Tiêu đề 2. FC FUNDA (Dr. Iray) - SC ✅

1 | Page FINAL COACHING FUNDAMENTALS OF NURSING Prepared by: Dr. Aleni Iray, MD, RN November 2025 Philippine Nurse Licensure Examination Review NAME: DATE: SCORE: _____ “FIRST TAKER AKO, AT LAST TAKE KO NA ‘TO! 1. In the dermatology clinic, Nurse Des is about to administer an intradermal injection for allergy testing. She knows the importance of choosing the right needle gauge for accuracy and patient comfort. Which of the following needle gauges is most appropriate for intradermal injections? A. Gauge 22 B. Gauge 25 C. Gauge 26 D. Gauge 20 2. When preparing the epinephrine injection from an ampule, Nurse Andrae initially: A. Taps the ampule at the top to allow fluid to flow to the base of the ampule B. Checks expiration date of the medication ampule C. Removes needle cap of syringe and pulls plunger to expel air D. Breaks the neck of the ampule with a gauze wrapped around it 3. Mrs. David is obese. When administering a subcutaneous injection to an obese patient, it is best for Nurse Andrae to: A. Inject needle at a 15 degree angle' over the stretched skin of the client B. Pinch skin at the Injection site and use airlock technique C. Pull skin of patient down to administer the drug in a Z track D. Spread skin or pinch at the injection site and inject needle at a 45-90 degree angle 4. When preparing for a subcutaneous injection, the proper size of syringe and needle would be: A. Syringe 3-5ml and needle gauge 21 to 23 B. Tuberculin syringe 1 ml with needle gauge 26 or 27 C. Syringe 2ml and needle gauge 22 D. Syringe 1-3ml and needle gauge 25 to 27 SITUATION. Frank has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Mario's nursing care plan is to loosen and remove excessive secretions in the airway. 5. Nurse Mario knows he can perform chest physiotherapy: A. Immediately before meals B. One hour after meals C. During meals D. Before bedtime 6. When assessing Frank for chest percussion or chest vibration and postural drainage Mario would focus on the following, EXCEPT: A. Amount of food and fluid taken during the last meal before treatment B. Respiratory rate, breath sounds and location of congestion C. Teaching the client's relatives to perform 'the procedure D. Doctor's order regarding position restriction and client's tolerance for lying flat SITUATION. Using Maslow's need theory, Airway, Breathing and Circulation are the physiological needs vital to life. The nurse's knowledge and ability to identify and immediately intervene to meet these needs is important to save lives. 7. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues: A. Carol with a tumor in the brain B. Theresa with anemia C. Sonny Boy with a fracture in the femur D. Brigette with diarrhea 8. To determine how long the nasogastric tube must be to reach the stomach of the patient, the nurse should hold the end of the tube: A. From the tip of the nose to the base of the neck B. From the tip of the nose to the middle of the cheek to the xiphoid process C. From the tip of the nose to the tip of the ear lobe to the xiphoid process D. Eight to ten inches from the tip of the nose to the sternum SITUATION. Mrs. Sales, 49 years old, asks you about possible problems regarding her elimination now that she is in the menopausal stage. 9. Instruction on health promotion regarding urinary elimination is important. Which would you include? A. Hold urine, as long as she can before emptying the bladder to strengthen her sphincters muscles B. If burning sensation is experienced while voiding, drink cola C. After urination, wipe from anal area up towards the pubis D. Tell client to empty the bladder at each voiding 10. Mrs. Sales asked for instructions for skin care for her mother who has urinary incontinence and is almost always in bed. Your instruction would focus on prevention of skin irritation and breakdown by: A. Using thick diapers to absorb urine well B. Drying the skin with baby powder to prevent or mask the smell of ammonia C. Thorough washing, rinsing and drying of skin area that gets wet with urine D. Making sure that linen are smooth and dry at all times 11. Mrs. Sales also tells the nurse that she is often constipated. Because she is aging, what physical changes predispose her to constipation? A. Inhibition of the parasympathetic reflex B. Esophageal emptying hastens C. Loss of tone of the smooth muscles of the colon * NLE * NCLEX * CGFNS * HAAD * PROMETRICS * DHA * MIDWIFERY * LET * RAD TECH * CRIMINOLOGY * DENTISTRY * PHARMACY *
2 | Page D. Decreased ability to absorb fluids in the lower intestines 12. Chronic Obstructive Pulmonary Disease (COPD) is one of the leading causes of death worldwide and is a preventable disease. The primary cause of COPD is: A. High cholesterol diet B. Bronchitis C. Asthma D. Cigarette smoking 13. Nurse Davis is overseeing a patient in respiratory isolation and instructs her team on maintaining sterile technique. Which action is most likely to result in a breach of sterile technique in this setting? A. Omitting gloves during a bed bath. B. Opening the room door to the hospital corridor. C. Opening the window to the outside environment. D. Activating the room’s ventilation system. SITUATION: Nurse Corazon is assigned in the Manila Toprank Hospital. She is administering various medications and intravenous therapies to her patients. 