Title POST TEST - FUNDA (DR. IRAY) SC ✅

TOP RANK REVIEW ACADEMY, INC. Page 1 | COMPREHENSIVE PHASE POST TEST FUNDAMENTALS OF NURSING Prepared By: Dr. Aleni E. Iray, R.N., M.D. NOV 2024 Philippine Nurse Licensure Examination Review 1. Jessie is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jessie is tachypneic. The nurse understands that tachypnea means: A. Pulse rate greater than 100 beats per minute B. Blood pressure of 140/90 C. Respiratory rate greater than 20 breaths per minute D. Frequent bowel sounds 2. The nurse listens to Mrs. Santo’s lungs and notes a hissing sound or musical sound. The nurse documents this as: A. Wheezes B. Rhonchi C. Gurgles D. Vesicular 3. The nurse in charge measures a patient’s temperature at 101 degrees F. What is the equivalent centigrade temperature? A. 36.3 degrees C B. 37.95 degrees C C. 40.03 degrees C D. 38.01 degrees C 4. Which approach to problem solving tests any number of solutions until one is found that works for that particular problem? A. Intuition B. Routine C. Scientific method D. Trial and error 5. What is the order of the nursing process? A. Assessing, diagnosing, implementing, evaluating, planning B. Diagnosing, assessing, planning, implementing, evaluating C. Assessing, diagnosing, planning, implementing, evaluating D. Planning, evaluating, diagnosing, assessing, implementing 6. During the planning phase of the nursing process, which of the following is the outcome? A. Nursing history B. Nursing notes C. Nursing care plan D. Nursing diagnosis 7. What is an example of a subjective data? A. Heart rate of 68 beats per minute B. Yellowish sputum C. Client verbalized, “I feel pain when urinating.” D. Noisy breathing 8. Which expected outcome is correctly written? A. “The patient will feel less nauseated in 24 hours.” B. “The patient will eat the right amount of food daily.” C. “The patient will identify all the high-salt food from a prepared list by discharge.” D. “The patient will have enough sleep.” 9. Which of the following behaviors by Nurse Jane Robles demonstrates that she understands well the elements of effecting charting? A. She writes in the chart using a no. 2 pencil. B. She noted: appetite is good this afternoon. C. She signs on the medication sheet after administering the medication. D. She signs her charting as follow: J.R 10. What is the disadvantage of computerized documentation of the nursing process? A. Accuracy B. Legibility C. Concern for privacy D. Rapid communication 11. The theorist who believes that adaptation and manipulation of stressors are related to foster change is: A. Dorothea Orem B. Sister Callista Roy C. Imogene King D. Virginia Henderson 12. Formulating a nursing diagnosis is a joint function of: A. Patient and relatives B. Nurse and patient C. Doctor and family D. Nurse and doctor 13. Mrs. Caperlac has been diagnosed to have hypertension since 10 years ago. Since then, she had maintained low sodium, low fat diet, to control her blood pressure. This practice is viewed as: A. Cultural belief B. Personal belief C. Health belief D. Superstitious belief 14. Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated. Which of the following is an expected response? A. Low blood pressure B. Warm, dry skin C. Decreased serum sodium levels D. Decreased urine output 15. What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection? A. Use sterile gloves when obtaining urine. B. Open the drainage bag and pour out the urine. C. Disconnect the catheter from the tubing and get urine. D. Aspirate urine from the tubing port using a sterile syringe. 16. A client is receiving 115 ml/hr of continuous IVF. The nurse notices that the venipuncture site is red and swollen. Which of the following interventions would the nurse perform first? A. Stop the infusion B. Call the attending physician C. Slow that infusion to 20 ml/hr D. Place a clod towel on the site 17. The nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do? A. Leave the medication at the bedside and leave the room. B. After few minutes, return to that patient’s room and do not leave until the patient takes the medication. * NLE * NCLEX * HAAD * PROMETRICS * DHA * MIDWIFERY * LET * RAD TECH * CRIMINOLOGY * DENTISTRY * PHARMACY * MED TECH
TOP RANK REVIEW ACADEMY, INC. Page 2 | C. Instruct the patient to take the medication and leave it at the bedside. D. Wait for the patient to return to bed and just leave the medication at the bedside. 18. Which of the following is inappropriate nursing action when administering NGT feeding? A. Place the feeding 20 inches above the pint if insertion of NGT. B. Introduce the feeding slowly. C. Instill 60ml of water into the NGT after feeding. D. Assist the patient in fowler’s position. 19. A female patient is being discharged after thyroidectomy. After providing the medication teaching. The nurse asks the patient to repeat the instructions. The nurse is performing which professional role? A. Manager B. Caregiver C. Patient advocate D. Educator 20. Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68-year-old woman hospitalized due to Pneumonia? A. Oriented to date, time and place B. Clear breath sounds C. Capillary refill greater than 3 seconds and buccal cyanosis D. Hemoglobin of 13 g/dl 21. During a change-of-shift report, it would be important for the nurse relinquishing responsibility for care of the patient to communicate. Which of the following facts to the nurse assuming responsibility for care of the patient? A. That the patient verbalized, “My headache is gone.” B. That the patient’s barium enema performed 3 days ago was negative C. Patient’s NGT was removed 2 hours ago D. Patient’s family came for a visit this morning. 