient desires
D. St. Luke’s Hospital School of nursing
30. The scientific reason for selecting a specific nursing
intervention supported by clinical research is called a:
22. Anastacia Giron-Tupas was the first Filipino nurse to A. Criterion
occupy the position of chief nurse in this hospital. B. Rationale
A. St. Paul Hospital C. Strategy
B. Iloilo Mission Hospital D. Theory
C. Philippine General Hospital
D. St. Luke’s Hospital 31. An expected outcome on a patient’s nursing care plan
reads. “patient will be able to transfer from the bed to a
wheelchair without assistance by the end of the week.”
23. Period of nursing where religious Christian orders When the nurse evaluated the patient’s progress, the
emerged to take care of the sick patient was able to transfer from the bed to a
A. Apprentice period wheelchair to go to the physical therapy department
B. Dark period without any help from the nurse. Which of the following
C. Contemporary period would be an appropriate evaluative statement for the
D. Educative period nurse to place on the patient’s nursing care plan?
A. “Patient was able to transfer from the bed to a
wheelchair without assistance.”
24. This period marked the religious upheaval of Luther, B. “Goal impossible to measure.”
Who questions the Christian faith. C. “Goal met; patient was able to transfer from the
A. Apprentice period bed to a wheelchair without assistance.”
B. Dark period D. “Goal not met.”
C. Contemporary period
32. The goal or expected outcome “Patient will maintain
D. Educative period
current weight of 165 pounds” can best be evaluated
by which of the following measures?
25. She conceptualized that man, as an Open system is in A. Determining the patient’s food preferences
constant interaction and transaction with a changing B. Monitoring dietary intake for each meal
environment. C. Restricting high-calorie food
A. Roy D. Weighing the patient on the same scale
B. Levin 33. The nurse manager evaluates the quality of the nursing
care plans developed for the patients on the nursing
C. Neuman
unit. This is an example of which type of evaluation?
D. Newman A. Outcome
26. Two-year-old Jason’s mother states, “Jason vomited 8 B. Peer
ounces of his formula this morning.” This statement is C. Process
an example of: D. Structure
A. Objective data from a primary source
B. Objective data from a secondary source
34. In the implementing phase of the nursing process, the C. Secondary
nurse does which of the following tasks? D. Tertiary
A. Determines the patient’s health status
B. Identifies available resources 43. A nurse is a lifelong learner. The most important
C. Measures goal achievement reason for this is:
D. Puts the nursing care plan into action A. Accrediting agencies, such as the National League
for Nursing, require it
35. Collaborative nursing interventions: B. Employers require it to stay employed
A. Are based on the written instructions of another C. Doctors need to be ensured the nurse is
professional competent in nursing
B. Are determined solely by the nurse and patient D. Nurses must remain current in nursing research,
C. Reflect the overlapping responsibilities of health skills, and knowledge
care personnel
D. Require supervision by the doctor 44. Maslow’s hierarchy of basic needs is a common theory
that nursing education incorporates to explain the basic
36. When a assessing a patient’s level of pain, which type needs of people. What need must be met before the
of nursing intervention is the nurse performing? person can focus on safety and security?
A. Collaborative A. Love and belonging
B. Dependent B. Physiological
C. Independent C. Self-actualization
D. Professional D. Self-esteem

37. What should the nurse do after making a charting error 45. The nurse performs many roles in the practice of
in the nurses’ notes? nursing. Which role is defined as “the protection of
A. Draw a line through the error and write “Error” and human or legal rights and the securing of quality care
her initials above it for each patient”?
B. Obliterate the mistaken with a black felt pen A. Advocator
C. Recopy the page of nurses’ notes and start over B. Communicator
D. Report the incident immediately to the head nurse C. Counselor
D. Leader
38. Independent nursing interventions:
A. Are also known as standing orders 46. The nurse is teaching a diabetic patient how to inject
B. Are initiated based on the nurse’s own knowledge insulin and the dosages necessary for optimal control.
and skill This would be an example of what level of health care?
C. Consist primarily of health education A. Curative
D. Relate directly to the patient’s disease process B. Primary
C. Secondary
39. The head nurse wants to determine how the size and D. Tertiary
location of the nursing station influences the delivery of
nursing care on the unit. This is an example of which 47. Founder of the PNA
type of evaluation? A. JulitaSotejo
A. Outcome B. Anastacia GironTupas
B. Peer
C. Eufemia Octaviano
C. Process
D. Structure D. Anesia Dionisio

