Nursing.Criminology.LET.CSE.

NAPOLCOM
4th Floor Insular Life Bldg. Rizal St. Legazpi City
Take Home Exam: Fundamentals of Nursing 3
Instructions:
1. Choose the best answer and encircle the corresponding letter on the questionnaire.
2. Show your duly accomplished output to iMind Staff on next meeting.

SAFE NURSING PRACTICE

1. A client had an oral surgery following a motor vehicle accident, and the nurse assessing the client
find the skin flushed, warm and diaphoretic. Which of the following would be the best method to
assess the client’s body temperature?
a. Oral c. Forehead temperature strip
b. Axillary d. Rectal
2. The nurse has taught surgical aseptic technique to the family of a surgical client in anticipation of
the family changing the surgical dressings on discharge. The nurse observes a family member
changing the dressing and concludes that further education is needed after observing which
behavior of the family member?
a. Verbally describing to the nurse and client each phase of the dressing change process
while performing it.
b. Checking that sterile dressing packages are intact before opening
c. Opening gauze pads package before putting on sterile gloves
d. Ensuring that the table that will hold the sterile field is dry
3. Which action would the nurse take to use a wide base of support when assisting a client to up
from a chair?
a. Bend at the waist and place arms under the client’s arms and lift.
b. Face the client, bend knees, and place hands on client’s forearms and lift
c. Spread the feet apart before touching the client
d. Tighten the pelvic muscle before assisting the clients
4. The nurse is changing an abdominal dressing for a client. To prevent back injury while learning
over the client, the nurse should do which of the following?
a. Narrow the base of support.
b. Raise the bed to a comfortable position.
c. Move the client to the opposite side of the bed.
d. Position self near the client’s head.
5. Using the principle of standard precautions, the nurse decides to apply gloves when performing
which of the following nursing intervention?
a. Providing the back message c. Providing hair care
b. Feeding a client d. Providing oral hygiene
6. A nurse finds a client unresponsive in bed and is preparing to open the client’s airway. Which of
the following methods to open the airway would be most appropriate to use?
a. The jaw-trust method c. The chest trust method
b. The head tilt-chin lift technique d. The chin to sternum method
7. After correctly positioning a client for a urinary catheterization procedure, the nurse sets up a
sterile field and places the kit supplies on the area. The nurse hears a page to respond to another
client who has fallen in the hallway. Which of the following would be the most appropriate nursing
action?
a. Ensure the client’s safety, cover the field with a sterile towel, and respond to the other
client
b. Continue quickly to the procedure, then assist the other client, checking back with the first
client as soon as possible.
c. Ensure the client’s safety, discard the sterile equipment and respond to the other client.
d. Explain the situation to the client needing catheterization, leave the sterile supplies in
place, and attend to the other client.
8. The nurse is unable to palpate a client’s pedal pulse in an edematous right lower extremity. Which
of the following would be the best action at this time?
a. Notify the physician of the in ability to detect pedal pulse
b. Check the temperature of the lower extremities
c. Use a Doppler to check for the pedal pulse
d. Measure the right leg circumference and compare it to the left
9. Several clients are being admitted to the hospital unit at one time. There is only one private room
available. Which client has the highest priority for being admitted to this private room?
a. A client admitted for elective surgery who requested a private room prior to admission
b. A client with large infected abdominal wound
c. A client who has a communicable respiratory infection
d. A client under the age of 12
10. A nurse is preparing a teaching plan for a family member who will be caring for a client with an
abdominal incision. Which of the following concepts would have the first priority in the teaching
plan?
a. Surgical asepsis
b. Demonstration in sterile gloving technique
c. Hand washing
d. Signs of healing