22. Which statement is the most appropriate goal for a nursing diagnosis of diarrhea? A. “The patient will experience decreased frequency of bowel elimination.” B. “The patient will take anti-diarrheal medication.” C. “The patient will give a stool specimen for laboratory examinations.” D. “The patient will save urine for inspection by the nurse. 23. Which of the following is the most important purpose of planning care with this patient? A. Development of a standardized NCP. B. Expansion of the current taxonomy of nursing diagnosis C. Making of individualized patient care D. Incorporation of both nursing and medical diagnoses in patient care 24. Using Maslow’s hierarchy of basic human needs, which of the following nursing diagnoses has the highest priority? A. Ineffective breathing pattern related to pain, as evidenced by shortness of breath. B. Anxiety related to impending surgery, as evidenced by insomnia. C. Risk of injury related to autoimmune dysfunction D. Impaired verbal communication related to tracheostomy, as evidenced by inability to speak. 25. When performing an abdominal examination, the patient should be in a supine position with the head of the bed at what position? A. 30 degrees B. 90 degrees C. 45 degrees D. 0 degree 26. A male client undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. Nurse Trish first response is to: A. Call the physician B. Place a saline-soaked sterile dressing on the wound. C. Take a blood pressure and pulse. D. Pull the dehiscence closed. 27. Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne- Strokes respirations. Cheyne-strokes respirations are: A. A progressively deeper breaths followed by shallower breaths with apneic periods. B. Rapid, deep breathing with abrupt pauses between each breath. C. Rapid, deep breathing and irregular breathing without pauses. D. Shallow breathing with an increased respiratory rate. 28. Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are: A. Tracheal B. Fine crackles C. Coarse crackles D. Friction rubs 29. The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and breath sounds aren’t audible. The reason for this change is that: A. The attack is over. B. The airways are so swollen that no air can get through. C. The swelling has decreased. D. Crackles have replaced wheezes. 30. Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should: A. Place the client on his back remove dangerous objects, and insert a bite block. B. Place the client on his side, remove dangerous objects, and insert a bite block. C. Place the client o his back, remove dangerous objects, and hold down his arms. D. Place the client on his side, remove dangerous objects, and protect his head. 31. After insertion of a cheat tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for? A. Infection of the lung. B. Kinked or obstructed chest tube C. Excessive water in the water-seal chamber D. Excessive chest tube drainage 32. Nurse Maureen is talking to a male client, the client begins choking on his lunch. He’s coughing forcefully. The nurse should: A. Stand him up and perform the abdominal thrust maneuver from behind. B. Lay him down, straddle him, and perform the abdominal thrust maneuver. C. Leave him to get assistance D. Stay with him but not intervene at this time. 33. Nurse Ron is taking a health history of an 84 year old client. Which information will be most useful to the nurse for planning care? A. General health for the last 10 years. B. Current health promotion activities. C. Family history of diseases. D. Marital status. 34. When performing oral care on a comatose client, Nurse Krina should: A. Apply lemon glycerin to the client’s lips at least every 2 hours. B. Brush the teeth with client lying supine. C. Place the client in a side lying position, with the head of the bed lowered. D. Clean the client’s mouth with hydrogen peroxide. 35. A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He’s being hydrated with L.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F (39.4°C) a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may have which of the following conditions? A. Adult respiratory distress syndrome (ARDS) B. Myocardial infarction (MI) C. Pneumonia
TOP RANK REVIEW ACADEMY, INC. Page 3 | D. Tuberculosis 36. Nurse Oliver is working in a out patient clinic. He has been alerted that there is an outbreak of tuberculosis (TB). Which of the following clients entering the clinic today most likely to have TB? A. A 16-year-old female high school student B. A 33-year-old day-care worker C. A 43-yesr-old homeless man with a history of alcoholism D. A 54-year-old businessman 37. Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is aware that which of the following reasons this is done? A. To confirm the diagnosis B. To determine if a repeat skin test is needed C. To determine the extent of lesions D. To determine if this is a primary or secondary infection 38. Kennedy with acute asthma showing inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated with which of the following classes of medication right away? A. Beta-adrenergic blockers B. Bronchodilators C. Inhaled steroids D. Oral steroids 39. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema and cyanotic nail beds. Based on this information, he most likely has which of the following conditions? A. Adult respiratory distress syndrome (ARDS) B. Asthma C. Chronic obstructive bronchitis D. Emphysema Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia. 40. The treatment for patients with leukemia is bone marrow transplantation. Which statement about bone marrow transplantation is not correct? A. The patient is under local anesthesia during the procedure B. The aspirated bone marrow is mixed with heparin. C. The aspiration site is the posterior or anterior iliac crest. D. The recipient receives cyclophosphamide (Cytoxan) for 4 consecutive days before the procedure. 41. After several days of admission, Francis becomes disoriented and complains of frequent headaches. The nurse in-charge first action would be: A. Call the physician B. Document the patient’s status in his charts. C. Prepare oxygen treatment D. Raise the side rails 42. During routine care, Francis asks the nurse, “How can I be anemic if this disease causes increased my white blood cell production?” The nurse in-charge best response would be that the increased number of white blood cells (WBC) is: A. Crowd red blood cells B. Are not responsible for the anemia. C. Uses nutrients from other cells D. Have an abnormally short life span of cells. 43. Diagnostic assessment of Francis would probably not reveal: A. Predominance of lymhoblasts B. Leukocytosis C. Abnormal blast cells in the bone marrow D. Elevated thrombocyte counts 44. Robert, a 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency embolectomy. Six hours later, the nurse isn’t able to obtain pulses in his left foot using Doppler ultrasound. The nurse immediately notifies the physician, and asks her to prepare the client for surgery. As the nurse enters the client’s room to prepare him, he states that he won’t have any more surgery. Which of the following is the best initial response by the nurse? A. Explain the risks of not having the surgery B. Notifying the physician immediately C. Notifying the nursing supervisor D. Recording the client’s refusal in the nurses’ notes 45. During the endorsement, which of the following clients should the on-duty nurse assess first? A. The 58-year-old client who was admitted 2 days ago with heart failure, blood pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/minute. B. The 89-year-old client with end-stage right-sided heart failure, blood pressure of 78/50 mm Hg, and a “do not resuscitate” order C. The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving L.V. heparin D. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem) 46. Honey, a 23-year old client complains of substernal chest pain and states that her heart feels like “it’s racing out of the chest”. She reports no history of cardiac disorders. The nurse attaches her to a cardiac monitor and notes sinus tachycardia with a rate of 136beats/minutes. Breath sounds are clear and the respiratory rate is 26 breaths/minutes. Which of the following drugs should the nurse question the client about using? A. Barbiturates B. Opioids C. Cocaine D. Benzodiazepines 47. A patient is admitted to the medical surgical unit following surgery. Four days after surgery, the patient spikes a 38.9 degrees C oral temperature and exhibits a wet, productive cough. The nurse assesses the patient with understanding that an infection that is acquired during hospitalization is known as: A. community acquired infection B. an iatrogenic infection C. a nosocomial infection D. an opportunistic infection 48. A client with anemia has a hemoglobin of 6.5 g/dL. The client is experiencing symptoms of cerebral tissue hypoxia. Which of the following nursing interventions would be most important in providing care? A. Providing rest periods throughout the day B. Instituting energy conservation techniques C. Assisting in ambulation to the bathroom D. Checking temperature of water prior to bathing 49. A client was involved in a motor vehicular accident in which the seat belt was not worn. The client is exhibiting crepitus, decrease breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34 breaths per minute. Which of the following assessment findings would concern the nurse most? A. Temperature of 102 degrees F and productive cough B. ABG with PaO2 of 92 and PaCO2 of 40 mmHg C. Trachea deviating to the right D. Barrel-chested appearance 50. The proper way to open an envelop-wrapped sterile package after removing the outer package or tape is to open the first position of the wrapper: A. away from the body B. to the left of the body C. to the right of the body D. toward the body 51. Nurse Clementine was assessing a patient’s priority nursing needs. She has been employed in Toprank Medical Center for 4 years now. Under Patricia Benner’s Ladder of Clinical Proficiency, At which stage does nurse Clementine belong? A. Advance Beginner B. Proficient C. Competent D. Expert 52. When a client has a retention catheter, the nurse is expected to: A. Clean the urinary meatus and adjascent skin periodically. B. Encourage liberal amount of fluid intake. C. Flush the catheter as needed. D. Perform perineal flushing as needed.