40. Which of the following statements about the term 48. A woman undergoing radiation therapy developed
nursing process is true? redness and burning of the skin around the best. This
A. It is used only in the United States is best classified as what type of disease?
B. It originated with Florence Nightingale A. Neoplastic
C. It was first used by Lydia Hall in 1955
B. Traumatic
D. It was initiated by the national league for Nursing
in 1983 C. Nosocomial
41. The nurse has organized an immunization clinic for D. Iatrogenic
healthy babies and preschool children. This would be
an example of what level of preventative health care? 49. The classification of CANCER according to its etiology
A. Curative Is best described as
B. Primary 1. Nosocomial
C. Secondary
2. Idiopathic
D. Tertiary
3. Neoplastic
42. The nurse is caring for a patient in the hospital after the 4. Traumatic
surgical removal of his gallbladder. This would be an 5. Congenital
example of what level of preventative health care? 6. Degenerative
A. Curative a. 5 and 2
B. Primary
 b. 2 and 3 A. The patient was found soiled in bed by this RN. she
c. 3 and 4 reports being left alone all night by the night shift RN,
d. 3 and 5 who did not clean her before the change of shift. She
was given a bed bath and provided skin care. Her skin
50. Term to describe the reactiviation and recurrence of was reddened on her buttocks; emollient applied. 
pronounced symptoms of a disease
A. Remission B. The patient was found soiled in bed by this RN. She
B. Emission was incontinent of urine and feces and she said she
C. Exacerbation was "ignored for hours" by the night shift RN. She was
D. Sub acute given a bed bath and provided skin care. Her skin was
reddened on her buttocks; emollient applied.
51. A foley catheter operates by the principle of
a. Inertia c. diffusion C.The patient was found soiled; incontinent of urine
b. Gravity d. osmosis and feces. She was given a bed bath and provided skin
52. The client is receiving total parenteral nutrition (TPN). care. Her skin was reddened on the buttocks; Emollient
Which lab test should be taken daily?
a. Hemoglobin applied. Incident report made.
b. Creatinine
c. Blood glucose D. The patient was found soiled; incontinent of urine
d. White blood cell count and feces. She was given a bed bath and provided skin
care. Her skin was reddened on the buttocks; emollient
53. Nurse Honeyboy is suctioning a client via a applied.
tracheostomy tube. When suctioning, he must limit the
58. A home health nurse makes weekly visits to an 87-
suctioning to a maximum of :
a. 5 seconds year-old client who lives with her son. When home
b. 15 seconds alone, the client is talkative and friendly, but when the
c. 10 seconds son is home, the client is observed to be withdrawn and
d. 20 seconds appears anxious. The client has bruises, which she
states is from "bumping into things" and a weight-loss
54. The client with Cirrhosis is scheduled for a of 10 pounds in the past month. With these objective
parencentesis. Which instruction should be given to the
findings, the nurse is required to do which of the
client before the exam?
a. “You will need to lay flat during the exam.” following? Select all that apply.
b. “You need to empty your bladder before the
procedure.” A. ask the client if she has any concerns about her
c. “You will be asleep during the procedure.” living situation, maintaining an objective, non-
d. “The doctor will inject a medication to treat your accusatory role.
illness during the procedure.” B. Confront the son about the abuse, demanding that
he turn himself in to seek help for the abusive pattern
55. After undergoing a liver biopsy, the client would be
placed in which position? of behavior.
a. Semi- fowler C. Question the client's son privately about the
b. lateral on affected site suspicions of his mother's condition and about possible
c. supine abuse or neglect.
d. prone D. Report suspected abuse to adult protective services
so investigation into the clients welfare can be
56. Which medication administration situations should be
performed.
documented in a healthcare facility's incident reporting
system?
59. The nurse understands the following about informing
A. Medication errors and adverse drug reactions only and obtaining consent for an eight-year-old patient who
B. Medication errors that cause patient harm is undergoing a heart transplant:
C. Near misses and medication errors only
D.near misses, medication errors, and adverse drug Select all that apply.
reactions
A. Since the child is a minor, he does not need to be
57. A nurse is assessing his patients in the morning and
informed about the surgery
finds that a frail a 85 year-old female patient is soiled in
B. The child must be informed about the surgery.
bed. The patient reports that she has been asked to
C. The child must sign the informed consent form along
cleaned numerous times and has been ignored. Of the
with their parent
following, which demonstrates appropriate
D. The child only needs to know the risks of the
documentation in the patient's chart.
surgery.
 E. The parent/guardian must be informed of the risks
and benefits of the procedure and sign the informed
consent on behalf of the child
60. The patient refuses chemotherapy based on religious
beliefs. The hospital staff must follow his decision
based on which patient right?
A. The right to counsel
B. The right to informed consent
C. The right to refuse treatment
D. The right to suffer
61. The patient was recently admitted to hospice care for
lung cancer. After filling out his advanced directive, the
patient says that he worries his physician will be
uninterested in his care. Which of the following
statements made by the nurse best addresses the
patient's concerns?
A. "After you fill out an advance directive, the physician
plays a limited role to allow you space and time to be
with your family."
B."Once you are admitted to hospice, the physician
plays a passive role." 
C. "Your physician is required by law to help you, so
don't worry."
D. "Your physician will continue to take care of you.
The advanced directive just states what type of care
you want, so we can provide that care even when you
cannot tell us too."
62. A physician involved in the patient's care asks to see
the results of his HbA1c. How should the nurse
respond?
A. "Asked the clerk for that information."
B. "I can't give you that information."
C. "It is 8.5."
D. "You can look it up on the computer"
63. A living will includes which of the following?
Select all that apply:
A. Documentation requirements
B. How and when the Living will takes effect
C. How the patient's valuables are distributed among
the family
D. Immunity from liability for following the living will
E. Which family member will inherit the patient's home
64. The circulating nurse in the OR notices a small