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BASIC HUMAN NEEDS
11. The family member of an elderly client objects that restraints are being used to prevent the client
from wondering to other clients’ rooms, especially in the evening. In order to avoid the use of
restraints the nurse should consider:
a. Provide visual and auditory stimuli
b. Using anxiety medications as prescribed
c. Assigning client to a room near the nurse’s station
d. Locking the other client’s room
12. A client is hospitalized for the first time. Which of the following actions would be the nurse take to
ensure the safety of the client?
a. Keep unnecessary furniture out of the way
b. Keep lights on all the time
c. Keep side rails up all the time
d. Keep all equipment out of view
13. A client who is unconscious needs frequent mouth care to place the client in which of the following
positions?
a. Fowler’s c. Supine
b. Side-lying d. Trendelenburg
14. The nurse is providing health teaching to the client about life style factors that affect oxygenation.
The most accurate explanation the nurse should include is that:
a. Epinephrine and nor epinephrine released under stress decrease blood pressure and
cardiac rate.
b. Long-term use of alcohol stabilized blood pressure and cardiac functioning
c. Nicotine increase heart rate, blood pressure, and peripheral resistance and produces
vasoconstriction which decrease oxygenation to tissues
d. Physical exercises decrease the depth of respirations and cardiac rate and eventually
lowers the need for oxygen by the tissues
15. A nurse is performing oropharyngeal suctioning on an unconscious client. The nurse should
perform which of the following action? Select all that apply.
a. Insert the catheter approximately 20 cm while applying suction
b. Allow 20 to 30 second intervals between each suction attempt, and limit suctioning to a
total of 15 minutes
c. Gently rotate the catheter while applying suction
d. Apply suction for 5 seconds while inserting the catheter and continue for another 5
seconds before withdrawing
e. Provide oxygen to the client prior to suctioning
16. A client with chest tube is admitted to the nursing unit. The nurse should place the highest priority
during admission on which of the following.
a. Monitoring client’s vital sign, respiratory and cardiovascular status regularly
b. Explaining the importance of deep breathing and coughing regularly
c. Reporting if drainage exceeds 100 ml/hour
d. Placing rubber-tipped clamps, sterile water, and sterile occlusive dressing materials at the
bedside.
17. While doing the physical assessment on a client, the nurse suspect that the client has poor
nutritional status. The nurse concludes that this concern is validated when the nurse observes
which of the following.
a. Delayed wound healing.
b. Firm, smooth pink nails
c. Moist buccal cavity mucous membranes
d. Erect posture
18. The nurse evaluates the result of laboratory test completed on a client. The nurse concludes that
the client may have an abnormality related to nutritional status based on the following values?
a. Blood urea nitrogen (BUN) 15mg/dl
b. Urinary creatinine 800 mg/ 24 hr. in an adult female
c. Albumin 5 grams/ dL
d. Serum potassium 2.4 mEq/L
19. The nurse has taught a client measure to avoid complications associated with urinary elimination.
Which of the following indicates to the nurse that the expected outcome is achieved? The client;
a. Identifies symptoms of and measures to prevent urinary tract infection
b. Is able to perform perineal care by self
c. Maintains proper disposal of urinary output
d. Makes regular tub baths and appropriate personal hygiene measures.
20. A client with a colostomy asks the nurse about types of food that may loosen stool and cause
leakage into the pouch. In order to avoid leakage, the nurse should instruct the client to consume:
a. Asparagus, beans, eggs, fish, onions.
b. Applesauce, bananas, rice, tapioca, yogurt.
c. Fried foods, highly spiced foods, raw fruits and vegetables.
d. Carbonated drinks, fruit juices, greasy and pureed foods.
PAIN
21. An anxious-appearing client with acquired immunodeficiency syndrome (AIDS) tells the nurse that
he has a burning sensation with shooting pain to both feet that is excruciating in nature. The
nurse should interpret this client’s report as indicating:
a. The clients is experience neuropathic pain to the distal lower extremities
b. Psychogenic pain to both feet is accompanied by an anxious appearance.
c. There is referred pain describe as excruciating to the bilateral feet

