Nursing Practice 1 – Foundation of Professional Nursing Practice
Fundamentals of Nursing
PART 1 Board Exam test questions 1 - 50
Situation 1: Nursing is a profession. The nurse should have a background on the theories and foundation of nursing as it influenced what is nursing today.
1. Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of the individuals, families, communities and population. This is the most accepted definition of nursing as defined by the:
A. PNA
B. ANA
C. Nightingale
D. Henderson
2. Advancement in Nursing leads to the development of the Expanded Career Roles. Which of the following is NOT expanded career role for nurse?
A. Nurse practitioner
B. Clinical Nurse Specialist
C. Nurse Researcher
D. Nurse anaesthesiologist
3. The Board of Nursing regulated the Nursing profession in the Philippines
A. Issue, suspend revoke certificates of registration
B. Issue subpoena duces tecum, ad testificandum
C. Open and close colleges of nursing
D. Supervise and regulate the practice
4. A nursing student or a beginning staff nurse who has not yet experienced enough in a situation to make judgments about them is in what stage of Nursing Expertise?
A. Novice
B. Newbie
C. Advanced Beginner
D. Competent
5. Benner’s “Proficient” nurse level is different from the other levels in nursing expertise in the context of having:
A. The ability to organize and plan activities
B. Having attained an advanced level of education
C. A holistic understanding and perception of the client
D. Intuitive and analytic ability in new situations
Situation 2: The nurse has been asked to administer an injection via Z TRACK technique. Questions 6 to 10 refer this.
6. The nurse prepares an IM injection for an adult client using the Z track techniques, 4 ml of medication is to be administered to the client. Which of the following site will you choose?
A. Deltoid
B. Rectus Femoris
C. Ventrogluteal
D. Vastus lateralis
7. In infants 1 year old and below, which of the following is the site of choice in intramuscular injection?
A. Deltoid
B. Rectus Femoris
C. Ventrogluteal
D. Vastus lateralis
8. In order to decrease discomfort in Z track administration, which of the
A. Pierce the skin quickly and smoothly at 90 degree angle
B. Inject the medication at around 10 minutes per millilitre
C. Pull back the plunger and aspirate for 1 minute t make sure that the needle did not hit a blood vessel
D. Pierce the skin slowly and carefully at a 90 degree angle
9. After injection using the Z track technique, the nurse should know that she needs to wait for few second before withdrawing the needle and this is to allow the medication to disperse into the muscle tissue thus decreasing the client’s discomfort. How many seconds should the nurse wait before withdrawing the needle?
A. 2 second
B. 5 seconds
C. 10 seconds
D. 15 seconds
10. The rationale in using the Z track technique in an intramuscular injection is:
A. It decreases the leakage of discolouring and irritating medication into the subcutaneous tissue.
B. It will allow a faster absorption of the medication
C. The Z track technique prevent irritation of the muscle
D. It is much more convenient for the nurse
Situation 3: A client was rushed to the emergency room and you are his attending nurse. You are performing a vital sign assessment:
11. All of the following are correct methods in assessment of the blood pressure EXCEPT:
A. Take the blood pressure reading on both arms for comparison
B. Listen to and identify the phases of Korotkoff sound
C. Pump the cuff to around 50mmHg above the point where the pulse is obliterated
D. Observe procedures for infection control
12. You attached a pulse oximeter to the client. You know that the purpose id to:
A. Determine if the client’s hemoglobin level 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-hypertension medications
D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops
13. After a few hours in the Emergency Room, the client is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be:
A. Inconsistent
B. Low systolic and high diastolic
C. Higher than what the reading should be
D. Lower than what the reading should be
14. Through the client’s health history, you gather that the patient smokes and drinks coffee. When taking the blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before taking the client’s blood pressure for accurate reading?
