Tiêu đề EVAL EXAM - FUNDA (KEY) ✅

REFRESHER PHASE EVALUATIVE EXAM FUNDAMENTALS OF NURSING NOV 2024 Philippine Nurse Licensure Examination Review 1. Which method is the best for the nurse to evaluate the effectiveness of tracheal suctioning? A. Note subjective data such as, “My breathing is much improved now.” B. Note objective findings such as decreased respiratory rate and pulse. C. Consult with respiratory therapist to determine effectiveness. D. Auscultate the chest for change or clearing in adventitious breath sounds. 2. Which of the following statements contains one of the basic rules to follow when caring for a client with a chest tube and water-seal drainage system? A. Ensure that the air vent on the water-seal drainage system is capped when the suction is off B. Strip the chest and drainage tubes at least every 4 hours if excessive bleeding occurs C. Ensure that the collection and suction bottles are at the client’s chest level at all times D. Ensure that the collection and suction bottles are below the client’s chest level at all times 3. Nurse Nikka is teaching a client on how to properly use an incentive spirometry to a client. Teaching is effective if which of the following sequence is observed; A. The client holds the spirometry in upright position, exhales normally, seal the lips tightly around the mouthpiece, takes a slow deep breath and hold breath for 2 seconds to keep the balls elevated. B. Exhales normally, hold the spirometer upright, seals the mouthpiece, takes a fast shallow breath and holds breath for 5 seconds to keep the balls elevated. C. Holding the spirometer above the head, seal the mouthpiece, and exhaling slowly for 3 seconds D. Holding the spirometer above the head, seal the mouthpiece around the lips, and holding breath for a while. 4. The nurse finds a container with the client’s urine specimen sitting on a counter in the bathroom. The client states that the specimen has been sitting in the bathroom at least 2 hours. What would be the nurse’s most appropriate action? A. Discard the urine and obtain a new specimen B. Send the urine to the laboratory as quickly as possible C. Add fresh urine to the collected specimen and send the specimen to the laboratory D. Place the specimen in the refrigerator until it can be transported to the laboratory 5. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? A. void a little, clean the meatus, then collect specimen B. clean the meatus, begin voiding, then catch urine stream C. clean the meatus, then urinate into container D. void continuously and catch some of the urine 6. Complications associated with a tracheostomy tube include: A. Decreased cardiac output B. Damage to the laryngeal nerve C. Pneumothorax D. Respiratory distress syndrome 7. A nurse is preparing to feed the client with mild dysphagia. The nurse would do which of the following to assist the client with swallowing? A. Place the food on the tip of the client’s tongue B. Provide foods that have a soft consistency C. Use water to help the client swallow food in the mouth D. Place the equivalent of 30 ml of food on the fork 8. A nurse is to collect a sputum specimen for culture and sensitivity from a client. Which action should the nurse take first? A. Assist with oral hygiene B. Ask client to cough sputum into container C. Have the client take several deep breaths D. Provide an appropriate specimen container 9. What is the priority of care after the urinary catheter is removed? A. Encourage the client to eliminate fluid intake. B. Document size of catheter and client’s tolerance of procedure. C. Evaluate the client for normal voiding. D. Documentation of client’s teaching 10. A client has a tracheostomy tube. The nurse knows that the obturator is kept at the client’s bedside because: A. The obturator is kept at the client’s bedside in case the tube becomes dislodged and needs to be reinserted. B. The obturator is a guide in inserting the tube. C. The obturator, after insertion, will be kept by the client. D. The obturator will be used to make an opening for the tube 11. Applying suction in the nasopharynx for too long may cause secretions to increase or decrease, therefore the nurse should: A. Allow 20 to 30 second intervals between each suction, limit suctioning to 5 minutes in total B. Allow 2 to 3 minutes between suction when possible C. Allow 5 minutes between each suction D. Allow 1 to 2 minutes between each suction 12. The following nursing interventions are appropriate for a nursing diagnosis of Ineffective Airway Clearance related to obesity EXCEPT? A. Diversional Activity B. Start weight reduction C. Place patient in high Fowler’s position D. Have client cough & deep breathe every 2 hours while wake 13. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative care includes daily urine specimen to be sent to the laboratory. Imelda has a foley catheter to a urinary drainage system. How will you collect the urine specimen? A. Remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container B. Empty a sample urine from the collecting bag into the specimen container C. Disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the specimen container. TOP RANK REVIEW ACADEMY, INC. Page 1 | 3
D. Disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into the specimen container. 14. While the client has pulse oximeter on his fingertip, you notice that the sunlight is shinning on the area where the oximeter is : Your action will be to: A. Set and turn on the alarm of the oximeter B. Do nothing since there is no identified problem C. Cover the fingertip sensor with a towel or bedsheet D. Change the location of the sensor every four hours 15. Nurse Jane evaluates a client with diagnosis of dehydration to have which of the following specific gravity reading? A. 1.000 B. 1.017 C. 1.023 D. 1.035 16. While you were making endorsement, you found out the chest tube of a client was disconnected. What would be your appropriate action? A. Assit the client back to his bed and place him on the affected side B. Cover the end of the chest tube with sterile gauze C. Reconnect the tube to the chest tube system D. Put the end of the chest tube into a cup of sterile normal saline 17. Organize the following steps of suctioning in chronological order: 1. Put on sterile glove. 2. Lubricate catheter with normal saline 3. Apply suction for 5-10sec. 4. Explain procedure to client. 5. Wash hands thoroughly. A. 54132 B. 45213 C. 54123 D. 45132 18. The primary reason in teaching pursed-lip breathing to persons with emphysema is to help: A. Promote oxygen intake B. Strengthen the diaphragm C. Strengthen the intercostals muscles D. Promote carbon dioxide elimination 19. During an assessment, the nurse expects that the average daily urinary output for the adult client will be: A. 500 to 1000ml B. 700 to 1500ml C. 1200 to 1500ml D. 2000 to 3000ml 20. What position will the nurse recommend to the patient during TPN administration? A. High Fowler’s position B. Trendelenberg C. Semi-Fowler’s Position D. Left sims lateral 21. Which of the following techniques is considered the best way to determine whether a nasogastric tube is positioned in the stomach? A. Aspirating with a syringe and checking pH of gastric contents B. Irrigating with normal saline and observing for the return of the solution C. Placing the tube’s free end in water and observing for air bubbles D. Instilling air and auscultating over the epigastric area for the presence of the tube 22. An appropriate technique for nasogastric tube insertion is for the nurse to: A. Position the client supine B. Ice the plastic tube C. Advance the tube while the client swallows D. Measure the tube length from the nose to the sternum 23. A nurse informs a client that the alarm on the pulse oximeter will not sound when: A. The client moves the probe B. The probe falls off C. The SpO2 falls below the set limit D. The display reaches full strength during each cardiac cycle 24. A postoperative client is on a clear liquid diet, what of the following are allowed on a clear liquid diet? A. Ice cream, butter, yoghurt, vegetable juices B. Mashed potatoes, fish, bananas, vegetable juices C. Gelatin, hard candy, tea, popsicles D. Milk, gelatin, canned fruits, bread 25. A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action? A. Discharge the client from home health care related to noncompliance B. Notify the health care provider of the client's failure to follow prescribed diet C. Discuss diet with the client to learn the reasons for not following the diet D. Make a referral to Meals-on-Wheels 26. Which of the following is most likely to yield accurate information about the quality of patient’s pain? A. “Tell me, what your pain feels like.” B. “Would you describe your pain as radiating? Acute or sharp?” C. Tell, how would you rate your pain in a scale to 1 to 5” D. “What events seemed to increase your pain?” 27. The physician orders a urine culture and sensitivity for a 36-year old patient with an indwelling Foley catheter. Which of the following action by the nurse is best? A. The nurse clamps the catheter tubing below the level of the port for 1 hour. B. The nurse removes 20ml from the catheter bag and places it in a sterile container. C. The nurse separates the catheter from the tubing and allows 30ml of urine to drain into a sterile cup. D. The nurse clamps the catheter just below the insertion site for 20 minutes 28. Which of the following measures should the nurse perform in relation to suctioning a tracheostomy tube? A. Apply suction while inserting the suction catheter into the tube B. Change the tracheostomy tube after suctioning the client C. Select a suction catheter that approximates the diameter of the tracheostomy tube D. Hyperoxygenate before suctioning the client 29. Assessment of the proper functioning of an oxygen device includes: A. No mist in the face tent B. The reservoir of the rebreathing mask collapsing on inhalation C. A flow rate between 1 and 6L/min for the nasal cannula D. The nasal cannula positioned below the nares 30. After suctioning a client’s tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse would use intermittent suction primarily to help prevent: A. Stimulating the client’s cough reflex B. Depriving the client of sufficient oxygen supply C. Dislocating the tracheostomy rube D. Obstructing the suctioning catheter with secretions 31. The nurse doing the health teaching to a client for testing feces for occult blood informs the client about what can produce false positive results: What should the nurse emphasize? A. If you have eaten red meat or raw radishes and melons, in the last couple of days, the test may be positive and it may be inaccurate. B. If you have taken more then 250 mg of vitamin C, it may produce a reading that is too high but is inaccurate. C. If you have recently eaten any colored vegetables, it may color the stool and produce an inaccurate test result. D. If you have been drinking tea, the result might be elevated. 32. Dr. Black Daclis asked you to assist him with the removal of jeld’s chest tube. You would instruct the client to: TOP RANK REVIEW ACADEMY, INC. Page 2 | 3