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 d. Severe phantom pain is present to the feet and is resulting in anxiety
22. A male client is very anxious about the pain he may experience postoperatively. Which
interventions would be most effective in helping him deal with this fear? Select all apply.
a. Teach him relaxation techniques such as deep breathing and guided imagery
b. Explain the availability of pain medications after surgery
c. Demonstrate various positioning techniques that promote post-op comfort.
d. Distract the client from discussing pain by focusing on surgical preparation
e. Encourage the client to verbalize his concern
23. When caring for client receiving epidural morphine (duramorph), the nurse would develop care
plan which nursing diagnosis?
a. Impaired urinary elimination related to polyuria
b. Ineffective breathing pattern related to tachypnea
c. Imbalance nutrition: less than body requirements related to nausea
d. Risk for impaired skin integrity related to pruritis
24. A nurse asks a client to describe the quality of pain currently experienced. The nurse would
anticipate documenting which of the following client symptoms?
a. Severe c. Intermittent
b. Aching d. Chronic
25. The nurse would be evaluate successful client teaching with regard to morphine administration via
patient controlled analgesia (PCA) when the clients makes which statement?
a. “ I will probably use less morphine this way than with taking injections in my hip”
b. “I will get a dose of morphine every time I push the button”
c. “using this device will keep me comfortable all this time”
d. “If I push the control button too often, I may get more medicine than needed”
26. A hospital discharge planning nurse is making arrangement for a client (who has an epidural
catheter for continuous infusion of opioids) to be placed in a long-term care facility has ever cared
for a client with this type of need. What would be the discharge planning nurse’s best action?
a. Ask the physician for an extension of hospitalization until epidural catheter is discontinued
to allow for placement at neighborhood facility.
b. Arrange for staff at the long-term-care facility to receive immediate in-services on pain
management using epidural catheters
c. Explain the situation to client and family and seek another long-term facility for discharge
from the hospital.
d. Encourage family to hire private-duty nurses skilled in epidural catheter pain management
to allow for client transfer to neighborhood facility.
27. Which of the following would be the most appropriate goal statement for teaching a client with
chronic pain how to use visual imagery?
a. Exercise will decrease the need for analgesia
b. Exercise will actively involve the client in his or her own pain management
c. Exercise will decrease pain sensation
d. Exercise will allow for better rest periods.
28. Which of the following clients would require the most frequent reassessment of pain after the
administration of analgesic?
a. An elderly client taking over-the counter (OTC) medication for osteoarthritis
b. A client taking oral narcotics regularly for chronic low back pain
c. A young adult taking medication for frequent migraine headache
d. A child with sickle cell anemia receiving IV analgesia for his or her first pain full crisis
29. A student is caring for a hospitalized client who is requesting medication pain rated as “severe”.
The client is watching television with visitors and is eating. Which statement indicates to the
nurse that the student understands principle of pain management?
a. “ his distraction must not be very effective”
b. “He’s probably anxious being in the hospital”
c. “ if he says he hurts, then he must hurt”
d. “ social stimulation can increase one’s pain”
30. A home health nurse is preparing to apply a fentanyl ( duragesic) transdermal patch to the client’s
upper arm if the client:
a. Had bilateral mastectomies performed a year ago
b. Has minimal hair distribution to this area
c. Has intravenous catheters placed in the hands
d. Uses an over head trapeze bar for feed mobility
PERI-OPERATIVE NURSING
31. A client is being admitted to the hospital on the day before a scheduled surgery. Which of the
following is the most appropriate initial question to ask this pre operative client?
a. “Has your doctor talked to you about the surgery you are having? What did the doctor
say?”
b. “What questions do you have about your surgery?”
c. “What type of surgery are you having and why are you having it done?”
d. “What do you know about what will be done to you?”
32. A pre-surgical clients ask the nurse to more information about the advance of a general
anesthetic. Which of the following would be appropriate for the nurse to include in a response to
the client?
a. Respiratory and circulatory functions are depressed.
b. Client loses consciousness and does not perceive pain
c. Anesthetic is not rapidly excreted so that the timing of surgery can be adjusted.
d. General anesthesia reduces the chance that the client suffers from amnesia

