Fundamentals of Nursing

Health Assessment
1. Direct percussion, involves striking of the area to be percussed directly with the pads of
two, three, or four fingers, or with the pad of the middle finger. You are to perform a
complete physical assessment to Mr. Mogul Khan, 48 years old, diagnosed with a certain
chronic obstructive pulmonary disease. You expect to hear which of the following sounds
during percussion of his lung fields?
a. Resonance
b. Hyperresonance
c. Tympany
d. Dullness

2. Skin lesions are classified as primary (those that appear initially in response to some
change in the external or internal environment of the skin) and secondary (those that do
not appear initially but result from modifications such as chronicity, trauma, or infection
of the primary lesion). You were assigned to care for a patient who has suffered from
second-degree burns all over his upper extremities just last night. During examination,
you noted circumscribed, oval masses, filled with serous fluids that are more than 1 cm.
You properly document this as:
a. Pustules
b. Bullae
c. Wheals
d. Vesicles

3. Examination of the eyes includes assessment of visual acuity (the degree of detail the eye
can discern in an image), ocular movement, visual fields, and external resources. Nurse
Gyrocopter was assigned to assist a patient who was admitted due to a certain central
nervous system disorder. While he’s reviewing his patient’s chart, he reads: “Right pupil
– 7 mm in diameter, left pupil – 4 mm in diameter.
a. The patient has anisocoria
a. The patient’s miosis could be the result of Morphine overdose
b. The patient has normal pupil size
c. The patient has mydriasis on the right pupil, and miosis on the left pupil

4. The child acquires normal 20/20 vision by 6 years of age. After Nurse Tinker has
performed visual assessment, using a Snellen chart, to her patient Drow Ranger, she
documented that this patient’s visual acuity is 20/40. She understands that:
a. It is a normal finding.
b. He is technically blind.
a. The patient can read at distance of 20 feet away from the Snellen chart, that an
individual with normal vision can read from 40 feet distance.
 c. Drow Ranger was able to read from 40 feet away from the Snellen chart, that an
individual with normal vision can read at 20 feet away.

5. Normal assessment of the pupils is recorded as PERRLA which means Pupils Equally
Round and Reactive to Light and Accommodation. Windrunner, 27, is admitted after a
massive car accident. Nurse Necrolyte, is to assess this patient’s pupil reactions and
accommodation. Which of the following indicates an abnormal response?
a. As Nurse Necrolyte illuminated Windrunner’ss right pupil, it constricted.
b. Windrunner’s pupil constricts when looking at the far object.
c. While the nurse shines the light on the patient’s right pupil, the other pupil also
constricts.
d. None of the above.

Pharmacology
1. Nurse Suzie is administering 12:00 PM medication in Ward 4. Two patients have to
receive Lanoxin. What should Nurse Suzie do when one of the clients does NOT have a
readable identification band?
a. Ask the client if she is Mrs. Santos
b. Ask the client his name
c. Ask the roommate if the client is Mrs. Santos
d. Compare the ID band with the bed tag

2. Miscommunication of Drug orders was identified as a probable cause of medication

error. Which of the following is safe medication practice related to this?
a. Maintain medication in its unit dose package until point if actual administration
b. Note both generic and brand name of the medication in the medication
administration method
c. The physician should use approved universal abbreviations
d. Encourage clients to ask questions about their medications

3. Baby Liza, 3 months old with a congenital heart deformity, has an order from her
physician: “give 3 cc of Lanoxin today for 1 dose only” Which of the following is the
most appropriate action by the nurse?
a. Clarify the order with the attending physician
b. Discuss the order with the pediatric heart specialist in the unit
c. Administer Lanoxin intravenously as it is the usual route of administration
d. Refer to the medication administration record for previous administration of
Lanoxin

4. You are to initiate an IV line to your patient Kyle, 5 who is febrile. What IV
administration set will you prepare?
a. Blood transfusion set c. Macroset
b. Volumetric chamber d. Microset
 5. Rudolf diagnosed with amoebiasis and is to receive Metronidazole (Flagyl) tablets 1.5
gram daily in 3 divided doses for 7 consecutive days. Which of the following is the
correct dose of the drug that the client will receive per oral administration?
a. 1000 mg TID c. 500 mg TID
b. 1500 mg TID d. 50 mg TID