laceration on the patients hip while positioning pre-op,
but this was missed and not reported during the pre-op
assessment. Of the following, which is the appropriate
action for the nurse to take?
A. At the laceration to the pre-op nurses documentation
so it won't be confused with a surgical injury
B. Document the laceration along with the surgical sites
in the peri-op note 
C. Document the presence of a preexisting skin
laceration in the peri-op now.
D. Report it to the receiving PACU nurse after the
procedure so she can document it.
65. Which of the following should the nurse delegate to the
LPN.
Select all that apply:
A. Administering a piggyback IV medication
B. IM medication administration
C. Initiating a primary IV medication
D. Oral medication administration
E. Urinary catheterization
66. Which of the following tasks can be delegated to a
nursing assistant?
Select all that apply.
A. Ambulating a stable patient
B. Emptying and measuring a foley catheter reservoir
C. Intake and output documentation
D. Irrigating a nasogastric tube
E. nasotracheal suctioning of a stable patient
F. Setting up patient controlled analgesia
67. The five-year-old is admitted to the hospital with
pneumonia. The nurse observes bruises on the child's
back and arms. The Mother is present in the patient's
room. What should the nurse do next?
A. Ask the mother if she is abusing her child
B. Call the police
C. Notify the physician of suspected child abuse
D. When the mother leaves, ask the child if she feels
scared or unsafe at home
68. A nurse on the medical surgical floor is caring for
patient who is confused and combative after abdominal
surgery. The patient has pulled out the nasogastric
tube required for gastric rest. The nurse called the
doctor to discuss these issues. The doctor has ordered
two point restraints , so the nurse creates a telephone
order read back. The nurse knows that the restraint
order will require which of the following?
Select all that apply.
A.The doctor must perform an in person assessment of
the patient's need for restraints within one hour
B. The doctor must sign a telephone order and assess
the need for continued restraints every four hours
C. The doctor must sign a telephone order and assess
 the need for continued restraints within 24 hours
D. The nurse assesses the patient's need for restraints
and obtain another telephone order each hour
69. Which of the following contributions of Florence
Nightingale had an immediate impact on improving
patient's health?
A. Providing a clean environment
B. Improving nursing education
C. Changing the delivery of care in hospitals
D. establishing nursing as a distinct profession
70. Which of the following is the most important reason for
nurses to be critical thinkers?
A. Nurses need to follow policies and procedures
B. Nurses work with other healthcare professionals  B. Fish
C. Nurses care for patients with multiple health issues
D. Nurses have to be flexible and work different
schedules
71. Which of the following includes objective and subjective
data?
A. Patient's BP is 132/68 and HR is 88
B. Patient's cholesterol is elevated, and stated that he
likes fried food
C. Patient states she is having trouble sleeping and
drinks coffee at night
D. Patient states he gets frequent headaches and
takes aspirin for it
72. Which of the following is an example of an active
listening behavior?
A. Taking frequent notes
B. Asking for more details
C. Leaning in, facing the patient
D. Sitting with legs crossed
73. Which of the following explains why it is important to
have the correct etiology for a nursing diagnosis? The
etiology:
A. is the cause of the problem
B. can not always be observed
C.directs nursing care
D. is an inference
74. Who is the primary decision maker when caring for
healthy adult clients?
A. Physician B. Family C. Patient D. Nurse
75. Which of the following nursing interventions is an
indirect-care intervention?
A. Emotional support C. Consulting
B. Teaching D. Physical care
76. A patient is having difficulty with feelings of self-
loathing and disgust after being attacked and raped.
According to Maslow, which level is the patient
struggling with? 
A. Physiological C. Love & Belonging
B. Safety & Security D. Self-esteem
77. The nurse is talking to a class of children ages 9-12.
For this group, it would be most important for the nurse
to discuss______. 
A. Safe sex practices
B. Healthy food choices
C. Importance of getting enough sleep
D. Use of seat belts and safety equipment
78. The nurse should encourage a group of teenagers to
eat plenty of _______________?
A. Dairy products C. Nuts & Legumes
D. High fiber products
79. A patient tells the nurse, "I can't see well enough to
read anymore. I have new glasses but it is still hard."
What should the nurse advise the patient to do first? 
A. Go back to the eye doctor and have the glasses
checked.
B. Buy some audio books and listen to those.
C. Adapt to reading less.
D. Install a bright, but glare-free light near where you
read.
80. When providing postmortem care, why would the nurse
place dentures in the mouth and close the eyes and
mouth of the patient within 2 to 4 hours after death?
A. To prevent blood from settling in the head, neck, and
shoulders
B. To perform these actions more easily before rigor
mortis develops
C. To set mouth in natural position for viewing by the
family
D. To prevent discoloration caused by blood settling in
the facial area.
81. A client who cannot manage a patient-controlled
analgesia pump is prescribed morphine 4mg IV q 1 hr
PRN for pain. When should the nurse administer the
medication?
A. Every hour around the clock
B. Immediately after taking off the order
C. As needed, but not more than once per hour
D. 1 hour after the last dose administered.
82. Which of the following nursing activities is of highest
priority for maintaining medical asepsis?
A Washing hands
B. Donning gloves
C. Wearing a gown
D. Wearing a face mask
83. Which of the following behaviors indicates the highest
potential for spreading infectious among patients. The
 nurse ___________________ B. Massage the site in a circular motion
A. disinfects dirty hands with antibacterial soap. C. Apply a soothing lotion
B. allows alcohol-based rub to dry for 10 seconds D. Put the patient in a sitting position
C. washes hands only after leaving patients room
D. uses cold water for medical asepsis. 92. When changing a diaper, the nurse observes that a 2
day old infant has a green, black, tarry stool. What
84. Alcohol-based solutions for hand hygiene can be used should the nurse do?
to combat which types of organisms? Select all that A. notify the physician
apply. B. Do nothing, this is normal
A. Virus C. Yeast C. Give the baby sterile water
B. Bacterial Spores D. Mold D. Apply a skin barrier