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33. A benzodiazepine has been administered to client preoperatively. After the drug has been
administered, the nurse plan to monitor the client for which side effects? Select all the apply.
a. Anxiety d. Extrapyramidal reactions
b. Hypotension e. Sedation
c. Hypocalcemia
34. A pre operative client has an elevated hemoglobin and hemotocrit. What would the nurse suspect
regarding the significance of this increase value?
a. Immune deficiency c. Malignancy
b. Kidney dysfunction d. Dehydration
35. The nurse has completed pre-operative teaching with a pregnant woman during the discussion,
the nurse describe the different types of anesthesia available. Which statement by the clients
indicates to the nurse an understanding of regional anesthesia?
a. “In spinal anesthesia, the anesthetic is injected into the subarachnoid space”
b. “The anesthetic is injected into the dura matter of the spinal cord for epidural anesthesia”
c. “I will be sedated and have some awareness of the event.”
d. “Regional anesthesia produces analgesia and amnesia”
36. The clients arrive in the postanesthesia care unit (PACU) in an unconscious client in the immediate
post-anesthesia stage?
a. Side lying with the face slightly down
b. Side lying with the pillow under the client’s head
c. Semi-prone position with the head tilted to the side
d. Dorsal recumbent with head turned to the side
37. The client has been in the postanesthesia care unit (PACU) for 1 hour. The client is now groggy
but able to respond to voice commands. While assessing the client, the nurse checks the
bedclothes underneath the client to detect which of the following?
a. Drainage from the tube of drain c. Possible hemorrhage
b. Fluid balance d. Perspiration
38. A client is in the postoperative stage and the physician has ordered ambulation. The client has
difficulty understanding the necessity for early ambulation. The nurse would formulate which
appropriate nursing diagnosis for the client?
a. Self –care deficit c. Ineffective coping
b. Deficient knowledge d. Risk for injury
39. The nurse is assisting the client upon return to the nursing unit from the postanesthesia care unit
(PACU) and notes the presence of drain in the surgical wound. A family member sees the drain
and asks why the tube was left in the wound. The nurse explains that drains;
a. Allow drainage of excessive fluids such as blood, edema, or pus from th surgical site
b. Allow healing to occur at a very rapid rate
c. Have to be shortened to allow healing to occur from the inside out
d. Have to be connected to suction tubes
40. A client is being discharged following outpatient surgery. The nurse who is providing the caregiver
with Instruction for wound care would instruct the care giver to report which finding to the
surgeon?
a. Scar formation c. No odor of the wound drainage
b. Increased redness of drainage d. Slight serious color of the drainage
SKIN INTEGRITY, PERCEPTION AND MOBILITY
41. A client has been on bed rest with cervical traction for 2 weeks. The traction is discontinued and
the client is to ambulate. Prior to getting the client out of the bed, it is important for the nurse to
take which of the following initial actions? Select all that apply.
a. Raise the head of the bed slowly
b. Assess lower leg muscle strength
c. Provide the client with a cane
d. Get a neck brace for a client
e. Take the client’s blood pressure prior to ambulation
42. A 76-year-old client is admitted to the hospital. In planning for client teaching, the nurse would
assess for which condition that is often associated with aging and that is most likely to interfere
with the client’s ability to participate in education activities?
a. Presbyopia c. Presbycusis
b. Conductive hearing loss d. Tinnitus
43. A client who visits the optometrist for an eye exam is told that he has myopia. The client asks the
nurse what the treatment will be. The nurse’s reply would include information about which of the
following standard treatment?
a. Surgical removal c. Glasses or contact lenses
b. Eye drops or ointment d. Oral antibiotics
44. The nurse is performing wound care on pressure ulcer. The doctor orders a wet-to-damp dressing.
A family member asks why the dressing is put on wet. The nurse explains that the purpose of this
type of dressing is to:
a. Protect the wound c. Promote collagen deposit
b. Dilute thick exudates d. Debride the wound
45. The nurse assesses a wound of a client and finds that a scab has formed. The nurse conclude that
this wound is at what point in the phases wound healing?
a. End of the inflammatory phase c. Midpoint of the reparative phase
b. End of the proliferative phase d. Beginning of the maturation phase
46. A client has a large pressure ulcer on his lower extremity. The nurse instructs the client about
nutrients needed for healing, especially vitamin c and protein. While evaluating intake, the nurse