A. 15 minutes
B. 30 minutes
C. 1 hour
D. 5 minutes
15. While the client has pulse oximeter on his fingertip, you notice that the sunlight is shining on the area where the oximiter 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
C. Cover the fingertip sensor with a towel or bedsheet
D. Change the location of the sensor every four hours
16. The nurse finds it necessary to recheck the blood pressure reading. In case of such reassessment, the nurse should wait for a period of:
A. 15 seconds
B. 1 to 2 minutes
C. 30 minutes
D. 15 minutes
17. If the arm is said to be elevated when taking the blood pressure. It will create a:
A. False high reading
B. False low reading
C. True False reading
D. Indeterminate
18. You are to assessed the temperature of the client the next morning and found out that he ate ice cream. How many minutes should you wait before assessing the client’s oral temperature?
A. 10 minutes
B. 20 minutes
C. 30 minutes
D. 15 minutes
19. When auscultating the client’s blood pressure the nurse hears the following: From 150 mmHg to 130 mmHg: Silence, Then: a thumping sound continuing down to 100 mmHg: muffled sound continuing down to 80 mmHg and then silence. What is the client’s pressure?
A. 130/80
B. 150/100
C. 100/80
D. 150/100
20. In a client with a previous blood pressure of 130/80 4 hours ago, how long will it take to release the blood pressure cuff to obtain an accurate reading?
A. 10 – 20 seconds
B. 30 – 45 seconds
C. 1 - 1.5 minutes
D. 3 – 3.5 minutes
Situation 4 – Oral care is an important part of hygienic practices and promoting client
comfort.
21. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presence of sores. Which of the following is BEST to use for oral care?
A. lemon glycerine
B. hydrogen peroxide
C. Mineral oil
D. Normal saline solution
22. When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs?
A. Put the client on a sidelying position with head of bed lowered
B. Keep the client dry by placing towel under the chin
C. Wash hands and observe appropriate infection control
D. Clean mouth with oral swabs in a careful and an orderly progression
23. The advantages of oral care for a client include all of the following, EXCEPT:
A. decreases bacteria in the mouth and teeth
B. reduces need to use commercial mouthwash which irritate the buccal
mucosa
C. improves client’s appearance and self-confidence
D. improves appetite and taste of food
24. A possible problem while providing oral care to unconscious clients is the risk of fluid
aspiration to lungs. This can be avoided by:
A. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid
rinsing the buccal cavity
B. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs
C. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue,
lips and ums
D. suctioning as needed while cleaning the buccal cavity
25. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using:
A. salt solution
B. water
C. petroleum jelly
D. mentholated ointment
Situation 5: Ensuring safety before, during and after a diagnostic procedure is an important responsibility of the nurse.
26. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the following prior to the procedure:
A. Clenching his fist every 2 minutes
B. Breathing in and out through the nose with his mouth open
C. Tensing the shoulder muscles while lying on his back
D. Holding his breath periodically for 30 seconds
27. Following a bronchoscopy, which of the following complains to Fernan should be noted as a possible complication:
A. Nausea and vomiting
B. Shortness of breath and laryngeal stridor
C. Blood tinged sputum and coughing
D. Sore throat and hoarseness
28. Immediately after bronchoscopy, you instructed Fernan to:
A. Exercise the neck muscles
B. Breathe deeply
C. Refrain from coughing and talking
D. Clear his throat
29. Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important function during the procedure is to:
A. Keep the sterile equipment from contamination
B. Assist the physician
C. Open and close the three-way stopcock
D. Observe the patient’s vital signs
30. Right after thoracentesis, which of the following is most appropriate intervention?
A. Instruct the patient not to cough or deep breathe for two hours
B. Observe for symptoms of tightness of chest or bleeding
C. Place an ice pack to the puncture site
D. Remove the dressing to check for bleeding
Situation 6: Knowledge of the acid base disturbance and the functions of the electrolytes is necessary to determine appropriate intervention and nursing actions.