14. Nurse Corazon has just received a unit of packed red blood cells from the blood bank to transfuse into a client as ordered. Before preparing the blood for transfusion, Nurse Corazon noticed the presence of bubbles in the bag. She should take which of the following actions? A. The nurse must look for another registered nurse to double check the bag B. The nurse must add 10ml of normal saline to the bag to remove the bubbles C. The nurse must return the bag to the blood bank for replacement D. The nurse must add 100 units of Heparin to the bag 15. Urethral catheterization requires a physician's order. Special care and strict I aseptic technique must be observed for clients with indwelling catheter.Anday after insertion of the urinary retention catheter, the client complains of discomfort in the bladder and urinary meatus. The initial action of the nurse would be to: A. Establish patency of the catheter. B. Milk the catheter towards the collecting receptacle. C. Check the bladder if distended. D. Inform the head nurse. 16. A physician tells Nurse Corazon that the client’s intravenous line will be discontinued. She should obtain which of the following supplies from the unit supply area for use in applying pressure to the IV site after removing the intravenous (IV) catheter? A. Sterile gauze B. Adhesive bandage C. Betadine swab D. Alcohol swab 17. The nurse is preparing to irrigate the indwelling urinary catheter of the client. As ordered by the physician, the client is to have closed intermittent catheter irrigation. The nurse performs the procedure in the following order: 1. Aspirate sterile solution into the syringe. 2. Using aseptic technique, put sterile solution in sterile graduated cup. 3. Clamp indwelling retention catheter. 4. Withdraw syringe, leave solution for around 20 minutes. 5. Slowly inject sterile irrigant into the catheter and bladder. 6. Remove the clamp and allow irrigant to drain into the collection bottle/bag. A. 2, 1, 3, 5, 4, 6 B. 3, 2, 1, 4, 5, 6 C. 3, 2, 1, 4, 5, 6, D. 1, 2, 3, 5,4, 6 18. At 8:00 a.m., Nurse Corazon is preparing to change the Total Parenteral Nutrition (TPN) solution bag and tubing. The client’s central venous line is located in the right subclavian vein. The nurse would instruct the client to do which of the following during the tubing change? A. Instruct the client to breathe normally B. The nurse must turn the head of the client to the right C. Ask the client to take a deep breath, hold and bear down D. Tell the client to exhale slowly and evenly until tubing change is done 19. Nurse Corazon is making initial rounds at the beginning of the shift. She enters the room of a client receiving total parenteral nutrition (TPN) and discovers that the bag is empty. Which of the following solutions readily available on the nursing unit should the she hang until another TPN solution is mixed and delivered to the nursing unit? A. 10% dextrose in water B. 5% dextrose in water C. 5% dextrose in 0.9% sodium chloride D. None of the above 20. The nurse selects which of the following materials to be used as the first layer of the dressing at the chest tube insertion site? A. The nurse must prepare a 4x4 dry sterile gauze B. The nurse must put absorbent kelix dressing C. Petrolatum jelly gauze D. Gauze with betadine 21. A nurse is caring for a client with a chest tube attached to a Pleurevac drainage system. Which of the following actions should the nurse avoid to prevent a tension pneumothorax? A. Clamping the chest tube B. Taping the connection between the chest tube and the drainage system C. Adding water to the suction chamber as it evaporates D. Maintaining the collection chamber below the client’s waist 22. A client with a chest tube attached to a Pleurevac drainage system wants to get out of bed. While the nurse is assisting the client, the chest tubing accidentally gets caught in the bed rail and disconnects and the Pleur-Evac drainage system falls over and cracks. The nurse takes which immediate action? A. Clamps the chest tube B. Applies a petroleum gauze over the end of the chest tube C. Immerses the chest tube in a bottle of sterile normal saline D. Calls the physician 23. In intravenous therapy, the rule is to use veins of the upper extremities first. The superficial veins of the dorsal aspect of the hand are the preferred site. Which area of the wrist is highly sensitive and most painful site of venipuncture and must be avoided by the nurse? A. outer aspect B. upper aspect C. lower aspect D. inner aspect 24. To reduce risk of airborne disease transmission from a client with infectious status in a private room, the nurse should do which of the following control measures? A. Use face mask when entering the room. B. Keep the door closed at all times. C. Limit visitors. D. Provide special ventilation. 25. As a safety precaution in handling contaminated needles, the nurses are instructed to observe which of the following protective measures: A. Discard contaminated needle immediately. B. Covered contaminated needle after injection. C. Detach the needle from the syringe and discards. D. Throw the needle in a covered receptacle. 26. Once the client is in position the nurse visualizes the anus and is ready to insert the rectal tip. She is doing the procedure correctly when she directs the rectal tip to the: A. Sigmoid B. Umbilicus C. Rectum D. Large intestine 27. A client has an order of small volume enema after an oral laxative fails to produce sufficient stool return. The nurse informs the client of the procedure. The client asks the nurse what small volume enema is all about. The nurse offered an APPROPRIATE answer when she states that small volume enema is: A. A laxative solution. B. Given to cleanse the colon. C. Used to clean the sigmoid and rectum. D. A commercially prepared enema.