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 determines that the instruction was successful after noting that the client is eating which of the
following breakfast?
a. Coffee, buttered toast with jelly, and bacon
b. Milk, scrambled egg, and cantaloupe
c. Pancakes with butter and syrup and hot tea
d. Oatmeal with butter, diet soda and bacon
47. The nurse is using the Braden scale to assess a client’s risk for developing a pressure ulcer and
calculates a score of 7. The nurse should interpret that this client has level of risk for development
of pressure ulcers?
a. High risk c. Low risk
b. Moderate risk d. Unlikely to develop pressure ulcer
48. During an exercise session with a client who had vascular surgery to the leg, the nurse dorsiflexes
and then plantar flexes the foot. The client looks surprised and asks why the nurse is performing
this activity. What should the nurse include in a response?
a. “Active range of motion will allow the fastest recovery for your leg.”
b. “Passive range of motion will help maintain muscle tone until you can participate more
actively in the exercise.”
c. “Isometric exercise such as this will use muscle to push against resistance and build up
the muscles in your leg.’’
d. “Isotonic exercise lets me do the work and your muscles get the benefit.”
49. Which assessment of the immobilized client would prompt the nurse to take further action?
a. Clients reports fatigue c. White blood cell count of
b. Urinary output of 50 ml/ hour 9500/mm3
d. Hypoactive bowel sounds
50. The nurse is assessing several client would prompt the nurse to take further action/
a. A contusion
b. A wound healing by second intention
c. A septic wound
d. A wound with purulent exudates
MEDICATION ADMINISTRATION AND INTRAVENOUS INFUSION
51. The nurse is caring for several clients for several clients with central venous access device
(CVADs). While changing the tubing on the central line, the nurse would need to do which of the
following? Select all apply.
a. Use strict aseptic technique
b. Use clean technique for the tubing and dressing change.
c. Assess the insertion site for signs of redness and drainage
d. Document the length of the external portion of the catheter
e. Remove any sutures at the insertion site if the lines have been in place more than 5 days.
52. The client is receiving 5% dextrose in 0.45% sodium chloride. The physician has ordered the
client receive one unit of packed red blood cells. Prior to hanging the blood, the nurse will prime
the blood tubing with which of the following solution
a. 5% dextrose d. 5% dextrose in 0.45 sodium
b. Lactated ringer’s chloride
c. 0.9% sodium chloride
53. While assessing client’s intravenous (IV) line, the nurse note that the area is swollen, cool, pale,
and causes the client discomfort. The nurse suspects which of the following problems?
a. Infiltration c. Infection
b. Phlebitis d. Air embolism
54. The client is receiving 5% dextrose in 0.45% sodium chloride intravenously (IV) and reports pain
at the IV site. The nurse assesses the site and notes erythema and edema. What would be the
appropriate action for the nurse to take?
a. Slow the infusion rate
b. Discontinue the IV and apply a warm compress to the IV site
c. Apply antibiotic ointment to the IV site
d. Gently pull back the IV access device to reposition it within the vein
55. The nurse has an order to administer 10 grains of aspirin. The tablets that are available contain
325 mg aspirin per tablet. The nurse would administer how many tablets? Provide a numerical
response rounded to a whole number.
a. 1.5 tab
b. 2 tabs
c. 2.5 tabs
d. 3 tabs

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56. While ad ministering an intramuscular (IM) injection of an analgesic medication, the nurse
aspirates and finds blood in the syringe prior to injecting the medication. Which action by the
nurse would be appropriate?
a. Continue to administer the medication as it would not have a harmful effect
b. Continue to administer the medication as the needle has hit a capillary and would not be
an intravenous administration
c. Withdraw the needle , cleanse the needle and the new injection site with alcohol, and
administer the medication.
d. Withdraw the needle , discard the medication, and prepare another dose
57. The nurse is starting a new peripheral intravenous (IV) line in a client. The client reports a latex
allergy. The nurse has a typical IV start kit for this procedure. Because of the latex allergy, what
action should be the next take
a. Obtain new tourniquet for this client and use standard IV tubing
b. Utilized a blood pressure cuff to distend the vein
c. Avoid putting providone iodine on the skin
d. Suggest an alternative therapy to a peripheral Iv line
58. The nurse has instructed the client in using a metered-dose inhaler. The nurse determines that the
client understands instruction after observing the client doing which of the following?
a. Administering the 2 puffs rapidly between breaths
b. Holding the inhaler 2 inches away from the mouth
c. Not shaking the canister before puffs
d. Exhaling immediately after administering the puff
59. A client is receiving a continuous enteral feeding via a percutaneous endoscopic gastrostomy
(PEG) tube. The physician has ordered phynetoin (dilantin) to be administered to the PEG tube.
The nurse notes that the medication cannot be administered by tube feeding. What action (s)
should the nurse take at this time? Select all apply.
a. Contract prescriber for an order o administer phynetoin by another rout
b. Contract prescriber to change the type of tube feeding to one that is compatible
c. Stop tube feeding for at least 30 minutes before and after administration phynetoin.
d. Stop tube feeding, flush the feeding tube with water, administer phynetoin, flush the tube
feeding again with water, and continue the tube feeding.
e. Flush tube before and after administering the medication
60. An alert, competent client refuses to take her daily antihypertensive medication. The nurse has
explained to the client why medication is important and the clients states she understands but
insist she doesn’t want to take the medication. Which of the following is the best nursing action?
a. Administer the medication anyway because it is important to client
b. Inform the client that the medication must be taken until the nurse gets an order to
discontinue it.
c. Withhold medication and report it to the prescriber
d. Withhold medication and complete an incident report

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