A. A continuously breathe normally during the normal of the chest tube B. Take a deep breath, exhale, and bear down C. Exhale upon the actual removal of the tube D. Hold breath until the chest tube is pulled out 33. A nurse suctioning a client through a tracheotomy tube. The nurse plans to apply suction during the withdrawal of the catheter for a period of time no greater than? A. 10 seconds B. 15 seconds C. 20 seconds D. 30 seconds 34. A nurse is performing oropharyngeal suctioning on the unconscious client. Which of the following actions is safe? A. Insert the catheter approximately 20 cm while applying suction. B. Allow 20 to 30 second intervals between each suction, and limit suctioning to a total of 15 minutes. C. Gently rotate the catheter while applying suction. D. Apply suction for 5 minutes while inserting and continue for another 5 seconds before withdrawing. 35. You attached a pulse oximeter to the client. You know that the purpose is to: A. Determine if the client’s hemoglobin is low and if he needs blood transfusion B. Check level of client’s tissue perfusion C. Measure the efficacy of the client’s anti-hypertensive medications D. Detect oxygen saturation of arterial blood before a symptoms of hypoxemia develops 36. A nurse has an order to obtain 24-hour urine collection on a client with renal disorder. The nurse avoids which of the following to ensure proper collection of the 24-hour urine specimen? A. have the client void at the start time, and place he specimen in the container B. discard the first voiding, and save all subsequent voiding during 24-hour time period C. place the container on ice or refrigerator D. have the client void at the end time, and place the specimen in a container 37. The health care provider order reads "aspirate nasogastric feeding (NG) tubes every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? A. Apply intermittent suction to the feeding tube B. Hold the tube feeding and notify the provider C. Administer the tube feeding as scheduled D. Irrigate the tube with diet cola soda 38. The physician orders nasogastric tube insertion to irrigate a client’s stomach. Which of the following insertion techniques would most likely make it more difficult for the nurse to insert the tube? A. Lubricating the tube with water-soluble lubricant B. Asking the client to swallow while the tube is advanced to the stomach C. Sitting the client upright in a Fowler’s position D. Having the client tilt the head toward the chest while inserting the tube into the nose. 39. The nurse collects a urine specimen for routine urinalysis from a client. She is aware that: A. A sterile specimen is required B. Standing at room temperature for a prolonged period may alter the urine chemistry C. The external meatus should be cleaned with antiseptic soap and water before voiding. D. A clean-catch, midstream specimen is required 40. The nurse is cleaning the incision site and tube flange of a client with tracheostomy. A sterile applicator soaked in what solution is used in removing crusty secretions? A. Isopropyl alcohol B. Hydrogen peroxide C. Hydrogen peroxide D. Ammonia 41. The correct pressure of the wall suction unit when suctioning a child patient is? A. 95 – 100mg Hg B. 50 – 95 mm Hg C. 100 – 120mm Hg D. 10 – 15mm Hg 42. Tracheostomy tubes used among adults often have cuffs. This inflatable cuff functions by: A. Producing an airtight seal to prevent aspiration of oropharyngeal secretions and air leakage B. Anchoring the tube in place C. Distributing a low even pressure over the trachea D. A guide for easy removal of the tracheostomy tube 43. What position will the nurse recommend to the patient during NGT insertion? A. Semi-Fowler’s Position B. Trendelenberg C. High Fowler’s position D. Left sims lateral 44. The most concentrated source of energy in the body is: A. Protein B. Carbohydrates C. Fat D. Macro minerals 45. Which of the following most appropriately describe pain sensations that has periods of remission and exacerbation? A. Acute B. Chronic C. Intractable D. Neuropathic 46. A client who requires a central vein access for parenteral nutrition is to receive a solution with: A. Fat emulsion B. 5% dextrose C. Amino acids D. 10% dextrose 47. You are obtaining a history of Jessie D. who is admitted with acute chest pain. Which question will be most helpful for you to ask? A. Why do you think you had a heart attack? B. Do you need anything now? C. What were you doing when the pain started? D. Has anyone in your family been sick lately? 48. The nurse is caring for a client who has been admitted to the hospital with a diagnosis of malnutrition. The nurse most effectively monitors the client’s status by which measure? A. Intake measurement B. Calorie counts C. Skinfold measurements D. Daily weights 49. The nurse is caring for a group of adult patients who require pain management. It is most important for the nurse to remember: A. to use medication only as a last resort after trying to distract the patient B. that medicating a patient with chronic pain is a lower priority than medicating a patient with acute pain. C. that medication should be given based on the patient’s perception of pain. D. to wait for 15 minutes after a patient’s request for pain medication to be sure the pain is real. 50. For a client with CAL, a nurse anticipates the use of oxygen equipment? A. Face tent B. Face mask C. Nasal cannula D. Nonbreathing mask TOP RANK REVIEW ACADEMY, INC. Page 3 | 3