31. A client with diabetes milletus has glucose level of 644 mg/dL. The nurse interprets that this client is at most risk for the involvement at which type of acid base imbalance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
32. In a client in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, PCO2 32mmHg, PO2 94 mmHg, HCO3 24 mEq/L. The nurse interprets that the client has which acid base disturbance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
33. A client has an order for ABG analysis on radial artery specimens. The nurse ensures that which of the following has been performed or tested before the ABG specimen are drawn?
A. Guthing test
B. Allen’s test
C. Romberg’s test
D. Weber’s test
34. A nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31, Pco2 is 500 mmHg, and the bicarbonate is 27 mEq/L. The nurse concludes that which acid base disturbance is present in this client?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
35. Allen’s test checks the patency of the:
A. Ulnar artery
B. Radial artery
C. Carotid artery
D. Brachial artery
37. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes “daily urine specimen to be sent to the laboratory” . Eileen has a foley catheter attached 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.
D. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into the specimen container.
38. Where would the nurse tape Eileen’s indwelling catheter in order to reduce urethral irritation?
A. to the patient’s inner thigh
B. to the patient’s lower thigh
C. to the patient’s buttocks
D. to the patient lower abdomen
39. Which of the following menu is appropriate for one with low sodium diet?
A. instant noodles, fresh fruits and ice tea
B. ham and cheese sandwich, fresh fruits and vegetables
C. white chicken sandwich, vegetable salad and tea
D. canned soup, potato salad, and diet soda
40. Howe will you prevent ascending infection to Eileen who has an indwelling catheter?
A. see to it that the drainage tubing touches the level of the urine
B. change he catheter every eight hours
C. see to it that the drainage tubing does not touch the level of the urine
D. clean catheter may be used since urethral meatus is not a sterile area
Situation 7: Hormones are secreted by the various glands in the body. Basic knowledge of the endocrine system is necessary.
41. Somatotropin or the Growth Hormone releasing hormone is secreted by the anterior pituitary gland:
A. Hypothalamus
B. Anterior pituitary gland
C. Posterior pituitary gland
D. Thyroid gland
42. All of the following are secreted by the anterior pituitary gland except:
A. Somatotropin/Growth hormone
B. Follicle stimulating hormone
C. Thyroid stimulating hormone
D. Gonadotropin hormone releasing hormone
43. All of the following hormones are hormones secreted by the Posterior pituitary gland except:
A. Vasopressin
B. Oxytocin
C. Anti-diuretic hormone
D. Growth hormone
44. Calcitonin, a hormone necessary for calcium regulation is secreted in the:
A. Thyroid gland
B. Hypothalamus
C. Parathyroid gland
D. Anterior pituitary gland
45. While Parathormone, a hormone that regulates the effect of calcitonin is secreted by the:
A. Thyroid gland
B. Hypothalamus
C. Parathyroid gland
D. Anterior pituitary gland
Situation 8 – The staff nurse supervisor requests all the staff nurses to “brainstorm” and
learn ways to instruct diabetic clients on self-administration of insulin. She wants to ensure
that there are nurses available daily to do health education classes.
46. The plan of the nurse supervisor is an example of
A. in service education process
B. efficient management of human resources
C. increasing human resources
D. primary prevention
47. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide
who is an unlicensed staff, Mrs. Guevarra
A. makes the assignment to teach the staff member
B. is assigning the responsibility to the aide but not the accountability for
those tasks
C. does not have to supervise or evaluate the aide
D. most know how to perform task delegated
48. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six
weeks ago when she started the job. The nurse supervisor should
A. empathize with the nurse and listen to her
B. tell her to take the day off
C. discuss how she is adjusting to her new job
D. ask about her family life
49. Process of formal negotiations of working conditions between a group of registered
nurses and employer is
A. grievance
B. arbitration
C. collective bargaining
D. strike
50. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and
required by the hospital employing you. This is
A. professional course towards credits
B. inservice education
C. advance training
D. continuing education
is this blog legit? are the answer key here correct? please help im reviewing for up coming nursning board exam. thanks
ReplyDelete