85. A patient infected with a virus but who does not have 93. A patient suddenly develops right lower quadrant pain,
any outward signs of the disease is considered a: nausea, vomiting. How should the nurse classify this
A. pathogen C. vector patient?
B. fomite D. carrier A. Acute C. Intralatable
B. Chronic D. neuropathic
86. The nurse is instructing a client how to appropriately
dress an infant in cold weather. Which of the following 94. A patient who underwent a left above the knee
instructions would be most appropriate for the nurse to amputation complains of pain in his left foot. What type
include?  of pain is he experiencing?
A. Be sure to put mittens on the baby A. psychogenic
B. Layer the infant's clothing B. phantom
C. Place a cap on the baby's head C. reffered
D. Put warm booties on the baby D. radiating

87. Bathing a patient with liver dysfunction, the nurse notes 95. A patient has an area of non-blancheable erythemia on
yellow skin tone. The nurse should document this his coccyx. The nurse has determined this to be a
finding as: stage I pressure ulcer. What would be the most
A. Edema C. Cyanosis important treatment for this patient?
B. Jaundice D. Pallor A. transparent film dressing
B. sheet hydrogel
88. Where should the nurse assess skin color changes in C. frequent turn schedule
the dark-skinned patient?  D. debridement
A. Nailbeds C. Oral mucosa
B. Any exposed area D. Palm of hands 96. Which electrolyte is the primary regulator of fluid
volume?
89. What is the body's first line of defense against A. potassium
bacteria?  B. calcium
A. intact skin C. immune system C. sodium
B. hair D. lymph glands D. magnesium