Nursing Therapeutics

11. Good oral hygiene includes daily stimulation of the gums, mechanical brushing and flossing
of the teeth, and flushing of the mouth. Nurse Wako Wako instructs the nursing assistant on how
to provide oral hygiene for a client who cannot perform this task for himself. Which of the
following techniques should nurse Wako Wako tell the assistant to incorporate into the client’s
daily care?

a. Swab the client’s tongue, gums, and lips with a soft foam applicator every 2 hours.

b. Use a soft toothbrush to brush the client’s teeth after each meal.

c. Rinse the client’s mouth with mouthwash several times a day.

d. Assess the oral activity each time mouth care is given and record observations.

12. The feet are essential for ambulation and merit attention even when people are confined to
bed. Each foot contains 26 bones, 107 ligaments, and 19 muscles. A client with diabetes is
explaining to nurse Budoyl how she will care for her feet at home. Which statement indicates
that the client understands proper foot care?

a. “I should inspect my feet at least once a week”

b. “I do not plan to wear shoes while I am in the house.”
c. “When I injure my toe, I will plan to put iodine on it.”
d. “It is important to dry my feet carefully after my bath.”s

13. Oxygen therapy is prescribed by the primary care provider, who specifies the concentration,
method of delivery, and depending on the method, liter flow per minute. An oxygen delivery
system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise
oxygen concentration. Which oxygen delivery system would the nurse anticipate to be
prescribed?

a. Face tent
 b. Venturi mask
c. Non Rebreather mask
d. Tracheostomy collar

14.. Bronchoscopy is a medical procedure that allows a doctor to see inside a person's airways.
The airways are called the bronchial tubes or bronchi. A client is being prepared for a
bronchoscopy. Which of the following preoperative activities would be appropriate for the nurse
to delegate to the unlicensed assistant?

a. Instructing the client about the procedure.

b. Evaluating the client’s level of anxiety.
c. Obtaining the signed consent form.
d. Placing the client on NPO (nothing by mouth) status.

15. Chest drainage therapy is done to relieve pressure on the lungs, and remove fluid that could
promote infection. Installing a chest drainage tube can be either an emergency or a planned
procedure.Nurse BJ instructs the unlicensed assistant how to care for a client with chest tubes
that are connected to water-seal drainage. Which of the following instructions would be
appropriate for nurse BJ to give the unlicensed assistant?

a. Attach the chest tubes to bed linen to avoid tension on the tubing.
b. Mark the time and amount of drainage on the collection container.
c. Milk the chest tubes every 4 hours.
d. Raise the collection apparatus to the height of the bed to measure the fluid level.

16. In June 2011, the USDA stopped using the food guide pyramid and decided to go with a food
guide that reflects the food choices that would contribute to fitness (Comprehension, QI)

a. MyGoodFood Food Guide

b. MyRightDiet Food Guide
c. MyPlate Food Guide
d. MySilverSpoon Food Guide

17. For the client’s stool to be “formed” which of the following food are added to the diet?
a. Boiled rice
b. Spaghetti and Macaroni
c. Cheese
d. Bran

18. While doing a nutritional assessment of a low-income family, the community health nurse
determines the family’s diet is inadequate in protein content. The nurse could suggest which of
the following foods to increase protein content with little increase in food expenditure
a. Oranges and potatoes
b. Potatoes and rice
c. Rice and Macaroni
d. Peas and Beans

19. It provides a reliable indicator of body fatness for most people (Comprehension, HE)
a. BMR c. BMX
b. BMI d. BMO

20. Fat-soluble vitamins are absorbed through the intestinal tract with the help of lipids (fats).
Excessive intake of these vitamins may result to which condition (Comprehension, SQC)
a. Avitaminosis
b. Hepatotoxicity
c. Cardiomegaly
d. Diarrhea

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