TOP RANK REVIEW ACADEMY, INC. Page 4 | 53. When considering the safety needs of a client with a urinary catheter, which of the following should the nurse observe? A. Keep a closed sterile drainage system. B. Irrigate catheter daily C. Keep the bag lower than the bed. D. Measure intake and output daily. 54. A client practices Islam and his diet must consider his religious practices and beliefs. You are aware that this client would avoid which of the following food? 1. Shrimps and crabs 2. Wine and alcoholic drinks 3. Fish with scales. 4. Pork products like bacon 5. Caffeinated products like cola drinks. A. 2, 4, and 5 B. 3, 4 and 5 C. 1, 4 and 5 D. 1, 2 and 4 55. When the nurse assist the client to identify and cope with stressful emotional problems of the nurse is assuming the role of: A. advocate B. Teacher C. Counselor D. Leader 56. The expanded role of the nurse acquired after specialized training and credentialing is described as: A. Primary care nurse B. Private duty nurse C. Clinical nurse specialist D. Visiting nurse 57. When the hospital director gives the nurse a position of authority within a formal organization, she assumes the role of: A. Manager B. Advocate C. Leader D. Teacher 58. The nurse uses his interpersonal skills to guide the client in making decisions about his health care acting the role of: A. Leader B. Advocate C. Liaison D. Counselor 59. In nutrition education, your targeted participants include all EXCEPT: A. Food handlers B. Young children C. Food service people D. Mothers 60. What kind of dressing and grooming would the nurse do for a client who is semi-dependent? A. Client dresses self and nurse supervises. B. Nurse dresses client and assist in zipping or buttoning clothing. C. Nurse combs client’s hair and assists with dressing. D. Nurse gathers the items for the client and client dresses self. Nurse may button, tie, or zip clothing. 61. While the nurse is giving a sponge bath to the client, what action can facilitate venous blood flow? A. Rubbing with long smooth strokes from the distal to the proximal parts of the extremities. B. Circular massage strokes from the distal to the proximal parts of the body. C. Rubbing with short smooth strokes from the proximal to distal parts of the extremities. D. Smooth long strokes alternating with chopping motions on the limbs. 62. The client is for occult blood test. Which of the following statement would indicate to the nurse that the client understood the instructions for occult blood test preparation. A. “I will avoid all types of meat.” B. “I will refrain from eating dark colored foods for a day.” C. I shouldn’t smoke. D. I will avoid aquamephyton. 63. A nurse is caring for a client following a bronchoscopy. Which sign if noted in the client should be reported immediately? A. Blood streaked sputum B. Dry cough C. Hematuria D. Stridor 64. All of the following except one are done to assess the scrotum. A. palpation B. auscultation C. percussion D. inspection 65. The nurse inspects a patient’s pupil size and determines a result of OD = 2mm and OS = 3mm. Unequal pupils are known as: A. Enteric B. Diplopia C. Anecteric D. Anisocoria 66. Using Maslow’s Hierarchy of human needs. Which of the following nursing diagnoses has the highest priority? A. Anxiety related to impending surgery, as evidenced by insomnia. B. High risk for impaired tissue perfusion (decrease blood supply) related to hemorrhage C. Ineffective breathing pattern related to pain, as evidenced by shortness of breath D. Ineffective airway clearance related to dyspnea as evidenced by impaired tissue perfussion 67. A client who will have mastectomy expresses sadness about losing her breast. The most appropriate nursing diagnosis is: A. Ineffective Individual Coping B. Anticipatory Grieving C. Knowledge deficit D. Fear 68. The nurse performs a neurologic exam on a patient. After the exam which of the following should be recorded as objective data? A. + 4 Patellar reflexes on both the patient’s legs B. Patient’s description of ringing in his ears C. Patient’s sensations of numbness in his right arm D. Patient’s statement, “The room is spinning” 69. Which of the following nursing diagnoses is in PES format? A. Fluid volume deficit related to prolonged vomiting B. Risk for impaired skin integrity as manifested by poor skin turgor and old age C. Ineffective airway clearance related to retained secretions as manifested by infectious process D. Self-esteem disturbance related to rejection by the husband as manifested by crying and isolation. 70. When the arm is above the heart, what will be the result of the BP reading? A. False High B. False Low C. Undetermind D. Slightly increased by 2-3 mmHg 71. Which nursing role does the nurse performs when she provides health teaching to effect behavior change w/c focuses on acquiring new knowledge or technical skills.