90. Before administering medication, the nurse must verify 97. Which of the following terms refers to the ethics
the rights of medication administration which include: questions that arise out of nursing practice?
A. right patient, right room, right drug, right route, right A. nursing ethics
time B. bioethics
B. right drug, right dose, right route, right physician, C. ethical dillema
right time D. moral distress
C. right patient, right drug, right route, right equipment,
right time 98. Which form of communication is the nurse using when
D. right patient, right drug, right dose, right route, right interviewing the patient during the admission health
time, right documentation history and physical assessment?
A. small group
91. Which action should the nurse take to relax the vastus B. interpersonal
lateralis muscle before administering an IM injection C. group
into this site? D. intrapersonal
A. Apply a warm compress
99. The patient refuses chemotherapy based on religious
beliefs. The hospital staff must follow his decision
based on which patient right?

A. The right to counsel

B. The right to informed consent
C. The right to refuse treatment
D. The right to suffer

100.A nurse stops to help in an emergency at at the scene

of an accident. The injured party files a suit and the
nurse's employing institution insurance does not cover
the nurse. What would probably cover the nurse in this
situation?
A. The nurse's auto insurance
B. The nurse's homeowner's insurance
C. The Good Samaritan laws, which grant immunity
from suit if there is no gross negligence. 
D. The Patient Care Partnership, which may grant
immunity from suit if the injured party contends.

----GOOD LUCK!!---